Backstreet abortion deaths: not as common or preventable as thought

By Calum Miller.

One of the foremost arguments for legalising abortion in developing countries attempts to bypass fetal moral status by appealing to practical considerations: 1) banning abortion doesn’t prevent abortions, but 2) it does put women at risk of dangerous backstreet abortions, killing women in large numbers. Since 3) legalising abortion significantly reduces unsafe abortions, without increasing overall abortions, abortion should be legal.

Many would argue that serious rights, like the right to life, should be upheld regardless of the consequences (as in the ICCPR, article 4.2). And there is overwhelming empirical evidence that banning abortion does reduce the numbers, as economic theory would predict. In a recent paper, however, I challenge what is often thought to be the least controversial part of the argument: that large numbers of women die from backstreet abortions, and that legalising abortion will prevent many of these deaths.

In my research, I found how frequently and demonstrably these statistics are misrepresented or even fabricated, even at elite professional levels. Just a few weeks ago, the International Federation of Gynaecology and Obstetrics claimed that unsafe abortions accounted for 13% of global maternal mortalities. They cite the World Health Organization, which in fact says 4.7-13.2% – the lower estimate, and even mean estimate, being omitted by FIGO. Moreover, the study on which this figure is based explicitly says that this statistic includes deaths from ectopic pregnancy, miscarriage, and a number of other conditions. The WHO misrepresented this statistic from the study, even though the study was conducted by its own researchers. To claim that 13% – or even 4.7-13.2% – or maternal deaths are attributable to unsafe induced abortion alone is a clear misrepresentation of the facts.

In many cases, the statistics are simple misrepresentations like this, usually by conflating miscarriage and induced abortion. But in some cases the statistics appear entirely fabricated. The Royal College of Obstetricians and Gynaecologists recently tweeted a claim from The Telegraph that 12,000 women in Malawi die from unsafe abortions each year. But the latest estimate for total maternal deaths in Malawi each year is 1,150 – less than 10% of that figure. And as I argue in my paper, the latest evidence (now 15-20 years old) suggests that only 6-7% of these deaths are due to miscarriage and induced abortion combined. Hence, the RCOG has overestimated the number of deaths at least one-hundredfold. Such radical overestimates are not uncommon. In the paper, I point to various studies suggesting that the majority of these 6-7% are in fact due to miscarriages, not induced abortions.

Still, the women who no doubt do die from unsafe abortion clearly matter. I therefore address the question of whether legalising abortion significantly reduces mortality from unsafe abortion, arguing that it does not – in some cases, it can increase abortion mortality. I point to countries such Rwanda, the Netherlands, and Ethiopia, where abortion mortality or morbidity increased upon liberalisation, as well as to Chile and Poland, whose abortion mortality and maternal mortality continued falling after abortion was criminalised.

Why is this? A few reasons:

  • Legalising abortion increases abortions. Not only total abortions, but in many cases, even illegal abortions increase, and in many others, illegal abortions stay constant, upon legalisation.
  • The clientele for legal and illegal abortion are often different; many women who are aware of legal and available abortion choose clandestine abortion for reasons of privacy, inter alia.
  • Good post-abortion care is usually sufficient to prevent abortion mortality; hence affluent countries restricting abortion have the lowest maternal mortality rates in the world, while poorer countries with liberal abortion laws still have significant abortion-related deaths.
  • Illegal and legal abortion are both converging on the same practice: self-managed medical abortion, without the need to see a clinician in person. While some (mostly pro-life) researchers and advocates have challenged the safety of this, it is considered by pro-choice advocates to be so safe that it should be the norm of 21st century clinical practice – so much so that the Women’s March advised against coathanger imagery on the grounds that self-managed abortion being unsafe was now considered a ‘right-wing talking point’. One recent study in Nigeria found self-managed abortion to be largely safe even in the absence of inadequate information given to the woman.

You might think this is all irrelevant anyway, since abortion should be legalised for other reasons – maybe the fetus has relatively little moral worth, or the woman’s bodily autonomy rights outweigh those of the fetus. But the research has other implications: I draw attention to the paucity of evidence for the cost-effectiveness of abortion advocacy in reducing maternal mortality, while other interventions are considerably more successful. Those interested in effective altruism, or in using limited resources to save as many lives as possible, should prioritise other interventions in global health and international development, even if they happen to think that abortion should be legalised.


Author: Calum Miller

Affiliations: St Benet’s Hall, University of Oxford

Competing interests: None

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