Sunday, July 7, 2013

Increased Access to Health Care May Decrease Abortions

By Brian Fung

The number of abortions in Massachusetts has decreased despite predictions that health-care reform would have the opposite effect. Can the health insurance expansions part of Obamacare do the same nationally?

Kevin Lamarque/Reuters

President Clinton once famously remarked that abortion should be safe, legal, and rare. The unspoken challenge to him since then has always been, but how do we agree on a path that gets us there? As the controversy over Missouri Rep. Todd Akin continues to burn, it seems we won't have a resolution to our national abortion debate any time soon.

From Massachusetts, though, comes growing evidence that the quest for lower abortion rates may not be at a standstill -- and the key may be better insurance coverage. As the number of insured has gone up in Massachusetts, new state data show a corresponding decline in the number of abortions performed there since 2006.

Massachusetts, of course, is known nationally as the state that launched an ambitious project to insure almost all of its residents -- a proposal that helped give rise to President Obama's own health-care law. Census statistics reveal that in the three years before Governor Mitt Romney enacted the program in 2006, 10.7 percent of state residents lacked health insurance, on average. That three-year average was nearly halved after Romneycare took effect. From 2008 to 2010, Massachusetts boasted the best uninsured rate in the nation: just 5 percent, on average.

Meanwhile, as more people were benefiting from expanded coverage, the abortion rate was quietly coming down. Many states keep detailed records on all the legal abortions they perform, and Massachusetts is no different. According to data from the Department of Public Health and the U.S. Census Bureau, from 2006 to 2008 the annual abortion rate in Massachusetts fell from 3.8 per 1,000 state residents to 3.6 per 1,000. The findings, first reported in 2010 by Harvard rheumatologist Dr. Patrick Whelan, contradicted some forecasts that better coverage would simply drive up the abortion rate rather than bringing it down.

Not only were these predictions proven false in the first couple years of Romneycare -- they grew even more wrong with time. Whelan's study couldn't have predicted this, since it didn't have the data to hand, but the drop in abortion rates has accelerated even more in 2010 and 2011:

And that's just the statewide abortion rate. Drill down to specific demographics, and the improvements are in places even more pronounced. Among pregnant teens, for example, abortions fell by nearly 7.5 percent from 2006 to 2008. By 2011, they were down by more than 21 percent.

Now, for a quick reality check: it's possible that the decline in the abortion rate had nothing to do with Romneycare. In fact, Massachusetts has generally performed fewer abortions every year than the year before it going back to 1991. In the 17 years between then and 2008, Massachusetts' abortion rate fell by more than a third, indicating a long-term trend that may have as much to do with politics or culture as it might with Romney's health-care policy. Distinguishing cause from correlation here is next to impossible without writing a book about it.

That said, scientists think the latest drop in abortion rates is at least partly tied to a couple recent factors. According to Danielle Bessett, a sociologist at the University of Cincinnati who has studied small samples of low-income Massachusetts residents, patients who became eligible for state-subsidized insurance under Romneycare were "delighted" at the prospect of improved access to contraception. People no longer have to rely on condoms alone. Now they can get birth control pills or shots if they prefer. (Of course, conservatives argue that contraception does nothing to reduce abortions; rather than hash out that discussion here, I'll direct you to Conor Friedersdorf.)

Whelan, the Harvard specialist who pointed out the abortion pattern in 2010, thinks that better access to contraception -- and the concomitant decline of abortion -- is the byproduct of broader improvements in public health brought on by Romneycare.

"When women have more stable access to medical care, they're more likely to see doctors, they're more likely to have somebody inquiring about their sexual health," Whelan told me in a phone interview. "The fact that you have somebody who cares about you results in people being healthier, and that includes not getting pregnant if they don't want to be."

Massachusetts is just one state. Luckily, we're soon going to be able to replicate this experiment on a much larger scale, thanks to the Affordable Care Act. If expanded health insurance coverage can put a lid on abortion rates, then states like Texas, New Mexico, and Florida that lead the nation in terms of the rate of uninsured should also see some improvements in their abortion rates as health coverage grows. Keep your eyes peeled.

This article available online at:

http://www.theatlantic.com/health/archive/2012/08/increased-access-to-health-care-may-decrease-abortions/261463/

Contraceptive Use Is Key to Reducing Abortion Worldwide

The Guttmacher Report on Public Policy

October 2003, Volume 6, Number 4

Special Analysis

Contraceptive Use Is Key to Reducing Abortion Worldwide

By Amy Deschner and Susan A. Cohen

In countries around the world, women who are determined to limit their family size and time their childbearing will use all available means to do so; if contraception is not a viable option, women will turn to abortion—even if it is illegal. Extensive evidence demonstrates, however, that when modern contraceptives are made available to women, their increased use over time replaces previous reliance on abortion and becomes the major factor associated with reduced abortion rates. Policymakers seeking to reduce the incidence of abortion would do well to address its root cause—unintended pregnancy—by facilitating widespread access to modern contraceptives and by promoting their effective use.

This past summer, the government of Russia issued new regulations restricting the availability of legal abortions in response to the country's high abortion rate. Indeed, Russia's abortion rate is among the world's highest, although it is less than half of what it was little more than a decade ago. Between then and now, while the incidence of abortion was dropping, there was no change in the legal status of abortion. Rather, as modern contraceptives became available in the early 1990s, contraceptive use among Russian women increased sharply.

It is ironic that Russian policymakers are now leaping to a legal fix to reduce the abortion rate, considering that large numbers of Russian women have already stopped relying on abortion for birth control and, instead, have begun practicing contraception. The Russian response, however, may be just the latest example of an apparently universal political reflex: use restrictive laws to drive down the incidence of abortion rather than address its underlying cause.

Abortion Legality and Incidence

Throughout history, abortion's legal status has rarely been a reliable predictor of whether and the extent to which it occurs. Before abortion became legal throughout the United States in 1973, an estimated 200,000-1.2 million procedures occurred annually ("Lessons from Before Roe: Will Past Be Prologue?" TGR,March 2003, page 8). But it is not necessary to look back into U.S. history to discover that legal restrictions have little impact on whether women have abortions. Today, in countries around the world, large numbers of women have abortions even where the procedure is illicit and often unsafe.

Abortion is prohibited in almost all circumstances in Chile and Peru, for example, yet clandestine abortion is common. Indeed, illegal abortion in these countries is estimated to occur more than twice as often as legal abortion does in the United States (see table). And the story is similar in other Latin American countries and elsewhere. In Nigeria and the Philippines, abortion is banned, and strong conservative religious and cultural traditions would seem to militate against women resorting to abortion. Yet, the abortion rate in both countries is estimated to be 25 per 1,000 women of reproductive age—slightly higher than the U.S. rate.

