require a large-scale cultural shift, but also the political will to create an environment favorable to implementation. Establishing and improving essential health infrastructure, as well as training a sufficient number of providers, are time-consuming Nepal enacted more sweeping legal change than any other country since 2000 24 GUTTMACHER INSTITUTE • NOTES TO FIGURE 4.2 *Vacuum aspiration and D&C. Abortions classified by countries as using both vacuum aspiration and misoprostol were considered to be surgical. †Combination medication abortion for all countries and years, except for Mexico City. In that single district, the only area of Mexico where abortion is legal, medication abortion refers to misoprostol alone before mifepristone was approved in 2011 (i.e., from legalization in 2007 through 2010). ‡Includes traditional methods of abortion and other unspecified methods for Cambodia only, because of the way the data were collected. Sources: For all countries except Cambodia and Georgia, the data are the most recent government data; for Cambodia, the data come from DHS surveys conducted in 2000, 2010 and 2014; and for Georgia, the data come from RHS surveys conducted in 1999, 2005 and 2010. The proportion of all abortions that are combination medication abortions has increased in most countries and areas with data, although the pace of this increase has been slow in some. 25 only doctors to provide abortions or that require abortions to be provided only in certain levels of health facilities—restrictions that likely date from when operating-room D&C procedures were the norm—can further reduce the availability of legal procedures, especially in resource-poor settings. Sometimes, safe services can coexist with clandestine and unsafe ones years after liberalization. In Ethiopia,o for example, only a little over half (53%) of abortions in 2014 were legal procedures about nine years after law reform; nevertheless, that constituted significant progress as the level in 2008 was about half that (27%).125 In Nepal, which enacted more sweeping legal change than any other country since 2000, 63% of health facilities provided legal abortions as of 2014, and 42% of all abortions that year were legal.95 Barriers to safe abortion care that persist in Nepal include women’s inadequate knowledge of its legality and of where to obtain services; poor availability, especially in rural areas; long distances to health facilities; and high costs, despite legislation ensuring the contrary. Provision of abortion is safest where it has long been legal The third group of countries are those where abortion has been legal for 20 years or more under broad criteria (categories 5 and 6). Most of the 69 countries in this group are in the developed world (Appendix Table 1, page 50). As expected, most have robust health care systems and low ratios of population to trained providers; many have national health insurance that covers abortion services. These conditions allow the majority of women in these countries to exercise their right to a safe and legal abortion. That said, in some of these countries, services tend to be proportionately less available in the areas where the majority of women live. For example, in six Indian states,p just 5–34% of health facilities that provide induced abortions are located in rural areas,126 even though 49–87% of the population of reproductive-age women in these states lives in rural areas.127 In addition, access to services in this group of countries is often worse among women who are disadvantaged in some respect, including women who are young or single, those who live in poverty or lack health insurance, and those who are recent immigrants and thus may have inadequate knowledge of the legality of abortion and the availability of services.25 The institutional framework of service delivery also varies markedly across countries where abortion is broadly legal. For example, in some countries, clinics that specialize in providing abortions can be the main or sole source of abortion care, whereas in others, abortion can be offered as one of an integrated range of reproductive health services. In addition, countries vary in the extent to which abortion services are provided by public, private and nongovernmental-organization facilities. Aspects of high-quality care that should apply to all service delivery contexts include providers’ nonjudgmental and supportive attitudes, and their counseling on and provision of contraceptive options following an abortion. However, in Georgia and Russia, just 7% and 20% of recent abortion clients, respectively, left the source of their abortion with a contraceptive method.21,22 This service component is amenable to improvement, as results from a comprehensive three-year intervention in India show: Only about one-third of abortion clients at baseline left with a postabortion contraceptive method, compared with two-thirds at the study’s midpoint and nearly nine-tenths by the end.128 The specific methods of abortion used in broadly legal countries have undergone a sea change since mifepristone was approved, starting with China and France in 1988.110 By about the mid-2000s, combination medication abortions outnumbered surgical procedures in several countries, including Finland, France and Sweden (Figure 4.2). However, use of the surgical D&C procedure, which is no longer recommended by WHO, was still