Abortion in practice

How many abortions are there per year?

Why do abortions occur?

What proportion of women aborting are married?

What proportion of abortions are repeat abortions?

What proportion of abortions occur among women with children?

What proportion of abortions occur among ethnic minority women?

At what gestation do abortions occur?

What does abortion involve?

Is abortion killing?

Is medical abortion just a heavy period?

Which disabilities are abortions performed for?

Is sex-selective abortion a serious problem?

Is abortion on demand legal?

How many abortions are there per year?

In the UK, there are just over 200,000 abortions a year, an increasing trend. In the US, there are around 800-900,000, a decreasing trend. Around 1 in 3, or 1 in 4, women are estimated to have an abortion in their lifetimes in these countries. That is a huge number of people affected by abortion.

There is considerable variation in the abortion rate between different pro-choice countries. The WHO keeps data on abortion rates in pro-choice European countries, by abortions per 1,000 live births. By 2016, Croatia had the lowest rate at 67, followed by Slovakia on 105 and Switzerland on 115. Bulgaria was highest at 406, with Russia at 355 and Estonia at 328 (Romania and Moldova were higher but no data were available in 2016). In general, rates were higher in many (though not all) former Soviet bloc countries, and in Northern Europe, with lower rates in central Europe and the Mediterranean (Poland and Ireland did not have legal abortion at the time, along with a few other smaller countries; data for Austria, Turkey, and some smaller countries were unavailable).

This raises the question of factors affecting the abortion rate. This will be covered under ‘How to reduce the abortion rate’.

Globally, it has been claimed that there are now over 70 million abortions year. This is almost certainly a significant overestimate, since estimates of abortion in countries where abortion is illegal are based on the Abortion Incidence Complications Method, which has a number of substantial problems (see ‘How many abortions occur when abortion is illegal?’). Nevertheless, it is evident that there are tens of millions abortions globally per year.

Fortunately, the UK collects good data on the basic reasons for abortion, as a legal requirement, along with data on gestational age, previous abortions, age of the mother, and so on. Although these will obviously differ between countries, the UK offers a helpful baseline, especially for the much-discussed cases such as foetal disability, late-term abortions, and so on.

Why do abortions occur?

The UK only allows abortion in accordance with specified grounds, though these grounds are so vague that one (or maybe two) effectively allow abortion on demand. For grounds 1 and 2 here, abortions are allowed up to 24 weeks. For the other grounds, including disability, abortion is permitted up to and during birth. The number of abortions for each legal justification are as follows:

  1. Abortion for physical or mental health: 205,930 abortions. 99.9% of these were classified as F99 (mental disorder, not otherwise specified – the catch-all ‘diagnosis’ allowing abortion for any reason at all)
  2. Abortion for the physical or mental health of ‘existing’ children: 776 abortions
  3. Abortion for a ‘substantial risk’ that the child would be ‘seriously handicapped’: 3,083 abortions
  4. Abortions because the pregnancy poses a greater risk to the life of the woman than abortion: 91 abortions
  5. Abortions to prevent ‘grave permanent injury to the physical or mental health of the woman’: 30 abortions
  6. Abortions to save the life of a woman, or prevent grave permanent injury to a woman, in an emergency situation: 7 abortions

This is illuminating in various ways. It can be seen that only a tiny percentage of abortions are to save the life of a woman or prevent grave permanent injury – 128 at most. But in fact, because of the phrasing of the Act, these do not need to be situations where the woman’s life is at risk. The risk of death just needs to be higher than that of pregnancy – it could still be a miniscule risk. Abortion on demand was provided under this ‘life-saving’ clause for many years by some clinicians. Freedom of Information data confirm that a significant proportion of these 98 abortions did not involve situations where abortion was medically necessary. Very few occur – less than 0.01% – occur for other physical health reasons.

Likewise, relatively few abortions occur because the child has a disability – around 1.5% of the total. More statistics about these will be discussed elsewhere.

The overwhelming majority of abortions are performed under the ‘mental health’ clause, and it is widely agreed that this includes abortion for virtually any reason, including sex-selective abortion (see ‘Is sex-selective abortion a serious problem?’ and ‘Is abortion on demand legal?’).

