When Abortion Is Illegal, Women Rarely Die. But They Still Suffer.

A look at what happens when abortion is forbidden, from countries where it still is

In August, the Argentine Senate rejected a bill that would have decriminalized abortion in the country within the first 14 weeks of pregnancy. Less than a week later, the newspaper Clairín reported that a 34-year-old woman died from septic shock after attempting to terminate her own pregnancy using parsley.

The woman, referred to only as Elizabeth, became one of the 40-some Argentine women who die each year from unsafe abortions. “Illegality forces the poorest women to use the most desperate practices,” one doctor was quoted as saying.

In the United States, abortion is expected to become further restricted with Brett Kavanaugh on the Supreme Court. Legal experts believe that the majority-conservative court likely won’t overturn Roe v. Wade, but rather will chip away at abortion rights by narrowing the circumstances in which a woman can obtain the procedure. Some women’s-rights advocates fear this might lead to more and more women like Elizabeth in the United States. But while the Argentine woman’s story is horrifying, it’s becoming less and less common—and it likely doesn’t represent America’s abortion future.

If other countries are a guide, abortion restrictions won’t reduce the number of abortions that take place: According to the Guttmacher Institute, abortion rates in countries where abortion is legal are similar to those in countries where it’s illegal. In parts of the world where abortion is illegal, botched abortions still cause about 8 to 11 percent of all maternal deaths, or about 30,000 each year.

But abortion-related deaths are much less common than they were a few decades ago, especially in countries with functional health-care systems. Since the early ’90s, abortion fatalities have declined by 42 percent globally. This is despite the fact that about 45 percent of all the abortions in the world are still performed in “unsafe” circumstances—meaning without the help of a trained professional or with an outdated medical method. Unsafe abortions are more common in countries where the practice is illegal.

While fewer women are perforating their uterus or dying of sepsis, if women who attempt to perform their own abortion are taken to the hospital with complications, they might be reported to the authorities and face jail time.

When Michelle Oberman, a Santa Clara University law professor, began her research on abortion in El Salvador, where abortion is outlawed, she expected to enter hospital wards full of women dying of perforated uteruses. But that isn’t quite what she found.

For one thing, doctors have gotten better at controlling bleeding in recent decades. But there has also been a major revolution in how clandestine abortions are performed. Since the 1970s, women around the world have been able to take a common and cheap stomach-ulcer drug, misoprostol, to end their pregnancies without anyone knowing. It’s even more effective when taken in combination with another drug, mifepristone.

The drug combination has made it so that in Brazil alone, since 1992, the treatment rate for severe complications from abortion has declined by 76 percent. In Latin America overall, the rate of complications from abortions declined by a third since 2005. Meanwhile, the rate of abortions there has only increased.

Even though abortion is illegal in El Salvador, one in three pregnancies still ends in abortion, Oberman says. Many women there who want to abort their pregnancies do it by finding misoprostol on the street. Those who have internet access and reading skills can look up information about how to take it properly.

According to Oberman, those who do die from abortion-related causes in the country fall into roughly three categories, none of which resembles a case like Elizabeth’s in Argentina. First, some doctors refuse to treat pregnant women with chemotherapy or other potent medications because they are worried they might harm the fetus. Second, some doctors allow ectopic pregnancies—in which a fertilized egg grows outside the womb and can’t survive to birth—to continue until the woman’s fallopian tube explodes, because they fear that eggs in even ectopic pregnancies will be considered living beings under the law. In the third category are teenage girls who kill themselves because they are distraught over their pregnancies. These teenage deaths account for three-eighths of all maternal deaths in El Salvador.

Oberman noticed that federal prosecutors in El Salvador visited hospitals and encouraged doctors to report to authorities any women who were suspected of self-inducing their abortions. When the reports rolled in, however, Oberman found that they were all from public hospitals. Doctors in public hospitals, which treat poor women, were younger, less experienced, and eager to please the hospital’s hierarchy. “They were attentive to the government’s request, and they willingly made the reports,” she told me. “Meanwhile, there was not a single report from a private hospital.” In other words, poor women were much more likely to be reported for their illegal abortions than rich women were.

However, most doctors can’t tell the difference between a miscarriage and an abortion induced by misoprostol, so they would occasionally report genuine miscarriages as abortions. In instances where police have searched a woman’s house and found a fetus, they have sometimes brought charges against her. Oberman says 129 women have been charged in this way, and about 36 have been charged with homicide and sentenced. Fewer than five of the 129, she estimates, were actual abortions.

Certainly the experiences of some countries suggest that self-induced abortions can be dangerous in their own right. In Brazil, where abortion is also illegal, it’s estimated that 250,000 women are hospitalized from complications from abortions, and about 200 women a year die from the complications. Most women there buy misoprostol—a WhatsApp group has started up to help in the process—but those who are further along in their pregnancies or who have more money might visit an illegal abortion clinic. If women are hospitalized, they can be reported to the police by their doctors. About 300 abortion-related criminal cases were registered against Brazilian women in 2017.

Debora Diniz, a professor of law and public health at the University of Brasília, says the 200 deaths might be an undercount, since families often won’t admit that a woman has died from an abortion. The deaths, she says, are “a reduction from 20 years ago, but at the same time, I’m not confident that we have good data. What I know is that women put their lives at risk buying medicine on the clandestine market, not knowing how to use it, and going to a hospital because of complications.”

Compare this picture with the situation in Ireland, which only repealed its abortion ban this past May, though the procedure remains illegal in Northern Ireland. Abigail Aiken, a University of Texas health-policy professor who has studied abortion rights in both countries, says women there would travel to England to get their abortions—often using a fake English address so they could get the procedure for free under the United Kingdom’s National Health Service. Others would order abortion pills from Women on Web, a Canada-based service that ships the pills to women in countries where abortion is illegal. More rarely, women there would attempt to induce a miscarriage by using herbs and teas.

Unlike women in Brazil, however, Irish women had good outcomes using the Women on Web pills. In a study Aiken conducted in 2016 of 1,000 self-managed abortions, 95 percent were able to end their pregnancies without surgical interventions, and just 3 percent required a blood transfusion or antibiotics. There were no deaths.

Whether a self-induced abortion is dangerous appears to depend on where a woman gets her pills and what kind of information is available to help her. Aiken suspects that the Irish women’s outcomes were better than the Brazilian women’s because they had access to regulated services like Women on Web. Brazilian customs officials, meanwhile, confiscate shipments of abortion pills into the country, so women often turn to the black market.

Given the relative rarity of deaths—and even complications—from self-induced abortion, one might wonder, why worry that the U.S. Supreme Court might restrict the procedure?

I posed this question to Aiken, who pointed out that Women on Web does not currently serve the United States, and that most American women do not live as close to Canada as Irish women do to England. What’s more, Irish women were not thrilled to take abortion pills they ordered on the internet secretly, alone, in their homes. “Although the abortion itself is acceptable, they were terrified,” she said. “They were isolated; they felt like they couldn’t tell anyone. They had to lie to doctors when they did see them, [and] say they had a miscarriage.”

Oberman predicts the American market for abortion drugs will boom. Yet it will also grow more difficult to penalize “abortion doctors” for illegal abortions, since with abortion pills, there is no doctor, only the woman. In that case, she says, “everything I saw there will happen here”: The hospital reports, the prosecutions, the jail sentences.

Many states have already prosecuted women for doing drugs while pregnant or for otherwise allegedly harming their fetuses. Overwhelmingly, those punished tend to be poor women and women of color. If abortion is secretive and illegal, “who is going to be left out?” Oberman said. “The poorest women who have trouble accessing information.”