death and denial unsafe abortion and poverty

8/3/2019 Death and Denial Unsafe Abortion and Poverty

1/20From choice, a world of possibilities

Death and Denial: Unsafe Abortion and Poverty


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Access to legal and safe abortioncare - as well as to care totreat incomplete abortion or

complications from unsafeabortion - would help save thelives of thousands of women everyyear. It would also provide a vitalopportunity to ensure women cansubsequently access familyplanning and contraception tohelp avoid repeat abortions.

Punitive legal measures andrestricting access to safe abortiondo not reduce the incidence ofabortion; they just make it moredangerous. The result is that morewomen suffer. Not surprisingly, itis the poorest women - womenleast able to pay for any minimallevel of care - who end up payingthe highest price. I welcome thisreport as an important contributionto dealing with a subject whererational debate and consideredaction are much needed.

Gareth ThomasJanuary 2006

Parliamentary Under-Secretary ofState for International Development

Millions of women have no accessto reproductive health services;many more have little or no

control in choosing whether tobecome pregnant. As a result,every year, some 19 millionwomen have no other choice thanto have an unsafe abortion. Manyof these women will die as aresult; many more are permanentlyinjured. Nearly all the women whodie or are injured are poor and livein poor countries.

Preventing these deaths andinjuries will not be achievedwithout stopping unsafe abortionswhich cause around 13 per centof all maternal deaths. Virtually allthe deaths of women from unsafeabortion are in fact preventable.A woman facing an unwantedpregnancy should not have to riskdeath through having an unsafeabortion.

Foreword by Gareth Thomas MP

No woman should anywhere

have to face death or disability

for the want of a safe

abortion. Is there anybody whowould disagree with the right

of a woman not to die in

pregnancy? Anybody? No.

The Rt Hon Hilary Benn, MP,Secretary of State for InternationalDevelopment, Countdown 2015,The Global Roundtable,London, 2004.


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This year alone, an estimated19 million women and girls, facedwith unintended and unwantedpregnancies, will face the deadlyconsequences of unsafe abortion.Nearly 70,000 of these women and

girls will die, and hundreds-of-thousands of others will be leftwith debilitating, and frequentlylifelong injuries, as a result. Over 96per cent of these women will comefrom the worlds poorest nations.

For reasons ranging from humanrights to religion, abortiongenerates more political and socialdisagreement than almost anyother subject. It remains a singularlyemotive and complicated issue inmany countries, at times seeminglywithout any room for balanceddiscussion.

This report offers an overview ofthe current situation regardingunsafe abortion around the world.In doing so it seeks to open amuch needed and timely debateamong governments,parliamentarians, public health,development and medical experts,as well as service providers andglobal advocates for legal and safe

abortion such as IPPF.

Unsafe abortion is one of thelargest contributors to globalmaternal mortality: a verypreventable human tragedy thathighlights the failure of nationalgovernments and the internationalcommunity to address a publichealth issue that perpetuates oneof the greatest social injusticesseparating rich and poor nations.

Unsafe abortion is a cause andconsequence of poverty; it is alsointimately linked to gender

inequality within societies. It is theinability of women, especiallyyoung women and girls, to fulfiltheir basic sexual and reproductiverights, and to have control overtheir own bodies, which forces

upon them a stark choice - facesocial exclusion or risk their livesand health through unsafe abortion.

During last Septembers UnitedNations World Summit, worldleaders reaffirmed theircommitment to the MillenniumDevelopment Goals, including thegoal of reducing maternal mortalityand improving maternal health.The Summit also reasserted aprevious global commitment toachieve universal access toreproductive health. The reviewprocess noted that little progresshad been made towards achievingeither since the MillenniumDevelopment Goals were firstadopted five years ago. It furtherhighlighted the fact that unsafeabortion is a major contributor tothese stubbornly high levels,particularly in developing countries.

Extensive independent researchshows that restricting access to

abortion does not make it goaway; it only makes it clandestineand unsafe. Health authoritiesand political leaders in more andmore countries are prepared tore-examine abortion policy whenthey understand how unsafeabortion contributes to maternalmortality and ill health. Moreover,renewed interest in the issue ofpreventing unintended pregnancieshas brought renewed focus onthe role family planning andreproductive health services play inpreventing unwanted pregnancies.

Lack of access to moderncontraception as a factor drivingunwanted pregnancies to unsafeabortions cannot be ignored.

There is a pressing need for an

open and informed discussion toaddress the fundamental injusticeof the causes and consequences ofunsafe abortion. There are fewgovernments with the courage totake a leadership position onabortion rights and there areequally few internationalorganisations with such courage.The Government of the UnitedKingdom and IPPF are two of thefew that have both the courageand the resolve to act in a struggleso crucial to womens well-being.

Through the work of theDepartment for InternationalDevelopment, the United Kingdomhas promoted an approach toaddressing abortion based onsound public health evidence. Indoing so, the UK has establishedan international reputation for bothleadership and wisdom. IPPF isdetermined to play a constructiverole as partner with the Departmentfor International Development in

this undertaking. With upwards of15 per cent of maternal mortalitydirectly attributable to illegal andunsafe abortion perhaps as muchas 50 per cent in some countriesin Africa and South East Asia tackling head-on the reductionand even the elimination of thispreventable cause of maternaldeath is of paramount importance.

Steven W. SindingDirector-General,International Planned ParenthoodFederation

Introduction

A straightforward public health

problem with a known solution has

been allowed to become the killing

fields of women in developing

countries, particularly Africa.

Fred Sai, Special Adviser to the President of Ghana, speaking on unsafeabortion, Countdown 2015, The Global Roundtable, London, 2004.


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complications from unsafe abortionaccount for approximately 70,000,or 13 per cent, of all deaths.

Achieving the MillenniumDevelopment Goals, especially thegoal of improved maternal healthand reduced maternal mortality, will

require action across a broad front.The causes of maternal mortalityand morbidity are numerous andcomplex, but in countries wherewomen can be responsible for upto 100 per cent of householdincome and for raising a family,death and morbidity from unsafeabortion exacts a heavy economicand societal toll.

Equal access to education for girlsis another key aim of theMillennium Development Goals.The failure to fulfil her educational

Poverty has multiple dimensionswhich include a lack of economicresources, an absence of humanrights, poor health and thedeprivation of choices. At theUnited Nations Millennium Summit,in October 2000, 191 countriesagreed on the imperative of

reducing poverty and inequityworldwide. Improving maternalhealth and reducing by three-quarters the number of maternaldeaths were identified as one ofthe Millennium Development Goalskey to addressing inequality.

