The fight for abortion rights will never end-PART 1

02Oct 2018
By Guardian Reporter
Tanzania
The Guardian
The fight for abortion rights will never end-PART 1

SEPTEMBER 28th marked World Safe Abortion Day. Initiated by movements championing reproductive rights and reproductive justice, the right to safe abortion remains one of the lesser recognised, greater contested rights by governments, especially right-wing ones.

In these last weeks, we have seen the wheels set in motion to overturn the landmark 1973 judgement Roe vs Wade with the US President, Donald Trump, nominating Brett Kavanaugh to the Supreme Court. While this nomination has been hampered by pending sexual assault charges, the fear is very real that it is just a matter of time.

Abortion access in the U.S. has become increasingly limited: fewer clinics sometimes just one clinic in states like Mississippi; services available only a few days a week; unnecessary tests including making the girl or the woman see the ultrasound - an attempt to personify the fetus and hence dissuade abortion; parental consent if it involves a minor and a 24-hour waiting period after signing the consent form; and in some cases, even the need to obtain a court order.

While attempts to overturn Roe vs Wade will have devastating effects on American women, women all across the world will feel the aftermath.

Not only will this affect America's global policy across the world, even when a progressive President is in place, but it also plays the role of a standard bearer of human rights and women's rights. When the U.S. enacted recognition of gay marriage, other countries were encouraged to do away with anti-sodomy laws, and enable recognition of LGBT rights.

Hence policy decisions in the U.S always have a cascading effect on human rights standards across the world. Developing countries will resist the pressure to change restrictive abortion laws, or will review existing progressive laws.

This will be especially felt in countries which already receive U.S. development aid, and already have a strong evangelical anti-abortion movement imported from the U.S in place.

Global abortion data released earlier this year by the New York-based Guttmacher Institute, a research and policy organisation committed to advancing sexual and reproductive health and rights (SRHR), was very concerning.

The report, Abortion Worldwide: Uneven Progress and Unequal Access, found that unsafe abortions occurred overwhelmingly in developing regions, where countries that highly restrict abortion are concentrated.

But even where abortion is broadly legal, inadequate provision of affordable services can limit access to safe services, and persistent stigma makes providers reluctant to offer abortions, forcing young girls and women to "prioritise secrecy over safety."

This year has been a critical juncture in the fight for abortion rights. On May 26th, the Irish people overwhelmingly voted to overturn the abortion ban.

Irish women working and living abroad returned home to take part in the referendum to ensure they are able to exercise the full range of choices and decision-making around motherhood.

In August, Argentina saw narrow votes for and against legalising abortion at the lower and upper houses. South Korea is also looking to review its abortion ban from the 1950s. In July, a 15-year-old Indonesian girl, who was raped and impregnated by her brother, was sentenced to six months jail for having an abortion beyond the legal time limits.

Indonesia's law is highly restrictive, and only available for cases of rape and incest, and to save the life of the mother. But abortions must be performed within six weeks of pregnancy - an incredibly short window as many may not even realise they are pregnant. Her jail term was overturned after protests by women's rights, human rights and SRHR activists.

The right to safe abortion is a fundamental human right which needs to be fought for. It is because in this particular right that unqualified recognition of women's agency, decision-making power, and bodily integrity lies.

That she is owner of her body and sexual and reproductive capacity, and not others: the State, her husband or her partner, or her unborn child.

The right to safe abortion is inalienable from the right to sexual consent, the right to sexuality, which is separate from marriage and reproduction, the right to choose and marry a partner, the right to decide the number and spacing of children and the right to choose motherhood - all of which help define women's bodily autonomy, bodily integrity and equality.

The fight for abortion rights and safe abortion will never end.

Sivananthi Thanenthiran is the executive director of the Asian-Pacific Resource and Research Centre for Women (ARROW), a regional NGO based in Malaysia championing sexual and reproductive health and rights.

Abortion - SA must speak up

By Colleen Lowe Morna and Manteboheleng Mabetha

"I woke up this morning and a nurse told me that I have been I a comma since I came in," says Ntsoaki* from her bed in Lesotho's only referral hospital.

"I don't know where I will go when I leave the hospital. I do not have money to pay and I do not have any clothes with me. I was not trying to abort the baby, I was trying to commit suicide using rat poison because my boyfriend did not want the baby and my mother said she could not support us. Unfortunately for me I survived and only my baby died."

