INTERNATIONAL SAFE ABORTION DAY
28 September 2019
Abortion is Healthcare: 28 Providers
Prof Fred Sai – global champion, pioneer and leader
Prof Fred Sai died on 17 September 2019 at the age of 95. He had a career spanning over 50 years. Born in 1924 near Accra, Ghana, he spent most of his early life with his mother and her female relatives. Growing up, he said, he saw “what women were going through, having children, being pregnant, going to the hospital and coming back without a child, sometimes not coming back themselves.”
In 1947, he travelled to England to study medicine at the University of London, where he witnessed the case of a girl who committed suicide because she was pregnant and couldn’t face it. Another tried but she was saved. When he returned to Ghana as a doctor, one of his first jobs was assisting with autopsies, including many on young women who had died as a result of unsafe abortions, which he described as “heart-rending”. He believed that any young girl or woman who wants an abortion should be allowed to have one in a safe medical environment.
He was best known as a passionate advocate for family planning and maternal health. He served in several positions in the Ghana Health Services and was a professor of Preventive and Social Medicine at the University of Ghana Medical School. He was Director of Medical Services and Professor of Community Health at the University of Ghana, Legon, and served as an advisor to the Government of Ghana on Reproductive Health, and HIV/AIDS. He co-founded the Planned Parenthood Association of Ghana in 1967 and was the first African President of the International Planned Parenthood Federation from 1989 to 1995. He was also the President and Honorary Secretary of the Ghana Academy of Arts and Sciences. He became the first Head of the National Population Council, and was instrumental in setting up the IPPF Africa Regional Office as well as the Centre for African Family Studies in Nairobi. He chaired the UN conferences on Population and Development in 1984 and 1994. He was a Nutrition Advisor to the Food and Agriculture Organisation, Africa Region as well as the coordinator of the World Hunger Programme of the United Nations University and a Senior Population Advisor to the World Bank. He received a number of awards, including the United Nations Population Award in 1993 and an honorary doctorate and fellowship
In 2012, the Lancet called him the godfather of family planning. At the age of 88, only semi-retired, he sat on the boards of Women Deliver and Population Action International.
The Fred Sai Institute was established in 2014 in Nairobi by the IPPF Africa Region in his honour, as a “pioneer public health research institute, championing research on population, sexual and reproductive health to generate evidence on effective health strategies aimed at improving the health of the population in sub-Saharan Africa”. The Institute was re-launched in Accra in July 2018 by IPPF Africa Region and the Planned Parenthood Association of Ghana, so that he could participate.
Abortion in Afghanistan is a life-threatening matter
by Anonymous Doctor
Abortion in Afghanistan is a life-threatening matter both for the mother and the service provider. It is a task for which the provider has neither the support of the government nor mercy from the community. It is even more challenging when it is a rape victim who has not only gone through this bad experience but also according to the law must deliver the rapist’s child. Any doctor who decides to support the victim by providing an abortion will face enormous, life-threatening challenges. I have been lucky to help some of these victims thanks to the support of international associations of which I am a member, like the Asia Safe Abortion Partnership and FIGO, who trained me and taught me best practices, as adopted by these associations.
One day a mother came to my clinic with her 12-year-old daughter, saying her daughter was complaining of heavy cramps. The girl was unable to speak; there were black shadows under her eyes, she was underweight and her hands were cold, like a dead body. After doing some tests, I found that she was pregnant, and informed her mother about the pregnancy. The mother lost control and started hitting the child in front of the other patients, who were awaiting their turn. I had to calm down the mother and separated her and the child. I asked the mother to sit outside the room till she calmed down. She was too much worried since her husband, if informed of this news, would kill both her and her daughter without a second thought. She was shaking and begging me for help.
It was a difficult situation for me. On the one hand, it was a rape case. On the other hand, I was told they would both be killed if the pregnancy was revealed. The only thing that was important to me was how to save the child. Luckily, that day, a lady police officer who is my patient was present in my clinic. I asked her for help and advice. She did some investigating and found that a 45-year-old man, who was a neighbour of the family, had raped the girl and threatened that if she complained about it to anyone he would kill her family. The girl was in the first trimester so I used my own judgment and provided a safe abortion. Two years later, the mother sometimes visits my clinic with her daughter; they are very happy. The girl is going to school and living a normal life.
PHOTO, by AFP, Strait Times, 30 December 2018
DEMOCRATIC REPUBLIC OF CONGO/SOUTH KIVU
Youth for Peace in the Great Lakes Region
by Gabriel Ngabe, Coordinator
We provide medical abortion services, family planning and STI care in Eastern DR Congo/South Kivu.
In view of all the dangers and deaths experienced by young girls who are having illegal abortions in our community, these services have responded to an extremely difficult challenge and succeeded in significantly reducing the number of deaths from unsafe abortions and the number of girls dropping out of school as a result of unwanted pregnancies.
Among the biggest hurdles are the restrictions on safe abortion under Congolese law, which does not recognise safe abortion as an inalienable right for any woman. Another is the lack of funds to ensure the availability of medical abortion pills, allowing access for all women to be able to decide about their own lives.
However, our efforts have succeeded in involving the local authorities. Although they do not have the last word as to what is decided at the national level, thanks to our lobbying locally, neither women nor clinicians who offer these services will be arrested, including for medical abortion, provided it is done in the hospital.
Not everyone understands the problem of illegal abortions, or know how many girls die as a result of illegal abortions, or the numbers of girls who drop out of school due to unwanted pregnancies. Not everyone knows about the high numbers of women who have to live with the lifelong ordeal of having an illegitimate child following an unwanted pregnancy. But I am very sure, without any risk of being mistaken, that this is a serious public health problem and that there is a need to protect all these women.
For us, this theme is very inspiring, that is, that safe abortion saves lives and promotes women’s health.
I joined HRP at the World Health Organization in 1984…
by Paul FA Van Look
I joined the Special Programme of Research, Development and Research Training in Human Reproduction (HRP) at the World Health Organization (WHO) in Geneva in 1984. Prior to that I had obtained an MD at the University of Ghent, a PhD in reproductive endocrinology at the University of Edinburgh, and qualified as an obstetrician/gynaecologist at the universities of Leiden and Edinburgh. In both Scotland and the Netherlands safe abortion services were generally widely accessible in practice. My time in the Netherlands also exposed me to research on the post-coital administration of large doses of synthetic oestrogens. These aspects of women’s health care later played an important part in my career in HRP, and WHO more generally.
On joining HRP, I was asked to take charge of the Task Force on Post-Ovulatory Methods of Fertility Regulation, which had recently started multi-centre research on the repeated use of levonorgestrel as a post-coital agent and concluded a collaborative agreement with the French pharmaceutical company Roussel-Uclaf to gain access to the company’s newly developed anti-progestational steroid RU486 (now known as mifepristone), which had shown promise for the termination of early pregnancy. Initial research results proved disappointing, however. Complete abortion occurred in only 60-70% of women with pregnancies of up to 56 days of amenorrhoea. The logical solution was to enhance uterine contractions with prostaglandins. The approach proved successful: a combination treatment of RU486 followed by the prostaglandin analogue sulprostone was shown to terminate early pregnancy in 94% of women in a clinical study conducted at our Collaborating Centre in Stockholm in 1985.
