Abortion Law Around the World: Progress and Pushback There is a global trend

toward the liberalization of

abortion laws driven by

womensrights,publichealth,

and human rights advocates.

This trend reflects the reco-

gnition of womens access

to legal abortion services

as a matter of womens

rights and self-determination

and an understanding of

the dire public health im-

plications of criminalizing

abortion.

Nonetheless, legal strate-

gies to introduce barriers

that impede access to legal

abortion services, such as

mandatory waiting periods,

biased counseling require-

ments, and the unregulated

practice ofconscientiousob-

jection, are emerging in re-

sponse to this trend. These

barriers stigmatize and de-

mean women and compro-

mise their health.

Public health evidence

and human rights guaran-

tees provide a compelling

rationale for challenging

abortion bans and these re-

strictions. (Am J Public

Health. Published online

ahead of print February 14,

2013: e1e5. doi:10.2105/

AJPH.2012.301197)

Louise Finer, LLM, and Johanna B. Fine, JD, MIA

ACCORDING TO THE MOST RE-

cent research, the legal framework in 68 countries worldwide cur- rently prohibits abortion entirely or permits it only to save a wom- ans life. Conversely, 60 countries allow a woman to decide whether to terminate a pregnancy. A fur- ther 57 countries permit abortion to protect a womans life and health, and an additional 14 per- mit abortion for socioeconomic motives.1 These figures indicate that roughly 39% of the worlds population lives in countries with highly restrictive laws governing abortion.2

Following World War II, abor- tion was highly restricted through- out most of the world.3 Since the 1950s, when the liberalization of abortion laws began in Eastern and Central Europe, an unmistak- able global trend toward easing legal restrictions on abortion has ensued. The landmark decision of Roe v. Wade in the United States can be seen against the backdrop of liberalization of abortion laws in the developed world through the 1960s and 1970s.4 Between 1950 and 1985, nearly all indus- trialized countriesand several othersliberalized their abortion laws.5 Furthermore, since 1994, when 179 countries committed to preventing unsafe abortion under the International Conference on Population and Development Programme of Action, more than 25 countries have liberalized their abortion laws. During the same period, only a handful have tight- ened legal restrictions on abortion.6

Despite some notable excep- tions,7 nearly all countries in the global north and central and eastern Asia currently have liberal abortion

laws, authorizing the service with- out restrictions as to reason during certain gestational limits or on broad grounds, such as for socio- economic reasons. By contrast, countries in the global south gen- erally have restrictive abortion laws on the books, with abortion criminalized except for limited cir- cumstances, such as if a womans health or life is at risk, or in cases of rape, incest, or fetal impairment.8

The legal framework for abor- tion in a given country can be derived from multiple sources, in- cluding statutes enacted by legis- latures, regulations created by ad- ministrative agencies, and court decisions. Many of these laws and policies apply concurrently. Al- though abortion is a medical pro- cedure, it has historically been addressed in penal codes and characterized as a crime. Penal codes generally set out criminal sanctions for the abortion pro- vider and in some instances also for the woman undergoing the abortion. However, these same penal codes normally recognize exceptions under which perform- ing an abortion does not carry any criminal penalties.9

The liberalization of abortion laws using legal means has gener- ally been achieved by amending criminal bans to specify certain circumstances in which there is no legal penalty for abortion. Thus, countries in the first wave of liberalization, in Central and Eastern Europe, saw the intro- duction of specific circumstances in which abortion carried no criminal sanction.10 In addition, although most countries (including those with liberal abortion laws) still maintain penal code provisions

delineating the circumstances in which abortion is a crime, penal code provisions have been in- creasingly replaced or supple- mented by public health codes, court decisions, and other regula- tions and laws addressing the provision of reproductive health care.11 In 2010, for example, Spain (one of the few European coun- tries that had maintained a restric- tive abortion law) enacted a law on sexual and reproductive health that eliminated a penal code pro- vision punishing women for ille- gally procuring abortions and rec- ognized their right to abortion without restrictions as to reason during certain gestational limits and thereafter on specific grounds.12

Active campaigning from the womens rights, public health, and human rights fields has worked to considerable effect,13 with achievements in law reform re- flecting both the recognition of the dire public health implications of criminalizing abortion and the identification of womens access to lawful termination of a preg- nancy as a question of womens rights and self-determination. Concurrently, international stan- dards on the protection of womens reproductive rights and their ap- plication to abortion have devel- oped considerably.14 This trend persists despite the recent emer- gence of an increasingly organized and vehement opposition that seeks to restrict abortion laws and im- pose barriers to womens access to abortion globally.

