Increasing Contraception Reduces Abortion

Complex relationship between contraception and induced abortion grows clearer.

Network: 2002, Vol. 21, No. 4

Copyright Family Health International, 2002. 
Network is reprinted with permission from Family Health International.

Recent studies offer strong evidence of a widely supposed but difficult-to-demonstrate benefit of reproductive health services: that increasing the use of effective contraception leads to declines in induced abortion rates.

"It is something people have assumed all along, but it is very hard, for a number of reasons, to show that increasing contraception reduces abortion," says Dr. Julie DaVanzo, director of the U.S.-based RAND’s Population Matters Project and a coauthor of studies on the relationship between family planning and abortion in Bangladesh and Russia.

Dr. DaVanzo notes that this challenge is becoming easier with the availability of more accurate, reliable data, including data from a number of countries on trends in contraceptive use and abortion during the 1990s.

The most striking examples of declines in abortion associated with increased use of effective contraception are found in the states of the former Soviet Union and Eastern and Central Europe, where abortion rates dropped by 25 percent to 50 percent during the past decade.¹ Strong data linking lower abortion rates with better access to high-quality family planning services and greater contraceptive use come from a study in Bangladesh that is one of the few to address the question through an experimental design.²

The results of such studies can help dispel misconceptions about the relationship between family planning and abortion. They can also help policy-makers, program managers, and providers identify ways to improve reproductive health services.

Demonstrating that increased contraceptive use leads to fewer abortions is particularly important in countries where unsafe abortion poses a serious threat to women’s health and survival. Unsafe abortion claims the lives of almost 80,000 women every year. It causes 13 percent of all maternal mortality worldwide and as much as 60 percent of maternal deaths in some countries.³ Life-threatening complications occur in about a third of women undergoing an unsafe abortion.⁴

Although about half of all women with abortion complications do not seek care at a hospital, treating abortion complications still severely drains the limited resources of many hospitals. Some hospitals in developing countries spend one-third of their budgets treating the effects of unsafe abortions.⁵

A complex relationship

That increased contraceptive use reduces abortion by helping women avoid unplanned pregnancy may seem obvious. However, in some countries, contraceptive prevalence and abortion rates have risen together when access to effective contraception failed to keep pace with a growing desire for smaller families, leading some to conclude that family planning increases abortion.

Global and Regional Mortality due to Unsafe Abortion, 1995-2000

Click to view a full-size version of the chart.

Researchers have struggled for years to explain the complex relationship between contraception and abortion. The most basic limitation to such research is the scarcity and poor quality of most abortion data. Many women are reluctant to admit that they have had an abortion, particularly in countries where they could face severe legal sanctions. Even in countries where abortion is legal, women may seek abortions outside the public health system, where they are more confidential or convenient. Other factors that make it difficult to interpret the relationship between contraception and abortion include the lack of reliable information in many countries about contraceptive use among unmarried, sexually active women and about method failure and incorrect use among all users.⁶

Comparisons of abortion rates in many countries, however, suggest that increases in contraceptive prevalence are associated with reductions in abortions. The world’s lowest abortion rates are recorded in Belgium and the Netherlands, where contraception is used extensively, while the highest rates are found in Cuba and Vietnam, where clients have access to a limited range of contraceptive methods.⁷

An analysis of data from 11 countries with reliable information and similar fertility rates (1.7 to 2.2 children per woman) for a number of years showed the expected inverse relationship between use of modern contraception and abortion. Abortion rates were 10 to 30 abortions per 1,000 women of reproductive age when the prevalence of modern method use was about 70 percent, but they rose to 30 to 50 per 1,000 when the proportion of women using modern methods was only 40 percent to 60 percent.⁸

The dramatic impact of a reduction in contraceptive use on abortion is illustrated by the reaction to reports in two European countries about possible adverse effects of oral contraceptives. After two such studies published in the journal The Lancet in October 1983 received extensive media coverage, the number of oral contraceptives prescribed by pharmacists in England and Wales fell by 14 percent from November to December that year, and the number of abortions reported in the first quarter of 1984 rose markedly.⁹ A similar "pill scare" in Norway resulted in a 17 percent drop in the use of oral contraceptives over two months and an interruption of the country’s steady decline in abortion rates among women younger than 25. In fact, the abortion rate among young women increased by 36 percent during the following quarter.¹⁰

