Abortion Law Around the World: Progress and PushbackThere is a global trend

toward the liberalization of

abortion laws driven by

women’srights,publichealth,

and human rights advocates.

This trend reflects the reco-

gnition of women’s access

to legal abortion services

as a matter of women’s

rights andself-determination

and an understanding of

the dire public health im-

plications of criminalizing

abortion.

Nonetheless, legal strate-

gies to introduce barriers

that impede access to legal

abortion services, such as

mandatory waiting periods,

biased counseling require-

ments, and the unregulated

practiceofconscientiousob-

jection, are emerging in re-

sponse to this trend. These

barriers stigmatize and de-

mean women and compro-

mise their health.

Public health evidence

and human rights guaran-

tees provide a compelling

rationale for challenging

abortion bans and these re-

strictions. (Am J Public

Health. Published online

ahead of print February 14,

2013: e1–e5. doi:10.2105/

AJPH.2012.301197)

Louise Finer, LLM, and Johanna B. Fine, JD, MIA

ACCORDING TO THE MOST RE-

cent research, the legal frameworkin 68 countries worldwide cur-rently prohibits abortion entirelyor permits it only to save a wom-an’s life. Conversely, 60 countriesallow a woman to decide whetherto terminate a pregnancy. A fur-ther 57 countries permit abortionto protect a woman’s life andhealth, and an additional 14 per-mit abortion for socioeconomicmotives.1 These figures indicatethat roughly 39% of the world’spopulation lives in countries withhighly restrictive laws governingabortion.2

Following World War II, abor-tion was highly restricted through-out most of the world.3 Since the1950s, when the liberalization ofabortion laws began in Easternand Central Europe, an unmistak-able global trend toward easinglegal restrictions on abortion hasensued. The landmark decisionof Roe v. Wade in the United Statescan be seen against the backdropof liberalization of abortion lawsin the developed world throughthe 1960s and 1970s.4 Between1950 and 1985, nearly all indus-trialized countries—and severalothers—liberalized their abortionlaws.5 Furthermore, since 1994,when 179 countries committed topreventing unsafe abortion underthe International Conference onPopulation and DevelopmentProgramme of Action, more than25 countries have liberalized theirabortion laws. During the sameperiod, only a handful have tight-ened legal restrictions on abortion.6

Despite some notable excep-tions,7 nearly all countries in theglobal north and central and easternAsia currently have liberal abortion

laws, authorizing the service with-out restrictions as to reason duringcertain gestational limits or onbroad grounds, such as for socio-economic reasons. By contrast,countries in the global south gen-erally have restrictive abortionlaws on the books, with abortioncriminalized except for limited cir-cumstances, such as if a woman’shealth or life is at risk, or in cases ofrape, incest, or fetal impairment.8

The legal framework for abor-tion in a given country can bederived from multiple sources, in-cluding statutes enacted by legis-latures, regulations created by ad-ministrative agencies, and courtdecisions. Many of these laws andpolicies apply concurrently. Al-though abortion is a medical pro-cedure, it has historically beenaddressed in penal codes andcharacterized as a crime. Penalcodes generally set out criminalsanctions for the abortion pro-vider and in some instances alsofor the woman undergoing theabortion. However, these samepenal codes normally recognizeexceptions under which perform-ing an abortion does not carry anycriminal penalties.9

The liberalization of abortionlaws using legal means has gener-ally been achieved by amendingcriminal bans to specify certaincircumstances in which there isno legal penalty for abortion.Thus, countries in the first waveof liberalization, in Central andEastern Europe, saw the intro-duction of specific circumstancesin which abortion carried nocriminal sanction.10 In addition,although most countries (includingthose with liberal abortion laws)still maintain penal code provisions

delineating the circumstances inwhich abortion is a crime, penalcode provisions have been in-creasingly replaced or supple-mented by public health codes,court decisions, and other regula-tions and laws addressing theprovision of reproductive healthcare.11 In 2010, for example, Spain(one of the few European coun-tries that had maintained a restric-tive abortion law) enacted a lawon sexual and reproductive healththat eliminated a penal code pro-vision punishing women for ille-gally procuring abortions and rec-ognized their right to abortionwithout restrictions as to reasonduring certain gestational limits andthereafter on specific grounds.12

Active campaigning from thewomen’s rights, public health, andhuman rights fields has workedto considerable effect,13 withachievements in law reform re-flecting both the recognition of thedire public health implications ofcriminalizing abortion and theidentification of women’s accessto lawful termination of a preg-nancy as a question of women’srights and self-determination.Concurrently, international stan-dards on the protection of women’sreproductive rights and their ap-plication to abortion have devel-oped considerably.14 This trendpersists despite the recent emer-gence of an increasingly organizedand vehement opposition that seeksto restrict abortion laws and im-pose barriers to women’s accessto abortion globally.