Despite the overall global trend of easing legal restrictions on abortion, legal strategies have emerged to introduce new types of barriers that impede womens

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access to legal abortion services. An increasingly global and coor- dinated movementwhich prona- talist and religious concerns have fueled in direct response to the worldwide trend toward abortion law liberalizationhas instigated such strategies. Although in some countries progressive or retro- gressive steps can be classified simply, in others political tugs-of- war have led to measures that pull the specific elements of the legal status of abortion back and forth. Retrogressive steps have been added that introduce new barriers to abortion access rather than al- tering the overall legal status of abortion, making the achievement of broader reform unrealistic be- cause of the political context or established legal framework.

In Poland, for example, a liberal abortion law in place until the fall of the Soviet Union was restricted in 1993.15 In 1996, the law was again liberalized, but subsequent efforts, through amendments to the law and a ruling from the constitutional court, again restricted the law.16 The Polish parliament narrowly rejected a bill that would have introduced an absolute ban on abortion in 2011.17

Strategies to restrict abortion access have increasingly focused on introducing procedural bar- riers, through law or policy, that limit the availability of abortion services. Such barriersintro- duced primarily in countries with liberal abortion laws, including the United States and Central and Eastern Europe countriesinclude mandatory and biased counseling requirements,18 waiting periods,19

third-party consent and notifica- tion requirements,20 limitations on the range of abortion options (e.g., restrictions on medical abor- tion, including specific bans on misoprostol21), and limitations on abortion funding.

Currently, 26 US states have a waiting period, which is nor- mally 24 hours,22 and nine states require counseling that provides inaccurate information about neg- ative mental health consequences of abortion.23 In 2011, the Rus- sian parliament established a man- datory waiting period for abor- tions and considered several other procedural barriers to abortion.24

In 2009, the Slovak Republic in- troduced several procedural bar- riers to abortion access, including a mandatory counseling require- ment, a 48-hour waiting period, and the extension of the parental con- sent requirement to all minors25

when previously it had applied only to girls younger than 16 years.26

A further impediment to abor- tion access results from the un- regulated conscientious objection of health care providers and others. The right to refuse to per- form services because of moral or religious objections is governed by national laws that vary in the scope of limits of conscientious objection and that invite differing interpretations.27 Although insuf- ficient research has been con- ducted into the prevalence of un- regulated conscientious objection, case law and limited research shows that it is increasingly invoked in countries where opposition to recent liberalization is strong (e.g., Colombia)28 and where there are attempts to reverse the legalization of abortion (e.g., Poland).29 A growing body of jurisprudence delineates the justifiable limits on the exercise of conscientious objec- tion in this context, including when pharmacists, nurses, judges, and health care institutions invoke it.30

ABORTION LAW AND PUBLIC HEALTH

The World Health Organiza- tion has identified unsafe abortion

as a serious public health problem since 196731 and affirms in its most recent technical guidance the scale of this public health im- pact.32 World Health Organiza- tion evidence shows that when faced with an unplanned preg- nancy and irrespective of legal conditions, women all over the world are highly likely to have an induced abortion. Legal restric- tions that limit the grounds on which a woman may terminate a pregnancy increase the percent- age of unlawful and unsafe pro- cedures.33 The maternal mortality ratio per 100 000 live births ow- ing to unsafe abortion is generally higher in countries with major re- strictions and lower in countries where abortion is available without restrictions as to reason or under broad conditions.34 Thus, the pub- lic health impact of unsafe abortion is directly linked to its legal status.

Abortions legal status affects its access in numerous ways, both directly and indirectly. Criminali- zation renders the procedure ille- gal and, for many women, unsafe. In addition, criminalization and other legal restrictions can indi- rectly produce a chilling effect that makes even legal abortions diffi- cult to access.35 A recent report of the United Nations high com- missioner for human rights to the United Nations Human Rights Council in examining the prevent- able causes of maternal mortality and morbidity finds that restrictive abortion laws lead to health providers, polices, and others responses that discourage care- seeking behavior.36 These re- sponses include withholding care until a woman confesses to having had an illegal abortion and reporting women who have sym- ptoms of a spontaneous or in- duced abortion to the police be- cause of perceived or real pressure or legal requirements.37

