Decriminalisation of abortion: a public health and human rights issue
27/09/2012 § Leave a comment
International Campaign for Women’s Right to Safe Abortion
Public statement for:
28 September 2012 International Day of Action for the Decriminalisation of Abortion
In spite of increased attention to sexual and reproductive health and rights, and particularly to maternal mortality, in spite of the development of effective technologies to make abortion very safe, and in spite of the growing involvement in women’s health issues on the part of UN agencies, many governments, and a large number of NGOs – as well as women’s health advocates – pregnancy-related deaths and unsafe abortion remain a major public health problem in large parts of the world. Most countries that allow women to die in childbirth also allow them to die and suffer from unsafe abortions. Why? Because they do not value women’s health and lives, including when they are pregnant. This is what makes women’s right to safe abortion a public health and human rights issue.
There have been improvements for women in some countries, as global data show. The number of maternal deaths has declined substantially globally between 1990 and 2008, while the number of deaths from unsafe abortion has fallen to 47,000 per year in 2008. However, the proportion of all maternal deaths due to unsafe abortion has not been reduced but remained at 13% of all maternal deaths in that period. In 2008, of the 43.8 million induced abortions globally, 21.6 million were unsafe, 98% of them in developing countries. (Sedgh et al, Lancet 2012) And an estimated 5 million of those 21.6 million women each year had to be hospitalised for treatment of complications of unsafe abortion, (Singh et al, Lancet 2007) putting a heavy burden on scarce hospital resources (up to 50% of hospital maternity beds in some countries).
The number of unsafe abortions among total abortions has increased by about two million since 2003, mainly due to the increasing numbers of women entering reproductive age in developing countries, and without an accompanying decline in unsafe abortions of any significance. (Shah, RHM May 2012)
Adolescent girls suffer the most from complications of unsafe abortion and have the highest unmet need for contraception. More than 40% (8.7 million) of the 21.2 million unsafe abortions in developing countries in 2008 were in young women aged 15–24 years. Of these, 3.2 million were adolescents aged 15–19 years, and 5.5 million were aged 20–24 years. (Shah, RHM May 2012)
What is an unsafe abortion?
- The following clinical, legal and social determinants of health all characterise what we mean by “unsafe abortion”:
- Illegal or legally restricted
- Dangerous method
- Untrained/unskilled provider
- Unsafe conditions
- Self-induced without help or information
- Incorrect usage (of pills)
- Little or no access to treatment for complications
- Stigma and fear and isolation
- Violence, rejection (by family, school, work) and murder, including of doctors providing abortion care
- Threat of prosecution
- Prosecution and imprisonment
Not all abortions in illegal and legally restricted setting are unsafe as regards the abortion itself, and not all of these factors apply to every abortion, but legal restrictions are a central determinant of lack of safety (reported to police, closure of clinic) for the woman and provider, even if the procedure itself was safe.
“I am 20 years old and… have been in Karubanda prison since 2007 for committing abortion. I am the 3rd born in the family and the only girl. I was raised by my dad after my mum died when I was still young. I was in the 5th year of my secondary education when a teacher at my school started dating me. I needed school materials and since I could not afford them, I allowed to have sexual intercourse with this teacher at that tender age. With limited knowledge on contraceptive use, I got pregnant and had to drop out of school since it’s against school regulations. I decided to have an abortion and my elder brother out of fear reported me to the police. I am supposed to serve a period of 9 years of which I have so far completed 3 years.” Crying she says: “I have lost hope and this is the end of my life”. (Abortion and young people in Rwanda: a collection of personal stories about abortion. Family Planning Association of Rwanda (ARBEF), ARBEF Youth Action Movement Rwanda (YAM), Rutgers WPF)
But, yes, the situation has improved substantially in many countries over the past 30-40 years. The majority of women now live in countries where abortion is permitted on at least some grounds, and and a number of countries have instituted legal reforms or have active movements for law reform. In addition, some countries are allowing existing grounds to be interpreted more broadly and taking steps to implement them. As a result of these legal and policy developments, safe services are beginning to be provided in more countries, but with varying levels of accessibility for women. However, five countries still do not permit abortion on any grounds at all, and the fear of treating complications even of wanted pregnancies (in case it causes premature delivery and is perceived as abortion) in these countries has led to women’s deaths. Meanwhile, very few countries allow abortion for social, family planning or economic reasons, let alone on the request of the woman. Even when abortion is available on request, it is usually only in the first trimester of pregnancy, which means safe second trimester abortions may remain unattainable. Although legal does not equal safe, the more grounds on which abortion is permitted, the fewer the complications and deaths of women. (WHO data) And to date, only one country in the world, Canada, has completely decriminalised abortion, and that was in 1988. (van der Graff, ) No other country has yet followed their lead.