Since then, a large body of evidence has accumulated on this method. With the participation of our worldwide network of Collaborating Centres, HRP research established that the optimal treatment for termination of early pregnancy was a combination regimen of mifepristone and misoprostol. The intellectual property data generated by HRP in these studies were provided to the Concept Foundation. They have been the basis for the development and registration of a mifepristone-misoprostol combipack, Medabon®, by a public-private partnership between the Concept Foundation and an Indian pharmaceutical company. The simplicity of the combination regimen has played an important role in the success of self-medication approaches.
Much of this early work by HRP and others was published in Medical Methods for Termination of Pregnancy (WHO Technical Report Series No. 871, 1994). This report was critical, not only as a comprehensive record of work done but also for its “political” significance. Some of WHO’s Member States objected to the fact that HRP was engaged in abortion research and wanted to have it stopped. However, senior WHO management were able to turn down such requests using as a reason the special nature of HRP as a Special Programme, co-sponsored by UNDP, UNFPA, WHO and the World Bank, with its own governing body, which was strongly in favour of HRP continuing abortion research. When our publication on medical abortion in the WHO Technical Report Series was submitted to WHO’s Executive Board and to the World Health Assembly, no objections were voiced, which we interpreted as tacit approval of our work, which we always placed in a public health context (rights-based arguments for abortion became possible in the WHO environment only later).
While research on methods of safe abortion continued, much of our work on abortion focused on the management of complications of unsafe abortion. Strengthened by the messages of the 1994 Cairo and 1995 Beijing conferences (to which I contributed a now widely used definition of reproductive health that has had an important influence), and the changed environment in WHO under Gro Harlem Brundtland as Director-General in 1998, our attention also turned to developing several evidence-based guidelines. The most influential was undoubtedly Safe Abortion: Technical and Policy Guidance for Health Systems (2003), of which the third edition is currently in preparation. It took quite some time before this document was finally approved in-house.
Several other fields of work further strengthened HRP, including: regular assessment of global and regional levels of maternal mortality and the part played by unsafe abortion in these levels; social science research into the reasons why women have unplanned pregnancies and abortions (safe and unsafe); and health care assessments of the provision (or lack of) abortion services around the world.
During my time at WHO, from which I retired in 2009, I have been privileged to witness – and perhaps helped to facilitate – a gradual increase in the Organization’s willingness to deal with abortion not only as a public health issue but also, and increasingly so, as a human rights issue.
Safe abortion still an elusive dream
by D Selvi and G Kalavathy
Co-Coordinators, Rural Women’s Social Education Centre (RUWSEC), Tamil Nadu
In India, the Medical Termination of Pregnancy Act was enacted in 1971, but even today accessing safe abortion care is a lengthy process for women from marginalised sectors. A woman’s circumstances and her family situation make all the difference. Culturally, abortion is still considered as a social and religious ‘taboo’. Non-availability of services and poor quality of care in the public health sector force women to seek unsafe abortion and hesitate to reveal that they had had an abortion if treatment is needed afterwards. Incidences of unsafe abortion tend to be due to lack of support from family or partner and economic reasons, as well as non-availability of public sector services. In the private sector, abortion is very expensive and unaffordable for most.
Abortion services are provided only in district hospitals, comparatively far away from where women live. There is constant fear that neighbours or relatives talk ill about her if she is seen. Moreover, non-medical staff abuse women verbally and make them feel stressed and depressed.
Women tend to pawn jewellery or borrow money at a high rate of interest to access abortion in a private facility; later they find it very difficult to repay the loan. Many still use unsafe methods or buy medicines from the pharmacy without any information on how to use them, and face health problems and complications afterwards like severe bleeding, infection and severe pain in lower abdomen. There are many cases also of unmarried girls who experience post-abortion complications after unsafe abortion services, making them unable to get pregnant later.
Women’s reproductive health rights should be protected. Government should campaign for safe abortion services. Awareness sessions are also required to educate people in rural areas. It is imperative to increase the availability of safe abortion services in the public sector to safeguard the health and well-being of rural, poor and marginalised women.
RUWSEC is a non-governmental women’s organisation started in 1981 by a team of 13 women, of whom 12 were dalit women from the local villages. At RUWSEC, we provide counselling and medical abortion services. Our activities include innovative field programmes and research on gender, sexual and reproductive health and rights and social justice, and running a reproductive health clinic/hospital and resource centre. We see the clinic/hospital as an alternative health facility in all respects: in the good quality of health care it provides, its approach to women’s health as related to their low status, its focus on enabling women to take charge of their health instead of being passive recipients of health care, and in its treatment of women as intelligent and capable persons who will work towards improving their health if given the means to do so.
Below is the narrative of a rural woman’s abortion experience:
I am a 24-year-old woman belonging to ‘dalit’ caste. I got married at the age of 21 years and have a daughter aged one year old. The economic condition of my family is very poor. We live in a village in Tamil Nadu. My husband is an agricultural wage labourer. He works only 5-6 days a month. He is an alcoholic and does not care for the family. He frequently quarrels with me and will not give any money to run the family. I am also an agricultural worker and also work in the MGNREGA. This is the main source of family income and I manage the household expenses with this income.
After delivering my first child, I was in my natal home and my husband would visit me occasionally. I was under the impression that I would not conceive for one year after childbirth, as my menstrual cycle had not resumed. But, six months after childbirth, I had symptoms of severe vomiting and consulted a private doctor. A pregnancy test confirmed I was pregnant again. As the pregnancy had already crossed three months I was referred to the government hospital for abortion services.
At the government hospital, the very next day, the staff scolded me badly for getting pregnant without proper spacing and also for coming very late to seek abortion services, then they admitted me. They gave me medical abortion pills and I stayed there for a week, I did not get bleeding and abortion did not happen, so I came back home without informing the hospital staff. I continued the pregnancy and had vaccination. During check-up the doctor said there was no fetal movement, and the child was born dead.
by Sybil Nmezi, Founder of Generation Initiative for Women and Youth Network
I am Sybil Nmezi, I have formerly worked as an educator prior to my decision to work as a human rights activist. I have a Master of Arts degree and other certifications. I am a Nigerian and live in Nigeria. Access to safe abortion is an important issue for women because it allows them to enjoy their rights, decide on their body and health, control their childbearing and bodily integrity, achieve their plans and visions, end unwanted pregnancies, space births and save their lives
Barriers to my work include how to navigate the restrictive abortion regulatory environment, with the stigma and discrimination surrounding it. I believe denying women’s access to abortion is denying women’s access to health care. My advocacy efforts support women in a practical way with information about their reproductive health. I was the driving force for the initial establishment of a national coalition for reproductive justice in Nigeria, aimed at raising awareness on reproductive health information and access. Under my leadership my organization has established a helpline to support women with resources, information about their reproductive health, and tools for self-care and safe choices. This has proved to be an indispensable service, as they navigate their health literacy and self-empowerment. I have attended and presented in workshops and conferences both nationally and internationally, taking the issues of women in my community and country at large to the global world against all odds.
To me, the right to access safe abortion as a public health issue means safety, prevention of harm and protection of fundamental human rights.
VISUAL: GIWYN Video, 2017
Expanding mobilization of grassroots communities to ensure access and availability of comprehensive abortion care services in Uganda
by the Community Health Rights Network (COHERINET)
Abortion is health care beyond a reasonable doubt and the right to bodily autonomy is a fundamental human right.
