“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 Now all we need to do is liberate it from those who will use any means they can find ‒ out-of-date laws, punitive morality, clinically unjustified regulations, and even bald-faced lies ‒ to keep it difficult.

 

A Quiet Inquisition

A Quiet Inquisition

A film by Holen Sabrina Kahn and Alessandra Zek, Chicken & Egg Pictures, 2014 (65 min), in Spanish with English subtitles

A review by Marge Berer

This is a film about Daniel Ortega’s betrayal of Nicaraguan women. Made over a period of several years, this documentary film features the experiences of young, rural, pregnant women who arrive at a public hospital’s emergency room in Nicaragua, many of them adolescents, many as young as 13 years old, and anywhere from 16-17 weeks pregnant onwards, with life-threatening obstetric conditions.

These conditions range from placenta praevia in a twin pregnancy to advanced uterine cancer whose treatment might affect the embryo, to haemorrhage, sepsis and eclampsia. Some are miscarrying, some end up with stillbirths, and some have attempted unsafe abortions on their own. What happens to them in the hospital is shown through the eyes of a highly professional and highly caring obstetrician-gynaecologist, Dr. Carla Cerrato, who is often the first to arrive at the hospital each day and the last to leave. If there are 60 patients in a day, she says, she probably treats 30 of them and supervises three other doctors who treat the rest.

The story that emerges, as the film shows Dr. Cerrato helping one woman after another, is a familiar one by now from Central America, but also one that implicates the one-time superhero of the Sandinista revolution in Nicaragua, Daniel Ortega, who deposed a dictator and began to transform the country. However, when after many years he lost the presidency in an election, he sold out to the Catholic Church in order to obtain enough votes to win again in 2007. The payback, his betrayal of women, was to implement a total ban on abortion even when it is necessary to save a woman’s life ‒ even though Nicaraguan law had permitted therapeutic abortion for 130 years.

When the film opens, several women’s deaths are presented that occurred as a direct result of this law. Pregnant women with wanted pregnancies and serious but treatable complications were left untreated in their hospital beds by medical professionals too frightened to do anything to help. Why? Because although the pregnancies were nonviable, the law forbids terminating the pregnancy as long as a fetal heartbeat can be detected. The doctors involved are caught between implementing the medical protocols they had been taught, which unequivocally tell them to provide the treatment ‒ and an unjust law that forbids them to do so. Yet terminating the unviable pregnancy is the only way to hope to save the women’s lives.

We have published this story before ‒ Savita Halappanavar in Ireland at the end of 2012.[1] This is the Catholic Church’s so-called health policy, enshrined in law, which has a lot of pregnant women’s deaths on its hands.

The heroine of this film, Dr. Cerrato, a lifelong Sandinista supporter, a woman from a rural background who was only able to study medicine because of the Sandinista revolution and who still believes in the revolution and what the Sandinistas have accomplished ‒ but who condemns them on this issue. Her belief in the right of her patients to live, to get help in this hospital because the hospital is there to help them, shines out from this film from beginning to end. And she does help them, quietly and with great warmth and understanding ‒ every one of them ‒ a fact which only slowly emerges during the course of the film. But then one case comes up where she is going home for the weekend on the Friday and the young woman who comes in is bleeding, her life is at serious risk, the pregnancy is not viable, and she tells the resident to give the woman misoprostol to induce the pregnancy, but the resident doesn’t do it. The conversation among the medics in the absence of Dr. Cerrato is fraught; they don’t all support doing it, and the resident caves in. On Monday, when Dr. Cerrato arrives for work she learns that the young woman is still bleeding, and she gets so upset she’s sent home for a week with high blood pressure. In the interim, the young woman dies after lying for eight days untreated in her hospital bed.

The film is hard-hitting politically and heartwarming in equal measures in its portrayal both of the doctor and her patients. How long Dr. Cerrato will be able to go on saving these young women’s lives is the unanswered, breath-stopping question that dogs the entire film. No one is in prison in Nicaragua for illegal abortion, as they are in El Salvador, but that’s no guarantee for the future. Whether the hospital will be forced to let her go now that she has become known is perhaps a bigger risk. However, the film ends on a high note, with her reaffirming her commitment to her patients, come what may.

Like the film Al Jazeera made in 2014 about the young, rural poor women in El Salvador in prison accused of illegal abortion and homicide when they had only had miscarriages or stillbirths, this powerful film is important contribution to the continuing struggle to make abortion safe, which will only come about when pregnant women’s health and rights become more important to governments than the misogynistic ideology of the Catholic church hierarchy which condemns them to death. Don’t miss it!!

Shown at the Human Rights Watch film festival, 25-26 March 2015, in London.

Trailer: http://www.quietinquisition.com/#!video/cde1

To host a screening or bring the film to your University or organization, email: aquietinquisition@gmail.com

On general release for rental from 29 April.

[1] Berer M. Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women. An analysis of the death of Savita Halappanavar in Ireland and similar cases. Reproductive Health Matters 2013;21(41):9-17.

