Making Abortion a Woman’s Right Worldwide^☆

☆ This is a slightly revised version of the paper with the same title in Bulletin of World Health Organization 2000;78(5):580–92.

This is RHM's 10th anniversary year and the third journal issue in which RHM has focused on abortion since 1993 [1]. Looking back, it is heartening to see how much has changed internationally in the past 10 years with regard to abortion, which is reflected in the papers published here. These papers are by women's health advocates, medical professionals, researchers and others working for safe, legal abortion in their countries. They describe and analyse the history of efforts to make abortion safe and legal in their countries, as well as the setbacks and opposition they continue to meet. These papers advocate safe abortion as a public health goal and legal abortion as a woman's right, including for marginalised populations such as refugee women. Of particular note are a US police photograph of a mother of three found dead after a clandestine abortion in 1964, a photo which galvanised a movement (Figure 1), and poems by a former member of Jane, a group of “ordinary” women in Chicago, USA, who did thousands of safe, clandestine abortions until abortion was legalised in the USA in 1973. These pages from history serve as cogent reminders of what it is still like for women who have unsafe abortions in developing countries today, whose numbers thankfully appear to be falling, though not nearly fast enough. WHO estimates included in this issue show there were some 19 million unsafe abortions per year in the world in 2000, out of an estimated 46 million.

Figure 1 A page from US history 1964.

US/Vatican oppose reproductive health

The US government has taken upon itself many forms of international leadership of late, and leadership of the international anti-abortion movement is among the most unsavoury. George W Bush seems to be doing his best to out-Pope the Pope in anti-abortion activity. On 1 February, the US Secretary of Health and Human Services revealed an ingenious plan to reclassify fetuses as “unborn children” in order to give US women on low incomes access to antenatal care under state health insurance schemes, as presumably they do not deserve it in their own right [2]. Two days later it was announced that Bush had decided to suspend US$34 million in funding to the UN Population Fund, because of unfounded accusations that it is supporting forced contraception, abortions and sterilisations in China. [3]. It is unlikely that this decision will be overturned by the US Congress due to political trade-offs unrelated to the issue. Last year, in a closed session at the UN, due to pressure from the USA and the Vatican, the overarching reproductive health goal was removed from the Millennium Development Goals, leaving in only three of its constituent parts – maternal mortality, contraceptive prevalence and HIV/AIDS [4]. Participants at the Children's Summit in April and the World Health Assembly in May this year report that the USA continues to argue aggressively against supporting the provision of reproductive health services, in case these might include abortion services. In each of these meetings, there was considerable protest at this stance and those supporting reproductive health services remain in the great majority. Although the Millenium Development Goals were put through to the exclusion of the reproductive health goal, the importance of achieving reproductive health and providing reproductive health services was re-affirmed in both major meetings this year.

Time to move forward

The secular equivalent of Catholics for a Free Choice, who challenge the anti-abortion, anti-reproductive rights stance of the Vatican, is much needed internationally to challenge anti-abortion governments and movements. In the late 1970s there was an International Campaign for Abortion Rights which mostly included national movements in Europe, but also North American and Latin American groups. At the time, abortion was such a taboo subject in many parts of Asia and Africa that women's health advocates felt they could not even be associated with a network that used the word abortion in its name. The International Women and Health Meeting in 1984 agreed that it was necessary to fight for reproductive rights as a whole, a new concept at the time, because clandestine abortions were only one of many reproductive and sexual health problems that women faced. Ten years later, this concept and these problems were recognised in the ICPD Programme of Action. It is now time for the international women's health movement to campaign in a more focused way on abortion again, because abortion is being used as an excuse to renege on agreements to do with reproductive and sexual health altogether.

This year has seen some very positive steps in this direction. An International Consortium for Medical Abortion was formed in February (Round Up Networks) and Ipas has recently announced an important initiative on their parts on abortion as well. Fortunately, despite retrogressive forces, many countries are getting on with implementing the agreements of ICPD, Beijing and ICPD+5 because they, their parliamentarians, civil servants and NGOs have taken the decisions endorsed in those international meetings seriously. In one of the most resource-poor countries in the world, for example, Nepal's Family Planning Association and parliament have taken decisive action to reduce mortality from abortion in the past year, the FPA by refusing to sign the Global Gag Rule, the parliament by legalising abortion on a woman's request up to 12 weeks of pregnancy if the woman's life or health is in danger and in cases of rape, incest and fetal malformation (Round-Up Law and Policy). This is an example other countries can applaud and emulate.

