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• Asian Bioeth Rev
• v.14(1); 2022 Jan

The Moral Significance of Abortion Inconsistency Arguments

William simkulet.

1 Park University, Parkville, MO USA

2 Dodge City Community College, Dodge City, KS USA

Most opponents of abortion (OA) believe fetuses matter . Critics argue that OA act inconsistently with regards to fetal life, seeking to restrict access to induced abortion, but largely ignoring spontaneous abortion and the creation of surplus embryos by IVF. Nicholas Colgrove, Bruce Blackshaw, and Daniel Rodger call such arguments inconsistency arguments and contend they do not matter. They present three objections to these arguments — the other beliefs, other actions, and hypocrisy objection. Previously, I argued these objections fail and threaten to undermine ethical inquiry. Colgrove et al. have recently replied, but here, I argue their reply fails as well and raises a new criticism of the other actions’ objection. This essay sets out to show, as well as any philosophical argument can, that inconsistency arguments are morally significant.

Introduction

Nicholas Colgrove, Bruce Blackshaw, and Daniel Rodger ( 2020 ) set out to show that inconsistency arguments “do not matter”; by inconsistency argument , they mean to pick out a variety (Fleck 1979 ; Murphy 1985 ; Ord 2008 ; Lovering 2013 , 2014 , 2017 , 2020 ; Berg 2017 ; Simkulet 2016 , 2017 , 2019a , b , c , 2020 ; Bovens 2006 ; Schlumpf 2019 ) of disparate criticisms identifying apparent inconsistencies in how opponents of abortion (OA) treat fetuses. Unfortunately, this term is misleading, as practically all philosophical arguments involve identifying some form of inconsistency, confusion, or misunderstanding.

Critics of the prolife anti-abortion position argue that OA hold inconsistent moral beliefs; they claim to believe that fetuses are persons from conception, but they neglect the welfare of fetuses who are spontaneously aborted by natural causes, and overlook the well-being of the surplus frozen human embryos created for IVF. Perhaps the strangest argument that Colgrove et al. ( 2020 ) label as an inconsistency argument comes from Sister Joan Chittister (Schlumpf 2019 ), who chastises those who call themselves “pro-life” for neglecting the welfare of born persons. Proponents of inconsistency arguments argue that OA hold inconsistent moral beliefs, arguing that upon revision, they will conclude that they either (i) need to do more, or (ii) need not oppose abortion.

Colgrove et al. ( 2020 ) contend that such arguments “do not matter.” This paper interprets this as the claim that inconsistency arguments are morally irrelevant for any (widely held) OA view. This paper will show that such arguments are morally relevant to the most widely held OA position.

Another way to read Colgrove et al. is as claiming they “do not matter” because they cannot show that OA need to adopt (ii) over (i). They say, “Inconsistency arguments simply are not equipped to undermine OAs’ views; at most, they reveal what OAs should do (or believe).” (Colgrove et al. 2020 ) This is uncharitable. First, while some inconsistency theorists (Ord 2008 ; Berg 2017 ) might believe that OA do not really believe fetuses are persons from conception, these arguments identify apparent inconsistency, but need not take a stance on how OA ought to resolve this inconsistency. Second, even if OA choose (i) and conclude they ought to do more to prevent spontaneous abortion (education, research, increased access to healthcare (Simkulet 2017 , 2020 ), and perhaps a major shift in social priorities (Ord 2008 ; Berg 2017 ), and more for surplus IVF embryos (adoption, and gestation (Lovering 2020 ; Blackshaw and Colgrove 2020 ; Blackshaw 2021 ), this matters . Colgrove et al. jest that if OA embrace option (i) it would “make the world a (much) worse place (from the critic’s perspective)”; but fail to note that it would make the world a much better place from the perspective of OA!

Complicating matters, there seems to be disagreement among Colgrove, Blackshaw, and Rodger regarding what opposition to abortion requires. Notably, Bruce Blackshaw ( 2021 , 166) contends that Christians ought to act as neighbors, and offers a robust, clear account of what this requires:

Treating frozen embryos as neighbors requires securing them a life like ours through adoption and gestation, and as well as opposing abortion, Christians must work toward this goal for the vast numbers of frozen embryos that would otherwise be discarded.

Blackshaw and Rodger ( 2019 ) attempt to justify OA disinterest in spontaneous abortion, claiming that most cases of spontaneous abortion are not currently preventable; but Blackshaw ( 2021 ) notes that “if we regard all human life as equally valuable, we have at least some obligation toward helping reduce deaths from spontaneous abortion where possible”.

This paper argues that inconsistency arguments matter. It is divided into three main sections. The first draws a distinction between restrictivist and moralist views on abortion, arguing only restrictivist views are OA. The second sets out to defend my earlier criticism (Simkulet 2021 ) of the other beliefs, other actions, and hypocrisy objections from Blackshaw et al.’s ( 2021 ) recent response. The third offers a new argument against the other actions objection; I argue that if this objection were to succeed, it would undermine restrictivist opposition to abortion.

Opposition to Abortion

On miscarriage.

Before his collaboration (Colgrove et al. 2020 ) with Blackshaw and Rodger, Colgrove ( 2019 ) raised a different criticism of Berg’s ( 2017 ) inconsistency argument. Berg argues that because miscarriage is so common, if we believe fetuses matter , we ought to devote more medical resources to protecting them. Colgrove replies that “miscarriage is not a cause of death,” but rather “it is an outcome.” Blackshaw et al. ( 2021 ) accuse me of the same error.

This is rather uncharitable, but it also misses two key points common in inconsistency arguments. First, if OA believe that fetuses matter, one would expect them to be concerned with both spontaneous and induced abortion, as both are tragic. Second, even if spontaneous abortion has many disparate causes, there may be a common solution. For example, Aspirin can treat a wide variety of conditions, from scraped knee to eye strain to migraine. Many proposals inconsistency theorists discuss (for example, education, gene therapy, and ectogenesis technology) would prevent spontaneous abortion by many different causes.  In short, even if miscarriage is not a single cause of death, there is good reason to think a single solution might address many different cases, saving many fetal lives.

On Opposition to Abortion

To play on Colgrove, note that opposition to abortion is not a moral theory, it is an action or stance one can take toward abortion. There are many reasons why one might oppose abortion; one might merely find the word “abortion” to be distasteful, might oppose abortion on teleological grounds, argue that it is outside the scope of medicine, or that it violates the Hippocratic Oath.

However, most opposition to abortion rests on a single belief. Judith Jarvis Thomson ( 1972 ) says, “Most opposition to abortion relies on the premise that the fetus is a human being, a person, from the moment of conception.” Don Marquis ( 1989 ) says “Many of the most insightful and careful writers on the ethics of abortion… believe that whether or not abortion is morally permissible stands or falls on whether or not a fetus is the sort of being whose life it is seriously wrong to end.”

In short, most opposition to abortion turns on the belief that a fetus matters from conception (or soon afterwards (Marquis 2007 , 2013 ); that the fetus is morally comparable to an adult human person. This view is usually abbreviated as the view that fetuses are persons, broadly construed to mean one of many disparate theories about moral status; that human fetuses are human organisms (Mulder 2013 ), rational substances (Lee and George 2005 ; Beckwith 2007 ; George and Tollefsen 2008 ; Friberg-Fernros 2015 ), have a possible future it would be wrong to deprive them of Marquis 1989 ; Stone 1987 ), etc.

