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ABORTION IN

This issue is co-published with the IPPF European Network

THE EUROPEAN MAGAZINE FORNo. 55SEXUAL - 2003 AND No. 59 - 2005 The European Magazine for Sexual and Reproductive Health CONTENTS Editorial Entre Nous is published by: By Fred Sai 3 Reproductive Health and Research Programme WHO Regional Office for Europe in Europe: Ten years after Cairo Scherfigsvej 8 By Gunta Lazdane 4 DK-2100 Copenhagen Ø The state of in Europe today Tel: (+45) 3917 1341 By Hillary Bracken and Beverly Winikoff 7 Fax: (+45) 3917 1850 E-mail: [email protected] Abortion safety challenged in www.euro.who.int/entrenous By Silvia Sjödahl 10

Chief editor Why IPPF has chosen abortion as one of the five “A”s Dr Gunta Lazdane By Jeffrey V. Lazarus 11 Editor Shifting focus to the : comprehensive abortion care in central Jeffrey V. Lazarus and eastern Europe Editorial assistant By Traci L. Baird, Sarbaga Falk and Entela Shehu 13 Dominique Gundelach Layout HIV-positive women and their right to choose To om bord, Denmark. www.toombord.dk By Marcel Vekemans and Upeka de Silva 17 Print Central tryk Hobro a/s Why do women still die of abortion in a country where abortion is legal? The case of the Russian Federation Entre Nous is funded by the By Evert Ketting 20 Population Fund (UNFPA), , with the assistance of the World Health Organization : Are the and practices patient centred? Regional Office for Europe, Copenhagen, By Christian Fiala 23 Denmark. It is published three times a year. Present distri- Sexual and reproductive health and rights in the bution figures stand at: 3,000 English, 2,000 By Mirjam Hägele 26 Spanish, 2,000 Portuguese, 1,000 Bulgarian, 1,000 Russian and 500 Hungarian. Abortion in Europe “” debate at the Entre Nous is produced in: By Patricia Hindmarsh 29 Bulgarian by the Ministry of Health in as a part of a UNFPA-funded project; Resources 30 Hungarian by the Department of Obstetrics and Gynaecology, University Medial School of Debrecen, PO Box 37, Debrecen, ; Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, P-1056 Lisbon, ; Russian by the WHO Information Centre for Health for the Central Asian Republics; Spanish by the Instituto de la Mujer, Ministerio de Trabajo y Asuntos Sociales, Almagro 36, ES-28010 Madrid, . The Portuguese and Spanish issues are distri- buted directly through UNFPA representatives Page 4Page 7 Page 16 Page 30 and WHO regional offices to Portuguese and Spanish speaking countries in and South America. Material from Entre Nous may be freely translat- ed into any national language and reprinted in journals, magazines and newspapers or placed on the Web provided due acknowledgement is made to Entre Nous, UNFPA and the WHO Cover illustration: © To ombord. Regional Office for Europe. Articles appearing in Entre Nous do not THE ENTRE NOUS EDITORIAL ADVISORY BOARD necessarily reflect the views of UNFPA Dr Assia Brandrup- Dr Evert Ketting Dr. Peer Sieben or WHO. Please address enquiries to the Lukanow School of Public and UNFPA Representative and Country authors of the signed articles. Director, Division for Health, Occupational Health Director, Education and Social Protection Utrecht,The Netherlands Ms Vicky Claeys For information on WHO-supported activities German Agency for Technical Co- Dr Malika Ladjali Regional Director and WHO documents, please contact the Family operation (GTZ) and Community Health unit at the address Senior Programme Specialist International given above. Mr Bjarne B. Christensen UNESCO/Headquarters, Federation, European Network Please order WHO publications directly from the Head of secretariat, Sex & Samfund, Ms Adriane Martin Hilber (IPPF-EN), Brussels the Danish Member Association of WHO sales agent in each country or from Technical Officer, Department of Dr Robert Thomson IPPF Marketing and Dissemination,WHO, Reproductive Health and Research, Adviser on Sexuality, Reproductive CH-1211, Geneva 27, Dr Helle Karro WHO Headquarters, Geneva Health & Advocacy, UNFPA Country Head, Department of Obstetrics and Technical Services Team for Europe, ISSN: 1014-8485 Ms Nell Rasmussen LLM Gynaecology, Medical Faculty, Director, PRO-Centret, Copenhagen Bratislava University of Tartu, Jeffrey V. Lazarus EDITORIAL Fred Sai : Europe is not spared Photo: Lazarus Jeffrey

The high expectations for The ICPD Programme of Action, agreed omitted any mention of sexual and on by 179 countries in 1994, begins with reproductive health and rights, and thus reproductive health, the following words: “The implementa- missed the great opportunity of giving including sexual health and tion of the recommendations contained reproductive health the priority it in the Programme of Action is the sover- deserves in development planning. It rights, generated by the eign right of each country consistent must be stressed that without ensuring with national laws and development pri- that women know and exercise their full consensus reached at the orities, with full respect for the various sexual and and have International Conference on religious and ethical values and cultural full access to the benefits of modern con- backgrounds of its people, and in confor- traception, they will never be equal or Population and mity with universally recognized interna- able to properly be in control of planning tional ”.Yet the refusal to their lives. Development (ICPD) apply and respect this statement is the Europe is not an exception. Even have not been realized, cause of much unnecessary argument, today, millions of individuals and and nowhere is this truer than with in this Region, particularly in the more and even the principles regard to contraception and deprived countries of central and eastern on which agreements were termination. Europe, do not have access to quality The right to religious freedom, provid- contraceptive services and supplies – a based on are being ed by many constitutions, is flagrantly situation akin to the majority of Africans. abused by some religious zealots who Moreover, emergency contraception is challenged by some impose their dogma and ideology on either completely banned or wrapped in governments and non-adherents, at times by misusing sci- controversy. entific evidence. The imposed exclusion In parts of the Region, the unmet religious groups. of hormonal contraception, including needs for contraception, coupled with a emergency contraception, and the disin- tradition that promoted abortion, has led genuous statements about the ineffective- to abortion rates that are the highest in ness of condoms are but a refusal to work the world. Since the quality of services is according to the fundamental principle often poor (e.g. the use of outdated drugs of the ICPD Programme of Action. Such and equipment and no updating of propaganda does not matter much to the providers’ skills), there is an unacceptable highly sophisticated, well-informed soci- rate of morbidity and mortality associat- eties of the advanced countries. But in ed with legal abortion. And even in the many countries in the world, where reli- European Union, some countries still gious doctrine may be what the poor and restrict or even ban abortion, especially disempowered live by, such misinforma- medical abortion, or employ complicated tion almost always amounts to a denial of requirements that discourage women the basic rights to correct information from obtaining an abortion, which fos- and access to the fruits of modern sci- ters illegal and unsafe abortion. It is esti- ence. mated that there are more than half a The United Nations system decided, million unsafe throughout wisely, not to hold another international Europe annually. This timely issue of conference on population and develop- Entre Nous, following on the heels of the ment to mark the tenth anniversary of new WHO guidance on safe abortion, the highly successful ICPD. It was obvi- addresses these important issues and will ous from the five-year review to assess be one more tool to help women in progress and subsequent regional reviews Europe and all over the world. that that there are forces that would use any opportunity to seek a rewording of 3 the agreed positions rather than a sober assessment of what has been achieved Fred Sai and what more needed to be done. [[email protected]] Partly through the efforts of the same Presidential Advisor on groups, the United Nations Millennium Reproductive Health and Development Goals, launched in 2000, HIV/AIDS,

This issue of Entre Nous has been specially funded by the International Planned Parenthood Federation European Network in order to address one of the most important problems facing women in Europe today.

No. 59 - 2005 ABORTION IN EUROPE:TEN YEARS AFTER CAIRO By Gunta Lazdane

UN Millennium Fig. 1 Grounds on which abortion is permitted – percentage of Development Goal No. 5: WHO Member States in Europe “Improve : reduce by three quarters On request 69 between 1990 and 2015 the Economic and social reasons 79 maternal mortality ratio” Fetal impairment 88

During the last ten years, many countries and 87 in Europe have developed and approved To preserve mental health 90 national reproductive health strategies, policies and/or programmatic documents To preserve physical health 90 including the component of reproductive choice and access to abortion services. To save a woman's life 96 This is in line with the Programme of 0 102030405060708090100 Action of the United Nations Interna- tional Conference on Population and Development (ICPD), signed by 179 countries in Cairo in 1994. Of the 52 Fig. 2 Abortions per 1000 live births in the European Region WHO Member States in the European Region, all except , which submit- ted a reservation, agreed that: “In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovern- mental and non-governmental organiza- tions are urged to strengthen their com- mitment to women’s health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning <= 1500 services. Prevention of unwanted preg- <= 1200 nancies must always be given the highest <= 900 priority and every attempt should be <= 600 given to eliminate the need for abortion. Source: WHO European health for all database, <= 300 no data Women who have unwanted pregnancies December 2004 should have ready access to reliable infor- mation and compassionate counselling. Any measures or changes related to abor- tion within the health system can only be Fig. 3 Abortions per 1000 live births, 1991-2002 in the European Region determined at the national or local level 1300 according to the national legislative CIS average (Commenwealth process. In circumstances where abortion 1200 of Independent States) is not against the , such abortion 1100 should be safe. In all cases, women should Europe have access to quality services for the 1000 EU-25 average, 25 Member State management of complications arising 900 4 from abortion. Post-abortion counselling, Cark average 800 (Central Asia and education and family-planning services ) should be offered promptly, which will 700

also help to avoid repeat abortion” (1). 600

500

400

300 Source: WHO European 200 health for all database, 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Jan 2005 Today, in most of the WHO Member abortions in the fell to During the meeting of WHO European States in Europe (except and 11.3 in 2002 and is one of the lowest in Regional Advisory Panel on Research and Malta), the law permits abortion in order Europe, in certain age groups. Training in Reproductive Health in 2003, to save the woman’s life. And abortion is However, the number of abortions in its members analysed the present situa- permitted in the majority of other coun- adolescents and young women remains tion of reproductive health in WHO tries for a number of reasons, shown high and has even been increasing during Members States and concluded that one below in Fig. 1. the last ten years in several countries in of the three priorities in reproductive The analysis of the incidence of eastern and . Eleven per health in the European Region is induced abortion is very important to cent of all abortions in are per- “decreasing perinatal and maternal mor- evaluate the trends and impact of nation- formed on adolescents aged 15 to 19. tality and morbidity (including that from al reproductive health policies and pro- Although the total number of abortions abortion)”. grammes. Data on the number of abor- has decreased in the Russian Federation tions per 1000 live births in the European by almost half during the last ten years, Region (Fig. 2) is freely available from there is still high number of abortions Box 1. Unsafe abortion WHO from the online European health among those 19 years of age and younger Unsafe abortion is defined as a pro- for all database (2). When analysing the (242 722 in 1993 and 185 290 in 2003). incidence of induced abortion, three cat- The percentage of late abortions in this cedure for terminating an unwant- egories of countries can be distinguished age group remains high and it was 15.9% ed pregnancy either by persons in Europe: in the age group 15-19 and 27.6% in 1) countries with a reliable induced those younger than 15 (including 11.2% lacking the necessary skills or in an abortion surveillance system (e.g. at 22-27 weeks of gestation) in 2001. environment lacking the minimal Estonia, , , the From 1991 to 2000 the total number of Netherlands and the Nordic coun- abortions in decreased by more medical standards or both (based tries); than half. However, the decrease of abor- on WHO, the Prevention and 2) countries which have planned such a tions in the age group 18-19 has been system but where it remains incom- much slower, only 5.4% from 1997 to Management of Unsafe Abortion plete (e.g. , Spain, , 2000. (WHO/MSM/92.5). and many of the countries of the According to national statistics in the Commonwealth of Independent , in 2000 the conception States); rate was 63 per 1,000 females aged 15 to 3) countries without a surveillance sys- 19, and the proportion of conceptions ter- tem (e.g. , , Luxemburg minated by abortion among under 20- The reduction of maternal mortality and Portugal). year-olds has slightly increased from 36 due to induced abortion to less than 5 per cent in 1990 to 39 per cent in 2000 (4). per 100 000 live births in ten years is one National statistics, as well as surveys of the quantitative targets of the WHO results, have revealed substantial declines Unsafe abortion Regional Sexual and Reproductive Health in the incidence of abortion in the coun- Despite abortion’s legality in most coun- Strategy (3). In several eastern European tries of central and eastern Europe, which tries in the Region, the estimated number countries, a high percentage of all mater- in turn has influenced the average inci- of unsafe abortions (see Box 1) in Europe nal mortality cases is related to abortion. dence in Europe (Fig.3). varies from 500,000 to 800,000 unsafe The Russian Federation reported that One of the objectives of the WHO abortions annually. According to several 18.5% of all maternal in 2002 Regional Strategy on Sexual and studies carried out in the Russian were related to abortion; 22.3% in Reproductive Health (3) is to reduce the Federation, the number of unreported Kazakhstan in 2003; 13% in in number of abortions by providing ade- abortions is much higher than that offi- 2002; and 6% in in 2003. Fifty quate reproductive health services, by cially registered (5,6) and adolescents, per cent of maternal cases in 2003 integrating family planning into primary young, unmarried women and women in in the Republic of Moldova were the health care policies and programmes and rural areas are those who seek unsafe result of unsafe abortion and from 1990 by removing legal obstacles to contracep- abortion (7). The reasons for the high till 2002, 30% of all maternal deaths were 5 tive choices. complication rates for illegal abortion related to abortion in this country. vary according to the different settings: However, good progress has been Select abortion rates shortage of family planning commodities achieved in , where maternal Several countries have reported a rapid or medications, women unfriendly mortality as a result of unsafe abortion decline in abortion rates since 1994: the providers or facilities, crowded facilities, was 35% in 1998, 23% in 2002 and not a Russian Federation went from 75.1 abor- poor hygienic conditions, lack of proper single case was registered in 2003. There tions per 1000 women of reproductive abortion training and inadequate stan- have been no deaths due to abortion in age in 1994 to 45.8 in 2002; the Republic dards of care. It has been ten years since the Baltic countries during recent years. of Moldova from 53.5 in 1994 to 15.5 in ICPD and women are still dying from 2003; the total number of legally induced abortion in Europe.

