Improving maternal health and halving the maternal mortality ratio by 2015 is one of eight Millennium Development Goals (MDGs) endorsed by 189 countries in September 2000. There are some 19 million unsafe abortions every year. Deaths from complications of unsafe abortion are one of the five leading causes of maternal mortality, and constitute 13% of all maternal deaths globally, with an annual death toll of some 68,000 women. Yet unsafe abortion and associated morbidity and mortality are completely avoidable [1]
Expanding access to contraception, emergency contraception and safe abortion services is one of the best and most cost-effective ways of preventing these deaths and achieving the MDG on maternal health [2].
Experience in a growing number of countries around the globe shows that abortion mortality has been reduced to very low levels by making abortion legal and safe abortion services available [3]. Thanks also to advances in medical technology over the past 30-40 years, abortion is a very safe procedure. In most countries, policies and laws governing abortion services were developed at a time when surgical methods were the only safe way to terminate a pregnancy. With the emergence of medical abortion, it is possible to induce an abortion without surgical intervention or invasive procedures.
This chapter of ICMA’s information package is addressed to policy makers who are in a position to influence national and state policy on abortion. It presents the case for making medical abortion an integral part of abortion services, within the context of expanding access to safe abortion services more broadly, including in countries where abortion is still unsafe. One of the most important issues for policy makers is to review existing laws, policies and services to ensure that both vacuum aspiration and medical abortion can be introduced widely.
The chapter gives arguments as to why legal reforms to liberalise abortion are essential from a public health and women’s rights perspective, gives basic information on policy matters related to abortion, responds to some commonly held concerns about the consequences of expanding access to abortion services, and offers an action agenda for law reform and policy change.
About 60 per cent of women live in countries with liberal abortion laws, while 25 per cent of women live in countries where abortion is permitted only to save a woman’s life. In three countries, abortion is not legal for any reason [4]. The term ‘restrictive’ is used here to describe laws that permit abortion only when a woman’s life or health is at risk, and in cases of fetal abnormality, rape and incest. While these are crucial grounds for legal abortion, most abortions do not fall under them. The term ‘liberal’ is used to describe laws that permit abortions not only for those same reasons but also permit abortion on broad socio-economic grounds and/or at a woman’s request.
Most abortions become safe where women’s reasons for abortion and the legal grounds for abortion coincide [2]. Thus, historically, removal of legal restrictions on abortion services has led to a decrease in the rate of abortion deaths. For example, in the United States, within five years after legalisation in 1973, death rates due to unsafe abortion decreased by 85 per cent [5]. More recently, in South Africa, between 1996 when the abortion law was liberalized and a year later in 1997, the complication rate from unsafe abortion in one tertiary care hospital in Pretoria decreased from 50.7 per cent to 29.4 per cent [6] and this downward trend has continued across the country.
Law reform is a necessary but not sufficient condition for decreasing the incidence of unsafe abortion mortality and morbidity. It must be accompanied by improved access to safe and affordable abortion services. Governments are responsible for guaranteeing women’s right to life and health by ensuring that such services are available and accessible, including for the poorest women. In addition, women need to be informed of their right to obtain an abortion and where abortion services are located.
Growing international support for safe, legal abortion as a woman’s right
Since at least 1960, and even earlier in a few countries, support for making abortion safe and legal has been growing internationally alongside support for family planning. In those four decades, most European countries, the former Soviet bloc countries, the US and Canada, New Zealand and Australia, China and Cuba, Tunisia and Turkey, all passed liberal abortion laws. Gradually, other developing countries are following suit.
The Programme of Action of the International Conference on Population and Development (ICPD) in 1994 called upon governments to address unsafe abortion as a major public health problem. It said that where abortion is legal, it should be safe [7]. This was reaffirmed and strengthened by the Platform for Action of the 1995 Fourth World Conference on Women, which encouraged governments to review punitive abortion laws [8]. At the five-year review of ICPD in 1999, governments called upon health systems to ensure that safe abortion is accessible “in circumstances where abortion is not against the law” [9]. Moreover, it said post-abortion care should be provided for women who have had unsafe or incomplete abortions. Then, in 2000, the Millennium Development Goals included a maternal health goal, Goal 4, which de facto is partly about reducing deaths and morbidity related to unsafe abortion.
