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INDUCED ABORTION

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HISTORY   Etienne van de Walle

PREVALENCE   Stanley K. Henshaw

LEGAL ASPECTS   Laura Katzive
Stanley Henshaw

HISTORY

Women throughout the world have probably attempted to procure abortion–premature artificial termination of pregnancy–from before recorded history. The earliest recorded version of the Hippocratic Oath (c. 500 B.C.E.) includes the physician's pledge: "I shall not give women a [fetus]-destroying pessary." This constitutes a testimony both to medical attitudes and practices in antiquity, and to the technology of the time.

Attitudes

Plato and Aristotle accepted the practice of abortion for eugenic reasons. Roman and Jewish law considered that the fetus had no independent existence and was part of the woman's body, subject to the authority of her husband. Legal conflicts originated when the termination of pregnancy was the result of violence inflicted by a third party, or was carried out by a woman against her husband's wishes. Opposition to abortion, together with opposition to infanticide, crystallized under the influence of Christianity. The Church fathers associated abortion first with magical procedures, and second with fornication and adultery, as the epitome of sexual sin. The fetus was thought to become formed or alive only after a delay, such as 40 days; a corollary of this belief was that penalties for abortion increased with the duration of gestation. Christian beliefs from the fourth century on identified this stage–40 days after conception, called "quickening"–with animation, the time when the fetus was endowed with an immortal soul; a similar belief prevailed in Islam. The distinction between abortion before and after quickening survived for a long time in canon law and civil jurisprudence (including common law in England and the United States), although it was abandoned by the Catholic Church in modern times.

Physicians of antiquity generally admitted the legitimacy of therapeutic abortion when the woman was immature or ill-formed, where pregnancy or delivery would endanger her life. Soranus, the Greek gynecologist of the second century C.E., gave recipes for abortion under these conditions, although he preferred the use of contraception for the same purpose. Soranus's position influenced the western medical tradition through Rome, Byzantium, and the translations of Arabic medical texts in the Middle Ages, and justified the publication of Materia Medica featuring abortive herbs and their continued availability to physicians. Although some Christian theologians accepted abortions for therapeutic reasons, most were opposed to the practice. Civil codes condemned abortion with great severity, but it remained a rare event until the nineteenth century, reserved for desperate women. Its practice spread with the need for better methods of birth control, even against the increasing opposition of physicians. During the second half of the twentieth century, early-term abortion (with various definitions of what qualifies as such) was legalized in many countries of the world. However, the moral acceptability of abortion remains controversial. Powerful movements of public opinion support the right of the fetus to life; others, equally influential, support a woman's freedom to choose the outcome of her pregnancy.

Techniques

Methods of abortion in the past either were ineffective or endangered the life of the mother. Vaginal suppositories appear to have been the most commonly used medical technique in the ancient world, because of the intuitive appeal of this route of access to the uterus; they were still mentioned in medical texts of the eighteenth century. Reference to abortive drugs in classical writings or Church pronouncements may refer either to suppositories or oral poisons, or even to spells and magic. The most frequently mentioned alternative technique consisted of violent movements, massage or blows, although milder methods like bleeding or cold baths were also cited. The use of sharp objects is rare before the seventeenth century, although various obstetrical instruments that could have been used for abortion have been described or even unearthed by archeologists. Soranus cautioned against the use of "something sharp-edged to separate the embryo." Dioscorides's second-century C.E. Materia Medica mentioned a number of drugs that would kill a fetus. In addition he listed more than one hundred substances that hastened delivery, expelled a dead fetus, or stimulated the menses. The latter were not abortifacients, but were supposed to act on the uterus. Learned as well as popular medicine and folklore in Europe through the medieval and modern periods attributed abortive properties to many herbal substances, including rue, artemisia, pennyroyal, ergot of rye, tansy, and saffron. A tea or potion made from savin, a species of juniper, was the most widely reputed abortifacient. These substances are implicated in many court proceedings, although it was the attempt (often unsuccessful) to procure an abortion, rather than the actual abortion, that was prosecuted. (Abortion was featured much less often in the courts than infanticide.) Similar substances are reputed as abortifacients in all world cultures, but their effectiveness has never been reliably ascertained. It seems their reputation was greatly inflated, although their popular use in the nineteenth and twentieth centuries, and their deplorable reputation among physicians, suggest that attempts at abortion through oral means were sometimes successful.

Other techniques, such as injections and the use of sharp instruments to kill the fetus, became increasingly common from the seventeenth century in Europe. In the early nineteenth century, most professional abortionists who were prosecuted on the basis of existing penal codes appeared to belong to the medical professions and to use uterine sounds and curettes. By the end of the century, some relatively proficient abortionists operated underground. The numerical importance of abortion during the fertility transition is a matter of controversy.

