Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy (2007)

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Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy (2007)

  1. 1. ACKNOWLEDGMENTSThank you to all of the members of the Youth Coalition who helped in the writingand reviewing of this guide. The authors would also like to thank Emily Turk,Communications and Outreach Officer, for her help in the design and editing ofthis publication, and Laura Villa Torres for her valuable assistance. As well, alarge thank you goes to Ipas for their generous financial support of thepublication of this book.- Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy –A Publication of:The Youth CoalitionSuite 405, 260 Dalhousie StreetOttawa, OntarioK1N 7E4Tel +1 (613) 562-3522Fax +1 (613) 562-9502E-mail: admin@youthcoalition.orgWebsite: www.youthcoalition.orgCopyright © 2007 The Youth CoalitionThis publication may be reproduced in whole or in part for educational or non-profit purposes without special permission from the copyright holder, providedthat acknowledgment of the source is made. The Youth Coalition wouldappreciate a copy of any document that uses this publication as a source.No part of this publication may be used for commercial or resale purposes.The contents of this booklet solely represent the opinions of the authors and notnecessarily the views or policies of its financial contributors.
  2. 2. Freedom of ChoiceA Youth Activist’s Guide to Safe Abortion Advocacy By Pamela Pizarro, Tanya Baker, Joana Chagas, María Eugenia Miranda & Nadia Ribadeneira González
  3. 3. TABLE OF CONTENTSIntroduction 1Chapter 1Governing Abortion: Global Abortion Policies 3Chapter 2Access to Safe Abortion Care 14Chapter 3Abortion and Human Rights 28Chapter 4Mass Media, Abortion and Sexual and Reproductive Rights 44Conclusion 56Bibliography 58About the Authors 62
  4. 4. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyINTRODUCTIONThe Youth Coalition for Sexual and Reproductive Rights (YCSRR) is aninternational network of young people that works to increase access to, andquality of, sexual and reproductive health and the rights of adolescents andyoung people throughout the world. The Youth Coalition envisions a world wherethe diversities of all young people are respected and celebrated, and where theyare empowered and supported to fully and freely exercise their sexual andreproductive rights. Sexual and reproductive rights are human rights, andtherefore apply equally to young people. Young people have a valuablecontribution to make to society and must be given ample opportunities to voicetheir needs and opinions in all policy and decision-making processes in a waythat is respected and fully incorporated.The Youth Coalition also believes that all women, irrespective of age, have theright to access medically safe and legal abortion care. Unplanned and unwantedpregnancies are a common situation faced by women throughout the world.Many circumstances put women in situations where they have to make adecision regarding whether or not to continue their pregnancies. Ethical, legal,medical and social situations can influence a woman’s decision. However in theend, regardless of the legal or moral prohibitions, or the lack of economic orsocial resources, millions of women decide to electively terminate theirpregnancies even if it runs the risk of costing them their lives.Advocating for ChoiceFreedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy is a guidefor young people, individuals who work with young people, leaders, or advocatesfor any issue related to sexual and reproductive health and rights, who wouldlike to improve their information, knowledge and skills related to advocating forsafe abortion care services.This guide intends to: - Discuss the state of abortion legislation around the world, and how different restrictions affect access to abortion care for young women; - Give an overview of important human rights arguments that can be used when advocating for safe abortion care services; - Look at access to safe abortion care services around the world, as well as the impact of unsafe abortion; - Relate tips on how to deal with the media and the opposition; 1
  5. 5. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy - Demonstrate how to use the information contained in each chapter to advocate for safe abortion care services.The sexual and reproductive rights movement faces its biggest challenge when itcomes to abortion. In many countries, as we will review in Chapter 1, abortion isillegal, or is limited to specific circumstances. Yet, in other countries whereabortion has been decriminalized, access is not guaranteed by the state. Forthese reasons, the two main challenges when advocating for safe abortion are:1) liberalizing the legislation in those countries where abortion is restricted and2) guaranteeing access to comprehensive abortion care for all women. The taskis not easy, and we, as young people and as youth advocates, need to beprepared to take action in this area.Advocacy is a complex process that has the principal purpose of changingspecific situations affecting a specific group of society. Mapping the situation ofabortion in our own countries, reviewing international and local legislation in thefield, developing power maps, and building effective messages are just a few ofthe activities and skills we need to develop in order to have a clear and effectiveadvocacy process.By advocating for law reform and equal rights, pro-choice advocates are fightingto give women the opportunity to make autonomous choices and to exercisetheir sexual and reproductive rights.2
  6. 6. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy CHAPTER 1 Governing Abortion: Global Abortion Policies By Pamela Pizarro, CanadaIntroductionAround the world there are many laws and policies governing abortion. Most ofthese are meant to limit the circumstances under which a woman may accesssafe abortion care, and a few restrict access altogether by making abortioncompletely illegal. Abortion laws in different countries fall into seven generalcategories based on the conditions under which an abortion can be legallyprovided; sometimes these categories overlap (for example, a law may permitabortion to preserve physical and mental health and in cases of rape andincest):1. Completely illegal under any circumstance or only to save the life of the pregnant woman2. Preservation of a woman’s physical health3. Preservation of a woman’s mental health4. Pregnancy resulting from rape or incest5. Suspicion of foetal impairment6. Unwanted pregnancy for economic or social reasons7. Available on demand and without restriction1In some instances, abortion laws are decided at a regional (e.g., provincial orstate) or local level rather than a national one. For example, in Mexico, eachstate can determine its own abortion laws with its own restrictions, meaning thatwomen across the country do not have standardized access to abortion. In theUnited States, federal law guarantees a woman’s right to abortion, but somestates where legislatures do not support abortion impose restrictions (such asparental involvement requirements) or will not fund women’s clinics that offersafe abortion care.Currently, 40.5% of the world’s women live in countries where abortion isavailable without restriction2. This means that nearly half of the world’s womenlive in countries where they should theoretically be able to access safe abortionregardless of the reason behind their decision. In practice, however, access tosafe abortion is often complicated by obstacles such as: waiting times between1 United Nations Population Division, Department of Economic and Social Affairs, Abortion Policies – A Global Review, ExplanatoryNotes, 2001.2 Center For Reproductive Rights, The World’s Abortion Laws: Categories of Abortion Laws from Most to Least Restrictive,2005. 3
  7. 7. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyconsultation and abortion, having to go before a medical committee to explainwhy they want to have an abortion, requirements to undergo counselling beforehaving the procedure, and gestational limitations (weeks of pregnancy).Worldwide, 59.5% of women live in countries that restrict abortion on somegrounds, with a full 26% (of the nearly 60% who live with restrictions) of womenliving in countries where abortion is completely illegal or allowed only in order tosave a woman’s life3. Regrettably, even these statistics do not accurately reflectthe state of abortion access since many physicians refuse to perform abortionseven when there is grave danger to a woman’s life. Physicians may also refuseto provide care citing conscientious objection or fear of being legally prosecuted.Nearly every country in the world has abortion codified in some way under itslaws. This means that in every country some form of abortion can be: • illegal and a punishable criminal offence; • illegal but not a punishable criminal offence; or • legal under certain circumstances that are stipulated by the State as qualifying for safe abortion care.Abortion laws can not only stipulate punishments for women who have had aninduced abortion, but also for the health-care professionals who provide them,as well as for any other individuals who provide assistance (for example, thosewho help women locate or access abortion care). The legality of abortion, andthe circumstances under which it is a punishable offence, differ in each nation.For example, in a country like Nicaragua where abortion is illegal with noexceptions, safe abortions cannot be performed under any circumstances, evenif the life of the woman is in danger; in Indonesia, abortion is not allowed unlessit is to save a woman’s life. In contrast, Sweden’s laws allow abortion undermany circumstances, including risk of harm to the mental and/or physical healthof the woman, and socio-economic reasons.In some countries, abortion may either be illegal or legal only under certaincircumstances, but the procedure has been de-criminalized. For example, if awoman were to obtain an abortion under a circumstance that is not clearlydefined by law (for example, for socio-economic reasons in a country that doesnot have this exception), there is no legal punishment for her action or in otherwords she would not be sent to jail for her actions. Canada is the only countryin the world where no abortion legislation exists. In 1988, the Supreme Court ofCanada struck down the law that criminalized abortion, declaring the law to be3 Ibid.4