Almost all maternal mortalityoccurs in developing countries,representing one of the widest,and most unjust, health gapsbetween developed anddeveloping nations. Of the500,000 annual maternal deaths,

Unsafe abortion:a cause and consequence of poverty

The World Health Organization defines abortions as unsafe when theyare performed by persons lacking the necessary skills or in an environmentlacking the minimal medical standards or both. The impact of unsafeabortion casts a spotlight on the gaping social and public healthinequalities between developed and developing nations, as well as withinthose nations where abortion is illegal or severely restricted. There is onesimple truth: unsafe abortion disproportionately affects the poorestwomen in those countries where it occurs.

Unsafe abortion, maternal mortality andthe Millennium Development Goals

potential has an unequivocalimpact on a womans ability to playa full economic, social and politicalrole within her community, andis directly linked to poverty. Foryoung women and girls, unintendedand unwanted pregnancy frequentlyforces them to decide between

risking their lives and health to havean unsafe abortion or leaving schoolto continue with the pregnancy.

A poor woman in many parts

of Africa is over 200 times more

likely to die as a result of

pregnancy and childbirth than

a woman in the UK.

Department of InternationalDevelopment, UK.

IPPF/Chloe Hall

The EthiopianMember Associationstrives to reduce thenumber of unwantepregnancies byestablishingcommunity baseddistribution schemesfor contraceptiveservices in rural area

Latin Americans are beginning

to look at abortion as an issue

of maternal mortality, not

just maternal morality.

New York Times, 06 Jan 2006


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While the death of a mother,daughter or sister from unsafeabortion has a devastating impacton a family, equally devastating arethe debilitating injuries and illness orlifelong disability hundreds-of-thousands of women suffer as aconsequence of unsafe abortion.

Accessed early, medical care canaddress the complications in many

cases, but large numbers of womenhave no reliable access to primaryhealth care facilities. Not all womenare able to get hospital treatmentfor medical complications followingunsafe abortion; however, the datafrom 10 countries indicate the sheerscale of the problem and itssubsequent impact on healthcare systems.

Health impact caused byunsafe abortion

A WHO study from Nigeria in 2000showed that 75 per cent of womensuffered injury or illness. The studyof 144 women who underwentunsafe abortion in Ilorin, Nigeria,reported typical complications:

Sepsis 27%

Anaemia (haemorrhage) 13%

Death 9%

Cervical tear 5%

Injury to gut 4%

Chemical vaginitis 4%

Sepsis with anaemia 3%

Pelvic abscess 3%

Uterine perforation with

peritonitis 3%

Laceration of vaginal wall 3%

Vesicovaginal fistula 1%

A more recent Ipas study fromKenya (The Magnitude of Abortioncomplications in Kenya, InternationalJournal of Obstetrics andGynaecology) supports the Nigeriadata, declaring unsafe abortion asone of the most neglected health

care issues in Africa.

Over 80 per cent of the 809 casestudies from all levels of Kenyashealth care system hadcomplications as a result of unsafeabortion. Of the seven deathsrecorded, six were due to secondtrimester complications; underliningthe need for safe and accessibleabortion services as early as possibleduring the pregnancy. The studyestimates that annually 20,893Kenyan women will be hospitalizedfrom complications from unsafe

abortion.

In countries where abortion is permitted only on narrow grounds,thousands of women are hospitalized each year with serious complicationsfrom unsafe procedures.

HospitalizationsAbortion-related per 1,000 women

Country hospitalizations 1544

Africa

Egypt, 1996 216,000 15.3Nigeria, 1996 142,200 6.1

AsiaBangladesh, 1995 71,800 2.8Phillipines, 1994 80,100 5.1

Latin America

Brazil, 1991 288,700 8.1Chile, 1990 31,900 10.0Colombia, 1989 57,700 7.2Dominican Republic, 1990 16,500 9.8Mexico, 1990 106,500 5.4Peru, 1989 54,200 10.9

Alan Guttmacher Institute, Sharing Responsibility;Women, Society and Abortion Worldwide

Many women, married orunmarried, simply have no controlover their own sexual lives. Theycannot access, or are not permittedto access, safe family planningservices and as a consequence havelittle choice over when or if they

become pregnant. The prevailingcultural and religious norms ofmany societies leave women,especially young women and girls,facing death or injury from unsafeabortion, or social exclusion andabandonment.

Many girls and women areprevented from enjoying basicsexual and reproductive rights dueto their unequal status in society.

They lack control over their ownbodies, just as they lack decisionmaking power, mobility and controlof resources within the household.This social, political and economicinequity prevents many womenfrom accessing safe services or from

demanding the services they desire.

Young women, adolescents andgirls are particularly vulnerable tosexual coercion, abuse andexploitation. Almost 50 per centof sexual assaults worldwide areagainst adolescent girls of 15 yearsof age or below. They are powerlessin relationships where older mencontrol their lives. This not only putsthem at greater risk of unwanted

pregnancy and unsafe abortion, butit is also a significant factor fuellingHIV infection rates amongst youngwomen in many countries.

Gender inequality, cultural norms,religious practices and poverty are

all factors limiting opportunities forwomen and girls to make choicesabout their own sexual andreproductive lives. This leaves girlsand women without the choice tosay no to sex, especially if they arepoor or living in marginalizedcommunities. This has direconsequences for many women,especially the very poorest women.

Unsafe abortion:the cost of gender inequality

Millions of women suffer injury or illness from unsafe abortion


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There are approximately 211 millionglobal pregnancies annually; 87million women become pregnantunintentionally, with approximately46 million pregnancies ending ininduced abortion. A further 31

million pregnancies miscarry orresult in stillbirths.

Women in all parts of the worldseek to end unwanted pregnancythrough abortion: of the 46 millionwomen who choose to have anabortion each year, 78 per cent arefrom developing countries, 22 percent from developed countries.Annually 19 million abortions areconsidered to be unsafe, over 96per cent of which occur indeveloping countries.

A number of independent studieshave shown that, while there maybe country-to-country differences,

In compiling this report, IPPF has relied on statistical data from a numberof sources, most extensively from the Guttmacher Institutes landmark

publication Sharing Responsibility: Women, Society and Abortion

Worldwide, 1999.

across the world women chooseto end pregnancies for very similarreasons.

