In Brief 2008 Series, No. 2 in Indonesia

Each year in Indonesia, millions of women become pregnant about 29 occur for every 1,000 women of reproductive age. 4 unintentionally, and many choose to end their , despite the fact that abortion is generally illegal. Like their While the level of induced abortion is somewhat uncertain, there is clear counterparts in many developing countries where abortion evidence that of the 4.5 million births is stigmatized and highly restricted, Indonesian women that took place in Indonesia each year around the time of that study, 760,000 often seek clandestine procedures performed by untrained (17%) were unwanted or mistimed. 5,6 providers, and resort to methods that include ingesting Abortion clients are often unsafe substances and undergoing harmful abortive massage. married adults with unmet need for contraception. Although women of all walks of life likely Though reliable evidence does not exist, women’s experiences with abortion. Some utilize abortion services in Indonesia, researchers estimate that about two studies included women in rural areas information on the characteristics of million induced abortions occur each and those who sought abortions outside women who obtain abortions generally year in the country 1 and that deaths of clinics, but none were nationally comes from clinic- and hospital-based from unsafe abortion represent 14 –16% representative. Although these studies do studies. Thus, women who seek abortions of all maternal deaths in Southeast Asia. 2 not give a full picture of who is obtain - outside of facilities, including those who Preventing unsafe abortion is imperative ing abortions in Indonesia or what their induce abortions themselves, are not if Indonesia is to achieve the fifth experiences are, the evidence suggests represented by these studies. Millennium Development Goal of improv - that abortion is a common occurrence in ing maternal health and reducing the country and that the conditions The studies concur that the majority of maternal mortality. under which abortion takes place are women who obtain an abortion or often unsafe. menstrual regulation at a clinic or Current Indonesian is based hospital fit a certain profile: They tend on a national health bill passed in 1,7,8 Abortion is common in Indonesia. to be married and educated. For 1992. 3 Though the language on abortion It is estimated that about two million example, a study conducted in 2000 was vague, it is generally accepted that abortions occurred in Indonesia in 2000. 1 found that two-thirds of abortion clients the law allows abortion only if the were married, and nearly two-thirds had This number is derived from a study of a provides confirmation from a attained at least some secondary school sample of health care facilities in six doctor that her is life- education (Figure 1, page 2). 1 In regions, and it includes an unknown, threatening, a letter of consent from her contrast, only 38% of ever-married though probably small, number of husband or a family member, a positive Indonesian women have received any spontaneous abortions (miscarriages). pregnancy test result and a statement secondary schooling. 6 In a more recent However, this is the most comprehensive guaranteeing that she will practice study, 54% of abortion clients were high estimate currently available for the contraception afterwards. school graduates, and 21% were academy country. The estimate translates to an or university graduates; 87% of urban This report presents what is currently annual rate of 37 abortions for every clients were married. 7 Moreover, nearly known about abortion in Indonesia. The 1,000 women of reproductive age (15–49 every abortion client was older than 20 findings are derived primarily from small- years). This rate is high compared with (58% were older than 30), and almost scale, urban, clinic-based studies of that of Asia as a whole: Regionally, half had at least two children. Figure 1 Who Gets Abortions? birth attendants, traditional In a study of women who had Most abortion clients are married and educated, but few were using healers or masseurs to termi - obtained an abortion at a contraceptives. nate their pregnancy. (Women clinic, only 38% reported that their procedure had involved 100 who induce their own abor - 0

0 75 8 0 , a safe and 2 22 tions are not included in these , s t established method of early

n estimates.) i 80 o

p 50 14 abortion, or dilation and y 46 r

e 66

v curettage, an effective but

i While the number of successful l 60 e d self-induced abortions is somewhat less safe method e c

i 1

v 43 (Figure 2). Another 25% had r 40 unknown, one study suggests e s 33 received oral medication and t that most women who seek an a 37 s abortive massage; 13% had n abortion from a provider first o 20 i

t 33 r received an injectable abortifa - o attempt to induce the abortion b 21 18 a 10 cient; 13% had had a foreign g themselves. In a study of

n 0 i

k Age Marital status Education Contraceptive use object or preparation inserted e clients seeking menstrual e s ≤19 Married Primary Never used into their vagina or ; n regulation (locally known as e

