Abstract: This report reviews international abortion data relevant to claims being made in the debate over Ireland's abortion policy. Annual Ireland abortions obtained abroad peaked in 2001 and have since declined by 50%. Available data suggests only small numbers of unreported abortions abroad plus several hundred illegal abortions per year using abortifacients. Abortion declines are seen in all mothers' age groups, and abortions in cases of threat to the mother's life are very rare, consistent with other developed nations. Much international abortion data cited by abortion proponents has been either unreliable or of little relevance to Ireland. Examination of abortion trends across Europe suggests that, if Ireland were to broadly legalize abortion, in-country abortions would rise in a few years to exceed current levels (of combined abroad and in-country abortions), but trends after than are unpredictable—they could remain at similar levels or they could rise to levels several times higher than current levels.

On 25 May 2018 Ireland will hold a referendum on its constitutional protection of human life in the womb. Specifically, the government is proposing to abdicate its duty to protect children in the womb and legalize abortion by removing this provision of the Constitution under "Fundamental Rights":

The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right (Constitution of Ireland, 40.3.3).

The current Irish Government proposes to fully abdicate one of its foremost God-given duties to protect innocent human life during the first 12 weeks of pregnancy, and substantially for the remainder of pregnancy, by changing Article 40.3.3 to the following: Provision may be made by law for the regulation of termination of pregnancy (Government of Ireland, 2018a, "Thirty-sixth Amendment").

If the Irish people approve the 36th Amendment to their Constitution, then the "Regulation of Termination of Pregnancy" policy—already prepared, approved and published by the Government—would become the new abortion policy of Ireland. This policy would legalize abortion for the following reasons:

• "termination of pregnancy up to 12 weeks of pregnancy without specific indication," with "a time period ... between the initial assessment by a medical practitioner and the termination of pregnancy";
• "risk to the health (which would include risk to the life) of a pregnant woman," whether "physical or mental health," with the approval of "two appropriate medical practitioners";
• "risk of health" in an emergency would only require approval of "one medical practitioner";
• "on the grounds of a fetal condition which is likely to lead to death before or shortly after birth," with the approval of "two appropriate medical practitioners";
• anytime during pregnancy "for a fetal condition likely to lead to death before or shortly after birth or for maternal health" (Government of Ireland, 2018b, "Regulation of Termination of Pregnancy," Policy 1 to 9).

Organizations from outside Ireland are enhancing the pressure they have been applying for decades, seeking to bring Ireland in line with most of the rest of Europe in regard to abortion policy (Bottini, 2007; ECHR, 2010; Quinn, 2017).

Some abortion proponents are making claims referencing international abortion data or estimates, with many of these claims either erroneous or unsupported. This working paper will examine claims that can be weighed based on available data, including information from the recently published Abortion Worldwide Report (Jacobson and Johnston, 2018).

Current state of Irish abortions

The Eighth Amendment to the Constitution of Ireland in 1983 guarantees protection of the right to life of the unborn as well as right to life of the mother (quoted above).

Most abortions by residents of Ireland have been obtained abroad, with cumulative reported numbers of 184,270 in the United Kingdom from 1968 through 2016, and 1,611 in the Netherlands from 2005 through 2016. In 2013 Irish law was revised to permit abortion in limited circumstances, and there have been 77 abortions in Ireland in 2014-2016 (Dept. of Health, 2014-2017). Known annual abortions to Irish residents peaked at 6,673 in 2001, and have since declined to 3,312 in 2016. Figure 1 shows trends over time for abortion percentage, or abortions as a percentage of pregnancies ending in either live birth or abortion. Data for 2000-2016 is given in Table 1 (Johnston, 2018a).

Figure 1. Abortion percentage trends for Republic of Ireland.

Beginning in 2012 the British Government Statistical Service annual abortion bulletin began providing data on county of residence reported by Irish residents obtaining abortions in England and Wales. Abortion percentages by Republic of Ireland county are shown in Figure 2 (Johnston, 2017b). Of these abortions, 35% were for residents of Dublin county.

Figure 2. Ireland abortion percentages by county.