Last week Lesotho Minister of Health Nkaku Kabi announced that the hospital is bursting at the seams with 15 young women admitted each week following abortion complications.

According to the World Health Organisation (WHO), 35 out of 1000 pregnancies in Southern Africa end in abortions; one of the highest rates in the world.

Almost all of these are backstreet. Abortion is the third highest cause of already high rates of maternal mortality. Yet, according to WHO, safe abortion is one of the simplest and most effective procedures to administer.

Today is International Safe Abortion Day: a day first proclaimed by NGOs in Latin America and the Caribbean in 1990, but sadly not recognised by the majority of governments.

In South Africa, a broad coalition will be marching to demand access to safe abortion with only 7% of the country's health facilities providing abortions and many health workers refusing to perform the procedure.

But South Africa and Mozambique are the only Southern African Development Community (SADC) countries in which abortion is available on demand. Madagascar outlaws abortion under all circumstances.

In the other 13 SADC countries, abortion is only legal in limited circumstances including rape, incest, or danger to the life of the mother or child.

In Namibia, which generally has a strong human rights record, the pre-independence Abortion and Sterilization Act 2 of 1975 (still in place) gives as one of the few grounds for abortion "if a woman has been deemed to be an idiot or an imbecile.. which makes sex with her illegal." Zimbabwe has a policy on post abortion care even though abortion is illegal: a de facto recognition of the reality on the ground.

Explaining why she sought an abortion despite it being illegal in Lesotho, Matumelo*, 23, says: "I already know that the police are going to arrest me as soon as I leave the hospital.

The reason I underwent a backstreet abortion using pills I got from a Facebook acquaintance is because when I told my boyfriend of six years that I was pregnant, he told me he does not want the baby as my pregnancy will negatively affect his family. I never knew that he had a wife and children. As such I could not raise a child alone as I am not working."

Itumeleng*, a 15 year old rape victim, should have been able to have a safe abortion in Lesotho based on her circumstances, but the system failed her. "My case was referred to the children's court where the magistrate ordered some tests to be done on me," she recalls.

"All the other tests came back negative except for the pregnancy test that indicated that I was six weeks pregnant. The magistrate gave an order for a termination of such pregnancy.

At the hospital where I was supposed to be assisted with the abortion as dictated by the Penal Code, I was thrown from pillar to post.

At one time I was told the order should not be hand written but typed. When I came back with a typed order I was told the stamp was too vague. When that was corrected, I was told the signature did not seem legitimate.

This continued until I was six months pregnant and was no longer eligible for abortion. Today I have to raise a child I did not choose to have. I am raising a child when I am also a child myself. If abortion were legal in Lesotho, I would not have suffered like this."

Rather than fix the system and change the laws, Lesotho officials are known to surreptitiously advise women to go across the border for safe abortions in South Africa.

Few women can afford that; South Africa is not coping; and exporting the problem sidesteps the central issue of the right of women to make choices about their bodies and lives, not only when they are violated, but always.

Lesotho, a deeply Catholic country, could learn from the recent referendum on abortion in that most Catholic of countries - Ireland - that resoundingly put rights above religion or morality.

South Africa needs to learn that choice without the services to make the choices is a violation of the Constitution. And rather than become a place of refuge for women seeking abortion from the region, South Africa has a duty to speak up and speak out for women's rights, at home and in the region.

ABORTION is the ending of pregnancy due to removing an embryo or fetus before it can survive outside the uterus. An abortion that occurs spontaneously is also known as a miscarriage.

When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently as an "induced miscarriage".

The word abortion is often used to mean only induced abortions. A similar procedure after the fetus could potentially survive outside the womb is known as a "late termination of pregnancy" or less accurately as a "late term abortion".

When allowed by law, abortion in the developed world is one of the safest procedures in medicine.[3][4] Modern methods use medication or surgery for abortions.

The drug mifepristone in combination with prostaglandin appears to be as safe and effective as surgery during the first and second trimester of pregnancy.

The most common surgical technique involves dilating the cervix and using a suction device. Birth control, such as the pill or intrauterine devices, can be used immediately following abortion.

When performed legally and safely, induced abortions do not increase the risk of long-term mental or physical problems. In contrast, unsafe abortions (those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities) cause 47,000 deaths and 5 million hospital admissions each year. The World Health Organization recommends safe and legal abortions be available to all women.