ABORTION LAWS AND RATES
Country	Abortion rate per 1,000 women, 15-44
Where abortion Is Broadly Permitted
Belgium, 1996*	7
England/Wales, 1996	16
Finland, 1996	10
Germany, 1996	8
Netherlands, 1996	7
United States, 1996/2000†	23/21
Where Abortion Is Severely Restricted
Brazil, 1991	41
Chile, 1990	50
Colombia, 1989	36
Dominican Republic, 1990	47
Mexico, 1990	25
Nigeria, 1996	25
Peru, 1989	56
Philippines, 1994	25
Includes abortions obtained in the Netherlands. †Finer LB and Henshaw SK, Abortion incidence and services in the United States in 2000, Perspectives on Sexual and Reproductive Health,* 2003, 35(1): 6-15. Source: Henshaw SK, Singh S and Haas T, The incidence of abortion worldwide, International Family Planning Perspectives, 1999, 25(Supplement):S30-38.

Just as the data show that women have abortions despite restrictive laws, they also indicate that women do not have abortions because of liberal ones. Some of the world's lowest abortion rates are in western European countries, where abortion is not only legal but also covered as a standard service by national health insurance systems: For example, the abortion rate in Germany is less than one-quarter that in Columbia, and the rate in the Netherlands is some six times lower than the rate in the Dominican Republic.

The Case for Contraception

The trend toward women wanting and having smaller families, and trying to time their children's births, is nearly universal. For decades, women in the United States, like those in many European countries, typically have wanted no more than two children, whereas in Latin America, Asia, the Middle East and North Africa, women now generally want 2-3 children. Large families are still desired in Sub-Saharan Africa, 5-6 children on average, but even there, women want smaller families than their mothers and grandmothers did.

In societies in which the desire for smaller families is strong, women will use every available resource and method to control their fertility. In the case of Russia and many other eastern European countries—where small families have long been the norm but modern contraceptives have mostly not been available—abortion rates historically have been among the world's highest. (Until quite recently, the contraceptive options available to Russians were largely low-quality condoms and one-size-fits-all diaphragms.) Russia legalized abortion in 1955 in response to the public health problem of illegal procedures. At that time, it was not uncommon for a woman wanting only two children to have 10 or more abortions in her lifetime, and as late as 1990, Russia's abortion rate was well over 100 per 1,000 women of reproductive age.

The situation began to change in the late 1980s, when free market reforms opened the door to modern contraceptives made in western Europe. Then in 1992, the Russian government, which had always subsidized abortion services, began subsidizing family planning programs and promoting contraceptive use by distributing free contraceptives. The results have been dramatic: In the ensuing decade, contraceptive use rose and the abortion rate plummeted (see chart).

Dramatic Results

Between 1988 and 2001, modern contraceptive use increased in Russia by 74%, while the abortion rate declined by 61%.

Source: Westoff C, unpublished data, 2003.

Recent policy changes threaten this emerging success story, however. Antiabortion and anti-family planning sentiment has been growing among the country's policymakers amidst pressure from the Russian Orthodox Church and deepening social anxiety over an impending "birth dearth." (Some experts predict that rising death rates and low birthrates could shrink Russia's population by about one-third over the next 50 years.) The government ceased its support for contraceptive programs in 1997, and the abortion restrictions implemented this August sharply limit women's access to abortions after the first trimester by eliminating two-thirds of the "social" conditions previously justifying second-trimester procedures.

Although the impact of these policy changes remains to be seen, making later abortions harder to obtain is not likely to affect the country's birthrate. (Russian women say more favorable economic conditions will help that situation, according to a recent story in the Los Angeles Times.) Nor will it have much impact on the abortion rate, as more than 90% of all abortions in Russia take place in the first trimester. On the other hand, a leading antiabortion parliamentarian was quoted in the Times as declaring that the second-trimester restrictions are "only the first step."

Meanwhile, despite being cut off by the central government, many Russian family planning clinics continue to subsist on local funding. Tellingly, according to a recent report on CNN's Web site, while abortion rates continue to decline throughout Russia, they are dropping more rapidly where clinics remain. For example, in the region of Dubna, where clinics are still active, the abortion rate is only about half the national average. Vladimir Serov, deputy director of Moscow's Scientific Center for Obstetrics, Gynecology and Perinatology, believes that the government's lack of support for contraceptive services deserves much of the blame for why abortion is still so prevalent in Russia. "Restrictions [on abortion] are useless," asserts Serov. "We need to promote a healthy way of life and family planning."

Time, Method Mix and Quality of Care

In many countries, the shift from relying on abortion to more widespread contraceptive practice is neither as abrupt nor as dramatic as it was in Russia. Although the end result is almost always the same, the patterns can vary depending on many factors, including whether overall desired family size is still dropping or has already stabilized, how much women had been using abortion to control their fertility prior to the introduction of contraception, and the availability and accessibility of modern versus traditional methods.

South Korea, for example, experienced a dramatic decrease in desired family size beginning in the 1960s, and the average number of children per woman fell by more than half over a 20-year period. During most of this period, abortion and contraceptive prevalence rates rose simultaneously as women's motivation for small families intensified. Eventually, as the country's total fertility rate began to stabilize, the abortion rate stabilized and then began to fall, while contraceptive use continued to increase (see chart).

It Takes Time

Initially, rapid fertility decline in South Korea was accompanied by increases in both contraceptive use and abortion; over time, abortion rates turned downward while contraceptive use continued to climb.

Note: Abortion rates are expressed per 1,000 women of reproductive age, contraceptive prevalence per 100 married women of reproductive age and TFRs per 10 women. Source:Marston C and Cleland J, Relationships between contraception and abortion: a review of the evidence, International Family Planning Perspectives, 2003, 29(1):6-13.

Abortion rates in South Korea took so long to start their decline in large part because of women's continued reliance on less effective, traditional contraceptive methods. Above and beyond an overall increase in contraceptive use, a shift from traditional methods, such as withdrawal, to more effective, modern methods can have a significant impact on a country's abortion rate.

This can be seen in Turkey, where abortion rates dropped from 45 to 24 per 1,000 married women between 1988 and 1998, while overall contraceptive use rates remained essentially the same. According to an analysis by Pinar Senlet and colleagues published in the March 2001 issue of Studies in Family Planning,use of modern contraceptives in Turkey increased during that time, while use of traditional methods decreased. Between 1993 and 1998, the shift to modern method use was most pronounced among women in their peak reproductive years (25-39), the same age-group which had the most pronounced decline in abortion rate.

