Published on February 17, 2014
Abortion internationally: law and policy, services, and how the abortion pill is changing everything Marge Berer Editor, Reproductive Health Matters International Campaign coordination team ~~~~~~~~~~ 14 February 2014
Abortion: part of reproductive rights The need to control fertility is as old as history itself, and part of a much broader set of needs related to reproduction and sexuality, including being able to: have sex without fear of negative outcomes, have sex if and only if we want to and only when and with whom we want to, get pregnant, have the children we want, survive pregnancy in good health with a healthy baby, and have a safe abortion without fear of death or condemnation when pregnancy is unwanted.
One of the safest clinical procedures Abortion deaths are less than 1‒4/5 per 100,000 live births in North America, much of western Europe and NZ/Australia. It doesn't get any safer than that. Making abortion safe was one of the most important public health achievements of the 20th century. (Wendy Savage, BMJ, 2014)
Abortion in the criminal law With few exceptions, since the 19th century restrictions on abortion have existed in the criminal law or penal codes of most countries (in most cases spread via colonialism: e.g. British 1861 Act, French Napoleonic Code), covering at a minimum: the grounds on which an abortion is legal and/or illegal, up to what stage of pregnancy, who can determine whether an abortion is legal, who can authorise an abortion, and the criminal punishments for violating the law.
Legal grounds for abortion To save the woman’s life. Risk to the life, health and mental health of the woman greater than if the pregnancy were terminated. Fetal condition incompatible with life or fetal abnormality. Rape, incest or other sexual abuse. The woman’s social and economic situation and that of her existing children. At the woman’s request. Although legal does not equal safe, the more grounds on which abortion is legal, the fewer the complications and deaths. (Berer, RHM 2004; WHO 2008)
Deaths/legal grounds 160 countries (WHO in Berer 2004; updated World Health Report 2008)
Why different grounds? Grounds create gatekeepers Gatekeepers include: Providers (1-2-3 doctors) A hospital-appointed committee Partners Parents Grounds create barriers Grounds = control of women Only real ground should be "unwanted pregnancy".
Abortion laws in Europe Russia first to legalise abortion in 1920s, then all Soviet Union bloc. Poland went backward 1990+. Most laws permit abortion on request up to 12-14 weeks LMP, and on more limited, specific grounds after that, e.g. rape, fetal anomaly, risk to woman's health/life. (Spain, Portugal, Italy, France, Germany, Switzerland, Belgium, Netherlands, Norway, Denmark) In Belgium, the law changed long after the practice of abortion stopped being underground. The king, who was against abortion, abdicated his throne for 24 hours so that the bill could pass into law without his signature or his opposition. By early to mid-1980s, the law in most western European countries had changed. Portugal in 2006. Only to save woman's life in Malta.
Progress globally since 1997 Since 1997, at least 17 countries have liberalised their abortion laws, e.g. Guyana, St Lucia, Colombia, Uruguay, and Mexico City. At least 10 others increased access by speeding up the approval of facilities (India); expanding the cadres of providers (South Africa); expanding the range of methods (Ethiopia) or re-interpreting law to make more abortions legal (Thailand). (Boland & Katzive 2008) A few countries, e.g. Nicaragua, El Salvador, Dominican Republic, went backwards due to heavy pressure from the Vatican/Church. ± Half of all abortions unsafe. 85% of unsafe abortions in global South. 1990 = 69,000 deaths. 2008 = 47,000 deaths from 21.6 million unsafe abortions annually = 13% of total maternal deaths.
Trends Trend is towards safe, legal abortion as gender perspectives, increased girls’ education, work for women, falling fertility rates, acceptance of “family planning” in its full meaning and awareness of women’s reproductive health needs and rights have come into play. All but 5 countries globally permit abortion to save the woman’s life. By 2007, abortion was permitted for economic or social reasons in 78% of developed countries and 19% of developing countries, and on request in 67% of developed countries but only 15% of developing countries (on request usually = in the first trimester). The 5 countries do not permit abortion at all: Chile, El Salvador, Nicaragua, Honduras, Dominican Republic.
The most liberal laws In Sweden, abortion is on request up to 18 weeks of pregnancy and with the permission of a hospital panel after that. In Cuba, abortion is legal as long as it is at the request of the woman, provided within the health regulations and not for profit. In Canada, in 1989 the highest court removed abortion from the law altogether. (Access a problem) In 2008, abortion was decriminalised by the state of Victoria, Australia, up to 24 weeks of pregnancy. Therapeutic abortion after 24 weeks is also permitted. Termination of pregnancy is now regulated like any other medical procedure.
