Global Progress in Abortion Advocacy and Policy: An Assessment of the Decade since ICPD

Abstract

The 1994 International Conference on Population and Development (ICPD) Programme of Action represented a positive step toward legitimising abortion as a component of basic reproductive health services. This paper reviews how the ICPD principles and recommendations have been applied in the past decade toward increasing women's access to affordable, safe and legal abortion services. It examines advocacy efforts to increase understanding of abortion among policymakers and the public, policy and action at the global level, progress made in national-level policies and services, and obstacles encountered. Research and advocacy are helping to break the silence globally about unsafe abortion, and there is an emerging global movement supporting women's right to safe abortion. A great deal has been accomplished in the ten short years since ICPD, in spite of serious setbacks in some countries and continuing obstacles. A synthesis of public health and rights-based approaches, and strategic partnerships with other social justice movements are called for, as a foundation for effective legal reform efforts and to ensure that women have access to safe abortion services.

Résumé

Le Programme d'action de la Conférence internationale de 1994 sur la population et le développement (CIPD) représentait une avancée vers la légitimation de l'avortement comme élément des services de santé génésique de base. Cet article montre comment les principes et les recommandations de la CIPD ont été appliqués ces dix dernières années afin d'élargir l'accès des femmes à des services d'avortement abordables, sûrs et légaux. Il examine le plaidoyer pour relever la compréhension de l'avortement chez les décideurs et le public, les politiques et l'action au niveau mondial, les progrès accomplis dans les politiques et les services nationaux, et les obstacles rencontrés. La recherche et le plaidoyer aident à rompre le silence qui entoure les avortements à risque, et un mouvement mondial se fait jour pour soutenir le droit des femmes à un avortement sûr. Beaucoup a été fait depuis la CIPD, malgré de graves revers dans certains pays et les écueils persistants. Une synthèse des approches publiques fondées sur la santé et les droits, et des partenariats stratégiques avec d'autres mouvements de justice sociale sont nécessaires comme fondement d'une réforme légale efficace et pour garantir aux femmes l'accès à des services d'avortement sûr.

Resumen

El Programa de Acción de la Conferencia Internacional sobre la Población y el Desarrollo (CIPD), celebrada en 1994, representó un paso positivo hacia la legitimación del aborto como un componente de los servicios esenciales de salud reproductiva. En este artículo se revisa cómo los principios y las recomendaciones de la CIPD se han aplicado en la ãltima década para aumentar el acceso de las mujeres a los servicios de aborto seguro y legal, a precios asequibles. Se examinan los esfuerzos de promoción y defensa para crear mayor conciencia del aborto entre los formuladores de políticas y el pãblico, las políticas y medidas mundiales, los avances logrados en las políticas y los servicios a nivel nacional, y los obstáculos encontrados. Las investigaciones y la promoción y defensa están ayudando a romper el silencio global en torno al aborto inseguro. Un movimiento mundial emergente apoya el derecho de las mujeres al aborto seguro. En los ãltimos diez años, se han logrado grandes avances, pese a continuos obstáculos y graves contratiempos en algunos países. A fin de cimentar esfuerzos eficaces de reforma judicial y de garantizar que las mujeres tengan acceso a servicios de aborto seguro, es necesario realizar una síntesis de los enfoques de salud pãblica y aquellos basados en los derechos, y formar alianzas estratégicas con otros movimientos de justicia social.