These statistics do not say much about the specific reasons women have abortions, however. Studies from elsewhere confirm that when socioeconomic reasons are explicitly allowed, very few women cite mental health as a reason for abortion. Statistics across a wider range of countries suggest that the primary motivations are family size and spacing preferences, career and educational reasons, and economic concerns. Clearly, all of these can admit of varying degrees of seriousness.

Abortions resulting from rape will be addressed under ‘What about abortion in cases of rape?’

What proportion of women aborting are married?

In the UK in 2020, 17% of abortions were among married women. 23% were among single women with no partner, 51% among single woman with a partner, 7% were single and unstated, and 2% separated/widowed/divorced. These numbers obviously vary considerably by age group.

13% of abortions among 20-35 year olds were among married people, while around 28% of 20-35 year old women were married, giving a small confirmation that marriage is linked with lower abortion rates. Similar results are shown in American data.

What proportion of abortions are repeat abortions?

The UK 2020 data show that 42% of abortions were repeat abortions, meaning that the woman had previously had at least one abortion.

30% had previously had one abortion, 9% had had two abortions, 2% had had three abortions, and 1% had had 4 abortions previously. 131 individuals had had 8 or more previous abortions.

What proportion of abortions occur among women with children?

The UK 2020 data show that 58% of abortions occurred among women who had previously had a live birth or stillbirth.

What proportion of abortions occur among ethnic minority women?

The UK 2020 data show that 77% of abortions occurred among women identifying as White, 4.5% among women identifying as Mixed, 8.6% among women identifying as Asian, 7.4% among women identifying as Black, 0.6% among women identifying as Chinese, and 1.6% among women identifying as Other.

For comparison, around 3.9% of 18-24 year olds in the UK identify as Black, but 6.9% of abortions in the equivalent age group were among women identifying as Black. Likewise, 2.7% of 18-24 year olds in the UK identify as Mixed ethnicity, but 4.4% of abortions in the equivalent age group occur among women identifying as Mixed ethnicity. These figures suggest that abortion disproportionately reduces Black and Mixed ethnic populations. Similar figures hold in the US.

At what gestation do abortions occur?

The trend has been towards earlier abortions, though in recent years gestational estimates have been less reliable due to the trend away from examination and ultrasound prior to abortion. Since abortion has been available by telemedicine in early 2020, gestation has been measured by the time pills were sent, rather than the time they were taken (later), misleadingly skewing the results towards earlier abortions. It is known that some abortions happen many weeks later than recorded as a result of telemedicine (see my chapter on telemedicine).

Officially, 82% of abortions are under 9 weeks, 11.8% are between 9-12 weeks, 5.0% are between 13-19 weeks, 1.2% are between 20-23 weeks, and since the law becomes stricter at 24 weeks, 0.1% beyond 24 weeks.

It is undeniable that most abortions are early in pregnancy. But the numbers for late and very late abortions are hardly a relief to those who have moral concerns about abortion at later stages. Many people who are generally pro-choice still think that abortions at late stages, or very late stages (say, beyond 12 weeks or beyond 20 weeks), are tantamount to murder. If so, it is hardly consolation that the percentage of abortions which are murder is very low. The fact that there are tens of thousands of abortions which are morally permissible is hardly a reason not to worry about the 13,000 which occur beyond 13 weeks, or the 3,000 which occur beyond 20 weeks (in the UK each year).

Nor can it be argued that these late abortions are for rare cases. In fact, the empirical evidence suggests that for the most part, women obtaining abortions later in pregnancy are having abortions for the same reasons as women having abortions earlier in pregnancy, because the main delay was in identifying the pregnancy. This is confirmed by the UK data, which show that even after 20 weeks (viability is now coming down to around 21 weeks), the majority of abortions are for ‘mental health’ reasons (though a much bigger minority are for foetal disability, which is only diagnosable later  in pregnancy).

What does abortion involve?

