Politics, women’s health and prevailing double standards

The diagnosis of an unwanted pregnancy is a crisis situation for most women, even if the extent of the crisis varies greatly. With the recognition of women’s rights and the improvements in technology seen over the last 30 years, women or couples in developed countries now have a high degree of autonomy over their fertility. This fact, together with less restrictive abortion laws, has helped to reduce abortion-related mortality and morbidity dramatically in western Europe. However, some countries still have regulations that reflect outdated procedures and thinking and do not adhere to current medical and social service standards. Currently, women wishing to terminate an unwanted pregnancy find themselves in very different situations depending on the country they are living in. There are huge differences in the regulations of legal abortion when it comes to counseling, obligatory waiting periods for reflection between counseling and the abortion, and available abortion methods. Futhermore, there are currently four countries in the European community where women have no free access to first-trimester abortion: Ireland (Northern Ireland and the Republic of Ireland), Poland, Portugal and Malta. Each year, a large number of women from these countries are forced to travel to a neighboring country to access a legal abortion service or to pay a huge amount of money for a clandestine procedure with a local doctor.

Counseling

For most women, an unwanted pregnancy comes unexpectedly. The woman is therefore unprepared and may not be fully informed about all aspects of the matter or may not know where to turn to get counseling, be it for carrying the pregnancy to term or for having an abortion. In effect, the diagnosis of an unwanted pregnancy places the woman concerned in an informational state of emergency. She needs a great deal of information within a very short space of time. This search for information is made significantly more complicated by a number of factors:

•	The information concerns one of the most intimate areas of life, which is particularly taboo in many societies;
•	The pregnancy is sometimes not the result of an existing, socially-accepted relationship, which is why the fact of pregnancy itself must not become public;
•	The woman’s own social circles, as well as professionals in the social services field, often react with moral condemnation, refusal of assistance or even misleading information;
•	The information required is extensive and complex. It affects both physical and psychological processes;
•	There are fundamental questions about the social situation, relationship, economy and the abortion, as well as practical aspects;
•	The impending decision has major effects on the woman’s social environment and on her future life, and is irreversible;
•	With a partner or a family, more than one person is immediately and directly concerned and involved in the decision to a greater of lesser degree.

Not least, the information requirements are very different for each individual and sometimes vary widely, and as a result it is not always easy to provide the necessary information.

Societies react differently to these requirements, although the last 200 years have been dominated by a rigid paternalism. Coupled with religious beliefs in some countries, this was often the expression of a male-dominated conviction among the dominant social strata that pregnant women could not make decisions regarding their own pregnancy responsibly. Society therefore ‘had’ to intervene in order to ensure that the ‘right’ decision was taken. This paternalism led, among other things, to a ban on abortions, which again was one of the reasons for the very high level of maternal mortality. This is still the case in many low-income countries where abortions are illegal owing to the laws imposed by former colonial powers and upheld with the help of various religious groups.

With improvements in technology, especially during the second half of the 20th Century, and recognition of women’s rights, the situation has slowly changed over recent decades and women or couples now have a high degree of autonomy over their fertility. Over the last 40 years, abortion laws have become less restrictive in most developed countries, leading to a significant reduction in abortion-related morbidity and mortality. As another result of this autonomy, Dutch women, for example, have the lowest rate of abortions worldwide [1]. On the other hand, some countries with legal access to first-trimester abortion still have regulations that reflect outdated procedures and thinking and do not adhere to medical and social service standards that have been established. One example is a compulsory counseling session before an abortion. Even though this has been abolished in some countries (e.g., recently in France), it still exists with varying guidelines in other countries. For example, in The Netherlands and Austria, all doctors can provide this counseling and there is no regulation as to its content, while in Germany it is more rigidly prescribed and impedes access to abortion. It remains unclear why it is so difficult to offer counseling voluntarily, as this is the usual practice for other medical procedures.

Obligatory waiting periods

Another example of a restrictive regulation is an obligatory waiting period for reflection between counseling and the abortion. The very idea of a legally required waiting period between counseling and a medical treatment is, for good reason, unusual in medicine. Rather, the law has given a special status to the doctor–patient relationship and this is particularly protected. It is incumbent upon the two parties involved to find the best procedure for a particular situation. If there is a legally binding period for consideration before terminating a pregnancy, it seems to be based on three basic misunderstandings:

•	Pregnant women have to be protected from themselves so that they do not hastily decide against having a child;
•	Women with an unwanted pregnancy would only enter into the actual decision-making process after counseling with someone that they do not know;
•	A reflection period (usually of an arbitrary length) could reduce the number of abortions.

Obviously, all three assumptions are unfounded and wrong.

