1. Abortion internationally:
law and policy,
services, and
how
the abortion pill
is changing everything
Marge Berer
Editor, Reproductive Health Matters
International Campaign coordination team
~~~~~~~~~~
14 February 2014

2. Abortion: part of reproductive rights

The need to control fertility is as old as history itself,
and part of a much broader set of needs related to
reproduction and sexuality, including being able to:
 have sex without fear of negative outcomes,
 have sex if and only if we want to and only when
and with whom we want to,
 get pregnant,
 have the children we want,
 survive pregnancy in good health with a healthy
baby, and
 have a safe abortion without fear of death or
condemnation when pregnancy is unwanted.

3. One of the safest clinical procedures

Abortion deaths are less than 1‒4/5 per 100,000 live
births in North America, much of western Europe and
NZ/Australia.

It doesn't get any safer than that.

Making abortion safe was one of the most important
public health achievements of the 20th century.
(Wendy Savage, BMJ, 2014)

4. Abortion in the criminal law

With few exceptions, since the 19th century
restrictions on abortion have existed in the criminal
law or penal codes of most countries (in most cases
spread via colonialism: e.g. British 1861 Act, French
Napoleonic Code), covering at a minimum:
 the grounds on which an abortion is legal and/or
illegal,
 up to what stage of pregnancy,
 who can determine whether an abortion is legal,
 who can authorise an abortion, and
 the criminal punishments for violating the law.

5. Legal grounds for abortion

To save the woman’s life.

Risk to the life, health and mental health of the woman
greater than if the pregnancy were terminated.

Fetal condition incompatible with life or fetal
abnormality.

Rape, incest or other sexual abuse.

The woman’s social and economic situation and that
of her existing children.

At the woman’s request.
Although legal does not equal safe, the more grounds on
which abortion is legal, the fewer the complications and
deaths. (Berer, RHM 2004; WHO 2008)

6. Deaths/legal grounds 160 countries
(WHO in Berer 2004; updated World Health Report 2008)

7. Why different grounds?

Grounds create gatekeepers

Gatekeepers include:
 Providers (1-2-3 doctors)
 A hospital-appointed committee
 Partners
 Parents

Grounds create barriers

Grounds = control of women

Only real ground should be "unwanted pregnancy".

8. Abortion laws in Europe

Russia first to legalise abortion in 1920s, then all
Soviet Union bloc. Poland went backward 1990+.
 Most laws permit abortion on request up to 12-14
weeks LMP, and on more limited, specific grounds
after that, e.g. rape, fetal anomaly, risk to woman's
health/life. (Spain, Portugal, Italy, France, Germany,
Switzerland, Belgium, Netherlands, Norway, Denmark)
 In Belgium, the law changed long after the practice of
abortion stopped being underground. The king, who
was against abortion, abdicated his throne for 24 hours
so that the bill could pass into law without his signature
or his opposition.
 By early to mid-1980s, the law in most western
European countries had changed. Portugal in 2006.
 Only to save woman's life in Malta.

9. Progress globally since 1997

Since 1997, at least 17 countries have liberalised their
abortion laws, e.g. Guyana, St Lucia, Colombia,
Uruguay, and Mexico City.

At least 10 others increased access by speeding up
the approval of facilities (India); expanding the cadres
of providers (South Africa); expanding the range of
methods (Ethiopia) or re-interpreting law to make
more abortions legal (Thailand). (Boland & Katzive 2008)

A few countries, e.g. Nicaragua, El Salvador,
Dominican Republic, went backwards due to heavy
pressure from the Vatican/Church.

± Half of all abortions unsafe. 85% of unsafe abortions
in global South. 1990 = 69,000 deaths. 2008 = 47,000
deaths from 21.6 million unsafe abortions annually =
13% of total maternal deaths.

10. Trends

Trend is towards safe, legal abortion as gender
perspectives, increased girls’ education, work for
women, falling fertility rates, acceptance of “family
planning” in its full meaning and awareness of
women’s reproductive health needs and rights have
come into play.
