abortion legal research paper

• Open access
• Published: 28 June 2021

Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

• Foluso Ishola   ORCID: orcid.org/0000-0002-8644-0570 1 ,
• U. Vivian Ukah 1 &
• Arijit Nandi 1  

Systematic Reviews volume  10 , Article number:  192 ( 2021 ) Cite this article

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A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Peer Review reports

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 , 2 , 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 , 8 , 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 , 16 , 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 , 18 , 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 , 19 , 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 , 35 , 36 , 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.

Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].

Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].

Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].

Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

National constitutions;

Supreme court decisions, as well as higher court decisions;

Customary or religious law, such as interpretations of Muslim law;

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.

Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.

Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.

Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.

Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.

Fertility rate refers to the average number of children born to women of childbearing age.

Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.

Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

Ovid MEDLINE(R) (from 1946 to present)

Embase Classic+Embase on OvidSP (from 1947 to present)

CINAHL (1973 to present); and

Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

Information on the differential aspects of the abortion policy reforms.

Information on the types of study design used to assess the impact of policy reforms.

Information on main effects of abortion law reforms on primary and secondary outcomes of interest.

Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

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We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

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PRISMA-P 2015 Checklist. This checklist has been adapted for use with systematic review protocol submissions to BioMed Central journals from Table 3 in Moher D et al: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 2015 4:1

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Ishola, F., Ukah, U.V. & Nandi, A. Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol. Syst Rev 10 , 192 (2021). https://doi.org/10.1186/s13643-021-01739-w

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• Abortion law/policies; Impact
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Global Abortion Policies Database: a descriptive analysis of the legal categories of lawful abortion

• Antonella F. Lavelanet   ORCID: orcid.org/0000-0003-2159-2570 1 ,
• Stephanie Schlitt 2 ,
• Brooke Ronald Johnson Jr 1 &
• Bela Ganatra 1  

BMC International Health and Human Rights volume  18 , Article number:  44 ( 2018 ) Cite this article

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Texts and interpretations on the lawfulness of abortion and associated administrative requirements can be vague and confusing. It can also be difficult for a woman or provider to know exactly where to look for and how to interpret laws on abortion. To increase transparency, the Global Abortion Policies Database (GAPD), launched in 2017, facilitates the strengthening of knowledge and understanding of the complexities and nuances around lawful abortion as explicitly stated in laws and policies.

We report on data available in the GAPD as of May 2018. We reviewed the content and wording of laws, policies, standards and guidelines, judgments and other official statements for all countries where data is available in the GAPD. We analyzed data for 158 countries, where abortion is lawful on the woman’s request with no requirement for justification and/or for at least one legal ground, including additional indications that are nonequivalent to a single common legal ground. We classified laws on the basis of the explicit wording of the text. The GAPD treats legal categories as the circumstances under which abortion is lawful, that is, allowed or not contrary to law, or explicitly permitted or specified by law.

32% of countries allow or permit abortion at the woman’s request with no requirement for justification. Approximately 82% of countries allow or permit abortion to save the woman’s life. 64% of countries specify health, physical health and/or mental (or psychological) health. 51% allow or permit abortion based on a fetal condition, 46% of countries allow or permit abortion where the pregnancy is the result of rape, and 10% specify an economic or social ground. Laws may also specify several additional indications that are nonequivalent to a single legal ground.

Conclusions

The GAPD reflects details that exist within countries’ laws and highlights the nuance within legal categories of abortion; no assumptions are made as to how laws are interpreted or applied in practice. By examining the text of the law, additional complexities related to the legal categories of abortion become more apparent.

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Abortion is one of the few health procedures that is legally regulated in most countries, but this was not always the case. There were few restrictions on abortion prior to the nineteenth century; women could access abortion prior to quickening, the time at which a woman can feel fetal movement [ 1 ]. However, with growing concern related to surgical and medical infection risks, abortion came to be seen as a dangerous and life-threatening surgery, prompting greater regulation, including the inclusion of abortion in penal legislation. In addition to health justifications, restrictions were also based on religious ideology, regulating fertility, fetal protection including for eugenic purposes, and in some cases, desires by physicians to limit competitor practice [ 1 , 2 ]. These restrictions were progressively incorporated into countries around the world, threatening the lives and eroding the rights of women around the world [ 3 , 4 ].

In the twentieth century, some countries began to recognize the equal status of women [ 1 ], while other countries began to appreciate the dangers of unsafe abortion [ 3 , 5 ] leading to the liberalization of abortion laws and/or the enactment of new abortion laws [ 6 ]. Where abortion is allowed or permitted, three broad categories exist: 1) abortion on request with no requirement for justification; 2) based on common legal grounds and related indications (hereinafter referred to as legal grounds); or 3) based on additional indications that are nonequivalent to a single legal ground but could be interpreted under multiple grounds. Common legal grounds include abortion to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, and for economic or social reasons [ 7 ]. Abortion regulation may occur in legal texts beyond the penal code, including reproductive health acts, general health acts, and medical ethics codes.

Although expanded categories of lawful abortion potentially yield greater access to abortion, the way in which abortion is expressed in legal texts can be vague and confusing. When looking merely at the legal texts, women and providers may find it difficult to know when abortion is lawful and how to interpret information related to legal requirements to ensure compliance with the law. Additionally, abortion may be regulated as a health procedure; abortion may be criminalized in all cases; there may be uncertain prohibition where laws prohibit unlawful abortion but do not specify what constitutes a lawful abortion; or exceptions for permitted abortion access may be specified in the law. Such regulations may exist in a variety of documents including penal codes, ministerial decrees, abortion-specific acts, and court cases to name a few. The expanding range of regulatory documents can sometimes lead to conflicting directives in various sources or even within the same source [ 7 , 8 ] leading to even greater confusion for women and providers related to the circumstances under which abortion is lawful.

Several databases currently exist which provide information related to country specific abortion laws and may facilitate better understanding of the legal regulation of abortion [ 7 , 9 , 10 ]. These databases often classify countries as falling on a hierarchical spectrum of access to abortion based on the number and type of grounds under which abortion is permitted. To increase transparency, the Global Abortion Policies Database (GAPD) was launched in 2017 [ 11 ] and facilitates the strengthening of knowledge by demonstrating the complexities and nuances of legal texts. The GAPD also contains information related to authorization and service-delivery requirements, conscientious objection, penalties, national SRH indicators, and UN Treaty Monitoring Body concluding observations on abortion. The GAPD does not offer information related to the meaning of legal texts or how legal texts are interpreted or applied in society. The meaning of any legal text is informed by its context: the wider set of laws concerning access requirements and women’s reproductive health more generally, and the culture in which these texts are operationalized. However, the GAPD does provide a starting point from which to understand legal categories, including on request with no requirement for justification, legal grounds, and additional nonequivalent indications as set out in national laws.

In this paper, our main objective is to use data extracted from the GAPD, to report on the number of countries that allow or permit abortion within each legal category and describe the complexities and nuances of these laws, which have not been addressed by other databases or have been obscured by more simplistic classification schemes.

We use data available in the GAPD as of May 2018. Footnote 1 The GAPD contains data that was extracted onto a policy questionnaire, based on closed questions and a finite set of legal grounds. Unique or complex policy nuances that do not exactly match one of the common legal grounds are separately captured in the GAPD as other . Footnote 2 The methodologic details related to the classifying and coding used for the GAPD have been previously described [ 12 ]. In this paper, we diverge from the way in which legal grounds are displayed on the GAPD to better describe the complexities related to legal categories of abortion; we do not present data related to additional access requirements.

The GAPD treats legal categories as the circumstances under which abortion is lawful, that is, allowed or not contrary to law, or explicitly permitted or specified by law (legal grounds). We reviewed the content and wording of laws, policies, standards and guidelines, judgments and other official statements (referred to hereinafter as ‘law’ and ‘laws’) for all countries where abortion is lawful on the woman’s request with no requirement for justification and/or for at least one legal ground, including additional indications that are nonequivalent to a single legal ground. Countries where abortion is prohibited in all circumstances (Andorra, Dominican Republic, El Salvador, Gabon, Guinea-Bissau, Haiti, Holy See, Madagascar, Malta, Nicaragua, Palau, Philippines, Republic of Congo, San Marino, Senegal, and Suriname) and countries where laws prohibit unlawful abortion but do not specify lawful abortion (Antigua and Barbuda, Dominica, Gambia, Jamaica, Sierra Leone, Saint Kitts and Nevis, and Tonga) are also excluded.

We only report on data that is available in the GAPD. Countries which have no data available in GAPD include Democratic People’s Republic of Korea, Equatorial Guinea, Honduras, Maldives, Marshall Islands, Micronesia, Niue, and Saint Vincent and the Grenadines. Seven countries (Australia, Bosnia and Herzegovina, Canada, China, Mexico, Nigeria, the United Kingdom of Great Britain and Northern Ireland) that may regulate abortion at the subnational level are not included in the analysis as the GAPD may not have subnational level data or the data may vary significantly across the jurisdictions. Thus, we analyzed data for 158 countries.

The coding and classification of laws is based on the explicit text of the law. We do not make assumptions about the interpretation of laws. Each ground is treated independently; countries where abortion is permitted on request with no requirement for justification are not coded in the database as countries that permit any other legal ground unless those grounds are explicitly stated. The information in the database is limited by accessibility of source documentation and the ability to translate source documents.

On request with no requirement for justification

Abortion at the woman’s request with no requirement for justification is allowed or permitted in 50 countries (32% = 50/158); just over half of these are in Europe (54% = 27/50). In Asia, there are 14 countries where abortion on request is lawful, followed by six in Africa, three in Latin America and the Caribbean, and one in North America; there are no countries in Oceania where abortion is lawful on the woman’s request with no requirement for justification. All but one country (Viet Nam) impose gestational age limits on women accessing abortion on request. Footnote 3 In all other countries, abortion on request is typically available up to 12 weeks of gestation; the range is 8 to 24 weeks.

Legal grounds and related indications

Where abortion is not available on request or once the gestational limit associated with a woman’s request has been reached, abortion may be lawful based on legal grounds or related indications.

Life threat

Approximately 82% (129/158) of countries allow or permit abortion to save the woman’s ‘life’ (See Table  1 ). The threat to life is described in various ways.

Some laws reference the threats/risks the pregnant woman confronts as circumstances in which:

‘continuation of pregnancy endangers the life.’

Others qualify the level of the threat/risk the pregnant woman confronts when:

‘there is a substantial threat to the woman’s life in continuing the pregnancy.’

Yet others compare the risks the woman confronts:

‘if the continuance of the pregnancy would involve a risk to the life of the woman greater than if the pregnancy were terminated” or where “ abortion is the only way to save the woman’s life. ’

Seven of the 129 countries Footnote 4 (5%) utilize a medical or surgical operations clause to permit abortion to save the woman’s life, which exempts from criminal responsibility those who perform ‘in good faith and with reasonable care and skill a surgical operation upon an unborn child for the preservation of the mother’s life, if the performance of the operation is reasonable, having regard to the patient’s state at the time and to all the circumstances of the case.’

In 24 of the 129 countries (19%) where abortion is lawful based on a life threat, Footnote 5 this indication is the only permissible circumstance in which a woman may lawfully obtain an abortion. Most countries do not impose gestational age limits related to the life ground; however, gestational limits are present in 31 countries across the regions (See Table 1 ).

Health threat

The laws of most countries with a health-related ground refer to one or a combination of the following terms: ‘health’, ‘physical health’ and/or ‘mental (or psychological) health.’ Some laws specify limited lists of health conditions (See Fig.  1 ).

Relationship between health, physical health and/or mental health ground and related indications

Of 158 countries analyzed, 101 (64%) specify health in some form. Health alone is specified in 49 (31% = 49/158) countries; 36 (23% = 36/158) additional countries provide greater detail in their laws, specifying the lawfulness of abortion based on both ‘physical health’ and ‘mental health.’ In 10 countries, Footnote 6 laws specify ‘health,’ ‘physical health’ and ‘mental health.’ In Japan and Mongolia, ‘health’ and ‘physical’ health are specified, while in Finland and Iraq, ‘health’ and ‘mental health’ are specified. In Monaco and Zimbabwe, abortion may only be lawful based on a ‘physical health’ ground.