A few studies have demonstrated, through a rigorous experimental design that controls for improvements in reproductive health services, a relationship between reduced abortion and increased contraception. A recent study in Bangladesh analyzed the effect of high-quality family planning services on abortion.¹¹ Also, researchers in Chile conducted an experimental study in three low-income communities to test whether increasing contraceptive use among women at high risk of abortion reduces the incidence of abortion. After 18 months, contraceptive prevalence had increased in the two Santiago communities with enhanced family planning services and had decreased in a similar community that had received no additional family planning staff or supplies. Abortion rates dropped in all three communities, but the larger declines in the two intervention sites were statistically significant.¹²

 

Relationship between IUD Use and Abortion Rate in Shanghai

Click to view a full-size version of the chart.

Experimental studies such as the ones in Chile and Bangladesh are expensive, time-consuming, and therefore rare. Instead, some researchers have developed analytical models to quantify the relationship between contraception and abortion. A simulation analysis in Turkey showed that a shift from the use of traditional to modern methods of contraception, a decrease in the traditional method failure rate, and a reduction of abortions of pregnancies that resulted from method failures accounted for 87 percent of the decline in abortion there from 1993 to 1998.¹³

Another analytical model applied to data from the 1995 Demographic and Health Surveys (DHS) in Kazakhstan estimated that if contraceptive prevalence rose by 10 percent, the general abortion rate would drop by 13 percent — a scenario that matched the actual estimates from the 1999 DHS in Kazakhstan.¹⁴

Rapid declines in abortion rates in Kazakhstan and other countries where most women are likely to report abortions accurately have created new opportunities to study trends in contraception and abortion. As a result, notes Dr. Charles Westoff, author of a recent DHS study on contraception and abortion in Kazakhstan,¹⁵ "the laboratory for examining this correlation between contraceptive prevalence and abortion rates is that part of the world that was formerly the Soviet Union, where abortion was the principal method of birth control and does not have the stigma that it does in other countries."

Patterns of change

Demonstrating that contraception reduces abortion is primarily a matter of timing, Dr. Westoff notes. "It depends on when in the fertility transition you catch it," he says, citing as an example South Korea, where contraceptive prevalence and abortion rates rose together during the 1970s.

From 1970 to 1996, total fertility in South Korea dropped from 4.5 to 1.8 births per woman, and contraceptive prevalence rose from 25 percent to 79 percent. After peaking at 64 abortions per 1,000 women in 1981, South Korea’s general abortion rate had fallen to 20 per 1,000 by 1996.¹⁶

That pattern is typical of most countries as they make the transition to smaller families, particularly when desired family size declines quickly. This creates a sudden new demand for contraception that family planning programs are initially unable to meet. A rising number of women experience unplanned pregnancies, some of which they abort, increasing abortion rates. As access to family planning services improves, however, so does contraceptive prevalence. Consequently, abortion rates eventually decrease.

Abortion Trends in Hungary

Click to view a full-size version of the chart.

However, the rate at which contraception replaces abortion varies among and within countries. In Hungary, for example, the abortion rate began to fall shortly after an increase in contraceptive prevalence began in the mid-1960s.¹⁷ A study in three Latin American countries found regional differences in abortion trends, with rates increasing from the mid-1970s into the early 1990s in most of Brazil and Mexico but decreasing substantially in the largest metropolitan areas of Colombia and Mexico as contraceptive use stabilized or increased.¹⁸

Cultural and socioeconomic differences can explain some of these variations. Uneven access to contraceptives also seems to have contributed to the regional variations in Latin America. Other factors that influence the rate of abortion decline include the disparity between actual and desired family size and the extent to which women were relying on abortion to limit childbearing before the introduction of family planning programs. During Latin America’s fertility transition, abortion rates in many areas rose or were already high, despite laws restricting or prohibiting abortion. Contraceptive prevalence is increasing in the region, but the decline in abortion rates has been relatively slow as access to contraceptives and other reproductive health services gradually improves.¹⁹