Almost all women take the most intimate decision of continuing or terminating a pregnancy very early, sometimes even before the pregnancy is confirmed by a test. Also, this decision is often made after consulting their partner or closest friend. Any delay to the abortion only leads to increased psychological stress [3]. It is also unique in medicine to delay a treatment deliberately when it is known that a delay may increase the risks and side effects. In countries that do not have such an obligatory waiting period, women with an unwanted pregnancy, and professionals working in the field, see no need to introduce one [2]. The obligatory waiting period varies greatly from country to country regarding the length, how it is calculated and the possible exceptions. It can be assumed that the needs of the women in these countries are not essentially different, so that, for most women, the waiting period must seem arbitrary and not related to their needs.

Finally, there is no indication that an obligatory waiting period reduces the frequency of abortion.

Special regulations

Above and beyond this, in some countries there are special regulations, such as those stipulating that the woman may not be treated or cared for by the same specialists who are counseling her. Such a regulation is unique in medicine. In fact, it is self-evident that the specialists with whom one has established trust in the course of preliminary consultation and examination should also carry out any procedure, if possible, and are also responsible for care during the process. Continuity of care is particularly important in a crisis situation, such as an abortion, so that the women do not have to repeat their whole story every time they come to the service. Only in this way can a certain trust develop, which acts as a positive influence on the course of treatment. It is difficult to comprehend why this important quality standard should not be applied, in particular in the crisis situation of an unwanted pregnancy. In other branches of medicine, such an approach would be regarded as unethical or even as mental cruelty.

In Switzerland, even after the recently liberalized law, a woman still has to declare in writing that she is in distress before she can have a legal abortion. Here, too, this kind of procedure, unusual in medicine, accords no recognizable advantage to the woman concerned. Rather, it seems to be something that will provide legitimacy to the action, whereas it probably only serves to make the woman feel she has to justify herself to society for what she is doing.

Some examples of different procedures for abortion

There is a great difference in abortion procedures between countries. Whereas, for example, in The Netherlands, most surgical abortions in the first trimester are carried out under local anesthetic, in other regions, general anesthesia is the standard. Also, a surgical abortion at week 5 or 6 is a matter of course in The Netherlands and is even exempt from the legal waiting period. However, in other countries, surgical abortion at this early stage of pregnancy is not offered and is even considered to be medical malpractice by some doctors.

Some doctors believe that an intrauterine pregnancy or even a fetal heart rate needs to be seen on ultrasound before starting a medical abortion and therefore they unnecessarily delay the beginning of the treatment.

The upper limit for medical abortion is still 49 days in most European countries, despite the fact that the same treatment was approved up to 63 days in the UK and Sweden in 1991 and 1992 respectively. This upper limit was also accepted in Norway in 2000. Furthermore, medical abortion with misoprostol at home is still legally restrained in most European countries, with the exception of Sweden.

Whereas in Sweden, France, Scotland and Switzerland, approximately 50% of women choose medical abortion, in Germany, The Netherlands and Austria, medical abortions constitute only a very small percentage. It cannot be assumed that women’s needs in the above-mentioned countries are sufficiently different to explain this discrepancy. It must instead be assumed that the difference in the frequency of choice of methods is the expression of different organizational, legal or financial circumstances, or just a continuation of traditions that have not been called into question.

In summary, one can say that, in most countries, the general conditions in the run-up to an abortion, as well as in carrying it out, are hardly or not at all oriented to the requirements of the women concerned and often leave little room for individual needs. Rather, the professionally inexperienced and those not personally involved manifest themselves in an apparently arbitrary way, depending on the country and tradition. Unfortunately, these restrictive conditions lead to precisely the opposite of what they are intended to achieve. If one compares the frequency of abortions in various countries, it is clear that the countries with the lowest abortion rate are those where the general conditions are most oriented to women’s needs and where women have the greatest possible autonomy in access to sex education, contraception and abortion, for example, The Netherlands.

There is no evidence that restricting access by, for example, obligatory counseling or waiting periods, is of any benefit. These regulations do, however, lead to a delay in the provision of abortion and have negative effects on the physical and psychological experience of those affected. Consequently, all guidelines underline the advantages of early abortion [3–5]. These aspects should be highlighted in the public discussion and in the formulation of new general conditions. It is also worth pointing out that an unrestrictive upper limit for abortion does not encourage women to delay their decision or abortion, as seen, for example, in Sweden, where there is an upper limit of 18 weeks ‘on demand’ or 22 weeks after special permission, but a mean gestational length at abortion of less than 8 weeks.

Developments in recent decades have been encouraging in as much as the regulations in many countries have been changed and are now less restrictive. The example of Canada is particularly worth mentioning: the long-established view is that the abortion of an unwanted pregnancy is a medical treatment and requires no legal interference. Therefore, after long legal arguments, in 1988 the Supreme Court declared the law on abortion to be unconstitutional and abolished it. It will be interesting to see how long it will take for this solution-oriented approach to replace the existing ideologically motivated regulations in other countries, especially those in the European region.

Women should have the right to end an unwanted pregnancy in the best possible way and without unnecessary suffering or delay.

Information resource

The information on the legal situation and the practice in different countries is from national sources. Links to national institutions of different countries are available at the Link section of the FIAPAC website, www.fiapac.org/e/links1.html.