The sex ratio at birth is lower in sub-Saharan Africa than in other regions of the world. That is, fewer sons are born than is naturally expected. There has been little research on these “missing boys” compared to the opposite phenomenon of “missing girls” in many Asian nations. In India and China, for example, fewer daughters are born than sons, which generally results from selective abortion of female foetuses. In contrast, foetal loss (spontaneous miscarriage) could be driving the pattern of “missing boys” and low sex ratios at birth in sub-Saharan Africa (Morse, Luke 2021). 

The sex ratio at birth is normally around 105-107 males born for every 100 females. In sub-Saharan Africa, however, it is around 103-104 males for every 100 females. Some populations dip even lower; in Rwanda, for example, the ratio is 101-102:100 (UNPD 2019). Although these differences may seem small, when applied to a sizeable population, they translate into large numbers. Given the number of births in sub-Saharan Africa each year, the difference between a sex ratio at birth of 103:100 and 106:100 is approximately 250,000 male births every year. 

Maternal stress and male foetal loss

Research from the biological sciences shows that—on average—male foetuses are more likely to be miscarried than female foetuses when the mother faces severe stress which could compromise the pregnancy. This research is compatible with an anthropological theory which explains that—from an evolutionary perspective—sons are high-risk-high-reward children while daughters are low-risk-low-reward: a highly successful son can result in many more grandchildren than a highly successful daughter. Yet, unsuccessful males are much more unsuccessful than unsuccessful females (they are more likely to die before producing any children at all). From an evolutionary perspective, when a mother’s health is on the margins, it is better to avoid giving birth to a high-risk boy child.

As such, studies have documented declines in male births following traumatic events, such as earthquakes or terrorist attacks (Fukuda et al. 2019; Catalano 2006), or resulting from longer-term distress, such as during famines or food shortages (Song, 2012).

Given the link to maternal stress, some scientists have labelled a low sex ratio at birth in a population as a “sentinel health indicator” (Grech and Masukume, 2016). We continue this line of work to see if low sex ratios at birth in sub-Saharan Africa could be explained by foetal loss.

Measuring foetal loss: time between births

To study the connection between foetal loss and the sex ratio at birth, data on women’s experience of foetal loss are needed. Measuring foetal loss at the individual level is extremely difficult, however. Surveys that ask women to report spontaneous miscarriage produce unreliable information, since many losses occur without the mother’s knowledge or before pregnancy has been recognized. Large-scale clinical studies that track the outcomes for pregnant women over time would be enormously expensive. 

Our idea is simple and inexpensive: we looked at the time between women’s first and second births (the second birth interval) as an indication of foetal loss. All else equal, a foetal loss adds time to a birth interval because a second conception must take place. As intentional spacing of births due to contraceptive use leads to longer birth intervals, we used data from women in 17 sub-Saharan African countries who were not using any method to limit or space their births. We assumed that longer second birth intervals indicated foetal loss, possibly due to stress, and hypothesized that they would be associated with a higher probability of subsequent female birth.

Our findings

The findings from our analysis support our hypothesis. Women with longer birth intervals (who were more likely to have had a foetal loss) were less likely to have a son. We then translated this finding to the population level and found low sex ratios at birth with longer birth intervals. 

Our findings support the view that foetal loss could be driving the pattern of “missing boys” and low sex ratios at birth in many sub-Saharan African countries. Although we did not study the precise types of maternal stress that produce such high levels of foetal loss, it is likely that chronic conditions (such as malnutrition or lack of adequate prenatal care) or shorter-term stressors (such as armed conflicts or forced migration) lead to widespread maternal stress in these countries. Policies and programmes should aim to improve maternal health before and during pregnancy to reduce high rates of foetal loss.

References

Catalano, Ralph, et al. 2006. “Exogenous shocks to the human sex ratio: the case of September 11, 2001 in New York City.” Human reproduction 21.12: 3127-3131.