Induced abortion with (manual) vacuum aspiration or medical abortion pills is one of the safest and most common medical/surgical procedures. Yet mifepristone, one of the two medical abortion pills that should be taken in combination, has not yet been approved in the great majority of developing countries, while the other pill, misoprostol, which is far more effective when used in combination with mifepristone, is mostly obtained over the counter to self-induce abortion in countries where abortion is legally restricted. Indeed, use of misoprostol is rapidly replacing many more “traditional”, dangerous, often invasive, abortion methods, and making clandestine abortions far less unsafe than they used to be. On the other hand, far too many medical professionals providing treatment for post-abortion complications in developing countries are still using outdated methods, particularly D&C, which makes abortion care in hospital settings less safe than it needs to be. Why? Because they have never had access to training in the safer methods.
Why safe abortion is a women’s human right
Unsafe abortion is a major public health issue, acknowledged by almost all governments in 1994 in the ICPD Programme of Action. Public health reasons may be the best way to win over doctors, policymakers and politicians, as they are responsible for the public health, but:
“Dealing with abortion as a health issue does not necessarily lead to asserting a broad human right to abortion, although it may lead indirectly to asserting a right to health. Law is not just about rights — it is most often about giving legal effect to policies that will bring about desired outcomes.” (Reed Boland, 19 July 2010)
About one in three women will have an abortion in her lifetime, even in countries with very high contraceptive prevalence. Access to contraception must also become universal, but contraception has never been sufficient in itself, and abortion will always remain necessary for women. When pregnancy happens and is unwanted, however the pregnancy started, there is only one reason why women seek an abortion: “I cannot have this baby. I cannot.”
If the right to life and the right to health are human rights, then abortion is every woman’s human right. Addressing the public health dimensions of abortion is crucial, but arguing for safe abortion as a human right is the only way to argue that it is a universal right, no matter how sensitive or controversial, and notwithstanding any arguments against it, even for cultural or religious reasons.
In L.C. v. Peru, a 13-year-old girl, a victim of sexual abuse for many years, was denied a therapeutic abortion and jumped out of a window. She survived the jump, but because she was still pregnant, she was denied an operation on her spine because it might have caused a miscarriage. As a result, she was left paralysed, and she had a miscarriage anyway. CEDAW, considering this case, said: “The State should guarantee access to abortion when a woman’s physical or mental health is in danger, decriminalise abortion when pregnancy results from rape or sexual abuse, review its restrictive interpretation of therapeutic abortion and … ensure that reproductive rights are understood and observed in all health care facilities.” (Kismödi et al, RHM39, May 2012)
The CEDAW judgement wasn’t respected in the Dominican Republic earlier this year, however, where the law on abortion is interpreted to mean abortion is not permitted for any reason. A young woman there who was pregnant and had leukaemia was denied not only an abortion, even though the pregnancy represented a serious increased risk to her life, but also denied chemotherapy, because it might have caused a miscarriage. Thanks to national protests, with the whole country watching, she was finally started on chemotherapy, but by then she was very ill, the chemotherapy did not help, she did miscarry and began to haemorrhage, and died.
These were gross violations of women’s right to life and health. Much of this suffering could have been prevented. The word “unsafe” is completely inadequate to describe what can and does happen on a daily basis to women when they are denied a safe abortion.
