A call for consensus and cooperation to resolve differing estimates of abortion-related deaths

29/08/2016 Comments Off on A call for consensus and cooperation to resolve differing estimates of abortion-related deaths

This article, in press, is about the difference between estimates of maternal deaths from unsafe abortion from the World Health Organization and those from the Institute for Health Metrics and Evaluation (IHME), USA, both published in 2014 in two different Lancet journals. The article, co-authored by Iqbal Shah, Carla AbouZahr and me, is in the International Journal of Gynecology & Obstetrics (IJGO). The article begins:

“The publication of two papers with widely differing estimates of abortion-related deaths has caused concern and confusion among individuals who work on mortality and morbidity related to unsafe abortion. Both papers claim to offer correct estimates based on robust and rigorous methodologies. We wish to highlight this issue and discuss how the differences might be overcome.”

If you subscribe to the IJGO you can find it here: http://dx.doi.org/10.1016/j.ijgo.2016.05.012

It has taken submissions to three journals, Lancet, WHO Bulletin and IJGO, over a period of 11 months, the first two unsuccessful, to have this published.

The likelihood that the IHME and WHO staff responsible for their respective estimates on deaths from unsafe abortion will sit down together to resolve their differences is anyone’s guess.

Meanwhile, we are all left not knowing whose figures to use. I took a personal decision, based on the arguments made in our article, to go with the IHME figures, as there is no other way of resolving this. I am using IHME’s estimate that 43,684 (14.9%) maternal deaths in 2013 can be attributed to unsafe abortion (Lancet 2014). I am also sharing the Guttmacher Institute’s estimate that there were 56.3 million abortions per year globally for the years 2010-2014 (Lancet, 11 May 2016), as few people seem to be aware of this new estimate either.

Based on my own (limited) knowledge of other people’s articles and presentations, and from what I’ve seen quoted in the mainstream media, the out-of-date WHO figures for 2008, published in 2011 — 46 million abortions with 47,000 abortion-related deaths annually — are still commonly being used. For those who are aware of the conflicting WHO and IHME estimates, few will have the expertise to choose between the two methodologies, but the sad part is, that shouldn’t be necessary.

At the end of the article we say: “As the leader in global health, WHO has a constitutional responsibility to support countries in strengthening their health-information systems. Likewise, IHME has a stature commensurate with its technical expertise and generous funding. Surely it is incumbent upon both organizations to put their differences aside and reach a consensus on the method required to produce one set of estimates that are comparable over time and that everyone accepts as the best possible information to guide clinical practice, policy and program priorities. Yet they remain unwilling to do so. In the absence of a neutral body with comparable responsibility, we believe that WHO should insist that its experts invite IHME experts, and others who might be considered neutral, to reach an agreement on the way forward.”

That pretty much sums up what we had to say from an advocacy point of view. The article goes into more detail, and also on the methodological issues too.

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The Case of Dr Carlos Morín, Barcelona, Spain – “Hasta el final”

23/06/2016 Comments Off on The Case of Dr Carlos Morín, Barcelona, Spain – “Hasta el final”

The history of the persecution of Dr Carlos Morín, former director of the Ginemedex clinic in Barcelona, Spain, the staff of his clinic and the thousands of women who had abortions there began in Britain in 2004 and reached its climax, at least for the moment, on 17 June 2016, in the Regional Court of Barcelona, where during a re-trial ordered by the Supreme Court, three years after he and all his staff had been acquitted of all charges against them, Dr Morín was found guilty of having carried out 11 illegal abortions and a psychiatrist from the clinic, Dr Pascual Javier Ramón, was found guilty of signing the forms authorising the abortions.

What happened in between is the stuff of nightmares. The case was dragged through the justice system and the media for more than ten years by anti-abortion groups, who succeeded in having all Dr Morín’s clinics closed six years before he was even tried in court, and everyone who had been working in the clinics and the patients were investigated. Not only Dr Morín and his wife, who worked with him, but also many members of their staff were finally put on trial in 2012. In the interim, he was unable to practise his profession as a doctor and suffered from both public condemnation and bankruptcy, due to huge legal costs throughout the whole process.