Despite the overall global trendof easing legal restrictions onabortion, legal strategies haveemerged to introduce new typesof barriers that impede women’s

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access to legal abortion services.An increasingly global and coor-dinated movement—which prona-talist and religious concerns havefueled in direct response to theworldwide trend toward abortionlaw liberalization—has instigatedsuch strategies. Although in somecountries progressive or retro-gressive steps can be classifiedsimply, in others political tugs-of-war have led to measures that pullthe specific elements of the legalstatus of abortion back and forth.Retrogressive steps have beenadded that introduce new barriersto abortion access rather than al-tering the overall legal status ofabortion, making the achievementof broader reform unrealistic be-cause of the political context orestablished legal framework.

In Poland, for example, a liberalabortion law in place until the fallof the Soviet Union was restrictedin 1993.15 In 1996, the law wasagain liberalized, but subsequentefforts, through amendments tothe law and a ruling from theconstitutional court, again restrictedthe law.16 The Polish parliamentnarrowly rejected a bill that wouldhave introduced an absolute banon abortion in 2011.17

Strategies to restrict abortionaccess have increasingly focusedon introducing procedural bar-riers, through law or policy, thatlimit the availability of abortionservices. Such barriers—intro-duced primarily in countries withliberal abortion laws, including theUnited States and Central andEastern Europe countries—includemandatory and biased counselingrequirements,18 waiting periods,19

third-party consent and notifica-tion requirements,20 limitationson the range of abortion options(e.g., restrictions on medical abor-tion, including specific bans onmisoprostol21), and limitations onabortion funding.

Currently, 26 US states havea waiting period, which is nor-mally 24 hours,22 and nine statesrequire counseling that providesinaccurate information about neg-ative mental health consequencesof abortion.23 In 2011, the Rus-sian parliament established a man-datory waiting period for abor-tions and considered several otherprocedural barriers to abortion.24

In 2009, the Slovak Republic in-troduced several procedural bar-riers to abortion access, includinga mandatory counseling require-ment, a 48-hour waiting period, andthe extension of the parental con-sent requirement to all minors25

when previously it had applied onlyto girls younger than 16 years.26

A further impediment to abor-tion access results from the un-regulated conscientious objectionof health care providers andothers. The right to refuse to per-form services because of moral orreligious objections is governed bynational laws that vary in thescope of limits of conscientiousobjection and that invite differinginterpretations.27 Although insuf-ficient research has been con-ducted into the prevalence of un-regulated conscientious objection,case law and limited researchshows that it is increasingly invokedin countries where opposition torecent liberalization is strong (e.g.,Colombia)28 and where there areattempts to reverse the legalizationof abortion (e.g., Poland).29 Agrowing body of jurisprudencedelineates the justifiable limits onthe exercise of conscientious objec-tion in this context, including whenpharmacists, nurses, judges, andhealth care institutions invoke it.30

ABORTION LAW ANDPUBLIC HEALTH

The World Health Organiza-tion has identified unsafe abortion

as a serious public health problemsince 196731 and affirms in itsmost recent technical guidance thescale of this public health im-pact.32 World Health Organiza-tion evidence shows that whenfaced with an unplanned preg-nancy and irrespective of legalconditions, women all over theworld are highly likely to have aninduced abortion. Legal restric-tions that limit the grounds onwhich a woman may terminatea pregnancy increase the percent-age of unlawful and unsafe pro-cedures.33 The maternal mortalityratio per 100 000 live births ow-ing to unsafe abortion is generallyhigher in countries with major re-strictions and lower in countrieswhere abortion is available withoutrestrictions as to reason or underbroad conditions.34 Thus, the pub-lic health impact of unsafe abortionis directly linked to its legal status.

Abortion’s legal status affects itsaccess in numerous ways, bothdirectly and indirectly. Criminali-zation renders the procedure ille-gal and, for many women, unsafe.In addition, criminalization andother legal restrictions can indi-rectly produce a chilling effect thatmakes even legal abortions diffi-cult to access.35 A recent reportof the United Nations high com-missioner for human rights to theUnited Nations Human RightsCouncil in examining the prevent-able causes of maternal mortalityand morbidity finds that restrictiveabortion laws lead to healthproviders’, police’s, and others’responses that discourage care-seeking behavior.36 These re-sponses include withholding careuntil a woman confesses to havinghad an illegal abortion andreporting women who have sym-ptoms of a spontaneous or in-duced abortion to the police be-cause of perceived or real pressureor legal requirements.37

