The Right to Choose resources from the arrow srhr knowledge sharing centre 29—32

other resources 32

definitions 33—34

factfile 35—41

The Role of International monitoring countries and Human Rights Instruments regional activities 19—28 in the Advocacy for the Right to Safe Enhancing Women’s Sexual and Reproductive editorial and The Impact of the Global Health and Rights: A Brief production team 42 Gag Rule on Safe Abortion Review of the Menstrual Services: Sparking a Regulation Programme in Movement for Safe Abortion Bangladesh published by Telemedicine Abortion in Abortion in Vietnam: the asian-pacific resource and research centre for women Restrictive Settings Actions in a Legal Context (arrow) editorial 2—4 The Dilemma of Accessing Reaffirming the Right to Pills over Safe Abortion in our own words 14—18 the Counter in Nepal

Provider Attitudes, Serious Threats to published with the funding Perceptions, and support of spotlight 5—14 Conscientious Objections: in Poland The Battle Between “Right” Advancing Positive and Responsibility Compassion over Coercion: Sexuality and Abortion Ireland Repeals the 8th Rights by Tackling Stigma From Anti-choice to Amendment by Getting to the Abortion Provider Heart of the Matter Marginalised Women and Reproductive Rights: Who The Impact of Stigma: The Global Gag Rule on Safe arrow receives institutional support from the Ford Foundation Should Mediate Access to A Nepali Woman’s Abortion Services and the and the Foundation for a Just Safe Abortion? Experience of Abortion Cambodian Experience Society 2 arrow for change | vol. 24 no. 1 2018 editorial

By Sivananthi Thanenthiran REAFFIRMING THE RIGHT Executive Director, Asian-Pacific Resource and Research Centre for Women (ARROW), TO SAFE ABORTION and a SheDecides Champion for Asia Pacific Email: [email protected]

Sexual and reproductive rights comprise • 7.24, which does not recognise the of rights and fundamental freedoms about role of abortion in limiting births; our bodies—the most personal realm • 7.6, which limits service provision to Economic, Social, and Cultural Rights has each one of us possesses. Amongst these the prevention and management of recognised the right to safe abortion as rights, a woman’s right to safe abortion abortion complications; critical to realising gender equality and remains the most heavily contested • 8.19, which talks of abortion its denial as gender discrimination in its and the most frequently limited across prevention but not of provision of General Comment 22,4 while the CEDAW nations, cultures, and religions. safe abortion services; and Committee has affirmed that the denial or • 8.22, which again talks only of delay to access safe abortion services is a The right to safe abortion is service provision to treat abortion form of gender-based violence tantamount simultaneously an issue of gender complications.2 to torture in its General Recommendation equality, bodily integrity, and personal 35.5 Further, the Committee on the Rights liberty, and cannot be perceived as The state deciding which of the Child has recognised access to safe a separate right on its own but as abortion services as essential, especially one which helps define and clarify all pregnancies should be carried marginalised groups of women such as other rights, and contributes to the to term and which need not adolescent girls, in its General Comment overall framework on the sexual and be, as well as which groups of 20 on Adolescents.6 The UN Committee reproductive autonomy of individuals.1 women and girls may procure Against Torture in its reviews on Nicaragua Safe abortion services are required only (2009), Paraguay (2011), and Peru (2006 safe abortion services for by girls, women, and those who are and 2012) found the denial of safe abortion biologically born as females, and as such, particular reasons and which services—especially with regards sexual the denial of such services inflicts death, groups may not, violates violence, incest, and foetal abnormalities— disability, and psychological trauma personal decision-making on and the consequent forced carrying to only on them. Forced pregnancy by the individual reproduction. term of these pregnancies, as a form of state denies them the right to decide torture. on the number and timing of children to have, if at all. The state deciding which The compromises of 1994 led to safe Across the Asia-Pacific region, some pregnancies should be carried to term abortion being placed with caveats progressive changes in laws have and which need not be, as well as which at different policy levels, and the occurred since 1994. In 1997, Cambodia groups of women and girls may procure limiting of women’s access to services. decriminalised abortion in order to reduce safe abortion services for particular These compromises continue to haunt unsafe and reduce maternal reasons and which groups may not, us throughout inter-governmental mortality.7 In 1989, Vietnam legalised violates personal decision-making on negotiations till today, including for abortion and menstrual regulation.8 In individual reproduction. the 2030 Agenda for Sustainable 2002, Nepal legalised abortion without Development. restrictions as to reason during the Sexual and reproductive health and first 12 weeks of pregnancy.9 In 2005, rights (SRHR) advocates and activists The work of the Human Rights Committees Thailand amended and expanded a medical consider the International Conference has helped push the envelope on one of regulation governing abortion, which on Population and Development the key shortcomings of the ICPD PoA: permitted access to abortion services Programme of Action (ICPD PoA), as a “access to safe, legal abortion [is] not for reasons of mental health and foetal comprehensive, cohesive document on recognised as part of reproductive health impairment.10 In Indonesia, it was only sexual and reproductive health. Yet, it and rights; [in] deference to national laws; in September 2009 that the law was also presents compromises on abortion where illegal, [requiring] treatment of amended, and stipulating narrowly (within as seen in the following paragraphs: complications only.”3 The Committee on four weeks of pregnancy) that only women 3 editorial arrow for change | vol. 24 no. 1 2018

whose lives are in danger or those that in Asia, the Supreme Court sided with for the stronger implementation of the have been raped can have an abortion.11 anti-choice groups in affirming that life law especially against abortion service In 2009, in Fiji, abortion was permitted begins at fertilisation.13 In 2017, Buddhist, providers. There have been calls in on socioeconomic grounds or in cases of Muslim, and Christian religious leaders Vietnam for similar laws. In India, rape, incest, or foetal impairment.12 united to oppose legalising abortion in this has resulted in abortion service Sri Lanka14, 15 when the Cabinet approved providers becoming more reluctant to While we advocates celebrate progress the presentation of a bill to parliament provide abortion services, especially in enabling women to realise their right to legalise abortion when a pregnancy within the public sector due to hassles to safe abortion, we also need to be wary is due to rape or if a foetus is diagnosed with the law. Low-income women are as there are very real, continuous, and with a lethal congenital malformation. the ones who are most affected by this insidious attempts to restrict access to Leaders from these three religions told the development since they are dependent safe abortion. government that they all believe that life on public health services.18 This issue begins at conception. China, which has has then created deep fissures within In Asia and the Pacific, countries who had a liberal , has also seen a the feminist movement on the right to championed ICPD in 1994 now have burgeoning of “pro-life” Christian groups safe abortion. Anti-abortion groups have more conservative governments in and Buddhists,16 who are introducing also joined the sex-selective abortion place who have reversed governmental discourses on , and on bandwagon, amplifying the messages positions and commitments to ICPD ideals treating abortion as a sin since life begins of restricting access to safe abortions,19 of reproductive rights. These include at conception. but without presenting the nuances of Bangladesh, Indonesia, Iran, Malaysia, gender discrimination presented by those and Pakistan—Islamic countries who are When the right to safe abortion in the feminist movement. In reality, to influenced by the Middle Eastern nations, reverse sex selection, there need be laws such as Qatar and Saudi Arabia, to join is presented as contested and and policies that encourage parents and their groups. The caveats in ICPD against reduced by another right, it is families to have girl children and overall abortion have been firmly and consistently imperative that we view access legal reform recognising equal rights for held onto, without recognition of the to abortion in a humane women and girls within families to help advances in the human rights mechanisms. overturn son preference in societies. Additionally, some governments have and just way. introduced further restrictions. The third is the anti-promiscuity The second is the rights of the unborn rights view. The region is traditionally Moreover, these new challenges have also girl child. A number of Asian countries conservative and pre-marital sex is been divisive to the feminist movement with more liberal abortion laws—such frowned upon. Usage of contraception because they utilise the rights language as China, India, and Vietnam—are and abortion are traditionally associated and pit a number of different rights against known for a culture of son preference, with promiscuous women, especially women’s right to safe abortion. In Asia and have strong population policies. if unmarried, and service provision is and the Pacific, the pitting of other rights Sex selection occurs because of the regarded as encouraging promiscuity against the right to safe abortion occurs in inherent devaluation of girls and women. in society. In this regard, teenage four specific areas. All are aimed to whittle Both pre-conception and pre-natal sex pregnancies are analysed as the outcome down women’s rights to and access to determination techniques are utilised by of the low social morals of young women safe abortion services. These attempts to couples in these countries in order to who engage in premarital sex. These restrict safe abortion introduce a discourse have only male offspring, especially in young women are presented as then within society which powerfully drives and the light of hard-line government policies seeking and availing of safe abortion perpetuates abortion stigma. on smaller family sizes.17 services. The gender inequality is evident as sexually active boys are not labelled as The first is the rights of the unborn. However, the issue of eradicating sex promiscuous and are not usually punished. The belief that life begins at conception selection has been more narrowly is specific to Catholicism, which has focused on sex-selective abortion. This is a discourse reiterated in a number been heavily borrowed by other India has a national Pre-Conception of countries where abortion is accessible. religious fundamentalists. In 2014, in the and Pre-Natal Diagnostics Techniques This has been noted in Thailand, where Philippines, the sole Catholic country (PNDT) Act of 1994, and groups call availability of legally safe and inexpensive 4 arrow for change | vol. 24 no. 1 2018 editorial

abortions is seen as aggravating the Notes & References problem of teen pregnancy and abortion 1. Nancy Northup, “Roe Isn’t Just about Women’s Rights, It’s 8. Research Centre for Gender, Family and Environment in and encouraging promiscuity amongst about Everyone’s Personal Lliberty,” The Washington Post, Development (CGFED), Vietnam Country Report on ICPD+15 20 July 8, 2018, https://www.washingtonpost.com/opinions/ Implementation/Country Case Study/Draft (Kuala Lumpur: students. In Nepal, where abortion laws roe-isnt-just-about-womens-rights-its-about-everyones-personal- The Asian-Pacific Resource and Research Centre for Women— have been liberalised since 2006, data liberty/2018/07/08/527d8548-8160-11e8-b658-4f4d2a1aeef1_ ARROW, unpublished report, 2009). showing an increase of 42% in abortions story.html?noredirect=on&utm_term=.0275536df03b. 9. Centre for Reproductive Rights (CRR), Abortion Worldwide: 2. United Nations, International Conference on Population 12 Years of Reform (New York, USA: CRR, 2007), 3. and that 70% of these were for young and Development Programme of Action, 20th-anniversary ed. 10. CRR, Abortion Worldwide, 4. women under the age of 24 have been (New York: UNFPA, 2014), https://www.unfpa.org/publications/ 11. “Health Law Discriminates Marginalised Groups: international-conference-population-and-development- Activists,” The Jakarta Post, September 17, 2009, http://www. used as evidence that only promiscuous programme-action. thejakartapost.com/news/2009/09/17/health-law-discriminates- women and girls need abortion services. 3. Rosalind P. Petchesky, Global Prescriptions: Gendering against-marginalized-groups-activists.html. Health and Human Rights (London, UK: Zed Books, 2003), 44. 12. CRR, Abortion Worldwide: Seventeen Years of Reform (New There have been demands that access to 4. The general comment states: “The realisation of the rights of York: CRR, 2011), https://www.reproductiverights.org/sites/crr. safe abortion services should, therefore, women and gender equality, both in law and in practice, requires civicactions.net/files/documents/pub_bp_17_years.pdf. repealing or reforming discriminatory laws, policies and practices 13. Republic of the Philippines Supreme Court, “Decision: GR be restricted, and to amend the law in the area of sexual and reproductive health. Removal of all Nos. 204819, 2014934, 204957, 204988, 205003, 205043, accordingly.21 In Vietnam, there have been barriers interfering with access by women to comprehensive 205138, 205478, 205491, 205720, 206355, 207111, 207172, reports in 2016 that pregnant teenagers sexual and reproductive health services, goods, education, and and 207563,” Baguio City, April 8, 2014, http://sc.judiciary. information is required. To lower rates of maternal mortality and gov.ph/pdf/web/viewer.html?file=/jurisprudence/2014/ account for 70% of secret abortions in the morbidity requires emergency obstetric care and skilled birth april2014/204819.pdf. country, including repeat abortions.22 attendance, including in rural and remote areas, and prevention of 14. Micaiah Bilger, “Leaders United to Oppose Legalising unsafe abortions. Preventing unintended pregnancies and in Sri Lanka,” LifeNews, September 26, 2017, abortions requires States to adopt legal and policy measures http://www.lifenews.com/2017/09/26/buddhist-muslim-and- The last is disability rights. As recently as to guarantee all individuals access to affordable, safe and christian-religious-leaders-united-to-oppose-legalizing-abortion- effective contraceptives and comprehensive sexuality education, in-sri-lanka/. in 2017, the UN Committee on the Rights including for adolescents; to liberalise restrictive abortion 15. Kingsley Karunaratne,“Buddhist, Muslim, and Christian of Persons with Disabilities has objected laws; to guarantee women and girls access to safe abortion Leaders Oppose Abortion,” UCAnews, September 26, 2017, services and quality post-abortion care, including by training https://www.ucanews.com/news/buddhist-muslim-and-christian- to “fatal foetal impairments” being used healthcare providers; and to respect the right of women to leaders-oppose-abortion/80326. as a specific ground for abortion. The make autonomous decisions about their sexual and reproductive 16. Bethany Allen-Ebrahimian, “Meet China’s Pro-Life Christians Committee said such an approach was health.” See: United Nations Committee on Economic, Social, and (and Buddhists),” Foreign Policy Magazine, August 5, 2015, Cultural Rights, “General Comment No. 22 (2016) on the Right to http://foreignpolicy.com/2015/08/05/china-abortion-pro-life- risky given there was no guarantee as to Sexual and Reproductive Health (Article 12 of the International planned-parenthood-video-christian/. whether or not a foetal abnormality was Covenant on Economic, Social, and Cultural Rights),” May 2016, 17. TK Sundari Ravindran and Renu Khanna, Gender Manual http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4 (Kuala Lumpur: ARROW, unpublished, 2018). fatal. The recommendation to its sister slQ6QSmlBEDzFEovLCuW1a0Szab0oXTdImnsJZZVQfQejF41Tob4C 18. TK Sundari Ravindran, review communication, September 9, human rights bodies was to exercise vIjeTiAP6sGFQktiae1vlbbOAekmaOwDOWsUe7N8TLm%2BP3HJPz 2018. xjHySkUoHMavD%2Fpyfcp3Ylzg. 19. Ravindran and Khanna, Gender Manual. caution when advocating for the right 5. The general recommendation states: “Violations of 20. Jon Fernquest, “How Should Abortion Laws be Handled in to abortion in these cases.23 This has women’s sexual and reproductive health and rights, such Thailand?” Bangkok Post, November 4, 2010, 24 as forced sterilisation, forced abortion, forced pregnancy, https://www.bangkokpost.com/learning/advanced/204779/ also picked up momentum in India, criminalisation of abortion, denial or delay of safe abortion and/ how-should-abortion-laws-be-handled-in-thailand. where counselling is suggested as a key or post-abortion care, forced continuation of pregnancy, and 21. Kalpit Parajuli, “Nepal: Record in Abortions among Teenagers; intervention for women seeking abortions abuse and mistreatment of women and girls seeking sexual and Proposal to Revise Law,” AsiaNews.it, July 19, 2011, reproductive health information, goods, and services, are forms http://www.asianews.it/news-en/Nepal:-record-in-abortions- on the basis of foetal abnormalities. of gender-based violence that, depending on the circumstances, among-teenagers.-Proposal-to-revise-law-22135.html. may amount to torture or cruel, inhuman, or degrading 22. Bui Hong Nhung, “Teenagers Account for 70 Percent of treatment.” See: United Nations Committee on the Elimination Secret Abortions in Vietnam,” VN Express, July 1, 2016, https://e. When the right to safe abortion is of Discrimination against Women, “General Recommendation vnexpress.net/news/news/teenagers-account-for-70-percent-of- presented as contested and reduced by No. 35 on Gender-based Violence against Women, Updating secret-abortions-in-vietnam-3428414.html. General Recommendation No. 19,” July 26, 2017, https:// 23. Carl O’Brien, “UN Bodies Clash over Abortion in Cases of another right, it is imperative that we tbinternet.ohchr.org/_layouts/treatybodyexternal/Download. Fatal Foetal Abnormalities,” The Irish Times, October 27, 2017, view access to abortion in a humane aspx?symbolno=CEDAW/C/GC/35&Lang=en. https://www.irishtimes.com/news/social-affairs/ 6. With the general comment, the “Committee urges States to un-bodies-clash-over-abortion-in-cases-of-fatal-foetal- and just way. As Marge Berer said, decriminalise abortion to ensure that girls have access to safe abnormalities-1.3270579. “Women have abortions for only one abortion and post-abortion services, review legislation with a 24. K. Kannan, “A Tricky Debate on Abortion,” The Hindu, August reason—because they cannot cope with view to guaranteeing the best interests of pregnant adolescents 3, 2016 (updated September 20, 2016), http://www.thehindu. and ensure that pregnant adolescents’ views are always heard com/opinion/lead/A-tricky-debate-on-abortion/article14547721. a particular pregnancy at a particular and respected in abortion-related decisions.” See: United Nations ece?homepage=true. time. This can never be said enough. They Committee on the Rights of the Child, “General Comment No. 20 25. Marge Berer, “Making Abortions a Woman’s Right (2016) on the Implementation of the Rights of the Child during Worldwide,” Reproductive Health Matters 10, no.19 (2002): 3, may regret the reasons, but this does not Adolescence,” December 6, 2016, paragraph 60, http://www. https://doi.org/10.1016/S0968-8080(02)00010-1. alter the fact that abortion is the correct refworld.org/docid/589dad3d4.html. 7. Department of Economic and Social Affairs: Population decision for them and necessary in the Division, World Abortion Policies 2007 (2007), accessed circumstances of their lives.”25 There can September 24, 2018, http://www.un.org/esa/population/ publications/2007_Abortion_Policies_Chart/2007_WallChart.pdf. be no compromise on women’s right to safe abortion. 5 editorialspotlight arrow for change | vol. 24 no. 1 2018

By Leila Hessini ADVANCING POSITIVE Vice President of Programs, Global Fund for Women SEXUALITY AND ABORTION Email: [email protected] and Rufaro Kingai RIGHTS BY TACKLING STIGMA Program Director, Sexual Health and Reproductive Rights, Global Fund for Women