The Brazilian government pays compensation for a maternal death taken up by CEDAW – a decision that has global implications

Lisa Hallgarten, RHM

The Brazilian government has agreed to pay compensation for the death of a pregnant woman in 2002. The decision could have implications for governments around the world where women are dying from preventable deaths in pregnancy, childbirth and abortion. The Brazilian government’s move follows landmark decisions by the Committee on the Elimination of Discrimination against Women (CEDAW) in Brazil and Peru – reported in Reproductive Health Matters. CEDAW confirmed that all states have a human rights obligation to: guarantee good quality maternal health care; guarantee access to abortion when a woman’s mental or physical health is threatened by continuation of her pregnancy; and decriminalise abortion when the pregnancy results from rape or abuse.

The case of of Alyne da Silva Pimentel v. Brazil was taken up by CEDAW in 2011. Alyne died following a stillbirth towards the end of her second trimester of pregnancy as a result of misdiagnosis, inadequate treatment in her local health centre, failure of the centre to refer her for timely emergency obstetric care and inadequate care when she was finally referred. CEDAW found that she was a victim of discrimination because she was a woman, poor and of African descent. Following the CEDAW Committee’s recommendations, the Brazilian government has agreed to pay compensation for Alyne’s death in childbirth, and is to set up an inter-ministerial enquiry into where responsibility lies for the chain of events that result in a maternal death. It also plans to organise a seminar on the issue for lawyers and health professionals.

In the case of L.C. v. Peru, a young girl had been repeatedly raped by different men in her neighbourhood over a period of four years. At the age of 13 she learned that she was pregnant and made a suicide attempt which failed, but left her at risk of paralysis and in urgent need of spinal surgery. She was refused the surgery she needed because she was pregnant, and was also refused an abortion. Three months later she miscarried and doctors agreed to perform the surgery. Unfortunately the delay meant the intervention was unsuccessful and L.C. is now quadriplegic. Peruvian law already permits abortion in cases where a woman’s health or life is at risk. CEDAW ruled that access to abortion in these cases should be guaranteed.

CEDAW’s findings come in the context of legal and civil actions around the world aimed at making governments accountable for women’s health and lives in pregnancy, childbirth and abortion. We hope that the announcement from Brazil that it will act on CEDAW’s recommendations may encourage Peru to do so too, and will  help to reinforce the fundamental principle that women’s rights are human rights.

Other cases highlighted in RHM

Alyne’s case and the negligent, callous and discriminatory treatment she experienced, has echoes in stories we have published from all over the world including the testimony of a doctor in a sub-Saharan African country on this blog. Papers in May’s issue of Reproductive Health Matters demonstrate that failure to provide good quality, equitable and accessible maternal health care is widespread. Increasingly however, lawyers, families and health professionals have had some success in holding their governments and health services to account.

In India an investigation into maternal deaths in Madhya Pradesh documented lack of accountability, and discrimination against poor women, particularly tribal women. However, the authors report that since presenting the report some of their recommendations have been taken up. In another article from India authors explore the successful legal case made for compensation and accountability for the death of Shanti Dev in Haryana State.

Another article reports on opportunities for progress that could be learned from the success of HIV activism in sub-Saharan Africa where health professionals and civil society activists have formed alliances to demand constitutional rights to health care for people living with HIV. A recent attempt by health activists in Uganda to use the courts to establish the constitutional rights of women to quality maternal health care failed, but the NGOs involved have promised to appeal…watch this space.

Read the full editorial of RHM’s recent issue Maternal mortality or women’s health: time for action

China: how can the one-child policy and rights-based family planning be reconciled in the face of recently reported abuses?

Lisa Hallgarten, RHM social media and communications

Marge Berer, RHM editor

Two recent news stories from China have reawakened concern about overzealous enforcement of China’s one-child policy and the emergence of voices critical of the policy and its implementation. Historically, being a country with 25% of the total world population within its borders, China’s population policy has addressed a unique set of social, demographic and political circumstances, and overall, it appears to have had widespread support from the public. However, these two reports have resonated internally and far beyond its shores.

In the United States, the story of Chen Guangcheng ,the Chinese civil rights activist imprisoned and persecuted for exposing and protesting against abuses of women being forced to have abortions against their will, in the name of Chinese government policies, has been co-opted by anti-abortion US activists. Though he has spoken out mainly against the brutality of forced abortions, not abortion per se, he is being used as a poster boy by the US anti-abortion, anti-contraception movement. Stories of forced abortion, and other human rights abuses associated with the one-child policy, are being presented as the logical conclusion of all and any family planning policies.

In one of two recent stories that hit the press due to US publicity, a mother of one was snatched from her home and forced to have an abortion. The procedure went tragically wrong and just hours later the 38-year-old woman was dead.  In another report, a woman who was seven months pregnant was also forced to have an abortion.  The story and pictures of the woman lying beside the aborted fetus were posted on the internet, generating over a million hits on Chinese social media networks. In response, the officials in the second of these cases lost their jobs and were prosecuted  More recently the women was given financial compensation as well.

At the same time, a flurry of anecdotes from other parts of China have started to emerge about the practice of forced abortions: contradicting the official party line that such practices – especially abortions in late pregnancy – are illegal, rare and not countenanced by the government.

A look at the Population and Family Planning Law of China  is instructive. It aims to maximise contraceptive use and minimise population growth by providing local and district officials with financial and other rewards for meeting family planning targets. The motivation this might create for officials to be overzealous in their implementation of the policy is tempered with tepid instructions not to infringe the rights of women and families and to promote family planning using incentives rather than coercion. In one of the cases above, the woman and her husband were threatened with a huge fee if they wished to continue the pregnancy, which they could not have afforded. This raises questions of which incentives and disincentives, if any, are acceptable to the population, how to prevent coercion, what to do when it happens, and what rights women have to redress and compensation when coercion has been shown to take place. Underlying these questions are broader policy issues – whether it is possible to reconcile the need to limit population growth with its attendant targets for coverage of contraception and even abortion.