  8. 8. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyunconstitutional because it infringed upon a woman’s right to “life, liberty, andthe security of the person”.4The laws of many countries specify the process a woman must follow in order toobtain a legal abortion. This can include mandatory waiting times, parental orspousal consent laws, stipulations on who can perform the abortion, gestationallimitations, and whether or not the service is paid for by the state. In France, forexample, abortions are available under any circumstance. However, abortionsare only allowed up until 12 weeks’ gestation and only after a 7-day waitingperiod. Additionally, pre-abortion counselling is obligatory in France, but only forminors under 18, even though they do not need parental consent for abortions.5In Turkey, a married woman must obtain her husband’s authorization prior toobtaining an abortion; however, a single woman is not required to have herpartner’s consent.6For young women and youth, accessing abortion services is considerably morecomplicated. In many countries, even those with “liberal” abortion laws, thereare age restrictions, mandatory reporting to parents and the reluctance to takeyoung women’s requests for abortion seriously. Many women who becomepregnant at an early age are scared that if they visit a doctor or ask aboutabortion services, their parents will find out. This fear can cause young womento resort to unsafe abortions under unsanitary conditions and/or with unskilledpractitioners.This chapter will examine what types of abortion laws exist, and where youngpro-choice activists can advocate for change. The various laws and clausesexamined can highlight effective advocacy points for youth activists, with theultimate goal being to have abortion laws free from any restriction that impedesa woman in accessing safe abortion care.BackgroundRecently, there have been many articles from the medical and internationaldevelopment communities describing how illegal and unsafe abortions affectwomen’s health and longevity. By making abortion illegal, governments areendangering the lives of a significant portion of their population, not to mentionignoring the long-term effect of women’s death and disability from unsafeabortions on the population at large. In their 2006 “Sexual and Reproductive4 Canadians for Choice website, “Historical Background,” (Retrieved January 2006),http://www.canadiansforchoice.ca/historicalbackground.html.5 Pinter, B., et al., “Accessibility and Availability of Abortion in Six European Countries”, The European Journal of Contraception andReproductive Health Care (10.1: March 2005), 54.6 Ibid., 56. 5
  9. 9. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyHealth Series”, The Lancet medical journal described unsafe abortion as “thepreventable pandemic”.7 One article estimated that 19–20 million unsafeabortions take place every year, with 97% taking place in developing countries.8The authors also estimated that 68,000 women die every year from unsafeabortions (which translates into roughly 8 every hour), while many more areinjured during unsafe or illegal abortions.9 However, it should be pointed outthat illegal abortion does not automatically mean unsafe abortion. In somecountries, women who are in a position to pay more for the procedure can haveaccess to safe abortion care. It is largely women who cannot afford to pay forthe services that suffer the effects of unsafe illegal abortions.Many countries around the world have laws on abortion that date back tocolonial rule. Many nations that were colonized tend to maintain the coloniallaws that made abortion illegal. Today, most countries with liberal abortion lawsare in North America, Western and Eastern Europe, and parts of Asia. However,there are exceptions, such as South Africa, which has safe abortion availablewithout restriction, and Poland, which only allows abortion to preserve awoman’s physical health. In the latter case, women cannot even be sure thatthey can obtain such legal abortions. For example, Polish physicians refused togive one woman a legal abortion even though carrying her pregnancy to termworsened her deteriorating eyesight; she finally had to take her case to theEuropean Court of Human Rights to obtain compensation.10One of the most hazardous obstacles facing women today is restricted access tosafe abortion care. In many countries where abortion is free from numerouslegal restrictions, the lack of access prevents many women from obtaining safeabortions. In Canada, for example, there is no federal law against abortion andthere are no limits on terminations according to the gestational time of thefoetus; nevertheless, health care is managed provincially and many localgovernments restrict access to abortion by not funding these services inhospitals. Furthermore, in areas that are remote or rural, women often do nothave a choice about where to go for medical help. This means that if an anti-choice doctor is servicing the area, women could be intimidated into unwantedpregnancies or into having unsafe and clandestine abortions that could costthem their health or lives. The impediments to accessing abortion services andhow it affects young women will be covered in Chapter 2.7 Grimes, D., et al., “Unsafe abortion: the preventable pandemic.” The Lancet (Nov 2006), 1.8 Ibid.9 Ibid.10 Center for Reproductive Rights, “CENTER FOR REPRODUCTIVE RIGHTS APPLAUDS LANDMARK ABORTION DECISION BY EUROPEANCOURT OF HUMAN RIGHTS”, Press Release (March 20, 2007),http://cmiskp.echr.coe.int/tkp197/view.asp?action=html&documentId=814538&portal=hbkm&source=externalbydocnumber&table=F69A27FD8FB86142BF01C1166DEA398649.Federation for Women & Family Planning, Poland, Polish Repro news (2:21, March 20, 2007), http://Hwww.federa.org.plH.6
  10. 10. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyDefinitions of Restrictive LawsThe introduction of this chapter mentioned that abortion laws could be classifiedinto 7 – sometimes overlapping - general categories. Below we will examineeach one in detail.I. Completely Illegal or Only Allowed to Save a Woman’s LifeThroughout the world, the most common exception to laws that penalizeabortion is when an abortion is permitted to save a pregnant woman’s life. Somecountries may explicitly state what they consider to be life-threateningsituations, but in general it is left up to the physician(s) performing or approvingthe abortion to make that decision. The only countries that do not have anyexceptions to their abortion laws are: Chile, Malta, El Salvador, and mostrecently, Nicaragua.11 In the countries with this type of abortion law orrestriction, it is extremely difficult to obtain a safe abortion. Physicians are oftenunwilling to perform abortions even if it is medically necessary. This is also themost dangerous type of law as it forces women into unsafe situations. Incountries where induced or elective abortions are punishable by law, manywomen turn to unsafe methods to end their pregnancies. Because thesemethods are often performed by untrained individuals, oftentimes in unhygienicconditions or with unsafe instruments or drugs, or because women self-induceabortions, women who have undergone unsafe procedures frequently end upseeking emergency care in hospitals or other health facilities. Here they can bereported for inducing an abortion and can be reported to authorities. Thissituation obviously discourages women from seeking appropriate medicalattention and may lead to high numbers of maternal mortality or morbidity insome cases. However, in the case of Chile, although abortion is illegal, womenrarely die due to the complications of unsafe abortions because of the high levelof emergency medical care that they can access. Nevertheless, this is more of anexception than a rule.II. Preservation of a Woman’s Physical HealthThis indication for abortion permitted by law allows women to access safeabortion care when it is necessary to preserve their physical health. The term“physical health” is open to a variety of interpretations, with some countrieshaving narrow definitions and a list of conditions that they consider to fall underthis term, and other countries having no set definitions and thus allowing roomfor interpretation. In some countries, the term “health” is not specificallylimited to physical health and may encompass mental health as well; in thiscase, abortion is allowed for any threat or risk of injury to the pregnant woman’s11 Abortion Policies – A Global Review, op. cit. 7
  11. 11. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyoverall health. Although this exception to the term health is uncommon, it is aground on which many women have challenged abortion laws. 12III. Preservation of a Woman’s Mental HealthIn many countries, legal abortions may be obtained when pregnancy endangersa woman’s mental health. Definition of the term “mental health” varies fromcountry to country, with most British Commonwealth countries including:emotional distress caused to existing children, and/or emotional distress causedto the pregnant woman as a result of her situation. This allows for abortionsbased on socio-economic grounds. As well, many countries that permitabortions on the grounds of mental health follow the ruling of the British Courtsin Rex v. Bourne, which states that although a law may not specifically allowabortions for physical or mental health reasons, abortions performed for eitherreason are considered lawful.13IV. Unwanted Pregnancy Resulting from Rape or IncestThis indication for legal abortion allows women to obtain safe abortion care whenthey have suffered rape or incest. This indication for abortion permitted by law isvery common throughout the world; some countries name rape and incestspecifically in their laws, while others only mention “criminal offence” in the law,thus allowing abortions to be sought under other circumstances such asstatutory rape. However, some countries require that a woman first contact thepolice to bring charges against the rapist in court before they are grantedpermission for an abortion. This requirement is extremely detrimental anddiscourages many women from trying to obtain legal abortions. In other cases,authorities place the burden of proof of rape or incest on the woman, or take along time in filing the necessary documents, causing women to be unable toobtain abortions due to gestational time limitations.14V. Foetal ImpairmentSome countries allow women to obtain legal abortions if there are foetalimpairments. The term foetal impairment is open to interpretation and eachcountry has its own list of what constitutes such impairment. In general, foetalimpairment “refers to the existence of life-threatening or serious anatomicalsigns that will lead to either an impaired quality of life or at worst lethalanatomical malformations which renders the foetus unable to survive outside apregnant woman’s body.” 1512 Ibid.13 Ibid.14 Ibid.15 Wikipedia Online Encyclopedia, http://en.wikipedia.org/wiki/Foetal_impairment.8
