Legal Abortion: the Sign of a Civilized Society
by Joyce Arthur
Copyright © October, 1999
Abstract: This paper outlines some of the harsh realities about the incidence and safety of legal versus illegal abortion in the modern world. Countries where abortion is legal are compared to countries where it is illegal to highlight the shocking injustice being done to women who do not have access to safe, legal abortion. That, and the tragedy of unwanted children, highlights the far-reaching health and social benefits of legalized abortion.
Citations for Unwanted Children Studies
Civilization: a human society with a high level of intellectual, social, and cultural development.
Civilized: to be brought into a state of civilization; to be enlightened.
The process of becoming civilized is a long and painful one. 10,000 years ago, we lived short, brutish lives in caves. Although we soon advanced to huts and houses -- and palaces for the privileged few -- our lives largely remained short and brutish. Here and there over the past 2000 years, ordinary people were deemed to have some rights, too, not just kings, popes, and emperors. At first, these rights extended only to men, or to landowners, or to those of the right colour or heritage. Today, thanks to modern medicine, technology, education, and various social and political advances, a large proportion of the world's population has gained the ability to live in good health, and in relative peace, prosperity, safety, and freedom. Of course, these improvements in human welfare a not yet a reality for everyone, but the simple recognition that ALL people everywhere deserve basic human rights, dignity, and a good life is a major step towards achieving those goals.
Only 73 years ago, the world officially condemned slavery. The enlightened recognition that enslaving people was evil made it possible to actually try and stop it. Many minorities and ethnic groups still suffer heavily from persecution and discrimination, but there are two general categories of people whose rights the world has been very slow to recognize. Women and children. For example, in 1928 in Canada, three years after slavery was condemned by the world community (with Canada as a signatory), the Canadian Supreme Court unanimously declared that women were NOT persons. That decision was appealed and overturned by the highest court in England, which said that to deny rights to women was "a relic of days more barbarous than ours." As for children, they are still treated like chattel in many countries even today, slaving away in factories for 16 hours a day, or entirely subject to their family's treatment of them, with little recourse to legal rights of their own. Women have fared much better, but in a few countries today, the legal status of women is still hardly better than that of slaves. Afghanistan is the worst example that comes to mind.
Mandatory motherhood is a unique kind of slavery that specifically victimizes women and children. About one-third of the world's women live in countries where enforced motherhood rules the day. Not too long ago, perhaps women's biology was their destiny. But no more. With the advent of modern contraception and quality reproductive care, there's no excuse for forcing women to bear children against their will, or failing to provide basic maternal care, or compelling women to seek out illegal, unsafe abortions. There's no excuse for forcing children to be born unwanted, sentencing them to a probable life of dysfunction. The future of any society rests in its children, and a civilized society is one that invests in children and parents by providing a healthy, loving environment in which to raise kids.
Some Basic Information about Abortion Around the World
Abortion is probably the world's most common surgical procedure. About 46 million abortions are performed every year, 20 million of them illegal. Abortion is practiced widely by women all over the world, across all social classes, and regardless of laws against abortion. Since the beginning of recorded history, abortion has been commonly practiced by almost all societies, including ancient China, Egypt, Greece, Rome, and countless others. In fact, abortion could be called a fundamental aspect of human behaviour.
But because abortion is still illegal or restricted in many countries today, two out of every five abortions in the world are performed unsafely -- by an untrained provider or in an unclean setting. Every year, about 78,000 women die from unsafe and illegal abortions. For every death caused by unsafe abortion, several women are injured or left infertile. And countless unwanted children are born to women unable to obtain an abortion. Many of these kids will live a life marred by poverty, abuse, and neglect.
About 35 out of every 1000 women of childbearing age have an abortion each year. That's an average of one abortion for every woman over her lifetime. The abortion rate does not differ significantly between developed and less developed regions, but where it is illegal, it is very unsafe. One-third of the world's women do not have access to legal or safe abortion, and these women die at the rate of 330 deaths per 100,000 abortion procedures. In contrast, the death rate from legal abortion averages 0.7 deaths per 100,000 procedures. Over 30% of women who have an unsafe abortion suffer serious complications, such as hemorrhaging, sepsis, or infertility. In contrast, in countries where abortion is legal and safe, the complication rate is about 1-3%, and most of the complications are of a minor nature and do not require hospitalization.
Many women who suffer complications from unsafe, illegal abortion are afraid to come in for medical treatment, so they suffer or die without ever being counted as an abortion statistic. When they do make it to hospital, they take up to two-thirds of the maternity beds, and up to 50% of the hospital's maternity budget. Obviously, this seriously compromises other maternity and emergency services.