The Family Planning Summit in London this month said that the funding associated with the new FP Initiative will explicitly NOT be used to support coercive family planning. It did, however, set ambitious targets for contraceptive coverage, though when criticism was raised, the language was changed to read contraceptive access. Whether it will be possible to achieve a huge increase in contraceptive use without incentives and targets, and how this relates to donor expectations with “results-based financing”, remain on the table for discussion. The consequences for informed choice and the right to use or not to use a method hang in the balance. At the same time, given the many barriers to accessing as well as using contraception successfully in the world’s most underserved communities, there will be enormous pressure to prove that the initiative really can give 120 million more women access to contraception.

The anti-abortion, anti-contraception movement would love to discredit the whole programme, as they have sought to do for years in the United States as regards the Chinese policy. Everyone who supports the right to control fertility needs to be committed to ensuring that any new programmes providing contraception will have women’s rights at their heart in practice. If they don’t, this one-off commitment of money may never be repeated.

Also in the news on this issue:
A group of Chinese scholars have written an open letter calling for revision of the one-child policy. They argue that the policy is bad for human rights and also for sustainable economic development.  Some Chinese demographers have said the one-child policy will damage the country as low fertility rates threaten a shortfall in the productive labour force needed to fund the ageing population.

We have no idea whether these statements are typical of public views. The public debate that has ensued inside China since these reports have come out must be multi-faceted and far from one-sided. We would be happy to receive further reports of the many points of viewbeing expressed in this debate, including by the government, as it unfolds within China.

Race, Reproductive Politics and Reproductive Health Care in the Contemporary United States

This editorial from the journal Contraception offers an important analysis of population and family planning policy in the USA, both in the context of current politics and also from history, starting as far back as 100 years ago.

Carole Joffe, Willie J. Parker

From: Contraception [Editorial] July 2012 reprinted as a blog with kind permission of Carole Joffe

To paraphrase Leo Tolstoy, who famously wrote that all unhappy families are unhappy in their own way, we can say that all nations confront the thorny issue of demographics, but each in its own, typically controversial, way. Various European countries, for example, have anxieties about a “demographic winter,” which is a below replacement birth rate of the native population, which has led to corresponding fears about rising birth rates among Muslim immigrants. China, driven by worries about overpopulation, has instituted coercive reproductive policies that many observers find unacceptably harsh. The United States, a country marked by extreme stratification on both racial and economic grounds, is a particularly interesting case to consider from a demographic lens because there has been a history both of targeting the birth rates of people of color and at the same time deep political divisions about the provision of reproductive health services — particularly abortion but increasingly, as the current election season reveals, contraception as well.

We, a sociologist and physician, respectively, write here of our dismay about the contemporary state of reproductive politics in the United States and particularly the cynical manipulation of racial themes by the opponents of abortion and birth control. However, we are acutely aware of the mixed legacy of the United States with respect to demographic issues. To name but a few examples, in 1905, President Theodore Roosevelt warned of “race suicide” because of his concern about falling birth rates among white Anglo-Saxon women and the higher rates among immigrants.1 In the 1927 Supreme Court case, Buck v Bell, the Court upheld a statute instituting compulsory sterilization of the unfit, including the mentally retarded, “for the protection and health of the state”.2 In the 1960s, impoverished African-American and Latina women, along with some poor whites, were subjected to coerced sterilizations, often without these women fully understanding to what they had ostensibly agreed.3 When the first federally funded family planning centers were established in the early 1970s, as a result of the passage of Title X, they were disproportionately located in African-American communities, although the language of the legislation did not mention race but rather the income status of the intended recipients.4

Co-existing with these events, however, has been a longstanding reproductive freedom movement in the United States, made up of clinicians and lay activists alike. Starting in the early 20th century, doctors and nurses, along with lay allies, fought for the legalization of first, birth control, and, later, abortion, seeing the particular damage done to the most vulnerable women in the absence of such services. In the 1960s and 1970s, feminist health activists raised an outcry about the sterilization abuses mentioned above; indeed, among the most prominent of the reproductive rights organizations to emerge from the “second wave” feminism of that era was CARASA, the Committee for Abortion Rights and Against Sterilization Abuse, providing a template for the principle that abortion rights should ideally be considered in a broader context that includes the right to have children.5 That generation of feminist activists also severely criticized the then-common practice of testing new contraceptive methods on Third World women. Today, there are numerous reproductive rights/reproductive justice groups hard at work in the United States, a number of them specifically concerned with the situation of women of color.

In short, this very brief recapitulation of reproductive struggles in the United States reveals the truism that the world of sexual and reproductive health services is a complex terrain, always containing both liberatory and coercive possibilities, and always with particular implications for people of color in a white-dominated society. But with respect to present-day conflicts, no figure’s legacy has been more contested than that of Margaret Sanger, the founder of the organization that eventually became Planned Parenthood. Anti-abortion forces for years have accused Sanger of being a racist and a eugenicist. Currently, these groups have pounced upon the high rate of abortion within the African-American community — black women have abortions at nearly four times the rate of white women — and have joined forces with some conservative groups within that community to mount a vigorous campaign against Planned Parenthood in particular and abortion provision more generally. Starting in Atlanta, and spreading to other cities, these groups have sponsored controversial billboards — some proclaiming that “black children are an endangered species” and others comparing abortion to slavery.