Anti-abortionists and their influence

It is often difficult to understand why the anti-abortion movement should have such an impact, given that the basis for their influence is so often the rejection, distortion and denial of women's experience and the twisting of scientific evidence. However, this assumes that most people, especially those with power and influence, are familiar with the horrendous reality of women's experience of clandestine abortion or what the scientific evidence on abortion is, or even that they value such information, when in fact they may not. The misogyny of the anti-abortion movement and the desire to control women that underpins their actions should never be underestimated, however. The emotive language and horrific images they use are not easily countered by facts or rational argument. Indeed, it is usually a mistake to try to answer anti-abortion propaganda on its own terms. Instead, it is better to ensure that arguments in support of women's right to safe, legal abortion are unambiguously grounded in women's experiences, public health goals, scientific evidence, and health and rights principles.

It seems it is impossible, even after decades of legal abortion, to expect the media to understand that the label “pro-abortion” for the abortion rights movement misrepresents what we stand for. From their point of view, it is just too neat in juxtaposition to “anti-abortion” and has inflammatory news value of its own. However, no one is “pro-abortion” in that they think abortions are a good thing or that women should have one if they can. Rather, women have shown throughout history that they will have abortions when they consider it necessary and they feel entitled to make that decision about their own bodies and lives, and therefore abortions must be done safely and legally. Anti-abortionists, on the other hand, actively support criminalising women and abortion providers and making abortions illegal, which condemns women to suffer and even to die for having an unsafe abortion. This almost exclusively punishes poor women today, since those who can find the money can secure a safe abortion, even if they need to travel to another country for it.

Why is the anti-abortion focus on the fetus powerful? It is because of the image of “powerlessness” it projects while making women invisible. More importantly, however, I believe it is because women, people, care so much about babies. Does this mean an endless stream of babies in any and all circumstances? Of course not. The need to control fertility is central to the human condition. So why do anti-abortionist claims that abortion hurts women resonate? The answer is because pregnancy matters, and unwanted pregnancy and the circumstances surrounding it can hurt a great deal. At the same time, however, the punitive behaviour of others towards women having an abortion may be one of the most hurtful aspects, not to mention the morbidity and risk of death when abortion is clandestine. Hence, anti-abortion claims that abortion itself is a negative experience are one of the most important ways in which they distort the reality of what women experience.

Ultimately, women have abortions for only one reason – because they cannot cope with a particular pregnancy at a particular time. This can never be said enough. They may regret the reasons, but this does not alter the fact that abortion is the correct decision for them and necessary in the circumstances of their lives.

Against unsafe abortion, for a woman's right to decide

Women are usually changed by the experience of abortion, but it is often for the better. Abortion can be a signal that something has gone wrong in a woman's life. Often what has gone wrong is in her relationship with the man involved. An unwanted pregnancy is frequently a wake-up call to women, that they need to take control of their lives. It is not uncommon for women to leave failing and destructive relationships after an abortion either. Later, they do not want to remember the hurt caused by the relationship, so they remember the abortion. On the other hand, many abortions, probably the majority, are the result of unintended pregnancy in stable and good relationships, and as a form of birth control are sought as a back-up in cases of contraceptive failure or failure to use contraception [5]. These were lessons learned in Europe and North America during the height of the movement for abortion rights in the 1960s and 1970s. They need to be learned again and again in every country that strives to legalise and legitimise the practice of abortion in order to make it safe.

Several papers in this issue of the journal give the results of opinion polls on abortion among the general population and particularly among obstetrician–gynaecologists. These views are of great interest and importance for those campaigning for abortion rights and for those charged with changing the law, but it is useful to remember that the results mostly reflect what people think is socially acceptable to say at any given moment. Where most abortions are illegal and clandestine, few obstetrician–gynaecologists will feel safe in saying they disagree with the law, including or even especially those who are carrying them out.

Abortion is not just illegal and clandestine insofar as the law is concerned, but also in people's minds. Until a society accepts that abortion is needed by women and that women and abortion providers should not be punished for it, legal abortions will rarely be provided except in exceptional circumstances. Abortions on medical grounds (to save the woman's life or health) and in cases of rape and fetal abnormality appear to be more worthy abortions, because the woman in these cases is a victim of circumstances beyond her control, who needs protection. This is an important place to start when seeking to influence a society's views on abortion. It is not enough, however. It is only when women's autonomy to decide not to continue a pregnancy is recognised as an ethical imperative and in law, not only for health-related reasons but also for social, economic and psychological reasons, that abortion will become available to the vast majority of women if and when they need it.

