We are very grateful to Liza Caruana-Finkel for collaborating on this blog post. Liza is a sexual and reproductive health and rights researcher and activist currently based in the UK.

Rights and evidence-based knowledge on safe abortion matters!

The 28^th of September is International Safe Abortion Day. It is a day of action: when we celebrate past achievements, but crucially, when we look to the future with a will and determination to make safe abortion available, accessible and affordable for all – no one left behind!

In light of recent attacks around the globe on the availability of legal and safe abortion services and in the contexts of the Universal Health Coverage (UHC) agenda, pursuing the achievement of the Sustainable Development Goals, and reflecting on the implementation of the Programme of Action of the International Conference on Population and Development (ICPD), SRHM is encouraging the revitalisation of evidence, knowledge and analysis related to safe abortion as a matter of health care, with special attention to the impact of criminal and restrictive laws that  impede  access to safe abortion services.

The legal status of abortion cannot be disconnected from the realm of public health

Every human being has the right to the highest attainable standard of health, without impediments such as financial hardship. This is at the core of UHC, an essential framework for the promotion of health and wellbeing. UHC cannot be achieved unless sexual and reproductive health and rights (SRHR) and the intersecting elements of gender equality and human rights are properly addressed so that everyone, no matter their country of residence or socio-economic status, has access to safe and legal abortion.

In the current political climate, achieving UHC for SRHR can be challenging. There is under-representation of SRHR in broader public health discussions and longstanding neglect of the needs and rights of the most marginalised, including women and girls, refugees and migrants, people living with disability, people living with HIV, as well as transgender and non-binary people. 25 years after the ICPD acknowledged reproductive rights as human rights, it is vital that access to legal and safe abortion is regarded globally as a significant matter of public health, particularly by governments, parliamentarians, judges, policy makers, healthcare professionals, and other key influencers.

Due to the present relevance of ‘abortion as healthcare’, SRHM has issued a call for papers for a themed issue – Universal Health Coverage: Sexual and Reproductive Rights in Focus. Please see the full call for papers here: www.srhm.org/call-for-papers/

Below we have collected evidence on the importance of access to safe abortion from papers published in the SRHM Journal. Each section is followed by a selection of relevant articles.

The legal status of abortion has no effect on a woman’s need for abortion

Abortion bans are an insidious way that legislation is used to block access to healthcare services. However, the legal status of abortion has no effect on a woman’s need for abortion, because the likelihood of experiencing an unintended pregnancy and seeking abortion does not depend upon whether abortion is available or legally restricted. In fact, countries in which abortion is illegal and those where it is broadly legal have similar rates of abortion. What actually happens when abortion is legally restricted is that access to safe abortion is jeopardised, thus leading to unsafe abortion. In spite of major increases in contraceptive uptake and significant advances in safe abortion technologies, unsafe abortions continue to occur in much of the developing world, killing and injuring many women each year. When abortion legislation is highly restrictive, the incidence of unsafe abortion and related mortality may be higher compared to legislative settings that allows abortion in broader circumstances. When contraceptive services are unable to meet the demand for family planning, and when contraception fails, women and couples turn to abortion to regulate their fertility. Where access to safe abortion is restricted, women are forced to rely on unskilled providers or use methods and drugs without clinical support.

• Criminalisation under scrutiny: how constitutional courts are changing their narrative by using public health evidence in abortion cases, Verónica Undurraga, 2019
• Prevalence, attitudes and knowledge of misoprostol for self-induction of abortion in women presenting for abortion at Midwestern reproductive health clinics, Courtney Kerestes, Kelsey Sheets, Colleen K Stockdale, et al, 2019
• Unsafe abortion in 2008: global and regional levels and trends, Iqbal Shah & Elisabeth Ahman, 2010
• Unsafe abortion and abortion care in Khartoum, Sudan, Joyce Kinaro, Tag Elsir Mohamed Ali, Rhonda Schlangen & Jessica Mack, 2009
• National Laws and Unsafe Abortion: The Parameters of Change, Marge Berer, 2005
• Complications of Unsafe Abortion: A Case Study and the Need for Abortion Law Reform in Nigeria, Boniface A Oye-Adeniran, Augustine V Umoh & Steve NN Nnatu, 2002

Complications from unsafe and illegal abortion may financially cost more than access to safe and legal abortion

Unsafe and illegal abortion is costly to the health system, both for economic and health-related reasons. Improving access to safe, legal abortion leads to significant cost savings, because of the increased financial cost of curing post-abortion complications, which are far more common in unsafe, illegal abortion practices.