  12. 12. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyVI. Economic or Social ReasonsLegal permission to terminate a pregnancy for economic or social reasons variesgreatly among countries that have this indication for abortion. Some countriesspecifically mention social or economic conditions that may qualify. For example,in Barbados, the abortion law specifies that in determining whether thecontinuation of the pregnancy would involve a risk of injury to the health of thewoman, the medical practitioner must take into account the “pregnant woman’ssocial and economic environment, whether actual or foreseeable.” In New SouthWales, Australia, reference is made to social or economic stresses. Othercountries, such as Burundi and Ethiopia, do not permit abortions on social and/oreconomic grounds, but allow the reason to be taken into consideration whensentencing a woman who has obtained an abortion illegally. In the case ofEthiopia, there was a review of the country’s criminal code in 2005, whichincluded a revision of its abortion legislation. In this revision there was inclusionof abortion permitted for minors who are physically or psychologicallyunprepared to raise a child.16 Most countries that have laws that take social andeconomic grounds into consideration allow for very liberal interpretations of thelaw, and in practice are very similar to countries where abortions are availableon request.17VII. Availability upon Request: Abortion Permitted on all GroundsCountries with laws that permit abortion upon request do not ask the woman toqualify her decision. In these countries, women must only find a physician that iswilling to perform the abortion. Some countries, such as Albania, France andBelgium, require the woman to state that she is in a situation of crisis ordistress. However, in many countries with the most liberal abortion laws,gestational time limits are imposed, often making abortion available only in thefirst trimester. After this time, a woman must present a “valid” reason forterminating her pregnancy.18 Even if a country has laws and policies that allowabortion under any circumstance, this does not mean that the government willtake the responsibility to ensure that safe abortion care is accessible oravailable. In other instances countries allow for regulations that restrict accessto abortion care by applying some of the conditions explored below.How Do These Restrictions Impact Youth?All of the situations described above are situations in which abortion is permittedby law. However, young and adolescent women may have more difficulties in16 Ipas website (Retrieved April 25, 2007), http://www.ipas.org/english/press_room/2005/releases/06072005.asp.17 Abortion Policies – A Global Review, op. cit.18 Ibid. 9
  13. 13. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyaccessing legal abortions because of added stipulations regarding consent,mandatory reporting to parents, cost and other restrictions.Consent LawsAbortion consent laws require that women be of a certain age in order to giveconsent to an abortion. Consent conditions, which vary from country to countryand even within regions of the same country, mean that women under 18 or 16are seen as unable to make an individual choice and must consult their parentsor guardians when seeking an abortion. As we will see in Chapter 3 on abortionand human rights, there are many international treaties that govern sexual andreproductive health. In terms of adolescents’ ability to make their own decisions,the United Nation’s Convention on the Rights of the Child addresses youngpeople under the age of 18, and it distinguishes that while parents have the rightto make decisions in regards to their children’s welfare, parental rights should bebalanced with the evolving decision-making capacities of the child.19 This meansthat although parents have rights over their children, their decisions should nottake precedence over the decision of a minor who is capable of making it.Therefore if a young woman has taken the decision to seek an abortion free fromcoercion, then her decision supersedes the wishes of her parents.Mandatory Reporting to ParentsIn keeping with consent laws, mandatory reporting to parents implies thatwomen under a certain age must fully inform their parents of their pregnancyand their decision to obtain an abortion. In some cases, parents must be presentwhen a young woman or adolescent obtains an abortion.Waiting PeriodsAlthough not specific to young women, some countries have mandatory waitingperiods from the moment a woman requests an abortion to the moment it isperformed. In some countries it can be 24 hours, while in others it can be aslong as 5 days or a full week. This waiting time is proposed as a way to give awoman time to think over her decision. However, in reality, it means thatwomen may have to travel more than once to access abortion services, andmust spend more time and money that they may not necessarily have. Womenwho live in rural areas generally have to travel to urban centres to find a health-care provider willing and/or able to perform the procedure. By imposing awaiting time, this may incur greater costs, and if they hope to undergo theabortion without having a partner or family know, it may raise the risk of19 Ahumada, C. and Kowalski-Morton, S., A Youth Activist’s Guide to Sexual and Reproductive Rights (2005), 11.10
  14. 14. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacydiscovery. Often, waiting periods are not necessarily about allowing a womanthe time to “think over” a decision, but rather to give her the chance to “repent”and change her mind, or to keep her from accessing services.20PaymentIn some countries, where abortion is legal, services are covered by the state.This is usually in the case of countries that have state sponsored health-caresystems. However, in many countries, government support for safe abortioncare, even if abortion is legal, is non-existent and women are required to coverthe cost of care themselves. Payment restrictions mean that poor women, oftenyoung or adolescent women with little personal income or economic means, areunable to pay for needed services. For example, it may be difficult for youngwomen, who are not covered by health care, to earn income and pay forabortion care while going to school or working in the home.Location and Lack of ProvidersMany countries also restrict who can perform an abortion and in which type offacility it can be performed. For example, in The Netherlands, generalpractitioners are able to perform safe abortions in separate clinics. In contrast,other countries specify that only doctors specifically trained in abortion care canperform the procedure, or that abortion services can only be obtained inhospitals or operating rooms. While health facilities must guarantee adequateand appropriate equipment and spaces, unnecessary facility requirements arealso sometimes imposed.ConclusionWomen around the world are faced with many barriers and restrictions whenthey try to access safe abortion care. In most cases these barriers are built intothe laws of a county. For young women, abortion laws often not only define theage at which they can access services but may also demand that they informtheir parents of their decision. Young people already have hindered access tosexual and reproductive health services, and when facing unwanted pregnancies,the restrictions imposed on women due to their age may make it impossible forthem to access safe services, even if abortion may be legal in their country.It is crucial that laws take into consideration that young women have thecapacity to make informed decisions. Two-tiered laws, which restrict access on20 Center for Reproductive Rights, Crafting an Abortion Law that Respects Women’s Rights: Issues to Consider, Briefing Paper (August2004). 11
  15. 15. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacythe basis of age, are specifically discriminatory to young women. Other, moregeneral restrictions tend to impede young women’s access to safe abortion care,because they face more economic barriers than older women.Abortion laws can make abortion illegal with specific exceptions, or legal undercertain circumstances. When a country criminalizes abortion, the need forwomen to access safe abortion care is not acknowledged. The need for abortionservices does not disappear once a country decides to make abortion totallyillegal. Instead, it places women in desperate situations where they may risktheir lives by undergoing unsafe abortions. Universal access to safe abortion careshould be a right enjoyed by all women, regardless of their age, ethnicity, orcircumstance. Advocacy Tips: What Can I Do? • Find out about the law concerning abortion in your country. For which indications is it illegal or legal? Are there any restrictions? If you feel that the law in your country impedes a young woman’s ability to access abortion services, start researching ways in which to influence a progressive change in the law. • Research a case in your country where a woman has been denied an abortion. Has she been denied her rights, even though abortion is legal in certain circumstances in your country? • Research a case in your country where a woman has successfully challenged the abortion law in order to obtain a safe abortion. How can you use this case to change the law? Can you use this case to start lobbying decision- and policy-makers for a change in the law? Find out if there are any groups working to challenge the abortion laws in your country and get involved! • Join an abortion advocacy group. Usually there are groups of women who are trying to mount a challenge to restrictive abortion laws. • One organization that supports the autonomy of women over their own bodies and supports women’s reproductive rights is Ipas. They can provide you with advocacy resources (documents, statistics) and information about the training of providers and advocates, etc. Similar organizations include the International Planned Parenthood Federation12
  16. 16. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy (IPPF), local family-planning clinics and associations, feminist groups, and the United Nations Population Fund (UNFPA) offices. To get more information you may want to consult the following websites: Ipas - http://www.ipas.org/ IPPF – http://ippf.org/ UNFPA - http://www.unfpa.org/ WHRnet - http://www.whrnet.org/• Contact your country’s Ministry of Health. Inform them that you think that unsafe abortion is a serious threat to women’s life and that it is a public-health concern that must be taken seriously.• Contact your local government representative. Tell him or her that you think that your government should do more for women’s reproductive rights and that they should take the initiative to legalize abortion or strip away any restrictions that impede access to safe abortion care.• If your country has progressive or liberal abortion laws, research how this change happened. See if this process of change can be used to change laws in other countries that restrict abortion.• Start your own reproductive rights group. Using this guide, invite other young people or youth allies to a discussion on abortion and talk about the myths and challenges surrounding abortion. Discuss the abortion laws in your country and how they are hurting or supporting women’s health. Find ways for your group to get involved in pro-choice and equality movements: you could attend workshops relevant to the issue, research and write fact sheets about regional obstacles or initiatives, start a consciousness-raising group, or broaden your mission and ask other organizations that work in the field of sexual and reproductive rights to join you in discussing crosscutting issues (such as LGBTQ, gender, and social violence issues). 13
  17. 17. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy CHAPTER 2 Access to Safe Abortion Care By Tanya Baker, Canada/Trinidad and TobagoIntroductionDecriminalization and legalization of safe induced abortion is an important aspectof abortion advocacy. However, often the legal status of abortion may meanlittle for protecting women’s health or supporting their human rights. In fact, thelegal environment does not necessarily affect the incidence of abortion, butrather how a woman will end an unwanted pregnancy or how safe the procedurewill be.21 Since abortion is a medical procedure, it is part of a country’s broaderhealth system, which may already have significant barriers for women who wantto access health services. In many countries where abortion laws are liberal,such as India, safe abortion services are still not readily accessible.22Safe abortion, which involves a trained and properly equipped health-careprovider under sanitary conditions, is one of the safest medical procedures.23The provision of safe abortion care (SAC) is an essential medical treatment forany health system, not only to induce an abortion when the law permits, butalso to treat complications from unsafe or spontaneous abortions. Spontaneousabortions, also known as miscarriages, are a common occurrence endingapproximately 15% of all pregnancies; induced abortions end roughly another22% of all pregnancies.24 In order to reduce the mortality rate of young womendue to unsafe abortion and improve their lives, health systems must be able toeffectively manage SAC, which comprises three elements:251. Safe induced abortion for all indications permitted by law2. Treatment of abortion-related complications3. Provision of post abortion contraception.Unsafe Abortion: An OverviewAbortion has been present throughout history, sometimes as the only means offertility control; accordingly, many providers and techniques have emerged over21 Rao, K. A. and Faundes, A., “Access to safe abortion within the limits of the law.” Best Practice & Research Clinical Obstetrics &Gynaecology (2006).22 Duggal, R. and Ramachandran, V., “The abortion assessment project-India: Key findings and recommendations”. ReproductiveHealth Matters, (2004).23 World Health Organization (WHO), Safe abortion: Technical and policy guidelines for health systems, 2003.24 Rogo, K., “Improving technologies to reduce abortion-related morbidity and mortality.” International Journal of Gynecology &Obstetrics (2004).25 Healy, J., et al., “Counting abortions so that abortion counts: Indicators for monitoring the availability and use of abortion careservices”, International Journal of Gynecology & Obstetrics (2006).14
  18. 18. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacythe years. The World Health Organization (WHO) defines unsafe abortion as “aprocedure for terminating an unintended pregnancy either by persons lackingthe necessary skills or in an environment lacking the minimal medical standards,or both”.26 The procedure is associated with high rates of poor health outcomes,including death, and a significant strain on over-burdened health systems.Unsafe abortion primarily imperils women in developing countries. Conversely,legal abortion in industrialized countries has minimal hazardous outcomes orcomplications, and almost no risk of death.27The statistics are disturbing28: • 19–20 million unsafe abortions take place annually all over the world. • About 68,000 women die every year due to unsafe abortion, representing 13% of all maternal deaths; many more are permanently injured. • Although rates according to age vary by region, generally young women, between 15 and 25 years, are disproportionately affected by unsafe abortion. • In many countries, 50% of the hospital obstetric/gynecological budget is allocated to the treatment of unsafe abortion. Figure 2.0 Global and regional estimates of number of unsafe abortions and of mortality due to unsafe abortion, around the year 20002926 World Health Organization (WHO), 207.27 Grimes, 204.28 World Health Organization, “Unsafe abortion: Global and regional estimates of incidence of unsafe abortion and associate mortalityin 2000”, (2004).29 Ibid. 8. Note: Figures may not exactly add up to totals because of rounding; * Japan, Australia and New Zealand have beenexcluded from the regional estimates, but are included in the total for developed countries; ° no estimates are shown for regionswhere the incidence is negligible. 15
  19. 19. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyIt is important to be familiar with some public health concepts, such as mortalityand morbidity, in order to understand the impact of unsafe abortion on women’shealth.I. MortalityA death due to an unsafe abortion is categorized as a maternal death. Maternaldeaths are recorded or deduced to give a number of deaths in a given area,using the term maternal mortality. The exact definition from the InternationalClassification of Diseases defines a maternal death as “the death of a womanwhile pregnant or within 42 days of termination of pregnancy, irrespective of theduration and site of the pregnancy, from any cause related to or aggravated bythe pregnancy or its management but not from accidental or incidentalcauses.”30Although this definition may be helpful for epidemiologists who monitor healthtrends and statistics, the 42-day mark is actually arbitrary and the associationswith using the term ‘maternal’ have far-reaching implications.31 In the socialsphere, maternal is associated with motherhood, not specifically pregnancy.Many women, especially young women, seeking a termination of pregnancy donot wish to be associated with the term or concept of motherhood at the time.Rather they choose not to be a mother, to be a mother at a later date, or to be ahealthier mother to her current children; in any case, they are women with theirown agency separate from being a mother. Furthermore, when deaths due tounsafe abortions are grouped within a broader category of maternal mortality,the underlying cause of the death is not readily apparent, making the social,legal and political implications easier to ignore. Consequently, we recommendusing the more scientifically accurate terms: • Death due to unsafe abortion • Unsafe abortion mortality • Pregnancy-related death • Pregnancy-related mortalityImproving maternal health by reducing maternal mortality is Goal 5 of theMillennium Development Goals, which were agreed upon by all UN (UnitedNations) Member State leaders in 2000.32 Reducing the number of unsafeabortions is inherent in this Goal; however, measuring abortion-related deaths isdifficult. In general, pregnancy-related mortality is difficult to measure due tolack of vital registration systems and many deaths occurring outside of hospitals.30 World Health Organization (1992), 208.31 World Health Organization, “Maternal mortality: The measurement challenge”, (2001), https://www.who.int/reproductive-health/publications/maternal_mortality_2000/challenge.html.32 United Nations Millennium Development Goals, www.un.org/millenniumgoals/goals.html.16
  20. 20. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyAbortion-related mortality is further undercounted due to its illegal andclandestine nature, which promotes powerful disincentives for reporting. Thus,decriminalizing abortion is an important step towards providing safe pre- andpostabortion care.II. MorbidityMorbidity is the term used to designate illness, side effects and poor healthoutcomes that do not lead to death but that can be life-long and much morecommon. The risk factors for unsafe abortion mortality and morbidity are thesame, associated with an unskilled provider or an unclean/unequippedenvironment. There are high rates of complications with unsafe abortions, withan estimated 20–50% of women undergoing unsafe abortions requiringhospitalization post procedure.33 The complications associated with unsafeabortion that can lead to long-term poor health include: • Uterine perforation and haemorrhage (profuse bleeding) • Anaemia (low iron); malaria or HIV infection can worsen the effects of the bleeding • Sepsis (infection throughout the whole body) • Peritonitis (infection of the uterus/abdomen) • Trauma (to vagina, cervix, uterus and abdominal organs).It is very difficult to determine the rates of unsafe abortion morbidity; however,while an estimated 68, 000 women die yearly from unsafe abortion, millionsmore are significantly, and oftentimes permanently, debilitated34. Thesecomplications must be treated in a health centre with trained personnel, whichcan take significant health system resources.Young women are at increased risk for developing complications. They tend toundergo an abortion later in pregnancy, for various reasons including lack offinances, social networks and support, information and understanding of thehealth implications; abortions done after the first trimester (12 weeks ofgestation) are considered more difficult and have higher rates of complications.In addition, young women tend to seek treatment for complications later, citingstigma and discrimination and lack of funds, transportation and understanding ofwhen to seek help. Accordingly, young women have unique needs with respectto unsafe abortion.33 Grimes, D.A.,et al., 204.34 Grimes, D.A., et al., 2. 17
