Trends
The statistical processing and analyses of the notifications is undertaken by the Office for National Statistics (ONS) in England and Wales and by the Information and Statistics Division (ISD) in Scotland. In the first few years after 1967 there was a rapid increase in the annual numbers of abortions. After 1973 the increase was more gradual until 1991 when, firstly, the number of women in the fertile age group (15 to 44) rose as a reflection of the increase in birth rates between 1956 and 1963, and, secondly, the popularity of marriage declined leading to an increase in the number of unmarried women having unplanned pregnancies. The numbers of unplanned pregnancies declined in the second half of the 20th century, probably because of effective contraception, especially the pill. However, since the contraceptive pill scare in 1995, abortion rates have continued to rise and women now see the procedure as a legal and safe choice.
There is considerable focus on pregnancy rates among teenagers in Britain which are the highest in western Europe. However, the highest number of abortions is among the 20 to 24 age group. Many women are in stable relationships and one in five is married with about half the women having a child already.
Abortion services
Almost 90% of abortions are in the first 12 weeks of pregnancy with just 1% occurring after 20 weeks. Legal abortion is very safe especially if carried out in the first 12 weeks of pregnancy. Late abortions can be due to poor access to healthcare services in early pregnancy, the woman being unaware of being pregnant because of irregular periods, concealment or change in personal circumstances, and detection of fetal abnormality.
In England and Wales the NHS pays for about 74% of abortions with regional variations ranging from 50% to 90%. In Scotland more than 95% of abortions are free. A woman may have to pay £200 to £500 at a private clinic simply because of where she lives.3 In 1999 almost 10 000 women travelled to Britain for an abortion; most of these were from Northern Ireland and the Irish Republic. A small number came from countries such as France and Italy where the procedure is legal only until 12 weeks and from Arab states where the service is not available or in order to maintain confidentiality. There has been a rapid decline in this number as other European countries have laws that are less restrictive than those in Britain.
The method of abortion can vary according to the length of the pregnancy. Early medical abortion is performed until the ninth week of pregnancy, and suction termination or vacuum aspiration from the seventh week to about 12 to 15 weeks (also performed under the seventh week if strict protocols are adhered to). Medical abortion can also be performed after about 12 weeks and the procedure for terminations between 15 to 18 weeks is surgical dilatation and evacuation.4
Experience elsewhere
International experience varies and the World Health Organization estimates that about 25% of all pregnancies worldwide end in an induced abortion, approximately 50 million each year. Twenty million of these are performed using unsafe procedures by untrained personnel and lead to about 80 000 deaths a year. It is not only a major cause of obstetric hospitalisation in poor countries, but also a result of poor contraceptive awareness or advice. Continued and enhanced access to contraception is an important public health strategy.5
Unplanned pregnancies are not necessarily unwanted, and although contraception is freely accessible in Britain no method that is currently available is 100% safe and effective. Women may wish to terminate the pregnancy because of her age; unsuitable or difficult life circumstances; lack of financial and emotional support and security; competing responsibilities; presence of serious abnormalities in the unborn baby; if pregnancy was a result of rape or incest; serious maternal illness that could be worsened by pregnancy; presence of hereditary illness in the family; marital or relationship problems.3
Most countries that have legalised abortion have done so for public health purposes--namely, to reduce (with great success) maternal mortality and morbidity resulting from illegal abortions.6 The transition from unsafe to safe abortions demands changes at national policy level, adequate training, appropriate service provision, raised awareness among women, and easy access to services.7 The availability of medical abortifacients combined with strengthened post abortion care services can legitimately be considered a public health success in countries in which safe abortion services are non-existent and law reforms are unlikely.8
Conclusion
Abortion can spark a debate between people who support it and those who strongly oppose the procedure. Although public opinion polls show overwhelming support for the Abortion Act, there have been several attempts to restrict the law by antiabortion groups. But it should not be forgotten that in developing countries 13% of maternal mortality is abortion related.7 No woman should be forced to carry on with an unwanted pregnancy as this can have detrimental effects not only on her physical and mental health but more so on the unwanted child. It is important that the choice is made at an individual level with adequate support from both professionals and family involved in caring for the women.
Today more is known about the epidemiology of abortion than any other operation in the history of medicine. I agree with Cates and his colleagues that when future medical historians look back on the twentieth century the increasing availability of safe, legal abortion will stand out as a public health triumph.9