Research and practice show that Stigma manifests itself in challenging stigma is necessary in order different ways and over time. for all people to access comprehensive It intersects with personal sexual and reproductive health and stigma is what occurs when women are rights, including access to safe, non- attributes, geographic location, actually discriminated against or harmed judgmental, quality abortion care.1 access to services, the timing due to their need for an abortion or their Stigma occurs when individuals are of abortion, and other factors. having had one. labelled, dehumanised, and discriminated Stigmas can be intersecting against due to their need for, or It is important to understand that for women who come from association with, abortion. A central abortion stigma is never just about part of the stigmatisation process is socio-economic classes and abortion, but plays out and attaches to to label people who need abortions, identities that are undervalued different social issues and debates in health-care professionals who provide by dominant social norms and our respective societies. In countries abortion services, and pharmacists who practices. that are strongly influenced by Catholic disperse misoprostol2 as different and institutions and in the U.S., abortion undesirable. These labels can lead to has become a lynchpin in political status loss, discrimination, and violence. them to hide their pregnancies and debates and culture wars, while in While abortions are one of the most seek care from providers outside of countries where contraception is readily common medical procedures and can be their communities. Legal frameworks available, abortion stigma may be a managed safely by women and a range create categories of “acceptable” and form of punishment for women who of healthcare providers,3 abortion stigma “unacceptable” abortions. Structurally, choose not to or are unable to access contributes to its social, medical, and abortions have been separated from contraceptives. In pro-natalist countries, legal marginalisation.4 comprehensive reproductive healthcare abortions might be stigmatised due to services; for example, being excluded the desire by state powers for women How Is Abortion Stigma Produced from insurance programmes and totally to have large family sizes. Ultimately, and Reproduced? Abortion stigma dissociated from contraception. abortion stigma is directly related to is difficult to isolate as it is produced social and cultural norms related to and reproduced across different levels Stigma manifests itself in different ways women’s authority, place, and status in (including the individual, community, and over time. It intersects with personal society and is a direct way of controlling organisational, legal, and structural attributes, geographic location, access and subjugating women and limiting their levels) and is advanced through media to services, the timing of abortion, life opportunities. and public discourse. Even the language and other factors. Stigmas can be we use for abortion and the images intersecting for women who come from What Are the Consequences of that are associated with abortion socio-economic classes and identities Abortion Stigma? The consequences reveal stigma. Abortion images often that are undervalued by dominant social of abortion stigma are wide and deep. depict the foetus delinked from the norms and practices. Stigma furthermore In countries such as Nigeria, where womb from which it depends, rather can be anticipated, perceived, and/ maternal death from unsafe abortion than acknowledging the woman who or experienced. Some women may is exorbitantly high, the public health is pregnant. Entire communities anticipate that if they disclose their consequences of women not having have developed ways of separating, abortion experience they will be access to safe abortions truly is a matter stereotyping, and discriminating against stigmatised, or they may perceive that of life or death. Latin America has some women who need abortions by forcing others judge them. Experienced of the world’s most restrictive abortion 6 arrow for change | vol. 24 no. 1 2018 spotlight

laws—and high rates of maternal death quality, and non-judgmental care, address aspects of healthcare service and injury as a result.5 including for women with disabilities or delivery that stigmatise certain groups of marginalised women in hard to reach women, especially those who are young Even in countries where abortion is areas. The Nigerian organisation, and from disadvantaged social groups. legally available, stigma related to Education as a Vaccine, frames its sexual Mexico’s Fondo de Aborto para la Justicia abortion means that most women still and reproductive rights work within the Social MARIA seeks to destigmatise have abortions outside the formal context of the ability of young people to abortion by normalising its existence and healthcare system. In an interview with pursue their life goals and advance their providing women with easy to access the Global Fund for Women for an online own and their countries’ educational and information and care through hotline campaign in 2017 about sexual health and economic well-being. The Asian Safe- and in-person consultations. They also rights, we spoke with grantees about the Abortion Partnership organises an annual provide support for women from states range of ways their sexual health and youth advocacy institute that promotes where abortion is legally restricted to rights are limited, including access to learning, sharing, and strategising across travel to Mexico City where abortion is abortion. For example, while abortion is activists who are reframing abortion legal. legal in Nepal, stigma remains a powerful rights as an issue that is key to their barrier. Women who seek out abortions futures and rights. Decentralising care through informal are often ostracised “at the family level, networks of activists is a strategy used the community level, and at any religious Stigma is produced and by groups such as Centro Las Libres functions,” says Shanta Laxmi Shrestha, de Información en Salud Sexual Región reproduced at various levels Chairperson of Beyond Beijing Committee. Centro AC (Las Libres) in Mexico. Las “Unless we address abortion stigma, of the ecosystem and only a Libres supplies women with abortion kits even though the services are very much comprehensive approach— to conduct safe, self-induced medical available, women who need them will not reframing harmful language, abortions. Self–managed abortions are 6 an innovative strategy led by women- get them because of the stigma.” changing discriminatory policies led organisations that allow women to What Are Some Strategies Women’s and practices, and ensuring access abortions safely in their homes, Groups Can Use to Address Abortion implementation of quality reducing stigma, as well as reducing the Stigma? In response to the ongoing services—will result in the risk of being criminalised by a medical assault on abortion access, women’s right to self-determination and practitioner who may hand them over to rights organisations are addressing the authorities. The Line Aborto Libre, a stigma and affecting change at multiple abortion access for all. collective of feminists in Chile, operates levels. This ecosystem approach is a 24-hour hotline to ensure that women exemplified in the Global Fund for Discriminatory and punitive abortion have access to safe abortion information, Women’s theory of change, which is laws are major causes of institutional care, medicine, and counselling. These the framework for our grantmaking and abortion stigma. Laws perpetuate interventions are centred on the needs shows the change needed at institutional, stigma in numerous ways—they create of the women and are made to ensure structural, social, and individual levels.7 categories of “good abortions” versus women can safely access abortion “bad abortions” and who can and cannot services when and where they need At the individual level, our perceptions obtain an abortion. This is non-existent them. The Indonesia-based feminist and of abortion are shaped by the words for any other medical procedure. rights-based organisation, Samsara, we hear and use. Women’s rights Women’s movements have worked to promotes the access to education and organisations have shifted the language liberalise abortion laws across the globe; information on SRHR and safe abortion to be more about reproductive justice, Ireland recently liberalised its abortion in multiple languages through apps rights, health, and pro-woman laws and Chile expanded the legal accessible via mobile phones and tablets. movements. Young people across Europe indicators for abortion. have reclaimed the narrative of their How to Tackle Abortion Stigma. own abortion experiences in new and Working to ensure that abortion care is Stigma is produced and reproduced innovative ways.8 The Women’s Action offered in women-centred ways is also at various levels of the ecosystem Group in Zimbabwe frames abortion in critical to reducing stigma. Semillas, and only a comprehensive approach— terms of women’s access to holistic, a women’s fund in Mexico, works to reframing harmful language, changing 7 spotlight arrow for change | vol. 24 no. 1 2018

discriminatory policies and practices, Notes & References 5 Chimaraoke Izugbara, Frederick Wekesah, and Sunday Adedini, “Maternal Health in Nigeria: A Situation Update,” 2016, and ensuring implementation of quality 1. F. Hanschmidt et al., “Abortion Stigma: A Systematic https://doi.org/10.13140/RG.2.1.1291.9924; Andrzej Kulczycki, services—will result in the right to Review,” Perspectives on Sexual and Reproductive Health, “Abortion in Latin America: Changes in Practice, Growing 48 (2016): 169-177, https://doi.org/10.1363/48e8516; Conflict, and Recent Policy Developments,” Studies in Family self-determination and abortion access K. Le Tourneau, Abortion Stigma around the World: A Planning 42, No. 3 (September 2011): 199-220. for all. Linking organisations that work Synthesis of the Qualitative Literature: A Technical Report 6. Global Fund for Women, “Making it Concrete: Using the on abortion stigma and other forms of for Members of the International Network for the Reduction Sustainable Development Goals to Bring Sexual Health and of Abortion Discrimination and Stigma (inroads) (Chapel Rights to Women in Nepal,” October 2017, https://www. stigma—in the fields of HIV and AIDS, sex Hill, NC: inroads); Anuradha Kumar, Leila Hessini, and Ellen globalfundforwomen.org/beyond-beijing-committee/#. worker rights, and LBTQI organising— M.H. Mitchell, “Conceptualising Abortion Stigma,” Culture, W5qQTOhKiB0. Health, and Sexuality 11, no. 6 (2009): 625-639, https://doi. 7. “Our Impact,” Global Fund for Women, https://www. is also key. Global networks, like the org/10.1080/13691050902842741. globalfundforwomen.org/our-impact/#.W4Zs_9gzauU. International Network for the Reduction 2. A drug used to induce labour and abortions, treat stomach 8. YouAct, Speak My Language: A Toolkit Developed by ulcers, and prevent post-partum bleeding. and for Young People; Abortion Storytelling in Eastern 9 of Abortion Stigma and Discrimination, 3. World Health Organization, Department of Reproductive Europe from a Youth Perspective, with Inputs from Georgia, are also critical for sharing knowledge Health and Research, Safe Abortion: Technical and Policy Lithuania, Republic of Macedonia, Poland, and Romania (2016), Guidance for Health Systems, 2nd ed. (Geneva: World Health http://youact.org/wp-content/uploads/2016/01/YOUACT_ and strategies, building resistance and Organization, 2012), www.who.int/reproductivehealth/ ABORTION_STORYTELLING_IN_EE.pdf. resilience, and creating a future where publications/unsafe_abortion/9789241548434/en/. 9. International Network for the Reduction of Abortion abortion stigma is part of our past. 4. Kumar, Hessini, and Mitchell, “Conceptualising Abortion Discrimination and Stigma (INROADS), https:// Stigma.” endabortionstigma.org/.

By Bhuvaneswari Sunil MARGINALISED WOMEN AND Doctoral Research Scholar, Tata Institute of Social Sciences, Mumbai, India REPRODUCTIVE RIGHTS: Email: [email protected] Who Should Mediate Access to Safe Abortion?

Irrespective of their husbands’ desires, of these women. She experienced five me to come again [for the abortion Indian women of varying age, education, pregnancies, lost one child immediately procedure] after two days with caste, and class status desire to have after delivery, had a miscarriage at the Rs.5,000 (USD69.30). We went back small families with two children.1, 2 7th to 8th month of her pregnancy, to the hospital to ask if they could and now has two living children. She reduce the cost and as the doctor was Yet, rural women from lower socio- recollects her experience of abortion: not around, a nurse said she could economic backgrounds, young women, do it for Rs.2,000 (USD27.70). The and those from backward and scheduled When I was pregnant for the sixth same evening, my husband managed castes continue to experience unwanted time, I requested my husband to get to pawn my jewellery and got some pregnancies, miscarriages, and abortions. me [medical abortion] tablets from money. The nurse did it in the hospital Unable to exercise agency over their the medical shop…I just had three itself. It was so painful; much worse bodies and denied mobility in public days of menstruation after that and than a childbirth. I still have not been spaces, they are much more dependent did not get my periods again for sterilised; I am afraid of it. on government health facilities due to another two months. The lady doctor factors such as financial dependence, scolded me, saying I had lost my In these circumstances, women’s poverty, and their husbands’ apathy to senses for conceiving again despite autonomy, sexuality, and identity are pregnancy and the reproductive health the multiple pregnancies. She scolded questioned when seeking abortion experiences of women. me for getting the pills and asked services. The state and private providers me why I did not get sterilised in the neglect and deny women’s right to have Kalaimathi, a 25-year-old scheduled caste last delivery itself. I told her we were safe and dignified abortion services. woman and a homemaker, is one planning but still unsure. She asked Respondents felt that the doctors are 8 arrow for change | vol. 24 no. 1 2018 spotlight

desensitised to their plight. These health Radha, a 35-year-old homemaker who You people have no other business providers not only fail to recognise belongs to a backward caste and who than getting pregnant.”3 Those women’s subjective experiences, but agreed to wear a copper-T following an words hurt me very much. Then after also tend to objectify them as seekers abortion, shared: begging her so much, she said, “If you of sexual pleasure and judge them for get sterilised, I will do the abortion. their inability to restrict from conceiving. Most nights, he will scream and curse I agreed simply for the reason of me They also thrust the accountability of at me, saying that it is hurting him being accused as a whore. They got pregnancy solely on women. According like a blade when we are having sex. signatures from me and then did the to most respondents, “Doctors cannot The nurse at the clinic who inserted it operation. But now…I struggle to raise possibly understand the circumstances after the abortion refused to remove my daughter all alone as no man will in which these women have become it. After almost bearing three to consider marrying me now that I am pregnant, mainly by their inability to four months of ongoing abdominal sterile… deny their husband’s sexual demands.” and back pain, prolonged menstrual bleeding, fatigue, and my husband’s The shaming and blaming that women Moreover, the doctors were unconcerned constant assault, I had to travel to undergo in health institutions is a human about the fears and physical discomfort/ my hometown to get it removed… rights violation. A woman’s right to pain that women experienced when Eventually, I got pregnant again and live with dignity is neither recognised getting forced contraception, such as IUD had to deliver another girl. by these state actors nor by her family (as a prerequisite to providing abortion). members. The whole continuum of Some women referred to the practice of The doctors who deny abortion also unwanted pregnancy and denial of enforcing the IUD by service providers disrespect the women for their decision, abortion subjugates the woman to invasive. These contraceptive strategies hurling abusive language and displaying further marginalisation and exclusion. by the providers make these women— hostile behaviour. There is also increased who lack sexual autonomy—more apathy and judgement, especially if the The Medical Termination of Pregnancy vulnerable as they are forced to face woman is from a lower socio-economic (MTP) Act (1971) gives the authority their sullen husbands. background, based on her caste, skin to medical practitioners to provide colour/appearance, occupation, language induced abortion in good faith based slang, and place/location of residence. on the woman’s actual or foreseeable Rural women from lower environment. Yet health providers often socio-economic backgrounds, Ponnulatchmi, a 24-year-old labourer give the impression that it is only legal young women, and those from a scheduled caste who is working to carry out abortion when there are from backward and scheduled in the construction sector and is a sexual foetal abnormalities. The provider’s castes continue to experience violence survivor, shares her experience general use of the word “healthy foetus,” of seeking an abortion at a government while denying abortion to a woman is a unwanted pregnancies, hospital: value-laden normative conceptualisation miscarriages, and abortions. of disability and elimination of “unfit” Unable to exercise agency over I told the doctor that my husband (unhealthy) people. Such experiences their bodies and denied mobility was cheating on me and was getting have forced many respondents to believe married to another woman. He was that abortion is illegal in India for reasons in public spaces, they are much actually my second husband and other than foetal anomalies. This is more dependent on government I have a daughter from my first irrespective of the fact that the MTP Act health facilities due to factors husband. I conceived thinking he had created some avenues for women such as financial dependence, wanted a child from me, but now he to access induced abortion services. has left me and his mother has fixed These terminologies in the law, which poverty, and their husbands’ another bride for him. It has been 45 were conceptualised by health service apathy to pregnancy and the days since I got my period. Please do providers, ensure their authority in the reproductive health experiences something. The doctor scolded me, decision-making process is maintained, of women. saying exactly these words, “You will thus systematically removing women’s go and sleep with all men and it is my choices and denying them autonomy. responsibility to clean your stomach. 9 spotlight arrow for change | vol. 24 no. 1 2018

It is true that sex-selective part of their day-to-day lived reality, moral judgements, social, religious, and abortion is prohibited in the women rely on information from key cultural norms. The culpability of the social networks (neighbours or distant state apparatus in failing to provide easy, country. Nevertheless, it is also relatives) on access to cheaper and, informed, safe, and dignified access to an experiential understanding often times, harmful abortion providers. abortion pushes women to the margins. from my fieldwork that sex- Many women prefer to go to unqualified It is time that we review the MTP Act based foetus personification is providers simply because they do not and specifically address the issues of have to justify themselves, as well as to denial of women’s rights and active also a predominant strategy that avoid stigma and judgement. discrimination exercised by health doctors use to convince women providers. to continue their unwanted It is true that sex-selective abortion is 4 pregnancy. The issue becomes prohibited in the country. Nevertheless, Legal abortion provision should even more complex when it is also an experiential understanding from my fieldwork that sex-based foetus be provided to women without healthcare providers attach personification5 is also a predominant any interference of moral their personal values and faith- strategy that doctors use to convince judgements, social, religious, and based belief to deny an abortion women to continue their unwanted cultural norms. The culpability to women facing unwanted pregnancy. The issue becomes even more complex when healthcare providers of the state apparatus in failing pregnancies. attach their personal values and faith- to provide easy, informed, safe, based belief to deny an abortion to and dignified access to abortion An instance of this is the story of Kanaka, women facing unwanted pregnancies. pushes women to the margins. a 34-year-old rural homemaker with A retired gynaecologist justified her five living children and eight pregnancy decision to deny abortion by saying, experiences: “Now I have a grandson, I no longer perform any abortions. Moreover, when Notes & References The government hospital does not we deny abortion, they may decide to provide any abortion services! The continue their pregnancy; I convince and 1. The experiences of women that are shared in this article are based on the author’s doctoral work conducted in a small town doctor from the government hospital send them back.” Yet another doctor called Kumbakonam in Tamil Nadu, South India. The interviews runs a private clinic where abortion belonging to a higher caste hierarchy were collected from April 2015 to October 2016. 2. Culturally, families often desire to have one girl and one services are provided.…Often, if it reflected on her decision to deny boy. is in the initial weeks of pregnancy, abortion services saying, “I had vowed 3. The men and women working in the construction industry I request my husband to get the pill as masons and contractors belong to lower castes; being black- to my Guru that I will not perform any skinned, they are stereotyped to be “sexually loose.” Most of from the neighbourhood pharmacy. such acts as that of abortion…It is a sin!” the doctors in this locale belong in the higher hierarchy of caste These pills prove to be effective Corroborating the story of one of my status. 4. In India, the Pre-conception and Pre-Natal Diagnostics sometimes and many times the risk respondents, the continuous denial and Techniques Act makes the act of sex determination of the foetus prevails! [Meaning the pregnancy is delay in providing abortion by one of the illegal. This law prohibits active sex determination and abortion of female foetuses, given the cultural preference for boys. not effectively terminated with the provider resorted to her performing a 5. When women visit a provider seeking abortion, the provider use of self-induced medical abortion self-induced medical abortion.6 following a scan convinces a woman not to undergo abortion, whereby she personifies a foetus as a boy and also as healthy. pills.] On the other hand, if we go 6. Medical abortion (MA) pill in India cannot be legally to the government hospital at the Women who are denied access to safe obtained as an over-the-counter pill like many other medicines. district level, they will force us to do It has to be sold by a pharmacist through prescription. However, abortion services are denied crucial pharmacists sell MA pills mostly (to men) who are local an operation [tubectomy] following aspects of their human rights, most residents located within a particular geographic area around the the MTP! especially their sexual and reproductive pharmacy without prescriptions. rights. The law and policy on abortion These experiences often force many should acknowledge historical gender women to seek out the help of discrimination and active gender unqualified and unsafe providers to discrimination by health providers. Legal induce abortion. When unwanted abortion provision should be provided pregnancy and abortion become to women without any interference of 10 arrow for change | vol. 24 no. 1 2018 spotlight