Throughout most of history, abortion must have been a dangerous and rare procedure, probably practiced almost exclusively outside of marriage, and with little impact on fertility. With the development of antisepsis the procedure of dilatation and curettage could be performed with relative safety by skilled medical personnel. The introduction of methods of early abortion during the second half of the twentieth century–by vacuum aspiration, as well as chemical procedures such as the administration of prostaglandins–coincided with the widespread legalization of abortion, and the blurring of the boundaries between contraception (particularly its post-coital forms) and abortion.

See also: Birth Control, History of; Infanticide.

BIBLIOGRAPHY

Brodie, Janet Farell. 1994. Contraception and Abortion in 19th-Century America. Ithaca, NY: Cornell University Press.

McLaren, Angus. 1984. Reproductive Rituals: The Perception of Fertility in England from the Sixteenth to the Nineteenth Century. London: Methuen.

Noonan, John, ed. 1970. The Morality of Abortion: Legal and Historical Perspectives. Cambridge, MA: Harvard University Press.

Potts, Malcolm, Peter Diggory, and John Peel. 1977. Abortion. Cambridge, Eng.: Cambridge University Press.

Van de Walle, Etienne. 1999. "Towards a Demographic History of Abortion." Population. An English Selection 11: 115–132.

ETIENNE VAN DE WALLE

PREVALENCE

The term "abortion" as used in this article refers to the induced termination of a pregnancy with intent other than to produce a live birth. An abortion may be induced legally or illegally, according to the laws of each country. It is to be distinguished from spontaneous abortion, including stillbirth, which is a natural outcome for a small proportion of pregnancies.

Sources of Data

The most accurate sources of information on the incidence of induced abortion are official statistics in countries where abortion is legal. In most of these countries, abortions are required to be reported to health authorities. However, the completeness and accuracy of reporting and the quantity and quality of the resulting tabulations vary widely among and even within countries. Reporting is probably most complete where a procedure for authorization is prescribed by statute and where abortions are required to be performed in hospitals or other facilities subject to official licensure.

In countries where no statistics are kept because abortion is illegal or there is no reporting system, a number of methods have been used to estimate the incidence of abortion. Household surveys yield minimum estimates because underreporting of abortions is common, even where the procedure is legal. These estimates may nevertheless be useful where abortion is widely practiced and accepted. Several studies have estimated abortion rates from the number of women treated in hospitals for abortion complications. These estimates rely on assumptions about the proportion of treated complications that result from induced rather than spontaneous abortions, the proportion of women needing treatment who seek hospital care, and the proportion of induced abortions that cause complications requiring treatment. A third approach is to survey the providers of abortions; this is rarely possible in countries where abortion is illegal. A fourth approach is to infer the abortion rate from the difference between the fertility rate and natural fertility, taking

TABLE 1

into account the reduction in fertility caused by contraceptive use, women not in unions, and rates of infecundity. This method, however, is extremely sensitive to the assumed rate of natural fertility and to small errors in calculating the impact of the other factors.

Incidence

With appropriate caution regarding the high margin of error, it has been estimated that 46 million abortions were performed worldwide in 1995–about 26 million legal abortions and 20 million that were illegal (see Table 1). (The true numbers could be several million higher or lower.) This estimate implies an average annual rate of 35 abortions per 1,000 women aged 15 to 44. Cumulated, the estimate would mean that women, on average, have close to one abortion

TABLE 2

during their lifetimes. About 26 percent of all pregnancies, excluding miscarriages and stillbirths, were ended by induced abortion.

The abortion rates in developed and developing regions are broadly similar, despite the prevalence of restrictive laws in most developing countries. China, India, and Vietnam account for almost all of the legal abortions in the developing regions. Most abortions in other parts of Asia and also in Africa and Latin America are illegal.

Eastern Europe, including the Russian Federation, is the subregion with the highest abortion rate. In these countries, the lack of access to contraceptive methods and ready availability of abortion services under Communism resulted in heavy reliance on abortion to limit fertility. Western Europe, where abortion is legal and readily available, has the lowest rate. The percentage of pregnancies ending in abortion is lowest in Africa, a consequence of the region's high birth rates.

Abortion rates vary widely among countries, as indicated in Table 2. Among low-fertility countries, the level of abortion appears to be determined primarily by the availability, accessibility, and acceptability of contraceptive services. During the 1990s, the lowest recorded rate–less than 7 abortions per 1,000 women aged 15 to 44–was in the Netherlands, despite a low fertility rate and abortion services that are readily available without charge. Only 11 percent of pregnancies nationwide were ended by abortion, with only 3 to 4 percent among the Dutchborn population. The highest abortion rate ever recorded for a country was 252 per 1,000 women in Romania in 1964 and 1965.