No. 59 - 2005 Morbidity after abortion the law. It is available in English, French, 4. National statistics online. Morbidity after abortion has been Polish, Portuguese, Russian and Spanish. http://www.statistics.gov.uk (accessed analysed in some eastern European coun- This safe abortion guidance has been 21 December 2004). tries. Unfortunately, there is a lack of distributed to all ministries of health in 5. Гридчик А.Л., Тамазян Г.В. good evidence and properly designed and Europe and leading international agen- Материнская смертность: carried out research. In the Reproductive cies, professional associations and non- социальная или медицинская Health Surveys performed with the tech- governmental organizations and is avail- проблема?/Вестник акуш.и гин. nical assistance of the Centers for Disease able online. However, to improve the 1998; №1 [Gridchik AL, Tamazyan Control and Prevention (USA), respon- reproductive health of the population, it GV.“Maternal mortality: social or dents were asked about the occurrence of is not enough to publish evidence-based, medical problem?”]. medical complications for abortion in up-to-date guidelines. Their subsequent 6. Концепция охраны the five years preceding a survey. Early implementation in countries is the cru- репродуктивного здоровья complications (within 6 months) ranged cial component to achieve success. WHO населения России на период 2000- from 8 to 16 per 100 procedures. Most has assisted those Member States which 2004 годов и план мероприятий по early complications in Romania, have included reproductive health as one ее реализации; М:2000 [Concept on and the Republic of Moldova involved of the health priorities in their countries reproductive health in for severe or prolonged bleeding; in the and shared the experience from Roma- 2000-2004 and plan of its implemen- Russian Federation – pelvic , nia, and other countries in tation]. and prolonged pelvic pain in . combining strategic assessments and the 7. Аскалонов А.А., Перфильева Г.Н., Among late complications, chronic pelvic development of national reproductive Евтушенко Н.В. Обеспечение pain, irregular bleeding and chronic health programmes (8). This approach to качества медицинской помощи infection were most frequently reported. improving reproductive health services, матери и ребенку (на региональном However, the high incidence of sexual- including those for abortion, is also being уровне.Барнаул,1998. [Askalonov AA, ly transmitted in many of these considered by Latvia, Lithuania, the Parfilyeva GN, Yevtushenko NV. countries, the lack of evaluation of the Republic of Moldova, the Russian “Ensuring the quality of medical care possible presence of infection and the Federation and Ukraine, among others. for mothers and children (at regional prevention of complications, are most Currently, the Russian Federation, with level)”,Barnaul, 1998]. probably the causes of the high numbers the assistance of the Reproductive Health 8. The Strategic Approach to Improving of complications after induced abortions. and Research Programme at the WHO Reproductive Health Policies and In many countries, out-of-date methods Regional Office for Europe, is developing Programmes: A summary of experi- with higher complication rate are still national guidelines and standards for the ences, Department of Reproductive used for the termination of pregnancy in termination of pregnancy. Health and Research, WHO, Geneva, the first and second trimester of gesta- More is to be done in Europe to reach 2002. tion. a stage where not a single woman dies or 9. Reproductive, Maternal and Child has major health implications from abor- Health in Eastern Europe and WHO assistance tion. Essential steps to protect women’s Eurasia: A Comparative Report; At the Special Session of the United health and to achieve common goals U.S.Department of Health and Nations General Assembly in 1999, on requires the joint forces of policy-makers, Human Services, CDC Atlanta (2003) the five-year follow-up of the Cairo con- professionals, non-governmental organi- ference, governments agreed that: zations and the community at large. “… in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure References that such abortion is safe and accessible. 1. Programme of Action of the Additional measures should be taken to International Conference on safeguard women’s health”. Population and Development, 1994, 6 For more than three decades, WHO http://www.unfpa.org/icpd/icpd_poa. has assisted governments, international htm (accessed 21 December 2004) agencies and non-governmental organi- 2. WHO Regional Office for Europe. zations to develop norms and standards, European health for all database, to plan and deliver services. In 2003, www.euro.who.int/HFADB. Gunta Lazdane WHO issued the publication Safe abor- 3. World Health Organization Regional [[email protected]] tion: Technical and policy guidance for Office for Europe (2002). “WHO Regional Adviser for Reproductive health systems, which provides a compre- Regional Strategy on Sexual and Health and Research, hensive overview of the many actions Reproductive Health”,available at: Family and Community Health Unit that can be taken to ensure access to high www.euro.who.int/reproductive- World Health Organization quality abortion services as permitted by health. Regional Office for Europe THE STATE OF MEDICAL ABORTION IN EUROPE TODAY By Hillary Bracken and Beverly Winikoff

ifepristone, also known as the prostol (400 mcg) administered orally or tion in another member state, then “abortion pill”,RU-486 or by gemeprost (1 mg) administered vaginally. authorization at a national level proceeds Mthe tradename Mifegyne in Standard practice in most centres on the basis of the first registration. In much of Europe, has been approved for requires that women remain at the facili- accordance with the principle of mutual use together with a for ty for three to four hours following recognition, was registered ending in 21 countries of the prostaglandin administration and return in 1999 following the French (country of European Region. 14 days after mifepristone for a follow-up initial registration) label and is approved The method offers women a safe and visit. Mifepristone is approved for early for use up to 49 days’ in effective alternative to surgical abortion. abortion up to 49 days from the onset of the following EU countries: Austria, However, despite widespread approval the last menstrual period in France and , Denmark, , , and over a decade of experience provid- most of the other European countries, Greece, , the Netherlands ing the method, women’s access to and but up to 63 days in the United Kingdom and Spain. Because the United Kingdom use of this technology remains limited in and Sweden. and Sweden had prior registrations, they many settings. Existing , reg- In and Sweden, use of med- were not included in the group registra- ulations concerning where, when and by ical abortion has become more wide- tion of other EU countries. The method whom abortions may be performed, spread and includes off-label variants of is also registered in Azerbaijan, Belarus, standard medical reimbursement and the regimen, perhaps because these two Georgia, Latvia, the Republic of Moldova, payment practices, and local abortion are the only countries with registrations , the Russian Federation, Switzer- politics have shaped provider and to 63 days, have had experience with the land and Ukraine under various labels, women’s access to the method. Indeed, an medication for well over a decade and are mostly very close to the EU mutual overview of medical abortion services in home to some of the pre-eminent med- recognition label of 1999. The product the Region shows very clearly, once again, ical abortion researchers. The most com- was never offered for registration in that though technology may have a mon variant for abortion up to 63 days Portugal or , where abortion is strong impact on society, the existing since the last menstrual period is the use very highly restricted, or in Italy, for social, political and economic structures of a reduced dose of 200 mg mifepristone other reasons. in each country are crucial in shaping followed by 800 mcg vaginal . While a centralized approval process how technologies are used and how This regimen has been recommended has facilitated registration in most mem- accessible they are to people. This article both by the World Health Organization ber states, the approval process and later provides some insights into the forces (WHO) and the Royal College of use have also been shaped by local poli- that have conditioned the experience of Obstetricians and Gynaecologists tics surrounding abortion. For example, medical abortion introduction and use in (RCOG) (3,4). in Germany a new distribution system a small selection of countries in Europe. In all three of the early registration was introduced to ensure greater control Mifepristone was created in France by countries, medical abortion is now used over the distribution of the drug: Mife- a group of scientists and managers at the in a substantial proportion of all termi- gyne is delivered directly to every single Roussel Uclaf pharmaceutical company nations in the first trimester, except in doctor by the national distributor, which in Paris. France, the United Kingdom and and . In 2002, more than is completely different from the distribu- Sweden were the first countries to regis- half of abortions within approved gesta- tion system in place for all other drugs. ter the drug. tional limits were performed using In Austria, the Minister of Health at the Mifepristone was approved for use in mifepristone: in France (56%), Scotland time of mifepristone approval restricted France in 1988, the United Kingdom in (61%) and Sweden (51%) (5). Even in the use of Mifegyne to hospitals, 1991 and Sweden in 1992. Since 1992, the countries where mifepristone was more although most abortions are performed compound has also been judged to be recently approved, use is increasing. In by providers in private practice rather safe and effective by drug regulatory bod- 2003, only four years after mifepristone than public hospitals. Consequently, ies in over thirty countries worldwide. approval, approximately 40-50% of early providers who perform abortions have Mifepristone and misoprostol have now abortions in Switzerland were performed no legal right to prescribe mifepristone been used for early abortion by millions using mifepristone (6). and providers with the right to distribute of women and such use has been associ- the drug do not perform abortions (7). ated with a very low rate of complica- Drug approval processes In central and eastern Europe and in 7 tions, comparable to rates for early surgi- The registration of mifepristone in the countries of the former , cal abortion (1-2). European Union member states has been the drug approval process has also been The standard protocol requires 600 mg facilitated by the principle of mutual informed by local abortion politics. Since of mifepristone (or three 200 mg pills) recognition. Since 1995, the European the end of World War II, women in most provided to women in a licensed medical Agency for the Evaluation of Medicinal of the former Soviet bloc have had easy facility. Two days after the administration Products in London can shepherd the access to abortion, which was paid by of the mifepristone, the woman must process of multiple registrations after a social security. With the striking excep- return to the clinic, where she is given a product has been registered in one EU tions of Poland and , liberal prostaglandin. The approved regimens member state. If the product does not abortion laws remain in place in most of specify the prostaglandin as either miso- come into conflict with national legisla- these countries and recognize a woman’s

No. 59 - 2005 right to abortion without restriction up that providers are using medical abortion abortions that are performed in a public to at least 12 weeks of pregnancy. Despite (9). Nonetheless, under such circum- versus a private facility. Not surprisingly, the legal commitment to abortion, how- stances, lack of proper training of med- the availability of abortion providers ever, access to abortion services has been ical personnel and inadequate informa- shapes where the method is used. In challenged in recent years. Concerns tion may inhibit the access of women to Spain, while mifepristone is approved for about declining birth rates and pressure the method and to good quality services. use in all public and private facilities, from local and international religious there are very few abortion providers in groups have reduced support for family Existing abortion regulations the public sector. Consequently, most planning and abortion (8). In most countries, the provision of med- medical abortions, like abortions services Some governments have successfully ical abortion is regulated according to the more generally, are only availability at opposed the approval of medical abor- laws and regulations governing the prac- private facilities, which may be costly to tion. While mifepristone was finally tice of surgical abortion. Such laws and the client. In contrast to the highly regu- approved in Latvia in 2002, the approved regulations govern both who can per- lated abortion services of Europe, some protocol made the method unattractive form an abortion and where the proce- countries outside of Europe have liberally for both providers and women: The label dure may take place. In some instances, interpreted requirements for the use of required that women remain in an countries also require mandatory coun- medical abortion and consequently have approved facility for the duration of the selling and waiting periods for women made medical abortion more accessible procedure or up to ten days, at which seeking medical abortion. As most of to women. point completion would be confirmed by these laws were written and implemented ultrasound. In Lithuania, drug approval prior to the advent of the technology of Reimbursement practices met with similar opposition from indi- medical abortion, some of the provisions Standard insurance reimbursement prac- viduals within the Ministry of Health make little sense for the elaboration of tices may also shape the way the method and the . In 2002, a com- medical abortion services and may create is offered to women. In France, the mittee commissioned by the Ministry of distortions in the ways such services can implementation of the 2001 abortion Health to review the registration deter- be developed and offered. As one exam- reform law, as mandated by a decree mined that mifepristone presented signif- ple, most European countries maintain issued in July 2004, requires that a icant risks to women’s health including regulations that require a physician with provider must offer medical abortion the potential to increase the national sui- certain specialty qualifications to pre- clients four patient consultations over the cide rate. Both countries entered the scribe mifepristone and misoprostol. course of three weeks: A woman must European Union in 2004, which may When medical abortion was approved come to the clinic one week before make drug approval more likely in for use in the United Kingdom in 1991, receiving the drugs as part of the manda- Lithuania and more acceptable in Latvia. hospitals were initially slow to adopt the tory reflection period. She then returns a The expansion of the number of phar- drug. Two systems reasons may have minimum of one week later to diagnose maceutical companies that market been important in causing this effect: and confirm the pregnancy and swallow mifepristone in other areas of the world First, because existing abortion regula- the mifepristone. Next, she is required to has facilitated the availability of medical tions required that every patient getting a return 36-48 hours later for the adminis- abortion in some eastern European medical abortion was to have a hospital tration of misoprostol. Finally, she must countries. According to Dr. Rodica bed, the waiting time after the prosta- return two weeks later for her follow-up Comendant, Director of the Association glandin exhausted extra hospital visit (10). French guidelines stipulate that Against Infectious Diseases in Obstetrics resources. Second, the entire financial each 600 mg is to be used in only one and Gynecology of the Republic of burden fell on the pharmacy budgets, abortion procedure. Consequently, there Moldova, Shell Pharma Company recent- and these were managed separately from is little financial incentive for providers ly registered the MTPILL, produced by the overall budgets for beds and operat- in the public sector to use a reduced dose the Indian company Cipla, for medical ing theatres. Since drugs were replacing regimen (5). The same may be true in abortion in the Moldova. In Ukraine, a surgery, their provision was a net burden other countries where governments cover Chinese company recently registered a on pharmacies, which received none of most of the cost of the procedure accord- new product including both mifepristone the benefits of the savings incurred by ing to the registered norms. 8 (Mifolian) and a misoprostol product fewer surgeries. Once the method could Insurance reimbursement rates may manufactured by the same company. The be offered in the public sector as an out- also discourage providers from adopting new product promises to expand access patient procedure and administered by a the method. In Germany, Femagen, the to the method as misoprostol is not reg- nurse (as long as a physician prescribed German distributor for the French com- istered in Ukraine and is only available the medication), these impediments were pany Exelgyn, was forced to stop distrib- via the black market. Indeed, fluid bor- less serious and use increased (5). ution of Mifegyne only one year after the ders have made the method available Many other countries also have specif- drug was introduced, because of low prior to approval, even in countries ic regulations regarding where an abor- sales. Distribution was immediately taken where abortion is not legal under a wide tion may be performed – whether in a over by another company in 2000 yet range of conditions. In Poland, where public hospital or private clinic that today, five years after the approval of abortion is provided in very limited cir- meets established standards. Countries mifepristone, only 9-10% of all abortions cumstances, anecdotal evidence suggests also vary widely as to the proportion of are carried out using mifepristone. The number of medical abortions has been lines has encouraged the use of a reduced Acknowledgements: We would like to increasing slowly, and the low demand dose of mifepristone among physicians - thank Rodica Comendant, Dr. Christian may be attributed in part to reimburse- particularly in the private sector. Fiala, Dr. Danielle Hassoun and Dr. Ines ment practices that do not compensate According to an informal survey con- Thonke and Dr. for their contributions providers equally for medical and surgi- ducted recently by Dr. Danielle Hassoun, to this article. cal procedures. Other factors that may providers are beginning to adopt this contribute to low uptake are a lack of reduced dose. Of 194 French obstetri- Hillary Bracken technical support and practice guidelines cians and gynaecologists surveyed, almost [[email protected]] from professional groups and low knowl- one half reported that they were using a Gynuity Health Projects edge of the method among counsellors reduced dose of either 400 mg (21 per and the general public (11). cent) or 200 mg (25 per cent) of mifepri- Beverly Winikoff In the countries of central and eastern stone (10). [[email protected]] Europe, where abortion has historically Indeed, providers in many European Gynuity Health Projects been available free of cost in the public countries have been hesitant to introduce sector, health sector reforms have result- home administration of misoprostol, a Gynuity Health Projects is a research and ed in changes in the cost of abortion ser- practice which has been shown to be safe technical assistance organization dedicat- vices for women. In the Russian and effective in published studies con- ed to the idea that all people should have Federation, abortions are free in govern- ducted in the , , access to the fruits of medical science and ment hospitals and while state insurance , and Sweden (12-14). technology development. Gynuity works covers surgical procedures at certain ges- Demonstration studies can offer globally to ensure that reproductive tational ages, medical abortion is not providers practical clinical experiences health technologies are widely available covered at all. with new protocols, provide useful data at a reasonable cost, provided in the con- to revise professional clinical guidelines text of high-quality services, and offered Clinical practice patterns and counter providers’ fears, which are in a way that recognizes the dignity and The use of medical abortion may also be largely unfounded, that their innovations autonomy of each individual. Our efforts shaped by norms in clinical practice such are illegal. To this end, in August 2004 the are focused particularly on resource-poor as off-label drug use. For example, in the British Pregnancy Advisory Services, a environments, underserved populations, Russian Federation, the need for off-label primary abortion provider in the United and challenging subject matter. For fur- use of misoprostol in the prescribed Kingdom, pressured for medical abortion ther information about out activities and mifepristone regimen has proven a barri- to be offered in an easier and more for downloadable documents, please see er to use of the method. Indeed, several acceptable manner, including, potentially, our website, www.gynuity.org. mifepristone products are currently avail- home use of misoprostol (15). able in the Russian market, including Mifegyne, a Russian product called Conclusion Penkraston, and, most recently, the Now that mifepristone is registered in Chinese drug Mifolian. Unlike in many many European countries and the drug is countries of the former Soviet Union, off-patent, either the availability of a new misoprostol is also available in Russia. generic product or the importation of Nevertheless, misoprostol is only regis- drugs from outside Europe, meeting tered for gastro-intestinal indications, European standards, could make medical and Russian providers are reluctant to abortion more accessible to women use it for off-label indications. As a result, throughout the Region. Nonetheless, the very few providers offer medical abor- history of medical abortion introduction tion. in Europe, as well as in most other coun- References On the other hand, clinical guidelines tries, underscores how access to a new offered by professional bodies may be a reproductive technology is shaped by 1. Hausknecht, R. “Mifepristone and powerful tool for shaping clinical prac- existing regulatory mechanisms, insur- misoprostol for early medical abor- tice. As mentioned previously, both ance reimbursement schemes and politics tion: 18 months experience in the 9 RCOG and WHO have published clinical surrounding reproductive rights. United States”. Contraception. 2003; guidelines for the use of mifepristone- Technology alone does not ensure greater 67: 463-465. misoprostol for early abortion (3,4).In reproductive choice for women. Indeed, 2. UK Multicentre Study--final results, France, clinical guidelines issued by the the current state of medical abortion in The efficacy and tolerance of mifepri- Agence Nationale d’Accreditation et Europe highlights the need for creative stone and prostaglandin in termina- d’Evaluation en Sante, a professional and sustainable strategies to ensure that tion of pregnancy of less than 63 days organization sponsored by the French the technology is available and accessible gestation. Contraception 1997 Ministry of Health, has recommended in practice and not just in theory. Jan;55(1):1-5. the use of a reduced dose of mifepristone 3. Royal College of Obstetricians and of 200 mg for use in medical abortion up Gynaecologists. The care of women to 49 days. The existence of these guide- requesting induced abortion. 2000