Colgrove et al. ( 2020 ) seek to show that inconsistency arguments are morally irrelevant for any (widely held) anti-abortion view, and there seems to be widespread consensus the most widely held anti-abortion view claims fetuses are persons, broadly construed, from conception (PAC). This paper defends the position that inconsistency arguments are morally relevant to the PAC view.

Restrictivism and Moralism

It will be practical to distinguish between two groups of anti-abortion positions — Restrictivism  (Davis 1984 ; Carroll and Crutchfield Forthcoming ), the view that we should adopt social policies that restrict a woman’s access to induced abortion, and Moralism , the view that abortion is merely immoral, but that we do not need adopt Restrictivist social policies.

It is not hard to see why PAC theorists might embrace restrictivism. On this view, fetuses are comparable to adult human persons, and society has adopted policies aimed at protecting the rights of adult human persons, so it is prima facie plausible that we should adopt similar social policies regarding fetuses. However, Thomson ( 1972 ) demonstrates that it is not enough to show that fetuses merely have a right to life by way of the violinist case:

Violinist: The Society of Music Lovers kidnaps you and attaches your circulatory system to a famous, innocent, unconscious violinist suffering from a kidney ailment that will kill him unless he remains connected to your kidneys for nine months. (Adapted)

The violinist obviously has a right to life, but Thomson argues that the right to life does not give him the right to use your body; it is morally permissible for you to disconnect yourself from the violinist. Thomson says it would be a “great kindness” to stay attached to the violinist but that you do not have to accede to this.

Disconnecting the violinist from your body is comparable to disconnecting a patient from life support to let him die. Restrictivists might argue that induced abortion is not a matter of letting die; but of killing; but this will not do, as one can terminate a pregnancy without killing the fetus by severing the umbilical cord or removing the uterus, “merely” letting the fetus die. If this distinction mattered, restrictivists would not be anti-abortion, they would merely oppose how most abortions are currently performed.

Thomson shows it is not enough for restrictivists to believe fetuses are persons with a right to life, they must also believe something more , that (a) the fetus’s right to life is a positive right to assistance, or (b) the gestational mother somehow comes to have a special obligation to provide assistance to the fetus. She argues that this special obligation cannot be explained by merely risking the chance of pregnancy, as this would imply any woman who leaves the house without a hysterectomy has consented to pregnancy, even by rape. Furthermore, David Boonin ( 2002 ) argues that even if one consents to provide aid, one can withdraw consent.

Bone Marrow: Your neighbor is diagnosed with a condition that will kill him unless he receives monthly bone marrow transplants over the course of nine months from a match. You are a match and you agree to donate. However, it soon becomes clear that these surgeries ask more than you are willing to give, and you refuse to go in for the second surgery. (Adapted)

These thought experiments demonstrate that restrictivists must do more than argue fetuses are persons, they must argue that the fetus has a positive right to assistance.

However, one can believe abortion is immoral without believing we ought to adopt restrictivist social policies. There are many prima facie immoral things that it would be inappropriate to restrict by law. For example, I think most of us would agree that it is prima facie immoral to waste scarce resources, but that individuals might have a right to do so in some cases. One might hold that it is wrong to waste food without holding that throwing away leftovers should be illegal. Similarly, one might hold that adultery outside of an open marriage is immoral, but that adopting social policies that restrict such behavior would be undesirable, in part, because they are difficult to enforce, and in part because it might incentivize other immoral behavior, such as murdering one’s spouse to keep one’s adultery secret.

Moralism is the view that abortion is often, all things considered, immoral, but does not require that we adopt social policies that restrict woman’s access to abortion. There are many reasons why moralists might reject restrictivism independent of Thomson and Boonin-style concerns.

For example, restrictivist views have a hard time making exceptions for rape cases, despite the fact that many restrictivists believe such exceptions should be made. Rape victims are often reluctant to report rape and reluctant to take medical exams. Convictions in rape cases are difficult to obtain, especially within the short window in which inducing abortion would be medically preferable. As such, restrictivists face a dilemma – (a) if they require proof of rape, then few rape victims are allowed to abort; while (b) if they do not require proof of rape, they encourage women to merely say they were raped (whether true or not), failing to prevent most induced abortions and encouraging deception.

Restrictivists face a similar challenge with regards to self-defense, as all pregnancies are medically risky. The prospect of drawing a nonarbitrary line with regards to legally obligatory medical risk is dubious, but even if such a task could be achieved, those physicians sympathetic to abortion might overestimate risk and those opposing abortion might underestimate or ignore risk. Furthermore, medical risk of abortion increases with malnutrition and other medical emergencies, so those seeking abortion on medical grounds are incentivized to harm themselves to pass this threshold.

In light of these, and other, difficulties, many people who believe abortion are immoral reject restrictivism and adopt moralism. Notably, moralists need not hold that fetuses have a positive right to assistance, like restrictivists. I have contended (Simkulet 2021 ) that most OA believe fetuses have a positive right to assistance — that most OA are restrictivists. Blackshaw et al. ( 2021 ) claim that I miss “the target,” as one can be an OA without being committed to the belief that fetuses have a positive right to assistance.

Perhaps Colgrove et al. wish OA to pick out both restrictivist and moralist positions, but this will not do. Although moralists believe induced abortion is immoral, they are prochoice, while Colgrove et al. identify OA as prolife. Perhaps Colgrove et al. mean to say restrictivism does not require the belief that fetuses have a positive right to assistance, but this would merely introduce greater inconsistency regarding medical and legal ethics, as illustrated by Thomson ( 1972 ) and Boonin ( 2002 ).

Do Inconsistency Arguments Matter?

Colgrove et al. ( 2020 ) raise three objections to inconsistency arguments — the other beliefs, other actions, and hypocrisy objections. I contend (Simkulet 2021 ) these objections threaten to undermine moral analysis completely; opposing parties could always claim to have other beliefs, other actions, or interpret criticism as an ad hominem attack impinging their character.

This section is divided into four subsections. The first looks at two inconsistency arguments. The next three subsections briefly summarize Colgrove et al.’s objections, and my criticisms (Simkulet 2021 ) of these arguments.

Inconsistency Arguments

OA often point to high numbers of induced abortion as a call to action. Upwards of 60% (Boklage 1990 ; Léridon 1977 ) of human pregnancies end in spontaneous abortion, prompting critics to ask why OA do not see spontaneous abortion as a call to action. Toby Ord ( 2008 ) compares spontaneous abortion to a scourge that kills over half of humanity. Berg ( 2017 ) compares it to Heart Disease, Cancer, and Stroke. Faced with these overwhelming numbers, inconsistency theorists conclude that if fetuses matter, then the problem of spontaneous abortion calls for a massive shift in our social and political priorities. I have noted (Simkulet 2021 ) that we recently underwent such a shift to address the COVID-19 pandemic.

Henrik Friberg-Fernros ( 2015 , 2019 , 2018 ) challenges this position, contending that while fetal death is always tragic, not all fetal deaths are equally tragic; that killing is worse than letting die, and even that fetal lives are worth less than adult human lives because they lack time relative interests (Friberg-Fernros 2019 )! However, inconsistency arguments do not assume that all fetal deaths are equally tragic, merely that if fetuses matter, their deaths are tragic.

