In Brief Series 2012, No.1 Making Services Accessible in the Wake of Legal Reforms

The passage of a liberalized abortion is one of many media campaigns; and using legal strategies that frame access to safe abortion as a public changes that must take place if women are to gain access health issue and a human right. to safe and legal services. A study of the process following Less has been published about how are legal reforms in six settings in Asia, and Latin implemented and what impact they have on abortion services and women’s health. America confirms that the practical work of establishing safe Experience in several countries suggests that abortion services can take years and requires resources and legislative change does not automatically lead to universal access to safe abortion services commitment. Where these efforts have been undertaken and within the bounds of the law, especially in poor countries. In , for example, abortion information on trends in abortion-related illness and is has been legal on broad grounds since 1971, available, evidence is beginning to demonstrate that liberalized but four decades later, fewer than half of procedures are likely safe. Similarly, although laws are followed by improved health outcomes for women. a liberal abortion law was enacted in in 1997, the majority of terminations in 2008 in the Southern Africa subregion Induced abortion has been legal on broad or under unhygienic conditions, or they (where residents of South Africa account for grounds in most of the industrialized are induced by the pregnant woman her- nearly 90% of the female population) were world since the 1970s or earlier. How- self. In addition to endangering women, still unsafe. ever, the legal status of abortion in the and its consequences developing world is mixed, and interpreta- place a costly burden on health systems. This brief summarizes a longer report examin- tion of the laws varies. Nearly one-half of ing the implementation and impact of less re- Some countries have responded to these women of childbearing age in the devel- strictive revised abortion laws in six settings. concerns by making legal reforms. Since oping world live in countries that have Case studies presented in the report drew on 1995, legal restrictions on abortion have banned the procedure entirely or allow it findings from a wide range of reports, as well been reduced to varying degrees in 26 only to save a woman’s life or protect her as questionnaires and interviews with experts countries and in ’s capital city. health. Outside of India and , where from both government and nongovernmental Many of the reforms were spearheaded abortion laws are liberal, eight in 10 organizations. As part of this undertaking, by women’s health and rights organiza- women in the developing world live under Guttmacher researchers developed a frame- tions that waged hard-fought legal and highly restrictive laws. work for understanding and evaluating the educational campaigns to bring about processes that would ideally follow the pas- Yet, there is clear evidence that restric- change. Some successful strategies have sage of a revised abortion law (see box, page tive abortion laws are associated with a emerged and are well-documented. They 3). Each of the six case studies addresses the high incidence of unsafe abortion and its include conducting research on the inci- elements laid out in this framework. health consequences, and in dence, consequences and costs of unsafe these settings contribute substantially abortion; disseminating the findings to Six settings in which abortion laws to maternal illness and death. Abortions advocacy groups and political organiza- recently changed that occur outside of the law are usually tions; building coalitions among repro- Between 1997 and 2007, , , clandestine and unsafe because the proce- ductive rights activists and legislators; , , and South Africa dures are performed by unskilled providers mobilizing public opinion through mass undertook reforms to ease restrictions in their tion as a political liability) or Grounds for Legal Abortion Under Revised Laws abortion laws. These countries In Six Country Settings span the development spectrum. restrained by a lack of resources Cambodia, Ethiopia and Nepal or the persistence of widespread are among the world’s most stigma surrounding abortion. Cambodia, 19971 During the first 12 weeks,* permitted on any impoverished countries, with grounds. After 12 weeks, permitted if (1) the Despite the lack of comprehen- relatively low levels of educa- is abnormal or poses a risk to the sive public awareness cam- woman’s life, (2) the baby may develop an incur- tion, low health spending per paigns, knowledge of changes in able disease after birth or (3) the pregnancy capita, and high maternal and resulted from . Requests for abortion must be the abortion law appears to be . In contrast, made by a minor’s parents or guardians. high in the two most economi- South Africa, Colombia and cally developed settings, Mexico Colombia, 20062 Permitted with no gestational limit if (1) the Mexico City have relatively City and Colombia. Both have pregnancy threatens the woman’s life or health, advanced and health as certified by a doctor, (2) a doctor certifies numerous print and television systems. These differences that the has grave malformations incompat- news outlets with large audi- have had implications for each ible with life or (3) the pregnancy resulted from ences, which offer thorough criminal acts reported to proper authorities. country’s ability to translate coverage of outstanding politi- new laws into practice. Other 3 cal issues, including changes in Ethiopia, 2005 Permitted before the fetus is viable (conven- important contrasts between the tionally interpreted as 28 weeks after the last the abortion laws. menstrual period) if (1) the pregnancy resulted settings, including cultural fac- from rape or , (2) the health or life of the tors and religious beliefs, have Guidelines and their woman or baby is in danger, (3) the fetus has an also influenced the receptivity dissemination incurable and serious deformity, (4) the woman to abortion law reforms. has physical or mental disabilities or (5) the Clinical and administrative