m 20–29 Never married Junior Former user and 4% had been treated with o induksi haid ) at an urban clinic, w 30–39 Divorced Senior Current user f acupuncture. o women’s first step often was to ≥40 Academy/ % University use over-the-counter medicines Unsafe abortion leads to or herbal remedies ( jamu ) to Note: Percentages may not total 100 because of rounding. Source: Reference 1. an unknown number of induce menstruation. 11 Many complications and deaths. then took a pregnancy test. Evidence indicates that some Recent estimates of abortion- sought to terminate a preg - Once pregnancy had been women who have abortions had nancy in order to preserve associated mortality in confirmed, the most common been actively seeking to their physical health. 7 Indonesia are unavailable. The means women employed in prevent pregnancy when they World Health Organization their first abortion attempts conceived. In one study, about Many abortions in estimates that unsafe abortion was ingesting more herbal 19% of urban and 7% of rural Indonesia are unsafe. is responsible for 14% of products or receiving abortive abortion clients reported that Unlike safe abortions, unsafe maternal deaths in Southeast they had been using contracep - procedures are a threat to massage from a traditional Asia, and 16% of maternal tives when they became women’s health and survival, healer. If the abortion was deaths in regions of Southeast pregnant. 1 In another study, a and the relative safety of the unsuccessful, the women then Asia that have highly restric - much higher proportion—about procedure can depend on the terminated their pregnancy in tive abortion laws (including one-third of clients—reported provider and the method a clinic. Indonesia). 2 having experienced contracep - used. 9,10 A woman’s choice of Figure 2 tive failure. 7 Most abortion abortion provider varies clients, however, had an unmet according to her location. Methods of Abortion need for contraception, as they Researchers estimate that Vacuum aspiration is used in less than half of abortions in Indonesia. did not want a child soon or at hospital and family planning 8% all and were not using any clinic staff, obstetricians and 4% Vacuum aspiration or D&C contraceptive method. perform close to 85% 5% of abortions obtained at Oral medication and massage One of the most frequent 8% service delivery points in urban Injected reasons women give for seeking settings, and traditional birth 38% Foreign obj ect inserted into an abortion is that they have attendants perform 15%. 1 In vagina/uterus achieved their desired family rural areas, on the other hand, 13% Herbal/other p reparation inserted into vagin a/ut er us size. 1 In addition, many traditional birth attendants are Acupuncture unmarried women undergo the estimated to perform more 25% procedure because they wish to than four-fifths of abortions. Magic continue their education before Altogether, nearly half of all Abortions performed at service delivery points, 2000 getting married. In one study, women seeking abortion in only 4% of abortion clients Indonesia turn to traditional Notes: D&C=. Percentages do not total 100 because of rounding. Source: Reference 1.

