Is abortion worldwide becoming more restrictive?

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8161 (Published 4 December 2012)

by Sophie Arie, freelance journalist mail@sophiearie.com

Sophie Arie examines the differences in approach to abortion around the world

Abortion has always been a subject for passionate public debate. But recently the temperature has risen, especially in the United States and Ireland. The Republic of Ireland has seen nationwide protests over the death of Savita Halappanavar, who was refused an abortion during a long and painful miscarriage because the fetus was still alive. After the fetus was finally removed she died of septicaemia and organ failure. The debate has also been reopened in the UK, where health minister Jeremy Hunt recently declared a desire to see the limit in England, Wales, and Scotland drop from 24 weeks to 12 and the prime minister expressed an interest in a more modest reduction.

In recent decades, abortion has become legal in all but five countries if a mother’s life is threatened. There has also been a general decline in the numbers of abortions worldwide as contraception has become more widely available. But World Health Organization figures show that the decline has slowed recently. So what’s going on? Is there a general shift towards tighter restrictions? Are people being discouraged from using family planning as populations dwindle? And is that forcing more women to take clandestine routes to terminate unwanted pregnancies?

Ireland

Abortion is illegal under most circumstances in both the Republic of Ireland and Northern Ireland: it is allowed only when a mother’s life is in danger or her long term health seriously at risk. In Northern Ireland, the process for approving an abortion is very strict: two doctors must agree independently that the mother’s health is at risk and the abortion must take place within nine weeks of that decision. The NHS carries out between 30 and 50 abortions a year in Northern Ireland,1 and last year 1007 women travelled to other UK countries for abortions.2 In October, Marie Stopes opened the country’s first private abortion clinic in Belfast. The organisation says it plans to work within Northern Ireland’s legal framework, but anti-abortion groups say it aims to widen access to abortion on mental health grounds.3

In the Republic of Ireland the circumstances in which a woman’s life is deemed to be at risk are not entirely clear, and the recent case of Savita Halappanavar highlighted the fact that even when a woman’s life is threatened some doctors or institutions do not consider abortion an option. At least 4149 Irish women made the journey to the UK for abortions in 2011.2 Ireland is currently revising its guidelines on what constitutes a risk to a woman’s health after three women challenged the country’s constitution in the European Court of Human Rights.4 Anti-abortion groups argue that there are always ways to protect a woman’s health without carrying out an abortion and fear that the new regulations will be the first step towards widening access to abortion.

China

China’s single child policy means that there are an estimated 13 million abortions annually—making it the country with by far the highest number.5 The numbers are thought to have been rising since 2003, after a long period of decline, which has been attributed to increased premarital sex, disruptions in access to contraceptive services because of rapid urbanisation, and a lack of condom culture (six million abortions are in women under 25).6 However, the rapid changes in China have brought growing pressure for a change to the way the one child policy is enforced. Activists monitoring the policy say that instructions have been given to local authorities not to carry out late term forced abortions after one case involving a seven month pregnant woman caused national and international outcry this summer.7 India Abortion is legal in India to protect the mother’s health, after rape, in insane women and underaged girls, or if the fetus has serious malformations. It is not legal as a way to avoid giving birth to a girl. There are hefty fines for those offering sex tests or abortions for sex selection. But India’s 2011 census showed a growing imbalance between the numbers of girls and boys aged 0-6 years, which research suggests is due to an increase in selective abortion of female fetuses.8 The government has so far failed to change or control the culture that prizes boys over girls and contributes to India having an estimated 11 million abortions per year. India’s ministry for Women and Child development reportedly wants to introduce fines and even prison terms for entire families who force a woman to abort a female fetus. And one state, Uttar Pradesh has introduced baby hatches where people can leave their unwanted baby girls.

Russia

Russia was the first country to legalise abortion in all circumstances and has the highest rate of abortion worldwide—54/1000 women aged 15-44 (compared with 24/1000 in China). Over the decades the policy has been changed, and recently it has been restricted by the government of Dmitri Medvedev, which has close ties with the Orthodox church and is facing a low birth rate and shrinking population. In October, parliament voted to limit the period for abortion to 12 weeks of gestation and up to 22 weeks in the case of rape.9 There is no time limit if there is a risk to the mother’s life. Abortion providers are now required to spend 10% of advertising costs on warning of the possible dangers to a woman’s health, and it is illegal to describe abortion as safe. The president’s wife has taken a leading role in anti-abortion campaigns alongside leaders of the Orthodox church.