There are two broad kinds of abortion: medical and surgical. The balance of medical and surgical abortions differs significantly from country to country. In much of Europe, medical abortion is more common, but in the US and a few other countries, surgical abortion is much more common. From around 10 weeks, surgical methods are more common than medical, even in countries with mostly medical abortion. Medical abortion is much more common for illegal abortions since mifepristone and misoprostol became an accepted method of abortion, and widely distributed. This has significantly reduced the risks of illegal abortion, to the point that illegal abortion by this method is widely considered safe (though still with risks, as with all abortion).

Medical abortion

Medical abortion is broadly similar throughout pregnancy. It typically involves administration of a pill called mifepristone, which blocks progesterone receptors and thereby makes the uterus less hospitable to pregnancy in various ways, depriving the baby of oxygen and nutrients. Sometimes this kills the baby; sometimes it does not. Then, misoprostol is given. This essentially causes a miscarriage; the uterus contracts and the baby is expelled. If the mifepristone has not killed the baby, the misoprostol usually does, in the process or sometimes shortly after the baby has been miscarried, with the baby sometimes visibly moving after being delivered. Sometimes the baby dies from prematurity after expulsion.

Of course, if the medical abortion takes place after viability, there is a chance the baby could survive outside the womb if given medical treatment. In many countries, such as the UK, there becomes a legal obligation to rescue the baby, though in some countries the baby is left to die even if viable (sometimes seemingly contrary to the law, as in the UK) – the US Senate has attempted to ban this form of passive infanticide on many occasions but thus far failed.

To prevent the ‘problem’ of the baby surviving arising, a procedure is first performed for babies beyond the point of viability. This procedure is technically called ‘feticide’ – meaning ‘killing the offspring’, from Latin. Feticide ordinarily involves injecting a lethal chemical, usually potassium chloride, directly into the baby’s heart, to stop it. The use of potassium chloride for capital punishment has been widely protested as inhumane by human rights groups, because it is so excruciatingly painful. Its use is prohibited as a means of putting down any conscious vertebrate by veterinary associations worldwide. When it emerged that this procedure was being performed in Ireland after the legalisation of abortion, academic journals reported that feticide practitioners themselves described it as ‘brutal’ and ‘awful’, as ‘stabbing the baby in the heart’, with one ‘getting sick out in the corridors afterwards because I thought it was such an awful procedure’. Another paper reports one practitioner as saying, ‘a lot of people wouldn’t even know that feticide happened… a lot of people might be quite shocked… My partner is anxious that it doesn’t become too widely known… clearly some people will find the whole thing abhorrent.’

Overall, in the UK, 85% of abortions are medical, and of these, around 900-1000 babies are killed by feticide (sometimes before induction of labour – medical abortion – and sometimes before very late surgical abortion).

Surgical abortion

Surgical abortions differ depending on the gestation of the pregnancy, since the baby’s size and toughness make earlier methods difficult after around 13 weeks.

Up to around 13-14 weeks, vacuum aspiration is generally used. This involves sucking the baby out with a vacuum, killing it in the process. Formerly, a technique called dilation and curettage was used. This is generally discouraged because it is associated with increased risks, including placenta praevia and Asherman’s syndrome, as well as increased pain and bleeding. However, D&C is still widely used in many countries.

From 13-14 weeks (sometimes earlier), the baby is usually too big and tough to be removed by vacuum, so dilation and evacuation is usually used. Even in countries with predominantly medical abortion, D&E is the most common method of later abortions from around 15 weeks (vacuum aspiration is the main method from 10-14 weeks).

D&E involves dismembering the baby limb by limb with forceps. The baby’s skull is crushed in some cases, if it is too big to be removed intact (here and here). In this method, the baby must be pieced back together again outside the womb to ensure that it has all been removed.

Intact dilation and extraction (D&X), also known as ‘partial birth abortion’, was used in the US until it was federally outlawed in the 00s. The inventor of the method noted that ‘Classic D&E is accomplished by dismembering the fetus inside the uterus with instruments… However, most surgeons find dismemberment at twenty weeks and beyond to be difficult due to the toughness of fetal tissues at this stage of development’.