As Ellen Chesler, Sanger’s premier biographer, has argued, such accusations are a distortion of Sanger’s record.6 Although Sanger did receive some support from eugenicist organizations (at a time when eugenics was a far more mainstream movement than it is currently), her record cannot be construed as “racist.” Among her supporters were numerous black ministers, leading African-American intellectuals such as W.E.B. Dubois, and prominent community leaders such as Mary McLeod Bethune, founder of the National Council for Negro Women. In 1966, when Dr. Martin Luther King accepted the first Margaret Sanger award from Planned Parenthood, he praised Sanger for “her courage and vision,” comparing her struggle for birth control to the civil rights movement. One of the most effective critiques of the billboard campaign, and against the larger agenda of demonizing Planned Parenthood, has come from Sistersong, a coalition of reproductive justice groups of women of color. As Loretta Ross, the executive director of the group told the New York Times, “The reason we have so many Planned Parenthoods in the black community is because leaders in the black community in the ‘20s and ’30s went to Margaret Sanger and asked for them. Controlling our fertility was part of our uplift out of poverty strategy, and it still works”.7

This manipulation of the history of race and reproduction by those involved in the billboard campaigns and similar efforts obscures the contemporary facts of life faced by the most vulnerable black women. These women experience high rates of unintended pregnancy, low use of the most effective forms of contraception, deep poverty, inadequate educational opportunities, unacceptable levels of intimate partner violence and, very often, lack of support from their churches. It should come as no surprise that these same women would have the highest rates of abortion in this country. Given the conditions, these women need — among many other services — access to comprehensive health care that includes both family planning and abortion. Yet, abortion has long been excluded from most mainstream health care institutions and sources of public funding, and during the current political season, we have watched with dismay the severe attacks on contraceptive coverage as well. The isolation of abortion, in particular, from the rest of health care has contributed to its stigmatization and has helped the development of conspiracy theories, such as we see in the billboard campaign. We decry the inflammatory, false rhetoric of “black genocide” that has been used in this campaign by anti-abortion extremists, and we are hardly the first to point to the hypocrisy of those who oppose contraception and abortion, yet just as fervently oppose any spending for social services.

One of us (WP), speaking from my perspective as a member of the African American community and as a women’s health provider, asserts that this attempt to manipulate my community is made possible by our unresolved issues regarding gender roles and sexuality in a modern context. The failure of our community to promote the agency of our mothers, sisters and partners, and to deal forthrightly with sexual matters, leaves us treating abortion and HIV-related issues as “open secrets.” This evasion results in exorbitant rates for both. To truly confront these issues, our community desperately needs medically accurate sexuality education, improved health literacy and a constructive engagement of religious and spiritual leaders, given the central importance of religion in the African-American community. This type of empowerment effort towards shared reproductive health responsibility is the only effective rebuttal to the mischief occurring with race and reproduction in our community. To paraphrase Dr. King, just as individual wealth is always a function of the commonwealth, thus it too holds true that compromising the reproductive health and rights of individual black women results in jeopardizing the collective well-being of black communities.

If to know is to become responsible, my awareness of black women’s unmet reproductive health needs requires me to provide family planning and abortion care to those most in demand for them. Doing so represents a dual sense of responsibility that I feel as both a women’s health provider and as a member of the African-American community. I join with those in my community who have articulated a vision of reproductive justice, defined as creating a society that enables all women and families to have the children they want, the resources needed to raise them, and the ability to prevent or end the pregnancies that they do not want. I call on my fellow health care providers, of all races, to trust women to make the good and tough decisions about when and whether to expand their families. A fundamental respect for fairness necessitates it, and a respect for human rights demands it.

In conclusion, as already noted, we write in a period of unprecedented political attack on women’s health issues — not just abortion, but also contraception and a range of other reproductive health services. Even the seemingly long settled issue of the importance of programs to combat domestic violence is now being resisted by conservative forces.8 This “war on women,” as it has come to be known, has galvanized a countermovement of health activists, both women and men, who have effectively and creatively protested these developments in a variety of ways. We are greatly heartened by this mobilization, although its eventual impact on elections and restrictive measures is unclear at this time. We close by reminding our readers of what is perhaps obvious: the stakes in this “war” are inevitably the highest for the most vulnerable in our society — those poor women of color about whom we have written in this editorial.

