Liberalization of restrictive abortion laws is a critical step in transforming harmful clandestine procedures into safe terminations administered and monitored by trained professionals. However, reforms in abortion policy alone, which are often subject to local contextual influences, may not be sufficient for substantial change in practices or, ultimately, women's health. The countries in this study offer unique insights into the multi-faceted nature of abortion reform.
In all three cases examined here, liberal policies---with broad indications for legal abortion---were followed by strategies to implement abortion services, scale up accessibility and establish complementary reproductive and maternal health services. In Romania, the government and its partners coordinated efforts to train doctors in preferred abortion techniques, expand access to contraception, and address women's dependence on abortion as a method of fertility control. In South Africa, appropriate abortion technologies were rapidly disseminated throughout the country and abortion services were decentralized through training of physicians and midwives. Bangladesh, while not formally changing its abortion law, followed the establishment of a new menstrual regulation policy with national-scale MR training and improvements in family planning and obstetric care. Both South Africa and Bangladesh also made great strides in decentralizing and disseminating abortion care through the training of mid-level providers such as midwives, nurses and paramedical personnel. The examples in this study suggest that a confluence of political will, funding, partnerships between government and NGOs, additional policies supporting change in reproductive services and an overall commitment to improving women's health may contribute to declines in abortion-related mortality. In particular, investments in improved family planning services are essential to preventing unwanted pregnancies, thereby reducing overall demand for abortion. All three cases also demonstrate the important role of research infrastructure in tracking and documenting changes in abortion-related services and outcomes.
Despite their achievements, the long-term experience of these countries highlights the importance of continued support in maintaining gains made in women's health following changes in abortion policies and practices. Romania made early efforts to provide adequate abortion technologies, such as equipment for electric vacuum aspirators; however, with waning financial support, supply lines withered and physicians were forced to revert back to older, less safe methods of inducing abortion such as dilation and curettage. The resultant reduction in the quality of abortion services is compounded with continued gaps in post-abortion care. In South Africa, despite both political will and technical backing to decentralize and disseminate abortion services, safe abortion services are still highly concentrated in urban areas, leaving underserved sites challenged by limitations in providers and supplies. South Africa also continues to struggle with high levels of abortion-related stigma within the medical community. Furthermore, medical abortion drugs and services are only available in the private sector, greatly limiting access to their use. The slight rise in abortion deaths during the period from 2005 to 2007 could be due in part to a decline in abortion services in recent years and to a possible confounding of HIV/AIDS deaths among women of reproductive age in South Africa. In Bangladesh, family planning and obstetric services may not be comprehensive at all sites, leaving an unmet need in some vulnerable populations within the country. The current supply chains for MVA instruments and other supplies needed for MR services are also erratic, leading to periodic interruptions in supplies and re-use of MVA instruments beyond recommended applications. Improved access to high-quality second-trimester abortion services is also needed. General economic, social and cultural barriers may also play an important part in limiting access to comprehensive abortion care in all three study countries.
This review has a few limitations. Due to the reliance on published, available data, we may have omitted other countries with liberalized abortion laws and changes in abortion mortality where data were not available. For this reason, countries such as Turkey and Cuba, where there is anecdotal evidence of a decline in abortion-related mortality after abortion law reform and provision of legal abortion, were not included. Moreover, it was also not possible to include comparison countries where legal reform was not immediately accompanied by supplemental reproductive services. In these cases, such as in Zambia and Ghana, a failure to provide adequate safe abortion and reproductive health services following law reform has resulted in both a dearth of information on attempts to scale-up service provision as well as persistently high maternal and abortion-related death rates [73, 74]. In Zambia, despite law change in 1972, there has been little done to promote behavioral or service provision changes until recently . The abortion law in Ghana was liberalized in 1985, but coordinated efforts to improve abortion services and increase awareness of the law have only been implemented as recently as 2006 . In Cambodia, where abortion law reform in 1997 was originally not followed by targeted service provision, efforts are currently underway to increase access to safe abortion and reproductive health care, providing a forthcoming case study on delayed introduction of supplemental abortion and reproductive health services . Other countries with more recent abortion law reform and roll-out of safe abortion include Nepal (2002) and Ethiopia (2005), which will afford opportunities for further research on the impact of policy change on maternal health . Finally, the current review relies primarily on case study analysis methods, which cannot provide casual links between factors in abortion reform and resulting declines in abortion- and does not account for other possible ecological factors that may have contributed to changes in abortion-related mortality in the study countries.
Abortion related mortality continues to play a large role in all-too-high rates of maternal death in many other countries. The solutions for reducing the significant human and economic toll of abortion deaths and injuries are well-known, especially expanding access to effective modern methods of contraception and to safe abortion. The three countries highlighted in this paper have all managed to make considerable progress in implementing many of these solutions, in spite of limited resources. Romania and South Africa also underscore the rapid improvements possible in women's health once safe abortion becomes widely available. The evidence is compelling. For many countries that have yet to act, the political commitment to alter the current landscape of preventable deaths from abortion awaits.