The Human Rights Committee, which interprets and monitors States parties’ compliance with the International Covenant on Civil and Political Rights, has repeatedly emphasised the threat to women’s lives posed by prohibitions on abortion that cause women to seek unsafe abortions. It has also repeatedly called upon states to liberalise criminal laws on abortion [10].
The Committee on the Rights of the Child, the treaty body that interprets and applies the Convention on the Rights of the Child, has expressed repeated concern over adolescent girls’ lack of access to safe abortion services and the need for states ‘‘to provide access to sexual and reproductive health services, including… safe abortion services’’[11].
The Convention on the Elimination of All Forms of Discrimination Against Women does not explicitly protect the right to abortion [12]. However, when considering States’ reports, the CEDAW Committee has repeatedly expressed great concern about maternal mortality due to unsafe abortion, framing the issue as involving a woman’s right to life, and has called upon states to eliminate criminal laws and other barriers restricting access to safe abortion [13].
In Europe, the European Commission on Human Rights and the European Court have repeatedly reaffirmed in the cases brought before them that the 1953 European Convention for the Protection of Human Rights and Fundamental Freedoms protects women’s right to a safe abortion [10]. In Africa, a major recent development was the ratification in 2005 of the African Union Protocol on the Rights of Women in Africa, which provides that States’ parties should authorise abortion in cases of sexual assault, rape, incest and where a continuing pregnancy endangers the life or health of the woman [14].
Many national medical professional associations have also made statements upholding women’s right to safe abortion and contraception services and have been closely involved in promoting abortion law reform and setting up and providing services. At international level, the International Federation of Obstetrics and Gynecology’s Ethical Guidelines on Induced Abortion, passed in 2000, state:
“The Committee recommends that after appropriate counseling, a woman has the right to have access to medical or surgical induced abortion, and that health care services have an obligation to provide such services as safely as possible" [15].
The cost to health systems of providing safe abortion services must be contrasted with the the cost of treating complications of unsafe abortion, most commonly in tertiary level facilities, and the cost to families and society of morbidity and mortality from unsafe abortion. Some 19 million women have unsafe abortions annually, almost all of them in developing countries, and the costs of hospitalizing an estimated 5 million of them for complications of unsafe abortion [16] are high.
Medical abortion is a means of expanding access to safe abortion
Medical abortion is an important means of expanding access to safe abortion (see Box 1). Since abortion is legal for some indications in practically all countries of the world, making safe abortion available is relevant everywhere, including in legally restrictive settings. In fact, it may be especially important to make medical abortion available in legally restrictive settings where non-availability of services impedes access to abortion even for women who are eligible.
In countries where abortion is legally restricted and women are forced to resort to clandestine abortions, the use of medical abortion has still had a positive effect because it is safer than other traditionally used methods, particularly unsafe invasive methods. Indeed, in the few places where data have been recorded, the widespread use of misoprostol has led to a huge decrease in the numbers and seriousness of complications [17], [18], [19]. For example, in Gôiania, Brazil, between 1987 and 1991 the rate of deaths from unsafe abortions dropped almost to nil, as shown in Figure 1 [20].
Figure 1. Sales of Cytotec, number of abortion complications treated in hospitals and abortion-related deaths, Gôiania, Brasil, 1987–91 [20].
Source: Viggiano e cols., 1996
In 2003, the World Health Organization (WHO) included medical abortion in its technical and policy guidance on safe abortion [4], based on almost two decades of international research on its safety and efficacy. In 2005, WHO added mifepristone and misoprostol to its Model List of Essential Medicines. This list includes the most efficacious, safe and cost-effective medicines for priority health conditions, which are selected on the basis of current and future public health relevance, and potential for safe and cost-effective treatment [21].
Medical abortion is a suitable method for low-resource settings
Providing medical abortion services requires a modest initial investment in facilities and equipment, and training of appropriate providers. Medical abortion within 9 weeks of pregnancy can be provided in primary care settings, including in low-resource settings [23]. There are few complications and most do not require emergency referral [24]; it is adequate if there is an assured referral link to a secondary care centre. When abortion is incomplete or where pregnancy continues, surgical evacuation of the uterus may be needed [25].
Medical abortion can be provided by gynaecologists but it can also be provided safely by mid-level providers who may or may not also be skilled in early surgical abortion procedures. In France, Great Britain, Sweden, South Africa and some states of the United States, nurses and midwives are permitted to provide medical abortion under the supervision of a physician [26], [27], [28], [29]. After several decades of positive experience, the trend of giving mid-level providers responsibility for medical abortion is likely to increase.
