Introduction

Unsafe abortion is a leading preventable cause of pregnancy-related mortality and morbidity [1]. The World Health Organization (WHO) defines unsafe abortions as those performed by individuals without the necessary skills and/or in environments that do not conform to minimal medical standards [2]. Most unsafe abortions occur in countries where abortion is legally restricted [3]. Legalizing, or at least decriminalizing, abortion is proposed as one intervention to reduce unsafe abortions and thus maternal morbidity and mortality [4,5]. However, the current international legal landscape is largely heterogenous, undermining efforts to ensure access to safe abortion [6,7]. Further, domestic legislation regarding abortion is in flux in many settings, with some legal regimes becoming more restrictive even as others become more permissive [7–12]. Several legal grounds for abortion are recognized in international standards: to save a woman’s life; to preserve a woman’s health; in cases of intellectual or cognitive disability of the woman; in cases of rape, gender-based/sexual violence, or incest; in cases of fetal anomaly or impairment; for economic or social reasons; and upon a woman’s request [13,14].

Efforts within the international human rights space propose monitoring the legal status of abortion as one way to promote accountability and make the problem of unsafe abortion visible. Examples include human rights accountability mechanisms such as the Universal Periodic Review—a peer-review mechanism led by the United Nations (UN) Human Rights Council whereby every member state’s human rights record is reviewed and recommendations are issued to strengthen compliance with international human rights standards [15]—and the Committee on the Elimination of All Forms of Discrimination Against Women’s periodic review—similarly focused on women’s rights. Treaty bodies have successfully leveraged these mechanisms to induce states to take action to assure that domestic abortion legislation complies with international human rights standards [16–19].

With the mainstreaming of human rights across the UN [20], health-related UN agencies have begun to track the legal status of abortion as a proxy for and upstream determinant of access to safe abortion. In 2017, WHO and the UN Department of Economic and Social Affairs launched the Global Abortion Policies Database (GAPD), which compiles data on the legal status of abortion as reported by each country’s Ministry of Health or relevant national agencies/institutions [21,22]. Similarly, Countdown to 2030 (hereafter, Countdown) arises from a collaboration of academics, UN agencies, the World Bank, and civil society to track progress toward the health-related Sustainable Development Goals [23] and includes “legal status of abortion” as reported by the UN Population Division in its policy indicators [24]. Such groundbreaking efforts firmly establish legal abortion within a rights framework and provide an accountability mechanism for monitoring.

Despite these important advances, it remains unclear whether these monitoring efforts reflect the reality of access to abortions accurately and comprehensively such that the legal status of abortion can be used with confidence as a proxy measure for access to safe, legal abortion. A 2019 landscape analysis commissioned by the WHO “Mother and Newborn Information for Tracking Outcomes and Results” (MoNITOR) expert working group specifically flagged the lack of research evidence assessing the validity of indicators to monitor abortion care. The authors found that, in general, system- and policy-level maternal and newborn health indicators are seldom research-validated. Further, data on indicator validity was found to be poorly communicated in low- and middle-income countries, raising concerns about indicator selection in these settings [25].

Moreover, it is unclear whether monitoring data reported by countries are accurate. Indeed, an initial WHO review of GAPD data suggests there may be numerous inaccuracies [22]. In addition, both GAPD and Countdown consider only national legislation, which may not fully capture domestic policy landscapes—sub-national regulations, clinical guidelines, and other policy documents may also structure domestic legal frameworks [26,27]. These limitations challenge the criterion validity of the policy indicator, i.e., how well the indicator reflects actual policy.

Conceptually, the legal status of abortion may be a poor proxy for the accessibility of legal or safe abortion [28]—compliance with existing laws may be inconsistent [26,29,30], health facilities and healthcare providers may have differing interpretations of legal constructs [30,31], and some legal constructs may be more subject to variance in interpretation and implementation than others [32,33]. Facilities and providers may also discriminate in providing access to abortion, regardless of legality [34,35]. Thus, rights as guaranteed on paper may differ from rights enjoyed in practice. These limitations threaten the construct validity of the policy indicator, i.e., how well it captures the concept of accessibility of legal abortion. Determining the criterion and construct validity of this indicator is important to develop a more valid approach to assessing women’s access to abortion, which itself will bolster efforts to hold duty-bearers accountable to this health-related right.

