Background

The legal status of induced abortion has long been seen as a proxy for ease of access to safe abortion services.1 The notion that legality equals safety is simplistic; some illegal abortions are safe and even where abortion is legal, many women are unable to access these services.2 As misoprostol – an abortifacient that women can use to safely terminate their own pregnancies – becomes more widely available, women may be able to access safe abortions outside legal systems.3 While evidence is limited, it is likely that factors such as poverty, stigma, geographical distance from a provider and lack of knowledge about the legal status of abortion on the part of women and potential providers, prevent many women from accessing safe abortion services, even where abortion is legal.4

Both in contexts where abortion is legally restricted and where it is available, widespread stigma about unwanted pregnancy and abortion lead to substantial bias in data collected about abortion.5 The lack of reliable data makes it difficult to gain a broader understanding of abortion safety and access in legal contexts, or to fully understand the role of misoprostol in making abortions safer and more accessible in any context.3 The availability of new data from four countries sheds light on the extent of abortion denial in legal settings and sets the stage for studying the health and socioeconomic consequences of not receiving a wanted abortion.

Legal restrictions on abortion are often the cause of abortion denial. In Nepal, the law permits abortion on request up to a gestational age of 12 weeks. In South Africa, the law allows legal termination of pregnancy on request up until 12 weeks gestation, and for socioeconomic or medical reasons from 13 to 20 weeks. In Tunisia, abortion is legal on request during the first 12 weeks of pregnancy. In Colombia, abortion is permitted by law when the pregnancy endangers the life or health of the woman, the pregnancy is the result of rape or incest, or if the fetus has a life-threatening anomaly. While there is no legal gestational limit in Colombia, the largest provider of abortions in the country has a gestational age limit of 15 weeks.6

Study findings

We interviewed all women presenting for abortion at two clinics in each of four cities: Katmandu, Nepal; Cape Town, South Africa; Tunis, Tunisia; and Bogota, Colombia over a span of 1–6 weeks between 2012 and 2013. We administered questionnaires and documented each participant's gestational age at the time of the visit, whether she received the abortion she was seeking, and, in the case of denial of services, the reason for denial.

Women seeking abortion ranged in age from a mean of 26.4 years in Colombia to 30.6 years in Tunisia. The mean gestational age ranged from 6.1 weeks in Colombia to 9.9 weeks in South Africa, and the proportion of women presenting for abortions after 12 weeks’ gestation ranged from 2% in Colombia to 20% in South Africa (Table 1).

The incidence of abortion denial was overall much higher than we expected and varied significantly by country. In South Africa, 45% of women in our survey did not receive the abortions they sought at the clinic: 20% of all women interviewed were turned away for advanced gestational age, 20% because the clinic did not have the staff to perform their abortions that day, and 5% because of an inability to pay for their abortions. In Tunisia and Nepal, approximately one-quarter of women were denied wanted abortions. In Tunisia, 26% did not receive the abortions they sought; 7% of women were turned away for gestational age reasons, 15% were required by the clinic to undergo laboratory tests not required by law prior to receiving the abortion they requested, and 4% were either required by the clinic to have an ultrasound scan prior to the procedure or were referred to other providers. In Nepal, 26% of women did not receive the abortions they sought; 14% were turned away for gestational age reasons and 12% were turned away for other reasons including lack of availability of abortion medications at the facility, undetectable pregnancy, and medical contraindications. In Colombia, 2% of women surveyed did not receive the abortions they sought, all due to gestational age restrictions.

The findings in Nepal, South Africa and Tunisia that a large proportion of women seeking abortions are turned away are similar to results of a recent study among women seeking menstrual regulation services in Bangladesh,7 where one-quarter of women seeking menstrual regulation services in 2010 were turned away. The study found that health facilities denied services to women because too much time had elapsed since the last missed period or for other medical concerns. However, consistent with our findings in Tunisia where clinics required unnecessary tests, facilities also reported turning women away for reasons that were not legally required or medically necessary, such as being unmarried or not having the husband's consent.

Illegal abortions

What happens to women who are denied the abortion services they seek? Researchers have hypothesised that in some settings women who are denied abortions because of gestational age limits may go on to seek illegal abortions elsewhere.8 In each of the countries some women received referrals to other legal providers. It is, however, unknown whether women were able to pursue those referrals and receive a legal abortion, whether they sought illegal abortions, or whether they continued with their pregnancies.

Evidence suggests that with increased access to misoprostol, women seeking abortions outside legal systems may have a safer alternative to invasive and potentially life-threatening methods of self-termination.3 Data from Latin America indicate that misoprostol has contributed to a decrease in the mortality and morbidity associated with illegal abortion,9 but that it may also be contributing to a higher rate of facility visits for abortion-related complications as women seek services to complete the abortion once it is started with misoprostol.10 Outcomes associated with misoprostol use for self-induced abortions outside legal systems have been challenging to document,3 and how women access this medication, learn about its applications, and decide when and where to seek care is unknown.

CONCLUSIONS

The denial of legal abortion services may have serious consequences for the health and wellbeing of women and their families.11 Evidence from the Turnaway Study in the USA – a prospective, longitudinal study of women's access to legal abortion and the consequences of being denied an abortion in the USA on women's physical and mental health and socioeconomic well-being12 – has demonstrated substantial negative effects on physical health and socioeconomic outcomes among women denied abortions who carry their pregnancies to term compared to women who received wanted abortions.13 Additional evidence on the risk factors for seeking abortion later in pregnancy, predictors of seeking unsafe or illegal abortion, and the health consequences of illegal abortion and of childbirth after an unwanted pregnancy is needed. We are currently conducting in-depth interviews among women in Bangladesh, Colombia, Nepal, South Africa and Tunisia who were denied abortions, to document who has access to legal abortion and who seeks illegal abortion. The study ultimately aims to prospectively measure the health consequences of legal abortion, illegal abortion and childbirth. Such data will provide valuable evidence for the development of programmes and policies to improve access to and utilisation of safe abortion services where abortion is legal, and harm reduction models for women who are unable to access legal abortion services.