Senlet and colleagues conclude, "Marked reductions in the number of abortions have been achieved in Turkey through improved contraceptive use rather than increased use." Given that withdrawal is still the method of contraception most commonly practiced by Turkish women and that almost half of all abortions in Turkey are preceded by the failure or discontinuation of a traditional method, the authors suggest that "shifts in the method mix toward more effective methods and more effective use of methods have considerable potential to reduce abortion levels, even in the absence of increased use."

Meanwhile, a long-term study of the impact of family planning service delivery in the rural Matlab district of Bangladesh demonstrates the important role that quality of care can play in suppressing a country's abortion rate even in a period of rapid transition to smaller family size. Since 1977, the Maternal and Child Health and Family Planning Project (MCH-FP) has been providing family planning services in Matlab, and compared with the standard services provided by government Health and Family Welfare Centres, MCH-FP services are characterized by a broader mix of contraceptive methods, more home visits by family planning workers and more time spent counseling individual women. In 1979, the abortion rate in the MCH-FP area was the same as the rate in the comparison area, but by 1998, the abortion rate in the comparison area was three times higher than the MCH-FP area's rate. This is a direct result of the fact that unintended pregnancy, which declined in both areas, dropped much more where MCH-FP services were available (see chart, page 10).

Quality Counts

In Bangladesh, access to contraceptives reduced un-intended pregnancy both in areas served by MCH-FP clinics and in comparison areas, but rates dropped more sharply where the higher-quality MCH-FP services were available.

Note: MCH-FP=maternal child health and family planning. Source:Rahman M, Davanzo J and Razzaque A, Do family planning services reduce abortion in Bangladesh? The Lancet, 2001, 358(9287):1051-1056.

The authors of the analysis note that during this 20-year period, fertility in Bangladesh dropped dramatically, from about 6.5 to 3.3 births per woman. In addition, they observe that "the remarkable fertility declines that have occurred throughout Bangladesh have been achieved with much less abortion than in other countries with similar fertility declines." In large part, they credit "the political priority that the Bangladesh government has placed on fertility reduction and family planning services," stating that even in the comparison area, "it is very likely that abortion...would have been higher were it not for the family planning services the government provided."

Implications for the United States

In the United States, small families have been the norm since at least the 1920s, modern contraceptives are widely used and abortion rates—though higher than many countries in western Europe—have declined over the last two decades and fall in the lower-to-moderate range by worldwide standards. Clearly, progress has been made in reducing unintended pregnancy and abortion rates, but there is a distance to go.

Social conservatives argue that more emphasis should be placed on restricting or outlawing abortion and on promoting abstinence for young and unmarried people. Although encouraging and enabling young people to delay the initiation of sexual activity certainly has a role to play in further reducing U.S. unintended pregnancy and abortion rates, abstinence as a method of pregnancy prevention will not work for all young people. Furthermore, it will rarely suffice for almost any individual woman over the course of the 30 or so years of her life during which she could be at risk of unintended pregnancy. As for making abortion illegal, our own history as well as experience from around the world amply demonstrate that if legal restrictions work at all, they do so largely by driving abortion underground—which does not end abortion, but makes it more dangerous for women.

In contrast, the evidence clearly shows that contraceptive use works. On a personal level, it reduces the probability of having an abortion by an estimated 85%. And at the program level, publicly subsidized family planning services in the United States have been shown to have helped women prevent 20 million pregnancies over the last 20 years, nine million of which would have been expected to end in abortion. Indeed, in the United States today, the small fraction of women—some 7%—who are sexually active and at risk of unintended pregnancy but do not practice contraception are responsible for almost half of the unintended pregnancies and nearly half of the abortions.

The overwhelming majority of sexually active women in this country seek to prevent unintended pregnancy by practicing contraception; however, women, their partners and technology are not perfect. Therefore, one of the key challenges in further reducing the abortion rate in the United States (and in many other countries around the world) is to increase contraceptive access across the entire society and to facilitate more consistent and more effective contraceptive use.

Contraception Works—and Publicly Funded Family Planning Programs Are Essential to Reduce Unintended Pregnancy and Abortion

About the Institute

NEWS IN CONTEXT

Contraception Works—and Publicly Funded Family Planning Programs Are Essential to Reduce Unintended Pregnancy and Abortion

March 9, 2011

With tense discussions underway in Congress over publicly funded family planning programs, some long-discredited anticontraception arguments have once again come to the fore. These arguments include claims that contraceptive use is not effective in preventing unintended pregnancy or reducing the abortion rate.

In reality, there is a wealth of evidence demonstrating the obvious: Contraceptive use dramatically reduces unplanned pregnancy. By doing so, it also dramatically reduces abortion, since behind almost every abortion is an unplanned pregnancy.

Guttmacher Institute research shows that the two-thirds of U.S. women at risk of unintended pregnancy who use contraception consistently and correctly throughout the course of any given year account for only 5% of all unintended pregnancies. The 19% of women at risk who use contraception but do so inconsistently account for 44% of all unintended pregnancies, while the 16% of women at risk who do not use contraception at all for a month or more during the year account for 52% of all unintended pregnancies.

It should come as no surprise, then, that most women having abortions were either not using any contraception or were using a method inconsistently. In 2000, the most recent year for which data are available, almost one-half (46%) of abortion patients were not using a contraceptive method in the month they got pregnant. Among the 54% of abortion patients who were using some form of contraception, the overwhelming majority acknowledged that their use was inconsistent, including missing a pill or not using a condom every time. Moreover, this population does not include the large majority of consistent contraceptive users who never became pregnant, and therefore never had a need for abortion services.

The contraceptive method used is also a factor. Users of highly effective methods such as the pill and the IUD are underrepresented among women who have abortions, compared with the general population; users of less effective methods, such as condoms and withdrawal, are overrepresented.

Ensuring that every woman who is sexually active but not seeking pregnancy is able to obtain the contraceptive method that is right for her—meaning the method she will be able to use consistently and correctly—is, therefore, an urgent national priority. In this regard, publicly funded family planning programs such as Title X and Medicaid have a critical role to play, because unintended pregnancy and its consequences, either an abortion or an unplanned birth, are highly concentrated among economically disadvantaged women.

The body of evidence attesting to the effectiveness and cost-effectiveness of publicly funded family planning services is comprehensive and compelling. These services not only improve the health of mothers and babies by helping women time and space their pregnancies, they also prevent almost two million unintended pregnancies each year, which would otherwise result in 860,000 unintended births and 810,000 abortions. Without these services, the number of unintended pregnancies and abortions among poor women in the United States would nearly double, and the number of unintended pregnancies and abortions in the nation as a whole would be nearly two-thirds higher.

