Abortion restrictions and maternal mortality

In my previous post, I estimated that 47% of pregnancies are unintended, and of these, 43% occur in countries where abortion is illegal or severely restricted. Globally, 60% of unintended pregnancies are aborted.  In countries where abortion is widely available, 71% of unintended pregnancies are aborted compared to 46% in countries with severe restrictions. 

The World Health Organization (WHO) estimates that around one-third of the 23 million induced abortions carried out each year in countries where abortion is severely restricted are performed under the least safe conditions, by untrained persons using dangerous and invasive methods. Safe abortion is an essential health care service. It is a simple intervention that can be effectively managed by a wide range of health workers using medication or a surgical procedure. In the first 12 weeks of pregnancy, a medical abortion can also be safely self-managed by the pregnant person at home.

I’ve been involved in the estimation of global deaths due to maternal mortality for WHO and UNICEF since the early 2000s. WHO defines maternal mortality as death while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. This measure is reported by WHO and UNICEF as a maternal mortality ratio per 100,000 births (MMR) for international comparisons and monitoring.

The following plot shows average MMR for countries grouped by access to abortion and country zone for the year 2017. US states have been grouped according to abortion restrictions and state-level MMR estimates from GBD2019 used and adjusted to match the national average MMR reported by CDC. Only one country, Poland, in the three “West” culture zones restricts abortion and it has an apparently very low MMR. While countries that restrict abortion have higher MMRs than those that don’t for most of the culture zones, we cannot conclude that abortion restriction per se is responsible for the difference. Abortion restriction is also correlated with other determinants of higher MMR such as lower average income per capita, less access to health care, and higher levels of discrimination against women.

The global MMR has declined from 345 per 100,000 livebirths in 2000 to 212 per 100,000 livebirths in 2017, a 40% decrease in 17 years.  There have been substantial declines in MMR in every culture zone except for the Reformed West and Old West where MMR rates were already very low in 2000 and in the USA where rates have risen substantially during the 21st century.  The plot below takes a closer look at MMR trends in the USA, the Reformed and Old West, the Returned West and the Orthodox East. The latter two culture zones include the former Soviet bloc countries. With the exception of Poland in the Returned West, all these culture zones except the USA do not restrict access to abortion services and allow abortion on request or in some countries on “economic and social grounds”.

WHO/UNICEF estimates of MMR have been extended forward to 2019 using trend estimates from GBD2019. The US MMR estimates have been adjusted for consistency with CDC statistics on MMR for years 2000 to 2020.  The maternal mortality ratio for the USA has increased from around 15 per 100,000 livebirths in 2000 to 23.8 in 2020, a 62% increase.  Abortion rates in States which now restrict abortion were similar to those in states which don’t until 2008 and afterwards diverged substantially. The rate for states with restrictions was 26.4 in 2020, 30% higher than the MMR of 20.2 for states without restrictions.

There has been considerable controversy about the substantial increase in maternal mortality in the USA, particularly as to whether it is associated with improvements in the identification and reporting of maternal deaths.  Identification of pregnancy-related deaths has improved over time due to the use of computerized data linkages between birth and death records, and the addition of a pregnancy checkbox to death records from 2003 onwards. This checkbox is thought to have led to some increase in estimated MMRs in the early 2000s, but several studies have also identified that increasing restrictions on the general availability of reproductive health services have played a major role in the substantial increase in maternal mortality seen in the USA, particularly in states restricting access to abortion.

Hawkins et al (2019) found that a 20% reduction in the numbers of Planned Parenthood clinics resulted in an 8% increase in maternal mortality and states that enacted legislation to restrict abortions based on gestational age increased the maternal mortality rate by 38%.

A 2020 study by the Commonwealth Fund compared maternity care in the USA with 10 other developed countries and found that the USA has the highest maternal mortality among developed countries and that there is an overall shortage of maternity care providers (obstetrician-gynecologists and midwives). The USA has 12 to 15 providers per 1,000 livebirths, and all the other developed countries have a supply that is between two and six times greater. Although a large share of its maternal deaths occur postbirth, the U.S. is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period.

In the first five or so years I was at WHO, I worked with a maternal health colleague who provided estimates of deaths due to unsafe abortions using very uncertain estimates of the numbers of unsafe abortions and literature reviews of studies of death rates associated with unsafe abortion. Unsafe abortion was estimated to account for around 13% of total global maternal deaths, which were then estimated to be around half a million deaths per year at the beginning of the 21st century.

A more recent study by WHO staff and academic colleagues in 2014 estimated that abortion accounted for 7.9% of maternal deaths at global level between 2003 and 2009 (with uncertainty range 4.7 to 13.2%). An estimated 287 000 maternal deaths occurred worldwide in 2010, most of which were in low-income and middle-income countries and were avoidable. This would suggest there were around 22,700 maternal deaths per year associated with abortion.

Recent WHO estimates for global deaths by cause do not include deaths due to induced abortion. The IHME Global Burden of Disease Study 2019 has produced estimates of maternal deaths due to abortion and miscarriage for the period 1980 to 2019. These would also include induced abortion deaths as well as deaths due to spontaneous abortions and miscarriages. 

I have used IHME GBD estimates of the proportion of maternal deaths that are due to abortion and miscarriage to impute estimates for these deaths consistent with the latest available WHO/UNICEF estimates of maternal deaths for all countries for the year 2017. The figure below shows the average percent of maternal deaths attributed to abortion and miscarriage for countries with and without abortion restrictions in each culture zone.

Overall, I estimate that there were 75,500 deaths globally due to abortion and miscarriage in 2017 (these include spontaneous events as well as induced abortions). Of these 70,300 were in countries with abortion restrictions. I’ve done a very back of the envelope approximation of the abortion deaths that might be attributable to unsafe abortion by making the big assumption that the percent of deaths due to spontaneous abortion and miscarriage are the same as those for the countries in the region for which abortion access is not restricted. The excess deaths are then attributed to unsafe abortion. I estimate that abortion restrictions resulting in unsafe abortions caused 54,350 deaths in 2017.  If all abortions were safe, there would have been only 21,200 deaths due to spontaneous abortion and miscarriage in 2017.

At global level, 4.8 per cent of maternal deaths are classified as due to abortion or miscarriage (spontaneous or induced) In countries without abortion restrictions and 14.6% in countries with restrictions. Adjusting to removed estimated spontaneous events, I estimate that 6.9% of maternal deaths in countries with abortion restrictions are due to unsafe abortion. Its quite possible these very back-of-the-envelope estimates are under-estimates. Classification of maternal deaths due to abortion, and more specifically unsafe abortion, is associated with a risk of misclassification. Even where induced abortion is legal, religious and cultural perceptions in many countries mean that women do not disclose abortion attempts and relatives or health-care professionals do not report deaths as such. Under-registration of deaths might be the result of stigmatisation of abortion affecting what information is reported by relatives and informants or intentional misclassification by providers when abortion is restricted. In these circumstances, the overall number of maternal mortality might not be affected, whereas abortion-related deaths might be significantly underestimated because of this under-reporting.

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Global estimates of abortion rates by legality and region

A little under two months ago, the Guttmacher Institute and WHO released first-ever country-level estimates of unintended pregnancy and abortion (see here). The new study analyzed data for 150 countries for the period 2015-2019 and found that:

  • Almost half of the 220 million pregnancies globally per year are unintended.
  • Six in 10 unintended pregnancies end in an induced abortion (63 million per year).
  • Overall, 29% of all pregnancies globally end in an induced abortion.
  • Almost 30% of induced abortions occur in countries where abortion is either illegal or heavily restricted. Earlier estimates for 2010-2014 found that 45% of all abortions are unsafe, and around 15% were performed in the least safe conditions, by untrained persons using dangerous and invasive techniques.
  • Regional averages mask large disparities within regions for unintended pregnancy and abortion rates.

The Guttmacher/WHO study covers 90% of the 1.9 billion women of reproductive age. Almost all the missing countries (because of lack of data) are from the Western Asia and Northern Africa region, most of them Islamic states or with a dominant Islamic culture. I describe below how I imputed data for most of the missing countries, added data on legal grounds and restrictions regarding abortion and examine global patterns using 12 culture zones which group countries based on history, values and religion.

