Reproductive Justice in Europe: What is the state of reproductive justice in Europe? Going beyond the Pro-Choice and Legality debate

Master of Science in Political Science- International Relations June 26, 2020

Author: Mujinga-Clarisse Kombo (12545333) Supervisor: Dr. Franca van Hooren Second Reader: Dr. Afsoun Afsahi

(Word count: 23 942 words) Acknowledgments

I would like to thank my parents and my brother for their continuous moral support during my studies. I would also like to thank my friends who have made this a memorable experience.

My gratitude also goes to my supervisor, Dr. Franca van Hooren, for her continuous help during the completion of this thesis. It was not easy, and some tears were shed in the process. Thank you to Dr. Afsoun Afsahi from the UvA and Béatrice Châteauvert-Gagnon from the University of Montréal, for introducing me to the field of Politics and Gender, it has been a life changing discovery, both on an academic and personal level.

2 Table of content

List of Abbreviations…………………………………………………………4 Tables…………………………………………………………………………..5

1 Introduction ...... 6

2 Literature review ...... 9

3 Theoretical Framework ...... 17

4 Methodology ...... 21

5 Availability ...... 26 5.1 on the EU level ...... 26 5.2 Abortion laws in Europe ...... 32 5.3 Typology of countries ...... 41 5.4 The political actors in the availability debate ...... 42

6 Accessibility ...... 47 6.1 Barriers and obstacles to abortion ...... 47 6.2 Typology of countries ...... 66 6.3 Political actors in the accessibility debate ...... 69

7 Conclusion ...... 72

Bibliography……………………………………………………………………...75

3 List of Abbreviations:

CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CESCR Committee on Economic, Social and Cultural Rights ECHR European Convention on Human Rights ECtHR European Court of Human Rights EU European Union FRA Fundamental Rights Agency ICPD International Conference on Population and Conference IPPF International Planned Parenthood Federation MERJ Migrants and Ethnic Minorities for Reproductive justice NGO Non-governmental organization PFA Platform for Action PoA Program of Action RJT Reproductive Justice Theory SDG Sustainable Development Goal SRHR Sexual and Reproductive Health and Rights UN United Nations

4 Tables:

Table 1………….40 Table 2………….41 Table 3………….68

5 1 Introduction

Even though abortion has been made widely available in Europe, it is still considered as a controversial topic. The debate is not only addressed in politics but also in numerous academic fields such as political science, international relations, psychology, sociology, law, human rights studies and medicine. The mainstream debate on abortion is today dominated by the pro-choice and the pro-life movements. Pro-choice adherents advocate for giving women the ability to control their own body, hence they do not oppose abortion and put the emphasis on women’s ability to have the choice whether or not to have an abortion. On the other hand, pro-life adherents consider abortion as murder, the murder of the , who is considered a living human being from the moment of its conception. During the 1990’s in the United States of America, African American feminists claimed that the pro-choice movement did not take every woman into account and demanded for a more inclusive movement. This was the beginning of a new movement: the reproductive justice movement. Contrary to the pro-choice movement, reproductive justice considers itself to be more inclusive as it tries to take an intersectional lens to study reproductive politics and rights. Indeed, reproductive justice does not isolate abortion from other social justice issues such as “economic inequalities, immigrants’ rights, discriminations based on race or sexual orientation, age or disability rights” (Ross 2006, p.14). The goal is of this framework is to address the necessities of different groups of women and to place special emphasis on women who do not have access “to privilege, power and resources.” (Ross 2006, p.19). The criticism voiced against the pro-choice framework, is that not every woman has the choice to decide due to factors such as income, age and legal status that interfere in her decision-making process. Reproductive Justice theorists claim that the availability of abortion does not necessarily translate into accessibility for every woman. Since then, many American academics have dealt with the concept of reproductive justice that distinguishes between availability and accessibility when it comes to . Consequently, the debate on reproductive justice has been dominated by the American context and American politics. There is a gap in the literature when it comes to reproductive justice in Europe. Indeed, one can find isolated cases on reproductive justice in Europe, but there has been no systematic research on the topic. In Europe the debate on abortion is still heavily influenced by the pro-choice and pro-life division. Therefore, the European debate on abortion politics places the

6 emphasis on legality. Pro-choice adherents are in favor of the legality of and pro-life adherents oppose the lawfulness of termination of . At a time where many ask for more inclusiveness in society, the reproductive justice theory tries to include all the individuals in reproductive politics and give individuals from different backgrounds a seat at the table. The aim of this thesis will therefore be to go beyond the pro-choice and legality debate and to analyze the state of reproductive justice in a European context. Consequently, this research studies if the legality (availability) of abortion necessarily translates into its accessibility. Hence, my research question is: What is the state of reproductive justice in Europe? Furthermore, I have three sub- questions: What is the state of availability of abortion in Europe? What is the state of accessibility of abortion in Europe? Who are the actors in the political debate on abortion? To answer these questions, this research does a cross-national study of 14 European countries (the Netherlands, Germany, France, Luxembourg, Ireland, Great Britain, Sweden, Denmark, Poland, Slovakia, Spain, Portugal, Italy and Malta). The thesis will start with a literature review to give an overview of the academic contribution on the topic so far and show how this research will contribute to the existing literature. Then, the theoretical framework will present in more detail the reproductive justice theory. After the methodology, I will analyze the state of availability in Europe followed by an analysis of the state of accessibility of abortion in Europe. During the thesis I will show that even though abortion has been made widely available in Europe, this does not translate necessarily into its accessibility, specifically for vulnerable and marginalized groups. Indeed, there are several obstacles that obstruct women’s access to safe and legal abortion. The thesis will conclude with a discussion and try to pinpoint the most important elements of the thesis and emphasize on elements that need further research.

Societal and Academic relevance

Abortion is part of a wider concept called Sexual and Reproductive Health and Rights (SRHR). In the United Nations Sustainable Development Goal 5 (UN, SDG n°5), Gender equality, one of the targets is to “ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of

7 their review conferences” (PoA, 1994). The United Nations therefore states that gender equality can only be achieved if all women have access to SRHR which entails universal access to contraception and abortion care. Furthermore, the conversation on the topic concerns almost everyone “directly or indirectly”: the legislators create and amend the abortion laws; the politicians are often judged on their stance on abortion; the voters will vote for politicians who defend their ideology concerning abortion; health-care workers decide on conducting or not the and decide on the procedures to take; academics and activists can influence the policy-making process; and teachers and social workers are responsible for the sexual education of the society (Kaczor 2011, p.1). In the context of abortion, the concept of reproductive justice is also important, as it allows to take a more holistic and inclusive approach to reproductive rights and politics. Indeed, it shows how factors such as socio-economic and cultural inequalities allow some individuals to have “easier access to self-determination and bodily autonomy” concerning abortion rights than others (Higgins 2014, p.240).

8 2 Literature review

The following literature review will provide both a review of the scholarly contribution that has been made on the debate of abortion and provide an explanation in how this thesis will contribute to the existing literature. Hence it will also show that the concept of reproductive justice has not really been tackled in Europe. Indeed, the debate on the European level is still very much dominated by the pro-choice vs. pro-life framework.

Abortion as a Human Right

From a Health issue to a Human Right

According to the World Health Organization (WHO), every year 25 million unsafe abortions take place in the world (WHO 2019). At least 70 000 women die every year of the complications of and research has found a significant relation between the legality of abortion and its safety, hence individuals “living in countries with restrictive abortion laws often resort to unsafe abortions, jeopardizing their health” (Zampas and Gher 2008, p.250). Consequently, abortion has growingly been considered a health issue and human rights advocacy in favor of safe abortion has gathered momentum in the last decades (Zampas and Gher 2008). Today most literature addresses abortion as a human right, this change is in part due to the International Conference on Population and Development (ICPD) in Cairo which advanced the idea of a human right to (reproductive) health. Indeed, human rights law recognizes that restrictive abortion laws may violate an individual’s right to “freedom from cruel, inhuman, or degrading treatment” (De Londras and Enright 2018, p.46). Considering abortion as human right rather than just a health issue broadens the scope and takes elements such as power relations and social and economic factors into account. Therefore, the ICPD put the accent both on women’s reproductive health and rights (Porter 2013). Cook and Dickens claim that “the shift in focus to human rights”, is probably one of the most memorable moment has gone through (Cook and Dickens 2003, p.5).

9 The International Conference on Population and Development in Cairo

Since the 1990’s, abortion is considered a human right on the international scene, hence the issue has been tackled not only in national courts but also in international human rights courts, such as the European Court of Human Rights (ECtHR). Indeed, today abortion is part of a wider concept called sexual and reproductive health and rights (SRHR), a concept popularized in 1994, during ICPD in Cairo. The goal of this conference was to find an international agreement on development and population for the next two decades (MacIntosh and Finkle 1995). In this context, emerged the Program of Action which was adopted by 179 countries (PoA 1994). The program’s aim was to encourage governments to reconstruct their policies concerning “population control” and contend with issues such as “the prevention and treatment of unsafe abortion, and above all the empowerment of women” especially in the “developing world” (MacIntosh and Finkle 1995, p.225).

The PoA does not force its signatories to legalize abortion, but calls for abortion, “when it is not against the law”, to be “safe” and “women to have access to quality services” when it comes to abortion (article 8.25). Indeed, during the ICPD there was a shift in focus on the topic of population control. The Program of Action considers the control of the population growth through women’s fertility as “inherently coercive and abusive” and promotes a new model where women are free to choose the “number and the timing of their children” (MacIntosh and Finkle, 1995, p.227). Indeed, especially in the “Global South” in order to control the growth of the population, many women were coerced (in large part by international NGOs) into receiving “injectable contraceptives” and “the vaccine against pregnancy” (Porter 2013, p.138). The ICPD tried to shift from this paradigm, the goal was to “empower” women through not only education, but also the provision of work and the elevation of their status in our society. Instead of interfering in their fertility, women should have access to adequate services (MacIntosh and Finkle 1995, p.227).

Finally, the PoA defines reproductive health as a “complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes” and women should have the ability to have “a satisfying and safe sex life and (..) the capability to reproduce and the freedom to decide if,

10 when and how often to do so” (PoA 1994, article 7.2). Furthermore, reproductive rights were defined as “embracing certain human rights that are already recognized in national law” such as the right to education, freedom of expression, and the right to equality (non-discrimination) (Pizzarossa and Perehudoff 2017, 322) (PoA 1994, 7.3). By doing so, the Conference became the first place where SRHR were linked to human rights and gave SRHR more credibility on the national level (Pizzarossa and Perehudoff 2017).

Fourth World Conference on Women

The World Conference on Women in 1995 in Beijing was the fourth UN conference on women. As the ICPD the previous year, the goal was to uplift and reinforce women’s right “as an integral part of the human rights paradigm” (Plattner 1995, p.1249). Hillary Rodham Clinton, then First Lady of the US, set the tone by asserting that “human rights are women’s rights, and women’s rights are human rights once and for all (…)” (UNDP 1995). Many issues concerning women were addressed as for instance women’s health, specifically women’s reproductive health (Plattner 1995, 1249). The Beijing Conference underlined the definition of reproductive health and rights adopted in the Plan of Action of Cairo and from the Conference emerged the Beijing Declaration and the Beijing Platform for Action. The latter recognizes that the access to health is different both between men and women, and among women due to factors such as social classes and ethnicity (Beijing PFA 1995, article 89). Additionally, compared to the PoA, the PFA goes a step further and encourages governments to eliminate sanctions for women who “have undergone illegal abortions” (De Cruz 2001, p. 416).

Even though resolutions and documents such as the Program of Action, the Beijing Declaration and the Beijing Platform for Action are not legally binding, they are still relevant, because they have become part of the “the historical record of the United Nations, where they are included as recommendations that have been universally endorsed” (MacIntosh and Finkle 1995, p.226). Indeed, these international conferences have “internationally endorsed and legitimized” reproductive health and rights. Consequently, this has reconceptualized abortion as human right on the international scene, restrictive abortion laws are today considered disrespectful and as going against women’s “wish, interest, health, and bodily integrity” (Cook and Dickens 2003, p.12). In this context, the role of international organizations such as the UN are important as they have been

11 trying to find an international consensus and have been able to change the conceptualization of reproductive rights such as abortion (Cook and Dickens 2003).

The pro-choice vs. pro-life debate

Today the political debate on abortion is divided into two: the people who are in favor of its legalization and the ones who are opposed to it. The former group is part of the pro-choice movement and the latter of the pro-life movement. As Andrea Smith explains, the pro-life position asserts that “the fetus (or embryo)1 is life; hence abortion should be criminalized” (2005, p.121). On the other hand, the pro-choice camp maintains that the embryo/fetus is not life and in consequence a woman should have the power to control her own body (Smith 2005). Moreover, the pro-choice side asserts that legalizing abortion will allow society to attain gender equality as women who control their fertility can “participate equally in the nation’s social, political and economic life” (Borgmann and Weiss 2003). The argument of both medical and individual privacy is also often evoked by the pro-choice party to defend the right to abortion (West et al. 2014). Based on the pro-choice consensus, abortion should be an individual right protected by the constitution and protected against political changes (West and al. 2014). According to pro-choice defenders having the choice “opens doors that otherwise would be closed”, women can wait to have children when they have a secured job or when they are financially stable to support a baby (Borgmann and Weiss 2003). In this context, Bertha Alvarez Manninen underlines that there is a distinction to be made between the concepts of pro-choice and pro-abortion (2014, 89). In her book she analyzes the different values in the in the US through conducted interviews and the language used, based on this, the author notices that the terms pro-choice and pro-abortion are “frequently considered synonymous”, even though they are “vitally different” (Alvarez Manninen 2014, p.89). Indeed, as already mentioned before, the term pro-choice, is about giving women a choice, if they do or do not want to continue their pregnancy, it means “respecting the choice” (Alvarez Manninen 2014, p.90). The term pro-abortion on the other hand, refers to “someone who encourages, and

1 Smith just uses the term fetus, but I use the term fetus and embryo, because there is a distinction to make. Embryo is the scientific term used until the 8th week of pregnancy, only from then onwards, it’s called fetus.

12 celebrates abortion, who desires to see women choose it over other options” (Alvarez Manninen 2014, p.90). Forcing women to continue their pregnancy against their will is then considered a human right violation. The pro-choice ideology emphasizes the need for women to have a choice; the belief is that if abortion is legal, every woman will have the choice and the option to have a safe abortion if she wants to. Choice will give women autonomy over their bodies and allow society to attain gender equality (Smith 2005, Manninen 2014, Borgmann & Weiss 2003).