OA face a dilemma — either they (i) need to do more to prevent fetal death, or (ii) should withdraw opposition to induced abortion. Some proponents think OA should choose (ii) — that the argument demonstrates they do not really believe fetuses are persons. However, others propose a wide variety of methods by which OA might reasonably seek to confront the problem of fetal death, from increased education and better access to healthcare, to technologies like ectogenesis and gene therapy that those on both sides of the abortion debate could reasonably support (Simkulet 2020 ).

While many inconsistency arguments focus on unaddressed fetal loss, Colgrove et al. ( 2020 ) also categorize Chittister's tweet (Schlumpf 2019 ) as an inconsistency argument. She asks whether it makes sense to call OA “pro-life” merely because they oppose abortion, noting all OA seem to be concerned with is ensuring the child is born, not fed, educated, or housed; asserting “That’s not pro-life. That’s pro-birth.”

Colgrove et al. ( 2020 ) contend that Chittister is using the term “pro-birth” pejoratively, but this is rather uncharitable. The term “pro-life” carries with it a positive emotive context, and when OA present their view as “pro-life,” they may mislead their audience about their position. In contrast, the term “pro-birth” seems to capture the one unifying feature of OA.

Even if Chittister is angry or disappointed that OA misrepresent their position, neglect their moral obligations, or the like… so what? That is how moral judgements work. If you think Φing is wrong, and you see someone Φing, it makes sense to be angry or disappointed. Colgrove et al. speak as though this, and accusations of pro-life hypocrisy are ad hominem attacks on OA; not so. An ad hominem fallacy occurs when one attacks person rather than their argument or view. Inconsistency arguments do not do this; they identify apparent inconsistency within the OA view, and call for change, as Chittister does when she concludes, “We need a much broader conversation on what the morality of pro-life is.”

Other Beliefs Objection and Response

Colgrove et al. ( 2020 ) raise three objections to inconsistency arguments. In the first, they contend that inconsistency arguments do not matter because there is a diversity of beliefs among OA, suggesting that no one inconsistency argument undermine them all; “This diversity makes broad accusations of inconsistency problematic.” Following this, one might argue that when an OA is confronted with apparent inconsistency within one view, they can jump ship to another OA view. But moral analysis is not a shell game. If inconsistency arguments identify a problem within even one OA position, they matter; and if they threaten the most widely held OA position, it seems they matter quite a bit.

Colgrove et al. ( 2020 ) suggest that OA may have other beliefs which explain away apparent inconsistency and justify their inaction with regards to spontaneous abortion; for example they ask us to consider someone who both opposes induced abortion and opposes universal healthcare; noting these beliefs would justify rejecting the conclusion that we should adopt universal health care to help address the problem of induced and spontaneous abortion (and suffering and death due to lack of medical care, more broadly). To this, I reply (Simkulet 2021 ):

It is not enough to show that some [OA] have some beliefs that are prima facie at odds with some [inconsistency theorist] proposals; they must show that the current level of apparent indifference that many [OA] show is justified by their other beliefs; and it is not clear what set of other beliefs would be both internally consistent and justify the conclusion that while persons [matter], this right requires very little in the way of sacrifice from anyone but gestational mothers.

Blackshaw et al. ( 2021 ) contend that I argue “this [apparent] indifference must be justified by their other beliefs…” continuing “there is an obvious belief that justifies [OA]’s actions and priorities —… [OA] believe that induced abortion is a more important priority than these other issues.” However, this misses the point. As we have seen above, inconsistency theorists do not claim that OA need to treat the problem of spontaneous abortion as equally important to the problem of induced abortion, but rather they must consistently recognize both are tragic.

Blackshaw et al. ( 2021 ) continue “induced abortion is the leading preventable cause of death of human beings, as spontaneous abortions are largely unpreventable.” However, they seem to understand “preventable” in an opportunistically narrow way — as preventable with our current technology — to disregard the problem of spontaneous abortion. Amy Berg ( 2017 ) challenges this opportunistically narrow caveat:

But imagine throwing up our hands about a horrible disease… Imagine saying that we should let AIDS, or cancer, or heart disease take its course, rather than expending more effort researching how we might prevent that disease or treat people who contract it. That’s not what we do.

Berg ( 2017 ) notes that just because spontaneous abortion is medically intractable now does not mean it will be in the future, comparing to the AIDs epidemic, “In just a couple of decades, AIDS went from a mysterious underground disease, to a devastating and fatal epidemic, to a relatively manageable chronic condition.”

Perhaps more troublingly, Blackshaw et al. ( 2021 ) say, “If OAs sincerely believe these claims, then they are acting consistently with their beliefs, and the Other Beliefs Objection succeeds.” Above I have argued that even if one sees one form of abortion as a greater priority than another, this does not justify apparent indifference OAs show with regards to spontaneous abortion.

The real challenge here is “sincerity,” most people have inconsistent beliefs of one form or another and do not realize it; but it is possible that one can realize that they hold two sincere beliefs while also sincerely believing those beliefs to be inconsistent. Consider the problem of evil; one might sincerely believe that God exists, that evil exists, and that God would not allow evil to exist. This belief set is inconsistent, but does not necessarily yield conflicting implications for how we ought to live our lives.

But what if an OA sincerely believes the following?

• All human death is morally tragic.
• Not all human death is morally tragic.
• Propositions (a) and (b) are apparently a contradiction.

It is easy to imagine a Socratic dialogue in which Socrates helps an OA to express position (a) and proposition (b), prompting them to reconsider their position; what’s less easy to imagine is what would happen if an OA freely admits proposition (c), but refuses to reconsider. Moral agency requires some degree of reason-responsiveness, and at least with regards to the topic at hand, it is not clear such an OA would be able to function as a moral agent without rejecting one of these three propositions.

Blackshaw et al. ( 2021 ) end their reply as follows “If critics of [OA] want to change the subject – to examining whether the things [OA] believe are true or false, rather than fixating on [OA’s] alleged inconstancy — then [our] essay has succeeded.” Here, they again miss the point of inconsistency arguments, as these arguments do set out to examine whether the things [OA] believe are true or false; if the principle of non-contradiction is true, and OA hold contradictory beliefs, then at least one of their beliefs are false !

Why do they miss this point? I cannot be sure, but at times Colgrove et al. ( 2020 ) and Blackshaw et al. ( 2021 ) talk as though inconsistency theorists are uniformly prochoice and hope to convince OA to abandon restrictivism; however, inconsistency arguments might just as easily lead one to believe they ought to do more to prevent spontaneous abortion, address surplus frozen human embryos, and the like. Some inconsistency theorists believe both would lead to less restrictivist opposition to abortion, but this is irrelevant.

What matters is that inconsistency arguments share the same form as the Socratic method, highlighting apparent inconsistency and prompting introspection. Perhaps Colgrove et al. ( 2020 ) would also conclude that the Socratic method does not matter , but I hope not.