No. 59 - 2005 ABORTION SAFETY CHALLENGED IN SWEDEN By Silvia Sjödahl

March (www.nelh.nhs.uk/guidelines- Sweden has an established The Swedish Government has repeatedly db/html/front/InducedAbortion.html, made clear its intention to follow up on accessed 15 December 2004). tradition of playing a lead- sexual and reproductive health and rights 4. World Health Organization. Safe ing role with regard to issues with regard to the Millennium abortion: Technical and policy guid- Development Goals, asserting the notion ance for health systems. Geneva: issues of that the right of a woman to decide over World Health Organization; 2003. her own body is a precondition for their 5. Jones RK, Henshaw SK. both nationally and inter- achievement. In spite of this, challenges “Mifepristone for early medical abor- nationally. to legal abortion are still made in the tion: Some experiences in France, country, most recently at the parliamen- United Kingdom and Sweden”. tary level. Perspectives in Sexual and In the spring of 2004, a group of Reproductive Health 2002; 34: 154- Swedish parliamentarian, known as the 161. Forum for Family and Human Dignity, 6. Rey, A. Mifégyne (RU 486 / RU486) - hosted a seminar where Ms Wanda Franz la méthode médicamenteuse pour of the American National l'IVG. [Online]. [cited 2004 Committee spoke on the linkage between December 15]. Available from abortion and breast cancer, in spite of it http://www.svss-uspda.ch/fr/facts/ being scientifically unproven. One of her mifegyne.htm. main messages was that abortion should 7. Fiala, C. Personal communication. be opposed, even in cases of rape or 8. Center for Reproductive Rights. incest. As a reaction to this unusual posi- Women of the world: Laws and poli- tion in Sweden, a counter-seminar to dis- cies affecting their reproductive lives cuss this and abortion issues in general, (East and Central Europe). New York was organized by a women’s network (NY): Center for Reproductive within the Central Party. This seminar Rights, 2000. ultimately led to a meeting on abortion 9. Center for Reproductive Rights. hosted by the Swedish Association for Medical . [Online] Sexuality Education (RFSU) and involv- June 2003 [cited 2004 November 19]. ing representatives from all political par- Available from http://www.crlp.org/ ties, concerned ministries, researchers, ww_eu_polandmedab.html. NGOs and Sida (the Swedish 10. Hassoun D. Medical Abortion in International Development Agency). The France. Presentation at the American meeting provided a forum for discussions Public Health Association on the issue and strategies to be adopted Conference: 2004 Nov 9; , by different actors in their efforts to D.C. USA. increase access to safe abortion globally. 11. Thonke, I. Personal communication. 12. Elul B, Hajri S, Ngoc NN, et al. “Can For more information about this women in less developed countries meeting or other RFSU activities, includ- use a simplified medical abortion ing their recently published book Safe regimen?” Lancet 2001; 357: 1402-5. Abortion a Prerequisite for Safe 13. Schaff E, Eisinger S, Stadalius L, et al. Motherhood, please visit their website. “Low-dose mifepristone 200 mg and vaginal misoprostol for abortion”. Contraception 1999;59: 1-6. 14. Fiala C, Winikoff B, Helstrom L, 10 Hellborg M, Gemzell-Danielsson K. Acceptability of home-use of miso- prostol in medical abortion. Contraception. 2004 Nov;70(5):387- www.rfsu.se/rfsu_int/ 92. 15. British Pregnancy Advisory Service (BPAS). Early medical abortion. [Online] 2004 August 9 [Cited 2004 December 15]. Available from Silvia Sjödahl www.bpas.org. The Swedish Association for Sexuality Education (RFSU) WHY IPPF HAS CHOSEN ABORTION AS ONE OF THE FIVE “A”S By Jeffrey V. Lazarus

In its new Strategic taking up a rights perspective on abor- tion is that you can no longer be silent Framework 2005-2015, the on the need of women confronted with International Planned an unwanted pregnancy and their need for an abortion. The result is that you Parenthood Federation have to strive to make abortion accessible and affordable for all women. The full (IPPF) chose to set its priori- significance of the step from a health to a ties around five issues: ado- rights perspective becomes clear as we look at what happened at all internation- lescents, abortion, AIDS, al conferences since the ICPD [International Conference on Population access and advocacy. As and Development] in Cairo, in 1994. these issues all start with Since then, the opposition has successful- Carine Vrancken: Giving an answer to ly blocked all language in consensus doc- the letter “A”, they are this question is difficult, not because it is uments on women’s right to access safe referred to as the “five A’s”. difficult to find the reasons why, but abortion. It is not a surprise that at inter- because it is so self-evident for IPPF to national forums, abortion is mainly dis- Entre Nous interviewed set abortion as a priority. How could cussed in the context of reducing the IPPF, a human rights organization work- impact of unsafe abortions on women’s Carine Vrancken, the presi- ing in the field of sexual and reproduc- health rather than as a rights issue. dent of the IPPF European tive health and rights [SRHR], not take In IPPF we often quote the words of up the challenge to strive for the right of one of the founders, the Swede Elise Network and a member of every woman to have access to abortion? Ottesen Jensen, who was the one who Would it not be hypocritical to fight for said to be “be brave and angry”.After the Governing Council of accessible and affordable contraception, more than 50 years [IPPF was founded in IPPF, to hear why abortion but be silent about the needs of women 1952] these words are still relevant. I who are confronted with an unwanted refer to the relationship between being was chosen as a priority pregnancy? angry and at a certain point in time the need to act. Being angry because of the area, given both the contro- There has been much political taboo sur- fact that millions of women are denied versy around it and the loss rounding the abortion issue. How does the right to have access to safe abortions IPPF deal with this? is one step. An inevitable second step of funding from the US gov- CV: The taboo around abortion was should be that we “act bravely” to make ernment to IPPF. for a long time only broken by referring abortion accessible and affordable for all to abortion as a health risk for women. women. When you look at the issue from a health perspective the emphasis lies on the con- One of George Bush’s first acts as the new sequences of unsafe abortion. The conse- president of the US in 2001 was the rein- quence of this perspective is that you statement of the City Policy, also only see the “problem side” of abortion. known as “the Global Gag Rule”. This poli- When you look at abortion from a rights cy states that foreign NGOs receiving US perspective it is easier to see the ‘solution international family planning funds may side’ of abortion. The consequence of not use these funds and on top of that may

IPPF Mission Statement 11 As the largest voluntary organization in the field of sexual “To advance the basic human right of all people to make and reproductive health and rights, the International free and informed choices in their sexual and reproductive Planned Parenthood Federation (IPPF) helps improve the lives; and to fight for the accessibility to high quality infor- lives and well-being of hundreds of millions of individuals mation, education and health services regarding sexuality around the world.The IPPF European Network is one of and sexual identities, conception, contraception, safe abor- IPPF’s six regions.With 39 member associations in as many tion, sexually transmitted infection and HIV/AIDS.” countries, the Network increases support for and access to sexual and reproductive health services and rights through- out Europe and central Asia. not use their own funds to offer informa- IPPF argues that by using contraception, are examples of liberal abortion laws in tion about abortion, to perform abortions, abortion rates will fall as a result of fewer former communist countries that have to lobby their own governments to advo- unwanted pregnancies. But this does not gradually been restricted due to pressure cate for legal abortion or to provide infor- always seem to be the case, even in your from conservative groups. An extreme mation about the availability of abortion. home country of Belgium. Why is that? example is Poland, where abortion is How has IPPF reacted to this? CV: To answer this question we have to only available up to 12 weeks of pregnan- CV: When IPPF is attacked these days take into account the . cy in case of rape, if a woman’s life is at by anti-choice groups it is because of its The availability and use of contraception risk, or if there is a serious foetal malfor- stance on abortion, because it refuses to often goes hand in hand with a wish to mation. The reality is that even women be “gagged” when it comes to abortion. It have fewer children. The joint influence pregnant after rape rarely get an abortion would be much easier, financially, for an of increasing contraception use and because of unclear and complicated pro- organization like ours to be silent about decreasing TFR shows that the number of cedures. the issue of abortion, but when we really unwanted pregnancies increases instead For decades, the Netherlands was con- want to live up to the legacy of our of decreases under such circumstances. sidered the example of how things should founders, we have to take it on. IPPF has be done in the field of sexual and repro- to fight for a woman’s right to have Europe is usually considered the region of ductive health and rights: contraceptives access to abortion because it gives the world with the lowest and most liberal were free; prevention was high; they women the ability to make responsible abortion laws. Yet there are clearly differ- offered high-quality abortion services for decisions about when they consider it ences between countries. How does IPPF free and on top of that they had one of appropriate and sensible to have children. view the situation and what are you doing the lowest abortion rates in the world. And if this means losing part of our with regard to those countries where abor- But since the new government took funding, that is very sad, but we cannot tion is still illegal? office, it is not what it used to be: contra- ignore human rights for financial gain. CV: In the countries of the member ceptives are no longer for free (except for associations of the IPPF European girls under 21), the family planning ser- Opponents of abortion claim that it is Network, the abortion rates range from vices of the Rutgersstichting are no unnatural and “anti-life”. the lowest in the world to some of the longer subsidized and an evaluation of CV: Everybody knows that as long as highest. Generally speaking, the countries the current abortion law is planned. there will be men and women, these men with the lowest rates are countries in and women are going to have sex. When western Europe (e.g. Belgium has 111 What do you think the future holds? you don’t want to accept this fact, you abortions per 1000 live births; France CV: I’d like to conclude with a quote refuse to accept human nature. We also 263:1000). Countries in eastern Europe from Ann Furedi, the chief executive of know that the result of sex can be a preg- can have abortion rates that are ten times bpas, the leading abortion care provider nancy. Some of these pregnancies are higher (e.g. Russia 1416:1000 and in the United Kingdom: “The right to welcomed with indescribable happiness, Romania 1156:1000). But even in western abortion is a political issue. A woman’s others are an unbelievable nightmare. In Europe, where abortion is often available ability to control her fertility shapes her all times men and women have sought upon request (up to 12 weeks of preg- whole life. allows us to after methods, safe and unsafe, to termi- nancy), there are still countries with enjoy sex and participate in public life. nate unwanted pregnancies. The simple extremely restrictive abortion laws (e.g. Without it, the choice is between celibacy reason for this search was usually that Portugal, Ireland, Poland and Malta), and the constant risk of maternity. To they thought it would be irresponsible to resulting in women having to take the deny a woman the right to abortion is to have children they couldn’t take care of risk of an unsafe abortion or having to limit her human potential, which is why properly. This reality means that IPPF travel to another country to have a safe the right to abortion was one of the first cannot ignore the issue of abortion. It abortion. This practice is often called demands of women’s liberation. But the would even be an unethical stance to do “abortion tourism”,and is a sad reality individual choice of abortion is pro- so. But even apart from this ethical per- for far too many women in Europe, in foundly personal. A woman does not spective, there are figures you can’t addition to discriminating those with exercise her right to abortion like she ignore. I don’t know how many times fewer financial resources. exercises her right to vote. For a woman, 12 they have been mentioned, but they can But even in countries with women- abortion is the considered answer to her never be repeated enough: of all preg- friendly abortion laws, the defenders of personal, private problem; it is not a nancies 22%, or about 46 million, end in sexual and reproductive health and rights demonstration of her views or beliefs.” an induced abortion. Twenty million of have to be watchful because abortion When we really believe in sexual and these abortions are performed under laws and access to affordable abortion are reproductive health and rights, we should unsafe conditions and about 68 000 under attack. One subtle way is the never forget that abortion is not a prob- women die every year from the conse- increasing number of doctors and other lem; abortion is a solution for women quences. For me these figures are a good providers refusing to perform abortion who face an unwanted pregnancy. enough reason for IPPF to set abortion as on the grounds of conscientious objec- one of its priorities. tion, while at the same time they refuse to refer women to other providers. There Shifting focus to the woman: COMPREHENSIVE ABORTION CARE IN CENTRAL AND EASTERN EUROPE By Traci L. Baird, Sarbaga Falk and Entela Shehu