United States

Abortion has always been a subject of heated debate across the US, but in the past decade there has been a frenzied tightening of restrictions in many states that were previously moderate. Overall, according to the Guttmacher Institute, there were 92 new provisions restricting abortion in 2011, compared with 34 in 2005.10 This year there have been at least 39 new restrictions. In 2000, around a third of American women of reproductive age lived in states that were hostile to abortion rights, a third in states that were supportive, and a third in states that stood somewhere in between. By 2011, over half of American women lived in states that were hostile. States found different ways to obstruct women’s access to the procedure including insisting women must first receive counselling against it, restricting public or private insurance coverage, and making it difficult for physicians to obtain supplies of mifepristone, the FDA approved treatment for medical abortions. Seven largely rural states banned telemedicine for abortion in 2011, meaning a doctor has to be with the patient when prescribing the treatment.

In 2010, Nebraska came up with a new argument for restricting the period in which abortion is permitted. The state ruled to ban abortion after 20 weeks on the basis that the fetus can feel pain at that stage. This theory is not backed up by established science,11 but seven other states (Alabama, Idaho, Indiana, Kansas, Oklahoma, Georgia, and Louisiana) followed with similar rulings. Arizona restricted abortions beyond 18 weeks in March this year using a similar argument.

Critics argue that these laws are unconstitutional because the landmark 1973 Supreme Court ruling in the case of Roe versus Wade held that states could restrict or ban abortion only after fetal viability. It is generally agreed that a fetus could survive outside the womb from 24 weeks at the earliest. Critics also argue that if the concern is for the fetus not to experience pain it would suffice to use anaesthetics. Latin America and Africa

In most of Latin America abortion is either totally banned (Nicaragua, El Salvador) or tightly restricted. Across Africa colonial laws make it legal in only a few situations—usually if a woman’s life is in danger or in the case of fetal abnormality or rape or incest. Social and religious disapproval also contributes to large numbers of women seeking clandestine abortion, which often leads to complications and deaths. WHO estimates that 5.5 million women in Africa have abortions every year, 99% of which are unsafe, and around 36 000 women die from the procedure.12 In Ethiopia, for example, unsafe abortions are thought to account for up to half of maternal deaths. Some 95% of abortions in Latin America are also unsafe.12

In both regions, a few countries have recently decided to relax their laws and make safe abortion services accessible on the basis that criminalising it causes unnecessary deaths. In Kenya, the constitution was changed in 2010 after years of debate over the need to relax the laws and increase provision of safe abortions. Argentina legalised abortion for raped women in March this year and Uruguay legalised abortion up to 12 weeks in October and is providing government funded abortion services. And since 2009, Ethiopia has piloted an apparently successful programme in which trained health workers in one region provide safe medical abortions with misoprostol.

Arab world

Unlike most Muslim countries, Tunisia legalised abortion in the 1970s. The only conditions are that it must be carried out by a qualified practitioner within the first three months of pregnancy. The country’s leaders repressed the population in many ways before the Arab Spring of 2011 but they liberated women by encouraging all sorts of birth control in a bid to control population growth. As a result, the country has the lowest birth rate in the region—2.0 births/1000 women, according to the World Bank’s latest figures.13 It remains to be seen whether the Arab Spring will lead to a relaxing of laws across the Arab world, where abortion is generally available only if a woman’s life is in danger. Data are patchy but according to the International Planned Parenthood Federation, in the five years up to 2000, there were 15 million unwanted pregnancies across the Arab world and over seven million abortions in the same period.14 Clandestine abortions seem to be common, and it is estimated that 5% of maternal deaths are due to unsafe abortions. Because of cultural disapproval, most campaign groups are focusing on promoting better awareness and availability of contraception rather than safe abortions.

Iran

Iran has a relatively low abortion rate compared with other countries, probably because its well educated population makes better use of contraception. But the country’s leaders have begun slashing family planning services and appealing for bigger families in a bid to boost the population. It’s not yet clear how much families are heeding the call to procreate, but the changing government position is likely to produce an increase in the numbers of abortions.


Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Northern Ireland Health Ministry. Statistics on terminations of pregnancy. 
2. Department of Health. Numbers travelling to UK for abortions from the Republic of Ireland and Northern Ireland. Table 12a.  
3. Smyth L. Abortion clinic may exploit and break the law, claims opponent. Belfast Telegraph 2012 Oct 18.  
4. Houston M. Ireland looks at ways to bring its abortion law into line with European judgment. BMJ2012;345:e8165.
5. China has more than 13 million abortions a year. CNN 2009 Jul 30.
6. Guttmacher Institute. Facts on induced abortion worldwide. 
7. Chinese govt may seek end to late term forced abortions. LifeNews 2012 14 Sep.
8. Jha P, Kesler MA, Kumar R, Ram F, Ram U, Aleksandrowicz L, et al. Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011. Lancet2011;377:1921-8. 
9. Kishkovsky S. Russia enacts law opposing abortion. New York Times 2011 Jul 15.
10. Benson Gold R, Nash E. Troubling trend: more states hostile to abortion rights as middle ground shrinks.
11. Colghan A. 24-week fetuses cannot feel pain. New Scientist 2010 Jun 25.
12. WHO. Unsafe abortions. 5th ed. 2005. 
13. World Bank. Fertility rate. 
14. International Planned Parenthood Federation. Abortion.

Facts About Contraception

10 Facts About Contraception (And How It Changed the World) That Every Man and Woman Should Know

A few years ago at a book signing with fellow congresswoman Carolyn Maloney, former House Speaker Nancy Pelosi shared an anecdote about the sometimes strange experience of being a woman in the still predominantly man's world known as Congress. She recalled how early in her career she and another female elected official found themselves as the only women regularly dining at a table full of male elected officials. The men rarely acknowledged their female counterparts or asked their opinion on any political or policy issue. But one day the subject turned to childbirth. Being that she and the other female official were the only two real authorities on the subject (since they were the only two at the table who had actually given birth), Pelosi presumed that this would present an opportunity for their voices to be heard and valued by their male colleagues. Imagine her surprise when two of the men began speaking over one another to share their stories of "being there" for the birth of their children, before moving on to another topic before the women ever had a chance to speak.
I remember chuckling, along with the other women in the room, at how silly men in power used to behave, and being relieved that things have changed so much.
Apparently we laughed too soon.
Not only has the fight over access to contraception been led entirely by men (President Obama on one side, Sen. Marco Rubio and House Speaker John Boehner on the other), but a recent report has confirmed that the voices that have dominated this debate in media have been overwhelmingly male, as well. By a nearly 2-to-1 margin male guests and commentators outnumbered females in discussions of the contraception controversy on news programs. Sen. Rick Santorum's inaccurate remarks regarding the cost of contraception served as a powerful reminder of the severe handicap our political discourse suffers when women are not permitted to speak for themselves on the issues that directly affect them.
Before contraception was widely available, there were far fewer women able to do just that, because of the physical, emotional, and financial demands that giving birth to and raising sometimes more than a dozen children (something my great-grandmother did) required. Maybe that's the point. Maybe some of these elected officials fighting so hard to make contraception as inaccessible as possible want to return to the good old days when contraception was virtually impossible to come by, and therefore men were able to rule the world and, more importantly, their households. Men were able to enjoy absolute power in the legal system and in domestic life without fear that a woman could carve out some semblance of financial and political independence that would enable her to engage in such scandalous behavior as running for office or leaving an abusive relationship. Because after all, where would a woman with six, or seven, or eight small children to care for really go, even if she had a good reason to?
With that in mind, below is a list of the most powerful ways contraception has impacted and continues to impact the world, from issues such as literacy to life expectancy rates of women. I'm sure there are more than 10, so please feel free to add to the list in the comments section below.
1. In countries with the highest fertility rates, women have the shortest life expectancies.
Women in Sierra Leone live half as long as women in developed countries and 10 years less than their African counterparts in some African countries, and no, this is not merely due to the history of civil unrest. One in eight Sierra Leonean women die in childbirth. In other countries like Chad, where women are likely to give birth to six or more children, women are lucky to live to age 55.
2. In countries with the highest fertility rates, women have the fewest rights.
In countries like Niger and Mali, both of which fall in the top 10 for countries with the greatest number of births per woman, women and young girls can still be forced into marriages. A recent case in Niger documented a 9-year-old girl forced to "marry" a 50-year-old man.
3. Countries with low contraception usage have the lowest number of women who can read.
In Afghanistan, which continues to have one of the highest fertility rates in the world, and where contraception knowledge and access remains limited (and women give birth to an average of six children), 87 percent of women cannot read. In Sierra Leone the number is 71 percent.
4. Men who physically abuse their partners fear contraception. (Think about that for a moment.)
A national study of more than 3,000 abused women conducted by the National Domestic Violence Hotline found that one in four said their partners sabotaged, hid, or prohibited use of birth control as a form of control in an already abusive relationship. These findings confirmed those of a number of smaller studies.
5. When contraception availability goes down, abortion rates go up.
Abortion remains illegal in the Philippines, but for the last decade the nation's capital, Manila, has been at the heart of a battle over contraception. Contraception was stigmatized and difficult to access prior to 2000, when contraception was prohibited altogether by an executive order. (It is not unusual for women who have come of age in the city during the time period of the ban to have more than 10 children.) While the abortion rate in the country has barely changed in recent years, the rate in Manila increased by more than 10 percent. So has the number of women dying of complications from illegal abortions.
6. Countries with the highest fertility rates have the highest poverty rates.
Ten of the countries with the world's highest fertility rates are located in Africa. Between 1990 and 2001, the African continent experienced what is deemed "extreme population growth." The number of those on the continent living in "extreme poverty" ballooned from 231 million to 318 million.
7. Before contraception* American women were statistically more likely to die in childbirth than they are today.
At the start of the 20th century, the maternal mortality rate in America was approximately 65 times higher than it is today. During the 17th and 18th centuries, long before modern contraception became widely available, the average American woman gave birth to between five and eight children. Her likelihood of dying in childbirth increased with every birth. The number of women who died in childbirth or its immediate aftermath was one in every eight women.
*Forms of contraception have been available since ancient times (click here to see ancient forms of contraception), but contraception did not become widely available in the U.S. until the Supreme Court's landmark ruling in Griswold v. Connecticut in 1965. Click here to read about Griswold and other key contraception cases.)
8. Before contraception men greatly outnumbered American women in colleges.
Today, women outnumber men. In 1960, just before the Griswold decision, only 35 percent of college students were women. Today women represent at least 57 percent of students on most college campuses.
9. Before contraception there were no female CEOs of Fortune 500 companies.
Katherine Graham became the first female CEO of a Fortune 500 company when she became Chairman of the Washington Post Company in 1973. She inherited the publication from her husband, who had inherited the role from Graham's father, but Graham succeeded far beyond anyone's expectations. Since her trailblazing ascent, more than a dozen other women have reached the highest rung on the corporate ladder with a record-breaking 18 women serving as CEOs of Fortune 500 companies in 2011, the largest number in history.
10. Before contraception women were virtually invisible in Congress.
Just before contraception became officially legal in the U.S. (1965), there were 20 women in the House of Representatives and one female senator, Margaret Chase Smith. None of them were women of color. (Patsy Mink, an Asian American, was elected to her first term the year Griswold was decided by the Supreme Court.) Today there are 76 women in the House. Fourteen of them are African American, four of them are Asian American, and seven are Latina. There are 17 women in the Senate.
And for the record, I doubt any of them want to return to the days when men spoke and voted for them, or for any of the rest of us blessed with ovaries.
Source: Keli Goff, Huffington Post, 13 February 2012

Planned Parenthood Launches “Planned Parenthood Global”

Planned Parenthood Federation of America (PPFA) announced today the launch of “Planned Parenthood Global,” a new phase of international programs.  For 40 years, PPFA has worked with partner organizations in developing countries, providing financial and technical support for women’s health care delivery and advocacy.

Changing the name of PPFA’s international division to Planned Parenthood Global signifies a new era for the program, concentrating on targeted partnerships and the development of pioneering models that can be replicated and scaled up by others.

“We are an incubator; seeking innovative solutions from our partners on the ground and helping those ideas grow into national advocacy and health care campaigns,” said Latanya Mapp Frett, PPFA’s vice president – Global.

PPFA’s international division began in 1971, as Family Planning International Assistance (FPIA), with a grant from the United States Agency for International Development (USAID) to help improve reproductive health care delivery around the world.  In its early stages, the project operated in dozens of countries throughout Africa, Asia and Latin America.  The groundbreaking FPIA program dissolved in the 1980s when President Reagan first imposed the “global gag rule” on U.S. foreign aid.  Since then, PPFA has scaled back its global programming, focusing on partnerships in select countries in Latin America and Sub-Saharan Africa, where the need is the greatest.  The partners of Planned Parenthood Global work in places often overlooked by local governments and international aid agencies, from urban slums to rural river communities.

Headquartered in New York City, Planned Parenthood Global currently supports partnerships in 10 countries — Costa Rica, Ecuador, Ethiopia, Guatemala, Kenya, Nicaragua, Nigeria, Peru, Sudan and South Sudan — and maintains regional offices in Miami and Nairobi, Kenya.  In Washington, Planned Parenthood Global monitors issues of U.S. foreign policy.

As part of the program launch, Planned Parenthood Global released Health Has No Borders, a brochure detailing global projects, partnerships and models.

For more information visit www.plannedparenthood.org/global 


actually it is not that global ;)

The San Jose Articles

New Expert Document: 

No Right To Abortion Under International Law

A new document launched today in New York clarifies once and for all that there is no right to abortion under current international law.

The so-called ‘San Jose Articles’ contains nine articles which summarise the position of internationally binding treaties and customary law regarding abortion, drawing the conclusion that a right to abortion does not exist. Sovereign states, therefore, have no international obligation whatsoever to provide their citizens with access to abortion.

This holds true even for the frequent claim that access to abortion should be provided for health, privacy, sexual autonomy or non-discrimination reasons.

Despite the absence of a ‘right to abortion’, what legal scholar Mary Ann Glendon calls “rights talk” surrounding abortion has become commonly used language in international institutions such as the UN and the EU. Such rhetoric has become the key instrument used by such institutions to pressure countries around the world into allowing abortion – often against their will.

As recently as a few weeks ago the UN Special Rapporteur on Health, the High Commissioner for Human Rights and the UN Secretary General have all said a right to abortion exists. And, according to Human Rights Watch the CEDAW Committee has directed 93 countries to change their laws on abortion.

The San Jose Articles strongly condemn such pressure tactics and reminds treaty-monitoring bodies, UN Agencies and non-governmental organizations that by asserting a ‘right to abortion’ they may be acting beyond their authority and contrary to their mandate.

The purpose of the San Jose Articles is to prepare politicians, diplomats and citizens around the world to counter such assertions and calls on any state encountering abortion rights pressure from UN bodies, EU officials and others to demand accountability from their respective institutional system.

Ambassador Grover Joseph Rees, former US Ambassador to East Timor, said, “When I was in Timor I witnessed first-hand a sustained effort by some international civil servants and representatives of foreign NGOs to bully a small developing country into repealing its pro-life laws. The problem is that people on the ground, even government officials, have little with which to refute the extravagant claim that abortion is an internationally recognized human right. The San Jose Articles are intended to help them fight back.”

The San Jose Articles were drafted by a group of human rights lawyers, legal scholars, public officials and international policy experts, including Professor Robert P. George and Ambassador Grover Rees, along with Professors Carter Snead and Paolo Carozza, both of Notre Dame Law School. Carozza is also a member of the Inter-American Court of Human Rights.

They were then negotiated and ratified by 30 experts in international law, public health and public policy from around the world. They include Lord David Alton of the British House of Lords, Lord Nicholas Windsor of the British Royal Family, Professor John Finnis of Oxford University, Carl Anderson (Supreme Knight of the Knights of Columbus, and Giuseppi Benagiano of the World Health Organization and the International Federation of Gynecology and Obstetrics (FIGO).

The San Jose Articles will be released today at 11 a.m. (local time) at UN headquarters in New York. The European launch will take place in a press conference during the October plenary session of the European Parliament in Strasbourg. Subsequent press conferences and panel discussions will take place throughout October in London, Madrid, Rome, Strasbourg, Buenos Aires, San Jose, Santiago, Calgary, Washington (DC) and Manila.

For more information, please visit: www.sanjosearticles.org.

Actually, did not understand what are these artickes and who are those all people