Some abortion proponents suggest that large additional numbers of abortions are obtained by Irish residents, either in unreported numbers abroad or illegal abortions in Ireland. Available evidence does not support these claims. Regarding other abortions abroad, some sources claim (without offering data) that Irish women often give false addresses when obtaining abortions in England and Wales (Daniels et al., 2013; Doctors for Choice, 2017; Zebede, 2016). This is not consistent with declining numbers from 2012-2016 of women reporting Irish residency who did not also give their county, nor with a negligible number of women not reporting a country of residence, nor with rapidly declining numbers of privately funded abortions by those reporting residence in England and Wales. Numbers of foreign resident abortions in Northern Ireland and Scotland are very small—about 1 per year in Northern Ireland (Dept. of Health-NI, 2016-2018), and about 10 per year in Scotland. Non-resident abortions in Belgium are low, falling to only 109 from elsewhere in Europe in 2011 (Sante Publique, 2012). Spain is cited as a hypothesized location of substantial Irish abortions, but non-resident abortions in Spain have been declining from 3,423 in 2007 to 1,517 in 2014 (Johnston, 2018c), a trend far more consistent with the majority of these being abortions by Portuguese residents. Ireland has indicated that numbers of Irish abortions in Spain or Belgium were less than 10 in 2005-2007 (ECHR, 2010). Some have suggested that Irish women are traveling to more distant European countries for abortions, though such reports have been assessed as inconclusive with regard to generalizations (Bloomer and O'Dowd, 2014).

Regarding illegal abortions within Ireland, several abortion proponent organizations have been supplying abortifacient pills to women in Ireland in violation of Irish law. Efforts to provide abortions off the Irish coast by Women on Waves (Gomperts, 2002) transitioned to Women on Web (WoW) mail-order pills. WoW reported contacts with 5,650 Irish resident women in 2010-2015, with 1,642 orders for medical abortion pills fulfilled in 2010-2012, and responses from 1,023 women in 2010-2012 that they completed abortions using these pills (Aiken, 2016; Aiken et al., 2016, 2017). These statistics are for the Republic of Ireland and Northern Ireland combined. Independently, in a 2011 survey 11% of 325 Irish physician respondents indicated awareness of patients having illegally used abortifacients (Murphy et al., 2012). Table 2 shows estimated illegal abortions derived from these figures (assuming constant fractions of contacts resulting in abortions for 2010-2015, assuming half of orders without follow-up resulted in abortion, and dividing results between the Rep. of Ireland and Northern Ireland in proportion to population). Note that we do not have high confidence in these estimates, but they do illustrate the order of magnitude of illegal abortions that are plausible based on available data. Numbers of illegal medical abortions in Ireland have likely declined in subsequent years given that Women on Web have reduced their shipments to Ireland due to the effectiveness of seizures by Irish customs (The Journal, 2018).

It is worth noting that of the 1,023 women who reported using Women on Web pills to self-administer abortions, 93 reported "potentially serious complications" for which medical care was advised, 23 required antibiotics, and 7 required blood transfusions due to complications from abortifacient use; another 45 reported having to obtain a surgical abortion (Aiken et al., 2017). Ironically, despite the fact that abortion proponents are supplying these pills in contravention of Irish laws, abortion proponents nonetheless are willing to blame the lack of follow-up medical care on Irish policy (Zebede, 2016).

Irish abortions by mother's age

The changing trends in abortions by women from Ireland are affected in part by the changing age structure of Ireland's population. The figures below separate abortion rates and percentages by mother's age. Figure 3 shows abortion rates by age group. Rates have declined dramatically (about 70%) for teenagers in the past 15 years, and about 50% for women in their twenties in the same time period. Declines have been smaller for older women, with little decline in the past decade.

Figure 3. Reported abortion rates by age group, abortions by Ireland residents in the UK.

Abortion percentages by age group in Figure 4 reveal more clearly the age categories of Irish women choosing to terminate their pregnancies. For example, the moderate decline in abortion rates for women 40-44 is offset by older women more frequently deciding to have children (a trend seen in other developed nations), such that the abortion percentage for this group is currently about 6%. Irish women in their thirties have the lowest abortion percentages (3%), and teenagers the highest (18%), though all groups show declining abortion percentages from 2001 to 2008, followed by relatively little change since then.

Figure 4. Reported abortion percentages by age group, Ireland residents.

Irish abortions by reasons for abortion

There is only limited data available on reasons for abortions by Irish women, though it is worth reviewing given the role this plays in the current debate. Abortion proponents in Ireland, as they have in other countries, have tended to focus attention on cases such as threats to the mother's life or pregnancies resulting from rape—even though these are rare (Jacobson and Johnston, 2018, pp. 56-71). Nonetheless, they are frequently cited in efforts to legalize abortion on demand.

