What I learned trying to classify abortion access across the rich world

Rich countries are not monolithic. However, outside the US and a few microstates, they vary in a limited range.

dynomight.net/abortion

With abortion in flux in the US, I realized I didn’t have a clear picture of how things looked in the rest of the rich world. When I searched, I found lots of maps, like the following from Politico and Wikipedia:

These are helpful, but they’re very high level. If you read about individual countries, you’ll find that things are more complicated than these—or any—maps can coney.

I wanted to know: When is abortion available for what reasons? So I researched the policies in 27 countries, came up with a classification scheme, classified each week in each country, and then tried to visualize everything in a single graphic.

Here’s what I came up with:

The colors show “access scores” between 0 (no access for any reason) and 8 (available on-demand). Between those two extremes, there’s one point if abortion is allowed for each of the following reasons:

1. The woman’s physical life/health

2. Rape

3. Incest

4. Non-fatal fetal abnormalities

5. The woman’s mental health

6. The woman’s age

7. The woman’s social condition, e.g. ability to care for a baby

The country/time regions are labeled by policy. If abortion is on-demand, there’s no label. Otherwise, r, i, f, and + indicate when various reasons are allowed, while L indicates the (rare) cases when abortion is not permitted to save the woman’s life.

I think this gives a richer picture, but it’s still missing a lot of nuance. Honestly, I’ve begun to doubt if a truly fair visual summary is even possible. There are two basic problems:

• Formal policies are often vague, with decision-making delegated to boards or doctors. This makes everything illegible. In Switzerland, a woman can have an abortion after 12 weeks if there is a risk of serious psychological distress. But that risk is evaluated by individual doctors under varying guidelines set by each of the 26 Swiss cantons. How does that look in practice? I have no idea.

• Abortion access is multidimensional. In Italy, only 30% of gynecologists will perform abortions and there’s no directory of who they are. In Germany, abortion is always illegal (sort of) but simply not punished in the first 14 weeks. In many places, abortions are allowed for serious fetal defects, but the meaning of “serious” varies. It’s impossible to capture all these things with a small set of features.

(Also, with 8 binary attributes, 32 regions, and 38 weeks I essentially had to determine if 9,728 different things were true or false. So, there are surely some errors—let me know if you see any.)

Still, I learned a lot from all this, so I’ve tried to distill the biggest lessons below. I’d also like to tell my tale of woe, why classifying these things is hard.

Canada is misunderstood

Canada is often seen as the country with the strongest abortion rights in the world. That’s true in some sense: Legally, abortion is not a criminal offense in Canada at any stage of pregnancy, for any reason.

But just because abortions are not illegal doesn’t mean they are available. Provinces can set regulatory limits on abortion, and all of them do:

There are no providers in Canada that offer abortions past 24 weeks unless the woman’s life is in danger or there are serious fetal abnormalities. Canadians who seek abortions after the limit set by their province are often referred to clinics in the US. Provincial governments have programs to pay for women to travel to the US for this purpose.

Access ≠ rights

Technically, abortion is never available on-demand in Great Britain. (Northern Ireland is a bit different from England/Scotland/Wales.) However, the law allows abortions up to 24 weeks if there is a “grave risk to the mental health” of the woman and nowadays abortion providers—who make the determination—almost always view the fact that a woman wants an abortion as proof that such a risk exists. Thus, abortion is de-facto available on demand for 24 weeks.

So, while the legal right to abortion seems stronger in Canada than in Britain, the actual level of access is often higher in Britain.

Germany is another example. The law states that abortion is always illegal, but that the conditions for punishment (imprisonment of both the doctor and the woman) “are not deemed fulfilled” if (a) it’s during the first 14 weeks (12 since conception), (b) the woman has obtained counseling, and (c) there’s been a three-day waiting period. (There is also an exception after 14 weeks for the woman’s mental or physical health.) Until 2019 it was illegal for doctors to advertise that they performed abortions. The effect seems to be that abortion is available on-demand during the first 14 weeks, but can be tricky to access.