The following plots give a taste of the global patterns I found. Culture zone and other definitions, data and methods are given in more detail in the rest of this post.

Figure 1.
Figure 2.

*Note that USA results have been calculated by grouping States into those with and without significant abortion restrictions

The left-hand figure shows that abortion is universally legally available in most of Europe, Canada, Australia and New Zealand, in the Orthodox and Islamic countries of the former Soviet-bloc and in the non-Islamic countries of Asia. It is legally severely restricted in most Islamic countries and sub-Saharan Africa. Abortion rates are substantially lower in the high-income countries of Europe, North America and Australia and New Zealand than in the Asian regions where abortion is unrestricted AND in the countries in all developing regions irrespective of whether abortion is legally restricted or available. Note that USA results have been calculated by grouping States into those with and without significant abortion restrictions.

For 2015-2019, almost half of unintended pregnancies (46%) were aborted in countries where abortion was restricted (often severely) and a little over two-thirds (70%) in countries where abortion is accessible.  In the three regions where around 40-50% of women with unintended pregnancies have restricted access to abortions, overall abortion rates per 1,000 women of reproductive age differ by less than 2 abortions per 1,000 from those in countries (or US states) without restrictions.  

Imputation of data for countries in Western Asia and Northern Africa

The 150 countries with abortion-related data represent 90% of the 1.9 billion women of reproductive age 15-49 years in the period 2015-2019. Of the eight Sustainable Development Goals (SDG) regions used in the study, the coverage of reproductive-age women by countries with data fell below 95% only for Western Asia and Northern Africa, where data coverage was only 3.4%. However, the missing women are almost entirely in one SDG region, Western Asia and Northern Africa

The region includes 24 countries, mostly in North Africa and the Middle East. Data is available only for Azerbaijan, Armenia and Georgia. These are all former Soviet-bloc countries with legal abortion and high rates of termination of unintended pregnancies. In contrast, apart from Israel and Cyprus, the other 19 countries are all either explicitly Islamic states or with a predominant Islamic culture. Seventeen of the 19 either prohibit or severely restrict abortion.

To address the bias inherent in excluding these countries from global statistics, I decided to impute the unintentional pregnancy rates and abortion rates for the Islamic countries in North Africa and the Middle East and also for Afghanistan, Iran and Malaysia, using information on live birth rates for these countries along with the abortion data for 22 Islamic countries in the neighbouring regions Sub-Saharan Africa, South-central Africa and South-eastern Asia. Former Soviet-bloc Islamic countries were not included in this dataset.

Pregnancy rates were regressed against live birth rates for this dataset and the regression model (R-squared 0.91) used to predict pregnancy rates for the missing data. Unintended pregnancies are defined as pregnancies which were unwanted at the time they were conceived or occurred earlier than desired. Explorations of various covariates for predicting the proportion of pregnancies that are unintentional resulted in predicting of missing data using a regression on the log of GDP per capita measured in international (purchasing-power-parity adjusted) dollars and a continuous variable measuring average-religiosity for countries in 2017. Both these variables are significant predictors of the proportion of pregnancies that are unintentional and the regression on the prediction dataset has an R-squared of 0.52. I used previously estimated levels and trends in average religiosity (practicing, non-practicing, non-religious and atheist) for countries using data from the World Values Survey (WVS) and European Values Study (EVS) covering the period 1980 to 2020 (see previous post here). 

The only predictive variable found for the proportion of unintentional pregnancies resulting in induced abortion was the gender inequality index produced by United Nations Development Program. Regression of logit(abortion fraction of unintended pregnancies) against the logit of the 2017 value of the gender inequality index was used to predict missing abortion fractions of unintended pregnancies (R-squared 0.7).

Global and regional abortion rates for 2015-2019

With these missing values imputed for 23 countries, the abortion estimates now cover most countries in most regions, and 98.6% of women of reproductive age globally. Based on this extended dataset, the following table summarizes regional and global patterns of pregnancy and abortion for the period 2015-2019.

The Guttmacher/WHO paper in the British Medical Journal displays unintended pregnancy and abortion rates by country for the 150 countries included in their study. The estimates dataset is available here. It includes 80% and 95% uncertainty intervals.  In this post, I’m interested to see the big picture at regional and global level, and I’ve not done the additional work to estimate uncertainty intervals.  But it is important to keep in mind that there are many problems with data availability, reliability and completeness of reporting, particularly for an often stigmatized and contentious issue such as abortion.  So the broad patterns shown below likely convey a reasonable and evidence-based assessment, but small differences between countries or regions should not be over-interpreted.

Legal restrictions in countries and US States

The legality and acceptability of abortion varies widely across the world, from Europe where it is available without restriction in most countries, to the Middle East and Africa where it is largely illegal.

I’ve taken country-level information on abortion availability and restrictions from Wikipedia, which documents legal grounds on which abortion is permitted, and gestational age limits where relevant, using the following six categories: risk to life, risk to health, rape, fetal impairment, economic or social reasons, on request.  The first four of these grounds cover a fairly small percentage of unintended pregnancies and I have grouped in a single category “restricted or prohibited” countries  which allow abortion only on these grounds. Countries which allow abortions on economic or social grounds or on request (with any gestational age limit set at least 10 weeks or longer) are classified as “unrestricted”. The USA has widely varying legal restrictions on abortions across the 50 states and Washington DC. I have used information on abortion access from Planned Parenthood to classify abortion access as restricted (28 states) and unrestricted (22 states and Washington DC).

Revised culture groups for countries

In earlier posts, I analyzed religious and other values by culture groups for 110 countries using data from the World Values Surveys and the European Values Study. These culture zones were based on the 11 culture zones developed by Welzel (2013)

For this post, I’ve slightly revised the culture zones to group Canada with Australia and New Zealand in the “Reformed West” zone, and kept the USA as a single separate culture zone. I’ve also revised the categories “Indic East”, “Sinic East”, and Islamic East to group together all countries with a predominantly Islamic culture and values. The revised culture zones are as follows:

Reformed West — Western European societies strongly affected by the Reformation: Denmark, Finland, France, Germany, Iceland, Netherlands, Norway, Sweden, Switzerland, United Kingdom, plus Canada, Australia and New Zealand;

USA — The North American culture zone included only two countries, USA and Canada. Canada’s culture is very similar to the Reformed West, and it is moved there.

Old West — Mostly Catholic parts of Western Europe being core parts of the Roman Empire: Austria, Belgium, Cyprus, Greece, Ireland, Israel, Italy, Luxembourg, Malta, Portugal, Spain;

Returned West — Catholic and Protestant parts of post-communist Europe returning to the EU: Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia;

Orthodox East — Christian Orthodox or Islamic parts of the post-communist world, mostly parts of former USSR;

Indic East — Parts of South and South East Asia under the historic influence
of Indian or Buddhist culture: Bhutan, Cambodia, India, Laos, Malaysia, Myanmar, Nepal, Philippines, Singapore, Sri Lanka, Thailand, Timor-Leste;

Islamic East — Countries with predominantly Islamic religion and culture;

Sinic  East — Parts of East Asia under the historic influence of Chinese culture and/or Buddhism: China, Japan, Mongolia, North Korea, South Korea, Taiwan, Vietnam;

Latin America — Central and South America and the Caribbean;

Sub-Saharan Africa — African countries south of the Sahara.

Oceania — Papua New Guinea and other Pacific Island countries.

Patterns of abortion by culture group

The table below summarizes the abortion situation for countries without legal restrictions and countries with legal restriction in each culture zone. Country-level legal status is used except for the USA where the statistics relate to two groups of states: those with and without legal restrictions on abortion (as defined above). State level estimates are not available for the per cent of unintended pregnancies, or the per cent that are aborted. I have assumed that the national percent of all pregnancies that are unintended (34%) is the same in the two groups of states, and that the % aborted in states without restrictions is the same (38%) as that in the Reformed West where abortion is 100% unrestricted. Since the national level of unintended pregnancies that are aborted is 34%, this implies that the proportion of unintended pregnancies aborted in states with restrictions is 31%.

