Unintended pregnancy and abortion: what does it tell us about reproductive health and autonomy?

Globally, on average people have fewer children today than in the past. The global fertility rate has declined from 3·2 livebirths per woman in 1990 to 2·5 in 2019, and further declines are expected in the future. These trends are the consequence of profound changes in childbearing intentions that have resulted in more individuals and couples wanting to postpone or avoid pregnancy. Contraception is one of the most important tools for enabling couples and individuals to exercise the right to decide freely and responsibly the number and spacing of their children, and worldwide the use of contraceptive methods has increased. However, some women want to avoid pregnancy yet do not use any contraceptive method, because they do not have access to contraceptives or prefer not to use them for various reasons. Additionally, even those using contraception may do so imperfectly or experience method failure. Resulting unintended pregnancies can have serious consequences for women and their families. In this context, trends in unintended pregnancies and abortions provide crucial information on threats to women's sexual and reproductive health, the strength of family planning programmes, and reproductive autonomy.

In their modelling study in The Lancet Global Health, Jonathan Bearak and colleagues find that, since the early 1990s, the global unintended pregnancy rate has declined, whereas the percentage of unintended pregnancies ending in abortion has increased. As a result, the global abortion rate today roughly equals the levels of the early 1990s.

Bearak and colleagues employ a new model to derive simultaneously the estimates of unintended pregnancies and abortions, based on a framework that also incorporates previously published estimates of contraceptive use by specific methods and of the overall need for family planning.2, 6 This conceptual framework helps to illuminate the most critical mechanisms that determine the outcomes, in this case the fact that an increase in the use of effective contraceptive methods contributed to a reduction in the incidence of unintended pregnancies, despite an impressive increase in the need for family planning over the past three decades due to changing fertility preferences.

The current analysis also improves on previous research with respect to data availability, documentation, and transparency. The study uses comprehensive data on unintended pregnancies and/or abortion from 166 countries. The authors also published a study protocol, which describes their data classification processes. Data scarcity and bias necessitate a model-based approach, which for some regions results in wide uncertainty intervals around the estimate. This result reflects the continued need for reliable data sources that provide information on pregnancy intentions and abortions, as well as other sexual and reproductive health outcomes. Future research would ideally also include age-specific data as well as data on sexual activity by age and marital status.

The current study does not include results at the country level, which are essential to identify countries that were successful in reducing the incidence of unintended pregnancies and of unsafe abortions in order to learn from these achievements. These results would undoubtedly come with high levels of uncertainty, but they could still provide useful information about the scale of these outcomes and their trends. I encourage the authors, in consultation with countries, to publish these results.

To understand the overall extent of unintended pregnancies and abortions, we should also consider the absolute number of such outcomes. Despite the reported decline in unintended pregnancy rates and unchanged abortion rates globally, the annual number of unintended pregnancies worldwide increased from 108 million in 1990–95 to 121 million in 2015–19, and the number of abortions increased from 55 to 73 million over the same period, due to growth in the number of women of reproductive age and changes in childbearing intentions. Looking to the future, countries facing high population growth in sub-Saharan Africa and elsewhere will require a continued expansion of sexual and reproductive health-care services, including family planning, to meet the growing needs. Many of these countries are low-income countries that face funding gaps and will continue to need external assistance.

The Sustainable Development Goals (SDGs) address areas of sexual and reproductive health and reproductive rights under Goal 3, Healthy life for all, and Goal 5, Achieve gender equality and empower all women and girls. Only a small number of indicators, such as SDG 3.7.1. the proportion of women who have their need for family planning met by modern methods, are included in the SDG global monitoring framework. However, studies of all outcomes that are part of a comprehensive and integrated definition of sexual and reproductive health and rights are needed to improve our understanding of the progress made and to motivate the necessary investments to achieve universal access to sexual and reproductive health-care services, including family planning, and to protect and fulfil reproductive rights of everyone. At this moment, the access to sexual and reproductive health-care services need to be at the centre of COVID-19 pandemic response and recovery. If core sexual and reproductive health services are reduced or deemed non-essential during the pandemic, the incidence of unintended pregnancies and unsafe abortion is likely to increase.