By Jona Claire Turalde THE IMPACT OF THE SheDecides Champion Email: [email protected] GLOBAL GAG RULE ON SAFE and Dhivya Kanagasingam ABORTION SERVICES: Email: [email protected] Sparking a Movement for Safe Abortion

On January 23, 2017, United States recognise, respect, and enable women abortions are either less safe or least President Donald Trump reinstated and girls to decide and make choices for safe. the or the Global themselves. This was a pivotal moment Gag Rule. The policy disqualifies non- as there was a global, inter-governmental Already 9.8 million adolescent girls governmental organisations (NGOs) response to President Trump’s foreign in Asia-Pacific have an unmet need from receiving funds if they continue to policy. This moment was also based for contraception;6 one-third of all perform or promote abortions, including on the premise that women’s rights, adolescent pregnancies are unintended,7 offering legal advice or counselling especially their sexual and reproductive more than half of these end in abortion, related to abortion. Trump’s version of rights, should not be bargained away and 60% of these abortions take place in the Global Gag Rule dramatically and in political horse-trading. SheDecides countries where abortions are less safe. dangerously expanded the scope to helped unify different movements be applied to all US global health aid, working nationally and regionally, on a Trump’s policy hits the poorest nations, encompassing an estimated US$9.5 range of sexual and reproductive rights which are donor-dependent and have a billion,1 to the detriment of millions of and gender equality, and put abortion weak legal system in place. The policy women around the world, with only access at the forefront of these issues. hits hardest the poorest women and narrow exceptions being possible for Without compromise. the youngest women in every country cases of rape or incest.2 affected and goes against hard-fought Women’s rights, especially their global consensus agreements on As a response, the then Dutch Minister sexual and reproductive rights, women’s reproductive rights. Moreover, for Foreign Trade and Dutch Cooperation, the policy has shown itself as a failed should not be bargained away in Lillianne Ploumen, swiftly announced strategy: curtailing the funding and the that women and girls should have the political horse-trading. activities of organisations that provide right to choose, and that the Dutch modern contraception and safe abortion, government would step up funding for Every year, 275,288 women die of which the Global Gag Rule does, may safe abortion services. This move was pregnancy-related complications.3 In in actual fact lead to an increase in the rapidly supported by the respective 2014, at least 6% of all maternal deaths unsafe abortion rate.8 ministries of aid and trade of the (or 5,400 deaths) in Asia were from 4 Dutch, the Danish, the Belgian, and unsafe abortion. In the Asia-Pacific The need for strong platforms the Swedish governments, leading to region, it is estimated that about 35.5 the establishment of the SheDecides million abortions occur5 out of the global and alliances on the ground to initiative. This initiative, launched estimate of 55.9 million abortions, largely push for sexual and reproductive on March 2, 2017 at the SheDecides due to the sheer size of the population health and rights has never been conference, was strongly subscribed— of the region. As a regional average, more essential. The growing attended by 50 progressive governments most abortions in Asia are classified as and by 450 participants from UN safe, however, this number is weighted threats around women and girls’ agencies, NGOs, and foundations from favourably by the numbers in China and right to decide over their bodies both sides of the Atlantic. Vietnam, where almost all abortions are need a strong pushback. safe due to expansive laws which enable SheDecides pitched that governments access. In South Asia, the numbers and donors should, in essence, are reversed, where two-thirds of all 11 spotlight arrow for change | vol. 24 no. 1 2018

Despite the launch of SheDecides, large Nepal, and the Philippines—initiated the funding gaps loom at the global level. Solidarity Alliance for the Right to Safe For example, Marie Stopes International, Abortion with the aim of working towards which provides contraception and liberating abortion laws, while effectively abortion services in 33 developing implementing existing laws to increase countries, faces a US$80 million funding safe abortion services. gap. They estimate that 2 million women will no longer have access to sexual and With demand from women and girls on reproductive health services. This will the ground and stronger accountability result in an extra 2.5 million unintended measures within countries around sexual pregnancies, 870,000 unsafe abortions, and reproductive services, developing 6,900 avoidable maternal deaths, countries may not have to rely entirely and US$138 million increase in direct and heavily on inconsistent foreign aid healthcare cost.9 which shifts and dwindles at the snap of a finger. Until all governments realise Until all governments realise that they have state obligations to that they have state obligations protect women’s rights to their bodies, and women’s bodies are not theirs to to protect women’s rights to control or to wage war on, we will not be their bodies, and women’s bodies able to realise the full potential of women are not theirs to control or to and girls. wage war on, we will not be able to realise the full potential of women and girls. Notes & References

1. Ann M. Starrs, “The Trump Global Gag Rule: An Attack on 6. Jacqueline E. Darroch et al., Adding it: Up Costs and Benefits The full impact of the policy is also US Family Planning and Global Health Aid, The Lancet 389, Issue of Meeting the Contraceptive Needs of Adolescents (New York: difficult to distinguish and predict 10068 (February 4, 2017): P485-486, accessed August 29, 2018, Guttmacher Institute, 2016), https://www.guttmacher.org/ https://doi.org/10.1016/S0140-6736(17)30270-2. report/adding-it-meeting-contraceptive-needs-of-adolescents. because it applies to NGOs who receive 2. “Trump’s ‘Mexico City Policy’ or Global Gag Rule,” Human 7. Darroch et al., Adding it Up. any US health assistance, not just family Rights Watch, February 14, 2018, accessed 29 August 2018, 8. Eran Bendavid, Patrick Avila, and Grant Miller, “United https://www.hrw.org/news/2018/02/14/trumps-mexico-city- States Aid Policy and Induced Abortion in Sub-Saharan Africa,” 10 planning. As such, the Global Gag Rule policy-or-global-gag-rule. Bulletin of the World Health Organization 89 (2011):873-880C, leaves a chilling effect. At the country 3. Nicholas J. Kassebaum et al., “Global, Regional, and National accessed August 31, 2018, http://www.who.int/bulletin/ Levels of Maternal Mortality 1990-2015: A Systematic Analysis volumes/89/12/11-091660/en/. level, health providers have indicated of the Global Burden of Disease 2015,” The Lancet 388, Issue 9. Will Harris, “Trump’s Global Gag Rule One Year On: Marie confusion on implementation, lack of 10053 (October 8, 2016): P1775-1812, https://doi.org/10.1016/ Stopes International Faces $80m Funding Gap,” Marie Stopes S0140-6736(16)31470-2. International, January 19, 2018, accessed September 1, 2018, clear guidance on application, over- 4. Guttmacher Institute, Abortion in Asia (New York: https://mariestopes.org/news/2018/1/global-gag-rule- interpretation of the policy due to fear, Guttmacher Institute, 2018), https://www.guttmacher.org/fact- anniversary/. and de-prioritisation on integrated health sheet/abortion-asia. 10. Harris, “Trump’s Global Gag Rule One Year On.” 5. Susheela Singh et al., Abortion Worldwide 2017: Uneven 11. Vanessa Rios, Reality Check: Year One of Trump’s Global services, which affects the lives of Progress and Unequal Access (New York: Guttmacher Institute, Gag Rule (New York: International Women’s Health Coalition, women and girls across many developing 2018), 51, https://www.guttmacher.org/report/abortion- 2018), https://iwhc.org/resources/reality-check-year-one- worldwide-2017. trump-global-gag-rule/. countries.11

The need for strong platforms and alliances on the ground to push for sexual and reproductive health and rights has never been more essential. The growing threats around women and girls’ right to decide over their bodies need a strong pushback. Earlier this year, ARROW and her partners across five countries—Bangladesh, Cambodia, India, 12 arrow for change | vol. 24 no. 1 2018 spotlight

By Hazal Atay TELEMEDICINE ABORTION IN Ph.D. candidate in Sciences Po Paris, INSPIRE-Marie Skłodowska-Curie Fellow RESTRICTIVE SETTINGS: Email: [email protected] An Abortion Revolution and a New Velvet Triangle1

Abortion has long been a feverish topic The advancement of medical has shown that the procedure has few of discussion in different socio-political abortion and telemedicine did serious complications, which vary from realms. Amid the ongoing controversy, it heavy bleeding to incomplete abortion not only provide women with has been proven that restricting abortion and infection. Medical abortion, with does not end abortion, but rather leads an alternative method but also and , has proven to unsafe abortion practices. Today, it paved the way to redefine the to be 98.3% successful for women is estimated that among the 55.7 million ways in which women access with gestational ages below 60 days.6 abortions that took place between 2010 safe abortion. Given the low risk of complications and and 2017, around 25.1 million (45%) were high success rate, the World Health unsafe and potentially dangerous.2 In Organization (WHO) affirms that a medical effect, each year, unsafe abortion leads A lot has changed since the initial abortion does not need to take place in to 47,000 deaths and 5 million disabilities demands to control fertility and ensure a hospital or medical clinic; women can worldwide.3 reproductive justice. Research and carry out the treatment safely and deal scientific development have contributed with the process themselves at home. As Grimes et al. put it, unsafe abortions significantly to engender new terms The possibility of self-administration of appear to be a grave yet “preventable and conditions for women’s bodily medical abortion carries its potential pandemic” since these deaths can be autonomy. Medical abortion—abortion further, as it empowers women while prevented through adequate and efficient with pills—appears to be one of the most decentralising the abortion practice provision of safe abortion services.4 It remarkable changes. The advancement from medical circles towards women is in this framework that this article will of medical abortion and telemedicine themselves. investigate the advent of medical abortion did not only provide women with an service provision through telemedicine alternative method but also paved the Building on the principle of self- (online counselling) in restrictive settings. way to redefine the ways in which women administration, and following previous By revealing a ground for safe abortion access safe abortion. Moreover, this has models of helplines and the advent of provision beyond laws, it will demonstrate specific consequences and implications world wide web, internet-based how telemedicine is promising to change for women living in restrictive settings, telemedicine services provide help and the terms and conditions of safe abortion who now have a safe refuge in the face information in “cost-effective and access in countries with restrictive laws. of dangerous underground abortions and supportive ways.”7 Today, there are As such, it will illustrate how women’s legal containments. Self-administration several telemedicine services as such, quest for safe abortion and ensuring of medical abortion and telemedicine has including , Women Help anonymity and security has effused online offered women the chance to do abortions Women, Safe2choose, TelAbortion, and and how they are answered through on their own in early pregnancies Tabbot Foundation. Some of these telemedicine services and transnational regardless of legal status. As such, it also telemedicine services work globally feminist activism around it. Finally, the paved the way to lessen intimidation and across borders, whereas some like article will discuss how telemedicine can stigma around the experience of abortion. Tabbot Foundation (in Australia) works provide an alternative to unsafe abortion nationally.8 and how a new velvet triangle of women, According to Gomperts, medical abortion telemedicine, and transnational feminist with mifepristone and misoprostol is “one Telemedicine services do not only provide activism challenges restrictive abortion of the safest procedures in contemporary safe abortion, but they also transform the laws both in short term and long term. medical practice, with minimal morbidity abortion rhetoric around what constitutes and a negligible risk of death.”5 Research a “safe abortion.” Today, when we talk 13 spotlight arrow for change | vol. 24 no. 1 2018

about underground or clandestine might face harassment and prosecution. collectives constitute a successful strategy abortions, it is not the same phenomenon In addition, although these services to “disseminate information about using predominant years ago. Scientific promise to keep women’s information abortion pills for safe abortion and as a evidence shows that women can have confidential, it is difficult to ensure data vehicle for social change.” The study of medical abortions by themselves at security and privacy. Moreover, many Aiken et al. on self-reported outcomes home and this can be counted as a safe of the telemedicine services are pricey, after medical abortion through online procedure when proper instructions are and their sustainability is at risk if they telemedicine in Ireland12 suggests the followed. For example, Gomperts et al. are under-funded and not supported. The success of telemedicine services in concluded that outcomes of care following black market for telemedicine services restrictive settings. Aiken denotes that, telemedicine abortion is in the same range make it difficult for women to find reliable among 1,000 women who were pregnant as the termination of pregnancy provided and affordable services. Lastly, we need less than nine weeks and who received in outpatient settings.9 Moreover, WHO to acknowledge that knowledge gaps help from Women on Web between classifies medical abortion obtained could mean that women may need more January 2010 and December 2012, 94.7% through reliable telemedicine services as guidance and reassurance throughout the reported successfully ending their “safe abortion.”10 process, and follow-up may be needed. pregnancy and only 4.5% reported that they needed further surgical intervention Although restrictive laws drive abortions Although restrictive laws drive following self-administration of medical underground, with the advent of medical abortion. This success rate is noted to be abortion and telemedicine services, safe abortions underground, with similar to the rates of medical abortions abortion alternatives flourish despite the advent of medical abortion carried out in a clinical inpatient setting legal restrictions, including online. It is and telemedicine services, safe and reveals the effectivity of telemedicine noteworthy that the website of Women abortion alternatives flourish and of self-administration of medical on Web, which went online in 2006, abortion. The results are especially despite legal restrictions, currently has around 2 million unique significant for restrictive settings and visitors per year. Women on Web including online. enhance the validity of “strengthening announced during its 10th anniversary services outside the formal healthcare that over 200,000 women from over 140 Despite these limitations, one can as a vital component of strategies to countries did online consultation through still argue that telemedicine abortion reduce maternal mortality from unsafe its service, approximately 50,000 women revolutionised access to safe abortion by abortion.”13 received medical abortion at home, rendering a significant number of self- and the helpdesk answered more than managed abortions safe. As such, today As Petchesky notes, abortion has been 600,000 emails.11 As can be seen through it looms large as a key player in the new among the means which women have this example, in places where women’s abortion debates. resorted with the greatest persistence only resort are dangerous procedures, over time. Indeed, more than the unreliable sources, and the black market, However, telemedicine abortion cannot be suppression of abortion, it is the reliable telemedicine services provide a solution apart. Indeed, it is part of a persistence of it which grounds “women’s women with a safe alternative. larger struggle, which constitutes a specific relation to fertility and the terms new velvet triangle, for increasing and conditions of fertility control and Surely, there are limitations to access to safe abortion. As long as reproductive freedom for them.”14 By telemedicine services. As technology legal restrictions persist, telemedicine providing safe abortion alternatives brings along new opportunities, it also abortion is doomed to remain more of in restrictive settings, telemedicine brings risks. The internet is not available a cause or a strategy than a solution. In services, on the one hand, respond to everywhere and many women are fact, telemedicine services can only be women’s persistence, and on the other not internet literate. Moreover, such effective to foster a real change through hand, reduce abortion restrictions telemedicine services can easily be a velvet triangle of defiant women who to absurdity and futility. In a press censured and/or blocked so that women persist on their bodily autonomy and release dated June 21, 2016, Women have no access to them. Even when transnational feminist activism who on Web manifested: “Abortion pills these services are allowed to operate ensure the viability and continuity of such are everywhere!”15 As the access to online, the delivery of the pills might services. Jelinska and Yanow note that safe abortion increases, if not through be blocked by the customs and women services run predominantly by feminist public health services, but through 14 arrow for change | vol. 24 no. 1 2018 spotlight

reliable telemedicine services, women 2. Bela Ganatra et al., “Global, Regional, and Subregional 9. Rebecca J. Gomperts et al., “Using Telemedicine for Classification of Abortions by Safety, 2010-14: Estimates Termination of Pregnancy with Mifepristone and Misoprostol are less likely to be mere victims of from a Bayesian Hierarchical Model,” The Lancet, 390, no. in Settings Where There Is No Access to Safe Services,” British restrictive abortion laws. Women’s use 10110 (September 2017), accessed July 4, 2018, https://doi. Journal of Obstetrics & Gynaecology 115, no. 9 (August 2008): org/10.1016/S0140-6736(17)31794-4. 1171-1175, accessed July 2, 2019, https://doi.org/10.1111/j.1471- of telemedicine services and access 3. World Health Organization (WHO), Safe Abortion: Technical 0528.2008.01787.x. to safe abortion in restrictive settings and Policy Guidance for Health Systems, 2nd ed. (Geneva: 10. Sarah Boseley, “Almost Half of All Abortions Performed are promising to change the terms and WHO, 2012), accessed July 4, 2018, http://apps.who.int/iris/ Worldwide Are Unsafe, Reveals WHO,” The Guardian, bitstream/10665/70914/1/9789241548434_eng.pdf. September 27, 2017, accessed July 4, 2018, https://www. conditions of abortion access both in 4. David Grimes et al., “Unsafe Abortion: The Preventable theguardian.com/world/2017/sep/27/almost-half-of-all- long term and short term. Pandemic,” The Lancet 368, Issue 9550 (November 25, 2006): abortions-performed-worldwide-are-unsafe-reveals-who. P1908-1919, accessed July 2, 2018, http://www.who.int/ 11. Women on Web, “Online Abortion Service Women on Web reproductivehealth/publications/general/lancet_4.pdf. Is 10 Years!,” April 22, 2016, accessed July 4, 2018, https:// 5. Rebecca Gomperts, “Task Shifting in the Provision of www.womenonweb.org/en/page/11876/online-abortion- Medical Abortion” (Thesis, Karolinska Institutet, May 2014), service-women-on-web-is-10-years. accessed December 10, 2017, https://openarchive.ki.se/xmlui/ 12. Abigail R.A. Aiken, “Self-reported Outcomes and Adverse handle/10616/41984. Events After Medical Abortion Through Online Telemedicine: Notes & References 6. Mary Fjerstad et al., “Effectiveness of Medical Abortion Population-based Study in the Republic of Ireland and Northern with Mifepristone and Buccal Misoprostol through 59 Ireland,” BMJ, 357 (May 2017): J2011, accessed August 8, 2018, 1. The Velvet Triangle is a term developed by Alison E. Gestational Days,” Contraception 30, no. 3 (September 2009): doi: https://doi.org/10.1136/bmj.j2011. Woodward to describe strategic interactions “between policy 282-286, accessed July 3, 2018, https://doi.org/10.1016/j. 13. Cited in Diana Phillips, “Telemedicine for Medical Abortion makers and politicians, feminist academics and experts, and the contraception.2009.03.010. Safe, Effective,” Medscape (May 16, 2017), accessed August 8, women’s movement.” In this article, the term “velvet triangle” is 7. World Health Organization, “Resolutions and Decisions: 2018, https://www.medscape.com/viewarticle/880084. used to describe the collaboration and trilogy of women, WHA58.28 eHealth,” Fifty-Eighth World Health Assembly, May 14. Rosalind P. Petchesky, Abortion and Woman’s Choice: telemedicine, and transnational feminist activism to promote 2005, 121-123, accessed December 29, 2017, http://www.who. The State, Sexuality, and Reproductive Freedom (Boston: safe abortion. For more information on the concept, see: int/healthacademy/media/WHA58-28-en.pdf. Northeastern University Press, 1990), 26. Alison E. Woodward, “Travels, Triangles, and Transformations: 8. Kinga Jelinska and Susan Yanow, “Putting Abortion Pills Into 15. Women on Web, “Abortion Drone Ireland: Abortion Pills Implications for New Agendas in Gender Equality Policy,” Women’s Hands: Realising the Full Potential of Medical Are Everywhere!,” June 21, 2016, accessed July 4, 2018, https:// Tijdschrift voor Genderstudies 18, no. 1 (2015): 5-18, accessed Abortion,” Contraception 97, Issue 2 (2018): 86-89, accessed www.womenonwaves.org/en/page/6311/abortion-drone- July 4, 2018, https://doi.org/10.5117/TVGN2015.1.WOOD. July 4, 2018, https://doi.org/10.1016/j.contraception.2017.05.019. ireland--abortion-pills-everywhere.