In Uganda, provision of and access to abortion services is hindered by unclear law and policies, which is further fuelled by negative cultural/religious beliefs and norms. This makes it difficult for both women and medical service providers to understand their options, and hinder women’s access to safe, legal abortion services – this is a violation of women’s human rights.
Pre-marital sex is common in Uganda, and unintended pregnancies are on the increase, especially among adolescents and young adults from the community/grassroots level in Uganda. Major differences in socio-economic and demographic background mean that the well-off have access to a wider range of providers compared to their poorer counterparts, who can’t access skilled providers due to financial constraints and the geographic remoteness of services. This often forces poorer girls and women to resort to abortions provided by untrained providers using unsafe methods.
As the Community Health Rights Network (COHERINET), we are working towards ensuring availability and accessibility of good quality, cost-effective, comprehensive safe abortion services. We advocate for a conducive environment to make safe abortion health care available, and for empowerment of women and girls, men and boys, as agents of change and supportive allies from the community/grassroots level. We provide information so that everyone understands the need to break the silence and demand recognition of women’s bodily autonomy as a fundamental human right.
Finally, availability and universal accessibility of safe, legal abortion services is a proven way of saving and transforming women’s lives in a very personal sense and making a major difference at the community and society level.
Save a life or give up two lives
by Phan Bich Thuy, MD, MPH
Asia Safe Abortion Partnership
In a safe abortion training course, a doctor from the middle of Vietnam shared the following story with us:
There was a teenage girl who came to see her for an abortion. She refused to provide the service because she did not want to be related to anything that others considered a crime. The next day, the young girl came back to the hospital and begged her for help, because she had been kicked out of her home by her parents when they discovered she was pregnant. In addition, her lover had left her. Once again the doctor refused to help. The girl said, “If you don’t do this for me, I’ll have to die because I don’t have any other choice!”
Saying that, she left her home address on the doctor’s desk. Two days later the doctor received the news that the girl had hung herself and died. The doctor went to the girl’s funeral and cried a lot. She said: “If I had provided this service, I would at least have saved a life. But I didn’t do it and two lives were lost. I will regret this for the rest of my life!”
After this sad event, this doctor volunteered to provide safe abortion services. More than that, she especially cares for and sympathizes with young, unmarried women who have unwanted pregnancies who come for an abortion.
I and my husband do this work as a duty to save the lives of women and girls
by Chatro Dewi, Sartion Sehat Center
I am Chatro Dewi, I have been working with the Peace Foundation Pakistan since July 2014. I have also run the Sartion Sehat Center (Female Friend Health Center) since September 2014, supported by the Safe Abortion Action Fund. I provide contraceptives, insert IUDs, and provide misoprostol for safe medical abortion and manual vacuum aspiration (MVA) abortions. I see an average to 25-30 rural village women in the Center per week. I offer all services free. Despite threats by some local people, who told me to stop my work, I continued, and with the intervention of a notable person, the issue was settled. I do not want any woman or girl in my village to have an unsafe abortion, nor for any young girl to be killed in the name of “honor”.
I share here the story of the late Janat, who was beautiful girl who had passed her secondary school exams. She was married without her consent, and after just ten days, she was divorced. She terminated her pregnancy through a surgical operation. Her brother killed her with an axe and buried her in a ditch. There are so many sad stories like this one about women and girls in our society. Our society does not work to reduce unsafe abortions; they do not believe in safe abortion. They think abortion is an unforgivable sin. Such happenings motivated me, and I joined the Peace Foundation. I have a staunch belief that abortion is a genuine need of women and girls. There are so many stories of women and girls who did not know about medical abortion pills, who used unsafe methods and lost their lives. My community is marginalized because it is poor. The work in agricultural farms pays daily wages of less than US$1.50 per day. People hardly find work 18-20 days in a month. They cannot pay even the transportation cost to reach an urban area, and they have no money for surgical or medical abortion. They cannot even afford post-abortion care. I and my husband do this work as a duty to save the lives of women and girls.
A training course for midwives and nurses to provide abortion services
by Judiac Ranape, Clinical Nurse Practitioner, Western Cape
My name is Judiac Ranape from South Africa, born and brought up in Meadowlands (Soweto) and living in the Western Cape for the past 22 years. I am married with two wonderful sons aged 14 & 21 years. I am a Clinical Nurse Practitioner trained in Intensive Care Nursing and a first trimester medical (up to 9 weeks) and surgical abortion provider (up to 12 weeks).
I am employed by the Western Cape Department of Health as a Comprehensive Trainer in Child Health and Women’s Health. Included in my portfolio is training in Comprehensive Abortion Care of healthcare workers, mentoring them at high volume facilities and finding them competent in providing the service.
I assist the Provincial Department of Health with the inspection and accreditation of facilities according to requirements in the Choice on Termination of Pregnancy Act (CTOP Act) 1996 to offer abortion services. I am also a Master Trainer for the Leading Safe Choices Programme of the RCOG UK in Comprehensive Abortion Care and Post-partum Family Planning for doctors and nurses.
I train healthcare providers according to a planned programme to allow facility managers enough time to plan and release participants to attend the courses. But certain facilities do not send anyone to attend because some of the managers or the senior physicians in the facility do not support abortion services. Sometimes, healthcare providers attend the training and are even released for me to mentor them and find them competent. But when they get back to their facilities, they are not allowed to offer the much needed services to women and girls because it is against the operational manager’s religion.
Women often have to travel far to access services in South Africa because conscientious objection is not controlled and health care providers are not held accountable and are not reprimanded according to the CTOP Act for not providing the services.
The handful of willing and passionate nurse providers are not supported by the Department at all. There are no debriefing sessions available, and a lot of them suffer from burnout and eventually leave because they feel unappreciated, and they are not compensated according to the Occupation Specific Dispensation. Yet the doctors are being compensated per patient for doing the same procedure. This then leaves women and girls without the service and pushes them into the hands of illegal providers, so that they end up with infections, unsafe self-induced abortions, dumping fetuses in bins, face jail time for that and some even death.
Some providers would like to offer these services, but they can’t because of the stigma and personal attacks. They are being called names like “killer of innocent souls”, or being told by fellow healthcare providers, who end up isolating them, that they will be judged harshly by God one day.
Women are also mistreated, embarrassed and punished to spend the whole day at facilities by healthcare providers with bad attitudes, because they are perceived to be heartless killers and are not offered the correct information about the sexual and reproductive health choices that they are entitled to receive.
Sexual & reproductive health and abortion services are not prioritized in my region and this creates a great barrier for women and girls. Women are ill-informed about the different contraceptive methods available in the public sector, which are also not easily accessible due to the long waiting periods and negative, unskilled staff with bad attitudes.
We need present-day champions, policy-makers and decision-makers and providers like the ones who fought for the rights of women in 1994 – like Nkosazana Dlamini Zuma, Lillian Ngoyi, and a few others who advocated for women and pushed for the legalization of abortion in South Africa.
The CTOP Act 1996 was amended in 2008 to allow for task-shifting in which both registered midwives and registered nurses can offer first trimester abortions on demand. We have a very liberal law, but we are still failing a lot of women and girls.