That’s why policymakers—including conservatives of all stripes—should strongly support such services. Fiscal conservatives should applaud the fact that, by helping low-income women prevent births they themselves do not want, these services save almost $4 in public expenditures for every $1 invested. Social conservatives should be reassured that without publicly funded family planning services, the U.S. abortion rate would skyrocket. And probusiness conservatives should appreciate the value of enabling women to postpone childbearing while they complete their education, undergo job training or establish themselves in their career.

In short, the message is clear: Contraception works—and consistent, correct use of contraceptives comes close to eliminating the risk of unintended pregnancy. Making contraceptive methods easier to obtain and use is eminently sound public policy. Ultimately, supporting the use of contraceptives reflects the belief that women and their partners—and not politicians or other third parties—know best when the right time is to have children and how many children to have.

Click here for more information on:

The overall impact of publicly funded family planning services

The impact of the Title X family planning program nationally and in each state

Facts on Publicly Funded Contraceptive Services

Testimony to the Institute of Medicine: Contraception as a crucial preventive health service for women

The clear correlation between contraceptive use and lower abortion rates

MEDIA UPDATE

Receive brief summaries of upcoming Guttmacher Institute reports with links to full text and other helpful information on the Guttmacher Web site. When new social and political developments affect sexual and reproductive health and rights, this mailing list will also provide you with links to useful background information and contextual data.

Do better family planning services reduce abortion in Bangladesh?

The Lancet, Volume 358, Issue 9287, Pages 1051 - 1056, 29 September 2001

doi:10.1016/S0140-6736(01)06182-7

Do better family planning services reduce abortion in Bangladesh?

Mizanur Rahman PUD a

, Julie DaVanzo PhD b, Abdur Razzaque PhD c

Summary

Background

Fertility decline is often associated with an increase in contraception and abortion, but the causal relations are difficult to examine with non-experimental data. We aimed to assess the effects of family planning services on abortion rates in two similar areas.

Methods

We examined trends in overall abortion rates and rates for intended and unintended pregnancies in two similar areas typical of rural Bangladesh. We analysed Matlab Demographic Surveillance System (DSS) data on pregnancy outcomes between 1979 and 1998 in these areas, matching them to survey data on fertility preferences, which enabled us to identify pregnancies as intended or unintended.

Findings

Abortion rates were significantly lower in the area with better family planning services compared with the comparison area (1984—86, 2·2 vs 5·2; 1996—98, 2·3 vs 6·8). Abortion of unintended pregnancies is similar in both areas, but the higher levels of contraceptive use in the treatment area have led to lower levels of unintended pregnancy and abortion. The likelihood that an unintended pregnancy will be aborted has increased in both areas but the decrease in unintended pregnancies was sufficiently large in the treatment area to offset this increase.

Interpretations

Abortion may increase during the fertility transition in less-developed countries as the desire to limit family size increases unless there is widespread availability of quality family planning services.

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a Pathfinder International, 9 Galen St, Ste 217, Watertown, MA 02472, USA

b RAND, 1700 Main St, Santa Monica, CA 90401, USA

c ICDDR, B Centre for Health and Population Research, GPO Box 128, Dhaka 1000, Bangladesh

Correspondence to: Dr Mizanur Rahman

Relationships Between Contraception and Abortion: A Review of the Evidence

International Family Planning Perspectives

Volume 29, Number 1, March 2003

Relationships Between Contraception and Abortion: A Review of the Evidence

By Cicely Marston and John Cleland

CONTEXT: The relationship between levels of contraceptive use and the incidence of induced abortion continues to provoke heated discussion, with some observers arguing that use of abortion decreases as contraceptive prevalence rises and others claiming that increased use of family planning methods causes abortion incidence to rise.

METHODS: Abortion trends are examined in countries with reliable data on abortion and with contraceptive prevalence information from two points in time showing increases in contraceptive use. The role of changes in fertility in mediating the relationship between abortion and contraception is also explored.

RESULTS: In seven countries—Kazakhstan, Kyrgyz Republic, Uzbekistan, Bulgaria, Turkey, Tunisia and Switzerland—abortion incidence declined as prevalence of modern contraceptive use rose. In six others—Cuba, Denmark, Netherlands, the United States, Singapore and the Republic of Korea—levels of abortion and contraceptive use rose simultaneously. In all six of these countries, however, overall levels of fertility were falling during the period studied. After fertility levels stabilized in several of the countries that had shown simultaneous rises in contraception and abortion, contraceptive use continued to increase and abortion rates fell. The most clear-cut example of this trend is the Republic of Korea.

CONCLUSIONS: Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly.

International Family Planning Perspectives, 2003, 29(1):6-13

Common sense and an elementary understanding of the biological determinants of human reproduction indicate that contraception and induced abortion represent alternative means of achieving the same aggregate level of fertility in a population. If fertility and its other determinants (sexual exposure, lactation and pathological infertility, for example) remain constant, a rise in contraceptive use or in effectiveness of use must lead to a decline in induced abortion and vice versa.

Why, then, does the relationship between levels of contraceptive use and the incidence of induced abortion continue to provoke heated discussion?* And why do some observers claim that increased contraceptive use leads to higher abortion rates?¹

The reason for the confusion stems from the observation that, within particular populations, contraceptive prevalence and the incidence of induced abortion can and, indeed, often do rise in parallel, contrary to what one would expect. The explanation for these counterintuitive trends is clear.² In societies that have not yet entered the fertility transition, both actual fertility and desired family sizes are high (or, to put it another way, childbearing is not yet considered to be "within the calculus of conscious choice"³). In such societies, couples are at little (or no) risk of unwanted pregnancies. The advent of modern contraception is associated with a destabilization of high (or "fatalistic") fertility preferences. Thus, as contraceptive prevalence rises and fertility starts to fall, an increasing proportion of couples want no more children (or want an appreciable delay before the next child), and exposure to the risk of unintended pregnancy also increases as a result. In the early and middle phases of fertility transition, adoption and sustained use of effective methods of contraception by couples who wish to postpone or limit childbearing is still far from universal. Hence, the growing need for contraception may outstrip use itself;⁴ thus, the incidence of unintended and unwanted pregnancies rises, fueling increases in unwanted live births and induced abortion. In this scenario, contraceptive use and induced abortion may rise simultaneously.