PROVIDER ATTITUDES, in our own words PERCEPTIONS, AND By Professor Dato’ Dr. Ravindran Jegasothy CONSCIENTIOUS OBJECTIONS: Dean, Faculty of Medicine MAHSA University, Malaysia The Battle between “Right” and Email: [email protected] Responsibility

Pregnancy is a physiological event fall the responsibility of caring for and “either by persons lacking the necessary that may happen during a woman’s making decisions about the care of skills or in an environment that does not reproductive age. Often, this is a happy the pregnancy. Needless to say, what conform to minimal medical standards, occasion with positive connotations happens subsequently will depend on the or both.”2 An analogy can be drawn when the pregnancy is desired. However, prevalent health systems, the views of to maternal mortality where maternal some pregnancies are met with medical the patient, the partner, the HCP, and the mortality has been reduced when there is complications or the pregnancy itself laws of the particular country. skilled attendance at delivery. may be undesired. Then negative and emotive perspectives may pervade this Although abortions can be self-induced, Women across the age span experience event. These perceptions do not only abortion is safer when advice and care abortions. Most women who seek affect the pregnant woman but also the are provided by trained personnel in a abortion are married women, trying to man responsible for the pregnancy (if suitable environment.1 WHO defines limit their family size or space births present), as well as the healthcare unsafe abortion as a procedure for because of economic difficulties or other provider (HCP) on whose shoulders terminating an unwanted pregnancy reasons. What defines the perception 15 in our own words arrow for change | vol. 24 no. 1 2018

of women towards abortion? Their held ethical principle in medical practice views of the peers and community. educational level, social status, marital reflecting the sanctity of the doctor- At the national level, laws and policies status, the status of women in their patient relationship. The principle of are an important tool for assuring the community, access to healthcare and utilitarianism (the breaking of patient provision of quality services, whether contraception, and HCP attitudes towards confidentiality for the greater good of for safe abortion, post-abortion care, abortion seekers would all be important the community) often does not come or contraceptive provision. Laws may determinants of a woman’s perception of into play in the context of abortions range from total prohibition of abortion abortion. as pregnancy and the care of it closely to limiting the legal rights to abortion concerns only the woman and her to save the woman’s life, to preserve Healthcare providers form an important partner. physical health, and preserve mental element of the equation determining health, or more liberally to allowing the women’s access to services, as well as provision of abortions on socio-economic Ethical principles that govern the the quality of care provided for abortion grounds or without restriction as to seekers. Their perception of abortion actions of HCPs in any dilemma the reason. Myths that hinder women’s would be shaped by their own attitudes regarding medical care would ability to access abortion, such as that towards abortion, determined by their include autonomy (the patient the incidence of abortion will be lower upbringing and family values, societal who is above the age of majority if abortion is illegal or that abortion will values in which they grew up in, religious no longer occur if women have access and socio-cultural determinants, training and who is able to understand to family planning, should be addressed provided in medical or nursing schools, what is being informed to her and post-abortion care should always be their views on contraception, including should decide what is to be offered. its provision to unwed mothers, as done), non-maleficence (the well as their perception of the laws of There has been a debate whether there the country with regards to abortion. HCP’s duty never to harm), is a place for conscientious objection One would also be reminded that aside beneficence (duty to always do in medicine.4 If there is, then one could from national laws, each country’s good), and justice (always act in deny care that is required and dictated commitment to international policies the patient’s best interest). by clinical guidelines to a patient because and covenants on human and healthcare of a moral objection by the caregiver. rights relating to non-discrimination and Critics of conscientious objection cite reproductive self-determination would Conscientious objection has been the supremacy of patient autonomy and also shape the HCP’s perception. defined as “the refusal to participate in the professional duty of a physician as an activity that an individual considers reasons to oppose.5 On the other hand, Healthcare providers in any country incompatible with his/her religious, those in favour stress that the morality would be subject to the guidelines moral, philosophical, or ethical beliefs.”3 of the physician is an integral part in the and regulations of their own national It is compatible with the concept that all doctor-patient relationship and should professional regulatory bodies, such as healthcare providers have their own set not be ignored.6 the medical or nursing councils. Ethical of religious, cultural, and professional principles that govern the actions of beliefs which in the light of the ethical Some have argued that the personal HCPs in any dilemma regarding medical principle of autonomy has to be beliefs and morality of the doctor should care would include autonomy (the patient respected. However, it is also known that not enter into medical decision making.7 who is above the age of majority and communities and nations are governed Doctors, after all, are human beings with who is able to understand what is being along the principles of rules, regulations, their own set of values and judgements. informed to her should decide what is and laws that are set according to each Conscientious objection takes cognisance to be done), non-maleficence (the HCP’s nation’s philosophies and would evolve of individual variations but one has to duty never to harm), beneficence (duty with the views of the majority or ruling ensure that the health service is big to always do good), and justice (always parties. Professional practices in relation enough and has adequate safeguards act in the patient’s best interest). to abortion are dictated by the views to ensure access to the patients for The principle of deontology (one must of the medical councils as well as the procedures such as abortion.8 Doctors always do what is right irrespective of laws of the country. In other words, should ultimately agree that they should what happens to oneself) is a widely professional behaviour is guided by the do what is best for the patient as dictated 16 arrow for change | vol. 23 no. 3 2017 inspotlight our own words

by the evidence for any treatment or The International Federation of Notes & References procedure within the ambit of the laws Gynaecology and Obstetrics (FIGO) 1. Rasha Dabash et al., “How Provider Attitudes towards of the country. The health service should in their statement on Ethical Issues Abortion Can Impact the Quality of and Access to Abortion Services: An Assessment of IPPF/WHR Provider Knowledge, expand more to protect conscientious in Obstetrics and Gynaecology put Attitudes, and Practices in 6 Latin American and Caribbean objection as a concept, while ensuring in succinctly their stance in relation Countries” (Paper presented at the International Union for the universal access to healthcare. to professional standards of care Scientific Study of Population XXV International Population Conference, Tours, France, July 18-23, 2005), http://iussp2005. regarding conscientious objection to princeton.edu/abstracts/52409. Formulation of rules is one thing, abortion. While providers have a right 2. “Preventing Unsafe Abortion,” World Health Organization, http://www.who.int/en/news-room/fact-sheets/detail/ observance of them in the rough and to conscientious objection and to not preventing-unsafe-abortion. tumble of professional practice is quite suffer discrimination on the basis of their 3. Christopher Cowley, “A Defence of Conscientious Objection in Medicine: A Reply to Schuklenk and Savulescu,” Bioethics 30, another. A measure of the integrity of beliefs, conscientious objection must Issue 5 (December 10, 2015): 358-64, https://doi.org/10.1111/ the medical profession can be found in be secondary to the duty of healthcare bioe.12233. providers to treat (i.e., provide benefit 4. Julie D. Cantor, “Conscientious Objection Gone Awry— the degree to which each practitioner Restoring Selfless Professionalism in Medicine,” New England recognises his personal responsibility and prevent harm to) patients.9 Journal of Medicine 360,15 (April 9, 2009):1484-1485, https://doi. for the preservation, through his own org/10.1056/NEJMp0902019. 5. Julian Savulescu, “Conscientious Objection in Medicine,” BMJ example, of the honour and dignity of Patients have the right to be referred 332 (2006): 294-297, https://doi.org/10.1136/bmj.332.7536.294. the profession, and the fact that serious to practitioners who do not object to 6. Ishmeal Bradley, “Conscientious Objection in Medicine: A Moral Dilemma,” Clinical Correlations, May 28, 2009, accessed breaches of its ethical code are relatively procedures medically indicated for their July 3, 2018, https://www.clinicalcorrelations.org/?p=1454. rare. care. In emergency situations, providers 7. Gustavo Ortiz- Millán, “Abortion and Conscientious Objection: Rethinking Conflicting Rights in the Mexican Context,” must provide the medically indicated Global Bioethics 29, Issue 1 (2018): 1-15, https://doi.org/10.1080/ Any change of legal status will care, regardless of their own personal 11287462.2017.1411224. 10 8. Wendy Chavkin, Laurel Swerdlow, and Jocelyn Fifield, beliefs. “Regulation of Conscientious Objection to Abortion: An not bring changes without a International Comparative Multiple-Case Study,” Health and political commitment and clear Any change of legal status will not bring Human Rights Journal 19, Issue 1 (2017): 55-68, https://www. hhrjournal.org/volume-19-issue-1-june-2017/. directives to include abortions changes without a political commitment 9. FIGO Committee for the Study of Ethical Aspects of Human and clear directives to include Reproduction and Women’s Health, Ethical Issues in Obstetrics & as an essential component of Gynaecology (UK: FIGO, October 2012), 130-132, https://www. abortions as an essential component of reproductive health services. figo.org/sites/default/files/uploads/wg-publications/ethics/ reproductive health services. This will English%20Ethical%20Issues%20in%20Obstetrics%20and%20 This will help to destigmatise the Gynecology.pdf. help to destigmatise the issue to enable 10. Patty Skuster, When a Health Professional Refuses: Legal issue to enable universal access universal access to safe abortions for all and Regulatory Limits on Conscientious Objection to Provision of Abortion Care (Chapel Hill, NC: Ipas, 2012), 1-8, http://www. women a reality. to safe abortions for all women a ipas.org/en/Resources/Ipas%20Publications/When-a-health- reality. professional-refuses-Legal-and-regulatory-limits-on-conscientious- In conclusion, conscientious objection is objection-.aspx. an ethical option in the arena of abortion Physicians may experience conflict management. However, regulatory bodies between different ethical principles, should ensure access to management between ethical and legal or regulatory options is not curtailed if the rights of requirements, or between their own women and men affected by an unwanted ethical convictions and the demands of pregnancy are not to be infringed by the patients, proxy decision makers, other inclusion of conscientious objection in health professionals, employers, or other the regulatory area. involved parties. Ultimately, the physician has to make his own decision and be able to defend it, if required, in the court of public/professional opinion or a court of law. 17 in our own words arrow for change | vol. 24 no. 1 2018

FROM ANTI-CHOICE TO By Anna Maria* *Name changed to protect the identity and ABORTION PROVIDER institutional affiliation of the author Reflections of an Abortion Provider

I am personally responsible for hundreds got pregnant; too young and not yet ready advocates who kept on explaining to me of abortions in a country where abortion to raise a child, she had an abortion. Given the realities of unsafe abortion and how it is legally restricted. I provide counselling how restricted safe abortion is in our kills and makes women suffer, my biases and assist women to have a successful country, her procedure was performed and misconceptions were replaced by medical abortion. Before I became an by untrained providers, in a non-sterile compassion for women. abortion provider, however, I hated, even way. She was in pain for days and after condemned, women who had an abortion, the bleeding did not stop, she was rushed It was a long journey before I was finally or even those who were considering to the hospital. The doctors knew she convinced that abortion is a human right. having one. For me, they were induced an abortion and she was made to It took a few years to finally decide to irresponsible, promiscuous women who wait for hours before she was attended advocate for safe abortion and to provide did not have a conscience and sense of to. The hospital staff scolded her, even medical abortion. humanity. threatened her of being reported to the police. Worse, even in the delivery room, As a safe abortion advocate and provider What changed my mind from being she was still verbally abused while the in a country where abortion is heavily anti-choice to an abortion advocate and procedure was being performed. stigmatised and penalised, it has never provider? been easy. As a provider, I fear to be Sheena could not stop her tears while caught and condemned, while at the same Well, as much as I want to say that there she was reminiscing about this traumatic time, I know this should not stop me from was one heartbreaking encounter that experience. I could see in her eyes the providing the service. So I need to be very made me change my mind, the truth is, agony she had to bear. I felt guilty careful, especially as what I am doing is there wasn’t. It was a process—a long because I was also like those hospital just an individual initiative. There is no process—of not only getting new ideas staff that mistreated her. I hated and organisation that would bail me out if I but also of unlearning and reshaping the condemned women who had abortions, get caught. Aside from the legal penalties, beliefs and values I have. without considering what they were going what I fear the most is the stigma from the through. I was too blinded by my beliefs community. If women who had abortions My first encounter with abortion was with a to recognise that women like Sheena have are viewed as promiscuous, irresponsible, regional network in Asia that conducts safe suffered because of my prejudices. and immoral, abortion providers are abortion discussions. At that time, even perceived worse than these. They are though I was against abortion, I listened. I With this, I tried to slowly open, not represented in the media as terribly was totally confused after the discussion only my mind but also my heart for wicked and considered as “killers” of ended, but I pretended that I understood women who had an abortion. I tried innocent babies. They are the main villain everything, because it seems everybody to understand abortion, not based on in the whole story of abortion. It is as if was on the same page, except me. a judgmental position, but rather as a providing abortion, even if it is safe, is the person and a woman. It was not an easy most evil thing to do. Then, I conducted a research about process, because it is about challenging abortion realities in my country, where I my personal beliefs and values, which for But there is always hope. I believe we can met Sheena (not her real name). At first, I years have not been questioned. change this perception. Because abortion considered her just a case study, but along is happening, people are talking about the way, I felt her pain. She shared with It was difficult to admit that my perception it. It is just a matter of changing the me how she struggled for her life when that “women who had an abortion are conversation to be more compassionate she suffered from complications of unsafe irresponsible and immoral” is wrong. and respectful of women’s decision over abortion. She was 17 years old when she However, with the persistence of the their bodies. 18 arrow for change | vol. 24 no. 1 2018 in our own words

THE IMPACT OF STIGMA: A Nepali Woman’s Experience of Abortion

A 29-year-old, married, educated woman from urban Nepal shares her abortion experience.

Kamala (name changed to protect The lack of a separate waiting area in they think that abortion is morally her identity) was doing her post- the service centre made her long waiting wrong and a deviant behaviour. Despite graduate degree when she found out period even more uncomfortable. She experiencing heavy bleeding after the she was pregnant for the second time. was fearful of being recognised by abortion and having difficulty doing Although she had access to a range family or community members while household chores, she did not share the of contraceptives, she was allergic she waited. She felt that her privacy news with her family for fear of their to most of them, thus limiting her was not maintained, which resulted in reaction and judgement. So she lied, contraceptive options. Kamala felt her her decision to not go for post-abortion saying she was having her period. allergy resulted in contraceptive failure care. and subsequently led to an unintended Kamala strongly believes that there is pregnancy. She felt she would not be She strongly believes that there is a need to make women aware of safe able to take good care of herself and a need to make women aware of abortion services available to them. She continue her studies if she carried also feels that the quality of abortion the pregnancy to term and decided to safe abortion services available services have to be strengthened terminate it at six weeks. to them. She also feels that the by providing appropriate pre- and quality of abortion services have post-abortion counselling. Women’s Kamala was aware that safe abortion to be strengthened by providing privacy and confidentiality have to be services are available in Nepal, and maintained throughout the process so appropriate pre- and post- she knows of the service providers their right to safe abortion services is in her area. Being an educated and abortion counselling. Women’s secured. Equally important is the need to independent woman, she feels that she privacy and confidentiality have deconstruct abortion stigma was in a position to decide whether or to be maintained throughout prevailing in Nepalese society so that not to continue her pregnancy. However, the process so their right to safe women do not need to keep abortion a the process of making this decision was secret. very difficult for her as she feared to abortion services is secured. face abortion-related complications. Equally important is the need to deconstruct abortion stigma Kamala chose a private abortion service prevailing in Nepalese society so The Editorial Team is grateful to Kamala provider in her area with the hope for bravely sharing her story and to Aliza that it would offer a better quality of that women do not need to keep Singh from Beyond Beijing Committee, service and maintain her confidentiality. abortion a secret. Nepal for her assistance in compiling this Although the behaviour of service story. provider towards her was positive, she Kamala still keeps her abortion a secret was not satisfied with the offered pre- from most people, except for her and post-abortion counselling. She husband and a friend who helped her was not provided adequate information during the process. She believes her on what would happen to her body post-abortion experience would have after taking the abortion pills, what been less stressful (both mentally and complications could arise, and the family physically) if she had the support and planning methods she could use after understanding of her family and friends. abortion. However, she thinks that they would not have supported her decision because 19 monitoring national and regional activities arrow for change | vol. 24 no. 1 2018