Other Actions Objection and Response

Colgrove et al.’s second criticism of inconsistency arguments is that they are too specific with their recommendations, suggesting OA can address problems raised by these arguments with different actions than those proposed by inconsistency theorists. For example, rather than adopt and gestate frozen human Embryos, as Lovering ( 2020 ) (and Blackshaw 2021 !) advocate, Colgrove et al. ( 2020 ) suggest OA might fight “to change public perception of the status of embryos,” or lobby to change IVF laws.

There are three problems here. First, although inconsistency theorists propose a variety of recommendations, these recommendations are not meant to be exhaustive, but rather representative of the kinds of changes an OA would need to adopt to resolve their apparent inconsistency. Remember, inconsistency theorists argue that OA face a dilemma — either (i) do more, or (ii) abandon their opposition to abortion; to say that an OA can perform other actions to address the problem just is to embrace the first horn of the dilemma.

Second, I have pointed out (Simkulet 2021 ) that the other actions Colgrove et al. ( 2020 ) propose are not necessarily mutually exclusive; one might both lobby to change IVF laws and adopt and gestate frozen human embryos. The fact that one lobbies to change IVF laws may reduce the number of surplus embryos created and frozen in the future; but it fails to address the needs of currently existing frozen human embryos, highlighting a third problem, that many of Colgrove et al.’s “other actions” are simply not enough. I illustrate (Simkulet 2021 ) this with a case inspired by James Rachels ( 1979 ):

Jack 2 finds himself in a room with a starving child, surplus sandwich in hand. He receives a call… The caller asks, “Will you donate your sandwich?” and he replies, “I’ll do you one better; I’m going to fight to change the public perception of the status of such starving children and raise awareness!” He proceeds to tweet about the starving child, sets up a donation page to help spread awareness, and posts pictures and videos of the child’s deteriorating state. Jack 2 , an expert in such things, narrates as the child slowly dies.

Jack 2 ’s claim to act to raise awareness pokes fun at Colgrove et al.’s ( 2020 ) proposal to protect frozen embryos by fighting to change public perception. Despite his tweeting, it is clear Jack 2 fails morally — he lets a child starve to death when he could have easily saved that child’s life.

Blackshaw et al. ( 2021 ) argue that this case is disanalogous to OA (in)action, arguing that OA “live in a world where there are many important issues clamoring for their attention,” and suggest the following case is more analogous:

Jack 100 finds himself in a room with 100 needy children and only enough resources to save 1 child, which he does.

There are three substantive problems with this response. First, the case of Jack 2 is not meant to be analogous to OA inaction (despite poking fun at it); it is meant to demonstrate that merely having other actions is not sufficient to show that inconsistency arguments fail.

Second, the case of Jack 100 begs the question by assuming Jack is saving as many people as possible. However, as Lovering ( 2020 ) and Blackshaw ( 2021 ) seem to show, this simply is not how OA act. Inconsistency theorists argue that OA neglect to address the problems of spontaneous abortion, surplus frozen embryos, and even starving born children. Rather than save all they can, inconsistency theorists contend that OA act like Jack 2 , they do something , but fail to do everything they can.

Third, inconsistency theorists contend that most OA legislation and philosophical literature neglect to discuss the problems of spontaneous abortion, surplus frozen embryos, or starving born children. As such, perhaps the following case would be more analogous:

Jack 300 finds himself in a room with 300 needy children, and he says, “I see 100 needy children, but woe is me I can only save 1,” and so he saves 1 child.

It seems Jack 300 is unreliable; he says he sees 100 needy children in the room, but there are 300 needy children in the room. If we cannot trust Jack 300 to get an accurate headcount, it seems unreasonable to take his word that he is doing all he can.

With the Jack 100 case Blackshaw et al. ( 2021 ) seem to abandon the other actions objection, instead arguing that OA, like Jack 100 , do the “most good” they can. In short, Blackshaw et al. seem to treat the other actions’ objection as a surrogate for an argument from effective altruism, the view that we should try to do the most good we can. Colgrove et al. ( 2020 ) claim that there are many different beliefs about what it means to do the “most good”, and suggest that objectively measuring options might be difficult, as though to claim that it does not matter what other actions OA take as long as they are trying to do the “most good.”

But this will not do. Effective altruism asks us to use reason and empirical evidence to maximize the amount of good we do, and inconsistency arguments seem to show that OA fail to do just this. Like Jack 2 , OA seem to ignore the easily preventable deaths of some with an unearned confidence that their current course of action is sufficient. If OA strive for effective altruism, they should be at least open to the prospect of embracing the first horn of the inconsistency theorist’s dilemma — that maybe should do more. Suppose Jill 100 finds herself in the locked room with Jack 100 , and promises to show Jack 100 how he can save 3 needy children, rather than just 1, with the resources at hand; if Jack 100 seeks to be an effective altruist, should he not at least listen, time permitting?

Effective altruism requires that we guide our choices by reason and evidence; it is not enough to have a sincere belief that one is doing all that one can, the evidence has to back this up. If inconsistency theorists can show that OA are not doing all they can, then they have been succeeding in showing that OA fall short of effective altruism.

Of course, this is exactly what proponents of inconsistency theorists purport to show. Take the aforementioned inconsistency theorist Lovering ( 2020 ) who, like OA restrictivist Blackshaw ( 2021 ), argues that OA should do more than merely fight to change public perception or lobby to change IVF laws, in many cases they ought to also adopt and gestate actually existing frozen human embryos. Of course, not every OA can gestate frozen human embryos — without effective ectogenesis technology and universal healthcare this burden seems to fall on wealthy, female OA alone. However, few OA argue that adopting and gestating these embryos are obligatory for those with the means to do so, and this omission at least appears to be inconsistent with their assertion that all fetuses matter from conception, let alone the position that OA are acting as effective altruists.

Furthermore, Blackshaw ( 2021 ) does not merely side with Lovering regarding OA’s obligations regarding frozen human embryos; he says:

[I]f we regard all human life as equally valuable, we have at least some obligation toward helping reduce deaths from spontaneous abortion where possible. The parable of the Good Samaritan reinforces the notion that Christians do have some responsibility toward this neglected group of human beings, who are also our neighbors.

Here Blackshaw ( 2021 ) contends that these groups — frozen human embryos and those fetuses who die from spontaneous abortion — matter , and that at least some OA — those inconsistency arguments seek to criticize — neglect them. In short, Blackshaw’s ( 2021 ) view seems at odd with the view he expresses in Colgrove et al. ( 2020 ) and Blackshaw et al. ( 2021 ). This is not meant as a criticism of Blackshaw; philosophers revise their views over time, articles are often published long after their initial submission, and many articles are written for blind review which could disincentivize the author from discussing their previous works.

Note, however, that Colgrove et al. ( 2020 ) and Blackshaw et al. ( 2021 ) set out to argue that inconsistency arguments do not matter for any OA view and in doing so they bite off far more than they can chew. It is easy to contend that all OA have other possible actions – contra Frankfurt ( 1969 ), many philosophers believe alternate possibilities are required for moral agency and responsibility; but it is quite a different matter to argue that all OA are acting as effective altruists, or even that all OA merely sincerely believe they are acting as effective altruists, especially when confronted with criticism from inconsistency theorists. Blackshaw ( 2021 ) contends inconsistency arguments demonstrate that some OA neglect this group, and this alone seems sufficient to show inconsistency arguments are morally significant.