Italy is sort of the opposite of Germany. Legally, there are zero restrictions on abortion in the first 90 days. However, gynecologists in Italy have the right to refuse to perform abortions, and the percentage who do so is around 70% and growing. Here’s the percentage who refused in 2016, via Autorino et al. (2020).

There is no official list of who will perform an abortion, meaning that women may struggle to find a willing doctor. This right to conscientious objection by doctors is legally guaranteed in most of Europe. It gets the most attention in Italy but is probably an important factor in some other places too.

None of these subtleties are reflected in my classification scheme.

Israel is weird

I tried to fit Israel into the infographic—oh how I tried. But Israel breaks so many patterns that half my scoring system was becoming Israel-specific exceptions and in the end, I gave up. Here are the facts about Israel:

• Abortions are illegal unless approved by committee.

• The committees approve most but not-quite all requests (98%).

• They consider basically every possible reason including rape, incest, the age of the woman, fatal or non-fatal fetal defects, and emotional or psychological damage.

• Yet the most common reason by far (48%) is simply that the woman is unmarried.

• It’s unclear what things look like in the 2% of cases the committees reject.

• It’s illegal to perform an abortion in a private clinic.

• Yet, half of abortions are done illegally in private clinics and without committee approval.

• No one has ever been prosecuted for a non-approved abortion.

• As of 2014, abortion is also free for all women aged 20-33, seemingly with no medical reason needed and no gestational limits.

I, uhh, I guess that’s quite close to de-facto abortion on demand? Not sure what political dynamics led Israel to leave abortion “illegal” but also add multiple redundant layers of extremely broad exceptions. Maybe the country has other priorities.

Decisions are often highly devolved

Another thing that makes abortion access so difficult to categorize is that many places have vague laws and leave things to be decided at low-levels. We saw above that gynecologists can often refuse to perform abortions. In Canada, Australia, and the US, regulations are mostly made by the states or provinces. In Finland and Norway, abortions after 12 weeks are reviewed by a national board. And in many other places, the criteria for later abortions are evaluated by individual doctors.

The formal criteria for the boards/committees/doctors making these decisions are almost always high-level things like “serious risk to the health of the woman”. But what is “serious”? I imagine that cultural norms develop over time, but I could rarely figure out what they were.

Much of this is surely because lawmakers realize there’s no way to codify the infinite variety of situations that can arise in messy reality. But I wonder if this illegibility serves another purpose—given that abortion is so controversial, perhaps making it harder to figure out exactly what’s happening also reduces the amount of strife?

Abortion is illegal in few places

Abortion is illegal in Poland, with exceptions only for rape or the woman’s health. Policies there were fairly permissive during the communist era but were greatly restricted since the 1990s. As recently as 2020, abortions were permitted for non-fatal fetal abnormalities, but this was declared unconstitutional by the Constitutional Tribunal.

Abortion is illegal in Monaco and Liechtenstein, with exceptions only for rape, the woman’s health, and fetal defects. There was a referendum in Liechtenstein to legalize it in 2011, which was defeated 51.5% to 48.5%. But even if it had passed, Prince Alois had promised to veto it. (And if you expect people in Western Europe to chafe at hereditary monarchies threatening to bluntly overrule popular referenda, well, a follow-up campaign to eliminate the prince’s royal veto was defeated 76% to 24%.)

Abortion is also illegal in Andorra and Malta, with no exceptions, not even to save the life of the woman. Andorra considered legalizing abortion in 2018, which led to a strange situation: For that to happen, it would have to be approved by the co-prince of Andorra who also happens to be a Catholic bishop. But Pope Francis threatened that if the bishop approved it, he would immediately be expelled from the church, which would lead to his abdication as co-prince, putting Andorra in a governance crisis and endangering its independence from France and Spain. They did not legalize abortion.

As far as I can tell, if Malta wanted to change their law, there’s no medieval institution with the power to jump in and stop them.