Keywords:

• abortion law and policy
• abortion providers and services
• reproductive rights
• advocacy and political process
• International Conference on Population and Development

The Programme of Action of the International Conference on Population and Development (ICPD) in 1994 was the first major international agreement to make recommendations on unsafe abortion. It addressed abortion principally under the heading “Health, Morbidity and Mortality.” Paragraph 8.25 called attention to the public health impact of unsafe abortion and the need to reduce recourse to abortion by expanding family planning services. The paragraph also provided that women who have unwanted pregnancies should be able to receive reliable information, compassionate counselling and safe abortion services where abortion is not against the law. It also called for access to quality services for the management of complications that may arise from the procedure and post-abortion counselling, education and family planning services aimed at preventing repeat abortions. Elsewhere in the document, governments agreed to support comprehensive reproductive health services including choice of regulation of fertility, with the provision that access should be available for services “which are not against the law”.¹

Women's access to safe abortion was one of the most difficult issues to negotiate at ICPD and again when progress on implementing ICPD recommendations was reviewed five and ten years later. Governments ultimately agreed to address the public health impact of unsafe abortion, but the problem of unsafe abortion persists. In 2000, an estimated 19 million women had unsafe abortions and some 68,000 died. Almost 14% of them were under the age of 20 and 95% lived in developing countries.² In addition, five million women were temporarily or permanently injured.³ While these numbers have shown some decrease over the past decade, differences in deaths and injuries from unsafe abortion still constitute one of the greatest disparities in reproductive health between the developed and developing worlds.⁴ Lack of political and financial commitment to addressing unsafe abortion, religious and ideological conservatism, and silence and stigma have made this experience life-threatening for 190-200 million women in the past decade alone. Yet abortion is one of the safest medical procedures when performed by a skilled provider in a facility that meets medical standards.⁵

While the PoA represented a breakthrough at the time, internal contradictions and weaknesses in the abortion provisions prevented it from providing governments with a clear directive for action. The PoA fell short of explicitly recognising women's right to make the decision to terminate a pregnancy. Whether reproductive rights included abortion remained a matter for interpretation, however.^*

The PoA also provided that “in no case should abortion be promoted as a method of family planning” (ICPD paragraph 8.25). This language, based on a political compromise, is ambiguous at best, because it is not clear what constitutes “promoting” abortion.^† It also calls into question the meaning of “family planning;” a woman's decision to have an abortion is always related to her desire to plan whether and when to have children. Furthermore, the language neglects the realities of women's lives and the causes of unwanted pregnancy. In many settings, women are denied sex education, information, contraception and all of the prerequisites for informed decision-making about sex and fertility. The sexual act is too often far from consensual, especially for young women under the age of 15,⁶ who are also vulnerable to transactional and “sugar daddy” sex.

This paper reviews how the ICPD principles and recommendations have been applied in the past decade toward increasing women's access to affordable, safe and legal abortion services. It examines advocacy efforts to increase understanding of abortion among policymakers and the public; policy and action at the global level; progress made in national-level policies and services and obstacles encountered.

Breaking the silence: from research to mobilisation

Research, advocacy and mobilisation efforts have grown and diversified since the ICPD. Studies in numerous countries have helped to: i) increase knowledge of the magnitude and consequences of unsafe abortion; ii) raise awareness of women's experiences in undergoing unsafe abortions; iii) comprehend the varying needs and circumstances of young women and other subgroups; and iv) link abortion with other key public health and women's rights issues. Advocacy groups are using these findings and incorporating public health, social justice, human rights and legal reform approaches into their work.⁷, ⁸, ⁹ New groups and actors have become involved in abortion advocacy, including policymakers, government officials, health and medical professionals, women's groups, legal advocates, human rights experts, journalists, young people and in some countries trade unionists.¹⁰

Public health approaches have sought to raise awareness of the incidence and prevalence of unsafe abortions, assess the capacity of health systems to provide abortion services (both post-abortion care and elective abortion), identify gaps in service availability and quality, and estimate costs.¹¹ The magnitude of abortion complications has been documented in a variety of settings; for example, a recent study estimated that over 20,000 women annually are being treated for abortion-related morbidity in Kenyan public hospitals.¹² Facility-based studies have been conducted in Ethiopia,¹³ Indian¹⁴ Kenya,¹⁵ Nicaragua,¹⁶ Nigeria,¹⁷ South Africa,¹⁸ and Thailand.¹⁹ This research has revealed the challenges that still remain in ensuring access and quality of care.