To graphically illustrate these variations across culture zones, I repeat the two figures included near the beginning of this post:

Figure 1.
Figure 2.

Globally, 60% of unintended pregnancies ended in abortion in the period 2015-2019. People seek and obtain abortions in all countries, even in those with restrictive abortion laws, where barriers to safe abortion care are high. In fact, over the past three decades, the proportion of unintended pregnancies that end in abortion has increased in countries that have many legal restrictions in place. For 2015-2019, almost half of unintended pregnancies (46%) were aborted in countries where abortion was restricted (often severely) and a little over two-thirds (70%) in countries where abortion is accessible. 

In the three regions where around 40-50% of with unintended pregnancies have restricted access to abortions, overall abortion rates per 1,000 women of reproductive age differ by less than 2 abortions per 1,000 from those in countries (or US states) without restrictions. These are the USA (11 versus 13 per 1,000), the Returned West (11 versus 10 per 1,000) and Latin America (30 versus 31 per 1,000). The Returned West consists of former Soviet-bloc countries that have joined the EU, and the largest of these, Poland, is the only one to have restricted abortion, prohibiting it for fetal impairment, economic or social reasons, or on request.

The figures presented above suggest that the illegalization of abortion will not substantially reduce its incidence.  Over recent decades, most of the changes to the legal grounds for abortion have been in the direction of recognizing women’s rights to reproductive autonomy (recent examples include Ireland, Argentina, Mexico and Columbia). Removal of a right that women have had for 50 years in the USA is an entirely different situation.

The increasing restrictions in the USA are one of the few examples of major reductions in women’s rights occurring outside the Islamic countries where religious extremists have taken control of government. In the case of the USA, these changes are to rights that women have had for half a century and are being driven by an anti-democratic coalition of white nationalists and religious extremists who do not represent the majority views of the population. A recent issue of the Economist identified white evangelicals as the one major group with majority opposition to the legal availability of abortion. A majority of Catholics, mainline Protestants and those with no religious identification think that abortion should be mostly or always legal in the USA, and support is over 75% for Jewish, atheists and non-religious with college education.

Reproduced from: Religion, not gender, is the best predictor of views on abortion.The Economist, May 7th 2022.

The rhetoric of some US extremists, and actions already taken to restrict health insurance coverage for contraceptive use, suggests that further restriction on abortion access may well also be accompanied by further reductions in contraceptive availability. The unintended pregnancy rate may well increase, resulting in an overall increase in numbers of abortions occurring, even if the restrictions reduce the percentage of unintended pregnancies that end in abortion.

In my next post, I will examine differences in maternal mortality across countries and the extent to which they are associated with legal restrictions on abortion.

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Projections of global deaths from 2016 to 2060

Sixteen years ago, I published a paper in PLoS Medicine with detailed projections of deaths by age, sex and cause for all regions of the world, from year 2002 to 2030.  That paper has proved very popular, with over 14,100 citations to date. Following the release in 2018 of the latest WHO update of causes of death for years 2000-2016, I carried out another update of projected global causes of death, extending the projections for the first time beyond 2030 to 2060.

These projections were also released on the WHO website in 2018 along with documentation describing the methods used. In the original projections, separate projection models were developed for HIV/AIDS, tuberculosis, lung cancer, diabetes mellitus and chronic respiratory diseases. As well as revisions to these models, additional special projection models were developed for malaria, maternal deaths, road injury, homicide, natural disasters and war and conflict.

I recently wanted to check up on some of the methods used, and discovered that the projections are no longer available on the WHO website. During my two decades with WHO, I always tried to ensure that older versions of WHO statistics and the methods used to produce them were archived on the WHO website in such a way that they continued to be available.  This is important as WHO statistics get quoted and cited by many other publications and websites, and it is immensely frustrating when they cease to be available for anyone wanting to follow up citations of them. Particularly for global health statistics which are regularly or irregularly updated, it is important for transparency and replicability that revised data and methods can be compared with earlier versions.  For this reason, the 2016-2060 projections and methods paper have been made available for download here. While the projections are outdated now, and also don’t take into account the impact of the Covid-19 pandemic, the novel methods developed for specific causes may also be of interest, particularly for road injury, natural disasters and conflicts.

Global mortality 2016-2060 — Business-as-usual scenario

See here for a previous post giving an overview of the projection results. These projections are “business-as-usual” projections under specified assumptions that do not specifically take account of trends in major risk factors apart from tobacco smoking, and to a limited extent, overweight and obesity. The downloadable spreadsheets includes point estimates for projected deaths by region, cause, age and sex under a business-as-usual scenario for projected covariates. Explicit uncertainty ranges were not included here, uncertainty in projections is better conveyed through comparison of optimistic and pessimistic scenarios with varying input assumptions (these were carried out but not released).

The number of significant figures displayed in worksheet cells in the Excel workbooks do not provide  information on uncertainty ranges of projected estimates. The base scenario does not necessarily represent the best predictions or potential range of future global and regional health trends; it is possible that more sophisticated causal models incorporating projections of important determinants may provide better predictions for specific diseases.

Apart from synchronising the new projections with the 2016 cause of death estimates, the cause-specific trends in the near term are synchronized with estimated recent trends over the last 10 to 15 years. In the longer term, broad trends are largely driven by projection equations which model the epidemiological transition from infectious to non-communicable diseases in terms of projections of average income per capita, average years of education, time, and for some causes also projections of smoking impact. At the global level, age-standardized death rates for most important causes are falling with time, faster in most cases for infectious, maternal and perinatal causes than for non-communicable diseases (see figures below). The main exceptions are for diabetes, breast cancer and road injuries. The specific projection model for diabetes is based on projections of the prevalence of overweight and obesity and that for road injury is based on projections of vehicles per capita with continued economic development.

IHD = Ischaemic heart disease, COPD = Chronic Obstructive Pulmonary Disease,
ARI = Acute respiratory infection (mainly pneumonia), TB = tuberculosis

However, for many of these causes, the total projected deaths are rising with time because of population growth and ageing. Only the relatively fast declining infectious, maternal and perinatal causes are likely to also have declining total numbers of deaths (see the following two figures).

The projections of deaths by cause are not intended as forecasts of what will happen in the future but as projections of current and past trends, based on certain explicit assumptions. The methods based the disease burden projections largely on broad mortality projections driven by projections of future growth in income and increases in human capital in different regions of the world, together with a model relating these to cause-specific mortality trends based on the historical observations in countries with death registration data over the last 60 years. The results depend strongly on the assumption that future mortality trends in poor countries will have a similar relationship to economic and social development as has occurred in the higher income countries. If economic growth in low income countries is lower than the forecasts used here, and global warming results in additional adverse impacts on economic and social development, then the world may achieve slower progress and widening of health inequalities.

Projected global deaths in 2030 and 2060 under the business-as-usual scenario  are 68.2 million and 101.8 million respectively. Projected global deaths in 2030 under the UN medium variant projections of the World Population Prospects 2017 (WPP2017) are 2% higher in 2030 at 69.5 million and 0.7% lower at 101.1 million in 2060. These global projections for all-cause mortality are remarkably close to the UN projections given that these are the sum of independent projections for 20 separate cause groups, whereas the UN projections are based on estimated trends in all-cause mortality and fertility. The results are also very similar for all regions except the South East Asian Region and the African Region.  For the South East Asian Region, the UN projections are higher, with 3.5% more deaths in 2030 rising to 12% more deaths in 2060. For the African Region, the UN projections are slightly higher in 2030 but by 2060 are 12% lower.

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Australia now has one of the highest Covid new case rates in the world

In the last two weeks, Australia has gone from having one of the lowest rates of new Covid cases per million population in the world to one of the highest. Most of these new cases are in NSW and according to the Guardian today, if NSW were a country it would be in the top 10 for new cases notified per million population.