In countries that permit abor-tion only on narrow legal grounds,information about legal services isoften unavailable. Consequently,some women presume that theyare not entitled to a legal abortionalthough this may not be thecase.38 Health providers may alsolack training in safe abortion pro-cedures, have insufficient infor-mation to be able to act within thelaw, or be reluctant to interpretlegal grounds. The lack of careprotocols and effective proceduresto guide health providers’decision-making to ensure lawsare correctly interpreted has ledto devastating consequences forwomen seeking abortions.39

Moreover, health providers’ fearsof criminal sanction promote arestrictive interpretation of lawsand, as a result, more unsafe abor-tions or delays that have secondaryhealth consequences.40

Procedural barriers, such as themandatory waiting periods and bi-ased counseling requirements wehave mentioned, can delay careand hinder access to safe services,which in turn demean women ascompetent decision-makers and in-crease health risks.41

Notably, however, the technicaladvancement of medical abortion,particularly through the use ofmisoprostol, has been a revolu-tionary development in reducingrates of abortion-related morbidityand mortality.42 Misoprostol wasoriginally marketed to preventand treat gastric ulcers, but it isalso a safe and effective meansof pregnancy termination.43

Women worldwide, particularlyin Latin America, are increasinglyself-administering misoprostoloff-label to terminate their preg-nancies.44 Thus, in settings withrestrictive abortion laws or signi-ficant access barriers, women areincreasingly able to self-inducesafe abortions.45 Moreover, as

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misoprostol can be stored at roomtemperature and administered bynonphysicians, it has increasedwomen’s access to safe abortionservices in many resource-limitedsettings.46

Nonetheless, not only does evi-dence clearly illustrate the nega-tive public health impact of exces-sive abortion restrictions, but italso supports the case for abortionlaw liberalization. According toSouth Africa’s National Committeeof Confidential Inquires into Ma-ternal Deaths, liberalization in thecountry47 in 1996 led to a 91%decline in abortion-related mater-nal mortality between 1994 and1998---2001. One study showedan “immediate positive impacton morbidity,”48 in particulararising from infection, and anotherconcluded that a “cautious assess-ment of the magnitude of the re-duction [in maternal mortality]confirms that it is large.”49

Evidence from Nepal, whererevisions to the country’s legalcode in 2002 granted womenthe right to terminate a pregnancyup to 12 weeks without restrictionas to reason and later on specificgrounds, suggests that liberaliza-tion has contributed to a declinein complications from unsafeabortion.50 Following the liber-alization of Romania’s abortionlaw in 1989, maternal mortalitydramatically decreased.51 In theUnited States, in the years followingthe Roe v. Wade decision, maternalmortality significantly declined asa result of the decrease in unsafeabortions, clearly demonstratingthe public health impact of Roe v.Wade’s implementation.52

CONCLUSIONS

Evidence of the public healthimplications of excessive legal re-strictions on abortion cannot beignored. Authoritative research

conducted in the wake of liber-alization provides a further ratio-nale for contesting such restric-tions on public health grounds.This public health rationale hassupported many efforts towardabortion law reform in suchcountries as Colombia, Ethiopia,and Guyana.

However, those who seek tomaintain or introduce restrictivelegal regimes for abortion contestthe public health evidence thatsupports the case for lifting exces-sive legal restrictions on abortion.Such efforts either deliberatelyavoid the facts or rely on de-bunked public health evidence tomotivate ideology-driven agendas.In the United States, for example,several states have mandatedcounseling for women seekingabortion services and requiredthem to receive information aboutpurported negative mental healthconsequences of abortion or a linkbetween abortion and increasedrisk of breast cancer in an attemptto coerce women to continue un-wanted pregnancies.53 These ef-forts overlook, or ignore, authori-tative studies that debunk themyth of a connection betweenhaving an abortion and increasedmental health risks and disproveany link between abortion and anincreased risk of breast cancer.54

Other purported justificationsfor abortion restrictions on publichealth grounds misrepresent andoversimplify risks and other con-siderations related to women’shealth during pregnancy. In Russia,for example, recent restrictions onabortions after 12 weeks of preg-nancy have been justified bypointing to an increased risk ofmaternal mortality resulting fromlater term abortions.55 Althoughabortion does indeed carry agreater risk of potential complica-tions the later it is performed, thisapparent concern for women’s

lives is seen to be disingenuouswhen examined in the light ofstudies showing that the risk ofdeath associated with childbirth isfar greater than is the risk associ-ated with legal abortion.56

The argument that forcingwomen to carry pregnancies toterm will reverse trends of demo-graphic decline also underpinsrestrictions on women’s access toabortion in countries such as Rus-sia.57 There is no evidence ofa connection between restrictionson access to abortion and in-creased birth rates. As we havediscussed, women who wish toterminate their pregnancies willseek this service whether it is legalor not. When abortion servicesare highly restricted, women areoften forced to procure unsafeabortions, which may jeopardizetheir health and lives.