Carole Joffe
Advancing New Standards in Reproductive Health
Bixby Center for Global Reproductive Health
University of California, San Francisco
Oakland, CA

Willie J. Parker
Board member
Physicians for Reproductive Choice and Health
New York, NY

1. Roosevelt T. On American Motherhood. Available at http://www.nationalcenter.org/TRooseveltMotherhood.html (accessed July 20, 2012).
2. Buck v. Bell, 274 U.S. 200 (1927). Available at http://www.oyez.org/cases/1901-1939/1926/1926_292 (accessed July 20, 2012)
3. Schoen J. Choice and coercion: birth control, sterilization, and abortion in public health and welfare. Chapel Hill: University of N. Carolina Press; 2005;
4. Gordon L. In: The moral property of women: a history of birth control politics in America. Urbana, IL: University of Illinois Press; 2002;p. 289–291
5. Petchesky R. In: Abortion and woman’s choice: the state, sexuality and reproductive freedom. Boston: Northeastern University Press; 1990;p. 392
6. Chesler E. Was Planned Parenthood’s founder racist?. Salon. 2012;Nov 2. Available at http://www.salon.com/writer/ellen_chesler/(accessed July 20, 2012).
7. Dewans S. Antiabortion ads split Atlanta. New York Times. 2012;Feb 5. Available at http://www.nytimes.com/2010/02/06/us/06abortion.html?scp=1&sq=Shaila%20Dewan%20Margaret%20Sanger&st=cse (accessed July 20, 2012).
8. Joffe C. All common ground lost: the right’s opposition to the Violence Against Women Act. Rhrealitycheck.org. Available at http://www.rhrealitycheck.org/article/2012/03/16/all-common-ground-lost-rights-opposition-to-violence-against-women-act (accessed July 20, 2012).

Family planning and safe, legal abortion go hand in hand

Marge Berer

Editor, Reproductive Health Matters

One in three women in the UK will have an abortion in her lifetime, most of whom will have been using contraception of some kind. Yet since as long ago as the late 1930s, there has been a split in the UK between those who insisted on promoting contraception on its own because they thought abortion was too controversial and would hold back acceptance of family planning, and those who insisted that the two go hand in hand. This split exists in many countries, not just the UK, and also within many organisations with a large membership in different countries, such as the International Planned Parenthood Federation (IPPF). It is reflected most recently in a comparison of the list of 600 groups and individuals who have endorsed the International Campaign for Women’s Right to Safe Abortion this year, and the 1300 that signed a letter circulated by the IPPF supporting the Family Planning Initiative – very different groups are on those lists. Yet all of them support the right to control fertility.

In 1994, the ICPD Programme of Action, a consensus document on the integration of sexual and reproductive health and rights, was only able to be passed if it included a “compromise” clause that called for abortion to be safe only if it was legal. This compromise was and remains a violation of public health principles and women’s human rights. ICPD failed to condemn the often 19th century, often colonial laws on abortion still in place in the criminal code in many countries. However, the Programme of Action did recognise that unsafe abortion was a major public health problem, one which to this day still affects some 22 million women every year, among whom 5 million end up in hospital with complications annually and tens of thousands die (WHO, Guttmacher). And young women, whom everyone wants to be  seen to be supporting these days, are in fact most at risk of unsafe abortion and also have the least access to contraception (Shah & Åhman, RHM, May 2012).

The answer is not to promote contraception in order to reduce unsafe abortion, as the FP Summit did. The answer is to promote contraception to reduce unwanted pregnancy and provide safe abortion to every woman who finds herself with an unwanted pregnancy. That is the way to make unsafe abortion history. Abortion will not go away unless men and women stop having sex with each other or everyone is sterilised. So forget it! The growing number of countries in both the north and south, east and west, where there is 60-80% contraceptive prevalence proves that. Research shows that women and men take up contraception in large numbers if they feel they have the right to control their fertility and have access to the means to do so. There is a huge need for information, because every new generation of young women and men will know nothing about contraception or abortion unless they have access to this information. But there is no need for “demand creation”, a retrograde concept which implies lack of interest. The steadily falling fertility rate globally, falling since the 1970s, proves that, and in every country, abortion is in there, safe or unsafe, reducing the number of births. Forty-four million abortions globally and hundreds of millions of people using contraception and sterilisation prove the huge demand for the means of fertility control. “Unmet need” is more than just lack of knowledge or interest on the part of the women and men who aren’t using contraception, or using it erratically or unsuccessfully.

Women seek an abortion if they have an unwanted pregnancy, legal and safe or not, because it’s too late for contraception. There is no split between contraception and abortion from women’s perspective, they are two sides of the same coin. Even so, many of the biggest supporters of “family planning” refuse to support women’s need for safe, legal abortion. Even worse, they always talk about abortion in negative terms. They mention it along with STIs, as if it were a disease, or treat it as an annoying problem that they wish would go away, and consider it inferior to use of contraception. They even claim that use of contraception will (or should) make it go away. But this is about the realities of people’s sex lives and how sex happens, not just about well-thought-out, planned-in-advance decisions about family formation. Many pregnancies are started without any forethought at all, and all too often as one of the consequences of sexual pressure and coercion.

Campaigns for women’s right to safe, legal abortion have been going on for at least 100 years. Many of us involved in these campaigns are still seen as annoying by people who are supposed to be our colleagues. We’re told it’s sensitive, controversial, difficult, it can’t be put on the agenda, including in the FP Summit. At the same time, many of us who are fighting for abortion rights stopped supporting “family planning” years ago, because of what happened in the past, when coercive programmes put many people off “family planning” and gave it a bad name. Some family planning supporters have blamed ICPD for the neglect of family planning, because it placed family planning in a wider context. But as Gita Sen said at the Summit, ICPD in fact sought to rehabilitate family planning and restore its good name, while the barriers to safe abortion were left in place.

Today’s supporters of family planning would like everyone to forget the coercive programmes of the past, which were target-based. But they may yet become target-based again because of “results-based financing”. So let’s not confuse opposition to coercive family planning policies with being anti-family planning. Yet, it is absolutely true that provision of contraception has been neglected in recent years – and yes, this neglect must stop. At the same time, neglect also characterises how women’s unmet need for safe abortion is treated. What needs to change is that both forms of unmet need should be taken into account – together – starting with donor and national government policies.