They choose not to have anymore children

They are too young or have toofew economic resources to havechildren

They wish to complete theireducation

They wish to postponechildbearing to space births

Their relationship with theirpartner has ended or is unstable

Childbearing would adverselyaffect their health

The pregnancy was a result of

rape or incest Social or religious beliefs make it

impossible for unmarried womento continue pregnancy

Worldwide unplanned pregnancyand unsafe abortion Unsafe abortion in Europe

Unsafe abortions indeveloping countries

Africa 4.2 millionAmerica and the Caribbean3.8 millionAsia 10.5 million

All abortions byglobal region

Africa 11 per centAsia 58 per centEurope 17 per centLatin America andCaribbean 9 per cent

WHO estimates that there are

between 500,000 800,000

unsafe abortions in Europe each

year. Women are still dying in

Eastern Europe from unsafe

abortion, but the situation is

improving. Between 6 and 23per cent of maternal deaths in

Eastern and Central Europe are

as a result of unsafe abortion.

In order to improve womensaccess to safe legal abortion, IPPFEuropean Network, in partnershipwith other organizations, organizeda two-day workshop of staff andvolunteers from the MemberAssociations of Albania, Armenia,Bosnia and Herzegovina, Georgia,

Kazakhstan, Poland, Tajikistan andUzbekistan. An additional meetingwas held with other EuropeanMember Associations to assistthem in improving the quality ofabortion services provided.

A law banning abortion was

passed in Romania in 1966.

There was a dramatic rise in

maternal mortality from 80

deaths per 100,000 live births

in 1964 to 180 in 1988. After therepeal of this law in 1989, the

maternal mortality ratio fell to

around 40 deaths per 100,000

live births in 1992. This fall was

almost entirely due to women

being able to access safe

abortion services and

consequently fewer deaths

caused by the complications of

unsafe abortion. During the

period 1966-1988, some 20,000

Romanian women are estimated

to have died as a result of

unsafe abortion.

Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide

In the face of growing conservatism in many parts of the world, as

well as competition for resources, the great challenge is to maintain

the focus of development efforts, as embodied in the MillenniumDevelopment Goals, on the centrality of sexual and reproductive

health and rights for poverty reduction. This requires that IPPF step

up its advocacy efforts, in partnership with like-minded governments

and organizations, even as it expands its services in traditional

family planning and especially safe abortion.

Dr. Jacqueline Sharpe, President IPPF.


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Unplanned births are common eventsfor women around the world

0 10 20 30 40 50 60

Cote DIvoire

Kenya

Nigeria

Zimbabwe

Egypt

Morocco

Tunisia

Bangladesh

India

Indonesia

Philippines

Brazil

Colombia

Mexico

Peru

France

Japan

Canada

Sweden

United States

% of births in last five years

Unwanted Preferred at later time

Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide

Asia

North

Africa&

MiddleEast

Sub-SaharanAfrica

LatinAmerica

Dev

elopedcountries

The causes of unplanned andunwanted pregnancy

Gender inequality means womenhave less control over theirown bodies

Lack of access to family planningservices

Lack of information on moderncontraceptive methods andreliance on traditional methods

The failure of, or irregular use of,contraception

Stigma surrounding single womenand contraceptive use

Lack of a womans control overthe circumstances of sexualintercourse

Sexual violence, rape and incest

Cultural and religious norms meanwomen have less power tonegotiate contraception

Better contraceptive choices

To have full control over the spacingof children and to achieve desiredfamily size, women and men mustuse, correctly and consistently,reliable contraception for themajority of a womans fertile years.

Evidence suggests that globally thenumber of married and unmarriedwomen regularly using modernmethods of contraception to avoidunplanned pregnancy is well belowthe numbers who wish to delay orbetter space their pregnancies.

The reasons for this are complex,ranging from ingrained social andcultural attitudes, economiccircumstances and the inability ofwomen to negotiate contraceptiveuse in relationships. Another reason

is that in large parts of the worldthere is an unmet contraceptiveneed, and women and men simplycannot access the family planningservices they want and need. Manycouples are forced to rely ontraditional methods which are noteffective in preventing pregnancy.This inevitably leads to unplannedpregnancies.

Increasingly women desire smaller families. With the exception of sub-Saharan Africa and a handful of other countries this largely means havingtwo or three children. In much of the developed world a small family sizeis the cultural norm. Yet many women throughout the world still havemore children than they would desire.


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Nepal

In Nepal early marriage andmultiple unplanned pregnancieshave lead many women to seeksecret and unsafe abortions.Abortion was legalized underspecific conditions in 2002, and theimplementation of the legislationwas approved in early 2004. Thislegal reform was contained withinthe Pregnancy Protection legislationwhich addressed other rights forwomen. IPPF Member Association,the Family Planning Association ofNepal (FPAN), began providingabortion services in 2004 in threedifferent clinics.

A 14-year old girl arrived at

FPANs Valley clinic and requestedan abortion. Initially she wasreluctant to speak to the staff,but she eventually revealed thatshe had been involved in a sexualrelationship with a distantrelative and had becomepregnant. A bright student, shewas worried that a pregnancywould affect her forthcomingexams and would prevent herfrom completing her education.

It was the first time that such a

young person had requested theseservices from the clinic, so staff didnot have a standard procedure tofollow. A meeting was quicklycalled with service providers andsenior staff to discuss the legalimplications and how best to helpthe girl. In Nepal it is illegal toprovide abortion services to anyoneunder the age of 16 unless she hasthe consent of her parents orguardian. The staff decided thatthey would provide safe abortion

services the following day, so longas the girl could return to the clinicthe following morning with aguardians consent letter.

The next day, she did not comeback to the clinic and staff becameworried. FPAN field staff madediscreet enquiries, and they metwith the girl in confidence andprovided additional counselling.

They discovered that she had notreturned to the clinic that morningbecause she had been sitting anexam. By now it was the weekend,and although the clinic wasofficially closed for the day, thebranch manager was concernedabout further delays and openedthe clinic especially for the girl, whowas accompanied by her guardian.