Excessive legal restrictions havemyriad repercussions in additionto whether abortion services areavailable. Excessive restrictionsstigmatize women seeking abor-tions and discriminate againstthose who lack the knowledgeand understanding of legalgrounds for abortion and vulner-able groups, such as poor andrural women and girls. Furtherresearch should be conductedinto the regional and subnationaldiscrepancies in abortion accessresulting from excessive legal re-strictions. Where legal restrictionsrender abortion inaccessible ordifficult to access, wealthierwomen and those based in urbanareas may be the only ones ableto access private services or travelto obtain abortion services.58

Such restrictions on abortionalso create systemic problemsleading to practices that are in-evitably unsafe. Where abortionis prohib-ited, public health andsafety regulations for its provisioncannot exist; thus the training and

licensing of health providers islimited.59 On these and othergrounds, the United Nations specialrapporteur on the right to health hascharacterized the criminalizationof abortion as incompatible withthe right to the highest attainablestandard of health.60

We believe that, with time, thepublic health impact of new kindsof legal and policy barriers intro-duced to restrict abortion accesswill become evident. Evidence al-ready shows that mandatorywaiting periods compromisewomen’s health by delaying careand women’s ability to access safeand legal abortion services,61 butfurther research is essential. Al-though the risks associated withabortion are small, waiting periodscause greater numbers of womento delay the procedure until thesecond trimester of pregnancy,when the risk of complications risesgeometrically.62 Similarly, the co-ercive nature of biased counselingrequirements providing medicallyinaccurate information could leadwomen to make decisions thatjeopardize both their physical andmental health. Such restrictionsdemean and stigmatize women.63

The public health implicationsof excessive legal restrictions onabortion are devastating. Reliablepublic health evidence and theapplication of human rights guar-antees provide a compelling ratio-nale for challenging abortion bansand other restrictions.64 The waveof liberalization of abortion lawsresponded to public health evi-dence and, more recently, humanrights arguments. The ideologi-cally and religiously motivatedbacklash against abortion is in-creasingly resorting to misrepre-sentations and avoidance of publichealth evidence, and it is under-mining human rights standardsapplicable in this context. Themovement that has so successfully

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campaigned for abortion liber-alization must continue to assertthese strong grounds or facepushback on the gains achieved. j

About the AuthorsAt the time of the research and writing,Louise Finer and Johanna B. Fine were withthe Center for Reproductive Rights, NewYork, NY.Correspondence should be sent to Louise

Finer, Managing Editor, Reproductive HealthMatters, 444 Highgate Studios, 53-79Highgate Road, London NW5 1TL, UK(e-mail: louisefiner@gmail.com). Reprintscan be ordered at http://www.ajph.org byclicking the “Reprints” link.

This commentary was acceptedDecember 21, 2012.

ContributorsL. Finer and J. B. Fine contributed equallyto the research and writing of thecommentary.

AcknowledgmentsWe wish to thank Kathryn Meyer for herhelp preparing the commentary.

Endnotes1. Center for Reproductive Rights,“The World’s Abortion Laws 2012,”http://worldabortionlaws.com (accessedSeptember 20, 2012).

2. Center for Reproductive Rights, TheWorld’s Abortion Laws 2011 (New York,2011).

3. Stanley K. Henshaw, “InducedAbortion: A World Review, 1990,”Family Planning Perspectives 22, no. 2(1990): 76---89.

4. P. 753 in Julia L. Ernst, LauraKatzive, and Erica Smock, “The GlobalPattern of U.S. Initiatives CurtailingWomen’s Reproductive Rights: A Per-spective on the Increasingly Anti-ChoiceMosaic,” Journal of Constitutional Law 6,no. 4 (2004): 752---795.

5. P. 60 in Anika Rahman, Laura Kat-zive, and Stanley K. Henshaw, “A GlobalReview of Laws on Induced Abortion,1985---1997,” International Family Plan-ning Perspectives 24, no. 2 (1998): 56---64.

6. Rahman et al., “Global Review of Laws;Reed Boland and Laura Katzive, “Develop-ments in Laws on Induced Abortion: 1998---2007,” International Family Planning Per-spectives 34, no. 3 (2008):110---120; Centerfor Reproductive Rights, Abortion World-wide: 17 Years of Reform (New York, 2011),http://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_bp_17_years.pdf (accessed September 20,2012); Rebecca J. Cook, BernardM.Dickens,and Laura E. Bliss, “International Devel-opments in Abortion Law From 1988

to 1998,” American Journal of PublicHealth 89, no. 4 (1999): 579---586.