• Medical abortionand manual vacuum aspiration for legal abortion protect women’s health and reduce costs to the health system: findings from Colombia, Maria Isabel Rodriguez, Willis Simancas Mendoza, Camilo Guerra-Palacio, Nelson Alvis Guzman, Jorge E Tolosa, 2015
• Exploring the costs and economic consequences of unsafe abortion in Mexico City before legalisation, Carol Levin, Daniel Grossman, Karla Berdichevsky, Claudia Diaz, Belkis Aracena, Sandra G Garcia & Lorelei Goodyear, 2009

Criminalisation and restrictive abortion laws can perpetuate stigma which is associated with  negative health consequences

Criminalisation and restrictive abortion laws can also perpetuate stigma, which may lead to negative health consequences through delays in seeking care, essentially jeopardising access to safe services. Abortion stigma drives women and pregnant people to keep their abortions secret, perpetuating the false notion that abortion is uncommon. Within a restrictive legal framework, fear of negative social consequences can lead to adverse health consequences, whereby women do not seek medical post-abortion care, which puts them at a higher risk of injury and death. Although stigma is more prevalent in countries with restrictive laws, it exists even in more liberal legal settings, and can still be a significant barrier to seeking medical care.

• Abortion and contraceptive use stigma: a cross-sectional study of attitudes and beliefs in secondary school students in western Kenya, Ulrika Rehnström Loi, Beatrice Otieno, Monica Oguttu, et al. 2019
• Exploring stigma and social norms in women’s abortion experiences and their expectations of care, Shelly Makleff, Rebecca Wilkins, Hadassah Wachsmann, et al. 2019
• “You must first save her life”: community perceptions towards induced abortion and post-abortion care in North and South Kivu, Democratic Republic of the Congo, Sara E Casey, Victoria J Steven, Julianne Deitch, Erin Files Dumas, Meghan C Gallagher, Stephanie Martinez, Catherine N Morris, Raoza Vololona Rafanoharana & Erin Wheeler, 2019
• Stigma and agency: exploring young Kenyan women’s experiences with abortion stigma and individual agency, Deeqa Mohamed, Nadia Diamond-Smith & Jesse Njunguru, 2018

In addition, psychologically negative effects, which occur in a very small number of women, are likely to be the continuation of pre-existing mental health conditions rather than a consequence of the experience of abortion. Most women experience relief, rather than regret. On the other hand, inaccessibility of abortion can cause devastating consequences, including emotional trauma and risk of suicide. The circumstances in which the abortion is carried out can also lead to negative emotional and psychological feelings. One reason is that restrictive laws punish women who have abortions and treat them as criminals. A second reason is the socio-cultural environment which may classify abortion as a ‘grave sin’ or a ‘moral transgression’. This may lead to feelings of shame and guilt, which relates to stigma and the fear of negative social repercussions.

Criminalisation of abortion is a matter of inequality and social injustice

Criminalisation of abortion is a matter of inequality and social injustice, because it disproportionally discriminated against the most marginalised in society. In many circumstances people with financial means are still able to access safe abortion. Those without such means – the poor, rural, young and/or vulnerable women – resort to unsafe abortion instead. In most restrictive settings, it is often the poorest and most marginalised women who are discriminated against and prosecuted for illegal abortions (and sometimes even for miscarriages), highlighting deep inequality.