In most cases, unsafe abortion equals illegal abortion, but even where abortion is legal, it may be unavailable or too expensive, forcing many women to still resort to unsafe abortion. The quality and skill of medical care also affect abortion safety. Unsafe abortion is defined by the World Health Organization as an "abortion not provided through approved facilities and/or persons." Legality is not the only factor that makes abortion safe, but it's the major one, by far.
Legal abortion is also a very critical factor in improving survival rates for women. About 600,000 maternal deaths related to pregnancy and childbirth occur every year in the world, mostly in the developing world. 13% of these deaths are due to unsafe abortion. But almost all maternal deaths are preventable, simply by providing safe abortion; improving pre-natal care, nutrition, and contraceptive use; and preventing common obstetrical complications.
How did the world manage to arrive at this troubling state of affairs? After all, abortion has been generally legal throughout history. It was only during the 19th century that abortion was made illegal in most parts of the world for the first time. Doctors led the crusade to criminalize abortion, partly to protect women from dangerous abortion techniques, but also to exercise more control over the practice of medicine, since abortions were being performed by mostly female practitioners, such as midwives. Restrictions against abortions started to lift after the 2nd World War, primarily in socialist countries like the former Soviet Union. Most western and European countries liberalized their abortion laws over the following decades, an ongoing trend that is now spreading to developing countries. By 1986, 36 countries had liberal abortion laws, and as of 1997, an additional 10 developed and 9 developing countries had also eased their laws.
The driving forces behind liberalization, then and now, were the threat to public health of illegal abortion, increasing social support for women's rights, availability of modern contraceptives, concern for the equal treatment of both poor women and rich women, decreasing influence of organized religion, and in some countries, thalidomide babies and epidemics of rubella, which created an awareness of the need for legal abortion.
Countries Where Abortion is/was Illegal
Roughly one-third of the world's women live in countries with strict abortion legislation, where women are not allowed abortion under any circumstances, or only in cases of rape, incest, or where the woman's life or health is in danger. Here are some specific examples from a few countries where abortion is or was illegal.
In 1967, Romanian dictator Nicolai Ceausescu came to power and reversed that country's policy of legal and safe abortion. Although the birth rate initially increased, by the 1980's, it had shrunk back down to the mid-60's level because underground abortion networks had mushroomed. The drive to increase births was not accompanied by any basic medical or social improvements. Countless mothers and babies died for lack of medical care, food, and maternity beds. The country was so embarrassed at its soaring maternal and infant mortality rates that it abandoned international standards for recording them. Over the course of 20 years, an estimated 10,000 women died needlessly from illegal abortions alone. Ceausescu's action led to his downfall (he was executed in 1989), and it resulted in thousands of abandoned and neglected children whose plight moved the world.
One of the succeeding government's first acts was to legalize abortion as an emergency health measure. International family planning agencies were invited to set up clinics in Romania, and they found that 40% of women of childbearing-age had reproductive tract damage left by illegal abortions. Continued economic chaos and lack of medical care means than Romania has a very high abortion rate even today, about 1.3 million for every half-million live births. Even so, almost 2,000 babies were abandoned at maternity hospitals in 1994. Countless thousands of children still languish today in orphanages, in squalid conditions, and another 10,000 wander the streets of Romanian cities, homeless. School enrollment has dropped by 21% since 1992 and over 400,000 children have quit school since 1992. About 2,500 Romanian kids are HIV positive, more than the combined total of all Western Europe. And dozens of pedophiles from Western Europe travel regularly to Romania because of its reputation as a country where children are desperate and vulnerable.
Given these deplorable conditions, it will probably take Romania several generations before it can hope to heal the human misery caused by Ceausescu's brutal policy against abortion and contraception. This country serves as a malignant example of the uncivilized consequences of so-called "pro-life" policies.
In Central and South America, abortion is illegal in every country except Cuba and Guyana, but it's widely practiced by all social classes. At least four million illegal abortions take place in Latin America every year, despite its being the most devoutly Roman Catholic region in the world. That's one of the highest documented rates of unsafe abortion in the world. In Brazil, about 1.5 million abortions occur every year, 250,000 women are hospitalized, and many thousands die. Perhaps you've heard of the serious epidemic of street kids in Rio de Janeiro, who are forced into crime and prostitution to support themselves. The police consider them vermin, sometimes shooting them like rats.