The author then described a new method. After delivering the baby in breech position (legs first), so that everything except the head is delivered:

‘the surgeon takes a pair of blunt curved Metzenbaum scissors… the surgeon then forces the scissors into the base of the skull… having safely entered the skull, he spreads the scissors to enlarge the opening. The surgeon removes the scissors and introduces a suction catheter into this hole and evacuates the skull contents. With the catheter still in place, he applies traction to the fetus, removing it completely from the patient.’ (Martin Haskell MD, “Dilation and Extraction for Late Second Trimester Abortion”, presentation at the National Abortion Federation Risk Management Seminar, 1992.)

That is to say, when the baby is almost entirely delivered – the doctor forces scissors into the baby’s skull and sucks its brain out with a catheter. This is the specific event which kills the baby. It was generally used late in pregnancy when the baby was clearly able to feel pain.

The procedure was outlawed in the US, but remains legal in the UK. It is unknown whether it occurs in the UK, but there is a consensus that it is legally permitted (as in many other countries). While it was initially claimed that very few partial birth abortions took place, and only in extreme circumstances, a proponent of the method later admitted in the media that this was a lie, and that it was usually used on healthy babies with healthy mothers.

Other methods of abortion have been used in the past, but are rarely used now. For example, saline abortions used hypertonic saline (salt water) to dehydrate the baby and derange its electrolytes such as sodium. This could cause death by dehydration, cardiac arrest, or otherwise. Pictures of the effect of the hypertonic saline on the skin of the baby are easily available online. Alternatively, hysterotomy abortions use a similar procedure to a caesarean section, with the baby being killed by feticide beforehand or being left to die (or smothered, thrown away, or drowned, in various historical cases) once removed from the womb. Saline and hysterotomy abortions are now rare.

Typically, even late abortions do not involve painkillers for the baby. Painkillers for very late term abortions are routine in France, but not in many other countries, like the UK or USA, in part as a vestige of the outdated and misleading guidance from the RCOG. Indeed, abortion groups vigorously protest attempts to mandate painkillers for late-term abortions, at which point the baby undeniably feels pain. By contrast, fetal analgesia is used for fetal surgery, when babies are operated on before birth. And certain national laws (for example, the UK’s Animals Act 1986) require the humane killing and treatment of any mammal, reptile or bird in the final third of pregnancy. Human foetuses are the only exception.

Is abortion killing?

To kill means, roughly, to end a life. Abortion clearly does this, and in more candid moments this will be conceded by abortion advocates and practitioners. An obvious example is that late abortion involves ‘feticide’, which literally means ‘killing the offspring’. The RCOG guidance on feticide says that ‘failure to perform feticide could result in a live birth and survival, which contradicts the intention of the abortion’. Elsewhere they say that ‘Intrauterine fetal death refers to babies with no signs of life in utero’ – presumably in contrast to ‘babies’ who do show signs of life in utero, who are alive. The prestigious Cochrane Library defines miscarriage as ‘the spontaneous death and/or expulsion of an embryo or fetus from the uterus before it is able to survive on its own’, and the National Institute for Clinical Excellence, the leading clinical guidance body in the UK, says that ‘Intrauterine fetal death is when an unborn baby (fetus) dies inside the womb before birth’. Ann Furedi, until recently the CEO of the UK’s leading private abortion provider, defines abortion as ‘the intentional destruction of the fetus in the womb, or any untimely delivery brought about with intent to cause the death of the fetus’.

Hence, it is uncontroversial from a medical point of view that abortion involves ending a life, and hence is killing.

Is medical abortion just a heavy period?

After the recent shift towards medical abortion rather than surgical abortion, there has been an attempt to sanitise it by describing it as simply a ‘heavy period’. This is neither accurate nor reflective of how women experience it. Studies show women frequently feel unprepared for the amount of pain, bleeding, and seeing the visible human embryo or foetus, which can sometimes move after it has been expelled.