Women find medical abortion highly acceptable
Studies show that women like medical abortion for a range of reasons: it is more natural, it does not involve surgery or anaesthesia, it can be performed as soon as a woman learns that she is pregnant, and women feel more in control of the process because it happens in their bodies (See Chapter 1, 10. Why do women choose medical abortion?). In most studies, almost all the women who have used medical abortion have said they would use it again or recommend it to a friend [25].
As has been shown with contraception, choice of abortion method is an important feature of quality of care. Medical abortion provides women with the option of an early abortion that is safer, more easily accessible and less medicalised, while surgical abortion with manual or electric vacuum aspiration offers a procedure that takes only a short time and is carried out by the provider. Offering a choice between medical and surgical abortion allows women to choose the method that is more suited to them and upholds women’s right to benefit from the fruits of technological and scientific advances.
Health professionals have often taken the lead in advocating for medical abortion
Health professionals have played a pivotal role in many parts of the world in campaigns to make abortion services legal and accessible, and in promoting access to medical abortion, including developing countries such as China, Cuba, India, South Africa, Tunisia, Turkey and Viet Nam.
Once medical abortion has been introduced, most providers are generally in favour of the method. Some of the reasons they have given are that it decreases staff workloads, there are lower rates of complications where abortions were previously unsafe [26], it is safe and can be made available at affordable cost [30].
Policy makers recognise several advantages of medical abortion
Policy makers in a number of developing countries view medical abortion as having several advantages over surgical procedures. The modest requirements in terms of investment in equipment, facilities and personnel and the relative ease of provision should make medical abortion valuable for policy makers charged with the commitment to make abortions safe.
In Viet Nam, for example, policy makers interviewed as part of WHO’s strategic assessment for introduction of medical abortion stated that the major benefits of medical abortion were that it avoids infection, uterine perforation and cervical laceration, that it is non-invasive and could enhance women’s privacy [31].
In South Africa, policy makers highlighted choice of method as an important advantage. They also felt that medical abortion might be easier for providers to offer as they do not directly do the abortion [26].
Medical abortion is the termination of pregnancy through the use of a drug or a combination of drugs. The most commonly used combination of drugs for medical abortion is:
mifepristone, an anti-progestogen drug, taken first, and
misoprostol, a prostaglandin, taken 36-48 hours later
In some settings, misoprostol alone is used for medical abortion because mifepristone is not available or affordable.
More than 22 million women in China and about four million in the rest of the world have used the combination of mifepristone and misoprostol to terminate a pregnancy, and have found it safe and effective [22]. Uncounted numbers have used misoprostol alone in legally restricted settings.
Forinformation on safety and efficacy, dosages and regimens of medical abortion, and on how the method is used, go toChapter 1. For more detailed clinical information, go to Chapter 3.
Those responsible for making policy decisions about the legal status of abortion and investing in abortion services are often confronted with a number of assertions about the negative effects of legal abortions by those who are opposed to abortion. Available evidence runs contrary to many of their assertions; the facts are presented and discussed below.
Fact 1: Even with high levels of contraceptive use, and for other reasons, there will be unintended pregnancies and the need for abortion services.
Unintended pregnancies are a fact of life. Even in societies where contraceptive use is very high, women (and their partners) may end up with an unintended or an unwanted pregnancy for many reasons, ranging from sexual abuse or coercion to contraceptive failure or failure to use contraception. The World Health Organization estimates that even if all contraceptive users were to use methods perfectly all the time, there would still be six million accidental pregnancies annually [4]. Moreover, some initially wanted pregnancies may become unwanted due to the diagnosis of serious fetal impairment or the woman’s life or health may become at risk during or due to the pregnancy, in which case she is advised to have a termination
Fact 2: Legalisation of abortion does not increase the number of abortions.
When abortion law is liberalised, it sometimes appears as if there are more abortions, but this is mostly because more abortions are being recorded for the first time as more women start to receive services openly instead of clandestinely. Numbers tend to stabilise within a few years [32].
In Sweden, France and Great Britain, availability of medical abortion when abortion was already legal did not increase the number of abortions either [28].
Fact 3: Where medical abortion is accessible, women can have very early abortions.
Pregnancy tests can now identify a pregnancy even before a woman misses her period. Where medical abortion is accessible, this means the pregnancy can be terminated very early and effectively. This is preferable for women, providers and the health system, but it also means that barriers imposed through policy need to be removed.