As fertility decreases toward replacement level (two births per woman), or even lower, the length of potential exposure to unwanted pregnancies increases further. For instance, in a society in which the average woman is sexually active from ages 20 to 45 and wants two children, approximately 20 of those 25 years will be spent trying to avoid pregnancy. Once use of highly effective contraceptive methods rises to 80%, the potential demand for abortion, and its incidence, will fall. Demand for abortion falls to zero only in the "perfect contraceptive" population, in which women are protected by absolutely effective contraceptive use at all times, except for the relatively short periods when they want to conceive, are pregnant or are protected by lactational amenorrhea.⁵Because such a state of perfect protection is never actually achieved, a residual demand for abortion always exists, although its magnitude varies considerably among low-fertility societies, according to levels of contraceptive use and choice of methods.

The purpose of this article is to summarize what is known about the relationship between abortion and contraception. We start with a description of a recently proposed model of the relationship,⁶ and provide empirical illustrations to assess the validity of this model. We then review trends over time in the incidence of abortion and contraceptive use for specific countries based on published articles. Finally, we present a comprehensive examination of such trends in all countries thought to possess reliable trend data on abortion and contraceptive use and in which major changes in contraceptive prevalence or effectiveness have been recorded.

MODEL AND EMPIRICAL ILLUSTRATIONS

Bongaarts and Westoff have identified and described mathematically parameters that account for the relationship between contraception and abortion levels.⁷ They show that the abortion rate (the number of abortions per 1,000 women of reproductive age) in a population is related to the number of years in which women are both fecund and exposed to the risk of childbearing by being sexually active, the reproductive time taken for each live birth and the reproductive time for each abortion. The latter two time periods constitute waiting time to conception, pregnancy and the postpregnancy period of insusceptibility. Abortion rates are also related to the prevalence and effectiveness of contraceptive use, and the probability of aborting unintended pregnancies. The total fertility rate (TFR) equals the number of births a woman would expect to have over her lifetime under prevailing fertility rates, and it comprises two components: intended births and unintended births. The total abortion rate is the number of abortions a woman would expect to have under prevailing abortion rates, and can be linked mathematically to the TFR using the parameters just described.

The mathematical links between the TFR and abortion rates and the derivation of these links have been described in detail.⁸ By varying the different parameters one by one, the authors examine the relative effect of each factor on the abortion rate. The practical implications of the model include the following: Early onset of sexual activity, leading to a longer sexual and reproductive span, will tend to be positively related to the abortion rate. In addition, the number of children desired and the length of lactational amenorrhea will be negatively related to the abortion rate. Finally, at a given TFR, contraceptive effectiveness exerts an increasingly important effect on abortion rates as prevalence increases—in other words, as contraceptive prevalence rises, contraceptive failure or misuse becomes a more important factor in determining abortion rates.

The expected relationship between abortion and contraception can be seen in the first of our three illustrations, which comes from a prospective study of married couples in Shanghai, China.⁹ The women have all had one child and, because of the one-child policy, second births are extremely rare. Following the birth of their first child, many women initially use relatively ineffective methods: withdrawal, periodic abstinence and condoms. With each successive year following childbirth, use of these methods is progressively replaced by use of the IUD—a highly effective method. The proportion of women using IUDs rises from 20% in the first postnatal year to more than 75% in the fifth postnatal year (Figure 1 [pdf]). In the first year following childbirth, the induced abortion rate is 16 abortions per 1,000 months of exposure. By the fifth year, the rate is close to zero, thus providing a vivid demonstration of the trade-off between contraceptive effectiveness and induced abortion.

The second illustration involves a compilation of data on abortion and contraceptive use for a set of countries having approximately the same level of fertility and reliable information on contraception and abortion. The countries selected had a TFR between 1.7 and 2.2 births per woman, because this choice maximized the number of countries and years that could be included. Relevant information was obtained for a total of 36 time points from 11 countries. We included all available data points from all periods in which the TFR was within the specified range.

Figure 2 [pdf](page 8) shows a plot of abortion rates and prevalence of modern contraceptive use. The least-squares regression line shows the expected inverse relationship between prevalence of use and the abortion rate. When prevalence of modern method use is around 70%, the abortion rate is typically in the range of 10-30 abortions per 1,000 women in the reproductive ages. When prevalence is 40-60%, abortion rates rise to 30-50 per 1,000. Considerable dispersion from the regression line is evident, reflecting, in part, a mismatch of denominators for the contraceptive and abortion data. Contraceptive-use data pertain to married or cohabiting women, whereas abortion rates are based on all women. Nevertheless, Figure 2 [pdf] provides convincing support for the Bongaarts-Westoff model.

The model is further buttressed by the plot in Figure 3 [pdf]. In Figure 3, the proportion of married, reproductive-age women using traditional methods (e.g., withdrawal and periodic abstinence) has been plotted against abortion rates, for countries and periods in which total contraceptive prevalence exceeds 65%, and in which the TFR, as in Figure 2 [pdf], is 1.7-2.2 children per woman. At a given TFR, reliance on abortion rises with the proportion of women using traditional methods—the inverse of the relationship shown in Figure 2. Where modern contraceptives are the principal methods used, abortion rates are far lower.

The third and final illustration comes from the well-known Matlab intervention in Bangladesh.¹⁰ Trends in abortion rates in two areas were examined using longitudinal data collected over the period 1979-1998. These data were matched with information on fertility preferences from two surveys, conducted in 1984 and 1990, to examine differences between intended and unintended pregnancies. In one area, there was a highly active family planning intervention; in the other, the comparison area, only the normal government services were in place. At the beginning of the study period, abortion rates were similar in the comparison and intervention areas. From 1983 on, the abortion rate increased in the comparison area, while decreasing in the intervention area. At the end of the study period, the comparison area had an abortion rate more than three times as high as the rate in the intervention area.

On the basis of the survey data from 1984 and 1990, the authors report that unintended pregnancies declined in both areas, but that the rate of unintended pregnancy was significantly lower and the decline greater in the intervention area. As would be expected, in both areas and both time periods, unintended pregnancies were much more likely than intended pregnancies to end in abortion. However, women in the intervention area were much less likely to abort intended pregnancies than were women in the comparison area. Women in the intervention area had better access to reliable contraceptive methods, an advantage that the authors suggest assisted them in spacing and timing their births as they wished, hence decreasing the proportion of intended pregnancies aborted because of poor timing. In both areas, the percentage of pregnancies aborted increased significantly between the early 1980s and the late 1990s, but in both periods, the percentage was significantly lower in the intervention area than in the comparison area.