In countries that permit abor- tion only on narrow legal grounds, information about legal services is often unavailable. Consequently, some women presume that they are not entitled to a legal abortion although this may not be the case.38 Health providers may also lack training in safe abortion pro- cedures, have insufficient infor- mation to be able to act within the law, or be reluctant to interpret legal grounds. The lack of care protocols and effective procedures to guide health providers decision-making to ensure laws are correctly interpreted has led to devastating consequences for women seeking abortions.39

Moreover, health providers fears of criminal sanction promote a restrictive interpretation of laws and, as a result, more unsafe abor- tions or delays that have secondary health consequences.40

Procedural barriers, such as the mandatory waiting periods and bi- ased counseling requirements we have mentioned, can delay care and hinder access to safe services, which in turn demean women as competent decision-makers and in- crease health risks.41

Notably, however, the technical advancement of medical abortion, particularly through the use of misoprostol, has been a revolu- tionary development in reducing rates of abortion-related morbidity and mortality.42 Misoprostol was originally marketed to prevent and treat gastric ulcers, but it is also a safe and effective means of pregnancy termination.43

Women worldwide, particularly in Latin America, are increasingly self-administering misoprostol off-label to terminate their preg- nancies.44 Thus, in settings with restrictive abortion laws or signi- ficant access barriers, women are increasingly able to self-induce safe abortions.45 Moreover, as

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misoprostol can be stored at room temperature and administered by nonphysicians, it has increased womens access to safe abortion services in many resource-limited settings.46

Nonetheless, not only does evi- dence clearly illustrate the nega- tive public health impact of exces- sive abortion restrictions, but it also supports the case for abortion law liberalization. According to South Africas National Committee of Confidential Inquires into Ma- ternal Deaths, liberalization in the country47 in 1996 led to a 91% decline in abortion-related mater- nal mortality between 1994 and 1998—2001. One study showed an immediate positive impact on morbidity,48 in particular arising from infection, and another concluded that a cautious assess- ment of the magnitude of the re- duction [in maternal mortality] confirms that it is large.49

Evidence from Nepal, where revisions to the countrys legal code in 2002 granted women the right to terminate a pregnancy up to 12 weeks without restriction as to reason and later on specific grounds, suggests that liberaliza- tion has contributed to a decline in complications from unsafe abortion.50 Following the liber- alization of Romanias abortion law in 1989, maternal mortality dramatically decreased.51 In the United States, in the years following the Roe v. Wade decision, maternal mortality significantly declined as a result of the decrease in unsafe abortions, clearly demonstrating the public health impact of Roe v. Wades implementation.52

CONCLUSIONS

Evidence of the public health implications of excessive legal re- strictions on abortion cannot be ignored. Authoritative research

conducted in the wake of liber- alization provides a further ratio- nale for contesting such restric- tions on public health grounds. This public health rationale has supported many efforts toward abortion law reform in such countries as Colombia, Ethiopia, and Guyana.

However, those who seek to maintain or introduce restrictive legal regimes for abortion contest the public health evidence that supports the case for lifting exces- sive legal restrictions on abortion. Such efforts either deliberately avoid the facts or rely on de- bunked public health evidence to . In the United States, for example, several states have mandated counseling for women seeking abortion services and required them to receive information about purported negative mental health consequences of abortion or a link between abortion and increased risk of breast cancer in an attempt to coerce women to continue un- wanted pregnancies.53 These ef- forts overlook, or ignore, authori- tative studies that debunk the myth of a connection between having an abortion and increased mental health risks and disprove any link between abortion and an increased risk of breast cancer.54

Other purported justifications for abortion restrictions on public health grounds misrepresent and oversimplify risks and other con- siderations related to womens health during pregnancy. In Russia, for example, recent restrictions on abortions after 12 weeks of preg- nancy have been justified by pointing to an increased risk of maternal mortality resulting from later term abortions.55 Although abortion does indeed carry a greater risk of potential complica- tions the later it is performed, this apparent concern for womens

lives is seen to be disingenuous when examined in the light of studies showing that the risk of death associated with childbirth is far greater than is the risk associ- ated with legal abortion.56

The argument that forcing women to carry pregnancies to term will reverse trends of demo- graphic decline also underpins restrictions on womens access to abortion in countries such as Rus- sia.57 There is no evidence of a connection between restrictions on access to abortion and in- creased birth rates. As we have discussed, women who wish to terminate their pregnancies will seek this service whether it is legal or not. When abortion services are highly restricted, women are often forced to procure unsafe abortions, which may jeopardize their health and lives.