Among its many accom- Addressing needs: woman-centred opportunity to make choices about their comprehensive abortion care bodies and health without interference plishments related to repro- Fortunately, these problems are not with- from others. With regard to pregnancy ductive health and rights, out solutions, and the CEE region offers and abortion, this includes the right to numerous excellent examples of innova- determine whether and when to become the International tion in abortion care. A key strategy pur- pregnant, to continue or terminate a sued by Ipas, in partnership with a num- pregnancy, and to select among available Conference on Population ber of regional organizations, is the contraceptives, abortion methods, and Development (ICPD) introduction of woman-centred, compre- providers and facilities. hensive abortion care (4). This model The “access” element emphasizes the was notable for calling approach to providing abortion services importance of abortion services being takes into account various factors that available and accessible to women who attention to the need for influence a woman’s individual physical need them. In virtually every country, concerted action to address and mental health needs—including her women with money and connections can personal circumstances and her ability to obtain safe abortions. But everywhere, the public health crisis of access services. economic, geographic, linguistic and cul- unsafe abortion. In the ten tural barriers impede many women – The objectives of woman-centred, especially poor women - from accessing years since that landmark comprehensive abortion care (CAC) such services. In Romania, for example are: (as in many other countries), abortion conference, numerous • to provide safe, high-quality services; facilities are located in urban areas, leav- groups and individuals in • to decentralize services to the most ing rural women with limited access to local level possible; services (5). central and eastern Europe • to make services affordable and Ensuring the “quality” of services acceptable for all women; requires attention to many factors that (CEE) have worked hard to • to help health-care providers under- vary within local contexts and according improve the quality of abor- stand each woman’s particular social to available resources. Fundamental com- circumstances and individual needs ponents of high-quality abortion care tion care available to the and to tailor her care accordingly; include: tailoring care to each woman’s • to reduce the number of unplanned individual needs; providing accurate, millions of women living in pregnancies and abortions; appropriate information and counselling; the region. • to identify and serve women with offering post-abortion contraceptive ser- other sexual or reproductive health vices, including emergency contracep- needs; tion; referring to or providing reproduc- • to make abortion care affordable and tive and other health services; and ensur- The challenges are significant, however, sustainable within mainstream health ing confidentiality, privacy, respect and and despite these efforts, too little has systems. positive interactions between women and improved for women and the health care health care staff. providers who serve them. Reliance on Adoption and use of abortion for fertility control is still wide- internationally recommend- spread and well-accepted, resulting in ed medical technologies are some of the highest abortion rates in the particularly important in world (1). Yet widespread shortages of any effort to improve the equipment and medications, crowded quality of abortion care. In facilities, poor hygienic conditions, lack its 2003 publication Safe of training, use of out-dated abortion Abortion: Technical and technologies, inadequate standards and Policy Guidance for Health guidelines, and the fact that post-abor- Systems (see the Resources 13 tion contraception is often not provided, section of this issue), the combine to create an unnecessarily low World Health Organization standard of care (2). Although many recommends use of manual fewer women die from abortion-related and electric vacuum aspira- causes in Europe than in other parts of tion and medical abortion the world, abortion-related deaths repre- for first-trimester abortion, sent just over a quarter of maternal The CAC approach comprises three key to minimize risk of procedural or post- deaths in the region – an unacceptably elements: choice, access and quality. In its abortion complications which can lead to high toll (3). broadest definition, “choice” means infertility or other morbidities. In the ensuring that women have the right and second trimester, WHO recommends

No. 59 - 2005 shifting services to dilatation and evacua- woman to continue her pregnancy, fol- method with or med- tion and medical methods (6). lowed by a mandatory waiting period. ical abortion. Appropriate clinical standards and proto- The new law also restricts government cols for infection prevention, pain man- funding of abortion (9). Progress in select central and east- agement, complications and other clini- In light of these tendencies, an essen- ern European countries cal components of care are also essential. tial component of Ipas’ and its partners’ The transformation to woman-centred strategy in central and eastern Europe is comprehensive abortion care is in Introducing woman-centred, com- policy advocacy aimed at increasing pub- process in several CEE countries, which prehensive abortion care lic and policymakers’ awareness of have followed different paths to improv- Conditions and practices in the CEE women’s rights and the public-health ing abortion care. region offer specific challenges to intro- imperative to protect them. A key region- Romania ducing the CAC model. Regarding al actor in this arena is the ASTRA net- In Romania, for example, the Ministry of women’s choice, for instance, with fertili- work, which comprises European NGOs Health and a broad range of internal ty rates having fallen below replacement working on sexual and reproductive stakeholders worked with the World level in most countries in the region, health and rights. (Ipas is an associate Health Organization and Ipas on a strate- some policy-makers, health care member). ASTRA’s activities include gic assessment of abortion and contra- providers and non-governmental organi- country-level projects and regional ceptive services in 2001 (5). zations (NGOs) have called for limiting efforts to advocate for better policies on Through fieldwork including more comprehensive contraception and abor- sexual and reproductive health and rights than 500 interviews with policy-makers, tion programmes, in the false hope that (SRHR), including those focused on the health care providers, women, and oth- such actions would lead to increases in role of the European Union in protecting ers, the Romanian assessment team ascer- birth rates (2). SRHR. tained that the quality of abortion ser- In some countries, such as Poland and Among the challenges in ensuring vices was poor and that adoption of a the Russian Federation, more restrictive women’s access to high-quality abortion model of comprehensive abortion care abortion laws have been enacted since care in the CEE region is making services would address many of the deficiencies. ICPD. Russia’s recent curtailment of available closer to where women live - at The team identified a number of priori- women’s rights to second-trimester abor- additional hospitals and clinics, through ties including: introducing vacuum aspi- tion seems especially counter-productive, private practices or other primary-care ration where sharp curettage was used, since women seeking abortion after the settings. This strategy runs counter to improving pain-management practices, first-trimester bear a large part of the evolving health systems’ continuing focus linking contraceptive services to abortion burden of unsafe or inaccessible services. on closing hospitals and prioritising ter- care, and improving the privacy and con- Fully 80% of abortion-related deaths of tiary health facilities rather than primary fidentiality of services. Russian women result from clandestine health care, in some countries. It is also Health care leaders moved quickly to abortions performed in the second- difficult to realize in regions enduring develop and implement national stan- trimester of pregnancy outside medical political conflict, where many displaced dards and practice recommendations for institutions (7). or refugee women rely on health services abortion consistent with WHO guidance. In other countries, such as Slovakia, in temporary camps, which rarely, if ever, In 2004, the Romanian Parliament Lithuania, and Hungary, conservatism is offer abortion services, even if they are approved the reproductive health bill, contributing to increased barriers to legally permitted. Accessing safe abortion which will become a law if approved by women exercising their rights regarding care from health facilities in the host the president. It calls for the provision of pregnancy and abortion. For example, in country is difficult for many refugee high-quality abortion care with manual Slovakia the government and the Holy women who may not speak the language, vacuum aspiration (MVA) (see box) and See drafted an agreement designed to leaving them at risk of seeking services medical abortion. Additional steps taken enable health care providers to “conscien- from untrained providers. to facilitate access to MVA services tiously object” to performing abortions In terms of quality of abortion care, a included the establishment of commer- or prescribing contraception (2). primary challenge in central and eastern cial distribution for MVA instruments Lithuania has a liberal abortion law; Europe is the need to update the clinical and the translation of technical materials 14 however, negative population growth and methods used, since – along with the skill on providing high-quality abortion care the increased influence of the Catholic of the practitioner - the choice of tech- into Romanian. Although funding con- Church are making it challenging to pro- nique may influence abortion-related straints currently hinder broad-scale mote advances in reproductive health. morbidity. In many countries in the training, the groundwork laid through For example, the Lithuanian parliament region, sharp curettage is still used for the assessment process and subsequent has voted against passing a reproductive most first-trimester abortions, despite activities has resulted in consensus health and rights law (8). Hungary made evidence that it is associated with higher among policy-makers on the importance its abortion law more restrictive in 2000, procedural complications than vacuum of improving quality of care, leaving the now requiring women to have “coun- aspiration (10). As previously suggested, Romanian health care system poised to selling” by a health employee whose the World Health Organization recom- transform services. responsibility it is to try to persuade the mends that health systems replace this Republic of Moldova For instance, vacuum aspiration is not the region are supported by technical In nearby Moldova, the transformation available in all abortion settings; general assistance from WHO, the International of abortion services started in 2002, anaesthesia is widely used for first- Planned Parenthood Federation Euro- when the US-based National Abortion trimester abortions; and many women pean Network and Ipas, among others. Federation (NAF) trained seven provi- leave health-care facilities where they They also require donor funding, which, ders at the Clinical Municipal Hospital have obtained abortions without receiv- with a few notable exceptions, is in un- N1 in Chisinau in the use of MVA for ing counselling or contraceptive methods fortunately short supply for abortion- outpatient early abortion. By 2003, the to help them avoid repeat unwanted related programmes in this region. The abortion caseload had more than tripled pregnancies. local, regional and international expertise at the new MVA Centre created by the In a growing number of Albanian set- that is primed to collaborate to improve hospital’s gynaecology unit. The caseload tings, however, care is improving, and the abortion care in this region, and the his- increase is attributed to the high quality Ministry of Health is poised to support tory of success in the countries where of care, which drew women from other the broad introduction of WHO’s techni- limited investments have prompted last- facilities, and to the fact that most proce- cal and policy guidance. Services are ing changes, should motivate donors to dures are done with local, rather than already using recommended abortion consider funding this scope of work. general, anaesthesia. As providers shifted methods in facilities at the Marie Stopes By mobilizing resources, sharing expe- from use of general to local anaesthesia, Clinic and the University Maternity Hos- riences across countries and fostering the they learned to talk with and support pital in Tirana, as well as district hospi- energies and efforts within countries, their patients, treating them as partners tals in three other cities, where first-tri- Ipas and its partners hope to see more in their care. To date in 2004, MVA train- mester abortions are offered with MVA countries transform their abortion ser- ing is incorporated into the university and local anaesthesia. Ipas looks forward vices so women have access to truly high- curriculum and a total of 80 gynaecolo- to working with the Ministry to expand quality, woman-centred, comprehensive gists have received MVA training. In awareness and use of the WHO guidance abortion care. addition, the MVA Centre holds one-day and is working with other partners to Manual Vacuum Aspiration trainings for other doctors. help realise a broader transfor- (MVA): Providers are pleased with MVA ser- mation of abortion care. Ipas’ work to improve the quality of vices, which, they say, are not only safe abortion care in Europe includes and effective but also save time and costs. In other countries, too, efforts are training and equipping health-care Women who received care are also underway to conduct strategic assess- providers to provide safe, effective pleased: ongoing monitoring during ments on abortion care, to introduce and abortion services. Consistent with 2003-2004 at the MVA Center shows that implement the WHO safe-abortion guid- WHO recommendations, Ipas aims to more than 90% were very satisfied with ance, to improve clinical care and tech- replace sharp curettage with safer their care and would recommend it to nologies available for abortion, and to methods, including manual or others needing an abortion (11). develop national standards and guide- electric vacuum aspiration and With support from Ipas and NAF in lines for abortion care. Experience both medical abortion. developing providers’ training skills, the within the CEE region and throughout Safety and effectiveness data show MVA Centre has trained gynaecologists the world shows that, regardless of the that MVA leads to fewer complica- from all over Moldova and in other approach taken, the step with the largest tions than sharp curettage and is a countries. Other steps that have been positive impact for women, health care very safe modern method of abor- important in transforming and sustain- providers and the health care system is tion appropriate for a variety of set- ing the quality of abortion care in conceptual rather than practical: Once tings (12). Qualities that make MVA Moldova include registration of MVA for health leaders and practitioners fully more appropriate for low-resource commercial distribution, dissemination understand and embrace the idea of settings and outpatient services of technical materials on MVA and abor- woman-centred, comprehensive abortion include being portable, non-electric, tion care in Romanian, and the Ministry care, they usually have the internal reusable and relatively low-cost. MVA of Health’s 2004 recommendation of momentum to promote desired changes instruments are easy to use, and MVA for first-trimester abortion, accom- and to make them sustainable. A key abortion procedures with MVA are 15 panied by approval of clinical guidelines. underlying goal of the CAC model, sus- quiet and convenient. Local rather Currently, a team from Moldova is plan- tainability, occurs when training, super- than general anaesthesia is recom- ning a national strategic assessment of vision, equipment provision and facili- mended for pain management, and fertility regulation to expand understand- ties’ maintenance are integrated into rou- are easily vis- ing of the situation in the country and tine operations of the health-care system ible, enabling accurate assessment of ultimately to design additional strategies such that supplies and standards of care procedure completion. MVA can be to address current needs. are maintained without interruption. used for: Albania Clearly, efforts to improve the quality • first-trimester abortions As in most of the rest of the region, abor- and accessibility of abortion care require • treatment of incomplete abortion tion services in Albania lack key elements the energy of committed professionals • menstrual regulation of woman-centred, comprehensive care. and organizations. Many such efforts in •