Contraceptive effectiveness also influences the rate at which contraception replaces abortion, as illustrated by the findings from Turkey and another study in Shanghai, China, where many women initially use relatively ineffective methods such as withdrawal, periodic abstinence, or condoms after the birth of a first child but often switch to intrauterine devices (IUDs). In this study, the proportion of women using IUDs rose from 40 percent in the first postnatal year to 75 percent in the fifth postnatal year, while the abortion rate dropped from 20 abortions per 1,000 months of exposure to risk of pregnancy to almost zero.²⁰

Preventing abortion

Studies on trends in contraception and abortion can point to ways of improving reproductive health services. For example, the finding that abortion decreased in Turkey because of better traditional method use and a shift to modern contraception — rather than an increase in contraceptive prevalence — illustrates the importance of improving clients’ use of contraceptives through provider training and quality of service. The Turkish reproductive health program has also emphasized family planning counseling and services for women who have undergone abortions to break the cycle of repeat abortions.²¹

Likewise, surveys in two Russian cities found that abortion rates dipped from 1996 to 1999 while already high rates of contraceptive prevalence did not change.²² In these cities, further reductions in abortion may best be achieved by ensuring access to contraceptives appropriate to women’s needs, including more long-term methods in the method mix, and counseling women in effective and consistent use of their chosen methods.²³

Studies in Japan, Cuba, and South Korea have found increasing or higher rates of abortion among women younger than 25 years, leading to recommendations on ways to better meet the reproductive health needs of young women and adolescents.²⁴

A better understanding of the relationship between contraception and abortion can help policy-makers, program managers, and providers identify the points at which intervention could have averted deaths and disability from abortion complications, says Dr. Oladapo Shittu, head of obstetrics and gynecology at Ahmadu Bello University Teaching Hospital in Zaria, Nigeria, who has advised many reproductive health programs in Africa and has helped lead efforts to improve postabortion care in Nigeria.

Women who survive unsafe abortions often suffer complications that affect their health, livelihoods, and social status for the rest of their lives, notes Dr. Shittu. Some long-term complications — including chronic pelvic pain, pelvic inflammatory disease, and infertility — can be physically incapacitating or emotionally devastating to women in societies where their status depends on the ability to bear children.

Many women hospitalized for abortion complications are adolescents. In Kenya and Nigeria, more than half of women with the most serious complications are younger than 20 years old. This is because young women are more likely than older women to delay an abortion, obtain an abortion from an unskilled provider, use dangerous procedures, and delay seeking care when complications arise.²⁵

"Society needs to be enlightened on how these unsafe abortion problems arise, to make the linkages between a woman or a girl dying or suffering abortion complications and all the factors that lead to death or complications," Dr. Shittu says.