Fukuda, Misao, Kiyomi Fukuda, Shawn Mason, Takashi Shimizu, and Claus Yding Andersen. 2019. Effects of earthquakes and other natural catastrophic events on the sex ratio of newborn infants, Early Human Development104859.

Grech, Victor, and Gwinyai Masukume. 2016. “The sex ratio at birth in South Africa may be a sentinel health indicator.” Early human development 103: 225-227.

Morse, Anne, and Nancy Luke. 2021. “Foetal loss and feminine sex ratios at birth in sub-Saharan Africa.” Population Studies: 1-16.

Song, Shige. 2012. “Does famine influence sex ratio at birth? Evidence from the 1959–1961 Great Leap Forward Famine in China.” Proceedings of the Royal Society B: Biological Sciences 279.1739: 2883-2890.

UNPD. 2019. World Population Prospects 2019, Online Edition. Rev. 1. United Nations, Department of Economic and Social Affairs, Population Division.

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Have conditions under which women undergo abortion improved around the world? Access to safe and legal abortion informs on a key aspect of women’s status, namely their ability to control whether and when to have children. Guillaume and Rossier (2018) examine recent progress in women’s use of abortion worldwide, from legal, public health and sociodemographic perspectives.

Legalization of abortion at the global level: one step forward, one step back

Legalization of abortion represents a crucial step in securing women access to safe abortion. While a few countries have recently liberalized their abortion laws (Ireland, Argentina,…), progress at the global level remains slow. The Global Abortion Policies database (WHO, 2017) shows that abortion laws are still closely related to countries’ level of development. In developed countries, 95% of women of reproductive age benefit from liberal laws (i.e., abortion is legal on request, or at least on economic or social grounds), compared to 45% of women in less developed countries, and only 8% in least developed countries (Figure 1). In addition, and whatever the region, numerous barriers, such as short gestational limits, compulsory parental or spousal consent, requirements for medical or legal approval, or mandatory waiting periods, can jeopardize access to legal abortion services. Moreover, in certain liberal countries, such as Uruguay or Italy, providers frequently use their right to conscientious objection, further limiting access.

Two opposing positions have weighed equally in legal debates around the world in recent decades: those promoting women’s sexual and reproductive rights as defined in international conferences, and those seeking to protect the rights of the embryo. As a result, laws tend to oscillate between periods of easing and tightening of restrictions, liberalization is rare, and the right to abortion can be challenged even when it has already been established. In Nicaragua, for example, even therapeutic abortion was banned in 2006, despite the resulting risks for women’s health and lives. Active and widespread campaigns at both national and international levels are currently attempting to reverse these measures. Conversely, in late 2016, the Polish government abandoned its plan to limit access to abortion, but a new law has been in preparation since January 2018, aimed at restoring measures that restrict the right to abortion to two situations: cases where the woman’s health or life are in danger; and cases of rape or incest. Recently in the Unites States, where laws are defined at the state level, the right to abortion has been contested in certain states.

Abortions have become safer around the world, but many women are excluded

While legality and safety were closely associated in the 1980s, that is no longer the case thanks to the diffusion of new abortion techniques (aspiration and medical method) since the 1990s and 2000s. Use of medical methods (mainly misoprostol) has increased in both restrictive and liberal countries, decreasing the risk of illegal abortions. In settings where abortion is legal, aspiration has replaced curettage at longer gestational periods, except in a number of Asian and former Soviet countries. As a result, three categories of risk are now recognized for abortions, independently of legal status: safe (recommended techniques and providers), less safe (recommended technique or provider), and least safe (neither of these safety criteria are met). Estimates of abortion safety in different world regions indicate that just over half (55%) of the 56 million annual induced abortions in 2010–2014 were safe, 31% less safe and 15% least safe (Table 1) (Ganatra et al., 2017).