As Ross and Sollinger explain the pro-choice vs. pro-life debate has “dominated the headlines and mainstream political conflict” (2017, p.1). The conversation on abortion is monopolized by this dichotomy in the political as in the academic sphere. Many academics papers dealing with the issue of abortion especially in Europe look and analyze this dichotomy opposing the camps in favor vs. the camps who oppose abortion. For instance, the (academic) debate on , where abortion laws count among the most restrictive in Europe, is monopolized by the opposition between pro-choice and pro-life camps. In their article, Paprzycka, Dec-Pietrowska and Lech analyze the stance and language used by the two opposing camps. As the authors explain, in Poland there are the ones defending women’s rights to control their bodies and their reproductive rights relying their arguments on the human rights norms (pro-choice) and the conservative side, heavily influenced by the powerful catholic church of the country, who argue that abortion is murder (2019). The national poll the authors refer to, shows that 38% of Poles are against abortion (pro-life) vs only 18% in favor (pro-choice) (Paprzycka and Dec-Pietrowska 2019). Many other researchers have dived into the subject of abortion in Poland and in Europe in general, always with a focus on the pro-life vs. pro-choice stance (Paprzycka, Dec-Pietrowska and Lech; Jelen and Wilcox; Klugman and Budlender).

This topic is relevant for the thesis, because it shows that abortion is a controversial issue and still divides society. Furthermore, it raises the question of legality of abortion that will play a role in this thesis. The following thesis will go beyond the dichotomy between pro-choice and pro-life as the research will analyze the access women have to abortion and will not solely focus on the debate concerning the legalization of abortion. Indeed, the pro-choice position often comes under

13 criticism by the reproductive justice theory because it does not take an intersectional approach and presumes that if abortion is legal, all women will automatically have access to it.

Abortion access in the United States

The US represents an interesting case when it comes to the study of abortion. In both activism and literature, one can find a significant shift from the pro-choice framework to the reproductive justice framework. Indeed, the concept of reproductive justice was born in the US and is firmly rooted in the American political and cultural context. Therefore, it is important to look at the American situation when it comes to the difference between availability and accessibility of abortion care.

Marlene Gerber Fried is an American academic focusing her scholarship on “reproductive rights, health and justice” (Hampshire College). In her article she analyzes “the extreme dissonance between the wide availability of abortion and its inaccessibility to women on the social and economic margins” in the US (2000, p.177). She explains that abortion has been legalized in 1973 in the US, after the famous Roe vs. Wade judgement. However, since then, many anti-choice forces have been trying to undercut this right. Consequently, restrictive laws, policies and practices have limited the access to abortion care for women, especially “low-income women, women of color and young women” (Fried 2000, p.178).

Factors such as class, race and age do play a role when it comes to the access of abortion care in the US. Moreover, the American private health care system has had a negative impact when it comes to accessibility. Indeed, in 2000, 37 million Americans did not have a health insurance among them were 9 million women who were in “childbearing age”. Moreover, one third of health insurances do not cover abortion, and one third of women do not benefit from “employment-linked health insurance” (Fried 2000, p.179). Last but not least, Medicaid, a federal and state funded program that provides health care for low income people for “necessary medical services”, does not cover abortion (Fried 2000, p.180). As class is often racialized, many women of color (Black and Latina) are more likely to be low-income and to benefit from Medicaid. About 24% of Latina

14 women and 30% of Black women are registered for Medicaid in contrast to only 14% of White women (Planned Parenthood). This is due to the huge wealth gap between white women and women of color. In consequence, even though abortion is available in the US, it is not always accessible, especially to low-income women, and women of color as they do have to pay the medical procedure with their own money, without financial aid on the federal or state level.

Furthermore, although abortion is legal, it is not always within reach. Fried underlines that 9 out of 10 abortion providers in the US are today located in metropolitan areas hence approximately 25% of women seeking an abortion have to drive for about 80 km to the nearest abortion provider (2000). This makes the access difficult for women who do not have a driving license and a car, especially for adolescents under the age of 16 and for low-income women who cannot afford a car. Another barrier for accessing abortion can be age. In the US 39 out of the 50 states require underaged girls to have the authorization of their parents to have an abortion (Fried 2000). Consequently, girls who are under 18 do not have their bodily integrity and are dependent on their parents’ approval which can be an obstacle to receive abortion care.

Taking a simple pro-choice perspective in these cases is not sufficient, because even though the law is theoretically on women’s side, in practice there are huge discrepancies in access and certain women are more impacted than others (Fried 2000). This is why in 1994, Loretta Ross and 11 other Black feminists, called Women of African Descent for Reproductive Justice created the reproductive justice framework during a pro-choice conference in Chicago that was organized in reaction to President Clinton’s health care reform which was not taking women’s reproductive health into consideration (Ross and Solinger 2017). For the 12 Black feminists present at the conference it was important to redefine reproductive rights and to put themselves at the center of the debate, as they thought they had been ignored so far (Ross et al. 2004). Indeed, they believed “that the women’s rights movement, led by and representing middle class and wealthy white women, could not defend the needs of women of color and other marginalized women and trans* people” (SisterSong). The new reproductive justice lens started to explicate how different people “experience reproductive capacity according to multiple intersecting factors including their class, race, gender, sexuality, status of their health, and access to health care” (Ross and Solinger 2017, p.66). As Ross claims, women of color’s ability to control their body “is constantly challenged by

15 poverty, racism, sexism (..) and injustice in the United States” (Ross et al. 2004, p.43). The starting point for reproductive justice in the USA was therefore race and all the factors it can bring with itself, the concept has since then been broadened and encompasses many different factors.

Conclusion

On the international scene, abortion is today regarded as a human right. On the national, the discussion on abortion is still dominated by the mainstream pro-life versus pro-choice debate. This field of study usually concentrates its research on the legality of abortion, and rarely takes an intersectional approach and barely systematically studies the impact of the law and practices on women’s access to abortion, especially in a European context (Berer 201; Simon 1998; Machteld 1990). Indeed, in the United Sates, since the end of the 1990’s, there has been a shift in focus from the pro-choice paradigm to the reproductive justice lens. The reproductive justice framework considers itself to be more inclusive. It takes an intersectional and human rights lens and studies how the availability de jure does not translate into its accessibility de facto. The literature on reproductive justice is mainly focused on the United States (Ross and Solinger 2017; West et al. 2014; Luna and Luker 2013; Smith 2005). When it comes to the European context, we can find isolated academic texts, but there is no systematic study that has been done so far, this will therefore be the aim of this research.

16 3 Theoretical Framework

For my theoretical framework I will use the reproductive justice theory (RJT). The latter analyzes the unequal access to sexual and reproductive rights for women. The RJT takes an intersectional approach, that is why I will start with an introduction on intersectionality. I will then continue with the RJT.

Intersectionality

First, I will briefly tackle the theory of intersectionality in order to make the following segment on reproductive justice theory more comprehensive.

The term intersectionality was coined in 1989 by Kimberlé Crenshaw. She used the term to underline “the various ways in which race and gender interact to shape the multiple dimensions” of Black women’s lives (1991, 1244). Indeed, Crenshaw tried to illustrate how Black women in the US were simultaneously marginalized in feminist and in anti-racism movements and politics (Crenshaw et al. 2013, 303). They were marginalized in women’s movements, because they were black and marginalized in the anti-racism movement, because they were women. In her book Black Feminist Thought, Patricia Hill Collins explains how Black women find themselves in the intersection of “gender, race, class and sexuality” (1990, 22). Indeed, a Black woman does not only face discrimination because of her gender, but also because of her race.

Today the theory of intersectionality has been broadened and captures a wide “range of issues and social identities” (Crenshaw et al. 2013, p.304). Indeed, the concept is not limited to Black women’s experience anymore and encompasses a variety of different characteristics (class, sexual orientation, religion, education, legal status etc.) and still underlines how these characteristics can intersect with each other and lead to a specific way of marginalization. Intersectionality has become a tool to analyze the complexity of the human experience. For instance, when it comes to social inequalities, people’s experiences are more comprehensive “as being shaped not by a single axis of social division, be it race or gender or class, but by many axes that work together and influence each other” (Hill Collins and Bilge 2016, p.22). In other words, when a person is facing

17 inequalities it is often due to many characteristics that work together and shape a person’s experience. For instance, in a country where abortion is illegal, a woman faces discrimination against her gender. However, a woman who has enough financial resources will be able to travel to another state to receive an abortion. On the other hand, a woman who lacks the necessary financial resources, will not be able to travel to another state. Consequently, in this experience, gender is not the only axis, but other characteristics like social class will come into play too and shape a woman’s experience on her quest to abortion care. Without taking an intersectional approach the following analysis is not possible. The intersectional lens allows to realize that people, in this case women, do not form a “homogenous, undifferentiated” group and it explains how factors such as race, class, legal status, sexual orientation, nationality can work together and shape someone’s experience and “position (people) differently in the world” (Hill Collins and Bilge 2016, p.49). The intersectional approach shows that the issue of sexual and reproductive health and rights is not only gendered but encloses many more factors.

Reproductive Justice Theory

The term “reproductive justice” was coined in the 1990’s by Loretta J. Ross and 11 other African American feminists. The concept was born in the U.S. and is strongly rooted in the theory of intersectionality and the theory of human rights (Ross and Solinger 2017). The concept needs to be understood in its American context, where it was countermovement. Indeed, there was a feeling among African American feminists that reproductive politics did not take factors such as race and class into consideration (Ross and Solinger 2017). Ross and Solinger define reproductive justice theory (RJT) as a “contemporary framework for activism and thinking about the experience of reproduction” (2017, p.9). It lies on three principles: “(1) the right not to have a child, (2) the right to have a child, (3) the right to parent children in safe and healthy environments.” (2017, 9).

As mentioned previously, the reproductive justice theory is rooted in the theory of human rights. Consequently, the human rights analysis of RJT rests on the claim that the intrusion in the well-being of reproductive people is a “blow against their humanity” and preventing this intrusion is a way to protect their human rights (Ross and Solinger 2017, p.10). The intersectional analysis of RJT rests on the fact that RJP pays attention to laws, policies and practices that are based on

18 “racial, gender and class prejudices” (Ross and Solinger 2017, p.10). In other words, RJT is aware of how different laws, policies and practices can affect people differently depending on their race, class and gender. As Fried explains in 1976 the American Congress passed an amendment that banned federal Medicaid funding for abortion and many states followed by banning state aid. The result was that poor women, disproportionately women of color, saw their abortion access evaporate” (2017, p.143). Indeed, many of them did not and do not have the financial resources to afford an abortion without the government’s help. Here the author stresses the difference between availability and access. In 1976, abortion became legal and available in the US, but it was not accessible to everyone, women who did not have the resources (e.g. financial), did not have access. That is why Fried claims that “women must have the resources necessary to turn their rights into realities” (2017, p.144). As reproductive justice theory takes an intersectional approach it shows that people do not have an equal access to sexual and reproductive health and rights. Fried explains that Black women in the U.S. complained about the fact that reproductive activism did not take an intersectional approach after the Roe vs. Wade judgment (2017). Therefore, Ross and Solinger claim that the debate of reproductive justice is different from the pro-choice/pro-life debates that “have dominated the headlines and mainstream political conflict for so long” (2017, p.1). Indeed, putting the focus on choice, as the pro-choice framework does, suggests that if abortion is legal, it is accessible to everyone, which is not the case (Thompson 2017). Indeed, taking an intersectional approach as RJT does, shows that the accessibility to abortion is still unequal among women.

In the book Radical Reproductive Justice: Foundation, Theory, Practice, Critique, Beverly Yuen Thompson explains the dichotomy between availability and accessibility, through a negative and positive liberty framework. She explains that the (American) government presents a “negative liberty”, when it comes to abortion. In other words, abortion is “free from legal restrictions”, it is “available” (2017, p.251). This in contrast with “positive liberty” that wants to ensure that abortion is “accessible for all” (Thompson 2017, p.251). In mainstream politics it is often thought that if abortion is legal/available, it can “be chosen by any woman”, but as Thompson underlines “this is only the case for women who have the necessary resources” and these resources can be different in origin, for instance financial, legal or educational (2017, p.252). The author gives several examples that do illustrate the obstacles women can face in order to get an abortion: (In this context, it is important again to keep in mind that the author talks from an American perspective.)

19 In the USA, “9 out of 10 abortion providers are located” in cities, women who live in rural areas do often have to drive (if they have a license and a car) for long hours to get to an abortion provider (Thompson 2017, 252). Then, there are often “mandatory-waiting-periods”, which means that women are restricted by time and this varies considerably depending on the states (USA again). Last but not least, as Thompson explains many obstetricians/gynecologists (OB/GYN) in the US are rarely taught the abortion procedure in their “residency programs” and are therefore not able to conduct an abortion (2017). She concludes that the “narrow focus on choice has consistently overlooked the reality of access many women face” (2017, p.252).

This why RJT goes beyond the legal framework and beyond the pro-choice debate. Indeed, as Solinger explains taking a human rights approach and talking about rights is more accurate, because everyone is entitled to human rights. The concept of choice on the other hand, is often related to the “possession of resources” (Smith 2005, 128) (Solinger 2001). As a consequence, as Andrea Smith explains, in a capitalist society, women who have more resources (e.g. financial), have more choices (2005). The theory, therefore, contributes to a more holistic and inclusive view of reproductive rights.

20 4 Methodology

First, it is important to note, that the reproductive justice theory does not only concentrate on abortion or contraption. Indeed, RJT asserts that individuals should have “(1) the right not to have a child, (2) the right to have a child, (3) the right to parent children in safe and healthy environments.” (Ross and Solinger 2017, p.9). In the context of point (1) points out to abortion but also contraception. Points (2) and (3) make reference to individuals who have been forced to abortion or sterilization against their will. Mobley mentions Jewish women who underwent on grounds of , the same goes for African American women in the US and women in “developing countries” (2006, p.22). However, for the following thesis, my focus will lie solely on abortion within the reproductive justice framework.

Assessment of availability and accessibility of abortion care

As we have seen in previous chapters, RJT underlines how factors such as socio-economic and cultural inequalities allow some individuals to have “easier access to self-determination and bodily autonomy” than others (Higgins 2014, p.240). Consequently, RJT tries to assess accessibility of reproductive rights and distinguishes between legality (availability) and accessibility. RJT has no clear predefined model to assess these two concepts. This is why for this research, I decided to use the definition used by the Committee on Economic, Social and Cultural Rights (CESCR) of the UN to comment article 12 on “the right to the highest attainable standard of health” of the International Covenant on Economic, Social and Cultural Rights (UN 2000). The normative comment of the CESCR does not mention abortion specifically. However, it talks about goods and services related to health and as we have seen in the literature review abortion has been considered as a health issue by the UN, thereafter, these recommendations do apply to abortion as well. Furthermore, the criteria used by CESCR align with the existing literature on reproductive justice. According to the CESCR’s definition, abortion is considered available when it is legal (UN 2000, article 12). When it comes to accessibility, there are four dimensions to consider. (1) Abortion is considered accessible when the service and good is non-discriminatory, especially to vulnerable and marginalized part of the population. (2) Then abortion is considered accessible

21 when it is physically accessible, in other words abortion should be “within safe physical reach for all section of the population” even in rural areas, especially for marginalized and vulnerable people, such as ethnic minorities, women and people with physical disabilities (UN 2000, article 12). (3) Furthermore, abortion is considered accessible when it is affordable for the population, specifically for “socially disadvantaged groups” (UN 2000, article 12). Poorer groups should not be “disproportionally be burdened by health expenses” compared to their richer counterparts. (4) Last but not least, information should also be accessible for all. Everyone should have the right to “seek, receive and impart” information related to abortion (UN 2000, article 12).