No. 59 - 2005 7. Zhirova, Irina A, Olga Frolova, Recommended websites Ipas Tatiana Astakhova and Evert Ketting. www.astra.org.pl Central and Eastern Ipas works globally to increase “Abortion-related Maternal Mortality European Women’s Network for Sexual women’s ability to exercise their sex- in the Russian Federation.” and Reproductive Health and Rights. ual and reproductive rights and to Studies in Family Planning, www.reproductiverights.org The Center reduce abortion-related deaths and 2004:35(3):178-188. 8. International Planned Parenthood for Reproductive Rights is a non-profit injuries. For three decades, Ipas has Federation. Country profiles. legal advocacy organisation. sought to expand the availability, Available online at quality and sustainability of abortion http://ippfnet.ippf.org/pub/IPPF_Reg www.ipas.org –For information on and related reproductive health ser- ions/IPPF_CountryProfile.asp?ISOCo women’s reproductive health, rights and vices. Ipas believes that no woman de=LT (accessed January 2005).; policy, and Ipas products, publications, should have to risk her life or health and personal communication with activities and news. because she lacks safe reproductive E. Kuliesyte, Executive Director of health choices. Ipas’s global and Seimos Planavimo ir Seksualines www.ipas.org/english/womens_rights_an country programmes include train- Svelkatos Asociacija (IPPF Member d_policies/policy_updates/2004/updates ing, research, advocacy, information Assocation), January 2005. Ipas has recently launched the Global Abortion News Updates feature on its dissemination and distribution of 9. Center for Reproductive Rights. Letter to the Committee on the website. reproductive health technologies. Elimination of Discrimination against Women www.ippfen.org The IPPF European (CEDAW Committee). Network (IPPF EN) is a voluntary organisa- December, 2004. Available online at tion in the field of sexual and reproduc- http://www.reproductiverights.org/pd tive health and rights. References f/sl_hungary_2004.pdf (accessed 1. Henshaw, Stanley K., Susheela Singh January 2005). www.prochoice.org The National Abortion and Taylor Haas. 10. Baird, Traci L. and Susan K. Flinn. Federation (NAF) is the professional asso- “Recent trends in abortion rates Manual vacuum aspiration: ciation of abortion providers in the United worldwide.” Expanding women’s access to safe States and . International Family Planning abortion services. 2001. Chapel Hill, Perspectives, 1999:25(1). NC, USA, Ipas. 2. Ipas. 2003. Achieving ICPD commit- 11. Comendant, Rodica, ments for abortion care in Eastern Eva Sahatci, Entela Shehu and and Central Europe: Traci Baird. The unfinished agenda. “Improving Abortion Care in Eastern Chapel Hill, NC, Ipas. and Central Europe.” 3. World Health Organization (WHO). Poster presented at the 2004 meeting 2004a. Unsafe abortion: of the European Association of Global and regional estimates of the Gynecology and Obstetrics. Athens, incidence of unsafe abortion and Greece. associated mortality in 2000, fourth 12. Greenslade, Forrest C., et al. edition. Geneva, WHO. Manual Vacuum Aspiration: 4. Hyman, Alyson and Anu Kumar. A Summary of Clinical & Traci L. Baird “A woman-centered model for com- Programmatic Experience [[email protected]] prehensive abortion care.” Worldwide, 1993. Chapel Hill, NC, Regional Director, Asia, Europe, International Journal of Gynecology USA Ipas. USA and Obstetrics, 2004:86:409-410. 16 5. WHO. Abortion and contraception Sarbaga Falk in Romania. A strategic assessment of [[email protected]] policy, programme and research Programme Associate issues. 2004b. Bucharest, Romania. (in print) Entela Shehu 6. WHO. Safe Abortion: Technical and [[email protected]] Policy Guidance for Health Systems. Programme Director for Europe 2003. Geneva, World Health Organization. Ipas PO Box 5027 Chapel Hill, NC 27516 USA HIV-POSITIVE WOMEN AND THEIR RIGHT TO CHOOSE By Marcel Vekemans and Upeka de Silva

Women of childbearing age to secure the reproductive rights of all health, then every woman’s right to women, regardless of their age, or marital reproductive self-determination should living with HIV, like those or HIV status. be upheld, including that of women liv- who are HIV negative, are ing with HIV/AIDS. A global overview In other words, as there is no univer- faced with the decision to In countries with a high HIV prevalence, sally valid approach to specialized girls and young women are at greater risk HIV/pregnancy counselling, and there have children or not. than men of HIV infection, accounting will be as many different solutions to the However, in the case of the for over 50% of people living with HIV. problems raised by pregnancy in Nearly 230 million women worldwide - HIV/AIDS patients as there are various HIV positive woman, the one in six women of reproductive age - individual situations, the need to listen to lack information on and access to a full and respect a woman’s decisions becomes issue is more complex, for range of contraceptive methods. Often, crucial. She has the right to have children personal, familial, social, they are also unable to negotiate contra- and the right not to have children, ceptive use (1). At present, less than one secured by access to affordable contra- cultural, religious and in ten people who need antiretroviral ception including emergency contracep- medical reasons. therapy receive it (2). In some parts of tion and, if needed, to safe, legal abor- Africa one-third or an even higher pro- tion. These are difficult reproductive These women are often stigmatized for portion of all pregnant women are HIV decisions that we need to pay greater being HIV positive and, if pregnant, for positive or have AIDS. In and attention to by ensuring that our pro- irresponsibly being sexually active and Swaziland, for example, nearly 40% of grammes and policies are based on becoming pregnant while HIV positive. pregnant women are HIV positive (3). respect and an understanding of the Sometimes, they are under pressure by Unfortunately, in many countries, only a complexities of women’s lives. family or health workers to have their small proportion of those living with pregnancy terminated, while in other HIV know their status, so the size of the International policies cases they are pressured by partners and problem is most likely much larger. The World Health Organization (WHO) families to have children. Women living HIV positive women are a heteroge- stated in 2004 that service providers with HIV can also be demonized for neous group; there are women who have should “ensure that access to abortion seeking or having an abortion. Finally, only one partner, women who have or services, where legal, for women with when they do decide to carry their preg- have had more than one partner; married HIV infection is provided in an equitable nancy to term, they are often blamed for and unmarried women; women of all and non-coercive manner” (4). bringing an HIV-infected child into the ages, including very young women; and The International Planned Parenthood world. women who are injecting drug users, sex Federation (IPPF), adopting a similar Some HIV-positive women are preg- workers and those who have been infect- stand in terms of HIV-positive women’s nant as a result of rape, entailing further ed as a result of female genital mutila- options for , states stigmatization. On top of all these soci- tion, rape, unsafe blood transfusions or that “if the client is currently pregnant etal pressures, they invariably suffer from through medical care provided in settings but does not wish to continue her preg- feelings of guilt, low self-esteem and self- where universal infection prevention nancy, she should be referred to safe stigmatization. Stigmatization or other measures are inadequately performed. abortion services where legally permitted. factors can also lead to women preferring Given the variety of situations, it is vital Post-abortion contraception should be to rely on unskilled service providers that services are tailored to individual offered as an option for those who do not instead of utilizing official services, for circumstances, with the provision of clear wish to become pregnant again” (5). fear that the service will not remain con- and factually correct information, based While it is important to be aware of fidential. on respect for the woman’s sexual and such international policies relating to the This is a tragic picture, which paints reproductive health rights. To date, few reproductive options of HIV-positive HIV-positive women as both culprits and studies have explored how HIV positive women, service providers and advocates victims. While this is fortunately not nec- women make childbearing decisions and also need to be fully aware of the intense 17 essarily true for all women, it is neverthe- more research is required on this issue. emotional struggles that these women less all too often a reality. This article face when exercising their decisions addresses the overall situation, what we Making choices about childbearing about childbearing and rearing. are doing, and what we could do to pro- and rearing Although policy documents speak of tect the sexual and reproductive health The discussions around childbearing and consent, free will, choice and safe abor- rights of women living with HIV. living with HIV are dynamic and com- tion, they are rarely part of the realities of The discussion below raises some plex, making it impossible and even many HIV-positive women’s lives. rather controversial questions, intended inappropriate to prescribe a unique and to challenge those of us who are service ideal approach. Yet, if we truly believe in Wanted pregnancies providers and/or advocates of sexual and promoting a holistic rights-based The right to found and plan a family and reproductive rights to take positive steps approach to sexual and reproductive decide whether and when to have chil-

No. 59 - 2005 dren is a fundamental part of a woman’s increases by 5-20% in breastfeeding pop- At no time should an HIV-positive sexual and reproductive freedom. Yet, ulations. The risk of MTCT can be woman be forced to undergo an abortion women living with HIV are frequently reduced to below 2% by interventions or sterilization. denied this right primarily because soci- that include antiretroviral prophylaxis ety and service providers, in particular, given to women during pregnancy and Unwanted pregnancies more often than not do not believe that labour and to the infant in the first weeks The stigma attached to a woman who is HIV-positive women should have chil- of life, obstetrical interventions including HIV positive and faced with an unwanted dren or even be sexually active in the first elective caesarean delivery and complete- pregnancy is, in many societies, immense. place. On the other hand, we live in a ly avoiding breastfeeding (6). Being HIV This is even more so if the woman is world where motherhood is seen as an positive also increases the risk of sponta- young and unmarried and further com- integral part of being an adult woman neous abortion, anaemia and haemor- pounded if she chooses to have an abor- and in some societies childless women rhage related complications, and post- tion. Today, an estimated two in five are often stigmatized. For many women partum infections. Yet, we need to be pregnancies worldwide are unplanned. living with HIV, bearing children is also aware that given these figures, women Women living with HIV are no less likely something to look forward to as it pro- who choose to have children often focus than other women to become pregnant, vides hope and an increased sense of self- on the 55% chance of not transmitting and are no more likely to terminate a esteem and pride. So whether they are the infection and are willing to take on pregnancy. forced into motherhood or whether they the risks. In addition to the reasons that an HIV- truly wish to experience motherhood, we Our role then is to dispel myths about negative woman might have for choosing as advocates of sexual and reproductive living with HIV and parenting, to pro- an abortion, an HIV-positive woman health rights and providers of compre- vide information on breastfeeding and to might also be concerned about her lack hensive rights-based services need to support them in safe conception, deliv- of access to antiretroviral therapy, feel make sure that their choices are safe for ery, labour and childrearing. The guilty about bringing an infected child them and can be realized. woman’s right to benefits of scientific into the world and be anxions about HIV transmission from an infected progress should form the basis of our being unwell. She may also be unable to mother to a child can occur during preg- interventions so that we enable HIV-pos- make an independent and informed deci- nancy, labour and delivery, or during itive women to not miss out on the expe- sion due to the judgemental attitude of breastfeeding. In the absence of any rience of motherhood. Furthermore, heath care workers or the lack of proper intervention, the risk of mother-to-child wherever possible, assisted reproductive counselling. transmission (MTCT) of HIV is 15–30% techniques should also be made available Arguments have been presented in in non-breastfeeding populations, and to women who choose to have children. support of making HIV infection a rea-

Recommendations Services • ensure that counsellors have clear pro- We can no longer adopt a blinkered view tocols on pre and post-test HIV coun- initiatives we take, we on HIV prevention or safe abortion. selling and are aware of the emotional need to always be aware that Instead, we need to ensure that service impact of receiving a positive diagno- women, especially young women, providers in vertical health care pro- sis especially during pregnancy; often have very little control over grammes such as family planning and • train staff to understand and address their sexual and reproductive HIV programmes work together to adopt the links between sexual violence, HIV lives. a positive attitude towards women’s sex- and unwanted pregnancies; uality and provide comprehensive ser- • ensure that women living with HIV are vices including: made to feel welcome and reassure them of their right to privacy and con- • service providers should address the fidentiality; 18 needs of women living with HIV with • train staff to work with HIV-positive confidence and in a manner which is women to enable them to access con- respectful of their dignity and rights; traception and have a safe and satisfy- • keep staff up to date with the latest ing sex life; information on safe abortions, safe • services that provide post-abortion pregnancies and HIV treatment; care should pay special attention to • build staff capacity to enable them to whether or not the woman is HIV posi- deal not only with the medical aspects tive so that they are able to provide of living with HIV, pregnancy and the necessary extra care to prevent abortion but also the psychological post-abortion complications; and emotional needs of the clients; • ensure that emergency contraception son for legal abortions. The risks that this reproductive rights, and are faced with 4. WHO, Policy and Coordination runs are, among others, that women difficult reproductive decisions, the need Committee, Special Programme of might be obliged to disclose their HIV to adopt a holistic and rights-based Research, Development and Research status in order to have an abortion and approach to sexual and reproductive Training in Human Reproduction, that HIV-positive women might then be health becomes imperative. We would July 2004 coerced into undergoing an abortion and like to take this opportunity to call on 5. IPPF Medical Bulletin, International concomitant sterilization based on the you to take urgent action to pay greater Planned Parenthood Federation belief that they should not be bearing attention to giving women reproductive 2004; 38(3):1-3. children or be sexually active. options, enabling them to exercise those 6. Antiretroviral drugs for treating On the other hand, there are, for choices, and to ensure that programmes pregnant women and preventing HIV example, some anti-choice groups that and policies are based on respect and an infection in infants, UNAIDS and claim that the increased availability of understanding of the complexities of WHO 2004:4 www.who.int/hiv/en antiretroviral therapy should mean that women’s lives, as outlined in our recom- HIV-positive woman should no longer be mendations. allowed to abort on the grounds of HIV infection. Despite these arguments, making avail- able safe abortion services is extremely important for HIV-positive women as References unsafe abortions become unsafer due to 1. Contraception, Centre for Marcel Vekemans the greater risks these women face of suf- Reproductive Rights, www.reproduc- [[email protected]] fering complications such as sepsis and tiverights.org, accessed November Senior Adviser/Theme haemorrhage. 2004. Leader/Abortion 2. UNAIDS. Report of the global AIDS International Planned Parenthood Conclusion epidemic, UNAIDS, Geneva, Federation What emerges from the documentation Switzerland, 2004, pp 14, 102. relating to HIV-positive women and their 3. UNAIDS. “Epidemiological fact Upeka de Silva sexual and reproductive health is the lack sheets on HIV/AIDS and sexually [[email protected]] of respect and value placed on women’s transmitted infections”. Technical Knowledge and Support lives. As more and more women of www.unaids.org, accessed 25 January International Planned Parenthood reproductive age face violations of their 2005. Federation

is widely promoted and made avail- have access to safe abortion services many of these women have little or able especially for young women; and comprehensive high quality no control over decisions about preg- • propose HIV testing for those who counselling. nancy; test for pregnancy or are planning a • advocate for and ensure greater pregnancy to enable them to take Programmes and policies access to antiretroviral therapy and advantage of prevention of mother- • in order to ensure that programmes reinforce prevention messages when to-child transmission measures and and policies respond to the real needs people are feeling better after anti- provide them with options on the of the intended beneficiaries, identify retroviral treatment; outcome of the pregnancy and infor- mechanisms for involving HIV-positive • undertake campaigns to protect the mation on a safe pregnancy.This women and especially young women right to choose; should not be used to coerce termina- at all levels of decision-making; • work with men to help them under- tions or sterilizations; • address the absence or limitations of stand the issues around being HIV • if they choose to have a baby, infor- existing health care services in terms positive and pregnant and help them 19 mation and services should be provid- of human resources and finances; to support their partners; ed on safe conception, pregnancy, • have clear policies on meeting the • work with donors to ensure that fund- delivery and breastfeeding and post- needs and rights of women living ing is not compartmentalized and partum contraceptive services and with HIV and promote these in such a that comprehensive programmes can counselling; way that those who need the services be implemented. • provide access to support groups for the most are able to access them; positive mothers so that they receive • strategies to preventing unwanted continued care and support; pregnancies among HIV-positive • if they choose not to have a baby, women should go beyond contracep- providers should ensure that they tive use and should recognize that