A 36 year old pregnant womanwho had learned about theservices of the Family PlanningAssociation of Nepal throughoutreach workers, came to a clinicin mid-2005. She and herhusband, a labourer, were poor

and were already struggling tobring up their seven youngchildren. She was clearly distressedthat an eighth child would meanthat none of her children could beprovided for adequately.

Unfortunately, FPAN is unable tooffer free services for all clients, andthe woman could not afford the750 rupee (approximately 6) fee.Realizing that she was in anextremely vulnerable condition,and fearing the woman might

resort to an unsafe, traditionalabortion method, FPAN staffdecided to raise the money forthe operation themselves.

For many women, safe abortionsare very expensive andunaffordable, and going into debtis not an option. This is one of themany reasons women resort tounsafe abortion.

The woman received a safe

abortion and post-abortioncounselling, including contraceptivecounselling. The woman told staffthat had she known about FPANsfamily planning services sooner, shewould have taken steps to havefewer children.

Peru

Carmen, a 19-year-old woman,came to a clinic of IPPFs PeruvianMember Association, INPPARES,depressed and emotionally upset.She revealed during the conversationthat she had been raped six weeksearlier, but had not reported it orsought medical care because shefelt ashamed. In desperation, shehad attempted to induce anabortion using medication and wassuffering from vaginal bleeding.

Carmens boyfriend and motherwere with her during the visit, andshe was able to talk openly aboutwhat had happened and to discussthe options available to her. In

addition to information on post-abortion care, she was offeredcounselling on testing for HIV andother sexually transmittedinfections. The woman decided tohave a manual vacuum aspiration,which was completed withoutcomplications. When she returnedfor a follow-up visit, she wascounselled on differentcontraceptive methods. She saidthat her boyfriend had left her dueto the stigma associated with rapeand abortion, and that she no

longer needed contraception.

All case studies in this report came from IPPF Member Associations

Case studies:unplanned pregnancies

IPPF/Chloe Hall

Women accesscontraceptiveservices in theNouadhibou clinicof the MauritanianMember Association,these servicesare fundamentalto preventingunwantedpregnancies

IPPF/ChristianSchwetz

The MemberAssociation inThailand ensuresthat women areeducated aboutdifferent methodsof contraception


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The Global Gag Rule

First introduced in 1984 andreintroduced by President GeorgeW. Bush in 2001, the Global Gag

Rule puts non-governmentalorganizations from outside theUnited States in an untenableposition, forcing them to choosebetween carrying out their worksafeguarding the health and rightsof women or losing their fundingfrom the US. The Gag Rule prohibitsorganizations in receipt of US fundsfrom using their own money toprovide abortion information,services and care, or even discussingabortion or criticizing unsafeabortion. It even preventsorganizations from working onthese issues at the request of theirown governments.

The Gag Rule severely restrictsfreedom of speech; it interferes withthe doctor-client relationship; andhinders balanced consideration ofliberalizing abortion laws based onpublic health concerns and human

rights. Around the world this hashad a dramatic impact on the abilityof IPPF Member Associations, and

many other organizations, whichhave rejected the Gag Rule, andconsequently lost much of theirfunding, to provide full sexual andreproductive health services. Thepolicy has restricted the freedom ofspeech and association of thoseorganisations who are bound by itsregulations. However, anti-abortionadvocacy is allowed, underscoringthe ideological nature of the GagRule.

The Gag Rule fails in its statedintent to reduce the globalincidence of abortion. Rather, bydramatically impairing the deliveryof sexual and reproductive healthservices, its actual impact has beento increase the number ofunintended pregnancies and theabortions that inevitably follow.

It has never been easy to fully

quantify the impact of the Gag

Rule. Its ramifications are

insidious and have occurred overmany years. It is impossible to

track how many deaths have

been associated with services

that could have been provided

in the absence of a Gag Rule,

how many advocates were

silenced from speaking out about

a devastating public health issue,

or how many organizations were

prohibited from working with

their governments and other

Non-GovernmentalOrganisations to meet the

serious health care needs of their

own communities.

Planned Parenthood Federation ofAmerica, Report on Global GagRule 2003.

At the International Conference onPopulation and Development in

Cairo in 1994, the internationalcommunity pledged to makeuniversal access to family planningand sexual and reproductive healthservices a reality by 2015. Over adecade later, and despite furtherpledges to deliver universal access,

world leaders are as far away asever from delivering on their

commitment. Indeed, funding forglobal family planning services hasactually fallen during this period.

Non-existent or poor quality familyplanning services, whether frominadequate funding or political and

religious opposition, contributedirectly to unintended and

unwanted pregnancies and tosubsequent high levels of maternalmortality and ill health from unsafeabortion.

The global commitment to family planning

IPPF/Chloe Hall

Buzensu walks forseveral hours toattend the marketday outreach servicesin Wondogonet,Ethiopia. TheSaturday clinic is heronly point of accessfor contraceptiveservices


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size and the governments launchof a national family planningprogramme, Kenya saw a rapiddecline in its birth rate, on averagefrom eight children per woman

to slightly over four. Yet maternalmortality hardly declined andabortion rates remained high(estimated at over 300,000per year).

As abortion is severely restrictedunder Kenyan law, the onlyexception being to save the life ofthe mother, the vast majority ofabortions are illegal and unsafe,accounting for some 30-50 percent of national maternal mortalityrates. The impact on the resourcesof Kenyas healthcare system isenormous, with as much as60 per cent of the resources ofKenyatta National Hospitalsmaternity ward taken up byvictims of unsafe abortions.

Unmet need for family planningthroughout Kenya remains very

Country profile: Kenya

high, with 24 per cent of couplesunable to access the services theydesire, and family planning serviceshave been reduced, largely due tothe imposition of the Global Gag

Rule. Yet the abortion rate remainshigh, indicating that Kenyanwomen continue to turn toabortion to manage their fertility.

Access to contraceptive servicesreduces the number of unplannedpregnancies and subsequently thenumber of abortions. Where thereis an unmet need for familyplanning and contraception, as theKenyan experience demonstrates,women resort to abortion to avoidchildbearing. In countries whereabortion is illegal or restricted, thismeans women put their lives andwell-being at risk by resorting tounsafe abortion. Safe and legalabortion services must existalongside effective family planningand reproductive health services toprevent deaths and tackle thehealth impact of unsafe abortion.

