Abortion rates, which were once dropping worldwide, are no longer decreasing, according to new reports from the Guttmacher Institute and the World Health Organization (WHO).

The study, published in The Lancet, reported 28 induced abortions for every 1,000 women of childbearing age globally in 2008. Abortion rates had previously fallen from 35 per thousand in 1995, to 29 in 2003.

Twenty one percent of all pregnancies worldwide ended in abortions in 2008, and 86 percent of the nearly 44 million abortion procedures were performed in developing countries.

“We are also seeing a growing proportion of abortions occurring in developing countries, where the procedure is often clandestine and unsafe,” Gilda Sedgh, lead author of the study and a senior researcher at the Guttmacher Institute, said. “This is cause for concern.”

In 2008, 97 percent of all abortions performed in Africa and 95 percent in Latin America were classified as “back-street” abortion procedures, leading to complications and death for women.

Nearly half of all abortions around the world were performed this way in 2008, according to the study, with the most dangerous procedures in developing countries. Unsafe abortions continued to account for nearly 13 percent of all maternal deaths worldwide.

“Deaths and disability related to unsafe abortion are entirely preventable, and some progress has been made in developing regions,” said Iqbal H. Shah, of the WHO and a co-author of the study. “Africa is the exception, accounting for 17 percent of the developing world’s population of women of childbearing age, but half of all unsafe abortion-related deaths.”

Africa also has the widest range of abortion rates compared to other world regions. In Middle and Eastern Africa, abortion rates were as high as 38 and 36 for every 1000 women of childbearing age. In comparison, abortion occurred at more than half this rate in Southern Africa where there were 15 abortions for every 1000 women of childbearing age.

Legal restrictions on abortion were surprisingly associated with higher abortion rates, according to the data. In contrast, South Africa, which has some of the most liberal abortion laws, had lower abortion rates than other African regions.

“Restrictive abortion laws are not having the impact that was intended,” Sedgh observed. “The abortion rate is lower in sub-regions characterized by liberal laws.”

While the study found that abortion occurred in every country with regional variations, lower abortion rates were associated with better access to family planning options, leading study authors to argue for more investment in family planning services.

“Within developing countries, risks are greatest for the poorest women,” said Shah. “They have the least access to family planning services and are the most likely to suffer the negative consequences of an unsafe procedure. Poor women also have the least access to post-abortion care, when they need treatment for complications.”

However, despite evidence about the risks of unsafe abortions, and the benefits of family planning, addressing the issue of abortion at an international level remains problematic.

“American representatives explicitly came to me and asked me to remove the word abortion from our draft,” said Richard Horton, editor of The Lancet, referring to the final report on women and children’s health from an international working group.

“Even under an Obama administration, it is not possible to have an open discussion about abortion in international agencies and commissions.”

United States dialogue about abortion may remain limited, but essentially abortions in America remain safe for women, with associated rates of 0.6 deaths for every 100,000 procedures. Following unsafe abortions in some other world regions, death occurs at 350 times the U.S. rate.

At least half of all American women will experience at least one unwanted pregnancy before the age of 45, according to the Guttmacher Institute. In 2008, among African-American women, 67 percent of all pregnancies were unintended, while 53 and 40 percent of pregnancies were unintended for Hispanic and white women, respectively.

U.S. abortion rates, which had been dropping, also stalled in 2008 when there were almost 20 abortions for every 1000 women. There were over 1.2 million abortions in the United States in 2008, with 36 percent of these procedures for white women, 30 percent for African-American women and 25 percent for Hispanic women.

Abortion remains an issue to be addressed by both national and global health policies. While global abortion rates have stalled overall, absolute numbers of abortions rose in developing countries by almost 3 million to nearly 38 million.

“Abortion is ignored, marginalized and stigmatized,” concluded Horton. “And yet it is absolutely essential to the health of women worldwide. This stigmatisation, this censorship around the issue of abortion is what is causing the enormous distortion of priorities in women’s health today.”