How to make abortion rarer

ABORTION, says Theodora, a Greek civil servant, was “an absolute necessity” when she became pregnant last year. Her husband had lost his job and money was too tight for a third child. The procedure, at a private clinic, was “efficient”; she was in and out in three hours. Hers was a typical experience for a middle-class Athenian woman. It is not uncommon for one to have four or five abortions, says a gynaecologist in Athens. In Greece abortion is seen as an ordinary form of birth control.

Most modern contraceptives, however, are not viewed that way. More than half of married Greek women use none at all. Withdrawal and condoms are the methods of choice for most couples who are trying not to have a baby—even medical students, who should know that these fail about a fifth of couples who rely on them for a year. Greeks commonly believe that the pill and other hormonal contraceptives cause infertility and cancer. They also distrust intrauterine devices (IUDs), possibly because they have been taught that tampons are unhealthy.

The same sort of nonsense keeps abortion rates high in many other countries. Statistics are patchy, especially in places where many abortions are done in private clinics or the procedure is illegal. But a recent study in the Lancet, a medical journal, estimated that 56m abortions are carried out each year worldwide, ending a quarter of all pregnancies. The annual rate, of 3.5 abortions per 100 women of childbearing age, is only slightly lower than it was in the early 1990s.

Although the abortion rate is stable or falling in most rich countries, it is rising in Latin America and some parts of Africa and Asia (see chart 1). Former communist countries have some of the world’s highest rates. During Soviet times abortion was the only method of birth control, and in some countries the average woman would have five to eight abortions during her lifetime. By the time the Soviet Union fell apart it was spending about half of its reproductive-health budget on abortions and associated complications.

Zero tolerance, zero result

For many pro-life politicians, the answer to high abortion rates is to make abortion illegal or harder to get. Donald Trump, a recent convert to the pro-life cause, has vowed to appoint a conservative to America’s Supreme Court. Many religious leaders fulminate against abortion, although Pope Francis softened the Catholic church’s line slightly on November 20th. Abortion remains a grave sin, but penitent women can now be forgiven by parish priests and do not have to go to a bishop.

International comparisons show that bans and restrictions do little to cut the number of abortions. Most women will do what it takes to end an unwanted pregnancy, even to the point of risking their lives. According to the Lancet study, abortion is as common in countries where it is illegal or allowed only to save a woman’s life as it is in those where it is provided on demand.

In many countries the authorities turn a blind eye when the rules are broken. Most of Latin America has strict laws, but a woman able to afford high fees can get a safe illegal abortion in a private clinic. (Poor women go to backstreet abortionists, and are sometimes seriously injured or even killed.) In South Korea abortion is legal only in cases of rape, incest or severe fetal abnormalities, or to save a woman’s life. Still, a study for the government in 2005 estimated that 44% of pregnancies were aborted. A 35-year-old housewife in Seoul who had an abortion in 2011 says she simply went to the doctor who had delivered her two children and said she did not want the baby. Women who call clinics in Seoul to seek an abortion are told that the procedure is not provided but are often invited to come for a “consultation”.

Where the authorities are more vigilant, women often go abroad or buy abortion pills on the black market. Women from Ireland, Poland and Malta can easily get abortions elsewhere in Europe. In 2015 nearly 3,500 women who gave Irish home addresses had abortions in public clinics in England. The internet has made it easier to arrange a safe abortion. Women on Web, a Dutch pro-choice group, offers online consultations on how to use misoprostol and mifepristone, a drug combination approved by the World Health Organisation for abortions during the first 12 weeks of pregnancy. It ships them all over the world. In many Latin American countries misoprostol is available as a treatment for stomach ulcers. To avoid suspicion, a woman might ask an elderly relative to buy the drugs for her.

Anti-abortion groups have grown louder in many countries in recent years. But they struggle to enact bans. In October conservative politicians in Poland, where abortion is available only in rare circumstances, backed away from a plan to ban it entirely, following large street protests. Women marched waving coat-hangers, which are sometimes used in do-it-yourself abortions.

When the patriarch of the Russian Orthodox Church called for a ban in Russia, the country’s minister of health explained that this had been tried for a time under Stalin. It resulted in many deaths from illegal abortions but no change in the birth rate. Mr Trump’s Supreme Court appointee will make little difference to America’s abortion law in the short term. The court has a solid majority for keeping it legal.

Pro-life campaigners have succeeded in making abortions harder to get. In some American states a woman who seeks one must be told that it might cause cancer—a claim unsupported by scientific evidence. In recent years Russia and several other former communist countries have brought in mandatory counselling and “reflection periods” of several days before an abortion can be carried out. Russia’s guidelines describe abortion as the “murder of a living child” and instruct counsellors to “awaken maternal feelings”, convince the woman of “the immorality and cruelty” of abortion and lead her to conclude that the means to raise the baby can be found. Evidence of success is thin. Abortions declined slightly when the state of Mississippi insisted on counselling and a waiting period, but the proportion carried out after the first trimester rose and more women travelled to other states.