No. 59 - 2005 Why do women still die of abortion in a country where abortion is legal? THE CASE OF THE RUSSIAN FEDERATION By Evert Ketting

In its previous report, published in 1998, recently carried out. The results were WHO estimated this number to be 500 published in the September 2004 issue of cases annually (2), indicating that the Studies in Family Planning (4). This arti- number of fatal cases is probably still cle summarizes and discusses some of the declining. Almost all these fatal cases are main findings of this study, excluding believed to occur in Eastern European technical medical information. countries, particularly in the Russian Federation. The Russian legal and social con- According to data released by the text of abortion Ministry of Public After the Communist revolution of 1917, Health of the Russian Russia became the first country to Federation, 233 legalise abortion, on 16 November 1920. Maternal mortality women died from Under Stalin, this law was repealed in abortion related caus- 1936, mainly for pronatalist reasons. es in 1991, and this Abortion remained illegal until 1955, but due to unsafe abortion number gradually it is likely that women quite massively declined to 122 in resorted to illegal abortion during the is very rare in Europe. year 2000. This period 1936-1955. After 1955, when means that almost abortion became legal on request of the half of all abortion woman in the first trimester of pregnan- According to the most recent 2004 related maternal cy, the number of women having legal deaths in Europe abortions increased to about 7 million occur in the Russian annually in the 1970s (5), but the actual estimates of the World Health Federation. But the number of abortions, including those Russian Federation that were illegal, was still much higher. Organization (1) 300 out of 67,900 does not even have Surveys during the period 1965-1982 the highest maternal suggested total annual numbers of abor- death rate due to tions between 8.5 and 11.7 million, and unsafe abortion death cases world wide abortion in Europe. abortion rates between 170 and 220 per In Romania, 38 and 1000 women of fertile age (5). 37 cases were report- In 1987, the law was further liber- in the year 2000 occurred ed in the years 2000 alised, also permitting so called “mini- and 2001 respectively abortions” within 20 days of a missed (3) while the popula- period on an outpatient basis, and it in Europe. tion size of Romania extended the number of legal grounds for is only about 16% obtaining abortion in the second that of the Russian trimester. Further liberalisations were Federation, thus indicating a mortality adopted in 1993 and 1996, extending the rate due to abortion which is almost number of medical and social indications double the Russian one. Data from other in the second trimester. By that time, the central and eastern European countries, Russian Federation had one of the most particularly Poland, where abortion is liberal abortion laws in Europe, which basically illegal, are largely unknown or made it even more surprising that some probably unreliable. 150 women annually died from the con- In general, reliable data on abortion sequences of abortion. 20 related maternal mortality in Europe are In August 2003, after data for the mor- very scarce, and even less was until tality study had been collected, the num- recently known about the background ber of social reasons for abortion was factors to this tragic phenomenon. With reduced from 13 to only four: rape, assistance from the Open Society imprisonment, death or severe disability Institute, an in-depth study on some of a husband, or a court decree stripping characteristics and background factors of the women of her parental rights. Access women who had died after abortion in to second trimester abortion will proba- the Russian Federation in 1999 was bly be severely restricted by this measure, which could have serious consequences preparing the English language report and older, whereas less than 40% of all because 6-7% of abortions in Russia are published in Studies in Family Planning. women having abortions are in that age usually performed in the second All data presented below are taken from group. trimester. this report, unless otherwise indicated. One of the main results of the study is Following the introduction of modern Three datasets were used for this study. that particularly women who have abor- family planning in Russia in the early The first were national data on abortion tions in the second trimester of pregnan- 1990s the abortion rate gradually and abortion-related mortality reported cy are at increased risk of dying from the declined. The reported rate dropped to the Ministry of Health in 1999. The procedure. Whereas only 6.6% of all from 100.3 to 50.5 between 1991 and number of reported abortion-related women having abortions in 1999 were in 2000. However, it is unclear to what maternal deaths was 153. The second the second trimester, among those who extent this decline is real or caused by dataset was obtained from the State died this was 76%, and of those women increased underreporting, particularly in Statistical Committee (SSC), where the 24% were more than 21 weeks pregnant. the larger cities where private abortion number of abortion-related deaths was This means that ARMM is mainly con- clinics have been established. It seems 130. The difference between the two centrated in the late abortion cases. unlikely that this impressive decline in numbers is caused by differences in defi- Undoubtedly, the most important abortion rate is entirely caused by nitions and in reporting procedures. The result of the study has been that most improved prevention of unwanted preg- third dataset was compiled especially for fatal cases resulted from abortions per- nancy through better contraceptive use. this study. It consisted of detailed med- formed outside medical institutions. Unfortunately, reliable recent data on ical files of the women who died after Among the 113 fatal cases studied in- contraceptive use are not available in the abortion in 1999. A total of 113 files was depth, there were 10 cases of sponta- Russian Federation. In 1998, UNFPA still obtained in this way, that is 74% of the neous abortion (9% of the total). estimated that only 21% of Russian cou- total number of abortion-related mater- Furthermore, 27 women (24%) had an ples were using any method of contra- nal deaths reported to the Ministry of abortion inside a medical institution; and ception and only 13% a modern method Health and 87% of those reported to the 76 women (67%) had an abortion out- (6), but in the 2004 edition of the State SSC. The remaining cases could not be side a medical institution. of the World Population, an estimate for traced. The fact that only 24% ARMM cases Russia is not included anymore, probably The outcomes of the study indicate occurred after a legal abortion in a quali- because recent data are non-existent. In a that abortion-related maternal mortality fied medical institution should be national survey carried out in 2000 (ARMM) is a national problem, and that stressed. This outcome means that the among 15-18-year-old boys and girls it it is not concentrated in some remote or risk of dying after such a procedure is not was found that only 6.4% of sexually rural regions. This is quite remarkable, substantially higher than in western active girls used oral contraception dur- because one would expect that the quali- countries, particularly if performed at an ing their last , and ty of abortion provision could be lower early stage of pregnancy. Among abor- 40.7% used a condom. More than 50% in remote areas, or that women in those tions performed in the first trimester of did not use a method or an unreliable areas could have more problems in pregnancy, the risk of death is 0.54 per one (7). The same study indicated that obtaining access to legal and safe abor- 100,000 abortions, and that is almost 9.3% of the sexually active girls had tion services as a result of very long dis- equal to the 0.4 per 100,000 found in the already been pregnant, and most of them tances to health facilities in sparsely pop- United States (US). As in other countries, had had an abortion. This percentage is ulated regions in Russia. This is not the the death risk from abortion in the first high if we take into account that the case; there are no real regional or urban- part of the second trimester is substan- average period since the debut of sexual rural differences in ARMM. tially higher compared to the first activity of these girls was only 1.3 years. Another remarkable outcome is that trimester. In Russia this risk is about 11.5 This means that more than 7% had young women do not have a higher risk per 100,000, which is higher than in the become pregnant after one year of sexual of dying from abortion related causes US, where this is about 6.9. The most activity. than relatively older women. On the con- risky legal abortions in Russia are those trary, women under 20 and women in performed after 21 weeks, with a relative 21 The Abortion-Related Maternal the age group 20-29 are underrepresent- death risk of 45.1 per 100,000. This very Mortality study ed among the ARMM cases. This is an small category is responsible for 37% of This research project was carried out by outcome that would not immediately be ARMM inside medical institutions. the Scientific Research Centre for expected because young women are usu- However, the main cause of the high Obstetrics, Gynaecology and Perinatolo- ally at greater risk of having late abor- ARMM is that probably fairly large num- gy of the Russian Academy of Medical tions, which are more dangerous. This is bers of Russian women have abortions Sciences in Moscow. The author of this not the case in Russia: 55% of women outside (qualified) medical institutions. article assisted in data analyses and in dying from abortion related causes are 30 This factor explains two thirds of the

No. 59 - 2005 ARMM. Moreover, these fatal cases tend only the risk of serious complications if References to have been performed late in pregnan- the abortion is carried out illegally, but cy: 58% after 13-21 weeks of pregnancy also to some extent if performed in a 1. World Health Organization. “Unsafe and 20% after 22 or more weeks. Also hospital by qualified doctors. Therefore, abortion; global and regional esti- here we see that it is particularly older it is important that measures are taken mates of the incidence of unsafe women who are at risk; almost two- that enable women to seek and have abortion and associated mortality in thirds of these fatal cases occurred in abortions early in pregnancy. 2000”.Fourth edition. WHO, Geneva, women 30 years or older. Only third, in terms of reasons why 2004. women die, comes the medical compe- 2. World Health Organization. “Unsafe Causes of ARMM tence of doctors and the quality of health abortion; global and regional esti- The abortion-related maternal mortality facilities and procedures used for abor- mates of incidence and mortality due ratio in the Russian Federation is 6.3 per tion, particularly in the second trimester. to unsafe abortion with a listing of 100,000 known abortions, which is about Although there is still a need for available country data” Third edition. 10 times higher than in western Europe improvement in this respect, the main WHO, Geneva, 1998. and North America, and it explains about causes are in the legal and public health 3. Romanian Ministry of Health and a quarter of maternal mortality in gener- field. Family. “Maternal Mortality in al. Based on the results of our study, the An important unanswered question is Romania in the year 2000”. question formulated in the title of this the extent of what is called here “abor- Bucharest, 2001. (Idem year 2001, article “why do women still die in a tion outside medical institutions”.It is Bucharest, 2002). In Romanian. country where abortion is legal?” may be not only known where these abortions 4. Zhirova IA, Frolova OG, Astakhova answered as follows: are carried out and by whom, but it is TM, Ketting E. Abortion-related In the first place, this is because proba- also very difficult to estimate the total Maternal Mortality in the Russian bly large numbers of women have abor- number. In its 1998 overview (2) WHO Federation. Studies in Family tions outside medical institutions, where estimated that in all of central and east- Planning, 2004, 35, 178-188. the procedures are not safe, and particu- ern Europe 500 women would die from 5. Henshaw SK, Morrow E. Induced larly because some of these women have unsafe abortion, and the total number of abortion; a world review 1990 sup- these abortions at advanced stages of unsafe procedures was estimated at plement. New York, The Alan pregnancy, which makes the procedures 900,000. In the most recent 2004 Guttmacher Institute, 1990. even more risky. The questions that can- overview (1) these estimates have been 6. UNFPA. “State of the World not be answered by this study is what reduced to 300 and 400,000 respectively. Population 1998”.New York, UNFPA, causes women to make these risky choic- If these latter estimates are realistic this 1998. Idem, 2004. es, and where and from whom did they could mean that 150-200,000 unsafe 7. Ketting E, Averin YP, Dmitrieva EV. actually get this risky procedure? Our abortions are still performed annually in “Being young and in love in Russia”. data seem to suggest that many women the Russian Federation, which would be Utrecht/Moscow/St Petersburg, seek such abortions when their pregnan- 8-10% of all abortions. Because this is a NSPH, Moscow State University, The cy is too far advanced for them to obtain serious and sizeable public health prob- Nevsky Institute of Language and a legal abortion. The difficulties these lem, of which the true extent is virtually Culture, 2001. women potentially face include ignorance unknown, additional social scientific of the legal right to obtain an abortion, research in this area is crucial. being ineligible for legal abortion, short- age of specialized second trimester abor- tion services, financial barriers, and a fear of seeking official permission from a committee for an abortion. Unfortunate- ly, it should be feared that more women 22 could face such difficulties after the sharpening of legal social reasons for sec- Evert Ketting ond trimester abortion in August 2003. It [[email protected]] should not be excluded that as a result of Coordinator sexual and that measure, the ARMM could increase. reproductive health The second reason why women still die Netherlands School of Public and from is that many of Occupational Health and them tend to have abortions at advanced International sexual and stages of pregnancy. This increases not reproductive health consultant ABORTION IN EUROPE: ARE THE LAWS AND PRACTICES PATIENT CENTRED? By Christian Fiala

The diagnosis of an For most women the diagnosis of an sions regarding their own pregnancy. unwanted pregnancy is unexpected. The Society therefore “had” to intervene in unwanted pregnancy is a women are therefore unprepared and order to ensure that the “right” decision crisis situation for most may not fully comprehend the matter or was taken. This paternalism led, among know where to go to get counselling, be it other things, to a ban on abortions, women, even if the extent for carrying the pregnancy to term or which again was one of the reasons for of the crisis varies greatly. having an abortion. In effect, the diagno- the very high level of maternal mortality. sis of an unwanted pregnancy places the This is still the case in many low-income women concerned in an informational countries, because abortions are illegal state of emergency. She needs a great deal there owing to the laws imposed by for- of information within a very short space mer colonial powers. of time. This search for information is With the improvements in technology, made significantly more complicated by a especially during the second half of the number of factors: twentieth century, and a recognition of • The information concerns one of the women's rights, the situation has slowly most intimate areas of life; changed over recent decades and women • This area is particularly taboo in or couples now have a high degree of many societies; autonomy over their fertility. As a result • The pregnancy is sometimes not the of this autonomy, Dutch women, for result of an existing, socially accepted example, have the lowest rate of abor- relationship, which is why the fact of tions worldwide (1). On the other hand, pregnancy itself must not become some countries still have regulations that public; reflect outdated procedures and thinking • The woman’s own social circles, and and do not adhere to medical and social also professionals in the social-ser- service standards that have been estab- vices field, often react with moral lished in the meantime. One example is a condemnation, refusal of assistance compulsory counselling session before an or even misleading information; abortion. Even though this has been • The information required is extensive abolished in some countries, such as and complex. It affects both physical France two years ago, it still exists with and psychological processes; varying guidelines in some other coun- • The impending decision has major tries. For example, in the Netherlands effects on the woman's social envi- and Austria all doctors can provide this ronment, on her future life, and is counselling and there is no regulation as irreversible; to its content, while in Germany it is • With a partner, a second person is more rigidly prescribed and impedes immediately and directly concerned access to abortion. It remains unclear and more or less involved in the deci- why it is so difficult to offer counselling sion; voluntarily, as this is the usual practice • Not least, the information require- for other medical procedures. ments are very different for each individual, and sometimes vary wide- Obligatory waiting periods ly, as a result of which it is not always Another example is an obligatory waiting easy to provide the necessary infor- period for reflection between counselling mation. and the abortion. The very idea of a legally required waiting period between 23 Societies react differently to these counselling and medical treatment is, for requirements, although the last 200 years good reason, unusual in medicine. were dominated by a rigid paternalism. Rather, the law has given a special status Coupled with religious beliefs in some to the doctor-patient relationship and it countries, this was often the expression is particularly protected. It is incumbent of a male-dominated conviction among alone upon the two parties involved to the dominant social strata that pregnant find the best procedure for a particular women could not responsibly make deci- situation. If there is now a legally binding