Data Collection and processing

To analyze how this dichotomy between availability and accessibility translates into practice, I use secondary literature. On the one hand, for the study of availability (legality), I worked mainly with legal documents (abortion bills, Criminal Codes). On the other hand, for the study of accessibility, I made use of academic papers, newspapers (e.g. The Guardian), legal texts, and studies conducted by international organizations and NGOs. I focused my study on secondary literature that concentrates on Europe and reproductive health, rights and politics but also on concepts such as intersectionality. Then, I analyzed the existing literature, brought it together and synthesized it.

Furthermore, I conducted interviews to find out further information that were not necessarily available in the secondary literature. Furthermore, as the topic of reproductive justice underlines the discrepancies between theory (availability) and practice (accessibility), it was important to have the expertise/testimonies of people working or/and studying the field. I chose to conduct semi-structured interviews as they allowed me to address specific topics while also allow the appearance of new issues and/or topics (Wilson 2013).Additionally, semi-structured interviews are perfectly suited for “small-scale research”, as they are very flexible and allow interviewees to express themselves more freely (Drever 1995). Consequently, my interviewees were able to raise issues that I had not think of and not find in secondary literature. The interviews were conducted both on Zoom and by phone. There was no face to face interview, as all of them were conducted in the midst of the Covid-19 pandemic, hence traveling and meeting in person was not possible during this time. All interviews were recorded with my phone (with the consent of the

22 interviewees), and then transcribed and labelled in relevant sections (repeated concepts, words, sentences). These were then grouped into themes. Some themes came up repeatedly, therefore, I created a hierarchy of themes.

Conducted interviews:

Interview 1 Legal advisor Center for Reproductive Rights

Interview 2 Volunteer Ciocia Basia Interview 3 Volunteer Abortion Network Amsterdam (ANA) Interview 4 Journalist France Inter Interview 5 Project Manager CESAS (National Center for the promotion of sexual and reproductive health)

(1) The Center of Reproductive Rights is an international NGO with offices in Africa, Latina America, North America and Europe. The goal of the Center is to advance gender equality by defending individual’s access to contraception and abortion care. The center regroups attorneys who plead in front of both national and international courts in order to contribute to the adoption of inclusive laws that guarantee the access to contraception and abortion services (interview 1; 2020). Additionally, the Center engages with policymakers and also conducts research on the issue. I was able to interview a legal advisor of the Center who focuses on Europe. (2) Ciocia Basia is Polish/German NGO that helps individuals from Poland to receive safe and legal abortions in Germany. Their expertise lies primarily on Poland and Germany. (3) Abortion Network Amsterdam (ANA) is a Dutch NGO that helps women from all over the world to get safe and legal abortion care in the Netherlands. For both NGOs, I interviewed a volunteer from the organization. (4) Furthermore, I interviewed a journalist based in Paris, she has conducted several interviews on the accessibility of abortion in Europe, specifically in Poland, Ireland and Luxembourg. Last but not least, I interviewed a project manager at the (5) CESAS, the Luxembourgish Center for the Promotion of Sexual and Reproductive Health.

23 Choice of countries

My thesis consists of a cross-national study. I chose 14 European countries (Malta, Italy, Portugal, Spain, Poland, Slovakia, Luxembourg, Ireland, France, Great Britain, the Netherlands Germany, Sweden and Denmark). There are multiple reasons for my selection of countries. First, I tried to have a representation of the different European regions. Indeed, I included Scandinavian countries, but also Western, Southern, Eastern and Central European countries. Furthermore, I used large countries such as France and Germany, but also small countries such as Luxembourg and Malta, which is a microstate. I also decided to include countries with different political and religious backgrounds. For example, Poland and Slovakia are former communist countries and have only changed their political and economic model in the beginning of the 1990’s. When it comes to religion, I selected countries with different relationships to the Church. France, for instance, is famous for being an openly secular country. On the other hand, Italy, even though it is a secular state, has still a deep connection to the Catholic Church. Additionally, the diversity of the population was also taken into account during the selection of the countries. Sweden’s immigrant population accounted in 2016 for 16% of the overall population (Larsson et al. 2016, 14). In Poland, on the other hand, immigrants account for only 1% of the population (Kafkadesk 2019).

Moreover, when it comes to abortion care, I tried to have countries with different regulations. The aim was to have a representation of extremes and everything in between. For instance, in the Netherlands abortion care on request is legal until the 24th week of pregnancy. In Malta, on the other hand, abortion is forbidden under any circumstance. Additionally, I chose countries with different time regulations, as we have seen in the Netherlands, abortion care can be sought until the 24th week, in Portugal this is only possible until the 10th week. The aim was to have different countries in order to perhaps find patterns.

24 Language

As I have mentioned previously, my thesis will use the reproductive justice theory. The goal of this theory is to be the as inclusive as possible and to include all the individuals in the debate of reproductive politics. In this context, the language is important, in my research, I use both the term “women”, but also “individuals”. Indeed, women are not the only ones who can get pregnant, I am here thinking of transmen. On the other hand, some women are biologically not able to get pregnant as for instance transwomen. However, in some instances, I believe that it is important to use the term women as it is an issue that concerns them particularly, because of their biological and reproductive features. Furthermore, the lack of abortion availability is often due to a long history of sex discrimination.

Covid-19

Some interviews were cancelled due to the pandemic, as the latter completely changed the situation for many potential interviewees. For instance, due to the circumstances, many Planned Parenthood organizations in Europe were not available for interviews. Indeed, many health care providers had to reconfigure their job and interviews in March and April were not convenient for them. Furthermore, in many organizations and NGOs the number of members of staff was reduced, consequently some people who had accepted to be interviewed, cancelled during the outbreak of the pandemic.

25 5 Availability

This next chapter will focus on the state of availability of abortion in Europe, which means on the legality of abortion care in Europe. As mentioned before, this thesis is a cross-national study of 12 countries. Consequently, I will analyze the lawfulness of termination of pregnancy in these 12 countries. However, as all the countries in my study are part of the European Union, I will first analyze the regulation on the EU level. Indeed, if there is a common regulation laid out by the EU, member states need to apply it in their country. It is therefore interesting to look at the EU level first. Then, I will continue with the regulations in the different countries and try to categorize the states into groups. Finally, I will study the political actors who have played a role in the debate on legality of abortion in Europe. To conclude, this chapter will give an overview of the information collected.

5.1 Abortion on the EU level

The EU and SRHR within its borders

In 1957, six countries (France, Germany, Belgium, the Netherlands, Luxembourg, and Italy) signed the Treaty of Rome, which established the European Economic Community. The treaty does not mention human rights because as the name indicates, the community was purely based on economic interests (Du Bois 2007). Indeed, as Miller explains, the EU was founded “primarily for economic reasons” (1999, p.198). However, 35 years later, in 1992, the Treaty of Maastricht was signed, and the question of human rights appeared for the first time on the EU level. Indeed, Miller evokes the clause F of the treaty which reads: “The Union shall respect fundamental rights” (1999, p.200). The “fundamental rights” the EU refers to here, are the rights granted by the European Convention for the Protection of Human Rights and Fundamental Freedoms today known as the European Convention on Human Rights (ECHR) (Treaty of Maastricht, article F).

26 Since then, the EU has fixed itself the goal to “protect the fundamental human rights for EU citizens, and (..) promote human rights worldwide” (European Union)2. Moreover, gender equality has become an issue addressed and tackled by the EU through several reports, but also directives, “a legislative act EU states must achieve” on their own terms (EU law definition)3. Indeed, through directives such as Directive 2004/113/EC “which implements the principle of equal treatment between men and women in access to and the supply of goods and services”, the EU has tried to achieve gender equality (European Commission 2008, p.13). It is the first EU directive that recognizes that sex discrimination can happen outside of the workplace and demands people who supply good and services to not discriminate on the grounds of sex (European Commission 2008). Many feminist scholars assert that the EU has become an “an increasingly important arena for gender equality policy-making.” (Liebert 2003, p.188).

The EU was also present during the Cairo Conference in 1994 and the Beijing Conference of Women in 1995. After the Beijing Conference Ms. Cristina Alberdi, who then occupied the presidency of EU Council, stated “on behalf of the EU”:

“The European Union wishes to express its firm belief in the importance of promoting sexual and reproductive health for women and men (..). The European Union reaffirms its commitment to ensure the full enjoyment by women and the girl child of all human rights and fundamental freedoms, including their sexual and reproductive rights, and to take effective action against violations of these rights and freedoms.” (EU, 1995)

However, the decision-making power concerning SRHR was deferred to the member states and the EU had no legal competence on this issue (1999). A turning point came in 2013, when the Committee on Women's Rights and Gender Equality (FEMM) and Portuguese Member of Parliament, Edite Estrela, presented to the , “The Report on Sexual and Reproductive Health and Rights”, also known as the Estrela Report (Hentges et al 2017, p.194). The aim of the latter was to demand EU member states to guarantee their citizens, without discrimination, legal access to information on SRHR, modern contraception and abortion care if necessary (Hentges et al 2017). The Estrela report underlines that abortion is not a method of

3 EU laws: “Regulations, Directives and other acts.” https://europa.eu/european-union/eu-law/legal-acts_en.

27 contraception but recognizes that some individuals might still need it. Furthermore, the report asked member states to guarantee its citizens sex education in respect with different sexualities and different genders in mind (Hentges et al 2017). The European Parliament recognized SRHR as human right and their importance. However, it rejected the report, claiming that it was on member states to implement SRHR in their policies and this without the intervention of European institutions (Hentges et al 2017). The adoption of the report would have been a stepping stone to harmonize European laws on SRHR and consequently to harmonize abortion laws in the EU. Nevertheless, this has not been the case and SRHR and abortion were left in the sole hands of the member states.

The EU and SRHR outside its borders

On the other hand, outside its borders, the EU has not only been promoting, but also financing SRHR. In this context, the New European Consensus on Development (2017), inspired by the 2005 edition, constitutes the EU’s objectives concerning development. In article 34 of the document, the EU reiterates its commitment “to the promotion, protection and fulfilment of the right of every individual to have full control over, and decide freely and responsibly on matters related to their sexuality and sexual and reproductive health” and underlines the “need for universal access to quality and affordable comprehensive sexual and reproductive health information, education, including comprehensive sexuality education, and health-care services” in developing countries (EU 2017).

Moreover, through some of its Regulations, the EU has created a legal tradition when it comes to the promotion and funding of SRHR in developing countries. For instance, in Regulation (EC) No 1567/2003, the European Parliament and the Council, express their concerns on the state of “reproductive and sexual health conditions of women and men (…) in developing countries”, due in part to “the lack of a full range of safe and reliable reproductive and sexual health care and services, supplies and information” ((1), 2003). Furthermore, in the4 same regulation, the EU commits to “provide financial assistance and appropriate expertise with a view to promoting a holistic approach to, and the recognition of, reproductive and sexual health and rights as defined in the ICPD Programme of Action” to the poorest countries in the developing world (article 1 (2),

28 2003). The Regulation underlines, as did the ICPD and the Estrela report, that abortion is not a method of contraception ((16), 2003). In 2017, Member of Parliament (MP), Louis Michel, asked a parliamentary question on “the right to abortion in developing countries”.4 Indeed, as President Trump decided to cut financial aid to international NGOs helping women to receive abortion care, the European MP was wondering how the Commission would “compensate for this shortfall”5. On this, the Commission responded that it was dedicated to SRHR and trying to assess how to “mobilize additional funding” due to the American financial cut.6

Moreover, when it comes to financial aid, In 2017 the “Annual Report on the implementation of the European Union's instruments for financing external actions in 2016”, stated that the EU institutions had spent 33 million Euros to African, Caribbean, and Pacific states on “population policies/programs and reproductive health” (Countdown2030 2018).

Conclusion

To conclude, one can notice a clear distinction between the EU’s role within its borders and its actions outside its borders when it comes to SRHR. Indeed, within its borders, the EU institutions claim that reproductive health and rights are a competence of the member states and do not wish to interfere in national politics. On the other hands, in developing countries, the EU does not only promote SRHR, but also offers financial help. The reasons mentioned for this intervention are gender equality and human rights.

4 Parliamentary questions: “Question for written answer E-001401-17 to the Commission Rule 130.” https://www.europarl.europa.eu/doceo/document/E-8-2017-001401_EN.html. 5 Idem. 6 Parliamentary questions: “Answer given by Mr. Mimica on behalf of the Commission, Question reference: E- 001401/2017.” https://www.europarl.europa.eu/doceo/document/E-8-2017-001401-ASW_EN.html.

29 The European Court of Human Rights

The European Court of Human rights (ECtHR) is an international Court which controls appeals made by states or individuals concerning the violation of the European Convention on Human Rights (ECHR), the same convention mentioned by the Treaty of Maastricht of the EU. The ECHR does not guarantee the right to abortion, but some articles are often invoked in this context: article 2 on the “right to life”, article 8 on “the right to respect for private and family life” and article 14 on the “prohibition of discrimination” (ECHR). The following section will analyze two landmark cases on abortion which were presented to the Court.

Tysiąc v. Poland

In 2000, Alicja Tysiąc, a Polish citizen, got pregnant. However, there was a risk that the pregnancy could lead to the complete loss of her eyesight, therefore, she sought an abortion in her country. The risk was also observed by three ophthalmologists, however, they refused to hand her a certificate that would made her eligible for abortion care on medical grounds. Finally, she found one medical provider who issued her a certificate on therapeutic grounds. However, when Ms. Tysiąc arrived at the clinic for the abortion procedure, the gynecologist did not recognize any medical reason to conduct an abortion. The ECtHR considers that under article 8 of the Convention, states have to respect the bodily integrity of pregnant women and as abortion is allowed for medical reasons in Poland, the country should ensure that women have the accessibility of abortion care in these cases. Secondly, the Court issued that Poland had to find a solution in case of disagreement between medical providers and patients. Finally, the court found that the Polish Sate had not protected Ms. Tysiąc’s private life and had breached article 8 of the convention (ECtHR) by not guaranteeing the complainant safe abortion in an instance where it was legal (ECtHR).