Women still face numerous medical, political, institutional and social barriers even in countries where abortion is legal. In India, where abortion has been legal for over 30 years, 76% of abortion facilities are not licensed, 68% of abortion providers are not registered, and dilatation and curettage (D&C) is the preferred method in 89% of facilities surveyed.¹⁸, ²⁰, While recent studies point to a decrease in the number of untrained providers in India, the quality of services as well as their safely, are still major problems. In a community-based study in Tami Nadu, India, for example, close to 30% of the women seeking legal abortions experienced moderate to serious post-abortion complications.²¹

Cost studies are increasingly being used to underscore the drain on health system resources associated with restrictive laws, unsafe abortions and poor standards of care, as well as the cost to individual women and their families.²², ²³, ²⁴ Using African data, a recently developed model of costs for abortion care shows that treating incomplete abortions in tertiary facilities costs tens times more than providing elective abortion in a primary health centre.²⁵ The findings from this study are corroborated by others which show that costs drastically decrease when services are provided in ambulatory versus inpatient settings and when manual vacuum aspiration (MVA) instead of D&C is used.²⁶, ²⁷, ²⁸, ²⁹ Even in countries where abortion is legal, public sector investment is often limited. In India, a six-state study found that 75% of abortion services were carried out in the private sector.³⁰

Qualitative studies have contributed new knowledge by examining women's experiences and understanding of reproductive rights and their decision-making processes concerning abortion.³¹ The differences between women's expressed opinions on abortion and their actual behaviour have been documented.³², ³³, In South Africa, the concept of “dual morality” has been used to refer to women who, while publicly opposed to abortion, will seek abortion when they have an unwanted pregnancy.³⁴ Researchers have examined how experiences with unwanted pregnancy and abortion are conditioned by social and cultural constructions of motherhood and abortion.³⁵³⁶ Another area of investigation are religious doctrines that are used to maintain restrictions on abortion,⁸ as well as the role of progressive religious leaders in supporting women's reproductive autonomy.³⁷ Other studies have documented the relationship between women and providers, and women's experiences in obtaining services.¹⁹, ³⁸,

The abortion-related experiences of young women,³⁹, ⁴⁰, HIV positive women⁴¹ and displaced and refugee women⁴² are receiving increased attention. Poor and rural women suffer disproportionately when access to safe abortion services is limited, as they often live far from services and struggle to find funding, leading to delays and increased costs and risks of the procedure.⁵, ²³, Women often make their abortion-related decisions in conjunction with others and research has focused on the role of religious groups and leaders,³⁷, ⁴³, and of men, communities and families in providing support to women⁴⁴, ⁴⁵, ⁴⁶, ⁴⁷, ⁴⁸ as well as inhibiting women's access to abortion.⁴⁹

Additional issues have emerged since the ICPD, including the link between abortion and sexual violence. Globally, one in five women has been physically or sexually abused in her lifetime, most frequently by someone she knows.⁵⁰ Studies in India and the Philippines confirm that women survivors of violence are at higher risk of unwanted pregnancy.⁵¹, ⁵², In Mexico and Brazil, women's groups have linked services on sexual violence, unwanted pregnancy and abortion for vulnerable women which have generated public discussion.⁵³ Laws in 11 countries in the Latin American and Caribbean region permit abortion if pregnancy results from rape or incest.⁵⁴ In Mexico, a model of comprehensive care for women survivors of sexual violence, including legal abortion, has been developed through a participatory process that includes NGOs and the government. To date, this model has been introduced by the Ministry of Health in seven states, involving close to 4,000 health care providers.⁵⁵

Advocacy on abortion is most effective when it incorporates this range of issues. In Mexico, the National Alliance for Choice (Andar) was formed to serve as a forum for open debates around bioethics, reproductive health and sexuality education. Regional networks and campaigns have gained added energy and focus in Latin America; these include the 28^th of September Campaign for the Decriminalisation of Abortion and an initiative led by the Latin America and Caribbean Committee for the Defense of Women's Rights (CLADEM) to create a Convention on Sexual and Reproductive Rights. In addition, the Latin American Federation of Obstetricians and Gynecologists (FLASOG) has established a Sexual and Reproductive Rights Committee, which makes recommendations to member societies in 20 countries, and is publicising violations of reproductive rights in the region.