Ensuring monitoring data are accurate and reflect implementation of the law (not just its existence) is essential for promoting reproductive health and rights [26]. Thus, this study aims to assess the validity of a critical policy indicator for ending preventable maternal deaths by: verifying that the legal status of abortion was accurately reported to GAPD and Countdown via in-depth policy analysis (criterion validity), and exploring whether there is provider-level variation in the implementation of domestic abortion law (construct validity) in three diverse countries (Argentina, Ghana, and India). This indicator validation study is part of a larger effort to validate ten policy indicators drawn from the monitoring framework for the “Strategies toward Ending Preventable Maternal Mortality (EPMM)” [36].

Methods

Results

Legal framework for abortion, as reported in global monitoring frameworks

For each ground for abortion, we specified whether it was legal, not legal, not specified, or not reported by each source (Table 1). For Argentina, Countdown and GAPD reported that economic or social reasons did not constitute legal grounds, although the current domestic legal framework leaves this unspecified. For Ghana, GAPD reported that saving a woman’s health, intellectual or cognitive disability of the woman, and economic or social reasons did not constitute legal grounds; however, the domestic legal framework considered them to be legal grounds. In addition, Countdown reported that abortion was legal at a woman’s request, while domestic law in Ghana documented it was not. For India, GAPD reported that preserving a woman’s health, intellectual or cognitive disability of the woman, incest, rape, and economic and social reasons were not legal grounds; in contrast, the Indian domestic framework indicated all were legal grounds. In addition, Countdown reported that incest was not a legal ground and did not specify whether rape constituted a legal ground in India, although both were legal grounds per domestic sources. The documents cited by GAPD for all three countries were the same as those reviewed by our team.

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Table 1. Validation of international databases against domestic legal frameworks.

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Health care providers’ knowledge and application of the law

Argentina.

In Argentina, 89 of 112 eligible providers consented to participate (79.5% consent rate); 87 of those who consented completed the survey (97.8% response rate). The sample was unevenly split across the four participating provinces, with Province 2 contributing 41.4% of the sample and Province 3 contributing 10.3%. All participants worked in public facilities, and the majority worked in tertiary-level facilities (66.7%), were female (65.5%), and were experienced (median years of practice: 12.0) (Table 2).

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Table 2. Characteristics of participating providers.

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Most respondents knew that abortion was legal to save a woman’s life, to preserve a woman’s health (overall, physical, mental), in cases of rape, and on request (proportions ranged 81.6%–96.5% across the six legal grounds). Only 5.7% indicated that cases of intellectual or cognitive disability of the woman and 13.8% that cases of incest were not explicit legal grounds for abortion. Only 10.3% and 17.2% of respondents knew that cases of fetal impairment and economic or social reasons, respectively, did not constitute explicit legal grounds for abortion (Table 3).

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Table 3. Providers’ knowledge of legal grounds for abortion and willingness to perform an abortion by legal ground.

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While most respondents (>90%) knew that abortion was legal to save a woman’s life and when the pregnancy was the result of rape, half of respondents were not personally willing to perform an abortion on these two grounds (52.4% and 47.4%, respectively). Less than half were willing to perform an abortion to preserve a woman’s health (47.1% for physical health, 42.9% for mental health, and 42.6% for health overall). Further, 42.3% said they would perform an abortion on a woman’s request. The main reason for refusing to provide an abortion, irrespective of grounds, was personal religious or moral beliefs (i.e., self-identified as a conscientious objector) (Table 3).