The need to accesscontraceptive services

IPPF is committed to a two-pronged approach to reducing, andeliminating, abortion-related

maternal mortality. The first is toprovide those services that reducethe need for abortion; where goodcontraceptive services are providedabortion rates decline. However, nomatter how effectively contraceptiveservices are provided and used,unintended pregnancies will stilloccur.

IPPFs second goal is to makeabortion legal and safe everywhere.The evidence is clear: only when

women have the right to accesssafe abortion services do medicalcomplications from unsafe abortionand maternal mortality becometruly rare.

This approach is dramaticallyhighlighted in Kenya. Between1980 and 2000, driven by demandfrom couples to limit their family

Kenya and the Global Gag Rule

IPPFs Member Association in Kenya, the Family Planning Association ofKenya (FPAK), provides a significant share of the countrys contraceptiveand reproductive health services. Faced with a choice between losing allits funding and technical aid from the US Agency for InternationalDevelopment and stopping all its work on safe abortion, FPAK chose toforfeit the aid to be free to advocate for the health and well-being ofKenyan women. The resulting loss of funding saw the closure of threeFPAK clinics, the scaling back of services in its remaining clinics and theslashing of funding to outreach programmes. This has made it muchharder for poor Kenyans to access family planning services andinformation, and must inevitably lead to more unwanted pregnanciesand unsafe abortions.

The need to review abortion legislation

In early 2004, a number of Kenyan medical practitioners, accused ofperforming abortions, were put on trial for murder. In response theKenyan Reproductive Health Steering Committee was established,comprising representatives from across Kenyan society, to defend theaccused and to extend reproductive health and rights in Kenya.

Through the Steering Committees work, a draft motion to liberalizethe law on abortion will soon be tabled in the Kenyan parliament anda comprehensive national review of abortion is being undertaken. Themobilization of those who support improved access to safe abortionhas lead directly to the challenge to Kenyas abortion laws. Had thoseorganizations, including FPAK, signed the Gag Rule this challenge couldnot have happened, even at the behest of their own government.

Continuing unmetcontraceptive need and

contraceptive failure will

invariably be associated with

high rates of unplanned and

unwanted pregnancies, forcing

many women to resort to

unsafe termination of

pregnancy with a consequent

unacceptably high rate of

complications including

infertility, long term morbidity

and death.The Magnitude of Abortioncomplications in Kenya, RCOGInternational Journal of Obstetricsand Gynaecology


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South America has longexperienced the ravages of severerestrictions on abortion with someof the highest maternal mortalityrates from unsafe abortion in

the world. In Venezuela, abortionis legal only to save the life ofa woman, and there are noexceptions for rape, incest orto preserve a womans health.Additionally, the law prescribes upto two years imprisonment for awoman who undergoes anabortion and up to 30 monthsimprisonment for the provider.

On 1 December 2004, a proposalto decriminalize abortion was

presented publicly before theNational Assembly. For healthprofessionals, weary of seeingwomen die from complicationsresulting from unsafe abortion,this was a momentous event.The bill represented the efforts ofmany womens organisations,universities, obstetrics andgynaecological societies, theMinistry of Health andreproductive health providers,including the IPPF MemberAssociation in Venezuela,

Asociacin Civil de PlanificacinFamiliar. In a country where theCatholic Church exerts a powerfulinfluence over society, theproposal for decriminalization is a

first step in opening up a muchneeded public and legislativediscussion on abortion.

The Asociacin Civil dePlanificacin Familiar helped draftthe proposals and presented thepublic health concerns of unsafeabortion to the CongressionalCommission on Women, Familyand Youth, which now supportsthe proposals. The Commissionchanged its position significantly

once members heard the storiesof women who needed access tosafe abortion facilities, and sawfirst hand the impact of maternalmortality and morbidity. Theyrecognized that criminalizingabortion was neither preventing itfrom taking place nor reducing thedemand for it, but only makingwomen suffer; they subsequentlyagreed that current legislationneeded to be reformed.

Abortion law reform efforts in Venezuela

29 Countries have liberalized

their abortion laws despite

the imposition of the Global

Gag Rule in 1984

Albania - 1996

Algeria - 1985

Australia - 2002 (two States)

Belgium - 1990

Benin - 2003

Botswana - 1991

Bulgaria - 1990

Burkina Faso - 1996

Cambodia - 1997

Canada - 1988

Chad - 2002

Czech Republic - 1986

Ethiopia - 2004

France - 2001

Ghana - 1985

Guinea - 2000

Greece - 1986Iran - 2005

Malaysia - 1989

Mali - 2002

Mexico - 2000 (two States)

Mongolia - 1989

Nepal - 2000

Pakistan - 1990

Romania - 1989

Slovakia - 1986

South Africa - 1996

Spain - 1985

Switzerland - 2002

IPPF/Asociacin Civilde Planificacin

The VenezuelanMember Associationand their volunteersare key playersin the campaignto decriminalizeabortion inVenezuela


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IPPF/Chloe Hall

The free familyplanning servicesoffered bythe MemberAssociation clinicin Nouakchott,Mauritania are

fundamental toensuring thatwomen likeMimoona do notbecome anothermaternal mortalitystatistic.

Accessible, effective family

planning services may avert up

to 35% of maternal deaths

Reducing Maternal Death:

Evidence and Action, A Strategy

for DfID, September 2004.

A study of 15 West African

countries found that those with

the highest contraceptive

prevalence had the lowest

maternal mortality rates, and

vice versa.

The sexual and reproductivehealth and rights communityfaces increasingly hostile politicalopposition from the United States,the Vatican and other conservativegovernments and religious leaders.

This has ensured that universalaccess to reproductive healthservices remains a distant hope forthe majority of the worlds poor.The direct result is that womenand girls across the globe continueto bear the brunt of policies thatfail to address the nature andscale of maternal mortality andunsafe abortion.

Opposition to family planning undermines efforts toreduce unwanted pregnancy and unsafe abortion

Where access to

comprehensive family

planning services and

information is available

abortion levels have fallen:

The number of abortions inArmenia, Kazakhstan, Kyrgyz

Republic, and Uzbekistan could

be halved if women who do

not use contraceptives or use

traditional methods switched

to modern contraceptives.

Bangladeshi women with

good access to high quality

family planning services have

an abortion rate of 2.3 per

1000 compared with 6.8 for

women without access. (DuffGillespie, The Lancet, Vol. 363,

January 2004).


