Complications”

Breanna Tauschek, Summer Research Associate Summary of Research for Chapter 2 of “Complications”

The Example of Chile: Restrictive Abortion Laws and Low Maternal Mortality Rates: In 2017, Chile’s maternal mortality rate (MMR) was less than the USA, with the former having 13 deaths per 100,000 live births and the latter having 19.1 This is a slight continued decrease from 2009 on, despite the fact that in 2017 the already restrictive abortion laws in Chile became even more restricted, with the expansion of conscientious objection rights to include entire private healthcare institutions rather than simply individuals involved directly in the procedure.2 Further, it is still very difficult to get an abortion in Chile due to lack of knowledge of the law, private clinics insisting on showing women their ultrasounds, and lots of documentation required to be transferred to a hospital that will perform the procedure.3 In 2017, the lifetime risk of maternal death was 0.022%, a continual decrease from 2000 on (in 2000 it was 0.067%).4 In fact, in 2017 Chile remained one of the countries with the lowest MMR (in the top 37). While the top 37 may not sound very impressive, it is important to note that there is repetition amongst countries with the lowest MMRs; multiple countries will share the same MMR. This means that, while Chile is in the top 37 in terms of countries, it is actually in the top 12 (the lowest MMR is 2) if we’re simply counting the number of deaths. In all of the countries with the lowest MMRs abortion is legal to some extent; in most of them it is legal on demand.5 However, a study performed on 13 of these countries (Belgium, The Netherlands, France, Spain, Sweden, Denmark, Belgium, Czechia, Austria, Germany, Greece, Italy, and Poland) found that, with improvements to healthcare, there was a steady (although slightly unequal if you were of a lower socioeconomic status) increase in the overall health of the population; this needs to be taken into account when discussing MMR for these countries as it will no doubt have an effect on it.6 The use of external assessment strategies for healthcare providers is common practice in Europe (where most of these countries are).7 Those countries

1 World Health Organization (2019). Maternal Mortality Ratio (per 100 000 live births): 2017. https://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html. Accessed 10 August 2020. 2 Maira, Gloria, Casa, Lidia, and Vivaldi, Lieta. Abortion in Chile: The Long Road to Legalization and its Slow Implementation. Health and Human Rights Journal December 2019; 21(2), pp. 121-131, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927382/. Accessed 10 August 2020. 3 Ibid, see pp. 126-27 4 The World Bank. Lifetime risk of maternal death (%) - Chile. World Bank Group, https://data.worldbank.org/indicator/SH.MMR.RISK.ZS?display=graph--%3E&locations=CL&name_desc= false. Accessed 10 August 2020. 5 World Population Review. Countries Where Abortion is Illegal 2020. World Population Review, https://worldpopulationreview.com/country-rankings/countries-where-abortion-is-illegal. Accessed 10 August 2020. 6 Abeliansky, Ana Lucia, and Strulik, Holger. Long-run improvements in human health: Steady but unequal. The Journal of the Economics of Ageing 2019; 14, DOI: https://doi.org/10.1016/j.jeoa.2019.01.003. Accessed 10 August 2020. 7 Busse, Reinhard, Klazinga, Niek, Panteli, Dimitra, and Quentin, Wilm. Improving healthcare quality in Europe - Characteristics, effectiveness and implementation of different strategies. The European © deVeber Institute 2020 2 that do not have their own form of internal accreditation are often accredited by organizations with international standards.8

French Study: More Repeat Abortions In France in 2011, it was found that the number of abortions had not actually decreased with the cutoff for abortion increasing to 14 weeks.9 Instead, while the number of women having abortions overall had declined, the number of repeat abortions had increased.10 Further, while first abortions in those older than 25 had decreased, they had actually increased in 18 - 25 year olds.11 This is concerning because it is known that repeat abortions lead to a greater risk of premature births which can cause a host of potential ailments, including cerebral palsy (this is discussed in length in chapter 15 of “Complications: Abortion’s Impact on Women”). If abortions are happening increasingly with younger women, then this becomes a very serious problem. Women between the ages of 18 - 25 in Europe and North America are likely to still be in school. In fact, in the French study it was found that one-fifth of women who had abortions were in school, be it high school or post-secondary.12 As such, women of this age are likely not financially stable enough to care for a child. Young women who are financially unstable/unfit to be parents at the time of their first abortion (or first few abortions depending on if they have repeat abortions) may want a child later in life when they are in a more secure socioeconomic position. Abortion is increasing their risk of having a premature birth.

Maternal, Infant, and Child Mortality in India, Bangladesh, Poland, Hungary, Russia, Uganda, and South Africa: Comparing the Statistics:

Maternal Mortality: India: In India in 2017, maternal mortality was down to 122/100,000 live births; this is a decline from 2015, and translates to 2,000 additional mothers being saved from maternal-related causes of death each year in 2017 as compared to 2015.13 Bangladesh:

Observatory on Health Systems and Policies. World Health Organization 2019, p.211-12, https://apps.who.int/iris/bitstream/handle/10665/327356/9789289051750-eng.pdf?sequence=1&isAllowed =y. Accessed 10 August 2020. 8 Ibid, see p. 213 9 Mazuy, Magali, et al. “A Steady Number of Induced Abortions, but Fewer Women Concerned.” Population (English Edition, 2002-), vol. 69, no. 3, 2014, pp. 323–356. JSTOR, www.jstor.org/stable/24638241. Accessed 11 Aug. 2020. 10 Ibid 11 Ibid 12 Ibid, see p. 329 13 UNICEF India. Maternal Health: UNICEF’s concerted action to increase access to quality maternal health services. UNICEF, https://www.unicef.org/india/what-we-do/maternal-health. Accessed 19 August 2020. © deVeber Institute 2020 3

In 2017, the maternal mortality ratio in Bangladesh was 173 per 100,000 live births, a decrease from 2015.14

Uganda: In Uganda in 2017, the maternal mortality rate was 375/100,000 live births.15 While this is quite high, it is a decrease from 2000 on.