For abortions obtained in England and Wales by non-resident women, the vast majority cite ground C, risk to the physical or mental health of the mother. In 2000-2014, an average of 2.9% of non-resident abortions cited grounds other than ground C, varying from 4.0% in 2000 to 1.2% in 2006, then back to 3.6% in 2014. Despite the legal basis for ground C, this is typically cited by doctors granting abortion on demand (Saunders, 2011). In 2015 data on reasons for abortions in England and Wales was first reported separately for residents of Ireland. Ground C was cited for 96.1% of cases in 2015 and 95.3% of cases in 2016. Six cases in 2016 cited ground D, risk to children the mother already has; otherwise, the non-ground C cases all cited fetal health issues, amounting to 276 cases in 2015-2016. Nearly a third of these cases (83) involved Downs syndrome children, and 4 cases were selective reductions of multiple pregnancies. Overall, reasons cited are consistent with trends in the United Kingdom, including rarity of threats to the mother's life: none of the cases in 2015-2016 cited risk to the mother's life, and only one non-resident abortion in 2000-2001 cited this risk (such data was not reported for 2002-2014).

Of the 77 abortions performed in Ireland in 2014-2016, 36 (47%) cited physical illness of the mother, 34 (44%) cited an emergency involving physical illness of the mother, and 7 (9%) cited suicide risk to the mother. Together, these cases represent 0.75% of abortions obtained by Irish women in any location during those years, and this level is consistent with the reporting for those obtained in England and Wales (Johnston, 2012), as well as general trends in developed countries (Jacobson and Johnston, 2018, pp. 58-63). Despite claims that Ireland's abortion restrictions put mother's lives at risk, women are apparently able to obtain in-country abortions in cases of ectopic pregnancy (Spillane et al., 2018).

The more typical abortion-on-demand reasons are predominant in responses to Women on Web from Irish women (in both the Republic of Ireland and Northern Ireland) using abortifacients to induce abortions (Aiken, 2016). Only 1-2% cited health reasons. The most frequently cited reason was, "I just cannot cope with a child at this point in my life," in ~62% of cases. Economic reasons were cited by 42-43% of women, desire to have no more children by ~22%, interference with schooling by ~15%, and age (too young or too old) in ~20% of cases.

Worldwide abortion estimates

In the Irish abortion debate, proponents of legalization have repeatedly made reference to studies by the World Health Organization (WHO) and the Guttmacher Institute (GI), claiming that abortion bans are associated with higher, not lower abortion levels (ARC, 2016a; Bloomer and Pierson, 2016; IFPA, 2016). The studies in question (Sedgh et al., 2012, 2016) provide estimates of global abortion numbers and rates by geographic regions. Regarding these claims and studies:

• The specific claims by abortion proponents of higher abortion levels in countries with more restrictive laws is not a claim of the WHO/GI studies' authors. The more recent study states in the abstract "We did not observe an association between the abortion rates for 2010–14 and the grounds under which abortion is legally allowed" (Sedgh et al., 2016), and the lead author in a presentation to the Irish Citizen's Assembly stated "The abortion rate is similar in countries grouped by legal status" (Sedgh, 2017).
• The WHO/GI studies are metastudies incorporating reported abortion numbers (when reporting is available) and estimates of abortion rates from multiple published studies (when reporting is not available). For the latter, these estimations tend to be methodologically flawed by extrapolating from limited samples using assumptions regarding uniformity in reproductive practices, adjustments for underreporting, and relative numbers of medical complications for spontaneous vs. induced abortion. Deficiencies in such estimates have been documented (Antkowiak and O'Bannon, 2003; Koch et al., 2012a, 2012b, 2012c), and these deficiencies undermine the resulting claims regarding regional and global abortion rates.
• Comparison of the resulting regional estimates (where reporting is lacking) to empirical data shows they are unlikely to be correct in that they are uniformly high for restrictive countries despite very different cultures, health care systems, policies, etc., and that for these countries they are higher than the 95th percentile of measured abortion rates anywhere (Johnston, 2017a; Jacobson and Johnston, 2018, pp. 195-199).