Abortion in Indonesia 2 Guttmacher Institute The rate of complications from procedure itself; the broader Many Indonesians are who have an unmet need for unsafe abortion is likely far costs, including loss of income in need of effective contraception are relatively higher than that of deaths. and the price of postabortion contraception. unlikely to oppose contracep - Again, the rate for Indonesia is care; the physical and mental While contraceptive use has tion or to face opposition from unknown, but in Southeast trauma to the woman; the been on the rise in Indonesia their husbands about contra - Asia, it is estimated that three social costs, including stigma for most of the past two ceptive use, but they are more out of every 1,000 women aged and isolation; and the decades, there has been likely to cite concerns about 15–44 are hospitalized each expenses to the health care relatively little change since health risks or side effects year for abortion-related system and society. Most of the mid-1990s (Figure 3). 6,13 associated with contracep- complications. 12 This translates these costs are difficult to Many married women (61%) tives. 15 Given the prevalence of to about 130 hospitalizations measure; the available data use contraceptives and 57% these concerns, many women for every 1,000 women who primarily address the monetary use a modern method (not would likely benefit from obtain an unsafe abortion. The costs to women and their shown), but nearly one in 10 contraceptive services that true complication rate, which families. are not using any method even offer a full range of methods, includes complications for though they are fertile and do provide education on contra - which women do not seek A clinic-based study conducted not want a child soon or at all. ceptive use and options, and treatment at a hospital, is in 2004 measured the total This level of unmet need for include thorough counseling to believed to be much higher cost of pregnancy termination contraceptives among married help women identify accept - than the hospitalization rate. among clients, many of whom women has remained constant able methods. The most common abortion had made at least two for more than a decade. complications are severe attempts to terminate their Evidence from developing Religion influences views bleeding, infection and pregnancy before going to the countries indicates that the on abortion in Indonesia. poisoning from substances used clinic. 11 Including transporta - vast majority of unintended In Indonesia, religion helps to induce abortion; many tion costs and the direct pregnancies occur among shape public opinion on issues women also experience genital expenses incurred during each women with an unmet need, 14 such as abortion. A recent and abdominal injuries and attempt, the women paid and this has been corroborated survey of 105 Muslim, Catholic uterine perforation. 9 between 530,000 and 3.6 by research in Indonesia. 1 and other Christian religious million rupiah (Rp) apiece to Sexual activity and contracep - leaders in Yogyakarta illumi - Because so many abortions in terminate their pregnancy. The tive use among unmarried nates the stances on abortion Indonesia are performed by mean cost was Rp1.2 million, a women have not been studied of Indonesia’s main religious unskilled providers and an significant expense given that at the national or regional groups. 16 While not nationally additional unknown number are the respondents’ average level in Indonesia. representative, the study self-induced, the rates of both income was Rp2 million per indicates the presence of medical complications and month. Compared with their counter - multiple views on abortion, maternal deaths from unsafe parts in other developing some of which are less conser - abortion are expected to be According to a separate study countries, women in Indonesia vative than the national policy. high. And because abortions conducted in 2000, abortions performed by lay providers tend performed by skilled providers to be less costly than those can cost many times more than Experiences of Unsafe Abortion performed by health care those performed by traditional In-depth interviews with 50 disadvantaged women about their experience professionals under hygienic birth attendants. Traditional with abortion provide insights into the risks women take to terminate a preg - nancy. 1 One woman described the following scene: “First, my belly was mas - conditions, poor women—who providers charged Rp7,000– saged, from slow to really hard and painful massage. Then my legs were bent may not be able to afford the 350,000 to perform abortions, and the witch doctor inserted her fingers into my vagina and scraped the services of a trained provider— while midwives charged inside all over. When she took her hand out, I felt something coming out from likely suffer a disproportionate Rp35,000–526,000, doctors at my vagina, and I felt so weak. An hour later, I was given a concoction and…given a massage again. It made me scream, because I couldn’t bear the share of abortion complications hospitals charged Rp420,000– severe pain….After 10 minutes, the witch doctor stopped her activity and (see box). 876,000 and doctors in private again I felt something coming out of my vagina.” practice charged Rp700,000– 1 Another woman shared the experience of her close friend: “After drinking the Unsafe abortion can 1.8 million. concoction from a witch doctor, she felt a terrible headache. It was so terri - be costly. ble that she knocked her head on the wall repeatedly because she couldn’t The costs of unsafe abortion stand the pain. Then her condition got worse; she was having a fever, a high can be viewed from many temperature, and after she was given a massage on her abdomen, blood started to come out and it kept coming out more and more….She was in pain angles: the money paid for the and getting weaker, then she finally died.”

Abortion in Indonesia 3 Guttmacher Institute Figure 3 Need for Contraception In addition, in-depth research of reducing the maternal Although contraceptive use in Indonesia has increased, one in 10 on women’s experiences—the mortality ratio by three- women continue to have an unmet need for contraception. obstacles that limit their quarters between 1990 ability to use contraceptives and 2015: 100 effectively, the decision- 21 18 9 38 31 30 making process they undertake • Preventing unintended 4 10 35 33

– 80 5

1 in the face of an is the first step d e

g pregnancy, their attitudes toward reducing the number of a 60 n toward abortion and the steps unsafe abortions. The govern - e m

o they take to terminate a ment should identify steps w 40 50 55 57 60 61 d

e pregnancy—would help leaders needed to end the stall in i r r

a understand and respond to the family planning uptake, reduce m

f 20 o problems women face in their unmet need for contraception % efforts to control their fertility. and promote investments in 13 10 9 9 9 0 1991 1994 1997 2003 2007 family planning services at the Assessments of the costs of district level. These efforts No need Me t need Unmet need (contr aceptive unsafe abortion—both should ensure that women prevalence) monetary and social—to have accurate information on a