Excessive legal restrictions have myriad repercussions in addition to whether abortion services are available. Excessive restrictions stigmatize women seeking abor- tions and discriminate against those who lack the knowledge and understanding of legal grounds for abortion and vulner- able groups, such as poor and rural women and girls. Further research should be conducted into the regional and subnational discrepancies in abortion access resulting from excessive legal re- strictions. Where legal restrictions render abortion inaccessible or difficult to access, wealthier women and those based in urban areas may be the only ones able to access private services or travel to obtain abortion services.58

Such restrictions on abortion also create systemic problems leading to practices that are in- evitably unsafe. Where abortion is prohib-ited, public health and safety regulations for its provision cannot exist; thus the training and

licensing of health providers is limited.59 On these and other grounds, the United Nations special rapporteur on the right to health has characterized the criminalization of abortion as incompatible with the right to the highest attainable standard of health.60

We believe that, with time, the public health impact of new kinds of legal and policy barriers intro- duced to restrict abortion access will become evident. Evidence al- ready shows that mandatory waiting periods compromise womens health by delaying care and womens ability to access safe and legal abortion services,61 but further research is essential. Al- though the risks associated with abortion are small, waiting periods cause greater numbers of women to delay the procedure until the second trimester of pregnancy, when the risk of complications rises geometrically.62 Similarly, the co- ercive nature of biased counseling requirements providing medically inaccurate information could lead women to make decisions that jeopardize both their physical and mental health. Such restrictions demean and stigmatize women.63

The public health implications of excessive legal restrictions on abortion are devastating. Reliable public health evidence and the application of human rights guar- antees provide a compelling ratio- nale for challenging abortion bans and other restrictions.64 The wave of liberalization of abortion laws responded to public health evi- dence and, more recently, human rights arguments. The ideologi- cally and religiously motivated backlash against abortion is in- creasingly resorting to misrepre- sentations and avoidance of public health evidence, and it is under- mining human rights standards applicable in this context. The movement that has so successfully

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campaigned for abortion liber- alization must continue to assert these strong grounds or face pushback on the gains achieved. j

About the Authors At the time of the research and writing, Louise Finer and Johanna B. Fine were with the Center for Reproductive Rights, New York, NY. Correspondence should be sent to Louise

Finer, Managing Editor, Reproductive Health Matters, 444 Highgate Studios, 53-79 Highgate Road, London NW5 1TL, UK (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the Reprints link.

This commentary was accepted December 21, 2012.

Contributors L. Finer and J. B. Fine contributed equally to the research and writing of the commentary.

Acknowledgments We wish to thank Kathryn Meyer for her help preparing the commentary.

Endnotes 1. Center for Reproductive Rights, The Worlds Abortion Laws 2012, http://worldabortionlaws.com (accessed September 20, 2012).

2. Center for Reproductive Rights, The Worlds Abortion Laws 2011 (New York, 2011).

3. Stanley K. Henshaw, Induced Abortion: A World Review, 1990, Family Planning Perspectives 22, no. 2 (1990): 76—89.

4. P. 753 in Julia L. Ernst, Laura Katzive, and Erica Smock, The Global Pattern of U.S. Initiatives Curtailing Womens Reproductive Rights: A Per- spective on the Increasingly Anti-Choice Mosaic, Journal of Constitutional Law 6, no. 4 (2004): 752—795.

5. P. 60 in Anika Rahman, Laura Kat- zive, and Stanley K. Henshaw, A Global Review of Laws on Induced Abortion, 1985—1997, International Family Plan- ning Perspectives 24, no. 2 (1998): 56—64.

6. Rahman et al., Global Review of Laws; Reed Boland and Laura Katzive, Develop- ments in Laws on Induced Abortion: 1998— 2007, International Family Planning Per- spectives 34, no. 3 (2008):110—120; Center for Reproductive Rights, Abortion World- wide: 17 Years of Reform (New York, 2011), http://reproductiverights.org/sites/crr. civicactions.net/files/documents/pub_bp_ 17_years.pdf (accessed September 20, 2012); Rebecca J. Cook, Bernard M. Dickens, and Laura E. Bliss, International Devel- opments in Abortion Law From 1988

to 1998, American Journal of Public Health 89, no. 4 (1999): 579—586.