By Jamil H. Chowdhury, MPH ENHANCING WOMEN’S Executive Director, Action for Social Development (ASD) SEXUAL AND REPRODUCTIVE Email: [email protected] Altaf Hossain, PhD HEALTH AND RIGHTS: Executive Director, Association for Prevention of Septic Abortion, Bangladesh (BAPSA) A Brief Review of the Menstrual Email: [email protected] Shamima Akther Chowdhury, MA Regulation Programme in Bangladesh Project Manager, BAPSA Email: [email protected] and M. Zobair, BA In Bangladesh, abortion is prohibited government has updated the definition Project Manager, BAPSA under the Penal Code of 18601 and of MR in 2013 as the “procedure of Email: [email protected] permissible only for saving the life of regulating the menstrual cycle when the mother. In all other cases, abortion, menstruation is absent for a short self-induced or otherwise, is a criminal duration.”7 As per a government circular offence punishable by imprisonment or of February 2015, MR can be performed fines.2 In 1972, this law was waived for by an MR-trained registered medical free-of-charge in government facilities, a very short period for rape survivors practitioner up to 12 weeks and by and has gained enormous success over of the War on Liberation.3 Using this as trained Family Welfare Visitors, Sub- the past decades with the effort of the a premise, the government cautiously Assistant Community Medical Officers, government and the other stakeholders. began its Menstrual Regulation (MR) paramedics, and nurses up to 10 weeks programme in 1974 in selected urban from the last menstrual period under the Until 2010, the only approved methods clinics. The clear objective was “birth supervision of a physician.8 The earlier for MR were manual control,” with MR used as a back-up approved duration was 10 and 8 weeks (MVA)9 and to a contraceptive failure.4 In 1976, respectively. (D&C).10 In 2014, the Ministry of Health legalisation of first-trimester abortion and Family Welfare formally approved on broad medical and social grounds SRHR policies should be geared the provision of MR using a dual regimen was proposed, but legislative action was to respecting, protecting, and of mifepristone and misoprostol up not taken due to fear of opposition from to nine weeks after a woman’s last religious quarters and thus the 1860 law fulfilling the human rights of menstrual period (LMP) after several still stands.5 women, including their dignity successful pilots in selected facilities. and freedom of choice, and must Doctors are now authorised to provide In 1979, the Bangladesh government address the needs of women MR using the two-drug regimen, which is included MR in the national family commonly referred to within Bangladesh belonging to vulnerable and planning (FP) programme and as MRM (MR with medication).11 The encouraged doctors and paramedics to disadvantaged groups. approval of this method, which is less provide MR services in all government invasive and typically less expensive, has hospitals and Family Planning complexes. The introduction of menstrual regulation the potential to increase access to MR This was done through a government in the FP programme in Bangladesh and improve quality of care. However, circular citing the Bangladesh Institute was marked as a significant event, users’ lack of proper knowledge and of Law and International Affairs, which particularly because this had happened information, inadequate information declared menstrual regulation as an despite the restrictive legal status of provided by the drug sellers, and “interim method of establishing non- pregnancy termination, and also because indiscriminate use of MRM are affecting pregnancy” for a woman at risk of being proper programmatic utilisation of this the effectiveness of use and increasing pregnant, whether or not she is actually method can profoundly influence the health risks.12 pregnant and can be legally performed up country’s ability to achieve the desired to 10 weeks following a missed period.6 demographic goal. Since its introduction, A study by Guttmacher-BAPSA13, 14 in MR is, therefore, not regulated by the MR has been playing a crucial backup for 2014 estimated 430,000 MR procedures Penal Code restricting abortion. The contraceptive failure, available performed at facilities nationwide which 20 arrow for change | vol. 24 no. 1 2018 monitoring national and regional activities

is a sharp decline (40%) in the number respecting, protecting, and fulfilling the of MR (surgical) services from 2010 when human rights of women, including their 653,000 MR were performed. This is a dignity and freedom of choice, and must decline from 17 to 10 per 1,000 women address the needs of women belonging aged 15-49 age group. Several reasons to vulnerable and disadvantaged groups. have been identified for this decline in surgical MR: lack of awareness of women on MR (more than half of ever-married women had never heard of MR); lack Notes & References of MR equipment and trained staff in 1. Penal Code of India of 1860, Section 312-316. instruments to empty the uterus, usually under general and the facilities (30% of lacked basic MR 2. Janie Benson, Kathryn Andersen, and Ghazaleh Samandari, local anaesthesia or heavy sedation. It also requires operation theatre facilities and skilled staff. It is used for the treatment of equipment, trained staff, or both); and “Reduction in Abortion-related Mortality Following Policy Reform: Evidence from Romania, South Africa and Bangladesh,” incomplete abortion in the middle to late second trimester and refusal due to exceeding the approved Reproductive Health 8 (2011): 39, https://doi.org/10.1186/1742- should be used by a very skilled and experienced clinician in time limit (27% reported turned away). 4755-8-39. a well-equipped facility. Nowadays its use is declining sharply 3. Ubaidur Rob, Marium UI Mutahara, and Noah Sprafkin, because of the invention of newer techniques in treating post- However, the most valid reason may be Development of Population Policy in Bangladesh, International abortion complications (MVA+). the wide use of MRM drugs, an easy and Quarterly of Community Health Education 23, 1 (2004): 25-38, 11. Directorate General of Family Planning, Vide Memo. https://doi.org/10.2190/YY8D-MJ85-B4GM-H7GE. 12. Katharine Footman et.al., “Feasibility of Assessing the affordable method. 4. J Nany and Piet-Pelon, South & East Asia Regional Working Safety and Effectiveness of Menstrual Regulation Medications Papers 1998, No. 14, Population Council Dhaka, Bangladesh. Purchased from Pharmacies in Bangladesh: A Prospective 5. Ubaidur Rob et al., Development of Population Policy in Cohort Study, “ Contraception 97, no. 2 (2018): 152-159, 15, 16 Two studies by Guttmacher-BAPSA Bangladesh. https://doi.org/10.1016/j.contraception.2017.08.002. have provided evidence that the MR 6. Bangladesh Institute of Law and Internal Affairs, Dhaka 13. Susheela Singh et al., “The Incidence of Menstrual Regulation Procedures and , 2014,” programme has contributed to the Report on Legal Aspects of Population Planning in Bangladesh, Chapter 11 Abortion (Dhaka: Bangladesh Institute of Law and International Perspectives on Sexual and Reproductive Health sharp decline in maternal mortality in Internal Affairs, 1979), 31. 43, no.1 (March 2017): 1-11, https://doi.org/10.1363/43e2417. Bangladesh over the past two decades. 7. Directorate General of Family Planning, Bangladesh National 14. Susheela Singh et al., “The Incidence of Menstrual Menstrual Regulation Services Guidelines (Dhaka: 2013), 5. Regulation Procedures and Abortion in Bangladesh, 2010,” However, the proportion of complication 8. Directorate General of Family Planning, MCH Service Unit, International Perspectives on Sexual and Reproductive has also risen significantly. According Vide Memo DGFP/MCH-RH/Admin 23/05/108 of February 3, Health 38, no.3 (September 2012): 122-32, https://doi. 2015. org/10.1363/3812212. to the Guttmacher-BAPSA study, 9. MVA: MR is done by Manual Vacuum Aspiration Technique 15. Singh et al., “MR Procedures and Abortion in Bangladesh, the proportion of complication with up to ten completed weeks of missed periods from the first day 2014.” of the last menstrual period. MVA uses a hand-held syringe to 16. Singh et al., “MR Procedures and Abortion in Bangladesh, haemorrhage increased from 27% in 2010 generate a vacuum manually and attached to a cannula ranging 2010.” to 48% in 2014.17 It is possible that this from 4-10mm in diameter. 17. Singh et al., “MR Procedures and Abortion in Bangladesh, 2014.” rise is related to an increased incorrect 10. D&C: Dilatation (of the uterus and cervix) and curettage (of the endometrium), also called instrumental Uterine Curettage or clandestine use of misoprostol. With the Sharp Curettage, is a technique that uses metal surgical government approval of MRM drugs, it is being widely administered by the drug sellers without any formal training. This may be the main reason for the increase in post-abortion complications.

Proper training of services providers and drug sellers may reduce the risk of complications resulting from the indiscriminate use of MRM. Dissemination of information and education on how women can protect themselves from unintended pregnancies and what to do if they have one, support from husbands, counselling, and trustworthy and ethical providers are much-needed to ensure women are able to exercise their reproductive rights. SRHR policies should be geared to 21 monitoring national and regional activities arrow for change | vol. 24 no. 1 2018

By Son L.H. Minh ABORTION IN VIETNAM: Center for Creative Initiatives in Health Actions in a Legal Context and Population Email: [email protected] and Thuy B. Phan Asia Safe Abortion Partnership Email: [email protected] A Snapshot of Abortion in Vietnam. purpose of abortion is gender-related or Abortion is legal upon request until 22 might cause serious health consequences weeks of pregnancy in Vietnam, services to the mother.” should be accessible, affordable, stigma- free, and non-judgmental. However, This crucial event sparked a new Following this RHAG meeting, UNFPA abortion remains a taboo issue, while movement of professionals and young took the lead to write a feedback letter inaccurate information about the health people getting involved in abortion to the Ministry of Health (MoH) analysing consequences of having an abortion discussion and advocacy. The Law the root causes of the imbalanced sex proliferates on mainstream media and the Development Team did not seem to ratio at birth (SRB) and adolescent internet. favour second-trimester abortion because pregnancies. The letter also highlighted they believed that it would help reduce the possible reasons why women find out Stigma around abortion is under- adolescent abortion, as well as limit sex- about their pregnancies only during the researched, but a rapid assessment selective abortion. second trimester, including inadequate from the Center for Creative Initiatives information and counselling, as well as in Health and Population (CCIHP) in The most recent version of the lack of comprehensive sexuality 2012 on perspectives about sexual and law, submitted in June 2018 education. reproductive health in the mainstream retains the former legal status for media demonstrated that none of 56 The Asia Safe Abortion Partnership published articles had a rights-based abortion services in Vietnam. This (ASAP), along with Dr. Thuy and the view on abortion, whereas 69.6% of the shows the transformative power youth group Vietnam Youth Action for content presented negative attitudes of civil society and young people Choice (VYAC), collaborated in organising toward abortion. Instead of recognising in Vietnam to come together a policy dialogue with the law-making the barriers faced by young people in committee of the General Office for accessing sexuality education, and sexual to advocate for change in the Population and Family Planning (GOPFP) and reproductive health services and country. in the MoH. During the first stage, the information, most of the articles described youth co-founders recruited youth allies young people who had pre-marital sex When this draft law was presented during and trained their peers on sexual and and abortion as irresponsible, easygoing the Reproductive Health Affinitive Group reproductive health and rights (SRHR) and people who indulged their sensual desires Meeting (RHAG), Dr. Phan Bich Thuy2 advocacy to establish a working group. but lacked self-esteem and understanding raised her concerns over the law being Each week, they wrote an essay sharing about sex. A study by Tine Gammeltoft potentially restrictive. She believed that their views on why they support safe also showed a strong influence of ethics this will likely result in the increase of abortion. and morality in young adults’ perceptions the maternal mortality ratio (MMR), as regarding abortion.1 women who require abortion during the The policy dialogue was held in September second trimester might resort to unsafe 2015 with 70 participants, including 20 Actions in a Legal Context and the abortion. Fifty-three percent of abortions young people, GOPFP representatives, Voices of CSOs and Young People. Public that happen during this period is by UNFPA, WHO, NGO partners, and other discourse on abortion was rarely opened unmarried women.3 Moreover, Dr. Thuy experts working in the population field. until the new draft of the Population Law reasoned that the majority of women who At the dialogue, VYAC emphasised the was issued in 2015 by the government. require this service are from vulnerable challenges that young people face in The draft law stated, “Women are entitled groups, such as young unmarried women, term of SRHR and stressed that legal to: a) end a pregnancy by abortion as premenopausal women, and women who restrictions on second-trimester abortion request before 12 weeks, unless the have difficulties in accessing abortion would push young women into having service. unsafe abortions, which could risk their 22 arrow for change | vol. 24 no. 1 2018 monitoring national and regional activities

health and lives. VYAC recommended led by ASAP with the support of 24 meeting. However, the most recent policymakers to open the discussion individuals and organisations, wrote version of the law, submitted in June and listen to youth voices before an advocacy letter explaining the need 2018, retains the former legal status for implementing the restriction on second- for second-trimester abortion and the abortion services in Vietnam. This shows trimester abortion. This presentation negative consequences of restricting this the transformative power of civil society received support from other civil society health service. The letter also provided and young people in Vietnam to come organisations and the law drafting suggestions for policies supporting safe together to advocate for change in the committee stated they will reconsider the abortion. At the same time, Le Hoang country. changes in the draft population law. Minh Son4 and his colleague wrote another letter emphasising the importance

At the end of 2015, the Vietnam National of Comprehensive Sexuality Education for Notes & References Assembly delayed the approval of the young people to reduce abortion cases, 1. Tine Gammeltoft, “Between ‘Science’ and ‘Superstition’: new Population Law although public rather than restricting second-trimester Moral Perceptions of Induced Abortion among Young Adults in perception towards abortion was abortion. Vietnam,” Culture, Medicine, and Psychiatry 26, Issue 3 (2002): negative and the policymakers were 313-338, https://doi.org/10.1023/A:1021210405417. 2. Co-author of this article. still concerned about the high number Since then, the population law has been 3. Maria F. Galloa and Nguyen C. Nghia, “Real Life Is Different: of abortions and the imbalance in sex edited many times and is still pending as it A Qualitative Study of Why Women Delay Abortion until the Second Trimester in Vietnam,” Social Science and Medicine 64, ratio at birth. During Vietnam’s Women could not get the majority of agreements 9 (2007 May): 1812-22. Day in 2016, Safer Abortion Partners, during the 2018 National Assembly 4. Co-author of this article.

By Shreejana Bajracharya THE DILEMMA OF ACCESSING Young Leader/SRHR activist, Women Deliver MEDICAL ABORTION PILLS OVER Email: [email protected] THE COUNTER IN NEPAL

Selling of medical abortion pills is major counselling and information It is important to recognise restricted in Nepal and is only sold centres in Nepal. Given this role, they the role that pharmacists and with a prescription in a few pharmacies need to be strengthened and their staff pharmacy workers can play in near Safe Abortion Service Sites. Only need to be aware of major health issues four medical abortion pills—Medabon, to minimise harm and deliver healthcare improving the safety, efficiency, Mariprist, Pregno Kit, and MTP Kit—are solutions. and acceptability of medical registered in the Nepal Department of abortion services. Strengthening Drugs Administration (DDA). Despite the clear government guidelines the partnership and referral to use prescribed medical abortion Despite these policy restrictions, both drugs for the termination of pregnancy, system between pharmacies and registered and unregistered brands unsafe abortion practices take place due providers may be an important of medical abortion pills can easily be to self-medication from unregistered opportunity to improve access. obtained at pharmacies. Many women outlets. Due to abortion stigma amongst visit pharmacies for abortion information, other factors, women resort to self- and ensuring that they receive effective induced medical abortion without proper abortion services. Strengthening the care from pharmacy workers remains counselling. It is important to recognise partnership and referral system between an important challenge. Pharmacies the role that pharmacists and pharmacy pharmacies and providers may be an are usually many Nepalis’ first point of workers can play in improving the safety, important opportunity to improve access. healthcare services, and are seen as efficiency, and acceptability of medical As the demand for medical abortion 23 monitoring national and regional activities arrow for change | vol. 24 no. 1 2018

continues to increase, it will be imperative Women should be able to would be the Meri Saathi helpline to invest in parallel efforts, such as task access medical abortion to (16600119756/9801119756) initiated shifting, supply chain management, terminate their pregnancy from by Marie Stopes Nepal. and collaboration with pharmacies to 3. Regulate the cost of medical abortion ensure that these services are widely everywhere. However, they drugs in pharmacies, and widely available and well-regulated with high should be made aware of the advertise existing free abortion quality. To prevent the adverse effects proper use of abortion pills with services in government health of unregistered drug dispensing, it is counselling. It would be ideal if facilities. necessary to conduct proper orientation 4. The DDA and Nepal Chemist and to pharmacists and pharmacy workers on women could be provided with Druggists Association (NCDA) should the legal conditions for providing medical pictorial instructions to further regularly monitor the availability abortion, including the importance of aid understanding. of non-registered medical abortion history taking, gestation period, accurate drugs in the market and strong action drug regimen and route, and information is recommended by working closely and referral for complication management. knowledge about the correct medication with Family Health Welfare Division to use for safe abortion is low even to recommend policy on selling only Abortion has been legal in Nepal for the in districts where medical abortion authorised four medical abortion pills past 15 years, while medication abortion services have been introduced by the with accurate instructions to women has been introduced in 2008, significantly government. Access to information about via pharmacies. The pharmacies contributing to reducing maternal medical abortion—its safety, efficacy, should be authorised by Family mortality. Yet, despite the legality and the and acceptability—is also still limited.3 Health Welfare Division to sell MA availability of legally registered medical Another issue is cost, as the price of pills. abortion on the market and actions by medical abortion drugs varies from the Nepali government,1 many women pharmacy to pharmacy, with women continue to face barriers to obtain safe, reportedly paying between Rs. 500 (US quality products and services. According $4.40) to Rs. 10,000 (US $88). This, Notes & References to a study conducted by the Center despite abortion services being free of 1. Considering the limited access to safe abortion services for Research on Environment, Health, charge in government facilities. among women in rural and remote areas, the Health Minister approved the “Strategy for Service Extension for Safe Abortion and Population Activities (CREHPA) in Using Medicines Following the MA Service Guideline, 2066” 2014, 58% of the estimated 323,000 Women should be able to access medical on June 4, 2008. Clause 6.1.5 of the guidelines states that abortions performed in 2014 were illegal, “health workers working at different levels in the community abortion to terminate their pregnancy level health facilities shall be provided training on safe abortion potentially putting women’s health at from everywhere. However, they should services using medicine and will be listed at Family Health risk.2 be made aware of the proper use of Welfare for service authorisation.” Further, the “Nepal Health Sector Strategy 2015-2020” emphasises service extension for abortion pills with counselling. It would wider reproductive health service coverage under “Universal Dr. R.P Bichha, Director of Family Health be ideal if women could be provided Health Coverage” and increased accessibility to everyone to reduce maternal mortality rate below 70 (per 100,000 live Welfare Division, claimed that the open with pictorial instructions to further aid births) and meet the Sustainable Development Goals. border with neighbouring countries has understanding. 2. Mahesh Puri et al., “Abortion Incidence and Unintended Pregnancy in Nepal,” International Perspectives on Sexual and facilitated illegal entry of various brands Reproductive Health 42, no. 4 (2016): 167–179, https://doi. of medical abortion pills. There are more Some recommendations to improve the org/10.1363/42e2116. than 100 brands of pills available in the 3. A. Tamang, S. Tuladhar, and J. Tamang, “Factors Associated proper use of self-medication abortion with Choice of Medical or Surgical Abortion among Women in market and are sold in pharmacies which drugs are: Nepal,” International Journal of Gynecology and Obstetrics, 118 are ineffective or unsafe for terminating (2012): 52–56, https:/doi.org/10.1016/j.ijgo.2012.05.011. pregnancies. The 2011 Nepal 1. Provide orientation on harm Demographic and Health Survey showed reduction approach on safe abortion that among the women who had an to pharmacists and pharmacy abortion in the five years preceding the workers. survey, 19% had used pills for their last 2. Provide women with proper abortion. Moreover, 5% of them had counselling and refer them to obtained the pills from a pharmacist or helplines providing information medicine shop. Nepalese women’s on medical abortion. The best 24 arrow for change | vol. 24 no. 1 2018 monitoring national and regional activities

By Krystyna Kacpura SERIOUS THREATS TO Executive Director, Federation for Women and Family Planning/ASTRA Network Secretariat REPRODUCTIVE RIGHTS IN Email: [email protected] POLAND

