15 February 2008 Abortion is here to stay Debating the abortion rate is futile - we need to focus on providing information and contraception By Sam Rowlands Recourse to abortion is a feature of all societies and is as old as humanity. Women have abortions regardless of the legal situation in their country. It’s clearly much safer for a woman to have an abortion in proper medical surroundings than as a clandestine procedure performed by untrained personnel. Younger generations need to be told and older generations reminded of the results of backstreet abortion: death and permanent injury from sepsis, mechanical trauma and chemical burns. Globally there are about 42 million abortions annually, of which nearly a half are unsafe. 68,000 deaths occur annually from unsafe abortion, almost exclusively in the developing world. It’s true that in the past, in countries like the former Soviet Union, because of almost complete lack of access to contraceptives women used abortion as a primary means of fertility control. This is not so nowadays in the West. But women clearly use abortion as an adjunct to contraception in the event of non-use, incorrect use, inconsistent use or failure of contraception. The most commonly used methods, the pill and condoms, have substantial failure rates in everyday use. This is why there is a current push from the National Institute for Health & Clinical Excellence for wider adoption of long-acting reversible methods (injections, implants and intrauterine devices). Emergency contraception (pills or intrauterine devices administered after unprotected sex) have the potential to make inroads into the abortion rate. So far though, its use is not widespread enough to make any detectable difference. An estimated 108 million married women in developing countries have an unmet need for contraception. So, there is potential here for reducing abortions in these countries. Availability of contraception in Eastern Europe has improved and abortion rates have fallen, but rates remains much higher than in the rest of Europe with more abortions than births. Countries such as Belgium, Germany, the Netherlands and Switzerland have low abortion rates. High use of contraception and universal sex education almost certainly play an important part there. The specifics of their abortion laws and how they operate in practice will be relevant too. Abortion rates are determined by a complex range of factors including family size intentions, confidence in the safety of contraceptives, amount of sexual activity in adolescents and where the country concerned is in its demographic transition. There has been a continuing decline of the abortion rate in the United States since it peaked in 1981, although it remains well above that of Western Europe. Increased use of contraception has contributed to this decline. Much of the decline took place in eight states in which efforts have been made to deliver good sex education, not the Bush administration’s abstinence-only approach. One suspects some of the decline is due to restrictive state laws causing delays or preventing some women altogether from having an abortion. These restrictions unfortunately have a disproportionate effect on the poor. And such a decline is not a unique trend - it may be part of a global decline which has been measured between 1995 and 2003. In Britain the abortion rate has increased year on year since legalisation in 1968, but after 1998 this increase has been slower. There are signs that women’s desire to control their fertility is now being met by service availability. Abortion is here to stay. There is little point debating whether our abortion rate is too high. What we should be concentrating on is making sure that women requesting abortion are supplied with evidence-guided information on which to base their decision. They should all be offered medical abortion: in this respect England and Wales are lagging behind Scotland. All women should be offered screening for infection. And all women should be offered contraception, including long-acting methods. Further research is needed on factors that detract from consistent use of contraception and from this possible effective interventions can be developed. Dr Sam Rowlands is a freelance specialist in contraception and reproductive health and a Visiting Senior Lecturer at the University of Warwick.