The Lancet Supports Legal, Safe, and Rare Abortion

The July 28 edition of the Lancet has a superb editorial about the need for legal and safe abortion in the developing world, particularly in Latin America (I've snipped parts; italics mine):

...Irrespective of an individual's viewpoint, the debate over abortion in Latin America cannot be ignored. In Brazil, which has the world's largest Roman Catholic population, abortion is only permitted after rape or to save a mother's life. Yet every year 1·4 million women undergo the procedure, terminating one in three pregnancies. Almost 250 000 Brazilian women seek treatment in public hospitals for subsequent complications, even though this action may make them liable for prosecution for performing or consenting to an abortion. Across the continent, 3·8 million women underwent such unsafe abortions in 2000, resulting in 12% of the region's maternal mortality.

The burden of unsafe abortion is borne disproportionately by the poor, the disadvantaged, and the young. Each year there are an estimated 210 million pregnancies worldwide. One in five women will choose an abortion. Over three-quarters live in developing countries, where 97% of the estimated 20 million annual unsafe abortions are done. A quarter of the women are aged 15-19 years. 68 000 women die from unsafe abortions and 5·3 million are left with temporary or permanent disabilities. In Kenya, where abortion is legal only to save a mother's life, the 300 000 unsafe abortions every year account for 50% of maternal mortality. High death rates from unsafe abortion are also seen in refugee settings. Clearly, Millennium Development Goal 5, to reduce the maternal mortality rate by three-quarters before 2015, is unlikely to be achieved without abolishing unsafe abortion.

A woman's decision to seek an abortion arises from many complex factors, including failures in preventive health-care provision and social support. Hence there is a need for a respectful and comprehensive debate informed by all who have a genuine interest in improving public health, reducing poverty, and achieving gender equity. Because reasons leading to abortion are many, so are the opportunities for harm reduction--with valuable roles to be played by those of any ideology.

Examples of ways forward are given in the World Bank's discussion paper, Population issues in the 21st century, published on July 19, in which the Bank regards financial and physical access to effective contraception as essential for economic security. The report finds that negative attitudes to women create barriers to receiving reproductive health services, particularly among adolescents. The Bank calls on governments and donors to honour their commitments to family planning, so that services can be expanded to meet people's needs, to empower women, and to address unsafe abortion and highlight its dangers.

Providing women with a choice of contraceptive services reduces demand for abortion. If contraception were provided to the 137 million women estimated to want contraception, but who lack access, maternal mortality could fall by an additional 25-35%, and improved maternal health would benefit child survival. In the Netherlands, where contraception is both freely available and openly discussed, the need for abortion is below ten per 1000 women. Around the world, aggregate patterns show that contraceptive accessibility is inversely proportional to abortion rates.

Although accessible contraception and safe abortion are a start, additional steps are required. Pregnant women need to be reassured that society will respect their decision:: whether it be abortion, adoption, or raising a child perhaps as a single parent. Attitudes to motherhood at a young age, to non-nuclear families, and to children influence this choice, as do practical measures to affirm support during pregnancy and afterwards.

Former President Bill Clinton argued that abortion should be "legal, safe, and rare", but for many of the world's most vulnerable women it remains illegal, unsafe, and common. Making abortion illegal, starving development agencies of funds to promote all forms of contraception, or suppressing discussion by fear will not cause the problem of abortion to disappear. Instead, it is time to remove the gag and ensure that all women have access to safe, which means legal, abortion.

Leaving aside the freedom of religion issues, legal and safe abortion has always been, for me, a public health issue: women will get pregnant, women will not want to carry the pregnancy to term, and women will actively do something to prevent that from happening. The question then becomes how many women have to die so others can satisfy their own sectarian dogmatic needs. As the editorial notes, the attempt "to reduce the maternal mortality rate by three-quarters before 2015, is unlikely to be achieved without abolishing unsafe abortion."