Attention to the need for abortion on grounds of rape in several papers from Latin America in this issue are a reminder that many unwanted pregnancies are the result of non-consensual sex. It was quite a shock to learn that half of women in one study in Mexico who became pregnant following rape tended not to seek an abortion if the rapist was known to them, and that they only reported the rape to the police an average of nine months after they became pregnant, i.e. around the time they were to give birth. Non-consensual or forced insemination is a form of rape I had never heard of before working on this journal issue. Forced pregnancies in Bosnia using the weapon of rape represent a similar form of sexual violence, exposed in the 1990s. Now it seems women are being impregnated against their wishes through insemination as an act of political violence in several places in Latin America (Marta Lamas, personal communication, February 2002). In fact, this form of violence against women is known sufficiently in the region for two groups of authors whose papers are in this issue, from Mexico and Colombia, not even to feel they had to explain this when reporting that abortion following forced insemination had been made legal in their city/country. Indeed, all the papers from Latin America in this issue indicate that pregnancy following rape is increasingly seen as a legitimate reason for providing legal abortion. Thus, women who have experienced sexual violence are beginning to have access to legal abortions, thanks also to the growing activity against violence against women around the world in recent decades.

Most women who have abortions also have children. Yet it is easier to be against unsafe abortion than to be for safe abortion, and it is easier to be for safe abortion than to insist that it must be legal to be safe. Most people still think that some abortions are more acceptable than others. Yet it is not possible to discuss which abortions are acceptable and which are not until we answer the prior question – who has the right to judge? Or to put it another way – can motherhood ever legitimately be forced on women? Even so, it is easier to support some abortions than all abortions, and to support some women who seek abortions more than others. To believe that abortion is a woman's right, however, makes these distinctions redundant. A woman's reasons are important and rarely trivial, but in fact they are no one else's business. Women know what they can and cannot cope with in their bodies and their lives. Children are a lifetime commitment, and the difference between a wanted and an unwanted pregnancy is enormous, representing an often impassable gulf. What the movement for abortion rights is really about is gaining recognition on the part of society that when faced with an unwanted pregnancy, whatever the reasons and however the pregnancy came about, women – who have a right to life and health – have a right to a safe, legal abortion. The way a country deals with abortion is highly symbolic of women's status and how it treats women generally. Those who believe there are more important things to put right than unsafe abortion are, in effect, making a statement that women's health and lives do not count.

Medical abortion: the abortion pill

The abortion pill is practically unmentioned in this journal issue, to my great regret. Yet country by country where abortion is legal, slowly, the use of mifepristone + misoprostol for early abortion is being piloted and approved. Misoprostol (Cytotec), a prostaglandin, is available over the counter in most of Latin America, the Caribbean and parts of Asia, though not widely in Africa. The availability and low price of misoprostol has contributed to its use on its own by women to self-induce an abortion when legal abortions are not available. In fact, women have been using it clandestinely for more than a decade, based mostly on the recommendation and directions for use of friends and pharmacists. No reliable information is yet available as to what constitutes the safest and most effective dose or regimen, but research on this is in progress.

Research has been initiated on the use of misoprostol on its own for first trimester abortions, because mifepristone may not be approved for some time in many countries. The WHO Department for Reproductive Health and Research agreed, on the advice of its Scientific and Technical Advisory Group, to carry out research to this end. In early 2002, they began preparing a randomised multi-centre trial in 11 centres in six developing countries, that will involve 2100 pregnant women, up to 63 days of pregnancy, who have requested legal terminations. Eligible women will be randomised to four treatment groups, using three doses of 0.8 mg each of misoprostol at either 3 hours or 12 hours intervals, either orally or vaginally. The four regimens will be compared for effectiveness in inducing complete abortion, induction-to-abortion interval, acceptability and occurrence of side effects. The trial is expected to last about a year [6].

In the meantime, the only thing women can most safely be advised to do on their own if they are going to use misoprostol, is to use it up to 63 days after the first day of their last menstrual period only and to seek treatment from a competent health care facility for incomplete abortion once they have used it. It cannot be emphasised enough, however, that even in the absence of reliable information on the “correct” regimen, the extent of morbidity and mortality from complications related to more dangerous techniques has fallen hugely as a result of women using misoprostol. All praise for brave women for taking technology into their own hands and thereby pressuring the scientific and medical community into helping them to do so more safely.