Abortion was legalised in Poland in 1956 called home methods or services offered blocking progress not only on abortion, and, until the early 1990s, services were by unknown people, risking their health but also sexuality education and widely accessible, both for medical and and even lives. emergency contraception, is a form of social grounds. At the beginning of the demanding a “payback” for the support of 90s, however, civic groups close to According to the official statistics,6 the Church during the elections. the Polish Catholic Church initiated a 1,055 legal abortions were performed in campaign against legal abortion. After Poland in 2016. The general public knows This was only a preview of the more than three years of discussions little about the dramatic reality of Polish fundamental changes aimed at the between politicians and the Catholic underground abortion, of the women complete deprivation of reproductive Church, the Polish Parliament voted who lose their health or even their lives. rights of Polish women. In April 2016, the for the new abortion act which limited Dramatic stories rarely hit the headlines, Stop Abortion civic initiative presented an abortion to only three grounds.1 Polish because women who have been put extremely restrictive draft law introducing women were totally neglected in this through such trauma do not often have a total ban on abortion. Entitled “On process. the will and strength to pursue legal action Universal Protection of Human Life and or talk to the media. Education for Family Life,” the draft law Since 1993, the Act on Family Planning, introduced the term “unborn child” and Human Embryo Protection, and Conditions The struggle for women’s offered equal rights both to the foetus and of Permissibility of Pregnancy Termination the woman. Moreover, it considered an has been in force in Poland. It is one reproductive rights has only “unborn child” to be vulnerable, and the of the most restrictive regulations not just begun in Poland. It is woman exactly the opposite. In addition only in Europe but also in the world. fundamental that Polish women to the total ban on abortion, the draft Moreover, the law is even more restrictive understand the need to act law introduced criminalisation of up to in practice than on paper. Access to five years of imprisonment for women legal abortion is extremely limited due together, in solidarity, and are (currently the woman is not punished for to the widespread use of conscientious determined to continue their fight terminating her pregnancy), physicians, objection2 among gynaecologists—the to regain their rights. They are not and anyone who provided help. In case right to avoid referring patients to another going to give up so easily. Their of miscarriage, an investigation might hospital3 where obtaining abortion could be initiated. If the Court found that the “umbrellas are at the ready.” be possible—as well as the complicated woman unintentionally contributed and often unrealistic hospital procedures towards the death of the embryo/ applied to prolong the process so that it Shortly after the election of right-wing foetus, she may face up to three years of becomes impossible to conduct abortions. party Peace and Justice in 2015, the imprisonment. newly appointed Minister of Education Yet, the number of illegal abortions in the announced that sexuality educators from It became too much to stand for Polish country ranges from 100 to 150 thousand non-governmental organisations would women who have been silently bearing yearly.4 The quality of the procedure not be allowed to enter public schools as, the restrictive law. As a counterweight and the woman’s safety depends on her in her opinion, comprehensive sexuality to the Stop Abortion proposal, a newly economic status. Those who have more education leads to the sexualisation of formed citizens’ initiative Save the Women7 resources and access to information may young people. The new Minister of Health submitted the draft law “On Women’s easily terminate pregnancy abroad or withdrew the approval for over-the- Rights and Conscious Parenthood,” underground,5 while women from small counter sales of emergency contraception. liberalising the restrictive 1993 Act. towns and poorer areas often resort to so- It needs to be highlighted that 25 monitoring national and regional activities arrow for change | vol. 24 no. 1 2018

On September 23, 2016, both proposals women’s rights. The Stop Abortion draft Notes & References were put before the Parliament. Stop bill is pending before the sub-committee 1. Polish regulations currently allow abortion in three cases: Abortion was sent for further proceedings, of the Parliamentary Committee on Social if the pregnancy constitutes a threat to the life or health of while Save Women was rejected upon first Policy and Family. A challenge to the the woman; if the prenatal examination points at the high probability of severe and irreversible damage to the foetus, or reading. This caused massive women’s constitutionality of some legal grounds on an incurable disease; and if the pregnancy is a result of a protests in the whole country. The wave for abortion is also now pending before criminal circumstance entitling lawful abortion, which has to be confirmed by a prosecutor. of activism reached its peak moment Poland’s Constitutional Tribunal. This 2. The conscientious objection clause as in force in Poland is on October 3 called “Black Monday.”8 petition has been brought by a group of universally formulated and does not refer directly to any aspect of reproductive rights; however, in practice, it is most widely Thousands of people dressed in black MPs from the ruling party, in order to applied in relation to SRHR. clothes stood for many hours in protest effectively ban women from access to 3. Judgement of the Constitutional Tribunal of 7 October 2015, case no. K 12/14. in the pouring rain (hence the umbrella . 4. “Underground”—abortion services delivered in private as the demonstration’s emblem) in many gynaecological cabinets (either in safe conditions, or by persons Polish cities and even small towns. On The struggle for women’s reproductive with no proper qualifications, often in unsafe conditions). 5. CBOS, “Polish Women’s Abortion Experiences” (Poland: October 6, the Parliament somewhat rights has only just begun in Poland. CBOS, 2013). nervously rejected the draft bill on a total It is fundamental that Polish women 6. The report of the Council of Ministers on the Implementation of the Family Planning, Protection of Human ban of abortion in Poland. understand the need to act together, in Fetus and Conditions for Termination of Pregnancy Act of solidarity, and are determined to continue 7.01.1993 in 2016. 7. Save Women is a civic initiative of women’s progressive Polish women won the battle! Yet this their fight to regain their rights. They groups and left-wing parties outside of the Parliament. is just the first step. Fundamentalists are not going to give up so easily. Their 8. It was dubbed “Black Monday” since as a sign of their protest women decided to wear black on this day. have been continuing their attacks on “umbrellas are at the ready.”

By Caroline Hickson COMPASSION OVER COERCION: Director, European Network of the Ireland Repeals the 8th Amendment by International Planned Parenthood Federation Email: [email protected] Getting to the Heart of the Matter

Just after 10 pm on Friday, May 25, Abortion was not allowed in the case crusade in the US to the Russian- 2018, Irish women at home and across of rape, incest, or when the foetus was influenced push back on human rights in the globe were waiting anxiously. It was guaranteed not to survive birth. It has Eastern Europe, including EU states.4 the day of the referendum to repeal forced over 170,000 Irish women to the Eighth Amendment1 from the Irish leave Ireland to access abortion care, Opposition tactics mirrored those being Constitution and, for the first time in to undergo illegal abortions, or to go used elsewhere, ugly and ideological. the history of such referenda, a national through a full pregnancy against their However, an early attempt to co-opt media outlet was about to release an consent.3 people concerned about disability went exit poll. I do not think mine was the awry when many disability rights activists only household where a scream lifted Despite the enormous social and political spoke out about the importance of the rafters. The referendum had not change experienced by Ireland during the disabled women being able to access only passed, but it had done so with an 35 years of the amendment’s existence, abortion care should they need it, while overwhelming landslide of over two- the nervousness of those advocating for parents of children with disabilities were thirds of the vote.2 a Yes vote was palpable during the final furious at the imputation that it was only weeks. Opposition forces were, as had the non-existence of abortion in Ireland The Eighth Amendment, introduced in been expected, throwing everything they that had led them to welcome their much- 1983, constitutionally guaranteed that could at the campaign, bolstered by a beloved children into their lives. abortion would be illegal in all cases save wave of regression across the world from where the mother’s life was at risk. Trump’s anti-reproductive freedom 26 arrow for change | vol. 24 no. 1 2018 monitoring national and regional activities

This deeper reflection on the complexities However, if there is one lesson from If there is one lesson from the of life was mirrored across the country. the campaign that can immediately campaign that can immediately The sex abuse scandals and resulting be embraced by those working to end be embraced by those working cover-ups had rocked once deep loyalty reproductive coercion across the globe, to the Roman Catholic Church. People it is that we must leave our ivory towers to end reproductive coercion were already beginning to question an and our lofty discourse. It is important to across the globe, it is that we must ideology which was prepared to defend work within a human rights framework, leave our ivory towers and our a foetus, but which was so obviously but the language we use is often technical lofty discourse. It is important uncaring about the suffering of children at and divorced from the real experience 5 to work within a human rights the hands of paedophiles. of women. Irish activists went to the heart of the matter, not just focusing framework, but the language In 2012, the death of Savita Halappanavar the discussion on choice and rights but we use is often technical and from sepsis due to a miscarriage where talking about what happens when people divorced from the real experience an abortion was not permitted in time, have their choices taken from them. of women. Irish activists went to despite her family’s pleas, was another massive shock to the Irish system. This Women told their own stories about the the heart of the matter, not just became a tipping point.6 Silenced for so harm that the 8th Amendment had caused focusing the discussion on choice long because of the stigma attached to them, emotionally, psychologically, and and rights but talking about what 10 abortion, brave women began to tell their physically. Men shared how it made happens when people have their personal stories. them feel to see their partners in distress and be powerless to help them; mothers choices taken from them. One cannot deny that the road to told of the horrors of a total absence of abortion reform in Ireland has been care for their daughters who had been However, as anticipated, opposition a long one, and that many different raped. Many doctors spoke of their forces are now turning their sights from factors played. Work done by NGOs like frustration at their inability to provide maintaining the ban to placing barriers in IPPF member, the Irish Family Planning support to their patients when it was the way of implementation.13 Pro-choice Association, over decades was vital. most needed and campaigned vigorously activists are all too aware of countries They and their partners opened spaces for a Yes vote.11 like Italy where abortion is legal in theory, for discussion and worked with regional but, where in practice, denial of care on and global human rights mechanisms— As the weeks went by, the campaign grounds of individual conscience is so including the European Court of against repeal had only their ideology, institutionalised that more than 70% of Human Rights (ECHR),7 the UN Treaty which rests on the idea of moral gynaecologists refuse women who come Monitoring Bodies, and the Universal absolutes, a world that is only black and to them for care.14 Those who worked so Periodic Review—keeping the pressure white. But the stories and discussions hard during the campaign will not rest on on during a series of conservative and across the country demonstrated that their laurels but will continue to fight so apathetic governments who preferred our world is not like that. It is a world of every woman can access abortion care to keep the lid on a difficult and divisive messy realities and difficult decisions, when and where she needs it. The strong issue. Between 2012 and 2016, five where no one woman’s story is the mandate given by the Irish public is the UN human rights bodies examined and same as another. It is a world that needs best encouragement possible. criticised Ireland’s restrictive abortion empathy, understanding, and compassion. laws.8 In 2016, the UN Human Rights Ultimately, the Yes vote sends a Committee found that Ireland’s refusal Irish Prime Minister Leo Varadkar is strong message around the world that to allow abortion in the case of a fatal confident that he will deliver on his compassion can win out. When people foetal abnormality violated the plaintiff’s commitment to delivering legislation are informed, when they hear women’s right to freedom from cruel, inhuman, which legalises abortion care on a voices and listen to their stories, they or degrading treatment.9 It mattered woman’s own indication in the first understand that health and lives are at of course that Ireland is a massively trimester of pregnancy before the end stake. When they feel in their gut that different country in 2018 than it was in of this year, bringing it in line with the reproductive coercion is incompatible 1983. majority of European countries.12 with their own values, they will reject 27 monitoring national and regional activities arrow for change | vol. 24 no. 1 2018

it. Part of the reason for the incredible https://www.irishtimes.com/opinion/fintan-o-toole-abortion- 8th,” Her, https://www.her.ie/news/in-her-shoes-the-powerful- fake-news-firestorm-heading-our-way-1.3440927. new-platform-for-women-brutally-impacted-by-the-8th-393655. success of the Irish Yes campaign is that 5. Liam Stack, “How Ireland Moved to the Left: ‘The Demise of 11. “How the Eighth Amendment Impacts on Consultations it made this connection, enabling ordinary the Church,’” The New York Times, December 2, 2017, https:// with Doctors,” Doctors for Choice Ireland, https:// www.nytimes.com/2017/12/02/world/europe/ireland-abortion- doctorsforchoiceireland.files.wordpress.com/2018/03/dfc-how- people from all walks of life to stand up abuse-church.html. the-8th-amendment-impacts-on-consultations-with-doctors- for what they knew to be right. 6. Kitty Holland, “How the Death of Savita Halappanavar factsheet.pdf. Revolutionised Ireland,” The Irish Times, May 28, 2018, https:// 12. Sarah Bardon, “What Next: When Will Abortion Legislation www.irishtimes.com/news/social-affairs/how-the-death-of- be Passed?” The Irish Times, May 26, 2018, https://www. savita-halappanavar-revolutionised-ireland-1.3510387. irishtimes.com/news/politics/what-next-when-will-abortion- Notes & References 7. “ABC v. Ireland,” IFPA, https://www.ifpa.ie/Hot-Topics/ legislation-be-passed-1.3509858. Abortion/ABC-v-Ireland. 13. Evelyn Ring, “: All Publicly Funded Hospitals 1. Government of Ireland, “Eighth Amendment of the 8. Maeve Taylor, “Using Human Rights Instruments to to Provide Legal Health Services, Says Health Minister,” The Constitution Act, 1983,” http://www.irishstatutebook.ie/ Advance Sexual and Reproductive Health and Implementation Irish Examiner, July 26, 2018, https://www.irishexaminer.com/ eli/1983/ca/8/enacted/en/print#sec1. of the Sustainable Development Goals in Ireland,” Entre Nous ireland/abortion-debate-all-publicly-funded-hospitals-to-provide- 2. “Referendum Results: At a Glance,” RTE, May 26, 2018, 84 (2006), http://www.euro.who.int/__data/assets/pdf_ legal-health-services-says-health-minister-473045.html. https://www.rte.ie/news/newslens/2018/0526/966234- file/0007/319309/7-Using-human-rights-instruments-advance- 14. Chris Harris and Lillo Montalto Monella, “Abortion Is Legal referendum-results-at-a-glance/. SRH-implementation-SDGs-Ireland.pdf?ua=1. in Italy—So Why Are Women Being Refused?” EuroNews, May 3. “Abortion in Ireland: Statistics,” Irish Family Planning 9. “Case in Focus: Amanda Mellet,” Irish Council for Civil 22, 2018, http://www.euronews.com/2018/05/22/abortion-is- Association (IFPA), https://www.ifpa.ie/Hot-Topics/Abortion/ Liberties, https://www.iccl.ie/her-rights/privacy/case-focus- legal-in-italy-so-why-are-women-being-refused-. Statistics. amanda-mellet/. 4. Fintan O’Tool, “Fintan O’Toole: Abortion Fake-news 10. See this example: Taryn de Vere, “In Her Shoes...The Firestorm Heading Our Way,” The Irish Times, March 27, 2018, Powerful New Platform for Women Brutally Impacted by the

By Dr. Var Chivorn THE GLOBAL GAG RULE ON SAFE Executive Director, Reproductive Health Association of Cambodia (RHAC) ABORTION SERVICES AND Email: [email protected] THE CAMBODIAN EXPERIENCE

Background. The Global Gag Rule (GGR), abortion services would also integrate High awareness of RHAC’s first announced in 1984, prohibits non- other services most needed by women programme and the trust by USA non-governmental organisations and girls, such as voluntary family the community enable RHAC (NGOs) that receive certain categories planning information, education and of U.S. foreign assistance from using services, HIV testing and treatment, to generate income from its their own, non-U.S. funds to perform or cervical cancer screening, and other services while keeping approach actively promote abortion as a method maternal health services. For example, in addressing the poor and of family planning. In May 2017, under the International Planned Parenthood marginalised groups. President Donald Trump, the policy Federation (IPPF), a global network of was reinstated as “Protecting Life In local service providers, delivers more Global Health Assistance.”1 This latest than 300 sexual and reproductive health The Impact of GGR on the Reproductive GGR is applied to sectors beyond services every minute daily. During Health Association of Cambodia family planning, including HIV and AIDS President Trump’s term, IPPF does not (RHAC). Established in 1996, the prevention and treatment, malaria, and receive approximately USD$100 million Reproductive Health Association infectious diseases. Trump’s Global Gag funding from the US government, which of Cambodia’s (RHAC) was heavily Rule applies to almost US$9 billion in US would have supported IPPF’s family dependent on USAID with almost 100% foreign assistance.2 planning and HIV programmes for of its funding came from the aid agency. women with the greatest need for these RHAC understood the uncertain nature Imposing a condition on abortion services healthcare services.3 of this funding, however. We then put has a knock-on effect on an array of in place strategies to diversify funding sexual and reproductive health services sources, including our own income since healthcare providers who do generation through service fees. Both 28 arrow for change | vol. 24 no. 1 2018 monitoring national and regional activities

donors and the beneficiaries who receive Nevertheless, our government cannot understanding that the GGR will continue RHAC services are considered “clients,” shy away from their responsibilities of to come and go for the foreseeable and RHAC always understands that the providing universal access to health and future. beneficiaries are RHAC’s long-term and SRHR to all, which includes access to safe loyal clients. abortion. Hence, we should not lose sight of holding governments accountable as Notes & References While receiving assistance from USAID part of our advocacy work. and other donors, RHAC was able to 1. USAID, “Standard Provisions for Non-US Nongovernmental Organizations,” 84. establish its reputation among the Ways Forward to Address the Impact 2. International Women’s Health Coalition (IWHC), Trump’s Cambodian people as the leading of the GGR. There are reports providing Global Gag Rule at One Year: Initial Effects and Early Implications (May 2018), accessed June 26, 2018, https://iwhc. women’s healthcare provider in the recommendations to overcome the org/resources/trumps-global-gag-rule-one-year-initial-effects- country, and had established good track GGR,4, 5 including: to permanently early-implications/. 3. International Planned Parenthood Federation (IPPF), “IPPF records in its programme implementation repeal the GGR through legislation Projects at Risk Because of the Global Gag Rule,” accessed June and management. High awareness of by the US Congress; to improve the 10, 2018, https://www.ippf.org/global-gag-rule. RHAC’s programmes and the trust by understanding of the GGR by direct or 4. IWHC, “Trump’s Global Gag Rule at One Year.” 5. Center for Health and Gender Equity (CHANGE), Prescribing the community enable RHAC to generate prime recipients of US Global Health Chaos in Global Health: The Global Gag Rule from 1984-2018 income from its services while keeping Funding, sub-recipients, and front line (Washington, DC: CHANGE, June 2018), accessed June 23, 2018, http://www.genderhealth.org/files/uploads/change/ its approach in addressing the poor and workers, including through translation publications/Prescribing_Chaos_in_Global_Health_full_report. marginalised groups. With this modality, of the policy into local language; for pdf. RHAC has been able to continue service all relevant groups, including research provision even after USAID ceased institutions, to document the impact of funding RHAC in early 2014. the GGR, including the spillover effects of the policy; for donors, governments, NGOs at the country level need and international organisations to increase funding for comprehensive to have solutions suitable for sexual and reproductive health services their own context, in addition and to avoid applying conditionality on to having access to the funding development funding for health, including flow through the global and counter-conditionality intended to respond to the GGR; and for UN agencies international networks. or governments to advocate to the US government or publicly speak out against NGOs receiving USAID funding to the GGR. address the population’s health must not forget addressing the NGO’s “health” Immediately after the announcement of at the same time. Usually, donors are the GGR, the Dutch Minister for Foreign more interested in the sustainability of Trade and Development Cooperation their funded projects, and not that of the launched the SheDecides initiative to NGOs; it is the duty of the NGOs to think mobilise funding to help with the funding about organisational sustainability. gap the policy caused. However, most of the funding goes to large and well-known Many NGOs have now started discussing international and UN organisations. about establishing social enterprises as a way to address sustainability issues NGOs at the country level need to and the organisation’s cost recovery. have solutions suitable for their own There are other models addressing context, in addition to having access to funding concerns such as public-private the funding flow through the global and partnership or partnership with private- international networks. NGOs need to for-profit organisations. prepare themselves with an 29 resources arrow for change | vol. 24 no. 1 2018

Compiled by Seow Kin Teong RESOURCES FROM THE Senior Programme Officer, ARROW ARROW SRHR KNOWLEDGE Email: [email protected] SHARING CENTRE

ARROW’s SRHR Knowledge Sharing Centre (ASK-us) hosts a special collection of resources on gender, women’s rights, and sexual and reproductive health and rights (SRHR). It aims to make critical information on these topics accessible to all. ASK-us is also available online at http://www.srhr-ask-us.org/. To contact ASK-us, please email: [email protected].