No. 59 - 2005 period for consideration before terminat- for most women the waiting period must other branches of medicine such an ing a pregnancy, it seems to be based on seem arbitrary and not corresponding to approach would be regarded as unethical three basic misunderstandings: their needs. or even as mental cruelty. • pregnant women have to be protect- Above and beyond this, in some coun- In Switzerland, even after the recently ed from themselves so that they do tries there are special regulations, such as liberalised law, a woman still has to not hastily decide against having a those stipulating that the woman may declare in writing that she is in distress child; not be treated or cared for by the same before she can have a legal abortion. • women with an unwanted pregnancy specialists who are counselling her. Such Here, too, this kind of procedure, unusu- would only enter into the actual deci- a regulation is unique in medicine. On al in medicine, accords no recognizable sion-making process after counselling the contrary, it is self-evident that the advantage for the woman concerned. with someone they do not know; specialists with whom one has estab- Rather, it seems to be something which • a reflection period (usually of an lished trust in the course of preliminary will provide legitimacy to the action, arbitrary length) could reduce the consultation and examination should whereas it probably serves only to make number of abortions. also carry out any procedure and are also the woman concerned feel she has to jus- responsible for care during the process. tify herself to society for what she is In countries that do not have such an The continuity of care is particularly doing. obligatory waiting period, women with important in a crisis situation such as an an unwanted pregnancy and profession- abortion, so that the women do not have Positive developments als working in the field, see no need to to repeat their whole story every time There are nevertheless some important introduce one (2). As shown in Table 1, they come to the service. Only in this way positive developments. One of them is this obligatory waiting period varies can a certain trust develop which acts as the increasing spread of the internet. This greatly from country to country regard- a positive influence on the course of brings many advantages to women with ing the length, how it is calculated and treatment. It is hard to comprehend why an unwanted pregnancy. Without a great possible exceptions. It can be assumed this important quality standard should deal of effort, they have unhindered that the needs of the women in these not be applied in particular in the crisis access to a large amount of information countries do not essentially differ, so that situation of an unwanted pregnancy. In from varying perspectives. Most impor- tantly, their private sphere is secure; they do not have to explain anything about themselves nor do they have to justify Table 1. Overview of obligatory waiting periods in selected themselves to anybody. We found that European countries visiting websites on abortion had a posi- tive influence on counselling and treat- Country Waiting Period Details ment, provided that these sites had no religious background. There are two Belgium Six days From first contact with any main disadvantages to the internet in this counselling body regard: on the one hand, not all women have access to it. On the other hand, it is Germany Three days Three full days, certified by confirma- often hard to distinguish between factual tion from an approved counselling centre evidence and emotional propaganda and misinformation. France Seven days From first contact with a specialist, Multiple methods for abortion doctor/counsellor//nurse; can be shortened near the end of the There is a great difference in abortion term of legal abortion procedures between countries. Whereas, for example, in the Netherlands most 24 The Netherlands Five days (applicable Five full days after the first contact with surgical abortions in the first trimester only after the 44th a specialist, with many exceptions: can are carried out under local anaesthetic, in day since last be shortened near the end of the term other regions general anaesthesia is the menstrual period) standard. Also, a surgical abortion in the fifth or sixth week is a matter of course Italy Seven days From first contact with a doctor in the Netherlands and even exempt from (certification required) the legal waiting period. But in other countries, surgical abortion at this early No waiting period in Austria, Denmark, Finland, Norway, Spain, Sweden, Switzerland stage in pregnancy is not offered and is even considered to be medical malprac- lations in many countries have been Christian Fiala tice by some doctors. changed and are now less restrictive. The [[email protected]] Whereas in France, Scotland and example of Canada is particularly worth Gynmed Clinic for Abortion and Sweden in some institutions more than mentioning. There, the long established Family Planning 50% of women choose a medical abor- view is that the abortion of an unwanted Vienna, Austria tion, in Germany, the Netherlands and pregnancy is a medical treatment and President of the International Austria this is only a very small percent- requires no legal interference. Therefore, Federation of Professional age. after long legal arguments, in 1988 the Abortion and Contraception It cannot be assumed that women’s Supreme Court declared the law on abor- Associates (FIAPAC) needs in the aforementioned countries tion to be unconstitutional and abolished are so different as to explain the so wide- it. It will be interesting to see how long it The information on the legal situation and ly varying frequency of the various meth- will take for this solution-oriented the practice in different countries is from ods. It must instead be assumed that the approach to replace the existing ideologi- national sources. Links to national institu- difference in frequency of methods is the cally motivated regulations in other tions of different countries are available at expression of different organizational, countries, especially those in the the Link section of the FIAPAC website: legal or financial circumstances, or just a European Region. www.fiapac.org/e/Links1.html continuation of traditions that have not Finally, I would like to introduce been called into question. another gender aspect. As men, it is well- In summary, one can say that in most known that we cannot get pregnant, let References countries the general conditions in the alone have an abortion ourselves. Main- run-up to an abortion, as well as in car- taining the reproductive health of 1. Stanley K. Henshaw, Susheela Singh rying it out, are hardly or not at all ori- women, however, is also in our interests. and Taylor Haas. “The Incidence of ented to the requirements of the women We are directly affected by and depen- Abortion Worldwide”.International concerned and often leave little room for dent on it. We should therefore argue for Family Planning Perspectives, individual needs. Rather, the profession- conditions which permit women, who 1999;25(Supplement):S30–S38 ally inexperienced and those not person- have after all become pregnant through (www.guttmacher.org/pubs/jour- ally involved manifest themselves in an our actions, to end an unwanted preg- nals/25s3099.html). apparently arbitrary way depending on nancy in the best possible way and with- 2. VI Conference of International the country. Unfortunately, the restrictive out unnecessary suffering. Federation of Professional Abortion conditions lead to precisely the opposite and Contraception Associates, of what they are intended to achieve. September 2004, Vienna, www.fia- If one compares the frequency of abor- pac.org. tions in various countries, it is clear that 3. Holmgren K. “Time of decision to the countries with the lowest rate of undergo a legal abortion” .Gynecol abortions are those where the general Obstet Invest.1988;26(4):289-95. conditions are most oriented to the needs 4. Royal College of Obstetricians and and where women have the greatest pos- Gynaecologists. “The Care of Women sible autonomy in access to sex educa- Requesting Induced Abortion - tion, contraception and abortion, e.g. the Evidence-based Clinical Guideline Netherlands. Number 7”.London, September 2004. There is no evidence that restricting 5. Agence Nationale d’Accréditation et access by e.g. obligatory counselling or d’Évaluation en Santé (ANAES). waiting periods is of any benefit. They “Prise en charge de l’interruption do, however, lead to a delay in the provi- volontaire de grossesse jusqu’à 14 sion of abortion and have negative effects semaines”.Paris, 2001. on the physical and psychological experi- 25 ence of those affected. Consequently, all guidelines underline the advantages of early abortion (3-5). These aspects should be highlighted in the public dis- cussion and in the formulation of new general conditions. Developments in recent decades have been encouraging inasmuch as the regu-

No. 59 - 2005 SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS IN THE EUROPEAN UNION By Mirjam Hägele

On 3 July 2002, the The Van Lancker Report not only reveals women aged 15-44. In eastern Europe, a lack of statistical information regarding Romania is highest with 52 per 1,000 European Parliament SRHR in Europe, but also large differ- ending in abortion. A Romanian woman passed a resolution on sex- ences with regard to SRHR in individual can expect to have a pregnancy terminat- countries. The report highlights the fact ed on average more than twice in her life ual and reproductive health that abortion rates in the new Member (2.2)(4). States and current candidates for acces- Ultimately, reported abortion rates and rights (SRHR) (1).The sion countries are significantly higher reflect, in part, the legal status of abor- resolution was a result of a than in the 15 pre-enlargement member tion, which in Europe varies greatly from states, attributing it to a greater lack of country to country. Most EU Member report officially presented modern contraceptives. According to the States and candidates for accession have report, “Due to limited availability and liberal abortion laws. However, Ireland, by the Belgian member of the high cost of appropriate contracep- Malta, Poland, Portugal, Spain and European Parliament (MEP), tives, as well as the lack of counselling pursue a very restrictive abortion services in central and eastern Europe, policy. In Poland, the former liberal law Anne E. M.Van Lancker, for abortion still remains the principal has been changed and after 40 years, the Committee on Women’s means of fertility reg- ulation”. Rights and Equal The report contin- Modern contraceptive prevalence in Europe ues, that 65 per cent in per cent in select countries Opportunities (2).It of women in the “old” 0 European Union analysed the SRHR situation 0 Member States (i.e. 0 in the European Union (EU) the 15 members prior 81 0 to enlargement in 71,8 and the ten countries that 68,4 May 2004) use contra- 0 joined the EU in May 2004. ceptives; this figure 0 56,4 drops to 31 per cent 0 46,8 in the new members 38,9 39,3 41 and candidates for 0 32,8 29,5 30,5 accession countries. 0 19 Poland is at the bot- 0 tom of the table in the 0 region, with only 19 tria and Italy mani per cent of women Pol Latvia Aus Estonia RomaniaLithuaniaPortugal Slovakia HungaryGer said to be using mod- Kingdom ern contraceptives (3). United The Van Lancker Source: Modern Contraceptive Use 2003. United Nations 2004 report also identifies that family planning does not form part abortion is now permitted only on a very of general health policy in Greece and limited basis, while in Malta it is not Spain, and that Ireland only supports allowed under any circumstances. “natural methods” of contraception at the city and state levels, and there is a Contraception and abortion in serious deficiency in the dissemination of Europe contraceptives. General inadequate provi- Due to a lack of information in the area sion in the candidates for accession of family planning and a high unmet 26 countries and new Member States gives need of modern contraception, the pro- great cause for concern on account of portion of unplanned pregnancies in high rates of sexually transmitted infec- eastern and central European countries is tions and high abortion rates in some particularly high; 80 per cent of these countries. unplanned pregnancies are also unwant- It is known that abortion rates are ed (5). In former Soviet and other east- much higher in many of the new mem- ern European countries, most of these ber and current candidates for accession pregnancies end in abortion (5). This is states than in the old EU member states. especially the case in those countries Amongst this group, Sweden has the where abortions are cheaper than contra- highest abortion rate, with 18 per 1,000 ception. In Romania, for example, cou- ples are expected to pay for their own Population and Development (ICPD) in tries, the European Parliament’s resolu- contraceptives, whereas pregnancy termi- Cairo (1994) and the Fourth World tion has continued to lead to controver- nations are paid for by the state. Conference on Women (FWCW) in sial discussions. It is especially the recom- The Van Lancker Report also con- Beijing (1995). The resolution further- mendation of the Van Lancker report to cludes that sexual education for young more recommends the following mea- legalise abortion under certain circum- people is unsatisfactory, contributes to an sures to all EU Member states and acces- stances, which has continued to spark increased number of teenage pregnancies sion countries in order to improve the controversy, especially since the passing throughout Europe and ultimately a high SRHR situation in Europe: of the Parliament’s resolution. Although number of abortions. The disparity • the introduction of uniform data col- the resolution is not binding, Poland and amongst the old EU member states, for lection; Malta have protested strongly against it example, is startling: in the UK, 28 out of • the development of national policies and claim that SRHR is a matter for each every 1,000 girls between the age of 15 to improve SRHR; individual state and thus does not fall and 19 get pregnant; in the Netherlands, • blanket provision of free or cheap under the jurisdiction of the EU. Both the rate is 7 out of every 1,000 girls. The contraception and family planning governments fear that the EU wants to report especially criticises the fact that services; put pressure on national abortion laws. It young people in Bulgaria can only take • promotion of emergency contracep- is for this reason that Poland and Malta – part in sexual education classes with the tion; as well as Ireland – demanded supple- written consent of a parent, though this • legalisation of safe pregnancy termi- mentary clauses when they signed their is considered to be better than no sex nation for all. The resolution explicit- accession declarations. These clauses education at all, as is the case in Poland. ly mentions that abortion should not allow them to reserve the right to take all The Van Lancker report stresses that be promoted as a form of family decisions with regard to abortion laws, abortion in the new member and acces- planning and that preventative mea- under all circumstances. sion states is one of the leading causes of sures to avoid abortion should be A powerful opponent of many of the maternal mortality in central and eastern taken; ICPD Programme of Action points is the Europe. WHO estimates that these abor- • governments should never prosecute Vatican, which has a strong influence in tions are responsible for more than 20 women who have had an illegal abor- many Catholic countries, and is also a per cent of all cases of maternal mortality tion; leading advocate in Brussels. Through in some central and eastern European • increase the level of information on Article 51 of the EU constitution, which countries (6). This can be traced back to SRHR in the public domain; calls on the EU to pursue regular dia- the fact that many of these abortions are • improvement of sexual education logue with churches as part of its deci- unsafe. and the provision of family planning sion-making process, the church has services for young people; secured an influential position for the Recommendations of the Van- • orientation of national SRHR policies future. Lancker report in alignment with the decisions made Furthermore, an increasing number of The resolution passed by the European at the ICPD, FWCW and their fol- anti-abortion organizations are making Parliament in July 2002 and based on the low-up conferences. their voices heard within the European Van Lancker report (2) clearly supports Union. Letter and e-mail campaigns, the Programmes of Action agreed on at Political controversy within the EU which lobby for their issues, sometimes the International Conference on Within the EU and the accession coun- with false or incomplete information, form the backbone of their targeting of members of the European Parliament Unplanned Pregnancy and Abortion (MEPs). Last year, for example, the British organization “CARE for Europe (Christian Action Research and Region Total annual Planned Unplanned Unplanned Education)” sent a letter to MEPs, which pregnancies pregnancies pregnancies pregnancies that stated that people in developing coun- (in millions) and births that end in birth end in abortion tries did not need more money for family planning, as they had better access to 27 condoms than to clean water. Worldwide 210 62 % 16% 22% Furthermore, condoms did not protect against HIV and were thus, according to Eastern Europe 11 37% 6% 57% CARE for Europe, “as safe as Russian Rest of Europe 7 67% 12% 21% Roulette” (7). The organizations World Youth Alliance, KALEB e. V. (“Kooper- ative Arbeit Leben Ehrfürchtig Bewah- Source: Alan Guttmacher Institute: Sharing Resposibility: Woman Society & Abortion ren” – Co-operative work to preserve the Worldwide, New York and Washington 1999 honour of life), Pro Life Berlin and euro- fam work in much the same way.