7. For example, Poland, Malta, and theRepublic of Korea.

8. Center for Reproductive Rights,“World’s Abortion Laws 2012.”

9. Boland and Katzive, “Developmentsin Laws: 1998---2007,” 110.

10. Henshaw, “Induced Abortion:1990,” 78.

11. Boland and Katzive, “Developmentsin Laws: 1998---2007,” 110.

12. Ley Orgánica 2/2010, de saludsexual y reproductiva y de la interrupciónvoluntaria del embarazo [Organic law 2/2010, on sexual and reproductive healthand the voluntary interruption of preg-nancy], B.O.E. (Spain), no. 55 (March 4,2010): 21001---21014.

13. Boland and Katzive, “Developmentsin Laws: 1998---2007,” 117; Cook et al.,“International Developments from 1988to 1998,” 584; Rebecca J. Cook andBernard M. Dickens, “Human Rights Dy-namics of Abortion Law Reform,” HumanRights Quarterly 25, no. 1 (2003):1---59;Leila Hessini, “Global Progress in AbortionAdvocacy and Policy: An Assessment ofthe Decade Since ICPD,” ReproductiveHealth Matters 13, no. 25 (2005): 88---100.

14. Ernst et al., “Global Pattern of U.S.Initiatives,” 753. The Protocol to theAfrican Charter on Human and Peoples’Rights on the Rights of Women in Africaexplicitly recognizes that the right tohealth includes access to safe and legalabortion. It requires states’ parties to“ensure that the right to health of women,including sexual and reproductive healthis respected and promoted” by takingappropriate measures to authorize abor-tion “in cases of sexual assault, rape,incest, and where the continued preg-nancy endangers the mental and physicalhealth of the mother or the life of themother or the foetus” (p. 15---16). Protocolto the African Charter on Human andPeoples’ Rights on the Rights of Womenin Africa, 2nd Ordinary Sess., Assembly ofthe Union, adopted July 11, 2003, art. 14,CAB/LEG/66.6 (entered into force No-vember 25, 2005).

15. Law of January 7, 1993 on FamilyPlanning, Human Embryo Protection, andConditions of Legal Pregnancy Termina-tion. This law permits abortion whena pregnancy threatens the life or health ofthe woman, when there is justified suspi-cion that the pregnancy resulted froma “criminal act,” or in cases of fetalimpairment.

16. In 1996, Poland’s abortion law wasliberalized to permit abortion on socialand economic grounds. Act of August 30,1996. However, the constitutional courtinvalidated the revised law the followingyear. Ruling of the Constitutional Tribu-

nal of May 28, 1997, sign. of the recordsK 26/96 (Pol.) (unofficial translation). InDecember 1997, the parliament enactednew legislation eliminating social andeconomic grounds for abortion. Law ofJanuary 7, 1993 on Family Planning,Human Embryo Protection, and Condi-tions of Legal Pregnancy Terminationamended as of December 23, 1997 (Pol.)(unofficial translation provided by Feder-ation for Women and Family Planning).

17. “Sejm odrzuci1 obywatelski projektzakazujacy aborcji,” Gazeta Wyborcza,August 31, 2011, http://wiadomosci.gazeta.pl/wiadomosci/1,114873,10209867,Sejm_odrzucil_obywatelski_projekt_zakazujacy_aborcji.html (accessed Sep-tember 20, 2012).

18. Some laws require that women re-ceive counseling before undergoing anabortion. Rather than providing a neutraldiscussion of the nature and risks ofabortion, such counseling can be intendedto discourage women from undergoing anabortion by providing inaccurate infor-mation. Rahman et al., “Global Review:1985---1997,” 59.

19. Some laws establish waiting orreflection periods during which womenmust wait one to several days beforebeing permitted to undergo an abortion.Cook et al., “International Develop-ments: 1988 to1998,” 584.

20. “Some laws require a woman orgirl to obtain the consent of her spouseor parent before undergoing an abor-tion, whereas others require abortionproviders to secure approval from an-other physician, medical committee orcourt before performing an abortion”(p. 73). Reed Boland, “Second TrimesterAbortion Laws Globally: Actuality,Trends and Recommendations,” Repro-ductive Health Matters 18, no. 36(2010): 67---89.

21. For example, in 2002, the Philip-pines’ Food and Drug Administrationissued a circular prohibiting the distribu-tion, sale, and use of misoprostol. Bureauof Food and Drugs Advisory 2002---02(August 12, 2002) (on file with the Centerfor Reproductive Rights).

22. Guttmacher Institute, “State Policiesin Brief: Counseling and Waiting Periodsfor Abortion”; 2012, http://www.guttmacher.org/statecenter/spibs/spib_MWPA.pdf (accessed September 20,2012).