Women’s reports of abortion with illegal providers
published by Rappler.com
Abortion is illegal in the Philippines. Widespread poverty, high birth rates and poor access to contraception have created an enormous illegal abortion underground. A video and several recent in-depth articles share many stories of women’s experiences, both safe and unsafe. Here are a few of them:
In the video “The Woman Who Had Two Abortions”, a young woman with three children describes the life-threatening experience of her first abortion, where she used unknown pills that caused stabbing abdominal pains, gushing bleeding, and made her unable to eat for weeks. She was too frightened to seek any help. With her second abortion, she received pills from a doctor and had a safe abortion. SOURCE: Rappler.com, August 2018
“Mylene [was] a young doctor who was raped by a local politician who paid for her education. After finding out she was pregnant, she attempted to self-induce an abortion, since the law forbids abortion even in instances of pregnancies resulting from sexual violence. Mylene ended up dying from complications that arose from her unsafe abortion and inability to access critical reproductive health care services.” SOURCE: Rappler, by Jihan Jacob, 29 July 2019
“The Reproductive Health Law provides humane, non-judgmental, compassionate post-abortion care and, a law known as RA 8344 provides for stabilizing patients in serious cases such as when a woman is bleeding due to complications from self-induced unsafe abortion. Even with RA 8344, the problem, in past years and until now, is that some medical health care providers erroneously deny life-saving procedures even in cases of intrauterine fetal death where therapeutic abortion is needed to save the life of the woman. In cases of ectopic pregnancy, [treatment] is necessary to save a woman’s life…. Many medical providers threaten women with prosecution in cases of intrauterine fetal death, spontaneous abortion, abortion due to trauma from intimate partner violence and self-induced abortion. As a consequence of these threats of prosecution, women end up dying because they delay going to hospitals or do not seek emergency medical care at all.” SOURCE: Rappler, by Clara Rita Padilla, 13 September 2015
“The methods used by backstreet abortionists in the Philippines are barbaric, as told by women who experienced it themselves: The advertisements on the online forum are clear and compelling, vowing painless abortions for pregnant women. They assure Filipinas they can terminate pregnancies at any stage, even up until 7 months, without much pain. The women believe them. It’s a mix of desperation and a lack of knowledge on safe abortion methods that drives Filipinas to put their faith – and their lives – in the hands of other women they don’t know, backstreet abortionists they meet online, who assure them they can help for a low price.
“For some, Miss Shine and Miss Julie, two of the most discussed backstreet abortionists in the online forum, are heaven-sent, the answer to their prayers. They say as much in the reviews they leave online. [One] said she met a staff member named Jen at a mall in the northern part of Metro Manila. She said Jen was kind to her, and brought her to an “okay and clean place” for her Dilation and Curettage (D&C) procedure, wherein the woman’s cervix is opened, and her uterus scraped. “It was painful and I felt a twinge in some places, but I had to endure it for the sake of all. It was done in 15-20 minutes and I rested for almost an hour before going home,” she said. “Thank God everything went well.” A check-up with doctors at a private hospital two days after cleared her of any infection and confirmed she was no longer pregnant…”
“…Yet… the negative reviews are chilling in their details… Aside from the account of a certain aifa2500, who allegedly died after a procedure with Miss Shine, there are numerous tales of painful procedures that don’t use anesthesia, botched abortions, and nightmarish post-abortion complications. Women shared stories of being yelled at and blamed when they complained of the pain. Others complained that abortionists extorted more money on the spot or asked them to give up their watches or jewellery to pay for additional pills or treatment, and still others said their phone calls and messages about post-abortion care were ignored as soon as payments were settled.” SOURCE: Rappler.com, by Natasha Gutierrez, 15 August 2018
I enjoy my work of assisting women to make an informed choice
by Dr John Nyamu
My name is Dr John Nyamu, an Obstetrician and Gynaecologist based at the Reproductive Health Services (RHS) Clinic in Nairobi. I am a women’s rights defender and safe abortion advocate and some of my work is to advocate for policy change and development of safe abortion care standards and guidelines at the national level.
I also train reproductive health care providers, pharmacists, youth and women on the information to access safe abortion information and services. I have assisted in creating networks for local NGOS working on abortion, reproductive health and safe abortion providers, and a network of youth advocates and peer educators to increase access to safe abortion information and services.
At the RHS clinic, I attend to women who have come to seek my opinion on abortion information and services and also those who have been referred by other doctors and clinicians. I see all my clients irrespective of whether they have enough money or not. All of them go home satisfied with my services, including provision of post-abortion contraception to avoid another unintended pregnancy and abortion. After talking to the women and counselling them, I always give them all the options at their disposal – such as adoption, parenting, and safe abortions within the confines of the law. For those whom I am not able to assist, I usually refer them to other providers who have the capacity and expertise to help them.
I enjoy my work of assisting women to make an informed choice about their sexual and reproductive health, which includes enjoying sex devoid of sexually transmitted infections and responsible parenting.
SOME HISTORY: In 2004 there was a crackdown on clinics accused of providing illegal abortions in Kenya. The RHS Clinic was raided and Dr Nyamu and two of his staff were charged with two counts of murder and spent a year in remand awaiting trial. When the case came to court, it was ruled as improper, the charges were dropped, and all three were released. This prosecution galvanised the creation of the Reproductive Health and Rights Alliance by a large group of medical, legal, women’s and human rights organisations, with the aim of contributing to the prevention and reduction of the high number of maternal deaths and disabilities caused by unsafe abortion. The Alliance has remained active ever since. SOURCE: Trials & Imprisonment: Kenya, by Alice E Finden, ICWRSA, Updated 2018
Ambassador Dr Eunice Brookman-Amissah, champion of abortion rights and services in Africa
Ambassador Dr Eunice Brookman-Amissah from Ghana was the first woman vice-president of the Ghana Medical Association 1992-95 and Minister of Health of Ghana from 1996-98. During her tenure as Minister, the Ghana Health Service Bill was enacted by Parliament and Health Sector Reforms were institutionalized. These appointments came after a long career in clinical medicine spanning both the public and private sectors in the UK and in Ghana. She was elected a Fellow of the West African College of Physicians in 1989, and in 1998 was awarded a Fellowship of the UK Royal College of Obstetricians & Gynaecologists, in recognition of her enormous contribution to the field.
She was Vice-President of the Ipas Africa Alliance from 2001 to 2015 and worked tirelessly to support efforts to make abortion safe across the region. This culminated in the launch of the Campaign for the Decriminalization of Abortion in Africa by the African Commission on Human and Peoples Rights (ACHPR), through the mechanism of the Special Rapporteur on the Rights of Women in Africa.
She has promoted the private and public sectors working together for the equitable provision of health care in Ghana and in the wider Africa region. Throughout her career, she has been committed to women’s reproductive health and women’s rights to equity in health care, supporting safe abortion as part of Safe Motherhood when that was very controversial. She also pioneered what has come to be known as Community Gynaecology in West Africa. She has also been a temporary consultant to the World Health Organization on several occasions. SOURCE: Global Philanthropy Forum, undated.
In 2016, she wrote: “In Biblical times, the Prophet Hosea lamented, ‘[M]y people die for lack of knowledge.’ In the 21st century, African women are dying for lack of knowledge, but also in the name of religion. In my life as an African woman, a physician and former minister of health in Ghana – and more recently in my work as an advocate for sexual and reproductive rights – I have seen too many African women die a senseless and painful death because they were unable to realize their reproductive rights.