The plot below shows my selection of European countries plus USA and Australia. Australia for the first time is now in with the crowd, currently sitting between the rate for Germany and the Netherlands. I’ve also added the 7-day rolling average for NSW to 30 December, which puts it between Switzerland and the USA.  Based on the daily new cases reported for NSW today (31 December, https://covidlive.com.au/nsw), the NSW rate has jumped to 2,580 per million today. Figures for today are not yet available for Northern hemisphere countries, but I suspect NSW rate has jumped above all the countries in the plot except Denmark and possibly the UK.

The good news is that hospitalizations and deaths remain low compared to previous waves, and the booster dramatically lowers Covid risk.

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Update on Swiss Covid-19 situation

Switzerland now has the third highest daily new confirmed cases per million (averaged over last 7 days) at 1,045 per million. This is exceeded only by Denmark (1,417) and Slovakia (1,130).  The UK is not far behind Switzerland at 990. At least the daily new death rate per million (7 day average) is quite low for Denmark (1.43) and Switzerland (2.69) compared to many countries (eg. USA and Germany both 3.9 per million). The comparability of these figures is influenced by differences in testing rates and differences in data collection, definitions etc.

Apparent case fatality rates are low for Switzerland, UK and Denmark at 0.25% or lower. Germany and Slovakia have higher rates at around 0.7% and the USA even higher at 1.1%. Based on the limited genetic analyses available, omicron still accounts for only a few per cent of cases, ranging from 1% in USA to 4% in Slovakia, and all the rest is essentially delta now.

The Swiss government is tightening restrictions from 20 December onwards. For settings where it is not possible to wear a mask or be seated, you must be fully vaccinated or recovered within last 4 months, or provide a negative test. Working from home will be mandatory.

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Values and religion in 2020: an updated map

In my previous post, I presented results for an updated version of the latent variable analyses I carried out last year on data from the World Values Survey and European Values Study [1-4]. I have re-estimated a latent variable for religiosity on a continuous scale running from very religious (low values) to non-religious and atheist (high values) and also a latent variable for values running from strongly pre-modern values (low) to modern values (high).  I estimated these values for 110 countries for years from 1980 to 2020. The map below plots these countries according to their latent variable values for modernity (horizontal axis) and religiosity (vertical axis). The colours indicate culture zone and the shading roughly indicates the main domain of countries in each culture zone. Moving downwards to the right on this graph indicates increasing modern values and decreasing religiosity. The inspiration for this map presentation was the culture zone maps produced for earlier waves of these surveys by the political scientists Ronald Inglehart and Christian Welzel [5].

The North America culture zone includes only two countries, the USA and Canada. It is clear from the map that Canada belongs with the Reformed West countries in contrast to the USA, which sits in the Old West zone close to Italy, and also not far from three South American countries: Argentina, Chile and Uruguay. Malta and Cyprus are also outliers for the Old West culture zone, with higher levels of religiosity and less modern values. Along the decreasing religiosity-increasing modernity axis, Qatar is at the top end and Sweden at the bottom end. China is an outlier to the lower left, with the lowest level of religiosity of all the countries, but also a modernity value towards the middle of the scale between modern and pre-modern.


  1. Inglehart, R., C. Haerpfer, A. Moreno, C. Welzel, K. Kizilova, J. Diez-Medrano, M. Lagos, P. Norris, E. Ponarin & B. Puranen et al. (eds.). 2014. World Values Survey: All Rounds – Country-Pooled Datafile Version: https://www.worldvaluessurvey.org/WVSDocumentationWVL.jsp. Madrid: JD Systems Institute.
  2. Haerpfer, C., Inglehart, R., Moreno,A., Welzel,C., Kizilova,K., Diez-MedranoJ., M. Lagos, P. Norris, E. Ponarin & B. Puranen et al. (eds.). 2020. World Values Survey: Round Seven–Country-Pooled Datafile. Madrid, Spain & Vienna, Austria: JD Systems Institute& WVSA Secretariat[Version: http://www.worldvaluessurvey.org/WVSDocumentationWV7.jsp].
  3. Gedeshi, Ilir, Zulehner, Paul M., Rotman, David, Titarenko, Larissa, Billiet, Jaak, Dobbelaere, Karel, Kerkhofs, Jan. (2020). European Values Study Longitudinal Data File 1981-2008 (EVS 1981-2008). GESIS Datenarchiv, Köln. ZA4804 Datenfile Version 3.1.0, https://doi.org/10.4232/1.13486.
  4. EVS (2020): European Values Study 2017: Integrated Dataset (EVS 2017). GESIS Data Archive, Cologne. ZA7500 Data file Version 3.0.0,doi:10.4232/1.13511
  5. Ronald Inglehart; Chris Welzel. “The WVS Cultural Map of the World”. WVS. Archived from the original on October 19, 2013.

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Modern and pre-modern religious values: an update

In a previous post, I developed a continuous latent variable for pre-modern/modern religious values based on data for waves 5 to 7 country surveys in the  World Values Survey (WVS) and European Values Study (EVS). I used this data to estimate average values of the latent variable for 104 countries for the period 2017-2020. I have recently re-analysed the combined updated IVS dataset released earlier this year [1-4]. In a recent post, I presented revised estimates for trends in the prevalence of atheism and religiosity. The main revision to the dataset was to correct an error in the data for the USA which had led to overestimates of atheism prevalence in my original analysis.

My earlier post discusses in some detail the conceptualization and operationalization of modern and pre-modern religious values. I will give a very brief overview of this in terms of Kohlberg’s three stages of moral development. Stage 1 moral values and  related religious values focus on absolute rules, obedience and punishment and an individual is good in order to avoid being punished. In stage 2, the individual internalizes the moral standards of the culture and is good in order to be seen as a good person by oneself and others. Moral reasoning is based on the culture’s standards, individual rights and justice. In stage 3, the individual becomes aware that while rules and laws may exist for the greater good, they may not be applicable in specific circumstances. Issues are not black and white, and the individual develops their own set of moral standards based in universal rights and responsibilities. As moral values evolve through the three broad stages, the size of the in-group (“us”) with which an individual identifies typically expands from tribe to ethnic group or nation to all humanity.

Because pre-modern religious teaching is expressed and interpreted in mythic terms, it may appear to conflict with scientific understanding of the natural world. A person with pre-modern values may thus reject scientific findings, whereas another with modern values will understand that the myths communicate aspects of the human condition, but are not to be interpreted literally, and that the domain of religion relates to meaning, values, ethics, and does not generally conflict with the domain of science.

In revising my analysis of pre-modern versus modern religious values, I have slightly revised the set of IVS questions used to construct the latent variable. I dropped the question concerning belief in heaven and added a question concerning sexual freedom (approving of sex before marriage). Belief in heaven is highly correlated with belief in hell but has a somewhat higher population prevalence and is less discriminatory between modern and pre-modern values. In constructing the previous version of the modernity latent variable, I argued that sexual freedom issues were associated with the pre-modern values of the era when high fertility was important to ensure some children survived to reproductive age, and societies thus discouraged divorce, abortion, homosexuality. I excluded sexual freedom questions from the analysis on the grounds that the demographic transition to low child mortality, low fertility and widespread availability of reliable contraception is very recent and values are still changing in this domain. However, this is actually an argument to include at least one sexual freedom variable as a sensitive indicator of modern versus pre-modern values.   

I have revised the estimation of the modernity latent variable (referred to hereafter as “modernity”) based on the categorical responses to the 12 questions shown in the following plot. This plot shows the item response cut-points for these questions on the estimated latent variable scale. The analysis was implemented as an ordered probit model using the stata procedure gsem for generalized structural equation models. The model was fit to the entire IVS dataset, not just the most recent survey waves 5 to 7 as previously.

For ease of presentation in the following plots, I applied a linear transformation of the estimated modernity values latent variable by multiplying it by 6 and adding 4.5. This resulted in the average value of the latent variable  at country level ranging from 0.28 for Pakistan to 9.54 for Sweden in the year 2020. At individual level, 90% of values of the values latent variable for all respondents in all surveys fall in the range –0.21 to 9.60 with a median value of 4.52.