In Chile, one in three pregnant women choose to have an abortion -- that's 160,000 a year -- and hundreds die. Wealthy women in Chile (as in any country) can arrange a safe abortion in a hospital or private clinic for large sums of money. Poor women have to rely on unskilled practitioners, and when these women arrive in hospital emergency rooms with complications -- 37,000 women a year -- they're often interrogated by medical staff and then reported to the police. Although only a handful of Chilean women are convicted and sent to jail, it's common for women to spend days or weeks in jail awaiting trial.
In Africa, very few countries allow abortion, and problems related to pregnancy are the leading cause of death for women of child-bearing age, with complications from abortion consistently ranking at the top of the list. For every 100,000 abortions in Africa, 680 women die. That's over twice the average for developing nations, and about 680 times the number of developed countries. 58 women are known to die each day from trying to end their pregnancies with homemade cures or in unsafe underground clinics. Many public health experts say these figures likely represent a tiny tip of the iceberg.
In Ethiopia, 55 percent of maternal mortality stems from illegal abortion. In Nigeria, half of maternal deaths can be traced to this cause. Forty percent of the women who come to some public hospitals are there because of abortion complications and about a third of those die without leaving the hospital.
In Nepal, abortion is illegal under all circumstances, even to save the life of the mother or for rape or incest. The punishment is imprisonment for both women and abortion doctors, but no doctor has ever been charged in Nepal for doing an abortion. However, two-thirds of women in Nepalese jails are there because they had an abortion. As in Chile, when women show up at hospital emergency departments in a very sick condition, medical staff must report them to the police. When women are sent to prison, they are often torn from their families, and their children are left to fend for themselves on the streets.
Countries Where Abortion is Legal
Let's turn to a few countries that have more liberalized abortion policies. About two-thirds of the world's women live in countries with liberal or fairly liberal abortion laws, where women are allowed abortion to preserve their mental or physical health, or for social and economic reasons, or upon request without regard to reason.
The Netherlands (Holland)
In the Netherlands, abortion is freely available on demand. Yet the Netherlands boasts the lowest abortion rate in the world, about 6 abortions per 1000 women per year, and the complication and death rates for abortion are miniscule. How do they do it? First of all, contraception is widely available and free -- it's covered by the national health insurance plan. Holland also carries out extensive public education on contraception, family planning, and sexuality. An ethic of personal responsibility for one's sexual activity is strongly promoted. Of course, some people say that teaching kids about sex and contraception will only encourage them to have lots of sex. But Dutch teenagers tend to have less frequent sex, starting at an older age, than American teenagers, and the Dutch teenage pregnancy rate is 9 times lower than in the U.S.
An important message that we can learn from Holland and other European countries is that even the most comprehensive family planning programs and widespread contraceptive use will never completely eliminate the need for abortion. Abortion is a critical backstop to contraception, which is not 100% effective. And people do make mistakes -- they sometimes forget to use their contraception, or they use it wrong. Motherhood should never be a punishment for human error.
In Sweden, abortion has been available upon request since 1973 up till the 18th week of pregnancy, and sex education has been a compulsory subject in schools since 1956. At 19 abortions per 1000 women per year, Sweden's abortion rate is three times higher than Holland's, and only 20% less than the rate of the United States, but the abortion rate for women under 25 is half that of the U.S.
Sweden is particularly interesting because their birth rate increased to more than two children per woman during the 1990's. The reason for the baby boom was the creation of a 15-month paid parental leave, a doubling of the number of day care centres, and other perks, such as paid leave for parents of sick children. The government's policy is not to increase the birth rate, though -- it's to help children successfully integrate into society. A lesson can be learned from that policy, because many countries that made abortion illegal -- Nazi Germany for instance -- did it to increase the birth rate. Obviously, a far more humane and effective way of increasing the birth rate, as demonstrated by Sweden, is to give parents the time and the resources to raise children well.
Canada has no law at all restricting abortion. The safety of abortion is governed just like any other medical procedure, and most abortions are funded by government health insurance. Because there's no law, anti-choice groups in Canada complain about how women are having casual abortions right up to their ninth month of pregnancy, but in practice, 90% of abortions are performed in the first trimester, and no doctor will perform abortions past about 20 or 21 weeks unless it's for compelling health or genetic reasons. Just over 100,000 abortions are performed per year in Canada, a reasonably low rate of 16 per 1000 women.