Beyond post-abortion: the role of the medical profession

“Once a woman has decided to abort, the abortion is already underway. What the provider does is to complete the process.” [7]

Although providing treatment for the complications of dangerous abortions is better than doing nothing to prevent women dying of haemorrhage or infection, it is far less ethically acceptable than providing safe abortions to begin with. Post-abortion care is what clinics should be doing after they have provided safe abortions, not instead. However, they cannot be expected to do so in any numbers until the law permits it.

It would be wrong to generalise about the role of the medical profession in relation to abortion. On the one hand, doctors and nurses are some of the most powerful obstacles to the legalisation and provision of safe abortion. Others risk their professional lives in illegal situations to do abortions clandestinely, whether from a humanitarian motive or for profit, and deal with botched abortion cases as best they can. In either case, it is never in their interests for the women they help to die. In fact, some of the most supportive medical professionals are those who have had to cope with the horrors of botched abortions, who have watched helplessly when women die from them, making them realise how universal the legal grounds of “preserving the woman's health and life” actually are, as a single case history reported here from Africa illustrates graphically.

Abortion techniques have become much safer and easier to carry out in the past 20 years. Trained mid-level providers are more than able to carry out first trimester abortions with (manual) vacuum aspiration and to administer medical abortion in primary care settings rather than hospitals. Obstetrician–gynaecologists should be considered much less necessary as abortion providers, apart from second trimester surgical procedures. At the same time, however, it is unfair to expect sufficient numbers of mid-level providers to be properly trained or for outdated abortion procedures to be replaced on a national scale until abortion has been normalised as a legitimate service in countries' health systems. Thus, D & C (dilation and curettage), though much less safe, is still widely practised in far too many countries. Efforts are being made in some countries to get health professionals, including gynaecologists, nurses and midwives, to help ensure that legal abortions can be provided. This is an important step in opening doors to a better quality of abortion service provision.

Who to work with, what to do?

Historically, it has been shown to be crucial for women's health advocates and progressive policymakers, medical professionals and pro-choice religious groups to work together to achieve the legalisation of abortion and the inclusion of abortion services within health systems. It is equally crucial to bring women in the community on board, especially those who have had abortions, and with them also community groups, trades unions, other civil society organisations, the media and public opinion generally. This was done, for example, in all the western European countries and North America where abortion was made legal in the 1960s to 1980s. In other countries, a few high-ranking individuals brought about law change, e.g. in the Soviet Union, the first country to legalise abortion in the 1930s. In still others, the family planning movement was influential and abortion was made available as part of population policy, e.g. in India and Tunisia.

It often comes as a surprise to those who form coalitions to work for abortion rights that their most radical supporters are grassroots women, who are quite clear about their need for abortions and their sense of entitlement to abortion services as mothers of children. Often, advocates for safe abortion themselves may take more ambivalent positions because they have something to lose personally by being identified with an unpopular cause, and this seems to become truer the higher they are on the totem pole of power. Thus, leadership for abortion rights must often come from the grassroots. Certainly today, the international level, especially in the UN and its agencies, where anti-abortion political pressure is currently causing havoc, seems to have become one of the most problematic as far as progress is concerned, a big change from a decade ago.

There is much to achieve at the national level in many countries. Not only do laws need to be liberalised, but also enabling regulations are needed, i.e. stipulating where services should be provided and by whom, and requiring training for providers and information for women seeking abortions. At the service level, dedicated clinic space for day procedures and health workers' time need to be allocated, medical curricula altered, in-service training carried out, and equipment and drugs purchased. For medical abortion, beds are not required but women may prefer to spend several hours at the clinic once misoprostol has been taken, so a waiting room is needed. Post-abortion contraceptive services also need to be made available. In addition, women in the community need to be widely informed that legal abortion services are being made available. Where the law is changed, those in prison for abortion need to be released, as has been recognised in Nepal. Clandestine abortion services tend to be more common in the private health sector than the public sector, and any training of providers, safety in service provision and quality of care are almost totally unregulated. Medically untrained clandestine providers need to be shut down; legitimate providers need to be required to register so that they can be properly regulated. These are important transition steps until a sufficient number of approved services are in place and being used.

While the great majority of abortions are required by women for birth control and socio-economic reasons, abortion on medical grounds is also necessary. The higher the fertility rate and the poorer the health of women of reproductive age in a country, the more women there will be who need abortions on medical grounds. No matter how good women's health is, however, some abortions on medical grounds will always be needed. To claim, as some anti-abortionists do, that medical science has made the need for abortions on medical grounds disappear, is absurd. Furthermore, it can and has been argued in courts of law that because clandestine abortion threatens the health and life of women, safe abortions are always justified to protect women's health and lives. Thus, it is not only the content of the law but also its interpretation that counts.

