A Common Argument for Legalizing Abortion Is Wrong

Pro-choice activists at a “Stop Abortion Bans Day of Action” rally hosted by the Tennessee chapter of Planned Parenthood in Memphis, Tenn., May 21, 2019.(Karen Pulfer Focht/Reuters)


January 5, 2024. Legalizing abortion does not keep women from dying from it.

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Perhaps the most powerful argument for legal abortion throughout history has been the threat of what happens when it is banned: Countless women will die from backstreet abortions, we are told, because that is what used to happen before it was legalized. Legalization, so the received wisdom goes, put an end to all that.

This argument still has considerable traction in the U.S., where abortion bans are once again a live option in some states. One need not look far to find scaremongering about all the American women — especially poorer women and women of color — who will die in the new Confederate States of Gilead.

The argument also remains a foundation for Western foreign policy, which is centred on the unifying, decolonial idea of forcing sexual rights (including for children) and, in particular, abortion, on countries that don’t agree. It is the desire to save lives that supposedly justifies the West’s interfering in other sovereign states, erasing their cultural values, and pressuring them to legalize abortion against the will of their citizens. As influence in Africa passes from the West to Russia and China, and with a renewed push to remove the Helms amendment (blocking U.S. funding for abortion overseas), this question is more important than ever — not only as a human-rights issue but even as a geopolitical issue. Africa is projected to have nearly half the world’s population by 2100.

Those who are more comfortable with the erasure of other cultures point to women dying as a reason to intervene. But the problem is, as my new research shows, it simply doesn’t work. Legalizing abortion does not cause fewer deaths from backstreet abortions — in fact, sometimes it causes more deaths.

This might seem counterintuitive: Surely making something legal and allowing it to be performed in sanitary conditions would make it safer and cause fewer deaths?

Reality is, as usual, far more complex. Legalizing abortion might empower credible, skilled doctors — but it also often empowers quacks and reduces the perceived risk among women. Many women continue to seek less reputable sources of abortion for reasons of privacy, finance, or simply because they are unaware of any legal change. This leads to far more abortions in general, many of which remain unsafe. Moreover, even abortions performed in sanitary conditions can easily become unsafe if there is poor access to emergency care in the — very common — event of complications. As I explain elsewhere, the legalization of abortion can cause increased maternal mortality in general for many other reasons: higher suicide rates, higher drug/alcohol use and smoking, more unintended pregnancies, and so on.

This new research focuses on the frontier of this argument: sub-Saharan Africa, where two-thirds of global maternal deaths occur, and the specter of unsafe abortion is felt most acutely. I studied the countries in the region that have legalized abortion to examine what happened when they did so. The results were — at least to many — surprising.

South Africa is often cited as a success story of legalized abortion, with many people claiming a 90 percent reduction in deaths after legalization in 1996, from 425 deaths a year previously. But as I show, these data are highly unreliable and at points do not even make sense. For example, one study citing this figure confidently asserts that “all 425 women who died from illegal abortion were black.” This is a baffling claim, since the figure of 425 was merely an (unexplained and seemingly incorrect) extrapolation of just three deaths in the original study.

In South Africa, the number of hospitalizations for incomplete abortion (in which the child dies from miscarriage or illegal abortion but is not fully expelled, so used as a proxy for illegal abortion) was the same before and after legalization. So, any potential reduction in maternal deaths could not possibly be due to fewer unsafe abortions — there weren’t any fewer! It is estimated that 58 percent of abortions in southern Africa are still unsafe, and South Africa constitutes 90 percent of this regional population.

Even worse, the actual maternal-death statistics from South Africa show very clearly that maternal deaths from abortion have been steadily increasing since abortion was legalized. Maternal deaths in general doubled or tripled in the years following legalization, mostly because of the HIV/AIDS epidemic, but evidence shows that legalized abortion contributes significantly to STD transmission.

Zambia was the first African country to legalize abortion on broad socioeconomic grounds, in 1972. But it is widely — perhaps universally — accepted that 50 years later, there is little evidence of any improvement in unsafe-abortion mortality. Most remarkably, in a study of increasing abortion complications in sub-Saharan Africa in 1980, the authors found that “the greatest increase in admissions is found in Zambia, the only country in sub-Saharan Africa where abortion is legal.” In just four years from 1972, abortion complications requiring admission to the hospital in the capital, Lusaka, more than doubled from 1,448 to 2,991.

More recently, Rwanda legalized abortion in 2012. Prior to this, abortion was responsible for around 3 percent of maternal deaths, but upon legalization this doubled to 6–7 percent of maternal deaths. Ethiopia legalized abortion in 2006, and I have shown elsewhere that this resulted in an increase in complications of abortion across the country. Mozambique legalized abortion too recently to gather reliable data on the consequences, but we know that prior to legalization, the country had already almost eliminated the problem, reducing abortion deaths by 82 percent in the five years before legalization. This fits with evidence from the developed world showing that deaths from unsafe abortion are radically exaggerated and that legal abortion is unnecessary as a solution: Malta and Poland have the lowest maternal mortality ratios in the world, and they prohibit more than 99 percent and 98 percent of abortions, respectively. Malta has had no maternal deaths in over ten years.

Every life lost to unsafe abortion is a tragedy, and we should make every effort to protect these women’s lives, in our own countries and abroad. But legalizing abortion on demand, the evidence increasingly shows, is only likely to worsen the problem.

CALUM MILLER is a medical doctor and a research fellow at the University of Oxford, U.K., where his research focuses on abortion policy internationally. @DRCALUMMILLER