Canada also boasts what I believe is the lowest maternal mortality rate for early abortion in the entire world, 0.1 per 1000 abortions. (In contrast, the Netherlands' rate is 0.2 per 1000 abortions.) Canada serves as an excellent example of why any kind of legal restriction on abortion is completely unnecessary. Women exercise their sensible moral judgement and doctors exercise their professional medical judgement, and that's all that's needed to regulate the process.
America has had legal abortion on request since 1973. Before legalization, abortion complications accounted for 23% of all pregnancy-related admissions to municipal hospitals in New York City. After legalization, that number fell by 75% almost immediately, and continued to fall through the 70's and 80's. Today, the complication rate for early abortion in the United States is less than 1%, and the maternal mortality rate is .6 per 100,000 abortions.
However, the American woman's right to abortion and contraception has been undermined by extreme anti-choice violence and harassment, and numerous legal, social, and political obstacles. America's large and politically powerful anti-choice movement is also against contraception, with the result that 1.3 million American women still have abortions every year, a rate of 24 per 1000 women, unnecessarily high for such an advanced, democratic country. The abortion rate has declined from a high of almost 1.6 million abortions in the early 1990's, due mostly to increased contraceptive use and reduced sexual activity amongst young people. However, America still has a very high rate of unintended and teenage pregnancies, and its mortality and complication rates from abortion, while low, could probably be improved.
Significantly, it's been shown that the presence of anti-abortion protesters outside clinics actually increases the rate of abortion complications. A more tolerant attitude towards sexuality, contraception, and abortion would undoubtedly serve to reduce America's unplanned pregnancy and abortion rates, and further improve the safety of abortion. The experience of America shows that legal abortion makes a tremendous improvement to women's lives, but that an anti-choice backlash can remove hard-won gains, resulting in more danger and less freedom for women.
The Critical Role of Contraception
When quality contraception is made available to people, and they use it properly, rates of unplanned pregnancy and abortion tend to go down significantly. In countries where abortion is legal, the differences in abortion rates can largely be attributed to effective contraceptive use. For example, in eastern Europe, where contraceptive use is very low, there are about 50-70 abortions per 1000 women of childbearing age each year. By contrast, in western Europe where contraception is used widely, the average rate is 11 per 1,000 women. In general, the more widely available and accepted contraception is, and the more effective its use, the lower the rate of unintended pregnancy, and the lower the abortion rate. Of course, other factors affect the abortion rate, such as desired family size, economics, available social supports, and so on, but contraception probably contributes to larger reductions in abortion rates than all other factors combined.
Most countries, even in western Europe, could still do a lot to improve their use of contraception and reduce their rates of unplanned pregnancy and abortion. But even so, Planned Parenthood of America has said that if it wasn't for contraceptive use, the American abortion rate would be about double what it is now. In fact, contraception reduces the probability of having an abortion by 85%.
30 years ago, only 10% of couples in the world used contraception, but this has increased today to about 58% of couples. In countries with active family planning programs, average family size has dropped by about one-third since the 1960's. However, there are still 120-150 million women around the world who want to limit or space their pregnancies, but they lack information about contraception and access to family planning services. The failure to meet family planning needs has negative effects on women and their families. Effective family planning services help women improve their lives, stay healthy, and provide for their families. This in turn has a positive impact on the whole community. And of course, without legal abortion, contraception, and the education and empowerment of women, we're not going to win the battle against global overpopulation that's threatening our planet right now. In fact, no country has been able to successfully reduce their population growth without resorting to abortion.
The Plight of Unwanted Children
The anti-choice suffer from what I call the "fetus focus fallacy." They put fetuses ahead of just about everything else, including women's lives and rights, the alleviation of human suffering, freedom of conscience and religion, and truth itself. But let's take a look at these "unborn children", the ones who end up being aborted, but who should, according to anti-abortionists, be forced to live.
Unwanted childbearing has long been linked with adverse consequences to children. Several studies, conducted in countries like the U.S., Czechoslovakia, and Sweden, have documented the long-term developmental problems suffered by children whose mothers did not want to bear them. The findings point to various emotional, educational, and functional disorders that get worse as children become adults. These difficulties happen even to children born to healthy, adult women who have stable marriages and adequate economic resources. The problems are compounded for the majority of unwanted children who are born to poor, unhealthy, unmarried, or teenage mothers.