Today, misoprostol is used illegally throughout Latin America and in Asian countries with restrictive legislation, such as the Philippines. In Africa, it is less common, but its use is growing in some countries, such as Uganda, Gabon, and Nigeria. Across regions, it is increasingly common for women to obtain these medications through informal markets or online; some international and local NGOs also sell and deliver these products or provide helplines offering guidance to women.

Thanks to the growing use of misoprostol and the implementation of post abortion care programs since the 1990s, the frequency of abortion-related deaths has decreased worldwide. There is today about one complication for every four or five unsafe abortions worldwide (Singh and Maddow-Zimet, 2016). However, abortion complications and deaths are still distributed very unequally, and disproportionately affect the world’s poorest women and less developed countries, especially in sub-Saharan Africa.

Better contraception means fewer abortions, but other factors are involved

It is estimated that today (2010–2014), on average, at global level, 35 out of every 1,000 women aged 15 to 44 years have an induced abortion each year (Sedgh et al., 2016). This corresponds to 56 million annual abortions, or 25% of pregnancies worldwide. While abortion is frequent everywhere, its rate is lower in liberal countries with better sexual and reproductive programs and higher contraceptive prevalence.

However, other important factors determine women’s need for abortions, as shown by a review of abortion seekers’ profiles in different world regions. In Asia, women who have abortions are often older, already mothers, and married. Premarital sex remains rare, and family formation begins early; abortion thus serves mainly at the end of reproductive life to limit the number of children if contraception fails, or to obtain male children in settings where sex-selective abortion is practiced. In Africa, by contrast, the desired family size remains large, which limits the number of abortions within marriage and at the end of reproductive life. And while premarital sexual activity is more common than in Asia, it is nonetheless socially condemned and often poorly protected, which can lead to unwanted pregnancies and abortions at young ages. The profile of Latin America is intermediate, between Asia and Africa: it is closer to Africa at young ages, but as in Asia, many women also seek to limit births at the end of their reproductive life.

In Europe and North America, where effective contraception is widely used by women both at the beginning and the end of reproductive life, abortions are less frequent but more linked to the phase of family formation, when fertility intentions are ambivalent and changing, and contraceptive failures more frequent. The proportion of repeat abortions among all abortions has increased in countries such as Sweden, New Zealand and France. Paradoxically, this reflects improvements in the contraceptive practices of the population as a whole, with abortions concentrated among women who repeatedly experience contraceptive failure or use methods ill-suited to their situation.

In general terms, abortion has become safer across the world, but inequalities in the risks associated with illegal abortion have increased. Securing abortion as a right is not making much progress, despite the international recognition of rights to equality, health, and free and responsible decision-making on the number and spacing of children. And while effective contraceptive services lower the occurrence of unintended pregnancies and the need for abortion, other factors such as emerging premarital sexuality, delayed parenthood, smaller desired family size, sexual violence and prenatal sex selection, all pull in the opposite direction.

References

Ganatra Bela, Gerdts Caitlin, Rossier Clémentine, et al. (2017) “Global, regional, and subregional classification of abortions by safety, 2010–14: Estimates from a Bayesian hierarchical model”, The Lancet, 390 (10110), pp. 2372–2381.

Guillaume Agnès, Rossier Clémentine (2018) Abortion around the world. An overview of legislation, measures, trends, and consequences. Population, 73(2), 217-306.

Sedgh Gilda, Bearak Jonathan, Singh Susheela, Akinrinola Bankole, Anna Popinchalk, Bela Ganatra, Clémentine Rossier, et al. (2016) “Abortion incidence between 1990 and 2014: Global, regional, and subregional levels and trends”, The Lancet, 388(10041), pp. 258–267.

Singh Susheela, Maddow-Zimet Isaac (2016) “Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: A review of evidence from 26 countries”, BJOG: An International Journal of Obstetrics & Gynaecology, 123(9), pp. 1489–1498.