— Kathleen Henry Shears

References

1. Henshaw SK, Singh S, Haas T. Recent trends in abortion rates worldwide. Int Fam Plan Perspect 1999;25(1):44-48.
2. Rahman M, DaVanzo J, Razzaque A. Do better family planning services reduce abortion in Bangladesh? Lancet 2001;358(9287):1051-56.
3. World Health Organization. Unsafe Abortion. Global and Regional Estimates of Incidence of and Mortality Due to Unsafe Abortion, with a Listing of Available Country Data. Geneva: World Health Organization, 1998.
4. Alan Guttmacher Institute. Sharing Responsibility: Women, Society and Abortion Worldwide. New York: Alan Guttmacher Institute, 1999.
5. Alan Guttmacher Institute.
6. Singh S, Sedgh G. The relationship of abortion to trends in contraception and fertility in Brazil, Colombia and Mexico. Int Fam Plan Perspect 1997;23(1):4-14; Senlet P, Curtis SL, Mathis J, et al. The role of changes in contraceptive use in the decline of induced abortion in Turkey. Stud Fam Plan 2001;32(1):41-52.
7. Henshaw SK, Singh S, Haas T. The incidence of abortion worldwide. Int Fam Plan Perspect 1999;25(suppl.):S30-S38.
8. Marston C, Cleland J. Relationships between contraception and abortion: review of the evidence. Unpublished paper. Centre for Population Studies, London School of Hygiene and Tropical Medicine, 2002.
9. Wellings K. Help or hype: an analysis of media coverage of the 1983 "Pill scare." Br J Fam Plan 1985;11(3):92-98.
10. Skjeldestad FE. Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third-generation oral contraceptives. Contraception 1997;55(1):11-14.
11. Rahman.
12. Molina R, Pereda C, Cumsille F, et al. Prevention of pregnancy in high-risk women: community intervention in Chile. In Mundingo A, Indriso C, eds. Abortion in the Developing World. London: Zed Books, 1999.
13. Senlet.
14. Westoff C. The Substitution of Contraception for Abortion in Kazakhstan in the 1990s. DHS Analytical Studies No. 1. Calverton, Maryland: ORC Macro, 2000.
15. Westoff.
16. Henshaw, 1999;25(1).
17. Alan Guttmacher Institute. The Role of Contraception in Reducing Abortion. New York: Alan Guttmacher Institute, 1997. Available: http://www.agi-usa.org/pubs/ib19.html.
18. Singh.
19. Alan Guttmacher Institute, 1997.
20. Marston.
21. Senlet.
22. Russian Centre for Public Opinion and Market Research, U.S. Centers for Disease Control and Prevention, U.S. Agency for International Development. 1999 Russia Women’s Reproductive Health Survey: A Follow-up of 3 Sites. Preliminary Report. Atlanta, GA: Centers for Disease Control and Prevention, 2000.
23. Russian Centre for Public Opinion and Market Research, U.S. Centers for Disease Control and Prevention, U.S. Agency for International Development. 1996 Russia Women’s Reproductive Health Survey: A Study of Three Sites. Final Report. Atlanta, GA: Centers for Disease Control and Prevention, 1998.
24. Goto A, Fujiyama-Koriyama F, Fukao A, et al. Abortion trends in Japan, 1975-95. Stud Fam Plan 2000;31(4):301-8; Noble J, Potts M. The fertility transition in Cuba and the Federal Republic of Korea: the impact of organised family planning. J Bio Sci 1996;28(2):211-25.
25. Ipas. Children, Youth and Unsafe Abortion. Chapel Hill, NC: Ipas, 2001. Available: http://ww.ipas.org/english/publications/children_youth_unsafe_abortions.pdf 

A Culture of Abortion?