For example, although DFID’s development aid policy has long been to fund both family planning services and abortion services, in their roll-out of these policies, funding for family planning is (I am told) separated from funding for safe abortion. That is, it is managed by different people and in different programmes within DFID and in the recipient countries, and these different people may not work closely together or know what each other are doing. Yet DFID did not see a problem in agreeing to a family planning initiative in which funding for abortion is excluded. They fund abortions anyway, they say, so what’s the problem? The problem is that separating abortion from family planning at the programmatic level allows some countries to keep abortion legally restricted and not take responsibility for unsafe abortion.

Then there’s the US, where support for family planning by USAID has been the highest in the world for many years now, while safe abortion services are not funded by them at all. Since ICPD, however, the US has funded post-abortion care, which was invented at ICPD as a way to save women’s lives who had had an unsafe abortion. Unfortunately, the evidence that post-abortion care has in fact saved many women’s lives since ICPD is sparse and not compelling. Yes, the number of deaths from complications of unsafe abortion has fallen a lot, but this may be due to self-medication with misoprostol replacing life-threatening methods.

In fact, once ICPD was over, this so-called post-abortion care should have been rejected as unethical, because it allows harm to be done unchallenged and forces health care providers to clean up the mess without the support of the law. Under US aid policy, even countries where abortion is legal who tried to use USAID funds for safe abortions as well as for contraception and sterilisation, in integrated programmes, had their “family planning” funding stopped. Research has now shown that this leads to higher rates of unwanted pregnancies and abortions in those very same countries, proving how illogical such a policy is/was. Will that evidence, published only recently, lead to a change in USAID policy? Unlikely. Too sensitive. And meanwhile, a violent and fanatical anti-abortion movement flourishes in the US, where some of the most punitive and misogynistic barriers to safe abortion are being implemented with near impunity, in one state after another.

The anti-abortion movement is also anti-family planning. For years, they were very circumspect about this as they feared, quite rightly, that it would lose them support. But the current Vatican has helped to bring anti-abortion opposition to contraception and assisted conception out in the open again. This is evidenced in campaigns to ban emergency contraception and assert conscientious objection to providing contraceptives, e.g. by pharmacists. But still, many in the family planning movement do not support the right to safe abortion.

In light of the Family Planning Summit, it is a good time for abortion rights activists who have ignored family planning to link up with the family planning movement, and help to ensure that services have a rights-based approach. It is also a good time for all family planning colleagues to support the right to safe, legal abortion alongside the right to access contraception and sterilisation – and talk about abortion as a legitimate part of fertility control, a solution to unwanted pregnancy, a public health necessity for women, and a legitimate health care service. All of us should acknowledge the huge unmet need for safe, legal abortion services as well as for contraception and sterilisation services, and ensure that they are provided – and funded – together.

Many effective contraceptive methods, condoms, two types of emergency contraceptive pill and two very safe methods of early abortion – all on the WHO essential medicines list – can and should be provided at primary health care level. This includes medical abortion pills and manual vacuum aspiration for abortions up to 9-10 weeks. Some of these can even be provided during home visits by community-based health workers – the pill, condoms, injectables, emergency contraceptive pills and medical abortion pills for early abortions – as long as there are nurses, nurse-midwives or other mid-level providers who have been trained to do so. The evidence is there– this is all safe and effective. Moreover, the legitimate sort of post-abortion care, i.e. the kind that happens after safe abortions, needs to include information about and provision of contraception, just as post-partum care ought to do. So, even programmatically and clinically, the integration of family planning and abortion makes more sense than ever.

The morning after: the beginnings of an assessment of the FP Summit

Marge Berer
Editor, Reproductive Health Matters

13 July 2012

From a communications point of view, the FP Summit was a raving success. Newspapers, TV and radio all over the world covered it. Around the globe everyone reached by the media heard how wonderful family planning is and how neglected it has been, the Lancet launched a special edition , Guttmacher and others released facts and figures showing the extent of unmet need. Across the women’s health movement the listserves, Facebook and Twitter were full of it. All in all, the day – and many of the messages it gave birth to – had enthusiastic, even missionary, overtones.

On the absolutely fabulous side, Melinda Gates’ challenge to the Pope to acknowledge that contraception is ‘not controversial’ even amongst Catholic women, is likely to rock the foundations of the Vatican’s whole policy on abstinence, condoms and contraception from the grassroots of the Catholic church up. It was God’s gift to Catholics for Choice, who will be promoting Condoms-for-Life and safer sex at the upcoming AIDS conference later this month.

Also on the plus side, there were representatives of governments and many, many others who are making progressive change happen in their countries, and who spoke out about it. These are people who can make a big difference when they get home who did support comprehensive sexual and reproductive health and rights from the podium and the floor of the meeting, and who insisted that family planning services can only be provided within that wider remit. There were people who needed to learn what it was all about, some of whom were too young to have lived the history, but who came with strong pro-choice views.

The media exposure of the value of family planning has a huge potential for good, because it will have reached people who didn’t know family planning existed or whether it’s good for them and safe, and others who have never had a chance to talk about these matters with others. It will also have put fertility control as a public good on the map around the world. And hopefully it will spur those with expertise in sexuality and reproduction to start talking about what they know, and what is and is not true amongst all the hoopla – and to assert that the power of money must not be allowed to take precedence over public health values and human rights principles, or the values of knowledge and truth.