  21. 21. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyYoung Women and Unsafe AbortionIt is important to understand the prevalent ages of women seeking unsafeabortions in order to target interventions and provide effective postabortioncare. The age distribution varies widely over regions. In Africa, almost 60% ofunsafe abortions are in women under the age of 25, while in Asia it is 30%.35Figure 2.1, a World Health Organization (WHO) graph, highlights the regionaldistribution, but generally unsafe abortion continues to be a young women’sissue. Figure 2.1 Per cent of all unsafe abortions, by age group36 Latin America and the 15 29 56 Caribbean Asia 8 22 70 15-19 20-24 25-49 Africa 26 33 41 Developing 14 26 60 countries 0% 20% 40% 60% 80% 100%The Public-Health PerspectiveIt is widely held that many women are dying and disabled due to an understoodand preventable cause - unsafe abortion. People working in public health analyzethe incidence, risks and causes of death and disability in a population with theprimary aim of preventing such an occurrence. However, it should be recognizedthat abortion will never be entirely prevented because contraceptives are not100% effective and sexual violence and coercion continue to exist; abortion willstill be necessary and provision of SAC should always be accessible.35 Shah, Iqbal and Elisabeth Åhman, "Age Patterns of Unsafe Abortion in Developing Country Regions", Reproductive Health Matters12, (No. 24, 2004), 206.36 World Health Organization website (Retrieved January 21, 2007), http://www.who.int/reproductive-health/unsafe_abortion/index.html.18
  22. 22. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyThe primary prevention strategy for unsafe abortion is to reduce the number ofunwanted pregnancies, primarily through the provision of legal, safe andaccessible abortion and the provision of contraception. Broader programs thataim at increasing knowledge and information, such as sexuality education orreducing sexual violence and coercion, also contribute to the primary preventionstrategy.Secondly, treatment of the complications that arise from an unsafe abortionmust be made available. This is included in the provision of SAC under the limitsof the law. Finally, those women who have long-term disabilities associated withunsafe abortion must be treated and cared for. Postabortion care services shouldalso include contraception counseling in order to prevent future unwantedpregnancies, especially in adolescents and young women. All three levels ofpublic health approaches are necessary to address some of the issues associatedwith unsafe abortion.Access to CareThere are 3 primary dimensions of access to health care: • Availability • Affordability • AcceptabilityThe following conditions are needed to ensure the availability of SAC for youngwomen:I. Health-care ProvidersHealth-care workers must be able to provide care to young women seeking SACin a non-judgmental, youth-friendly manner. Furthermore, they must be able todiagnose pregnancy and effectively determine the gestational age of the foetus,which informs them about the methods of abortion which can be safely used.Health-care providers should be trained in surgical and medical (pharmaceutical)methods for inducing an abortion, including treating or referring complicationsthat can arise, primarily haemorrhage and infection. Postabortion provision ofcontraception and counselling is an important component of SAC, which ideallywould be conducted by a peer counsellor or someone trained in the sensitivitiesof young women’s lives. Midlevel providers such as nurses and midwives havebeen shown to safely conduct first-trimester abortions (up to 12 weeks’gestation); however, second-trimester abortions require a specially trainedphysician.3737 WHO, 2003. 19
  23. 23. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyII. Equipped FacilitiesHealth-care facilities must meet sanitary standards and be sufficiently andsustainably equipped with necessary medical/surgical supplies (see Fig. 2.2 formethods of abortion): Figure 2.2 Methods of Abortion38Pharmaceuticals for medical abortion: • Mifepristone – an anti-progesterone agent. Progesterone is a hormone that is needed to keep a pregnancy viable; if mifepristone is used, the continuity of the pregnancy will be interrupted. • Misoprostol – a prostaglandin analogue, this enhances uterine contractions and helps expel the products of conception. This drug can also be used to treat excessive bleeding from the uterus (haemorrhage).38 WHO, Safe Abortion: Technical and Policy Guidance for Health Systems (2003).20
  24. 24. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyEquipment: • Vacuum aspiration - this involves evacuation of the contents of the uterus through a plastic or metal cannula attached to a vacuum source. It can be managed electrically (Electric Vacuum Aspiration - EVA) or manually (Manual Vacuum Aspiration- MVA). • Dilatation and evacuation (D&E) - this involves dilating the cervix with mechanical (laminara) or pharmacological agents (mainly misoprostol) and then using an electric vacuum aspirator and other instruments to evacuate the contents. Dilating the cervix adequately can require 2 hours to one day. This should only be used in the second trimester by a specially trained provider. • Dilatation and curettage (D&C) – this involves dilating the cervix and using a sharp metal curette to scrape the uterus. This carries significantly more risk of complications due to infection and haemorrhage than a vacuum aspirator and is no longer recommended in the first trimester.Postabortion care: • Antibiotics - used to treat bacterial infections, including some sexually transmitted infections. Routine use post-procedure is recommended; however, an abortion should not be denied if antibiotics are unavailable. • Contraceptives - used for post-abortion care, can include short- or long-term contraceptives.Pain management: • Pain management should be available but is not mandatory for early abortions. Options include oral painkillers and local anaesthetic (numbing) around the cervix. General anaesthesia (being put to sleep) is not generally recommended but can be considered under special circumstances such as an abortion following rape. Pain management also includes emotional and verbal support throughout and following the procedure.Other resources: • Ultrasound (optional) - this technology projects sound waves onto a computer screen to give a picture of the contents of the uterus. This is a helpful tool to determine the gestation of the pregnancy or whether all uterine contents have been effectively removed. 21
  25. 25. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy Ultrasound technology should be available in a centre that offers comprehensive SAC.It is recommended that there be a minimum of 5 facilities per population of500,000 that offer SAC, one of which can offer more comprehensive SAC (seetext boxes below).39 Functions of Basic SAC services Functions of Comprehensive SAC services Available during regular outpatient hours: Perform all basic SAC functions • Perform induced abortion for uterine size < 12 weeks for all legal Available during regular outpatient hours indications • Perform induced abortion for uterine • Provide postabortion contraception size > 12 weeks, for all legal indications Available 24h per day, 7 days per week • Administer essential antibiotics Available 24h per day, 7 days per week: • Administer intravenous replacement • Perform removal of retained products fluids for uterine size > 12 weeks • Administer oxytocics • Perform blood transfusion • Perform removal of retained products • Perform laparotomy for uterine size < 12 weeks • Provide postabortion contraceptionRoads and TransportationSince complications from an abortion can arise suddenly and constitute amedical emergency, the length of time required to reach a facility that providesSAC is crucial. Also, delays in accessing SAC can postpone procedures to a latergestation, increasing the risk of complications. UNICEF defines access to healthservices as the “percentage of the population that can reach appropriate localhealth services by the local means of transport in no more than one hour”.40Effectively distributing the centres that provide SAC and improving roads andtransportation will help improve access to services.Knowledge and InformationYoung women must be aware of when and how to access safe abortion serviceswhen needed; this includes an understanding of:• what an abortion is;39 Healy,J., et. al., “Counting abortions so that abortion counts: Indicators for monitoring the availability and use of abortion careservices”, International Journal of Gynecology & Obstetrics (95.2, November 2006), 200.40 UNICEF, 1996.22
