common in some former Soviet Bloc and satellite countries: In Armenia, nearly six out of 10 abortions in 2010 were by D&C, as were three out of 10 that year in Georgia129 and four out of 10 in Belarus in 2013.130 Combination medication abortion accounts for solid to vast majorities—from roughly 60% to 90%—of all induced abortions in nineq of 13 additional European countries with data. In just four European countries with data (Belgium, Germany, Italy and the Netherlands), the proportion accounted for by medication abortions is fairly low as of this writing (the situation is in flux), at less than 25%.131 Possible reasons for the predominance of surgical abortions in these four include preferences among women or providers for vacuum aspiration, because it takes much less time and costs far less. Indeed, mifepristone’s high cost can limit medication abortion’s availability in national health services, for example, if few dedicated products are on the market, lowering competition and raising costs; this was the case in the Netherlands until roughly p) Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh. q) Estonia, Finland, France, Great Britain, Portugal, Norway, Slovenia, Sweden and Switzerland. o) We use Ethiopia as an example even though its 2004 reform stopped short of making abortion broadly legal, because the law is liberally interpreted and comprehensive guidelines were fully implemented early on. Sometimes, safe services can coexist with clandestine and unsafe ones years after liberalization 26 GUTTMACHER INSTITUTE 2015.132 Moreover, extensive delays in registering mifepristone can result in this specific medication method being unavailable, which was the case in Canada until 2016.133 In some developing countries with legal abortion where surgical procedures had been the only choice, the introduction of combination medication abortion proved highly acceptable: In a province of South Africa, for example, the vast majority of patients given the choice decided on combination medication abortion.134,135 Having midlevel, public-sector health professionals provide medication abortion can not only satisfy many women’s preferences for female caregivers, but can also lower costs and improve overall access and availability. Innovations to the protocol hold further promise: Studies of combination medication abortion in seven countriesr have found no differences in terms of acceptability and efficacy between women who took the second drug—misoprostol— at the clinic and those who took it in the privacy of their home.136 For the vast majority of countries where abortion is broadly legal, abortion is part of the standard package of public-sector health services and is often covered by national health insurance. But for poorer countries in this group, such as Zambia, cost has been shown to limit access to the point that many women seek out cheaper, not necessarily safer, abortions.137 In other countries, such as Bangladesh, Cambodia and Turkey, some women use private-sector providers even though they usually have to pay more for them than for public services.138–140 Possible reasons for seeking highercost care include women’s expectations that, compared with public services, private services offer better overall quality, especially more privacy and confidentiality. In addition, women in the rural Indian states of Maharashtra and Rajasthan prefer more expensive private providers because of a perceived higher quality of care.141,142 In other countries, such as the United States, regulations enacted at the state level are chipping away at abortion access and creating a patchwork of availability. These laws, combined with other factors, have left broad swaths of the country severely underserved by abortion providers. As of 2011, 89% of U.S. counties lacked any abortion provider;143 thus, the 38% of women of reproductive age living in those counties would have to travel—great distances, for some—to obtain an abortion. Furthermore, the pace of such statelevel procedural and bureaucratic restrictions has quickened in recent years (Figure 4.3).73 In India, another country with long-standing legal abortion, public facilities at the primary level and higher are automatically approved as abortion providers, as long as they are staffed with a certified provider; however, private facilities are required to be registered and to use certified providers. Yet, even after the government tried to speed approvals by decentralizing the process to the district level in 2002, onerous requirements continue to be a barrier and many unregistered private facilities were still providing abortions as of 2015.126 Small-scale studies in Nepal, South Africa and Tunisia found that women are sometimes denied care even when they legally qualify for an abortion.33 Some of these women were turned away because they could not pay for their abortions; others because the clinics lacked the staff or equipment to perform the abortion, or required the woman to first undergo unnecessary laboratory tests. Women denied services might obtain referrals and receive legal abortions elsewhere, but they may also turn to unsafe abortions from untrained providers or continue with an unwanted pregnancy. • FIGURE 4.3 Source:reference 73. In the United States, the total number of state-level abortion restrictions enacted in 2011–2016 greatly exceeded the