The subject of this commentary is the complex interrelationship between abortion and contraceptive use in the control of fertility. While both are interventions designed to manage unwanted pregnancy, there are significant differences between the 'preventive' and 'curative' approaches. The significance stems from abortion being a procedure that provokes fundamental and contentious questions about human life, such as when life begins, as well as highlighting the rights of the mother versus the rights of the foetus, and the obligation of governments to protect the unborn child (1).
There is sufficient historical evidence to conclude that no societies have achieved low fertility without recourse to use of some form of contraception together with abortion. So, an important and topical question that arises from this inter-relationship is whether the provision of high-quality contraceptive services can reduce or substitute for abortion. A recent Lancet article based on data from the ICDDR,B fieldsite in Matlab supports the substitution argument, at least in the context of Bangladesh (2). These findings are discussed below.
A broader related issue here is whether all societies passing through the demographic transition follow a similar pattern. Such a pattern might hypothetically involve an initial stage where growing awareness of the concept of fertility regulation results in increasing contraceptive use and increasing use of abortion simultaneously, and fertility levels decline from high to intermediate levels. In the second stage of the fertility transition, contraceptive practice becomes more widespread and more efficient (reflected in fewer contraceptive failures), and the resort to abortion decreases, although it may never be completely eliminated.
This hypothesis assumes that the majority of couples would prefer to prevent unwanted pregnancies through contraceptive use rather than through abortion. An alternative hypothesis might be that if abortion is freely accessible, couples would have little incentive to practise responsible contraception. This raises the question of whether the balance between use of abortion and use of contraception depends on the availability of these two interventions.
It is instructive to review what the experiences of developed countries--both European and Asian--reveal about this issue of the balance between these two interventions. In fact, several patterns have been described by Potts et al. in their classic text (3). In periods of economic hardship in the late 19th and early to mid-20th centuries, a number of Western and Northern European countries, the United States, and Australia, experienced fertility declines nearly to replacement level well before effective modern contraception was available. The mechanism included resort to illegal abortion and remarkably effective use of inherently-inefficient contraceptive methods, such as withdrawal (coitus interruptus), in a social context of nuclear families and late marriage.
In the more eastern countries of Western Europe, such as Romania and Bulgaria, the effective practice of withdrawal had never been widespread, and abortion played the dominant role. In the former USSR--the first country to permit legal abortion (in 1920)--up to 3 of 4 pregnancies were being aborted, at least in Moscow. However, this pattern was not confined to the period prior to the availability of modern contraceptives. In the early 1960s, there were 14 abortions for every delivery in the largest obstetric hospital in Romania. As occurred earlier in the former USSR, the Romanian government restricted the liberal abortion law in 1966. Unfortunately, they also simultaneously restricted access to modern contraception. Consequently, the birth rate tripled from 13 to 40 per 1,000 in less than one year. As is often the case, the restrictive law was bypassed, and skyrocketing resort to illegal abortion brought the birth rate back to 20 within two years. …