There is a general trend of increasing modernity in the culture zones associated with Western Europe, the Americas, Australia, New Zealand and former Soviet regions, excluding the Orthodox East.  I have grouped these together as a single larger zone labelled “West” and the other regions are grouped as “East”. The following plot shows the trend in modernity (population average) for West and East from 1980 to 2020. There is a sustained increase in modernity in the West at a close to linear rate of increase over time. Despite the flat trend in the Sinic East and Orthodox East, the overall trend in the East is decreasing modernity with a somewhat faster decline during the years 2005-2010. These two trends largely cancel each other out, so that at the global level there has been little change in the average level of modern versus pre-modern values over the forty year period.

In every culture zone, practicing religious people have the lowest score for modern religious values, ie the most pre-modern values) and modern religious values increase with decreasing levels of religiosity. The variation across culture zones is approximately as substantial as the variation across religiosity categories.  To examine the combined evolution over time of religiosity and modern religious values, I also recomputed the religiosity latent variable that I previously estimated (see here). I also applied a linear transformation of the estimated religiosity latent variable by multiplying it by -1.22 and adding 5. This also reversed the direction of religiosity so higher values are associated with lower levels of religious belief and behaviour. This resulted in the average value of religiosity  at country level ranging from 9.6 for Ethiopia to 1.55 for Sweden and 0.20 for China in the year 2020. At individual level, 90% of values of religiosity for all respondents in all surveys fall in the range –2.2 to 11.2 with a median value of 4.9.,

The following plot shows the co-evolution over time for religiosity and modernity by culture zone from 1980 to 2020. For most regions, religiosity and modernity have evolved towards the upper right. Those regions where it has evolved in a different direction have arrows indicating the direction of time. For the Reformed West, Old West, Returned West, North America and Latin America, modernity has increased over time with religiosity (ie. with reducing religious belief and practice) at almost the same rate across all these regions. The Orthodox East in contrast has experienced a change in religiosity towards increasing belief (non-practicing) at the same time as modernity has slightly increased. This reflects the fact that in this culture zone in the post-Soviet period, “orthodoxy” has become an expression of national identity rather than increased religious belief/practice. The Sinic East has experienced some reduction in religious belief/practice, with little change in modernity.

In contrast, the Islamic East, Indic East and Sub-Saharan Africa have all evolved in the opposite direction towards higher prevalence of pre-modern religious values and greater religious belief/practice.  As a result, there has been negligible evolution of religiosity and modernity at the global average level.

Note on uncertainty

These plots, and the country or culture zone comparisons show broad patterns but specific small differences should not be over-interpreted. I have not attempted to estimate uncertainty ranges for these statistics because for surveys implemented in many countries by different study teams the most important contributors to uncertainty of statistics are generally not the survey sample size or sampling issues but other less quantifiable differences in survey implementation, design and translation. Also important and difficult to quantify are differences in translation, interpretation and choice of question response categories in different populations. Most of the IVS surveys are representative samples of adults with sample size ranging between 1 and 2 thousand.  This is quite similar to the typical national opinion poll where uncertainty of statistics is typically around 2 or 3 percentage points.

There are a substantial number of countries where the WVS and EVS both conducted a survey in the same wave. I’ve assessed the median difference between the two surveys for a country to provide some quantification of the typical variation induced by sampling methodology, survey design and implementation. It will not include cross-national differential response associated with language, translation and response category cut-point shifts.

For the religiosity categories at country-level, average prevalences differ by around a median 10% (relative difference). This drops to around 5% at culture zone level.  There is an additional layer of uncertainty added in the estimation of latent variables due to the uneven prevalence of missing questions and values across survey waves, with generally large proportions of missing values in earlier survey waves. So smaller differences and trends in results shown here should not be over-interpreted.


  1. Inglehart, R., C. Haerpfer, A. Moreno, C. Welzel, K. Kizilova, J. Diez-Medrano, M. Lagos, P. Norris, E. Ponarin & B. Puranen et al. (eds.). 2014. World Values Survey: All Rounds – Country-Pooled Datafile Version: https://www.worldvaluessurvey.org/WVSDocumentationWVL.jsp. Madrid: JD Systems Institute.
  2. Haerpfer, C., Inglehart, R., Moreno,A., Welzel,C., Kizilova,K., Diez-MedranoJ., M. Lagos, P. Norris, E. Ponarin & B. Puranen et al. (eds.). 2020. World Values Survey: Round Seven–Country-Pooled Datafile. Madrid, Spain & Vienna, Austria: JD Systems Institute& WVSA Secretariat[Version: http://www.worldvaluessurvey.org/WVSDocumentationWV7.jsp].
  3. Gedeshi, Ilir, Zulehner, Paul M., Rotman, David, Titarenko, Larissa, Billiet, Jaak, Dobbelaere, Karel, Kerkhofs, Jan. (2020). European Values Study Longitudinal Data File 1981-2008 (EVS 1981-2008). GESIS Datenarchiv, Köln. ZA4804 Datenfile Version 3.1.0, https://doi.org/10.4232/1.13486.
  4. EVS (2020): European Values Study 2017: Integrated Dataset (EVS 2017). GESIS Data Archive, Cologne. ZA7500 Data file Version 3.0.0,doi:10.4232/1.13511
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Covid-19 booster shots and the Delta variant

Switzerland is now offering a Covid-19 booster shot to to the 65+ and at-risk who has had their two Covid-19 vaccinations at least six months ago. It may soon be extended to all adults. I had my third shot last Thursday with no side effects (not even a localized sore spot) and was surprised to receive a Pfizer booster after being fully vaccinated earlier this year with the Moderna vaccine. The mRNA in both vaccines encode the same S-2P protein which differs from the covid19 spike protein by two amino acids only. These stabilize the spike protein so that it can train the immune system before it enters the host cell (see here for details).

However, they differ in the “packaging” regions around the actual genetic code for the protein. These leader and trailer regions are responsible for initiating and regulating the translation of the mRNA to produce the protein which stimulates an immune response. The other major difference between the two vaccines is that there is a much larger dose of vaccine (100 mg) in a Moderna dose compared to a Pfizer dose (30 mg). While the initial protectiveness of both vaccines is similar at around 94-95%, there is some evidence that the protectiveness may decline at a somewhat slower rate for Moderna than Pfizer.

There is also evidence that getting a different booster shot that the vaccine you originally received actually enhances the immune response more than getting the same type of vaccine for a third dose (see here and here). There is a small advantage mixing the two mRNA vaccines (Pfizer and Moderna) as I have done,  and a substantially enhanced immunogenicity when non-RNA vaccines (eg. Astrozenica or Johnson and Johnson).

So how effective is the booster shot? A large study published in the New England Journal of Medicine in October compared outcomes in 1.14 million Israeli adults aged 60 years and over who had received two Pfizer doses at least 5 months earlier, of whom around half received a Pfizer booster shot and the other half did not. The analysis controlled for possible confounding factors including age, sex, demographic group and the date of the second vaccine (to ensure there were not differences in the time since second vaccine between the control and booster group).

The results were dramatic. At least 12 days after the booster dose, the rate of confirmed infection was lower in the booster group than in the nonbooster group by a factor of 11.3; the rate of severe illness was lower by a factor of 19.5. These findings clearly show the effectiveness of a booster dose even against the currently dominant delta virus. Recent reports have suggested that the efficacy of a vaccine administered 6 months earlier  against the currently dominant delta virus is reduced by approximately 50% compared to the post-vaccination efficiency of 95% against the alpha variant (see here, here and here). So the susceptibility to the delta variant of a person who has received the third dose would be reduced from around 50% to 5%, and even less if they receive a different vaccine than their first two shots.

On July 30, 2021, Israel was the first country in the world to make available a third dose of the BNT162b2 vaccine against Covid-19 to all persons who were 60 years of age or older and who had been vaccinated at least 5 months earlier. Since then, Israel has extended the booster program to the entire population. The following graph shows trends in vaccination rates and booster doses for Israel and Austria (as a typical example of a Western European country). The fully vaccinated rate (two doses) is essentially identical for the two countries from August onwards at a little over 60%. Booster doses per 100 people rose from zero at the end of July to over 40 per 100 currently.

