The International Network for Epidemiology in Policy (INEP) is an international organization that promotes the use of epidemiology to develop evidence-based policies to improve equity, health, and wellbeing for the global population. With this Declaration, INEP joins other health organizations in condemning governments that are restricting access to safe abortions and affirms the right to safe reproductive healthcare for all.

Globally, almost half (48%) of all pregnancies are unintended and occur in a range of ages, circumstances, and backgrounds (1). An unintended pregnancy is a complex concept that includes affective, cognitive, cultural, and contextual issues and is defined as a pregnancy that was either a mistimed, unplanned, or unwanted (2). Between 2015-19 there were 121 million unintended pregnancies each year, a rate of ~62 unintended pregnancies per 1000 women aged 15-49 years per year (1). The most effective intervention to reduce unintended pregnancy is through access to modern contraception, however the unmet need for contraception remains high (3). Many unintended pregnancies end in abortion, with estimates of 73.3 million abortions worldwide each year, a rate of ~39 abortions per 1000 women aged 15-49 years per year (1). Globally, nearly half of all abortions (~45%) are unsafe, with lower-income countries in Asia, Africa, and Latin America accounting for 97% of these unsafe abortions (4). Unsafe abortion is a major contributor to maternal mortality(4), and accounts for 70000 maternal deaths each year, impacting families and communities (5).

Unsafe abortion usually occurs in settings that have restrictive abortion laws due to stigma, religious, and or other socio-political influences (5). Restrictive abortion laws do not lead to lower abortion rates, but to increased rates of unsafe abortions (1, 6). In countries without restrictive laws 87% of abortions are safe, whereas in countries with restrictive laws only 25% are safe (7). Access to safe abortion disproportionately impacts those who are racially minoritized, living below the poverty line, single, or people who are otherwise marginalised including those with other gender identities (4, 6, 8). Access to safe abortion also protects against the longer-term adverse effects that may result from continuing an unintended pregnancy (8). Restricting access to safe abortion also results in increased need for post-abortion services for women exposed to an unsafe procedure (9). The direct costs of treating abortion complications strain health systems in low- and middle-income countries, and the indirect costs also drain struggling economies (9).

The evidence of the benefit to women’s physical and mental health to access safe abortion services is clear and unambiguous (10, 11). Access to safe abortion is included in the World Health Organization’s list of essential health care services, (10) and is needed to achieve two of the United Nations Sustainable Development Goals; 3.1, reducing maternal mortality and 3.7, universal access to sexual and reproductive healthcare.

Unintended pregnancies will continue and without access to safe and legal abortion services we can expect increased mortality and morbidity (6, 12). Abortion is part of an evidence-based reproductive health care service (11). The International Network for Epidemiology affirms the right to safe reproductive healthcare for all. Legally restricting this right prevents evidence-based healthcare, and results in harm to women, girls and others who can become pregnant everywhere. We support adoption of evidence-based health policy that includes access to safe abortion globally.

Endorsed by the following member societies:

• Associação Brasileira de Saúde Coletiva (ABRASCO)

• American College of Epidemiology (ACE)

• Australasian Epidemiological Association (AEA)

• Epidemiology Section of the American Public Health Association (APHA-epi)

• German Society for Epidemiology (DGEpi)
  

REFERENCES

1. Bearak J, Popinchalk A, Ganatra B, Moller AB, Tunçalp Ö, Beavin C, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019. Lancet Glob Health. 2020;8(9):e1152-e61.

2. Santelli J, Rochat R, Hatfield-Timajchy K, Gilbert BC, Curtis K, Cabral R, et al. The Measurement and Meaning of Unintended Pregnancy. Perspectives on Sexual and Reproductive Health. 2003;35(2):94-101.

3. Moreau C, Shankar M, Helleringer S, Becker S. Measuring unmet need for contraception as a point prevalence. BMJ Glob Health. 2019;4(4):e001581.

4. Ganatra B, Gerdts C, Rossier C, Johnson Jr BR, Tunçalp Ö, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet. 2017;390(10110):2372-81.

5. Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J Obstet Gynaecol Can. 2009;31(12):1149-58.

6. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33.

7. Guttmacher Institute. Abortion Worldwide 2017: Uneven Progress and Unequal Access, . New York: Guttmacher Institute, 2018.; 2018.

8. Foster DG, Biggs MA, Ralph L, Gerdts C, Roberts S, Glymour MM. Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States. American Journal of Public Health. 2018;108(3):407-13.

9. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet. 2006;368(9550):1908-19.

10. World Health Organization. Factsheet: Preventing unsafe abortion. Geneva, Switzerland: WHO. 2018.

11. World Health Organization. Abortion care guideline. Geneva; 2022.

12. Ruha A-M, Babu K, Carey J, Stolbach A, Spyres MB, O’Connor AD, et al. Criminalization of Abortion Will Lead to Increased Poisoning Illness and Deaths. Journal of Medical Toxicology. 2022;18(3):185-6.

INEP MEMBER SOCIETY ENDORSEMENTS (beginning February 2023):