South Africa: In 2017, South Africa’s maternal mortality rate was 119/100,000 live births.16

Poland: The maternal mortality rate in Poland remained stable between 2014 and 2017, with just 2/100,000 live births.17 Hungary: Hungary’s maternal mortality rate went up and down during the early 2000s, but stayed steady at 12/100,000 live births between 2012 and 2017.18

Russia: Russia’s maternal mortality rate was 17/100,000 live births in 2017, which is a slight decrease from 2015 when it was 18/100,000.19

Infant Mortality:

14 WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Bangladesh. Geneva, World Health Organization 2019, https://data.worldbank.org/indicator/SH.STA.MMRT?locations=BD. Accessed 17 August 2020. 15 Internationally comparable MMR estimates by the Maternal Mortality Estimation Inter-Agency Group (MMEIG) WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Maternal mortality in 2000 - 2017: Uganda. WHO, https://www.who.int/gho/maternal_health/countries/uga.pdf?ua=1. Accessed 19 August 2020. 16 WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Maternal mortality ratio (modeled estimate, per 100,000 live births) - South Africa. Geneva, World Health Organization. World Bank Group 2019, https://data.worldbank.org/indicator/SH.STA.MMRT?locations=ZA&view=map. Accessed 21 August 2020. 17 WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Poland. World Bank Group 2019, https://data.worldbank.org/indicator/SH.STA.MMRT. Accessed 19 August 2020. 18 WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Hungary. World Bank Group 2019, https://data.worldbank.org/indicator/SH.STA.MMRT?locations=HU. Accessed 19 August 2020. 19 WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Russian Federation. World Bank Group 2019, https://data.worldbank.org/indicator/SH.STA.MMRT?locations=RU. Accessed 19 August 2020. © deVeber Institute 2020 4

Russia: Russia’s infant mortality rate was 6.1 per 1,000 births in 2018.20

Poland: Poland’s infant mortality rate was 3.8 in 2018.21

Hungary: Hungary’s infant mortality rate was 3.6 in 2018.22

South Africa: South Africa’s infant mortality rate was 28.5 in 2018.23

Uganda: Uganda’s infant mortality rate was 33.8 in 2018.24

India: India’s infant mortality rate was 29.9 in 2018.25

Bangladesh: The infant mortality rate in 2018 was 25.14 per 1000 live births (males had a higher mortality rate than females, with 26.9 and 23.3 respectively, as is to be expected). This is also a continual decrease, even from 2015.26 Neonatal mortality is also down, with 17.12 per 1000 live births, as compared to 20.8 in 2015 and 94.14 is 1970.27

Additional: Chile

20 Estimates developed by the UN Inter-agency Group for Child Mortality Estimation ( UNICEF, WHO, World Bank, UN DESA Population Division ) at childmortality.org. Mortality rate, infant (per 1,000 live births) - Russian Federation, United States, France, Japan, Kazakhstan, Ukraine, Poland, South Africa, Hungary, Chile, Uganda. World Bank Group, https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?end=2018&locations=RU-US-FR-JP-KZ-UA-PL-ZA -HU-CL-UG&name_desc=true&start=1960&view=map. Accessed 19 August 2020. 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 UNICEF Data: Monitoring the situation of women and children. UNICEF Data Warehouse, Cross-sector Indicators, Geographical area: Bangladesh, Indicator: Infant mortality rate. UNICEF, https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1. 0&dq=BGD.CME_MRY0.&startPeriod=1970&endPeriod=2020. Accessed 17 August 2020. 27 UNICEF Data: Monitoring the situation of women and children. UNICEF Data Warehouse, Cross-sector Indicators, Geographical area: Bangladesh, Indicator: Neonatal mortality rate. UNICEF, https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1. 0&dq=BGD.CME_MRM0.&startPeriod=1970&endPeriod=2020. Accessed 17 August 2020. © deVeber Institute 2020 5

Chile’s infant mortality rate was 6.2 in 2018.28

Under-Five Mortality:

Hungary: In Hungary, the under-five mortality rate was 4.3/1000 live births in 2018.29

Poland: In Poland, the under-five mortality rate was 4.4/1000 live births in 2018.30

Russia: In Russia the under-five mortality rate was 7.2/1000 live births in 2018.31

Uganda: In Uganda, the under-five mortality rate was 46.4/1000 live births in 2018.32

South Africa: In South Africa, the under-five mortality rate was 33.8/1000 live births in 2018.33

India: In India, the under-five mortality rate was 36.6/1000 live births in 2018.34

Bangladesh: In 2018, Bangladesh’s under five mortality rate was 30.2 per 1000 live births - a continual decrease from 1990 when it was 143.7.35

Additional: Chile In Chile, the under-five mortality rate was 7.2/1000 live births in 2018.36

Analysis and Comparisons:

28 Ibid 29 UN Inter-agency Group for Child Mortality Estimations. Most Recent Child Mortality Estimates, 2018. The United Nations (UN) 19 September 2019, https://childmortality.org/. Accessed 19 August 2020. 30 Ibid 31 Ibid 32 Ibid 33 Ibid 34 Ibid 35 UNICEF Data: Monitoring the situation of women and children. Country profiles: Bangladesh. UNICEF, https://data.unicef.org/country/bgd/. Accessed 17 August 2020. 36 Ibid © deVeber Institute 2020 6

South Africa vs. Uganda:

South Africa: Abortion Laws, Barriers to Access, and Declining MMR While the abortion law in South Africa is very liberal, it is still difficult to obtain an abortion due to a lack of information and low socioeconomic status.37 Further, many doctors invoke conscientious objection rights due to stigma and overwork, causing whole clinics to become de facto conscientious objectors even though they aren’t supposed to.38 Because of this, there are still many illegal abortions that happen. In Cape Town, South Africa, out of 42 women who were interviewed (nearly a third of which were sex workers), every one of them reported having one or more illegal abortion in the past five years.39 Fear of stigma and mistreatment in legal facilities was a leading cause of women seeking at-home remedies and illegal clinics.40 Further, in a study examining the illegal dumping of aborted foetuses and abandonment of babies in Gauteng and Mpumalanga it was found that there was an increase in the rate of nonviable dumped foetuses in both provinces from 2009 to 2011, and an increase in the rate of abandoned babies in Gauteng.41 After legalization of abortion in 1996, the maternal mortality ratio in South Africa rose sharply, peaking from 2005-2006 with 201 per 100,000 live births. However, in 2007 through the 2010s it began to decline, being 119 per 100,000 live births in 2017.42 Efforts in increasing HIV awareness, testing, and treatments has increased the amount of women treated for HIV (and men, to a lesser extent).43 This is important because women are disproportionately affected by HIV (in 2018, 4.7 million women were living with HIV compared to 2.8 million men).44 South Africa’s antiretroviral treatment programme (ART) has had great

37 Favier M, Greenberg JMS, Stevens M. Safe abortion in South Africa: "We have wonderful laws but we don't have people to implement those laws". International Journal of Gynecology & Obstetrics. 2018;143 Suppl 4:38-44. doi:10.1002/ijgo.12676. Accessed 13 August 2020. 38 Ibid 39 Gerdts C, Raifman S, Daskilewicz K, Momberg M, Roberts S, Harries J. Women's experiences seeking informal sector abortion services in Cape Town, South Africa: a descriptive study. BMC Womens Health. 2017;17(1):95. Published 2017 Oct 2. doi:10.1186/s12905-017-0443-6. Accessed 13 August 2020. 40 Ibid 41 Jacobs R, Hornsby N, Marais S. Unwanted pregnancies in Gauteng and Mpumalanga provinces, South Africa: examining mortality data on dumped aborted fetuses and babies. S Afr Med J. 2014;104(12):864-869, DOI:10.7196/samj.8504. Accessed 13 August 2020. 42 The Maternal Mortality Estimation Inter-Agency Group (MMEIG) WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Maternal mortality in 2000-2017: Internationally comparable MMR estimates, South Africa. World Health Organization (WHO), https://www.who.int/gho/maternal_health/countries/zaf.pdf?ua=1. Accessed 13 August 2020 and WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization 2019, https://data.worldbank.org/indicator/SH.STA.MMRT?locations=ZA. Accessed 13 August 2020. 43 HIV and Aids in South Africa. Avert 19 February 2020, https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/south-africa. Accessed 13 August 2020. 44 Ibid, see section on groups most affected by HIV in South Africa © deVeber Institute 2020 7 success. Implemented in 2005, the ART programme helped raise life expectancy in South Africa to 63 years in 2018 - a 7 year increase from the 56 year life expectancy in 2010.45 In 2018, 90% of people with HIV were aware of it, and 68% were on treatment.46 87% of those being treated for HIV were virally suppressed.47 South Africa has also increased its testing of pregnant women with 88% of pregnant women being tested for HIV in 2018, and 87% of those who tested positive receiving antiretroviral medication.48 While it is declining more slowly, MMR is declining.49 Clearly, abortion cannot explain the sudden decline in MMR in South Africa, as maternal mortality rose sharply in the ten years after abortion was legalized. So, we must ask ourselves this: What changed in 2007? One answer is that this is when the South African Government’s ART programme, which was created to combat the HIV/AIDS epidemic, began to see results. Its effects started to be seen in 2007 with a continuous decline in HIV/AIDS related deaths. This correlates to when the decline in the MMR started after its peak in 2005-06.50

Uganda: Moore et al found that, when interviewing policymakers, knowledge of Uganda’s very limited abortion law was not well-known, and that it was extremely difficult to obtain even a legal abortion in Uganda.51 Despite this, while it is still high, Uganda’s MMR has been declining. In fact it declined quite significantly between 2000 and 2017, with the numbers going from 578 to 375 per 100,000 live births.52 The Saving Mothers, Giving Life Initiative that was implemented in Sub-Saharan Africa has had huge success in Uganda. It reduced facility-based maternal mortality by 35% in the first year of its implementation.53 In the first year of this initiative, the number of births taking place in healthcare facilities rose by 62%.54 The number of facilities offering 24/7 delivery care increased to 95%, and a larger proportion of these facilities had uninterrupted access to electricity and water.55 This initiative has greatly improved the health of mothers in Uganda.

45 Ibid, see Introduction 46 Ibid, see Introduction 47 Ibid, see Introduction 48 Ibid, see section on prevention of mother-to-child transmission 49 Ibid, see section on prevention of mother-to child transmission 50 South African Government, Department of Health. Health. Official Guide to South Africa 2018/19, https://www.gov.za/about-sa/health. Accessed 13 August 2020. See section on life expectancy. 51 Moore, AM, Kibombo, R, Cats-Baril, D. Ugandan opinion-leaders' knowledge and perceptions of unsafe abortion. Health Policy Plan 2014; 29(7): 893-901. DOI:10.1093/heapol/czt070. Accessed 21 August 2020. 52 See WHO, “Maternal Mortality in 2000 - 2017 - Uganda.” 53 Serbanescu, F., Goldberg, H.I., Danel, I. et al. Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation. BMC Pregnancy Childbirth 2017; 17(42), DOI: https://doi.org/10.1186/s12884-017-1222-y. Accessed 21 August 2020. You can also view the Saving Mothers, Giving Life Initiatives website at http://www.savingmothersgivinglife.org/our-work/uganda.aspx for more information. 54 Ibid 55 Ibid © deVeber Institute 2020 8

Clearly, even without access to abortion, Uganda is doing fairly well in reducing maternal death due to The Saving Mothers, Giving Life Initiative. While South Africa (which has abortion on demand, although there are barriers as mentioned above) has a much lower MMR than Uganda, it is important to note that we are talking about to very different countries in terms of the economy. Not only is South Africa a much bigger country than Uganda, it also has a much higher gross domestic product (GDP). In 2019, South Africa’s GDP was 351.432 billion USD.56 Uganda, in contrast, had a GDP of only 34.387 billion USD in 2019.57 Uganda is a much poorer country than South Africa, so it makes sense that it would have a higher instance of MMR due to less resources available to allocate to healthcare. Further, as noted above, South Africa’s liberal abortion law cannot account for the decline in maternal mortality. Clearly, programs to address public health as a whole have had a much greater impact on falling mortality rates than abortion.