For most of the history of the Soviet Union, women relied primarily on induced abortion to control their fertility. Even today, though the use of contraception has increased markedly in the former Soviet Union, the region has one of the highest abortion rates in the world. Many believed that the Soviet "culture of abortion" was so ingrained that abortion rates would be slow to decline, regardless of the availability of contraceptives. The experience of most of the former socialist states in Eastern and Central Europe and Central Asia during the past decade suggests otherwise. Abortion was legalized in the Soviet Union in 1920, long before modern methods of contraception became widely available, to reduce the high number of maternal deaths associated with illegal abortions. Even when modern contraceptives became available some 50 years later, rates of induced abortion remained high because of the poor quality of Soviet-made contraceptives, erratic supplies, fears about the health effects of hormonal contraceptives, and opposition by government authorities and medical professionals to contraceptive use.1 All this began to change in the tumultuous period before and after the dissolution of the Soviet Union in 1991. "Because of changes in the government and the ability of international donors to start playing a role, contraception suddenly became much more available," says Dr. Julie DaVanzo, director of the U.S.-based RAND’s Population Matters Project and coauthor of a study on Russian population trends. About 70 percent of Russian pregnancies still end in abortion, and more than three in four Russian women who have ever been pregnant have had an abortion. But since the late 1980s, modern contraceptives have been the main method of controlling fertility. As the use of modern contraceptives roughly doubled in Russia from 1988 to 1997, abortion rates were cut in half. Since 1994, the number of abortions has dropped more sharply than the number of births, suggesting that women have been increasingly successful in preventing unplanned pregnancies.2 Experts familiar with the data caution that it may overstate the magnitude of abortion declines in Russia and other former Soviet republics.3 "Ministry of Health data are beginning to deteriorate rapidly in these countries because of the emergence of a private sector of mini-abortions that do not get reported to the government," explains Princeton University demographer Dr. Charles Westoff. "So you get the impression of an abortion rate that is declining more rapidly than it actually is." Few dispute, however, that abortion rates in these countries are going down. In the former republics where local experts believe that reporting is reasonably complete — Belarus, Estonia, Kazakhstan, and Latvia — abortion rates dropped by 28 percent to 47 percent from 1991 to 1996.4 "Kazakhstan is a pretty convincing case that family planning reduces abortion," says Dr. Westoff, who has analyzed survey results from that country and two other Central Asian republics. Dr. Westoff’s analysis of data from the 1999 Demographic Health Surveys in Kazakhstan showed that contraceptive prevalence rose by about 50 percent and abortion rates fell by the same proportion during the 1990s, when Kazakhstan was experiencing a rapid decline in fertility. From 1991 to 1998, the proportion of women using modern contraception increased from 26 percent to 39 percent and the general abortion rate dropped from 76 to 41 abortions per 1,000 women.5 Contraception and Abortion Trends in Kazakhstan, 1991-1998 Click to view a full-size version of the chart. Increases in contraceptive prevalence in the former Soviet republics have been attributed to greater availability of contraceptive services and supplies, primarily through the private sector and nongovernmental organizations.6 Support from international donors, such as the United Nations Population Fund and the U.S. Agency for International Development (USAID), has also been important.7 Since 1996, USAID has invested in a project in Russia to expand access to effective contraception and to reduce abortion.8 Results from reproductive health surveys conducted by the All-Russian Centre for Public Opinion and Market Research in 1996 and 1999 found reductions in abortion in two sites (the province of Ivanovo and the city of Yekaterinburg) that were included in the USAID-funded Reproductive Health Project in Russia, and no change in abortion rates in a third city, Perm, where standard government and private reproductive health services were available.9 Findings from these and other surveys conducted in former Soviet republics with technical assistance from the U.S. Centers for Disease Control and Prevention (CDC) also cast doubt on the theory of a deeply entrenched "culture of abortion." "We have found anywhere from 95 percent to 97 percent of women saying that they dislike abortion as a method of family planning," says Dr. Howard Goldberg, assistant director for global health in the CDC’s Division of Reproductive Health. Likewise, the assumption that many Russian providers prefer performing abortions to family planning counseling because abortions are more profitable has been overstated, says FHI senior research associate Dr. Vera Grigorieva, who trained hundreds of obstetrician-gynecologists, nurses, and midwives in family planning as an obstetrician-gynecologist at the Family Planning Center of the Ott Institute for Obstetrics and Gynecology in St. Petersburg, Russia. Financial incentives to perform abortion "may indeed limit some providers’ desire to facilitate access to contraceptive alternatives," says Dr. Grigorieva. However, she believes the main reason many Russian providers have failed to encourage contraceptive use is their lack of knowledge and training in reproductive health. "Most of them do not like performing abortions," Dr. Grigorieva says of the Russian providers she trained. "They accept new information positively and are eager to learn about preventive options." — Kathleen Henry Shears References Popov AA, David HP. Russian Federation and USSR successor states. In David HP, ed. From Abortion to Contraception. (Westport, Connecticut: Greenwood Press, 1999) 223-77; DaVanzo J, Grammich C. Dire Demographics: Population Trends in the Russian Federation. Santa Monica, California: RAND, 2001. DaVanzo. Popov; Henshaw SK, Singh S, Haas T. Recent trends in abortion rates worldwide. Int Fam Plann Perspect 1999;25(1):44-48. Henshaw. Westoff C. The Substitution of Contraception for Abortion in Kazakhstan in the 1990s. DHS Analytical Studies No. 1. Calverton, Maryland: ORC Macro, 2000. Popov A. Family planning in Russia in 1993-94: the role of NGOs in demonopolising population policy. Planned Parenthood in Europe 1995;24(2):26-30. Westoff. DaVanzo. Russian Centre for Public Opinion and Market Research, U.S. Centers for Disease Control and Prevention, U. S. Agency for International Development. 1999 Russia Women’s Reproductive Health Survey: A Follow-up of 3 Sites. Preliminary Report. Atlanta, GA: Centers for Disease Control and Prevention, 2000.

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