The role of fertility decline is key in explaining these results: Fertility declined in both areas over the study period, but the declines were achieved in different ways. In the intervention area, where there was easier access to family planning services, contraception provided the main method of fertility regulation. By contrast, in the comparison area, where these services were lacking, women had more unintended pregnancies and more abortions. In addition, despite similar desired family sizes in the two areas, fertility was still higher in the comparison area at the end of the study, suggesting that contraception is more effective than abortion in regulating fertility in Matlab. Similar results were obtained in a separate study of Matlab that also used longitudinal data (collected from 1982 to 1995) from the intervention and control areas.¹¹

EVIDENCE OF NATIONAL TRENDS: PUBLISHED STUDIES

The relationship between the incidence of abortion and the change from traditional to modern contraceptive methods was examined in a study of Turkey, primarily based on data from the nationally representative 1993 and 1998 Turkey Demographic and Health Surveys.¹² The authors found that the abortion rate rose sharply after legalization in 1983, but declined steadily after 1988, from 45 abortions per 1,000 married women in that year to 25 per 1,000 in 1998. During this period of decline in abortion rates, use of traditional methods of contraception declined moderately and use of modern methods increased. The authors found that unmet need for contraception (traditional or modern) did not change during the period of decline, suggesting that the reduced levels of abortion were partly due to this shift from less-effective to more-effective methods. By simulating different scenarios and comparing them to the empirical data, the authors conclude that the principal causes (in order of importance) were a lower propensity to abort accidental pregnancies while using traditional methods, a decline in failure rates of traditional methods, and finally, a shift in method mix toward modern contraception.

The direct impact of the shift from traditional methods to modern methods is, therefore, less important in this analysis than the decline in failure of traditional methods. The authors, however, point out that the shift in method use may also have contributed indirectly both to the decline in the failure rate of traditional methods and to the decline in the propensity to abort pregnancies resulting from traditional method failures: Women at particularly high risk of traditional-method failure, or those who were particularly likely to abort a pregnancy resulting from such failure, may have disproportionately switched to modern methods.

A detailed examination of the extent to which abortion can be replaced by contraception has been carried out by Westoff and colleagues,¹³ who examine trends in abortion and contraception in the populations of three central Asian republics (Kazakhstan, Uzbekistan and the Kyrgyz Republic) that were formerly part of the Soviet Union. In the Soviet Union, abortion was legal and widely available, whereas contraceptives were in limited supply. This situation led to a preference for abortion over contraception in some groups, and was associated with high rates of abortion, estimated in 1990 at around 181 per 1,000 women of reproductive age.¹⁴ Increases in contraceptive prevalence and reductions in abortion appear to be related. Abortion rates in the republics examined have declined over the last decade, and there has been a simultaneous rise in use of modern contraceptive methods. The authors show that levels vary within the populations by ethnic group, age and parity. Ethnic Russians have higher rates of abortion than other groups, and older women and higher-parity women are also more likely to abort their pregnancies. Abortion was found to be used both for spacing and for limiting births, and the authors conclude that abortion is used approximately equally for the two purposes.¹⁵

To analyze the abortion rate in these populations in more detail, the authors divided women into two groups—users and nonusers of contraceptive methods. Nonusers were subdivided into five groups, as follows: those who had never had sexual intercourse, so had had no pregnancies and, therefore, no abortions; currently pregnant women, some of whom would be expected to abort; women who were trying to become pregnant, some of whom might abort if they changed their minds after becoming pregnant; women who were infecund or at low risk of pregnancy because of infrequent sex or for other reasons; and women at risk of pregnancy who wanted to avoid conception, but were not using any method of family planning (i.e., those with unmet need). Of women who had aborted their last pregnancy, the largest group in each population comprised women with unmet need for contraception, suggesting that improved uptake of contraception was probably an important component in reduction of the abortion rate in these populations.

Subsequent analysis using data from the 1999 Kazakhstan Demographic and Health Survey revealed evidence both of a continuing increase in use of modern contraceptives and of declining recourse to abortion: Contraceptive prevalence in Kazakhstan increased by 50% in the 1990s, and abortion decreased by the same amount.¹⁶

NATIONAL TRENDS: NEW EVIDENCE

We used two criteria for inclusion of data in this part of the study. First, the country under examination had to have reasonably complete and accurate abortion data. In this regard, we followed the judgment of Henshaw and colleagues.¹⁷ In addition, for the analysis of trends, we needed contraceptive prevalence data representative of the population as a whole for at least two points in time. The criteria used to select populations for this analysis effectively excluded the many countries for which accuracy of abortion reporting is extremely questionable, for example, those where abortion is illegal or where there is no central reporting system. In addition, contraceptive prevalence data for many countries were unavailable for the same time period as abortion data, if at all. In some countries, contraceptive prevalence data were available for only two points in time; thus, any fluctuations between the two points are invisible. Countries for which data were available, but where very little change in contraceptive prevalence had taken place were also excluded (although some were included in the scatter plots in Figures 2 and 3). Data were obtained from a range of sources, which are cited in the text. The final selection included 11 countries: Bulgaria, Cuba, Denmark, Hungary, Kazakhstan, Netherlands, Singapore, South Korea, Switzerland, Tunisia and the United States.^†

Contraceptive Use Rising as Abortion Falls

Trends in abortion incidence and contraceptive prevalence over time in Bulgaria are consistent with evidence presented earlier that modern contraception can replace abortion (Figure 4 [pdf]). In Bulgaria, modern methods were difficult to obtain until around 1975.¹⁸ Fertility rates remained relatively steady across the period illustrated on the graph, but abortion incidence dropped in the 1980s and 1990s as use of modern contraceptive methods increased. Taken together, these patterns imply that modern method use reduced the need for induced abortion in the population.

This pattern of abortion apparently being replaced by contraception is also seen in trend data for Tunisia (1975-1995) and Switzerland (1980-1995); in both countries, modern method use rose as abortion incidence declined. The increase in contraceptive use and decline in abortion were less pronounced in Switzerland than in Bulgaria and Tunisia.

Simultaneous Rises in Abortion and Contraception

In many populations, rising levels of contraceptive prevalence are not associated over time with falling levels of abortion. It is likely that much of this divergence from the predicted inverse relationship can be explained by simultaneous changes in the TFR, which may mean that the proportion of couples practicing contraception is not keeping pace with the proportion desiring smaller families.

In Cuba, both contraceptive prevalence and abortion incidence increased between 1970 and 1985, with no decline evident in abortion levels in the period for which data are available (1967-1995).¹⁹ This simultaneous rise in both means of fertility regulation, however, coincides with a dramatic drop in fertility from more than four births per woman in 1965 to fewer than two births per woman in the 1990s. The increase in modern contraceptive use alone was probably not sufficient to reach this low level of fertility; therefore, women likely still resorted to induced abortion. Eventually, abortion should be replaced by contraception if levels of contraceptive prevalence continue to rise and fertility stabilizes.