“Patriarchy derives from some men’s need to control women’s ability to procreate. In most African traditional patriarchal societies, children belonged to the man, each child increasing his immortality. Hence, the practice of polygamy ensured that the man had as many children as he could afford, whereas the woman was only there to produce children.
“But we also know that in African traditions, older women cared for pregnant women and the traditional midwives knew how to assist them in childbirth. Women had supreme power in this area of procreation or reproductive health, and it was women who decided when it was time to have another child. Among the Maasai of Kenya, older women in the community decided whether a pregnancy should be terminated for several reasons, including incest and rape. (It is not clear if the woman had a say in this matter). In other societies, a woman who wanted to end a pregnancy for whatever reason went to the community abortionist, who was often also the traditional midwife…” SOURCE: Conscience, August 2016.
Mariana Romero: Providing technical assistance to health teams is what I enjoy the most
Although trained as a medical doctor in Argentina, I have been devoted to research, training and advocacy for most of my professional life. I became involved in the field of abortion while studying in Mexico and have never left it. In my experience, research has been key in introducing new technology (manual vacuum aspiration and medical abortion pills) and in considering providers’, women’s and managers’ perspectives. It also allows us to strengthen public policies and programmes by contributing to the knowledge base with local evidence, which has had an important impact in the field, on both the facilitators and outputs of its implementation.
Along with a group of colleagues, we brought together REDAAS, a network of safe and legal abortion teams from across the country who are working in public health sector facilities and at community level. Our aim is to increase and improve women’s access to safe and legal abortions, provided in Argentina’s public health system, using the best clinical and health practices available and applying the ethical standards set by the international human rights framework. Through REDAAS we have trained and technically assist providers, lawyers, psychologists, social workers, managers and policy-makers to design and implement services that better answer the challenges of their local context while responding to the needs and rights of women.
Along with other members of REDAAS, I had the opportunity to address members of the Senate and Chamber of Deputies of the national Congress during the debate on the bill to legalize abortion in Argentina in 2018. It was both an honour and a huge responsibility, in which the intersection of expertise and informed advocacy played a key role. We produced several documents that were disseminated among the Congress’s members, which were quoted on many occasions during the debate.
I also work internationally for abortion rights. Most recently, I’ve worked with the US National Abortion Federation to provide training in legal abortion service provision in Chile since the law was changed. I was a member of the Steering Committee of the International Consortium for Medical Abortion from 2006 and chaired the Steering Committee in 2011-12. I have also been involved in CLACAI, the Latin American Consortium against Unsafe Abortion, since its inception in 2005. And I have participated in the International Advisory Group of the International Campaign for Women’s Right to Safe Abortion since its first planning meeting in May 2012.
But providing technical assistance to health teams is what I enjoy the most. I conceive of this work as a place where bioethics, rights, health systems, beliefs, competency and empathy intersect. It is a never-ending challenge and I feel privileged to be part of it.
I began to be involved during the last year of my studies; it has become my life’s mission
by Rodica Comandent
Abortion has been legal in Moldova for more than 60 years, but much still needs to be done. I began to be involved in abortion during the last year of my studies at the Medical University of Chisinau, during the time of the Soviet Union. It was sad and terrible to see the rows of women in the corridors of the gynaecology department, waiting for their turn to have an abortion. They were only offered D&C, practically without anaesthesia… no one spoke with them, no support was offered.
The organization that I have run for 20 years now, Reproductive Health Training Center (RHTC), was fortunate to receive an Open Society Institute New York grant to promote the implementation of manual vacuum aspiration (MVA) in my region, which gave me the opportunity to learn about a much better quality of abortion services in US and French clinics, where women were treated with respect and dignity and offered counselling and psychological support.
It has become my life’s mission to ensure that women in Moldova and in our region are no longer discriminated against, but treated with that same respect when they need this important medical service.
On this basis we introduced MVA in Moldova, then together with colleagues from Ipas and the National Abortion Federation, we trained service providers in Kyrgyzstan, Ukraine, Russia, Armenia, Georgia, and other countries. It was very interesting to see how, during the trainings, the attitude of the doctors towards the women changes, becoming more empathetic and respectful.
Later, I was fortunate to participate with the World Health Organization in the Strategic Assessments of Abortion in Eastern European and Central Asian countries. I learned a lot from colleagues from WHO, including Ronnie Johnson, Peter Fajans, Gunta Lazdane. I understood that I could influence not only the quality of services in my country, but also in the region. In addition, I now have a network of friends –colleagues from all these countries – who have been just as enthusiastic as me to change the way things are going.
Since 2004, with the help of Gynuity Health Projects and its President Dr Beverly Winikoff, we have introduced medical abortion pills, first in Moldova, then in the region. I have coordinated numerous clinical studies, learning more about the method in depth and offering it to more and more to the patients.
Likewise, luck brought me in 2005 to the position of Coordinator of the International Consortium for Medical Abortion where, along with my friend and mentor, Marge Berer, we were able to influence and raise awareness of medical abortion worldwide. We also had the opportunity to organize four extremely interesting international conferences, to create and translate into six languages an Informational Package on Medical Abortion, to support the establishment of four regional networks: CLACAI in Latin America, ANMA in Africa, ASAP in Asia and EEARC in Eastern Europe. It was a fascinating time and full of wonderful experiences on how the landscape of medical abortion has broadened and transformed the way abortion services might be offered and put into women’s hands!
These days I continue to work with my colleagues from RHTC to raise the quality of abortion services in Moldova and in the region, with the support of the Safe Abortion Action Fund, in order to align national protocols with WHO recommendations. I am glad that DKT/Women Care Global have returned to our region to step up the use of vacuum aspiration instead of D&C, and that the Concept Foundation, for whom I have the honour to be a consultant, endeavours to ensure that women in this region have access to good quality abortion medications. I believe that every woman deserves this and that access to a safe and respectful abortion is her human right.
Today, the proportion of reported abortions with WHO-recommended methods stands at about 90%, versus 10% for D&C. In 2005, only about one-third of procedures were with WHO-recommended methods. Reported abortion complications today are remarkably low with a good level of post-abortion contraception counselling and methods. However, we still have a lot of education to do, for example explaining that having a safe abortion for an adolescent is far preferable than to bear a child at 15-16 years old, a phenomenon still very widespread in Moldova.
Lastly, in order to improve access to medical abortion pills, especially for rural areas, we want to implement provision via telemedicine, as part of public health service delivery, and I am sure we will succeed!
I quickly realized that paramedical staff and medical providers never miss an opportunity to stigmatize and blame these young women
by Selma Hajri, MD, Endocrinology, Tunisia
I am a researcher, provider and trainer in medical abortion and advocate for rights and access to safe abortion. During my student years, awareness of the injustices and humiliation that young women can experience when they are in a situation that leads them to seek an abortion was decisive for me. I did not start by choosing a specialty that led me to advocacy for women’s right to safe abortion. But when I started working in a family planning research unit a few years later, I got directly involved in operational research for the introduction of medical abortion. That was in the early 2000s.
The peculiarity of my experience is that although I am in a country where abortion is legal, done in safe conditions and accessible because it is available and free in the public sector, I quickly realized that paramedical staff and medical providers never miss an opportunity to stigmatize and blame these young women, especially when they are single. Across the Middle East and North Africa (MENA) region, non-marital sex is unacceptable.