7. For example, Poland, Malta, and the Republic of Korea.

8. Center for Reproductive Rights, Worlds Abortion Laws 2012.

9. Boland and Katzive, Developments in Laws: 1998—2007, 110.

10. Henshaw, Induced Abortion: 1990, 78.

11. Boland and Katzive, Developments in Laws: 1998—2007, 110.

12. Ley Orgnica 2/2010, de salud sexual y reproductiva y de la interrupcin voluntaria del embarazo [Organic law 2/ 2010, on sexual and reproductive health and the voluntary interruption of preg- nancy], B.O.E. (Spain), no. 55 (March 4, 2010): 21001—21014.

13. Boland and Katzive, Developments in Laws: 1998—2007, 117; Cook et al., International Developments from 1988 to 1998, 584; Rebecca J. Cook and Bernard M. Dickens, Human Rights Dy- namics of Abortion Law Reform, Human Rights Quarterly 25, no. 1 (2003):1—59; Leila Hessini, Global Progress in Abortion Advocacy and Policy: An Assessment of the Decade Since ICPD, Reproductive Health Matters 13, no. 25 (2005): 88—100.

14. Ernst et al., Global Pattern of U.S. Initiatives, 753. The Protocol to the African Charter on Human and Peoples Rights on the Rights of Women in Africa explicitly recognizes that the right to health includes access to safe and legal abortion. It requires states parties to ensure that the right to health of women, including sexual and reproductive health is respected and promoted by taking appropriate measures to authorize abor- tion in cases of sexual assault, rape, incest, and where the continued preg- nancy endangers the mental and physical health of the mother or the life of the mother or the foetus (p. 15—16). Protocol to the African Charter on Human and Peoples Rights on the Rights of Women in Africa, 2nd Ordinary Sess., Assembly of the Union, adopted July 11, 2003, art. 14, CAB/LEG/66.6 (entered into force No- vember 25, 2005).

15. Law of January 7, 1993 on Family Planning, Human Embryo Protection, and Conditions of Legal Pregnancy Termina- tion. This law permits abortion when a pregnancy threatens the life or health of the woman, when there is justified suspi- cion that the pregnancy resulted from a criminal act, or in cases of fetal impairment.

16. In 1996, Polands abortion law was liberalized to permit abortion on social and economic grounds. Act of August 30, 1996. However, the constitutional court invalidated the revised law the following year. Ruling of the Constitutional Tribu-

nal of May 28, 1997, sign. of the records K 26/96 (Pol.) (unofficial translation). In December 1997, the parliament enacted new legislation eliminating social and economic grounds for abortion. Law of January 7, 1993 on Family Planning, Human Embryo Protection, and Condi- tions of Legal Pregnancy Termination amended as of December 23, 1997 (Pol.) (unofficial translation provided by Feder- ation for Women and Family Planning).

17. Sejm odrzuci1 obywatelski projekt zakazujacy aborcji, Gazeta Wyborcza, August 31, 2011, http://wiadomosci. gazeta.pl/wiadomosci/1,114873, 10209867, Sejm_odrzucil_obywatelski_projekt_ zakazujacy_aborcji.html (accessed Sep- tember 20, 2012).

18. Some laws require that women re- ceive counseling before undergoing an abortion. Rather than providing a neutral discussion of the nature and risks of abortion, such counseling can be intended to discourage women from undergoing an abortion by providing inaccurate infor- mation. Rahman et al., Global Review: 1985—1997, 59.

19. Some laws establish waiting or reflection periods during which women must wait one to several days before being permitted to undergo an abortion. Cook et al., International Develop- ments: 1988 to 1998, 584.

20. Some laws require a woman or girl to obtain the consent of her spouse or parent before undergoing an abor- tion, whereas others require abortion providers to secure approval from an- other physician, medical committee or court before performing an abortion (p. 73). Reed Boland, Second Trimester Abortion Laws Globally: Actuality, Trends and Recommendations, Repro- ductive Health Matters 18, no. 36 (2010): 67—89.

21. For example, in 2002, the Philip- pines Food and Drug Administration issued a circular prohibiting the distribu- tion, sale, and use of misoprostol. Bureau of Food and Drugs Advisory 2002—02 (August 12, 2002) (on file with the Center for Reproductive Rights).

22. Guttmacher Institute, State Policies in Brief: Counseling and Waiting Periods for Abortion; 2012, http://www. guttmacher.org/statecenter/spibs/spib_ MWPA.pdf (accessed September 20, 2012).

23. Guttmacher Institute, News in Context: State Legislative Trends at Mid- year 2012, http://www.guttmacher.org/ media/inthenews/2012/07/10/index. html (accessed September 20, 2012).