guidelines are important to woman is a minor and is unprepared to raise a All of the settings had highly child. formalize and standardize restrictive laws before the abortion service delivery and Mexico City, 20074 During the first 12 weeks, permitted on request. reforms—abortion was either medical care. Where they exist, After 12 weeks, permitted only to protect the not permitted at all or was such guidelines are generally woman’s life or health and in cases of rape and only permitted in exceptional fetal impairment. developed and disseminated circumstances. The scope of by government agencies, often 5 the reformed laws varies widely Nepal, 2004 During the first 12 weeks, permitted on any with support from NGOs, in- grounds. In weeks 13–18, permitted if the (see table). In four countries, ternational agencies and other pregnancy resulted from rape or incest. At any abortion is now legal without stakeholders. The existence and gestation, permitted under an authorized medical restriction within set gestational practitioner’s recommendation if the woman’s life scope of such guidelines varies age limits (12 weeks in Cambo- or physical or mental health is at risk, or if there across the six settings studied, is a risk of fetal impairment. dia, Nepal and South Africa, and and comprehensive guidelines 28 weeks in Ethiopia) and on a 6 are widely available in two— South Africa, 1997 During the first 12 weeks, permitted on request. more limited basis after that. In weeks 13–20, permitted if a medical prac- Ethiopia and Colombia. The The Mexico City law permits titioner believes that (1) the pregnancy poses a Ethiopian guidelines have risk to the woman’s physical or mental health, abortion on request until the contributed to progress in (2) there is a substantial risk that the fetus 12th week of pregnancy, but not improving access to legal would suffer from a severe physical or mental later. The Colombian law allows abnormality, (3) the pregnancy resulted from abortion services. Colombia’s abortion only in cases of rape, rape or incest or (4) continuing the pregnancy service guidelines, based on would significantly affect the woman’s social or incest or fetal malformation, a manual by the World Health economic circumstances. After the 20th week, and to save the woman’s life permitted if a medical practitioner, in consul- Organization, are accessible or health; it does not specify a tation with another medical practitioner or a and complete, but because of registered midwife, believes that the continued limit. pregnancy would (1) endanger the woman’s life, unrelenting political opposition (2) result in a severe fetal malformation or (3) Public awareness of changes to abortion services and a host pose a risk of injury to the fetus. in the law of other factors, there has been Outreach activities occurred in little opportunity to use them. *The first trimester of pregnancy is usually calculated as 12 weeks from the most of the settings examined, Guidelines have also been devel- first day of the woman’s last menstrual period. though to different extents. oped and disseminated in South Outreach may have been limited Africa, though dissemination intentionally (because public was not as widespread there officials may view legal abor- as in Ethiopia or Colombia.

Abortion Services in the Wake of Legal Reform 2 Guttmacher Institute Framework for Action After Abortion Law Reform Africa, the overall abortion rate Resistance to the new laws has declined even while the rate The findings in the six settings The following steps are likely to help achieve successful implementation of safe abortion has increased. show that resistance to legal of a new law: Evidence suggests that the abortion can intensify after • Disseminate information about the new law to government agencies, revised law in South Africa abortion laws are reformed. public and private health care providers, and the general public. is associated with a dramatic In Colombia, for example, the • Publish and disseminate regulations, guidelines and protocols for provid- reduction in abortion-related assumed a ing safe abortion services. maternal in facilities. largely hands-off role before the • Train health workers to perform safe abortions, and provide supplies and 2006 court decision that liberal- equipment for safe abortion at authorized facilities. The measurable impact of the ized abortion, but opposition revised laws in the other set- • M onitor and evaluate of the incidence of safe and unsafe abortion and the intensified dramatically thereaf- tings has varied tremendously: health impact of new abortion services. ter. Opposition to implementing • In Ethiopia, where levels of safe and legal abortion services unsafe abortion prior to the can take many forms and must Guidelines exist in Mexico City An important factor determining new law are unknown, safe continually be addressed. and Nepal, though it appears access to safe abortion ser- legal procedures made up Across settings, the case studies that they have not been widely vices is the number of providers slightly more than a quarter showed that resistance among disseminated or used. trained in safe abortion tech- of all abortions in 2008. A health providers, political niques. In South Africa, Nepal subnational study indicates backlash and continuing stigma Creation and uptake of safe and, to a more limited extent, that the incidence of compli- abortion services are common reactions to abor- Cambodia, efforts to establish cations from unsafe abortion Providing safe abortions through tion law reform. Many laws services have benefited from au- has declined. the public health system is thorizing and training midlevel contain conscientious objection challenging for countries with providers, such as nurses and • In Mexico City, the very large provisions that allow hospital underfinanced, overburdened midwives, to perform abortions. gap between the number and clinic workers to opt out health systems. After revising of reported legal abortions of the service for religious or its abortion law, Nepal worked Impact of the revised law and the estimated number ethical reasons, and several with international NGOs to A critical question about abor- of abortions derived from