From that time, my commitment has become more oriented towards advocacy and the fight for the right to abortion for all women. The reluctance to provide abortion and the barriers created to accessing it, as well as the humiliating and stigmatizing remarks women seeking abortion face, transform having an abortion into a situation of risk, which women experience as a kind of psychological violence. Whatever the legal situation, there must be a clear political will to promote sexual and reproductive rights and also ensure that providers recognize their obligations to women, who are entitled to safe abortion care.
I decided long ago that medical abortion is the ideal method for women, as it puts abortion into their hands. With the collaboration and support of Gynuity Health Projects, I first introduced medical abortion in Tunisia through a research study showing the efficacy and safety of the method. This took place in a very hostile environment, as the majority of ob-gyns were against the method and considered it to be dangerous. Our good results convinced the head of the maternity unit and the president of the ONFP (National Family Planning Office) to facilitate the registration of the medications.
We proposed to introduce medical abortion progressively in family planning clinics through introductory trials that allowed providers to get used to and master the method. The results were published regularly in international reports from 2001 to 2016. At the same time, I developed trainings and symposiums on medical abortion, with both the local team from ONFP and international NGOs, and arranged study tours to Tunisia for providers from several African countries: e.g. Senegal, Burkina Faso, and the Middle Africa Network for Women’s Reproductive Health (GCG) whose members are midwives from Gabon, Cameroon and Guinea.
Finally, my role as coordinator of the African Network for Medical Abortion in 2008-10, led me to think about the importance of creating a network in the MENA region, the only region that has remained for more than a decade outside the circles advocating for the right to safe abortion. As part of the Groupe Tawhida Ben Cheikh, I organised the first meeting for the right to safe access to abortion in the MENA region, where we created RAWSA MENA (Right and Access for Women to Safe Abortion in the Middle East & North Africa) in May 2019.
Our bodies, our choices, our abortion story
by Jade Maina, one of the co-ordinators of the MAMA Network, a regional network of activists expanding access to medical abortion across Africa
One sunny day in April 2008, we sat in a room sharing our stories like we had for the past one year. This particular day the topic of discussion was abortion. In a room of 15 women, nine women shared personal abortion stories, most of which were unsafe. One woman had had her uterus removed. We asked what solutions we had for ourselves, what we would advise one of us if they had an unwanted pregnancy, and we realized that we did not have the answers. We all knew places women could go. But we also knew that those clinics (often privately owned) charged at least $70. In our communities that is often the total family income for a month. Those services were out of our reach. It was one of the rare times that we have walked out of one of our meetings feeling defeated. We knew that the solutions that existed were not meant for women like us.
So we set out to find solutions for ourselves and we found it not too far away, indeed just across the road, in our pharmacies. We found misoprostol – the best kept secret of sub-Saharan Africa. And it cost less than 5 dollars.
Together with other activists across Africa we started work focused on abortion pills and giving information through community-based training programmes for community health workers and mid-level health care providers; we started hotlines where people could call for practical information; and we developed resources and launched websites where they could read about this information in user-friendly ways. We focused on practical solutions that can help “right here, right now” and used our experience to build evidence for advocacy to change the norms, de-stigmatize abortion, and see abortion as a matter of health, rights and justice. This way safe information on abortion replaces unsafe methods, preventing unnecessary harm when women and girls access abortion within or outside medical health facilities.
The WHO recommendations on task-shifting clearly state that community health workers and mid-level providers, as well as women themselves, can be crucial in expanding access to abortion care, particularly in regions with infrastructural challenges and lack of availability of providers to engage in abortion care. Like here, in Africa. Each and every single one of us, no matter our background, can help expand abortion care.
Medical abortion centres the discussion on autonomy, choices and reproductive justice. Self-management of abortion using misoprostol and mifepristone shifts the conversation to ask who the provider for this health service is. It is critically important that people who need abortions and are unable or unwilling to go to health care facilities know the correct use of the medications. Self-managed abortion with pills democratizes access to abortion. Abortion with pills is changing the landscape of abortion provision. It provokes discussions about what the minimum requirements for provision of care are.
by Aníbal Faúndes
The experience that determined my interest in abortion happened during my practice of emergency care as a medical student. I could find myself doing one curettage after another for hours, all without using anaesthesia, because the emergency staff had decided these women were “criminals”, who had to suffer the full pain of curettage with no relief. Talking with the women, however, I realized that far from being criminals, they were victims of their social environments. I then decided, in 1954, that I would dedicate a good part of my work as a physician to reducing the number of women who have to go through the experience of unsafe abortion.
Initially, I thought that family planning could solve the problem, but I soon realized that unintended pregnancy cannot always be prevented, and termination of pregnancy was often the only solution. Consequently, in 1972, we decided to interpret the Chilean law, which allowed abortion to protect the woman’s life, given that unsafe abortion was a major cause of maternal death, that women who decided to abort were risking their lives and consequently, were eligible for legal abortion. By that time, I was in charge of the abortion section of the maternity hospital. Most of the staff were in favour, and we did “legal” termination of pregnancy with electric aspiration at a rate of 20 every morning, with the limit of up to 12 weeks’ gestational age. This was reported to the national health authorities, published in high circulation newspapers, and denounced in the parliament, but no action was taken to stop it until the military coup on 11 September 1973.
After I left Chile, I could only return to this issue in late 1980, living in Brazil. We studied the experiences of the few women who had legal abortions after rape in the four hospitals that occasionally provided such services. With that information, we called for a workshop to discuss the care of women who experienced sexual violence and required a pregnancy termination. Recommendations were prepared and the Ministry of Health, represented at the workshop, used those recommendations to dictate norms for the care of women who suffered sexual violence, including the procedures for pregnancy termination. The number of hospitals providing such care increased exponentially, facilitated by the availability of misoprostol, produced by a Brazilian pharmaceutical industry – also after we had lobbied them.
Dorothy Shaw, who became the first woman President of FIGO in 2006-2009, created the FIGO Committee on Unsafe Abortion and appointed me as Chair. We created the FIGO Initiative on Prevention of Unsafe Abortion, which has worked with FIGO’s member societies and Ministries of Health in over 45 low-resource countries. This initiative has been successful in promoting increased access to safe pregnancy termination in all participating countries. The Committee is now called Committee for Safe Abortion and I remain a member.