In addition to specifying ‘health’, ‘physical health’ and/or ‘mental (or psychological) health,’ 9 countries Footnote 7 narrow the lawfulness of abortion to certain specified health conditions, including HIV infection, severe depression or where a woman’s psychological equilibrium may be compromised by continuation of the pregnancy.

Most countries do not impose a gestational limit for any health indication, but in the 38 countries (38% = 38/101) where the law specifies an associated gestational limit, most fall between 19 and 24 weeks (See Table  2 ).

Limited lists of health conditions

Six countries (Azerbaijan, Georgia, Kyrgyzstan, Russian Federation, Tajikistan, and Turkey) have limited lists of specific health conditions; several types of diseases may be included on such lists. In one country, for example, the category “infectious and parasitic diseases” includes all active forms of tuberculosis, severe viral hepatitis, syphilis, Acquired Immunodeficiency Syndrome and rubella. The category “mental disorders” includes chronic alcoholism with personality change, transient psychotic conditions resulting from organic diseases, drug addiction and substance abuse, and mental retardation.

Fetal conditions

Laws allow or permit access to abortion based on fetal conditions; in some cases, countries provide a limited list of conditions or specify a single fetal condition for which abortion is lawful. (See Fig.  2 ).

Relationship between a ground based on fetal condition and related indications

In 80 of the 158 (51%) countries analyzed, abortion is allowed or permitted based on a fetal condition, with no restriction as to the type of fetal condition (See Table  3 ). In 35 of these 80 countries, gestational limits restrict a woman’s access to abortion based on a fetal condition. These gestational ages range from 8 to 35 weeks; the median is 22 weeks.

Limited lists of or single specified fetal condition

In six countries, an abortion is lawful if the fetus has a congenital or hereditary disease (Bulgaria and Lithuania), or where the fetus’s condition is lethal (Bolivia and Colombia) or ‘incompatible with extrauterine life’ (Chile and Uruguay). In Brazil, an anencephalic fetus is the only lawful fetal condition.

Fetal condition - presumption of another ground

In Thailand, if the woman suffers ‘severe stress’ due to the finding that the fetus is afflicted with a ‘severe disability, or has or has a high risk of having severe genetic disease,’ abortion is lawful under the mental health ground. A medical practitioner, other than the one who will perform the termination of pregnancy must authorize the abortion based on this ground in writing.

Many countries allow or permit abortion in cases where the pregnancy is the result of rape or gender-based/sexual violence; however, laws vary in how this ground is defined (See Fig.  3 ).

Relationship between rape ground and related indications

Abortion is lawful in 72 of the 158 countries analyzed (46%) if pregnancy is the result of ‘rape.’ In 61% (44/72) of countries where rape is a permitted legal ground, an accompanying gestational limit is imposed. The range between the lowest and highest limits varies across regions (See Table  4 ).

Rape - presumption of another ground

In Barbados and India, abortion is lawful under the mental health ground where pregnancy results from rape. In both countries there is a presumption that pregnancy resulting from rape is or can be injurious to the woman’s mental health, without the need for a health professional’s assessment.

Rape - as a consideration in conjunction with a different ground

One country, New Zealand, specifically states in its law that rape is not in and of itself a legal ground but may be considered if there are reasonable grounds for believing that the pregnancy is the result of sexual violation, where continuation of the pregnancy would result in serious danger to the woman or girl’s life, physical or mental health.

Gender-based/sexual violence

In 14 countries where abortion is permitted on the ground of rape, abortion is also allowed or permitted if the pregnancy is the result of another specific act of sexual violence including human trafficking, forced marriage, sexual assault, or unwanted implantation of a fertilized ovum.

In the laws of six countries, rape is not an explicit indication for abortion, however, similar indications exist. The laws in four countries (Angola, Bulgaria, Italy and Portugal) permit consideration of the circumstances in which the pregnancy occurred, such as if the pregnancy was the “result of a crime against freedom and sexual self-determination” or resulted “from an act of violence.” In Zambia and Bolivia, specific acts of gender-based violence, such as defilement or forced marriage are included in the law.

Of 45/72 (63%) countries that have a rape ground, abortion is also lawful if the pregnancy is the result of ‘incest’. Two countries (Bulgaria and New Zealand) do not explicitly specify a rape ground in their laws but do allow or permit abortion where the pregnancy is the result of incest. Gestational limits restrict a woman’s access to abortion based on incest in 26 of the 45 countries where abortion is lawful. These gestational ages range from 8 to 28 weeks; the median is 20 weeks.

Intellectual or cognitive disability

In 20 of the 158 countries, intellectual or cognitive disability of the woman is specified as a legal ground. In 13 of these 20 countries, gestational limits restrict the application of this indication. The range is between 12 and 28 weeks, the median is 21 weeks.

Economic or social ground

Economic and/or social grounds are specified in laws either as an independent ground or as a consideration in conjunction with a different ground. Alternatively, some countries’ laws have limited lists of or a single specific economic or social condition (See Fig.  4 ).

Relationship between economic or social ground and related indications

Of 158 countries analyzed, 16 countries (10%) allow or permit abortion based on an economic or social ground. In 13 of the 16 countries where abortion is permitted on an economic and social ground, gestational limits restrict the application of this indication. The range is between 12 and 22 weeks, the median is 21 weeks.

Economic or social ground -as a consideration in conjunction with a different ground

Six countries permit consideration of economic and social reasons in conjunction with another ground. In Barbados, Belize, and Zambia, a pregnant woman’s actual or foreseeable social environment may be considered in determining whether a risk to her life or health exists. Similarly, a woman’s living conditions or economic circumstances may be taken into account in Germany and Guyana where abortion is considered justified to avert injury to her health. In The former Yugoslav Republic of Macedonia, an abortion is lawful if a woman has seriously deteriorated marital and family relations or a difficult housing condition and these circumstances may be detrimental to her health.

Limited lists of or single specified economic and social conditions

In 16 countries, specific social indications or a limited list of social indications are specified within their laws. For example, in Israel, abortion is lawful where the pregnancy is the result of extramarital relations. In Guyana and Slovakia, abortion is permitted in cases of contraceptive failure. In Kazakhstan, the law includes a list of social circumstances, such as the death of a woman’s husband, the woman and her husband are recognized as officially unemployed, refugee status for the woman, and if the woman has four or more children, to name a few.

Non-equivalent indications

Abortion may also be lawful based on indications that are not equivalent to a single legal ground.

Claim of distress

In four countries, the law allows or permits abortion in the first 12 weeks of pregnancy to women who suffer from distress or similar impact from continuation of the pregnancy. In the Netherlands, a woman’s request for abortion must be based on her opinion that she is in an emergency situation which can only be alleviated by an abortion. In Switzerland, abortion is lawful if a woman provides a written request claiming that she is in distress. In Belgium and Hungary, the woman must be distressed or in a crisis situation, as assessed by her attending doctor.

Age qualification

In 22 countries, abortion is lawful for minors, or those below or above a specified age. In these countries, abortion is typically permitted for girls between 13 and 18 years of age, and women over 40 years. In 14 of the 22 countries, the law allows or permits abortion at one end of this age spectrum, either for those before 18 or after 40 years of age. In 6 countries, minority is accompanied by additional stipulations. For example, in Liberia, a girl under 16 is entitled to an abortion where the pregnancy is the result of illicit intercourse. In Denmark and Ethiopia, a minor whose immaturity renders her unfit to raise a child may have an abortion. In Liechtenstein, a girl under 15 is entitled to an abortion, if she is not married to the person who impregnated her at the time of conception or afterwards. In Benin and Central African Republic, where the pregnancy would constitute a handicap for the minor’s development or lead to a state of grave distress, abortion is lawful.

Various therapeutic indications

In 17 countries, the law allows or permits abortion in circumstances that may be categorized as potentially falling under several common grounds, including life, health, fetal condition, economic and social reasons, and rape. These countries’ laws allow or permit abortion where such procedures are for a “‘therapeutic purpose’ or ‘proven medical necessity,”’ to ‘avert the danger of serious harm to physical integrity’ or to prevent ‘serious and irreversible harm to the body.’ Some of these laws allow or permit abortion where a spouse suffers from a mental disease.

Two additional countries (Bahamas and Grenada) have a surgical operations clause but make no reference to preservation of the ‘mother’s’ life, while one country (Mozambique) permits health committees to examine cases not stipulated in the law on a case-by-case basis to protect pregnant women’s’ sexual and reproductive rights.

Menstrual regulation

In Bangladesh, ‘menstrual regulation’ is medically or surgically available to women as a method of uterine evacuation used to regulate the menstrual cycle when menstruation has been absent for a short duration.

While the GAPD does not provide information on how laws are interpreted or applied in practice, this analysis demonstrates that there are wide variations in how countries specify legal categories, including abortion on a woman’s request with no requirement for justification, legal grounds, and additional, but non-equivalent indications. Unpacking each category and revealing the nuances that exist within legal texts acts a starting point to the discourse around when abortion is allowed or permitted.

Determining what is included within a legal category

The circumstances under which abortion is lawful may be unclear to women and service providers attempting to navigate vague or complex laws . The World Health Organization (WHO) describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [ 13 ]. While all WHO Member States accept this definition of health, many countries’ laws do not refer to either the WHO definition or reference explicitly all the component parts of health. The results demonstrate that sometimes health is specified in a variety of ways in legal texts. Where laws contain a specific list of health indications for which an abortion can be performed, questions may arise as to whether service providers will interpret these lists restrictively or whether they will consider them as illustrations, which do not preclude clinical judgment [ 14 ]. Where mental health is not specified, it may not necessarily mean that women with mental health conditions are now lawfully entitled to abortion, given that service providers exercise sole discretion as to whether these conditions will be considered under a more broadly framed ‘health’ indication. Similarly, in cases such as New Zealand, where rape may be considered if the woman is faced with a serious danger in terms of a threat to her life or her physical or mental health, questions arise as to how that effect is assessed.

However, there may be value in the law being vague as it relates to health and other grounds, as access may be available more broadly, in line with the WHO definition. Similarly, countries’ laws that contain vague language, such as ‘therapeutic purposes’, ‘very serious medical reasons’, or ‘necessary treatment to the woman’ may permit health-care providers to apply these indications consistent with their obligation to the health and well-being of their patients. Thus, these indications may apply when there is a threat to the woman’s life or health, in cases where a fetal condition is present, or where a woman faces economic or social circumstances requiring necessary treatment.

Physicians may also apply such grounds against the knowledge that women may seek clandestine abortion, which depending on the context, can pose risks to life and health [ 14 ]. In one country (Bangladesh), despite a restrictive penal code, which offers only a life ground for abortion, menstrual regulation is a lawful way to “to reduce the incidence of unwanted pregnancies and unsafe abortions” [ 15 ]. Specifically, menstrual regulation is available “as a backup family planning method” to women with a last menstrual period of 10 weeks or less who may be “at risk of pregnancy, whether or not [they are] actually pregnant” [ 15 ]. Providers may also appreciate the risks associated with a continued pregnancy, including the fact that 75% of global maternal deaths are a result of direct obstetric causes [ 16 ], or that mortality associated with childbirth is approximately 14 times higher than that of abortion [ 17 ].

However, without specified legal categories or clear language, and where severe penalties may exist, health-care providers may interpret legal grounds narrowly, restricting access to safe abortion beyond what the law requires. For example, according to a study in Argentina, interpretation related to the scope of the health ground, as well as whether the rape ground applies to all women or only those with mental disabilities, has hindered access to abortion [ 18 ]. Even where a ground is explicitly stated in the law and supported by providers, this same study reveals that only 50% of providers are willing to perform an abortion [ 18 ]. These interpretations may be motivated by culture and gender stereotypes [ 18 ]. While almost all countries allow or permit abortion on the basis of some life-related ground ( N  = 133), variations in interpretation or lack of appreciation of the severity of the risk can have devastating consequences [ 19 ].