  26. 26. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy• who conducts it;• when it is allowed under the law;• when is the safest time to obtain an abortion;• what are the indications to seek treatment from complications arising from an abortion;• where are the facilities that provide SAC located;• what are the times of operation;• what are the costs associated, etc.This information needs to be provided in a clear, comprehensible, friendlymanner that is readily distributed to, and accessible to young people.Health-care providers must also be aware of Symptoms that could indicatetheir national laws governing legal complications resulting fromindications for inducing an abortion and the unsafe abortions:consent laws pertaining to minors or • Bleeding that lasts longer than 2spouses. If parental involvement is required, weeksthey should inform young women about • Fever, chills, weakness, nausea,exceptions, such as judicial bypass vomiting, muscle aches • Tenderness when pressure isprocedures, and how these exceptions can applied to the abdomenbe obtained. Patients must be informed and • Abdominal painsupported to provide SAC to the full extent • Cramping, backachespermitted by law. • Prolonged or heavy bleeding • Foul-smelling discharge from the vaginaWhen young women want to undergo an • Delay in the return ofabortion outside the law there is little menstruation for more than 6information regarding the safety and weekstraining of illegal abortion providers.Furthermore, such services often cost a significant amount, and the youngwomen and provider may live in fear of being caught and penalized.Affordability of Safe Abortion CareCost of ServicesSAC costs money, which often requires the woman to pay for some or all of suchcare. Unsafe abortion is firmly rooted in deep social and economic inequalities.41In countries where abortion is severely restricted, wealthy women may still beable to pay for SAC while poor women may have to use an untrained providerand/or unhygienic conditions. Governments must be held accountable to their41 Gasman, N., et al., “Abortion, social inequity, and womens health: Obstetrician-gynecologists as agents of change”, InternationalJournal of Gynecology & Obstetrics (94.3, September 2006), 310-316. 23
  27. 27. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacycitizens for essential medical procedures such as SAC, and in efforts to reducematernal mortality and improve women’s health.Young women are even less likely to be able to afford safe abortion services dueto their restricted economic and social independence. Alternativepayment/financial schemes must be developed to ensure that costs for servicesor transportation to the health centre are not the leading barrier to accessingSAC. Social health insurance, community-based health insurance, donor-fundednon-governmental organization services and vouchers can all play a role inreducing barriers associated with cost.Commodities/SuppliesSAC requires a sustainable supply of medical commodities includingpharmaceuticals and equipment. In 2005, WHO added mifepristone andmisoprostol to the essential medicines list, which advises governments on whichdrugs doctors should have available. As a result, these medicines along withantibiotics, painkillers and contraceptives should be readily and cheaply availablewithin a national health system.Safe abortion equipment is also a necessity; the safest and most economical forall settings is the Manual Vacuum Aspirator (MVA). Some MVA equipment can besterilized and reused, depending on manufacturing and local regulations.Acceptability of Safe Abortion CareEven when SAC is available and affordable, young women still may not accesssuch services due to a perceived or real mistrust of the care provided42. SACmay not adequately address the underlying issues associated with the need toseek such care, including sexual violence, coercion or the need for sexual andreproductive health counselling. Some health-care providers discriminate againstunmarried sexually active young women, while others may not respect therequirement of privacy and confidentiality. Policies and training must alsoincorporate non-discriminatory, youth-friendly services as part of acomprehensive sexual and reproductive health package.Quality of care is also an important factor. Many health systems and health-careprofessionals are working beyond capacity, which diminishes the quality andconsequently, the acceptability of such care. More resources must be added tostrengthen health systems and increase the number of health-care providers. Inaddition, the training that medical providers receive is primarily focused onphysiology and treatments; there is little focus on the gendered and human42 World Bank, 2003.24
  28. 28. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyrights aspects of the care that they provide. Consequently, it can be moredifficult to build capacity on the social issues associated with abortion intraditional or rigid hierarchal institutions.Additionally, social and cultural norms can pose a barrier to acceptability ofreceiving SAC. More efforts should be made to discuss issues surroundingabortion with communities and governments.ConclusionImproving access to health services is difficult and complex with a number ofactors and a significant amount of resources required. The barriers to providingSAC to young women are further compounded by the controversies and socialstigma associated with such an issue. In many countries there are currently anumber of health-sector reforms that are reviewing how to improve andstrengthen health systems, where to allocate finite resources and which carepackages are considered essential. Accordingly, it is an important time toadvocate for the inclusion of comprehensive SAC into the health-sector reformsof your country. This can be done by teaming up with health-care professionals,health-care policy-makers, women’s health activists, community leaders andyoung people. Advocacy Tips: What Can I Do?These advocacy points, actions and messages are specifically designed to helpyou advocate to professionals, policy makers or activists in the areas outlinedbelow. However, in order to build stronger advocacy messages, it is an excellentidea to build partnerships with professionals or other advocates workingspecifically in these fields.► Health-care Professionals Work with local professional health associations such as the obstetrics/gynaecology association or midwifery association to advocate for: • Adequate training of health-care workers to provide SAC • Sustainable and dependable medications and equipment for the provision of SAC • Mifepristone and misoprostol should be included on the national essential medicines list 25
  29. 29. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy • Postabortion contraceptives should be readily available and offered • Further training of health-care workers providing SAC in providing non- judgmental, youth-friendly services, counselling and comprehensive care (including violence and STI prevention), gender and human rights • Expansion of health-care providers’ knowledge and understanding of the laws and policies regulating provision of SAC and limits of using the conscientious objection clause (which is not applicable when the women’s life is at risk) • Increase statistics and research on the incidence and complications related to unsafe and safe abortion, disaggregated by age • Have real stories of women on hand. It is important to put a face to the numbers. Develop qualitative research as a powerful advocacy tool.► Health-Sector Reformists Develop an understanding of the health-sector reforms that are taking place in your country; many of these reforms began in the 1990s with loans or grants from the World Bank. Further review of national health-sector reforms should include civil society consultation. Possible advocacy points include: • Include SAC as part of an essential service package for every country as a means to reduce women’s mortality and improve women’s health • Include SAC as an indicator for access to emergency obstetric care • Design affordable payment schemes for essential services, including contraceptives and SAC • Special attention should be given to marginalized groups, especially young women • Strengthen broader health systems to improve regulations and quality of provision of health care.► Health-Policy Makers Health-policy makers in governments, hospitals, or large organizations have the ability to make and change policies related to the provision of SAC. • Remove policies related to parental/spousal consent for a safe abortion • Remove mandatory waiting periods and conscientious objection clauses for the provision of a safe abortion • Promote comprehensive sexual and reproductive health care policies related to safe abortion services (i.e. referrals for counselling, STI testing, contraceptives).26
  30. 30. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy► Community Leaders Social and cultural stigmatization related to abortion is significant and must be addressed through dialogue within a community. • Engage community leaders, teachers and young people in a discussion about young women’s health and abortion • Highlight indications where abortion is permitted under law • Inform young women of locations where they can receive good quality SAC • Advocate for comprehensive sexuality education.► Legal Framework – Lobbyists/ Human Rights Lawyers • Have available legislation, guidelines, technical norms or/and regulations of any sexual and reproductive issue that highlight specific responsibilities of the health sector to caring for the sexual and reproductive health of women and young people, specifically related to abortion and postabortion care. • Analyze the political environment to see the possibility of legislation change; this need not involve complete decriminalization but might move towards incremental change or changing policies to allow for abortion in certain circumstances. 27