It’s common to travel for abortion

Women in Liechtenstein typically travel to Switzerland or Austria, while women in Andorra usually go to France or Spain. Statistics are limited, but around 100 Andorran women have abortions in public Spanish hospitals every year. (Andorra’s population is only 77.5 thousand.) Before Ireland legalized abortion in 2019, thousands went to England or Wales for abortions each year.

I suspect that when it’s easier to travel for an abortion, this somewhat reduces the political pressure to change the law.

Here is per-capita GDP in 2020 in the most restrictive countries.

• Poland: $17.8k

• Malta: $33.3k

• Andorra: $37.4k

• Monaco: $137.7k

• Liechtenstein: $169.0k

Surely it’s no relevant that Andorra, Monaco, and Liechtenstein are tiny specks of land next to countries where abortion is legal. And it’s probably also relevant that Andorra is rich, while Monaco and Liechtenstein are very rich.

Malta is a bit of a bit different. Besides being less rich, it’s an island. The only place at all close is Sicily where abortion—while legal—is difficult to access. Women in Malta often travel to Rome, Milan, or further-away countries like the UK, Germany, or the Netherlands.

The issue of travel also shows the limits of categorizing access by country. Compare a woman in Liechtenstein (where abortion is illegal) to a woman in rural Austria (where abortion is legal on demand). Theoretically speaking, the Austrian has greater rights. Yet, almost all doctors in Austria outside major cities refuse to perform abortions. So both women would need to travel to get an abortion, but the Liechtensteiner is likely more wealthy and needs to travel a shorter distance.

Abortion pills can also travel through the mail. There are entire organizations dedicated to shipping abortion pills into jurisdictions where they are prohibited. This happens in Malta. It was also common in Ireland before abortion was legalized—Irish customs would sometimes seize the pills but rarely (if ever) prosecuted anyone for ordering them. To this day, the UK occasionally prosecutes and jails women for ordering and using medication for late-term abortions.

Health of the woman is a tricky concept

In almost every locality I studied (except Malta and Andorra) abortion is legal to preserve the life or health of the woman. But what does this mean, exactly?

For example, say a pregnant woman is diagnosed with cancer. Cancer treatments like radiation or chemotherapy can cause a miscarriage or birth defects. Is that treatment allowed if it has a 10% chance of saving the woman’s life? A 50% chance? Can a woman have an abortion before starting the treatment?

Irish history is instructive. In 1992 the Irish supreme court held in Attorney General v. X that women have the right to an abortion if their life is at risk. However, in 2012 Savita Halappanavar went to a hospital complaining of lower back pain. She was 17 weeks pregnant and doctors discovered that her pregnancy was doomed to fail. However, after her water broke, the fetus was not expelled. She asked doctors to perform an abortion but doctors refused to do so, which ultimately led to her developing sepsis and dying.

It was debated if the doctors correctly interpreted existing law. Still, Halappanavar’s death led to Protection of Life During Pregnancy Act of 2013 which expanded/clarified the situations in which abortions should be performed to prevent risk to a woman’s health. It also may have contributed to the population approving in 2019 the 36th amendment which legalized abortion in Ireland.

So while almost everywhere allows abortion to save a woman’s life or health, the exact criteria are varying and murky. Sometimes the criteria include things like risk of suicide that require significant judgement. And usually, the decisions are made by small committees or individual doctors with little public information on how they interpret the statutes in practice.

After a lot of research, I eventually concluded that I couldn’t fairly and reliably score these differences. So, while very important, they don’t factor into the visualization other than separating Malta and Andorra from the rest of the rich world.

Fetal abnormality is a tricky concept

Most places in the world seem to allow abortions at any time if the fetus has a fatal defect. For example, in Ireland, abortion is allowed after 12 weeks if the fetus would die within 28 days of birth. Similar things are true at least in Iceland, Sweden, Great Britain, and Singapore.