Note: Percentages may not total 100 because of rounding. Source: Indonesia Demographic women, their families, health range of contraceptive meth - and Health Surveys. care systems and the govern - ods, including their possible ment are also essential to side effects. The majority of religious for up to 120 days after understanding unsafe abor - leaders (82%) agreed that conception, while followers of tion’s impact on society. • Providing information and abortion is acceptable if a Syafi’i believed that abortion education on reproductive woman’s life is in danger. 16 must only take place within 40 Furthermore, policymakers in health and sexuality to young Many reasoned that a woman’s days of conception. Indonesia would benefit from men and women can go a long life is more important than the comparing Indonesia to other way toward helping them fetus’s, because she is needed More information Muslim countries with regard understand the risks associated to look after the children and is needed. to abortion incidence, rates of with unprotected intercourse, family she already has. It is clear that large numbers complications and maternal and toward preventing of Indonesian women experi - mortality resulting from unwanted pregnancies that Muslim leaders, while primarily ence unintended pregnancies abortion, and policies and could lead to abortion. conservative, tended to have a and that many of them seek to programs intended to reduce Sexuality education is a more tolerant stance on avoid unwanted childbearing unsafe abortion. controversial issue, but it is abortion than their Christian by resorting to abortion. worth noting that some counterparts. 16 For instance, However, the exact incidence programs already provide such while most leaders did not of these events and the Policymakers must take the next steps to end education through midwives agree that abortion was severity of the consequences of unsafe abortion. in rural communities and justified if the pregnancy would unsafe abortion are unknown. Even as the body of research through Islamic schools and interfere with a woman’s The greatest research priority, on abortion grows, unsafe organizations. schooling or affect her psycho - according to policymakers, abortions will continue to pose logical health, a higher program providers and other a threat to Indonesian • Women who seek abortions proportion of Muslim than stakeholders in the country, is women’s health and well-being, that are allowed by Indonesian Christian leaders supported to obtain up-to-date, national and will continue to add law because their pregnancies abortion on these grounds. No data on the incidence of untold numbers to maternal are life-threatening should be Christian leaders supported abortion and on maternal deaths and hospitalizations in able to obtain safe procedures. terminating pregnancies morbidity and mortality the country, unless adequate The World Health Organiza- following contraceptive failure, resulting from unsafe abortion steps are taken to prevent tion’s recommendations for but some Islamic leaders in Indonesia. Subnational them. The following sugges - ensuring that safe abortion is considered this acceptable. estimates of these events are tions aim to help the available to the extent allowed Among Muslim leaders, views also essential, in light of the Indonesian government prevent by law include training differed according to sect: recent decentralization of many unsafe abortion and meet the providers about safe and Followers of Imam Hanafi government functions. Millennium Development Goal aseptic abortion practice, considered abortion acceptable