Hypocrisy Objection and Response

In their third objection, Colgrove et al. ( 2020 ) contend that inconsistency arguments aim to show that OA are hypocrites, rather than demonstrate inconsistency. I note (Simkulet 2021 ) that Colgrove et al. equivocate between hypocrisy and inconsistency, and that they characterize hypocrisy as a moral failing. Colgrove et al. ( 2020 ) say:

[OA] are often described as ’inconsistent’ (hypocrites) in terms of their beliefs, actions and/or priorities…These objections notwithstanding, perhaps some OAs do act in ways that can be shown to be inconsistent with their beliefs. If so, then they are hypocrites. Hypocrisy is a serious charge regarding the character of OAs, but it has nothing to say regarding the validity and consistency of their beliefs—and OAs’ beliefs are surely what critics should primarily be targeting.

In short, it seems that Colgrove et al. mischaracterize inconsistency arguments as ad hominem fallacies; but as we have already seen there is a difference. Inconsistency arguments are simply not aimed at showing OA are hypocrites; only that they have inconsistent beliefs.

In their reply to my previous work (Simkulet 2021 ), Blackshaw et al. ( 2021 ) say something bizarre “Simkulet offers no empirical evidence regarding [OA’s] supposed lack of interest in relevant issues.” But inconsistency theorists do this ; Lovering ( 2020 ) goes to great lengths to discuss OA who do go out of their way to address these concerns and provides evidence such altruism is rare . Still, it is difficult to take this call for empirical evidence seriously, as neither Colgrove et al. ( 2020 ) nor Blackshaw et al. ( 2021 ) provide such evidence on behalf of OA.

Blackshaw et al. ( 2021 ) also challenge my claim (Simkulet 2021 ) that legislation seeking to reduce the creation of surplus IVF embryos would be relatively easy to pass:

Not so. Italy, for example, passed a law in 2004 prohibiting the freezing of embryos, and requiring that all embryos be implanted. (Riezzo et al. 2016 ) The law was swiftly condemned, eventually overturned and, in one case, actions prescribed by the law were declared by the UN to have constituted a ‘human rights violation.’ (Scaffidi 2019 ) Thus, relevant laws would likely face international resistance. So, a central problem Simkulet puts forth as having an ‘easy’ solution does not.

There are two big problems here. First, I propose (Simkulet 2021 ) passing legislation to limit the creation of surplus embryos, not to force all created embryos to be implanted. The difference is obvious, my restrictivist proposal would limit the number of embryos created at a time, so it might take multiple tries before a successful embryo is created.

In contrast, the Italian law seems to place no limits on how many embryos can be created, rather it sets out to force women to undergo invasive, risky medical procedures. IVF has a relatively low chance of success; but imagine more attempts at fertilization succeed than expected; this law would compel physicians to perform, and women to undergo, dangerous medical procedures against their wills. This is hauntingly similar to forcing you to donate bone marrow even at the cost of your life in Boonin’s ( 2002 ) bone marrow case. In short, the Italian law threatens to harm citizens and undermine professional ethics by requiring medically risky and unnecessary interventions without the patient’s consent.

In contrast, my proposal (Simkulet 2021 ) would merely require physicians limit the number of embryos created at one time; not entirely dissimilar from legal limits on how many drugs a physician can prescribe within a period of time. Furthermore, I do not say such legislation would be easy, only “relatively easy” compared to restrictivist legislation – legislation that has far more in common with the Italian law than Blackshaw et al. ( 2021 ) acknowledge. Both restrictivist legislation and the Italian law seek to undermine women’s rights to control their body and force them to risk their lives for the sake of others. Meanwhile limiting the number of embryos created does not limit one’s reproductive freedom, nor compel them to take on additional medical risk.

Both OA restrictivist legislation and the Italian law seek to limit women’s reproductive choices and force women to take on additional medical risk. Legislation of this kind faces strong opposition from those seeking to protect women’s liberty and reproductive freedom. This kind of legislation also faces strong opposition from biomedical ethicists and medical professionals, as it threatens to violate patient autonomy and the Hippocratic Oath by forcing patient and physician to perform risky medical procedures to benefit a third party, not unlike forcing you to remain attached to the violinist in Thomson’s infamous violinist case (Thomson 1972 ).

In contrast, it is not clear that my proposed legislation (Simkulet 2021 ) to limit the number of embryos that can be created at a single time, would face much opposition at all. Perhaps eugenicists would oppose such legislation for limiting a parent’s right to choose the “best” fetus from the widest possible net, but this does not seem like a widely held position. Perhaps bioethicists and medical professionals would oppose such legislation believing it cumbersome and impractical, but this seems like a much weaker ground for opposition than the autonomy and professional ethics violations epitomized by OA restrictivist legislation and the Italian law.

The Prochoice Other Beliefs Objection

I have argued (Simkulet 2021 ) that if the other beliefs, other actions, and hypocrisy objections are not successful in showing inconsistency arguments “do not matter,” they threaten to undermine the discipline of ethics. No person has merely one moral belief, so if a diversity of beliefs invalidates moral analysis, ethics is impossible. In all cases in which a person acts morally responsibly (save maybe some interpretations of Frankfurt-style cases (Frankfurt 1969 ), agents have other possible actions, so if merely having other actions was sufficient to disregard moral analysis, ethics fails. Finally, if interpreting moral analysis as an ad hominem attack of hypocrisy was sufficient to rebuff criticism, one can shut down all moral debate merely by being thin-skinned. Here, I have argued that Blackshaw et al. ( 2021 ) fail to defend these objections, and fail to show that inconsistency arguments do not matter.

However, these are lofty claims about the discipline of ethics; let’s consider something a bit more down to Earth. Consider the following case:

Jacqueline is surprised to find herself pregnant, calling into question her school’s sexual education program. While discussing the matter with her physician, she learns that some people believe embryos are persons from conception! She finds this view intuitive and compelling, and outraged by her school’s poor sexual education program, she endeavors to work tirelessly to change the public perception of the status of embryos. Later, her physician expresses concern about her exertion, recommending that she puts her efforts to educate on hiatus during the pregnancy, fearing the worst. Jacqueline faces a choice — (i) continue with her pregnancy for the next 6 months, losing ground on her fight to change public perception of embryos or (ii) induce abortion (perhaps by hysterectomy) and continue the fight. When speaking with her physician, Jacqueline quotes an influential piece of literature (Colgrove et al. 2020 ), “It may be unclear, however, which option is superior. Many considerations apply to each, and they may be highly individualistic.” She continues “Objectively evaluating options to determine the most appropriate action for a particular belief held by a specific individual seems a very difficult task.” Upon careful and thoughtful reflection, she chooses (ii), judging that it will do the most good. After all, her embryo is but one embryo and while it is tragic to disconnect it from her body and let it die, her tireless efforts might do more good overall.

If the other actions objection shields OA from inconstancy arguments, it seems that it equally shields Jaqueline from restrictivist OA arguments that seek to restrict her freedom. Therefore, it seems that Blackshaw et al. face a dilemma — (i) reject the position that merely having other actions, beliefs, etc. is sufficient to shield a position from criticism, or (ii) abandon their opposition to induced abortion. If (i), then inconsistency arguments matter. Then again, if (ii), then it seems as though no ethical arguments matter.