Regional and international networking

In Africa, the first ever regional conference on unsafe abortion, which brought together 112 medical providers, policymakers, Ministers of Health, women's health advocates, youth leaders and media representatives was held in Addis Ababa, Ethiopia, in 2003. The conference called on governments to review restrictive laws and increase funding for programmes that address unsafe abortion.⁵⁶ The African Partnership for Sexual and Reproductive Health and Rights of Women and Girls (Amanitare), which co-convened the conference, is an example of a network formed to promote the range of sexual and reproductive rights. Amanitare's overall objectives include the promotion of bodily integrity, sexual autonomy, sexual enjoyment and healthy reproduction, and the right to live free of coercion, violence or punishment related to sexuality or fertility.⁵⁷

Similar networks have also formed in other regions to promote sexual and reproductive rights, such as ASTRA in Central and Eastern Europe and the Asian-Pacific Research and Resource Center (ARROW). Longer-standing networks such as Development Alternatives for Women (DAWN) have increased their attention to reproductive rights generally and abortion in particular.

The Countdown 2015 Global Roundtable in London, September 2004, gave further reinforcement to this movement. Over 700 participants from 109 countries agreed on a declaration and an action agenda calling for a world where women and girls have access to safe, legal abortion and where women's reasons for abortion are respected.⁵⁸, ⁵⁹,

The role of medical abortion in expanding women's access to safe abortion was the focus of a conference involving participants from 50 countries in October 2004, organised in Johannesburg by the International Consortium for Medical Abortion. Its final statement calls for mid-level providers, including nurses, midwives, family planning workers and physician assistants, to be trained to provide early medical abortion services, and argues that “even in legally restricted environments, governments must recognise their responsibility to provide safe abortion services to the full extent of the law”.⁶⁰

Policy and action at the global and regional level

A strong alliance of those who support abortion rights is essential to translate the rhetoric of international agreements into action and mobilise the financial resources necessary to improve the availability and quality of abortion care. A positive international policy framework has continued to evolve since ICPD. The Platform for Action of the 1995 Fourth World Conference on Women at Beijing reaffirmed the ICPD Programme of Action and called upon governments to “review laws containing punitive measures against women who have undergone illegal abortions” (Para.106(k)).⁶¹ At the Special Session of the UN General Assembly to evaluate progress of the ICPD in 1999, governments adopted by consensus specific recommended actions to make abortion safe and more available. Paragraph 63iii states: “In circumstances where abortion is not against the law … health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible.”⁶² Subsequently, in 2003, the World Health Organization (WHO) issued policy and technical guidance for the implementation of this paragraph, and the World Health Assembly affirmed the mandate to support safe abortion services in the Strategy to Accelerate Progress towards the Attainment of International Development Goals and Targets Related to Reproductive Health in 2004.³⁵

Another key development is the increased attention to the application of human rights to abortion and other reproductive rights by the UN's Human Rights Committee (HRC), Committee on Economic, Social and Cultural Rights (CESCR), Committee on the Elimination of Discrimination Against Women (CEDAW), and Committee on the Rights of the Child (CRC).⁶³, ⁶⁴, CEDAW explains that neglecting health care that only women need is a form of discrimination against women which governments are obliged to remedy. They urged the Chilean government, for example, to “consider a review and amendment of the laws related to abortion, in particular to provide safe abortion and to permit termination of pregnancy for therapeutic reasons or because of the health, including the mental health, of the woman”.⁶⁵ The HRC has asked a number of States Parties to review legislation criminalising abortion, for example, it addressed some of the key barriers that Polish women face accessing abortion services and expressed “concern at the unavailability of abortion in practice even when the law permits it, for example in cases of pregnancy resulting from rape, and by the lack of information on the use of the conscience clause by medical practitioners who refuse to carry out legal abortion”.⁶⁶