Additionally, fear of liability may lead health-care providers to limit access well before a gestational limit has been reached for a permitted legal ground [ 20 ]. Interpretation may also impact available methods; for example, service providers may feel they cannot provide medical abortions in countries where the only legal basis for abortion is a medical or surgical operations clause. Thus, greater concerns about abortion access and safety arise when there is lack of clarity related to the law, as providers must balance the risk of potential criminal liability or other self-interests against the needs and desires of the woman.

The legal categories for abortion cannot be neatly packaged into discrete classes based on common legal grounds. It is only by examining the text of the law that nuances are exposed. Subsuming these specific circumstances under common legal grounds provides a false sense of certainty about the legal status and availability of abortion services within a country. For example, in Belgium, Hungary, Netherlands, and Switzerland, countries that have been previously classified as permitting abortion on request, are found on review of the text to permit abortion within the context of a claim of distress where a written or verbal statement is required by the woman describing her situation as one of crisis or emergency or distress.

Legitimizing or delegitimizing women’s claims to abortion

Laws that specify individual legal grounds reflect the perceived legitimacy of some of the reasons women may have for wanting an abortion. Our analysis demonstrates that in most countries’ laws, abortion based on the legal ground of life threat is the most common, followed by health threat, fetal condition and rape, suggesting a hierarchy in the acceptability of women’s reasons. It could be argued that entitlement to abortion is based on a cumulative effect – the more grounds that exist, the greater the likelihood that women in different circumstances may qualify under one of these grounds. However, this raises questions related to fairness and equity regarding why countries single out specific conditions for entitlement to abortion, especially when women more often seek abortion based on socio-economic issues, age, health, family life, and marital status [ 21 ], rather than based on a life threat or rape ground.

This issue is further compounded by associated gestational limits; the wide variation in gestational limits demonstrates that they are not based on evidence. In the case of a fetal impairment indication, for instance, it may be difficult for a woman to comply with a gestational limit of 8 weeks when this time limit is several weeks before usual diagnostic tests are undertaken. Gestational limits narrow a woman’s options as the pregnancy progresses making legal grounds with higher gestational limits appear as more significant than those with lower limits.

Moreover, laws that impose time limits on the length of pregnancy for which abortion can be performed can force some women to seek clandestine abortion or to seek services in other countries, which is costly, delays access (thus increasing health risk) and creates social inequities [ 22 ]. It is for this reason that reducing unsafe abortion and abortion-related morbidity and mortality are less related to the total aggregate of grounds available and more related to access based on broad socioeconomic grounds or at the woman’s request [ 21 ].

This paper focuses on only one aspect of legal abortion; access must be considered within the broader context of sexual and reproductive healthcare. For example, additional barriers may be linked to legal categories and are often inscribed in the law; such barriers include mandatory waiting periods, requirements for third-party authorizations, conscientious objection, and reporting requirements in cases of rape. Laws related to contraception, financing of abortion, and access to medical information also impact how laws and policies are translated into practice. Additionally, national laws exist within a greater international context. The GAPD includes all UN Treaty Monitoring Body concluding observations and Special Procedures reports that have addressed abortion since the year 2000; human rights and UN treaty bodies have reiterated state’s obligations in terms of regulation of abortion and that the “right to sexual and reproductive health is an integral part of the right to health” [ 23 ].

The GAPD aims to increase transparency of information and accountability of countries for the protection of individuals’ health and human rights in the context of abortion. The database expands on existing knowledge related to the legal categories of abortion by capturing unique or complex policy nuances, a starting point by which to better consider legal entitlements to abortion.

This paper highlights the wide variation that exists in legal texts across countries related to the legal categories of abortion demonstrating several indications that have previously been obscured behind more simplistic classification schemes. Illuminating the complexities that exist reveals additional burdens on women and health-care providers to interpret legal categories related to abortion. Moreover, women seek abortion services based on one or more reasons which do not neatly fit into distinct legal classifications, and providers are relied upon to determine a woman’s eligibility based on their interpretation of these laws, creating an illusion of transparency that does not necessarily reflect the actual scope and potential limits of the law. With so much variance in legal texts, questions arise as to how women and healthcare workers appreciate these nuances both within and among different legal categories. Further research is needed to investigate the interpretation and implementation of these laws in practice, including how abortion legal categories co-exist among other laws related to reproductive health and how they are applied across various social, cultural, political, and economic contexts.

Information in the GAPD changes as new sources are received and verified.

‘Other’ includes countries with caveats, stipulations or countries where additional qualifications linked to a woman’s request are required; these countries are not represented as having abortion on request in the GAPD. Results for these countries are presented as an access ground based on a specific legal indication.

In Tajikistan, an order of the Minister of Health containing National Standards for safe abortion and post abortion care exist and may contain information related to gestational limits, but is not reflected here as this source could not be translated.

Africa: Malawi and Uganda; Oceania: Kiribati, Nauru, Papua New Guinea, Solomon Islands, and Tuvalu.

Africa: Cote d’Ivoire, Democratic Republic of the Congo, Libya, Malawi, South Sudan, Uganda; Asia: Afghanistan, Bahrain, Brunei Darussalam, Lebanon, Myanmar, Oman, Sri Lanka, Syrian Arab Republic and Yemen; Europe: Ireland; Latin America and Caribbean: Guatemala, Paraguay, and Venezuela; Oceania: Cook Islands, Kiribati, Nauru, Papua New Guinea, and Solomon Islands.

Argentina, Bolivia, Chad, Columbia, Ecuador, Hungary, Iceland, Thailand, Trinidad and Tobago, and Uruguay.

Bulgaria, Cuba, Czech Republic, Guyana, Moldova, Mozambique, Timor Leste, Tunisia, and Uzbekistan.

Abbreviations

Global Abortion Policies Database

World Health Organization

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Acknowledgements

The authors would like to thank Rajat Khosla for his participation in early conceptualization discussions related to this manuscript. The authors also thank Joanna Erdman for her thorough review and suggestions for manuscript revision.

This work was funded by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). Collection of the data, analysis, and composition of this manuscript was performed by WHO staff members and a WHO consultant. AL’s, BG’s, BRJ’s, and SS’s salary is supported by the HRP Trust Fund.

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The data generated and/or analysed during the current study are available in the publicly available Global Abortion Policies Database [ srhr.org/abortion-policies /].

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Lavelanet, A.F., Schlitt, S., Johnson, B.R. et al. Global Abortion Policies Database: a descriptive analysis of the legal categories of lawful abortion. BMC Int Health Hum Rights 18 , 44 (2018). https://doi.org/10.1186/s12914-018-0183-1

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What can economic research tell us about the effect of abortion access on women’s lives?

Subscribe to the center for economic security and opportunity newsletter, caitlin knowles myers and caitlin knowles myers john g. mccullough professor of economics; co-director, middlebury initiative for data and digital methods - middlebury college @caitlin_k_myers morgan welch morgan welch senior research assistant & project coordinator - center on children and families, economic studies, brookings institution.

November 30, 2021

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On September 20, 2021, a group of 154 distinguished economists and researchers filed an amicus brief to the Supreme Court of the United States in advance of the Mississippi case, Dobbs v. Jackson Women’s Health Organization . For a full review of the evidence that shows how causal inference tools have been used to measure the effects of abortion access in the U.S., read the brief here .

Introduction

Dobbs v. Jackson Women’s Health Organization considers the constitutionality of a 2018 Mississippi law that prohibits women from accessing abortions after 15 weeks of pregnancy. This case is widely expected to determine the fate of Roe v. Wade as Mississippi is directly challenging the precedent set by the Supreme Court’s decisions in Roe , which protects abortion access before fetal viability (typically between 24 and 28 weeks of pregnancy). On December 1, 2021, the Supreme Court will hear oral arguments in Dobbs v. Jackson . In asking the Court to overturn Roe , the state of Mississippi offers reassurances that “there is simply no causal link between the availability of abortion and the capacity of women to act in society” 1 and hence no reason to believe that abortion access has shaped “the ability of women to participate equally in the economic and social life of the Nation” 2 as the Court had previously held.

While the debate over abortion often centers on largely intractable subjective questions of ethics and morality, in this instance the Court is being asked to consider an objective question about the causal effects of abortion access on the lives of women and their families. The field of economics affords insights into these objective questions through the application of sophisticated methodological approaches that can be used to isolate and measure the causal effects of abortion access on reproductive, social, and economic outcomes for women and their families.

Separating Correlation from Causation: The “Credibility Revolution” in Economics

To measure the causal effect of abortion on women’s lives, one must differentiate its effects from those of other forces, such as economic opportunity, social mores, the availability of contraception. Powerful statistical methodologies in the causal inference toolbox have made it possible for economists to do just that, moving beyond the maxim “correlation isn’t necessarily causation” and applying the scientific method to figure out when it is.

This year’s decision by the Economic Sciences Prize Committee recognized the contributions 3 of economists David Card, Joshua Angrist, and Guido Imbens, awarding them the Nobel Prize for their pathbreaking work developing and applying the tools of causal inference in a movement dubbed “the credibility revolution” (Angrist and Pischke, 2010). The gold standard for establishing such credibility is a well-executed randomized controlled trial – an experiment conducted in the lab or field in which treatment is randomly assigned. When economists can feasibly and ethically implement such experiments, they do. However, in the social world, this opportunity is often not available. For instance, one cannot feasibly or ethically randomly assign abortion access to some individuals but not others. Faced with this obstacle, economists turn to “natural” or “quasi” experimental methods, ones in which they are able to credibly argue that treatment is as good as randomly assigned.

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Pioneering applications of this approach include work by Angrist and Krueger (1991) leveraging variation in compulsory school attendance laws to measure the effects of schooling on earnings and work by Card and Krueger (1994) leveraging minimum wage variation across state borders to measure the effects of the minimum wages on employment outcomes. The use of these methods is now widespread, not just in economics, but in other social sciences as well. Fueled by advances in computing technology and the availability of data, quasi-experimental methodologies have become as ubiquitous as they are powerful, applied to answer questions ranging from the effects of economic shocks on civil conflict (Miguel, Sayanath, and Sergenti, 2004), to the effects of the Clean Water Act on water pollution levels (Keiser and Shapiro, 2019), and effects of access to food stamps in childhood on later life outcomes (Hoynes, Schanzenbach, Almond 2016; Bailey et al., 2020).

Research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers.

Economists also have applied these tools to study the causal effects of abortion access. Research drawing on methods from the “credibility revolution” disentangles the effects of abortion policy from other societal and economic forces. This research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers, outcomes which then reverberate through their lives, affecting marriage patterns, educational attainment, labor force participation, and earnings.

The Effects of Abortion Access on Women’s Reproductive, Economic, and Social Lives

Evidence of the effects of abortion legalization.

The history of abortion legalization in the United States affords both a canonical and salient example of a natural experiment. While Roe v. Wade legalized abortion in most of the country in 1973, five states—Alaska, California, Hawaii, New York, and Washington—and the District of Columbia repealed their abortion bans several years in advance of Roe . Using a methodology known as “difference-in-difference estimation,” researchers compared changes in outcomes in these “repeal states” when they lifted abortion bans to changes in outcomes in the rest of the country. They also compared changes in outcomes in the rest of the country in 1973 when Roe legalized abortion to changes in outcomes in the repeal states where abortion already was legal. This difference-in-differences methodology allows the states where abortion access is not changing to serve as a counterfactual or “control” group that accounts for other forces that were impacting fertility and women’s lives in the Roe era.

Among the first to employ this approach was a team of economists (Levine, Staiger, Kane, and Zimmerman, 1999) who estimated that the legalization of abortion in repeal states led to a 4% to 11% decline in births in those states relative to the rest of the country. Levine and his co-authors found that these fertility effects were particularly large for teens and women of color, who experienced birth rate reductions that were nearly three times greater than the overall population as a result of abortion legalization. Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For example, Myers (2017) found that abortion legalization reduced the number of women who became teen mothers by 34% and the number who became teen brides by 20%, and again observed effects that were even larger for Black teens. Farin, Hoehn-Velasco, and Pesko (2021) found that abortion legalization reduced maternal mortality among Black women by 30-40%, with little impact on white women, offering the explanation that where abortion was illegal, Black women were less likely to be able to access safe abortions by traveling to other states or countries or by obtaining a clandestine abortion from a trusted health care provider.

