1. Caitlin Gerdts, PhD, MHS
UCLA Fielding
School of Public
Health, Bixby
Lecture
November 26, 2012
Safe, Legal, and Rare?
An update on abortion around the world

2. Safe, Legal, and
Rare? An update
on abortion
Caitlin Gerdts, PhD,
MHS
November 2009 | Slide 2
Women all over the World have
Abortions for Similar Reasons

3. Safe, Legal, and
Rare? An update
on abortion
Caitlin Gerdts, PhD,
MHS
November 2009 | Slide 3
The Decline in Global Abortion Rates has Stalled
35 34
39
29 29
25
28 29
24
0
10
20
30
40
World Developing
countries
Developed
countries
1995 2003 2008
Abortions per 1,000 women aged 15–44

4. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 4
Stall in global abortion decline coincides
with plateau in contraceptive use
0
10
20
30
40
50
60
0
20
40
60
80
100
1980 1985 1990 1995 2000 2005 2010
Abortions per 1,000 women 15-44
Contraceptive prevalence (%)
Contraceptive prevalence (%) Abortion rate

5. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 5
The abortion rate is lower in developed
countries than in developing countries
34 29
29
39
25 24
20
19 17
0
10
20
30
40
50
1995 2000 2005 2010
Developing countries
Developed countries
Developed countries*
Abortions per 1,000 women aged 15–44
www.guttmacher.org
*Excluding Eastern Europe

6. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 6
Is Abortion Safe?

7. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 7
When performed in safe, sterile
conditions…
…abortion is safer than taking a dose of penicillin.

8. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 8
When performed in unsafe or unsterile
conditions…
• Maternal Morbidity
• Maternal Mortality
• Strains on Health Systems
• Strains on Families

9. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 9
Disproportionate Impact of Unsafe Abortion
“Deaths and disability related to unsafe abortion are
entirely preventable…Within developing countries, risks
are greatest for the poorest women. They have the
least access to family planning services and are the
most likely to suffer the negative consequences of an
unsafe procedure. Poor women also have the least
access to post-abortion care, when they need treatment
for complications.”
-Iqbal Shah, WHO

10. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 10
An increasing proportion of abortion are
unsafe
44
54
9
47
55
7
49
56
6
0
20
40
60
80
100
World Developing countries Developed countries
1995 2003 2008
% of abortions that are unsafe

11. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 11
By the WHO definition, virtually all Abortions
in Latin America and Africa are Unsafe
% of abortions
97 95
40
15 9
0
20
40
60
80
100
Africa Latin America Asia Oceania Europe North America
Unsafe Safe

12. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 12
Deaths from Unsafe Abortion are Highest
in Africa
10
350
650
300
50
0
100
200
300
400
500
600
700
Developed regionsDeveloping regions Africa AsiaLatin America & Caribbean
Deaths per 100,000 unsafe abortions, 2003

13. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 13
Is Abortion Legal?

14. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 14
Most women live in countries
where abortion is restricted
This is a slide to use for large images where you want to eliminate everything else but a two-line title
and caption. It’s based on the last slide master.
26%
10%
3%
21%
40%
Prohibited altogether
or only to save life
Physical Health
Mental Health
Socioeconomic
Without restriction

15. Global Abortion Legality

16. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 16
Consequences of restricting contraception
and legal abortion in Romania

17. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 17
Disproportionate Impact of Unsafe Abortion
“Deaths and disability related to unsafe abortion are
entirely preventable…Within developing countries, risks
are greatest for the poorest women. They have the
least access to family planning services and are the
most likely to suffer the negative consequences of an
unsafe procedure. Poor women also have the least
access to post-abortion care, when they need treatment
for complications.”
-Iqbal Shah, WHO

18. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 18
Abortion law reforms in developing
countries have been followed by declines
in morbidity and mortality
• South Africa (1997): Annual number of abortion-related deaths
decreased by 91% after the law was liberalized.
• Nepal (2002): Abortion-related complications as a proportion of
all of maternal illnesses decreased by 48% in a study of
facilities in eight districts.
• Ethiopia (2005): Abortion complications per 100,000 live births
(at one large hospital) decreased by about 70%.

19. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 19
Should Abortion be Rare?

20. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 20
Impact of contraception on reducing the
number of abortions
141 million
45 million
14 million
Without modern methods
Current use
If unmet need were met
Estimated number of induced abortions

21. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 21
Focus on Rare Abortion Increases
Stigma

22. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 22
Global Turnaway Study
www.indiegogo.com/theglobalturnawaystudy

23. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 23
Global Turnaway Study aim
To describe the mental health, physical health
and socioeconomic consequences of
receiving a legal abortion compared to being
denied a legal abortion in multiple
geographic, cultural, and legal settings.

24. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 24
Global Turnaway Study groups
4 6 8 10 12 14 16 18 20 22
24 26 28 …
Site A Gestational age limit = 12
4 6 8 10 12 14 16 18 20 22
24 26 28 …
Site B Gestational age limit = 20
Abortion comparison Turnaway

25. Safe, Legal, and
Rare? An update
on abortion
Caitlin
Gerdts, PhD, MHS
November 2009 | Slide 25
References
■ Weitz, T. Rethinking the Mantra that Abortion Should be “Safe, Legal, and Rare
■ Singh S, Sedgh G, Hussain R. Unintended Pregnancy: Worldwide Levels, Trends and Outcomes. Studies in
Family Planning. Dec 2010;41(4).
■ WHO. The prevention and management of unsafe abortion. Report of a technical working group. Geneva: World
Health Organization, 1992 (WHO/MSM/92.5).
■ Fawcus SR. Maternal mortality and unsafe abortion. Best Practice & Research Clinical Obstetrics and
Gynaecology. 2008; 22(3).
■ The Alan Guttmacher Institute (AGI), Sharing Responsibility: Women, Society & Abortion Worldwide, New York:
AGI, 1999
■ Sedgh G, Henshaw S, Singh S, Ahman E, Shah I. Induced Abortion: estimated rates and trends worldwide.
Lancet. 2007; 370.
■ Sedgh G, Singh S, Shah I, Ahman E, Henshaw S, Bankole A. Induced Abortion: incidence and trends worldwide
from 1995-2008. Lancet. 2012; 379.
■ Adler AJ, Filippi V, Thomas S, Ronsmans C. Quantifying the global burden of morbidity due to unsafe abortion:
Magnitude in hospital-based studies and methodological issues. International Journal of Gynecology and
Obstetrics. 2012.
■ Adler AJ, Filippi V, Thomas S, Ronsmans C. Incidence of severe acute maternal morbidity associated with
abortion: a systematic review. Tropical Medicine and International Health. 2011.
■ WHO. Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality.
Geneva: World Health Organization, 2007.
■ Gipson J, Koenig M, Hindin M. The effects of unintended pregnancy on infant, child and parental health: a review
of the literature. Studies in Family Planning. 2008; 39(1): 18-38.
■ Brown S, Eisenberg L (eds). The Best Intentions: Unintended Pregnancy and the Well-Being of Children and
Families. Washington, DC: National Academic Press.
■ Marston C, Cleland J. Do unintended pregnancies carried to term lead to adverse outcomes for mother and child?
An assessment in five developing countries. Population Studies. 2003; 51(1): 77-93.

26. Caitlin Gerdts, PhD, MHS
gerdtsc@obgyn.ucsf.edu
UCLA Fielding
School of Public
Health
November 26, 2012
Thank you