(1) Post-abortion care services are expensive and absorb a large portion of government health budgets.

Unsafe abortion is a major public health problem, especially in contexts where access to legal abortion is highly restricted. An estimated 7.9 percent of maternal deaths are due to unsafe abortion [7]; unsafe abortion is also a leading cause of maternal morbidity. Globally, almost 300,000 maternal deaths occur each year [7, 8]. In a comprehensive analysis of maternal mortality around the world using data from 2003 to 2009, Say et al. [7] found that unsafe abortion accounts for a higher percentage of maternal mortality in Latin America and the Caribbean than in any other region, followed closely by Sub-Saharan Africa. About 10 percent of all maternal mortality in Latin America and the Caribbean is caused by unsafe abortion. This region also has the most restrictive national abortion legislation in the world [9]. In contrast, unsafe abortion is found to cause less than one percent of maternal mortality in East Asia, a region with higher income and less restrictive abortion laws.

In countries with laws and policies restricting abortion access, post-abortion care is often prioritized as a way to address the issue of unsafe abortion. At least 50 developing countries had formal programs for post-abortion care as of 2018 [10]. The total cost of post-abortion care to public health systems in many countries is substantial. In particular, Vlassoff et al. [11] estimate that US$171 million is spent annually to treat abortion complications in Africa. Additional estimates for a sample of developing countries indicate that the total cost of post-abortion care per case ranges from $334 in Rwanda to $972 in Colombia, which constitutes up to 35 percent of annual per capita income depending on the country [12]. Governments would save money by refocusing their efforts on providing greater access to modern contraception and to safe abortion options. For example, South Africa’s public health sector could save over $28 million in a 10-year period if women had greater access to safe abortion services [13].

On average, the cost of meeting a woman’s unmet need for modern contraceptive supplies and services for one year would amount to just 3 to 12 percent of the average cost of treating a patient who requires post-abortion care [12]. In Ethiopia, the annual cost of providing post-abortion care at the national level totals $47 million per year, which comprises a substantial portion of total national expenditures on reproductive health [14]. Using a similar methodology, Vlassoff and his coauthors estimate this cost to be $20.8 million per year in Uganda [15] and $2.5 million per year in Rwanda [16].

Studies by other authors also find high post-abortion care costs. In Zambia, post-abortion care following an unsafe abortion can cost the health system 2.5 times more than safe abortion care [17]. Other countries for which relatively high post-abortion care costs have been documented include Malawi [18], Nigeria [19], South Africa [20], Colombia [21, 22], and Bangladesh [23, 24]. Furthermore, two studies for Latin American countries have found that treating post-abortion complications comprises over half of the countries’ public sector budgets for obstetric care [25, 26].

(2) Public sector coverage of abortion care services is sparse, and individuals often bear most of the financial costs.

Very few countries have public sectors that fully cover the financial costs of obtaining an abortion, resulting in large numbers of individuals globally who are forced to pay out-of-pocket for abortions. Making sure that people have access to financial resources to cover these costs is crucial in countries that have banned abortion so that individuals can access medically-supervised abortion services [27]. In countries where abortion is illegal, public health services may absorb the cost of post-abortion care, often in relatively expensive tertiary-level hospitals, but they do not cover access to safe abortions [28]. Closely related, a number of studies have estimated cost savings if more safe abortions were provided by the public sector. A related strain of this literature estimates cost savings to society from abortion services that have reduced the need for public spending on the medical and welfare costs of pregnancies carried to term among low-income women. For example, Murthy and Creinin [29] estimate that in the United States, every dollar that is spent on abortions for low-income women translates into $4 in savings that would have been spent on prenatal care, delivery services, and medical assistance over the next two years.