Poland and Hungary vs Russia:

Poland has one of the strictest abortion laws in Europe (abortion is only legal in cases of rape, incest, serious malformation of the fetus, and if the pregnancy poses a serious health risk to the mother as attested to by two physicians).58 In 2016, there was a credible movement to ban abortion altogether in Poland that made it all the way to the Polish parliament before ultimately being struck down.59 Recently, Poland has proposed another bill that would outlaw abortion in the case of severe/fatal fetal impairment, further restricting abortion (this bill has been sent to a parliamentary commission for further review, and so it is not known if it will be passed).60 Despite this, Poland has one of the lowest maternal mortality rates in the world (lower than Canada, where there are no laws governing abortion).61 In fact, it is tied with Belarus, Italy, and Norway for the lowest maternal mortality rate in the world.62 Hungary also has quite a restrictive abortion law, with abortion being legal up to 12 weeks if: 1. the woman is pregnant because of a criminal act, 2. the woman’s health is in serious jeopardy, 3. the woman is in a situation where continuing the pregnancy would result in serious psychological, bodily, or social harm, or 4. if the fetus will likely have a severe disability or

56 The World Bank. South Africa. World Bank Group 2019, https://data.worldbank.org/country/ZA. Accessed 21 August 2020. 57 World Bank national accounts data, and OECD National Accounts data files. GDP (current US$) - Uganda. World Bank Group 2019, https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=UG. Accessed 21 August 2020. 58 Human Rights Watch. Poland: Reject New Curbs on Abortion, Sex ed. Human Rights Watch 14 April 2020, https://www.hrw.org/news/2020/04/14/poland-reject-new-curbs-abortion-sex-ed. Accessed 19 August 2020. See also: Bateman, Jessica, and Kasztelan, Marta. In Poland, Abortion Access Worsens Amid Pandemic. Foreign Policy (FP) 1 May 2020, https://foreignpolicy.com/2020/05/01/poland-abortion-access-worsens-coronavirus-pandemic/. Accessed 19 August 2020. 59 See Bateman and Kasztelan, 2020. 60 See Bateman and Kasztelan and Human Rights Watch. 61 World Health Organization (2019). Maternal Mortality Ratio (per 100 000 live births): 2017. https://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html. Accessed 19 August 2020. 62 Ibid © deVeber Institute 2020 9 impairment.63 Abortion is legal up to 18 weeks if all of the above criteria are met and 1. the woman is incapacitated in some sense by the pregnancy, or 2. she did not become aware of the pregnancy in time because of either a health reason that she cannot control or a medical/health institution’s error.64 Legal abortion can further be extended up to 24 weeks if there is a 50% or greater risk that the fetus will have a serious malformation.65 Abortion is legal in all stages in extreme cases where the life of the woman is endangered by continuing the pregnancy due to a medical condition and/or it is determined that the fetus has a malformation that is so severe as to make life outside of the womb impossible.66 Despite this, Hungary still has one of the lowest maternal mortality rates in the world (in the top 36).67 While the top 36 may not sound very impressive, it is again important to note that there is repetition across countries, meaning that many countries in the same region will have the same maternal mortality rate. Globally, maternal mortality rates range between 2/100,000 live births and 1,150/100,000.68 Having just 12 maternal deaths per 100,000 live births is impressive, and it is considered very low. Russia, which has more liberal abortion laws than both Hungary and Poland, has a higher maternal mortality rate.69 While in 2011 Russia’s abortion laws did become more restrictive (women can have an elective abortion up to 12 weeks, and an abortion between 12 and 22 weeks in the case of rape or life/health of the mother)70 , this is still more liberal than both Poland and Hungary’s laws. Also, this is a fairly recent change. Further, Poland and Hungary both have lower under-five and infant mortality rates than Russia.71

63 Center for Reproductive Rights. Hungary’s Abortion Provisions. Act LXXIX of 1992 on the protection of fetal life, The Fundamental Law of Hungary, Article II (Apr. 25, 2011). Government of Hungary. Center for Reproductive Rights, https://www.reproductiverights.org/world-abortion-laws/hungarys-abortion-provisions#fund. Accessed 19 August 2020. See sections 5 and 6. See also: Béni, Alexandra. The abortion policty in Hungary. Daily News Hungary 30 May 2019, https://dailynewshungary.com/the-abortion-policy-in-hungary/. Accessed 19 August 2020. 64 Ibid 65 Ibid 66 Ibid 67 See WHO, 2019. 68 Ibid 69 See Geneva, World Health Organization. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Russian Federation. World Bank Group 2019, 70 Lyubov Vladimirovna Erofeeva. Traditional Christian Values and Women’s Reproductive Rights in Modern Russia—Is a Consensus Ever Possible?. American Journal of Public Health November 2013; 103(11): 1931-1934. DOI: 10.2105/AJPH.2013.301329. Accessed 19 August 2020. See also: Center for Reproductive Rights. Russia Piles on Tighter Abortion Restrictions. Center for Reproductive Rights 22 February 2012, https://reproductiverights.org/press-room/russia-piles-on-tighter-abortion-restrictions. Accessed 19 August 2020. 71 See “Mortality rate, infant (per 1,000 live births) - Russian Federation, United States, France, Japan, Kazakhstan, Ukraine, Poland, South Africa, Hungary, Chile, Uganda. World Bank Group,” and “Most Recent Child Mortality Estimates, 2018. The United Nations (UN) 19 September 2019.” © deVeber Institute 2020 10

