Portal de Periódicos da CAPES

International Perspective on Abortion Access for Improving Reproductive Rights and Freedom of Adolescents and Young Adults

2023; Elsevier BV; Volume: 73; Issue: 1 Linguagem: Inglês

10.1016/j.jadohealth.2023.03.014

1879-1972

Nuray Kanbur, Abigail Harrison, Preeti M. Galagali, Giuseppina Di Meglio,

International Human Rights and Reproductive Law

In May 2022, following a leaked draft opinion of the US Supreme Court which raised concerns that federal protections for abortion access might be at risk, the Society for Adolescent Health and Medicine (SAHM) responded with a press release announcing their objection to any restrictions on the reproductive rights and care of adolescents and young adults (AYAs), including access to safe abortion [[1]Available at: https://www.adolescenthealth.org/About-SAHM/Press-Releases/SAHM-NASPAG-Statement-on-leaked-draft-SCOTUS-opini.aspx. Accessed February 17, 2023.Google Scholar]. Thereafter, the Supreme Court ruled that there is no federal constitutional right to abortion in the United States [[2]Dobbs v Jackson Women's Health Org, 506 United States. 2022. Available at: https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf. Accessed February 17, 2023.Google Scholar]—a decision representing a reversal in reproductive rights of nearly 50 years in the country. International members of SAHM stand with all our SAHM colleagues in working toward improving reproductive rights and freedom of AYAs. As a group, we commit to advocate that abortion should be made available as a safe and essential component of comprehensive sexual and reproductive health (SRH) care for AYAs globally. This article provides a brief exploration of the current international abortion laws, the impact of legal frameworks on the outcomes of abortion and access to safe abortions in high-income as compared to low- and middle-income countries. Globally, 45% of the abortions that occur are unsafe and the proportion is higher in countries that have restrictive abortion laws compared to those with liberal laws [[3]Ganatra B. Gerdts C. Rossier C. et al.Global, regional, and subregional classification of abortions by safety, 2010–14: Estimates from a Bayesian hierarchical model.Lancet. 2017; 390: 2372-2381Abstract Full Text Full Text PDF PubMed Scopus (455) Google Scholar]. AYAs aged 15–24 years around the globe seek abortion care more often than any other age group [[4]Singh S., Remez L., Sedgh G., et al. Abortion worldwide 2017: Uneven progress and unequal access. Guttmacher Institute. 2018. Available at: https://www.guttmacher.org/report/abortion-worldwide-2017. Accessed February 17, 2023.Google Scholar] and account for 41% of the unsafe abortions [[5]Shah I. Åhman E. Unsafe abortion differentials in 2008 by age and developing country region: High burden among young women.Reprod Health Matters. 2012; 20: 169-173Crossref PubMed Scopus (111) Google Scholar]. In sub-Saharan Africa, 57% of the unsafe abortions occur in the age group of 15–24 years with 25% among those 15–19 years old [[6]Munakampe M.N. Zulu J.M. Michelo C. Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: A systematic review.BMC Health Serv Res. 2018; 18: 909Crossref PubMed Scopus (86) Google Scholar]. Worldwide, 100 countries permit abortion under specified conditions including socioeconomic conditions, risk to physical and mental health of the mother and fetal anomalies. Twelve countries have totally banned abortions. There is a global trend to ease legal restrictions on abortions. Recently, Argentina, Colombia, India, Ireland, Mexico, New Zealand, South Africa, South Korea, Thailand, Tunisia, and Zambia revised existing laws to decriminalize abortion and/or increased the permitted gestational limits, while a few countries including Honduras and United States tightened restrictions [[7]Global Abortion Policies Database (GAPD) [website]. Geneva: World Health Organization. Available at: http://abortion-policies.srhr.org/. Accessed February 17, 2023.Google Scholar]. Although international health organizations, such as the World Health Organization (WHO) have recommended liberal abortion laws, the ground reality is dismal for AYAs, who face many barriers in seeking private and confidential abortion care such as stigma, cost, and the legal need for parental consent [[4]Singh S., Remez L., Sedgh G., et al. Abortion worldwide 2017: Uneven progress and unequal access. Guttmacher Institute. 2018. Available at: https://www.guttmacher.org/report/abortion-worldwide-2017. Accessed February 17, 2023.Google Scholar,[8]WHO. Abortion care guideline. Geneva: World Health Organization. 