The story began in Britain on 10 October 2004, when the Sunday Telegraph ran a story, based on “undercover” work[1] by a woman journalist pretending to be pregnant, that women beyond the legal time limit for abortion in England and Wales were being helped by the British Pregnancy Advisory Service (Bpas) to obtain abortions in Dr Morín’s clinic in Spain. Following an investigation by the Chief Medical Officer for the Department of Health, Bpas were criticised for the way the undercover call was handled, but were exonerated of any wrongdoing.

Moreover, according to the Chief Medical Officer’s report, the Barcelona newspaper La Vanguardia reported on 14 October 2004 that the Health Department of Catalunya had come to the conclusion that the Barcelona clinic “attends patients in a correct and legal manner”. The Catalunyan Department added that they had carried out an inspection which confirmed that the clinic concerned had provided services within the terms defined by the regulatory and legal system.

The British Chief Medical Officer’s report also stated: “My investigation has shown that it can be difficult for women to access late abortion services.” (Chief Medical Officer report, 2005)

Thus, no wrongdoing was found in either Britain or Spain. The situation did not end there, however. It was advanced further following an undercover visit to the Ginemedex clinic by a Danish public television crew, which was aired on TV in 2006 in Denmark, France and the Netherlands. That led to an investigation of a clinic in the Netherlands who, like Bpas, sometimes referred women with late second trimester abortions (25-28 weeks) and rarely a third trimester abortion who were beyond the legal time limit in their countries to the Ginemedex clinic. The ultra-religious group E-Cristians used the Danish TV show to call for an investigation of whether the Ginemedex clinic was doing abortions outside the law.

Under the law in Spain until 2010, abortion was legal up to 12 weeks if the pregnancy resulted from rape, up to 22 weeks in cases of severe fetal anomaly, and with no time limit if it was necessary to avoid a grave danger to the life  or the physical or mental health of the pregnant woman. Throughout this period, the Ginemedex clinic followed the guidelines for assessing the women who came to them in line with legal protocols. The woman was seen by a psychiatrist who also authorised that the abortion was legal and on that basis, the staff carried out the abortions.

According to Anne-Marie Rey, an abortion rights activist in Switzerland since 1971, who has closely followed the case from the beginning:

“Up to 2007, the Ginemedex clinic was a last resort for women who sought an abortion in advanced stages of pregnancy. Women were sent to Barcelona from many countries, when it was not possible to help them at home. Personally I gave his address to several women from Switzerland and they were always treated with respect and empathy. Yes, Dr Morín did interpret the Spanish abortion law liberally. But, in fact, he only applied the World Health Organization definition of “health” as “a state of complete physical, mental and social well-being”. And he applied this interpretation also in the case of desperate women who needed an abortion late in pregnancy, after 24 weeks gestation.”

As has been shown all over Europe, women requesting an abortion after 24 weeks of pregnancy are rare. In Britain, for example, in 2002, of the 175,932 abortions that took place, only 117 were after 24 weeks of pregnancy, that is, 0.06% of the total. (Chief Medical Officer report, 2005) This number and proportion are not unusual. The Chief Medical Officer’s report stated that in 2003, of all the patients seen within the 26 abortion clinics in Catalunya, only 812 patients were foreign (of whom only 14 were from the UK). 98.9% of the abortions on foreigners were at less than 22 weeks of pregnancy. In 3 cases it was in the 24th week and in 5 cases in the 26th week. (Chief Medical Officer’s report, 2005)

What came next, according to an article by the anti-abortion group Religion en Libertad, with information they say came from E-Cristians, would not have taken place without; 1) foreign media involvement, 2) follow-up by anti-abortion groups who kept written records and spent money, 3) the written testimony of a woman who attended the Ginemedex clinic, who was given protected witness status, and 4) a judge and prosecutor who decided to pursue the case “hasta el final” (up to the very end).

In 2007, as part of what became a long investigation, Dr Morín was charged with carrying out “illegal abortions”. He was jailed for two months until a judge ruled that he could be released pending trial, his four Ginemedex clinics were closed, and the clinics’ records, including the personal records of several thousand women, were confiscated for examination. The investigation, including interviews with all the staff and many patients, took six years. In September 2012, the case opened in the Audiencia de Barcelona, a regional court.