Those countries that do use public sector funding to cover all or a large portion of the costs of abortion tend to be high-income economies, including Australia [30], Canada [31] and the United Kingdom [32, 33]. Overall, of all countries with liberal abortion laws, 34 countries have full public funding for abortion, 25 countries have partial funding, and 21 countries have no funding at all or only under exceptional cases [34]. A disproportionate share of countries that provide full public funding are high-income countries. Among developing countries, Nepal stands out for having recently instituted a set of safe abortion guidelines that includes free abortion services at all government facilities [35]. India (where abortion is legal) also provides free abortion services in the public sector, although some states have allowed public providers to start charging various user fees or to have private practices [36]. In some countries (such as South Africa) there may be state funding for abortion, but shortages of trained health personnel and insufficient technology mean that state-funded abortions are not available at most primary health facilities and local health clinics [37].

Several studies on the United States have examined how state-level restrictions on Medicaid funding–the need-based system of public health insurance–affect access to abortion and the affordability of abortion services. These state-level restrictions come on top of the Hyde Amendment at the national level, which restricts the use of federal funds to pay for abortions. Abortion is the only reproductive health service that is not covered by federal Medicaid [38]. Some states place further restrictions on the use of private insurance to pay for abortion services. Studies comparing states across the country generally find that state-level restrictions on Medicaid are correlated with lower abortion rates in states that have such restrictions [39–41], and they contribute to individuals’ resource constraints in seeking abortion services [42, 43]. Research also suggests that abortion-related restrictions on public funding for family planning services are costly on a broader scale: without publicly-funded family planning services, states would be spending more than $1.2 billion annually in their Medicaid programs to cover the costs of unplanned births [44].

(3) Restrictive abortion laws impose financial hardships on abortion seekers, often resulting in costly delays.

Since 2010 the United States has seen an unprecedented expansion in state-level policies that restrict abortion access. These policies can be grouped into six major types of restrictive abortion laws enacted by states, each of which the Supreme Court has found to be constitutional: (1) restrictions on Medicaid funds to pay for abortions, (2) parental involvement laws that require unmarried teen minors to obtain parental consent or require providers to notify the minor’s parent before an abortion is performed, (3) mandatory counseling laws that require providers to give patients state-mandated medical information about possible risks and side effects of abortion at least 24 hours before the procedure, (4) two-visit laws that require that abortion seekers receive the mandatory counseling materials in person, (5) Targeted Regulation of Abortion Provider laws (TRAP laws) that impose on abortion providers a variety of burdensome staffing and physical plant requirements not imposed on other clinics performing comparable medical services, and (6) laws banning a late-term abortion with dilation and extraction.

The most common of these state-level restrictions are mandatory counseling laws. Survey data indicate that over half of women in the Midwest and about two-thirds of women in the Northeast did not disagree with the idea of having a mandatory counseling law [45]. That said, survey respondents said they were more negatively impacted by state-level abortion restrictions than positively impacted, with the most common negative impacts including delays in receiving care, longer travel, and time away from work [45].

Abortion restrictions have aimed to reduce the overall demand for abortions by those seeking services as well as the overall supply of providers. A major channel through which they do so is to reduce accessibility and effectively raise the price of abortion, which is associated with fewer reported abortions [46, 47]. Anti-abortion activities by protesters such as picketing and blocking patients can have similar effects, with one set of estimates indicating that anti-abortion activities in the United States have raised the price of abortion by about 4 percent and reduced the overall abortion rate by 19 percent [48]. There is some variation across studies in the demand-side effects of abortion restrictions. For example, estimates of the aggregate demand for abortion services by minors suggest that in the United States, parental involvement laws reduce the aggregate demand for abortion services by minors anywhere from 13 to 25 percent [49]. Similarly, Medoff [50] finds that both parental notification laws and mandatory counseling laws increase the price of abortion and result in a decline in the aggregate demand for abortion by 7 to 14 percent. Lack of public funding can cause women to delay seeking abortion care until their pregnancies have advanced into the second trimester as they seek out financial resources to access abortion services [51, 52].