23. Guttmacher Institute, “News inContext: State Legislative Trends at Mid-year 2012,” http://www.guttmacher.org/media/inthenews/2012/07/10/index.html (accessed September 20, 2012).

24. “Federelnii Zakon Rossiiskoi Feder-atzii ot 21 noiabria 2011 g. N 323-F3:

‘Ob osnovah ohranai grajdan v RossiiskoiFederatzii,’” http://www.rg.ru/2011/11/23/zdorovie-dok.html (accessed Septem-ber 20, 2012). According to article 55,§3, if a woman is in her 4th to 7th week ofpregnancy or 11th to 12th week ofpregnancy, she must observe a waitingperiod of 48 hours before she can accessabortion services. For a woman in the 8thto 10th weeks of pregnancy, the waitingperiod is seven days. Additionally, onFebruary 6, 2012, the Russian govern-ment issued a decree, the Social Groundfor Artificial Termination of Pregnancy,signed by Prime Minister Vladimir Putin.This decree establishes that the onlysocial ground for abortion between the12th and 22nd weeks of pregnancy isrape. Previously, abortion was authorizedfor four social indications during thisperiod. “Postanovlenie Praviteltva Rossiis-koi Federacii ot 6 fevralia 2012 g. N 98 g.Moskva: ‘O socialnio, pokazanii dliaiskusstvenogo preriavania beremen-nosti,’” http://www.rg.ru/2012/02/15/98-dok.html (accessed September 20,2012).

25. Act No. 576/2004 Coll. of Laws onHealth Care, Health Care-Related Ser-vices, and Amending and SupplementingCertain Acts as Amended by Act No.345/2009 Coll. of Laws, 2004 (Slovak).

26. Act No. 73/1986 Coll. on ArtificialTermination of Pregnancy as Amended byAct No. 419/1991 Coll., 1986 (Slovak).

27. Judith Bueno de Mesquita andLouise Finer, “Conscientious Objection:Protecting Sexual and Reproductive HealthRights.” University of Essex; 2008, http://www.essex.ac.uk/hrc/research/projects/rth/docs/Conscientious_objection_final.pdf (accessed September 20, 2012);Bernard M. Dickens and Rebecca J. Cook,“Conscientious Commitment to Women’sHealth,” International Journal of Gynecol-ogy and Obstetrics 113, no. 2 (2011):163---166; Rebecca J. Cook, Monica Ara-ngo Olaya, and Bernard M. Dickens,“Healthcare Responsibilities and Consci-entious Objection,” International Journalof Gynaecology and Obstetrics 104, no. 3(2009): 249---252.

28. Previously, abortion was prohibitedwith no explicit exceptions. Penal Code,promulgated by Law 599 of 2000(Colombia). Following a ruling by theconstitutional court of Colombia, abortionis now permitted to save a woman’s life ormental or physical health or in cases ofrape, incest, or severe fetal impairment.Women’s Link Worldwide, “C-355/2005: Excerpts of the ConstitutionalCourt’s Ruling That Liberalized Abortionin Colombia”; 2007, http://www.womenslinkworldwide.org/pdf_pubs/pub_c3552006.pdf (accessed September20, 2012). Judges have subsequently in-voked conscientious objection when re-fusing to hear appeals in connection with

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the denial of legal abortion services. See,for example, the tutela claim rejected byJudge José Yañez Moncada in YolandaPerez Ascanio v. Saludvida EPS, JuzgadoDécimo Civil Municipal de Cúcuta,Colombia, quoted in Corte Constitucionalde Colombia, September 3, 2007. “T-171/07” (Colombia).

29. RRv Poland, No. 27617/04 Eur. Ct.H. R. (2011).

30. See, for example, Corte Constitucio-nal de Colombia, May 28, 2009, “T-388/09/Acción de Tutela” (Colombia) inwhich the constitutional court of Colom-bia noted that judicial authorities cannotrefuse a woman an abortion on the basisof conscience claims. It also noted thatinstitutions cannot refuse a woman anabortion on the basis of conscience claims.It indicated that only the physician di-rectly performing the abortion can objectto the provision of services and to do so,he or she must submit a written statementexplaining the objection and refera woman to a physician who is willing andable to perform the abortion. See alsoPichon and Sajous v. France, No. 49853/99, Eur. Ct. H. R., Admissibility Decision(October 2, 2001) (holding that “as long asthe sale of contraceptives is legal andoccurs on medical prescription nowhereother than in a pharmacy, the applicantscannot give precedence to their religiousbeliefs and impose them on others asjustification for their refusal to sell suchproducts” [p. 4]).

31. World Health Assembly, “HealthAspects of Population Dynamics,” WHA20.41; 1967, http://whqlibdoc.who.int/wha_eb_handbooks/9241652063_Vol1_(part1-2).pdf (accessed September20, 2012).