The ripple effects of abortion access on the lives of women and their families

This research, which clearly demonstrates the causal relationship between abortion access and first-order demographic and health outcomes, laid the foundation for researchers ­to measure further ripple effects through the lives of women and their families. Multiple teams of authors have extended the difference-in-differences research designs to study educational and labor market outcomes, finding that abortion legalization increased women’s education, labor force participation, occupational prestige, and earnings and that all these effects were particularly large for Black women (Angrist and Evans, 1996; Kalist, 2004; Lindo, Pineda-Torres, Pritchard, and Tajali, 2020; Jones, 2021).

Additionally, research shows that abortion access has not only had profound effects on women’s economic and social lives but has also impacted the circumstances into which children are born. Researchers using difference-in-differences research designs have found that abortion legalization reduced the number of children who were unwanted (Bitler and Zavodny, 2002a, reduced cases of child neglect and abuse (Bitler and Zavodny, 2002b; 2004), reduced the number of children who lived in poverty (Gruber, Levine, and Staiger, 1999), and improved long-run outcomes of an entire generation of children by increasing the likelihood of attending college and reducing the likelihood of living in poverty and receiving public assistance (Ananat, Gruber, Levine, and Staiger, 2009).

Access to abortion continues to be important to women’s lives

The research cited above relies on variation in abortion access from the 1970s, and much has changed in terms of both reproductive technologies and women’s lives. Recent research shows, however, that even with the social, economic, and legal shifts that have occurred over the last few decades and even with expanded access to contraception, abortion access remains relevant to women’s reproductive lives. Today, nearly half of pregnancies are unintended (Finer and Zolna, 2016). About 6% of young women (ages 15-34) experience an unintended pregnancy each year (Finer, Lindberg, and Desai, 2018), and about 1.4% of women of childbearing age obtain an abortion each year (Jones, Witwer, and Jerman, 2019). At these rates, approximately one in four women will receive an abortion in their reproductive lifetimes. The fact is clear: women continue to rely on abortion access to determine their reproductive lives.

But what about their economic and social lives? While women have made great progress in terms of their educational attainment, career trajectories, and role in society, mothers face a variety of challenges and penalties that are not adequately addressed by public policy. Following the birth of a child, it’s well documented that working mothers face a “motherhood wage penalty,” which entails lower wages than women who did not have a child (Waldfogel, 1998; Anderson, Binder, and Krause, 2002; Kelven et al., 2019). Maternity leave may combat this penalty as it allows women to return to their jobs following the birth of a child – encouraging them to remain attached to the labor force (Rossin-Slater, 2017). However, as of this writing, the U.S. only offers up to 12 weeks of unpaid leave through the FMLA, which extends coverage to less than 60% of all workers. 5 And even if a mother is able to return to work, childcare in the U.S. is costly and often inaccessible for many. Families with infants can be expected to pay around $11,000 a year for childcare and subsidies are only available for 1 in 6 children that are eligible under the federal program. 6 Without a federal paid leave policy and access to affordable childcare, the U.S. lacks the infrastructure to adequately support mothers, and especially working mothers – making the prospect of motherhood financially unworkable for some.

This is relevant when considering that the women who seek abortions tend to be low-income mothers experiencing disruptive life events. In the most recent survey of abortion patients conducted by the Guttmacher Institute, 97% are adults, 49% are living below the poverty line, 59% already have children, and 55% are experiencing a disruptive life event such as losing a job, breaking up with a partner, or falling behind on rent (Jones and Jerman, 2017a and 2017b). It is not a stretch to imagine that access to abortion could be pivotal to these women’s financial lives, and recent evidence from “The Turnaway Study” 7 provides empirical support for this supposition. In this study, an interdisciplinary team of researchers follows two groups of women who were typically seeking abortions in the second trimester: one group that arrived at abortion clinics and learned they were just over the gestational age threshold for abortions and were “turned away” and a second that was just under the threshold and were provided an abortion. Miller, Wherry, and Foster (2020) match individuals in both groups to their Experian credit reports and observe that in the months leading up to the moment they sought an abortion, financial outcomes for both groups were trending similarly. At the moment one group is turned away from a wanted abortion, however, they began to experience substantial financial distress, exhibiting a 78% increase in past-due debt and an 81% increase in public records related to bankruptcies, evictions, and court judgments.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase. Twelve states have enacted “trigger bans” designed to outlaw abortion in the immediate aftermath of a Roe reversal, while an additional 10 are considered highly likely to quickly enact new bans. 8 These bans would shutter abortion facilities across a wide swath of the American south and midwest, dramatically increasing travel distances and the logistical costs of obtaining an abortion. Economics research predicts what is likely to happen next. Multiple teams of economists have exploited natural experiments arising from mandatory waiting periods (Joyce and Kaestner, 2001; Lindo and Pineda-Torres, 2021; Myers, 2021) and provider closures (Quast, Gonzalez, and Ziemba, 2017; Fischer, Royer, and White, 2018; Lindo, Myers, Schlosser, and Cunningham, 2020; Venator and Fletcher, 2021; Myers, 2021). All have found that increases in travel distances prevent large numbers of women seeking abortions from reaching a provider and that most of these women give birth as a result. For instance, Lindo and co-authors (2020) exploit a natural experiment arising from the sudden closure of half of Texas’s abortion clinics in 2013 and find that an increase in travel distance from 0 to 100 miles results in a 25.8% decrease in abortions. Myers, Jones, and Upadhyay (2019) use these results to envision a post- Roe United States, forecasting that if Roe is overturned and the expected states begin to ban abortions, approximately 1/3 of women living in affected regions would be unable to reach an abortion provider, amounting to roughly 100,000 women in the first year alone.

Restricting, or outright eliminating, abortion access by overturning Roe v. Wade  would diminish women’s personal and economic lives, as well as the lives of their families.

Whether one’s stance on abortion access is driven by deeply held views on women’s bodily autonomy or when life begins, the decades of research using rigorous methods is clear: there is a causal link between access to abortion and whether, when, and under what circumstances women become mothers, with ripple effects throughout their lives. Access affects their education, earnings, careers, and the subsequent life outcomes for their children. In the state’s argument, Mississippi rejects the causal link between access to abortion and societal outcomes established by economists and states that the availability of abortion isn’t relevant to women’s full participation in society. Economists provide clear evidence that overturning Roe would prevent large numbers of women experiencing unintended pregnancies—many of whom are low-income and financially vulnerable mothers—from obtaining desired abortions. Restricting, or outright eliminating, that access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Caitlin Knowles Myers did not receive financial support from any firm or person for this article. She has received financial compensation from Planned Parenthood Federation of America and the Center for Reproductive Rights for serving as an expert witness in litigation involving abortion regulations. She has not and will not receive financial compensation for her role in the amicus brief described here. Other than the aforementioned, she has not received financial support from any firm or person with a financial or political interest in this article. Caitlin Knowles Myers is not currently an officer, director, or board member of any organization with a financial or political interest in this article.

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Joyce, Ted, and Robert Kaestner, 2001. “The Impact of Mandatory Waiting Periods and Parental Consent Laws on the Timing of Abortion and State of Occurrence among Adolescents in Mississippi and South Carolina.” Journal of Policy Analysis and Management 20(2) . Retrieved from https://www.jstor.org/stable/3325799 .

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• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief in Support of Petitioners, No. 19-1392.
• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief for Petitioners, No. 19-139, Retrieved from https://www.supremecourt.gov/DocketPDF/19/19-1392/184703/20210722161332385_19-1392BriefForPetitioners.pdf
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• Whitehurst, Grover J., April 19, 2018. “What is the market price of daycare and preschool?” Brookings Institution. Retrieved from https://www.brookings.edu/research/what-is-the-market-price-of-daycare-and-preschool/; Chien, Nina, 2021. “Factsheet: Estimates of Child Care Eligibility & Receipt for Fiscal Year 2018.” U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/20 21-08/cy-2018-child-care-subsidy-eligibility.pdf
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Economic Studies

Center for Economic Security and Opportunity

William A. Galston

May 1, 2024

John J. DiIulio, Jr.

April 15, 2024

April 4, 2024

Abortion in modern health care: Considering the issues for health-care professionals

Affiliations.

• 1 General Nursing Intern, School of Nursing, Waterford Institute of Technology, Cork Road, Waterford, Ireland.
• 2 Lecturer in Nursing, School of Health Sciences, Waterford Institute of Technology, Cork Road, Waterford, Ireland.
• PMID: 26818437
• DOI: 10.1111/ijn.12421

This paper explores the challenging and contentious issue of abortion and its ethical, legal and political significance regarding public health. It is intended as an educational guide for health-care professionals. A comprehensive search strategy of international health, law and political source materials was undertaken in order to benchmark from international approaches to abortion. Test cases illustrate the application of legislation, ethical, political and cultural issues surrounding abortion. Abortion is a complex contemporary issue where balancing the well-being of both the mother and the unborn has prompted considerable international discourse. The right to life of the woman and the unborn continues to lie in tension. Ambiguity surrounds the concept of personhood, and the inception of human life prevails across many International jurisdictions. Health-care professionals must be well informed in order to respond safely and appropriately to a diverse range of clinical scenarios in which decisions regarding abortion are required. Research and evidence of test cases will better inform how abortion issues evolve and are managed. Ultimately, the abortion debate requires a balance between legislation and clinical governance.

Keywords: abortion; clinical dilemmas; personhood; public health; right to life.

© 2016 John Wiley & Sons Australia, Ltd.

• Abortion, Legal* / ethics
• Abortion, Legal* / legislation & jurisprudence
• Abortion, Legal* / psychology
• Beginning of Human Life
• Ethics, Medical
• Health Personnel / education
• Health Personnel / ethics
• Health Personnel / legislation & jurisprudence
• Human Rights*
• Social Values

Legalized Abortion and the Public Health: Report of a Study (1975)

Chapter: summary and conclusions.

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

SUMMARY AND CONCLUSIONS The legal status of abortion in the United States became a heightened national issue with the January 1973 rulings by the Supreme Court that severely limited states' rights to control the procedure. The Court's decisions on the historic cases of Roe v. Wade and Doe v. Bolton precluded any state interference with the doctor-patient decision on abortion during the first trimester (three months) of pregnancy. During the second trimester, a state could intervene only to the extent of insisting on safe medical practices "reasonably related to maternal health." And for approximately the final trimester of a pregnancy—what the Court called "the state subsequent to viability" of a fetus—a state could forbid abortion unless medical judgment found it necessary "for the preservation of the life or health of the mother." The rulings crystallized opposition to abortion, led to the intro- duction of national and state legislation to curtail or prohibit it, and generated political pressures for a national debate on the issue. Against this background of concerns about abortion, the Institute of Medicine in 1974 called together a committee to review the existing evidence on the relationship between legalized abortion and the health of the public. The study group was asked to examine the medical risks to women who obtained legal abortions, and to document changes in the risks as legal abortion became more available. Although there have been other publications on particular relationships between abortion and health, the Institute's study is an attempt to enlist scholars, researchers, health practitioners, and concerned lay persons in a more comprehensive analysis of the available medical information on the subject. Ethical issues of abortion are not discussed in this analysis, nor are questions concerning the fetus in abortion. The study group recog- nizes that this approach implies an ethical position with which some may disagree. The emphasis of the study is on the health effects of abortion, not on the alternatives to abortion.