Some respondents believed that additional restrictions to abortion access were required, though these were not legally specified. Varying by grounds, respondents thought there were gestational age limits (range: 25.0%–50.0%), that abortion was only authorized in specially licensed facilities (40.5%–64.7%), that authorization of one or more other professionals was required to perform an abortion (23.5%–50.0%), that parental consent was required for at least some minors (40.8%–55.7%), and that it was necessary to seek judicial authorization to perform an abortion on someone younger than 18 (16.4%–35.3%). For all six legal grounds, some respondents said they would require a woman to undergo compulsory counseling (22.4%–41.2%), insist on a compulsory waiting period (9.5%–19.7%), and prohibit the detection of fetal sex before performing the abortion (14.3%–35.7%) (Table 4).

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Table 4. Evidence of potential provider-level barriers to accessing legal abortion in Argentina.

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Ghana.

In Ghana, 513 of 524 eligible providers consented to participate (97.9% consent rate). A total of 513 providers completed the survey (97.9% response rate), with 79.1% from a single district (District 2). The majority of respondents were from primary level facilities (58.7%). Most respondents worked in the public sector (87.3%) and were female (87.1%). Respondents had a range of 0–40 years in practice (median: 2.0) (Table 2).

Respondents had generally high knowledge of the grounds under which abortion was legal in Ghana. Nearly all (99.2%) knew that abortion was legal to save a woman’s life. Most knew that abortion was legal to preserve a woman’s health (80.5% for physical health, 77.6% for mental health, and 88.3% for overall health). Fewer respondents (61.6%) knew that abortion was legal in cases of intellectual or cognitive disability of the woman. The majority of respondents identified incest, rape, and fetal impairment as legal grounds for abortion (72.9%, 82.8%, and 86.9%, respectively). Yet only 33.3% knew that abortion was legal for economic or social reasons, and only 50.3% realized that abortion on request was explicitly not legal.

For each of the grounds upon which abortion is legal in Ghana, most respondents indicated willingness to perform the procedure, ranging from 75.4% for economic or social reasons to 86.2% to preserve a woman’s health. Among those who indicated that they would not be willing to perform an abortion, personal religious or moral reasons were most frequently cited (Table 3).

Some respondents thought there existed restrictions and requirements not specified in the law. Most respondents believed that abortion was only authorized in specially licensed facilities (range: 86.4%–94.7%, depending on the legal ground). Many stated that to perform an abortion they would require the authorization of one or more healthcare professionals (63.7%–82.9%), parental consent for adolescents and girls under 18 (81.7%–93.5%), spousal consent for married women (62.0%–82.3%), compulsory counseling (78.4%–93.6%), and compulsory ultrasound or Doppler to listen to the fetal heartbeat (65.2%–77.6%). Fewer respondents stated that they would require a compulsory waiting period (15.3%–34.5%) or prohibit detection of fetal sex (20.7%–31.3%) before performing the abortion (Table 5).

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Table 5. Evidence of potential provider-level barriers to accessing legal abortion in Ghana.

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India.

In India, 95 of 106 eligible providers consented to participate (89.6% consent rate). All 95 providers who consented to participate completed the survey (100.0% response rate). The population was distributed across the four participating districts, with one district contributing 36.8% of the sample. All providers worked in the public sector. A majority of participants worked in secondary- and tertiary-level facilities in the study districts (47.4% and 40.0%, respectively) and most were female (95.8%). Respondents reported a range of 1–36 years of practice experience (median: 7.0) (Table 2).

Respondents’ knowledge of the legal grounds for abortion was generally high, with >90% correctly indicating all legal grounds for performing an abortion (range: 81.0%–100%, varying by ground). Comparatively, fewer knew abortion was not explicitly legal on request (39.0%). Respondents’ willingness to perform an abortion varied notably based on the grounds, with far more respondents reportedly willing to perform an abortion to save a woman’s life (81.1%) than for economic or social reasons (55.3%) or to preserve a woman’s physical or mental health (47.9% and 51.1%, respectively). The reason most frequently given for not performing an abortion across all grounds was lack of clinical capacity (25.0%–60.6%) (Table 3).