RIGHTS TO SAFE ABORTION Advancing New Standards in when the two have nothing in common Reproductive Health (ANSIRH), 2013. (as objecting doctors are rarely ARTICLES AND BOOKS https://ibisreproductivehealth.org/ disciplined). The authors further publications/addressing-abortion-stigma- highlighted that refusals to treat are Barot, Sneha. “The Roadmap to Safe through-service-delivery-white-paper. often attributed to religious beliefs, Abortion Worldwide: Lessons from New which challenges the medical practices Global Trends on Incidence, Legality and This paper aims to provide the context that depend on scientific evidence and Safety.” Guttmacher Policy Review 21 and background of work done to address ethics. Medical practitioners citing CO (2018): 17-22, https://www.guttmacher. abortion stigma through service delivery. represents an abandonment of their org/sites/default/files/article_files/ Abortion stigma is a major barrier to professional obligations to patients. Thus gpr2101718.pdf. adequate reproductive healthcare for countries should strive towards mitigating women and a key challenge for service CO and its harm as much as possible until The article focuses on the evidence delivery providers to address. In the it can be feasibly abolished. that are continually being compiled by first part of the paper, the definition researchers and healthcare practitioners of abortion stigma was discussed with Ipas. Access for Everybody: Disability on the most effective means to decrease reviews of existing literature around this Inclusion in Abortion and Contraceptive the impact of unsafe abortion globally issue and its interventions. Opinions, Care – Guide. Chapel Hill, NC: Ipas, 2018. and the obstacles to implementing experiences, and programmes of http://www.ipas.org/en/Resources/ these measures. This body of evidence reproductive healthcare service delivery Ipas%20Publications/Access-for- provides a roadmap for policymakers organisations follow this. In the final everyone--disability-inclusion-in-abortion- to take concrete measures to protect section, recommendations for increasing and-contraceptive-care--guide.aspx. the health, rights, and lives of women and expanding programmes to address worldwide. Among the concrete measures abortion stigma are provided. This guide provides strategies for are adopting clinical guidelines on improving disability inclusion in policy, comprehensive abortion care, increasing Fiala, Christian and Joyce H. Arthur. service delivery, and community access to post-abortion care, facilitating “There Is No Defence for ‘Conscientious engagement interventions, which can correct use of medication abortion in Objection’ in Reproductive Health be adapted to cater to the specific clandestine settings, combatting stigma, Care.” European Journal of Obstetrics needs of each context. It is developed reforming restrictive abortion laws, and Gynecology and Reproductive as a resource to improve access to and investing in services to prevent Biology 216 (2017): 254-258. https://doi. abortion and contraceptive care for unintended pregnancies and the often org/10.1016/j.ejogrb.2017.07.023. programme implementers and managers, unsafe abortions that may follow. technical advisors, and trainers. The This paper argues that “conscientious recommendations highlighted are based Cockrill, Kate, Steph Herold, Kelly objection (CO)” in reproductive on the human rights model of disability Blanchard, Dan Grossman, Ushma healthcare should not be considered a that promotes the empowerment Upadhyay, and Sarah Baum. Addressing right, but an unethical refusal to treat. of people with disabilities through Abortion Stigma through Service Defenders of CO often mistakenly developing initiatives that are disability- Delivery: A White Paper. Sea Change assumed that CO in reproductive specific, as well as integrating disability Program, Ibis Reproductive Health, and healthcare is similar to CO in the military, inclusion in programmes. A core principle 30 arrow for change | vol. 24 no. 1 2018 resources

guiding the recommendations is that the policy will prevent women from LeTourneau, K. Abortion Stigma people with disabilities should actively accessing information about referrals around the World: A Synthesis of the and meaningfully participate through all for safe abortion services, leading to Qualitative Literature; A Technical stages of planning, implementing, and increased reliance on unsafe services. Report for Members of The International evaluating interventions in abortion and Recommendations put forth in the Network for the Reduction of Abortion contraceptive care. brief were directly targeted to the Discrimination and Stigma (inroads). US government; international NGOs Chapel Hill, NC: inroads, 2016. http:// International Planned Parenthood including prime recipients and others; www.safeabortionwomensright. Federation (IPPF). Youth and Abortion: donor governments and international org/wp-content/uploads/2016/05/ Key Strategies and Promising Practices and regional organisations; UN agencies; AbortionStigmaAroundtheWorld-HR-2. for Increasing Young Women’s Access governments in countries that received pdf. to Abortion Services. London: IPPF, global health funding; and the African 2014. https://www.ippf.org/sites/ Commission on Human and People’s This report provides grounding in the default/files/ippf_youth_and_abortion_ Rights. fundamental concepts of abortion guidelines_2014.pdf. stigma and a synthesis of the qualitative Jelinska, Kinga and Susan Yanow. literature around the world exploring This is an evidence-based guidance “Putting Abortion Pills into Women’s the way abortion stigma manifests. An document aimed at increasing young Hands: Realising the Full Potential of ecological model of abortion stigma that people’s access to high-quality youth Medical Abortion.” Contraception illustrates multiple levels at which stigma friendly abortion information, services, 97, no. 2 (2018): 86-89. https://doi. manifests—individual, social, institutional, and referral. It is designed to support org/10.1016/j.contraception.2017.05.019. legal, and media-based—was explored organisations who are interested in in the qualitative literature review. scaling up their work on young people’s According to the authors of this article, in Aside from presenting the findings at access to abortion and abortion-related order to realise the potential of medical each level, the report also explores services. The document was originally abortion to reduce maternal mortality how stigma at some levels may impact developed for the use of IPPF member and morbidity from unsafe abortion the manifestations of stigma at other associations, however, it can also be used and to expand the reproductive rights levels. Intersections of abortion stigma by advocates wishing to focus on young of women, information and reliable with other stigmatised characteristics— women’s access to safe, legal abortion. medicines must be made available to specifically HIV status and young all women, regardless of their location women’s sexuality—were also reviewed. International Women’s Health Coalition or legal system restrictions. Medical (IWHC). Trump’s Global Gag Rule at One abortion gives control to women who Pugh, Sarah, Sapna Desai, Laura Year: Initial Effects and Early Implications. need abortion. Ironically, in legally Ferguson, Heidi Stöckl, and Shirin New York: IWHC, 2018. https://iwhc. restrictive settings medical abortion is Heidari. “Not without a Fight: Standing org/wp-content/uploads/2018/05/GGR- currently more under women’s control up against the Global Gag Rule.” Policy-Brief_FINAL-May-2018.pdf. than in settings where medical abortion Reproductive Health Matters 25, no. 49 is used within the official healthcare (2017): 14-16. https://doi.org/10.1080/09 This policy brief is based on the system. The article further highlighted 688080.2017.1303250. documentation project by IWHC in 2017 on information and access, barriers, and aimed at capturing and analysing the strategies to overcome these barriers; the This article highlights the implications of the impacts of the Global Gag Rule (GGR), reconceptualisation of “provider” and the latest Global Gag Rule, which extends far in partnership with local organisations redefinition of “performing” an abortion, beyond access to safe abortion information in Kenya, Nigeria, and South Africa. as it is the woman herself who can be and services. The new policy applies not The GGR will jeopardise the health of in control of the process; and activist only to funding earmarked to organisations girls and women with organisations strategies to actualise the full potential of that focus on reproductive health, but to all and individuals heavily emphasising abortion pills. global health assistance by all departments the potential impacts to women’s and or agencies. However, despite these girls’ access to healthcare, particularly challenges, the authors acknowledge and for already-marginalised groups of celebrate the creativity, resistance, and women. Concerns were also raised that perseverance of the SRHR community, 31 resources arrow for change | vol. 24 no. 1 2018

whereby civil society, NGOs, health Publications/When-a-health-professional- the region through women’s lens. More practitioners, and government actors have refuses-Legal-and-regulatory-limits-on- on the documentary at: https://www. taken a strong stance of opposition through conscientious-objection-.aspx. ippfeseaor.org/resource/ending-unsafe- joint statements and advocacy efforts abortion-asia. to highlight the well-documented and The refusal of health professionals to profoundly damaging consequences of this provide services is a significant barrier From Danger to Dignity: The Fight for policy in terms of both health and human to women’s access to safe abortion Safe Abortion (1995), a documentary rights. It also provided an opportunity for and other reproductive health services. tracing the movement in the United governments to step into leadership roles, Although these providers have the States to decriminalise abortion of and for new partnerships in the global SRHR right to refuse service provision under “underground” networks to find illegal community to develop and ensuring that international and, in some, national law, abortions and the intensive efforts sustainable SRHR funding mechanisms are it is necessary to have national-level legal of activists and legislators to change put in place to protect the rights of women, or regulatory limits on conscientious the law. More on the documentary at: girls, and families around the world. objection to protect women’s rights https://en.wikipedia.org/wiki/From_ and their access to safe abortion Danger_to_Dignity:_The_Fight_for_Safe_ Radhakrishnan, Akila, Elena Sarver, and services. This publication contains Abortion and https://www.youtube.com/ Grant Shubin. “Protecting Safe Abortion recommendations for enacting laws watch?v=Vg4B-UmgfG8. in Humanitarian Settings: Overcoming and regulations that safeguard women’s Legal and Policy Barriers.” Reproductive access to services while still protecting If These Walls Could Talk (1996), a Health Matters 25, no. 51 (2017): 40-47. providers’ rights of conscience. It also made-for-cable movie on three different https://doi.org/10.1080/09688080.2017 provides information on human rights women and their experiences with .1400361. standards that address provider refusal abortion in the same house in 1952, 1974, and includes a list of further resources. and 1996 addressing the views of society Humanitarian laws, policies, and in each decade. More on the film at: protocols are not responding to the World Health Organization (WHO). https://en.wikipedia.org/wiki/If_These_ sexual and reproductive health and rights Safe Abortion: Technical and Policy Walls_Could_Talk and https://www. (SRHR) of women and girls in conflict Guidance for Health Systems. 2nd youtube.com/watch?v=PzfHXyk9TT0. settings, in particular safe abortion ed. Geneva: WHO, 2012. http:// services, which are routinely omitted. apps.who.int/iris/bitstream/ Obvious Child (2014), a film that follows This commentary addresses the gap in handle/10665/70914/9789241548434_ Donna, a stand-up comedian, who has abortion services within the SRH care in eng.pdf?sequence=1 a drunken one-night stand with a man conflict-related humanitarian settings. named Max after breaking up with her The authors highlight that abortion This edition provides policymakers, boyfriend. She subsequently finds out services fall within a type of medical programme managers, and health service she is pregnant and decides to have an care protected by the strongest legal providers with the latest evidence-based abortion. More on the film at: structure in the international community. guidance on clinical care in relation to https://en.wikipedia.org/wiki/Obvious_ The existing challenges affecting the the provision of safe abortion services. Child and https://www.youtube.com/ realisation of the rights protected by this Information on how to establish and watch?v=7nkXWkrT0zA. legal structure are then outlined. Finally, strengthen services is included together in order to ensure an all-inclusive care with an outline of a human-rights-based The Abortion Diaries (2005) is a for female survivors of armed conflict, approach to laws and policies on safe, 30-minute documentary featuring 12 an integration of current approaches is comprehensive abortion care. women of diverse backgrounds who proposed. speak candidly about their experiences FILMS/DOCUMENTARIES with abortion. More on the documentary Skuster, Patty. When a Health at: http://pennylaneismyrealname.com/ Professional Refuses: Legal and Ending Unsafe Abortion in Asia (2012), film/the-abortion-diaries-2005/ and Regulatory Limits on Conscientious a 10-minute documentary produced https://www.youtube.com/watch?v=av_ Objection to Provision of Abortion Care. by IPPF-ESEAOR (East and South East vwVYZOqc. Chapel Hill, NC: Ipas, 2012. http:// Asia and Oceania Region) examining www.ipas.org/en/Resources/Ipas%20 the effects of criminalising abortion in 32 arrow for change | vol. 24 no. 1 2018 resources

Abortion: Challenges and Opportunities.” Africa and Southeast Asia: A Systematic OTHER Reproductive Health Matters 44S (2015): Literature Review of Qualitative and 1-3. https://doi.org/10.1016/S0968- Quantitative Data.” BMC Public Health 15, RESOURCES 8080(14)43793-5. no. 139 (2015). https://doi.org/10.1186/ s12889-015-1502-2. Alford, Sue. Adolescents and Abortion: Guttmacher Institute. Adolescents’ Restricting Access Puts Young Women’s Need for and Use of Abortion Services Singh, Susheela, Lisa Remez, Gilda Health and Lives at Risk. Advocates in Developing Countries. New York: Sedgh, Lorraine Kwok, and Tsuyoshi for Youth, 2011. https://www. Guttmacher Institute, 2016. https:// Onda. Abortion Worldwide 2017—Uneven advocatesforyouth.org/storage/advfy/ www.guttmacher.org/sites/default/files/ Progress and Unequal Access. New York: documents/thefacts_adolescents_and_ factsheet/fb_adolescent-abortion-services- Guttmacher Institute, 2018. https:// abortion_us.pdf. developing-countries_1.pdf. www.guttmacher.org/sites/default/files/ report_pdf/abortion-worldwide-2017.pdf. Chavkin, Wendy, Laurel Swerdlow, International Planned Parenthood and Jocelyn Fifield. “Regulation of Federation (IPPF). Access to Safe Turner, Katherine L. and Kimberly Conscientious Objection to Abortion: An Abortion: A Tool for Assessing Legal and Chapman Page. Abortion Attitude International Comparative Multiple-Case Other Obstacles. London: IPPF, 2008. Transformation: A Values Clarification Study.” Health and Human Rights Journal https://www.ippf.org/sites/default/files/ Toolkit for Global Audiences. Chapel Hill, 19:1 (2017): 55-68. https://www.ncbi.nlm. access_to_safe_abortion.pdf. NC: Ipas, 2008. http://www.ipas.org/ nih.gov/pmc/articles/PMC5473038/pdf/ en/Resources/Ipas%20Publications/ hhr-19-055.pdf. Ipas. Access for Everybody: Disability Abortion-attitude-transformation-A-values- Inclusion in Abortion and Contraceptive clarification-toolkit-for-global-audiences. Dhillon, Jina. Protecting Women’s Care—Overview. Chapel Hill, NC: Ipas, aspx. Access to Safe Abortion Care: A Guide 2018. http://www.ipas.org/en/Resources/ to Understanding the Human Rights to Ipas%20Publications/Access-for- World Health Organization (WHO). Privacy and Confidentiality—Helping everyone--disability-inclusion-in-abortion- Health Worker Roles in Providing Advocates Navigate ‘Duty to Report’ and-contraceptive-care--overview.aspx. Safe Abortion Care and Post-abortion Requirements. Chapel Hill, NC: Ipas, 2014. Contraception. Geneva: WHO, 2015. www.ipas.org/~/media/Files/Ipas%20 Iyengar, Kirti and Sharad D. Iyengar. http://apps.who.int/iris/bitstream/ Publications/PGDTRE14.ashx. “Improving Access to Safe Abortion handle/10665/181041/9789241549264_ in a Rural Primary Care Setting in eng.pdf;jsessionid=E693FD9EA1E78D1E873 Faúndes, Anibal, and Laura Miranda. India: Experience of a Service Delivery 20C41B3EA66B4?sequence=1. “Ethics Surrounding the Provision of Intervention.” Reproductive Health 13, Abortion Care.” Best Practice and no. 54 (2016). https://doi.org/10.1186/ WHO. Mapping Abortion Policies, Research Clinical Obstetrics and s12978-016-0157-5. Programmes and Services in the WHO Gynaecology 43 (2017): 50-57. https://doi. South-East Asia Region. Geneva: WHO, org/10.1016/j.bpobgyn.2016.12.005. Norris, Alison, Danielle Bessett, Julia R. 2012. http://apps.searo.who.int/PDS_ Steinberg, Megan L. Kavanaugh, Silvia DOCS/B5034.pdf. Foster, Angel M., Grady Arnott, De Zordo, and Davida Becker. “Abortion Margaret Hobstetter, Htin Zaw, Cynthia Stigma: A Reconceptualisation of Maung, Cari Sietstra, and Meredith Constituents, Causes, and Consequences.” Walsh. “Establishing a Referral System Women’s Health Issues 21, no. 3S (2011): for Safe and Legal Abortion Care: A Pilot S49-S54. https://doi.org/10.1016/j. ARROW Project on the Thailand-Burma Border.” whi.2011.02.010. International Perspectives on Sexual and RESOURCES Reproductive Health 42, no. 3 (2016): 151- Rehnström Loi, Ulrika, Kristina Gemzell- 156. https://doi.org/10.1363/42e1516. Danielsson, Elisabeth Faxelid, and Marie Klingberg-Allvin. “Health Care All ARROW publications from 1993 to the Ganatra, Bela, Philip Guest, and Marge Providers’ Perceptions of and Attitudes present can be downloaded at http:// Berer. “Expanding Access to Medical towards Induced Abortions in sub-Saharan arrow.org.my/publications-overview/. 33 definitions arrow for change | vol. 24 no. 1 2018

Compiled by Seow Kin Teong DEFINITIONS Senior Programme Officer, ARROW Email: [email protected]