Of course, all abortion ends a life, so it is obviously far more significant than a period in that sense. Medical abortion also has a significant complication rate – far more so than a period and significantly more so than surgical abortion (see ‘Immediate complications of abortion’). Finally, as we will see, women are frequently misled about the experience itself.

The UK’s leading clinical guidance authority, NICE, released an evidence review of what women need to know prior to an abortion. It identified significant evidence from various studies about what women were told about pain, bleeding, and the embryo/foetus compared to what they experienced. Notably, many of these comments were even for very early medical abortions, before 9 weeks:

‘I kind of thought that I’d go there, bleed a little and then go back home, having it all done. But I learned that wasn’t the case.’ – 17-year old, first time pregnant.

‘There wasn’t enough information about the bleeding and the pain, I thought. The bleeding was massive. It was very frightening.’

‘Most of the women experienced the abortion with a bleeding that was larger than they were prepared for.’

‘I put a paper in the toilet so I would see that I had aborted… was totally unprepared for seeing the embryo… became very sad… I could clearly see that it would be a human being.’

‘You could see fetus, where the ears were, the arms, I was really frightened.’

‘In hindsight I wish I hadn’t looked but I did, and that was probably the most traumatic thing I’ve ever seen or done. I thought ‘what on earth…?’

‘Many participants undergoing medical terminations had not expected the procedure to last for as long as it did: ‘Nobody told me how long I might be in the labour ward for (I was told 6-12 hours and I was there for three days which I later found out was quite common)’.’

NICE found that ‘There was evidence that women wanted information about what to expect when viewing the pregnancy. The committee agreed this was important, that women should be aware that the pregnancy may be more identifiable after 9 weeks’ gestation and that there may be movement at later gestations’. In the final guidelines, they recommended that ‘For women who are having a medical abortion, explain:

  • that they may see the products of pregnancy as they are passed
  • what the products of pregnancy will look like and whether there may be any movement.’

While medical abortion often kills the baby by detaching it from endometrium, thereby depriving it of oxygen and nutrients, it has a variety of mechanisms (best summarised here). Sometimes it fails to kill the child by itself, and the child is then killed by the trauma of being squeezed by the contracting uterus and expelled from her mother’s body. Sometimes the child survives both of these and dies of the various difficulties of prematurity (or sometimes lack of care, or indeed survives, if after 21 weeks). As noted in ‘What does abortion involve?’, at later stages it requires feticide first.

There is more to be said (Skop has a helpful overview) but it is clear that women are frequently misled about the experience of medical abortion, and of course, all abortion ends a human life.

Which disabilities are abortions performed for?

The UK has recently stopped publishing the primary medical condition cited for disability-selective abortion, making the statistics more difficult to discern (since multiple conditions can be recorded and it is unclear which is the main reason). However, 2018 statistics did include primary medical condition, so these will be used.

In this year, 3,269 abortions for disability occurred. 1,079 were for chromosomal conditions, mostly Down Syndrome (618) and Edwards’ Syndrome (228). 696 were for neurological conditions, particularly anencephaly (203), a condition where the cerebral hemispheres do not develop at all or develop only partially (this means it is on a broad spectrum and some children can live a significant amount of time), and spina bifida, where the spine does not form properly, again, with a wide variety of severity. 895 were for other congenital malformations including cleft lip and cleft palate (generally easily correctable conditions), genital malformations, some very serious cardiovascular conditions, and a wide variety of others. 599 were for a wide variety of other conditions, including ‘selective reduction’ for multiple pregnancies, where one or more babies are killed and one or more babies are allowed to live.

Pressure to abort babies in these situations has been widely reported, with some mothers reporting how they even had abortions scheduled by the doctor without asking or agreeing. Abortion is legal up to birth if the child is disabled in many countries, including the UK. Mothers have been guilt-tripped into having abortions, and told that they can change their mind and have an abortion at any point, even a few days before delivery.

Disability-selective abortion, also known as eugenic abortion, has been widely criticised by disability rights group for discriminating against disabled people, in the same way that sex-selective abortion does. Even the UN Committee on the Rights of Persons with Disabilities has criticised the practice and urged countries to remove laws permitting it.