• Mortality in Rohingya refugee camps in Bangladesh: historical, social, and political context, Parveen K Parmar, Rowen O Jin, Meredith Walsh & Jennifer Scott, 2019
• The gender injustice of abortion laws, Joanna N.Erdman, 2019
• From hospital to jail: the impact on women of El Salvador’s total criminalization of abortion, Citizen’s Coalition for the Decriminalization of Abortion on Grounds of Health, Ethics and Fetal Anomaly, El Salvador, 2014
• Using litigation to defend women prosecuted for abortion in Mexico: challenging state laws and the implications of recent court judgments, Jennifer Paine, Regina Tamés Noriega & Alma Luz Beltrány Puga, 2014
• A strategic assessment of unsafe abortion in Malawi, Emily Jackson, Brooke Ronald Johnson, Hailemichael Gebreselassie, Godfrey D Kangaude & Chisale Mhango, 2011

Criminalisation of abortion creates a ‘chilling effect’

The criminalisation of abortion can also create a ‘chilling effect’ on healthcare providers as well as on women seeking abortion, with the possibility of endangering women’s health and lives. Healthcare professionals may be worried about providing abortion-related information, even when it is legal to do so. Therefore, the type and quality of information available to a person seeking abortion may be affected. This can delay receiving accurate information, which may jeopardise access to safe, quality services. This lack of information can lead to the ‘chilling effect’ in women who may worry about medical abortion-related complications as well as potential legal repercussions, such as being reported to the police if they seek post-abortion care.

Women seeking illegal abortion may be mistreated and discriminated against by health providers

Due of the clandestine nature of illegal abortion, women are at risk of being charged exorbitant prices by abortion providers. There is also a risk of sexual abuse, with studies showing that women have been asked for sex in exchange for abortion services. Because abortion is forbidden, these providers cannot be reported. When abortion is illegal, the harm is invisible. Moreover, when women seek medical assistance following illegal and unsafe abortion, initiation of care may be delayed by healthcare providers and pain can be used as punishment, which ties in with the stigma associated with abortion.

• Abortion in Chile: the practice under a restrictive regime, Lidia Casas& Lieta Vivaldi, 2014
• Delay in the provision of adequate care to women who died from abortion-related complications in the principal maternity hospital of Gabon, Sosthene Mayi-Tsonga, Litochenko Oksana, Isabelle Ndombi, Thierno Diallo, Maria Helena de Sousa & Aníbal Faúndes, 2009
• Easing the pain: Pain management in the treatment of incomplete abortion, Julie Solo, 2000

Reducing the time limit for abortion will not reduce the need for second trimester abortions

There are various reasons why an abortion may be needed in the second trimester, such as fetal anomalies, changes in personal circumstances, young age, and a delay in suspecting pregnancy. Restricting abortion to only the first trimester can lead to it being needed at an even later stage and push women to seek abortion from other countries where it is legally permissible. This links back to social justice, as travel is contingent on factors such as wealth and mobility, meaning adolescents, disabled women, poor women, and those within abusive relationships may not be able to access safe, legal abortion abroad.

• Factors Influencing the Percentage of Second Trimester Abortions in the Netherlands, Olga Loeber & Cecile Wijsen, 2008
• Reasons for Second Trimester Abortions in England and Wales, Roger Ingham, Ellie Lee, Steve Joanne Clements & Nicole Stone, 2008
• Who is Excluded When Abortion Access is Restricted to Twelve Weeks? Evidence from Maputo, Mozambique, Momade Bay Ustá, Ellen M.H Mitchell, Hailemichael Gebreselassie, Eunice Brookman-Amissah & Amata Kwizera, 2008
• Late Abortion: A Research Study of Women Undergoing Abortion Between 19 and 24 Weeks Gestation, Sarah Robotham, Louise Lee-Jones & Tony Kerridge, 2005

Allowing abortion only in certain circumstances delays the provision of safe, legal abortion

When abortion is legal but only in specific circumstances, there may be a delay in abortion access while checks are carried out by authorities to ensure that a woman’s circumstance is indeed acceptable by law. For example, in the case of a non-viable fetal anomaly legal authorisation might be needed to prove that the anomaly is indeed fatal. Unfortunately, even people who are legally entitled to abortion may be denied access. This often causes unnecessary emotional suffering and might lead to harmful health consequences if an illegal and unsafe (but secret) underground abortion is pursued instead.

• Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women, Marge Berer, 2013
• Women’s experiences of the abortion law in Cameroon: “What really matters”, Sylvie Schuster, 2010
• Termination of Pregnancy for Fetal Abnormality Incompatible with Life: Women’s Experiences in Brazil, Lúcia de Lourdes Ferreira da Costa, Ellen Hardy, Maria José Duarte Osis & Anibal Faúndes, 2005
• Constructing Access to Legal Abortion Services in Mexico City, Deborah L Billings, Claudia Moreno, Celia Ramos, Deyanira González de León, Rubén Ramı́rez, Leticia Villaseñor Martı́nez & Mauricio Rivera Dı́az, 2002
• Clear and Compelling Evidence: The Polish Tribunal on Abortion Rights, Françoise Girard & Wanda Nowicka, 2002

 Regulatory and service-related barriers are also affecting women’s health

 These include mandatory waiting periods, obligatory counselling, conscientious objection without ensuring access to safe abortion, not allowing medical abortion, exclusion of abortion services under health coverage, unavailability of health facilities, and untrained healthcare providers. Therefore, even where abortion may be less legally restrictive, such requirements and obstacles lead to delays in accessing safe abortion services. This means that some women might be unable to access legal, safe methods of abortion. These restrictions also cause undue burdens and unnecessary suffering for women.

• Legal barriers to access abortion services through a human rights lens: the Uruguayan experience, Lucía Berro Pizzarossa, 2018
• Using a harm reduction lens to examine post-intervention results of medical abortion training among Zambian pharmacists, Tamara Fetters, Keris Raisanen, Stephen Mupeta, Isikanda Malisikwanda, Bellington Vwalika, Joachim Osur & Sally Dijkerman, 2014
• Conscientious objection, barriers, and abortionin the case of rape: a study among physicians in Brazil, Debora Diniz, Alberto Madeiro & Cristião Rosas, 2014

Well informed health professionals are more likely to support access to safe abortion services

When women do seek medical assistance, studies show that initiation of care may be delayed by healthcare providers, who may prioritise pregnancy-related complications and disregard post-abortion complications, possibly due to abortion stigma. However, well informed health professionals are more likely to support access to safe abortion services. In fact, there appears to be a link between support of abortion access and the level of knowledge on the subject. Notably, obstetricians and gynaecologists, and particularly those who have been extensively trained on abortion, are more likely to support decriminalisation and an individual’s right to access abortion. On the other hand, non-medical personnel who are less informed of the safety of abortion may be more likely to perceive abortion as immoral and to only support access to abortion in limited circumstances, if at all.

• Dualities between Tunisian provider beliefs and actions in abortion care, Sarah Raifman, Selma Hajri, Caitlin Gerdts & Diana Foster, 2018
• The contribution of research results to dramatic improvements in post-abortion care: Centre Hospitalier de Libreville, Gabon, Sosthène Mayi-Tsonga,Pamphile Assoumou,Boniface Sima Olé, et al, 2012
• Abortion in a Restrictive Legal Context: The Views of Obstetrician–Gynaecologists in Buenos Aires, Argentina, Mónica Gogna, Mariana Romero, Silvina Ramos, Mónica Petracci & Dalia Szulik, 2002

As portrayed in the available evidence-based knowledge above, there is a clear link between access to safe abortion and women’s health. We recognise that there are many countries in the world where laws, policy restrictions, and practice barriers impede access to safe abortion, and we understand the negative implications that such restrictions have on people’s lives. We also know that when abortion is decriminalised and legal, and not constrained by restrictive grounds and other regulatory and service-related barriers, it is safer and more accessible.  It is imperative therefore, to eliminate all legal barriers in accessing safe  abortion services so to  protect women’s health and their human rights. Political will and programmatic development are crucial if we are to reach this objective.

Sexual and Reproductive Health Matters (SRHM) has been gathering evidence-based knowledge on SRHR– including abortion – for over 25 years. The SRHM journal contains academic, peer-reviewed evidence and rights-based perspectives on the harms of limiting access to safe abortion. We encourage you to visit our website, sign up to our upcoming webinar on abortion and UHC, and read more of our journal articles on abortion and other SRHR considerations, as well as to submit your own work. Peer-reviewed, evidence-based academic work with a human rights perspective is vital to inform fair and just legislation, policies and services. Now more than ever.