Fact 4: There are no major health risks associated with medical abortion.
The risk of developing a complication following any safe abortion procedure, including medical abortion, is very low. Less than 1% of women have been shown to develop infection after medical abortion in the first nine weeks of pregnancy [33], and no more than one in 1,000 women experiences heavy bleeding requiring a blood transfusion [34].
Policy makers who are committed to promoting women’s health and rights can take the following actions:
1. Support reform of restrictive abortion laws and policies to make abortion safe, legal, accessible and affordable
Policy makers have a fundamental role to play in supporting reform of restrictive abortion laws. It is important to make people aware that equality for women will not be possible while denying women the means to terminate an unwanted pregnancy safely and legally. Some of the abortion laws worth looking at both as models and to see their limitations in practice are those of Bangladesh, Canada, Cuba, India, Sweden, South Africa, Tunisia and the UK.
Canada is the only country to date which has decriminalised abortion entirely [35]. In 1988, Canada’s highest court struck down the federal law on abortion and the parliament did not replace it. Although there are abortion regulations at the state level, any re-criminalisation of abortion would be illegal. This represents the most complete form of normalisation and de-politicisation of abortion possible, bringing it in line with all other medical procedures, making good medical practice and quality of care in service provision the only “issues” involved. Any breaches of medical practice would be punishable under other existing laws. This has worked well in Canada and could work equally well elsewhere [36].
Cuba is an early example of a developing country that legalised abortion on broad indications. In the context of sweeping changes in the country’s health services in 1959, a 1936 law which had made abortion legal on grounds of serious risk to a woman’s health was officially interpreted to encompass the WHO definition of “health” as a total state of well-being. Abortion services were extended to all obstetric-gynaecology hospitals. In 1979, when a new Penal Code was drafted, instead of specifying when abortion was legal, it specified when abortion was illegal. Under this Code, abortion was determined to be illegal if it was carried out without the woman’s consent, or in other than hospital premises, or if the provider failed to comply with established norms, or if it was carried out for profit. As hospitals throughout the country provide abortions free, these conditions are enabling. Further, the law specified that menstrual regulation was not equivalent to abortion, as delay in menses may be due to causes other than pregnancy [37].
In Bangladesh, although the law permits induced abortion only to save the life of the woman, menstrual regulation is legally available. As early as 1978, a large-scale menstrual regulation training programme was organized for government physicians and family welfare visitors [38]. Today, menstrual regulation using vacuum aspiration is widely available in Bangladesh through public, NGO and private sector facilities and is permitted at a woman’s request up to 10 weeks of pregnancy (i.e. 12 weeks from first day of the last menstrual period). However, in spite of wide availability, barriers such as distance to health facilities and transportation costs, unofficial fees, lack of privacy, confidentiality and cleanliness in public health facilities, and in some cases attitudes of service providers, are limiting access to MR services. Quality of care is compromised by inadequacies in infection control and in provider training and counseling [39].
South Africa’s 1996 law is an example of a progressive law with a number of conditions after the first trimester of pregnancy. Its passage was accompanied by efforts to develop good service provision nationwide. Up to 12 weeks of pregnancy, abortion is on the request of the woman. From 13-20 weeks of pregnancy, abortion is permitted if there is a risk to the woman’s physical or mental health, there is a substantial risk of fetal abnormality, the pregnancy resulted from rape or incest, or the pregnancy would significantly affect the woman’s social or economic circumstances; in addition, a termination must be approved by one medical practitioner. After the 20th week, abortion is permitted if continuing the pregnancy would endanger the woman’s life, if there is a substantial risk of fetal abnormality; in addition, two medical practitioners, or one medical practitioner and a registered midwife, need to agree to the abortion [40].
In Sweden, abortion is available at a woman’s request up to 18 weeks of pregnancy and with the agreement of a medical board after that [41]. This allows almost all abortions to be the woman’s decision alone, a facilitating policy which evolved based on experience and a growing awareness on the part of medical professionals and policy makers of women’s needs .
2. Support government approval of mifepristone and misoprostol as essential medicines by your national drug regulatory agency and the availability of these drugs in your country
Medical abortion represents decades of medical research to develop and make available a safe alternative to surgical abortion. Misoprostol has also been shown to be valuable for other obstetric uses. The inclusion on the essential medicines list of mifepristone and misoprostol is an important goal. Since 1977, the World Health Organization (WHO) has been publishing a Model List of Essential Medicines which meets the priority health care needs of the population of developing countries. Medicines on this list are selected with regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Since mid-2005 WHO’s Model List of Essential Medicines has included mifepristone and misoprostol [21]. National essential medicines lists are meant to serve as the main basis for public sector drug procurement and distribution in countries with those lists. Inclusion of mifepristone and misoprostol for medical abortion and other obstetric and gynaecological uses in national essential medicines lists would pave the way for their wider availability in public health services.