32. World Health Organization, “SafeAbortion: Technical and Policy Guid-ance for Health Systems,” 2nd ed. (Ge-neva, 2012), http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en(accessed September 20, 2012).

33. World Health Organization, “UnsafeAbortion: Global and Regional Estimatesof the Incidence of Unsafe Abortion andAssociated Mortality in 2008” (Geneva,2011), http://whqlibdoc.who.int/publications/2011/9789241501118_eng.pdf (accessedSeptember 20, 2012); Gilda Sedgh, S.Singh, I.H. Shah, E. Ahman, S.K. Henshaw,and A. Bankole, “Induced Abortion: In-cidence and Trends Worldwide From1995 to 2008,” Lancet 379, no. 9816(2012): 625---632.

34. World Health Organization, “SafeAbortion: Technical and Policy Guid-ance,” 23.

35. Tysiac v. Poland, No. 5410/03 Eur.Ct. H.R. (2007); A, B and C v. Ireland, No.25579/05 Eur. Ct. H.R. (2010).

36. Office of the United Nations HighCommissioner for Human Rights, “Tech-nical Guidance on the Application ofHuman Rights-Based Approach to Imple-mentation of Policies and Programmes toReduce Preventable Maternal Morbidityand Mortality,” para. 56, U.N. Doc. A/HRC/21/22 (July 2, 2012).

37. Heathe Luz McNaughton, E.M.Mitchell, E.G. Hernandez, K. Padilla, andM.M. Blandon, “Patient Privacy and Con-flicting Legal and Ethical Obligations in ElSalvador,” American Journal of PublicHealth 96, no. 11 (2006): 1927---1933.

38. Center for Reproductive Rights,“Briefing Paper: A Technical Guide toUnderstanding the Legal and PolicyFramework on Termination of Pregnancyin Uganda” (New York, NY, 2012), http://reproductiverights.org/sites/crr.civicactions.net/files/documents/crr_UgandaBriefingPaper_v5.pdf (accessed Septem-ber 20, 2012). “The single most criticalfinding of our research is that Uganda’slaws and policies are more expansivethan most believe, and the current legaland policy framework offers ample op-portunities for increasing access to safeabortion services” (p. 6).

39. Tysiac v. Poland, No. 5410/03 Eur.Ct. H.R. (2007); L.C. v. Peru, CEDAWCommittee, Commc’n No. 22/2009, U.N.Doc. CEDAW/C/50/D/22/2009(2011); K.L. v. Peru, Human Rights Com-mittee, Commc’n No. 1153/2003, U.N.Doc. CCPR/C/85/D/1153/2003(2005); Corte Suprema de Justicia de laNación (National Supreme Court of Jus-tice), March 13, 2012, “F., A. L. s/ medidaautosatisfactiva,” (Argentina).

40. Tysiac v. Poland, No. 5410/03 Eur.Ct. H.R. (2007); A, B and C v. Ireland, No.25579/05 Eur. Ct. H.R. (2010); L.C. v.Peru, CEDAW Committee, Commc’n No.22/2009, U.N. Doc. CEDAW/C/50/D/22/2009 (2011).

41. World Health Organization, “SafeAbortion: Technical and Policy Guid-ance,” 96---97.

42. Guttmacher Institute, “In Brief: Factson Induced Abortion Worldwide”; 2012,http://www.guttmacher.org/pubs/fb_IAW.pdf (accessed December 21, 2012).

43. Joanna N. Erdman, “Harm Reduc-tion, Human Rights, and Access to In-formation on Safe Abortion,” Interna-tional Journal of Gynecology and Obstetrics118, no. 1 (2012): 83---86; BeverleyWinikoff and Wendy Sheldon, “Use ofMedicines Changing the Face of Abor-tion,” International Perspectives on Sexualand Reproductive Health 38, no. 3 (2012):164---166.

44. Erdman, “Harm Reduction,” 83---86;Winikoff and Sheldon, “Use of Medi-cines,” 164---166.

45. Winikoff and Sheldon, “Use ofMedicines,” 164---166.

46. Ibid.

47. Before 1996, abortion was legalonly to protect life and health or in thecases of rape, incest, other unlawful in-tercourse, and some fetal impairments. In1996, the law was liberalized to permitthe service without restrictions pertainingto the woman’s motive during the firsttrimester and thereafter on numerousgrounds. Choice on Termination of Preg-nancy, Act 92 of 1996 (South Africa).

48. P. 355 in Rachel Jewkes, H. Rees, K.Dickson, H. Brown, and J. Levin, “TheImpact of Age on the Epidemiology ofIncomplete Abortions in South AfricaAfter Legislative Change,” BJOG: An In-ternational Journal of Obstetrics and Gy-naecology 112, no. 3 (March 2005): 355---359.