Disability-selective abortion has led to huge reductions in the number of people with disabilities – not by treating or curing their disability at the request of them or their parents – but by ending their lives before birth. This has led to up to 90% of babies with Down Syndrome being aborted in the UK, and reportedly 100% in some other countries like Iceland.

I have a paper in progress on the topic of disability-selective abortion which will be available in due course.

Is sex-selective abortion a serious problem?

The overwhelming majority of pro-choice people still support some restrictions on abortion – one of those is sex-selective abortion, where a baby is aborted solely on the basis of their gender. In the UK, 91% of women think sex-selective abortion should be explicitly banned, with only 4% opposed.

Globally, this problem appears to be worsening. In India alone, there are thought to be 13.5 million missing girls due to sex-selective abortion – or perhaps as many as 22 million. The sex ratio at birth (used as a measure of sex-selective abortion) for China has been even worse for the last few decades. This means that, on a global scale, abortion is one of the most powerful tools the patriarchy has for eliminating the voice, visibility and even the presence of women. In some areas, this problem is particularly severe: it was reported that in 132 villages in Uttarkashi, 216 children were born over a three month period – and not a single one was a girl.

The sex imbalance caused by sex-selective abortion – which almost always selects girls, not boys, for abortion – has caused further downstream problems, such as women and girls being trafficked as brides or sex slaves.

Sex-selective abortion is known – though not on the same scale – in so-called developed nations. In 2012, the Canadian Medical Association Journal reported that Canada had become a ‘haven’ for sex-selective abortion because of its relaxed abortion laws – in Canada, abortion is legal at any point for any reason.

In 2018, it was found that sex-selective abortion was a significant problem in the UK, in particular due to earlier screening tools (non-invasive prenatal testing). An earlier investigation had found that 1,500-4,700 girls were missing in the UK as a result of the practice. In response to the recent findings, the Labour Party called for legal restrictions: the Shadow Minister for Women and Equalities said that ‘the government needs to look into this exploitative practice and enforce appropriate restrictions’. But just 3 years prior, the Labour Party overwhelmingly voted against a ban on sex-selective abortions, with considerable support from parts of the Conservative Party.

Although some claim that sex-selective abortion is not legal in the UK, and used this as a reason to vote against banning it (a bizarre rationale even if true), it is widely agreed that sex-selective abortion is legal. If a woman says that having a baby girl would adversely affect her emotionally, there is little to stop her from obtaining an abortion on ‘mental health’ grounds, especially if her doctor approves. The practice certainly does occur in the UK. The leading research team on this topic in the UK warned that ‘Any attempt to explicitly criminalise SSA would likely jeopardise Bangladeshi, Indian and Pakistani women’s access to abortion care’ – that is to say, sex-selective abortion in the UK is a real phenomenon that – apparently – needs to be protected.

Of course, abortion on demand is not legal in many countries. But some people doubt whether abortion on demand – including, for example, sex-selective abortion – is legal in countries like the UK, where abortion is ostensible available only for health reasons.

Despite the seemingly restrictive law in places like the UK, ‘mental health’ is often interpreted as including abortion for any reason at all. In practice, in the UK, a reason is given, the woman is asked whether this would affect her emotional health, and if so, it is typically authorised. Typically, abortion providers will explicitly say to clients that they will authorise abortion for any reason except sex-selective abortion. However, as we have seen in the question on sex-selective abortion, even sex-selective abortion is widely held to be legally permissible.

Another way that seemingly restrictive laws can be interpreted as abortion on demand is through a ‘life-saving’ clause. UK law says that abortion is permissible at any point in pregnancy if two doctors believe, in good faith, that the pregnancy poses more risk to the life of the woman than an abortion would. The risk does not need to be high – just higher than the risk of pregnancy, around 1 death in 10,000 pregnancies. Since many doctors claim that abortion is less risky still, this would authorise abortion on demand for any reason even up until birth. Although this clause is not routinely used in this way in the UK now, it has been in the past.

This means that any country allowing abortion for mental health reasons, or health reasons with no further specification, is at risk of permitting abortion on demand.

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