This pattern also seems to have occurred in Denmark (1970-1990), the Netherlands (1970-1995) and the United States (1965-1995).²⁰ In these countries, as in Cuba, abortion incidence rose noticeably as contraceptive prevalence increased, while fertility levels dropped. Unlike the case in Cuba, however, this initial simultaneous rise in levels of abortion and contraceptive use was followed in these countries by a decline in abortion. This occurred in the early 1970s in the Netherlands, in the mid-1970s in Denmark and in the early 1980s in the United States. In each country, the decline was accompanied by a continued rise in levels of contraceptive use, and the stabilization of fertility at a lower level than before.

In Singapore, the same pattern of an initial rise in both abortion and contraceptive use under conditions of fertility decline (1970-1985) was followed by a decline in abortion levels for the remaining period for which data are available (1985-1997), starting in the middle to late 1980s. Data on contraceptive prevalence are not available for this latter period, but it is probable that these levels have risen steadily as abortion has declined.²¹

Long time series of data on both contraception and abortion are available for the Republic of Korea, although the abortion data are not considered to be of very high quality.²² Nevertheless, the trends represent a very complete example of the type of pattern described for Denmark, Netherlands and the United States. Figure 5 [pdf]shows simultaneous increases in level of contraceptive use and the rate of abortion. In the late 1970s, however, abortion incidence peaked and subsequently fell, whereas contraceptive prevalence continued to rise. During the period shown, the Republic of Korea was undergoing a transition from high to low fertility: Desired family sizes were becoming smaller, and the TFR was falling. At the population level, because contraceptive adoption did not increase as quickly as the need for fertility regulation, many couples resorted to abortion to achieve their dramatically lower fertility desires.

Government Legislation and Abortion Levels

The legal status of abortion does not appear to affect levels of abortion in a population in a straightforward way. For example, some of the lowest abortion levels in the world occur in countries in which abortion is legal (e.g., Western Europe) and some of the highest abortion levels occur in countries in which abortion is illegal (e.g., Latin America).²³ Nevertheless, changes in legislation can have dramatic effects on rates of legal abortion. If these changes are not accompanied by corresponding changes in levels of contraceptive use or fertility, it is more likely that legal abortions will replace illegal abortions or vice versa rather than that the abortion level overall will change. Figure 6 [pdf] shows the case of Romania, where abortion became the principal method of fertility limitation when it was legalized in 1957. The effects of the sudden legislative change in 1966 that restricted legal abortion can be seen in the subsequent dramatic decrease in the abortion rate and the near doubling of the TFR. The restrictions on abortion were part of a set of pronatalist policies that also included restrictions on divorce and access to contraceptives, special taxes on childless individuals and incentives for childbearing, such as paid medical leave during pregnancy.²⁴

One of the first acts of the new government following the overthrow of Ceausescu in December 1989 was to reverse many of these restrictions, making legal abortion more accessible again.²⁵ Although the general trends shown in Figure 6 [pdf]are likely to resemble what occurred in the Romanian population, abortion was politically sensitive during the Ceausescu regime, and the levels reported, particularly during the 1980s, are probably too low.²⁶ As in other countries where abortion is illegal or very restricted, maternal mortality and morbidity rose to very high levels as soon as the restrictions were implemented. Abortion-related maternal mortality increased during the 1980s, when legal abortions were highly restricted, from low levels in the 1960s, when abortion was available on demand,²⁷ suggesting that many women may have resorted to unsafe, illegal abortions during the 1980s. An estimated 87% of all maternal deaths in Romania during this period were attributable to unsafe abortions.²⁸

Other examples of the link between legality of abortion and maternal mortality exist. In Sweden, abortion-related mortality was 99.9% lower in the 1970s than in the 1930s. This change has been linked to the legalization of abortion.²⁹

The change in abortion rates that occurred in Hungary as abortion laws changed was similar to that in Romania.³⁰In Hungary, however, the situation was less clearly related to legislative change, primarily because women could obtain abortions despite restrictions,³¹ but also because the decrease in abortion rates following legislative restrictions was accompanied by an increase in the use of modern family planning methods, which would be expected to reduce contraceptive failure and, consequently, abortion. Hungary was the only socialist country in Eastern Europe to promote family planning actively, a factor that has been credited for the subsequent decline in the country's abortion rate.³²

CONCLUSION

Empirical study of the aggregate relationships between contraceptive use and induced abortion has to be limited to the few countries where reasonably reliable information exists on both. Despite this severe limitation, our review of the evidence provides ample illustration of the interaction between these factors. When fertility levels in a population are changing, the relationship between contraceptive use and abortion may take a variety of forms, frequently involving a simultaneous increase in both. When other factors—such as fertility—are held constant, however, a rise in contraceptive use or effectiveness invariably leads to a decline in induced abortion—and vice versa.

References

1. Cohen SA, The role of contraception in reducing abortion, Issues in Brief, New York: The Alan Guttmacher Institute (AGI), 1998.

2. Bongaarts J, Trends in unwanted childbearing in the developing world, New York: Population Council, 1997; and Westoff CF, Unwanted fertility in six developing countries, International Family Planning Perspectives,1981, 7(2):43-51.

3. Coale A, The demographic transition, Proceedings of the International Population Conference, Liege, Belgium: International Union for the Scientific Study of Population, 1973, p. 65.

4. Westoff CF, The unmet need for birth control in five Asian countries, International Family Planning Perspectives, 1978, 4(1):9-18.

5. Bumpass L and Westoff CF, The 'perfect contraceptive' population, Science, 1977, 169(951):1177-1182.

6. Bongaarts J and Westoff CF, The potential role of contraception in reducing abortion, Studies in Family Planning, 2000, 31(3):193-202.

7. Ibid.

8. Ibid.

9. Che Y and Cleland J, Unintended pregnancy after marriage among newly married couples in Shanghai,International Family Planning Perspectives, 2003 (forthcoming).

10. Rahman M, DaVanzo J and Razzaque A, Do better family planning services reduce abortion in Bangladesh? Lancet, 2001, 358(9287): 1051-1056.

11. Ahmed MK, Rahman M and van Ginneken J, Induced abortion in Matlab, Bangladesh: trends and determinants, International Family Planning Perspectives, 1998, 24(3):128-132.

12. Senlet P et al., Abortion and Contraceptive Use in Turkey, Measure Evaluation Project working paper, Chapel Hill, NC, USA: Carolina Population Center, 2000; Senlet P et al., The role of changes in contraceptive use in the decline of induced abortion in Turkey, Studies in Family Planning, 2001, 32(1):41-52.

13. Westoff CF et al., Replacement of Abortion by Contraception in Three Central Asian Republics,Washington, DC: The Policy Project; and Calverton, MD, USA: Macro International, 1998; Westoff CF, The Substitution of Contraception for Abortion in Kazakhstan in the 1990s, DHS Analytical Studies, Calverton, MD, USA: Macro International, 2000, No 1.