Abortion legislation and practices are important factors in the relationship between abortion and health status. In order to examine legislation and court decisions that have affected the availability of legal abortion in the U.S., the study group classified the laws and practices into three categories: restrictive conditions, under which abortion is prohibited or permitted only to save the pregnant woman's life; moderately restrictive conditions, under which abortion is per- mitted with approval by several physicians, in a wider range of circumstances to preserve the woman's physical or mental health, prevent the birth of a child with severe genetic or congenital defects, or terminate a pregnancy caused by rape or incest; and non-restrictive conditions, under which abortion essentially is available according to the terms of the Supreme Court ruling. Before 1967, all abortion laws in the United States could be classified as restrictive. Easing of restrictions began in 1967 with Colorado, and soon thereafter 12 other states also adopted moderately restrictive legislation to expand the conditions under which therapeutic abortion could be obtained. In 1970, four states (Alaska, Hawaii, New York, and Washington) removed nearly all legal controls on abortion. Non-restrictive conditions have theoretically existed throughout all fifty states since January 22, 1973, the date of the Supreme Court decision. There is evidence that substantial numbers of illegal abortions were obtained in the U.S. when restrictive laws were in force. Although some of the illegal abortions were performed covertly by physicians in medical settings, many were conducted in unsanitary surroundings by unskilled operators or were self-induced. In this report, "illegal abortion" generally refers to those performed by a non-physician or the woman herself. The medical risks associated with the last two types of illegal abortions are patently greater than with the first. A recent analysis of data from the first year of New York's non- restrictive abortion legislation indicates that approximately 70 percent of the abortions obtained legally in New York City would otherwise have been obtained illegally. Replacement of legal for illegal abortions also is reflected in the substantial decline in the number of reported complications and deaths due to other-than-legal abortions since non- restrictive practices began to be implemented in the United States. The number of all known abortion-related deaths declined from 128 in 1970 to 47 in 1973; those deaths specifically attributed to other-than-legal abortions (i.e., both illegal and spontaneous) dropped from 111 to 25 during the same period, with much of that decline attributed to a reduced incidence of illegal abortions. Increased use of effective con- traception may also have played a role in the decline of abortion-related deaths. Methods most frequently used in the United States to induce abortion during the first trimester of pregnancy are suction (vacuum aspiration) or dilatation and curettage (D&C). Abortions in the second trimester are usually performed by replacing part of the amniotic fluid that surrounds

the fetus with a concentrated salt solution (saline abortion), which usually induces labor 24 to 48 hours later. Other second trimester methods are hysterotomy, a surgical entry into the uterus; hysterectomy, which is the removal of the uterus; and, recently, the injection into the uterine cavity of a prostaglandin, a substance that causes muscular contractions that expel the fetus. Statistics on legal abortion are collected for the U.S. government by the Center for Disease Control. CDC's most recent nationwide data are for 1973, the year of the Supreme Court decision. Some of those figures are: — The 615,800 legal abortions reported in 1973 were an increase of approximately 29,000 over the number reported in 1972. These probably are underestimates of the actual number of abortions performed because some states have not yet developed adequate abortion reporting systems. — The abortion ratio (number of abortions per 1,000 live births) increased from 180 in 1972 to 195 in 1973. — More than four out of five abortions were performed in the first trimester, most often by suction or D&C. — Approximately 25 percent of the reported 1973 abortions were obtained outside the woman's home state. In 1972, before the Supreme Court decision, 44 percent of the reported abortions had been obtained outside the home state of the patient, primarily in New York and the District of Columbia. — Approximately one-third of the women obtaining abortions were less than 20 years old, another third were between 20 and 25, and the remaining third over 25 years of age. — In all states where data were available, about 25 percent of the women obtaining abortions were married. — White women obtained 68 percent of all reported abortions, but non-white women had abortion ratios about one-third greater than white women. In 1972, non-white women had abortion rates (abortions per 1,000 women of reproductive age) about twice those of whites in three states from which data were available to analyze. A national survey of hospitals, clinics, and physicians conducted in 1974 by The Alan Guttmacher Institute furnished data on the number of abortions performed in the U.S. during 1973, itemized by state and type of provider. A total of 745,400 abortions were reported in the survey, a figure higher than the 615,800 abortions reported in 1973 to CDC. The Guttmacher Institute obtains its data from providers of health services, while CDC gets most of its data from state health departments.

Risks of medical complications associated with legal abortions are difficult to evaluate because of problems of definition and subjective physician judgment. Available information from 66 centers is provided by the Joint Program for the Study of Abortion, undertaken by The Population Council in 1970-1971. The JPSA study surveyed almost 73,000 legal abortions. It used a restricted definition of major complications, which included unintended major surgery, one or more blood transfusions, three or more days of fever, and several other categories involving prolonged illness or permanent impairment. Although this study also collected data on minor complica- tions, such as one day of fever post-operatively, the data on major com- plications are probably more significant. The major complication rates published by the JPSA study and summarized below relate to women who had abortions in local facilities and from whom follow-up information was obtained. — Complications in women not obtaining concurrent sterilization and with no pre-existing medical problems (e.g., diabetes, heart disease, or gynecological problems) occurred 0.6 times per 100 abortions in the first trimester and 2.1 per 100 in the second trimester. — Complications in women not obtaining concurrent sterilization, but having pre-existing problems, occurred 2.0 times per 100 in the first trimester and 6.7 in the second. — Complications in women obtaining concurrent sterilization and not having pre-existing problems occurred 7.2 times per 100 in the first trimester and 8.0 in the second. — Women with both concurrent sterilization and pre-existing problems experienced complications approximately 17 times per 100 abortions regardless of trimester. The relatively high complication rates associated with sterilization in the JPSA study would probably be lower today because new sterilization techniques require minimal surgery and carry lower rates of complications. The frequency of medical complications due to illegal abortions cannot be calculated precisely, but the trend in these complications can be estimated from the number of hospital admissions due to septic and incomplete abortion—two adverse consequences of the illegal procedure.

The number of such admissions in New York City's municipal hospitals declined from 6,524 in 1969 to 3,253 in 1973; most restrictions on legal abortion in New York City were lifted in July of 1970. In Los Angeles, the number of reported hospital admissions for septic abortions declined from 559 in 1969 to 119 in 1971. Other factors, such as an increased use of effective contraception and a decreasing rate of unwanted pregnancies may have contributed to these declines, but it is probable that the introduction of less restrictive abortion legislation was a major factor. There has not been enough experience with legal abortion in the U.S. for conclusions to be drawn about long-term complications, particularly for women obtaining repeated legal abortions. Some studies from abroad suggest that long-term complications may include prematurity, miscarriage, or ectopic pregnancies in future pregnancies, or infertility. But research findings from countries having long experience with legal abortion are inconsistent among studies and the relevance of these data to the U.S. is not known; methods of abortion, medical services, and socio-economic characteristics vary from one country to another. Risks of maternal death associated with legal abortion are low—1.7 deaths per 100,000 first trimester procedures in 1972 and 1973—and less than the risks associated with illegal abortion, full-term pregnancy, and most surgical procedures. The 1973 mortality rate for a full-term pregnancy was 14 deaths per 100,000 live vaginal deliveries; the 1969 rate for cesarean sections was 111 deaths per 100,000 deliveries. For second trimester abortions, the combined 1972-73 mortality ratio was 12.2 deaths per 100,000 abortions. (For comparison, the surgical removal of the tonsils and adenoids had a mortality risk of five deaths per 100,000 operations in 1969). When the mortality risk of legal abortion is examined by length of gestation it becomes apparent that the mortality risks increase not only from the first to the second trimester, but also by each week of ges- tation. For example, during 1972-73, the mortality ratio for legal abortions performed at eight weeks or less was 0.5, and for those performed between nine and 10 weeks was 1.7 deaths per 100,000 legal abortions. At 11 to 12 weeks the mortality ratio increased to 4.2 deaths, and by 16 to 20 weeks, the ratio was more than 17 deaths per 100,000 abortions. Hysterotomy and hysterectomy, methods performed infrequently in both trimesters, had a combined mortality ratio of 61.3 deaths per 100,000 procedures. Some data on the mortality associated with illegal abortion are avail- lable from the National Center for Health Statistics (NCHS) and from CDC. In 1961 there were 320 abortion-related deaths reported in the U.S., most of them presumed by the medical profession to be from illegal abortion. By 1973, total reported deaths had declined to 47, of which 16 were specifi- cally attributed to illegal abortions. There has been a steady decline in the mortality rates (number of deaths per 100,000 women aged 15-44) associated with other-than-legal abortion for both white and non-white women, but in 1973 the mortality rate for non-white women (0.29) was almost ten times greater than that reported for white women (0.03).

Psychological effects of legal abortion are difficult to evaluate for reasons that include lack of information on pre-abortion psychological status, ambiguous terminology, and the absence of standardized measurements. The cumulative evidence in recent years indicates that although it may be a stressful experience, abortion is not associated with any detectable increase in the incidence of mental illness. The depression or guilt feelings reported by some women following abortion are generally described as mild and temporary. This experience, however, does not necessarily apply to women with a previous history of psychiatric illness; for them, abortion may be followed by continued or aggravated mental illness. The JPSA survey led to an estimate of the incidence of post-abortion psychosis ranging from 0.2 to 0.4 per 1,000 legal abortions. This is lower than the post-partum psychosis rate of one to two per 1,000 deliveries in the United States. Psychological factors also bear on whether a woman obtains a first or second-trimester abortion. Two studies in particular suggest that women who delay abortion into the later period may have more feelings of ambiva- lence, denial of the pregnancy, or objection on religious grounds, than those obtaining abortions in the first trimester. It is also apparent, however, that some second-trimester abortions result from procedural delays, difficulties in obtaining a pregnancy test, locating appropriate counseling, or arranging and financing the procedure. Diagnosis of severe defects of a fetus well before birth has greatly advanced in the past decade. Developments in the techniques of amniocen- tesis and cell culture have enabled a number of genetic defects and other congenital disorders to be detected in the second trimester of pregnancy. Prenatal diagnosis and the opportunity to terminate an affected pregnancy by a legal abortion may help many women who would have refrained from becoming pregnant or might have given birth to an abnormal child, to bear children unaffected by the disease they fear. Abortion, with or with- out prenatal diagnosis, also can be used in instances where there is reasonable risk that the fetus may be affected by birth defects from non-genetic causes, such as those caused by exposure of the woman to rubella virus infection or x-rays, or by her ingestion of drugs known to damage the fetus. Almost 60 inherited metabolic disorders, such as Tay-Sachs disease, potentially can be diagnosed before birth. More than 20 of these diseases already have been diagnosed with reasonaable accuracy by means of amniocentesis and other procedures. The techniques also can be used to identify a fetus with abnormal chromosomes, as in Down's syndrome (mongolism), and to discriminate between male and female fetuses, which in such diseases as hemophilia would allow determination of whether the fetus was at risk of being affected or simply at risk of being a hereditary carrier of the disorder.

In North America, amniocentesis was performed in more than 6,000 second-trimester pregnancies between 1967 and 1974. The diagnostic accuracy was close to 100 percent and complication rates were about two percent. Less than 10 percent of the diagnoses disclosed an affected fetus, meaning that the great majority of parents at risk averted an unnecessary abortion and were able to carry an unaffected child to term. There are many limitations to the use of prenatal diagnosis, especially for mass screening purposes. Amniocentesis is a fairly expensive procedure, and relatively few medical personnel are qualified to administer it and carry out the necessary diagnostic tests. Only a small number of genetic disorders can now be identified by means of amniocentesis and many couples still have no way to determine whether or not they are to be the parents of a child with genetic defects. Nevertheless, the avail- ability of a legal abortion expands the options available to a woman who faces a known risk of having an affected child. Abortion as a substitute for contraception is one possibility raised by the adoption of non-restrictive abortion laws. Limited data do not allow definitive conclusions, but they suggest that the introduction of non-restrictive abortion laws in the U.S. has not lead to any documented decline in demand for contraceptive services. Among women who sought abortion and who had previously not used contraception or had used it poorly, there is some evidence that they may have begun to practice contraception because contraceptives were made available to them at the time of their abortion. The health aspects of this issue bear on the higher mortality and mor- bidity associated with abortion as compared with contraceptive use, and on the possibility that if women rely on abortion rather than contraception they may have repeated abortions, for which the risk of long-term compli- cations is not known. The incidence of repeated legal abortions is little known because legal abortion has only been widely available in the U.S. for a few years. Data from New York City indicate that during the first two years of non-restrictive laws 2.45 percent of the abortions obtained by residents were repeat procedures. If those two years are divided into six-month periods, repeated legal abortions as a percent of the total rose from 0.01 percent in the first period to 6.02 percent in the last. Part of this increase is attributable to a statistical fact: the longer non-restrictive laws are in effect, the greater the number of women eligible to have repeated legal abortions. Perhaps, too, the reporting system has improved. In any case, some low incidence of repeated abortions is to be expected because none of the current contraceptive methods is completely failureproof, nor are they likely to be used with maximum care on all occasions.