  31. 31. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy CHAPTER 3 Abortion and Human Rights By Joana Chagas, BrazilIntroductionToday, one of the biggest challenges facing the women’s rights agenda is gainingrecognition of abortion as women’s right. This chapter will focus on how thehuman rights language in international treaties and consensus documents can beinterpreted and used in advocacy for the recognition of women’s right toabortion. Furthermore, this chapter will introduce you to the main internationalhuman rights treaties and consensus documents and it will offer you aninterpretation of how specific human rights relate to women’s right to abortion.Although this chapter will only focus on human rights treaties and consensusdocuments adopted under the United Nations, it is worth mentioning thatregional human rights treaties and consensus documents have importantlanguage on human rights, sexual and reproductive rights and the right toabortion, and they sometimes have more progressive language than the UNdocuments.43Lastly, although much of the interpretation of how specific human rights relateto women’s right to abortion is derived from treaty monitoring bodies’ concludingand general recommendations/comments, it is not limited to them. Here you willfind a more progressive interpretation of rights, that is, how we would like to seesuch rights interpreted, rather than how they have been interpreted so far. Thisis what advocacy is for!The Right to Abortion is a Young Woman’s RightHuman rights advocacy means actively participating in decision-making spacesin order to influence policies and legislation so that they embrace human rights.Thus, it is fundamental that we know what ‘human rights’ means to us.Specifically, if we want to defend ‘abortion as a young woman’s right’, we needto have clear reasons, arguments and concepts.43 The Youth Coalition expects to expand this guide in the future to include regional systems for the protection of human rights. In themeantime, please check our website for updates: http://www.youthcoalition.org/.28
  32. 32. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyHuman rights are universal rights to which Some Basic Definitionsevery person is entitled, simply because theyare human. Women’s human rights mean Respect: States must refrain fromthat these same human rights also apply to violating human rightswomen and cannot be denied to them on thebasis of their sex. All human rights treaties Protect: States must prevent violations ofinclude the principle of non-discrimination human rights by third parties (individuals, corporations, etc)based on sex; the Universal Declaration ofHuman Rights (UDHR), for example, affirmed Promote: States must take action tothat “[e]veryone is entitled to all the rights realize human rights (policies, laws,and freedoms set forth in this Declaration, services, campaigns, etc)without distinction of any kind, such as race,colour, sex, language, religion, political or other opinion, national or social origin,property, birth or other status.”44 Similarly, both the International Covenant onCivil and Political Rights (ICCPR)45 and the International Covenant on Economic,Social and Cultural Rights (ICESCR)46 reaffirmed this principle.47 The equalitythat is formally recognized in legislation is called ‘formal equality’. However, thenon-discrimination-based-on-sex principle, despite its importance, has not beenable to prevent violations of women’s human rights.When we advocate for women’s human rights, we advocate for the recognition ofthe equality of women and men: that all the rights set forth in all human rightstreaties must be respected, protected and promoted without discrimination ofany kind, including discrimination based on sex. The term ‘of any kind’, can alsobe interpreted as including age-based discrimination, which is particularlyimportant for young people’s sexual and reproductive rights.Women’s rights, on the other hand, are rights that specifically pertain to humanbeings of the female sex who suffer discrimination due to the fact that they arefemale. So, when we advocate for women’s rights, we advocate for therecognition of the difference between women and men. Some examples ofwomen’s rights violations are harmful traditional or cultural practices such asfemale genital mutilation/cutting, child marriage, female infanticide, and violenceagainst women. Abortion is a women’s right, since pregnancies only take place inwomen’s bodies; it is therefore only women who have the right to choose tocontinue or interrupt a pregnancy.44 Universal Declarations on Human Rights (from now on, UDHR), article 2, http://www.unhchr.ch/udhr/.45 International Covenant on Civil and Political Rights (from now on, ICCPR), article 2, http://www.ohchr.org/english/law/ccpr.htm.46 International Covenant on Economic, Social and Cultural Rights (from now on, ICESCR), article 2,http://www.ohchr.org/english/law/cescr.htm.47 For a comprehensive account of how human rights instruments address equality and discrimination, see Charlesworth, H. andChinkin, C., The Boundaries of International Law: A Feminist Analysis (Manchester: Manchester University Press, 2000); and COOK R.(ed.), Human Rights of Women: National and International Perspectives (University of Pennsylvania Press, 1994). 29
  33. 33. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyLikewise, the right to abortion is a young woman’s right. All human rights mustbe respected, protected and promoted without discrimination of any kind,including that based on sex and age. Young women’s rights to safe legal abortionis of particular importance given that evidence shows young women representalmost half of the total number of women who go through unsafe abortionprocedures due to unwanted pregnancies (see data from the World HealthOrganization in Fig. 3.1). 48 Figure 3.1 Per cent of all unsafe abortions, by age group Latin America and the 15 29 56 Caribbean Asia 8 22 70 15-19 20-24 25-49 Africa 26 33 41 Developing 14 26 60 countries 0% 20% 40% 60% 80% 100%In addition, there are more obstacles for young women seeking safe abortionservices than for women of other ages (parental consent requirements, lack ofresources for private services, discrimination when accessing health services,lack of recognition as decision-makers over their own bodies, etc.). Laws thatrequire parental consent for an abortion procedure and non-accessible, non-affordable and non-youth-friendly health-care services constitute examples ofdiscrimination against young women.The History of Abortion in the Human Rights AgendaAt the UN – or international – level, abortion has not yet been explicitlyrecognized as a right.49 Nevertheless, the UN has recognized a set of human48 World Health Organization website (Retrieved January 21, 2007), http://www.who.int/reproductive-health/unsafe_abortion/index.html.49 At the regional level, however, more progressive language has been adopted. The Protocol to the African Charter on Human andPeoples’ Rights on the Rights of Women in Africa call on states to “take all appropriate measures”, to “protect the reproductive rights30
  34. 34. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyrights that can be interpreted to protect women’s right to abortion. Each of theserights will be analyzed in the last section of this chapter. Before that, let’s brieflysee how they came to be.Although some human rights principles can be traced back to ancient times, theunderstanding we have of them today dates back to the adoption of theUniversal Declaration of Human Rights (UDHR), in 1948. The UDHR emphasizesthat everyone, men and women, is equally entitled to the rights set forth in itstext, including: • right to life, liberty and security of person; • right to non-discrimination; • right to freedom of thought, conscience and religion; • right to seek, receive and impart information; • right to education; • right to health; • right to scientific advancement and its benefits; and • right not to be subjected to torture or to cruel, inhuman or degrading treatment or punishment.As a non-binding declaration, the UDHR does not have the weight ofinternational law and lacks a mechanism for enforcement. In order to make thehuman rights expressed in the UDHR binding and, therefore, enforceable, theUnited Nations Member States drafted two covenants. In 1966, the InternationalCovenant on Civil and Political Rights (ICCPR) and the International Covenant onEconomic, Social and Cultural Rights (ICESCR) were adopted, entering into forceten years later.Together, the UDHR, the ICCPR and the ICESCR and their protocols form theInternational Bill of Human Rights.50 Although these documents expressly affirmthe principle of non-discrimination based on sex, violations to women’s rights,and more specifically to young women’s rights, have continued to bewidespread. For this reason, in 1979 the United Nations General Assemblyadopted the Convention for the Elimination of All Forms of Discrimination AgainstWomen (CEDAW)51, which entered into force in 1981.52of women by authorizing medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers themental and physical health of the mother or the life of the mother or the foetus”, http://www1.umn.edu/humanrts/africa/protocol-women2003.html.50 International Bill of Human Rights, http://www.ohchr.org/english/about/publications/docs/fs2.htm.51 Convention on the Elimination of All Forms of Discrimination Against Women (from now on, CEDAW),http://www.un.org/womenwatch/daw/cedaw/cedaw.htm.52 For a short history of CEDAW, see http://www.un.org/womenwatch/daw/cedaw/history.htm. 31
  35. 35. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyAlso known as the Women’s Convention, CEDAW introduces the idea thatwomen, because of their sex,suffer specific forms ofdiscrimination and violence that Declarations are collective consensus statements onviolate their human rights. The principles that do not have the status of law. StatesConvention calls on States that sign them, however, express an intention toparties to modify or abolish honor their recommendations and these consensusdiscriminatory customs and statements can serve as sources of legalpractices carried out by interpretation for international law with the passage ofgovernment agencies, time.organizations, enterprises orindividuals; to revoke legislation Charters, Conventions, Covenants, Pacts,and penal codes that Protocols, or Treaties are all different names fordiscriminate against women; to international agreements that become legally bindingensure that women have access when States ratify them.to family planning educationand services; to decide thenumber and spacing of their children and to have access to the information andmeans to do so.In 1989, the General Assembly adopted the Convention on the Rights of theChild (CRC)53, recognizing various children’s rights, including the right to life; thefreedom to seek, receive and impart information of all kinds; the children’s rightto education; and the children’s right to the highest attainable standard ofhealth. This treaty entered into force in 1990.The ICCPR, IESCR, CEDAW and CRC are the most important international humanrights treaties that contain human rights provisions that can support youngwomen’s right to abortion. However, three other Conventions can also provideprotection under specific situations: the Convention for the Elimination of AllForms of Racial Discrimination (CERD)54, the Convention against Torture andOther Cruel, Inhuman or Degrading Treatment (CAT)55, and the InternationalConvention on the Protection of the Rights of All Migrant Workers and Membersof Their Families (ICRMW)56. The most recent international human rights treaty,the Convention on the Rights of Persons with Disabilities, is likely to enter intoforce in 2007; it, too, calls on States parties to “provide persons with disabilitieswith the same range, quality and standard of free or affordable health care and53 Convention on the Rights of the Child (from now on, CRC), http://www.unhchr.ch/html/menu3/b/k2crc.htm.54 Convention for the Elimination of All Forms of Racial Discrimination, http://www.ohchr.org/english/law/cerd.htm.55 Convention against Torture and Other Cruel, Inhuman or Degrading Treatment, http://www.ohchr.org/english/law/cat.htm.56 Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families,http://www.ohchr.org/english/law/cmw.htm.32
