• abortion, trap laws, health policy

Abortion is regulated by law in most (if not all) countries, with a view to preventing abortion except under defined circumstances, and ensuring that abortions are performed safely. Abortion is allowed in 97% of the United Nations´ member states in order to save pregnant women’s lives.1 Today abortions are increasingly provided by healthcare personnel other than doctors, in community settings or even at home rather than in hospitals,2 3 and have become very safe in most countries where they are legal and accessible.2 4 However, regulations vary significantly around the world.1

In considering what legal position should be advocated and how regulation affects women’s health, it should be remembered that provision of safe abortion services was driven by the public health necessity to reduce maternal mortality, not as a primary human rights issue. The proportion of unsafe abortions is significantly higher in countries with highly restrictive abortion laws compared with those with liberal and less restrictive laws.4 Maternal mortality still remains unacceptably high in countries where abortion is illegal.

Even in some highly developed, democratic and affluent countries, such as the UK and the USA, complete decriminalisation of abortion has not been achieved yet, and policies that impose impractical, costly and resource-intensive requirements on abortion providers may have a negative impact on abortion accessibility and on women’s health. However, reducing abortion numbers is also a worthwhile goal from the perspective of health policymakers, and of women themselves. How best to achieve that continues to dominate the political debate, especially in the USA.

Governments´ priorities and policies have an impact on both health and healthcare ethics. Undoubtedly, educating girls and women and providing easy access to birth control is an effective way of reducing the need for an abortion. However, enforcing policies such as so called Targeted Regulation of Abortion Providers (TRAP) laws may have a negative impact on the accessibility of abortion services, and is unlikely to support women’s health. Conversely, a government policy that encourages women to have an abortion to meet national family planning targets or a society that expects women to abort a female fetus cannot be considered humane or ethical even if the access to abortion services is excellent and procedures are medically safe. 

The systematic review by Austin and Harper5 published in this issue of the journal aimed to evaluate the impact of TRAP laws on population-level abortion trends, gestational age at presentation, and measures of self-perceived burden. The authors conclude that certain TRAP laws may have an impact on state-level abortion rates and the experience of obtaining an abortion in the USA.

The study is limited by small numbers (n=6) of included studies, and heterogeneity in design, methodology and reporting, preventing quantitative measurement of the impact of exposure to TRAP laws (composite or individual components) and meta-analysis. The resulting narrative synthesis inevitably carries the risk of desirability bias and limited generalisability. This systematic review does provide a welcome reminder that TRAP laws are not solely a US-specific phenomenon and their impact on abortion services needs to be investigated in other settings too. However, given abortion is already known to be safe in deregulated settings, the prior probability that extensive regulatory efforts will benefit women’s health is very low. It may, rather, be a question of measuring the degree of detriment.