Unsafe abortion deaths are a direct consequence of antiquated and cruel laws against abortion. About 21.6 million unsafe abortions occurred worldwide in 2008, almost all in developing countries where abortion is illegal. (This compares to 19.7 million in 2003, with the rise due to the increasing number of women of childbearing age in the world.) Among women who survive unsafe abortion, an estimated 8.5 million suffer complications, with 1 in 4 needing medical attention.

In contrast, death from unsafe abortion has been virtually eliminated in western industrialized countries that have legalized abortion, and the complication rate is extremely low. When abortion is legalized in a country, there is typically a dramatic decline in maternal deaths and complications due to abortion. This pattern has been repeated numerous times since the 1950’s when abortion was first legalized in former Eastern Bloc countries.

Legal abortion saves women’s lives and improves their health because without it, women risk their safety by resorting to unsafe illegal abortion. The right to abortion also advances women’s equality, liberty, and other human rights, freeing women to pursue an education and career and to participate fully in public life. Access to abortion allows women to better plan and provide for their families, which benefits the entire community and society. Unplanned births of unwanted children can be very crippling to women and families, leading to higher rates of poverty and dysfunction, including child abuse. These factors make the provision of safe and legal abortion a vital public health interest that negates any justification for criminalizing the procedure.

Yet here we are, one decade into the 21st century, and almost every developing country in the world continues to enforce a near-total criminal ban on abortion. Abortion is illegal primarily in Africa, Latin America, and some parts of Asia, as well as a tiny handful of developed countries like Poland and Ireland. However, all countries with more liberal abortion laws still retain abortion as a criminal offence with exceptions, or have enacted further legal restrictions that make it difficult to access.

If the intent behind banning abortions is to stop or reduce them, it’s been a total failure. In 2007, the World Health Organization and the Guttmacher Institute found that overall abortion rates around the world are similar, regardless of whether or not abortion is illegal in a country. This is because countries with strict anti-abortion laws have well-developed black markets for abortion. The global average abortion rate for women of childbearing age (15-44) was 29 per 1,000 women in 2003, with the highest number of abortions occurring in countries where it's highly restricted and in countries with poor access to contraception. Eastern Africa’s rate was 39 per 1,000 women, while South America’s rate was 33.

In countries with fewer restrictions where legal abortion is widely available, the rates are generally much lower, plus we see a decline in abortion rates as contraception use rises. Canada is the only democratic nation in the world with no abortion law or restrictions, but it has a low abortion rate of 14.1 abortions per 1,000 women of childbearing age. That compares favourably to western Europe’s rate of 12, the lowest abortion rate in the world and the region with the most liberal abortion laws. In contrast, the American rate is 19.4 (for 2005) and U.S. women must navigate through a thicket of abortion restrictions. There isn't a shred of evidence that such restrictions are effective or helpful for women or society; instead, they create arbitrary obstacles and delays for women seeking abortion care.

Who should we blame for this global travesty of injustice and for the continuing suffering and deaths of women? The obvious culprits, of course, are the Vatican, conservative countries and right-wing politicians, and various Catholic and fundamentalist religious organizations. But perhaps a better question is: Why does the world allow these entities to inflict such a terrible toll on women’s lives and health, year after year? The most obvious culprit in this case would appear to be sexism and patriarchy, which are very much alive and well in our modern age, and still socially acceptable compared to racism. Traditional views on women’s motherhood role are the main reason that women’s rights and equality still lag far behind the rights of minorities and other vulnerable groups. Much of the world still clings to the deeply-held assumption that women’s dignity and humanity is tied to being a mother, even though this subordinates women to a biological function. Moreover, our male-dominated patriarchal societies still try to guarantee paternity by controlling women's sexual and reproductive behaviour at the expense of their freedom and human rights.

The United Nations’ position on abortion reflects the world’s hostile attitude towards safe abortion as an essential part of women’s reproductive rights and the cornerstone of women’s health and survival. Although the UN’s purpose is in part to promote and encourage “respect for human rights and for fundamental freedoms for all without distinction as to race, sex, language, or religion,” the UN has essentially abandoned women who need abortions by caving to pressure from right-wing forces.