  36. 36. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyprogrammes as provided to other persons, including in the area of sexual andreproductive health and population-based public health programmes.”57The Covenants and Conventions are human rights treaties, that is, they have thevalue of international law, and countries that sign and ratify these documentsare bound to observe their provisions. But there are other documents thatidentify key issues and define strategies to be taken in order to advance humanrights. These consensus statements include plans, programmes or platforms foractions, which are the result of the negotiations and consensus-buildingprocesses during world conferences sponsored by the United Nations. Asmentioned before, these consensus statements are not legally binding, but theyimpose moral obligations on governments and provide guidelines for theinterpretation of already recognized human rights. The most importantconsensus statements regarding sexual and reproductive rights are:► The International Conference on Population and Development (ICPD)Programme of Action (PoA)58 was adopted in 1994 at a UN-sponsoredinternational meeting of States in Cairo, Egypt. The PoA defines reproductiverights as “Rest[ing] on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.”59Importantly, the document recognizes that reproductive rights are not just foradults, but that they are fundamental for the well being of adolescents andyouth as well.60 The ICPD PoA emphasizes that reproductive health servicesshould be designed to serve the needs of adolescent women61, safeguardingtheir right to privacy, confidentiality, respect and informed consent.62Furthermore, it affirms that in circumstances in which abortion is not against thelaw, such abortion should be safe and that in all cases, women should haveaccess to quality services for complications arising from abortion.6357 Convention on the Rights of Persons with Disabilities, article 25(a), http://www.ohchr.org/english/law/disabilities-convention.htm#II.58 International Conference on Population and Development (ICPD) Plan of Action, http://www.unfpa.org/icpd/icpd_poa.htm.59 Ibid., paragraph 7.360 Ahumada, C. and Kowalski-Morton, S., 2.61 ICPD, supra note 17, paragraph 7.7.62 Ibid., paragraph 7.45.63 Ibid., paragraph 8.25. 33
  37. 37. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacy► The Fourth World Conference on Women Platform for Action (PFA)64was adopted in 1995 at a UN-sponsored international meeting of States inBeijing, China. The PFA called on States to "consider reviewing laws containingpunitive measures against women who have undergone illegal abortions."65 Aswell, it demanded that States "understand and better address the determinantsand consequences of unsafe abortion."66► In 1999, when the United Nations General Assembly convened a specialsession to review and evaluate the implementation of the ICPD PoA, theyadopted the report ICPD +5: Key actions for the further implementation ofthe Programme of Action.67 This document called on States to “deal with thehealth impact of unsafe abortion as a major public-health concern and to reducethe recourse to abortion through expanded and improved family planningservices”68 and stated that “[c]ountries should ... remove legal, regulatory andsocial barriers to reproductive health information and care for adolescents69. Inaddition, it stated that States should “train and equip health-service providersand should take other measures to ensure that such abortion is safe andaccessible”,70 in circumstances where abortion is not against the law.► In 2000, a UN meeting entitled “Women 2000 – gender equality, developmentand peace for the twenty-first century”71 was convened to review and evaluatethe implementation of the Beijing Platform for Action. The political declarationand a consensus outcome document entitled Further actions and initiativesto implement the Beijing Declaration and Platform for Action (Beijing+5)72 reaffirmed the previous commitments to women’s sexual and reproductiverights.Abortion and Human Rights: Interpreting RightsAbortion has not yet been explicitly recognized as women’s right at the UnitedNations. However, as shown in the previous section, the international humanrights framework has developed a rich language of fundamental rights andfreedoms that can be interpreted to protect women’s right to abortion.64 Fourth World Conference on Women (FWCW) Platform for Action, http://www.un.org/womenwatch/daw/beijing/index.html.65 Ibid, paragraph 106(k).66 Ibid, paragraph 109(i).67 Key actions for the further implementation of the Programme of Action of the International Conference on Population andDevelopment, 8 November 1999, http://www.unfpa.org/icpd/icpd5.htm.68 Ibid, paragraph 63 (i).69 Ibid, paragraph 73(f).70 Ibid, paragraph 63(iii).71 To find out more about the Beijing+5 process, see http://www.un.org/womenwatch/daw/followup/beijing+5.htm.72 Further actions and initiatives to implement the Beijing Declaration and Platform for Action (Beijing +5),http://www.un.org/womenwatch/daw/followup/ress233e.pdf.34
  38. 38. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion AdvocacyMoreover, treaty-monitoring bodies (TMBs)73 – committees that oversee States-parties compliance with international human rights commitments – haveaddressed abortion in their recommendations to various governments. Thissection will give you some arguments that reflect and expand suchrecommendations.a) Right to life“Every human being has the inherent right to life. This right shall be protected by law. Noone shall be arbitrarily deprived of his [or her] life.” ICCPR, article 6(1)“States Parties recognize that every child has the inherent right to life.” CRC, article 6(1)• Forcing a woman to undergo a life-threatening pregnancy is a violation to her right to life;• Forcing a woman to undergo an unwanted pregnancy can severely affect her mental health; in cases where the pregnancy is a result of rape and/or incest, or when the foetus has a fatal abnormality, it may even drive her to suicide, constituting a violation to her right to life;• A lack of safe abortion care services may force a pregnant woman to seek unsafe procedures that may put her life under high risk;• Denying or delaying post-abortion care to a woman who presents with complications resulting from a miscarriage or an unsafe abortion violates her right to life;• The burden of child-bearing and -rearing can restrict a woman’s access to education, employment, and other opportunities for personal development, thus, violating her right to life, if we understand ‘life’ in an unrestrictive manner, as the ability of a person to have conditions to enjoy life (livelihood).The right to life is the claim most used by opposition against women’s right tochoose whether or not to have an abortion. There is a huge debate around theconcept of life and when it begins: from fertilization to conception to birth. Whilethe opposition argues that the foetus has a right to life, we argue that thewoman’s right to life takes precedence. A foetus cannot be considered a personand it cannot be more important than the life and rights of the woman.73 For more information on treaty monitoring bodies, see http://www.unhchr.ch/html/menu2/convmech.htm. 35
  39. 39. Freedom of Choice: A Youth Activist’s Guide to Safe Abortion Advocacyb) Right to liberty and security of person“Everyone has the right to liberty and security of person ... No one shall bedeprived of his liberty except on such grounds and in accordance with suchprocedure as are established by law.” ICCPR, article 9(1)• A woman is only free if she can control her own body;• Forcing a woman to undergo an unwanted pregnancy is a violation of her bodily integrity, that is, forcing her to experience something she does not want to experience;• Prohibitive legislation on abortion is a State’s arbitrary intrusion in a woman’s body and unnecessary to protect public health;• When a woman does not seek health-care services because she fears her confidentiality will not be respected, or she will be reported to parents, husband/partner, or the police, a violation of her right to liberty and security of person occurs;• Pressuring or forcing a woman to undergo an abortion (for example, because she is HIV-positive or of a certain ethnic/racial group) is a violation of her right to liberty.c) Right to privacy“No one shall be subjected to arbitrary or unlawful interference with his [or her]privacy, family, home or correspondence, nor to unlawful attacks on his [or her]honour and reputation.” ICCPR, article 17(1)“No child shall be subjected to arbitrary or unlawful interference with his or herprivacy.” CRC, article 16(1)• Decisions a woman makes about her body are private and individual and must not be subjected to interference or coercion from parents, husband/partner, or the State;• Policies and legislation that require parental or spousal authorization for abortion violates women’s right to privacy;• Policies and legislation that require health-care services providers to report abortion cases to law enforcement agencies violate women’s right to privacy and the doctors’ duty to observe physician-patient confidentiality;• A woman’s right to privacy entitles her to have access to confidential health services.36

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