On the supply side, evidence in Calkin [53] indicates that state-level abortion restrictions have contributed to clinic closures and reduced operations. At the time of the study, there were 27 American cities considered to be “abortion deserts” because women had to travel over 100 miles to reach the nearest abortion clinic. The inability to travel such distances to reach abortion providers disproportionately affects low-income women who are both income and time constrained. Evidence indicates that 89 percent of American counties have no abortion providers within their county borders [54].

(4) Some countries are actively working to provide more cost-effective and innovative options for abortion seekers.

The past few decades have seen improvements in reproductive-health technologies, the availability of online information on reproductive health, and the ability to order abortion pills online. A growing body of evidence indicates that the increased availability and affordability of misoprostol has made medical abortion more common. Not only do individuals often choose the cheaper option, but so do health insurance companies and public sector health officials. Because medical abortion does not usually require physicians with surgical skills or surgical facilities, medical abortion is often considered the cheaper option at the national level and more health systems are likely to move to medical abortion in the future [55]. Exceptions to this argument include Nigeria, where clinic-based manual vacuum aspiration is more cost effective than medical abortion [56].

Additional studies have looked at the macro-level cost savings of alternative abortion technologies, including manual vacuum aspiration and medical abortions. For example, in Mexico, greater access to manual vacuum aspiration and medical abortion could save the government up to US$ 1.6 million annually, with further cost savings if more safe abortion services were provided in outpatient settings at smaller public and private health facilities [57]. Similarly large savings to the government from providing greater access to manual vacuum aspiration and medical abortions are found for Colombia [22].

Some countries have experimented with medical abortion via telemedicine and hotlines to reach abortion seekers who may otherwise be harder to reach. This option was tried in Australia [58] and in several Latin American countries [59]. Some countries including the UK are also moving toward regulatory reforms in which nurses and midwives are allowed to perform more abortion services in order to provide cost savings to national health systems [60].

(1) Abortion regulations have spillover effects on women’s educational attainment and labor supply.

Abortion regulations can act to raise the price of abortion and reduce aggregate demand for abortion [50, 61–63]. Women’s fertility rates and even marital rates are also impacted by abortion regulations. In Eastern Europe, regulations that made abortion more accessible led to a large decrease in births [64] and an increase in marriage rates for non-teenage women [65]. In the United States, birth rates increased in states with more restrictive policies and higher contraception costs [66]. Further evidence indicates that states that funded abortion services had lower birth rates among teenagers [67]. A study of long-term trends in the United States confirms that the legalization of abortion has contributed to a decline in childbearing (largely due to an increase in the number of childless women) and to women’s economic progress [68]. The effects of abortion access were even stronger than access to the birth control pill in driving women’s decisions to delay marriage and childbearing [69].

A number of studies have linked the legalization of abortion to women’s advancement in education and in the labor market. In particular, Kalist [70] found that by reducing unwanted births, legalization of abortion in the United States led to increased labor force participation rates for women, especially for single black women. A similar result was found in Angrist and Evans [71], with substantial increases in high school graduation, college attendance, and employment for black women who were teenagers when state abortion laws were liberalized. Additional evidence indicates that women who were denied an abortion because of restrictive state laws not only were less likely to be employed full time, they were also more likely to live in poverty and to require public assistance compared to women who obtained abortions [72]. Bloom et al. [73] took this point about women’s employment one step further and found that lower fertility (instrumented by the legalization of abortion) increases women’s labor supply and contributes positively to GDP growth.

(2) Access to abortion services affects the human capital investment of the next generation.