Around 56 million abortions are performed each year in the world, with about 45 per cent done unsafely. Abortion rates changed little between 2003 and 2008, before which they decreased for at least two decades as access to family planning and birth control increased.

As of 2008, 40 per cent of the world's women had access to legal abortions without limits as to reason. Countries that permit abortions have different limits on how late in pregnancy abortion is allowed.

Historically, abortions have been attempted using herbal medicines, sharp tools, forceful massage, or through other traditional methods.

Abortion laws and cultural or religious views of abortions are different around the world. In some areas abortion is legal only in specific cases such as rape, problems with the fetus, poverty, risk to a woman's health, or incest.

In many places there is much debate over the moral, ethical, and legal issues of abortion. Those who oppose abortion often maintain that an embryo or fetus is a human with a right to life, and so they may compare abortion to murder.

Those who favor the legality of abortion often hold that a woman has a right to make decisions about her own body. Others favor legal and accessible abortion as a public health measure.

Induced
An induced abortion may be classified as therapeutic (done in response to a health condition of the women or fetus) or elective (chosen for other reasons).

Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion.

Most abortions result from unintended pregnancies. In the United Kingdom, 1 to 2 pc of abortions are done due to genetic problems in the fetus. A pregnancy can be intentionally aborted in several ways.

The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses. Specific procedures may also be selected due to legality, regional availability, and doctor or a woman's personal preference.

Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; to prevent harm to the woman's physical or mental health; to terminate a pregnancy where indications are that the child will have a significantly increased chance of mortality or morbidity; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.

An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons. Confusion sometimes arises over the term "elective" because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.

Spontaneous

Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation.

A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth". When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn". Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.

Only 30 pc to 50 pc of conceptions progress past the first trimester. The vast majority of those that do not progress are lost before the woman is aware of the conception, and many pregnancies are lost before medical practitioners can detect an embryo. Between 15 pc and 30 pc of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman. 80 pc of these spontaneous abortions happen in the first trimester.

The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus, accounting for at least 50 pc of sampled early pregnancy losses.

Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus. Advancing maternal age and a woman's history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.

Methods

Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486) in the 1980s.

The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.

Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone. This regime is effective in the second trimester. Medical abortion regiments involving mifepristone followed by misoprostol in the cheek between 24 and 48 hours later are effective when performed before 63 days' gestation.

In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.

Early medical abortion regimens using mifepristone, followed 24–48 hours later by buccal or vaginal misoprostol are 98 pc effective up to 9 weeks gestational age. If medical abortion fails, surgical abortion must be used to complete the procedure.

Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain, France, Switzerland, and the Nordic countries.

In the United States, the percentage of early medical abortions is around 30 pc as of 2014.

Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second-trimester abortions in Canada, most of Europe, China and India, in contrast to the United States where 96 pc of second-trimester abortions are performed surgically by dilation and evacuation.
Surgical

Up to 15 weeks' gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion. Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump.

These techniques differ in the mechanism used to apply suction, in how early in pregnancy they can be used, and in whether cervical dilation is necessary.

MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation. Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion.

Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable.

From the 15th week of gestation until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction.

After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion", which has been federally banned in the United States.

In the third trimester of pregnancy, induced abortion may be performed surgically by intact dilation and extraction or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy.

First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia.

Labor induction abortion

In places lacking the necessary medical skill for dilation and extraction, or where preferred by practitioners, an abortion can be induced by first inducing labor and then inducing fetal demise if necessary.

This is sometimes called "induced miscarriage". This procedure may be performed from 13 weeks gestation to the third trimester. Although it is very uncommon in the United States, more than 80 pc of induced abortions throughout the second trimester are labor induced abortions in Sweden and other nearby countries.

Only limited data are available comparing this method with dilation and extraction. Unlike D&E, labor induced abortions after 18 weeks may be complicated by the occurrence of brief fetal survival, which may be legally characterized as live birth. For this reason, labor induced abortion is legally risky in the U.S.

Other methods

Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine. Among these are: tansy, pennyroyal, black cohosh, and the now-extinct silphium.

However, modern users of these plants often lack knowledge of the proper use and dosage. The historian of medicine John Riddle has spoken of the "broken chain of knowledge, and historian of science Ann Hibner Koblitz has written,

U.S. women of European descent have perhaps become particularly ignorant about the wealth of herbal remedies that previous generations accumulated over the centuries.