14. Henshaw SK, Induced abortion: a world review, 1990, Family Planning Perspectives, 1990, 22(2):76-89.

15. Westoff CF et al., 1998, op. cit. (see reference 13).

16. Westoff CF, 2000, op. cit. (see reference 13).

17. Henshaw SK, Singh S and Haas T, Recent trends in abortion rates worldwide, International Family Planning Perspectives, 1999, 25(1):44-48.

18. Vassilev D, Bulgaria, in: David HP and Skilogianis J, eds., From Abortion to Contraception: A Resource to Public Policies and Reproductive Behavior in Central and Eastern Europe from 1917 to the Present, Westport, CT, USA: Greenwood Press, 1999, pp. 69-90.

19. Henshaw SK, Singh S and Haas T, 1999, op. cit. (see reference 17); United Nations (UN), Levels and Trends of Contraceptive Use as Assessed in 1998, New York: UN, 1998; Noble J and Potts M, The fertility transition in Cuba and the Federal Republic of Korea: the impact of organised family planning, Journal of Biosocial Science, 1996, 28(2):211-225; Ross JA, Mauldin WP and Miller VC, Family Planning and Population: A Compendium of International Statistics, New York: Population Council, 1993; and Tietze C, Induced Abortion: 1979, 3rd ed., New York: Population Council, 1979.

20. UN, Population Division of the Department of Economic and Social Affairs, World Population Prospects: The 2000 Revision and World Urbanization Prospects: The 2001 Revision, <http://esa.un.org/unpp/ index.asp?panel=2>, accessed Feb. 11, 2003; Henshaw SK et al., 1999, op. cit. (see reference 17); UN, 1998, op. cit. (see reference 19); Ross JA et al., 1993, op. cit. (see reference 19); and Tietze C, 1979, op. cit. (see reference 19).

21. Ibid.

22. Henshaw SK et al., 1999, op. cit. (see reference 17).

23. Dailard C, Abortion in Context: United States and Worldwide, Issues in Brief, New York: AGI, 1999.

24. Baban A, Romania, in: David HP and Skilogianis J, eds., 1999, op. cit. (see reference 18).

25. Ibid.

26. Ibid.

27. Ibid.; and Henshaw SK et al., 1999, op. cit. (see reference 17).

28. Hord C et al., Reproductive health in Romania: reversing the Ceausescu legacy, Studies in Family Planning, 1991, 22(4):231-240.

29. Högberg U and Wall S, Reproductive mortality and its relation to different methods of birth control, Journal of Biosocial Science, 1990, 22(3):323-331.

30. UN, 2003 (see reference 20); David HP, Hungary, in: David HP and Skilogianis J, eds., 1999, op. cit. (see reference 18); Henshaw SK et al., 1999, op. cit. (see reference 17); UN, 1998, op. cit. (see reference 19); Ross JA et al., 1993, op. cit. (see reference 19); and Tietze C, 1979, op. cit. (see reference 19).

31. David HP, 1999, op. cit. (see reference 30).

32. Ibid.

RÉSUMÉ

Contexte: Le rapport entre les niveaux de pratique contraceptive et l'incidence de l'avortement provoqué continue d'enflammer les débats. Certains observateurs estiment que le recours à l'avortement diminue lorsque la prévalence contraceptive augmente, tandis que d'autres voient dans la pratique accrue des méthodes de planning familial la cause d'une plus grande incidence de l'avortement.

Méthodes: Les tendances de l'avortement sont examinées dans des pays disposant de données fiables sur l'IVG et de l'information de prévalence contraceptive prélevée en deux points du temps qui révèle une hausse de la pratique contraceptive. Le rôle de l'évolution de la fécondité dans le rapport entre l'avortement et la contraception est également exploré.

Résultats: Dans sept pays (Kazakhstan, République kirghize, Ouzbékistan, Bulgarie, Turquie, Tunisie et Suisse), l'incidence de l'avortement a baissé tandis qu'augmentait la prévalence contraceptive. Dans six autres (Cuba, Danemark, Pays-Bas, Etats-Unis, Singapour et République de Corée), les niveaux de l'avortement et de la pratique contraceptive ont enregistré une hausse simultanée. Dans ces six pays, toutefois, la fécondité globale apparaît en baisse pendant la période à l'étude. Après stabilisation des niveaux de fécondité dans plusieurs des pays qui avaient présenté une hausse simultanée de la contraception et de l'avortement, la pratique contraceptive a continué de croître tandis que baissaient les taux d'avortement. L'exemple le plus clair de cette tendance est la République de Corée.

Conclusions: La hausse de la pratique contraceptive donne lieu à une incidence réduite de l'avortement dans les contextes où la fécondité reste constante. La hausse parallèle de l'avortement et de la contraception dans certains pays est le produit de l'incapacité de la contraception seule à satisfaire le besoin grandissant de limitation des naissances dans les circonstances où la fécondité baisse rapidement.

Acknowledgments

This project was funded by the World Health Organization (WHO). A longer version of this article that contains additional graphs will be published as part of Marston C and Cleland J, The Effects of Contraception on Obstetric Outcomes. It will be available from the WHO Department of Reproductive Health and Research (www.who.int/reproductive-health). The authors thank John Bongaarts, Sarah Harbison, Iqbal Shah, John Townsend and Charles Westoff for their comments on earlier versions.

*See for example, U.S. Senate debate, 105th Congress, 1st Session, Feb. 25, 1997, 2:15 p.m., Vote No. 13, on Mexico City Policy. Those in favor of passing the bill declared, "It is a very arguable assumption at best to say that the declining abortion rates [seen in selected developing countries] are a direct result of pregnancy prevention services." A synopsis is on the Internet at <http://www.senate.gov/~rpc/rva/1051/105113.htm#HEADING/>.

†Seven countries with reasonably accurate and complete abortion data—Belarus, Belgium, Estonia, Israel, Latvia, Slovenia and Sweden—were excluded from the final analysis because they had no information on levels of contraceptive use. Six countries—Canada, Finland, Great Britain, New Zealand, Norway and the Slovak Republic—were excluded because no change occurred in their levels of contraceptive prevalence over time or because no trend data were available.

AUTHOR AFFILIATIONS

At the time this article was written, Cicely Marston was a postdoctoral research fellow at the Centre for Population Studies, London School of Hygiene & Tropical Medicine; she is currently lecturer in social science and public health in the Department of Social Science and Medicine, Imperial College, London. John Cleland is professor of demography at the Centre for Population Studies.