WHO-recommended abortion methods First trimester Manual vacuum aspiration Electric vacuum aspiration Mifepristone + misoprostol Misoprostol alone Second trimester Mifepristone + misoprostol Misoprostol alone Dilatation & evacuation (D&E) D&E is main method for second trimester abortion in USA but declining in Europe. Almost all 2nd trimester abortions in Scandinavia are medical abortions (Sweden too few late abortions to maintain D&E skills). Both are safe and effective but big difference for woman/provider.
Public vs. private services Almost all abortions in Spain are done in private clinics. In Portugal almost all abortions are done in the public health services, including at primary level. In Scotland most abortions are done in NHS clinics, while in England and Wales, the majority of abortions (about 60%) are carried out in Bpas and MSI clinics but most are paid for by the NHS, while the rest are still done in hospitals.
Abortion services in Europe: some history Abortions services were set up soon after the laws were changed in Europe, when D&C was common and mostly before vacuum aspiration abortion or medical abortion pills became available. Hence, abortions were provided in hospitals by gynaecologists, often using general anaesthetic and involving an overnight stay. It has proved difficult in Britain to convince health officials and doctors that with the advent of far safer methods, first trimester abortions no longer need a physician, a hospital or general anaesthetic. Similarly, when medical abortion was first approved (1990 in Britain), a lot more restrictions were placed on its use than were necessary (e.g. women had to live no more than 1 hour from the hospital).
WHO guidance 2012 Abortion services should be provided at the lowest appropriate level of the health care system. Vacuum aspiration up to 14 completed weeks of pregnancy and medical abortion up to 9 (→ 10) completed weeks of pregnancy LMP can be provided at primary care level. Mid-level health workers (e.g. nurses/midwives, GPs) can be trained to provide both methods of abortion without compromising safety. (Safe Abortion: Technical and Policy Guidance for Health Systems, WHO, 2012)
Medical abortion: changing practice Medical abortion – popularly known as the abortion pill – is changing abortion practice all over the world. Where abortion is legal, use of medical abortion is steadily increasing and abortions are becoming much earlier in pregnancy. Where abortion is legally restricted, clandestine provision and self-medication with misoprostol have become a common reality of first trimester abortion. Growing number of pharmaceutical companies producing the drugs (mifepristone: China, France, India, USA, Viet Nam; misoprostol: 60 products), selling them together or separately (patents expired; drug quality of many uncertain).
Why is medical abortion so important? It offers a choice of method in both first and second trimesters, which is important for both women and providers. Early abortion encourages health systems to make abortion a primary care service. Medical abortion fundamentally alters the relationship between women and abortion providers, because the provider does not perform the abortion. Everything happens in the woman's body. Medical abortion, in a word, induces a miscarriage. Medical abortion pills can put the means of abortion into women’s hands. Don't forget that 100 years ago, use of contraception was illegal too.
How does it work? Mifepristone is an anti-progesterone and ends the pregnancy by stopping production of progesterone. Misoprostol is a prostaglandin and causes contractions that expel the pregnancy. ****** You take mifepristone one day, and take misoprostol bucally or vaginally 36-48 hours later. You wait 3-5 hours on average in the first trimester and 8 hours in the second trimester, after you take the misoprostol, for the pregnancy to miscarry (though it can take shorter or longer and a repeat dose(s) of misoprostol may be needed. You have a miscarriage.
Current roles of non-physicians In the following countries, non-physicians play a central if not complete role in providing first and second trimester medical abortion and also doing vacuum aspiration abortions: France Britain Sweden South Africa Viet Nam USA (some states) Over-medicalisation does not provide protection, it creates barriers, especially in countries with few trained physicians outside large urban centres.
Expansion of global availability Growing list of countries with mifepristone approval (51 in 2012) and increasing proportion of medical abortion usage in place of aspiration and surgical methods. National laws beginning to incorporate specifics of medical abortion in laws/regulations. Social marketing, web provision, telephone helplines, manuals and information packages in many languages. Additional obstetric indications for these medications being approved – such as misoprostol for prevention and treatment of post-partum haemorrhage – helping to make the pills more available.
The abortion pill in illegal settings Medical abortion has been in the news a lot in the past few years. That’s good, on one hand, because more women are getting to hear about it. Although the method has been around since the late 1980s, most women didn’t start hearing about it until the last ten years or so. On the other hand, anti-abortion media are demonising the abortion pill, e.g. Daily Mirror, 25 January 2014, "Deadly abortion pills sold to desperate teenage girls on internet for 78p". As it’s become more known, so has controversy begun to brew around because it potentially puts the control over fertility into women’s hands, as contraception does.