India vs. Bangladesh:

In India, abortion is legal under the Medical Termination of Pregnancy Act (MTP) of 1971. Abortion is legal up to 12 weeks, or 20 weeks if the pregnancy is deemed by two health professionals to be a risk to the mother’s life or physical or mental health (rape is automatically considered a grave danger to her mental health, as well as a pregnancy in which a woman and her husband had been using contraception and family planning methods to avoid getting pregnant) or if the child will most likely have a serious physical or mental disability. Abortion is not allowed for girls under the age of 18 and women deemed to be mentally incompetent without parental/guardian consent. Abortion is legal in all stages of pregnancy and with permission by only one physician if he/she deems that the continuation of the pregnancy is of immediate risk to the woman’s life.72 In 2020, the Indian government passed an amendment to the 1971 act, extending the timeframe in which a woman is allowed to terminate up to 24 weeks in the cases of rape, incest, otherly-abled women, and minors; it also replaced the term “any woman and her husband” when discussing the failure of contraception reason to “any woman and her partner.”73 In Bangladesh, however, abortion is illegal except to save the mother’s life. However, a practice known as “menstrual regulation” is allowed up to 12 weeks (this is when vacuum aspiration or medical abortion drugs are used to empty the uterus if menstruation has not taken place), but this is not considered to be abortion.74 Bangladesh’s abortion law is much stricter than India’s. India does have a lower maternal mortality rate than Bangladesh, with the former having 122 deaths per 100,000 live births and the latter having 173.75 However, India is a bigger country than Bangladesh. Further, India spends more of its GDP on healthcare than Bangladesh. In 2016, India saw a slight decline in its spending on healthcare, going from 3.596% in 2015 to 3.511% in 2016.76 However, it began to climb again in 2017, with 3.535% of GDP being spent on healthcare.77 Bangladesh, on the other hand, continued to see a slight decline in the percentage of

72 Ministry of Health & Family Welfare. The Medical Termination of Pregnancy Act, 1971. The Government of India 10 August 1971, https://main.mohfw.gov.in/acts-rules-and-standards-health-sector/acts/mtp-act-1971#:~:text=The%20Med ical%20Termination%20of%20Pregnancy%20Act%2C%201971&text=An%20Act%20to%20provide%20fo r,connected%20therewith%20or%20incidental%20thereto.. Accessed 21 August 2020. 73 Subramaniam, Chitra. India’s new abortion law is progressive and has a human face. Observer Research Foundation (ORF) 7 March 2020, https://www.orfonline.org/expert-speak/india-new-abortion-law-progressive-human-face-62023/. Accessed 21 August 2020. 74 Share-Net Team. Bangladesh’s Law on Abortion. Share-Net Bangladesh 22 May 2019, https://www.share-netbangladesh.org/bangladeshs-law-on-abortion/. Accessed 21 August 2020. 75 See UNICEF India. Maternal Health: UNICEF’s concerted action to increase access to quality maternal health services and Maternal mortality ratio (modeled estimate, per 100,000 live births) - Bangladesh. Geneva, World Health Organization 2019 76 World Health Organization Global Health Expenditure Database. Current health expenditure (% of GDP) - Bangladesh, India, Sri Lanka, United Kingdom, Germany, Nepal, United States. World Bank Group, https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=BD-IN-LK-GB-DE-NP-US. Accessed 21 August 2020. 77 Ibid © deVeber Institute 2020 11

GDP spent on healthcare, with 2.463% being spent in 2015 and 2.274% being spent in 2017.78 This is a continual decrease from 2012 when it was 2.573%.79 This puts Bangladesh in third place for the lowest percentage of GDP being spent on healthcare in 2017 (behind Venezuela with 1.18% and Monaco with 1.77% in 2017).80 While it still does not spend a lot of its GDP on healthcare, India was comparatively much better than Bangladesh in 2017. It was in 24th place for the lowest GDP spent on healthcare, putting it 21 places above Bangladesh.81 India is also richer than Bangladesh overall. India’s GDP in 2019 was 2.875 trillion USD. 82 Bangladesh, on the other hand, had a GDP of 302.57 billion USD in 2019.83 This is a significant difference in income. When you couple India’s higher GDP with the fact that India also spends a higher percentage of its GDP on healthcare, it is clear to see that Bangladesh is at a significant disadvantage. Still, when looking at Bangladesh it is interesting to note that it has made a lot of improvement in terms of both healthcare and GDP. Between 2010 and 2019, Bangladesh’s GDP increased by 62% (although it is expected to dip a bit because of covid-19).84 Its maternal mortality rate has declined continuously since 2000, going from 434-100,000 in 2000 to 173 in 2017.85 Without allowing abortion, Bangladesh has managed to significantly reduce its maternal mortality rate by taking initiatives to improve healthcare, nutrition, family welfare services, and female education.86

78 Ibid 79 Ibid 80 Ibid 81 Ibid 82 The World Bank. India. World Bank Group, https://data.worldbank.org/country/india. Accessed 21 August 2020. 83 Trading Economics. Bangladesh GDP. Trading Economics, https://tradingeconomics.com/bangladesh/gdp. Accessed 21 August 2020. 84 Ibid 85 See WHO, Maternal mortality ratio (modeled estimate, per 100,000 live births) - Bangladesh. 86 Mukul. Bangladesh, India Need to Strengthen Cooperation in Healthcare. The Enterprise of Healthcare 11 October 2018, https://ehealth.eletsonline.com/2018/10/bangladesh-india-need-to-strengthen-cooperation-in-health-secto r/. Accessed 21 August 2020. And Sosale, Shobhanna, Asaduzzaman, TM, and Ramachandran, Deepika. World Bank Blogs. Girls’ education in Bangladesh: A promising journey. The World Bank Group 24 June 2019, https://blogs.worldbank.org/endpovertyinsouthasia/girls-education-bangladesh-promising-journey. Accessed 21 August 2020. © deVeber Institute 2020 12

Resources

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Supplementary Sources

1. Bouvier-Colle, et al. What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG June 2012; 119(7): pp. 880-90, DOI: 10.1111/j.1471-0528.2012.03330.x. Accessed 10 August 2020. This article examines MMR rates from the European Union and Norway. It finds that the data is insufficient to give an accurate MMR. Abstract: “In 22 countries that provided data, the maternal mortality ratio was 6.3 per 100 000 live births overall and ranged from 0 to 29.6. Under-ascertainment was evident from comparisons with studies that use enhanced identification of deaths. Furthermore, routine cause of death registration systems in countries with specific systems for audit reported higher maternal mortality ratio than those in countries without audits. For severe acute maternal morbidity, 16 countries provided data about at least one category of morbidity, and only three provided data for all categories. Reported values ranged widely (from 0.2 to 1.6 women with eclampsia per 1000 women giving birth and from 0.2 to 1.0 hysterectomies per 1000 women).” 2. Heijink, Richard, et al. Spending More Money, Saving More Lives? The Relationship between Avoidable Mortality and Healthcare Spending in 14 Countries. The European Journal of Health Economics 2013; 14(3): pp. 527–538. JSTOR, www.jstor.org/stable/42002247. Accessed 10 August 2020. © deVeber Institute 2020 18

This article finds that, as healthcare spending increases, preventable mortality as a whole decreases.

3. MacDorman MF, Declercq E, Cabral H, Morton C. Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstet Gynecol. 2016;128(3):447-455. DOI:10.1097/AOG.0000000000001556. Accessed 10 August 2020.

This article points out that from 2004 to 2014 in 48 US states the MMR increased even though the global trend was that MMR was decreasing.

4. Zureick-Brown, Sarah, et al. Understanding Global Trends in Maternal Mortality. International Perspectives on Sexual and Reproductive Health 2013; 39(1): pp. 32–41, JSTOR, www.jstor.org/stable/23408825. Accessed 10 August 2020. This article finds that, while in 2013 we were not on track to meet the MDG 5 target, global MMR declined by one-third between 1990 and 2008.

5. Ringard Å, Sagan A, Sperre Saunes I, Lindahl AK. Norway: health system review. Health Syst Transit. 2013; 15(8): 1-162, https://pubmed.ncbi.nlm.nih.gov/24434287/. Accessed 11 August 2020.

Norway (which is one of the countries in the top 37 lowest MMR, see World Health Organization 2019) is one of the richest countries per head in the world. Overall life expectancy in Norway is 81.53 years, which is above the average for the EU. Norwegians also enjoy more healthy years than the EU average. They have a semi-decentralized healthcare system, with 9.4% of GDP going to healthcare (while this is less than fifteen other European countries, its high GDP makes its spending per head higher than most). Further, Norway also has more healthcare workers per 100,000 than other countries in the EU. Still, long wait times are a problem in Norway, and socioeconomic and geographical status does have an impact on the quality of healthcare a person receives. Despite this, Norway still has a lower overall mortality rate than many EU countries. (See abstract)

6. Brekke, M and Wisborg, T. What became of solidarity?. Hvor ble det av solidariteten?. Tidsskr Nor Laegeforen 2019; 139(16). Published 31 October 2019, DOI:10.4045/tidsskr.19.0489. Accessed 11 August 2020.

This article discusses the pitfalls of Norway’s healthcare system. It talks about the increasing use of private insurance as a detriment to the system because it allows people to skip the line and causes less people to pay into the public pool via paying for appointments. 7. Tschirhart, N, Diaz, E, and Ottersen, T. Accessing public healthcare in Oslo, Norway: the experiences of Thai immigrant masseuses. BMC Health Serv Res. 2019; 19(1): 722. Published 21 October 2019, doi:10.1186/s12913-019-4560-9. Accessed 11 August 2020. © deVeber Institute 2020 19

This article finds that, while Thai immigrant women (who are Norwegian citizens) have the same access to public healthcare as any other Norwegian, there are barriers because, if the woman has a Norwegian husband, healthcare providers will often rely on him to translate rather than providing the required translator regardless of the husband’s translating abilities. This article interviewed 14 women working as professional masseuses in Norway.

8. Mbanya, VN, Terragni, L, Gele, AA, Diaz, E, and Kumar, BN. Access to Norwegian healthcare system - challenges for sub-Saharan African immigrants. Int J Equity Health. 2019; 18(1): 125. Published 14 August 2019, DOI:10.1186/s12939-019-1027-x. Accessed 11 August 2020.

The authors interviewed immigrants from Sub-Saharan Africa and found that they also face barriers (including language barriers) in accessing Norwegian healthcare.

9. ESHRE Capri Workshop Group. Induced abortion [published correction appears in Hum Reprod. 2018 Apr 1;33(4):768]. Hum Reprod. 2017;32(6):1160-1169. DOI:10.1093/humrep/dex071. Accessed 11 August 2020.

This article argues for and gives examples of “safe and legal abortion.” Its section on long-term sequelae is brief. It acknowledges the increased risk of premature birth, especially after repeat abortions. It denies the relationship between breast cancer and abortion (even though, as shown in Complications, there is clearly a wide body of research to support a link), citing two studies: Reeves et. al., 2006, and Michels et. al., 2007. 10. Guttmacher Institute. State Facts About Abortion: Louisiana. Published March 2020 at https://www.guttmacher.org/fact-sheet/state-facts-about-abortion-louisiana#. Accessed 12 August 2020.