A, B, C vs. Ireland

In A, B, C vs. Ireland, two Irish women and one Lithuanian woman complained before the Courts, because abortion was illegal in Ireland, and they had to travel abroad to receive safe and legal abortion care. At their return, the three women complained of medical complications due to

30 the abortion procedure. The complainants affirmed that traveling abroad was a humiliating, and traumatic experience and therefore breached article 2 on “right to life” and article 8 on “the right to private life” of the Convention. Furthermore, the plaintiffs asserted that travelling abroad was expensive (especially for low-income women) and “excessive”. The three women also invoked article 14, “prohibition of discrimination”, as they claimed that this was a burden they had to bear because of their sex. The Court decided that article 2 was not breached, because even though travelling abroad was expensive for some women, there was no legal obstacle to do so. Furthermore, the complications due to the abortion procedures were not life-threatening. Then, the Court stated that article 8 of the Convention did not guarantee a right to abortion care and consequently, the national Irish law prevailed. Therefore, the request of applicants A and B was refused. However, the Court judged that the Irish law breached article 8 for the third applicant. Indeed, applicant C was scarred her cancer would reappear as a consequence of her pregnancy, but she had no access on information to know whether she was eligible for legal abortion or not in Ireland (ECtHR). The Court decided the Irish state had failed to ensure the accessibility of relevant information.

Conclusion

As illustrated in these two examples, the ECHR does not guarantee the right to legal abortion. Moreover, the ECtHR does not promote the liberalization of abortion care nor does it condemn member states for prohibiting the termination of pregnancy. However, once states legalize abortion, the Court requests the countries to ensure women’s access to abortion services. Indeed, as seen in Tysiąc v. Poland, the Court condemned Poland as the complainant was refused abortion care on medical grounds, even though it is legal in this instance. On the other hand, in the case, A, B, C vs. Ireland, the Court refused the complain of the complainants as abortion on request was (at that time) illegal in Ireland.

Moreover, as we have seen previously, SRHR has not become a competence of the EU Consequently, every member state can decide its own legislation on the availability of abortion care. Therefore, there are no harmonized abortion laws in the EU. Hence, in the following section, I will analyze the different abortion laws in Europe and their history. I will start with Scandinavian

31 countries, followed by Western and Southern European countries to finally finish with Central/Eastern European states.

5.2 Abortion laws in Europe

Scandinavia

Sweden

Sweden has had a long politics. The first abortion act came out in 1938 and allowed abortion on “humanitarian grounds” which meant in case of rape, incest or hereditary diseases (Knudsen et al. 2003). Throughout the years the act has been revised and grounds such as fetal anomality and socio-economic grounds were added. The latter could be invoked if a woman was too young or too poor to have child (1960s) (Knudsen et al. 2003). At that time this law became one of the most liberal and women from abroad (USA) travelled to Sweden to receive abortion care (Radio Sweden 2015). The current legislation is based on the Abortion Act 1975, which allows women to access abortion on request until the 18th week of pregnancy (Knudsen et al. 2003).

Denmark

In Denmark abortion was authorized in 1939 for medical reasons or in case of rape. The 1970 Abortion Act allowed women who were at least 38 years old and who had at least four kids to have an abortion on request until the 12th week of pregnancy (Knudsen et al. 2003). The 1973 Abortion Act, which is still in place today introduced abortion on request for all women over the age of 18 during the first trimester (Knudsen et al. 2003).

32

Western Europe

Luxembourg

In Luxembourg abortion on request was only made available in 2014. This law, now included in the Public Health Code, decriminalized the act of termination of pregnancy and allows women to have an abortion until the 12th week of pregnancy (Loi du 17 décembre 2014). Moreover, it has overhauled the 2012 law, which permitted abortion services only on grounds of distress, and the1978 law. The latter prohibited medical providers to conduct abortions and women to receive abortion care, unless the pregnancy represented a danger to the health of the woman (loi du 15 novembre 1978).

Germany

The German Criminal Code was written in 1871, and the paragraph on abortion was then characterized by a total prohibition of abortion. In 1926, the socialists and communists tried to legalize abortion during the 3 first months of pregnancy, as they claimed that the complete prohibition was mostly affecting working- class women who did not have the financial resources for safe backstreet abortions (Pro Familia 2017). Therefore, in 1927, abortion was allowed if the health of the mother was in danger. Later, in Nazi Germany, abortions were conducted on grounds of eugenics, specifically on Jewish women. After WWII, abortion laws were decriminalized and allowed abortion on broad socio-economic grounds in Eastern Germany governed by a Communist govergovernment (Pro Familia 2017). In West Germany, the debate started in the 1960s with feminist movements demanding safe and legal abortions (Pro Familia 2017). One major event was an article published by Stern magazine, in which over 350 German women admitted having had an abortion. This showed mainstream media that even though abortion was illegal in the country, women still found a way to have an abortion either illegally in Germany or legally abroad (Pro Familia 2017). In 1974, the social government of Willy Brandt tried to pass a bill that would allow legal abortion on request during the first three months of pregnancy (Kacher 1995). However, the Constitutional Court in

33 Karlruhe judged this bill unconstitutional in regard to article 2 of the Constitution, which ensures “the right to life (..) including to the unborn” (Kacher 1995, p.149). Finally, the same year, a compromise was found and the Bundestag (Parliament) voted in favor of a “deadline solution” that allowed women to have the right to safe and legal abortion within a determined time frame. After the reunification of Germany, Eastern Germany adhered to the laws of West Germany, even though these were more restrictive (Kacher 1995). Today, in Germany, the termination of pregnancy is still regulated by the Criminal Code, as it is still considered a crime except on a few instances enumerated in § 218a. Individuals are allowed to get access to abortion care on request until the 12th week of pregnancy (StGB §218a).

France

Abortion was legalized and decriminalized in 1975 in France. Today, women are allowed to have an abortion until the 12th week of their pregnancy, if the procedure is conducted by a medical provider (article L-2212-1). The law was presented and defended by the then minister of health and feminist, Simone Veil, and is today also known as the law Veil. Before the law Veil, the abortion politics were governed by the law of 31st of July1920, which banned “provoked abortion” and “contraceptive propaganda” (Pavard 2014, p.2). The legislation came after years of protests and demands from feminist movements. In this context, the French Movement for Planned Parenthood played a considerable role by trying to promote contraceptives and opening up the debate on . The goal was to broaden the grounds on which safe and legal abortions could be requested. The movement started lobbying politicians for a law reform (Pavard 2014). Later then, emerged the Movement for the Liberation of Women which published, like in Germany, an article in which over 340 French women admitted having had an abortion either illegally in France or legally abroad. The whole movement then used the slogan “a child, if I want and when I want”.

The Netherlands

In 1911 a Dutch abortion law passed and qualified the procedure as a “crime against morality” (Ketting and Schnabel 1980, p.385). Then in the 1960s family planning became popular

34 due to the introduction of the abortion pill in 1964. The new belief was then that if women used the abortion pill, there would be no need for abortion care in the country (Ketting and Schnabel 1980). Nevertheless, medical providers quickly had to realize that even with the use of contraceptives, an unwanted pregnancy was never excluded (Ketting and Schnabel 1980). The first abortion clinic then opened in 1971, there was no clear consensus at the time, but the idea was that an abortion conducted by a medical provider in an appropriate setting “was considered to be medically acceptable” (Ketting and Schnabel 1980, p.387). Many French and German women, who could afford it, then traveled to Netherlands to receive abortion care. However, it took 10 more years for abortion to be legalized as it was necessary to find a consensus between the socialist-led government and the Christian democrats, who opposed second trimester abortions and wanted to close the clinics (Kennedy 2017). However, abortion activists occupied abortion clinics which let the government to pass the Abortion Act of 1981, the law has been into effect since 1984 and allowes abortion until the 24th week on request (Government of the Netherlands). This is to today the longest period to receive abortion care in the EU, but as in Germany, abortion is still inscribed in the Dutch Criminal Code.

Great Britain

Abortion in Great Britain (England, Wales and Scotland) is governed by the . This legal tradition allows individuals to get access to abortion services until the 24th week of pregnancy on broad socio-economic grounds7 (“if continuance of pregnancy would involve risk, greater than if the pregnancy were terminated”) (Abortion Act 1967). The Act came in the 1960s, at a time when extensive “backstreet abortions resulted in significant maternal mortality and morbidity” (Sheldon and Wellings 2019, p.7). As Sheldon and Wellings explain today one in three women in Great Britain will have an abortion and the procedure has been growingly accepted throughout Great Britain (2019). However, contrary to countries such as France, abortion has not

7 Countries which allow abortion on broad socio-economic grounds “have laws that are generally interpreted liberally to permit abortion under a broad range of circumstances”, factors such as the environment and “social economic circumstances” are taken into account. (Center for Reproductive Rights) https://reproductiverights.org/law-and- policy-guide-broad-social-or-economic-grounds.

35 been decriminalized in the UK, but includes exceptions which were developed in the Abortion Act 1967 in which a woman can get a legal abortion (Sheldon and Wellings 2019). Indeed, the Infant Life Preservation Act 1929, (Wales and England), foresees punishment for everyone who tries to “destroy” the life of a child that “could be born alive” (Infant Life Act 1929). In Scotland, abortion is still considered as an “offence at common law”. In Northern Ireland, which is not part of Great Britain, but of the United Kingdom, abortion on request has been legalized at the end of 2019 and was supposed to come into practice in March 2020 (McDonald 2020).

The Republic of Ireland

Ireland has only made abortion on request available since January 2019. The topic has always been a difficult issue to tackle, because of the influence of the Catholic Church in the country. Abortion in Ireland is governed by the Health (Regulation of Termination of Pregnancy) Act 2018. The 2018 Act repealed the 8th amendment which considered the fetus’ live as equal to the mother’s and therefore criminalized abortion in any case (Murphy 2018, 129). The Act allows unrestricted access to abortion access during the first 12 weeks of pregnancy, if the procedure is supervised by a medical professional (2018, article 12). The legislation came after a referendum, characterized by a heated debate between pro-choice and pro-life activists. In May 2018, 66,4% voted in favor of the liberalization of abortion (Murphy 2018). The 2018 Act replaced the 2013 Protection of Life during Pregnancy Act, which allowed legal abortions in order to save a woman’s life. The latter came as a result of Savita Halappanavar’s death from a blood poisoning after “her inevitable miscarriage”. She was denied access to abortion care as medical providers claimed Ireland was a “Catholic country” (Burrel and Griffiths 2017, p.1217).

Southern Europe

Italy Italy was the first Southern European country to legalize abortion. Indeed, since 1978, the law 194 authorizes Italians to access abortion care until the 12th week of pregnancy. The request can be made on grounds of physical and mental health (law 194). The law came at a time when women’s groups started to be founded and women created “self-organized feminist health centers”

36 in which they started talking about their sexuality and provided information on contraceptives. In this context, the question of safe and legal emerged and many different feminist movements started to advocate in favor of the legalization of safe abortion. Finally, in 1978, the bill on the termination of pregnancy was passed. Even though abortion has been made available for over 40 in Italy, the right is still challenged the country, especially by pro-life movements and the Catholic Church, which plays a predominant role in the country. In 2018, Pope Francis claimed that abortion equaled “hiring a hitman to resolve a problem” and the city of Verona has been proclaimed “a pro-life city” by the City Council (Giuffrida 2018) (Caruso 2020).

Spain

Abortion on request until the 14th week of pregnancy has only been made available in 2010 (Ley Orgánica 2/2010, articúlo 14). This new legislation came to replace the previous legal tradition, the Law 9/1985 of 5 July 1985, which decriminalized abortion in cases of rape, fetal anomalies and on therapeutics indication (mental and physical health) (Requejo 2011). Nevertheless, thanks to well-built feminist movements, safe abortion care was often legally carried out in private clinics on grounds of safeguarding a woman’s mental health (Vilar 2002). In recent years, there has been a strong will by some political leaders to restrain the availability of abortion in the country. Indeed, in 2014, the government led by Mariano Rajoy, presented a bill that would limit abortion access on the grounds of rape, and if the “woman’s is at serious risk” (BBC 2014). The law was later withdrawn due to discontent (Popular Party, PP). However, no later than in 2019, the president of the Popular Party, Pablo Casado, claimed that Spain should return to its 1985 law and claimed that if Spain wants “to fund pensions and healthcare” , they “need to think about how to have more babies and not about how to have terminations” (El País, 2019).

Portugal

Until 1985, abortion was completely banned in Portugal. Then came a law that modified the Criminal Code, and authorized abortion care for medical reasons (physical and mental health of the mother and fetal anomality). Nevertheless, this change of law was barely applied in practice and women had to travel abroad to obtain abortion care (Stifani, Vilar and Vicente 2018). In 1998,

37 the government organized a national referendum to make abortion legal on request until 12th week, however the yes camp lost against the no camp by a small margin (50.5% vs. 49.5%) (Vilar 2002, p.158). The debate was then revived in the beginning of the 2000s, because of a highly publicized process against illegal abortion providers. The process showed the nation the state the of back street abortions and how poor women had to even sell their “wedding jewelry” in order to afford abortion care (Vilar 2002, 159). This was an opportunity for medical providers and feminist movements to put the question of safe abortion back on the agenda. Finally, in 2007, abortion was legalized on request, but only until the 10th week of pregnancy (Stifani, Vilar and Vicente 2018).

Malta

The case of Malta is exceptional, as it is the only country in the European Union that has a complete ban on abortion. Indeed, in the country termination of pregnancy is banned under any circumstance, women are not even allowed to receive abortion services for medical reasons or in case of rape (The Economist 2019). The country is today still strongly influenced by the Catholic Church and the abortion law dates back to 1724 and condemns women who seek abortion care to three years of jail (The Economist 2019). In order to receive safe and legal abortion care, women in Malta need to travel abroad, as it is not available in their country.

Central/Eastern Europe

Poland

In Poland, as in many other ex-Soviet states, in the 1950s, new plans were introduced to grant citizens, especially women, better access to education and employment. Furthermore, as there was a separation of state and church, reproductive rights and services were enlarged. In 1956, abortion was legalized in Poland during the first 14th of pregnancy on socio-economic grounds and medical reasons (Mishtal 2015). Even though there was progress on reproductive rights, women’s movements were not allowed in communist Poland as a defense against “state dissent”. The reason for allowing abortion were health related, the right for a woman to control her own body was never

38 part of the argument (Mishtal 2015, p.26). After the fall of the communist government, the Catholic Church, represented by the Polish Pope John Paul II, gained power and one of its goals was to restrict the access to abortion. In 1991, the first post socialist President, Walesa, introduced three more mandatory consultations before abortion care, which made it almost impossible for women to have a timely abortion (Mishtal 2015). In 1993, termination of pregnancy was banned in the country and only allowed on grounds of rape, incest and for medical reasons (Mishtal 2015). In 1996, a pro-choice president, tried to legalize abortion on social grounds, however, this legislation was overturned only one year later by the Polish Constitutional Tribunal (Nowicka 2015). In 2015, a civil initiative tried to introduce a complete ban on abortion, which was followed by a strike organized by women protesting against the initiative (BBC 2016). The parliament refused the initiative, however, further attempts to liberalize abortion throughout the years have failed. Today, Poland abortion law is governed by the restrictive law of 1993. Therefore, Poland is often considered as one of the most restrictive countries concerning abortion in the EU.