As a result of an NGO campaign, and lobbying on behalf of key governments, notably Brazil, the UN established a Special Rapporteur for Health in 2002.⁶⁷ The objectives of the Special Rapporteur are to gather health-related information, report on the realisation of the right to health, discuss areas of cooperation across UN, government and NGO bodies, and make recommendations on the steps needed to promote and protect the right to health. An additional objective is to increase the status of the right to health and ensure that it is given the same attention by UN agencies, governments and civil society as other human rights. The Special Rapporteur's 2004 report stresses the obligations of States to address the factors that lead to unsafe abortions, provide access to safe, accessible services where abortions are legal, and remove punitive measures against women who have undergone abortions.⁶⁸

Change is also taking place in European law. The European Parliament has passed several resolutions since ICPD, including one that calls on member states to “legalise induced abortion under certain conditions, at least in cases of forced pregnancy and rape, and where the health or life of the woman is endangered, on the principle that it must be the woman herself who takes the final decision”.⁶⁹ In a landmark case on 8 July 2004, the European Court of Human Rights refused to recognise a fetus as a human being under the European Convention for the Protection of Human Rights and Fundamental Freedoms.⁷⁰

In 2003, the African Union adopted the Protocol on the Rights of Women in Africa to supplement the African Charter on Human and Peoples' Rights adopted in 1981. Ten countries^* have ratified the Protocol as of February 2005; 15 are needed for it to enter into force.⁷¹ The broad protection of reproductive rights in the Protocol goes well beyond language agreed in international settings to date and is the first international treaty specifically to recognise abortion.⁷² States are called upon to protect women's reproductive rights by authorising abortion in cases of sexual assault, rape, incest, fetal impairment and where continuing the pregnancy would endanger the life or mental or physical health of the woman.

While the Inter-American system has not taken decisive action on abortion, it has begun to address reproductive rights more broadly. For example, reference to international human rights law is being used to call attention to the contradictions between international, constitutional and legislative norms, and to advance reproductive rights and access to legal abortion in some countries.⁷³

Progress in national-level services and policies

Norms and standards

Nearly every country permits abortion in some circumstances, and the development of norms and standards for health systems is critical to implementing the law. The Brazilian Ministry of Health recently published a four-year strategic plan of action, the National Policy for Comprehensive Care for Women's Health, which outlines a set of mutually-reinforcing activities to improve abortion care for women, including MVA services for post-abortion care (PAC) and elective abortion in close to 9,000 secondary and tertiary facilities.⁷⁴

Models of abortion care have been developed that incorporate internationally agreed best practices. The Post-Abortion Care Consortium has expanded its model for treating post-abortion complications to include partnerships between communities and providers, counselling, emergency obstetric treatment, family planning services and referrals for other health services.⁷⁵ The Bolivian government adopted these norms in 2004 and added the need to ensure the provision of services at all levels, including primary care.⁷⁶ Brazil also adopted these norms for PAC and elective abortion in March 2005.⁷⁷ In Peru, a model for comprehensive maternal health care has been adopted based on the PAC model. An evaluation of this model demonstrates that it leads to i) improved provider attitudes, ii) increased quality of care, iii) shorter hospital stays, iv) less use of general anaesthesia and v) lower facility costs.⁷⁸ In Ghana, the Ministry of Health revised its National Reproductive Health Policy in 2003 to incorporate the provision of comprehensive abortion care.⁷⁹

New models have also been created for the provision of safe abortion services, including the Ipas Woman-Centered Comprehensive Abortion Care Model, which seeks to: i) provide safe, high-quality services, ii) decentralise services to the most local level possible, iii) ensure that services are affordable and acceptable to women, iv) understand each woman's particular social circumstances and individual needs, v) reduce the number of unplanned pregnancies and abortions, vi) identify and serve women with other sexual and reproductive health needs, and vii) be affordable and sustainable to health systems.⁸⁰ This model is being introduced in India, Romania and Vietnam.