49. Guttmacher Institute, “MakingAbortion Services Accessible in the Wakeof Legal Reforms: A Framework and SixCase Studies” (New York, NY, 2012),http://www.guttmacher.org/pubs/abortion-services-laws.pdf (accessed Sep-tember 20, 2012).

50. Ibid., 27, 38.

51. Patricia Stephenson, Marsden Wag-ner, Mihaela Badea, and Florina Serba-nescu, “Commentary: The Public HealthConsequences of Restricted InducedAbortion—Lessons From Romania,”American Journal of Public Health 82, no.10 (1992): 1328---1331. “The maternalmortality rate fell by 50% in the first yearfollowing the change in the law” (p.1329).

52. Willard Cates, David A. Grimes, andKenneth F. Schulz, “Comment: The PublicHealth Impact of Legal Abortion: 30Years Later,” Perspectives on Sexual andReproductive Health 35, no. 1 (2003): 25---28; Council on Scientific Affairs, “InducedTermination of Pregnancy Before andAfter Roe v Wade: Trends in the Mortalityand Morbidity of Women,” Journal of theAmerican Medical Association 268, no.22: (1992): 3231---3239.

53. Guttmacher Institute, State Policies inBrief.

54. National Collaborating Centre forMental Health, Induced Abortion andMental Health. Academy of Medical RoyalColleges; 2011, http://www.nccmh.org.uk/publications_SR_abortion_in_MH.html (accessed September 20, 2012).“When a woman has an unwanted preg-nancy, rates of mental health problemswill be largely unaffected whether she hasan abortion or goes on to give birth” (p.123); American Psychological Associa-tion Task Force on Mental Health andAbortion, “Report of the APA Task Forceon Mental Health and Abortion”; 2008,http://www.apa.org/pi/wpo/mental-

health-abortion-report.pdf (accessed Sep-tember 20, 2012). “This Task Force onMental Health and Abortion concludesthat the most methodologically soundresearch indicates that among womenwho have a single, legal, first-trimesterabortion of an unplanned pregnancy fornontherapeutic reasons, the relative risksof mental health problems are no greaterthan the risks among women who deliveran unplanned pregnancy” (p. 92); WorldHealth Organization, “Safe Abortion:Technical and Policy Guidance,” 49.

55. See, for example, “Abort—bezplatno:Socailnaih osnovonii dlia prepaivaniabremennosti stalo menshem,” http://www.rg.ru/2012/02/17/abort.html(accessed September 20, 2012); “Min-zdrav ogranichil pokazania k poednemyabortu,” http://ryazan.kp.ru/online/news/1083714 (accessed September 20, 2012).

56. Elizabeth Raymond and David A.Grimes, “The Comparative Safety of Le-gally Induced Abortion and Childbirth inthe United States,” Obstetrics & Gynecol-ogy 119, no. 2 (2012): 215---219.

57. Steve Gutterman and Sonya Hepin-stall, “Church-Backed Abortion BillSparks Protest in Russia,” Reuters, No-vember 8, 2011, http://www.reuters.com/article/2011/11/08/russia-abortion-idUSL5E7M323R20111108 (accessedSeptember 20, 2012); Arash Ahmadi,“Turkey PM Erdogan Sparks Row OverAbortion,” BBC, June 1, 2012, http://www.bbc.co.uk/news/world-europe-18297760(accessed September 21, 2012).

58. Agata Chelstowska, “Stigmatisationand Commercialization of Abortion Ser-vices in Poland: Turning Sin Into Gold,”Reproductive Health Matters 19, no. 37(2011): 98---106.

59. Special rapporteur on the right ofeveryone to the enjoyment of the highestattainable standard of physical and men-tal health, “Interim Report of the SpecialRapporteur on the Right of Everyone tothe Enjoyment of the Highest AttainableStandard of Physical and Mental Health,Transmitted by Note of the Secretary-General,” para. 28, U.N. Doc A/66/254;August 3, 2011, by Anand Grover.

60. Ibid.

61. World Health Organization, “SafeAbortion: Technical and Policy Guid-ance,” 96.

62. Ted Joyce and Robert Kaestner,“The Impact of Mississippi’s MandatoryDelay Law on the Timing of Abortion,”Family Planning Perspectives 32, no. 1(2000): 4---13.

63. World Health Organization, “SafeAbortion: Technical and Policy Guid-ance,” 97.

64. Ibid., 23; SRRH, Interim rep. of theSpecial Rapporteur, U.N. Doc. A/66/254(2011).

ABORTION LAW AROUND THE WORLD

Published online ahead of print February 14, 2013 | American Journal of Public Health Finer and Fine | Peer Reviewed | World Abortion Laws | e5

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