Slovakia

The history of abortion in Slovakia is similar to the one of Poland and other ex-communist states. Indeed, termination of pregnancy was legalized in the 1950s in the country, then part of Czechoslovakia. Women were allowed to have access to abortion services for medical reasons and on socio-economic grounds (Kliment 1999). However, they had to present their demand in front of a commission, which had the power to refuse the procedure, but as Kliment explains, 95% of the demands were accepted (199). Right before fall of the iron curtain, in 1986, Slovakia made abortion on request available until the 12th week of pregnancy. Consequently, the country has had a long history of abortion politics (Kliment 199). However, in recent years pro-life movements, supported by the Catholic Church, have influenced abortion politics and many bills were introduced to curb the availability of abortion. Indeed, in 2019, the Slovak Parliament debated on a bill that would force women to undertake a mandatory ultrasound scanning. Many organizations criticized this bill as this would undermine a woman’s “privacy” and “autonomy” “in decision- making about health care” (Center for Reprodcutive Rights 2019). The bill did not pass but symbolizes the fragile position of abortion in Slovak politics.

39 Summary Table:

Table 1:

Country Year of legalization Grounds on which Number of weeks in (if applicable) abortion is legal which an abortion can be carried out Sweden 1975 On request 18 Denmark 1973 On request 12 Luxembourg 2014 On request 12 Germany 1974 On request 12 France 1975 On request 12 The Netherlands 1981 (came into On request 24 effect in 1984) Great Britain 1968 On broad socio- 24 economic grounds Ireland 2019 On request 12 Italy 1978 On request 12 Spain 2010 On request 14 Portugal 2007 On request 10 Malta / / Poland 1993 (1) In case of rape and/or incest, (2) Less than 12 weeks in case fetal anomality and (3) for medical reasons Slovakia 1986 On request 12

40 5.3 Typology of countries

So far, we have studied the different abortion laws in Europe. From what we have seen so far, today most countries in Europe do authorize abortion on request. The aim now is to categorize the countries into groups according to their abortion laws. To do so, I have decided to create 4 groups: “Liberal”8, “Least restrictive”, “Very Restrictive” and “the Most Restrictive”. The elements that were taken into account for this categorization, are the elements mentioned in the summary table above (the legality, the grounds on which abortion is legal and the number of weeks in which an abortion can be carried out legally). Following these criteria, Malta is categorized as “the most restrictive”, as abortion is completely banned. Poland is categorized as “restrictive”, as abortion is only allowed in limiting cases. The Netherlands, Sweden and Great Britain are grouped as “liberal” as they are the only countries in which second-trimester abortions are legal on request. The remaining countries are categorized in the “least restrictive” group. Indeed, in these countries, termination of pregnancy is legal on request, however, only in the first trimester. Some people have to travel to abroad when they have exceeded the 12-week window. Therefore, this typology distinguishes between these two types of countries.

Table 2: Liberal Least Restrictive Very restrictive Most restrictive The Netherlands Denmark Poland Malta Great Britain Luxembourg Sweden Germany France Ireland Italy Spain Portugal Slovakia

8 Liberal is here understood as “allowing a lot of personal freedom”, as second-trimester abortions expand women’s time limit. https://dictionary.cambridge.org/dictionary/english/liberal.

41 5.4 The political actors in the availability debate

So far, we have studied the different abortion laws in Europe, the following section will analyze who the main actors are in the political debate on the availability abortion care. I will deal with questions such as: Who are the political actors who have opposed the availability of abortion and who are the actors who have supported the legalization of abortion services?

The Church

As Warner notes, the Catholic Church has always been engaged in European politics (2000). First, through direct rule, then after the separation of Church and state, it allied itself with political parties such as the Christian Democratic parties, which were established on the Catholic doctrine (2000). The Catholic Church’s opposition to abortion has had a long history. In 1869, Pope Pius IX, banned abortions in all its forms and in any circumstances for Catholics (Blofield 2008). Pope John Paul, from Poland (1978-2005), made the opposition to abortion “a priority of the Church” (Blofield 2008, p.400). Moreover, the current Pope, Pope Francis, has recently stated that abortion was a sin in any circumstance and qualified abortion as hiring a “hitman” (Horowitz 2019). Indeed, the Church is known for its strong opposition to termination of pregnancy and has often underlined its position:

“Human life is sacred because from its beginning it involves the creative action of God and it remains for ever in a special relationship with the Creator, who is its sole end. God alone is the Lord of life from its beginning until its end: no one can under any circumstance claim for himself the right directly to destroy an innocent human being.” (Catechism of the Catholic church, article 5 (2258))9

In other words, the Church aims to protect the human life from the moment of its conception and takes a pro-life stance. Even on the transnational level, the Church has opposed women’s reproductive rights. During the ICPD in 1994, and the Beijing Conference on Women in 1995, the

9 Vatican. “Catechism of the Catholic Church: Article 5 (2258).” https://www.vatican.va/archive/ccc_css/archive/catechism/p3s2c2a5.htm.

42 Holy See10, as Non-Member State Permanent observer of the UN, successfully delayed the debate on abortion. Indeed, the Vatican opposed, on several instances, “language on women’s rights and reproductive rights in documents” (Roggeband 2019, p.7). For instance, the Holy See, was against the term “unwanted pregnancy”, as according to the Vatican, pregnancy is never a negative experience (Center for Reproductive Rights 2020, p.7). Moreover, the Holy See also opposed the term “unsafe abortion” as it considered that abortion could never be safe (Center for Reproductive Rights 2020, p.7). As the Church has played a predominant role in Europe for a long time, its views on issues such as abortion, were reflected in women’s reproductive rights for a long time. Consequently, until the 1970s, abortion on request was banned in most European countries. Furthermore, it is clear that not every European country is Catholic, Germany, for instance, is predominantly Protestant and the main Church in Great Britain is the Church of England. However, American studies have proven that when it comes to the abortion debate, the stance of Catholics and Protestants does not vary significantly (Sullins 1999)

Second-Wave feminists

If on the one hand, the Church advocates for the right to life of the fetus. Second-wave feminists on the other hand, have since the 1970s underlined women’s right to bodily integrity, the right for women to control their own body (Mosconi 2008).

The emergence of feminist movements in Europe “has made a crucial difference in abortion debates” (Outshoorn 2012, p.148). Indeed, before the appearance of these movements there was only little reform and women had no control over access to abortion services (Outshoorn 2012). Outshoorn takes the example of Sweden, where during the 1960s, before the appearance of the second wave feminism in the country, there was no reform in sight. Once the second wave took off in the country, the debate was pushed forward and the legislation changed drastically in the beginning of the 1970’s, with the legalization of termination of pregnancy in 1975 (Outshoorn 2012). Sweden is not the only case, as multiple examples can be found in Europe. In France, for instance, the debate on abortion was started with the emergence of pro-choice feminist associations

10 Government of the Vatican. https://dictionary.cambridge.org/dictionary/english/holy-see.

43 such as le Mouvement Français pour le Planning Familial (French Movement for Planned Parenthood, MFPF). The latter became the “most organized voice for abortion reform” in the 1970s in France (Robinson 2003, p.88). The MFPF was working alongside the Mouvement pour la Liberté de l’Avortement et de la Contraception (Movement for abortion and contraception, MLAC) which conducted illegal abortions for women. By doing so, they wanted to highlight that even when abortion is illegal, women will seek them (Robinson 2003). Both feminist movements lobbied for the availability of abortion as contraception might fail. The motto was “in order to suppress clandestine abortions, it is necessary that all abortions be on demand and free.” (Robinson 2003, p.88).

Consequently, in many countries, especially in Western and Northern Europe, feminist movements have succeeded in changing the legislation on abortion care during the 1970s and the 1980s. Indeed, second-wave feminists have played a central role in pushing the abortion debate and legislation forward. Furthermore, the decline of the Catholic Church during that period in this part of Europe was convenient for many feminist movements. Indeed, Brown explains that there was a clear “decline in religiosity” in Europe during the 1960s (2010, p.470). Brown explains that the decrease in churchgoers resulted in the division of the Church and popular culture which then resulted in the decrease of the influence of the Church in European culture (2010). This change happened mainly in Northern and Western Europe. Indeed, a recent study by Pew Research Center shows that the countries in this region of European tend to be less religious than in Southern and Eastern European countries11 .

The continuing power of the Church in Southern and Eastern Europe

As said before, in Southern and Eastern European countries such as Spain, Portugal, Malta and Poland, the Catholic Church still plays a predominant role and politics including reproductive politics are still significantly influenced by the Church. This explains the delay in the legalization of abortion or the complete ban of abortion in these countries.

11 Pew Research Center: “How do European Countries differ in religious commitment?” https://www.pewresearch.org/fact-tank/2018/12/05/how-do-european-countries-differ-in-religious-commitment/.

44 In Portugal, for instance, feminist movements have been campaigning since the 1970s in favor of the liberalization of abortion. However, the country has been exposed to a strong Catholic influence until very recently. Indeed, until the beginning of 21st century, the Church was able to keep the existing situation in place and was capable to rally the votes of its adherents, as for instance for the 1998 referendum on the legalization or not of termination of pregnancy (Blofield 2008). Therefore, despite the presence of feminist movements, abortion services were only made available in 2007. In Poland, as in many ex-communist countries, the situation was a bit different as in Southern Europe. Indeed, until the fall of the iron curtain in 1989, religion did only play a marginal role in communist countries. Consequently, until the beginning of the 1990s, the Catholic Church did not have any influence on women’s reproductive rights. However, in 1993, this changed, and abortion was banned in Poland, except on certain instances (Mishtal 2015). This was due to the Church as the fall of the iron curtain coincided with the rise of the Catholic Church in the country. The Church has become such a powerful actor in the country, that it menaces “to inflict damage” to every politician or political party that would dare to go against its political program (Mishtal 2015, p.60). As a result, there has been a status quo on questions such availability of abortion services and it has become difficult for feminist movements to push their agenda forward. Moreover, feminism and feminist efforts in that direction have often been publicly “mocked and discredited” (Mishtal 2015, p.83).

In conclusion, we can notice that feminist movements have had harder time to break through in Southern and Eastern Europe, due to the powerful position of the Church.

Conclusion

To conclude, we can say that today in Europe, abortion services have been widely recognized by national laws and the different legislations do grant women the legal access (availability) to abortion services. Malta is the only country to completely prohibit the termination of pregnancy in the EU. Nevertheless, abortion availability in Poland is also very restricted.

45 Historically, Eastern European countries were the first to legalize abortion on request as the example of Poland and Slovakia have shown. However, after the fall of the iron curtain, the Catholic Church gained power, and a more conservative influence started holding sway over issues such as reproductive services and rights. Today, in countries like Poland and Slovakia, the question of abortion availability is not tackled and still provokes heated debates between pro-choice and pro-life camps. In Scandinavian and Western European countries abortion has been liberalized in the 1970s and 1980s and today first trimester abortions are widely available on request. Ireland and Luxembourg represent exceptions, as abortion on request was only made available very late, in 2019 and 2014 respectively. In this context, the strong influence of the Church is in part responsible for the delay of the availability of abortion in these countries. Sweden, Great-Britain and the Netherlands are often considered to be the most liberal states in the EU, as second-trimester abortions on request are authorized. Southern European countries were among the last ones to legalize abortion services in Europe. In Spain and Portugal for instance, abortion on request was only made available in 2007 and 2010. This can be explicated by the power of the Catholic Church in this region of Europe. Indeed, the Catholic Church has had a conservative influence on the abortion debate in Europe and in countries where it still holds sways, the availability of abortion on request seems to be challenged repeatedly. This particularly concerns Southern and Eastern Europe, where the Church still holds a significant role. On the other hand, pro-choice feminist movements have opened the discussion on abortion rights and keep on defending abortion care from backlash from pro-life groups. In some countries, such as Germany, Great Britain and the Netherlands abortion is still part of the Criminal Code. The termination of pregnancy is legal on broad grounds but is still considered a crime. Some argue that this puts the procedure in a bad light as it “singles abortion out as different from other health care procedures” (interview 1, 2020).

Overall, we can assert that today, a majority of European countries have liberalized their abortion laws and removed the legal restrictions to abortion care.

46 6 Accessibility

As the Center for Reproductive Rights explains, today in Europe there is “only a very small minority of countries that maintain highly restrictive laws that prohibit abortion. In most countries now, we’ve seen that the law protects and seeks to allow women to have access to abortion care” (interview 1, 2020). Indeed, as we have seen in the previous chapter, today most European countries have established an on-request period in which women can seek abortion. However, “there are very significant differences between countries in how women, how individuals can access abortion care in practice” because “the legality of abortion does not necessarily translate in its accessibility” (interview 1, 2020). There are many barriers that obstruct women’s access to abortion. In the following chapter, we will analyze these different barriers and study how they affect some individuals differently. Indeed, in addition to the discrimination they face because of their gender, some women face some additional discrimination due to factors such as socio- economic status, race, age, disability, legal status.

The following will analyze the state of accessibility of abortion in Europe. When studying the accessibility of abortion care, the obstacles are in the forefront, as they define the level of accessibility. Therefore, contrary to the previous chapter, this chapter will be arranged by obstacles and not by countries.

6.1 Barriers and obstacles to abortion

Illegal abortions and restrictive abortion laws

The Center for Reproductive Rights points out that in countries where abortion is illegal, “the laws are the main barrier” (interview 1, 2020). Indeed, as mentioned in the previous part, the law is there to legalize abortion care and to guarantee individuals the right to this health care. If abortion is not legal or if there are only restrictive abortion laws in place, women are not guaranteed

47 this right, hence the main barrier will be the law. Today in Europe, there are six countries that have established restrictive abortion laws. Malta is the most severe case, as abortion is prohibited altogether (Center for Reproductive Rights)12. In Monaco, Liechtenstein, Andorra, San Marino and Poland abortion is not allowed on request, only on grounds of fetal anomaly, sexual assault and/or if a woman’s health is at risk (Center for Reproductive Rights)13. In this context, the case of Poland is interesting to analyze. As mentioned previously, abortion is just legal on specific grounds in the country. CioCia Basia explains, that very few women are able to receive an abortion in Poland (interview 2, 2020). As women are not able to receive safe and legal abortion care in their country, they need to travel abroad. However, as Ciocia Basia and ANA underline “travelling abroad is not that easy for every woman” (interview 2 and interview 3, 2020). In order to travel abroad, women need the financial resources and time off work. ANA explains that many of their “clients” are from Poland and try to travel to the Netherlands to access safe and legal abortion (interview 3, 2020). Their clients’ main concern is often the financial aspect of seeking abortion services abroad, as many of them live from the average Polish salary which amounts to only 1500€ (OECD). An abortion in the Netherlands costs between 800 and 1000€ without counting the travelling costs (interview 3, 2020). ANA is often confronted to women who are not able to afford abortion care and the related costs to it (interview 3, 2020). They told the story of a young Polish woman who found out she was pregnant in her 10th week, however, because she did not have the financial resources to travel, she started taking small jobs. Once she had collected the necessary money to travel abroad, she was already 20 weeks pregnant, which is the limit to receive abortion care in the Netherlands (interview 3, 2020). As ANA claims “money is the first thing you need” (interview 3, 2020). Therefore, the factor of social class plays a significant role in how women can access abortion care, when abortion is unavailable in their country. Indeed, Ciocia explains: “If a person from a higher class gets pregnant, it is going to be so easy for them to get an abortion. What we try to do, is going to the lower classes” (interview 2, 2020).