Women are denied abortions even when laws are liberal
In the UK, this month, a 35-year-old woman, who only confirmed she was pregnant at 30 weeks of pregnancy, was refused an abortion by two clinics because the law says she would need to have exceptional mental or physical health grounds to be permitted an abortion after 24 weeks. At 39 weeks of pregnancy, in a state of mind that must surely be recognised as extreme desperation, she apparently took enough misoprostol, purchased on the internet, to cause the baby’s death and to bring on labour. She then delivered the stillborn baby by herself at home and buried it, and has refused to say where in order not to incriminate herself further. She was pursued by medical professionals, who wanted know where the baby had gone, and they then reported her to the police, who have treated her like a criminal. Now, two years later, she has been sentenced by a judge who belongs to an anti-abortion organisation to 8 years in prison. Yet she has clearly had very difficult problems with recognising and dealing with the fact that she is pregnant and trying to terminate her pregnancies.
Her need not to continue her pregnancy and her actions illustrate the depth of what women feel and mean, and what they do when they say: “I cannot have this baby. I cannot”. Millions of women every year, with or without help and support, are doing whatever it takes, even at the risk of loss of their own lives, to have an abortion. This woman, like the young women in prison in Rwanda, should be freed immediately. She, like the young women in Peru and the Dominican Republic and millions of other women like them, should never have been denied a safe abortion, let alone any other medical treatment because it might cause a miscarriage.
International Campaign for Women’s Right to Safe Abortion
This is why representatives of several dozen NGOs from all world regions, consulted and called together by the International Consortium for Medical Abortion in 2011-12, decided to launch the International Campaign for Women’s Right to Safe Abortion in April 2012, which after only a few months has been endorsed by more than 620 groups and individuals all over the world.
This is why we have called for action in every country in support of 28 September, the International Day of Action for the Decriminalisation of Abortion and are organising public meetings, press conferences, demonstrations, debates, information days, solidarity campaigns, parliamentary lobbying, street theatre, flash mobs, discussion groups, tweetathons, blogs, reports, book launches, radio and TV programmes, films, videos, festivals, values clarification workshops, creating artwork and selling bags/shirts/hats with slogans on them, distributing informative newsletters and leaflets, and holding local and community-based awareness-raising activities in the days around 28 September this year. In every world region, abortion rights groups, SRHR and human rights groups and other NGOs, and national coalitions , are organising one or more events and actions in their countries.
Here are some of the aims and objectives of the International Campaign:
- To build an international campaign to promote universal access to safe, legal abortion as a women’s health and human rights issue.
- To support women’s autonomy to make their own decisions whether and when to have children and have access to the means of acting on those decisions without risk to their health and lives.
- To make the impact of unsafe and illegal abortion on women’s lives visible.
- To increase public awareness of women’s need for safe abortion, in order to increase public understanding and support.
- To commit ourselves to the protection of women having abortions and health professionals providing safe abortions, including in legally restricted settings.
- To promote the evidence-based guidance on abortion in the World Health Organization’s Safe Abortion: Technical and Policy Guidance for Health Systems, 2012.
And these are our guiding principles:
We believe in and advocate for safe and legal abortion as a woman’s human right. Women must be able to take decisions about their own bodies and health care free from coercion: this includes the decision to carry a pregnancy to term or seek an abortion. No woman should be obliged to continue an unwanted pregnancy.
- Women’s human rights should be respected, protected and fulfilled.
- No woman’s health or life should be placed at risk because safe abortion services are not available to her.
- Abortion should not be restricted, prohibited or criminalised.
We invite everyone who supports women’s right to safe abortion to join us
Demonstration for abortion rights, Istanbul, Turkey, 3 June 2012, Anatolian News on AlJazeera
Marge Berer [mberer(at)rhmjournal.org.uk]
26 September 2012 00:51
Dear Campaign supporters, Please feel free to translate and use part or all of this statement from the Campaign for your own public statement/press release for 28 September, with credit to the Campaign. Please send us your statements to post on the Campaign listserve too. A short statement from the Campaign, intended for the media, will follow.
In solidarity!!! ICMA Campaign coordination team: