The stigma-fuelled, legally restricted community

“And [having an abortion] in Senegal where sex, especially outside of marriage, is an enormous taboo, and where abortion is strictly illegal.”

Aminata’s story begins to enlighten us on the issues of social stigma, restrictive abortion laws and poor availability of services which operate on the community level to inhibit a woman’s ability to seek safe abortion.

Globally, laws surrounding the termination of pregnancy have a spectrum of restrictiveness: abortions may be legalised for reasons such us: in the interest of preserving the mother’s physical and mental health, on the basis of socioeconomic grounds, or when the mother and/or child’s life is at risk, or it may be completely unrestricted. Restrictive laws extend beyond the sphere of the developing world. For example, in the Republic of Ireland and Northern Ireland, abortion is against the law unless the pregnancy endangers the life of the woman. Abortion is not legal in Ireland even in cases of rape, incest or foetal anomaly – instead, it is punishable by a life sentence.1 In 2016, a Northern Irish woman faced up to life in prison after assisting her daughter in terminating her pregnancy, by helping her access abortion pills online.1 The prosecution was criticised by human rights bodies including Amnesty International who have called the trial a “grotesque spectacle.” 1

Restrictive legislation, which penalizes both the woman who seeks an abortion and the practitioner who offers abortion services, is considered the main determinant of unsafe abortion. Abortion legality has not been shown to impact incidence rates; instead, the effect of such laws is on safety. A strong correlation exists between abortion legality and safety: abortion-related deaths are much more frequent in countries with more restrictive abortion laws than in countries with less restrictive laws.2 In Western nations, only 3% of abortions are unsafe, whereas in developing nations, predominantly Africa, South-East Asia and Latin America, 55% are unsafe.2cartooon

Ethiopia’s decriminalisation of abortion in 2005, in which its law expanded to include cases of rape, incest and foetal impairment as legal grounds for abortion, acts as a strong, relevant example of the impact of legalisation of abortion.3 In addition to the liberalisation of laws, the government also introduced programmes to train health care providers, provide better equipment for facilities, and extend the availability of services, so as to ensure abortion care would be integrated as a sector of primary health care services. This resulted in significant improvements in the availability of and access to abortion and postabortion care. As illustrated in the graph below, from 2008 to 2014, the percentage of abortions performed outside of safe, reliable facilities decreased from 73% to 47%.3 Further progress however is still required by improving access to safe abortion services, especially for rural women, and current efforts are being invested in this.screen-shot-2017-02-14-at-1-59-00-pm

Poor availability of access to abortion as well as contraceptives is another significant barrier to one’s ability to obtain safe services. The availability of reproductive health clinics is limited, making it especially difficult for women who are not based in urban areas to reach them. In some parts of the world, abortions are offered only in the private sector, in which they can often be too expensive, causing women to opt for cheaper, smaller, unregulated centres.

Furthermore, even in countries where contraceptive and abortion are legal, health care providers often conscientiously object to providing the services, due to their personal standpoint and stigma amongst the community. For example, in Indonesia, although the use of contraceptives is approved by the Ministry of Health and they are available in urban centres, contraception is often inaccessible to unmarried women, due to societal non acceptance of premarital sex.4 A young unmarried Indonesian women is likely to face provider resistance to access to menstrual regulation services in hospitals and clinics as a result. 

The societal labelling of premarital or extramarital sex as taboo activities can make women fearful of judgement from both her community and family, as emphasised in Aminata’s story. As a result, women may seek out a discrete means of obtaining an abortion in order to prevent inflicting shame and humiliation to herself and her family, opting for clandestine centres, preferring to avoid public hospitals. In some cases, a woman’s family may even encourage or pressure her to seek out an alternative means of abortion in order to avoid judgement from the rest of the community. These establishments, which may be lacking in crucial components including proper equipment, adequately trained staff and hygiene facilities, pose a huge risk to the isolated, vulnerable and desperate women. Often, such facilities rely on ungrounded traditional beliefs rather than modern scientific evidence, with unpredictable consequences.

In the following video, Katriene Timmermans, a midwife working with MSF, reflects on her experience in providing post-abortion care to women in Haiti, where restrictive legislation, a lack of sexual education and stifling community attitudes contribute to the high incidence of unsafe abortion:

References 

  1. Fenton S. Second Northern Irish woman faces jail under abortion laws after helping daughter have termination. [Internet]. The Independent, UK. 2016 April 7. [cited 2017 February 16] Available from: http://www.independent.co.uk/news/uk/crime/second-northern-irish-woman-to-stand-trial-on-abortion-charges-a6972726.html
  2. Haddad LB, Nour NM. Unsafe abortion: Unnecessary Maternal Mortality. Reviews in obstetrics and gynecology. 2009 Spring; 2(2): 122-126
  3. Moore AM, Gebrehiwot Y, Fetters T, Wado YD, Bankole A, Singh S, Gebreselassie H, Getachew Y. The estimated incidence of induced abortion in Ethiopia, 2014: changes in the provision of services since 2008. International Perspectives on Sexual and Reproductive Health. 2016 September; 42(3): 111-120
  4. Mundigo AI. Determinants of unsafe induced abortion in developing countries. In: Warriner IK, Shah IH, editors. Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action. New York: Guttmacher Institute; 2006.
  • Cover image: https://mariestopes.org/where-we-work/tanzania/ 
  • Abortion Care in Ethiopia, 2014 [graph]: Moore AM, Gebrehiwot Y, Fetters T, Wado YD, Bankole A, Singh S, Gebreselassie H, Getachew Y. The estimated incidence of induced abortion in Ethiopia, 2014: changes in the provision of services since 2008. International Perspectives on Sexual and Reproductive Health. 2016 September; 42(3): 113. Available from: http://www.jstor.org/stable/10.1363/42e1816
  • Abortion cartoon [image]: http://en.hesperian.org/hhg/Where_Women_Have_No_Doctor:Chapter_15:_Abortion_and_Complications_from_Abortion
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