Abortion laws and severity of abortion-related morbidities: A cross-sectional analysis of the WHO multi-country survey on abortion (WHO MCS-A) in sub-Saharan Africa

Less and least safe abortion rates are higher in countries with restrictive abortion laws than in countries with less restrictive laws. Women seek out and procure services regardless of the legal status of abortion - in countries with restrictions, this means they may seek abortions outside of the legal system, which are more likely to be unsafe. In this study, we investigate whether the severity of abortion-related severe morbidity differs with varying levels of abortion legal restrictions. This is a secondary analysis using data from the WHOs MCS-A study, which was a cross-sectional study of 11 countries in sub-Saharan Africa. Abortion-related morbidity was categorized by severity. We divided abortion laws into three categories: abortion on request, abortion for health indications, and abortion prohibited altogether. We constructed a logistic regression model to understand the effect of restrictive abortion laws on the odds of more severe complications compared to less severe complications. We included 7,475 women across 210 health facilities. More women lived in countries with abortion for health indications (74%) than countries with abortion on request (19%) or countries where abortion was prohibited altogether (8%). Most women (91%) had less severe abortion-related complications. Women living in countries where abortion is legal for health indications were significantly more likely to experience severe complications than those living where abortion is available on request (1.10 OR, 95% CI 1.07-1.12). Women in countries where abortion is prohibited altogether similarly had significantly higher odds of more severe abortion complications than those living in countries where abortion is available on request (1.10 OR, 95% CI 1.07-1.14). In sub-Saharan Africa, abortion complications are statistically significantly higher in countries with restrictions compared to those with abortion on request. While easing restrictions on abortion could significantly reduce abortion complications, initiatives to increase access to timely and quality comprehensive abortion care is an urgent matter, as it would likely improve outcomes. These initiatives should focus on raising awareness about the law, values clarification for health workers and policy makers, and targeting other barriers at the facility- and community-level that might delay or prevent care.