WHO – World Health Organization (2017) Global Abortion Policies Database, Geneva, WHO,

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To overcome this limitation, I used administrative data, where data on abortion experiences come from women’s medical records rather than self-reports and thus are not underreported. A shortcoming of administrative data is that it does not provide information on some relevant individual traits, such as attitudes or religious beliefs. However, with the help of appropriate statistical models, the influence of unobserved characteristics on the decision-making processes around abortions and union dissolutions can be quantified and analysed.

The context

In Finland, it has been relatively easy to obtain an abortion since legislation was liberalised in the 1970s. All municipalities have been legally required to provide family planning services since 1972. Many policies that reduce the cost of childbearing have been implemented over time: education is free of charge at all levels, day-care of children is subsidised by the government to enable both parents to work, and parental leave is subsidised at around 70% of the income level prior to childbearing.

Unstable union experiences associated with more abortions

In my analysis, I followed 17,666 women born in 1965-69 from the year they turned 15 until year 2010, when they were in their early 40s. The data included information about the women’s level of education, relationship status, births and abortions in each year. Twenty-three percent of women in the sample had at least one abortion in the course of this study.

Women who experienced a higher number of marriages or cohabiting unions also obtained a higher number of abortions. This could also be due to individual characteristics, which could not be observed in this study, such as religiousness, attitudes, and personality. Religiousness is often associated with negative attitudes towards abortion (Ellison, Echevarría, and Smith 2005; Hess and Rueb 2005) and lower approval of divorce. Thus, religiousness may be associated with a lower likelihood of separating from a partner as well as obtaining an abortion. Personality traits, such as high extraversion, low emotional stability, and low conscientiousness, have been associated with a higher likelihood of experiencing an unintended pregnancy (Berg et al. 2013) – perhaps these traits also correlate with union stability.

When it comes to characteristics that were observed in these data, interestingly, divorce was associated with a higher likelihood of obtaining an abortion during the same calendar year than separation from a cohabiting partner (Figure 1). Women may be less likely to want children due to the added cost of breaking up if children are involved (Lillard and Waite 1993): they are therefore more likely to terminate a pregnancy than those in a stable relationship.

Previous pregnancies also mattered for abortion decisions: women whose youngest child was 18 months old or younger had a higher likelihood of abortion than women with no children or older children (Figure 1). Those with a previous experience of abortion had a slightly higher likelihood of terminating a pregnancy than those without previous abortion(s), but the effect was relatively small (Figure 1).

Does it matter if you are married or cohabiting?

The likelihood of abortion was higher for women who were cohabiting with a partner than for married women during approximately the first five years of the relationship (Figure 2). Perhaps some cohabiting women decided to terminate an unintended pregnancy because they felt that the relationship was not yet ready for childbearing, whereas it may be less likely for married women to feel that way. However, only a very small difference in abortion levels remained after the first five years of co-residence. This is in line with studies showing that cohabiting couples tend to become similar to married couples over time, even if the initial decision to cohabit may have been only a small step beyond dating.

Conclusions

This study identified the characteristics of women that jointly affect the likelihood of experiencing an abortion and ending a romantic relationship. Such characteristics may include, for instance, personality, attitudes, and beliefs. Given that there was an elevated likelihood of obtaining an abortion around the time of a divorce, care should be taken in ensuring that women who face this difficult experience receive the family planning services and counselling they need. Overall, however, abortion rates in Finland are low compared to most other Western countries with liberal abortion legislation, indicating that the family planning health care system and sexuality education provided in schools cater satisfactorily to women’s needs.

References

Berg, Venla, Anna Rotkirch, Heini Väisänen, and Markus Jokela. 2013. ‘Personality Is Differentially Associated with Planned and Non-Planned Pregnancies’. Journal of Research in Personality 47 (4):296–305. https://doi.org/10.1016/j.jrp.2013.01.010.