settings have demonstrated that implement a carefully planned tion law reforms is whether independent research suggests antiabortion legislators often strategy to make services avail- they affect the number and that most abortions are still capitalize on such provisions. In able, which included developing safety of abortions performed, obtained outside of officially such settings, health planners manuals, training public- and and ultimately whether they sanctioned facilities. may have to anticipate staffing private-sector providers, and contribute to improvements in shortages due to the reluctance • In Nepal, the impact of the issuing necessary supplies and women’s health. The evidence of some health professionals to new abortion law on the equipment. In Mexico City, high- is limited, however, because address sexuality, unplanned overall incidence of abortion level Ministry of Health officials many women and providers are pregnancy and abortion, and to cannot be determined because started planning for the provi- reluctant to report abortion due participate in related services. there were no reliable esti- sion of safe abortion services to the stigma associated with it, mates of abortion incidence Once law reform has taken before the new law passed, and particularly when it is restricted. before the law was revised. place, educating women and training of doctors began soon Moreover, in Colombia and There is evidence that the law men about the new right to after the law was enacted. In Mexico City, legal services have reform has contributed to a abortion, helping them pro- South Africa, safe abortion ser- not been available long enough decline in complications from tect this right and overcoming vices have been made available to allow measurement of their unsafe abortion. related stigma may pose new in many public health facilities, impact. challenges to providers and though the provision of services • In Colombia, the narrow terms In South Africa, where the other stakeholders involved in is not sufficient to meet the of the law reform preclude new law has been in place making safe abortion available. overall demand. Even in Ethiopia any notable impact on the the longest, the difference in In addition, establishing a pub- and Cambodia, where health incidence of safe and unsafe national abortion incidence lic health service to provide a care infrastructures are relative- abortions or on related mater- before and after reform is not procedure that had been previ- ly weak, limited services have nal mortality or morbidity. ously outlawed, stigmatized and been instituted, and one-fourth known; however, in the South- clandestine is no simple task. to one-half of abortions are now ern African subregion, which is It may require acknowledging performed legally in facilities. comprised primarily of South

Guttmacher Institute 3 Abortion Services in the Wake of Legal Reform pervasive societal and cultural • To address shortages of skilled References Credits disapproval of abortion and providers, partnerships should 1. Population Division, United This report, written by Lori Ashford, developing educational strate- be encouraged between Nations Department for Economic independent consultant, and Gilda gies to counteract deep-seated ministries of health, medical and Social Development, Abortion Sedgh and Susheela Singh, both of attitudes. schools and nurse-training Policies: A Global Review, Volume I, the Guttmacher Institute, summa- to , : rizes the findings of Making Abortion colleges to recruit and train , 2002, p. 80. Services Accessible in the Wake of Further actions needed providers in safe abortion Legal Reforms: A Framework and Six Strong policy and program techniques, as well as other 2. Congress of Colombia Law 599, Case Studies, New York: Guttmacher which issues the Penal Code with actions are needed to ensure skills related to reproductive Institute, 2012, . that the provisions of the new health. Advocates should 2006,, accessed Mar. 15, 2012. longer report. This brief was edited well-understood by health pro- legally permitted to perform 3. Ethiopian National Legislative by Haley Ball, Guttmacher Institute. fessionals and the public, and abortions. Bodies No. 414, The Criminal Code of The authors thank the following col- implemented in ways that make the Federal Democratic Republic of leagues for reviewing early drafts of safe and legal abortion services • Pr ogram planners and legal Ethiopia, 2004, , accessed Dec. 15, Luisa Cabal and Lillian Sepulveda, include the following: abortion law reforms. Consci- 2011. Center for ; entious objection should be • Governmental and nongovern- 4. Office of the Governor of the Tamara Fetters and Charlotte Hord addressed clearly in laws and Smith, Ipas; and Iqbal Shah, World mental stakeholders should Federal District, Mexico City, Decree official guidelines, explicitly Reforming the Federal District Penal Health Organization. use the media and other avail- spelling out what actions Code and Amending the Federal Dis- able avenues to inform the This brief was made possible by facilities must take to ensure trict Health Law (in Spanish), 2007, grants from the Dutch Ministry of public and health providers that women are able to obtain pp. 2–3, , accessed Feb. 10, 2012. needed, by referral to other Suggested citation: Ashford L, dures can be obtained legally staff or facilities that will 5. Nepal Department of Health Ser- Sedgh G and Singh S, Making abor- and which health profession- provide the services. vices Division, National Safe Abortion tion services accessible in the wake als provide them. Policy, Kathmandu, Nepal: Ministry of of legal reforms, In Brief, New York: • Don ors, researchers and public Health, 2002. Guttmacher Institute, 2012, . health systems, useful strate- toward improved reporting of mination of Pregnancy Act, 1996, , accessed lection of data on abortion- Nov. 22, 2011. ing low-cost, safe abortion related maternal deaths and techniques and increasing the illnesses, and robust estima- use of midlevel providers. Re- tion of the incidence of un- ferral to facility-based services safe abortion. for complications must be provided on an ongoing basis.

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April 2012