It was difficult to find clear answers about where abortion is allowed for fatal defects. Often there would not appear to be any such exception in popular descriptions, but after a lot of digging—like finding and reading the actual law—-I would find that it did in fact exist. While it is not true everywhere (e.g. it was not true in Ireland before 2019) I decided it was common-enough and hard-enough to determine that I gave up on using it as a criterion.

Some places also allow abortions for non-fatal defects. Here the exact criteria are again difficult to evaluate. Is it allowed for Down syndrome? Tay-Sachs? Phenylketonuria? Hemophilia? In most cases it’s hard to find clear answers—the decisions seem to be delegated to small committees or individual doctors.

Ultimately, I decided to classify countries by a simple binary “is abortion allowed for at least some non-fatal fetal abnormalities?” This captures only a fraction of the spectrum of policy differences but was the most informative thing I could check semi-reliably.

Weeks are defined in different ways

When determining the number of weeks, most places count since the start of the last menstrual perio. This is a little odd, since one can’t actually become pregnant until around 2 weeks after this, but I suppose it makes counting easier. A couple places define limits with respect to conception (Belgium, Germany—contact me if you are aware of others). In my graphic, I added two weeks to any limit defined with respect to conception.

Late-term abortion on-demand is nonexistent outside the US

Most abortions in the US take place in the first trimester and the vast majority before the end of the second trimester (around 24 weeks). Here are the statistics from the CDC for 2019:

Still, several US states allow abortion on-demand with no gestational limits: Colorado, the District of Columbia, New Jersey, New Mexico, Oregon, and Vermont. It’s also legal in Alaska, but there do not appear to be any clinics that actually do it. As far as I can tell, there is no other place in the rich world where abortion on-demand exists after the second trimester except (maybe-sorta-kinda) Israel.

Florida still has more access than much of Europe

In April of 2022, Florida passed a law that bans abortion after 15 weeks of pregnancy, with exceptions only for fatal fetal abnormalities or a serious health risk to the woman. This is being challenged in court based on the Florida state constitution’s right to privacy, but remains in effect in the meantime. Virginia is considering something similar, perhaps with more exceptions.

How should this change be contextualized? Well, previously abortion was available on-demand in Florida for 24 weeks, equivalent to the most permissive countries like the Netherlands, Singapore, or some parts of Canada. It’s now more restricted but is still broader than countries that restrict abortion earlier than the 15th week, like France, Germany, Spain, Belgium, Ireland, Greece, Austria, Portugal, or Italy. (Although Florida has fewer exceptions than most of these places after the on-demand period.)

Near-total abortion bans are rare

On the other hand, several states have banned abortion from conception, with only exceptions for the life of the woman (no exceptions for rape, incest, or lethal fetal abnormalities): Alabama, Arkansas, Kentucky, Missouri, Oklahoma, South Dakota, and Texas. (For Texas, the law is currently held up in court.)

These laws are more restrictive than almost anywhere else in the rich world. Poland is similar, but is it “rich”? Poland’s per-capita GDP is only 26% as high as the US and 42% as high as the poorest US state (Mississippi). In truth, I included Poland but skipped many countries that are richer (Cyprus, Slovenia, Estonia) just because Poland has unusually restrictive abortion laws and it felt weird to omit it.

Aside from Poland, the only other places with similar restrictions are Liechtenstein, Monaco, Malta, and Andorra—a bunch of heavily Catholic microstates. These countries have a combined population of around 680k people, 44 times smaller than the state of Texas. If El Paso was a country, it alone would have a larger population.

If you take all the people in the rich world who currently live somewhere where abortion is almost fully banned, almost all of them live in the United States.

Summary

Rich countries are not monolithic. However, outside the US and a few microstates, they vary in a limited range: Abortion is available on-demand (de-jure or de-facto) for between 12 and 24 weeks, plus later under varying exceptional circumstances.

The US is unusual in both directions. Some states now ban abortion from conception with exceptions only for the pregnant woman’s life. This is more restrictive than almost anywhere else. But some states also allow abortion on-demand at any time. This also does not exist almost anywhere else in the rich world.