Editorial
Abortion: access and safety worldwide
44% of the world’s annual 227 million pregnancies
are unintended, of which 56% end in abortion, 32%
in an unplanned birth, and 12% in miscarriage. These
estimates—from a modelling study authored by the
Guttmacher Institute and the University of Massachusetts
and published by The Lancet Global Health—form the basis
of a Guttmacher report on global abortion published on
March 20. This analysis was last performed in 2009, since
when the rate of unintended pregnancy and abortion in
high-income countries has fallen significantly, concurrent
with both an increase in the rate of modern contraception
usage and a decrease in the number of unintended
pregnancies ending in abortion. Low-income and middle-
income countries have a higher abortion rate than high
income countries, and there has been no significant
change in the rate since the 1990s.
Unsafe abortions cause 8–11% of global maternal
deaths and occur predominantly in low-income and
middle-income countries where the most restrictive
access policies are concentrated and socioeconomic
factors further affect access. Since 2009, the report
concludes, a significant rise in medication abortions
(using the combination of mifepristone and misoprostol,
or misoprostol alone) has substantially improved the
safety of clandestine abortions. Misoprostol, which is also
used to treat gastric ulcers and therefore often relatively
widely available, is now the most common method of
abortion in many countries with restricted access. In
high-income countries, which usually have the most
liberal access policies, the vast majority of abortions are
conducted under safe conditions. Many high-income
countries have transitioned from majority surgical to
majority medication abortions (using the more efficacious
combination of misoprostol and mifepristone). This
transition, in combination with increasing early detection
of pregnancy, has increased the rate of early and very
early abortions. The high cost of mifepristone and lack
of an alternative mean that surgical vacuum aspiration
still predominates in some high-income countries—for
example, Germany.
Since 2000, 27 countries have expanded the legal
grounds for abortion, and only one country (Nicaragua)
has restricted access. However, in countries where
abortion is legally permitted, access can be compromised
in several ways. In the USA, since 2010, 32 states have
www.thelancet.com Vol 391 March 24, 2018 1121
collectively enacted 338 laws restricting access to legal
abortion. On March 16, the National Academies of
Sciences, Engineering, and Medicine (NASEM) released
a comprehensive review of the safety and the quality of
abortion care in the USA. The committee who conducted
Philippe Plailly/Science Photo Library
this study concluded that legal abortions in the USA are
safe and effective. However, they found that abortion-
specific state regulations have created barriers to optimal
care for US women and that quality of care was highly
dependent on where women lived. 39% of US women of
reproductive age currently live in states with no abortion
provider and the number of facilities continues to
decrease, with the greatest proportional decline in states
with the most abortion-specific legislation.
The evidence behind some of these state limitations of
otherwise legal abortion services is examined by NASEM.
The committee recommends that most abortions
could safely be carried out in office-based settings, with
requirements depending, as for other procedures, on the
level of sedation necessary. Providing that the practitioner
could arrange safe transfer if complications arose, the
committee found that trained physicians, physician’s
assistants, nurse-midwives, and nurse practitioners could
all perform medication and aspiration abortions safely
and effectively, without the need for hospital privileges.
The committee also recommended further research
around the restricted distribution of mifepristone and its
potential impact on timeliness, patient centredness, and
equity. Surgical abortion procedures still predominate
in the USA, with aspiration accounting for 68% of all
abortions in 2013.
Abortion has become the subject of a highly politicised
debate and of the worst kind of value signalling from
those in positions of power, who are often protected
from the consequences of their policies by gender, For more on Estimated trends
geography, and economics. The burden of unintended in unintended pregnancy and
its outcomes see Articles
pregnancies falls hardest on the most vulnerable Lancet Glob Health 2018;
women. Reducing the stigma, minimising the social and 6: 380–89
economic consequences of unintended pregnancies, For the Guttmacher report see
https://www.guttmacher.org/
improving access to highly effective modern contra­ report/abortion-worldwide-2017
ception, and ensuring legal and safe abortions would For the NASEM report
Reproductive Health Services:
generate tangible improvements to health. Those with Assessing the Safety and Quality
real motivation to protect and support women and of Abortion Care see http://
nationalacademies.org/hmd/
children should look to research, not misconceptions, to Activities/Women/
inform decision making. n The Lancet ReproductiveHealthServices.aspx