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The ideological debate surroundingabortion masks an unspoken truth:when faced with an unwantedpregnancy many women will seekan abortion regardless of its legalityor safety. The deadly consequences

of this are all too evident; womenslives are put at risk and all toooften they die or suffer lifelongdisability. The illegality and thestigma attached to abortion makeevidence difficult to find. However,when research is undertaken andthe facts are analyzed, the case for

liberalizing abortion laws andsimultaneously increasing access tosafe services is compelling.

Proof that criminalizing abortiondoes not reduce abortion rates, but

instead endangers womens lives,can be seen across all globalregions. In Latin America abortionis illegal or severely restricted invirtually every country, yet theabortion rate is one of the highestin the world, far exceeding that ofWestern Europe or North America.

Colombia, which prohibits abortioneven to save a womans life,averages one abortion per womanthroughout her reproductive years.In Peru, this rises to an average oftwo abortions per woman. For

poor women, unable to afford safetreatment, this means resorting toillegal unsafe abortion at the handsof unqualified people in unsanitaryconditions.

Creating the platform for change:evidence-based interventions

The controversy surrounding whenand how abortion should be legalin Uganda hides a vicious reality forwomen. Currently abortion is illegalwith the exception of saving awomans life, or to preserve herphysical and mental health.However, additional administrativebarriers exist as an abortion has tobe performed by a registeredphysician, and the consent of twoadditional doctors is usually sought.Under the Ugandan penal code,

performing an illegal abortion ispunishable by up to seven years inprison for both the woman and thedoctor, yet this has done little toreduce the level of unsafe illegalabortions.

Uganda is one of the worldspoorest countries, with nearly 40per cent of people living below thepoverty line. DfID funded researchreleased in 2005 has shown thatone third of Ugandan women are

denied contraception because theyhave no access to services. Thissupports evidence from the FamilyPlanning Association of Ugandaand builds a real and tangibleargument to generate public

support and political commitmentfor legal reform of abortion laws.

The result of restricted access tofamily planning services is that theaverage Ugandan woman givesbirth to seven children during herlifetime, two more than she wouldprefer. Many women break the lawto end unwanted pregnancies inunsafe and unhygienic conditions.The greatest impact of this is felt bythe poorest women in Ugandan

society, especially those living inrural areas who are driven to usingsharp instruments and herbs in adesperate attempt to end anunwanted pregnancy. Upwards ofseventy-five per cent will sufferhealth complications, and unsafeabortion now accounts for onethird of all maternal deaths inUganda.

Such strong factual evidencecannot be ignored. There is already

a groundswell of support forchange. In September 2005, IPPFand the Family Planning Associationof Uganda facilitated a fact-findingmission by some NorwegianMembers of Parliament. The

Country profile: Uganda

findings led the delegation to makea declaration that stressed theimportance of increasing access tosafe, legal abortion, particularly forpoor, vulnerable and rural women.This declaration was publiclydiscussed with Ugandan Membersof Parliament, Ministry of Healthofficials and the media whichstimulated considerable publicdebate. This has lead the Headof the Reproductive HealthProgramme to acknowledge

publicly that legal abortion wouldreduce the maternal death rate.The Ministry of Health is planningto review the abortion law andis considering how the currentabortion law can be betterinterpreted so as to prevent furtherunnecessary mortality andmorbidity from unsafe abortioncomplications.

Using evidence to support the casefor reducing rates of unwanted

pregnancy through improvedaccess to safe abortion, IPPFsMember Association has appealedto the Government for repeal ofthe current restrictive abortion lawson public health grounds something that could not havehappened had the Family PlanningAssociation of Uganda signed theGlobal Gag Rule.


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Gete (not her real name), a 22year old Ethiopian woman, cameinto a Family Guidance Associationclinic in Addis Ababa because shehad been raped. She originally

came from Gondor in the northbut moved to Addis to find work,living with her aunt and unclesince 2004.

Gete was raped by a friend of hercousin. At the time abortion wasillegal in Ethiopia other than incases of rape and incest, and toaccess abortion services a womanneeded to obtain a police reportconfirming rape (this law hasrecently been liberalised). Thestigma surrounding rape and

abortion is great and she wasreluctant to go to the police,thinking they would not believeher. When she told her uncle shehad been raped he threw her out.

When she found out she waspregnant Gete decided shewanted an abortion and,overcoming her fears, she went tothe police. They sent her to the

clinic to get confirmation, butbecause she was already fourmonths pregnant clinic staff wereunable to confirm whether shehad been raped and were limitedto providing counselling andconfirming pregnancy for thepolice.

If the woman does not receivethe correct documentation fromthe police, the clinic will be unableto refer her for a safe abortion. Incases like this it is common for

women to visit illegalabortionists.

Sister Mekele, head nurse of theAddis Ababa model clinic.

Country profile: Ethiopia

Medical abortion, a combination ofmedications, is a safe and highly

effective method for ending anunwanted pregnancy, and isincreasingly the preferred methodin many developed and somedeveloping countries. At present itis largely unavailable to womenliving in the latter. Provided bytrained personnel, complicationsare rare.

Using the antiprogestogen,mifepristone, in conjunction with asynthetic prostaglandin analogue,

the effects of medical abortion aresimilar to those of spontaneousabortion. In countries wheresurgical abortion presents severemedical or financial difficulties forprimary healthcare systems,medical abortion has proved to beeffective and user friendly, andoffers real hope of making safeabortion much more accessible tothose women who need it most.

Medical abortion up to nine weeksgestation requires two clinical visits

to administer two separate drugs,but can also be administered athome which is increasingly the casefor its second administration.Following administration of theprostaglandin on the second visit,90 per cent of women will abortwithin 4-6 hours.The procedure hasa 98 per cent efficacy rate. Beyondthe nine week period there is arequirement for additionaltreatment, although never asinvasive as surgical abortion, and it

has a 97 per cent efficacy rate.

One of the major benefits ofmedical abortion in developingcountries is that, for the vastmajority of women, the procedurecan be carried out on an outpatientbasis, requiring far fewer medicalresources.

Medical abortion: Saving lives inresource poor settings

Sarawati, a 37 year old healthcare worker from India said

I wish this method [medicalabortion] was available when Iwas young and had anunwanted pregnancy. I went toa Dai [traditional healer]because I did not want to havesurgery done by the maledoctor; I had pain and fever formany days. I never could getpregnant after that, and myhusband left me.