Some respondents believed that additional restrictions to abortion access were required, although they were not legally specified. Many believed providers could legally "opt-out" of providing an abortion (range: 44.2%–85.9%, depending on ground). A proportion believed that providers who “opted out” of performing an abortion had no obligation to refer the woman to another provider (7.7%–43.8%). By law in India, 1–2 physicians must authorize an abortion, but there was confusion about which physicians could provide such authorization. For example, respondents believed that generalist physicians (72.1%–85.1%) and specialist physicians including OB/GYNs (6.6%–15.3%) were not permitted to provide authorization (data not shown). In addition, some respondents erroneously stated that adolescents and girls under the age of 18 required judicial authorization to access legal abortion (25.6%–72.7%). Further, 25.3% said they would require spousal consent before performing an abortion to save a woman’s life, while 85.9% would require spousal consent for economic or social reasons. Responses were similarly heterogeneous for other types of requirements among the legal grounds, such as requiring a woman to view ultrasound images or listen to the fetal heartbeat, endure a compulsory waiting period, or undergo HIV or other STI tests (Table 6).

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Table 6. Evidence of potential provider-level barriers to accessing legal abortion in India.

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Discussion

This study sought to validate the accuracy of data reported by global monitoring mechanisms and determine whether domestic laws are being implemented as written, to assess use of the “legal status of abortion” as a proxy for actual access to legal abortion. We identified discrepancies between the global monitoring mechanisms and domestic policy review, although all referenced the same source documents. Specifically, we found variation between the data reported by Countdown and GAPD and the validation data in Ghana and India, while data reported for Argentina were accurate according to our findings. The provider surveys offered substantial evidence that domestic laws were not reliably being implemented as written, including due to conscientious objection and imposition of restrictions at the provider’s discretion (e.g., soliciting parental or spousal consent when not required by law) in the three countries. Our results raise important questions regarding the validity of the indicator as a measure of access to legal abortion and also the accuracy of global data collection on laws governing abortion and policy implementation.

Given that the documents cited by GAPD for the three countries are the same as those selected through the desk review, the discrepancies observed are probably not due to omission of key documents but to varied interpretation. It is possible that the legal interpretation in force has evolved since the data reported in Countdown and GAPD were compiled, leading to the identified discrepancies. Researchers, advocates, and decision-makers working on abortion policy may elect to review local documentation and consult local subject matter experts to complement data reported in Countdown and GAPD to ensure a complete legal picture. Our findings are consistent with the results of WHO’s own internal validation of the data reported in GAPD, which found extensive mismatch between reported data and uploaded source documents, and many entries that could not be validated based on provided source documents [22]. These findings raise questions about accuracy of the data reported in global monitoring frameworks.

While global monitoring frameworks focus on the overall legal status of abortion, the existence of progressive abortion legislation does not guarantee implementation. Gaps in provider knowledge about the legality of abortion can hinder implementation, as can provider-imposed barriers that go above and beyond the law [43]. The provider surveys in our study surfaced evidence of provider-level barriers to accessing legal abortion in all three countries.

In Argentina, the landmark December 2020 legislation legalizing abortion on request up through 14 weeks and 6 days of gestation dramatically expanded access to legal abortion, including by harmonizing the domestic legal framework through the passage of a single nationally applicable law. However, widespread conscientious objection may curtail access despite the favorable legal context. Previous research in Argentina suggests conscientious objection may be multi-faceted, reflecting stigma, positions of hospital leadership, and workload as much as personal religious and moral beliefs [35]. High rates of conscientious objection may leave facilities with few providers willing to perform abortions [44–47]. Despite the legal obligation to refer to a non-objecting provider, pervasive refusals may force women to travel further, incur additional costs, and face delays [47,48]. The Argentine Ministry of Health states that conscientious objection must not hinder abortion access and that conscientious objector status may be overruled in emergencies or when no other professional is available [49], thus aligning Argentine policy with global guidance regarding conscientious objection [50]. Still, further research is needed to understand if such common conscientious objection in practice translates to reduced access. In the meantime, provider training to increase knowledge not only of the laws surrounding abortion but the ethics of conscientious objection may be merited, in light of the potential impact on the right to health [51].