On the oh-God-help-us-no-no-no side, though, Melinda Gates anointed herself as the new saviour of women’s and children’s health, and the press ate it up in both pictures and words. Some of the best people in the field of sexual and reproductive health, were unexpectedly uncritical, singing the praises of this wonderful opportunity. Perhaps not surprising given the historical shortfall in funding for family planning.

A golden moment, the kind that big money and a Tory government are at home in, stage-managed by a slick public relations company called McKinsey (who describe themselves as “the trusted advisor and counsellor to many of the world’s most influential businesses and institutions”). With big pharma, having abandoned contraceptives for many years, talking about the opportunity (“70% of this market is under-served”) to make a profit from family planning needs and then give some of it back to women – as a charitable gift. Patting each other on the back for being so wonderful as to finally have recognised that women have health needs they can exploit. A truly Hollywood event, except this is not entertainment. This is women’s lives.

This golden moment, which had to happen mainly because so many governments have failed to take responsibility for the public health needs of their citizens, for maternal health, family planning, abortion, sexual health, in the only equitable manner that works – by providing publicly funded, well-resourced services.

It was a day that showed the world it was possible for one very well-meaning woman, backed by the power and money of her husband, to direct global policy and claim ownership of the provision of family planning to 120 million women and at the same time, to disparage and stigmatise women’s need for abortion to the entire world – and get away with it without being challenged. She had the courage to challenge the Pope. It is a shame that a summit attended by many of the world’s experts on these subjects could not emulate her bravery and challenge her in return.

She was not the only one who got away with it. The Summit also gave the podium to and applauded politicians from countries where millions of women have the very unmet need for contraception in whose name this Summit was called: women who are still dying from unsafe abortions because their governments are too cowardly to make abortion legal and safe; and women who are dying from complications of pregnancies because they have no access to life-saving maternity care. Countries that since the 1960s have received hundreds of millions if not billions of US dollars for family planning, which have as good as disappeared, or been squandered and misspent.

It included representatives of the very same private sectors whose services and prices for contraceptive methods and safe abortions remain inaccessible to and unaffordable for many in the world’s population who need them, especially young women and men. And not only in low- and middle-income countries, but also in the United States, a country whose health industry has made life hell for Barack Obama for trying to make health care even a little bit more affordable, excluding abortion of course, for millions of disenfranchised people. The United States – a country that has the biggest and most violent and aggressive anti-abortion movement on earth, second only to the Vatican, and some of the highest unintended pregnancy rates in the developed world, especially among poor women.

It was addressed by the Prime Minister of the UK, the Right Honourable David Cameron, who got a standing ovation for a speech about the importance of empowering women, a speech that stank of hypocrisy. A Prime Minister who is responsible for indefensible, swingeing spending cuts that are adversely affecting women, young people and children above all, including cuts in family planning, sexual health services and welfare, at a time when it has never before cost so much to raise a family. Whose Secretary of State for Health is selling off our National Health Service piece by piece, who has wasted public time and at least £1 million in public money harassing some of the real heroes of women’s rights, that is, abortion service providers, for no credible reason. Whose Minister for Public Health put an anti-abortion group on the government’s sexual health advisory group “for the sake of balance” and to propitiate anti-abortion fanatics in Parliament – a Minister who described abortion as a “sensitive” issue, after 45 years of safe, legal abortions (except for women in Northern Ireland, of course).

And now it’s the morning after. How to go on from here and engage in what will happen? It’s a pity about Melinda Gates’ prejudices against abortion. I hope she will reconsider them because it would make her a far more credible ambassador for this cause which, after all, does not belong to her.

Making change happen is in the air

Marge Berer

Editor, Reproductive Health Matters

Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.

Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…

The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…

Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…

In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…

In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…

Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).

In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.

Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).

The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).

full editorial

All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

Marge Berer, Editor, Reproductive Health Matters

I was among the first generation of women in the 1960s to experience the miracle of the pill just at the age when I was wanting to start having sex. All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant if I didn’t want to, and it worked! But oh, if only it had all turned out to be that easy! Like one in three women in the UK today, a country where contraceptive prevalence is almost as high as it can get, I needed an abortion several years later. Again, I was lucky, the 1967 Abortion Act meant I was able to get a legal abortion. The lesson is simple – while contraception continues to be a miracle, because it helps people not to have children if and when they don’t want to, it is not enough on its own and it never has been.

Family planning has been out of the news for a long time, and suddenly it’s back. Welcome!! Bring out the red carpet, and I mean it!! Women and men need contraception now as much as they have ever done, and young women and men who are beginning to explore their sexuality together need contraception and condoms more than anyone. But there has been a lot of water under the bridge since family planning was promoted as the cure-all for the world’s ills in the 1960s when the pill came out, and everyone needs to study that history anew so that the same mistakes, of which there have been many, and the same narrow vision, are not repeated.