This article takes issue with Louisiana’s abortion law. It includes an update of amendments made to Louisiana’s abortion law in 2020. It inaccurately states that the reason for the 20 week cutoff is because of dubious claims that a fetus can feel pain at that point, but, while their Right to Know pamphlet does state that fetuses can feel pain at 20 weeks, in reading the law it is actually about viability. It also states that a patient must receive counselling designed to dissuade her from having an abortion. This is a mischaracterization of the law. The intention of the law is to ensure informed consent by making a woman aware of the procedure she will undergo, its risks and implications, and what other options are available for her.

11. Louisiana State Legislature. RS 40:1061.10. Government of Louisiana, http://legis.la.gov/Legis/law.aspx?d=965003. Accessed 12 August 2020. According to Louisiana law, a doctor is not actually required to force a woman who is requesting an abortion to look at the ultrasound image or listen to the fetal heartbeat. What the doctor is required to do is make these things visible/available so that the woman © deVeber Institute 2020 20

has the right to choose whether she wants to look/listen or not. It is meant to offer the woman the ability to see this information if she chooses, preventing doctors from trying to hide it from her. Doctors are also required to give the woman an image of the ultrasound if she requests one. One thing that doctors are required to do regardless of whether the woman wants to hear it or not is give a plain, factually accurate description of what is happening on the screen - age of the fetus, development, etc.. The woman is then, given the information she has been told/shown, asked to sign a consent form. This is designed to ensure that no details are kept from the woman so that she is fully aware of the procedure she is about to undergo. While some articles have claimed that the limit of 20 weeks for Louisiana’s abortion law is because of the theory that the fetus can feel pain at that point, it is actually because of the fact that 20 weeks is the earliest age at which a fetus is viable with medical intervention. You can only abort a viable fetus if the mother’s life is at risk, and you must perform a kind of abortion that you feel will give the fetus the most chance of survival, unless you feel that that method wouldn’t be in the best interest of the woman (e.g. the procedure is more dangerous than one that would likely kill the fetus). The law also requires that minors gain parental consent before having an abortion. This is nothing new considering the fact that parental consent is required for minors for many different medical procedures.

12. Louisiana. Department of Health and Hospitals. Women’s Right to Know. The Louisiana Department of Health and Hospitals 2011, https://ldh.la.gov/assets/oph/Center-PHCH/Center-PH/familyplanning/WmnsRghtToKno w.pdf. Accessed 12 August 2020. While this document is slightly outdated because it’s from 2011, it’s not completely irrelevant. It is designed for women considering an abortion. It contains information about Louisiana’s abortion law, your rights (including your right not to be forced into an abortion no matter how old you are and the right to demand child support from the father even if he has paid you to have an abortion), what happens at each stage of fetal development, a detailed explanation of abortion procedures and their risks, the risks of continuing pregnancy and potential complications (life threatening or not) that you can have during pregnancy and birth, and information about required counselling services designed to make known to women all of their options in order to allow them to make a more informed decision.

13. Guttmacher Institute. State Facts About Abortion: Louisiana. Published March 2020 at https://www.guttmacher.org/fact-sheet/state-facts-about-abortion-louisiana#. Accessed 12 August 2020.

mischaracterization of the law. The intention of the law is to ensure informed consent by making a woman aware of the procedure she will undergo, its risks and implications, and what other options are available for her.

14. Glenza, Jessica, and Gabbatt, Adam. Supreme court strikes down restrictive Louisiana abortion law. The Guardian 29 June 2020, https://www.theguardian.com/world/2020/jun/29/abortion-ruling-supreme-court-strikes-d own-louisiana-law. Accessed 12 August 2020. In 2016, Louisiana struck down an abortion law that required doctors performing abortions at private clinics to have admission privileges at nearby hospitals.

15. America’s Health Rankings. Maternal Mortality. United Health Foundation 2019, https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/ maternal_mortality_a/state/ALL. Accessed 12 August 2020. Louisiana has the highest maternal mortality rate in the US.

16. Carroll, Aaron E. Why is US Maternal Mortality Rising?. JAMA 2017; 318(4): p. 321, DOI: 10.1001/jama.2017.8390. Accessed 12 August 2020.

This article states that increasingly restrictive abortion laws in some states (particularly in the south and the midwest) are partially responsible for the US’s rising maternal mortality ratio.

17. ACLU Texas. Abortion in Texas. ACLU of Texas, https://www.aclutx.org/en/know-you-rights/abortion-in-Texas. Accessed 12 August 2020. The abortion law in Texas is very similar to Louisiana’s, and yet Texas’ maternal mortality ratio is 39.2 (which is still high) compared with Louisiana’s 72.0 (see America’s Health Rankings). This suggests that something other than just restrictive abortion laws is at play.

18. Ehrenfeld, Temma. Why Texas’ Healthcare System is One of the Worst in the Country. Healthline 24 September 2018, https://www.healthline.com/health-news/texas-healthcare-system-one-of-the-worst-in-co untry#5. Accessed 12 August 2020. This article discusses the serious problems with Texas’ healthcare. It has a section on maternal mortality that details some of the issues with medicaid not covering long enough after pregnancy.

19. Mammoser, Gigen. Why is Louisiana’s Healthcare so Bad?. Healthline 29 August 2017, https://www.healthline.com/health-news/why-is-louisianas-healthcare-so-bad#2. Accessed 12 August 2020. © deVeber Institute 2020 22

Louisiana has an even worse healthcare system than Texas. Louisiana is a very poor, rural state. A third of its population were on Medicaid in 2017.

20. Klausen, Susanne M. ‘The Trial the World is Watching’: The 1972 Prosecution of Derk Crichton and James Watts, Abortion, and the Regulation of the Medical Profession in Apartheid South Africa. New Directions and Challenges in Histories of Health, Healing and Medicine in South Africa April 2014; 58(2), pp. 210-29. Published online by Cambridge University Press, DOI: https://doi.org/10.1017/mdh.2014.6. Accessed 13 August 2020.