In Ghana, despite a generally high level of knowledge about the grounds on which abortion is legal, respondents held many erroneous beliefs about the existence of additional restrictions or requirements for providing abortion on those grounds. Although providers did not often cite being conscientious objectors, it is possible that providers’ responses regarding imposing additional discretional barriers to access may reflect providers’ religious and personal ideologies relating to abortion (particularly given the largely Christian religious base of the country). Other research suggests that ambiguity in abortion law combined with low provider knowledge may fuel misinterpretations and provider-level barriers [52]. Further, censure from colleagues may cause providers to artificially constrain access to avoid performing abortions and become stigmatized by association [34]. Clarifying policy guidance combined with provider education may help ensure provider-level barriers do not impede access and violate rights.

In India, our findings were mixed. We found a high degree of knowledge of the legal grounds for abortion and of restrictions for which the law is clear. However, many restrictions are not expressly permitted or prohibited, and thus providers’ reported knowledge and practices showed substantial variation. It can be challenging for busy medical practitioners to stay abreast of guideline changes, which may result in women having different experiences when attempting to access care. Policies that clearly specify the legal requirements to access abortion and explicitly limit the authority to impose additional barriers could help ensure access to the full set of legally guaranteed rights.

Despite differing precedents and legal frameworks, we found commonalities across countries. Certain constructs consistently proved confusing for respondents, namely “compulsory counseling” and “compulsory waiting period.” WHO recommends that all women seeking abortions be offered voluntary, confidential, non-directive options counseling and information regarding abortion methods as a component of quality care, even as it discourages mandatory or directive counseling aimed at dissuading or denying women access to abortion [2]. Respondents seemed unclear on this distinction, and many expressed confusion regarding this question in the survey. Similarly, some respondents interpreted “compulsory waiting period” as indicating the maximum amount of time that could legally lapse between a woman’s request for an abortion and the health system’s provision of care (e.g., Argentinian national policy explicitly states that the health system must complete the procedure within ten days of the request). These divergent respondent interpretations raise questions about the construct validity of these items in our survey and other policy surveys.

Methodologically, our study has several key strengths. We developed a rigorous, systematic approach to identify all relevant documents and extract data for the secondary review. We also used source documents as the unit of analysis rather than geographic/political units so that policy surveillance methods could be deployed in a validation study. This innovation responds to an identified need to better validate policy indicators [36]. We also included all providers legally authorized to perform abortions in the survey, not only those who indicated they actively performed abortions. We did this to avoid selection bias and explore the knowledge and provider beliefs that women could encounter when seeking an abortion, allowing us to identify and characterize provider-level barriers. Our systematic approach to document provider knowledge and practice across all legal grounds afforded us a high level of granularity compared to other studies [53].

Our study also has several limitations. As our policy analysis was descriptive, we cannot identify the causes or contributing factors that led to the discrepancies in different sources, and we cannot comment on the extent to which they affect countries not included in our review. The structured surveys did not probe more deeply into why providers would impose restrictions. For example, facility-level policy may drive these practices, or providers may exert discretional authority to impose additional barriers to sexual and reproductive health care [34,54–56]. More research is needed to understand what is driving these reported attitudes and behaviors. Additionally, our study relied on provider self-reports, which may not accurately reflect true practices. Direct observation of the client–provider interaction or use of mystery/simulated clients (actors who present as real abortion clients to assess the quality of care) might produce more accurate representations of actual practice, as done to assess quality of care in family planning [57,58]. Finally, our study only sought to capture providers’ perspectives, not the experiences of women seeking abortion care.

