We must act now to protect them, warn Herminia Palacio and Susheela Singh

A perfect storm of unfortunate events—the covid-19 pandemic, the attendant economic collapse, and potential funding reductions due to the United States’ announced withdrawal from the World Health Organization—is threatening to undo decades of progress in access to sexual and reproductive health care, particularly for those in the poorest countries.

A new Guttmacher study, in collaboration with the Human Reproduction Programme (HRP), which was published last week in the Lancet Global Health, shows that the rate of unintended pregnancies worldwide has fallen since the 1990s, mostly due to increases in contraceptive use.

But progress has been limited, unequal, and uneven. About half of all pregnancies reported every year are unintended; and of the 122 million unintended pregnancies occurring annually, half end in abortion—many in places where abortion care is legally restricted.

Most of the progress over the past 30 years has been in wealthier countries, while unintended pregnancy rates have remained consistently higher in low- and middle-income countries (LMICs). Estimates from 2015­–2019—before the pandemic—show that women in the poorest countries already experienced unintended pregnancy rates that were nearly three times those in the wealthiest countries.

Many of the women facing unintended pregnancies live in places where abortion is legally restricted. In such countries, there has been a 39% increase in the proportion of pregnancies ending in abortion in the past 30 years. Restrictions do not stop abortions from happening—they just force some people, especially those with limited resources, to resort to unsafe practices. Globally, unsafe abortions already contribute between 5% and 13% of all deaths during pregnancy and childbirth, resulting in between 22,800 and 59,280 lives lost every year, mostly in LMICs.

In high-income countries, the abortion rate is lowest (11 per 1,000 women of reproductive age) where abortion is broadly legal and much higher (31 per 1,000 women) where it is restricted.

The current global crisis is exacerbating these multiple inequities. In countries around the world, lockdowns, curfews and other actions taken by governments in response to covid-19 have caused disruptions in production and supply chains of contraceptive methods and in access to contraceptive and other sexual and reproductive health services—all of which hamper people’s ability to protect themselves from unintended pregnancy and to obtain pregnancy-related care. The pandemic has also limited healthcare organizations’ ability to conduct outreach in hard-to-access areas. Moreover, increased unemployment and loss of income are likely to further reduce access to contraception.

The Guttmacher Institute recently estimated that even a relatively modest 10% decline in the provision of essential reproductive health services as a result of the pandemic could result in an additional 15 million unintended pregnancies and 3.3 million more unsafe abortions over a one-year period. To prevent an alarming increase in unintended pregnancies and unsafe abortions, and to protect the health and lives of people around the world during and after the pandemic, governments must take meaningful and durable actions. Specifically, they need to make two key commitments:

First, governments must prioritize sexual and reproductive healthcare, including safe abortion, because it is time sensitive, lifesaving, critical healthcare that should not be denied to those in need. Accordingly, health systems must ensure that the full range of sexual and reproductive health services, including abortion services, remain accessible to people seeking them. Health systems should also adopt protocols to overcome barriers to access caused by nationwide lockdowns or the need to self-isolate.

Second, the global recovery effort must include a focus on building back better and addressing the challenges that prevented many people from receiving care before the pandemic. This includes properly funding and strengthening contraceptive supply chains, as well as embracing newer models of care, such as telemedicine. It also means addressing the social, legal, and economic conditions that have led to unequal access and inability to exercise rights, including for marginalized communities.

Forewarned is forearmed. We are committed to digging deeply to surface the many implications of the current global crisis on sexual and reproductive health. But we can reasonably predict that this crisis will have significant negative consequences and will widen existing inequities. Governments can still arm themselves with a comprehensive plan to prioritize sexual and reproductive health and rights across the world, support individuals’ right to decide when and if to have children, and provide essential health services, including access to contraception, and legal and safe abortion care.

Herminia Palacio, President and CEO, Guttmacher Institute.

Susheela Singh, Distinguished Scholar and Vice President for Global Science and Policy Integration, Guttmacher Institute.

Competing interests: None declared.