Women have the right to enjoy the fruits of scientific progress and to have the choice between surgical and medical abortion. ICMA believes the conditions exist to support the availability of mifepristone and misoprostol for medical abortion in every country where abortion is permitted for at least one indication.
Approval by national drug regulatory agencies for mifepristone has been complicated in some countries, however. ICMA’s membership includes organisations with expertise in this area, who can advise and help with this process.
As part of this process, it is necessary to ensure that one or more pharmaceutical companies is willing to make mifepristone and misoprostol available in the country. Misoprostol may already be available in the country for other indications. There was a recent instance in 2006, in Australia, where after successful advocacy to have medical abortion approved by the drug regulatory agency [42], no pharmaceutical company applied to import and distribute mifepristone and it was left to individual doctors to apply to the Therapeutic Goods Administration for permission to import the drug to supply only to their own patients, which a few doctors had begun doing by mid-2006 [42].
3. Ensure that abortion services, including medical abortion, are accessible to women who are legally eligible for an abortion
In countries where abortion is legal only under limited circumstances (e.g. rape, incest, risk to woman’s life or health), women who are in such circumstances must be guaranteed safe legal abortions – including medical abortion. Oftentimes professionals at public health services feel unable to provide abortion even when it is legal, because they do not feel they have been authorised to do so, or they request women to produce a judicial authorisation. Sometimes, third parties (often conservative religious groups) try to take legal action to prevent the provision of abortion even though it is legal under the country’s law. Policy makers are in a position to facilitate the necessary mechanisms to allow clinicians to carry out legal abortions. In both Mexico and Brazil, local and/or state-level governments have worked with hospitals to provide integrated services for women who have been raped, including counselling and support, treatment for sexually transmitted infection, emergency contraception and abortion if required [43], [44].
4. Remove barriers that make it difficult or impossible for women to access a legal abortion in a timely manner
Even in countries where abortion is permitted for a broad range of indications, there may exist barriers to accessing abortion services. These include, for example, mandatory as opposed to voluntary counseling, a waiting period that has no basis in good medical practice, the consent of a third part such as a husband or parent even though the (young) woman is able to give her own consent, allowing providers or others to refuse a legal abortion, and conscientious objection by service providers who are unwilling to refer the woman elsewhere [45]. These barriers only serve to make women have later abortions than is medical necessary (see Box 2). Many may seek an unsafe abortion instead, especially if they are poor, with all the risks to health and life that this may entail. It is important that these barriers be removed. This may require changes in regulations, but the result will be that many more abortions will be earlier and safer.
5. Invest in provider training
Access to abortion is constrained in many setting owing to a shortage of trained providers. Medical abortion training may be offered to providers already trained in vacuum aspiration abortion so that they are able to offer women a choice of abortion methods. In addition, training on medical abortion can also be organised for general practitioners, midwives and other mid-level providers who may or may not also be skilled at vacuum aspiration abortion. This training can be included in both pre-service and in-service training for these cadres. Training should not only cover technical skills (including pain control) but also social, and ethical aspects of abortion, as well as counselling and contraceptive provision.
6. Improve quality of abortion care
Service delivery standards, protocols and guidelines need to be developed where these do not already exist. WHO’s comprehensive guidance, Safe Abortion: Technical and Policy Guidance for Health Systems, is an excellent document for programme managers [4].and for clinicians, there are the guidelines of the Royal College of Obstetricians and Gynaecologists [49]. Other guidance includes Providing Medical Abortion in Developing Countries: An Introductory Guidebook [25]. and in French, Prise en charge de l’interruption volontaire de grossesse jusqu’à 14 semaines [50].
Quality of care is not only about technical quality but also about promoting women’s autonomy in making the abortion decision and providing abortion services in a manner that respects women’s dignity. Medical abortion services should include good quality counselling services. Protocols for service delivery should include mechanisms for redress for women who experience ill-treatment or abuse when seeking abortion services.