Women should be encouraged to seek abortions as early in pregnancy as possible and methods now exist to support them to do so. As long as early abortion services are easily accessible, the great majority of women seek abortion within a few weeks of missing a period, and those needing second trimester procedures are a minority (4–10%). Early medical abortion is best before 63 days of pregnancy, manual vacuum aspiration by 12 weeks and electrical vacuum aspiration up to 14 weeks. However, although this may change in the near future, most screening for fetal conditions must wait until the second trimester, and there are always going to be women who fall through the net and who require a later procedure, especially young and single women who have the least access to services generally. Hence, it is short-sighted for countries to legalise abortions only up to the first 12 weeks of pregnancy while restricting second trimester procedures, as continuing morbidity and mortality in the minority are likely to result. Far better to make abortion on request up to 18 weeks, as Sweden did many years ago, so that women seeking abortions after that are truly the exceptions, usually with medical grounds.

Clearly, leadership and action at many levels in making these changes is the key to their success. A myriad of efforts have been made in the past ten years to make more abortions safe, and in spite of setbacks and opposition, much progress is visible. To make abortion a woman's right to decide worldwide, what is needed? A strong and diverse women's health advocacy movement is the most likely to succeed, though in many countries this is only nascent. Most abortion rights advocacy, however, has been started off by only a handful of committed individuals and groups and grown from there, often only over the course of many years. Support is needed from at least one political party and even more a government that takes responsibility for public health, including women's health in spite of the controversy it may cause. Third, the involvement of health professionals is needed whose commitment to health care includes a commitment to providing abortion in a supportive way, using the safest available methods and without unnecessary barriers, to every woman who requests it. These do not appear overnight; all must be fostered.

At the national level, for women's groups, developing and raising the arguments for liberal abortion laws and services in the public sphere is self-educative and a good way to educate the public, find supporters and reach policymakers, health care professionals and the media. Readable publications and leaflets, describing women's experiences, and optimal use of sympathetic media and communications technology are crucial. Action can include lobbying and working with parliamentarians to table and debate bills, promoting a model law, court cases to challenge restrictive laws or appeals against criminal action against women and providers, events such as concerts or health fairs for awareness raising and fund-raising, petitions, press releases, press conferences, public meetings, tribunals, demonstrations and pickets, resolutions in the annual meetings of trades unions and other civil society groups, and other means of putting abortion on the agenda. Inviting important public figures and celebrities to “speak out” at a big event, whether singers, actors, politicians or major religious figures, can give an important boost. If a group of prominent women will agree to state in public that they have had abortions, it brings a lot of credibility. Even T-shirts, car bumper stickers, badges, scarves and bags containing slogans in support of a woman's right to decide on abortion are effective in making a campaign visible to the public eye.

Perhaps most important is the need to overcome fear and find the courage to act and speak out in the face of anti-abortion opposition, especially conservative religious and governmental forces which command respect on so many levels. In many countries, direct action - women and doctors learning how to do abortions and providing services to other women clandestinely-has been the first and most important catalyst for change. In France in the 1970s, this was done systematically by women activists working with pro - choice doctors in the bigger cities. After some years of public campaigning, on a pre-set date, they announced together to the country what they were doing and defied arrest. Efforts to change the law followed not long after. To work for women's right to decide on abortion requires neither more nor less than a profound belief in the right of women to control their own bodies and to make decisions about their own lives, including whether and when to have children.

Making Abortion a Woman's Right Worldwide^☆

The above picture is a police photo of Gerri Santoro, who died in 1964 at the age of 27 in a Connecticut [USA] motel room after a botched illegal abortion. Gerri Santoro was the beloved sibling of 14 brothers and sisters and the loving mother of two daughters. She endured the verbal and physical abuse of her spouse for the sake of the marriage – and then left the marriage for the sake of the children. She put her life in peril to try to keep her estranged husband from coming to visit and taking her children. And then she panicked at what he might do if he found out she was pregnant by another man. The man who did the abortion used borrowed medical implements and a textbook and left Gerri Santoro to die alone in the motel room, where her body was found [1].

Notes

☆ This is a slightly revised version of the paper with the same title in Bulletin of World Health Organization 2000;78(5):580–92.

☆ This is a slightly revised version of the paper with the same title in Bulletin of World Health Organization 2000;78(5):580–92.