No. 59 - 2005 EU development policy on SRHR References Mirjam Hägele One focus of the European Parliament’s 1. European Parliament: Resolution of [mirjam.haegele@dsw- resolution on SRHR is the EU’s develop- the European parliament on Sexual hannover.de] ment policy as a whole. It calls for this and Reproductive health and Rights Media officer policy “to take into account the devastat- (2001/2128(INI)) of July 3rd, 2002: German Foundation for World ing impact of the policy of http://www2.europarl.eu.int Population (DSW) the Bush Administration.” When 2. Anne E.M. Van Lancker (2 April Translation: Thomas Crowe President Bush froze the annual US con- 2002): Draft report on sexual and tribution to the United Nations reproductive health and rights Population Fund (UNFPA), the EU (2001/2128(INI)). Committee on replaced the funds. Under the leadership Women’s Rights and Equal of Poul Nielson, then EU Commissioner Opportunities: for Development and Humanitarian Aid, http://www.europarl.eu.int/meet- the EU granted 32 million Euros in the docs/committees/femm/20020417/46 autumn of 2002 to UNFPA and the 3603EN.pdf International Planned Parenthood 3. United Nations (2004): Modern Federation (IPPF). In addition, the EU Contraceptive Use 2003. approved a further 73.95 million Euros in 4. Florina Sebanescu (2004): the summer of 2003 for the support of “Reproductive Health in Transition reproductive health in developing coun- Countries in the European Context”. tries until 2006. In: European Population Forum In the spring of 2004, the European 2004: Population Challenges and Parliament passed the report “Population Policy Responses. Background Paper. and Development: ten years after the UN 5. WHO (2004). Unsafe abortion: glob- conference of Cairo.” Karin Junker, then al and regional estimates of incidence social democratic MEP from Germany of unsafe abortion and associated and Member of the European mortality in 2000. Geneve, 4th edi- Parliamentary Committee for tion. calls for bet- Development and Co-operation, drafted 6. http://www2.europarl.eu.int ter promotion of sexual and the report. The report calls on the (accessed 21 November 2004) reproductive health in Europe European Union, the EU Member States 7. CARE for Europe – Sandbaek Report On 5 October 2004, the Parliamentary and the accession countries to fulfil the – Giving Aid or Pushing an Agenda. Assembly of the Council of Europe obligations they promised at ICPD, in Fax to an MEP. called on member states to provide Cairo. The MEPs passed the report after a 8. Karin Junker (2004): Report on pop- Europeans with more information and few amendments with 287 to 196 votes, ulation and development: 10 years better education on sexual and repro- and 13 abstentions (8). after the UN-Conference in Cairo ductive health. Problems include a The most recent proof of Europe’s (2003/2133(INI)). Committee on sharp rise in teenage pregnancies, commitment to the ICPD Programme of Development and Cooperation: rates of sexually transmitted diseases, Action was the announcement of the http://www2.europarl.eu.int including HIV/AIDS, and an increase in EU’s and EU Member States’ intention – sexual violence, the parliamentarians on the occasion of the United Nations said.The Assembly also wants mem- General Assembly Special Session to ber states to share information about commemorate 10 years since the ICPD in their more successful experiences, and Cairo (14 October 2004) – to grant to provide adequate funds for the UNFPA a further US $75 million for con- development of STI screening, as well traceptives. Thus, Europe has effectively as counselling, services, and contra- closed the resource gap left by the with- ception, including for young people. 28 drawal of the US contribution. US President Bush has now withheld pay- See the Council of Europe website for ments to UNFPA for the third year in a the text and recommendation. row, in spite of the contribution being passed by the US Congress. Moreover, as http://assembly.coe.int/Main.asp?link shown in the box, the European Council =http://assembly.coe.int has called on member states to provide Europeans with more information and better education on sexual and reproduc- tive health. Abortion in Europe “WOMEN ON WAVES”DEBATE AT THE EUROPEAN PARLIAMENT By Patricia Hindmarsh

t the end of August 2004, the Por- Ms Figueiredo called on the Commission mocracy group) - all four Polish speakers tuguese Government banned a to state its view on the situation and urge being anti-choice. ADutch ship belonging to the orga- Portugal to change its attitude and lift the In order to calm the emotional debate, nization “Women on waves” from enter- ban on the Women on Waves ship. During EU Commissioner Margot Wallström said ing Portuguese waters or docking at a the debate, Ms Figueiredo referred to the that "The Commission intends to seek Portuguese port. It cited local laws and so-called “van Lancker” report, adopted by information on the precise motives and public health concerns and even ordered the European Parliament in July 2002 (2) implications of the decision”,before con- the Navy to deploy a warship to shadow and called on the EU member states to sidering legal action as to whether Lisbon the boat and ensure it stayed outside its make abortion safe and accessible where violated EU law. She added that under EU territorial waters. This action prevented legal, and refrain from prosecuting women law, member states could restrict funda- debates and information sessions on sex- for illegal abortions. She also stressed that mental rights such as freedom of move- ual and reproductive rights scheduled by the situation in Portugal is one of hypocri- ment of people "only when it is justified Women on Waves with Portuguese and sy and , as it often ... for public security and public health". European parliamentarians. In reaction, results in clandestine and therefore unsafe She added that "The Commission believes the Socialist, United Left and Green par- abortions. that any member state adopting a deci- ties within the European Parliament cal- Instead of focusing on the question of sion restricting the free movement of per- led for a debate to urge the European the legality of Portugal’s action, several sons must respect fundamental rights, Union (EU) to take legal action against parliamentarians took this opportunity to including the freedom of expression as Portugal for breaching rights to freedom call for a complete ban on abortion general principles of [EU] community of expression and information, as well as throughout the EU, a matter over which law." (3) free movement of persons and services. the EU has no competence. Hans A strengthened anti-choice sentiment Blokland, Dutch member of the Inde- within the newly enlarged European Par- The current situation in Portugal pendence/Democracy group, stated that liament cannot be denied - this debate Portugal has a very restrictive abortion law, “The Portuguese government should be provided an excellent opportunity to gage which only recognizes legal grounds if the praised that it deems unborn life worthy the mood of the European Parliament - pregnancy poses a risk to the woman’s of protection”,while Urszula Krupa, and the increasing number of con- health or life, in the case of foetal malfor- member from Poland for the Polish servative female parliamentarians bent on mation or if the pregnancy is the result of League for Families, stated: “I am thank- reversing women’s rights is cause for rape. Yet, even within this legal framework, ful to God that I have the opportunity of alarm. Therefore, eyes are now turned women are sometimes denied termina- speaking in the European Parliament towards the Commission to take a firm tions because health care professionals are about the most important contemporary stand to uphold women’s rights across the not prepared to confront the social taboo issue – protection of life, especially in the EU. of abortion. However, there are no restric- situation where every year 50 million tions on organizations promoting women’s children are killed in their mother’s References rights or advocating for changes to wombs”.She embarrassed other members, 1. Women on Waves. Portugal’s current legislation. Women on however, when she went on to ask: “Is http://www.womenonwaves.org/arti- Waves does not offer medical abortion in killing helpless children in their mothers’ cle-1020.273-en.html, accessed 27 countries where it is not legal (1).There wombs different from the extermination January 2005. was, therefore, arguably no legal provision in Beslan? On what basis would the 2. Anne E.M. Van Lancker (2 April to prevent Women on Waves from enter- European Union usurp the right to decide 2002): Draft report on sexual and ing Portuguese waters. about the life and death of humans?” (3) reproductive health and rights In the past, there have been several at- According to Michal Tomasz Kaminski, (2001/2128(INI)). Committee on tempts to change Portugal’s abortion laws. Polish member of the Union for Europe Women’s Rights and Equal For instance, in January 2004, pro-choice of the Nation's group, it was also a debate Opportunities. groups in Portugal gathered 120 000 signa- about how contemporary Europe is treat- 3. Debate held at the European tures calling for a new referendum to legal- ing unborn children: “In this room, after Parliament on 16 September 2004, ize abortion. However, Prime Minister Jose new European elections, there are more Dutch boat belonging to the 'Women Manuel Barroso (the new President of the MEPs who have the courage to say: on Waves' association, following an 29 European Commission) decided against unborn children have the right to life! oral question posed by MEP Ilda holding one. They have the right to life in Europe and Figueiredo The debate in the European Parliament everywhere!” (3) (http://www.europarl.eu.int/) was initiated by Ms Ilda Figueiredo, In total, 27 parliamentarians took the Portuguese member of the United Left and floor: 14 were pro-choice (members of Patricia Hindmarsh of the Working Group on Population, the Socialist, United Left, Liberals and [Patricia.Hindmarsh@mariestopes. Sustainable Development and Repro- Democrats, and the Green parties) while org.uk] ductive Health in the European Parlia- 11 were anti-choice (members of the Director of External Relations ment, an all-party group that advocates for People’s party, Union for Europe of Marie Stopes International sexual and reproductive health and rights. Nations, and the Independence and De- www.mariestopes.org.uk

No. 59 - 2005 RESOURCES

Q Web – Women’s Empowerment Base contributed to the compilation of this resource section. See www.qweb.kvinnoforum.se for additional resources.

Safe Abortion: Unsafe abortion Technical and Policy Global and regional estimates of the incidence of unsafe Guidance for Health abortion and associated mortality in 2000 - 4th edition Systems www.who.int/reproductive-health/pages_resources/list- World Health ing_unsafe_abortion.html Organization, 2003 WHO has developed a systematic approach to estimating www.who.int/reproduc- the regional and global incidence of unsafe abortion and tivehealth/publications/- the mortality associated with it. Estimates based on figures safe_abortion/safe_abor- for the year 2000 indicate that 19 million unsafe abortions tion.html take place each year, that is, approximately one in ten This is a comprehensive pregnancies end in an unsafe abortion, giving a ratio of overview, including tech- one unsafe abortion to about seven live births. The publi- nical and policy guidance, cation stresses that: “Where contraception is inaccessible on the provision of safe or of poor quality, many women will seek to terminate abortion. It is available in unintended pregnancies, despite restrictive laws and lack English, French, Polish, of adequate abortion services. Prevention of unplanned Portuguese, Russian and pregnancies must therefore be the highest priority, fol- Spanish. lowed by improving the quality of abortion services and of post-abortion care”.

Maternal Mortality in 2000: Estimates Abortion Policies: A Global developed by WHO/UNICEF and UNFPA Review www.who.int/reproductive- United Nations Population Division, health/publications/maternal_mortality_2000/ Department of Economic and Social Published in 2004, this report defines and measures Affairs, 2003 maternal mortality in all countries and provides www.un.org/esa/population/publica- comparisons with data from 1990 and 1995. tions/abortion/ Margins of uncertainty associated with the esti- Abortion Policies: A Global Review mates are still wide, but the current estimates indi- presents a country-by-country exami- cate that maternal mortality is still a major problem nation of national policies concerning globally, and also a problem in parts of the induced abortion and the context European Region. within which abortion takes place.

Ipas - Global Abortion News Update

www.ipas.org IPAS has recently launched a Global Abortion News Updates feature on its website. It provides 30 Held to ransom an overview of new developments in www.heldtoransom.org abortion law and pol- This IPPF website is dedicated to addressing the icy from around the world, including links and contact details. policy implication of the US , Updates are posted regularly. Other valuable Ipas resource include: the so-called Global Gag Rule. This rule states “Making safe abortion accessible: A practical guide for advocates” that the United States will not allow its financial and “Abortion methods and Post-abortion care”. aid to be used to fund groups that provide abortions or any kind of abortion-related advice or referrals. East Central Europe Abortion Laws and Policies in Brief EuroNGOs www.crlp.org The Center for Reproductive Rights is a non-profit US-based legal advo- cacy organization working to ensure safe, legal and accessible abortion care worldwide through a range of legal and policy strategies. The Center produced this and similar web resources such as “Safe and legal abortion is a woman’s human right“ to outline arguments for why abortion is to be considered a human right and to provide reference material on policy and rights related to abortion.

Catholics for a Free Choice www.cath4choice.org CFFC is a non-governmental organization based in Washington, DC, that has special consultative status with the Economic and www.eurongos.org Social Council (ECOSOC) of the United The European NGOs for Sexual and Nations. CFFC shapes and advances sexu- Reproductive Health and Rights, Population al and reproductive ethics that are based and Development (EuroNGOs), formed in on justice, reflect a commitment to 1996, seeks to increase awareness and support women’s well-being and respect and for the ICPD Programme of Action in affirm the moral capacity of women and Europe. EuroNGOs unites and collaborates men to make sound decisions about their with a wide range of sexual and reproductive lives, and works to infuse these values into health and rights advocates, including NGOs, public policy, community life and parliamentary groups, foundations and donor Catholic social thinking and teaching. agencies from Europe and other parts of the Most recently, they launched a “Catalyst for Change Speakers Bureau” to world. Through its newly launched website, inter alia provide recommendations for the US government, the United annual meetings, publications and multiple Nations Population Fund (UNFPA) and religious communities aimed at listserves, EuroNGOs shares information and fostering human rights and informed choice. encourages cooperation with many different groups, particularly young people.

FIAPAC www.fiapac.org The International Federation of Professional Abortion and Contraception Associates (FIA- PAC) is a leading professional organization in the field. They seek to secure the right to a legal and safe abortion for all women who desire it. Through congresses and other meetings they work to harmonize legislation con- cerning abortion and for freedom of access to all abortion methods in all countries. See their website for more details and information from their XVII World Congress of Sexology last international meeting, held in Vienna in September 2004. 10-15 July 2005, Montreal, Canada 31 www.montrealsexo.com The conference theme “Unity in Diversity” highlights the diversity of approaches and dis- ASTRA Network in Eastern and Central Europe ciplines in the field of Sexology, and partici- ww.astra.org pants will include clinicians, researchers, edu- ASTRA is a network composed of sexual and reproductive health and cators, activists and policy-makers. See the rights organizations in central and eastern Europe. Their website website for the full scientific programme and includes policy documents related to sexual and reproductive health and registration details. rights with links to abortion-related materials

No. 59 - 2005 The European Magazine for Sexual and Reproductive Health

WHO Regional Office for Europe

Reproductive Health and Research Programme

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