8 A recent study has suggested that one additional factor contributing to the incidence of repeated abortions is that abortion facilities may not routinely provide contraceptive services at the time of the procedure. This is of concern because of recent evidence that ovulation usually oc- curs within five weeks and perhaps as early as 10 days after an abortion. The conclusions of the study group: — Many women will seek to terminate an unwanted pregnancy by abortion whether it is legal or not. Although the mortality and morbidity . associated with illegal abortion cannot be fully measured, they are clearly greater than the risks associated with legal abortion. Evidence suggests that legislation and practices that permit women to obtain abortions in proper medical surroundings will lead to fewer deaths and a lower rate of medical complications than restrictive legislation and practices. —• The substantial differences between the mortality and morbidity associated with legal abortion in the first and second trimesters suggest that laws, medical practices, and educational programs should enable and encourage women who have chosen abortion to obtain it in the first three months of pregnancy. — More research is needed on the consequences of abortion on health status. Of highest priority are investigations of long-term medical complications, particularly after multiple abortions the effects of abortion and denied abortion on the mental health and social welfare of individuals and families the factors of motivation, behavior, and access associated with contraceptive use and the choice of abortion.

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How treatment of miscarriages is upending the abortion debate

For decades, the abortion wars have centered on whether a woman should be able to decide when and if she has a child. But with increasingly strict restrictions on reproductive rights being enacted across the United States, these debates are charting new, unfamiliar territory — medical care for women who have had miscarriages.

Up to one in four women who know they are pregnant will miscarry, according to the National Library of Medicine. Although most miscarriages resolve naturally, some require medical intervention that is similar to an elective abortion.

Democrats, who believe abortion led to strong outings in the 2020 and 2022 elections, are now showcasing the dangers of miscarriages as another reason to support abortion rights — and Democrats.

A seven-figure April ad buy in battleground states by President Biden’s reelection campaign highlights the story of a happily married pregnant Texas woman named Amanda Zurawski.

“At 18 weeks, Amanda’s water broke and she had a miscarriage,” the ad reads, with white lettering against a black background. “Because Donald Trump killed Roe v Wade, Amanda was denied standard medical care to prevent an infection, an abortion.”

The 60-second ad concludes “Donald Trump did this,” after showing Zurawski and her husband, Josh, looking through a box of items that they had bought in anticipation of the birth of their first child, including a baby book and the outfit they planned to dress her in to bring her home from the hospital.

The Biden campaign launched this ad a day before the Arizona Supreme Court upheld a near-total abortion ban dating back to 1864, a ruling that former President Trump, the presumptive 2024 GOP presidential nominee, Arizona Senate hopeful Kari Lake and other Republicans have struggled to explain as they simultaneously celebrate the U.S. Supreme Court overturning a federal right to abortion.

But the ad also reflects a reframing of how abortion is discussed as a moral issue. Democrat Bill Clinton famously said the procedure should be “safe, legal and rare” during his successful 1992 presidential bid.

But now even liberals say the emphasis on “rare” failed to recognize the medical necessity of some abortions, such as those performed after a miscarriage. Clinton’s framing also carried a connotation of shame for a woman seeking an abortion, whatever the reason.

“That framework was harmful and perpetuates stigma,” said Kelly Baden, vice president of public policy at the Guttmacher Institute, a nonprofit research organization that supports abortion access. “Every situation is complex and every situation is unique. People would rather err on the side of having government stay out of it all together rather than have politicians practice medicine.”

“Everyone knows someone who has been pregnant or loves a pregnant person,” she added. “To think that somebody’s health might not be protected even in a wanted pregnancy really cuts through some of the stigma abortion has had to face in the last 50 years.”

Evangelical leader Ralph Reed, the founder of the Faith and Freedom Coalition, counters that focusing on potential restrictions on miscarriage care — or fertility treatments in the aftermath of an Alabama Supreme Court ruling earlier this year — are red herrings put forth by liberals.

“This is a strategy to try and change the subject and shift the narrative,” Reed said.

“I know the Democrats want to develop it as a talking point,” he added, “but I can’t imagine that pro-life laws are going to lead women to not be able to get treated for a miscarriage. I think that’s the talking point they are trying to develop because they don’t want to talk about their own position on abortion. And frankly, I don’t blame them.”

About 80% of miscarriages among women who know they are pregnant resolve by themselves within eight weeks, with the fetus passing through the woman’s body without medical intervention, according to a 2018 paper by the American College of Obstetricians and Gynecologists and a 2019 report by KFF, an independent health policy organization.

But if the fetus or some of the tissue doesn’t pass, it needs to be removed to avoid potentially fatal medical complications for the woman, such as a sepsis infection, through drug-induced or surgical treatment.

Reproductive rights have been a political flash point for decades. But in addition to core ideological disagreements, both parties are hyper-focused on this issue this electoral cycle because of the Supreme Court’s 2022 decision to overturn Roe vs. Wade, the landmark 1973 ruling that granted federal protection of abortion rights. Since then, several states have severely restricted abortion access, while others have enshrined such access in their state constitutions.

The Supreme Court on Wednesday heard arguments in a case about whether the federal government can make hospitals that receive Medicare funding perform emergency abortions. Several justices appeared skeptical of an Idaho law that would make it illegal for physicians to perform such a procedure for a woman whose health was seriously jeopardized, but life not at risk.

Restrictions on reproductive rights are expected to be a pivotal issue among suburban, college-educated women, a key voter bloc in places like Orange County, as well as the suburbs of Philadelphia and Atlanta, critical regions that could determine control of Congress, and in some states, the presidency.

“Politically speaking, this is a big problem for Republicans,” said Barrett Marson, an Arizona-based GOP strategist. Still, Marson called on Republicans to support the 1864 anti-abortion law, even if it meant losing some elections.

“I have actually just started to say Republicans should embrace this law and go down with the ship,” he said. “Republicans should stand their moral ground. They have wanted to overturn Roe vs. Wade for generations. They finally have, and in Arizona, abortions are so limited, they literally only have one exception — the life of the mother. They should celebrate. That is horrendous campaign advice, but at least stick to your principles.”

The Arizona Supreme Court ruled recently that the 1864 law, which banned all abortions except to save the life of the woman and carried a two- to five-year prison sentence for abortion providers, could be enforced.

The Arizona House voted to repeal the law Wednesday and the state’s Senate is expected to vote to repeal it next week.

But even if repealed, the 1864 law would still go into effect for a period of time because repeals do not take effect until 90 days after the end of the legislative session. Then the state would revert to its prior restrictions on abortions after 15 weeks except for medical emergencies. (There is no exception for rape or incest.)

The uncertainty over legal restrictions on abortion and elsewhere is prompting women to seek out states where the procedure is still available.

Planned Parenthood Los Angeles, one of the nation’s largest abortion providers, has already seen women from Arizona and elsewhere seeking medical treatment here because they miscarried and couldn’t receive care in their home states.

“The impact of abortion bans extends far beyond what many people think of when they hear the word abortion,” said Sue Dunlap, president and CEO of Planned Parenthood Los Angeles.

“We have seen multiple patients travel from out of state for miscarriage care,” Dunlap said. “In at least one example, a patient flew to Los Angeles because she was unsure of the status of her pregnancy and felt unable to access the care she needed in her local community.

“Ultimately, patients are traveling hundreds of miles for care that theoretically should be permissible in their home state but that, in practice, becomes impossible to access due to fear and legal confusion.”

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Tracking Abortion Bans Across the Country

By The New York Times Updated May 1, 4:40 P.M. ET

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Twenty-one states ban abortion or restrict the procedure earlier in pregnancy than the standard set by Roe v. Wade, which governed reproductive rights for nearly half a century until the Supreme Court overturned the decision in 2022.

In some states, the fight over abortion access is still taking place in courtrooms, where advocates have sued to block bans and restrictions. Other states have moved to expand access to abortion by adding legal protections.

Latest updates

• The Arizona state legislature voted to repeal an 1864 ban on nearly all abortions. Officials warned that the near-total ban may be briefly enforceable this summer until the repeal takes effect in the fall. A 15-week ban remains in effect.
• A ban on abortion after about six weeks of pregnancy took effect in Florida , following a ruling by the Florida Supreme Court that the privacy protections of the state’s Constitution do not extend to abortion.

The New York Times is tracking abortion laws in each state after the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization , which ended the constitutional right to an abortion.

Where abortion is legal

In a few states that have enacted bans or restrictions, abortion remains legal for now as courts determine whether these laws can take effect. Abortion is legal in the rest of the country, and many states have added new protections since Dobbs.

Ban in effect

Note: TK note here.

Legal for now

State details.

More details on the current status of abortion in each state are below.

An earlier version of this article misstated the legal status of abortion in Utah. As of 4 p.m. on June 24, the state attorney general had issued a statement saying the state’s abortion ban had been triggered, but it had not yet been authorized by the legislature’s general counsel. By 8:30 p.m., the counsel authorized the ban and it went into effect.

A table in an earlier version of this article misstated which abortion ban is being challenged in Texas state court. Abortion rights supporters are challenging a pre-Roe ban, not the state’s trigger ban.

An earlier version of this article referred incorrectly to the legal status of abortion in Indiana. While Indiana abortion providers stopped offering abortion services in anticipation of an abortion ban taking effect on Aug. 1, the law did not take effect.

The Arizona State Senate voted 16 to 14 to repeal an abortion ban dating back to 1864, leaving it to Democratic Governor Katie Hobbs to sign the repeal into law, which she has committed to do.

The State Senate’s debate was contentious, with lawmakers delivering theatrical monologues frequently punctuated by cries of protest in the gallery.

The vote follows a ruling by Arizona’s Supreme Court that the 159-year-old law banning abortion was enforceable in the aftermath of the US Supreme Court’s 2022 decision to overturn abortion rights case   Roe v Wade,   sending a 52-year-old case back to trial court.

The Arizona State House took up and passed the bill to repeal the ban, HB2677, two weeks following the state Supreme Court’s ruling, sending the bill to the State Senate.

Arizona’s abortion ban was enacted shortly after it was designated as a   US territory and decades before it attained statehood. The ban was part of the   Howell Code , a comprehensive set of laws enacted by the territory’s First Legislative Assembly, encompassing procedural regulations and establishing criminal laws ranging from bigamy to duels to mayhem.

That code stated, in relevant part:

Every person who shall administer or cause to be administered or taken, any medicinal substances, or shall use or cause to be used any instruments whatever, with the intention to procure the miscarriage of any woman then being with child, and shall be thereof duly convicted, shall be punished by imprisonment in the Territorial prison for a term not less than two years nor more than five years.

The 1864 version provided an exception if a physician were to perform an abortion in order to save the mother’s life. The following year, the provision was amended slightly to stipulate that the life-saving exception could apply to anyone performing an abortion. The regulation has remained largely unchanged since 1865, and the near-total abortion ban was codified into Arizona state law in the early 20th century.

Acts of Union creates Great Britain

On May 1, 1707, the two Acts of Union went into effect, implementing the Treaty of Union and thereby uniting the Kingdom of England and Kingdom of Scotland to create the United Kingdom of Great Britain. The Union with Scotland Act was passed by the Parliament of England in 1706, and the Scottish Parliament promulgated the Union with England Act . Learn more about the Acts of Union from the Parliament of the United Kingdom.

First US trade union formed

On May 1, 1794, the Federal Society of Journeymen Cordwainers (shoemakers) was organized in Philadelphia to negotiate wages for its members, becoming the first trade union in the United States. Learn more about the history of the labor movement in the United States , and visit the website of the AFL-CIO , the federation of America's labor unions, representing more than 13 million workers.

US Supreme Court faces fight over emergency abortions after toppling Roe

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Tank fire echoed from the Gaza strip on Wednesday as U.S. Secretary of State Antony Blinken visited an aid inspection point, where he heard from Israeli officials including Defense Minister Yoav Gallant about efforts to increase assistance to the Palestinian enclave just a few hundred meters away.