Between 2007 and 2012, when the case was finally heard, many other clinics in Spain were also affected. According to one report,[2] there were increased political inspections and administrative and judicial harassment for all abortion clinics and the women patients they cared for, and there was more radical anti-choice activity. Complaints were laid against other abortion providers in registered clinics. One clinic especially suffered “virulent persecution by both anti-abortion groups and by the government itself” for a time, until the situation was clarified.

Some 115 charges of illegal abortion were laid against 12 people, including Dr Morín, his wife (who helped to run his clinics), the psychiatrist Dr Pascual Javier Ramón, and 9 other physicians and nurses. There were hundreds of statements submitted by the prosecution and thousands of pages of judicial and police reports.

According to Religion en Libertad, up to 2012 when the case came to court, E-Cristians had spent 55,000 Euros, including for “extra-judicial actions” and the involvement of lawyers who “knew the terrain” and another 39,000 Euros for other costs (Defiende usted la vida? 2012) [3]

The case concluded with a verdict on 31 January 2013. The verdict was the acquittal of every person charged and on every charge, as reported in El País on 1 February 2013. The court accepted that the abortions were performed “with the consent and at the express request of pregnant women” despite some administrative irregularities. However, both the Prosecutor in the case and the anti-abortion groups who had accused Dr Morín and his staff (E-Cristians, Spanish Alternative, Thomas More Foundation and the College of Physicians of Barcelona) did not accept the verdict and appealed to the Supreme Court. Nine months later, the Supreme Court criticised the Regional Court’s judgement and ordered a re-trial in the Regional Court with different judges. They gave two reasons: first, they argued that the Danish television programme should have been taken in evidence, which the Regional Court had decided against doing. Second, they said that because Dr Morín exercised his right not to testify, the judges did not allow the prosecutor to read out the questions they had prepared to ask him. The Supreme Court thought, however, that these had to be made public and answered, in order to determine, as claimed by the Prosecutor, whether there were contradictions between the pre-trial and the trial evidence.

In March 2015, Dr Morín appealed to the European Court of Human Rights in Strasbourg. Within less than two months, the Court replied that they would not consider the case because the request did not comply with the requisites of admissibility of articles 34 and 35 of the Convention. (CEDH-Lesp11.00R, MMI/MCM/agz, Demanda No.13465/15, letter dated 30 April 2015) The presumption is that he had not exhausted his right of appeal to the very top of the Spanish court system.

The re-trial took place in the Regional Court of Barcelona in January-February 2016. This time, both Dr Morín and Dr Ramón were found guilty and sentenced – not to 390 years or 278 years in prison as the Prosecutor had asked for originally, but to 18 months in prison – and not for over 100 illegal abortions but for 11 illegal abortions. All the other defendants in the case were again acquitted. One could be forgiven for asking whether this new judgement was in fact safe, let alone just.

The final irony, however, is that according to El País of 17 June 2016, the sentence is not firm and can actually be appealed, once again, to the Supreme Court. [4] Thus, it would appear that in Spain, if ultra-religious, anti-abortion NGOs, who have no legal standing, don’t like the verdict of a court of law, the defendants can be tried again in the same court on the same charges by different judges, with different verdicts and opinions on what constitutes evidence, for as long as it pleases the courts to take, and the European Court of Human Rights is prevented by its own rules from considering whether the human rights of the defendants have been and continue to be violated.

A note of thanks to Carlos Morín – I join with Anne-Marie Rey who said on 20 June upon hearing of the verdict: “This latest sentence is a scandal. Thank you, Dr Morín, and all your staff, for all you did for those women! And for your standing up for the right of women to decide for themselves in difficult life situations. I do hope some help is still possible for Dr Morín in return.”

Acknowledgement Thanks to Anne-Marie Rey for providing a wide range of documentation about this history over several years and for her help in preparing this article. Any errors are the author’s alone.

References

An Investigation into the British Pregnancy Advisory Service (BPAS) Response to Requests for Late Abortions. A report by the Chief Medical Officer. Department of Health, September 2005.