Training and decentralising services

Health services in developing countries are concentrated predominantly in urban centres. Increasing the access of rural women to health care services is thus essential. Training mid-level providers can result in increased access to abortion services because such providers are more numerous than physicians in most countries, they work in closer proximity to women and can give more cost-effective services than physicians.⁸¹, ⁸², ⁸³, ⁸⁴ Training of mid-level providers in abortion care has increased in Kenya, Nigeria, Mexico, Peru, South Africa and Vietnam since ICPD.⁸⁵, ⁸⁶, ⁸⁷ The impact of such training has been varied, however, and numerous barriers exist to decentralising abortion care, e.g. many countries still have “physician-only” regulations.⁸⁸ As a result, mid-level providers do not receive in-service abortion training, and physicians are reluctant to expand the responsibilities of mid-level providers. In Vietnam, mid-level providers can provide abortions only up to six weeks of pregnancy.⁸⁹ Recent amendments to South Africa's Choice of Termination of Pregnancy Act (November 2004) replace registered midwives with registered nurses as the legal providers of first-trimester abortions, to broaden the range of authorised providers. In addition, the bill decentralises responsibility for approving facilities from the Minister of Health to provincial authorities, to increase women's access.⁹⁰

Improved abortion methods

Since ICPD, new abortion technologies have been introduced around the world. Medical abortion and vacuum aspiration are the two preferred methods of abortion during the first nine and 12 weeks of pregnancy, respectively. MVA is a safe, simple and cost-effective technology, consisting of a plastic cannula connected to a hand-held aspirator, and can be used by a range of qualified providers.⁵ Numerous studies show that MVA is associated with fewer complications, reduced need for pain management and lower costs compared to D&C.⁹¹ As result, MVA is replacing D&C from Nigeria to South Africa, Nicaragua and Vietnam, though far too slowly in many other countries.

Medical abortion regimens using mifepristone and a prostaglandin, usually misoprostol, have been approved in a growing number of countries in all regions. Misoprostol is also widely available over the counter as a gastric ulcer drug and is being used by women in legally restricted settings on its own to terminate pregnancy. Misoprostol is also used for treatment of post-partum haemorrhage and incomplete abortion. Access to mifepristone in public health systems is impeded by issues of registration and cost, though this should now change as the patent has run out (Marge Berer, Co-Chair, International Consortium for Medical Abortion, personal communication, January 2005).

Laws and policies

Since ICPD, while nearly 40% of women still live in countries where abortion is restricted by law, over a dozen countries have gone beyond the ICPD recommendations to reform their abortion laws: Albania, Benin, Burkina Faso, Cambodia, Chad, Ethiopia, Germany, Guinea, Guyana, Mali, Nepal, South Africa and Switzerland.⁹² In addition, efforts to improve access to legal services and to reform restrictive laws are underway in Brazil,⁹³, ⁹⁴, Portugal,⁹⁵ Indonesia,³⁷ Kenya, (Eunice Brookman-Amissah, Ipas Vice President for Africa, personal communication, 2004) Mexico (states of Guanajuato and Morelos),⁹⁶ Thailand,⁹⁷ Trinidad,⁹⁸ St Lucia⁹⁹ and Uruguay.¹⁰

Different approaches to legal reform have been used, including decriminalising abortion by removing it from penal or criminal codes and legalising abortion. In Uruguay and Nepal, reform efforts situated abortion in broader reproductive health laws and gender equity bills. While these are all positive steps, most reform efforts have been more limited and expanded the legal indications, most often to include rape, incest and women's health. Fewer countries have permitted abortion at the woman's request.