Abortion rates are generally higher in developing countries, because of less established contraceptive use, less accessible contraceptive services, and the limited range of contraceptive methods available. The example of Tunisia, however, demonstrates that the use of modern contraceptives can keep the rate low even where abortion services are available and free. Vietnam, on the other hand, had one of the highest abortion rates in the 1990s as a consequence of a rapid drop in desired family size and limited access to modern contraceptive methods. Including abortions performed in the private sector and not counted officially, the abortion rate in Vietnam was estimated to be 111 per 1,000 women in 1996. Estimates of abortion rates in several countries where abortion is illegal are in the range of 23 to 41 per 1,000 women, and the percentage of pregnancies ended by abortion ranges from 12 to 30.

Trends

During the 1990s, abortion rates fell slowly in several Western European countries and the United States, and they fell rapidly in most of the formerly-Communist countries as contraceptive supplies and services became more available. In many developing areas, the demand for both abortion and contraception increased as desired fertility fell, marriage was delayed, and sexual activity before marriage became more common.

In developed countries, non-surgical abortion by means of mifepristone (RU-486) together with a prostaglandin became increasingly common but did not appear to affect overall abortion rates. In developing countries where abortion is illegal, misoprostol, a prostaglandin used to prevent stomach ulcers among long-term users of pain medications, is increasingly used to induce abortion, although it is not always effective. Its effect on abortion rates is unknown, but in Brazil and other countries it has reduced the number of serious complications of illegal and unsafe abortions.

See also: Contraceptive Prevalence; Fertility, Proximate Determinants of; Spontaneous Abortion.

BIBLIOGRAPHY

Henshaw, Stanley K., Susheela Singh, and Taylor Haas. 1999. "The Incidence of Abortion Worldwide." International Family Planning Perspectives 25(Supplement): S30–S38.

Henshaw, Stanley K., Taylor Ann Haas, Kathleen Berentsen, and Erin Carbone, eds. 2001. Readings on Induced Abortion, Volume 2: A World Review 2000. New York: The Alan Guttmacher Institute.

Koonin, Lisa M., Lilo T. Strauss, Camaryn E. Chrisman, and Wilda Y. Parker. 2000. "Abortion Surveillance–United States, 1997." Morbidity and Mortality Weekly Report, CDC Surveillance Summaries 49(SS—11): 1–43.

World Health Organization Division of Reproductive Health. 1998. Unsafe Abortion: Global and Regional Estimates of Incidence of and Mortality Due to Unsafe Abortion, with a Listing of Available Country Data (WHO/RHT/MSM/97.16). Geneva: World Health Organization.

STANLEY K. HENSHAW

LEGAL ASPECTS

Around the world, the widely varying legal status of abortion reflects a range of social priorities and values, including women's health, views on religion or morality, and reproductive rights. While over 60 percent of the world's population lives in countries where abortion is a woman's choice or available on broad grounds, in many countries it is a crime and the procedure is permitted by law only under limited circumstances.

In any given country, abortion may be treated in multiple legal codes, statutes, and regulations. Where abortion is or has historically been criminalized, it is usually included in the country's penal code. Numerous other sources of law, including judicial opinions and health codes, may elaborate upon and sometimes moderate criminal laws, delineating the circumstances in which abortion may be legally performed. Abortion's legal status may also be affected by "general principles" of law, which are widely recognized legal norms used to interpret legislation. Many countries that ostensibly prohibit the procedure under all circumstances may permit life-saving abortions under the general principle of necessity, which justifies actions taken reasonably to save one's life or the life of another.

Abortion laws within one country also may vary according to jurisdiction. Several countries, including Australia, Canada, Mexico, and the United States, have legal systems at the provincial or state level as well as the national level, creating variations in abortion regulation among jurisdictions. While constitutional guarantees in Canada and the United States provide protection for women's right to choose abortion, its legality varies by state in Australia and Mexico, where no such guarantees have been recognized.

Categories of Abortion Laws

The world's abortion laws can be classified into five broad categories, reflecting varying degrees of restrictiveness. They are described below, in order from the most to the least restrictive.

