Restrictive abortion laws and fertility in Sub-Saharan Africa: a hierarchical modelling of 31 countries

Evidence suggests that fertility rates are largely influenced by education, wealth, and urbanization. However, limited research has examined how abortion laws might affect fertility rates, especially in Sub-Saharan Africa (SSA), where many countries have restrictive abortion laws. Our study assessed the association between restrictive abortion laws and fertility (number of children ever born) in SSA. We analyzed recent Demographic and Health Surveys and global abortion laws data from 31 SSA countries. Abortion laws were categorized into two ordinal levels (broadly liberal and restrictive laws) while fertility was a count variable (the number of children ever born). We conducted multivariable multilevel quasi-Poisson regression with interaction between age group and abortion law in the final model. We also conducted stratified analyses by place of residence, and several sensitivity analyses to test the robustness of our findings. The weighted sample included 476,924 women, of whom 88.7% lived in countries with restrictive abortion laws. We observed that restrictive laws were associated with higher fertility (adjusted prevalence ratio, 1.24; 95% CI: 1.15, 1.34). When we stratified by place of residence, restrictive laws were associated with higher fertility in rural areas, but not in urban areas. We also found that the association of restrictive laws varied by age group: an additional 0.4 children per woman among 15–19 years, 1.1 children per woman among 20–29 years, and peaked at 1.3 children per woman among 30–39 years, though there was no statistical significance across age groups. The results were consistent across multiple sensitivity analyses. We found that restrictive abortion is associated with higher fertility in SSA, with greater magnitudes among women in their prime childbearing years and those in rural areas. Policy reforms expanding access to safe abortion and strengthening contraceptive services may help mitigate the influence of restrictive abortion laws on fertility.