24. Federelnii Zakon Rossiiskoi Feder- atzii ot 21 noiabria 2011 g. N 323-F3:

Ob osnovah ohranai grajdan v Rossiiskoi Federatzii, http://www.rg.ru/2011/11/ 23/zdorovie-dok.html (accessed Septem- ber 20, 2012). According to article 55, 3, if a woman is in her 4th to 7th week of pregnancy or 11th to 12th week of pregnancy, she must observe a waiting period of 48 hours before she can access abortion services. For a woman in the 8th to 10th weeks of pregnancy, the waiting period is seven days. Additionally, on February 6, 2012, the Russian govern- ment issued a decree, the Social Ground for Artificial Termination of Pregnancy, signed by Prime Minister Vladimir Putin. This decree establishes that the only social ground for abortion between the 12th and 22nd weeks of pregnancy is rape. Previously, abortion was authorized for four social indications during this period. Postanovlenie Praviteltva Rossiis- koi Federacii ot 6 fevralia 2012 g. N 98 g. Moskva: O socialnio, pokazanii dlia iskusstvenogo preriavania beremen- nosti, http://www.rg.ru/2012/02/15/ 98-dok.html (accessed September 20, 2012).

25. Act No. 576/2004 Coll. of Laws on Health Care, Health Care-Related Ser- vices, and Amending and Supplementing Certain Acts as Amended by Act No. 345/2009 Coll. of Laws, 2004 (Slovak).

26. Act No. 73/1986 Coll. on Artificial Termination of Pregnancy as Amended by Act No. 419/1991 Coll., 1986 (Slovak).

27. Judith Bueno de Mesquita and Louise Finer, Conscientious Objection: Protecting Sexual and Reproductive Health Rights. University of Essex; 2008, http:// www.essex.ac.uk/hrc/research/projects/ rth/docs/Conscientious_objection_final. pdf (accessed September 20, 2012); Bernard M. Dickens and Rebecca J. Cook, Conscientious Commitment to Womens Health, International Journal of Gynecol- ogy and Obstetrics 113, no. 2 (2011): 163—166; Rebecca J. Cook, Monica Ara- ngo Olaya, and Bernard M. Dickens, Healthcare Responsibilities and Consci- entious Objection, International Journal of Gynaecology and Obstetrics 104, no. 3 (2009): 249—252.

28. Previously, abortion was prohibited with no explicit exceptions. Penal Code, promulgated by Law 599 of 2000 (Colombia). Following a ruling by the constitutional court of Colombia, abortion is now permitted to save a womans life or mental or physical health or in cases of rape, incest, or severe fetal impairment. Womens Link Worldwide, C-355/ 2005: Excerpts of the Constitutional Courts Ruling That Liberalized Abortion in Colombia; 2007, http://www. womenslinkworldwide.org/pdf_pubs/ pub_c3552006.pdf (accessed September 20, 2012). Judges have subsequently in- voked conscientious objection when re- fusing to hear appeals in connection with

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the denial of legal abortion services. See, for example, the tutela claim rejected by Judge Jos Yaez Moncada in Yolanda Perez Ascanio v. Saludvida EPS, Juzgado Dcimo Civil Municipal de Ccuta, Colombia, quoted in Corte Constitucional de Colombia, September 3, 2007. T- 171/07 (Colombia).

29. RRv Poland, No. 27617/04 Eur. Ct. H. R. (2011).

30. See, for example, Corte Constitucio- nal de Colombia, May 28, 2009, T-388/ 09/Accin de Tutela (Colombia) in which the constitutional court of Colom- bia noted that judicial authorities cannot refuse a woman an abortion on the basis of conscience claims. It also noted that institutions cannot refuse a woman an abortion on the basis of conscience claims. It indicated that only the physician di- rectly performing the abortion can object to the provision of services and to do so, he or she must submit a written statement explaining the objection and refer a woman to a physician who is willing and able to perform the abortion. See also Pichon and Sajous v. France, No. 49853/ 99, Eur. Ct. H. R., Admissibility Decision (October 2, 2001) (holding that as long as the sale of contraceptives is legal and occurs on medical prescription nowhere other than in a pharmacy, the applicants cannot give precedence to their religious beliefs and impose them on others as justification for their refusal to sell such products [p. 4]).