12 Center for Reproductive Rights: “Europe’s Abortion Laws: A Comparative Overview.” https://reproductiverights.org/europes-abortion-laws-comparative-overview. 13 Ibidem.

48 Another aspect that plays a role when seeking abortion abroad is the legal status of the individuals. In August 2014, an asylum seeker in Ireland, called Ms. Y, was raped and therefore sought abortion care (Fletcher 2014, 10). However, until January 2019, abortion was illegal in the Republic of Ireland and no medial provider was willing to provide abortion care to Ms. Y (Fletcher 2014, 11). As the latter was an asylum seeker, travelling aboard was not an option. Indeed, under European law, asylum seekers are not allowed to travel freely in the Schengen area (UNHCR)14. Consequently, Ms. Y had to carry her unwanted pregnancy until the end, which resulted in her suffering from mental health issues (Fletcher 2014).

To conclude, one can see that abortion bans and restrictive abortion laws do not affect women equally. Factors such as class and legal status do play a role in how individuals can access abortion care. Even if abortion is illegal or restricted by law, individuals with the necessary financial resources and the right legal status will be able to travel abroad and access safe and legal abortion care. The absence of the right to abortion, the unavailability of abortion services does not translate into its inaccessibility for every person. Moreover, for some women it is still possible to receive a safe abortion in their own country if they have the right connections. Indeed, in their interview with Caroline Gillet, Planning Familial Luxembourg (Planned Parenthood Luxembourg) explains that before abortion was legalized on request in Luxembourg in 2014, there were (illegal) abortions conducted by gynecologist in the country but they were reserved for “ social- economically, well-integrated women who had the resources to afford the price of an abortion” (Gillet 2020).

When abortion is legal

In countries where abortion is legal on both grounds: on request and on broad socio- economic grounds, there are other barriers. In the following section of thesis, we will discuss the obstacles individuals face in order to access abortion care, even though it is legally allowed.

14 UNHCR. “The Schengen area and Me.” https://www.unhcr.org/si/wp-content/uploads/sites/25/2017/06/The- »Schengen-Area«-and-Me_SLO.pdf.

49 Mandatory waiting periods

In this context, the NGOs interviewed mention the mandatory waiting periods (interview 1, 2020; interview 2, 2020; interview 3, 2020). In several European countries where abortion can be accessed safe and legally, there are mandatory waiting periods. These have been established in order to “protect” women and give them the time to reflect on their decision (Hoctor and Lamackova 2017, 255). The waiting periods vary between countries, in Italy the period amounts to 7 days (Legge 194/78), in the Netherlands it is 5 days (Government of the Netherlands), in Germany it is 4 days (§218 StGB), in Luxembourg, Portugal, Spain and Ireland the waiting period has a duration of 3 days (Loi du 17 décembre 2014, art. 12) (Health Act 2018 (12)) (Popinchalk and Sedgh 2019). In France, Great Britain, Denmark and Sweden there are no required waiting periods. These compulsory waiting periods can have negative effects on a woman’s health as they can retard women’s access to “timely” safe and legal abortion care (Hoctor and Lamackova 2017, 255). Indeed, this can lead women to have recourse to unsafe and illegal abortion, because they have missed the legal deadline to receive safe abortion services.

An American study has shown that an only 48-hour long waiting period caused an increase in second-trimester abortions, as women advanced in their pregnancy (Lindo and Torres 2019). However, in Europe, in most countries second trimesters abortions are forbidden. Additionally, these waiting periods do increase the costs of abortion care as they force women to travel to healthcare facilities at least twice. This is time that women in rural areas sometimes do not have. ANA points out that in some Dutch provinces there are no nearby abortion clinics (interview 3, 2020). For women living in the province of Zeeland, it takes almost 3 hours to the nearest abortion clinic. Consequently, it is not possible for every woman to travel several times to abortion clinics (interview 3, 2020). For instance, minor girls who do not have a driving license or adolescents who do not own a care, traveling becomes a burden (interview 3, 2020). Moreover, some women might not be able to get off work to visit the healthcare facility multiple times. Hoctor and Lamackova underline that for single mothers, who do not have another care giver available for their little children, this can become a considerable barrier to abortion care and women living in abusive household might also not like to travel multiple times in fear of awakening suspicion at home (2017).

50 Ciocia Basia explains that for women who seek abortion care abroad mandatory waiting periods represent an obstacle as well (interview 2, 2020). Indeed, for women from abroad this makes the procedure more costly as they have to travel from aboard twice or they need to book a hotel, which again costs money. In this context, the organization also mentions individuals with a physical disability, who might have difficulties travel several times to health care facilities (interview 2, 2020).

As illustrated in this part, mandatory waiting period are present in most European countries and represent an additional barrier to safe and legal abortion care. Furthermore, it does not affect individuals in the same way. Indeed, vulnerable women tend to be the most affected by this measure. For opponents, mandatory waiting periods implicitly state that women are not capable decision-makers and need additional time to make-up their time. The WHO has explicitly stated that governments should eliminate compulsory waiting periods:

“States (…) should ensure that abortion care is delivered in a manner that respects women as decision-makers. Waiting periods should not jeopardize women’s access to safe, legal abortion services. States should consider eliminating waiting periods (…) to serve all eligible women promptly.” (2012, p.96)

Mandatory Counselling Requirement

Closely linked to mandatory waiting periods are the mandatory counselling requirements. As the mandatory waiting period, they are present in many European countries such as Italy (Legge 194/78), Germany (§218 StGB Absatz 1), Slovakia (Hoctor and Lamackova 2017, 256), Portugal (Stifani et al.2018, 33), and Spain (Popinchalk and Sedgh 2019). In the Netherlands, in the Republic of Ireland, and in Great Britain there is no compulsory counseling prescribed by the law. In Luxembourg and in France, women can choose to attend counseling before or after the abortion procedure, if they wish so (Loi du 17 décembre 2014 art.12) (Article L2212-4). In Sweden and Denmark there are no mandatory waiting periods and no mandatory counselling requirements.

51 What NGOs often criticize is that these mandatory counseling can be biased and intent to deter women from choosing an abortion instead of simply providing scientific and objective information (interview 1, 2020). For instance, in Slovakia before abortion care, women need to obtain the information on “physical and psychological risks” and “the alternatives to abortion” which include adoption (Hoctor and Lamackova 2017, p.258). In Italy, the law declares that the family counseling centers should try to help women “overcome the causes that could lead (them) to terminate the pregnancy” (Legge 194/78). In Germany, the Criminal Code claims that the counselling “serves to protect the unborn life. It must be guided by the effort to encourage the woman to continue her pregnancy and to open up perspectives for a life with the child; it should help her make a responsible and conscientious decision.” (§219 StGB).

As for the mandatory waiting periods, mandatory counseling requirements cost women additional time and money. Indeed, women need to visit a healthcare facility several times to have access to abortion care. Additionally, one tries to deter women to have an abortion instead of offering them scientific and objective information. This is particularly detrimental for women with a lower education level, who might not know have or know how to have access to objective information. Furthermore, by doing so, many governments undermine women’s decision-making capacity, as many women have already made a decision before visiting a medical provider. Indeed, in most other medical procedures there are no mandatory counselling requirements. As the WHO states women should be given information, however, the latter ought to be scientific and without judgment:

“Providing information and offering counselling can be very important in helping the woman consider her options (…). Many women have made a decision to have an abortion before seeking care, and this decision should be respected without sub- jecting a woman to mandatory counselling. Provision of counselling to women who desire it should be voluntary (…).” (2012, p.36)

52 Requirement of permission

In some instances, individuals need the permission from someone else in order to access abortion care. In most cases it is the authorization of a parental authority, a judge or a medical provider (interview 1, 2020).

For instance, in Italy, individuals under the age of 18 need the consent of their parents or of a person having authority over them (Legge 194/78, article 12). If the decision of the person who has parental authority and the adolescent should diverge, the final decision will be given to a judge (Legge 194/78, article 12). Adolescent are therefore refused their bodily integrity as they need to have the permission of someone else to access abortion services (interview 1, 2020). The need for parental consent then becomes an obstacle to abortion care access. Indeed, Part et al. notice that teenage girls living in European countries where parental consent is not necessary (e.g.

Sweden and Germany) tend to have lower adolescent birth rate as the consent of parental authority does not represent an additional barrier (2013). An American study has found that many adolescents who sought a judicial bypass in order to get abortion without their parents’ consent, were more likely to get a second trimester abortion, as the judicial process required additional time

(Joyce 2010). However, as we have seen in the previous chapter, in most EU countries, second trimester abortion are not legal, which can lead many adolescent girls in distress when they do not get the authorization of their parents or do not wish to talk about their pregnancy to them. Many teenage girls do not have the financial resources to then travel aboard and keep their pregnancy a secret.

Italy is not the only European country to require permission from parental authority, this is also the case in Denmark, Poland and Slovakia (FRA 2018). In Luxembourg, minors need to have the consent too, however the consent does not have to be from a parental authority but can

53 just be from a trusted adult (loi du 17 décembre 2014, art. 12). This is also the case in France

(article L2212-4). Nevertheless, adolescents still do not dispose of their bodily integrity as they still need the consent of another person to access abortion care. In Germany, adolescents between the age of 16 and 18 are considered to be able to decide for themselves, however under the age of

16, it is the medical provider who has the right to require parental consent (ProFamilia)15. In Spain, the government has recently promised to remove the parental consent requirement for adolescents between the ages of 16 to 17, after a young adolescent girl was found drowned in the river, as she could not access abortion care without the consent of her parents. Her boyfriend had just before thrown their baby in the river (Morel 2020).

Age can consequently become a barrier to access to abortion services. Many adolescents who face an unwanted pregnancy and need the consent of a parent do feel distress. This can take a toll on their mental health and can lead to thoughtless actions.

Refusal by medical providers

Another issue mentioned by the Center for Reproductive Justice is the refusal by medical providers to conduct an abortion (interview 1, 2020). Indeed, some health professionals do refuse to give their patients abortion services due, for instance, to their political or religious beliefs. It concerns most of the time medical professionals that defend a pro-choice stance. In most countries of the European Union (22 out of 28), there is a clause that allows medical providers to reject the provision of certain medical goods and services, if this goes against their personal belief (Heino et al. 2013). This clause is called conscientious objection. In our list of countries, Sweden is the only country where the conscientious objection does not apply (Heino et al. 2013).

15 ProFamilia. “Deine Rechte als Mädchen bei (ungewollter) Schwangerschaft und bei einem Schwangerschaftsaabruch.” https://www.profamilia.de/fuer-jugendliche/rechte-und- sexualitaet/schwangerschaftsabbruch.html.

54 This conscientious objection affects all countries in which the clause applies. For instance, in Slovakia many health care providers make use of their conscientious objection to deny women’s abortion requests. Indeed, the CEDAW points out in its concluding observations on Slovakia that in over 1/3 of districts of the country, abortion services are unavailable and in more than four districts this is due to conscientious of objection (CEDAW 2015, 30 (d)). In consequence, some Slovak women do need to travel abroad or to another district to receive safe abortion care.

Poland is another good example for the conscientious objection clause. The country is today considered to have some of the most restrictive abortion laws in Europe. As we have seen in the previous chapter, abortion is just legal in some restricted cases. In theory, in case of rape, fetal anomality, incest, a Polish woman has the right to have access to safe and legal abortion in her country. Nonetheless, in practice this is not the case due to medical providers denying women the medical care (interview 1, 2020; interview 2, 2020). “In reality in Poland (…) very few abortions are actually carried out (…) women who meet the criteria to get an abortion are usually unable to get the care they need.” (interview 1, 2020). Consequently, in order to receive a safe and legal abortion, many Polish women are forced to travel abroad, even on the grounds that are legal in their own country. Ciocia Basia explained that sometimes they help Polish women receive abortion care abroad even though they would theoretically be entitled to legal abortion in Poland (interview 2, 2020).

The most emblematic case when it comes to the conscientious objection in Europe is Italy (interview 1, 2020). Indeed, in Italy 70% of gynecologists refuse to provide abortion on grounds of conscientious objection (Minerva 2015). Objection is present throughout the country but is especially prevalent in the south “where lower-income regions are concentrated” which makes think that the conscientious objection “affects disproportionally low-income women” (Autorino et al. 2020). Indeed, in the south, the number of conscientious objectors goes up to 80% (Minerva 2015, 173). This is a double burden for low-income women who might not necessarily have the financial resources to travel to another region or abroad to receive safe abortion care (Autorino et al. 2020). Even though the Italian Foreign Ministry claims that abortion is always guaranteed in the country, the fact is that many Italians travel abroad to receive safe abortion services. In Nice, France, there have been so many Italians seeking an abortion, that one hospital has decided no stop accepting them (Minerva 2015). The International Planned Parenthood Federation (IPPF) has filed

55 a complaint against Italy to the European Commission, stating that the right to health is not ensured for Italian women as the high number of conscientious objectors can delay and even prevent a “timely” and safe abortion (Minerva 2015, p.173). Moreover, the CEDAW has declared:

“It is discriminatory for a State party to refuse to provide legally for the performance of certain reproductive health services for women. For instance, if health service providers refuse to perform such services based on conscientious objection, measures should be introduced to ensure that women are referred to alternative health providers.” (art. 12 (11))

Italy is not the worst country when it comes to conscientious objection, it is just the “best documented” country, as all the gynecologists need to officially declare their stance on the topic to the Ministry of Health (Autorino et al. 2020). There is in general a “lack of official data” in other European countries concerning conscientious objection. Through the Italian example, Autorino et al. show the individuals who are the most affected by this common practice. The study shows that non-Italian women were less likely to travel to another region for abortion care. Immigrant women might “have fewer economic resources” and therefore less resources to travel to another region or abroad (Autorino et al. 2020). Furthermore, the study shows that the likelihood to travel to another region “decreases as the number of women’s children rises” (Autorino et al. 2020). Women with children may not be able travel if they are the main care giver. In consequence, women who cannot afford to travel abroad because the lack of money and/or because of their social situation, or because of a physical disability or their legal status or age, are the most impacted by this practice.

In Portugal, from 2007 to 2009, 80% of medical providers made use of their right of conscientious objection (Oliveira da Silva 2009). However, compared to other countries which have been mentioned previously, there has been no shortage of medical providers as the law requires medical professionals who deny women abortion care to refer them to a “willing clinician”, this is also the case in Great Britain (Chavkin et al. 2017). To ensure the availability of medical providers throughout the whole country, the Portuguese health system called Serviço Nacional de Saude (SNS), posts “travelling teams of willing physicians” (Chavkin et al. 2017). Nevertheless, there are also drawbacks to the Portuguese model. Some raise the issue of the risk

56 of burnout for medical providers, who work in areas with a shortage of willing health providers, as this put a “excessive abortion-related workload” on their shoulder (Chavkin et al. 2017).