Legal reform is a long process, often not linear in nature, and sometimes with mixed results. In Nepal and South Africa, campaigns were closely tied to broader national discussions about women's rights to equality and non-discrimination, and human rights violations arising from the criminalisation of abortion. The Nepalese law addresses abortion as part of a range of other provisions including the right to divorce, inheritance and property to increase women's overall status and well-being.⁹¹⁰⁰

South Africa is the only country that has adopted a new law since ICPD explicitly giving women the right to terminate a pregnancy safely and legally, according to their individual beliefs.⁸⁷ Key provisions in the law aim to guarantee universal access to services for all women, such as: i) placing no restrictions on women's choice in the first trimester, ii) authorising nurse-midwives to perform first trimester abortions and iii) giving women the sole right of consent.⁸¹ Nurses, in particular, are not yet always aware of the provisions of the law and their professional duties under it.¹⁰¹

Guyana was the second country in Latin America, after Cuba, to liberalise its abortion law. Reform efforts in Guyana focused both on reducing maternal deaths and morbidity from unsafe abortion and on reducing the incidence of abortion.¹⁰² This strategy was effective in bringing both opponents and supporters of law reform to the table. However, research conducted five years after the introduction of the new law demonstrated that women were still unable to access abortion services in any of the public hospitals. In addition, no clear guidance had been given to hospitals on providing legal services. Key lessons from this experience are: i) include a wide range of stakeholders and medical professionals in discussions of reform, ii) prepare for implementation before the legislation actually changes and iii) if a progressive law is not accompanied by steps to ensure its implementation, there may be little improvement or even increased abuses.¹⁰³

Several positive steps have taken place across Europe. Two countries, Switzerland and France, have improved their abortion laws in recent years, and the UK Royal College of Obstetrics and Gynaecology has developed comprehensive abortion guidelines on quality of care.¹⁰⁴

Where legislation allows abortion on broad indications, there is a lower incidence of unsafe abortion and much lower mortality from unsafe abortions, as compared to legislation that greatly restricts abortion.¹⁰⁵ However, legal reform does not automatically translate into access to services; India being a case in point. Legal reform efforts must focus both on reforming legislation and building the capacity of health systems to provide safe, quality services for women. Addressing the factors that lead to unprotected sex and unwanted pregnancies is also critical.

Obstacles to implementing ICPD recommendations

Since 1994, active attempts to undermine ICPD principles and recommendations concerning reproductive rights have increased, led by conservative political and economic forces at the national and international levels.¹⁰⁶ Since 2001, the US government, which was a supportive leader at ICPD, has reversed its position and joined these forces. In Peru, the Philippines, and the United States, human rights arguments are being used to invoke the concept of fetal rights, even though human rights apply only to those already born.⁷⁰ Unwarranted claims about the risks of abortion to women's mental and physical health are also being put forward, which have no basis in evidence.

National level challenges identified in surveys in four regions⁵³, ¹⁰⁷, ¹⁰⁸ include structural adjustment programmes, gender discrimination, the stigma associated with abortion, lack of political will, weak health systems and paucity of trained providers, lack of awareness of legal grounds for abortion and the active efforts of anti-abortion forces. Abortion laws are still restrictive in many countries, and services are often inaccessible and of poor quality. Even in countries of eastern and central Europe where abortion is legal and maternal mortality rates are low, arguments to improve quality of care are compelling; providers still commonly use sharp curettage and women do not have access to adequate pain management and infection-prevention measures.¹⁰⁸ In many countries, the restrictive environment is reinforced by inequalities between men and women, between providers and clients, and between policymakers and those most affected by policies and programmes.

