Chapter 2. Abortion regulation including relevant recommendations
Law & policy Recommendation 3: Gestational age limits (2.2.3)
2.2.3 Gestational age limits
Gestational age limits are commonly specified in both liberal and restrictive abortion laws and policies. Imposed through formal law, institutional policy or personal practice by individual health workers, these limits restrict when lawful abortion may be accessed by reference to the gestational age of a pregnancy. In many countries gestational age limits are linked to grounds-based approaches, with gestational age limits varying according to the grounds or circumstances under which abortion is permitted. While methods of abortion may vary by gestational age (see Chapter 3, section 3.4.3), pregnancy can safely be ended regardless of gestational age. Gestational age limits are not evidence-based; they restrict when lawful abortion may be provided by any method.
International human rights law requires that quality of care be central to the provision and regulation of SRH, and thus that regulation of abortion is evidence-based, scientifically and medically appropriate, and up to date (3, para. 21). Under international human rights law, States may not regulate pregnancy or abortion in a manner that is contrary to their duty to ensure that women and girls do not have to resort to unsafe abortion, and are required to revise their laws accordingly (see Web annex A: Key international human rights standards on abortion).
LAW & POLICY Recommendation 3: Gestational age limits
Recommend against laws and other regulations that prohibit abortion based on gestational age limits.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO’s 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of gestational age limits on abortion seekers and health workers, a systematic review of studies published between 2010 and 2020 was undertaken, identifying 21 studies conducted in Australia, Belgium, Mexico, Nepal, South Africa, the United Kingdom and the United States of America (USA). A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Gestational age limits. The reviewed evidence demonstrated that – alone or in combination with other regulatory requirements, including grounds-based approaches – gestational age limits delayed access to abortion, especially among women seeking abortions at later gestational ages, women close to the gestational age limit and those living in areas with limited access to clinics. Gestational age limits have been found to be associated with increased rates of maternal mortality and poor health outcomes. International human rights law requires States to reform law in order to prevent unsafe abortion and reduce maternal mortality and morbidity.
The studies also showed that where women requested an abortion and were denied care due to gestational age this can result in the unwanted continuation of pregnancy, especially among women with cognitive impairments or those who presented at 20 weeks’ gestation or later. This outcome can be viewed as incompatible with the requirement in international human rights law to make abortion available when carrying a pregnancy to term would cause the woman substantial pain or suffering, regardless of pregnancy viability.
The evidence from these studies showed that women with cognitive impairments, adolescents, younger women, women living further from clinics, women who need to travel for abortion, women with lower educational attainment, women facing financial hardship and unemployed women were disproportionately impacted by gestational age limits. This points to the disproportionate impact of gestational age limits on certain groups of women, with implications for States’ obligation to ensure non-discrimination and equality in provision of SRH services.
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO GESTATIONAL AGE LIMITS
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health (SRH) services.
- States may not regulate abortion in a manner that forces women to resort to unsafe abortion.
- States must take steps, including revising laws, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with resorting to unsafe abortion.
- Everyone has a right to non-discrimination and equality in accessing SRH services.