Beyond this, the WHO/GI studies are of little relevance to the situation in Ireland. The assertion is that countries with restrictive abortion policies have high levels of illegal abortions resulting in greater maternal health hazards. However, even if this contested claim could be proven to apply to some developing countries, it certainly does not apply to Ireland. Ireland has a well-developed health care system leading to a maternal mortality rate as low as most other nations of Europe (O'Hare, 2017). Thus these two claims by abortion proponents—restrictive abortion policies produce high illegal abortion rates, and high illegal abortion rates produce high maternal mortality—clearly cannot both be true with regard to Ireland (and in fact for Ireland both are false).

Country-level abortion data

Abortion proponents have also claimed that comparison to other European countries lends confidence that legalization of abortion in Ireland would be followed by a decline in abortion rates. Examples of their statements of such claims include:

• "A few countries, such as Spain, have shown increases in abortion rates following liberalization of the abortion law. These are exceptions however..." (Faundes and Shah, 2015)
• "In France and Spain, minor increases in abortion rates happened for two to three years after it was legalised, but this was probably explained by the fact that secret abortions are always underreported." (ARC, 2016a)
• "States that have achieved significant reductions in their abortion rates have done so by a combination of liberalising their abortion laws and ensuring [access to] contraception information and services... As a result of such policies, the rate has come down dramatically, for example, in France, Turkey and Italy." (IFPA, 2016)

Further, when European countries are considered in a comprehensive sense, they give rather mixed indications regarding post-legalization trends in abortion rates. This is examined in the Abortion Worldwide Report (Jacobson and Johnston, 2018, pp. 172-185), which found both in Europe and worldwide that after the initial rapid rise in known abortions—particularly after full legalization—in a country, long-term trends are divided into about half with sustained high levels and about half with slow declines. There is no immediately clear indicator for what produces one behavior over the other. Abortion proponents claim that use of contraceptives causes these declines, but this is contradicted by the sustained high levels of abortions in multiple European countries with high access to contraceptives, including the United Kingdom. Figure 5 below (Jacobson and Johnston, 2018, p. 176) shows averaged trends for Western European countries, scaled to respective peak levels and relative to the point in time when abortions reached half their peak levels: nine countries are in the sustained high abortion levels group and seven in the post-peak declining abortions group.

Figure 5. General trends in numbers of abortions for Western European countries.

Figure 6 shows abortion percentages over time for various Western and Southern European countries based on reported data (Jacobson and Johnston, 2018, p. 125-144), for countries with relatively uniform reporting. Note that there is little uniformity in terms of highest abortion percentages attained or behavior over time. Among limited patterns is a tendency for initial rise in abortions to be rapid (less than ten years).

Figure 6. Abortion percentages for various European countries.

The countries of Europe, however, represent varying cultures, religions, economic conditions, and demographic situations, all of which are factors contributing to varying levels of abortion when it is legal. Limiting instead to countries comparable to Ireland in terms of religion (as an example) produces the sample in Figure 7. Of six countries with widely legalized abortion, only one (Italy) has shown a long-term drop in abortions, while for Spain and Portugal it is too early to draw conclusions. Data for Ireland and Northern Ireland are for abortions abroad, and both have shown significant declines in abortions since 2000.

Figure 76. Abortion percentages for European countries with greater than 30% Catholic population.

What could happen with legalization of abortion in Ireland?

What, then, might future levels of Irish abortions be like if abortion were broadly legalized? We caution that the following points are speculative, but they are nonetheless grounded in review of empirical trends in other countries. If Ireland were to reject protection of human life in the womb in the upcoming referendum, the future could bring (with the noted degrees of likelihood) the following results:

1. In-country abortions in Ireland would rise to about 4,000 per year within a few years (lower red line in Figure 8). This would represent the equivalent of all abortions now occurring abroad being instead obtained at home, with a delay primarily dictated by the time to stand up large-scale provision of abortions.
2. Abortions would probably rapidly rise to a level higher than current totals (perhaps up to twice as high), for two reasons: women who cannot afford to travel abroad would be able to obtain abortions in country, and additional women would obtain abortions more impulsively (upper red line in Figure 8). This is consistent with data from both Europe and the United States suggesting that minimal obstacles to abortion produce significant reductions in abortion rates, e.g., in terms of waiting periods or counseling requirements (Joyce and Kaestner, 2000; Johnston, 2007) or in terms of having to travel a greater distance to reach an abortion provider (Grossman et al., 2014). Stately differently, lower obstacles to abortion leads significantly more women to obtain abortions. This further rise in Irish abortions above current levels would likely be rapid (within a few years) because the Irish population has been familiar with abortion for decades now. Comparison of country trends show that legalization of abortion on demand is followed by the most rapid rise in abortions when abortion has already been available in more limited circumstances (Jacobson and Johnston, 2018, pp. 189-190).
3. The ultimate peak level of abortions reached is rather uncertain. Countries of Europe show a wide variety of abortion levels, i.e. 5% to 30% of live births (Figure 6). Even when limiting to countries more similar to Ireland (in terms of culture, religion, or economic status), this range is only slightly smaller (Figure 7). States of the United States show a similar range of levels, from 4% to 32% in recent years (Johnston, 2017c), but this does appear to be related at least in part to cultural and socio-economic differences. Given Ireland's majority rejection of abortion for decades, levels at the low end of this range are perhaps more likely (red lines in Figure 8). One argument for higher levels is the fact that Ireland's culture has become increasingly secular in recent decades (purple and brown lines in Figure 8). To show what these peak levels would mean in Ireland, consider that there are 16 countries of Western and Southern Europe with abortion permitted in broad circumstances, and these countries had abortion percentages peak anywhere from 13% to 32% with a median of 20%—for Ireland's current level of known pregnancies this would translate to 9,000 to 21,000 abortions per year, or 13,000 abortions per year for the median value. Even if the rest of Europe is a bad analogy, a peak of at least 6,000 per year is likely as discussed above.
4. Whether Irish abortions would remain at high levels or decline in following decades is extremely uncertain; despite claims by abortion advocates, there are no obvious predictors for this behavior. Several factors argue slightly that Ireland would be unlikely to see a later decline: Ireland has already experienced its post-peak decline in abortions (i.e., since 2000); and Ireland has already seen as much uptake of contraceptive usage as it is likely to see (O'Mahony et al., 2015), with the result that this cannot produce a future decline.
5. While Ireland currently has one of the highest fertility rates in Europe, Ireland would eventually emulate much of Europe in seeing a decline in birth rates. Consequences could include pressures on health care and social services for future generations. Health consequences of abortion would increase, including higher levels of premature or low birth weight births and higher levels of breast cancer (Carroll, 2011).
6. Even if Ireland implements abortion on demand, there is one known circumstance that could drive a truly significant future drop in abortions: if the people of Ireland as a society subsequently rejected abortion. In the early 1980s, Poland had 130,000 abortions per year, but after the fall of communism they rejected broadly available abortion, and known Polish abortions in-country and abroad now number 1,200 per year (Johnston, 2018c).

Figure 8. Speculative futures for Ireland abortion levels, were abortion to be broadly legalized.

Conclusions

In this report we have shown the following regarding Irish abortions:

• Available data on abortions by residents of Ireland includes abortions obtained in Ireland, in England and Wales, and in the Netherlands. Irish abortions in countries other than these appear to be small in numbers. Estimates of several hundred illegal abortions per year using abortifacients are consistent with available information.
• Since 2000, abortion rates by age group of mother have declined for all groups, more so for younger groups. Abortion percentages dropped for all age groups in 2000-2008 but have been relatively stable since then.
• Abortions in cases of risk to the mother's life are extremely rare, similar to other developed nations; the majority of abortions appear to be for socio-economic reasons.
• In current debate, abortion proponents have claimed higher abortion rates are associated with more restrictive abortion policies, but these claims are inconsistent with findings in the cited studies, plus even the weaker claims of those studies are questionable, and in any case are irrelevant to the situation in Ireland.
• Despite claims to the contrary, examination of abortion trends in European countries does not support claims that Irish abortions would decline if abortion was legalized; objective review of available data is inconclusive in this regard.
• Were abortion to be broadly legalized in Ireland, in-country abortions would likely rise within a few years to levels above current combined totals (obtained in other countries or in-country). If the rest of Western Europe plus Ireland's past is any guide, abortions could eventually peak anywhere from 6,000 to 21,000 per year. Trends further into the future are more speculative, but would arguably be less likely to exhibit significant declines in later decades.

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Copyright © 2018 by Wm. Robert Johnston.
Last modified 10 May 2018.
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