My generation of women’s health activists, along with a whole generation of researchers, service providers and policymakers who brought their knowledge together at the International Conference on Population and Development in 1994, got the world to recognise that the need for the means to control fertility, which is as old as history itself, was part of a much broader set of needs related to reproduction and sexuality, and that these were inextricably connected. These include: being able to have sex without fear of negative outcomes, being able to have sex if and only if we want to and only with whom we want to, being able to have the children we want, being able to get pregnant at all, being able not only to survive pregnancy but also still be in good health, being able to have a safe abortion without fear of death or condemnation when an unwanted pregnancy occurs, being able to protect ourselves from sexually transmitted diseases, and being able to get treatment for all the many causes of reproductive and sexual ill-health, which start with menstruation and menstrual problems, and continue into old age with things like breast and prostate cancer and uterine prolapse.

There is indeed a huge unmet need in today’s world, but the unmet need for contraception is only a fraction of the unmet need for sexual and reproductive health, and for sexual and reproductive rights. The results we should be working for encompass every aspect of the issues I have just named, and those in turn must be seen in the even wider context of the right to health, social justice and an end to poverty and violence – which were the real point of the Millennium Development Goals – not the measurable targets.

I will be blogging about these issues in the light of the FP Summit over the next weeks – watch this space!

An unholy alliance: religion, neo-liberal economics and good old fashioned patriarchy – restricting women’s abortion rights in Eastern Europe

A report from guest blogger Charlotte Gage on ‘How much does abortion cost?’ a session organised by ASTRA Central and Eastern European Women’s Network for Sexual and Reproductive Health and Rights at the AWID Forum in Istanbul.

I attended this session where speakers from Poland, Romania, Hungary and Slovakia outlined the economic dimension of sexual and reproductive rights in their countries, and the increasing restrictions on access to abortion.

Provision of abortion and other reproductive health services are under threat from neo-liberal economics which is increasingly restricting state-funded services throughout the region. This is being fuelled, by ideological opposition to abortion from both the Catholic and Orthodox Churches, sometimes with funding and support from US anti-choice organisations which is thought may include the US-based Human Life International and Opus Dei.

Most countries in the region have experienced reforms to health systems following democratic transition from Communism, but the results of these vary. The restrictive abortion laws in countries such as Romania and Albania under Communism were seen as a social experiment to increase the population and provide new generations of workers, and have since been relaxed. More recently however, Ukraine and Russia have tried to implement restrictive laws, to reverse a decline in population.

The influence of religion varies throughout the region. In Poland the Catholic Church still has a strong influence, and as its access to public resources increases, through provision of adoption services, it has a vested financial interest – as well as ideological one to opposing reproductive rights. In other countries it is the influence of, and funding from, the US anti-choice movement that is driving forward an anti-choice agenda.

The increasing reluctance by governments to pay for contraception and abortion services is also having an impact.

In Hungary, an advertising campaign in which images of fetuses asked not to be murdered was funded by PROGRESS EU funding – a fund aimed at supporting equality. The Government was forced to stop the campaign after feminist organisations complained to the European Parliament.

In tandem with ideological tactics aimed at creating attitudinal change, the budget for reproductive health in Hungary, which supported women who could not afford to pay for an abortion, has been significantly reduced with no explanation. Women seeking home birth are subject to unaffordable insurance premiums and in one case a midwife has been imprisoned for supporting a woman to give birth at home. For PATENT – People Opposing Patriarchy these were all cited as examples of the continued repression of women’s reproductive rights in Hungary, patriarchy in action, and the denial of women’s autonomy.

Freedom of Choice, Slovakia,  has campaigned against the lack of unbiased and accurate information on family planning. It also takes on the  influence of the Catholic Church hierarchy which is opposing progressive policies such as inclusion of more information in school textbooks and making contraception more affordable.

The Polish Federation for Women and Family Planning described how in 1993 Poland became the first country in Eastern Europe radically to restrict abortion and is now, regrettably, serving as a model for other  Governments in the region. Official figures show just 600 abortions were performed in Poland in 2010 (compared to 8,000 in 1989), but this figure hides the large number of privately performed abortions and those provided to Polish women abroad.

In many of the countries it is the actual cost of abortion for women that creates the main barrier to accessing services. Women on low wages sometimes pay the equivalent to the average monthly wage for an abortion. In Slovakia, where there are no state controls on the maximum price of contraception, prices are rising and contraception is becoming unobtainable for many women. Moreover, across the region professional resistance to medical abortion combined with high costs means women are denied the option of choosing this extremely safe method of abortion.

An interesting response to the economic and ideological squeeze on abortion access came from a speaker from the Romanian organization European Centre for Public Initiatives (ECPI) which said that Romania has not yet fully learned the lessons from its past. Though the liberalisation of abortion in Romania has led to significant reductions in maternal mortality there have been recent attempts to restrict and limit abortion in Romania, including proposing mandatory (biased) counselling and a three day waiting period before a woman is able to have an abortion.

ECPI believes that calculating the financial benefits of providing reproductive health care may be a powerful tool in opposing further restrictions. To this end, it is attempting to estimate the full cost of unsafe abortion including:  the health care costs following unsafe procedures; social costs including sick leave and disability benefits if the woman is injured; the costs of childcare if the woman dies;  and violence against women services for those who experience violence following abortion.

It may ‘leave a bad taste in the mouth’ to try to put a monetary value on women’s lives, but in the face of ideological opposition to women’s reproductive autonomy, and governments’ focus on cutting budgets, it might be the most powerful argument we can make.

Charlotte Gage

With thanks to Katarzyna Pabijanek – ASTRA Network Coordinator