Ellison, Christopher G., Samuel Echevarría, and Brad Smith. 2005. ‘Religion and Abortion Attitudes Among U.S. Hispanics: Findings from the 1990 Latino National Political Survey*’. Social Science Quarterly 86 (1):192–208. https://doi.org/10.1111/j.0038-4941.2005.00298.x.

Hess, Jennifer A., and Justin D. Rueb. 2005. ‘Attitudes toward Abortion, Religion, and Party Affiliation among College Students’. Current Psychology 24 (1):24–42. https://doi.org/10.1007/s12144-005-1002-0.

Jones, Rachel K., and Kathryn Kost. 2007. ‘Underreporting of Induced and Spontaneous Abortion in the United States: An Analysis of the 2002 National Survey of Family Growth’. Studies in Family Planning 38 (3):187–197. https://doi.org/10.1111/j.1728-4465.2007.00130.x.

Lillard, Lee A., and Linda J. Waite. 1993. ‘A Joint Model of Marital Childbearing and Marital Disruption’. Demography 30 (4):653–81. https://doi.org/10.2307/2061812.

Steele, Fiona, Constantinos Kallis, Harvey Goldstein, and Heather Joshi. 2005. ‘The Relationship between Childbearing and Transitions from Marriage and Cohabitation in Britain’. Demography 42 (4):647–73. https://doi.org/10.2307/4147333.

Väisänen, Heini. 2017. ‘The Timing of Abortions, Births, and Union Dissolutions in Finland’. Demographic Research 37 (28):889–916. https://doi.org/10.4054/DemRes.2017.37.28.

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From moral rejection to public policies

The moral perception of induced abortion (referred to simply as abortion in the following) has varied greatly over time and space from the earliest known traces of the practice in ancient times. In the Christian world – the Roman Catholic Church especially – many centuries of theological debate revolving around the beginning of life and the ontology of the fetus divided the authorities until a definite and stable position was found. It was not until the late 19^th century that the Catholic Church expressed an unconditional condemnation of abortion, which was part of its broader view on procreation and medical progress (Betta, 2006). However, even ecclesiastics were aware of how difficult it was for ordinary households to respect all the religious requirements about sexuality and reproduction. Priests tended to close their eyes on many intimate arrangements (like the emblematic “Onan’s crime”) and, until the early 20^th century, usually avoided any mention of abortion in their pastoral activities (Sevegrand, 1995). In France, after the post-revolutionary civil laws of 1791 and 1810 banning abortion, the state’s approach to abortion was generally similar to that of the Church regarding withdrawal or the Ogino-Knaus method (a method that Pius XII eventually recognized in 1951): it was considered opportune to avoid a campaign which would use up considerable resources for an uncertain result. It was tacitly understood that the realm of procreation was one of the most difficult to regulate, due to what Sarah Hanley, analysing early-modern rules governing pregnancy and birth, would later call a “counterfeit culture” (Hanley, 1989). If the number of convictions was low in the 19^th century, this was not only because abortions were rarely detected and the juries often indulgent; it also reflected the state’s principle that the “tranquillity of families” should not be needlessly disturbed .

The French anti-abortion crusade

A notable change took place around the time of the Great War, however. The emergence of a powerful moral and pronatalist crusade gave rise to growing involvement of bureaucracies and civil servants, a wave of forensic investigations and medical suspicion, along with a wide array of judicial and extra-judicial penalties. While countries such as the United Kingdom, Denmark or Sweden were becoming increasingly tolerant of abortion, officially for eugenic reasons, France entered a combative phase. In the interwar period – that of unprecedented low fertility in France (roughly 620,000 annual births after 1935 and a TFR below 2.10, compared with 910,000 and 2.9 in 1901) – hardly more than a hundred people were actually convicted each year for abortion in French courts, whereas the annual number of “crimes” ranged between 300,000 and 1,000,000, according to the activists’ rough estimates. After the radical change of attitude in the 1930s, however, 26,000 cases were tried between 1940 and 1949. This resulted from the unprecedented mobilization of the police and physicians, as well as various official or unofficial agents supported by Vichy’s authoritarian regime, and then by post-war governments. The anti-abortion crusade also involved health propaganda, family (including antenatal) benefits and the propagation of a “pro-family culture” which were maintained after 1945.