The next graph shows the daily new cases per million for Israel and Austria (which is currently experiencing one of the largest increases in Delta cases in western Europe).  Israel had a huge spike in infections this summer due to the highly infectious Delta strain, together with a combination of waning immunity five or six months after the second jab. Its clear that the booster shots were definitely a game changer.  Over time, there was a very steep reduction in infections, hospitalizations and deaths among the people that got the booster shot. Israel went from over 11,000 new cases a day at the peak, down to a few dozen today. Before the booster campaign started hospitalizations were rising among vaccinated people whose immunity had waned, but the overwhelming majority of hospitalizations now are of people who are unvaccinated.

The same combination of waning immunity and Delta are now causing rising cases in Europe, as illiustrated in the following plot. Austria, Belgium and the Netherlands are currently the hardest hit (see graph below), with average daily new cases well over 1,000 per million, higher than any previous wave. In most of the countries on this graph, fully vaccinated rates are somewhere between 60 and 75%. That means around 25 to 40 percent of these populations are unvaccinated and their much higher susceptibility to infection is driving the latest surge in Delta infections.

Germany, Austria and the German-speaking region of Switzerland have the largest shares of unvaccinated populations in all of Western Europe. About one in four people over 12 is unvaccinated, compared with about one in 10 in France and Italy, and almost none in Portugal.

Governments are struggling to address this shortfall in vaccination levels. Austria has introduced a lockdown for anyone over the age of 12 who is not vaccinated and foreshadowed compulsory vaccination for all adults. Germany is considering new restrictions and in Saxony the unvaccinated are already barred from non-essential shops and other locations. The Netherlands has flagged that they will move to full lockdown for the unvaccinated but not the vaccinated. Switzerland has a referendum next weekend on whether to continue with the vaccine mandate which allows only fully vaccinated people to go to theatres, restaurants, gyms and other indoor public venues.

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A fourth Covid-19 wave hits Europe and Switzerland has a second referendum to end vaccine certificate requirements

Covid-19 cases rose by 7% and deaths by 10% over the last week in Europe, as it enters a fourth (or fifth) wave and currently accounts for about two-thirds of infections reported globally. Belgium and the Netherlands, which have fully vaccinated 73-74% of their populations, have the highest new case rates in Western Europe, almost double those of Britain. The fully vaccinated rate is Switzerland is 64%, higher than the USA at 57% but lower than Australia now at 69%.

I drove past the UN Palais de Nations yesterday, which had a crowd of around 2000 anti-vaccination protesters outside it, apparently concerned about loss of “freedom”.  The Netherlands has just reimposed a partial lockdown to address the rapidly rising case numbers and Switzerland won’t be far behind if the protestors have their way. I am way more concerned about the potential loss of freedom of association, ability to work and earn money, for students to attend schools and universities, ability to participate in social, sporting and cultural events etc etc than the freedom of a minority to be evidence-averse idiots who incubate the virus to continue to spread it and make life difficult for the vaccinated (who still have a small but non-zero risk of catching Covid from the unvaccinated in which it is spreading like wildfire).

Later this month, Switzerland will be holding its second referendum in less than six months on the Covid-19 law under which the government has made the Covid-19 certificate compulsory since September 13 to access indoor spaces (movie theatres, gyms, restaurants etc). This law was accepted by 60.2% of voters on June 13, and opinion polls indicate it will be accepted again. The Covid certificate has allowed the (intelligent) population to return to an almost normal social life. I’ve gone to the cinema, been training at the gym mask-free, and met up with friends for coffee, lunch or dinner.  All at risk if the anti-vax people get more support than before. The proposed revisions to the law also put other covid initiatives at risk. If passed, they would end government financial support for big events and end all government funding programs for the development of drugs or other important medical goods.

While death rates are substantially lower than in previous waves, death rates are starting to rise reflecting rising case rates. And apart from death, there is significant disability with “long-Covid” which affects a significant proportion of people who are infected.

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Religiosity and atheism: revised estimates for 1980-2020

In previous posts, I have summarized various analyses of the World Values Survey (WVS) and the European Values Study (EVS), altogether including more than 110 countries, and focusing on trends and differences religious affiliation, religious beliefs and practices, as well as traditional and modern values.  I examined the prevalence of religious people, non-religious people and atheists across 110 countries in 2020 here, and trends from 1980 to 2020 here.

Checking in on the World Values website earlier this year, I discovered that the World Values Survey dataset has been updated to fix some errors in the coding of data for. Some data collected using a mobile phone app in the most recent US survey was incorrectly coded and this mainly affected the religiosity categories.  Comparison of the US prevalences for religiosity show that the coding errors resulted in an overestimate of the atheist and non-religious categories as shown in the following table:

Comparison of religiosity prevalence estimates
 for USA in year 2020

This post provides updated estimates of religiosity levels and trends for countries, regions and world based on the 2021 release of the combined data for the WVS and EVS in the Integrated Values Surveys (IVS) 1981-2021 [1-3]. In carrying out these updates, I also addressed some definitional issues which have resulted in mostly slight changes to estimates for other countries.

The atheist and other categories of religiosity are constructed from the following survey questions:

Survey questionResponse categories
Are you a religious person?A religious person / Not a religious person / A confirmed atheist
Importance [in life: religion] Very, Rather / Not very / Not at all
How often do you attend religious services?More than once a week / Once a week / Once a month / Only on special holy days / Once a year / Less often / Never, practically never
Pray to God outside of religious services?More than once a week / Once a week / At least once a month / Several times a year / Less often / Never
Belief in godYes / No / Don’t know
Importance [in life: God]1 (Very important), 2…9, 10 (Not at all important)
Religious affiliationNone, 9 or more religion/denomination categories, Other

Estimates of atheism prevalence based on WVS/EVS, or the Pew or Gallup surveys addressing this question often quote statistics based on question categories such as “confirmed atheist” or “not religious” or “religion: none” (see Wikipedia for more information on these). The first of these provides low estimates of overall atheist prevalence, since the qualifying adjective “confirmed” will result in many atheists avoiding this category. In the full IVS dataset (645,249 respondents), 5.5% of respondents said they were “confirmed atheists” whereas 13.3% stated they did not believe in God and a further 3.2% did not know whether they believed in God (note these figures are unweighted for sampling or country population size at this stage). In contrast, the “non-religious” and “religion: none” categories will include theists who have rejected organized religion as well as atheists.

I suspect the term “confirmed atheist” is intended to exclude agnostics (who say they don’t know whether God does or does not exist. I prefer to use the modern widely accepted definition of atheism as “lacking belief in God or gods”. This will include gnostic atheists (those who say they know gods don’t exist) and agnostic atheists (those who say they don’t know whether God or gods exist and lack a belief in any). So for the belief in God question I have recoded “Don’t know” to “No”, as a person is highly unlikely to have a belief in God which they don’t know about. This resulted in an overall distribution of 79%  Yes, and 21% No (comprised 16.8% No and 4.0% recoded Don’t know).

There is an additional complexity in defining religiosity for people who are affiliated with non-theist religions such as Buddhism, Jainism, or Confucianism. This mainly relates to Asian countries, as the proportion of people who are belong to non-theist religions is generally small in other regions. The religiosity categories I defined for previous analyses moved practicing and non-practicing non-theist religious people from the atheist category to the relevant religious categories, meaning that the atheism category essentially excluded atheists who practiced non-theist religions. Asian religious practice tends to be syncretic, so for example, many people in Japan practice follow both Buddhist and Shinto religious practices. Additionally, in some cultures and non-theist religious traditions, there are mythic gods and for many people, the historical Buddha is essentially considered to be a god. In the IVS dataset, 61% of Buddhist say they believe in God, and 39% say they do not believe in God.

To obtain a complete estimate of the prevalence of atheism (those who lack a belief in God or gods), I have assigned all people who do not believe in God to the atheist category. This will thus include some religious people who practice non-theist religions. The practicing religious and non-practicing religious categories who thus be understood to refer to religious practice/belief including a belief in God or gods, including some but not all followers of non-theist religious traditions.