Florida Democrats Hope Abortion and Marijuana Questions Draw Young Voters Despite Low Enthusiasm

Democrats believe young Florida voters will go to the polls in November because of the abortion and marijuana measures on the ballot

Cody Jackson

Jayden D'Onofrio passes out Plan B, condoms and rolling papers to educate young voters at Florida Atlantic University on Thursday, April 11 in Boca Raton, Fla. Abortion and marijuana will be on Florida's November ballot, and these issues are critical issues for young voters. (AP Photo/Cody Jackson)

WEST PALM BEACH, Fla. (AP) — Jordan Vassallo is lukewarm about casting her first presidential ballot for President Joe Biden in November. But when the 18-year-old senior at Jupiter High School in Florida thinks about the things she cares about, she says her vote for the Democratic incumbent is an “obvious choice.”

Vassallo will be voting for a constitutional ballot amendment that would prevent the state of Florida from prohibiting abortion before a fetus can survive on its own — essentially the standard that existed nationally before the U.S. Supreme Court struck down the constitutional protections to abortion and left the matter for states to decide.

Passage of the amendment would wipe away Florida's six-week abortion law, which is set to take effect Wednesday. Vassallo says the ban makes no sense.

“Most people don't know they are pregnant at six weeks,” she said.

Biden, despite her reticence, will get her vote as well.

In Florida and across the nation, voters in Vassallo's age group could prove pivotal in the 2024 election , from the presidency to ballot amendments and down ballot races that will determine who controls Congress. She is likely to be among more than 8 million new voters eligible to vote this November since the 2022 elections, according to Tufts University Center for Information and Research on Civic Learning and Engagement.

Photos You Should See - April 2024

While some of those voters share Vassallo's priorities of gun violence prevention and abortion rights, recent protests on college campuses about the war between Israel and Hamas, including at some Florida campuses, have thrown a new element of uncertainty into the mix. In Florida and elsewhere, observers across the political spectrum are looking on with intense interest.

Florida Democrats hope young voters will be driven to the polls by ballot amendments legalizing marijuana and enshrining abortion rights . They hope the more tolerant views of young voters on those issues will reverse an active voter registration edge of nearly 900,000 for Republicans in Florida, which has turned from the ultimate swing state in 2000 to reliably Republican in recent years.

According to AP VoteCast , an expansive survey of the electorate, about 8 in 10 Florida voters under age 45 in the 2022 midterm elections said the Supreme Court decision overturning Roe v. Wade had an impact on their decision to vote and who to support. The youngest voters, under age 30, appeared more likely than others to say the decision was the single most important factor in their votes, with about 3 in 10 saying that, compared with about 2 in 10 older voters.

Nathan Mitchell, president of Florida Atlantic University’s College Republicans, questions how impactful abortion will be in the election.

According to AP VoteCast, relatively few Florida voters in the 2022 midterms believed abortion should be either completely banned or fully permitted in all cases. Even among Republicans, just 12% said abortion should be illegal in all cases. About half of Republicans said it should be banned in most cases.

Voters under 45 were slightly more likely than others to say abortion should always be legal, with 30% taking that position.

Mitchell said while abortion is a strong issue, especially for women, he doesn't think it will drive many younger voters to the polls.

“I think other amendments will probably do that, especially the recreational marijuana amendment,” Mitchell said. “I think that’s going to bring out a lot more voters than abortion will.”

The AP VoteCast survey lends some credence to his thinking. About 6 in 10 Florida voters in the 2022 elections favored legalizing the recreational use of marijuana nationwide, the survey found. Among voters under 45, that was 76%. Still, it’s unclear how important that issue is for younger voters compared with other issues.

The big question is whether other issues can override Biden's enthusiasm problem among young Florida voters, and elsewhere.

Six in 10 adults under 30 nationally said in a December AP-NORC Center for Public Affairs Research poll that they would be dissatisfied with Biden as the Democratic Party nominee in 2024. And only about 2 in 10 said in a March poll that “excited” would describe their emotions if Biden were re-elected.

Young voters were crucial to the broad and racially diverse coalition that helped elect Biden in 2020. About 6 in 10 voters under 30 backed Biden nationally, according to AP VoteCast. A Pew Research Center survey showed that those under age 30 made up 38% of new or irregular voters in that election.

In Florida, Biden won 64% of young voters – similar to his national numbers.

New issues that concern young voters have emerged this year. Biden's handling of the Israel-Hamas war has sparked protests at college campuses across the country, and Biden's inability to deliver broad-based student loan forgiveness affects many young voters directly. Concern about climate change also continues to grow. AP-NORC data from February shows that majorities of Americans under 30 disapprove of how Biden is handling a range of issues, including the conflict between the Israelis and Palestinians, immigration, the economy, climate change and abortion policy.

But in Florida, it will be abortion rights and marijuana that give voters actual control over issues beyond a presidential rematch most did not want but got anyway, said Trevian Briskey, a 21-year-old FAU student.

Tony Figueroa, president of Miami Young Republicans, said the abortion issue is important to many young voters, regardless of where they stand. He noted, however, that Florida “is a very conservative state.” That means some of the young voters motivated by the issue favor stricter abortion laws.

“Given how Florida has become so much more red over the past couple of years, really it’s more of a way to galvanize or mobilize young voters where this is an important issue for them,” Figueroa said. “It’s really a way to get them to come out in droves.”

Matheus Xavier, 21, who studies biology at Florida Atlantic University, said he considered voting for Trump at some point, but changed his mind since Biden fell more in line with the things he cares about, including the preservation of abortion rights.

“At the end of the day, you gotta go with what you support," he said. "I guess Biden kinda shows more of that. If there was another option that was actually good, I’d probably go for that.”

AP Director of Public Opinion Research Emily Swanson and staff writer Linley Sanders in Washington contributed to this report.

Copyright 2024 The  Associated Press . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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• The Buzz on Florida Politics

Do Florida Hispanics support abortion, marijuana amendments?

• Syra Ortiz Blanes and Max Greenwood Miami Herald (TNS)

Democrats are hoping that an explosive debate in Florida over abortion rights will drive fired-up voters to the polls this November, amid a wave of new restrictions that are limiting access to the procedure in the state and across the U.S.

But for Florida’s vast and influential Hispanic electorate, it’s not clear if abortion access is going to be the winning issue that Democrats and activists hope it will be. While polls show that many Hispanic Floridians support a measure to protect abortion rights, they are less likely to embrace it than state voters as a whole.

In Florida, a law banning abortion after six weeks of pregnancy — a time when many women don’t yet know they are pregnant — is set to go into effect May 1. Abortion-rights activists in the state are seeking to rally support for a proposed constitutional amendment that would safeguard access to the procedure up to the point of fetal viability — the point at which the baby can survive out of the womb, generally understood to be around 24 weeks of pregnancy — or when deemed medically necessary by a physician.

That measure will need to win at least 60% of the vote in November to be enshrined into state law. Early polling shows that the proposal is more popular than not among Florida voters: One recent poll found that more than half of all Floridians would back Amendment 4, while another poll showed that roughly half would support it.

Nationwide, more than half of Hispanics believe abortion should be legal in most or all cases, according to a July 2022 Pew Research Center polling. But research shows that abortion access might enjoy a smaller share of support among Florida Hispanics.

A survey from Florida International University and the marketing company Adsmovil asked Hispanics in Florida whether doctors should be banned from performing abortions after six weeks except in cases of rape, incest or human trafficking. Thirty-five percent of those polled said they strongly or somewhat agreed, while the other 36% strongly or somewhat disagree; 27% said they neither agree nor disagree. Meanwhile, a higher percentage of Hispanics at the national level, 42%, said they are against banning abortions after six weeks except for rape, incest or human trafficking; 34% were in favor.

Floridians Protecting Freedom, a citizen-led coalition, sponsored the amendment and gathered nearly a million signatures to get it on the ballot. But Hispanics, who make up more than a quarter of the state’s population, will be critical to getting the amendment on the books.

“Latinos make or break elections in Florida. The Latino vote is so important,” said Michelle Quesada, the vice president of communications for Planned Parenthood of southeast and north Florida.

A USA Today/Ipsos poll this month found that only 34% of Hispanic Floridians would vote in favor of the abortion ballot measure, while 42% said they were not in favor of legalizing abortion. That’s a statistically significant difference compared to white and Black Floridians, who said they would vote in favor of the measure at 57% and 67% respectively.

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Polling from Boston’s Emerson College released earlier this month found that Florida Hispanics are less likely than white Floridians to support the proposed abortion rights amendment. While nearly 39% said that they would vote in favor of the ballot measure in November, about 25% said they plan to oppose it. Another 36% said that they’re still undecided on the proposal.

Yet a majority of Florida Hispanics — nearly 57% — also said that the state’s six-week abortion ban is too strict.

U.S. Sen. Rick Scott, a Republican and former Florida governor who’s up for reelection this year, said that the proposed constitutional amendment is out of step with where most Florida Hispanics are on the issue of abortion.

“Hispanics are compassionate people,” Scott told The Miami Herald. “They actually have faith, they cherish life.”

While Scott has said that he would have signed the six-week abortion ban into law if he were still governor, he argued that most voters would accept a ban on the procedure after 15 weeks. He also said that lawmakers should take steps to support access to contraceptives and safeguard reproductive treatments like in vitro fertilization.

“If you look at where the consensus is in our state, the consensus isn’t even close to where the Democrats are. The consensus is around 15 weeks with exceptions for rape incest and life of the mother.”

Quesada said there is polling to suggest different outcomes in November, and that the survey results are constantly evolving. One UnidosUS poll from November 2023 showed that 65% of Florida Hispanics “oppose efforts to restrict/ban abortion rights, no matter their own beliefs on the issue.”

The Floridians Protecting Freedom coalition has several initiatives to mobilize and educate Hispanics on the amendment, including regularly hosting Spanish-language volunteer calls and deploying organizers on the ground to spread the word about the proposal, Quesada said.

“I think many Latino families know what it’s like to live under an authoritarian government, they know what it’s like to live under a government that tries to control our lives and restrict our freedom. They understand what’s at stake with Amendment 4,” Quesada said.

Quesada emphasized that Hispanics are not a monolith, which means that engagement that the coalition is attempting to have with Florida Hispanics is not one-size-fits all. Studies have shown that language fluency and religious beliefs can play a role in how Hispanics view abortion. For example, the Pew Research Center found that more than two-thirds of Hispanic evangelicals believe abortion should be outlawed in most or all cases, while the majority of Spanish-dominant Hispanics hold the same view.

Studies show that Hispanic women experience reproductive and sexual-health disparities, including higher rates of cervical cancer, HIV and other STIs, and unintended pregnancies. A March of Dimes report from August 2023 also found that there were several counties that were maternity health care deserts in Florida. In Okeechobee County, which is more than a quarter Hispanic, there was low access to maternity care for expectant mothers and their babies.

“These are laws that are affecting people and putting people in harm’s way. People that are not able to stay pregnant because of health conditions, birth control failing, or having several children at home. Every reason is a valid reason and people need to be able to make these decisions,” Quesada said.

Anothe r proposed amendment on the Florida ballot in November would legalize recreational use of marijuana. If it passes, adults 21 and over could buy and use marijuana in Florida. Smart & Safe Florida, a political action committee that sponsored the measure, gathered more than 1 million signatures to get the measure on the ballot.

Floridians in general appear to be supportive of legalizing recreational marijuana. A poll from Ipsos puts 56% of Floridians in favor of the measure, while another from Florida Atlantic University says 47% would vote for it

Gov. Ron DeSantis has been vocal about his opposition to the measure, saying that if the amendment passes Florida’s streets will reek of marijuana. Smart & Safe Florida did not respond to multiple interview requests from The Miami Herald. But the group’s lawyers have argued that the governor and the Legislature could establish a regulatory framework should the amendment pass that could eventually serve as a national model.