Instead of spearheading the crucial task of decriminalizing abortion throughout the world, the UN has only a few timid suggestions to offer the governments of the world. The 1994 UN International Conference on Population and Development (ICPD) passed a resolution calling for governments to “deal with the health impact of unsafe abortion as a major public health concern.” The 1995 Fourth World Conference on Women urged governments to “consider reviewing laws containing punitive measures against women who have undergone illegal abortions.” The 1999 ICPD approved a provision that stated: “In circumstances where abortion is not against the law, health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible.” Such lackadaisical band-aid suggestions don’t come close to attacking the root of the problem – the criminal abortion laws that kill or injure over 8 million women a year.  

A UN fact sheet entitled “What is the United Nations stand on the issue of abortion?” contains numerous statements, that when juxtaposed together, betray a shockingly contradictory position on abortion:

“Restrictive abortion laws do not prevent abortion but force women to seek illegal and usually unsafe abortions.” But: “The legal status of abortion is the sovereign right of each nation.”

[Because of contraceptive failure] “Women will continue to seek abortion services -- this is a social reality.” Nevertheless: “…to eliminate the need for abortions is UNFPA's goal.”

“Of the estimated 45 million abortions worldwide annually, only 25 million are legal. At least 70,000 women die each year as a consequence of unsafe abortion, and millions more suffer severe health problems.”  But: “The United Nations does not provide support for abortion or abortion related activities anywhere in the world.”

“Unsafe abortions account for some 25 - 50 per cent of maternal deaths in refugee situations.” But: “The reproductive health care package [for refugee camps] does not include abortion.”

“More women resort to abortion where family planning services and sex education are poor.” But: “The United Nations does not promote abortion as a method of family planning.”

These cowardly and even anti-choice statements have no place in any human rights organization or document. The only reason they are there is because the UN has allowed the Vatican and anti-abortion countries to force their ideology into wording and positions that conflict with evidence-based medicine, violate women's rights, and put their health and lives at risk. The now common rallying cry that countries should provide “safe abortion where legal” means that the UN has made it an acceptable global policy to deny women the basic right to control their fertility, to the extent of ignoring needless deaths of women who are unlucky enough to live in a country where abortion is illegal.

Such poor direction from the UN makes it difficult to lobby for the repeal of abortion laws (which would actually cost little or nothing for countries to do, compared with other measures to reduce maternal mortality). Further, the Reagan/Bush presidencies created a big chill on any funding or advocacy of abortion in other countries, which continues to this day. Because peoples' hands are tied, 21 million women a year continue to risk unsafe abortion, and continue to be mistreated when they seek help for complications. Unsafe abortion gets short shrift as a health problem from the global community at large, undermining efforts to bring attention to the problem and resolve it. For example, Canada has cited the UN’s anti-abortion statements to avoid funding safe abortion in developing countries.

This silencing and denial allow right-wing forces to engage in "plausible deniability" about the existence of unsafe abortion. Anti-abortionists claim that its incidence is highly exaggerated or not a problem that needs addressing. They also assert that prohibiting abortion does not increase maternal mortality because women’s lives can be saved by improved education and access to healthcare. Of course those factors are key, but deaths from unsafe abortion add an extra layer of completely unnecessary mortality that will not end until the laws change. Even if illegal abortion becomes increasingly safer because of do-it-yourself medical abortions and upgraded health systems, there will still be many unsafe abortions. The laws are profoundly wrong regardless, because they reinforce abortion stigma, cause great distress and suffering to women, and turn women into criminals, along with those who help them.

Ironically, anti-abortionists claim that advocating for a change in laws in places like Africa amounts to “neo-colonialism,” the imposition of white western customs and morality onto other cultures. But anti-abortion laws in developing countries were first enacted by the former colonial powers of Britain, France, and Spain, which liberalized their own laws long ago (as well as Portugal more recently) because the injustice of women dying or being criminalized finally became socially unacceptable.