This article examines the trial of Derk Crichton and James Watts, doctors who were jailed for performing illegal abortions on young white women. It talks about the trials and how they led up to the restrictive 1975 Abortion and Sterilization Act. It notes that doctors still continued to do illegal abortions and that women sought out illegal abortions both from doctors and elsewhere. However, it notes that, due to the very public trials and police clampdown, many doctors wouldn’t even perform legal abortions anymore (abortions where the mother’s life was at risk). It attributes part of the high MMR to botched abortions due to these restrictive laws.

21. Harries, J, Gerdts C, Momberg M, Greene Foster D. An exploratory study of what happens to women who are denied abortions in Cape Town, South Africa. Reprod Health. 2015;12:21. Published 2015 Mar 21. doi:10.1186/s12978-015-0014-y. Accessed 13 August 2020.

This study looks at women in Cape Town who were denied abortions (usually because they were past 12 weeks or because they couldn’t pay the fee). It found that there were significant barriers to women obtaining legal abortion despite the liberal law, and it also found that some of these women turned to the Internet to try to obtain illegal forms of abortion, as well as searching for illegal providers or finding another physician who would perform the abortion.

22. Mahlathi, Percy, and Dlamini, Jabu. Minimum Data Sets for Human Resources for Health and the Surgical Workforce in South Africa’s Health System: A rapid analysis of stock and migration. African Institute for Health and Leadership Development September 2015. WHO, https://www.who.int/workforcealliance/031616south_africa_case_studiesweb.pdf?ua=1. Accessed 13 August 2020. See abstract.

There is an issue with healthcare workers moving away from rural areas to cities (and sometimes other countries) due to urbanization, which causes a disparity in access to healthcare. This paper proposes a system to deal with that. It proposes improving “collaboration between stakeholders that have human resources for health data management systems,” strengthening “the use of the current public service-wide human resources system (Vulindlela) to cater for health-specific human resources data,” and © deVeber Institute 2020 23

strengthening “its workforce planning capability by ensuring the existence of an appropriate national health workforce information system.” It states that this “should straddle both public and private health sectors, including the statutory health councils.” It calls for more collaboration between The National Ministry of Health and Ministry of Home Affairs to measure and monitor emigration of South African healthcare workers.

23. Maphumulo, Winnie T, and Busisiwe, R Bhengu. Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review. Curationis 29 May 2019; 42(1), DOI:10.4102/curationis.v42i1.1901. Accessed 13 August 2020. This article finds that South Africa’s healthcare system is still lacking despite government programmes to restructure the healthcare system and improve patient care (see conclusion section). 24. Connolly, Marie-Louise. Northern Ireland Abortion Law Changes: What do they mean?. BBC News 22 October 2019, https://www.bbc.com/news/uk-northern-ireland-50125124. Accessed 14 August 2020.

This article talks about the decriminalization of abortion in 2019. It is too early to know what its effects on MMR will be. 25. UNICEF Data: Monitoring the situation of children and women. Ireland. UNICEF, https://data.unicef.org/country/irl/. Accessed 14 August 2020. Trends in under 5 mortality have been declining since 1990, with a rate of 3.7 per 1000 live births in 2018. It is too early to know how the decriminalization of abortion will effect this.

26. UNICEF Data: Monitoring the situation of children and women. Maternal Mortality. UNICEF September 2019, https://data.unicef.org/topic/maternal-health/maternal-mortality/. Accessed 14 August 2020.

In 2017 (while abortion was still illegal in Ireland), Ireland’s MMR was lower than the UK’s.

27. Chowdhury, Mahbub Elahi, et al. Causes of Maternal Mortality Decline in Matlab, Bangladesh. Journal of Health, Population and Nutrition 2009; 27( 2): pp. 108 - 123, JSTOR, www.jstor.org/stable/23499518. Accessed 21 Aug. 2020. This 2009 study finds that female education, better access to emergency obstetric services, and lower fertility rates lead to improved MMR.

28. Paul, Stella. India’s Liberal Abortion Law, Nullified by Social Stigma. Inter Press Service News Agency 14 April 2020, http://www.ipsnews.net/2020/04/india-liberal-abortion-law-nullified-social-stigma/. Accessed 21 August 2020. © deVeber Institute 2020 24

This article talks about the social stigma around abortion in India, particularly for sex workers. It also praises the new (but yet to be implemented) 2020 reforms, but worries that they won’t increase accessibility to abortion due to social stigma.

29. Abbasi, K. The World Bank and world health: focus on South Asia-I: Bangladesh. British Medical Journal (Clinical research ed.) 1999; 318(7190): 1066-9. DOI:10.1136/bmj.318.7190.1066. Accessed 21 August 2020.

This article is old (1999). It assesses the World Bank’s impact on healthcare in Bangladesh.

30. Wu, Daphne CN, et al. Health-care investments for the urban populations, Bangladesh and India. Bulletin of the World Health Organization 2020; 98(1): 19-29. DOI:10.2471/BLT.19.234252. Accessed 21 August 2020.

This article looks at improving healthcare outcomes and achieving the 2030 sustainable development goals in Bangladesh and India from 2020-2030 by investing in a package of 208 essential health interventions.

31. Tikkanen, Roosa, et al. International Healthcare System Profiles: India. The Commonwealth Fund 5 June 2020. https://www.commonwealthfund.org/international-health-policy-center/countries/india#: ~:text=The%20constitution%20of%20India%20obliges,right%20to%20health%E2%80% 9D%20for%20all.&text=Each%20state%20is%20required%20to,India%20has%20been %20chronically%20underfunded. Accessed 21 August 2020. This article explains universal and private healthcare coverage in India, how it works, and its limitations and areas for improvement.