Insights from Nepal’s abortion legalization
What is the issue?
The World Health Organization estimates that at least 13 percent of maternal deaths worldwide are linked to unsafe abortions. In trying to reduce those numbers, how much emphasis should policies place on making the procedure safer and more accessible, versus making contraceptives cheaper and more available? Addressing that question requires an understanding of the extent to which abortion and contraception are used interchangeably — namely, whether the use of one reduces the use of the other.
In "Population Policy: Abortion and Modern Contraception are Substitutes," Grant Miller, a senior fellow at the Stanford Institute for Economic Policy Research and director of the Stanford Center for International Development, uses Nepal's 2004 abortion legalization legislation to study how the use of modern contraception (such as pills, condoms, sterilization and injectables) changes in response to abortion availability. Miller, a professor of medicine, co-authored the paper with Christine Valente, a senior lecturer in economics from the University of Bristol.
Prior to 2002, Nepalese women could be charged with infanticide and imprisoned for terminating their pregnancies. Under the new policy, senior gynecologists from central and regional hospitals as well as from some NGOs and private clinics were trained to perform abortions and teach other doctors how to perform the procedure.
Registered abortion-providing health centers expanded rapidly in response, rising from practically zero to 141 by 2006, and to 291 in 2010. By 2010, the number of registered abortion providers per capita in Nepal was nearly twice that of the United States.
Notably, the new legislation only affected abortion and did not affect the price or availability of contraceptives, make changes to other health services, or expand the health care workforce. An isolated change such as Nepal’s abortion law is atypical in heath policy, and affords researchers a rare opportunity to parse out causality.
Miller and Valente use data on more than 32,000 women aged 15 to 49 from four waves of the Nepalese Demographic and Health Survey before and after the legalization to understand fertility regulation practices and women’s fertility histories. Combining this data with an official census of all legal abortion centers to track abortion availability, they are able to isolate how contraceptive use changes with abortion access.
Miller and Valente find evidence that abortion and modern contraception substitute for one another. When abortion becomes cheaper and/or more accessible, abortion rates rise and contraceptive use falls. In the case of Nepal, they find that when an abortion facility opened in a woman’s district, her odds of using contraception fell by nearly 3 percent. Moreover, her odds of getting an abortion increased by 1 percent.
On average, the abortion legalization led to a fall in contraceptive use – from 35 to 33 percent – by those who are sexually active. Most of this decrease was among women who stopped using reversible methods of birth control, such as pills or injections. The use of more permanent contraception such as female sterilizations was largely unaffected. The greatest shift in contraceptive use was by women aged 15-19 and 30-34.
This research shows that one way to reduce expensive and potentially unsafe abortions may be to expand the supply of modern contraceptives. That would mean making birth control cheaper and/or more socially acceptable.
Conversely, policies that reduce the cost of abortions should also seek to reduce the cost of contraceptives if policymakers want to prevent abortion from being used as an alternative to birth control.
This relationship in family planning options also has important implications for foreign aid. The U.S.’s Mexico City Policy for example, prohibits international NGOs from receiving federal funding from the United States if they perform, advise on, or endorse abortions. In related work on the Mexico City Policy, Miller finds that the reduction in funding for family planning – as some international organizations elected to forgo U.S. support – reduced contraception access and inadvertently drove up abortion rates as women relied more heavily on abortion in the absence of contraception.