An illuminating example of the “dynamic of denial” over unsafe abortion occurred in April 2010. The prestigious journal The Lancet published a paper by researchers from the Institute for Health Metrics and Evaluation (IHME), announcing a reduced estimate of 342,900 maternal deaths for 2008 (In 2005, the WHO estimated 536,000 deaths of women each year due to pregnancy-related causes, with 13% – 70,000 – because of unsafe abortion). Although the new lower numbers are cause for celebration, the authors of the Lancet paper inexplicably made no mention whatsoever of unsafe abortion as a major cause of maternal mortality. This was a highly regrettable and damaging omission, considering the article was published amidst renewed global awareness of the need to combat maternal mortality leading up to the June G8/G20 summit in Canada – and during the political firestorm in Canada when Conservative Prime Minister Stephen Harper refused to fund safe abortion in his G8 maternal/child health initiative.

Why did this crucial omission occur? The Lancet study authors failed to itemize causes of maternal mortality and simply lumped most of them into “direct obstetric causes” and “causes aggravated by pregnancy.” When questioned on the omission, IHME’s Director of Communications, Jill Oviatt, responded that their research “did not look at specific causes of maternal deaths” because “this is a different research area, and one that we are currently working on.” (Personal communication, July 14). However, the study authors did list various causes of maternal deaths that are often misclassified, while still managing to omit induced abortion – surely one of the most misclassified causes of maternal death in the world. Complications and deaths from illegal abortion are frequently reported as caused by miscarriage or other factors, and it’s well known that many women deny having had an abortion if asked.

The total lack of mention of unsafe abortion in the Lancet paper provoked criticism from some, including in a subsequent Lancet letter (see here, here, and here). It also gave a tremendous boost to anti-choice groups, who in numerous articles, pointed to that omission in order to minimize deaths from unsafe abortion and claim that WHO’s estimated numbers are “creative math.” (Also see here, here, here, here, here, here, here, and here.)

The Lancet study was funded by Bill and Melinda Gates, who refuse to directly address unsafe abortion or fund safe abortion care. However, the IHME said that the Gates did not require the omission of abortion as a condition of funding for their study. “The [Gates] Foundation is not involved in our daily activities and does not supervise our work. …  The Foundation has no approval process over what we publish and how our research articles are worded.” (Personal communication, July 14)

The Gates Foundation has probably been the most prominent and generous funder of maternal and child health initiatives, pledging $1.5 billion for that purpose at the 2010 G8 summit. But when asked about abortion, Melinda Gates, who is Catholic, said: “The foundation specifically doesn't take a stance on abortion for exactly this reason, is we don't want to be part of the controversy or stem that controversy.” She added that giving women family planning tools can reduce the demand for abortions. While that is true, there will always be a need for abortion, as the UN itself admits by acknowledging that contraception is not always available or effective and that women will resort to abortion when faced with an unwanted pregnancy.

It is an absolute disgrace that so little is being done to change the punitive abortion laws in developing countries, when the evidence of their grave harm is so conclusive and overwhelming. The absurdity of enforcing laws that produce zero benefits and numerous, often catastrophic harms is a consequence of allowing religious beliefs to govern law and politics. Also scandalous is the imposition of criminal laws onto the field of evidence-based medicine, because political interference with the doctor/patent relationship obstructs best care practices and puts lives and health at risk.

Why is legalizing abortion not a top priority in development efforts or global human rights dialogues? Why are people listening to and respecting the voices of anti-abortion countries and religious fundamentalists? Why does patriarchy and sexism still rule the day, at the expense of women’s lives?

Maternal mortality and morbidity from unsafe abortion will never end until women live in a safe and respectful environment, free of laws that criminalize them for being women – because most women everywhere will resort to abortion in order to support their families, protect the children they already have, and save their own lives. As long as abortion remains illegal, this much-cited comment will remain true:

“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” — Mahmoud Fathalla, Former President of the International Federation of Gynaecology and Obstetrics, 1997

(The author would like to thank Christian Fiala, MD, PhD, for contributing to this article.)