Medical abortion has been

used for over a decade in manyEuropean countries. In some

countries it now accounts for

over 50 per cent of abortions

undertaken (Sweden 51 per

cent; France 56 per cent;

Scotland 61 per cent).

IPPF/Chloe HallGette preferrednot to have heridentity revealed inthis photograph


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IPPF/Chloe Hall

Itenesh is HIVpositive and visitsYouth Centresrun by the FamilyGuidanceAssociation ofEthiopia to talk toyoung peopleabout what being

positive meansfor their futurereproductivehealth

access to comprehensiveprevention of mother-to-childtransmission programs, HIVpositive women who give birthto HIV positive children are oftenblamed.

The right to have a family anddecide whether and when to havechildren is a fundamental part of a

womans sexual and reproductivefreedom. Yet, women living withHIV are frequently denied thisright because society and serviceproviders do not believe that HIVpositive women should havechildren, or should even besexually active.

This is a tragic picture, whichpaints HIV positive women as bothculprits and victims, and implies adegree of coercion in the decision-

making process. To date, fewstudies have explored how HIVpositive women make childbearing

Women of childbearing age livingwith HIV are as likely to have anunplanned pregnancy as thosewho are HIV negative, and areequally faced with the question ofwhether to have a child or not.However, in the case of the HIVpositive woman, the issue is morecomplex, for personal, familial,social, cultural, religious and

medical reasons.

Women living with HIV are oftenstigmatized for being HIV positiveand, if pregnant, for irresponsiblybeing sexually active andbecoming pregnant while HIVpositive. Sometimes they areunder pressure by family or healthworkers to have their pregnancyterminated, while in other casesthey are pressured by partners andsociety to have children. Women

living with HIV can also bedemonized for seeking or havingan abortion. In the absence of

HIV-positive women and their right to choose

decisions. However, whatemerges from current researchis the lack of respect and valueplaced on HIV positive womenslives.

It is clear that provision ofservices needs to be based onthe respect for the womanssexual and reproductive rights

and decisions, including, ifneeded, the right to safe andlegal abortion. Making availablesafe abortion services isextremely important for HIVpositive women as unsafeabortions become significantlyless safe due to the greater risksHIV positive women face ofsuffering complications such assepsis and haemorrhage.

No matter what their status

women should have the right todecide for themselves whetheror not to bear a child.


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Every week at the Hospital dasClinicas in Sao Paulo, Brazilslargest public hospital, women arerushed to the emergency roomwith severe vaginal bleeding.

Most are in their teens or early20s and live in the dirt-poor slumsthat encircle South Americasbiggest city. Some say they haveno idea what caused the bleeding.Others tell elaborate stories ofmenstruation gone awry.

But hardly any own up to the

truth; scared of being turned in tothe authorities in a country whereabortion is illegal, they are reluctantto admit they induced miscarriageby inserting a black-market ulcermedication into their vaginas.

Although abortion is outlawed inBrazil except in rare circumstances,the country has one of the highestabortion rates in the developingworld. The Health Ministryestimates that 31 percent of allpregnancies end in abortion. Thatworks out to about 1.4 millionabortions a year, mostly clandestine.

In the United States, whereabortion was legalized in 1973,about 25 per cent of allpregnancies end in abortion. Inthe Netherlands, a country withsome of the worlds most liberalabortion laws, the ratio is closerto 10 per cent.

Despite its prevalence, abortionlargely remains a taboo subject inBrazil, the worlds biggest RomanCatholic country. But that is nowchanging as civic groups and somemedical professionals prompt a

public debate on abortion bychampioning a womans right toend an unwanted pregnancy. Theywant to prevent women fromdying from clandestine abortions.

Currently, abortion is only allowedin cases of rape or when themothers life is in danger. But eventhen, getting a judge to authorizethe procedure can be difficult, andsome doctors refuse to performabortions on religious grounds.

Botched abortions are the fourth-leading cause of maternal deaths

in Brazil. In 2004, some 244,000women were treated forcomplications from clandestineabortions in public hospitals,costing the government 35 millionreals (9 million).

Brazils abortion laws alsohighlight its gaping socialinequalities. Well-to-do womenresort to clandestine but safeclinics to end their pregnancies,paying as much as 1,500 reals(400) - five times the monthlyminimum wage - for an abortion.

Most poor women, by contrast,turn to an ulcer drug calledmisoprostol, better known by thebrand name Cytotec. Wheninserted into the vagina Cytoteccauses the uterus to contract,expelling the embryo or fetus.

Reuters news agency report,10 January 2006

Country profile: Brazil

IPPF/JennyMatthews

Although abortionin Nepal has beendecriminalisedand many womenimprisoned forillegal abortionhave beenreleased, they arestill aware of thepotential stigmasurrounding

abortion

Thats how so many women confront

the problem: ALONE.

Dr. Gladys Bazan Gynaecologist, IPPF Member Association in Peru.


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A future free from death and denial?

IPPF advocates for:

A universal recognition of

a womans right to choose

and have access to safe

abortion, and a reduction in

the risk of unsafe abortion.

IPPF Strategic Framework

When abortion is legal and servicesare both accessible and safe, thechance of a woman dying or beingphysically harmed from eithersurgical or medical abortion isnegligible. Indeed, abortion is oneof the safest medical procedures. Itis a public health tragedy then thatalmost 200 women around theworld continue to die each andevery day due to complicationsfrom unsafe abortion, virtually all of

them living in the developing world.

Women who are already facing afuture of limited opportunities andsocial inequalities, who findthemselves with an undesiredpregnancy, must also encounterthe often deadly risk of an abortionperformed by someone withoutany medical training in unsanitaryconditions, or by attempting to endan unwanted pregnancy themselveswith traditional methods.

This report has sought to highlightsome of the key issues related toabortion in countries where it iseither illegal or severely restricted.Our hope is that one day womenwill no longer have to put theirlives and health at risk from unsafeabortion; for this to be a realityabortion must be both legal andsafe everywhere. It is IPPFs beliefthat a womans right to choosewhether to have an abortionshould never be compromised by

unwarranted intrusion from thelaw, or the very real risk of deathdue to the lack of minimal medicalstandards and skills.

It has been shown that by makingfamily planning and reproductivehealth services available, the rateof unintended pregnancy dropssignificantly, thus decreasing theneed for abortion.

However, even with the mostefficient use of contraceptionunwanted pregnancies will stilloccur.

