Worldwide Abortion Rates and Access to Contraception

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Strong evidence from work done in the United States shows that the availability and appropriate use of affordable, effective, and safe contraception is associated with decreasing abortions. As one example, the CHOICE study provided free contraceptives of their choice to women in the St. Louis area, with the aim to reduce unintended pregnancies.1 During the years of their study, the authors found that one abortion was prevented for every 79–137 women and teenagers provided access to the contraceptive of their choice free of charge.
Similar data from countries in sub-Saharan Africa lead to the same conclusion. Kelly Jones, of the International Food Policy Research Institute, notes that 80% of contraceptive supplies in the region are provided by international population assistance.2 The supply of contraceptives fell following policy changes in the United States in 2000. Health care services were reduced owing to significant budget shortfalls for nongovernmental organizations operating in Ghana. These changes led to reduced availability of contraception in rural area outreach services in the country. She calculates that this change led to about 200,000 more abortions each year—a 50% increase—compared with the prior period when contraceptive services were available. In a different study, Bendavid reports that, in 20 countries in sub-Saharan Africa, the induced abortion rate increased by 40%, from 10.4 per 10,000 women-years from 1994 to 2001 to 14.5 per 10,000 women-years from 2001 to 2008.3
In addition to decreasing unplanned and mistimed pregnancies and associated increased abortions, contraceptive availability also significantly affects both maternal and child health. In a 2012 study in The Lancet, Ahmed and co-authors4 used data from the Maternal Mortality Estimation Inter-Agency Group database, the United Nations World Contraceptive Use 2010 database, and the United Nations World Population Prospects 2010 database to estimate the effects of contraception on maternal mortality. Their analysis shows that contraceptive use reduced maternal deaths by 44% worldwide by averting 272,040 maternal deaths (uncertainty interval 127,937–407,134).4 They conclude that, “without contraceptive use, the number of maternal deaths would have been 1.8 times higher than the 2008 total.”4 Similarly, Cleland and co-authors report that child-spacing by 2 years—which is dependent on contraceptive use—would decrease the rate of deaths of children less than 1 year of age by 10% and for children from 1–4 years of age by 21%.5
Improving maternal and child health, decreasing maternal mortality, and decreasing abortions are goals that all obstetrician–gynecologists—indeed all people—can agree on. We must be aware that U.S. policy is critically important in reaching these goals. The time periods of the Jones and Bendavid studies, showing an increase in abortions in sub-Saharan Africa following a decrease in contraceptive availability, were the years following the reinstatement of the Mexico City Policy by President George W. Bush immediately after his inauguration in 2001.
The Mexico City Policy, also known as the Global Gag Rule, was first put into place by President Reagan and has been reinstated by every Republican president and reversed by every Democratic president immediately after their inauguration since then. The original language stated that, “[T]he United States does not consider abortion an acceptable element of family planning programs and will no longer contribute to those of which it is a part…[T]he United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations.”6
Nongovernmental organizations were prohibited from accepting any U.S.
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