2022. Available at: https://www.who.int/publications/i/item/9789240039483. Accessed February 17, 2023.Google Scholar]. In a substantial proportion of countries, parental consent is mandatory for adolescents seeking abortions [[7]Global Abortion Policies Database (GAPD) [website]. Geneva: World Health Organization. Available at: http://abortion-policies.srhr.org/. Accessed February 17, 2023.Google Scholar]. In only a small number of countries and a few states within the United States, minors (defined as those aged less than 16 or 18 years depending on the territory) can access abortion care without parental consent [[7]Global Abortion Policies Database (GAPD) [website]. Geneva: World Health Organization. Available at: http://abortion-policies.srhr.org/. Accessed February 17, 2023.Google Scholar,[9]American Academy of Pediatrics, Committee on AdolescenceThe Adolescent's right to confidential care when Considering abortion.Pediatrics. 2022; 150e2022058780Google Scholar]. Despite the United Nations (UN) Sustainable Development Goals 3.7 and 5.6 referring to universal rights and access to SRH services within a gender-equitable context, availability of and access to abortion services remain suboptimal in most countries globally [[10]Starrs A.M. Ezeh A.C. Barker G. et al.Accelerate progress-sexual and reproductive health and rights for all: Report of the Guttmacher-Lancet Commission.Lancet. 2018; 391: 2642-2692Abstract Full Text Full Text PDF PubMed Scopus (457) Google Scholar]. There is no evidence that liberalizing access to safe, legal abortion services increases the rate of abortion. In fact, the opposite is often the case. High-income countries with better access to abortion services as part of a full suite of SRH services have significantly lower rates of abortion per 1000 women. This may be because safe, legal abortion services within a nonjudgmental setting increase the use of contraceptive services thereafter [[11]Faúndes A. Shah I.H. Evidence supporting broader access to safe legal abortion.Int J Gynaecol Obstet. 2015; 131: S56-S59Crossref PubMed Scopus (51) Google Scholar]. Also, it is important to note that a small but growing number of low- and middle-income countries from the global south including Nepal, Ethiopia, and Mexico are improving legal access to safe abortion care [[7]Global Abortion Policies Database (GAPD) [website]. Geneva: World Health Organization. Available at: http://abortion-policies.srhr.org/. Accessed February 17, 2023.Google Scholar]. Access to abortions is impacted by AYA's socioeconomic status with the more vulnerable girls in lower socioeconomic contexts facing greater barriers to accessing safe abortion services, so compounding their risk. Although seen more in low- and middle-income countries, even within high-income countries, in-country variations in access reveal the pervasive nature of barriers globally [[10]Starrs A.M. Ezeh A.C. Barker G. et al.Accelerate progress-sexual and reproductive health and rights for all: Report of the Guttmacher-Lancet Commission.Lancet. 2018; 391: 2642-2692Abstract Full Text Full Text PDF PubMed Scopus (457) Google Scholar]. Improved access to abortion services for AYAs will require the removal of multilevel barriers—at the service level inclusive of privacy and confidentiality concerns, financial and logistical challenges, legal and policy-level barriers, training and education of AYAs and providers alike [[12]Bearak J. Popinchalk A. Ganatra B. 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: e1152-e1161Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar]. WHO recently released evidence-based guidelines on abortion care based on the international law framework ratified by various global conventions such as the UN Convention on Economic, Social and Cultural Rights, the Convention on the Rights of the Child, and the Convention on the Elimination of all kinds of Discrimination against women. The guidelines recommend that countries must respect the right of women to make autonomous decisions about their SRH, liberalize abortion laws, guarantee access to comprehensive and quality abortion care, prevent unsafe abortions, provide postabortion care, even when abortion has been conducted outside the law, and provide universal access to informed contraceptive usage. The legal framework and policy recommendations include decriminalization of abortion, elimination of grounds-based approaches to permitting abortion (like medical or judicial proof of rape or incest), gestational age limits, mandatory waiting periods before receiving a requested abortion, compulsory third-party authorization for abortion (e.g., parental or partner consent), restrictions in law or policy on which type of health workers may provide abortion services (i.e., limiting to gynecologists) and techniques to deal with refusal by providers [[8]WHO. Abortion care guideline. Geneva: World Health Organization. 2022. Available at: https://www.who.int/publications/i/item/9789240039483. Accessed February 17, 2023.Google Scholar]. While all these legal framework and policy recommendations are valid for AYAs health, the elimination of parental consent requirement is particularly important for adolescents. Abortion rates were reported to be higher among countries where it was restricted than in countries where it is legal, after excluding China and India [[12]Bearak J. Popinchalk A. Ganatra B. 