 All but 5 countries globally permit abortion to save the
woman’s life. By 2007, abortion was permitted for
economic or social reasons in 78% of developed
countries and 19% of developing countries, and on
request in 67% of developed countries but only 15% of
developing countries (on request usually = in the first
trimester).
 The 5 countries do not permit abortion at all: Chile, El
Salvador, Nicaragua, Honduras, Dominican Republic.

11. The most liberal laws

In Sweden, abortion is on request up to 18 weeks of
pregnancy and with the permission of a hospital panel
after that.

In Cuba, abortion is legal as long as it is at the
request of the woman, provided within the health
regulations and not for profit.

In Canada, in 1989 the highest court removed
abortion from the law altogether. (Access a problem)

In 2008, abortion was decriminalised by the state of
Victoria, Australia, up to 24 weeks of pregnancy.
Therapeutic abortion after 24 weeks is also permitted.
Termination of pregnancy is now regulated like any
other medical procedure.

12. WHO-recommended abortion methods

First trimester





Manual vacuum aspiration
Electric vacuum aspiration
Mifepristone + misoprostol
Misoprostol alone
Second trimester
 Mifepristone + misoprostol
 Misoprostol alone
 Dilatation & evacuation (D&E)
D&E is main method for second trimester abortion in
USA but declining in Europe. Almost all 2nd trimester
abortions in Scandinavia are medical abortions (Sweden
too few late abortions to maintain D&E skills). Both are
safe and effective but big difference for woman/provider.

13. Public vs. private services

Almost all abortions in Spain are done in private
clinics.

In Portugal almost all abortions are done in the public
health services, including at primary level.

In Scotland most abortions are done in NHS clinics,
while in England and Wales, the majority of abortions
(about 60%) are carried out in Bpas and MSI clinics
but most are paid for by the NHS, while the rest are
still done in hospitals.

14. Abortion services in Europe: some history

Abortions services were set up soon after the laws
were changed in Europe, when D&C was common and
mostly before vacuum aspiration abortion or medical
abortion pills became available. Hence, abortions were
provided in hospitals by gynaecologists, often using
general anaesthetic and involving an overnight stay.

It has proved difficult in Britain to convince health
officials and doctors that with the advent of far safer
methods, first trimester abortions no longer need a
physician, a hospital or general anaesthetic.

Similarly, when medical abortion was first approved
(1990 in Britain), a lot more restrictions were placed on
its use than were necessary (e.g. women had to live no
more than 1 hour from the hospital).

15. WHO guidance 2012

Abortion services should be provided at the lowest
appropriate level of the health care system.

Vacuum aspiration up to 14 completed weeks of
pregnancy and medical abortion up to 9 (→ 10)
completed weeks of pregnancy LMP can be provided
at primary care level.

Mid-level health workers (e.g. nurses/midwives, GPs)
can be trained to provide both methods of abortion
without compromising safety.
(Safe Abortion: Technical and Policy Guidance for Health Systems,
WHO, 2012)

16. Medical abortion: changing practice

Medical abortion – popularly known as the abortion
pill – is changing abortion practice all over the world.

Where abortion is legal, use of medical abortion is
steadily increasing and abortions are becoming much
earlier in pregnancy.

Where abortion is legally restricted, clandestine
provision and self-medication with misoprostol have
become a common reality of first trimester abortion.

Growing number of pharmaceutical companies
producing the drugs (mifepristone: China, France, India,
USA, Viet Nam; misoprostol: 60 products), selling them
together or separately (patents expired; drug quality of
many uncertain).

17. Why is medical abortion so important?

It offers a choice of method in both first and second
trimesters, which is important for both women and
providers.

Early abortion encourages health systems to make
abortion a primary care service.