Publisher’s Note

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• Beckwith, Francis J. 2007. Defending life: A moral and legal case against abortion choice . New York, NY: Cambridge University Press.
• Berg Amy. Abortion and miscarriage. Philosophical Studies. 2017; 174 (5):1217–1226. doi: 10.1007/s11098-016-0750-z. [ CrossRef ] [ Google Scholar ]
• Blackshaw, Bruce Philip. 2021. Is pregnancy really a Good Samaritan act? Christian Bioethics 7(2): 158–168. 10.1093/cb/cbab004.
• Blackshaw, Bruce Philip, and Daniel Rodger. 2019. The problem of spontaneous abortion: is the pro-life position morally monstrous? New Bioethics 25(2): 103–120. 10.1080/20502877.2019.1602376. [ PubMed ]
• Blackshaw Bruce Philip, Colgrove Nicholas. Frozen embryos and the obligation to adopt. Bioethics. 2020; 34 (8):857–861. doi: 10.1111/bioe.12733. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Blackshaw, Bruce Philip, Nicholas Colgrove, Daniel Rodger. 2021. Inconsistency arguments still do not matter. Journal of Medical Ethics . 10.1136/medethics-2021-107644. [ PubMed ]
• Boklage, C.E. 1990. Survival probability of human conceptions from fertilization to term. International Journal of Fertility 35(2): 75–94. [ PubMed ]
• Boonin, David. 2002. A defense of abortion . New York, NY: Cambridge University Press. 10.1017/CBO9780511610172.
• Bovens Luc. The rhythm method and embryonic death. Journal of Medical Ethics. 2006; 32 (6):355–356. doi: 10.1136/jme.2005.013920. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Carroll, Emily, and Parker Crutchfield. Forthcoming. The duty to protect, abortion, and organ donation. Cambridge Quarterly of Healthcare Ethics .
• Colgrove, Nicholas. 2019. Miscarriage is not a cause of death: a response to Berg’s “abortion and miscarriage”.  Journal of Medicine and Philosophy 46(4): 394–413. 10.1093/jmp/jhab010. [ PubMed ]
• Colgrove, Nicholas, Bruce Philip Blackshaw, Daniel Rodger. 2020. Prolife hypocrisy: why inconsistency arguments do not matter. Journal of Medical Ethics . 10.1136/medethics-2020-106633. [ PubMed ]
• Davis, Nancy. 1984. Abortion and self-defense. Philosophy and Public Affairs 13(3): 175–207. [ PubMed ]
• Fleck, Leonard M. 1979. Abortion, deformed fetuses, and the Omega pill. Philosophical Studies 36(3): 271–283. 10.1007/BF00372631. [ PubMed ]
• Frankfurt, Harry G. 1969. Alternate possibilities and moral responsibility. Journal of Philosophy 66(23): 829–839. 10.2307/2023833.
• Friberg-Fernros, Henrik. 2015. A critique of Rob Lovering’s criticism of the substance view. Bioethics 29(3): 211–216. 10.1111/bioe.12080. [ PubMed ]
• Friberg-Fernros, Henrik. 2018. Within the limits of the defensible: A response to Simkulet’s argument against the pro-life view on the basis of spontaneous abortion. Journal of Medical Ethics 44(11): 743–745. 10.1136/medethics-2017-104688. [ PubMed ]
• Friberg-Fernros, Henrik. 2019. Defending the two tragedies argument: A response to Simkulet. Journal of Medical Ethics 45(6): 417–418. 10.1136/medethics-2019-105489. [ PubMed ]
• George Robert P, Tollefsen Christopher. Embryo: A defense of human life. New York, NY: Doubleday; 2008. [ Google Scholar ]
• Lee, Patrick, and Robert P. George. 2005. The Wrong of Abortion. In Contemporary Debates in Applied Ethics , ed. Andrew I. Cohen, and Christopher Heath Wellman. Malden, MA: Wiley-Blackwell.
• Léridon, Henri. 1977. Human fertility: The basic components . Translated by Judith F. Helzner. Chicago, Il: University of Chicago Press.
• Lovering, Rob. 2013. The Substance View: A Critique. Bioethics 27(5): 263–270. 10.1111/j.1467-8519.2011.01954.x. [ PubMed ]
• Lovering, Rob. 2014. The Substance View: A Critique (Part 2). Bioethics 28(7): 378–386. 10.1111/j.1467-8519.2012.02006.x. [ PubMed ]
• Lovering, Rob. 2017. The Substance View: A Critique (Part 3). Bioethics 31(4): 305–312. 10.1111/bioe.12330. [ PubMed ]
• Lovering Rob. A moral argument for frozen human embryo adoption. Bioethics. 2020; 34 (3):242–251. doi: 10.1111/bioe.12671. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Marquis, Don. 1989. Why abortion is immoral. Journal of Philosophy 86(4): 183–202. 10.2307/2026961. [ PubMed ]
• Marquis, Don. 2007. The moral-principle objection to human embryonic stem cell research. Metaphilosophy 38(2–3): 190–206. 10.1111/j.1467-9973.2007.00481.x.
• Marquis Don. An argument that abortion is wrong. In: Shafer-Landau Russ., editor. Ethical theory: an anthology. 2. Oxford: Blackwell; 2013. pp. 400–409. [ Google Scholar ]
• Mulder, Jack. 2013. A short argument against abortion rights. Think 12(34): 57–68. 10.1017/S1477175613000080.
• Murphy, Timothy F. 1985. The moral significance of spontaneous abortion. Journal of Medical Ethics 11(2): 79–83. 10.1136/jme.11.2.79. [ PMC free article ] [ PubMed ]
• Ord, Toby. 2008. The scourge: Moral implications of natural embryo loss. American Journal of Bioethics 8(7): 12–19. 10.1080/15265160802248146. [ PubMed ]
• Rachels, James. 1979. Killing and starving to death. Philosophy 54(208): 159–171. 10.1017/S0031819100048415. [ PubMed ]
• Riezzo, Irene, Margherita Neri, Stefania Bello, Cristoforo Pomara, and Emanuela Turillazzi. 2016. Italian law on medically assisted reproduction: Do women’s autonomy and health matter? BMC Women’s Health 16: 44. 10.1186/s12905-016-0324-4. [ PMC free article ] [ PubMed ]
• Scaffidi, Sarah. 2019. Forced pregnancy in Italy violated ‘woman’s human right to health’, UN experts rule. UN News , 27 March 2019. https://news.un.org/en/story/2019/03/1035601 . Accessed 11 July 2021.
• Schlumpf, Heidi. 2019. Sr. Joan Chittister’s 2004 quote on ’pro-life’ versus ’pro-birth’ goes viral. National Catholic Reporter , 23 May 2019. https://www.ncronline.org/news/politics/sr-joan-chittisters-2004-quote-pro-life-versus-pro-birth-goes-viral. Accessed 11 July 2021.
• Simkulet William. A critique of Henrik Friberg-Fernros’s defense of the substance view. Bioethics. 2016; 30 (9):767–773. doi: 10.1111/bioe.12289. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Simkulet, William. 2017. Cursed lamp: The problem of spontaneous abortion. Journal of Medical Ethics 43(11): 784–791. 10.1136/medethics-2016-104018. [ PubMed ]
• Simkulet William. Substance, rights, value, and abortion. Bioethics. 2019; 33 (9):1002–1011. doi: 10.1111/bioe.12616. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Simkulet William. The two tragedies argument. Journal of Medical Ethics. 2019; 45 (5):304–308. doi: 10.1136/medethics-2018-105145. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Simkulet, William. 2019c. Two tragedies argument: Two mistakes. Journal of Medical Ethics 45(8): 562–564. 10.1136/medethics-2019-105587. [ PubMed ]
• Simkulet William. Abortion and ectogenesis: Moral compromise. Journal of Medical Ethics. 2020; 46 (2):93–98. doi: 10.1136/medethics-2019-105676. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Simkulet, William. 2021. The inconsistency argument: why apparent pro-life inconsistency undermines opposition to induced abortion. Journal of Medical Ethics . 10.1136/medethics-2020-107207. [ PubMed ]
• Stone, Jim. 1987. Why potentiality matters. Canadian Journal of Philosophy 17(4): 815–830. 10.1080/00455091.1987.10715920.
• Stone, Jim. 1994. Why potentiality still matters.  Canadian Journal of Philosophy  24(2): 281–293. 10.1080/00455091.1994.10717370.
• Thomson, Judith Jarvis. 1972. A Defense of Abortion. Philosophy & Public Affairs  1(1): 47–66.