The most important message fromthis report for governments to

understand is that by criminalizingabortion the issue does not goaway; women will continue to seekabortions for all the reasons outlinedin this document, and women willcontinue to die. We therefore needto make sure that if a womanchooses to have an abortion, it isboth safe and legal.

This report has highlighted that weneed to create the political will to:

1.Reduce unwanted

pregnanciesBuild upon past gains in sexual

and reproductive health

Increase access to familyplanning

Focus on the needs of poorand rural women and men

Promote womens statusand rights

2.Make safe and legalabortion available to everywoman who wants it

3.Address gender inequalityCreate the circumstances in

which women are socially,politically and economicallyempowered

4.Ensure that post abortioncare services to womenwho have incompleteabortions or medicalcomplications following anabortion are included inboth public and privatehealth services

5.Eradicate unsafe abortion

Increase access to safe andlegal abortion

Reduce legal and socialbarriers to safe abortion

6.Hold governments in bothdeveloped and developingcountries accountable forprogress

Document the impact ofunsafe abortion on women,families and society

Educate the public about theconsequences, the costs andthe social injustice of unsafeabortion

7.Tackle the stigma anddiscrimination attached toabortion and promote theopen and frank discussionof abortion and its impacton women

The commitment of theDepartment for InternationalDevelopment means that theUnited Kingdom continues topromote a global approach tolegalizing abortion based on

public health evidence. IPPFstrongly supports this approachand will continue to work withthe Government of the UnitedKingdom, as well as otherdonors, to spearhead thisundertaking.

Without the hard work of so manyof our Member Associations whohave refused funding from theUnited States due to their belief insafe, legal abortion, and who

continue to confront policy makersaround the world, the future forwomen in many countries wouldremain unchanged.

There is a gradual shift in theabortion paradigm and amovement towards liberalizingabortion laws. This report shouldhelp to keep up this momentum.By providing real evidencedemonstrating the public healthimpact of unsafe abortion,particularly its links to social

inequality and poverty, we canhope to persuade governments tomake abortion both legal and safe.We must continue to make thearguments for a womans right tochoose whether to have anabortion and to ensure that, if shedoes, she is not putting her life orhealth in jeopardy. Only then canwe look towards a brighter futurewhere women no longer face therisk of death and denial.


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Bibliography

Access Denied. (2005) The Impactof the Global Gag Rule in Kenya.(http://www.globalgagrule.org/)

Access Denied. (2005) The Impactof the Global Gag Rule in Nepal.(http://www.globalgagrule.org/)

Alan Guttmacher Institute. (1999)Sharing Responsibility: WomenSociety and Abortion Worldwide.Alan Guttmacher Institute,Washington DC, USA.

Bradford, Carol and Holmes, Sue.(2005)Joint Output to PurposeReview of DFID Funded Projects onAccess to Safe Abortion.Department for InternationalDevelopment, London UK.

Centre for Reproductive Rights.

(2004) Making Abortion Safe, Legaland Accessible: A Toolkit forAction. Centre for ReproductiveRights, New York, USA.

Department for InternationalDevelopment. (2004) ReducingMaternal Deaths: Evidence andAction. Department for InternationalDevelopment, London UK.

Gillespie, Duff. (2004) MakingAbortion Rare and Safe. TheLancet, 363:74.

Global Health Council. (2002)Promises to Keep: The Toll ofUnintended Pregnancies onWomens Lives in the DevelopingWorld. Global Health Council,Washington DC, USA.

International Centre for Researchon Women. (2005) TowardAchieving Gender Equality andEmpowering Women. InternationalCentre for Research on Women,Washington DC, USA.

Ipas, (1995) Ten Ways to EffectivelyAddress Unsafe Abortion, Ipas,Chapel Hill, USA.

Ipas. (2003) 5 Portraits, Many Lives:How Unsafe Abortion AffectsWomen Everywhere. Ipas, ChapelHill, USA.

Ipas. (2005) Global AbortionNews Update.

Nerquaaye-Tetteh, Joana. (no date)Access to Reproductive HealthServices: Political Reality in Africa.Planned Parenthood Association ofGhana, Ghana.

Planned Parenthood Federation ofAmerica. (2003) The BushAdministration, The Global GagRule, and HIV/AIDS Funding.Planned Parenthood Federation of

America, Washington DC, USA.

Vekemans, M and De Silva U.(2005) HIV Positive Women andTheir Right to Choose. Entre Nous,No. 59.

United Nations Population Fund.(2005) The State of World

Population 2005. United NationsPopulation Fund, New York, USA.

World Health Organization. (2003)Safe Abortion: Technical and PolicyGuidance for Health Systems.World Health Organization,Geneva, Switzerland.

World Health Organization. (2004)Unsafe Abortion: Global andRegional Estimates of Incidence ofUnsafe Abortion and AssociatedMortality, 4th Ed. World HealthOrganization, Geneva, Switzerland.

World Health Organization. (2005)World Health Report 2005: MakeEvery Mother and Child Count.World Health Organization,Geneva, Switzerland

Deliver. 2003. No Product? NoProgram! Reproductive HealthCommodity Security for ImprovedMaternal and Child Health. Paperpresented at the Fourth OrdinaryMeeting of the West African HealthOrganization, Banjul, Gambia,

1418 July

Who we are

The International Planned Parenthood Federation(IPPF) is the strongest global voice safeguarding sexualand reproductive health and rights for peopleeverywhere. Today, as these important choices andfreedoms are seriously threatened, we are needednow more than ever.

What we do

IPPF is both a provider and an advocate of sexual andreproductive health and rights. Our voluntary, non-governmental organization has a worldwide networkof 151 Member Associations in 183 countries.

Our visionWe see a world where women and men everywherehave control over their own bodies, and thereforetheir destinies. A world where they are free to chooseparenthood or not; free to decide how many childrentheyll have and when; free to pursue healthy sexuallives without fear of unwanted pregnancies andsexually transmitted infections, including HIV.

We will not retreat from doing everything we can tosafeguard these important choices and rights forcurrent and future generations.


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International Planned Parenthood Federation4 Newhams Row, London, SE1 3UZ, United Kingdom

Tel +44 20 7939 8200Fax +44 20 7939 8300

Email [email protected]

Cover photo: IPPF/Jenny Matthews

death and denial unsafe abortion and poverty

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