In our list of countries, Sweden is the only country where the conscientious objection is not recognized by law (Heino et al. 2013). Consequently, medical providers are not allowed to deny individuals abortion care on grounds of personal beliefs. In 2014, a Swedish midwife, Ellinor Grimmark, refused to provide abortion care to her patients. However, this is part of a midwife’s job and she was therefore turned down several jobs at clinics in Sweden (Radio Sweden 2017). In 2020, the ECHR rejected her appeal, observing that Sweden provides abortion and therefore needs to make sure that the refusal by medical providers does not obstruct women’s access to abortion. Furthermore, the Court cites that Ms. Grimmark did know what she got into when she signed the work contract as a midwife (ECHR 2020).

The Center for Reproductive Rights points out that the termination of pregnancy is still found in the penal code of numerous countries, which often singles abortion care out as different type of health care (interview 1, 2020). This could be one of the causes of abortion stigma and can explain why many health care providers refuse to conduct the procedure.

Cost of care

As we have seen so far in the thesis, women with fewer financial resources are often among the individuals who are the most impacted by the barriers established by the law. However, for some individuals, the cost of care and the lack of financial resources represents a barrier in itself. For instance, in many countries abortion care is reimbursed by the health insurance but this is not the case everywhere and not for everyone.

In Slovakia, abortion on request is not reimbursed by the health insurance. Indeed, if abortion is not required on medical grounds, Slovak women are required to pay 257$ out of pocket (Le Planning Familial 2016). The issue is that abortion then becomes inaccessible to low-income women or for instance for students who live on a limited budget. Therefore, in its observations on Slovakia, the CEDAW committee has recommended the Slovak state to “ensure universal

57 coverage by public health insurance of all costs relating to legal abortion, including abortion on request (..)” (2015 31 (b)). Slovakia is not the only country exercising this practice. This is the case in many Central and Eastern European countries, as for instance in Latvia, Croatia, and the Czech republic (Le Planning Familial 2016). In some countries such as Germany abortion is paid by the women themselves, however in cases of financial difficulties, it can be paid by the government (Le Planning Familial 2016).

On the other hand, in countries where abortion care is covered by the government or by public health insurances, it is only accessible for individuals, who are registered and/or have a national health insurance. In consequence, undocumented women or even foreign students who are not registered to any national health insurance have to pay for their own abortion, as they are not legally entitled to financial help. In this context, ANA has described, that their organization has been contacted several times by organizations who work with undocumented sex workers in the Netherlands (interview 3, 2020). Even though abortion is legal in the country and fully reimbursed by health insurances, for undocumented sex workers this is not the case and they have to pay between 800 and 1000€ out of pocket to have access to abortion care, a sum that is often not affordable for undocumented migrants (interview 3, 2020). Grassroot organizations such as ANA then try to help women financially in order for them to receive the care they need (interview 3, 2020).

The Platform for international Cooperation on Undocumented Migrants (PICUM) explains that in Great Britain undocumented migrants need to pay their abortion “out of the pocket” as it is not considered “immediately necessary” (2016, p.19). In Poland, the situation is ambiguous, undocumented migrant women can access sexual and reproductive health care through emergency groups located outside of hospitals. However, migrants might be required to bear the expenses. Moreover, health care providers and civil society have reported instances in which undocumented migrants “were reported to the authorities” after seeking care (PICUM 2016, p.20).

Consequently, undocumented migrants bear several burdens, and these are also illustrated in their quest for safe and legal termination of pregnancy. Indeed, their legal status and the (often) related economic status become an obstacle for them to receive safe and legal abortion care. Consequently, they often have to fall back on unsafe and illegal abortion or have to parent against

58 their will. The Program of Action, adopted at the ICPD in 1994 in Cairo, underlines that “(…) migrant and displaced persons in many parts of the world have limited access to reproductive health care and may face specific threats.” (PoA 7.11).

Covid-19 Pandemic

The Covid-19 pandemic has proven itself to be a barrier to abortion for many women in the world. Indeed, the Center for Reproductive Rights has filled several lawsuits in American states, as some used the recent pandemic to stop the access to abortion services. In Europe, the situation is not much different, some countries have stopped the access to abortion care during the pandemic. In this context, Slovakia has been criticized on several occasions by international organizations, as many hospitals have stopped performing abortions after the government decided “to postpone all planned surgeries except life-saving ones due to the risk of infections during the coronavirus pandemic” (Gabrizova 2020). Furthermore, the abortion pill which would be the safest method during the pandemic, as it can be taken at home, is prohibited in Slovakia (Gabrizova 2020).

Slovakia’s neighbor Poland has even tried to slip a bill that would undermine women’s right to abortion care even more. Indeed, the president of the country, Andrzei Duda, has backed a citizen bill that would ban the termination of pregnancy on grounds of fetal anomality. The bill was drafted by pro-life activist Kaja Godek and signed by over 830 000 Poles (Bateman and Kasztelan 2020). Indeed, under Polish law, citizens can draft new legislation if they can assemble at least 100 000 signatories. Godek has stated that abortion was “a pandemic much worse than coronavirus” (Bateman and Kasztelan 2020). The bill was not passed, but was not rejected either, instead Duda’s party has sent it to a parliamentary commission to be amended. Many Poles have denounced the government’s move to start the public debate at this particular time, as mass protests were forbidden at that time (Bateman and Kasztelan 2020). Moreover, NGOs helping women to get an abortion abroad, have stated that it has become more expensive for Polish women to get abortion care abroad (interview 2, 2020; interview 3, 2020). Indeed, during the pandemic, numerous international flights and trains were cancelled.

59 Consequently, only women who could travel by car, could receive abortion care abroad (interview 3, 2020). However, not everyone owns a car or/and a driving license. Furthermore, for sanitary reasons during the pandemic, NGOs like ANA could no longer host foreign women for free at their hosts’ houses. Consequently, accommodation had to be paid by women themselves (interview 3, 2020). As was explained by a member of an NGO, during the pandemic receiving abortion care abroad “costs more and takes more time, the two things that you don’t have” (interview 3, 2020). The same applies for women in Malta, where abortion is completely banned and due to travel restrictions, many women were not able to leave the island to seek abortion care.

West from Poland, in Germany, abortion access has also been under threat. Indeed, as many reports state, numerous medical providers who conduct abortions, have become part of the risk groups for contracting the coronavirus, as they are elderly people (Taz 2020) (Fischhaber 2020). Fischhaber explains in the region of Niederbayern, Michael Spandaus has become one of the only non-objectors. However, as he is already 71 years old, he has decided not to work during pandemic. For many women from the region this means that they have to travel at least 120 km in order to find a willing medical provider and receive abortion care (2020). The German federal government has however decided that mandatory counseling session can be held over phone in order to keep the sanitary measures.

In the Netherlands pro-choice activists and the Bureau Clara Wichmann were not able to secure women’s right to receive the abortion pill without going to a clinic in Court. Indeed, in the Netherlands, women need to visit a health care facility to receive the abortion pill. However, for women in self-isolation this is not possible (Bureau Clara Wichmann 2020). Furthermore, during their plead, the Bureau Clara Wichmann has cited a woman who lives 4 hours from an abortion clinic away and another woman who lives with a partner who does not know that she is pregnant. For these women it has also been impossible to visit a health care facility during the pandemic. However, the Court refused their request. (Bureau Clara Wichmann 2020).

In Italy, reports have stated that many women who requested abortion care during the pandemic were denied the services, especially in the regions most affected by the virus. Indeed, the Italian health system being overloaded due to the pandemic, abortion care has been considered

60 as a “minor issue” (Rita 2020). Moreover, as many non-objecting medical providers moved to the intensive care, there has been a shortage of medical professionals willing to conduct abortions, which has not helped women’s access to abortion care at all (Rita 2020).

In Spain, many feminist movements have also advocated in favor of the removal of the mandatory waiting period and the mandatory counseling requirements as visiting health care facilities multiple times during the pandemic was difficult. In this context, the Planned Parenthood organization in Catalonia underlined that some women had to travel long distances to reach a health care facility. Indeed, they point out at an “enormous territorial disparity in accessing them”

(Kohan 2020).

On the other hand, France decided in April to extend for two more weeks, the time in which women can take abortion pills. Indeed, before the pandemic, the limit for a was fixed to the 7th week of pregnancy and now it has been extended to the 9th week (LeMonde 2020). This has also been the case in Great Britain (Connolly 2020). Moreover, the pills can be taken at home without visiting a hospital. Nonetheless the amendment, presented by the French senator Laurence Rossignol, to extend the time limit of abortion care until the 14th week of pregnancy for the COVID-19 bill, was refused by the Health Minister (Charrier 2020). Many women who have now exceeded the limit of 12 weeks, now have to travel abroad, but as we have seen in this chapter this is not possible for every woman.

The pandemic caused by Covid-19 has become a new barrier for women who wish to access abortion care. Furthermore, it has also emphasized the already existing obstacles many women face when seeking an abortion, such as the time restriction, shortage of non-objecting medical providers, mandatory counselling requirement, the cost of care, travelling abroad, the distance, the socio-economic status but also the legal status of women. Many international feminist NGOs have underlined the issues and demanded governments to take action to protect women, especially the most vulnerable “including women living in poverty, women with disabilities, Roma

61 women, undocumented migrant women, adolescents, and women at risk or who are survivors of domestic and sexual violence” (Human Rights Watch: Joint Civil Society Statement 2020).

The question of race and ethnicity in the European abortion debate

As we have seen in the theoretical framework, the question of race has played a central role in the creation of the reproductive justice theory in the US. Indeed, the latter was created by women of color, because they felt left out of the debate. In this thesis, the question of race has been left out so far. This is because there is barely any literature available on the topic in Europe. The racial component in the abortion debate has been poorly studied in the European context. Often the European research concerns immigrant women. However, this is not sufficient, as racialized women are not necessarily immigrants and immigrants are not necessarily racialized. There’s only little literature and studies on the intersection of abortion and race or ethnicity in Europe and it mainly concerns Great Britain, France, Sweden, Denmark and some parts of Eastern Europe.

Studies conducted on that field in Europe show that non-Western immigrants are more likely to have more than one abortion in their lifetime (Rasch et al. 2007; Helström et al. 2003; Oliver-Williams and Steer). These statistics can partly be explained through the precarious position, in which many immigrant women find themselves. Indeed, experts point at obstacles such as income inequality, and the lack of access to reproductive health care and information (Helström et al. 2003; Desgrées du Loû and Lert 2017). When it comes to the latter, the Center for the promotion of sexual and reproductive health in Luxembourg (CESAS) explains: “Access to information is "equal", but the possibilities and abilities to find information are influenced by a lot of things: income, nationality, social class (…). Indeed, it is not always as easy as "when you want, you can". Sometimes our possibilities are limited by our history and our development.” (interview 5, 2020). In this context, factors such as language and form can also play a factor in how easily information can be accessible. When it comes to reproductive health care, it is important to note that contraception in Europe is only reimbursed until a certain age and in many cases it is also not fully reimbursed,

62 which means that it can become a financial burden for low-income individuals and the “financial burden for (contraception) is more often borne by women than by their sexual partner” (interview 5, 2020). Consequently, there is an unequal access to contraception. All these factors explain partly why the rate of induced abortion is higher for non-European immigrant women than for nationals. However, all these factors do also represent obstacles to abortion care access as we have seen in this chapter. This leads therefore to think that non-Western immigrant women might have a difficult time access abortion care.

Furthermore, a Swedish study has found through interviews with midwives and doctors, that abortion care and contraceptive counselling for foreign-born women was more time consuming, as there were more barriers between the health care provider and the patient, such as the language (Larsson et al. 2016, 18). Many medical providers also admitted finding it demanding to advice immigrant women on SRHR, because of culture differences. However, the study found that it was difficult to “extend appointments” for this “purpose”. Larson et al. therefore conclude that the experience of immigrant women on abortion care is not equal to that of their Swedish-born counterparts (2016, p.17). Indeed, many of these women do not receive the necessary time. Furthermore, abortion services and contraceptive counselling is free for every resident living in Sweden, however, due to barriers such as language and lack of information, many immigrant women do not know where to look for help (Akerman 2019).

In Eastern Europe, the case of the Romani women has been studied particularly. A study conducted by the European Agency for Fundamental Rights (FRA), found that Romani women were often denied or only granted restricted access to health care facilities, because of their ethnicity (2003). For instance, for gynecological care in the city of Kosice in Slovakia, sometimes dubbed the “largest (Roma) ghetto in Central Europe”, Romani women are only granted gynecological care on Fridays, the other women are allowed to come from Monday to Thursday (FRA 2003, p.42). This discrimination is purely based on ethnicity and as a result Romani women’s access to timely abortion care is obstructed.

This section has shown that there are in fact discrepancies in health care access based on race or ethnicity in Europe, it is not just an issue in the US. However, the research done so far is not

63 complete enough to jump into generalizations. My interviewees have claimed that immigrant women are often impacted the most by the barriers to abortion care, due to their precarious position. However, they were not able to give me any statistics (interview 1, 2020; interview 2, 2020; interview 3, 2020). In consequence, this area needs to be explored further in new studies.

Abortion services for non-binary and transgender people

As for the literature on the intersection of race (or ethnicity) and abortion care, the literature on the topic of abortion services for non-binary and transgender people in Europe is very limited to non-existent in many European countries. The information on this topic was received through interviews. Indeed, Ciocia Basia explained that they also help transmen get access to abortion care (interview 2, 2020). The main barrier for transmen is often the lack of information. As a volunteer explains, most information on SRHR does follow a heteronormative logic and does therefore often not provide adequate information for the needs of transgender people (interview 2, 2020). The volunteer continued by telling the story of a transmen who got pregnant. The man thought that because he was starting to take his hormones, he could not fall pregnant anymore and when he realized his pregnancy, he did not know how to access abortion care and sought help from CioCia Basia (interview 2, 2020). As in the previous section, this shows that information regarding abortion services and SRHR in general is not always accessible for everyone and that it is not always inclusive enough to provide information for everyone.