And sometimes their fumbling attempts to recover the knowledge can be disastrous.
For example, in 1978 one woman in Colorado died and another was seriously injured when they attempted to procure an abortion by taking pennyroyal oil.

Because the indiscriminant use of herbs as abortifacients can cause serious—even lethal—side effects, such as multiple organ failure, such use is not recommended by physicians.

Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.

In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage. One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.

Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These and other methods to terminate pregnancy may be called "induced miscarriage". Such methods are rarely used in countries where surgical abortion is legal and available.
Safety

The health risks of abortion depend principally upon whether the procedure is performed safely or unsafely.

The World Health Organization defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities. Legal abortions performed in the developed world are among the safest procedures in medicine.

In the US, the risk of maternal death from abortion is 0.7 per 100,000 procedures, making abortion about 13 times safer for women than childbirth (8.8 maternal deaths per 100,000 live births). In the United States from 2000 to 2009, abortion had a lower mortality rate than plastic surgery.

The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth through at least 21 weeks' gestation. Outpatient abortion is as safe and effective from 64 to 70 days' gestation as it is from 57 to 63 days. Medical abortion is safe and effective for pregnancies earlier than 6 weeks' gestation.

Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. Complications, which are rare, can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate. Infections account for one-third of abortion-related deaths in the United States.

The rate of complications of vacuum aspiration abortion in the first trimester is similar regardless of whether the procedure is performed in a hospital, surgical center, or office.

Preventive antibiotics (such as doxycycline or metronidazole) are typically given before elective abortion, as they are believed to substantially reduce the risk of postoperative uterine infection.

The rate of failed procedures does not appear to vary significantly depending on whether the abortion is performed by a doctor or a mid-level practitioner. Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen. Second-trimester abortions are generally well-tolerated.

There is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 9 weeks gestation.

Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion.

Some purported risks of abortion are promoted primarily by anti-abortion groups, but lack scientific support. For example, the question of a link between induced abortion and breast cancer has been investigated extensively. Major medical and scientific bodies (including the World Health Organization, National Cancer Institute, American Cancer Society, Royal College of OBGYN and American Congress of OBGYN) have concluded that abortion does not cause breast cancer.

In the past even illegality has not automatically meant that the abortions were unsafe. Referring to the U.S., historian Linda Gordon states: "In fact, illegal abortions in this country have an impressive safety record." According to Rickie Solinger,
A related myth, promulgated by a broad spectrum of people concerned about abortion and public policy, is that before legalization abortionists were dirty and dangerous back-alley butchers.... [T]he historical evidence does not support such claims.

Authors Jerome Bates and Edward Zawadzki describe the case of an illegal abortionist in the eastern U.S. in the early 20th century who was proud of having successfully completed 13,844 abortions without any fatality. In 1870s New York City the famous abortionist/midwife Madame Restell (Anna Trow Lohman) appears to have lost very few women among her more than 100,000 patients—a lower mortality rate than the childbirth mortality rate at the time.

In 1936 the prominent professor of obstetrics and gynecology Frederick J. Taussig wrote that a cause of increasing mortality during the years of illegality in the U.S. was that

With each decade of the past fifty years the actual and proportionate frequency of this accident [perforation of the uterus] has increased, due, first, to the increase in the number of instrumentally induced abortions; second, to the proportionate increase in abortions handled by doctors as against those handled by midwives; and, third, to the prevailing tendency to use instruments instead of the finger in emptying the uterus.

Mental health

Main article: Abortion and mental health

Current evidence finds no relationship between most induced abortions and mental-health problems other than those expected for any unwanted pregnancy.

A report by the American Psychological Association concluded that a woman's first abortion is not a threat to mental health when carried out in the first trimester, with such women no more likely to have mental-health problems than those carrying an unwanted pregnancy to term; the mental-health outcome of a woman's second or greater abortion is less certain.

Some older reviews concluded that abortion was associated with an increased risk of psychological problems; however, they did not use an appropriate control group.

Although some studies show negative mental-health outcomes in women who choose abortions after the first trimester because of fetal abnormalities, more rigorous research would be needed to show this conclusively.

Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", but this is not recognized by medical or psychological professionals in the United States.

Unsafe abortion

Women seeking to terminate their pregnancies sometimes resort to unsafe methods, particularly when access to legal abortion is restricted.

They may attempt to self-abort or rely on another person who does not have proper medical training or access to proper facilities.
This has a tendency to lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.

Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97 pc taking place in developing countries.[3] Unsafe abortions are believed to result in millions of injuries.

Estimates of deaths vary according to methodology, and have ranged from 37,000 to 70,000 in the past decade; deaths from unsafe abortion account for around 13 pc of all maternal deaths. The World Health Organization believes that mortality has fallen since the 1990s.

To reduce the number of unsafe abortions, public health organizations have generally advocated emphasizing the legalization of abortion, training of medical personnel, and ensuring access to reproductive-health services.

In response, opponents of abortion point out that abortion bans in no way affect prenatal care for women who choose to carry their fetus to term. The Dublin Declaration on Maternal Health, signed in 2012, notes, "the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women."

A major factor in whether abortions are performed safely or not is the legal standing of abortion. Countries with restrictive abortion laws have higher rates of unsafe abortion and similar overall abortion rates compared to those where abortion is legal and available.

For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications, with abortion-related deaths dropping by more than 90pc.

Similar reductions in maternal mortality have been observed after other countries have liberalized their abortion laws, such as Romania and Nepal. A 2011 study concluded that in the United States, some state-level anti-abortion laws are correlated with lower rates of abortion in that state.

The analysis, however, did not take into account travel to other states without such laws to obtain an abortion. In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by up to 75 pc (from 20 million to 5 million annually) if modern family planning and maternal health services were readily available globally.

Rates of such abortions may be difficult to measure because they can be reported variously as miscarriage, "induced miscarriage", "menstrual regulation", "mini-abortion", and "regulation of a delayed/suspended menstruation".

Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits, while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria. While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year.

Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide, though this varies by region. Secondary infertility caused by an unsafe abortion affects an estimated 24 million women. The rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008.

Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon.

Live birth
Although it is very uncommon, women undergoing surgical abortion after 18 weeks gestation sometimes give birth to a fetus that may survive briefly. Longer term survival is possible after 22 weeks.

If medical staff observe signs of life, they may be required to provide care: emergency medical care if the child has a good chance of survival and palliative care if not. Induced fetal demise before termination of pregnancy after 20–21 weeks gestation is recommended to avoid this.

Death following live birth caused by abortion is given the ICD-10 underlying cause description code of P96.4; data are identified as either fetus or newborn. Between 1999 and 2013, in the U.S., the CDC recorded 531 such deaths for newborns, approximately 4 per 100,000 abortions.

Incidence

There are two commonly used methods of measuring the incidence of abortion:

• Abortion rate – number of abortions per 1000 women between 15 and 44 years of age

• Abortion percentage – number of abortions out of 100 known pregnancies (pregnancies include live births, abortions and miscarriages)

In many places, where abortion is illegal or carries a heavy social stigma, medical reporting of abortion is not reliable. For this reason, estimates of the incidence of abortion must be made without determining certainty related to standard error.

The number of abortions performed worldwide seems to have remained stable in recent years, with 41.6 million having been performed in 2003 and 43.8 million having been performed in 2008.

The abortion rate worldwide was 28 per 1000 women, though it was 24 per 1000 women for developed countries and 29 per 1000 women for developing countries.

The same 2012 study indicated that in 2008, the estimated abortion percentage of known pregnancies was at 21pc worldwide, with 26 pc in developed countries and 20 pc in developing countries.

On average, the incidence of abortion is similar in countries with restrictive abortion laws and those with more liberal access to abortion.

However, restrictive abortion laws are associated with increases in the percentage of abortions performed unsafely. The unsafe abortion rate in developing countries is partly attributable to lack of access to modern contraceptives; according to the Guttmacher Institute, providing access to contraceptives would result in about 14.5 million fewer unsafe abortions and 38,000 fewer deaths from unsafe abortion annually worldwide.

The rate of legal, induced abortion varies extensively worldwide. According to the report of employees of Guttmacher Institute it ranged from 7 per 1000 women (Germany and Switzerland) to 30 per 1000 women (Estonia) in countries with complete statistics in 2008.

The proportion of pregnancies that ended in induced abortion ranged from about 10 pc (Israel, the Netherlands and Switzerland) to 30 pc (Estonia) in the same group, though it might be as high as 36% in Hungary and Romania, whose statistics were deemed incomplete.

The abortion rate may also be expressed as the average number of abortions a woman has during her reproductive years; this is referred to as total abortion rate (TAR).