31. World Health Assembly, Health Aspects of Population Dynamics, WHA 20.41; 1967, http://whqlibdoc.who.int/ wha_eb_handbooks/9241652063_ Vol1_(part1-2).pdf (accessed September 20, 2012).

32. World Health Organization, Safe Abortion: Technical and Policy Guid- ance for Health Systems, 2nd ed. (Ge- neva, 2012), http://www.who.int/ reproductivehealth/publications/ unsafe_abortion/9789241548434/en (accessed September 20, 2012).

33. World Health Organization, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008 (Geneva, 2011), http://whqlibdoc.who.int/ publications/2011/ 9789241501118_eng.pdf (accessed September 20, 2012); Gilda Sedgh, S. Singh, I.H. Shah, E. Ahman, S.K. Henshaw, and A. Bankole, Induced Abortion: In- cidence and Trends Worldwide From 1995 to 2008, Lancet 379, no. 9816 (2012): 625—632.

34. World Health Organization, Safe Abortion: Technical and Policy Guid- ance, 23.

35. Tysiac v. Poland, No. 5410/03 Eur. Ct. H.R. (2007); A, B and C v. Ireland, No. 25579/05 Eur. Ct. H.R. (2010).

36. Office of the United Nations High Commissioner for Human Rights, Tech- nical Guidance on the Application of Human Rights-Based Approach to Imple- mentation of Policies and Programmes to Reduce Preventable Maternal Morbidity and Mortality, para. 56, U.N. Doc. A/ HRC/21/22 (July 2, 2012).

37. Heathe Luz McNaughton, E.M. Mitchell, E.G. Hernandez, K. Padilla, and M.M. Blandon, Patient Privacy and Con- flicting Legal and Ethical Obligations in El Salvador, American Journal of Public Health 96, no. 11 (2006): 1927—1933.

38. Center for Reproductive Rights, Briefing Paper: A Technical Guide to Understanding the Legal and Policy Framework on Termination of Pregnancy in Uganda (New York, NY, 2012), http:// reproductiverights.org/sites/crr. civicactions.net/files/documents/ crr_Uganda BriefingPaper_v5.pdf (accessed Septem- ber 20, 2012). The single most critical finding of our research is that Ugandas laws and policies are more expansive than most believe, and the current legal and policy framework offers ample op- portunities for increasing access to safe abortion services (p. 6).

39. Tysiac v. Poland, No. 5410/03 Eur. Ct. H.R. (2007); L.C. v. Peru, CEDAW Committee, Commcn No. 22/2009, U.N. Doc. CEDAW/C/50/D/22/2009 (2011); K.L. v. Peru, Human Rights Com- mittee, Commcn No. 1153/2003, U.N. Doc. CCPR/C/85/D/1153/2003 (2005); Corte Suprema de Justicia de la Nacin (National Supreme Court of Jus- tice), March 13, 2012, F., A. L. s/ medida autosatisfactiva, (Argentina).

40. Tysiac v. Poland, No. 5410/03 Eur. Ct. H.R. (2007); A, B and C v. Ireland, No. 25579/05 Eur. Ct. H.R. (2010); L.C. v. Peru, CEDAW Committee, Commcn No. 22/2009, U.N. Doc. CEDAW/C/50/D/ 22/2009 (2011).

41. World Health Organization, Safe Abortion: Technical and Policy Guid- ance, 96—97.

42. Guttmacher Institute, In Brief: Facts on Induced Abortion Worldwide; 2012, http://www.guttmacher.org/pubs/fb_IAW. pdf (accessed December 21, 2012).

43. Joanna N. Erdman, Harm Reduc- tion, Human Rights, and Access to In- formation on Safe Abortion, Interna- tional Journal of Gynecology and Obstetrics 118, no. 1 (2012): 83—86; Beverley Winikoff and Wendy Sheldon, Use of Medicines Changing the Face of Abor- tion, International Perspectives on Sexual and Reproductive Health 38, no. 3 (2012): 164—166.

44. Erdman, Harm Reduction, 83—86; Winikoff and Sheldon, Use of Medi- cines, 164—166.

45. Winikoff and Sheldon, Use of Medicines, 164—166.

46. Ibid.

47. Before 1996, abortion was legal only to protect life and health or in the cases of rape, incest, other unlawful in- tercourse, and some fetal impairments. In 1996, the law was liberalized to permit the service without restrictions pertaining to the womans motive during the first trimester and thereafter on numerous grounds. Choice on Termination of Preg- nancy, Act 92 of 1996 (South Africa).