Defiende usted la vida? El caso Morín ouede cambiar la historia del abortion…pero requiere dinero. http://www.religionenlibertad.com/articulo_imprimir.asp?idarticulo=22994. 5 June 2012.

Condenado por abortos ilegales un médico absuelto hace tres años, El País, 17 June 2016.

Visit the website of the International Campaign for Women’s Right to Safe Abortion, where this article was first published on 22 June, for the Annex that lists the 34 articles from El País covering this history from 2006 to 2016. The titles and first lines are in Spanish, translated by me, with the help of SDL Free Translation, into English. The articles are in Spanish.

Footnotes

[1] Some might call it attempted entrapment.

[2] Anonymous, personal communication, October 2011.

[3] This is a direct translation from the Spanish.

[4] “La sentencia tampoco es firme y puede ser recurrida, de nuevo, ante el Tribunal Supremo.”

“Just because abortion is easy doesn’t mean it’s right” : do you agree?

26/03/2016 Comments Off on “Just because abortion is easy doesn’t mean it’s right” : do you agree?

During a day of excellent presentations on the question of “How can a state control swallowing?” on medical abortion and the law, organised by Prof Sally Sheldon of Kent University Law School, an unexpected question was asked from the floor, during the session I chaired: “Just because it [abortion] is easy doesn’t mean it’s right: do you agree?”

The questioner did not at that stage state his views but the question sounded, even on the surface, anti-abortion. I decided to respond myself. Of course not, I said. But no matter what aspect of reproductive health we look at, tradition as developed by the law and the medical profession has been to make things as difficult for women as possible. When doing surgical abortions, pain relief is often not offered at all, or too little is offered or too late. When pain relief during labour and delivery was finally developed in the 20th century, many were against it because the Old Testament talks about Eve being punished for her sin by having to suffer pain during labour and delivery. And although contemporary abortion methods, both manual vacuum aspiration and medical abortion, are extremely easy to provide, are very safe, take very little time and are very low tech, they are fenced in with a huge range of barriers and regulations. Gynaecologists in many countries still insist on using D&C, which takes much more time and skills, requires general anaesthetic and an overnight stay in hospital, as well as carrying a higher risk of complications. The fact that WHO has not recommended using D&C for something like two decades makes no difference. In short, things are often made as difficult for women as possible when it comes to pregnancy, and especially when it comes to abortion.

This is the same kind of myth as the one which says: if you make abortion easily available, everyone will want to have one. Thus confusing abortion with ice cream or sweets.

What I should have said, in order to keep the exchange as succinct as possible, was: “It doesn’t make it wrong either…”.

In fact, it’s wonderful for women that abortion has become so easy. Now all we need to do is liberate it from those who will use any means they can find ‒ out-of-date laws, punitive morality, clinically unjustified regulations, and even bald-faced lies ‒ to keep it difficult.

 

Opposing the criminalisation of self-use of abortion pills

14/03/2016 Comments Off on Opposing the criminalisation of self-use of abortion pills

More officials in European governments seem to have discovered that women are buying MA pills over the internet and are having abortions outside their health systems. The immediate response to this is that these abortions are or should be “illegal”; indeed, they are illegal under the law in Ireland, the UK and Italy, if not also elsewhere. Two women were charged last year in Northern Ireland and are awaiting trial, three women are in prison in England (two for self-use of MA pills for very late abortions, one for selling them). Italy has just increased the fine for these abortions from €51 to €5,000-10,000. In Ireland the punishment is up to 14 years in prison. Women in the US have also faced criminal charges for this, and a case was heard in Australia as well, though in that instance the couple involved were let off.

Is the abortion rights movement ready for this new form of criminalisation of abortion to spread? I don’t think so, and I think we need to be talking about it quite urgently, especially in Europe.