1. Abortion is prohibited entirely or permitted only to save a woman's life. This category, the most restrictive, applies to 73 countries with about one-quarter of the world's population. These countries, primarily in Africa, Asia, and Latin America, include Brazil, Chile, Colombia, Ireland, Iran, Indonesia, Kenya, the Philippines, Senegal, Syria, and Uganda. In some countries in this category, including El Salvador and Guatemala, criminal prohibitions of abortion are supported by constitutional provisions protecting life from the moment of conception.
2. Abortion is permitted only when a woman's life or physical health is in jeopardy. Laws in this only slightly less restrictive category apply in 33 countries, affecting nearly 10 percent of the world's population. Argentina, Bolivia, Peru, Morocco, Saudi Arabia, Pakistan, Thailand, Poland, Burkina Faso, and Zimbabwe are among the countries in this category. While some of the laws in this category may be interpreted to permit abortion on mental health grounds, none does so expressly.
3. Abortion is explicitly permitted on the grounds of mental as well as physical health. Laws in this category are in effect in 19 countries with just over 2.5 percent of the world's population. These include Israel, Malaysia, Portugal, Spain, Ghana, Namibia, and New Zealand. The term "mental health" is potentially open to broad interpretation; it can, for example, address the psychological distress associated with pregnancy resulting from rape or incest in situations where abortion on these grounds is not explicitly recognized in the law.
4. Abortion is permitted on socioeconomic grounds. These laws are in force in 14 countries accounting for nearly 21 percent of the world's population, including Great Britain (not Northern Ireland), India, Japan, and Zambia. They typically permit consideration of a woman's economic resources, her age, her marital status, and the number of children she has. Such laws tend to be interpreted liberally and, in their implementation, may differ very little from laws in category 5.
5. Abortion is permitted without restriction as to reason during a prescribed period of the pregnancy. In most countries, this period corresponds to the first 12 or 14 weeks of the pregnancy. Among the 52 nations in this category, representing about 41 percent of the world's population, are most industrialized countries, including the United States, Canada, China, Vietnam, France, Germany, Italy, the Russian Federation, and South Africa. Countries that require a woman to affirm that she is in a state of "distress" or "crisis" in order to terminate a pregnancy–like Belgium, France, and Hungary–have been included in this least restrictive category, because it is the woman herself who ultimately decides whether she qualifies for an abortion.

Additional Grounds and Requirements

Countries that fall into any of the five categories described above may permit abortion on other grounds, such as in cases of rape, incest, and fetal impairment. Likewise, a country may place additional legal restrictions on abortion. These may include requirements that women obtain permission for abortion from spouses or parents, conditions on the type of providers who may perform abortions and the facilities in which they may be provided, mandatory counseling and waiting periods, constraints on abortion advertising, and restrictions on public funding for abortion. Where son preference is widespread, some countries have adopted legal measures to prevent the practice of sex-selective abortion. India has prohibited prenatal sex determination for the purpose of sex-selective abortion and, more recently, China and Nepal have adopted similar provisions while also prohibiting sex-selective abortion itself.

Even where abortion laws are highly restrictive, criminal prosecutions of abortion providers and patients may be rare or inconsistent. Similarly, laws providing for legal abortion do not guarantee access to the service for all women who qualify under the law.

Trends over Time

Abortion laws are not static. A global trend toward liberalization began during the latter half of the twentieth century and has continued into the twenty-first century, albeit with some signs of a restrictive counter-trend in Latin America and Central Europe. Some countries, such as Malaysia and Ghana, have made incremental steps toward liberalization, maintaining abortion's criminal status while recognizing therapeutic and/or juridical grounds for abortion. Other countries, such as Nepal and Cambodia, have rejected longstanding criminal bans on abortion in favor of laws that are among the world's least restrictive.

In societies that have traditionally placed a high value on fertility, abortion is often illegal and the prohibition is supported by strong social norms. Women in these societies who seek to limit their family size because of changing economic and social conditions often turn to illegal abortions performed by poorly trained practitioners. The need to protect women's health from unsafe abortion providers has historically been the main impetus for liberalizing abortion laws. Other motivations for reducing abortion restrictions have included bringing the law into conformity with practice, responding to demographic considerations, and, most recently, recognizing women's reproductive rights.

The world is likely to see further liberalization of abortion laws in the years to come, as reform movements develop momentum in countries around the world. In national and international forums, governments have shown increasing recognition of the costs of restrictive abortion laws, which are borne not only by the women immediately affected, but also by their families, communities, and societies.

See also: Feminist Perspectives on Population Issues; Reproductive Rights.

BIBLIOGRAPHY

Rahman, Anika, Laura Katzive, and Stanley Henshaw. "A Global Review of Laws on Induced Abortion, 1985–1997." International Family Planning Perspectives 24(2): 56–64.

INTERNET RESOURCES.

United Nations Department for Economic and Social Development. 1999. Abortion Policies: A Global Review. <http://www.un.org/esa/population/publications/abortion/abortion.htm>.

United Nations Population Fund and Harvard Law School. 2002. Annual Review of Population Law.<http://www.law.harvard.edu/programs/annual_review/annual_review.htm>.

LAURA KATZIVE

STANLEY K. HENSHAW