The Catholic Church is pressuring policymakers and health professionals, particularly in Latin America, not to be involved in abortion-related work or support the need for safe abortion. In Slovakia, the government is negotiating a treaty with the Vatican on the unlimited right of health care providers to conscientious objection on abortion, contraceptive prescription and provision of sex education, which would ignore the central medical ethic of putting the patient's well-being first.¹⁰⁸¹¹⁰ In the United States, a series of laws and policies are being proposed that allow insurance companies, health care professionals and institutions to use moral and religious objections to refuse to provide sexual and reproductive health services.¹¹¹

In contrast, a Mexico City health law of 2002 which covers abortion posits the right to conscientious objection only if providers are able to ensure access to services elsewhere within a reasonable vicinity, as does the South African law. Refusing emergency care, including in relation to abortion, is both illegal¹¹²¹¹³ and unethical, however.

Reversing positive laws has also been a strategy of opposition groups since the ICPD. In 1997, Poland passed a law restricting access to abortion services and El Salvador removed the only legal grounds for abortion from its law – to save the life of the mother. Movements in countries with more liberal laws, including Hungary and Russia, have also been working to inhibit women's access to safe abortion services by implementing restrictions such as parental notification requirements and limits on second trimester procedures.¹⁰⁸ In the United States, hundreds of barriers to abortion access have been put into place at state level since 1995, including waiting periods before abortion and regulations that force physicians to read women anti-abortion information. Several restrictive federal laws have also been passed, including one establishing fetal rights, called the Unborn Victims of Violence Act, and the Global Gag Rule is again being enforced through funding of NGOs internationally.¹¹⁴, ¹¹⁵, ¹¹⁶ While the United States and a handful of other countries have attempted to undermine global consensus around reproductive health and rights, the regional meetings commemorating the ICPD resulted in near universal support for the ICPD PoA.

Conclusion

There is an emerging global movement supporting women's right to safe abortion, and a great deal has been accomplished in the ten short years since ICPD, in spite of serious setbacks in some countries and continuing obstacles. Context determines which strategies will be successful. In some cases, a public health approach has worked well. In others, the synthesis of a public health and women's/human rights approach has succeeded, in which the human rights implications of existing laws, policies and programmes on health have been included with data on the health consequences of unsafe abortion, e.g. in South Africa, Nepal and Ethiopia, bringing together the perspectives of women's rights advocates and medical leaders (Saba Kidanemariam, Ipas Ethiopia Country Director, personal communication, 2004).

In the context of increasing public debates in many countries, it is more important than ever that advocates pay attention to the findings of abortion-related research and draw on medical, ethical, and legal principles and reasoning. Through a deep and well-informed understanding of abortion, advocates will be able to articulate rights-based and health-based approaches to the issue. In addition, strategic partnerships with other social movements, in particular those working in the areas of HIV/AIDs, social justice, globalisation, poverty eradication and economic, cultural and social rights are needed. Linking women's access to safe abortion to broader debates about the right to health, the need to eradicate poverty and the importance of promoting gender equality is critical.¹¹⁷ The result will be a more effective movement, ensuring that women everywhere can gain access to safe abortion care and fully exercise their sexual and reproductive rights.

Acknowledgements

The author wishes to acknowledge insights and perspectives of the co-organisers and participants in the Abortion Agenda Setting Session, Countdown 2015. This paper draws on the background paper for Countdown 2015 prepared with Laura Katzive. The author is grateful for valuable comments by Traci Baird, Maria de Bruyn, Barbara Crane and Charlotte Hord. Thanks to Kezia Scales for editing advice, and Sarah Packer and Mary Johnson for assisting with references.

Notes

* “Reproductive rights … rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.” (ICPD Paragraph 7.2)

† Notably, the current US government adheres to the view that making abortion services available constitutes “promoting abortion”. This position is reflected in the first and subsequent Mexico City policies and affects USAID policy on abortion. Women's health activists argue that making quality services available contributes to women's ability to make voluntary, informed choices, rather than promoting one decision over another.

* Comoros, Djibouti, Lesotho, Libya, Mauritius, Namibia, Nigeria, Rwanda, Senegal and South Africa.