A recent Guardian article about the extent of conscientious objection to abortion in Italy(http://www.theguardian.com/world/2016/mar/11/italian-gynaecologists-refuse-abortions-miscarriages), misses the point that for more than 90% of abortions, i.e. those in the first trimester, and indeed uncomplicated abortions up to 18-20 weeks, women don’t need a gynaecologist. Care from a trained nurse or midwife or other mid-level provider, with home use in the first trimester and in a day clinic in the second trimester are fine for uncomplicated abortions; WHO recommendations support this. It is primarily women with fetal anomalies and other later and complicated cases who need hospital-based abortion services under a gynaecologist, as these are understood today, and while it is crucial to provide and protect these services, they are not the model for all abortions.

Based on the evidence, we can push this a step further and say that for most women, abortion “services” should be offered mainly by pharmacies, and for the rest the health professionals who become abortion “providers” and the education and training they receive needs to change a lot. Pro-choice gynaecologists should be among those to take the lead in arguing this as they have the standing to be listened to.

We need to start arguing that medical abortion pills are safe enough that they should be as readily available for early abortions as emergency contraception is for the morning after. And we need to be informing women of this because most women probably don’t know it. Not the way we know it.

Do we even have a consensus on these points among ourselves? I’m not sure. But what I hope we all do agree on is that criminalising the self-use of MA pills is happening and must be opposed, and I believe urgently.

Most of the mainstream media articles on women self-inducing abortions quote one official or other that the pills are dangerous if used without the supervision of a health professional. The article about Italy is an example. There is a lot of evidence to the contrary that needs to be shared as widely as possible.

What kind of research is needed for abortion advocacy?

24/12/2015 Comments Off on What kind of research is needed for abortion advocacy?

At the 5th Research Meeting on Unwanted Pregnancy and Unsafe Abortion, Mexico City, 28-30 September 2015, Silvina Ramos presented an excellent new CLACAI publication (in Spanish) on a renewed agenda for abortion research in the LAC region: “Investigacion sobre aborto en America Latina y el Caribe: una agenda renovada para informar politicas publicas e incidencias”. I was asked to comment in the session:

DATA FOR ADVOCACY

-We need to know more about what post-abortion care involves in order to showcase the failure of post-abortion care to resolve the serious public health problem of unsafe abortion. In 2012 an estimated 6.9 million women globally were treated for complications of unsafe abortion. In Latin America, new estimates of the rate of complications show a 31% decline between 2005 and 2012, from 7.7 per 1,000 women to 5.3 women per 1,000. (Singh et al, 2015) But this is still far too high and there is no excuse for it.

-As regards the incidence of abortion, we need to know more about pregnancy among girls aged 8-14 resulting from sexual abuse and whether or not they have access to safe abortion, including as a form of emergency obstetric care given how small they are. This emerged as an issue in Paraguay this year. There is little information on this subject though some research has been done (see http://conta.cc/1NNx4FD, http://conta.cc/1NN3sIn and http://conta.cc/1NMS9zS).

HEALTH PROFESSIONALS

-It is important to underscore the importance of the attitudes towards abortion of health professionals, and the importance of promoting training in abortion provision only for those who support women’s right to safe abortion. The current deficit in training should be a major advocacy issue. Why nurses should be less supportive to women needs to be better understood because abortion no longer requires doctors except in emergencies. Abortion care should be in hands of nurses and/or midwives at primary care and community level today.

-The prevalence of abortions among nurses/midwives and how they themselves are treated as patients might help to explain their views and bring them on board as a profession (http://www.rhm-elsevier.com/article/S0968-8080(07)30314-5/pdf).

-Attitudes towards 2nd trimester abortion are a particular problem. Can the number/proportion of second trimester abortions be reduced with better laws and services? Evidence from Sweden and Norway, particularly with good access to medical abortion, shows this can be done. If we knew why women have abortions after 12 weeks of pregnancy in more countries, it would contribute to change. However, this is not an issue of “women’s fault” but of systemic failures on the part of health and sexuality education, laws and policies, and health systems.

CONSCIENTIOUS OBJECTION

-Many who support abortion rights call for restrictions on conscientious objection but few oppose it altogether. Joyce Arthur of Canada and Christian Fiala of Austria have written several articles together and separately on this subject, opposing the whole concept.

-Sweden does not permit conscientious objection. This policy was challenged earlier this year at European level and their law was upheld.