Conclusion

As we have seen in the methodology chapter, the assessment of accessibility is made on 4 different dimensions: (1) Abortion is considered accessible when the service and good is non- discriminatory, especially to vulnerable and marginalized parts of the population. However, as we have seen, in Eastern Europe, Romani women are denied access to health care because of their ethnicity. Moreover, as we have seen, most obstacles to abortion such as the conscientious objection clause, affect predominantly vulnerable and marginalized groups. Indeed, conscientious objection is particularly detrimental for low-income, and undocumented women as they might not

64 have the financial or legal resources to travel to another area in case a medical provider denies them the medical procedure.(2) Then, abortion is considered accessible when it is physically accessible, in other words abortion should be “within safe physical reach for all section of the population” even in rural areas, especially for marginalized and vulnerable people, such as ethnic minorities, women and people with physical disabilities (UN 2000, article 12). As we have seen in this chapter, obstacles like “mandatory waiting periods” are especially detrimental for women who live in rural areas such as Zeeland in the Netherlands. Indeed, requirements such as “mandatory waiting periods” require women to visit health care facilities several times. This is not always convenient for women living in rural areas. (3) Furthermore, abortion is considered accessible when it is affordable for the population, specifically for “socially disadvantaged groups” (UN 2000, article 12). Poorer groups should not “disproportionally be burdened by health expenses” compared to their richer counterparts. As we have seen in countries like Slovakia, individuals need to pay for abortion services out of pocket, without financial help from their healthcare insurance, this is especially detrimental for low-income women. Furthermore, in Great Britain asylum seekers need to pay abortion services “out of pocket”, impossible for most of them, as they already live in precarious conditions. (4) Last but not least, information should also be accessible for all. Everyone should have the right to “seek, receive and impart” information related to abortion (UN 2000, article 12). As we have seen in the last part, non-Western immigrant women tend to be more likely to need abortion care, as they tend have insufficient information on SRHR. Furthermore, non-binary and trans people do not always have the adequate information for their specific needs.

Consequently, this chapter has shown that every European country has, to a greater or lesser degree, barriers that obstruct individuals’ access to abortion care. The people most affected by these barriers are mostly vulnerable and marginalized groups such as low-income women, asylum seekers, immigrants, ethnic minorities, adolescents and transmen.

65 6.2 Typology of countries

As done in the previous chapter, in this chapter I will categorize the countries in different groups. Indeed, in the previous chapter, I have grouped countries according to the availability of abortion care, in other words, I grouped countries according to how restrictive abortion laws were. In this chapter, I group countries according to how restricted abortion access is. I analyze 5 types here: (1) Least restricted access, (2) moderately restricted access (3) restricted access, (4) very restricted access, (5) most restricted access. “Restricted” is here understood as “limited” but also as “excluding”.16 Indeed, the following typology on access, illustrates how in practice countries offer some individuals only limited access to abortion care or even sometimes exclude some individuals. Contrary, to the previous typology, this typology does not use the category “liberal”. Indeed, as this research has just shown, there is no country that can claim to have no restrictions to abortion access. Indeed, even in countries with the most progressive abortion laws such as the Netherlands, we have seen barriers to abortion access. A volunteer at ANA also claims: “The Netherlands are not perfect, it’s just better than in other places (...).” (interview 3, 2020).

The criteria used to determine the groups of the countries, are the obstacles mentioned above. According to them, I decided to put Malta and Poland in the “most restricted access” category. Indeed, in Malta abortion is completely banned and consequently only individuals who have the financial resources can receive abortion by traveling abroad. In Poland, abortion laws are very restrictive and abortion care is restricted to three instances by the law. In practice, however, we have seen that even in these instances, many women are not able to receive abortion care due to barriers such as conscientious objection. Furthermore, the Polish government has used the current pandemic to introduce tougher restrictions on abortion law.

Italy and Slovakia are in group 4, “very restricted access”. Indeed, in Italy abortion has been legal for over 40 years, however, today 70% of gynecologist invoke their conscientious objection, which makes abortion care almost inaccessible in the country. In Slovakia, abortion care has been legal since 1986, but Slovak women need to pay the procedure out of pocket.

16 Restrictive: “limited” ; “excluding other”, https://www.merriam-webster.com/dictionary/restricted.

66 Consequently, the procedure is only accessible for people with sufficient financial resources. Romani women are discriminated against because of their ethnicity and access to health care including abortion care is almost impossible for them. Moreover, during the Covid-19 pandemic, abortion services were completely put on hold as they were not considered “necessary”.

In this typology, Portugal is in category 3 “restricted access”. The country is ranked in category 3, because compared to the countries in category 2, Portugal does only allow abortion care until the 10th week. The other countries allow abortion until the 12th week, which gives individuals more time, and time is often the issue when it comes to accessibility. Indeed, as this chapter has shown, the problem with the barriers is often that they are time-consuming and hinder women to receive timely abortion care. By limiting abortions to the 10th week of pregnancy, individuals are even more under time pressure.

Denmark, Germany, France, Luxembourg, Ireland, and Spain and are in category 2, “moderately restricted access”. Indeed, first trimester abortion are legal in these countries, but as we have seen, in every of these countries, there are several barriers that hinder people’s access to abortion care.

Sweden, Netherlands, and Great Britain are categorized in the “least restricted access” group. This categorization was more difficult to establish. Indeed, the Netherlands has barriers such as mandatory waiting periods and the cost of care is extremely high for undocumented women. However, as abortion care is available until the 24th week, it often gives individuals more time, and time is key when it comes to abortion care. The same applies for Great Britain. Indeed, many women in Europe also travel to the Netherlands and to Great Britain to receive abortion care when the barriers in their country do not allow them to have a timely abortion. In Sweden, abortion services are “only” available until the 18th week, but it is the country with the least barriers. However, the country is not perfect either, as the high number of induced abortions among non- Western immigrant women is in part due to a lack of accessible information concerning SRHR.

67 Observations

What is observable, is that every country has lost at least one spot compared to the previous typology. Indeed, governments have relaxed abortion laws in recent years. Consequently, abortion has been made widely available in Europe. However, the barriers to abortion access have stayed in place. As a result, most countries rank higher in the availability typology that in the accessibility typology. There is a clear discrepancy between theory (availability) and practice (accessibility). Indeed, legal barriers to abortion have been removed, but the access is not ensured for everyone. Overall, we can claim that time is key when it comes to abortion care. Indeed, the countries which allow second-trimester abortion, rank the highest in the typology as they give women more time despite the barriers. Furthermore, when it comes to Southern Europe, Italy was the first country to legalize abortion in 1978. However, today it has become more difficult to receive abortion care there than in other South European countries such as Spain and Portugal. In Eastern Europe, abortion care is more difficult to access than in Western and Northern Europe. Since the fall of the iron curtain, abortion services have been difficult to access. In Northern and Western Europe, abortion care is the is the most accessible, even though one can observe discrepancies between countries.

Table 3:

Least restricted Moderately Restricted Very restricted Most restricted access restricted access access access access Sweden Denmark Portugal Italy Malta the Netherlands Luxembourg Slovakia Poland Great Britain France Germany Ireland

68 6.3 Political actors in the accessibility debate

On the one hand, the availability debate opposed the Church and feminist movements, more specifically, second-wave feminists. Indeed, if the Church has taken a pro-life stance and protests against the legality of abortion care, second-wave feminists have defended a pro-choice stance, defending women’s right to control their own body. On the other hand, the accessibility debate is dominated by different arguments. Indeed, Ross and Solinger assert that the debate on reproductive justice is different from the pro-choice/pro-life debates that “have dominated the headlines and mainstream political conflict for so long” (2017, p.1). The debate on accessibility was put on the forefront by reproductive justice activists and theorists, which were mainly Black feminists. They criticized pro-choice activists in the US for not taking an intersectional lens while defending people’s reproductive rights (Gerber 2017). Organizations like SisterSong have since challenged the pro-choice framework, claiming that emphasizing choice, leads to the belief that if abortion is available, it will automatically be accessible, which is not the case (Thompson 2017). As Ross notes, reproductive justice equals to intersectional feminist activism (2018, 286). Consequently, reproductive justice is part of the third-wave feminism. Indeed, third wave-feminism aims “to be more inclusive and global and to connect gender issues with broader social concerns” such as racism, and poverty (Gibbard Cook 2014, p.7).

The debate on accessibility of abortion care is therefore a debate that opposes second-wave feminists who defend a pro-choice framework and third-wave feminists who defend a reproductive justice framework that goes beyond the availability debate. During the March for Women’s Lives, one organizer of color claimed:

"When we try to explain how choice is an inappropriate term even for many white women, some allies—especially older feminists—take offense. They feel as though they had been fighting for "choice" for the past 30 years and that it was insulting to tell them that choice was not inclusive of many women of color, low- income, and gay and lesbian communities" (Ross 2006, p.15)

69 In practice, one can notice that mainstream reproductive movements and organizations tend to be rather pro-choice. However, Ross says that “while most resources are located in the hands of the mainstream pro-choice organizations, it is grassroots organizations like SisterSong that offer the most significant social change” (Ross 2006, p.15).

The same pattern can be found in Europe as well. Many reproductive justice activists tend to be part of grassroots organizations, such as Ciocia Basia in Poland and Germany and ANA in the Netherlands. Another good example to illustrate the situation in Europe, is the case of Ireland and the 2018 campaign to repeal the 8th. Indeed, the campaign was dominated by the pro-choice and pro-life divisions. The Pro-choice camp was mainly defended by Together for Yes (a group constituted by 70 pro-choice organizations), that has claimed to take an intersectional approach (de Londras 2020). However, Migrants and Ethnic Minorities for Reproductive Justice (MERJ), an Irish grassroot organization, claims that “migrants’ issues were in fact brushed aside during the campaign and during conversations about the legislation” (MERJ statement)17. Furthermore, MERJ underlined the “continued exclusion of migrants and ethnic minorities from Irish feminist discourse” and asked for a “more radical and inclusive feminist movement in Ireland” (de Londras 2020). During the campaign, MERJ pointed out that factors such as conscientious objection and mandatory waiting period would become obstacles to timely abortion that would mostly affect migrant women and therefore campaigned against them, however, without success (de Londras 2020).

Today these grassroot organizations do fill in the gap left by governments. Indeed, abortion laws have become more liberalized in recent years. However, as we have seen in this chapter, there are many barriers that obstruct women’s access to abortion services. Reproductive justice organizations, such as ANA, Ciocia Basia, have therefore, started to organize ways in which they can help individuals gain access to abortion care: for instance, by providing financial help, providing objective and inclusive information, mental support and free accommodation for people who travel from abroad (interview 2, 2020; interview 3, 2020). In Europe, a network is being developed by these organizations called Abortion without borders. This network is constituted of

17 MERJ: “Migrants and Ethnic Minorities for Reproductive Justice on Ireland’s Abortion Legislation.” http://merjireland.org/index.php/2019/09/09/migrants-and-ethnic-minorities-being-left-behind-by-irelands-abortion- legislation/.

70 6 organizations in Europe and aims to help people from Poland and other countries in Europe to travel abroad to receive abortion care (interview 1, 2020; interview 2, 2020). The goal of the network is to provide the different grassroot organizations with enough funding to help women and create a coordinated network in Europe (interview 1, 2020; interview 2, 2020).

To conclude, we can see that the debate on reproductive politics has shifted from a pro- choice vs. pro-life/ second-wave feminists vs. Church debate to a debate between second and third- wave feminists, which opposes the pro-choice vs reproductive justice stance. Today the debate is still dominated by the former, however, grassroots organizations, in the US as in Europe, continue to advocate for a more inclusive approach to reproductive politics in order to help all women receive abortion care.

71 7 Conclusion

Abortion has always been a controversial issue. The argument between pro-choice and pro- life advocates is still ongoing. The European Union has decided to keep itself out of the debate, at least within its own borders. Today abortion care has been made widely available by national laws in Europe. Most European countries have established laws in order to guarantee women the right to access abortion on request. There are only rare exceptions such as Malta and Poland where this right to abortion services is extremely restricted or completely banned by law. In consequence, the state of availability of abortion can be considered positive in Europe. Nevertheless, the previous chapter has shown that the availability of abortion does not necessarily translate into its accessibility. There are numerous barriers that obstruct women’s access to safe, timely and legal abortion access. Indeed, for instance, abortion has been legalized for over 40 years in Italy, but due to a high number of conscientious objections, it is almost impossible to receive abortion care. The barriers to abortion access concern every country of the EU, however it impacts individuals differently. Indeed, barriers impact mostly vulnerable groups such as low-income women, adolescents, non-documented workers and immigrant women. Furthermore, it is not because abortion is illegal that women will not have them. As we have seen, Polish women who have the financial resources and the right legal status travel abroad to receive safe and legal abortions. On the other hand, asylum seekers and undocumented migrants have limited possibilities to travel abroad due to their legal status. For them the unavailability of abortion results into its inaccessibility. Consequently, the availability of abortion care does not necessarily translate into its accessibility and unavailability does not necessarily translate into inaccessibility. A reproductive justice lens takes an inclusive approach and draws attention to these inequalities in the quest to access SRHR. Consequently, this research has illustrated that the state of accessibility in Europe is not as positive and there are considerable barriers that hinder individual’s access to safe and legal abortion care.

When it comes to political actors, reproductive justice activists have become essential political actors in the sphere of reproductive politics. Indeed, they try to fill the gap left by many governments by going beyond the simple pro-choice stance that dominates the debate. To do so, they try to provide individuals with information, with free accommodation if women travel from

72 abroad and even try to take the cost of the abortion procedure, when women do not have sufficient financial resources (interview 2, 2020; interview 3, 2020). Furthermore, they lobby politicians and international organizations to bring change not only in the availability of abortion, but also in its accessibility (interview 1, 2020). This civil society movements range from grassroots movements such as ANA in the Netherlands to large international NGO such as the Center for Reproductive Rights.

As Marlene Gerber Fried noticed in the US, this research shows that there is a “dissonance between the wide availability of abortion and its inaccessibility to women on the social and economic margins” in Europe as well (2000, p.177). Indeed, on paper abortion is widely available, but in practice the access is restricted, especially for marginalized groups. In order to attain accessibility, “women must have the resources necessary to turn their rights into realities” (2017, 144). Indeed, in order to achieve reproductive justice and guarantee access to abortion care to everyone, it is important to plan a system with the most vulnerable and marginalized groups in mind. This system would most likely decriminalize abortion, because as this research has shown, the illegality of abortion affects mostly individuals who cannot travel abroad due to a lack of financial resources, or their age or their legal status. Furthermore, obstacles to abortion care would also be eliminated, as they impact mostly vulnerable and marginalized groups. So far, most governments in Europe have freed abortion care from legal restrictions but have not ensured that it is accessible for everyone.

Discussion

To conclude, one can assert that this research has contributed to the academic literature on reproductive justice. Indeed, the latter focuses mainly on the US, the aim of the thesis was therefore to shift the focus on Europe and analyze several countries in the EU. In doing so, this research is one of the first to do a systematic analysis of reproductive justice in Europe. This study has shown that even in Europe, there are many barriers to abortion access. Furthermore, this research has used interviews and therefore gives a glimpse into the work of activists in the field reproductive justice in Europe. Going beyond the academic relevance, this research has taken an inclusive lens and emphasized on the inequalities in reproductive politics. One weakness is that the following

73 research only concentrates on abortion access, and not on issues such as contraception or in vitro fertilization (IVF). Further research on the topic could therefore concentrate on these topics in a European context. Moreover, further research needs to concentrate on aspects such as the intersection of race and the access to abortion care in Europe. Additionally, the access to abortion services for trans people in Europe is another field that requires further research.

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