Studies of Western countries suggest that few women who have had an abortion regret their choice. Although women with pre-existing mental-health problems can see them worsen following an abortion, such problems also tend to worsen if they carry an unwanted baby to term. But in poor countries, where sterile rooms and well-trained doctors are in short supply, even legal surgical abortions can be risky. In the West less than 1% of abortions carried out by manual vacuum aspiration are followed by complications. In Bangladesh the share is 12%.

Much the best way to make abortion rarer is to prevent unwanted pregnancies. What works is well known: campaigns to educate couples about the various methods; training for doctors and nurses in birth-control counselling; and making contraceptives easy to get. Even in rich countries, however, some or all of these are missing. Bangladeshis and Malawians are keener users of contraceptives than Greeks or Italians (see chart 2). In plenty of countries, including Ireland and Russia, more than a third of married couples who use contraceptives rely on condoms. In Japan that share is an astonishing 90%.

The Catholic church continues to frown on contraception. And many couples fear social stigma and mythical side effects. In South Korea fewer than 5% of women use the pill because they think it is harmful to ingest artificial hormones. Even so, unmarried couples often forgo condoms to signal commitment; men know that women can obtain the morning-after pill without much difficulty and that abortions are a possibility. Professional advice is scarce. A gynaecologist who gave a lecture about sex and contraception at a nursing college was told afterwards that it had made the students “feel uncomfortable”.

A fetish for latex

The head of one HIV clinic in Athens says Greek hospitals often recommend condoms as the most reliable method for avoiding pregnancy. In fact, of every 100 couples who rely on condoms for a year 18% will conceive, compared with 9% for the pill and under 1% for the IUD. Roula, a 30-year-old architect from Crete who studied in England, where four-fifths of women use contraceptives and hardly any rely on condoms to prevent pregnancy (as opposed to sexually transmitted diseases), describes the counselling on the range of contraceptives at her university’s clinic as “enlightening”. In Macedonia, where less than a fifth of women use contraceptives, some doctors view the IUD as a “foreign body” akin to a surgical tool accidentally left inside a patient. Others are averse to prescribing the pill to young women, believing that it will harm their physical development. (It won’t.)

In former communist countries, few older doctors are trained to prescribe modern contraceptives. Luybov Erofeeva of the Russian Association of Population and Development, an advocacy group, says Russian women prefer condoms or withdrawal because they have heard from their mothers and aunts about the complications and side effects from contraceptive pills with high doses of hormones and primitive IUDs used in Soviet times.

In many countries, sex education in schools is woeful. A review of 16 European countries by the International Planned Parenthood Federation (IPPF), a campaign group, found that the subject was compulsory in only half of them and rarely included scientific information about contraceptives. The main message of a recent pamphlet offering guidance to South Korean teachers is to make the case that students should not have sex. One of the suggestions is to ask pupils to write letters to their imaginary future spouses, to focus their minds on remaining chaste.

Simply getting hold of contraceptives can be such a hassle that women give up. Russian women who want the pill often undergo an unnecessary pelvic exam by a gynaecologist. Some Greek doctors are unwilling to write a prescription for the pill that covers more than six months. Doctors in eastern Europe routinely order all sorts of unnecessary tests before prescribing contraceptives, contravening official medical guidelines.

Cost is often an even bigger deterrent. A Russian woman who wants an IUD has to pay for the device and for the appointment to have it inserted. Abortions in state hospitals, by contrast, are free. Half of the 16 European countries in the IPPF review provide no reimbursement for contraceptives; none fully covers all methods. Even in some countries with generous social welfare systems, including Germany and Italy, women have to pay for contraceptives, no matter how low their income.

This is despite contraception being cheap for governments to provide. England’s National Health Service (NHS) offers every type of contraceptive free to everyone (better-off people must pay part of the cost for other prescriptions). Its buying power means it can pay less than £10 ($12.50) for a year’s supply of the pill and just £18 for an IUD that prevents pregnancy for five years. England has one of the world’s highest rates of contraceptive use.

Contraception also offers an excellent return on public investment. An abortion costs the NHS 13 times the amount it spends on the average contraceptive user per year. The Copenhagen Consensus, a think-tank, estimates that making contraception and sexual-health advice universally available would bring returns worth $120 for every $1 spent, mostly by reducing deaths in pregnancy and childbirth in poor countries.

Many miles to go

Even in England, with its well-run sexual-health clinics and policy of providing contraceptives free, about a fifth of pregnancies end in abortion. And a third of women who have abortions have had at least one before. It cannot be abolished, no matter how enlightened a government’s policy. But the English have more-or-less the right attitude. A high abortion rate is best viewed as a public-health problem that can be cheaply addressed—not through pointless bans or restrictions, but by providing the means to avoid unwanted pregnancies in the first place.