What results?

Yet, the outcome of this crusade – in terms of “saved lives” (i.e., avoided abortions) – was probably close to zero. Historical documents reveal that most of the clear-sighted stakeholders of the time, including some of those who considered abortion as incompatible with their own (personal) moral values, had already warned that it would be utopian to combat such a social phenomenon, short of implementing total(itarian) social control. They knew that when confronted with events, risks or conditions that threatened their life or livelihood, most individuals managed to bypass the law, sometimes in the most ingenious and unexpected ways. The range of historically documented instruments and abortifacients is wide: herbs, everyday utensils, gynaeco-obstetrical instruments, hormones, etc.

Among them, the “Chaumel dilators” provide a telling historical example. Despite the official ban on abortifacients or obstetrical instruments, these glycerine-based fusible sticks could be legally bought in drugstores, as “treatments for gonorrhoea”. One of the great advantages of these thin and non-rigid dilators was that they left no trace, so that their use could not be detected. In the late 1940s, an estimated 2% of women who aborted are thought to have resorted to this technique (Dourlen-Rollier, 1963).

Some conclusions

As with Mifepristone or Misoprostol pills today (Rossier, 2014; Sheldon, 2016), people quickly learn how to divert pharmaceutical products for abortion purposes. Multiplying bans and penalties pushes “violators” into using their capacity for innovation and adaptation. It also stimulates illegal behaviours, backdoor business and shadow networks, as shown by the example of Prohibition in the US, and the consequent flourishing of bootleggers and organized crime.

It is therefore often wiser to move from opposition to regulation, as was the case in France in 1975. Simone Veil’s 1975 Law, permitting abortion, is not only a result of feminist mobilization, it is also the expression of a new paradigm in public health and bio-political regulation, namely the transition from criminalization to medical and social care. While it constitutes a major historical step forward, the medicalization of abortion has not put an end to moral stigmatization, nor has it guaranteed simple and universal access to this service. These limits are still evident today.

The “individual choice” argument has been a crucial element in the fight for reproductive rights. But its connotation of “freedom of choice” should not overshadow the fact that for many women, and not only in France up to 1975, there is just no valid alternative to terminating an ongoing pregnancy. The policy choice that faces societies is not really between “abortions or no abortions”, but between legal or illegal abortion, the latter being nothing but a social hypocrisy, which encourages underground (if not criminal) activities, stigmatizes women, and jeopardizes their health and sometimes also their lives.

References

Betta (2006) Animare la vita. Disciplina della nascita tra medicina e morale nell’ottocento. Bologna: Il Mulino.

Cahen (2016) Gouverner les mœurs. La lutte contre l’avortement en France, 1890-1950. Études & enquêtes historiques. Paris: Ined éditions.

A-M. Dourlen-Rollier (1963), La vérité sur l’avortement, deux enquêtes inédites, Paris. Maloine.

Hanley (1989) “Engendering the State: Family Formation and State Building in Early Modern France.” French Historical Studies, vol. 16, no. 1, p. 4–27.

Rossier (2014), « L’avortement non sécurisé reste fréquent dans le monde, mais il est moins souvent fatal », Population et Sociétés, n° 513, août.

Sevegrand (1995) Les enfants du bon Dieu. Les catholiques français et la procréation au XXe siecle. Paris: Albin Michel.

Sheldon (2016), « How can a state control swallowing? The home use of abortion pills in Ireland », Reproductive Health Matters, 24, p. 90-101.

Sutter (1950), « Résultats d’une enquête sur l’avortement dans la région parisienne », Population, nº 1.

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