• Open access
• Published: 28 June 2021

Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

• Foluso Ishola   ORCID: orcid.org/0000-0002-8644-0570 1 ,
• U. Vivian Ukah 1 &
• Arijit Nandi 1  

Systematic Reviews volume  10 , Article number:  192 ( 2021 ) Cite this article

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A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Peer Review reports

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 , 2 , 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 , 8 , 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 , 16 , 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 , 18 , 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 , 19 , 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 , 35 , 36 , 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.

Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].

Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].

Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].

Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

National constitutions;

Supreme court decisions, as well as higher court decisions;

Customary or religious law, such as interpretations of Muslim law;

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.

Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.

Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.

Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.

Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.

Fertility rate refers to the average number of children born to women of childbearing age.

Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.

Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

Ovid MEDLINE(R) (from 1946 to present)

Embase Classic+Embase on OvidSP (from 1947 to present)

CINAHL (1973 to present); and

Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

Information on the differential aspects of the abortion policy reforms.

Information on the types of study design used to assess the impact of policy reforms.

Information on main effects of abortion law reforms on primary and secondary outcomes of interest.

Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

Ganatra B, Gerdts C, Rossier C, Johnson BR, Tuncalp O, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet. 2017;390(10110):2372–81. https://doi.org/10.1016/S0140-6736(17)31794-4 .

Article   PubMed   PubMed Central   Google Scholar  

Guttmacher Institute. Induced Abortion Worldwide; Global Incidence and Trends 2018. https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide . Accessed 15 Dec 2019.

Singh S, Remez L, Sedgh G, Kwok L, Onda T. Abortion worldwide 2017: uneven progress and unequal access. NewYork: Guttmacher Institute; 2018.

Book   Google Scholar  

Fusco CLB. Unsafe abortion: a serious public health issue in a poverty stricken population. Reprod Clim. 2013;2(8):2–9.

Google Scholar  

Rehnstrom Loi U, Gemzell-Danielsson K, Faxelid E, Klingberg-Allvin M. Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data. BMC Public Health. 2015;15(1):139. https://doi.org/10.1186/s12889-015-1502-2 .

Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):E323–E33. https://doi.org/10.1016/S2214-109X(14)70227-X .

Article   PubMed   Google Scholar  

Benson J, Nicholson LA, Gaffikin L, Kinoti SN. Complications of unsafe abortion in sub-Saharan Africa: a review. Health Policy Plan. 1996;11(2):117–31. https://doi.org/10.1093/heapol/11.2.117 .

Abiodun OM, Balogun OR, Adeleke NA, Farinloye EO. Complications of unsafe abortion in South West Nigeria: a review of 96 cases. Afr J Med Med Sci. 2013;42(1):111–5.

CAS   PubMed   Google Scholar  

Singh S, Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries. BJOG. 2016;123(9):1489–98. https://doi.org/10.1111/1471-0528.13552 .

Article   CAS   PubMed   Google Scholar  

Vlassoff M, Walker D, Shearer J, Newlands D, Singh S. Estimates of health care system costs of unsafe abortion in Africa and Latin America. Int Perspect Sex Reprod Health. 2009;35(3):114–21. https://doi.org/10.1363/3511409 .

Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive services. Estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund; 2012.

Auger N, Bilodeau-Bertrand M, Sauve R. Abortion and infant mortality on the first day of life. Neonatology. 2016;109(2):147–53. https://doi.org/10.1159/000442279 .

Krieger N, Gruskin S, Singh N, Kiang MV, Chen JT, Waterman PD, et al. Reproductive justice & preventable deaths: state funding, family planning, abortion, and infant mortality, US 1980-2010. SSM Popul Health. 2016;2:277–93. https://doi.org/10.1016/j.ssmph.2016.03.007 .

Banaem LM, Majlessi F. A comparative study of low 5-minute Apgar scores (< 8) in newborns of wanted versus unwanted pregnancies in southern Tehran, Iran (2006-2007). J Matern Fetal Neonatal Med. 2008;21(12):898–901. https://doi.org/10.1080/14767050802372390 .

Bhandari A. Barriers in access to safe abortion services: perspectives of potential clients from a hilly district of Nepal. Trop Med Int Health. 2007;12:87.

Seid A, Yeneneh H, Sende B, Belete S, Eshete H, Fantahun M, et al. Barriers to access safe abortion services in East Shoa and Arsi Zones of Oromia Regional State, Ethiopia. J Health Dev. 2015;29(1):13–21.

Arroyave FAB, Moreno PA. A systematic bibliographical review: barriers and facilitators for access to legal abortion in low and middle income countries. Open J Prev Med. 2018;8(5):147–68. https://doi.org/10.4236/ojpm.2018.85015 .

Article   Google Scholar  

Boland R, Katzive L. Developments in laws on induced abortion: 1998-2007. Int Fam Plan Perspect. 2008;34(3):110–20. https://doi.org/10.1363/3411008 .

Lavelanet AF, Schlitt S, Johnson BR Jr, Ganatra B. Global Abortion Policies Database: a descriptive analysis of the legal categories of lawful abortion. BMC Int Health Hum Rights. 2018;18(1):44. https://doi.org/10.1186/s12914-018-0183-1 .

United Nations Population Division. Abortion policies: A global review. Major dimensions of abortion policies. 2002 [Available from: https://www.un.org/en/development/desa/population/publications/abortion/abortion-policies-2002.asp .

Johnson BR, Lavelanet AF, Schlitt S. Global abortion policies database: a new approach to strengthening knowledge on laws, policies, and human rights standards. Bmc Int Health Hum Rights. 2018;18(1):35. https://doi.org/10.1186/s12914-018-0174-2 .

Haaland MES, Haukanes H, Zulu JM, Moland KM, Michelo C, Munakampe MN, et al. Shaping the abortion policy - competing discourses on the Zambian termination of pregnancy act. Int J Equity Health. 2019;18(1):20. https://doi.org/10.1186/s12939-018-0908-8 .

