Abortion rights are set to become a political football again in the US and, by extension, in all the countries where US funding is used for women’s health and reproductive care.
US president-elect Donald Trump indicated this week that he plans to roll back abortion rights. He chose the vehement anti-abortionist Mike Pence as his vice president, and the Republican party that nominated him has a long history of trying to restrict such rights.
But a look at countries and states where abortion rights are heavily restricted shows that reducing access to legal abortions doesn’t stop women from having them. The Guttmacher Institute, a non-governmental organization that tracks global maternal health, reports that in places where abortion is restricted, roughly as many women have the procedure as in places where it’s legal—but abortions are likely to be more expensive and more dangerous.
That’s because rather than stopping abortions from taking place, restriction drives them underground or over borders. Unsafe abortion kills up to 44,000 women a year globally, according to Guttmacher, while damage to health is even more widespread: 6.9 million women in developing regions were treated for the consequences of unsafe abortion in 2012, the institute found. And 40% of women who are harmed during unsafe abortions are never treated at all.
In developed countries, the consequences are more likely to be on the mental health and financial stability of women seeking abortions. And in all cases, the effect is most acute for the poor.
Trump cannot, of course, outlaw abortions with the stroke of a pen as president. Abortion rights are currently upheld in the US under the Supreme Court decision known as Roe vs. Wade. But by appointing anti-abortion justices to the country’s highest court and to lower courts, Trump could remove protections for women’s access to the procedure, advocates for reproductive rights worry.
Lessons from a land of restriction
If the US were to outlaw abortions, there’s no perfect comparison in another country.
Abortion is legal (and not highly politicized) in plenty of countries, including most developed countries. A lot of others technically allow abortion in some cases, but many restrict and stigmatize it to the point where it can be almost impossible to obtain one safely—as is the case in Ireland and much of Africa. South America has some of the most restrictive abortion laws. It also has the highest abortion rates in the world, according to the Guttmacher Institute.
The best comparison, perhaps, is Poland, since it moved from having fairly non-restrictive abortion laws to much more restrictive ones.
Between 1965 and 1988, abortion in Poland was legal and accessible, according to a 2011 paper by Agata Chełstowska, a cultural anthropologist at the Polish Observatory of Gender Equality. Then, in the late 1980s, Solidarność, a strong opposition movement closely aligned with the Catholic church, began to gain power. As the movement gained more control of the country it campaigned against abortion rights and eventually brought in legislation which made it illegal in all but the most extreme cases, such as a threat to the life of the woman and cases of rape or incest.
(In practice, even in these cases Polish women find it very hard to obtain abortions. Chełstowska sites the 2004 cases of a young woman who died after being denied a life-saving abortion, and the 2008 case of a 14-year-old rape victim who was hounded by the press and the church when she sought a legal termination.)
Between 1988 and 1993, the number of legal abortions in Poland fell by 99%, from 105,333 to 685. But people didn’t stop needing or having abortions. Rather, they were driven to travel abroad—mostly to Germany and the UK—or to pay for private abortion services within Poland which, despite the law, advertise in newspapers.
The laws hurt the poor the most. “The higher the income, the more immune a person is to the restrictions of the law,” Chelstowska writes. Women with lower incomes and less education, single women, people in rural areas, and teenagers are all at a particular disadvantage.
Chełstowska estimates that Polish women still have about 150,000 abortions each year—about the same as before it was made unavailable. That’s an incidence rate of about 15 per thousand women aged between 15 and 44 years old. For comparison, Western Europe has the lowest incidence rate in the world, at about 11. In America it is 22. (Data providers note that it’s difficult to get hard numbers when something is illegal.)
Meanwhile, the imposition of abortion restrictions on a society that had for a long time had access to abortion created a ”vast, new, profitable market, “ Chełstowska writes. The industry generates around $95 million annually, and there is no incentive for doctors to campaign for abortion rights because that income is unofficial and therefore tax-free. Polish society today ”is divided into those who can and those who cannot find acceptable ways of getting around the law.”
Poland is seeking to make its abortion laws even more restrictive, and women are vehemently protesting.
Trump, when promising that under his administration states would be allowed to decide on whether to allow abortion or not, said women needing terminations would “have to go to another state.” His comment indicates that he understands that restricting legal abortions in one state will not prevent abortions but simply force women to travel for them. (It’s unclear what motivates Trump’s opposition, since his early campaign didn’t include an anti-abortion platform.)
To see what happens on a state level when abortion is restricted, he could look to Texas. In June 2016, the US Supreme Court finally ruled that a law imposed on clinics in the state, which came into effect in 2013 and made it all but impossible for them to function, placed an “undue burden” on women’s access to abortion. But by the time the ruling came through, 19 clinics had closed, out of just 40 in a state home to 27 million people.
After much more restrictive laws came into place, recorded medical abortions fell by about three quarters, though surgical abortions rose by 7%. But that’s just the official figures. Women who needed abortions in Texas in recent years had to travel long distances to clinics, and many couldn’t afford the fees they charged, writes Daniel Grossman, a professor in the department of obstetrics, gynecology and reproductive sciences at the University of California. Some went to Mexico, while others bought pills online to induce abortion.
In fact, the use of the drugs mifepristone and misoprostol to bring about “medical” abortion means that women in the earlier stages of pregnancy now have another option than travel or paying a doctor. They can buy the pills online in the first ten weeks of pregnancy, and some services exist that cover the pills for those who can’t afford it.
Getting drugs this way, however, relies on information, internet access and web literacy, as well as factors such as women knowing their mail isn’t going to be intercepted. Again, the rich will find it easier, and poor will be disadvantaged.
What’s this all for?
If the goal of anti-abortion legislation is to prevent or reduce abortions, policymakers would do well to look to the Netherlands. It has relatively unrestricted access to abortion, coupled with high levels of sex education. A 1994 study found that these factors contributed to it having the lowest abortion rate in the world—between five and seven per 1,000 women annually, at the time.
Whether or not the Republican leaders of the US see these comparisons as valid, women across the country are taking them seriously. Marge Berer, who leads the International Campaign for Women’s Right to Safe Abortion, says that if the incoming US government were to try to roll back abortion rights, US women will rise up in protest.
“I think all hell’s going to break loose,” she said.