Borders, Barriers, and Burdens: A Global Comparative Study of Abortion Policies and Access

Background: Abortion is a core component of reproductive healthcare and a critical determinant of maternal health outcomes. Globally, approximately 73 million abortions occur annually, with unsafe abortion contributing to 4.7–13.2% of maternal deaths, primarily in low- and middle-income countries (LMICs). Legal frameworks governing abortion vary widely, ranging from total prohibition to fully integrated care systems. Access is further shaped by health system capacity, procedural barriers, and socio-economic inequities. In an increasingly globalised world, migration adds complexity, as individuals move between countries with differing policies, influencing both direct access to care and regional healthcare dynamics. Understanding these intersecting factors is essential for improving reproductive health equity and reducing preventable morbidity and mortality. Methods: A global comparative analysis was conducted using two integrated datasets covering 100 countries. The first dataset captured legal, operational, and contextual variables, including gestational limits, funding mechanisms, provider cadres, and telemedicine availability. The second dataset provided demographic, socio-economic, and health system indicators. Access Scores were derived from weighted indicators on a 0–10 scale. Analyses included descriptive statistics, bivariate associations, and multivariable ordinal logistic regression. An intersectional approach explored disparities across income groups, geographic regions, and migration pathways, with visualisation tools such as heatmaps, bubble plots, and diaspora exposure differentials. Results: Countries with telemedicine-enabled early medical abortion (tele-EMA) were significantly associated with higher Access Scores (OR ≈1.45), while each additional mandated waiting day reduced odds of liberal access by 7%. Mid-level provider authorisation and public funding alone did not predict improved access. Migration analysis revealed that LMIC-to-HIC flows resulted in marked improvements in abortion access, though benefits were unevenly distributed, leaving vulnerable populations behind. African and Asian LMICs had the lowest Access Scores, reflecting systemic underfunding and restrictive laws. Conclusion: Abortion access is shaped by functional health system design rather than geography alone. Removing procedural barriers, expanding telemedicine, and embedding services within integrated health systems are essential to achieving equitable, sustainable reproductive healthcare worldwide.