Schatz JJ. Zambia’s health-worker crisis. Lancet. 2008;371(9613):638–9. https://doi.org/10.1016/S0140-6736(08)60287-1 .

Erdman JN, Johnson BR. Access to knowledge and the Global Abortion Policies Database. Int J Gynecol Obstet. 2018;142(1):120–4. https://doi.org/10.1002/ijgo.12509 .

Cleeve A, Oguttu M, Ganatra B, Atuhairwe S, Larsson EC, Makenzius M, et al. Time to act-comprehensive abortion care in east Africa. Lancet Glob Health. 2016;4(9):E601–E2. https://doi.org/10.1016/S2214-109X(16)30136-X .

Berer M, Hoggart L. Medical abortion pills have the potential to change everything about abortion. Contraception. 2018;97(2):79–81. https://doi.org/10.1016/j.contraception.2017.12.006 .

Moseson H, Shaw J, Chandrasekaran S, Kimani E, Maina J, Malisau P, et al. Contextualizing medication abortion in seven African nations: A literature review. Health Care Women Int. 2019;40(7-9):950–80. https://doi.org/10.1080/07399332.2019.1608207 .

Blystad A, Moland KM. Comparative cases of abortion laws and access to safe abortion services in sub-Saharan Africa. Trop Med Int Health. 2017;22:351.

Berer M. Abortion law and policy around the world: in search of decriminalization. Health Hum Rights. 2017;19(1):13–27.

PubMed   PubMed Central   Google Scholar  

Johnson BR, Mishra V, Lavelanet AF, Khosla R, Ganatra B. A global database of abortion laws, policies, health standards and guidelines. B World Health Organ. 2017;95(7):542–4. https://doi.org/10.2471/BLT.17.197442 .

Replogle J. Nicaragua tightens up abortion laws. Lancet. 2007;369(9555):15–6. https://doi.org/10.1016/S0140-6736(07)60011-7 .

Keogh LA, Newton D, Bayly C, McNamee K, Hardiman A, Webster A, et al. Intended and unintended consequences of abortion law reform: perspectives of abortion experts in Victoria, Australia. J Fam Plann Reprod Health Care. 2017;43(1):18–24. https://doi.org/10.1136/jfprhc-2016-101541 .

Levels M, Sluiter R, Need A. A review of abortion laws in Western-European countries. A cross-national comparison of legal developments between 1960 and 2010. Health Policy. 2014;118(1):95–104. https://doi.org/10.1016/j.healthpol.2014.06.008 .

Serbanescu F, Morris L, Stupp P, Stanescu A. The impact of recent policy changes on fertility, abortion, and contraceptive use in Romania. Stud Fam Plann. 1995;26(2):76–87. https://doi.org/10.2307/2137933 .

Henderson JT, Puri M, Blum M, Harper CC, Rana A, Gurung G, et al. Effects of Abortion Legalization in Nepal, 2001-2010. PLoS ONE. 2013;8(5):e64775. https://doi.org/10.1371/journal.pone.0064775 .

Goncalves-Pinho M, Santos JV, Costa A, Costa-Pereira A, Freitas A. The impact of a liberalisation law on legally induced abortion hospitalisations. Eur J Obstet Gynecol Reprod Biol. 2016;203:142–6. https://doi.org/10.1016/j.ejogrb.2016.05.037 .

Latt SM, Milner A, Kavanagh A. Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries. BMC Women’s Health. 2019;19(1). https://doi.org/10.1186/s12905-018-0705-y .

Clarke D, Muhlrad H. Abortion laws and women’s health. IZA discussion papers 11890. Bonn: IZA Institute of Labor Economics; 2018.

Benson J, Andersen K, Samandari G. Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh. Reprod Health. 2011;8(39). https://doi.org/10.1186/1742-4755-8-39 .

Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj-Brit Med J. 2015;349.

William R. Shadish, Thomas D. Cook, Donald T. Campbell. Experimental and quasi-experimental designs for generalized causal inference. Boston, New York; 2002.

Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017;46(1):348–55. https://doi.org/10.1093/ije/dyw098 .

Bernal JL, Cummins S, Gasparrini A. The use of controls in interrupted time series studies of public health interventions. Int J Epidemiol. 2018;47(6):2082–93. https://doi.org/10.1093/ije/dyy135 .

Meyer BD. Natural and quasi-experiments in economics. J Bus Econ Stat. 1995;13(2):151–61.

Strumpf EC, Harper S, Kaufman JS. Fixed effects and difference in differences. In: Methods in Social Epidemiology ed. San Francisco CA: Jossey-Bass; 2017.

Abadie A, Diamond A, Hainmueller J. Synthetic control methods for comparative case studies: estimating the effect of California’s Tobacco Control Program. J Am Stat Assoc. 2010;105(490):493–505. https://doi.org/10.1198/jasa.2009.ap08746 .

Article   CAS   Google Scholar  

Abadie A, Diamond A, Hainmueller J. Comparative politics and the synthetic control method. Am J Polit Sci. 2015;59(2):495–510. https://doi.org/10.1111/ajps.12116 .

Moscoe E, Bor J, Barnighausen T. Regression discontinuity designs are underutilized in medicine, epidemiology, and public health: a review of current and best practice. Journal of Clinical Epidemiology. 2015;68(2):132–43. https://doi.org/10.1016/j.jclinepi.2014.06.021 .

Dennis A, Blanchard K, Bessenaar T. Identifying indicators for quality abortion care: a systematic literature review. J Fam Plan Reprod H. 2017;43(1):7–15. https://doi.org/10.1136/jfprhc-2015-101427 .

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4 .

Jackson JL, Kuriyama A, Anton A, Choi A, Fournier JP, Geier AK, et al. The accuracy of Google Translate for abstracting data from non-English-language trials for systematic reviews. Ann Intern Med. 2019.

Reeves BC, Wells GA, Waddington H. Quasi-experimental study designs series-paper 5: a checklist for classifying studies evaluating the effects on health interventions-a taxonomy without labels. J Clin Epidemiol. 2017;89:30–42. https://doi.org/10.1016/j.jclinepi.2017.02.016 .

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. https://doi.org/10.1136/bmj.39489.470347.AD .

Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58. https://doi.org/10.1002/sim.1186 .

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Acknowledgements

We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

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FI and AN conceived and designed the protocol. FI drafted the manuscript. FI, UVU, and AN revised the manuscript and approved its final version.

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Additional file 1:.

PRISMA-P 2015 Checklist. This checklist has been adapted for use with systematic review protocol submissions to BioMed Central journals from Table 3 in Moher D et al: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 2015 4:1

Additional File 2:.

LMICs according to World Bank Data Catalogue. Country classification specified in the World Bank Data Catalogue to identify low- and middle-income countries

Additional File 3: Table 1

. Search strategy in Embase. Detailed search terms and filters applied to generate our search in Embase

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Ishola, F., Ukah, U.V. & Nandi, A. Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol. Syst Rev 10 , 192 (2021). https://doi.org/10.1186/s13643-021-01739-w

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Received : 02 January 2020

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DOI : https://doi.org/10.1186/s13643-021-01739-w

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