Abortion in Indonesia 4 Guttmacher Institute ensuring the availability of REFERENCES 2005, pp. 65–84 (in Indonesian) . CREDITS needed equipment and supplies, 1. Utomo B et al., Incidence and 12. Singh S, Hospital admissions This In Brief was written by Gilda Social-Psychological Aspects of Sedgh and Haley Ball. The authors and promoting the use of the resulting from unsafe abortion: Abortion in Indonesia : A thank Akin Bankole, Leila Darabi safest methods for first- estimates from 13 developing Community-Based Survey in 10 Major countries, Lancet, 2006, and Susheela Singh, all of the trimester abortions, including Cities and 6 Districts, Year 2000, 368(9550):1887–1892. Guttmacher Institute, for their and manual Jakarta, Indonesia: Center for comments and suggestions. They 13. BPS and ORC Macro, Indonesia vacuum aspiration. 17 Health Research, University of also thank the following reviewers Indonesia, 2001. Demographic and Health Survey for their invaluable input on 2007 Preliminary Report, Jakarta, earlier drafts of this report: Dr. 2. World Health Organization • It can be useful to consider Indonesia: BPS and ORC Macro, Djajadilaga, Indonesian Obstetrics (WHO), Unsafe Abortion: Global and new policy options to reduce 2008. and Gynecology Association; Laily Regional Estimates of the Incidence Hanifah, Mitra Inti Foundation; unsafe abortion. These could of Unsafe Abortion and Associated 14. Singh S et al., Adding It Up: Pilar Jimenez, Ford Foundation, include reconsidering the Mortality in 2003, fifth ed., Geneva: The Benefits of Investing in Sexual Indonesia; Budi Utomo, Center for conditions under which women WHO, 2007. and Care, New York: The Alan Guttmacher Health Research, University of can obtain legal abortion and 3. Health Law 23/1992 (1992). Institute, 2003. Indonesia; Iwu Utomo, Australian the steps they need to take to Demographic and Social Research 4. Sedgh G et al., Induced 15. Sedgh G et al., Women with an obtain approval for such abortion: estimated rates and Institute, Australian National unmet need for contraception in University; and Ninuk Widyantoro, abortions. trends worldwide, Lancet, 2007, developing countries and their 370(9595):1338–1345. Indonesian Women’s Health reasons for not using a method , Foundation. • Postabortion care should be 5. United Nations Department of Occasional Report, New York: Guttmacher Institute, 2007, No. 37. made easily accessible so that Economic and Social Affairs, Suggested citation: Sedgh G and Population Division , World women who experience compli - 16. Andari B et al., Abortion from Ball H, Abortion in Indonesia, Population Prospects: the 2006 the Perspectives of Various Religions, In Brief, New York: Guttmacher cations from unsafe abortion Revision , New York: United Nations, Yogyakarta, Indonesia: Ford Institute, 2008, No. 2. receive prompt treatment. Such 2007. Foundation and Center for care should be comprehensive 6. Badan Pusat Statistik (BPS) and Population and Policy Studies, ©Guttmacher Institute, 2008 and include contraceptive ORC Macro, Indonesia Demographic University of Gadjah Mada, 2005 counseling, services and and Health Survey 2002–2003, (in Indonesian). supplies. To ensure that all Calverton, MD, USA: BPS and ORC 17. WHO, Safe Abortion: Technical Macro, 2003. health centers that provide and Policy Guidance for Health Systems, Geneva: WHO, 2003. postabortion care use safe 7. Widyantoro N and Lestari H, Counseling-Based Safe Termination techniques, it has been 18. Department of Community of Unwanted Pregnancies , Jakarta, Medicine, University of Indonesia, suggested that medical school Indonesia: Women’s Health Study Report: Post Abortion Care curricula include training on Foundation , 2004 (in Indonesian) . Assessment , Jakarta, Indonesia: the use of manual vacuum 8. Indonesian Planned Parenthood University of Indonesia, 2008. aspiration, and that all Association (IPPA), Retrospective facilities have access to Study on Menstrual Regulation in 9 BOX REFERENCE Cities in Indonesia: 2000–2003, continuous technical assistance 1. Thanenthiran S and Khan A, Jakarta, Indonesia: IPPA, 2005. and replenishment of the eds., Rights and Realities: 9. Grimes DA et al., Unsafe Monitoring Reports on the Status of equipment needed for this abortion: the preventable pan - Indonesian Women’s Sexual and technique. 18 demic, Lancet, 2006, Reproductive Health and Rights , 368(9550):1908–1919. Kuala Lumpur, Malaysia: Asian- Pacific Resource & Research Centre 10. WHO, Unsafe Abortion: Global for Women, 2008. and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000, fourth ed., Geneva: WHO, 2004. 11. Sucahya PK, The cost to terminate pregnancy based on clients’ perspective and service delivery, in: Mitra Inti Foundation , Recent Findings on Regulating Unwanted Pregnancy : A One -Day Seminar Proceeding , Jakarta, Indonesia: Mitra Inti Foundation,

Abortion in Indonesia 5 Guttmacher Institute Advancing sexual and reproductive health worldwide through research, policy analysis and public education

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Abortion in Indonesia 6 Guttmacher Institute