In addition to these general limitations, we encountered some COVID-19-specific limitations. The pandemic delayed launch of the provider surveys in all three countries. This altered the sample in all sites, as some providers declined to participate due to being on medical leave after testing positive for COVID-19 or being redeployed for COVID-19 response. In India, the pandemic complicated completion of interviews and changed the modality of the survey from face-to-face to telephone. In addition, providers who did not consent to participate cited responding to COVID-19 as the rationale for non-participation. In Ghana, individuals who did not consent to the in-person interviews cited being away from work either recovering from COVID-19 infection or supporting family infected by the virus. While the pandemic may have reduced the sample of participants in these settings, there is no reason to believe that the attrition would have been differential or that it would have introduced systematic bias. In Argentina, COVID-19-related delays may have significantly impacted the outcomes of interest, as by chance the domestic legal framework radically changed just before the survey launched. Significant social movements both for and against legalization of abortion on request preceded the historic legislation change, which may have influenced providers’ willingness to participate. This could explain the lower consent rate in Argentina compared to Ghana and India. These limitations mean that our findings should be taken as a detailed snapshot of the moments at which the study was conducted in each country, which can provide insight into the validity and challenges of global monitoring indicators rather than as generalizable findings that can be applied broadly to other contexts and historical moments.

Conclusion

Several global monitoring frameworks track the legal status of abortion, yet there are lingering questions about measurement validity of current indicators. Our findings suggest there may be substantial problems with criterion validity of the “legal status of abortion” indicator for at least some countries. As policymakers, researchers, and advocates routinely use the Countdown and GAPD databases, inaccurate or incomplete information may jeopardize efforts to advance reproductive health and rights. The rapid changes in abortion-related laws around the world also complicate efforts to maintain accurate, complete, and updated records [8,9]. Our findings also suggest construct validity problems both with discrete sub-constructs (e.g., “compulsory counseling” and “compulsory waiting period”) and with the broader construct of “legal status of abortion” as a proxy for access. Indeed, our results suggest that even comparatively liberal legal frameworks can leave open considerable room for differences in provider-level interpretations or implementation of the law, which may obstruct abortion access. Relying solely on the legal status of abortion may lead the sexual and reproductive health and rights community to overstate abortion access and thus neglect efforts to ensure rights. These findings serve as a foundation to develop future studies and as impetus for renewed legal advocacy to assure abortion rights around the globe.

Acknowledgments

The authors would like to thank the following people, without whose efforts the publication of this manuscript would not have been possible:

In Argentina, we gratefully acknowledge the support of the National Directorate of Maternal, Child and Adolescent Health and the Directorate of Sexual and Reproductive Health of the Ministry of Health of the Nation. We commend the commitment and dedication of the provincial teams, and the following members of the Maternal and Child Health Programs of the Provincial Ministries of Health: Dr. Adriana Martirena, Dr. Daniel Nowacky, Dr. Adriana Allones, Marta Ferrary, Dr. Claudia Castro, Ana Seimande, Antonio Tabarcachi, Noelia Coria, Cintia Jacobi, Laura Soto, Dr. Mara Bazán, Dr. Susana Velazco, Dr. Patricia Leal, and Marcela Tapia. Finally, we would like to express our deepest gratitude to all of the health workers who participated in the study as data collectors, working through the height of the COVID-19 pandemic in Argentina.

In Ghana, we gratefully acknowledge the support of the Ghana Health Service Family Health Division, The Director General–Ghana Health Service–Dr. Patrick Kuma-Aboagye; Dr. Ernest Konadu Asiedu, Ms. Roberta Asiedu, Dr. Margretta Chandi and Ms. Catherine Adu Asare; Dr. Benedicta Mensah, Ms. Keziah Dampare, and all regional and district health workers and field teams for their persistence in data collection despite the challenges.

In India, we gratefully acknowledge the support of Dr. Dinesh Baswal, Ex Deputy Commissioner at Maternal Health Division, Ministry of Health & Family Welfare, India; the Mission Directors, State Health Departments of Tamil Nadu and Uttar Pradesh, and the District health Officials of study districts. We also acknowledge the support of Dr. Manju Chhugani and Dr. Renu Kharb for their guidance in review of the secondary data on many indicators. Finally, we sincerely thank the district field teams for their untiring efforts and adaptation to new methodologies to collect good quality data, in the midst of COVID in India. We also thank all the health workers and facility staff who participated in the study despite their busy schedules due to COVID situation.

In addition, we are grateful for the support of Ronnie Johnson and Tiziana Leone whose inputs in the formative stages of this research guided our thinking.