The legalization of abortion is also linked to various measures of investment in children’s human capital. In the United States, children born after the Supreme Court’s 1973 Roe v Wade ruling were more likely to graduate from college and less likely to be welfare recipients or single parents [46]. Children’s outcomes may have improved on average because they were more likely to be born into a household in which they were wanted. Follow-up research indicates that these kinds of effects on cohort characteristics for children were different depending on whether the births were avoided due to abortion access versus access to the birth control pill. In particular, Ananat and Hungerman [74] find that the effect of abortion access on the living situation of an average child is smaller than the effect of access to the pill, largely because pill access increased the likelihood of a child having a college-educated, married, “upwardly-mobile” mother. Other evidence indicates that abortion legalization led to a sharp decrease in unintended births, which in turn is associated with increased schooling and greater earnings of children born after abortion legalization [75]. Some of these effects may have a race dimension, with results in Whitaker [76] pointing to a stronger association between abortion rates and high school graduation rates for young black men than for other demographic groups.

There is also evidence on abortion and children’s human capital from outside of the United States. In particular, Romania’s abortion ban is associated with worse educational outcomes and labor market achievements of children born after the ban [77, 78]. And in Sub-Saharan Africa, abortion law liberalization is linked to greater parental investment in girls’ schooling, with the rationale that access to abortion lowers the likelihood of a girl child dropping out of school in the event of an unplanned pregnancy [79]. In Taiwan, legalization of abortion as well as sex-detecting technology also impacted girls’ education. Girls born at a higher birth order were born into families where they were wanted and where parents invested in their educations. The outcome was an increase in university attendance for girls born after the legalization of abortion [80].

(3) Abortion law liberalization may lead to lower crime rates.

Perhaps most famously among studies on abortion in the economics literature, the legalization of abortion has been linked to crime reduction. In a widely-cited study for the United States, Donohue and Levitt [81] found that crime rates across states appear to have dropped as a result of Roe v. Wade. The main channel through which this outcome occurred is that children who were born unwanted in low-income households in underprivileged communities before the legalization of abortion grew up to be at greater risk of engaging in crime as adults. Abortion liberalization reduced the incidence of such unwanted births, with a subsequent reduction in crime years later when those babies would have been adults. This study has prompted several article-length critiques [82, 83] disputing the findings based on the construction of age cohorts, data on crime rates, and assumptions about abortion rates before Roe v. Wade. These critiques in turn were countered with adjusted estimates from Donohue and Levitt showing that abortion legalization does have a causal effect in reducing crime [84, 85]. However, the finding may not be generalizable to other countries. Buonanno et al. [86] show that in Europe, abortion liberalization is not associated with reduced crime, most likely because strong welfare systems and family ties serve to minimize the risk that unwanted childbearing results in greater crime [86].

(4) The political economy around abortion law is complicated and controversial.

From the complete criminalization of all abortions to abortion upon request, legislation on abortion varies substantially across countries. Countries with no restrictions are largely found in the Global North, while countries with the most restrictions tend to be in the Global South, especially in Latin America and the Caribbean and in Sub-Saharan Africa. As of 2019, abortion was completely prohibited or only permitted to save a woman’s life in 65 countries, accounting for 27 percent of the world’s population [87]. In contrast, 66 countries accounting for about 36 percent of the world’s population allowed individuals to have an abortion without restriction as to the reason [87]. Legislation not only varies geographically, it has slowly changed over time [88]. Between 1994 and 2019, almost 50 countries liberalized their abortion laws, with some countries overturning their complete abortion bans and other countries incrementally allowing more reasons (such as health and economic necessity) for which individuals may obtain an abortion [87].

It is not feasible to cleanly summarize the political economy of these legislative changes, given that most studies uncovered by our scoping review focus on individual countries, each with particular contexts and political environments. Several studies have pointed to the high costs of post-abortion care as a key impetus to motivate legislative reforms that improve access to safe abortions [11, 17, 25, 28]. Other studies have pointed to weaknesses in national health systems in providing cost-effective abortions and the need to reform health system financing and to strengthen public abortion services [13, 23, 27, 36, 89]. Overall the evidence makes clear that the countries that have seen the most rapid change in women’s health indicators are those that have changed their laws while simultaneously improving their service delivery.