Discovered on the grapevine Women all over the world have discovered medical abortion in the past 10-30 years, because the women’s grapevine and the internet are more powerful than laws prohibiting abortion. Pills can be transported all sorts of ways, and clearly that is happening. Newspapers in the Republic picked up the story a few years ago of a Chinese woman in Dublin who imported medical abortion pills from China and was selling them over the counter in her supermarket. She had to pay a €5,000 fine and €5,500 costs. In almost every country in the world where abortion is legally restricted‒ across Latin America, Asia and many parts of Africa ‒ medical abortion pills are available in pharmacies, drug shops, and markets.
Reducing deaths from unsafe abortion The fact is, abortion pills, even taken by a woman on her own, are reducing the number of serious complications and deaths from unsafe abortion in many countries. These pills do not kill women the way invasive methods, such as putting a stick or a coat hanger up your vagina into your uterus can do. Two studies in Brazil found a reduction in deaths and serious complications as early as the late 1980s. Mifepristone and misoprostol were added to the WHO Essential Medicines list in 2005 – and one of the reasons was to reduce unnecessary deaths from unsafe abortion. (Hans Hogerzeil, Director of Medicines Policy and Standards, WHO, and Secretary of its Essential Medicines Committee in 2005)
Is self-medication dangerous? No. Self-medication is far from ideal, but in a clandestine situation, the choices are limited. For a start, only misoprostol tends to be available on its own, and it is not as effective (even with the right dose) as it is when taken in combination with mifepristone. Secondly, women and drug sellers may not know what the correct dosage and procedure to follow are. While overdosing is not considered to be dangerous, things can go wrong. What can go wrong is that the pills don't work at all, or the abortion is incomplete and leaves some of products of conception in the uterus, or bleeding doesn't stop and becomes very heavy. In these cases women need medical back-up. Most know and/or are advised to go straight for help and are easily treated.
Risk reduction: Uruguay Uruguay decided about six years ago that, as a form of risk reduction, doctors would be allowed to advise women to go to the pharmacy and get the right number of pills, would give them information on how to use the pills at home, and come to the hospital afterwards for a check-up to ensure that the abortion was complete. So ‒ everything except supply the pills. Within six months unsafe abortion complications began to disappear from the main maternity hospital in the capital. On this evidence, the law was reformed to allow first trimester abortion on request in Oct 2012. In January 2014, the Minister of Health announced that 5,000 legal abortions had been performed in the course of the first year after the law was changed. No maternal deaths due to unsafe abortion were recorded in that period.
How we usually address illegal abortions Since ICPD, supporters of safe abortion have focused on abortions outside the law as being unsafe and on preventing high rates of mortality and morbidity from avoidable complications. We call for women’s right to safe abortion and to treatment of complications after unsafe abortion. We also call for reform of the law, either to make abortion legal (on more grounds) or decriminalise it. We rarely focus on the active application of existing criminal laws on abortion and whether and how they are being applied to individual cases. There have been only a few important exceptions to this: e.g. the discovery of women in prison in Nepal before and after the law was reformed 2002. (RHM)
International Campaign for Women’s Right to Safe Abortion Launched April 2012. Aims/objectives endorsed by almost 400 organizations and 460 individuals in 106 countries globally. Aims to serve as an umbrella for everyone campaigning for the right to safe abortion, nationally, regionally and internationally. (ICMA) In October 2013, we published a report on the application of criminal law on abortion, based on research and action by ± a dozen groups in the Campaign, with information from 24 countries. This report covers the use of the criminal law against abortion, and its negative consequences for individual women and providers.
Overall findings of the report Many abortion providers are risking their professional careers and even their lives to help women get safe abortions in legally restricted settings. Other health professionals, including those who treat complications of unsafe abortions, are implicated in reporting women to the justice system for punishment. Women who have had unsafe abortions (young/poor) have been subjected to degrading and humiliating treatment and have had their civil, political and legal rights violated by the police/courts in multiple ways. One of the worst cases reported was a woman in Mexico who had spent most of her adult life, 30 years from when she was an adolescent, in prison.