Training midwives to do post-abortion care: Réseau d’Afrique Centrale pour la Santé Reproductive des Femmes: Gabon, Cameroun, Guinée Équatoriale / Middle Africa Network for Women’s Reproductive Health (GCG)
by Aimée Patricia Ndembi, GCG President, Justine Mekuí, GCG Medical Coordinator, Gail Pheterson, GCG Research Director, Marijke Alblas, GCG Expert Medical Consultant
In Gabon, women in need of post-abortion care are among the most regular patients in medical emergency facilities. Whereas the juridical prohibition of induced abortion does not deter women from ending unwanted pregnancies, the risk of criminal sanction does oblige them to do so without medical assistance until complications arise. The main goal of GCG, founded in 2009, is preventing avoidable death and disability from pregnancy complications and doing so quickly, since women are dying on a daily basis. In 2010-11, we organized training sessions and workshops in different rural and urban sites in Gabon, Cameroon and Equatorial Guinea. The workshop training consisted of manual vacuum aspiration (MVA), misoprostol protocols and insertion of Copper-T IUDs. We concentrated on these methods as they are feasible in settings where electricity, refrigeration and an operating theatre with an anaesthetist were unavailable. Our initial workshops included theoretical classes, demonstrations on a pelvic model, and occasional clinical practice in emergency rooms. Then, in 2011, we organized our first intensive, hands-on training of trainers in Tunis for GCG practitioners from Gabon and Cameroon (5 midwives and 1 ob-gyn specialist). This allowed the midwives to become fully qualified to do post-abortion care, to exercise their skills independently and to transfer those skills to other midwives as well as to physicians. Over 500 hospital practitioners in Gabon, mostly midwives, have been trained in manual vacuum aspiration since then, though we think as many as half of them are not practising. From discussions at regular GCG workshops and from ongoing requests for additional materials, however, we know that the method is now integrated into routine emergency care. Studies have confirmed the correlation between midwife provision of post-abortion MVA in health centres and spectacular decreases in treatment delays experienced by women, with corresponding decreases in mortality from abortion complications. An unexpected factor in expanding access to this form of care is the frequent transfer of midwives from one medical facility to another, often from one rural zone to another. We have seen that midwives bring their own materials with them to new settings where they can train colleagues to work in a post-abortion medical team. Where there is no physician, the usual case in rural villages and small towns, midwife authority goes uncontested. Where there is a physician in provincial referent hospitals, most are relieved to have midwife partners for outpatient emergency care, thus freeing them to attend to patients needing advanced surgeries. We see providing these skills as a direct-action strategy that circumvents restrictive abortion laws by the provision of expert assistance to women. The use of our protocols has received the encouragement of the Gabon Ministry of Health.
Excerpted from a paper currently being considered for journal publication, September 2019
by Lynette Shumack FCCLP, FCFP, MAPs, CPsychol MBPsS, MAICD
Forensic and Clinical Psychologist
Australian women have been able to access abortion in most Australian states for decades now. This has been possible because authorities here have mostly ‘turned a blind eye’ to the provision of this service through independent clinics or private hospitals. Medical practitioners and their staff have performed the service with relative impunity from prosecution, and in recent years most states have taken abortion out of the criminal code, now regulating abortion as a normal health service.
In 2015, Dr Paul Hyland embarked on an initiative to provide abortion Australia-wide via tele-medicine so that a women anywhere in Australia could simply phone the hotline and arrange an appointment for appropriate medical tests. Following an interview by phone with a doctor, or where necessary by law two doctors, they would be sent medication, and thereafter supported through the process of abortion 24/7 by a medical practitioner.
This service was the first in the world to provide abortion nation-wide using a telephone service. Research results indicated that the women who used our service, no matter how remotely they lived, or where they were located, were very pleased with the service and had no problem with it being provided via telemedicine.
This was possible using a sophisticated software system which could coordinate medical test data, interviews, distribution and follow-up, as well as message patients directly to ensure they could be reminded of appointments and follow-up results.
This system was designed for the Australian situation, since medical tests are covered under our universal health system, Medicare, and we have nation-wide registration of medical practitioners that meant they could provide a service across any state of Australia. It was very costly to develop, but was especially efficient for this kind of to service. It was a profitable business, and gave all staff a sense of great satisfaction that they were trail-blazers for women’s reproductive rights.
Earlier this year Dr Hyland decided he must retire, and despite his best efforts was not able to find a buyer for this service. We had worked very hard for four years, during which time abortion was taken out of the criminal code in all but one Australian state. We would like to think that we provided some of the impetus for lawmakers to finally bring the law in line with public opinion.
The business has now be properly dissolved, and the staff have moved on. Should any business-minded medical provider be interested in purchasing the software, it is quite adaptable and still for sale. Thanks so much to all our supporters, to our dedicated staff, and I hope the rest of the world can succeed in the same way in decades to come.
Oriéntame: providing reproductive health services to women for over 40 years.
In 1977, Dr Jorge Villarreal started Oriéntame, a women’s reproductive health clinic now credited with inspiring more than 600 outposts across Latin America “and for reshaping abortion politics across the continent,” writes Joshua Lang in a story about the Villarreal family, published in 2014 in California Sunday.
Jorge Villarreal Mejía graduated from medical school in 1952 and soon took the reins of the obstetrics department at Colombia’s national university. During that time, botched abortions caused nearly 40 percent of the country’s maternal deaths. “Women in slum areas were putting the sonda (catheter) inside of them without any sonography,” his daughter Cristina Villarreal told Lang. “They used ganchas de ropa (coat hangers), anything.” When these women showed up at general hospitals, they were shamed and quickly given basic medical attention at most.
So in 1977, Jorge opened a stand-alone health clinic in Bogotá called Oriéntame. Abortions were illegal, so Oriéntame had to focus on helping women who were already suffering from bad abortion attempts, or “incomplete abortions.” Colombians had to wait another 30 years before their country legalized abortion on certain grounds, under pressure from a coalition that included Cristina Villarreal. (Abortion is now legal in Colombia when the woman’s physical or emotional health is in danger.) In the meantime, Oriéntame has continued its mission to heal and empower women, using a sliding-scale payment model in order to include poorer women and girls. In 1994, Cristina assumed leadership of the organization, which had grown to include a second non-profit to help doctors around Latin America open their own clinics. Dr Jorge Villarreal Mejia died on 8 December 2001. Now the reins have now been handed on once more; Cristina Villarreal retired at the end of 2018.
Today, the Oriéntame team comprises 120 people, of whom 16 are doctors, 19 counsellors, 11 nurses, 6 social workers and 68 support personnel, including front desk staff, cleaners, administrative assistants, keeping records and statistics and filing, and security and customer service staff. It is the doctors, nurses, counsellors and social workers who have the most direct contact with the women who come in.
The criteria for selection and ongoing evaluation of the staff have to do with their technical skills and ability and, equally importantly, their compassion and ability to relate to the problems and crises of others. Each person that works for the institution, from the doorman to the doctors, has received special training in the technical, practical and ideological aspects of unwanted pregnancy and abortion, appropriate to the job each is doing.
In addition, all personnel receive continuing education through workshops and talks, given either by external specialists or specialists from within the foundation. For example, during 2001 there was a medical update on STIs, specifically looking at modes of transmission and treatment, and a discussion of new strategies for providing services to adolescents, based on the results of research presented to the staff, which helped in the creation of a special waiting room for teenagers, and shedding new light on counselling for teenagers. These activities help to improve the quality of the services being offered. Furthermore, the recent changes in the Colombian Penal Code were also analysed and discussed, which now allow a judge to decide not to punish a woman who has aborted a pregnancy if it results from rape or non-consensual insemination, depending on the circumstances surrounding the case.
Following the line of constant improvement, there are also evaluation forms filled in by each patient, in which they assess all aspects of the services. Staff analyse the results to see where improvements can be made, such as in waiting times. Educational sessions for staff are also partly determined through the suggestions of clinic users, to help us respond better to their needs.
Today, on Oriéntame’s website, there is a page called “Frequently asked questions about how to legally abort in Colombia”. The introduction on the page says: “Every day we receive thousands of questions about termination of pregnancy and other issues related to unwanted pregnancy and its prevention. Here a series of short videos gives you simple answers to these questions.”