The four religiosity categories have thus been defined as:

Practicing religious person: A religious person who believes in God and is practicing*, OR a non-religious person who believes in God, is practicing, and rates the importance of God in range 1-5.

Non-practicing religious person: A religious person who believes in God and is non-practicing OR a non-religious person who believes in God, is non-practicing, and rates the importance of God in range 1-6.

Non-religious: A non-religious person who believes in God but rates the importance of God as 7-10 at the not important end of a 10-point scale.

Atheist: A “confirmed atheist” and/or does not believe in God

* Respondents are classified as “practicing” if they attend religious services or pray to God outside of religious services at least once a month. Otherwise, they are classified as non-practicing.

For the 110 countries with IVS survey data for years 2000 or later, the prevalences of the four religiosity categories across survey waves were projected forward to 2020 (Endnote a). The following plot shows the estimated prevalence of all religiosity categories in 2020 for countries ranked in descending level of irreligion (atheist + non-religious).

There are 18 countries where more than half the population are estimated to be atheist in 2020. These include China,  South Korea, Japan, Vietnam and Thailand, all Asian countries with Buddhist and non-theist religious traditions. They also include all the Scandinavian countries and European countries such as France, the Netherlands and the United Kingdom, as well as Australia and New Zealand.     At the other end are six countries where the prevalence of irreligion is estimated at less than 1% of the population.

Full time series of religiosity trends from 1980 to 2020 were imputed for the 110 countries using the same methods as developed for the earlier analyses (see endnote a). The updated trends are generally similar to those previously posted (see here), except for the USA. The revised data for the USA shows that the prevalence of atheism has increased rapidly in the 21st century from around 6% to almost 23% in 2020 and the prevalence of non-religious has also increased from 2.2% to 6.9%. 

The prevalence of irreligion (atheists and non-religious) has increased in the USA by an estimated 21.5 percentage points over the last two decades, the fourth largest increase of any country included in this analysis. The largest increase occurred in neighboring Canada with a 36.7% increase since year 2000.  Apart from two Asian countries (South Korea and Singapore) and Hong Kong, all the other countries in the top 20 for increase in irreligion since 2000 are high income countries. And apart from Chile, Australia and New Zealand, all of these are in Europe and North America.

To compute regional and global trends in religiosity, I have also imputed religiosity for 75 countries not included in the IVS using data from Win/Gallup and Pew Research Centre surveys (Endnote b). These 75 mostly small countries (apart from in Africa) account for 8% of the world population, mostly in the Islamic East and Sub-Saharan Africa (23% and 41% respectively of the populations of those regions).

I have computed revised trends for the 11 culture zones used in previous posts. These are based on those originally defined by Welzel [4], with one modification. Because Australia’s and New Zealand’s culture values are much closer to the countries of the Reformed West than to those of the USA and Canada, I have included Australia and New Zealand in the Reformed West and renamed the New West as North America (see Endnote c for details). In summary, these are:

Reformed West — Western European societies strongly affected by the Reformation;
North America — USA and Canada;
Old West — Mostly Catholic parts of Western Europe being core parts of the Roman Empire;
Returned West — Catholic and Protestant parts of post-communist Europe returning to the EU;
Orthodox East — Christian Orthodox or Islamic parts of the post-communist world, mostly parts of former USSR;
Indic East — Parts of South and South East Asia under the historic influence of Indian culture;
Islamic East — Regions of the Islamic world formerly parts of the Arab/Caliphate, Persian and Ottoman empires;
Sinic East — Parts of East Asia under the historic influence of Chinese culture ;
Latin America — Central and South America and the Caribbean;
Sub-Saharan Africa — African countries south of the Sahara.
Oceania — Pacific Island states with predominantly Melanesian and Polynesian populations

The following plots show estimated religiosity trends for the world as a whole and for these 11 culture zones:

These plots illustrate the extreme diversity of religiosity trends across regions. Western countries (Reformed West, Old West, North America) are characterised by rapidly rising prevalence of atheism and corresponding decline in practicing religious. The former Eastern bloc countries (Returned West, Orthodox East) are characterised by a large drop in atheism prevalence and corresponding rise in religious categories following the collapse of the Soviet Union around 1991. More recently, atheism is rising and practicing religious falling in the Returned West, following a similar path to that taken by Western Europe.

The Orthodox East has had continuing decline in atheism and the non-practicing religious have become the dominant group at around 55% of the population, far more than the practicing religious. A 2018 Pew Research Center Report [5] examined this more closely and found that for most people in the former Eastern bloc, being Christian (whether Catholic or Orthodox) is an important component of their national identity, with many people embracing religion in the post-Communist period as an element of national belonging, even though they are not highly religious.

Latin America, the Islamic East and Sub-Saharan Africa are the “religious” culture zones characterised by very high prevalences of practicing and non-practicing religious people and very low prevalences of non-religious and atheists. The Indic East also has very low prevalences of the irreligious, but in contrast to the other “religious” zones, has had a shift from practicing to non-practicing religious. This may very well be largely reflecting the increasing levels of Hindu nationalism in India.

Iran and other Islamic countries generally report very low levels of atheism, 2.4% on average, and I suspect this is lower than reality because of the quite severe social and legal consequences in many Islamic countries. The WVS uses telephone interviews and its quite likely irreligious respondents would be fearful of being identified if they respond honestly to a telephone interview. A recent internet survey provides some support for this concern. A June 2020 internet-based survey collected responses from 40,000 Iranians living in Iran. Respondents took part in the survey anonymously, and would have felt safer to express their real  opinions than in telephone surveys or surveys conducted at respondents’ residence.

The contrast with the results of the most recent 2020 World Values Survey for Iran are extreme. The latter found that 43% of Iranians are practicing Muslims (similar to the online survey estimate for total Muslims, 53% are non-practicing and only 1.5% say they do not believe in God. In the WVS, 91% say they believe in life after death, 92% believe in heaven and 88% believe in hell. The online survey found that over 60% said they did not perform the obligatory daily Muslim prayers. This is in the same ballpark as the 53% who were classified as non-practicing in the WVS.

Reading between the lines of the WVS, and taking into account the severe consequences of being apostate or atheist in Iran, it supports the conclusion of Arab and and Maleki [6] that Iran is becoming much more secular. Around 53% of respondents in their online survey reported coming from practicing religious families but losing or changing their religion in their lifetime. This increasing secularity is also supported by the evidence of dramatic declines in the fertility of Iranian women over recent decades, with population growth in 2020 dropping below 1%. It’s quite likely that real levels of irreligion are higher in many other Islamic countries than the survey data suggest.

The Sinic East is of course dominated by China. Around 1980, apparently equal numbers of people in this region identified as atheist and non-religious. There has been a dramatic drop in the non-religious prevalence with a corresponding rise in the prevalence of atheism. The overall prevalence of irreligion has remained fairly stable and high. Its difficult to know what to make of this, or whether it reflects any real change, given the possibility that the Chinese language version of the WHS questions may have changed in some way over time, or their interpretation has changed given the overall lack of fit of the WVS religious questions with the non-theist religions that are most common in China.

At global level, the prevalence of practicing religious has barely changed over the last 40 years, as has the prevalence of atheism, but there has been a shift from non-religious to atheist and to non-practicing religious, the latter reflecting mainly the change in former Soviet bloc countries. The relatively small changes in prevalence of religiosity at global level over the last 40 years conceal quite substantial changes in developed countries and in former Soviet countries, in opposing directions. The following table summarizes global changes in the prevalence of religiosity categories over the 40-year period 1980 to 2020.

The overall global prevalence of irreligion (atheist plus nonreligious) has declined somewhat, but a substantially higher proportion of the irreligious identify as atheist in 2020 compared to 1980. Is irreligion likely to increase in the future. If the economies of developing countries continue to grow, with decreasing levels of poverty, and education levels continue to improve, it is likely that religiosity in these countries will decline in the longer term. But if the pandemic and global heating crises derail the historical development trends, then population growth due to the higher fertility levels of Islamic and African countries will ensure that the overall religiosity of the world will increase in the future. 