Medical abortion fundamentally alters the relationship
between women and abortion providers, because the
provider does not perform the abortion. Everything
happens in the woman's body. Medical abortion, in a
word, induces a miscarriage.

Medical abortion pills can put the means of abortion
into women’s hands. Don't forget that 100 years ago,
use of contraception was illegal too.

18. How does it work?


Mifepristone is an anti-progesterone and ends the
pregnancy by stopping production of progesterone.
Misoprostol is a prostaglandin and causes
contractions that expel the pregnancy.
******



You take mifepristone one day, and take misoprostol
bucally or vaginally 36-48 hours later.
You wait 3-5 hours on average in the first trimester
and 8 hours in the second trimester, after you take the
misoprostol, for the pregnancy to miscarry (though it
can take shorter or longer and a repeat dose(s) of
misoprostol may be needed.
You have a miscarriage.

19. Current roles of non-physicians


In the following countries, non-physicians play a
central if not complete role in providing first and
second trimester medical abortion and also doing
vacuum aspiration abortions:
 France
 Britain
 Sweden
 South Africa
 Viet Nam
 USA (some states)
Over-medicalisation does not provide protection, it
creates barriers, especially in countries with few
trained physicians outside large urban centres.

20. Expansion of global availability

Growing list of countries with mifepristone approval
(51 in 2012) and increasing proportion of medical
abortion usage in place of aspiration and surgical
methods.

National laws beginning to incorporate specifics of
medical abortion in laws/regulations.

Social marketing, web provision, telephone helplines,
manuals and information packages in many
languages.

Additional obstetric indications for these medications
being approved – such as misoprostol for prevention
and treatment of post-partum haemorrhage – helping
to make the pills more available.

21. The abortion pill in illegal settings

Medical abortion has been in the news a lot in the past
few years.
 That’s good, on one hand, because more women are
getting to hear about it. Although the method has been
around since the late 1980s, most women didn’t start
hearing about it until the last ten years or so.
 On the other hand, anti-abortion media are demonising
the abortion pill, e.g. Daily Mirror, 25 January 2014,
"Deadly abortion pills sold to desperate teenage girls
on internet for 78p".
 As it’s become more known, so has controversy begun
to brew around because it potentially puts the control
over fertility into women’s hands, as contraception
does.

22. Discovered on the grapevine



Women all over the world have discovered medical
abortion in the past 10-30 years, because the women’s
grapevine and the internet are more powerful than laws
prohibiting abortion.
Pills can be transported all sorts of ways, and clearly
that is happening. Newspapers in the Republic picked
up the story a few years ago of a Chinese woman in
Dublin who imported medical abortion pills from China
and was selling them over the counter in her
supermarket. She had to pay a €5,000 fine and €5,500
costs.
In almost every country in the world where abortion is
legally restricted‒ across Latin America, Asia and many
parts of Africa ‒ medical abortion pills are available in
pharmacies, drug shops, and markets.

23. Reducing deaths from unsafe abortion

The fact is, abortion pills, even taken by a woman on
her own, are reducing the number of serious
complications and deaths from unsafe abortion in
many countries. These pills do not kill women the way
invasive methods, such as putting a stick or a coat
hanger up your vagina into your uterus can do.

Two studies in Brazil found a reduction in deaths and
serious complications as early as the late 1980s.

Mifepristone and misoprostol were added to the
WHO Essential Medicines list in 2005 – and one of the
reasons was to reduce unnecessary deaths from
unsafe abortion. (Hans Hogerzeil, Director of Medicines Policy and
Standards, WHO, and Secretary of its Essential Medicines Committee in
2005)

24. Is self-medication dangerous? No.



Self-medication is far from ideal, but in a clandestine
situation, the choices are limited. For a start, only
misoprostol tends to be available on its own, and it is
not as effective (even with the right dose) as it is when
taken in combination with mifepristone.
Secondly, women and drug sellers may not know what
the correct dosage and procedure to follow are. While
overdosing is not considered to be dangerous, things
can go wrong.