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: e1152-e1161Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar]. Evidence suggested that these countries were atypical within this category, but skewed the averages in countries where abortion was legal because of their large populations which comprised 62% of women who were at reproductive age globally [[12]Bearak J. Popinchalk A. Ganatra B. 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: e1152-e1161Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar]. Decriminalization has reduced abortion incidence rates in many countries over the past decades, particularly when paired with improved access to contraception [[11]Faúndes A. Shah I.H. Evidence supporting broader access to safe legal abortion.Int J Gynaecol Obstet. 2015; 131: S56-S59Crossref PubMed Scopus (51) Google Scholar]. Liberalization of laws around abortion has been shown to have a positive health impact by reducing rates of unsafe abortions, improved maternal outcomes, and decreased maternal mortality [[11]Faúndes A. Shah I.H. Evidence supporting broader access to safe legal abortion.Int J Gynaecol Obstet. 2015; 131: S56-S59Crossref PubMed Scopus (51) Google Scholar]. Recently, a new global database incorporating data from 166 countries was built and a new statistical model concurrently developed estimating unintended pregnancy and abortion rates globally within a Bayesian framework [[12]Bearak J. Popinchalk A. Ganatra B. 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: e1152-e1161Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar]. To date, this is the most comprehensive study to generate estimates of unintended pregnancy and abortion between 1990 and 2019, including the highest number of countries and their data are validated by inviting the countries to provide feedback on the data sources, methods and preliminary estimates as part of a WHO country consultation process. Although there are no age-disaggregated data reported for AYAs, their data incorporate information about unmarried women aged 15–49 years which includes AYAs; while previous studies [[13]Sedgh G. Bearak J. Singh S. et al.Abortion incidence between 1990 and 2014: Global, regional, and subregional levels and trends.Lancet. 2016; 388: 258-267Abstract Full Text Full Text PDF PubMed Scopus (437) Google Scholar,[14]Sedgh G. Singh S. Shah I.H. et al.Induced abortion: Incidence and trends worldwide from 1995 to 2008.Lancet. 2012; 379: 625-632Abstract Full Text Full Text PDF PubMed Scopus (461) Google Scholar] estimated married women's abortion incidence only. This study suggested that in 2015–19, there were 121 million unintended pregnancies annually with an 80% uncertainty interval, corresponding to a global rate of 64 unintended pregnancies per 1000 women aged 15–49 years. Sixty-one percent of unintended pregnancies ended in abortion, totaling 73.3 million abortions annually, corresponding to a global abortion rate of 39 abortions 1000 women aged 15–49 years. In countries where abortion was restricted, the increased proportion of unintended pregnancies ending in abortion was noted in 2015–2019 compared with that for 1990–94 and further, unintended pregnancy rates were higher than in countries where abortion was legal. Also, the increasing availability of medical abortion during the time frame of the study was reported to pose challenges for capturing the accurate abortion incidence as use of these medications likely occurred outside of the formal health systems in countries where abortion was restricted [[12]Bearak J. Popinchalk A. Ganatra B. 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: e1152-e1161Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar]. In conclusion, laws and policies supportive of AYA's rights to comprehensive SRH services including abortion access are required globally. Furthermore, training of health professionals in the delivery of confidential and quality SRH care inclusive of abortion care, in an effective, efficient, accessible, acceptable, patient-centered, equitable and safe, enabling healthcare environment cannot be understated. This should include provision of evidence-based information, abortion counseling and management, postabortion care, and optimized access to contraceptives, to ensure SRH rights of all AYAs. The recent reversal in SRH rights regarding abortion access in United States is concerning both at the national and international levels because this may eventually lead to global discussions and controversies that may adversely affect the health and well-being of AYAs. As international members of SAHM, we call for renewed effort on the part of our collaborators across the globe to advocate for the sexual and reproductive rights and freedom of AYAs in their countries, including access to safe abortion.