The following three reports have already appeared in the Campaign newsletter during 2019 as part of the lead-up to this year’s International Safe Abortion Day:
ICPD at 25 and the changes I’ve seen over my career
by Prof Mahmoud F Fathalla
This year, FIGO (International Federation of Gynecologists & Obstetricians) celebrates 65 years as a federation committed to improving the health and well-being of every woman worldwide. Professor Mahmoud F Fathalla, FIGO Past President 1994-1997, has spent his career documenting, researching and advocating for women’s health and rights. Here, he reflects on the changes, challenges and vision for FIGO’s future.
Across the decades of my career, I have seen how international approaches to critical issues of women’s health – particularly reproductive health and choice – have changed.
The first United Nations International Conference on Population (ICPD), convened in Bucharest in 1974, upheld the slogan that family planning is the solution. Ten years later, the second ICPD in Mexico City put forward that development is the solution, development is the best contraceptive pill. The third conference, in Cairo in 1994, when I became president of FIGO, recognised these and more. It upheld the importance of family planning, the importance of development, but affirmed a greater truth: women are the solution.
My generation of women’s health professionals has been fortunate to witness how women across the world, empowered by family planning, were able to regulate and control their fertility, broadening their life choices and pursuing a productive and not only a reproductive career. So when concerns about population growth are raised, FIGO has a critical role to play in explaining that in spite of all the rhetoric, women in many countries around the world still have a large unmet need for family planning.
Women also have need of safe abortion. Millions of women around the world risk their lives and health to end an unwanted pregnancy, but the controversy surrounding it tends to obscure its dimension as a health problem. Laws that allow legal termination of pregnancy only when the life of the mother is in danger paradoxically put the life of the mother in danger. Unsafe abortion is one of the great neglected problems of health care, and a serious concern to women during their reproductive lives.
“Mothers are not dying because of diseases we cannot prevent or treat. They are still dying because societies have yet to make the decision that their lives are worth saving.” I made this observation many years ago, and sadly it remains a glaring, inconvenient truth. Progress has been made and should be applauded, but in many countries, maternal deaths are still a major health scandal. Mothers are left to die undertaking the risky process of giving us a new life; to die when their lives can be saved.
As the Nairobi Summit on ICPD+25 approaches, my message will be: take care of women’s health and rights, and the ‘population problem’ will take care of itself. If the world needed evidence about the health hazards for women denied equality and empowerment, the AIDS pandemic provided a hard lesson. What started as a mostly male epidemic has now left women, particularly young girls, more vulnerable.
Women do not need a “big brother” to dictate decisions for them about what to do with their own bodies. They can be trusted to make informed decisions about their reproductive health, and their decisions should be respected and implemented. It should be a responsibility of the whole international community to ensure that women, wherever they are, are given a choice in their lives and are given the means to implement their choice. This is where our FIGO stands.
Our profession is more than a medical technical specialty, only to deliver babies and fix pelvic organ disease. We see first-hand how women’s health is often compromised, not because of lack of medical knowledge, but because of infringement on women’s human rights. As we mark 65 years of FIGO’s work to improve the well-being of all women, we renew our commitment to a future where every woman is empowered to achieve active participation in her own health and rights.
SOURCE: FIGO, by Professor Mahmoud F Fathalla, 10 July 2019
CROATIA/SLOVENIA/BOSNIA & HERZOGOVINA
Croatian women are accessing abortions in Slovenia and in Bosnia & Herzogovina too
from International Campaign Newsletter
In February 2019, we reported that the cost of an abortion in Bosnia & Herzegovina was two times lower than in Croatia, and that some women from Croatia were consequently deciding to have an abortion in Bosnia & Herzegovina.
Now, a recent investigation has found that Croatian women who live near the border with Slovenia are crossing that border for abortions too, in spite of the fact that both countries have a similar abortion law. The smallest general hospital in Slovenia, in the town of Brežice near the Croatian border, saw 54 women for abortions in 2018 and 25 women in the first three months of 2019, most of them from Zagreb, which is only 32 km away. Almost all the women asked for medical abortion pills, which required them to travel twice, once for the mifepristone and again for the misoprostol. On the second visit, they are given a room where they wait until the abortion has taken place. Most of them are in their late teens or early 20s, some are older, but can be as young as 15.
Their reasons include better access to medical abortion pills, lower cost of the services, wanting to be away from home where no one knows, and the growing problem of conscientious objection in Croatia. In Croatia, anti-abortion organisations have received at least half a million Euros from foreign sources over the last five years. These donors are not named in annual reports. In contrast, anti-abortion influence in Slovenia is low and conscientious objection is rare. Hospital director Anica Hribar argues that the Catholic Church’s influence on women’s choices is not having so much of an effect: “I think women [in Slovenia] are quite strong, they don’t want to take us back 50 years.”
In Croatia, the upsurge in “objection” has shocked many in the medical profession. Jasenka Grujić, a pro-choice gynaecologist, argues that behind this boom is “the silent work of the Catholic church” and “many loud organisations” who speak on the Church’s behalf: “I think my colleagues who use the conscience clause are not on the side of women, but on the side of the Catholic church. They are traitors of the women, they are not professionals.”
Because the majority of doctors in Croatia are invoking conscience, many junior doctors feel they have to conform, argues Grujić. But there are also other sensitive situations which touch on political tensions. “One of my colleagues is of Serbian nationality, and he had no conscientious objection to abortion,” says Grujić. “But somebody told him he was a killer of the Croats, and after that he said: ‘From today I have conscientious objection, and I am not doing abortions’.” Other doctors are claiming abortion is not a medical procedure, but something cosmetic.
Medical Students for Choice promotes knowledge among future health care providers of abortion
from International Campaign Newsletter
Medical Students for Choice is a network of over 10,000 medical students and residents around the world.
In Rwanda, a 4th year medical student at the University of Rwanda recalls that since childhood, she has been hearing elders describe abortion as a crime and a taboo, and has shied away whenever the subject comes up among her peers, most of whom she says feel the same. As a result of such experiences, in 2012, a group of medical students at the University of Rwanda formed a chapter of Medical Students for Choice (MSFC) to help to promote the importance of reproductive health topics, including abortion care.
MSFC has provided the main opportunity for Rwandan medical students to discuss abortion issues, and the burden of restrictions weighing on women’s health and reproductive rights in general, Dr Jean Berchmans Uwimana, an MSFC Rwanda programme facilitator, reported at a 9 June 2019 workshop on abortion care for medical students.
“It is the role of healthcare providers to render stigma free medical services. In this regard, MSFC aims at empowering future healthcare providers to create a safe and favourable environment for girls with unintended pregnancies, as a way of preventing unsafe abortion,” said Jules Iradukunda. an MSFC trainer. “Few women understand that the law has recently changed and what their rights to abortion are under the new conditions, and a lot needs to be done to train healthcare providers to provide quality services to patients.”
MSFC works closely with Health Development Initiative Rwanda (HDI) – a non-profit organization that supports improvements in both the quality and accessibility of healthcare through advocacy, education and training. Dr Athanase Rukundo, programmes director at HDI, said, “As an organization that deals with sexual and reproductive health, we believe that medical students are future healthcare providers,” he told KT Press. Through Medical Students for Choice, students should have clinical exposure to abortion care.”
For more information about 28 September, International Safe Abortion Day 2019 – click here