7. Promote research and documentation on abortion service delivery
Documentation of information on abortion availability and changes subsequent to efforts to expand access could prove to be an important tool to inform further policy changes. This includes improvements through making medical abortion available. Investment is also needed in operations research to track the quality of abortion services, both vacuum aspiration and medical abortion, from the perspective both of the providers and women. Documentation of the logistical, administrative and organisational challenges involved in introducing vacuum aspiration and medical abortion services in the process of scaling up these services would help those working locally at the policy and programmatic level.
8. Support public health funding to make abortion services, including medical abortion, affordable for all women who need it.
The cost of mifepristone tablets is one of the biggest components of the cost of providing medical abortion. Misoprostol, on the other hand, is affordable in most countries where it is available. Indeed, in many countries, misoprostol is being used alone for medical abortion because of its lower cost.
Adopting a 200mg regimen of mifepristone, as recommended by WHO, rather than the outdated 600mg regimen in the labelling information for mifepristone, as most countries have done, means a substantial cost reduction. This dosage change was recommended by WHO early on [4]. Moreover, there are several efforts in the pipeline at this writing to produce low-cost 200mg mifepristone pills. There are also efforts to negotiate a public sector price for both drugs now that they are on the WHO List of Essential Medicines.
The other major cost factor is to do with the type of facility where medical abortion is offered and type of provider. It costs far more for a gynaecologist to provide medical abortion in a hospital-based clinic. Putting mid-level providers in charge of providing medical abortion in a primary care setting reduces the cost of medical abortion considerably. If women who are up to nine weeks pregnant can use misoprostol at home (whether following mifepristone or alone) – an option confirmed by many studies to be safe and efficacious, including in developing countries [25] – costs are further reduced.
Finally, health insurance schemes aimed at low-income groups need to provide coverage for abortion services, including medical abortion. In the absence of such schemes, public sector facilities with low or no fees are critical for supporting the access of poor women to abortion. This is another reason why it is important to provide medical abortion at primary care level.
Provision of information about abortion methods and the abortion process, after-care, and provision of information about contraception and the woman’s choice of method are an integral part of providing an abortion. Counselling is not the same as information provision. Most women know they want to terminate their pregnancy when they come to a clinic seeking abortion. However, if a woman appears uncertain what to do or seems to be under pressure from her partner or family, she should be offered non-directive counselling to help her make her own decision. Mandatory counselling, in the other hand, is too often meant to discourage women from having an abortion. Counselling in this sense should never be mandatory.
There should be no mandatory waiting period
Mandatory waiting periods are also intended to discourage women and have no basis in good medical practice. Before abortion was legal in most European countries, a few countries such as France instituted a mandatory waiting period of several days to discourage women from Spain and Portugal from entering France for abortions. Instead, abortion clinics should book abortions in a timely manner. There will always be a few women who change their minds and cancel, without the need for a mandatory waiting period [45].
The consent of third parties should not be required
Several countries require a married woman seeking abortion to obtain the consent of her spouse [45]. While most married women involve their husbands and make a joint decision for abortion, the involvement of her spouse should remain the woman’s own decision. A number of countries require girls under a certain age to obtain consent from a parent or guardian for abortion, or as an alternative a court’s authority [45].
An alternative model is South Africa’s abortion law, which says that the only consent required for abortion is that of the woman herself. In the case of girls who are still minors in law, the law requires the abortion provider to advise the young woman to “consult with her parents, guardians, family members or friends”, but may still have an abortion if she does not [46].
Permit abortion on request or for a broad range of indications up to 24 weeks of pregnancy
Most countries where abortion is available for a broad range of indications or at a woman’s request place limits on the duration of pregnancy up to which abortion may be obtained. Abortion at a woman’s request is usually permitted up to 12–14 weeks or as in Sweden, 18 weeks. After this period, abortion may be permitted only under specific circumstances, such as risk to the woman’s life or health, or in cases of rape or fetal abnormalities. In a few countries, permission of one or more medical practitioners or a medical board may be needed. Although these restrictions may at one time have been intended to avoid morbidity and mortality associated with second trimester abortions, today second trimester procedures, including medical abortion. Second trimester abortions form only a small minority of total abortions. Many of the women seeking a late termination in one study did not recognise the signs of pregnancy; others found the decision whether to have an abortion very difficult, while many others were delayed by obstacles in obtaining an abortion or finding a provider willing to do the abortion [47]. Restrictions on access to second trimester abortion may push women to seek an abortion under unsafe conditions, making the risk of morbidity and mortality far higher than with a safe procedure in a clinic setting.