48. P. 355 in Rachel Jewkes, H. Rees, K. Dickson, H. Brown, and J. Levin, The Impact of Age on the Epidemiology of Incomplete Abortions in South Africa After Legislative Change, BJOG: An In- ternational Journal of Obstetrics and Gy- naecology 112, no. 3 (March 2005): 355— 359.

49. Guttmacher Institute, Making Abortion Services Accessible in the Wake of Legal Reforms: A Framework and Six Case Studies (New York, NY, 2012), http://www.guttmacher..pdf (accessed Sep- tember 20, 2012).

50. Ibid., 27, 38.

51. Patricia Stephenson, Marsden Wag- ner, Mihaela Badea, and Florina Serba- nescu, Commentary: The Public Health Consequences of Restricted Induced AbortionLessons From Romania, American Journal of Public Health 82, no. 10 (1992): 1328—1331. The maternal mortality rate fell by 50% in the first year following the change in the law (p. 1329).

52. Willard Cates, David A. Grimes, and Kenneth F. Schulz, Comment: The Public Health Impact of Legal Abortion: 30 Years Later, Perspectives on Sexual and Reproductive Health 35, no. 1 (2003): 25— 28; Council on Scientific Affairs, Induced Termination of Pregnancy Before and After Roe v Wade: Trends in the Mortality and Morbidity of Women, Journal of the American Medical Association 268, no. 22: (1992): 3231—3239.

53. Guttmacher Institute, State Policies in Brief.

54. National Collaborating Centre for Mental Health, Induced Abortion and Mental Health. Academy of Medical Royal Colleges; 2011, http://www.nccmh.org. uk/publications_SR_abortion_in_MH. html (accessed September 20, 2012). When a woman has an unwanted preg- nancy, rates of mental health problems will be largely unaffected whether she has an abortion or goes on to give birth (p. 123); American Psychological Associa- tion Task Force on Mental Health and Abortion, Report of the APA Task Force on Mental Health and Abortion; 2008, http://www.apa.org/pi/wpo/mental-

health-abortion-report.pdf (accessed Sep- tember 20, 2012). This Task Force on Mental Health and Abortion concludes that the most methodologically sound research indicates that among women who have a single, legal, first-trimester abortion of an unplanned pregnancy for nontherapeutic reasons, the relative risks of mental health problems are no greater than the risks among women who deliver an unplanned pregnancy (p. 92); World Health Organization, Safe Abortion: Technical and Policy Guidance, 49.

55. See, for example, Abortbezplatno: Socailnaih osnovonii dlia prepaivania bremennosti stalo menshem, http:// www.rg.ru/2012/02/17/abort.html (accessed September 20, 2012); Min- zdrav ogranichil pokazania k poednemy abortu, http://ryazan.kp.ru/online/news/ 1083714 (accessed September 20, 2012).

56. Elizabeth Raymond and David A. Grimes, The Comparative Safety of Le- gally Induced Abortion and Childbirth in the United States, Obstetrics & Gynecol- ogy 119, no. 2 (2012): 215—219.

57. Steve Gutterman and Sonya Hepin- stall, Church-Backed Abortion Bill Sparks Protest in Russia, Reuters, No- vember 8, 2011, http://www.reuters. com/article/2011/11/08/russia-abortion- idUSL5E7M323R20111108 (accessed September 20, 2012); Arash Ahmadi, Turkey PM Erdogan Sparks Row Over Abortion, BBC, June 1, 2012, http://www. bbc.co. (accessed September 21, 2012).

58. Agata Chelstowska, Stigmatisation and Commercialization of Abortion Ser- vices in Poland: Turning Sin Into Gold, Reproductive Health Matters 19, no. 37 (2011): 98—106.

59. Special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and men- tal health, Interim Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, Transmitted by Note of the Secretary- General, para. 28, U.N. Doc A/66/254; August 3, 2011, by Anand Grover.

60. Ibid.

61. World Health Organization, Safe Abortion: Technical and Policy Guid- ance, 96.

62. Ted Joyce and Robert Kaestner, The Impact of Mississippis Mandatory Delay Law on the Timing of Abortion, Family Planning Perspectives 32, no. 1 (2000): 4—13.

63. World Health Organization, Safe Abortion: Technical and Policy Guid- ance, 97.

64. Ibid., 23; SRRH, Interim rep. of the Special Rapporteur, U.N. Doc. A/66/254 (2011).

ABORTION LAW AROUND THE WORLD

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