What can go wrong is that the pills don't work at all, or
the abortion is incomplete and leaves some of products
of conception in the uterus, or bleeding doesn't stop
and becomes very heavy. In these cases women need
medical back-up. Most know and/or are advised to go
straight for help and are easily treated.

25. Risk reduction: Uruguay


Uruguay decided about six years ago that, as a form
of risk reduction, doctors would be allowed to advise
women to go to the pharmacy and get the right
number of pills, would give them information on how to
use the pills at home, and come to the hospital
afterwards for a check-up to ensure that the abortion
was complete. So ‒ everything except supply the pills.
Within six months unsafe abortion complications
began to disappear from the main maternity hospital in
the capital. On this evidence, the law was reformed to
allow first trimester abortion on request in Oct 2012.
In January 2014, the Minister of Health announced
that 5,000 legal abortions had been performed in the
course of the first year after the law was changed. No
maternal deaths due to unsafe abortion were recorded
in that period.

26. How we usually address illegal abortions

Since ICPD, supporters of safe abortion have
focused on abortions outside the law as being
unsafe and on preventing high rates of mortality and
morbidity from avoidable complications.

We call for women’s right to safe abortion and to
treatment of complications after unsafe abortion.

We also call for reform of the law, either to make
abortion legal (on more grounds) or decriminalise it.

We rarely focus on the active application of existing
criminal laws on abortion and whether and how they
are being applied to individual cases.

There have been only a few important exceptions to
this: e.g. the discovery of women in prison in Nepal
before and after the law was reformed 2002. (RHM)

27. International Campaign for Women’s Right
to Safe Abortion

Launched April 2012. Aims/objectives endorsed by
almost 400 organizations and 460 individuals in 106
countries globally. Aims to serve as an umbrella for
everyone campaigning for the right to safe abortion,
nationally, regionally and internationally. (ICMA)

In October 2013, we published a report on the
application of criminal law on abortion, based on
research and action by ± a dozen groups in the
Campaign, with information from 24 countries.

This report covers the use of the criminal law against
abortion, and its negative consequences for individual
women and providers.

28. Overall findings of the report

Many abortion providers are risking their professional
careers and even their lives to help women get safe
abortions in legally restricted settings.

Other health professionals, including those who treat
complications of unsafe abortions, are implicated in
reporting women to the justice system for punishment.

Women who have had unsafe abortions (young/poor)
have been subjected to degrading and humiliating
treatment and have had their civil, political and legal
rights violated by the police/courts in multiple ways.

One of the worst cases reported was a woman in
Mexico who had spent most of her adult life, 30 years
from when she was an adolescent, in prison.

29. Countries in the report

Argentina
 Bolivia
 Brazil
 El Salvador
 Mexico
 Nicaragua
 Peru

Kenya
 Malawi
 Nigeria
 Rwanda
 Senegal
 Algeria
 Morocco
***


Jamaica
Dominican Republic
***



USA
Canada
Australia
***

Nepal
***




Poland
Moldova
United Kingdom
Spain

30. Two recent RHM papers + Ipas videos

Chantal Umuhoza et al. Advocating for safe abortion in
Rwanda: how young people and the personal stories of
young women in prison brought about change. (RHM
2013;21(41):49–56)

Anibal Faúndes et al. Brazilians have different views on
when abortion should be legal, but most do not agree
with imprisoning women for abortion. (RHM
2013;21(42):165-173)

Ipas videos interviewing people in the street in three
Latin American countries:
 Are you for or against abortion?
 Do you know someone who has had an abortion?
 Do you think that person should be put in jail for having an
abortion?

31. Rwanda

32. Positive role of the justice system

There are of course many crucial ways in which the
law and the justice system, human rights bodies and
human rights law, are all supportive of women’s rights
in relation to abortion. For example:
 partial decriminalisation in Colombia in 2006 by the
Constitutional Court (RHM 2010;18(36):118-26);
 a ground-breaking CEDAW decision on the failure
of Peru to provide safe, legal abortion to a 13-yr-old
girl who had been raped (RHM 2012; 20(39):31-39).
 European Courts of Human Rights and of Justice
have ruled favourably in cases from Ireland and
Poland, for example, since the 1990s.

33. Everywhere you look,
abortion is in the news
http://safe-abortion-womens-right.tumblr.com

34. Spain
Pre-1985 law reform ‒ 20,000 women a year to Britain
for abortions. Women also went to midwives in
Portugal and in the south crossed to North Africa.
 Trial in 1981 ‒ 7 women, families and TBAs acquitted.
Led to law reform in 1985.
 Last year, Justice Minister threatened to return the law
to pre-1985 limits. It would mean 90% of women
having legal abortions would no longer be able to have
a legal abortion.
 86% of Spaniards consider this Bill an abuse of
women’s freedoms. 75% consider it unnecessary.
 Written Declaration signed by 107 Parliamentarians of
the Parliamentary Assembly of the Council of Europe,
opposing the law reform.
 Protests all over Europe.


35. El Nuevo Dia, 8 Feb 2014, Photo: Agencia EFE

36. Secret ballot

On 11th Feb, the Spanish parliament had a vote in a
secret ballot on the abortion bill, put forward by the
Socialist Parliamentary Group, asking the government
to withdraw the reform. MPs voted 183 to 151 against
the withdrawal.

On 12th Feb there was to be a new vote on a motion
put forward by the Left-Wing Parliamentary Group,
similar in content, but not by secret ballot.
(www.alianzaporlasolidaridad.org)

37. http://www.thejournal.ie/ireland-abortion-protest-spain, 13 Feb 2014

38. France

From 1975 until this year, the French law guaranteed
all pregnant women whose condition "puts them in a
situation of distress" the right to terminate a
pregnancy up to 12 weeks. The new law (Jan 2014)
states that a "woman has the right to choose whether
or not to continue her pregnancy" up to 12 weeks.
And more limited grounds after that.

Abortions, like contraception, will be paid for by the
French health system.

The law also punishes those who try to prevent a
woman from entering a place where she can receive
information on abortion.
(http://safe-abortion-womens-right.tumblr.com/search/France)

39. Switzerland

In Switzerland in a national referendum on Monday 10
Feb 2014, a 69.8% majority of voters rejected an antiabortion initiative aimed at cancelling the
reimbursement of the costs of abortion through public
health insurance.

People thus reaffirmed their vote of 2002, when 72%
voted to adopt new legislation granting women
abortion on request in the first 12 weeks of pregnancy
and for medical reasons later in pregnancy.

40. Catholic survey

A private poll of 12,000 Catholics in 12 countries
showed that 78% backed contraception, rising to more
than 90% in Argentina, Colombia, Brazil, Spain and
France, that 50% said priests should be able to marry,
51% favoured female priests and 65% said abortions
should be allowed — 8% in all cases, and 57% in
some cases, including when a woman’s life is at risk.

The decision to carry out the survey reflects Pope
Francis’s promise to listen to Catholics’ concerns, but
the Catholic Church in Luxembourg warned that
results from the survey were “alarming” and showed
that the importance given to Church teaching was in
“free fall.” (http://news.nationalpost.com/2014/02/09/popesglobal-survey-reveals-more-catholics-support-abortion-divorcethan-previously-thought/)

41. Information sources

World Health Organization. Safe Abortion: Technical
and Policy Guidance for Health Systems, 2012
 International Consortium for Medical Abortion
information package (7 languages) and websites
 International Campaign for Women's Right to Safe
Abortion (http://safe-abortion-womens-right.tumblr.com)
 Ipas
 Reproductive Health Matters ±160 articles on abortion
 Center for Reproductive Rights, USA
 Guttmacher Institute
 Global Doctors for Choice
 Women on Web