Replace physician-only laws and restrictive health care setting requirements with policies enabling mid-level providers to carry out abortions in primary care settings
In a large number of countries where abortion is available, there are ‘physician-only’ laws, which prevent any abortion from being provided by mid-level providers in primary care settings. Because of the limited number of gynaecologists in many countries, particularly in developing countries, only by allowing mid-level providers to provide medical abortion will it be possible to increase access to safe abortion significantly [23].
Even where medical abortion has been approved and available for some time, regulations have been slow to change. Health care setting requirements intended for surgical abortion need to be updated so that medical abortion can be provided in primary care settings by general practitioners, nurse-midwives family planning nurses and other mid-level providers.
Ensure that conscientious objection does not excuse professional responsibility
Some providers do have a valid conscientious objection to providing abortions. In settings where abortion is legally restricted and unsafe, however, some providers use conscientious objection as an excuse not to provide abortions in the public health system but offer women their services for a fee privately. This is an abuse of women’s right to care. The Ethical Guidelines on Conscientious Objection of the International Federation of Obstetricians and Gynaecologists state that practitioners who have personal objections to providing a medical service have an obligation to refer the patient to another provider or facility where the service is available. They also state that
“Practitioners must provide timely care to their patients when referral to other practitioners is not possible and delay would jeopardise patients\' health and well-being, such as by patients experiencing unwanted pregnancy” [48].
Moreover, conscientious objection applies to individuals, not institutions. It is a violation of medical ethics for a clinic or hospital to refuse to perform legal abortions on these grounds.
[1] - World Health Organization. Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000. Geneva,WHO, 2004. Available at: http://www.who.int/reproductivehealth/publications/unsafe_abortion_estimates_04/estimates.pdf
[2] - Ipas. Ensuring women’s access to safe abortion: Essential strategies for achieving the Millennium Development Goals. Chapel Hill, Ipas, 2005.
[3] - Berer M. National laws and unsafe abortion: the parameters of change. Reproductive Health Matters 2004;12(24):1-8
[4] - World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2003
[5] - Indriso C and Mundigo A. Introduction in Indriso C and Mundigo I (eds), Abortion in the developing world, 1999.
[6] - Dickson-Tetteh K, Rees H. Efforts to reduce abortion-related mortality in South Africa. In Berer M and Ravindran TKS (eds), Safe Motherhood: Critical Issues. London, Reproductive Health Matters, 2000
[7] - Programme of Action of the ICPD, Cairo, Egypt, 5-13 September 1994, para 8.25, UN Doc.A/CONF.171/13/Rev.1(1995)
[8] - The Beijing Declaration and The Platform for Action. Fourth World Conference on Women, Beijing, China, 4-15 September 1995, para 106K, UN Doc. A/CONF.177/20(1995)
[9] - Key Actions for the Further Implementation of the Programme of Action of the International Conference on Population and Development, UN GAOR, 21st Special Session, New York, United States, June 30-July 2, 1999. UN Doc. A/S-21/5/Add.1(1999) para 63(iii)
[10] - Centre for Reproductive Rights. Safe and legal abortion is a woman’s human right. Briefing paper. New York, Centre for Reproductive Rights, August 2004
[11] - Committee on the Rights of the Child, General Comment No.4: Adolescent health and development in the context of the Convention of the Rights of the Child (33rd Session 2003) at Para. 31, reprinted in Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, 12/05/2004, UN Doc. HRI/GEN/ Rev.7. Referenced in (10)
[12] - Convention on the Elimination of All Forms of Discrimination Against Women, G.A. Res. 34/180 (18 December 1979)
[13] - Center for Reproductive Rights and University of Toronto International Programme on Reproductive and Sexual Health Law. Bringing Rights to Bear: An Analysis of the Work of the U.N. Treaty Monitoring Bodies on Reproductive and Sexual Rights, New York: CRR, 2002. Referenced in (10)
[14] - African Union. Protocol to the African Charter on Human Rights and Peoples’ Rights relating to the Rights of Women. Maputo, African Union, 2003. as quoted in Hessini L. Global progress in abortion advocacy and policy: An assessment of the decade since ICPD. Reproductive Health Matters, 2005, 13(25):88-100
[15] - FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. Gynecologic and Obstetric Investigation 1999;48:73-77
[16] - Singh S.Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006; 368(9550):1887-1892
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