Abortion: “The World Health Menstrual Regulation (MR): “Uterine Organization (WHO) defines an abortion evacuation without laboratory or as safe if it is provided both by an ultrasound confirmation of pregnancy appropriately trained provider and for women who report recent delayed their choice, as well as other methods 5 using a recommended method. Less- menses.” of their choice for regulation of fertility safe abortions meet only one of these which are not against the law, and the two criteria—for example, if provided Post-abortion Care (PAC): “Post- right of access to appropriate health-care by a trained health worker using an abortion care refers to a specific set services that will enable women to go outdated method or self-induced by a of services for women experiencing safely through pregnancy and childbirth woman using a safe method (such as complications of spontaneous or and provide couples with the best chance the drug misoprostol) without adequate induced abortion, including retained of having a healthy infant.”7 information or support from a trained tissue, hemorrhage and infection. individual. Least safe abortions meet PAC consists of several elements: (1) Reproductive Rights: “[E]mbrace certain neither criteria; they are provided by Uterine evacuation with medications human rights that are already recognised untrained people using dangerous or vacuum aspiration; (2) Counseling in national laws, international human methods, such as sharp objects or toxic to identify and respond to women’s rights documents, and other consensus 1 substances.” emotional and physical health needs documents. These rights rest on the and other concerns; (3) Contraceptive recognition of the basic right of all Conscientious Objection (CO): information and method provision for couples and individuals to decide freely In reproductive health care, CO is women who desire to postpone or limit and responsibly the number, spacing, defined as “the refusal by a healthcare future pregnancy; (4) Reproductive and and timing of their children and to have professional (HCP) to provide a legal other health services that are preferably the information and means to do so, and medical service or treatment for which provided on-site or via referrals to the right to attain the highest standard they would normally be responsible, other accessible facilities in providers’ of sexual and reproductive health. It also based on their objection to the treatment networks; and (5) Community and service includes their right to make decisions 2 for personal or religious reasons.” provider partnerships to help prevent concerning reproduction free of unwanted pregnancies and unsafe discrimination, coercion, and violence, as Induced Abortion: “The termination of a abortion and mobilise resources to help expressed in human right documents.”8 pregnancy by a procedure or action taken women receive appropriate and timely 3 6 by a provider or a woman herself.” care for complications of abortion.” Sexual Health: “A state of physical, emotional, mental and social well-being Medical Abortion: “The use of one or Reproductive Health: “A state of in relation to sexuality; it is not merely more medications to end pregnancy. complete physical, mental, and social the absence of disease, dysfunction These medications terminate the well-being and not merely the absence of or infirmity. Sexual health requires a pregnancy, which is then expelled by the disease or infirmity, in all matters relating positive and respectful approach to uterus in a process similar to miscarriage. to the reproductive system and to its sexuality and sexual relationships, as well Medical abortion is sometimes called functions and processes. Reproductive as the possibility of having pleasurable medication abortion, pharmacological health therefore implies that people are and safe sexual experiences, free of abortion, pharmaceutical abortion, or able to have a satisfying and safe sex coercion, discrimination, and violence. the abortion pill. Medical abortion does life and that they have the capability to For sexual health to be attained and not include emergency contraception reproduce and the freedom to decide if, maintained, the sexual rights of all (EC), also known as the ‘morning-after when and how often to do so. Implicit in persons must be respected, protected, pill,’ which prevents pregnancy from this last condition are the right of men and fulfilled.”9 occurring.”4 and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of 34 arrow for change | vol. 24 no. 1 2018 definitions

Sexual Rights: “[E]mbrace human Surgical Abortion: “Use of transcervical of external force. In some settings, rights that are already recognised in procedures for terminating pregnancy, traditional practitioners vigorously national laws, international human including vacuum aspiration and pummel the woman’s lower abdomen to rights documents, and other consensus dilatation and evacuation (D&E). Vacuum disrupt the pregnancy, which can cause documents. They include the rights of all aspiration involves evacuation of the the uterus to rupture, killing the woman.”14 persons, free of coercion, discrimination, contents of the uterus through a plastic and violence, to the highest attainable or metal cannula, attached to a vacuum standard of health in relation to source. Electric vacuum aspiration (EVA) sexuality, including access to sexual employs an electric vacuum pump. With Notes & References and reproductive healthcare services; manual vacuum aspiration (MVA), the 1. Barot, Sneha. “The Roadmap to Safe Abortion Worldwide: seek, receive, and impart information in vacuum is created using a hand-held, Lessons from New Global Trends on Incidence, Legality and relation to sexuality; sexuality education; hand-activated, plastic 60 ml aspirator Safety,” Guttmacher Policy Review 21 (2018): 18, https://www. guttmacher.org/sites/default/files/article_files/gpr2101718.pdf. respect for bodily integrity; choose their (also called a syringe). D&E is used after 2. Christian Fialaa and Joyce H. Arthur, “There is No Defence for partner; decide to be sexually active 12–14 weeks of pregnancy. It is the safest ‘Conscientious Objection’ in Reproductive Health Care,” European or not; consensual sexual relations; and most effective surgical technique for Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017): 254, http://dx.doi.org/10.1016/j.ejogrb.2017.07.023. consensual marriage; decide whether later abortion, where skilled, experienced 3. Altaf Hossain et al., Access to and Quality of Menstrual or not, and when, to have children; and providers are available. D&E requires Regulation and Postabortion Care in Bangladesh: Evidence from a Survey of Health Facilities, 2014 (New York: Guttmacher Institute, pursue a satisfying, safe, and pleasurable preparation of the cervix using osmotic 2017): 7, https://www.guttmacher.org/report/menstrual- sexual life.”10 dilators or pharmacological agents and regulation-postabortion-care-bangladesh. 4. Katherine L. Turner (ed.), Medical Abortion Study Guide evacuating the uterus using EVA with (2nd edition) (Chapel Hill, NC: Ipas, 2013): 88, https://ipas.org/ Sexuality: “Sexual health cannot be 12–16 mm diameter cannulae and long resources/medical-abortion-study-guide-second-edition. 5. World Health Organization (WHO), Safe Abortion: Technical defined, understood or made operational forceps. Depending on the duration and Policy Guidance for Health Systems (Geneva: WHO, 2012), without a broad consideration of of pregnancy, preparation to achieve iv, http://www.who.int/reproductivehealth/publications/unsafe_ sexuality, which underlies important adequate cervical dilatation can require abortion/9789241548434/en/. 6. Turner, Medical Abortion Study Guide, 88. behaviours and outcomes related to from 2 hours to 2 days. Many providers 7. United Nations, Programme of Action Adopted at the sexual health. The working definition of find the use of ultrasound helpful during International Conference on Population and Development Cairo, 5–13 September 1994, 20th Anniversary Edition (New York: sexuality is: …a central aspect of being D&E procedures, but its use is not UNFPA, 2014), para 7.2, http://www.unfpa.org/sites/default/ human throughout life encompasses essential.”13 files/pub-pdf/programme_of_action_Web%20ENGLISH.pdf. 8. United Nations, Programme of Action, para 7.3. sex, gender identities and roles, sexual 9. This is a working definition, not an official WHO position. See: orientation, eroticism, pleasure, Unsafe Abortion: The World Health WHO, “Sexual and Reproductive Health,” http://www.who.int/ reproductivehealth/topics/gender_rights/sexual_health/en/. intimacy and reproduction. Sexuality is Organization (WHO) defines unsafe 10. WHO, “Sexual and Reproductive Health.” experienced and expressed in thoughts, abortion “as a procedure for terminating 11. Extracted from WHO website: http://www.who.int/ fantasies, desires, beliefs, attitudes, a pregnancy performed by persons reproductivehealth/topics/sexual_health/sh_definitions/en/. 12. Turner, Medical Abortion Study Guide, 89. values, behaviours, practices, roles, lacking the necessary skills or in an 13. WHO, Safe Abortion, iv, 40-42. and relationships. While sexuality can environment not in conformity with 14. WHO, Safe Abortion, 18-19. include all of these dimensions, not minimal medical standards, or both”. all of them are always experienced or It further highlights that “the health expressed. Sexuality is influenced by the consequences of unsafe abortion interaction of biological, psychological, depend on the facilities where abortion social, economic, political, cultural, is performed; the skills of the abortion legal, historical, religious, and spiritual provider; the method of abortion factors.”11 used; the health of the woman; and the gestational age of her pregnancy. Spontaneous Abortion: “A miscarriage; Unsafe abortion procedures may involve the natural, involuntary termination of a insertion of an object or substance pregnancy before viability. Spontaneous (root, twig or catheter or traditional abortion occurs in at least 15-20 percent concoction) into the uterus; dilatation of all recognised pregnancies and usually and curettage performed incorrectly takes place before the 13th week of by an unskilled provider; ingestion of pregnancy.”12 harmful substances; and application 35 factfile arrow for change | vol. 24 no. 1 2018

By Dhivya Kanagasingam THE ROLE OF INTERNATIONAL Email: [email protected] and Mala Chalise HUMAN RIGHTS INSTRUMENTS Email: [email protected] Asian-Pacific Resource and Research Centre IN THE ADVOCACY FOR THE for Women (ARROW) RIGHT TO SAFE ABORTION

This factfile attempts to map and situate integrity; the right to be free of sexual and upon ratification of a treaty, states agree women’s right to safe abortion within the gender violence; the right to decide the that instruments such as treaty bodies play broader scope of human rights. It will number of spacing of one’s children; the a role in the interpretation of the treaty.7 explore the relevant core human rights right to privacy; the right to equality and Therefore, progressive interpretation treaties to understand and elucidate the non-discrimination; the right to consent of human rights by treaty bodies that rights that are pertinent to abortion. to marriage and equality in marriage; the include abortion puts advocates in a better right to employment and social security; position to hold state parties accountable Sexual and reproductive health and rights the right to education; towards obligations that ensures access (SRHR) advocates have situated abortion the right to be free from practices that to safe abortion services. In this light, within the larger realm of reproductive harm women and girls; and the right to international human rights bodies can, rights. However, the term “reproductive benefit from scientific progress.3 It is indisputably, be a catalytic tool in rights” has not yet been adequately through this encapsulation of reproductive advocating for the rights to safe abortion defined by any international human right rights that the right to safe abortion can services. convention and its content and scope clearly be positioned in existing treaties remain controversial even today. and conventions. It is imperative that advocates keep pushing for abortion through these existing An early, narrow interpretation of the term Progressive interpretation of rights, especially in the absence of an confined reproductive rights to access independent recognition of “the human rights by treaty bodies to family planning. The International right to safe abortion.” Advocates must Conference on Population and that include abortion puts use this trend towards a more progressive Development (ICPD) held in Cairo in 1994 advocates in a better position to interpretation of treaties and conventions marked a paradigm shift in addressing hold state parties accountable by human rights bodies to push for issues human reproduction and health, where towards obligations that ensures such as access to post-abortion care, for the first time, “women’s reproductive decriminalisation of abortion for women capacity was transformed from an access to safe abortion services. in general, and women’s right to access object of population control to a matter abortion on request, which is currently of women’s empowerment to exercise Aspects of the right to safe abortion not covered by any general comment and personal autonomy in relation to their are cited within different human rights recommendation. sexual and reproductive health within their framework. Such international social, economic and political contexts.”1 instruments have evolved to recognise The proceeding table demonstrates The ICPD Programme of Action presented the denial of abortion care as a violation the areas within core human rights a wider position on reproductive rights of women’s and girls’ fundamental conventions, which maps where the right which “embrace certain human rights human rights.4 to abortion stands as per the current already recognised in national laws, interpretation of treaty body experts. international human rights documents and General comments/recommendations5 This mapping process also identifies the other relevant UN consensus documents.”2 published by human rights treaty bodies human rights which are clearly interlinked Scholars and organisations supporting this are not legally binding but have a highly with access to abortion but has not been position encapsulates 12 rights within this: authoritative character with a legal basis.6 explicitly recognised by human rights the right to life; the right to health; the As espoused by Article 31 of the 1965 committees through general comments right to personal freedom, security, and Vienna Convention on Law of Treaties, and recommendations. 36 arrow for change | vol. 24 no. 1 2018 factfile 37 factfile arrow for change | vol. 24 no. 1 2018 38 arrow for change | vol. 24 no. 1 2018 39 arrow for change | vol. 24 no. 1 2018 40 arrow for change | vol. 24 no. 1 2018 41 arrow for change | vol. 24 no. 1 2018

Notes & References

1. Carmel Shalev, “Rights to Sexual and Reproductive 19. CEDAW, General Recommendation No. 24 on article 12: Health: The ICPD and the Convention on the Elimination of All Women and Health, para 12 (d), U.N. Doc. HRI/GEN/1/Rev.5 Forms of Discrimination Against Women (Paper presentation, (2001). International Conference on Reproductive Health, Mumbai, 20. CEDAW, General Recommendation 24, para 11. India, March 15-19, 1998), http://www.un.org/womenwatch/ 21. CEDAW, General Recommendation 24, para 31(c). daw/csw/shalev.htm. 22. CEDAW, General Recommendation 24, para 31(e). 2. United Nations, International Conference on Population 23. CEDAW, General Recommendation 33: Women’s Access to and Development Programme of Action (ICPD PoA) (October Justice, para 47(b), U.N. Doc. CEDAW/C/GC/33 (2015). 18, 1994), para 7.3, http://www.un.org/popin/icpd/ 24. CEDAW, General Recommendation 33, para 49. conference/offeng/poa.html. 25. United Nations Convention against Torture and Other 3. Julia Gebhard and Diana Trimiño, “Reproductive Rights, Cruel, Inhuman or Degrading Treatment or Punishment, International Regulation,” Max Plank Encyclopedia of Public https://en.wikisource.org/wiki/United_Nations_Convention_ International Law (Heidelberg and Oxford University Press, against_Torture_and_Other_Cruel,_Inhuman_or_Degrading_ 2012), http://www.corteidh.or.cr/tablas/r16912.pdf. Treatment_or_Punishment. 4. Johanna B. Fine, Katherine Mayall, and Lillian Sepulveda, 26. The Committee against Torture (CAT), General Comment “The Role of International Human Rights Norms in the No. 2 (22), http://docstore.ohchr.org/SelfServices/ Liberalisation of Abortion Globally,” Health and Human Rights FilesHandler.ashx?enc=6QkG1d%2FPPRiCAqhKb7yhskvE%2BT Journal 19, no. 1 (2017): 69-80. uw1mw%2FKU18dCyrYrZhDDP8yaSRi%2Fv43pYTgmQ5n7dAGF 5. Each of the treaty bodies publishes its interpretation of the dDalfzYTJnWNYOXxeLRAIVgbwcSm2ZXH%2BcD%2B%2F6IT0p provisions of its respective human rights treaty in the form of c7BkgqlATQUZPVhi. general comments or general recommendations. 27. CAT, General Comment No. 2, 22. 6. Deutsches Institut fur Menschenrechte, “What Are General 28. Committee on the Rights of the Child (CRC), General Comments?” accessed July 3, 2018, https://www.institut-fuer- Comment No. 20 (2016) on the Implementation of the menschenrechte.de/en/topics/development/frequently-asked- Rights of the Child during Adolescence (para 60), https:// questions/9-what-are-general-comments/. tbinternet.ohchr.org/_layouts/treatybodyexternal/Download. 7. United Nations, Vienna Convention on Law of Treaties aspx?symbolno=CRC/C/GC/20&Lang=en. 1965, Article 31, https://treaties.un.org/doc/publication/unts/ 29. CRC, General Comment No. 20 (para 39). volume%201155/volume-1155-i-18232-english.pdf. 30. CRC, General Comment No. 20 (para 60). 8. Office of the United Nations High Commissioner for 31. CRPD, General Comment No. 3 (para 32). Human Rights , General Recommendation XXV: Gender Related 32. CRPD, General Comment No. 3 (para 40). Dimensions of Racial Discrimination (March 20, 2000), para 3, 33. CRPD, General Comment No. 3 (para 44). http://www.bayefsky.com/general/cerd_genrecom_25.php. 9. Human Rights Committee (HRC), General Comment 6, Article 6 (16th Sess., 1982), in Compilation of General Comments and General Recommendations by Human Rights Treaty Bodies, at 114, 5, U.N. Doc. HRI/GEN/1/Rev.5 (2001). 10. HRC, General Comment No. 28: Equality of rights between men and women (Art. 3) (68th Sess., 2000), para. 10, U.N. Doc. CCPR/C/21/Rev.1/Add.10 (2000). 11. Human Rights Committee, General Comment No. 28: Equality of rights between men and women (Art. 3) (68th Sess., 2000), para. 11, U.N. Doc. CCPR/C/21/Rev.1/Add.10 (2000). 12. HRC, General Comment 28: Equality of Rights Between Men and Women (Art. 3) (68th Sess., 2000), in Compilation of General Comments and General Recommendations by Human Rights Treaty Bodies, at 168, ¶ 20, U.N. Doc. HRI/GEN/1/Rev.5 (2001). 13. HRC, General Comment 28: Equality of Rights Between Men and Women (Art. 3) (68th Sess., 2000), in Compilation of General Comments and General Recommendations by Human Rights Treaty Bodies, at 168, ¶ 20, U.N. Doc. HRI/GEN/1/Rev.5 (2001). 14. Committee on Economic, Social and Cultural Rights (CESCR), General Comment 14: The Right to the Highest Attainable Standard of Health (Art. 12) (22nd Sess., 2000), in Compilation of General Comments and General Recommendations by Human Rights Treaty Bodies, at 90, 14, U.N. Doc. HRI/GEN/1/Rev.5 (2001). 15. CESCR, General Comment 14 (Art. 12). 16. CESCR, General Comment 14 (Art. 12). 17. CESCR, General Comment No. 16, Article 3: The Equal Right of Men and Women to the Enjoyment of All Economic, Social, and Cultural Rights (29), https://www.escr-net.org/ resources/general-comment-n-16-article-3-equal-right-men- and-women-enjoyment-all-economic-social-and. 18. Committee on the Elimination of Discrimination against Women (CEDAW), General Recommendation No. 35 on Gender-based Violence against Women, Para 18. We would also like to thank the following individuals who contributed their ideas during the conceptualisation of the bulletin: Azra Abdul Cader, Babu EDITORIAL TEAM Ram Pant, Bagus Sosroseno, Dhivya Kanagasingam, Hwei Mian Lim, Mangala Sivananthi Thanenthiran, Executive Director, Namasivayam, Mary Gyknell Tangente, Marevic (Bing) H. Parcon, Nisha ARROW Santhar, Preeti Kannan, Seow Kin Teong, Renu Khanna, Sai Jyothir Mai Racherla, Samreen Shahbaz, Sivananthi Thanethiran, and Sundari Ravindran. 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