  If on the other hand, the very low levels of irreligion in Islamic countries and Africa do not increase, then the higher fertility levels of these regions will ensure that the overall religiosity of the world will increase in the future. In an era of joint global environmental and pandemic crises, with rising populism and rejection of science and global institutions, its entirely possible that the developing countries will not pass through the equivalent of the Western Reformation resulting in freedom of thought and religion and decreasing levels of premodern religious values (see previous post here).


a. Interpolation and projection of religiosity trends from 1980 to 2020

For countries with data for three or more waves of the IVS, trends in the prevalence of the four religiosity categories were estimated at country-level as follows:

  1. Values for single missing waves between two other waves were estimated using the geometric average for the two waves with data
  2. For countries in the Returned West or Orthodox East, the average change in prevalence due to the breakup of the Soviet Union was estimated using the average for those countries with data for the first wave in the 1980s and the second wave in the 1990s. This average jump was used to estimate values for the first or second wave for countries where one of these was missing.
  3. For countries where one or more early waves or one or more late waves were missing, prevalences were projected forwards or backwards using the median annual rate of change calculated at culture zone level for countries without missing waves.
  4. Population-weighted average trends were then calculated for each culture zone with the following two exceptions. For the Returned West and Orthodox East, prevalences were assumed constant prior to 1991. For Islamic East countries, flat trends were assumed from 1980 to earliest available data, as Turkey is the only Islamic country with data prior to 2000, and its trends are probably not representative.

For countries with data from only one or two waves, forward and back projections to 1981 and 2018 were made using the average trends calculated in step 4 above for each culture zone.

For projections from the Wave 7 survey year to 2020, a conservative approach was taken to avoid making extreme projections based on substantial differences between Wave 6 and Wave 7 estimates which may reflect variations in survey sampling or procedures rather than real change. For each country, the recent trend was estimated using data from survey waves in the period 2000-2020, with each earlier wave being given 15% less weight in the regression than the subsequent wave.  Average annual rates of change (aar) were also calculate from the Wave 6 and Wave 7 average prevalence estimates for each culture zone.

Where the regression aar were more extreme than the culture zone average aar, an average of the two was used for projection to 2020. Where the regression aar and the culture zone aar were of opposite signs, the regression aar was halved before use for projection. To be even more conservative, if the last Wave for a country was more than a year earlier than 2020, the rate of change from the survey year to 2020 was assumed to be aar1.5.

Finally, annual estimates for all years from 1980 to 2020 were prepared as follows:

  • Values prior to 1981 (the actual or projected first wave values) were assumed to be constant at the first wave values
  • Values beyond 2020 were also assumed to be constant at the 2020 value
  • Annual values between waves were estimated by linear interpolation
  • Annual values from 1980 to 2020 were smoothed using a 5-year moving average.

b. Imputation of religiosity for countries not included in the WVS/EVS.

Religiosity categories were imputed for 12 countries using data from Win/Gallup surveys for years 2012, 2015 and 2017 [7-9] which includes a question “Are you a religious person?” with the same response categories as the WVS/EVS question. These countries were Afghanistan, Cameroon, the Democratic Republic of the Congo, Cuba, Fiji, Kenya, Mongolia, Panama, Papua New Guinea, North Korea and South Sudan. Religiosity category prevalences for Israel were imputed from a Pew Research Centre survey which also included similar questions on religiosity [10].

For the remaining 63 mostly small countries, religiosity was imputed using culture-zone-specific regressions of the IVS religiosity prevalences against Pew Research Centre country-specific estimates for the year 2020 of religious affiliation distributions for 8 religious categories, including “other” and “none” [11].

c. Definitions of culture zones used to group countries

I am using the 10 culture zones defined by Welzel [4], with one modification. Because Australia’s and New Zealand’s culture values are much closer to the countries of the Reformed West than to those of the USA and Canada, I have included Australia and New Zealand in the Reformed West and renamed the New West as North America. The culture zones are defined as follows:

Reformed West — Western European societies strongly affected by the Reformation: Denmark, Finland, France, Germany, Iceland, Netherlands, Norway, Sweden, Switzerland, United Kingdom, plus Australia and New Zealand;
North America — USA and Canada;
Old West — Mostly Catholic parts of Western Europe being core parts of the
Roman Empire: Austria, Belgium, Cyprus, Greece, Ireland, Israel, Italy, Luxembrg, Malta, Portugal, Spain;
Returned West — Catholic and Protestant parts of post-communist Europe returning
to the EU: Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia;
Orthodox East — Christian Orthodox or Islamic parts of the post-communist world,
mostly parts of former USSR;
Indic East — Parts of South and South East Asia under the historic influence
of Indian culture: Bhutan, Cambodia, India, Indonesia, Laos, Malaysia, Maldives, Myanmar, Nepal, Pakistan, Philippines, Singapore, Sri Lanka, Thailand, Timor-Leste;
Islamic East — Regions of the Islamic world that have been parts of the Arab/Caliphate,
Persian and Ottoman empires;
Sinic East — Parts of East Asia under the historic influence of Chinese culture: China, Hong Kong, Japan, Macau, Mongolia, North Korea, South Korea, Taiwan, Vietnam;
Latin America — Central and South America and the Caribbean;
Sub-Saharan Africa — African countries south of the Sahara
Oceania — Melanesian and Polynesian countries: Fiji, Kiribati, Nauru, Palau, Papua New Guinea, Samoa, Solomon Islands, Tonga and Vanuatu.


  1. EVS (2021): EVS Trend File 1981-2017. GESIS Data Archive, Cologne. ZA7503 Data file Version 2.0.0, https://doi.org/10.4232/1.13736
  2. EVS/WVS (2021). European Values Study and World Values Survey: Joint EVS/WVS 2017-2021 Dataset (Joint EVS/WVS). JD Systems Institute & WVSA. Dataset Version 1.1.0, doi:10.14281/18241.14.
  3. Haerpfer, C., Inglehart, R., Moreno, A., Welzel, C., Kizilova, K., Diez-Medrano J., M. Lagos, P. Norris, E. Ponarin & B. Puranen et al. (eds.). 2021. World Values Survey Time-Series (1981-2020) Cross-National Data-Set. Madrid, Spain  &  Vienna,  Austria:  JD  Systems  Institute  &  WVSA Secretariat. Data File Version 2.0.0, doi:10.14281/18241.15.
  4. Welzel C. Freedom Rising. Human Empowerment and the. Quest for Emancipation. 2013. Cambridge: Cambridge University Press. https://www.cambridge.org/core/books/freedom-rising/80316A9C5264A8038B0AA597078BA7C6
  5. Pew Research Center, Oct 29, 2018. Eastern and Western Europeans Differ on Importance of Religion, Views of Minorities, and Key Social Issues. https://www.pewforum.org/2018/10/29/eastern-and-western-europeans-differ-on-importance-of-religion-views-of-minorities-and-key-social-issues/
  6. Arab TA, Maleki A. Iran’s secular shift: new survey reveals huge changes in religious beliefs. The Conversation, Sept 10 2020. https://theconversation.com/irans-secular-shift-new-survey-reveals-huge-changes-in-religious-beliefs-145253
  7. WIN Gallup International. Global Index of Religiosity And Atheism – 2012.  WIN-Gallup International. 27 July 2012.
  8. WIN Gallup International. Losing Our Religion: Two Thirds of People Still Claim to Be Religious. WIN/Gallup International. 13 April 2015. https://www.gallup-international.bg/en/33531/losing-our-religion-two-thirds-of-people-still-claim-to-be-religious/
  9. WIN Gallup International. Religion Prevails in the World. WIN/Gallup International. 10 April 2017. https://www.gallup-international.bg/en/36009/religion-prevails-in-the-world/
  10. Pew Research Center, March 8 2018. Israel’s Religiously Divided Society. https://www.pewforum.org/2016/03/08/israels-religiously-divided-society/
  11. Pew Research Center, April 2 2015. Religious Composition by Country, 2010-2050. https://www.pewforum.org/2015/04/02/religious-projection-table/2020/number/all/
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