The studies focused on women who tried to get abortions and were denied them by law or by circumstance. Some used control groups of wanted children and compared them to groups of unwanted children. The studies found that when compared to wanted children, unwanted children are more likely to suffer from:
For example, unwanted children are:
The findings of these studies of unwanted children paint a clear and disturbing picture of what happens to children when abortion and family planning services are restricted. Forced motherhood and a lack of social support mean that unplanned children too often become victims of life, simply through an accident of birth. And an unwanted child may become an unwanted adult. A recent study in the United States concluded that the legalization of abortion there in 1973 may account for half of the 30-40% reduction in crime that America has experienced since 1991. Legal abortion allows women and men to plan their families and provide for wanted children adequately. The result is more confident, happier, healthier children, who will be more likely to lead fulfilling and constructive lives than their unwanted counterparts.
Legal abortion benefits the health and well-being of children in other ways, too. Children are no longer orphaned when their mothers die from dangerous, illegal abortions, leaving their families without the critical economic and social contributions of a mother. And safe abortions enable women to bear wanted children later, instead of never, because of infertility due to botched abortions.
Benefits of Legal Abortion
Besides the tremendous benefit to society of ensuring that every child is a wanted child, legal abortion has clearly been a significant factor in saving women's lives and health:
The Anti-choice Campaign Against Abortion
Despite the obvious health and social benefits, legal abortion continues to be the victim of profound, sometimes violent, controversy. The controversy is fueled by religious dogma, particularly that of the Catholic Church and fundamentalist religions, which claim that all life is sacred, and human life starts at conception. Even beyond religious doctrine, the social message is that choosing to continue a pregnancy is good; terminating it is bad, regardless of the circumstances. This attitude has a deep effect on women having abortions. Some women feel embarrassed, guilty, and ashamed for deciding to have an abortion. In fact, women who come to abortion clinics are often surprised when they receive professional, compassionate medical care. Abortion is probably the only medical service where the patient expects shabby treatment and an atmosphere of disapproval. That's because the well has been poisoned by years of anti-choice propaganda, much of it inflammatory and grossly inaccurate.
This poisonous attitude about abortion also has a strong effect on those providing abortion services. In some parts of the world, physicians and medical staff feel stigmatized by their colleagues and society. Being an abortion provider does not carry social approval, prestige, or financial reward, compared with other specialties. Many medical schools and departments of obstetrics and gynecology don't even require students to learn abortion techniques, and coursework in that field often does not even mention abortion. And remember, abortion is probably the most common surgical procedure in the world!
For the anti-choice, I believe the heart of the abortion controversy is not about the fate of unborn babies. It's about the value of women in society. In North America, for example, many anti-abortion leaders oppose ideas and programs that could help women achieve equality and freedom, and protect the health and well-being of families. For instance, they oppose affirmative action programs that help women gain equity in the job market. They force poor women to have babies and then cut off their welfare. They lobby against health and nutrition programs for children. They condone the bombing of clinics providing reproductive services, and the killing of doctors and staff. These uncivilized actions reveal the true nature of anti-choice goals. They want a return to the days when women had few choices in life. They don't like women having too much freedom, especially in controlling their reproductive lives. They're convinced that women can't be trusted to make their own decisions. And they certainly don't like women having sex for fun without paying for it.
The high rates of death and serious injury associated with unsafe and illegal abortion prove that governments, public health officials, and right-wing religious groups are blind and indifferent to the realities of women's lives. These people continue to believe that laws against abortion will stop abortion, in spite of obvious contrary evidence. The only thing that laws against abortion do is make abortion dangerous, turn most women into criminals, produce millions of disadvantaged children, and create wide disrespect for the law. When it's plain to see that tens of millions of women willingly risk their lives to end an unwanted pregnancy, the hypocrisy of those in power is nothing less than criminal. Much of the blame for this probably rests on the shoulders of more developed nations, who have failed to share enough of their wealth, technology, and experience with the rest of the world.
However, through the United Nations, the world has recently recognized the right of women everywhere to education and reproductive healthcare, the right to participate in the political process, and other important rights. In addition, there is an increasing amount of open discussion and concern about unsafe abortion within the international community. Efforts are being made in many countries to make abortion safer and more accessible even where it is illegal. These are very positive developments. But unfortunately, you won't find any United Nations document that asserts legal abortion as the right of all women everywhere. Safe abortion, yes. But not legal. It seems the world is not quite ready for that yet, even though I don't believe there can ever be such a thing as safe, illegal abortion.
We probably won't be able to change laws against abortion without some kind of universal consensus, like we have on slavery, but I believe we're getting closer and closer to that universal consensus. The day may soon come when women all around the world will have the legal right to decide for themselves when and whether to have children, and the means to exercise that right, safely. And children will have the fundamental right to be wanted, to grow up safe, happy, and healthy. On that day, the world will become truly civilized.
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