Countries in the report Argentina Bolivia Brazil El Salvador Mexico Nicaragua Peru Kenya Malawi Nigeria Rwanda Senegal Algeria Morocco *** Jamaica Dominican Republic *** USA Canada Australia *** Nepal *** Poland Moldova United Kingdom Spain
Two recent RHM papers + Ipas videos Chantal Umuhoza et al. Advocating for safe abortion in Rwanda: how young people and the personal stories of young women in prison brought about change. (RHM 2013;21(41):49–56) Anibal Faúndes et al. Brazilians have different views on when abortion should be legal, but most do not agree with imprisoning women for abortion. (RHM 2013;21(42):165-173) Ipas videos interviewing people in the street in three Latin American countries: Are you for or against abortion? Do you know someone who has had an abortion? Do you think that person should be put in jail for having an abortion?
Positive role of the justice system There are of course many crucial ways in which the law and the justice system, human rights bodies and human rights law, are all supportive of women’s rights in relation to abortion. For example: partial decriminalisation in Colombia in 2006 by the Constitutional Court (RHM 2010;18(36):118-26); a ground-breaking CEDAW decision on the failure of Peru to provide safe, legal abortion to a 13-yr-old girl who had been raped (RHM 2012; 20(39):31-39). European Courts of Human Rights and of Justice have ruled favourably in cases from Ireland and Poland, for example, since the 1990s.
Everywhere you look, abortion is in the news http://safe-abortion-womens-right.tumblr.com
Spain Pre-1985 law reform ‒ 20,000 women a year to Britain for abortions. Women also went to midwives in Portugal and in the south crossed to North Africa. Trial in 1981 ‒ 7 women, families and TBAs acquitted. Led to law reform in 1985. Last year, Justice Minister threatened to return the law to pre-1985 limits. It would mean 90% of women having legal abortions would no longer be able to have a legal abortion. 86% of Spaniards consider this Bill an abuse of women’s freedoms. 75% consider it unnecessary. Written Declaration signed by 107 Parliamentarians of the Parliamentary Assembly of the Council of Europe, opposing the law reform. Protests all over Europe.
El Nuevo Dia, 8 Feb 2014, Photo: Agencia EFE
Secret ballot On 11th Feb, the Spanish parliament had a vote in a secret ballot on the abortion bill, put forward by the Socialist Parliamentary Group, asking the government to withdraw the reform. MPs voted 183 to 151 against the withdrawal. On 12th Feb there was to be a new vote on a motion put forward by the Left-Wing Parliamentary Group, similar in content, but not by secret ballot. (www.alianzaporlasolidaridad.org)
http://www.thejournal.ie/ireland-abortion-protest-spain, 13 Feb 2014
France From 1975 until this year, the French law guaranteed all pregnant women whose condition "puts them in a situation of distress" the right to terminate a pregnancy up to 12 weeks. The new law (Jan 2014) states that a "woman has the right to choose whether or not to continue her pregnancy" up to 12 weeks. And more limited grounds after that. Abortions, like contraception, will be paid for by the French health system. The law also punishes those who try to prevent a woman from entering a place where she can receive information on abortion. (http://safe-abortion-womens-right.tumblr.com/search/France)
Switzerland In Switzerland in a national referendum on Monday 10 Feb 2014, a 69.8% majority of voters rejected an antiabortion initiative aimed at cancelling the reimbursement of the costs of abortion through public health insurance. People thus reaffirmed their vote of 2002, when 72% voted to adopt new legislation granting women abortion on request in the first 12 weeks of pregnancy and for medical reasons later in pregnancy.
Catholic survey A private poll of 12,000 Catholics in 12 countries showed that 78% backed contraception, rising to more than 90% in Argentina, Colombia, Brazil, Spain and France, that 50% said priests should be able to marry, 51% favoured female priests and 65% said abortions should be allowed — 8% in all cases, and 57% in some cases, including when a woman’s life is at risk. The decision to carry out the survey reflects Pope Francis’s promise to listen to Catholics’ concerns, but the Catholic Church in Luxembourg warned that results from the survey were “alarming” and showed that the importance given to Church teaching was in “free fall.” (http://news.nationalpost.com/2014/02/09/popesglobal-survey-reveals-more-catholics-support-abortion-divorcethan-previously-thought/)
Information sources World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems, 2012 International Consortium for Medical Abortion information package (7 languages) and websites International Campaign for Women's Right to Safe Abortion (http://safe-abortion-womens-right.tumblr.com) Ipas Reproductive Health Matters ±160 articles on abortion Center for Reproductive Rights, USA Guttmacher Institute Global Doctors for Choice Women on Web
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