However, Hispanics in the state don’t appear to be in favor of legalizing pot compared to other voters in the state. While 55% of white Floridians and 65% of Black Floridians said they are in favor of the amendment, only 32% of Florida Hispanics said the same, according to the Ipsos/USA Today poll. Nearly half, or 45%, said they would oppose it. However, the researchers noted that the sample size of Black Floridians in the poll was small.

An FAU/Mainstreet Research survey found that only about 30% of Hispanics would vote in support of the measure, while roughly 45% oppose it. One-quarter of respondents said they were unsure. However, FAU researchers noted that the survey was not designed with representative samples of each smaller group in mind and that subsamples have higher margins of error.

Republicans in Florida are skeptical that Democrats will be able to gain the momentum they are looking for with the proposed amendments come November.

“They want to say that abortion and marijuana are these silver bullets,” said Kevin Cabrera, a Miami-Dade County commissioner who served as Florida state director for Donald Trump’s 2020 presidential campaign. “I just don’t see it happening.”

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By more than two-to-one, Americans say medication abortion should be legal in their state

With the future of abortion pills in legal jeopardy, more Americans say medication abortion should be legal than illegal in their state, according to a new Pew Research Center survey. The survey – conducted in the days before the conflicting court rulings on medication abortion by federal judges in Texas and Washington state – also finds stark divides by age and partisanship in Americans’ views of the issue.

Pew Research Center conducted this survey to assess the public’s attitudes about medication abortion. For this analysis, we surveyed 5,079 adults from March 27 to April 2, 2023. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for the analysis and its methodology .

Overall, 53% of adults say medication abortion – that is, the use of a prescription pill or a series of pills to end a pregnancy – should be legal in their state, while fewer than half as many (22%) say it should be illegal. About a quarter (24%) say they aren’t sure.

As is the case with views about the legality of abortion overall, the Center survey, conducted from March 27 to April 2, finds that there are wide partisan divides in views of abortion pills.

A majority of Democrats and Democratic-leaning independents (73%) say medication abortion should be legal in their state, while fewer than half as many Republicans and GOP leaners (35%) say the same.

Americans’ perceptions about the prevalence of medication abortions in the U.S.

The survey also asked Americans, in an open-ended format, to estimate the percentage of all abortions in the U.S. that are medication abortions. In 2020, the most recent year with available data, medication abortions accounted for 53% of all facility-based abortions in the United States , according to data from both the Centers for Disease Control and Prevention and the Guttmacher Institute.

In the Center’s survey, about a third of adults estimate that 40% to 60% of abortions in the U.S. are medication abortions. About four-in-ten say medication abortions make up less than 40% of all abortions in the country. Roughly a quarter say they think medication abortions account for more than 60% of all abortions.

About a third of Republicans (32%) and Democrats (33%) alike estimate that medication abortions account for 40% to 60% of abortions in the country. However, Republicans are somewhat more likely than Democrats (46% vs. 36%) to estimate that medication abortions account for fewer than 40% all abortions. Democrats, in turn, are more likely than Republicans (29% vs. 19%) to say medication abortions account for 60% or more of all abortions in the U.S.

Demographic differences in views of whether medication abortion should be legal

Overall, younger adults are more likely than older Americans to say medication abortion should be legal in their state. Two-thirds (66%) of adults under 30 say abortion pills should be legal, compared with half of adults 30 and older.

Opinions also vary by race and ethnicity. While majorities of White, Black and Asian adults say abortion pills should be legal in their state, views among Hispanic adults are slightly more mixed: 46% say they should be legal, while 25% say they should be illegal and 29% are not sure.

While there are stark partisan divides on the legality of medication abortion, there are also sizable ideological gaps within the parties.

Among Republicans and Republican-leaning independents, nearly half of conservatives (47%) say medication abortion should be illegal in their state, while 24% say it should be legal. But views among moderate and liberal Republicans are the reverse: Half say it should be legal, while 20% say it should be illegal.

While a majority of Democrats – regardless of ideology – say abortion pills should be legal, liberal Democrats are particularly likely to say this. Nearly nine-in-ten liberal Democrats (88%) say it should be legal, compared with 59% of conservative and moderate Democrats.

The survey, conducted prior to news of the court decisions issued April 7, finds that 22% of Americans say they have heard a lot about medication abortion. A majority (56%) have heard a little, while 21% say they have heard nothing at all.

Among adults who said they’d heard or read a lot about medication abortion, 72% say it should be legal. This compares with 55% of adults who said they’d heard a little about medication abortion, and 30% who said they had heard nothing at all about it.

Younger women are particularly likely to say medication abortion should be legal in their state: 71% of women under 30 say this, while just 12% say it should be illegal. By comparison, about half of women 30 and older (51%) say medication abortion should be legal in their state.

There is a more modest age gap among men on this issue: Six-in-ten men under 30 say medication abortion should be legal in their state, compared with half of those 30 and older.

As is true with views of the legality of abortion overall , there are large divides by religion in Americans’ views of abortion pills. While Protestants overall offer mixed views about whether medication abortion should be legal in their state, White evangelical Protestants are about twice as likely to say it should be illegal than legal (50% vs. 23%). In contrast, slight majorities of White non-evangelical Protestants and Black Protestants say abortion pills should be legal.

Catholics are more likely to say abortion medication should be legal than illegal in their state (46% vs. 26%). Religiously unaffiliated adults overwhelmingly say it should be legal (74%). (Note: This analysis cannot report the views of Jews, Muslims, Buddhists, Hindus, Orthodox Christians and other  smaller religious groups due to sample size limitations.)

Note: Here are the questions used for the analysis and its methodology .

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Hannah Hartig is a senior researcher focusing on U.S. politics and policy research at Pew Research Center .

What the data says about abortion in the U.S.

Support for legal abortion is widespread in many countries, especially in europe, nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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Florida Democrats hope abortion and marijuana questions draw young voters despite low enthusiasm

Abortion and marijuana will be on Florida’s November ballot, and these issues are critical issues for young voters. (AP Video/Cody Jackson)

Jayden D’Onofrio passes out Plan B, condoms and rolling papers to educate young voters at Florida Atlantic University on Thursday, April 11 in Boca Raton, Fla. Abortion and marijuana will be on Florida’s November ballot, and these issues are critical issues for young voters. (AP Photo/Cody Jackson)

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A QR code sign is displayed at Florida Atlantic University on Thursday, April 11, 2024, in Boca Raton, Fla. for students to register to vote. Abortion and marijuana will be on Florida’s November ballot, and these issues are critical issues for young voters. (AP Photo/Cody Jackson)

College students pass out Plan B to educate young voters at Florida Atlantic University on Thursday, April 11, 2024, in Boca Raton, Fla. Abortion and marijuana will be on Florida’s November ballot, and these issues are critical issues for young voters. (AP Photo/Cody Jackson)

WEST PALM BEACH, Fla. (AP) — Jordan Vassallo is lukewarm about casting her first presidential ballot for President Joe Biden in November. But when the 18-year-old senior at Jupiter High School in Florida thinks about the things she cares about, she says her vote for the Democratic incumbent is an “obvious choice.”

Vassallo will be voting for a constitutional ballot amendment that would prevent the state of Florida from prohibiting abortion before a fetus can survive on its own — essentially the standard that existed nationally before the U.S. Supreme Court struck down the constitutional protections to abortion and left the matter for states to decide.

Passage of the amendment would wipe away Florida’s six-week abortion law, which is set to take effect Wednesday. Vassallo says the ban makes no sense.

“Most people don’t know they are pregnant at six weeks,” she said.

Biden, despite her reticence, will get her vote as well.

In Florida and across the nation, voters in Vassallo’s age group could prove pivotal in the 2024 election , from the presidency to ballot amendments and down ballot races that will determine who controls Congress. She is likely to be among more than 8 million new voters eligible to vote this November since the 2022 elections, according to Tufts University Center for Information and Research on Civic Learning and Engagement.

While some of those voters share Vassallo’s priorities of gun violence prevention and abortion rights, recent protests on college campuses about the war between Israel and Hamas, including at some Florida campuses, have thrown a new element of uncertainty into the mix. In Florida and elsewhere, observers across the political spectrum are looking on with intense interest.

Florida Democrats hope young voters will be driven to the polls by ballot amendments legalizing marijuana and enshrining abortion rights . They hope the more tolerant views of young voters on those issues will reverse an active voter registration edge of nearly 900,000 for Republicans in Florida, which has turned from the ultimate swing state in 2000 to reliably Republican in recent years.

A QR code sign is displayed at Florida Atlantic University on Thursday, April 11, 2024, in Boca Raton, Fla. for students to register to vote. (AP Photo/Cody Jackson)

According to AP VoteCast , an expansive survey of the electorate, about 8 in 10 Florida voters under age 45 in the 2022 midterm elections said the Supreme Court decision overturning Roe v. Wade had an impact on their decision to vote and who to support. The youngest voters, under age 30, appeared more likely than others to say the decision was the single most important factor in their votes, with about 3 in 10 saying that, compared with about 2 in 10 older voters.

Nathan Mitchell, president of Florida Atlantic University’s College Republicans, questions how impactful abortion will be in the election.

According to AP VoteCast, relatively few Florida voters in the 2022 midterms believed abortion should be either completely banned or fully permitted in all cases. Even among Republicans, just 12% said abortion should be illegal in all cases. About half of Republicans said it should be banned in most cases.

Voters under 45 were slightly more likely than others to say abortion should always be legal, with 30% taking that position.

College students pass out Plan B to educate young voters at Florida Atlantic University on Thursday, April 11, 2024, in Boca Raton, Fla. (AP Photo/Cody Jackson)

Mitchell said while abortion is a strong issue, especially for women, he doesn’t think it will drive many younger voters to the polls.

“I think other amendments will probably do that, especially the recreational marijuana amendment,” Mitchell said. “I think that’s going to bring out a lot more voters than abortion will.”

The AP VoteCast survey lends some credence to his thinking. About 6 in 10 Florida voters in the 2022 elections favored legalizing the recreational use of marijuana nationwide, the survey found. Among voters under 45, that was 76%. Still, it’s unclear how important that issue is for younger voters compared with other issues.

The big question is whether other issues can override Biden’s enthusiasm problem among young Florida voters, and elsewhere.

Six in 10 adults under 30 nationally said in a December AP-NORC Center for Public Affairs Research poll that they would be dissatisfied with Biden as the Democratic Party nominee in 2024. And only about 2 in 10 said in a March poll that “excited” would describe their emotions if Biden were re-elected.

Young voters were crucial to the broad and racially diverse coalition that helped elect Biden in 2020. About 6 in 10 voters under 30 backed Biden nationally, according to AP VoteCast. A Pew Research Center survey showed that those under age 30 made up 38% of new or irregular voters in that election.

In Florida, Biden won 64% of young voters – similar to his national numbers.

New issues that concern young voters have emerged this year. Biden’s handling of the Israel-Hamas war has sparked protests at college campuses across the country, and Biden’s inability to deliver broad-based student loan forgiveness affects many young voters directly. Concern about climate change also continues to grow. AP-NORC data from February shows that majorities of Americans under 30 disapprove of how Biden is handling a range of issues, including the conflict between the Israelis and Palestinians, immigration, the economy, climate change and abortion policy.

But in Florida, it will be abortion rights and marijuana that give voters actual control over issues beyond a presidential rematch most did not want but got anyway, said Trevian Briskey, a 21-year-old FAU student.

Tony Figueroa, president of Miami Young Republicans, said the abortion issue is important to many young voters, regardless of where they stand. He noted, however, that Florida “is a very conservative state.” That means some of the young voters motivated by the issue favor stricter abortion laws.

“Given how Florida has become so much more red over the past couple of years, really it’s more of a way to galvanize or mobilize young voters where this is an important issue for them,” Figueroa said. “It’s really a way to get them to come out in droves.”

Matheus Xavier, 21, who studies biology at Florida Atlantic University, said he considered voting for Trump at some point, but changed his mind since Biden fell more in line with the things he cares about, including the preservation of abortion rights.

“At the end of the day, you gotta go with what you support,” he said. “I guess Biden kinda shows more of that. If there was another option that was actually good, I’d probably go for that.”

AP Director of Public Opinion Research Emily Swanson and staff writer Linley Sanders in Washington contributed to this report.