-I agree with these views. I believe anyone who is unwilling to carry out an essential task in their job description should find another job. Abortion services are almost unique in allowing conscientious objection. It is a leftover of anti-abortion hegemony and should be removed.

PUBLIC HEALTH vs. HUMAN RIGHTS POSITIONS TO SUPPORT ABORTION

-I would like to disagree with one of the book’s authors that the public health arguments for safe abortion are less radical than those related to women’s bodily autonomy and rights.

-Public health arguments are not only relevant but also extremely powerful. I don’t think we use them enough anymore. Yet they are likely to have more resonance with health professionals.

-How to get past the huge, irreconcilable differences in thinking? Especially in the face of growing anti-abortion fanaticism?

RESEARCH FOR LAW AND POLICY ADVOCACY

-Campaigns for safe abortion often focus on calling for specific grounds for abortion to be decriminalised. For example, health grounds, rape, serious fetal abnormality, and in some countries in Latin America even for risk to the woman’s life to be permitted.

-I recently looked at the history of how abortion laws in several countries have changed over time, from almost complete criminalisation to allowing abortion at a woman’s request. This showed that a step-by-step process has taken place in some countries over a period of years, but often over decades. The current, limited law reform bill in Chile and recent examples in Africa show this has resonance as a way forward. But is it the only or best way forward?

-It would be good for this history to be studied in depth in many more countries, across both the 19th and 20th centuries and today.

RESEARCH ON ABORTION LAWS & GOALS

-For me, one of the biggest unresolved advocacy issues is whether we are seeking legalisation of abortion or decriminalisation of abortion.

-There a difference between these legal categories and we need to study it more.

-What reforms should we propose to our current laws on abortion that will lead to health system changes that will meets women’s needs and protect and fulfill their right to a safe abortion as part of their sexual and reproductive health and rights?

-In different countries, the answers may be different, depending on the origins of the laws, and more research and critical thought and analysis are needed.

Women’s right to safe abortion: interview for London School of Hygiene & Tropical Medicine Online Course

24/12/2015 Comments Off on Women’s right to safe abortion: interview for London School of Hygiene & Tropical Medicine Online Course

Improving the Health of Women, Children and Adolescents: from Evidence to Action is a free online course of the London School of Hygiene & Tropical Medicine. I was interviewed on the subject of abortion for one of the sessions; this is what I said below. The course first ran in autumn 2015 and is due to be run again from 29 February – 8 April 2016. Find out more at: http://www.lshtm.ac.uk/study/freeonlinecourses/women-children-health/#sthash.tI7kCuOn.dpuf

1. Please introduce yourself

>>My name is Marge Berer. Since May 2015 I have been the Coordinator of the International Campaign for Women’s Right to Safe Abortion (www.safeabortionwomensright.org), which is a network of over 960 groups and individuals in 100 countries who are working for the right to safe abortion. From 1992 to 2015, I was the editor of the journal Reproductive Health Matters, which I founded with TK Sundari Ravindran. The International Campaign is important because abortion is still restricted by the criminal law in almost every country in the world, including countries where it is widely available, yet approximately one in five to one in three women globally will have an abortion in her lifetime. It is also important because the practice is under constant attack from a small but powerful minority of right-wing and conservative groups who believe women should be forced to carry every pregnancy to term whether they can cope with all the children that would result from this or not. We believe that universal access to safe abortion at a woman’s request is essential for women’s health and a necessary aspect of women’s right of autonomy over their bodies and lives.

2. Can you explain the human rights dilemma that affects access to safe abortion?

>> As a human rights issue, access to safe abortion is inextricably linked to the first principle of human rights, that is, the right to life. An estimated one million women have died from the complications of unsafe abortion in the past 20 years, and almost all their deaths would have been prevented had abortion been safe and legal in their countries. The anti-abortion movement claims that the right to life begins at conception. If this were accepted in human rights principles it would subsume a woman’s right to life to that of any pregnancy she was carrying, making her into a vessel, and would mean that no abortion would be permissible. In fact, every human rights body, from CEDAW to the Committee that interprets the Convention on the Rights of the Child, agrees that rights in general, including the right to life, begin at birth

3. What are some examples where the rights of the woman are violated?

>> There are unfortunately many examples of the ways in which the rights of women are violated, and one of them is when abortion is illegal.  For example, let’s take 3 cases that were determined by Catholic health policy.

The first is the case of a woman who was 17 weeks pregnant, and began to miscarry. The miscarriage was inevitable, and the baby could not have survived no matter what was done because it was too early in the pregnancy. Because her cervix was open, the woman was highly susceptible to infection even though she was in hospital, and in fact she did develop a life-threatening uterine infection. Yet the hospital failed to provide the only treatment that would have saved her life before the infection became uncontrollable, that is, an abortion, because they waited until there was no longer a fetal heartbeat, even though the fetus was not viable. She was a young healthy woman and she died completely unnecessarily.

The second case is of another young woman who was an asylum seeker. She fled the conflict situation in her country of origin, where rape was being used as a weapon of war. She had been raped herself. After she arrived in the country that gave her asylum, she discovered she was pregnant as a result of the rape. She was unable to obtain a visa to travel for an abortion. She became suicidal and although the threat of suicide should have meant she had a legal right to an abortion, it was refused. Instead, she was locked up in a hospital, supposedly for her own protection, until her pregnancy was far enough advanced that the baby could survive independently and then she was forced to have a caesarean section.

Both these cases come from Ireland. Something similar happened to a ten-year-old child in Paraguay this year who had been sexually abused by her stepfather for two years. She too was locked up in a hospital and subjected to a caesarean section to save the baby, instead of an abortion.

These cases are horrific; they represent the worst sort of misogynistic treatment of girls and women. But there are thousands of cases every day in many countries, especially in the global South, where safe abortions are not available. Some 42 million women have an abortion every year. Half of those abortions are unsafe in the following ways:

  • Illegal or legally restricted
  • Dangerous method
  • Untrained/unskilled provider
  • Unsafe conditions
  • Self-induced without help or information
  • Incorrect usage of abortion pills through lack of information
  • Little or no access to treatment for complications
  • Stigma, fear and isolation
  • Violence, rejection (by family, school, work) and murder, both of women and of doctors providing abortion care
  • Threat of arrest, and prosecution and imprisonment.

Here is what a young girl who was put in prison in Rwanda at the age of 17 for having an abortion said:

“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, Rutgers WPF

This young girl’s story is why I am devoting my time to campaigning for women’s right to safe abortion, along with thousands of others all over the world.

4. Do you see the situation changing? Are more women around the world being given the right to safe abortion?

>> The situation is improving in many ways in many places. Countries are reforming their abortion laws, for example, just this year Mozambique completed a change for the better in its law, and in Chile, Morocco and Malawi positive law reform is being proposed. At the same time, women who do not have access to safe abortion services are learning from other women through safe abortion information hotlines and from courageous health professionals in their countries about how to have a safe abortion with medical abortion pills on their own. They are accessing the pills from pharmacies and from trustworthy providers through the internet, and taking control of their lives in spite of the laws against abortion. This is not an ideal situation but deaths from unsafe abortion have been decreasing rapidly because of it and that can only be a good thing.

Let me close by saying that one in three women is a lot of women who will need an abortion in their lifetimes. It was me once, and it could be many of you who are listening today, or your partners. Safe sex is sex in which you and your partner protect yourselves and each other from unintended and unwanted pregnancy and from sexually transmitted infections. Protection can fail, however, and sometimes people fail to use it. We need our health systems to be there before and after to help us ‒ with contraception, condoms, emergency contraception, safe abortion, and treatment for HIV and other sexually transmitted infections. Each of these is part of a larger package of essential sexual and reproductive health care. I invite you to study how well your countries are doing in offering these services and get involved today to make the situation better for everyone, especially for young women, and also for yourself ‒ in case you may need it.

Abortion today: what women need and want

18/10/2015 Comments Off on Abortion today: what women need and want

Berer Presentation to Gynuity Medical Abortion Meeting NY 9 June 2015

This is a presentation I gave to a meeting about medical abortion, organised by Gynuity Health Projects in New York, 9 June 2015.

Click on the link to read it.

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