Ipas ICPD Book.Qxd

Advancing reproductive health as a human right: Progress toward safe abortion care in selected Ipas Asian countries since ICPD Advancing reproductive health as a human right: Progress toward safe abortion care in selected Asian countries since ICPD

Leila Hessini

Ipas © Ipas 2004

Ipas 300 Market Street, Suite 200 Chapel Hill, NC 27516 USA Tel:+1-919-967-7052 Fax: +1-919-929-0258 E-mail: [email protected] Website: www.ipas.org

ISBN: 1-882220-76-5

Suggested citation: Hessini, Leila. 2004. Advancing reproductive health as a human right: Progress toward safe abortion care in selected Asian countries since ICPD. Chapel Hill, NC, Ipas.

Edited by: Jill Molloy & Kezia Scales Design: Rachel Goodwin Layout:Valerie Holbert Printed by: Graphics Ink, Durham, NC, USA

Cover photograph: Courtesy of the David and Lucile Packard Foundation

This publication may be reproduced in whole or in part, without permission, provided the material is distributed free of charge and the publisher and authors are acknowledged.

The photographs used in this publication are for illustrative purposes only; they do not imply any particular attitudes, behaviors, or actions on the part of any person who appears in the photographs.

About Ipas Ipas is an international nongovernmental organization that has worked for three decades to reduce abortion-related deaths and injuries; increase women’s ability to exercise their sexual and reproductive rights; and improve access to reproductive-health services, including safe abortion care. Ipas’s global and country programs include training, research, advocacy, information dissemination and the distribution of reproductive-health technologies.

Printed on recycled paper. Table of Contents

Acknowledgements ...... 4 Executive Summary ...... 6 Unsafe Abortion and the ICPD ...... 7 Survey Methodology ...... 9 Introduction to the Region ...... 11 Violence against women ...... 11 Reproductive health and population planning ...... 12 Abortion ...... 13 Challenges to Implementing the Cairo POA ...... 15 Conceptual and structural challenges ...... 15 Underserved populations ...... 16 Poverty and financial barriers ...... 17 Increasing conservative trends ...... 17 Restrictive U.S. government policies ...... 18 A Regional Assessment of Progress ...... 20 Clear indicators and research ...... 20 Presence of effective policy entrepreneurs and national organizing efforts ...... 21 Organizing prominent events and public awareness activities ...... 23 Policy and legal alternatives ...... 24 Postabortion care ...... 24 Elective abortion services ...... 25 Country Highlights ...... 27 India ...... 27 Indonesia ...... 31 Malaysia ...... 34 Nepal ...... 37 The Philippines ...... 43 Thailand ...... 40 Conclusion ...... 46 The Unfinished Agenda: Moving Forward Until 2015 ...... 48 Notes ...... 50 Statistical Definitions and Acronyms ...... 50 Sources ...... 53

3 Acknowledgements

Ipas would like to thank the many colleagues who helped make this document possible. In particular, we thank the following individuals who spoke with us about progress since ICPD in the area of abortion in their countries:

India 1. Dr. R.N. Gupta, Chief, Social and Behavioral Research Unit, Indian Council of Medical Research 2. Dr. Shireen Jejeebhoy, Senior Program Associate, Population Council of India 3. Mr.A.R. Nanda, Executive Director, Population Foundation of India 4. Ms.Vimala Ramachandran, Managing Trustee and Joint Coordinator, HealthWatch Trust 5. Ms. Sudha Tiwari, Executive Director, Parivar Seva Sanstha 6. Dr. Leela Visaria,Professor, Gujarat Institute for Development Research (GIDR) 7. Dr. Nozeir Sheriar, Chairperson, MTP Committee, Federation of Obstetrics and Gynaecological Societies of India 8.Anonymous 9.Anonymous 10.Anonymous

Indonesia 1. Dr. Meiwita Budi Harsana, Community Resource Development Officer, the Ford Foundation 2. Dr. Ramona Sari, Head of Reproductive Health Division, Perkumpulan Keluarga Berencana Nasional (PKBI) 3. Ms. Maria Ulfah, Chairperson, PP Fatayat NU 4. Dr. Sri Hermiyanti MSc, Director of Family Health, Department of Health 5. Ms. Neng Rina, Community Leader, Karawang,West Java 6. Ms. Ninuk Widiantoro, Chairperson,Women’s Health Foundation

Malaysia 1. Dr.Ang Eng Suan, Executive Director, Federation of Family Planning Associations 2. Ms. Ivy Josiah, Executive Director,Women’s Aid Organisation 3. Dr. Milton Lum, the International Federation of Gynecology and Obstetrics (FIGO), Assunta Hospital 4. Ms. Rashidah Abdullah, Executive Director, the Asian Pacific Resource and Research Center for Women (ARROW) 5. Dr. Raj Karim, Regional Director, International Planned Parenthood Federation, East and Southeast Asia and Oceania Region (IPPF-ESEAOR) 6. Dr. Ravindran Jegasothy, Chairperson of Ethics Committee, Consultant Obstetrician and Gynaecologist, Malaysian Medical Association 7. Ms.Yeoh Yeok Kim, Programme Officer, United Nations Population Fund (UNFPA), Kuala Lumpur

Nepal 1. Ms.Anjana Shakya, Executive Director, Beyond Beijing Committee 2. Ms. Sirjana Shah, Beyond Beijing Committee ,Women’s Health Rights and Advocacy Partnership (WHRAP) 3. Ms. Renuka Gurung, Programme Manager, Center for Research on Environment, Health and Population Activities (CREHPA)

4 4. Dr. Nirmal K. Bista, Director General, Family Planning Association of Nepal 5. Ms. Pinky Singh Rana, Rural Women’s Development and Unity Centre (RUWDUC) 6. Ms. Sapana Pradhan-Malla,Advocate and President, Forum for Women, Law and Development (FWLD) 7. Dr. Laxmi Raj Pathak, Director, Family Health Division, Department of Health Services, Ministry of Health 8.Anonymous

Thailand 1. Ms. Pornpich Patanakullert, Member of Parliament 2. Ms. Nattaya Boonpakdee (Pheung), Secretary General,Women’s Health Advocacy Foundation (WHAF) 3. Mr. Montri Pekanan , Deputy Executive Director, Planned Parenthood Association of Thailand (PPAT) 4. Dr. Kritaya Archavanitkul,Associate Professor, Institute for Population and Social Research 5.Anonymous

The Philippines 1.Atty. Carol Austria, Executive Director,Womenlead Foundation 2. Dr. Sylvia Estrada-Claudio, Chairperson of the Board, Likhaan, Inc. 3. Dr. Mythyl Vallejera, Private Practitioner, Executive Director, Parola Outreach 4. Dr. Eden R. Divinagracia, Executive Director, Philippine NGO Council (PNGOC) on Population, Health and Welfare, Inc. 5. Mr. Jomar Fleras, Reach Out Foundation

Many other colleagues provided guidance and review of this report. Reed Boland provided important information regarding the abortion laws of the countries included in this survey. Sarah Packer helped gather statistical information referenced in the document. Ellen Mitchell provided guidance in the survey design.Additionally, we greatly appreciate the efforts of Shveta Kalyanwala,Angela Kuga Thas and Nani Zulminarni, who conducted the interviews and provided additional information and personal knowledge of women’s reproductive health in the Asian countries included in this report.

We would also like to thank Traci Baird, Barbara Crane, Bela Ganatra, Niki Jagpal, Mary Luke and Charlotte Hord Smith for their careful review and editing of this document.

5 Executive Summary

Abortion is one of the most common medical procedures in the world. Globally, women average one abortion during their reproductive years (Alan Guttmacher Institute (AGI), 1999). When performed by a skilled provider in an environment with appropriate medical standards, abortion is one of the safest medical procedures. However, close to half of all abortions are not performed under these desirable conditions and can be considered unsafe for women’s health (World Health Organization (WHO), 2003). In low-income countries, women have an average of one unsafe abortion during their reproductive years (Shah and Åhman, forthcoming, emphasis added); close to 70,000 women die annually as a result of these unsafe procedures. In Asia, unsafe abortions are a leading cause of death, and the region accounts for 50% of all global maternal deaths due to unsafe abortions (Shah, 2004).Thirty percent of the region’s maternal deaths occur in India, where abortion is legal (Shah and Åhman, forthcoming).

The international community first recognized unsafe abortion as a major public-health concern at the International Conference on Population and Development (ICPD) held in Cairo in 1994. Governments agreed that, in circumstances where they are legal, abortions should be safe, and that all women should benefit from life-saving postabortion care (PAC) services. In 1999, country delegates to the United Nations special session on review of ICPD implementation (ICPD+5) called on health systems to train and equip health-care providers and take other measures, in circumstances where abortion is not against the law, to increase women’s access to services (United Nations Population Information Network (POPIN), 1994; POPIN, 1999).While the language on abortion in the ICPD and ICPD+5 documents did not include a commitment to ensuring that safe, elective abortion care is guaranteed as a human right, it did stress the obligation of every government to ensure the provision of safe abortion in circumstances where it is legal and to address the array of reasons that lead women to experience unwanted pregnancies. Despite these commitments, it is estimated that over 200,000 women died from unsafe abortion in Asia in the first six years following the ICPD. That amounts to more than 34,000 deaths per year, with approximately four maternal abortion deaths occur- ring every hour (Global Health Council, 2002). For every death, countless women experience severe maternal morbidities as a result of unsafe abortion.

The goal of this report is to review implementation of the ICPD recommendations linked to safe abortion care through the experiences and opinions of key stakeholders in six select countries in the region: India, Indonesia, Nepal, Malaysia, the Philippines and Thailand.These countries were chosen because of their different approaches to abortion and reproductive- health issues, as well as the presence of civil society organizations interested in these issues. The illustrative examples in this report highlight the diversity related to reproductive-health and abortion laws, policies and services that exists across a purposively select sample of countries.As a result, none of these countries should be considered as representative of the region, given the incredible diversity and breadth of experience that exists across Asia.

In the six countries under review, the ICPD has undoubtedly served as a catalyst for increased discussion on family planning, reproductive health, and the status of women. Prior to 1994, the population policies of the six countries discussed in this report were typically characterized by the use of demographic targets, a focus on long-acting hormonal methods and sterilization, and dependence on donor funds (Corrêa, 2002). Since the ICPD, India, Indonesia and Thailand have all moved away from an emphasis on demographic targets in their population policies. Nepal has implemented a law with sweeping implications for women’s rights, and new reproductive-health bills have been proposed in the Philippines and Indonesia.

6 Governments and nongovernmental entities are working to highlight the magnitude and consequences of unsafe abortion. Networks and stakeholder groups have formed to seek solutions to the problem. Different aspects of abortion are being addressed at roundtables, conferences and public events. Groups have proposed and advocated for the expansion of policy and legal alternatives to restrictive abortion laws. Legislation and technical guidelines have been developed, and new technologies for safe abortion-related care are being introduced across the region. In addition to national-level activities, several regional initiatives and south- to-south exchanges have been launched.While all these activities are steps in the right direction, more needs to be done.

Policy and legal change often do not translate into the provision of comprehensive, affordable, high-quality abortion services.Various political, economic, medical, social and cultural barriers serve to limit women’s reproductive options. Gender discrimination, stigma and social taboos regarding women’s equality and autonomy affect all women, but especially adolescents, poor and unmarried women, and those who live in rural areas.These factors, combined with the presence of vocal and powerful religious and conservative entities, have rendered implementation of the ICPD abortion-care recommendations difficult in the six countries included in this report. However, most of these countries are also reviewing existing laws and policies, indicating their desire to go beyond the recommendations made in Cairo. Unsafe Abortion and the ICPD "In developing regions, a woman is likely to have on average about one unsafe abortion before reaching the age of 44 years” – Shah and Åhman, forthcoming. Unsafe abortion is a major public-health problem and constitutes a flagrant violation of women’s most basic human rights: the rights to health and life.While abortions have existed since time immemorial and are one of the most common medical procedures experienced by women around the world, the choices a woman has when faced with an unwanted pregnancy depend on her location in the world and her social class.

Close to half (20 million) of the total number of abortions performed each year are unsafe1, resulting in nearly 70,000 deaths and countless injuries. Most of these unsafe procedures take place in low-income countries where health services are often lacking and abortions are highly restricted by law and in practice. Globally, there is a greater discrepancy between developed and developing countries in terms of maternal mortality than for any other public-health issue, including immunization and HIV/AIDS (Cook et al., 2001). A Nepalese woman is 99 times more likely to die in pregnancy or childbirth than her Italian counterpart (Population Action International (PAI), 2001).The premature loss of women’s lives and health, the impact of this loss on families and communities, and the costs to already over-stretched health-care systems are especially unconscionable given that the provision of safe abortion services would be possible in most countries if political commitment, supportive policies and accessible services were in place.

A global consensus was achieved in Cairo at the 1994 International Conference on Population and Development (ICPD) about the importance of addressing sustainable development, population dynamics, reproductive health and women’s rights in an integrated manner.The process used to achieve global consensus around women’s reproductive rights during the ICPD was unprecedented.Through a series of collaborative meetings, extensive networking and intense negotiation, the global women’s movement worked closely with key government allies, progressive religious leaders and members of civil society to include the perspectives and needs

7 of diverse groups of women.Women’s groups based in the global South participated as never before in the regional meetings leading up to the ICPD as well as in the conference itself.

The Programme of Action (POA) agreed to in Cairo moved from an approach based on population policies designed to reduce women’s fertility and increase contraceptive prevalence rates, to one that embraces women’s reproductive health and individual choice.The POA is unique in that it is inherently a rights-based document that discusses women’s diverse roles and responsibilities and the broad range of factors that affect their lives. As a result, the POA addresses issues that have an impact on women’s reproductive options—such as sexuality, gender, male involvement, violence, female genital mutilation and unsafe abortion—that had not previously been addressed in an integrated manner by the international community.The recommendations that emerged from the ICPD include a set of objectives for policies, programs and budget allocations to be achieved by the year 2015.

One of the accomplishments of the ICPD was that, for the first time in a global forum, governments around the world agreed to address unsafe abortion as a public-health issue.This consensus builds on the recognition in human rights documents that women have the right to health and life and, as a result, the right not to have to risk their lives due to unprotected sexual acts, unwanted pregnancies or pregnancy complications. In 1999, country delegates to the UN special session on review of ICPD implementation called on health systems to train and equip health-care providers and to take other measures, in circumstances where abortion is not against the law, to increase women’s access to services (United Nations, 1994).

While the language on abortion in the ICPD and ICPD+5 documents did not include a commitment to ensuring that safe, elective abortion care is guaranteed as a women’s right, it did stress the moral obligation of every government to ensure the provision of safe abortion in circumstances where it is legal and to address the array of reasons that lead women to experience unwanted pregnancies. Despite these commitments, well over half a million women have died from unsafe abortions since the 1994 conference because the necessary changes have not been made.

“ Women are not dying because of diseases

we cannot treat. They are dying because

societies have yet to make the decision / Panos Stowers Pictures Chris

that their lives are worth saving.”

– Mahmoud Fathalla, MD, PhD, 1997

One of the reasons why maternal deaths have not decreased substantively since the ICPD is that, while the POA defines reproductive rights as “the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so,” it does not discuss the enabling conditions that women need in order to exercise this right. Feminist scholar Rosalind Petchesky puts it best when she says,“How can a woman avail herself of this right if she lacks the financial resources to pay for reproductive-health services, or the transport to get to them; if she is illiterate or

8 given no information in a language that she understands; if her workplace is contaminated with pollutants that have an adverse effect on pregnancy; or if she is harassed by parents, a husband or in-laws who will abuse or beat her if they find out that she uses birth control?” (Petchesky, 2003). Unwanted pregnancies and the unsafe abortions that often follow are among the most blatant examples of the extent to which economic, health and political systems do not recognize women’s needs and interests, and of the challenges faced by current family-planning and reproductive-health policies and programs.

ICPD paragraph 8.25 In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and all attempts should be made to eliminate the need for abortion.Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling.Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances in which abortion is not against the law, such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly which will also help to avoid repeat abortions. ICPD+5 paragraph 63iii …In circumstances where abortion is not against the law, health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health.

Survey Methodology In order to collect comprehensive, rich, high-quality information, 41 key respondents were identified in the following Asian countries: India, Indonesia, Nepal, Malaysia, the Philippines and Thailand. These countries were chosen for the following reasons: (1) they were all active in the ICPD process; (2) they have women’s nongovernmental organizations (NGOs) and medical groups working to improve family-planning and reproductive-health policies and programs; and (3) they provide examples of the diverse approaches that exist across the region with regard to abortion. Interviewees represent a variety of sectors, including multilateral and government organizations; medical and public-health groups; and women’s, human rights and legal associations. Interviews were conducted primarily by telephone; however, in some cases, person-to-person contact was made. Given the purposively selected sampling size of this survey, its results are solely illustrative and are used to demonstrate the variety of approaches to implementing the Cairo POA.The interviews took place from May through August, 2003.

This report reflects evidence and opinions from key stakeholders in six Asian countries regarding changes related to safe abortion care that have taken place since the 1994 ICPD and

9 its five-year review in 1999.The qualitative information gathered through the interviews has been supplemented with data and statistics supplied by the various respondents or gathered by the author.This report begins with an overview of the general challenges in implementing reproductive-health care in the region.The next section includes a regional presentation of common trends across the six countries under investigation, followed by country-specific examples of abortion policies and programs.The conclusion to this report offers suggestions for next steps and recommendations.

While several surveys on the overall recommendations in the POA have already been conducted, the particular focus of this survey is abortion, as it is one of the issues that has been the most neglected by the reproductive-health, safe motherhood, human rights and social justice movements.

10 Introduction to the Region Although this report focuses on national-level factors that influence the ability of governments and NGOs to implement the ICPD POA, local realities are influenced by global processes, policies and movements.Trade liberalization, structural adjustment programs and economic crises in Asia, for example, have negatively affected the availability of national public resources for social programs, such as health, environment, education, sanitary systems, and access to clean water, which are increasingly becoming privatized and less available to the poorest citizens (Third World Network, 2002; Samuel and Jagadananda, 2003).The economic crises that hit the region in 1997 have led to increased levels of absolute poverty and income inequities in India, Nepal and Indonesia (Knowles, 2000), and respondents in all six countries pointed to the economic barriers that limit implementation of the Cairo recommendations. Scarce government resources are being disproportionately allocated to military spending and debt serv- icing in several countries—Malaysia and Thailand are the only two countries in this report that contribute a greater percentage of their gross domestic product (GDP) to health than to the military—while donor funds are increasingly being used to fight disease in lieu of public-health and prevention programs.The growing power and influence of fundamentalist religious institutions and organizations, and other conservative ideologies that promote an idealized notion of the family and of women’s and men’s roles therein, have also had an impact on women’s status and reproductive options in Asia.

Every year, US$780 trillion are spent on arms, compared to US$12

trillion spent on women’s reproductive health (Sendón de León 2001).

Basic maternal-care services can cost as little as US$2 per woman

(Safe Motherhood Inter-Agency Group, 1998).

Violence against women Globally, one in five women have been physically or sexually abused in their lifetime, most fre- quently by someone whom they know (WHO, 1997).While penal codes criminalize sexual violence in the majority of countries included in this report, legal definitions of sexual violence are outdated and refer primarily to sexual intercourse (involving penetration) outside of marriage (Center for Reproductive Rights (CRR), 2004). In India, for example, a married woman must be under the age of 15 for a nonconsensual act to be considered criminal (CRR, 2004).

Adolescents and young women are at an even greater risk of rape and sexual violence than adult women (United Nations, 2003). In Nepal, data from Kathmandu’s Maternity Hospital shows that 45% of rape victims who sought treatment from 1994 to 1997 were under the age of 19 (Ministry of Health, 1997).An analysis of police reports in Thailand demonstrates that 40% of rape victims in 1995 were girls under 15 years of age (Archavanitkul and Havanon, 1998).

Despite its prevalence, sexual violence often goes unreported and can lead to reproductive morbidity and mortality, adverse pregnancy outcomes, and unwanted pregnancies. A study in

11 Uttar Pradesh, India, reveals that women whose husbands force them into having sexual relations are close to three times as likely to experience an unwanted pregnancy as women who are not in coercive situations (Martin et al., 1999). In the Philippines, data from the National Safe Motherhood Survey indicates that of 848 women who had been abused, 24% experienced unwanted pregnancies as a result (Govindasamy and RamaRao, 1999).

The options for girls and women who experience unwanted pregnancies are limited in many Asian countries by the stigma and silence that surround discussions about sexual issues, as well as by gender discrimination and the taboos associated with pregnancy outside of marriage. Legal protection and health services for rape survivors are often nonexistent (CRR, 2004).Two of the direct consequences of rape and sexual violence are the possibilities of con- tracting HIV/AIDS and other sexually transmitted infections and experiencing unwanted pregnancies. Girls and women will go to extremes when faced with unwanted pregnancies, as demonstrated by a study in India of girls and women who chose to end their own lives instead of continuing what would have been perceived of as socially unacceptable pregnancies (Ganatra, 2003).

Global estimates show that two million girls are forced into becoming commercial sex workers each year (United Nations, 2003). Due to increased levels of poverty and the lack of viable economic opportunities, commercial sex work is on the increase in certain Asian countries. In India alone, one million women and girls are currently involved in commercial sex work, which has become one of the biggest and fastest growing illegal trades in that region (CRR, 2004).As prostitution is illegal in India, sex workers are alienated from their most basic rights, including legal protection, freedom from violence and access to comprehensive health-care services (CRR, 2004). Sex workers need access to reproductive-health information and services to ensure their protection from unsafe sex and unwanted pregnancies. Migration and cross-border trafficking of commercial sex workers is on the rise from countries like Nepal to India. Trafficking of women has received increased attention, resulting in the passage of anti-trafficking laws in India, Nepal, the Philippines and Thailand (Asian Pacific Resource and Research Center for Women (ARROW), 2003).

Reproductive health Figure 1 and population Estimated number of unsafe abortions planning (millions), 2000 While great diversity exists across the six countries included in this survey, their population policies before the ICPD were typically characterized by the use of demographic targets, a focus on long-acting hormonal methods and sterilization, and dependence on donor funds (Corrêa, 2000). Since the ICPD, India, Indonesia and Thailand have all removed demographic targets from their population policies. Nepal has implemented a law with sweeping Source: Åhman and Shah, 2002 implications for women’s rights,

12 Figure 2 and new reproductive-health bills have been proposed in the Percentage of unsafe abortions by region, Philippines and Indonesia. 2000 4% In five of the six countries selected for study, the majority of women receive prenatal care. Nepal is the 19% exception, with only 24% of women receiving prenatal services. 55% In Nepal, 11% of births are attend- 22% ed by skilled health personnel; the figures stand at 43% for India, 56% for Indonesia and the Philippines, 85% for Thailand, and 96% for Source: Åhman and Shah, 2002 Malaysia. Contraceptive prevalence rates are close to 50% in India and the Philippines, 57% in Indonesia, 72% in Thailand, and 39% in Nepal.Total fertility rates remain high in Nepal at 4.3; in India and the Philippines the rates are 3.0 and 3.2, respectively. Indonesia and Malaysia are close to replacement fertility at 2.4 and 2.9, and Thailand is just under at 1.9 (United Nations Development Programme (UNDP), 2003).

While the World Health Organization (WHO) recommends that public-health expenditures account for 5% of national GDP,all the countries included in this survey are far below that figure. India, for example, has one of the lowest levels of public expenditure on health care in the world, and services in that country are increasingly becoming privatized (Third World Network, 2002). Indian citizens finance close to 80% of all health-care expenditures through user fees and the direct purchase of medical supplies.As a result, health care is the primary cause of debt among poor Indian households (Samuel and Figure 3 Jagadananda, 2003). New research since the ICPD clarifies the link Percentage of maternal deaths due to between poverty and poor mater- unsafe abortions by region, 2000 nal health (Graham et al., 2004). 6% Abortion Every year in Asia, 10 million 50% women undergo unsafe abortions 44% and 50% of all global maternal deaths due to unsafe abortions occur (Åhman and Shah, 2002). In the first six years following the ICPD, 204,190 women died from Source: Åhman and Shah, 2002 unsafe abortion in Asia.That amounts to 34,032 deaths per year or close to four maternal deaths from abortion every hour (Global Health Council, 2002). Despite the high prevalence of abortion, a great deal of diversity exists across the region related to abortion laws and policies.While abortion is legal on broad grounds in India and Nepal, abortion is outlawed in both the penal code and constitution of the Philippines. In Indonesia, Malaysia and Thailand, debates are taking place regarding whether and how to liberalize the existing restrictive laws. A common factor among the restrictive abortion laws and policies in Asia is that many are vestiges of colonial rule.

13 The example of India is important for the region as it points to the fact that liberalization of abortion laws, while important, is not sufficient unless it is accompanied by information, available and accessible services, and appropriate technology. In fact, changes in laws and policies are often not translated into the provision of comprehensive, high-quality, affordable abortion services. Political and economic factors in the region, combined with the presence of vocal and powerful religious entities, have led to infringements on women’s abilities to practice their reproductive options.And while Asia’s status as the region with the greatest prevalence of unsafe abortion indicates a great need to address the issue, stigma-free public discussions still remain taboo in many countries.

Figure 4 Grounds on which abortion is permitted, by country Fiji Iran India Nepal Turkey Bhutan Armenia Malaysia Pakistan Thailand Lao PDR Myanmar Viet Nam Indonesia Kyrgsztan Singapore Sri Lanka Cambodia Azerbaijan Uzbekistan Kazakhstan Philippines Bangladesh Afghanistan Papua New Guinea Turkmenistan Source: United Nations, 2001; UNFPA, 2003a

14 Why Women Choose Abortion Choose Why Women Challenges to In every part of the world, women who have had an Implementing the abortion give broadly similar reasons for their decision: Cairo POA To stop childbearing ● I have already had as many children as I want Conceptual and structural ● I do not want any children challenges ● My contraceptive method failed To postpone childbearing “They [policymakers] think that ● My most recent child is still very young ● I want to delay having another child reproductive health is family planning or Socioeconomic conditions maternal and child health, so they do not ● I cannot afford a baby now ● I want to finish my education see the need for a specific policy to ● I need to work full-time to support [myself or] my children address this issue.” Relationship problems – respondent from Thailand ● I am having problems with my husband [or partner] Respondents overwhelmingly noted that the con- ● I do not want to raise a child alone cepts of reproductive health and women’s need for ● I want my child to grow up with a father comprehensive services are neither well-under- ● I should be married before I have a child stood nor integrated in programs and policies in most countries. Maternal and child health and/or Age family-planning services are often identified as com- ● I think I am too young to be a good ponents of women’s reproductive-health care, but mother rarely, if ever, do definitions include the holistic ● My parents do not want me to have a approach that is outlined in the ICPD POA. In child some countries, population policies are still devel- ● I do not want my parents to know I am oped in a top-down fashion, focusing on contracep- pregnant tive prevalence rather than on women’s health, ● I am too old to have another child rights and options.While some governments have Health modified their policies to include language from the ● POA, this does not always translate into ameliorat- The pregnancy will affect my health ed services for women. Conceptual changes also ● I have a chronic illness need to be accompanied by structural changes, ● The fetus may be deformed including the decentralization of services and the ● I am infected with HIV implementation of successful programs on a nation- Coercion al level as well as the district level. Specific structur- ● I have been raped al changes that are needed will be discussed further ● in the Country Highlights section of this report. My father [or other male relative] made me pregnant The difficulty in understanding the concepts outlined ● My husband [or partner or parent] insists in the ICPD POA is coupled with the lack of aware- that I have an abortion ness of women’s diverse needs, interests and reali- Source: Alan Guttmacher Institute, 1999b ties. Respondents maintained that while abortion is

15 one of the most common practices experienced by women around the world, the pervasive stigma related to abortion in many parts of Asia prohibits open and needed discussions of the impact of unsafe abortion and the need for access to safe abortion services. It is essential for nations to adopt a continuum of care perspective—including access to family planning, emergency contraception, and other reproductive-health services—that moves beyond the provision of abortion simply as a medical procedure.Women-centered abortion care is an approach to providing services that takes into account the various factors that condition a woman’s individual health needs, as well as her personal circumstances and ability to access services.

Underserved populations “Consider the case of a single woman who goes to the public hospital for care. The path that she will have to negotiate is very challenging indeed due to the judgmental attitudes of health-care providers. As a consequence these women will not go to the public sector. They will go to the private sector. But if they can’t afford it [the private sector], then they won’t get medical treatment.”

– respondent from Malaysia Numerous survey respondents stressed the increasing need for reproductive-health services, including safe abortion, for adolescents, unmarried women, women living outside of urban centers and immigrant women. Several mentioned that there was a noteworthy gap between services available for married women and unmarried women—a group that can include adolescents, widows and divorced women. Unmarried women may not have access to reproductive-health and abortion services due to the following reasons: (1) they are explicitly excluded from abortion policies; (2) providers are reluctant to serve unmarried women and may demand spousal consent even when it is not required by law; and (3) social barriers preclude unmarried women from accessing services (see Country Highlights section on India). Due to the social stigma that is attached to pregnancies outside of marriage, adolescents often seek abortions for unwanted pregnancies at a later gestational age, which can potentially lead to greater obstetric complications, increased costs and fewer options.While many respondents stated that the use of self-induced abortions and procedures performed by unskilled providers had decreased for the general population, underserved cohorts of women may still be forced to resort to these options. Nepal’s recent law could serve as a model in this regard as it makes no distinction between married and unmarried women.

Many countries in the Asian region are experiencing increased migration, and the needs of immigrant women deserve further attention. Immigrant women may also be at higher risk for sexual violence, especially if they are in conflict situations. Respondents also highlighted the need to understand the power relations between providers and clients, especially for the most disadvantaged women, including tribal women and migrant workers.

16 Poverty and financial barriers “In the past we used to be forced to use a contraceptive device to prevent us from having more children. Nowadays, the contraceptive devices are more expensive and we can’t afford them.”

– respondent from Indonesia Poverty is a tremendous social barrier that acts in many ways to curtail access to reproductive-health care in Asia. Structural adjustment programs, often imposed on countries by world lending institutions to reduce external debt, either preceded or were introduced at the same time as the ICPD and have served to limit implementation of the recommendations outlined in the POA.While the private sector is often encouraged to fill in the gaps created by decreasing public-sector health services, this solution has not resulted in the provision of high- quality, affordable services for all.

While the awareness of the importance of family planning has increased in Asia, several respondents argued that the introduction of user fees in countries has led to a situation where contraceptives that used to be free are now too expensive for some women. For example, costs were said to have increased five-fold since donor provision of contraceptives was removed in countries like Indonesia. Many individuals and couples have been forced to use traditional methods of contraception that have higher failure rates. According to respondents, some women see more financial sense in taking a chance of becoming pregnant and then having an abortion, rather than paying exorbitant costs for contraceptives.

Increasing conservative trends “The [Catholic] Church has a very strong stand against population control, against contraception, against women’s reproductive rights and choice with abortion. And the Church strongly influences government policies in terms of contraception and women’s rights.”

– respondent from the Philippines The increased visibility, organization and impact of conservative movements whose goals are to block efforts to provide reproductive-health services, including abortion-related care, have greatly affected the implementation of ICPD-related recommendations in countries like the Philippines.The Catholic Church’s framing of abortion as morally condemnable severely limits open public discussion of abortion’s social consequences, the development of policies to com- bat unsafe practices, and the understanding of women’s diverse experiences with unwanted pregnancies. It also has a negative impact on health professionals’ willingness to provide appropriate care.The tactics used by Catholic organizations and institutions are diverse and include efforts to establish constitutional protection for the rights of the fetus from the moment of conception and to ban or prevent passage of legislation reforming restrictive laws and policies.

Fundamentalist interpretations of Islam influence Muslim discourse in Asia, as was mentioned by respondents who discussed the use of shari’a (“Islamic law”) in Malaysia and Indonesia.

17 Certain groups in those two countries are working to highlight the diversity of opinion in Islamic thought about the permissibility of abortion. Unlike Catholicism, life does not begin at conception in many Muslim traditions, but at ensoulment of the fetus which takes place between seven and 120 days.

Restrictive U.S. government policies “[The Global Gag Rule] creates a penumbra of messages that affect national policies. Donors will not participate in any activity that has the word abortion in it, even though it is legal in India.”

– respondent from India While the United States supported reproductive-health language during the ICPD, the Bush administration reversed this position in 2001 and made significant changes in U.S. support for the POA.

For example, at the Fifth Asian and Pacific Population Conference held in Bangkok in December 2002, the US delegation attempted to undermine regional consensus by refusing to reaffirm its commitment to the ICPD POA. All the Asian government delegates, however, rejected the United States’s intimidation and restated their commitment to the ICPD recommendations. A number of survey respondents mentioned their disappointment at U.S. attempts to both undermine global consensus and divide countries in the Asian region.

In January 2001, on the second day of his presidency, President Bush reinstated the Mexico City policy, also known as the Global Gag Rule (GGR).Through this policy, organizations that receive U.S. family-planning funds cannot perform, advocate for, or provide medical counseling or referrals for abortion services, even when those activities are supported by their own (non-U.S.) funds and are lawful under their national, sovereign legislation. In this manner, the United States is controlling what NGOs can accomplish with both their own funds and donor money (Global Gag Rule Impact Project, 2003).The impact of this policy is particularly great because the United States is the biggest bilateral donor in the fields of family planning and reproductive health.

Almost all of the respondents from the six countries highlighted the negative impact of the GGR on their work.The Family Planning Association of Nepal (FPAN), the largest NGO in Nepal, provides much needed sexual- and reproductive-health services.While this organization does not provide abortion services, it is involved in advocacy related to women’s rights and abortion and, as a result, was forced by the GGR to give up funds from the U.S.Agency for International Development (USAID).The majority of respondents rated the current U.S. administration’s anti-choice and anti-global positions as having a strong influence on abortion in Indonesia. In India, programs and projects that work on a comprehensive approach to reproductive-health care, including abortion, have been de-funded because of the GGR. One respondent underscored the impact on her organization’s work by noting the mixed messages that are a result of the GGR in a country like India: abortion is legal in India, yet the position of the U.S. administration reinforces abortion as a taboo subject.

The Global Gag Rule (GGR) punishes countries that would like to reform abortion laws as well as countries that already recognize women’s right to end an unwanted pregnancy. Not

18 only is the GGR unethical, but it would be unconstitutional if applied domestically. It goes against basic democratic principles such as free speech and free association. In addition, it dis- criminates against a particular point of view, restricts public education and sharing of information, and impinges on women’s rights to participate as full citizens in their respective countries (CRR, 2003b).

19 A Regional Assessment of Progress

Despite the significant challenges to implementing the recommendations outlined in the ICPD POA, reproductive health and rights in the region have received increased attention since the Cairo conference.The following sections in this report offer a regional assessment of progress based on a framework for change that was developed by Jeremy Shiffman to address safe motherhood in Indonesia (Shiffman, 2003).The components of the framework are:

1. Clear indicators that help mobilize attention and demonstrate that a problem exists;

2.The presence of effective policy entrepreneurs committed to addressing the problem;

3.The organization of prominent attention-generating events that raise widespread awareness of the problem;

4.The availability of feasible policy alternatives to effectively deal with the problem.

A fifth factor—the availability of high-quality postabortion and elective abortion care and services—has been added for the purposes of this report.

Of the six countries represented in this survey, most have adopted new policies to conform to the ICPD consensus. Governments and nongovernmental entities are working to highlight the magnitude and consequences of unsafe abortion. Networks and stakeholder groups have formed to address the problem. Different aspects of abortion are being addressed at roundtables, conferences and public events. Groups have proposed and advocated for the expansion of policy and legal alternatives to restrictive abortion laws. Legislation and technical guidelines have been developed, and new technologies for safe abortion-related care are being introduced across the region.While all these activities are steps in the right direction, more needs to be done. Clear indicators and research Measuring the impact of unsafe abortion is difficult due to the lack of reliable data, insufficient methodologies and the stigma associated with its practice. Nevertheless, NGOs and individuals with research skills have been identified by women and health advocates in each of the six countries under review to consolidate existing information on government programs and policies related to abortion and reproductive health. Drawing on a wide array of civil society and government materials, these NGOs and individuals have developed useful tools for activists, scholars and educators interested in underscoring the widespread impact of unsafe abortion and challenging national policies.

NGOs have initiated research projects to document the human rights abuse and social injustice of unsafe abortion in countries like Nepal (CRLP and FWLD, 2002) and the magnitude and consequences of unsafe abortion in Indonesia (Widyantoro and Lestari, 2003).The Nepal study, based on interviews with 19 women imprisoned on abortion-related charges, was instrumental in advocating for legal change in that country.The Indonesia report underscores the unmet need for access to safe abortion services for all women in Indonesia and highlights the specific needs of married women.The study reports that the vast majority of women seeking abortions (78%) are married and are supported by their husbands in their decision to have an abortion.These women opt for abortion after contraceptive failure, for socio-economic reasons, or because they are physically or emotionally too exhausted to continue a

20 pregnancy.The study also points to the increase in illegal abortions due to the rise in contraceptive costs in that country.

A nationwide survey on induced abortion was conducted in Thailand using hospital data cov- ering a period of 12 months in 1999.The goals of this study were to obtain abortion-related statistics, understand contributing factors and preventive measures, and develop recommendations for abortion-related policies and guidelines.The study demonstrates that unsafe abortions in Thailand are a major problem that primarily affects young women: of all the induced abortion cases in 1999, close to 47% were adolescents. One of the key recommendations of this study is to expand women’s access to safe services by reducing the medical restrictions on and expanding the indications for abortion (Warakamin and Boonthai, 2003). Research produced by the Women’s Health Advocacy Foundation (WHAF) on women who were hospital- ized for incomplete abortions was discussed by respondents. In that study, women only received the most basic postabortion care (PAC) services—they were neither properly coun- seled nor did they receive any postabortion family-planning services. In addition, dilatation and curettage (D&C) was often used to treat incomplete or unsafe abortions rather than the safer method of vacuum aspiration.

The Abortion Assessment Project (AAP) was founded in 2001 to conduct research on the status of abortion in India. Results from a facility-based survey point to the medical barriers to providing safe, legal abortions in that country. Research findings demonstrate that 68% of providers are not certified, licensed facilities account for only 24% of all private abortion services, and D&C is the preferred method in 89% of induced abortions (Duggal and Ramachandran, 2004). Social barriers also play a role, as women are often refused services if they travel alone or if a spouse or relative does not provide consent for the abortion.

While the Medical Termination of Pregnancy (MTP) Act in India includes a range of indicators for safe abortions, a study on women’s reasons for needing abortion services reveals that in only 15% of the cases did women need abortions for legal indicators. Eight qualitative studies further confirmed that women use abortions as a family-planning method to limit family size instead of modern methods such as intrauterine devices (IUDs) and oral contraceptives, which they are either unable to obtain or unlikely to use due to beliefs concerning their negative impact on health and safety (Duggal and Ramachandran, 2004).The AAP studies also draw attention to the gross imbalance in the provision of public versus private services in India: 87% of the abortions are provided in the private market where costs are 7.5 times greater on average than in public facilities. Presence of effective policy entrepreneurs and national organizing efforts One unique aspect of the ICPD has been the diversity of approaches taken to advocate for the implementation of the recommendations agreed to at that meeting. Groups have developed multiple approaches using public health, women’s rights and social justice angles to create spaces for dialogue and exchange, promote advocacy efforts, and ultimately engender positive changes. Networks and groups have formed across the region to address unsafe abortion, and public events have been organized to discuss strategic and practical approaches to dealing with unsafe abortion.

The types and number of stakeholders involved in women’s reproductive-health issues have expanded in Asia since the ICPD, and include women’s health and rights activists, lawyers, medical professionals, policymakers and religious leaders. Increasing numbers of groups are

21 using international consensus documents such as the ICPD POA to advocate for improved national-level policies, and to educate and influence those individuals who are not aware of the recommendations in these documents.

Working from a women’s rights perspective, NGOs in Nepal used both the ICPD language and Recommendation 19 of the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) to argue for broad changes in women’s status.They supported a sweeping women’s rights bill that covered issues of women’s property rights, inheritance, divorce and abortion.The Abortion Task Force (ATF) was created by the Family Health Division in the Ministry of Health (MOH/FHD) before the law was passed to prepare for its implementation.The ATF began by soliciting technical advice from local and international experts to avoid the mistakes made in other countries that have resulted in procedural and structural barriers to women’s access.As a result, the ATF has identified solutions to potential barriers to access that women face in countries such as Bangladesh, India, South Africa and the United States. Other preparatory steps included conducting an extensive literature review of abortion, developing a safe abortion policy, drafting the procedural order and developing a two-year implementation plan.

After a stakeholder’s meeting in early 2002, the ATF was replaced by the Technical Committee for Implementation of the Comprehensive Abortion Care program (TCIC), also headed by the MOH/FHD, which is in charge of leading the implementation plan and ensuring the quality of the safe abortion program. Diverse members comprise this committee, including other governmental units, such as the National Health Training Center, and the following national-level NGO groups: the Center for Research on Environment, Health and Population Activities (CREHPA), the Family Planning Association of Nepal (FPAN), the Nepal Safer Motherhood Project (NSMP), and the Nepal Society of Obstetricians and Gynaecologists (NSOG). International organizations, such as the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) and Ipas, are also members of the TCIC.The goal of the TCIC is to ensure implementation of the abortion law by strengthening the health-care system; this includes guaranteeing the development and monitoring of the "listing" procedure to approve trained providers in the provision of comprehensive abortion care. In addition, Ipas supported the design and opening of the first safe abortion unit in Nepal at Maternity Hospital in Kathmandu.This unit is the main training unit for providers in the country and also serves to train regional staff and trainers.

In other countries, coalitions have been created among key stakeholders, such as medical groups, women’s rights activists and researchers, to develop dialogue and partnerships around abortion issues. In India, the AAP was designed along these lines and is coordinated by the organizations Healthwatch, a national advocacy network of NGOs, and the Center for Enquiry into Health and Allied Themes (CEHAT), a leading research and advocacy-based NGO. Key objectives of the AAP are to review government policies, assess and analyze abortion services, and research users’ perspectives with a focus on women’s needs (CEHAT, n.d.).

In Malaysia, the NGO Coordinating Committee for Reproductive Health—a major umbrella committee that advocates for increased access and quality of health services, including sexual- and reproductive-health services—was created after the ICPD. Since its inception, this committee has organized a series of nationwide conferences that have included discussions about the reproductive rights and health of Malaysian women (2002), the needs and perspectives of youth (2002), and men as partners in sexual and reproductive health (2003).They have also developed an advocacy framework focused on promoting men’s responsibility and participation in the area of sexual and reproductive health and a gender training manual.

22 Respondents highlighted the importance of working with religious leaders in both Malaysia and Indonesia to dispel the myth that religion does not support abortion. For example, in Malaysia, different interpretations of shari’a are being used on a district level to either support or limit women’s rights.To challenge restrictive interpretations, women’s groups have invoked the right that all Muslims benefit from: the right to ijtihad (“interpretation”) of Islamic texts. They have used this right to show that Islam does support women’s rights to contraception, family-planning services, and abortion in some cases. In Indonesia, the Women’s Health Foundation (WHF), a coalition of women’s groups, obstetricians and gynecologists (ob-gyns) and medical associations, has incorporated progressive religious groups into its discussions on women’s reproductive health and abortion. In addition, advocates living in Muslim regions have used examples from other predominately Muslim nations that have liberalized abortion laws, such as Tunisia and Turkey2.

In the Philippines, women’s groups and health organizations have presented alternatives to conservative Catholic directives that limit women’s choices and rights, and have lobbied for reproductive-health issues since the ICPD, notably around the recent Reproductive Health Care Act. Organizing prominent events and public awareness activities Several events, including conferences and roundtables, were organized across the region to raise awareness of the ICPD recommendations and their implementation on a national level.

In India, the Ministry of Health and Ipas organized a national conference on making early abortions safe and accessible that was held in Agra in October 2000 (Ministry of Health and Family Welfare et al., 2000).The event was followed by the creation of an expert committee to develop guidelines on the use of manual vacuum aspiration (MVA) in primary-health centers. As a follow-up to the national conference in Agra, state-level workshops were conducted in Orissa (October 2001), Bihar (November 2002) and Jharkhand (December 2002).Workshop participants included individuals from national- and state-level NGOs, members of professional associations, public-sector policymakers, and service providers from the field.The objectives of the state-level workshops were to assess abortion services in different states, to inform participants of national polices and initiatives addressing safe abortion, and to recommend strategies for increasing access to safe abortion across India. Key recommendations from that meeting include: (1) simplifying and decentralizing site certifications, (2) endorsing vacuum aspiration as the safest and most cost-effective choice for first-trimester abortion, and (3) training and certifying more practitioners.

In Nepal, women’s groups, legal experts and government officials began to meet on a regular basis following the ICPD to discuss gender-based discrimination and the need to liberalize abortion laws.As part of that process, key workshops, conferences and public debates were held to discuss women’s status and rights in that country. CREHPA has networked with 45 district-based NGOs in Nepal to implement its Public Education and Advocacy Project (PEAP), which has been aimed at preventing unsafe abortion practices and saving women’s lives since 1999.To build on these efforts, CREHPA initiated a new program in 2003 entitled sumarga (“right path”) in partnership with regionally based NGOs to create an enabling environment for women to make informed reproductive decisions and to make them aware of their options (CREHPA, 2003). In March 2002, the Forum for Women, Law and Development (FWLD) joined with a group of NGOs to organize a national conference to advocate for the gender equality bill presented to members of parliament. Following the conference, over 1,000 women and men marched in Kathmandu, led by the Ministers of Parliament.The following day

23 the gender equality bill, which includes the legalization of abortion, was passed with only one dissenting vote.

In Indonesia, the WHF has organized roundtables with religious leaders and professional medical organizations to discuss safe abortion and the importance of working with the parliamentarian committee on health to develop an alternative abortion law.The WHF organized a study tour in Turkey, a predominantly Muslim country, for these parliamentarians to discuss the process that led to Turkish legalization of abortion and to learn about the current state of abortion care in that country.

In Malaysia, groups like ARROW organized meetings with health-care providers and others to discuss the impact of unsafe abortion on different groups of women in that country. In Thailand, meetings were organized with government officials, NGOs, the Royal College of Obstetrician-Gynecologists and the Senate Committee on Health to distribute and discuss the results from the national survey on abortion. In the Philippines, a coalition of groups has held several public events to discuss the reproductive-health law. Policy and legal alternatives Several policy and legal changes—either directly or indirectly related to abortion and decreasing unwanted pregnancies—have been introduced across the region. In India, a national population policy was created in 2000 and a reproductive- and child-health program was subsequently developed.Amendments were recently made to the 1971 Medical Termination of Pregnancy Act, including: (1) decentralizing the registration process for facilities wishing to provide MTP services, (2) increasing penalties for unauthorized practitioners, and (3) replacing the word “lunatic” with “mentally ill.” Women’s groups lobbied unsuccessfully to drop the words “husband” and “married” from certain sections of the law, as the inclusion of these terms could prohibit unmarried women from being able to end unwanted pregnancies that are the result of contraceptive failure (see Country Highlights section on India).

In Nepal, members of Parliament overwhelmingly approved legislation in March 2002 to support a comprehensive set of women’s rights issues, including abortion on request through the first 12 weeks of pregnancy and through 18 weeks with some limitations.This law received the royal seal of approval in October 2002, and groups are now working to ensure that those legal changes actually translate into accessible services for women.

In Malaysia, health advocates are working to further expand the amendments made to the abortion law in 1989 to include rape and incest as indications for legal abortion.A consortium of groups in Thailand are working together to expand the indications for abortion in that country. In the Philippines, NGOs have worked to develop alternative legislation in the form of the Reproductive Health Law and, in Indonesia, a coalition of interested parties have proposed an alternative abortion law. Postabortion care Postabortion care (PAC) is the emergency treatment provided to women suffering from complications of unsafe abortion or incomplete miscarriage.The provision of emergency treatment for abortion complications is a basic right and a medical necessity, and it is critical to reducing maternal mortality (WHO, 1994). However, while it is estimated that at least one- third of all women who undergo unsafe abortions will need PAC services, less than half of these women actually receive medical attention (AGI, 1999).

24 Official PAC programs were put into place follow- Care Essential Elements of Postabortion ing the ICPD in the following key countries: India Community and service-provider (1998), Indonesia (1995), the Philippines (2000) and partnerships Nepal (1994); in the first three countries, both pub- ● Prevent unwanted pregnancies and lic and private pilot programs have been launched, while in Nepal the program was limited to public unsafe abortion services until recently (Cobb et al., 2001). ● Mobilise resources to help women receive appropriate and timely care In Nepal, a model PAC service and training pro- for complications of abortion gram for the management of incomplete abortion services has been integrated into the National Safe ● Ensure that health services reflect and Motherhood and Emergency Obstetric Care pro- meet community expectations and grams.Through that framework, PAC has been used needs to provide essential obstetric care for women and has increased access to family-planning and repro- Counseling ductive-health services (Ghosh et al., 1999). ● Identify and respond to women’s emotional and physical-health needs In the Philippines, the Prevention and Management and other concerns of Abortion Complications (PMAC) program trained over 1,000 health workers between 2000 Treatment and 2002, who subsequently provided services for ● Treat incomplete and unsafe abortion over 15,000 clients. In addition, a shift in abortion and potentially life-threatening compli- technology from D&C to MVA led to a 62% cations decrease in cost per client (EngenderHealth, 2003). Family-planning and In Thailand, the Population Council is assessing the contraceptive services safety and effectiveness of using misoprostol to ● Help women practice birth spacing or treat incomplete abortions. Provisional results of prevent an unwanted pregnancy this study in Thailand and Vietnam indicate that misoprostol might avert the need for surgery in Reproductive and other health about nine out of 10 cases of incomplete abortion services (Blum et al., 2003). ● Preferably provided on-site, or via The Indonesian government has developed a PAC referrals to other accessible facilities manual for community health centers. in provider’s network

Source: Postabortion Care Consortium In Malaysia, PAC is available in some public and pri- Community Task Force, 2002 vate clinics in urban areas; however, no services are said to exist in rural settings.

Respondents critiqued PAC services as being provided only on a project basis and contingent on donor funding.The majority of survey respondents stated that PAC services were provided in a vertical fashion and did not include proper counseling or postabortion family planning. Elective abortion services In 2003,WHO issued Safe Abortion:Technical and Policy Guidance for Health Systems. These guidelines provide technical and policy guidance to government officials, policymakers and health professionals who wish to implement ICPD+5 recommendations from paragraph 63iii. This document was introduced at two key meetings held in Asia in October 2003: the International Agency Group (IAG) on Safe Motherhood in Kuala Lumpur and the 2nd Asia Pacific Conference on Reproductive and Sexual Health in Bangkok.The government in Nepal

25 used a draft version of the WHO document to develop its rules and regulations for the 2002 abortion law, and members of the Ministry of Health in Thailand have used the report to review their country’s guidelines for health workers on abortion services.

New abortion technologies have also been introduced in the various countries reviewed in this study. Vacuum aspiration and medical abortion are the two preferred methods of abortion during the first 12 weeks of pregnancy (WHO, 2003). MVA instruments are available in India and Nepal for elective services and in Indonesia and Thailand for PAC. Medical abortion (mifepristone) was registered in India in 2002.

Most respondents maintained, however, that abortion is performed in isolation and is not provided as part of a continuum of care with other family-planning, emergency-contraception and reproductive-health services.Where PAC and elective-abortion services do exist, they are often provided in a vertical fashion, separate from the broader context of women’s lives.As a result, they do not address the reasons women were compelled to seek such services or what factors need to be put into place so that they do not face unwanted pregnancies in the future.

26 Country Highlights Photo courtesy of the David and Lucile Packard FoundationPhoto courtesy

India

“Theoretically, abortions are available in all public hospitals. Practically, this is not so. In primary health centers where abortions are available, women are often coerced into accepting sterilization.There is the problem of staff asking for compensation for performing an abortion, and service providers ask for husbands’ consent even though the law does not require it.” – respondent from India

Abortion policies and services India Statistics Total population (millions),2001*: India provides an interesting example of the 1033.4 range of factors that need to be addressed in order to ensure that the ICPD paragraph 8.25 Population under age 15 (as % of total), recommendation that “where abortion is legal, 2001*: 33.7 it should be safe and accessible” becomes a reality for all women.According to India’s GDP per capita (PPP US$), 2001*: 2,840 Medical Termination of Pregnancy (MTP) Act, an abortion may be performed under a broad Population living below the national range of circumstances including: to save a poverty line (%), 1987–2000*: 28.6 woman’s life or health or in cases of rape, contraceptive failure in married women, fetal Total debt service (as % of GDP), 2001*: abnormality, or socio-economic hardship. In 1.9 reality, services are often not available for these indications. Public expenditure on health (as % of GDP), 2000*: 0.9 Survey respondents were united in their belief that the MTP Act, while a necessary legislative Military expenditure (as % of GDP), step to ensuring women’s health and rights, 2001*: 2.5 includes provisions that lead to numerous barriers that impede women’s access to services. Physicians (per 100,000 people), These barriers have resulted in a situation 1990–2001*: 48 where, thirty years after the enactment of the MTP Act, illegal abortions in India outnumber Health expenditure per capita (PPP legal abortion procedures; some studies show US$), 2000*: 71

27 that illegal services are two to 11 times more

prevalent (Hirve, 2003).To increase women’s India Statistics access to legal services, the government of Total fertility rate (per woman), India issued new regulations to the MTP Act in 2000–2005*: 3.0 2003, which address the qualifications to be Contraceptive prevalence rate (%), met by medical practitioners who perform 1995–2001*: 48 abortions and standards that must be met by establishments where abortions are per- Births attended by skilled health performed.The regulations simplify procedures sonnel (%), 1995–2001*: 43 for the approval of places where abortions can Maternal mortality ratio reported (per be performed, particularly during the first 12 * weeks of pregnancy. 100,000 live births), 1985–2001 : 540 Women receiving prenatal care (%)®: 62 Access to information about legal abortion services is a barrier in India; despite the fact Reproductive risk index®: 44.8 that abortion was liberalized over 30 years (moderate risk) ago, many women and men are not aware that abortion is legal. In order to raise awareness * UNDP,2003 of the provisions of the MTP Act, clarify any ® PAI, 2001 misunderstandings, and, ultimately, improve services for women among ob-gyns, the Federation of Obstetric and Gynecological Society of India (FOGSI) disseminated a booklet titled Safe Abortions Save Lives: Understanding the MTP Act (FOGSI, 2003).

There are clear differences between the opinions of survey respondents from the government and medical groups and the perspectives of women’s organizations about the accessibility of abortion services.While government and medical representatives felt that women could access abortions across the country, women activists maintained that few women have access to legal public-sector abortion services, and a choice of different providers and methods is not an integral part of the existing services. Registered service-delivery sites with trained providers are located predominantly in urban centers in select states, thus limiting access. Basic infrastructure, equipment and supplies to support such services, as well as appropriate technologies and trained providers, are often lacking. Poor-quality services and judgmental staff at public-sector facilities often lead women to opt for the private sector, which includes a wide range of legal, illegal, safe and unsafe procedures.

Respondents also differed in their interpretation of unmarried women’s access to abortion services. One of the indicators for abortion in the MTP Act is contraceptive failure; however, the law explicitly indicates “where any pregnancy occurs as a result of failure of any device or method used by any married woman or her husband for the purpose of limiting the number of children” (emphasis added, MTP Act, 1973).According to respondents, providers may either interpret this law to mean that it is illegal for an unmarried woman to obtain an abortion, or that the husband’s consent is needed even though this is not mandated by the law. Unmarried women can then either be denied services or be charged exploitatively high prices. The importance of shifting providers’ attitudes and interpretations of the law to focus more on women’s needs and complex realities was a recurring theme throughout the interviews.

The cost of abortions also serves as a barrier.While public-sector services are theoretically free, they entail hidden costs, such as additional medical and personnel fees, that often make the public sector as expensive as the private sector.Women often use illegal services because they are less costly than legal ones. Some respondents also maintained that MTP services in the

28 “While private practitioners need to be regulated and made accountable to the law as well as educated about safer technologies for improvement of both safety and quality of abortion services, the public sector needs to extend its presence, especially in rural areas, as well as strengthen the provision and quality of existing services to measure up to the satisfaction of abortion seekers” (Duggal and Ramacahandran, 2004).

public sector are at times only provided if a woman agrees to be sterilized after her abortion. Given these factors, women who can afford it often opt for the shorter waiting times and greater privacy offered by the private sector, where spousal consent may not be requested.

A factor specific to the Indian context that affects public discussion of abortion is the increased use of sex-selective abortions that results from the strong societal and familial preference for sons. Research furthermore demonstrates that men are often involved in decisions relating to all abortions, including sex-selective abortions. Reasons to end what is perceived as an undesir- able pregnancy are manifold. Male sons increase women’s status; therefore, as women and men want to limit their family sizes, they may decide to limit the number of female children. Some respondents pointed to the increase in urbanization and education, a trend that privileges male children, as a reason for the desire to decrease family size.The preference for male offspring must be seen in the context of economic incentive, since expensive dowries and weddings are borne by the family of the bride, and men in the workforce are paid more than women. Son preference also plays a role in the decision to abort even if the sex of the fetus is not determined beforehand; for example, if a woman has a boy child, she is more likely to abort a subse- quent unplanned or mistimed pregnancy than if her first child is a girl.

In order to counter the practice of sex-selective abortion, the Indian government enacted legislation prohibiting the use of prenatal diagnostic techniques that are used to determine the sex of the fetus.The Pre Natal Diagnostic Techniques (PNDT) Act of 1994 prohibits individual practitioners, clinics or centers from determining the sex of the fetus or informing the couple about the sex of their fetus.While the government has stated its commitment to monitoring implementation of the PNDT Act, the technology to detect the sex of the fetus has become easily and widely available in India, and studies demonstrate that there is an increase in the number of female-selective abortions that are performed.The attention given to reducing sex-selective abortion has resulted in a perception that there is a need to limit women’s access to all abortion services. Interviewees pointed to the dilemma faced by women’s groups who are working against sex-selective abortions, but also trying to preserve women’s rights to abortion services. Changes since the ICPD Since the ICPD, the MTP Act and regulations have been expanded to increase women’s access to legal abortions.While the types of abortion methods are expanding slowly in India to include MVA and medication abortion, the primary technology for abortion is still D&C, which

29 can only be used in a hospital setting, followed by electric vacuum aspiration. Interviewees responded that procurement of abortion equipment is low on the list of priorities for the Indian government and few facilities, especially those located in rural and peri-urban settings, are equipped in a way that would facilitate women’s access.The government has recognized that the use of electric vacuum aspiration at peripheral health centers is not feasible given erratic power supplies and is encouraging the use of MVA instead. FOGSI has undertaken a pilot project on MVA training in two districts in eight states; this may be scaled-up to other parts of the country.

30 Chris Stowers / Panos Stowers Chris Pictures Indonesia

“Those who understand the ICPD are NGOs and the relevant health departments at the central government, while at the practitioners’ level—for example, the doctors who work in the regional centers— most of them don’t understand this concept yet, and some of them have never even heard or read about it.” – respondent from Indonesia Indonesia Statistics Abortion policies and services Total population (millions),2001*: 214.4 Under Articles 346–348 of the Penal Code, the performance of all abortions is prohibited. Population under age 15 (as % of total), However, Article 15 of the Law on Health sets 2001*: 30.4 forth an exception to this general prohibition * for abortions carried out to save the life of GDP per capita (PPP US$), 2001 : 2,940 the woman, stating that “certain medical Population living below the national actions” can be performed in an emergency poverty line (%), 1987–2000*: 27.1 situation to save the life of “the pregnant mother and/or her fetus.” Total debt service (as % of GDP), 2001*: 10.7 According to both the penal code and the law, four conditions must be met in order for an Public expenditure on health (as % of abortion to be carried out: (1) there must be GDP), 2000*: 0.6 a medical indication; (2) the abortion must be performed by an obstetrician or gynecologist Military expenditure (as % of GDP), who must consult with a team of experts, 2001*: 1.1 which may consist of a medical expert, a the- ologian, a law expert and a psychologist; (3) Physicians (per 100,000 people), * the pregnant woman must consent to the 1990–2001 : 16 abortion unless she is in a state of uncon- Health expenditure per capita (PPP sciousness or is unable to provide consent, in US$), 2000*: 84 which case her husband or family may consent; and (4) the abortion must be performed Total fertility rate (per woman), in a health facility that has an adequate num- 2000–2005*: 2.4 ber of officers and equipment to carry out abortions, and is designated to do so by the Contraceptive prevalence rate (%), government. 1995–2001*: 57

31 Changes since the ICPD Indonesia Statistics While abortion is legal to save a woman’s life, Births attended by skilled health respondents claim that services often do not personnel (%), 1995–2001*: 56 exist for this indicator.At the same time, laws are not always strictly enforced, and Maternal mortality ratio reported (per Indonesian women therefore resort to a range 100,000 live births), 1985–2001*: 380 of services: legal, illegal, safe and unsafe.To counter the practice of illegal and unsafe abor- Women receiving prenatal care (%)®: 82 tions, individuals and a coalition of NGOs, ® including progressive Muslim groups, devel- Reproductive risk index : 42.4 oped a reproductive-health bill that was pre- (moderate risk) sented to the Indonesian parliamentarian committee responsible for mother and children’s * UNDP,2003 affairs. This bill will allow first-trimester abor- ® PAI, 2001 tions under a broad range of indications related to women’s health and well-being including: • In cases of contraceptive failure • If a women cannot afford another child • If a women has more than three children • In cases of rape • In cases of incest In addition, the removal of strict penalties for abortion providers and women seeking services has been proposed. As of the writing of this report, the bill has been approved by Parliament and is awaiting approval by the president.

Efforts have been made by the Indonesian government since the ICPD to expand women’s reproductive-health services; however, while demographic targets have been removed from its population program, reproductive-health policies have not been put into place.The respondents stated that an increasing number of civil society organizations believe that PAC and elective abortion are priority health concerns in Indonesia and are working to lobby the government in that country. Their work has included a multifaceted approach consisting of research, community outreach, training and advocacy around reproductive-health issues in general. In addition, several seminars, workshops and trainings have been organized to discuss research findings related to unsafe abortion and policy and legal considerations in Indonesia. Community outreach through district health centers has been one of the key strategies used.

While diversity existed among their responses, the respondents highlighted six key factors that influence abortion policies and access in Indonesia: (1) cultural and religious norms, (2) lack of political will, (3) political influence of key religious groups, (4) lack of awareness of the impact of abortion on women’s lives, (5) economic crises, and (6) increased cost of contraception.

One of the most prevalent responses was that dominant cultural and religious norms in Indonesian society prohibit public discussions of abortion and stigmatize its practice.As a result, little is known about women’s and providers’ experiences with abortion.

Another major aspect of the abortion debate is the position of political leaders who, according to respondents, are often unaware of the legal status of abortion and the impact of unsafe

32 abortions on women’s health and lives. In addition, little is know about the diversity of Muslim thought about and practice of abortion. Instead of seeking additional information, political leaders are often unwilling to take a stance; instead they seek refuge behind the positions of religious entities.

Religious leaders and organizations can be powerful allies or opponents in the formulation of less restrictive abortion policies. One of the strategies used by the women’s groups to address the area of religion is to underscore the diversity of Islamic thought in predominately Muslim countries as well as in the Asian region, and to emphasize how interpretations of Islamic texts have changed over time.The largest Muslim organization in Indonesia, the Ulemas Council (MUI), previously opposed the use of contraception; however, after several conferences and public discussions about the need for family-planning services, the MUI eventually supported the government’s program on a national scale. Discussions about other reproductive-health issues are taking place across the spectrum of Muslim groups, both progressive and moderate, in that country. A recent proposal by 13 Muslim scholars arguing that abortion is permissible in Islamic jurisprudence for cases of rape, incest, and fetal abnormalities and if a woman’s life is at risk was submitted to the MUI (Lifesite Daily News, 2003).While the MUI’s position has not changed as a result, the creation of an environment where such discussions can take place is critical.

A fourth factor highlighted by the respondents is the lack of understanding of why women need access to safe abortion services and what happens to women, their families and their communities when such services are not available.The WHF has conducted research that demonstrates who seeks abortion (primarily married women with their husband’s approval) and the main reasons why abortions are needed (contraceptive failure and socio-economic concerns).

The economic crises in Indonesia and the corresponding reduction in government spending on social services was named as another barrier to improving reproductive-health care for women. Several respondents claimed that financial concerns also had an impact on contraceptive use, stating that fewer Indonesians are able to purchase contraception due to increasing prices and the introduction of user fees.While awareness of the importance of family planning has grown, according to respondents, the introduction of user fees has led to a situation where contraceptives that used to be free are too expensive for some groups of women and men. Individuals and couples have thus been forced to use traditional methods of contraception with higher failure rates, potentially contributing to more unwanted pregnancies. Costs for contraceptives were said to have increased five-fold since donor provision of contraceptives was removed. Since contraceptives are so expensive, taking the chance of becoming pregnant and then having an abortion makes more financial sense to some women. Studies conducted by NGOs show that illegal abortions are increasing and that maternal mortality rates have not decreased significantly since the ICPD; in addition, research examining the cost of contraception and its impact on abortion and family welfare is currently being undertaken by the WHF.

33 Dominic Sansoni / Panos Pictures

Malaysia

“The legal indications [for abortion] are influenced by the political situation and not by health concerns and needs. Women and men know what they want and need. In my country there is a major gap between policy and implementation.” – respondent from Malaysia

Abortion policies and services Malyasia Statistics Total population (millions),2001*: 23.5 Under Section 312 of the Penal Code, the performance of abortions is prohibited Population under age 15 (as % of total), except when there is risk to the pregnant 2001*: 33.4 woman’s life or injury to her physical or * mental health.The government of Malaysia GDP per capita (PPP US$), 2001 : 8,750 has issued no regulations on the implementa- Population living below the national tion or interpretation of the abortion provi- poverty line (%), 1987–2000*: NA sions of the Penal Code; however, trained medical practitioners are permitted to pro- Total debt service (as % of GDP), 2001*: vide abortion services. 7.1

Public expenditure on health (as % of Changes since the ICPD GDP), 2000*: 1.5 Following the ICPD, a coordinating commit- Military expenditure (as % of GDP), tee on reproductive health was established 2001*: 2.6 to ensure the integration of aspects of reproductive health into primary health-care and Physicians (per 100,000 people), family-planning policies and programs and, in 1990–2001*: 68 1998, the Private Health Care and Facility Bill was enacted to expand women’s health-care Health expenditure per capita (PPP options. In 2001, the Ministry of Family and US$), 2000*: 310 Women’s Development was established to Total fertility rate (per woman), oversee the Population and Family * Development Board (LPPKN) and the 2000–2005 : 2.9 Women’s Development Division (HAWA). Contraceptive prevalence rate This ministry is currently reviewing the Plan (Peninsular) (%), 1994º: 54.5 of Action for the Advancement of Women. The Malay Constitution was also amended in Births attended by skilled health August 2001 to include provisions for the personnel (%), 1995–2001*: 96 elimination of gender-based discrimination.

34 In the area of abortion, a coalition of groups developed amendments to this law that would Malyasia Statistics decriminalize abortion and widen the legal indi- Maternal mortality ratio reported (per cations to include incest and rape.The pro- 100,000 live births), 1985–2001*: 41 posed amendments that are currently under ® review would allow two doctors to approve Women receiving prenatal care (%) : 90 the service without requiring parental consent Reproductive risk index®: 24.5 (low risk) for women who are below the age of 18 or mentally challenged. * UNDP,2003 While Malaysian women benefit from far ® PAI, 2001 greater reproductive-health indicators than do º United Nations Population Division, 2003 their counterparts in other countries included in this survey, the respondents raised various challenges to implementing the Cairo recommendations.These include: (1) moving from the medical provision of services to a rights-based approach, (2) working with medical providers, (3) dealing with religious opposition, (4) over- coming economic disparities, (5) addressing the needs of different sectors of Malaysian society, and (6) moving from macro- to micro-level change.

While the respondents acknowledged the importance of the Malaysian government’s support for reproductive-health programs, some respondents criticized the purely medical nature of these programs, as opposed to ones that are more centered on women’s rights and entitle- ments.As a result, while medical services are provided, efforts are not always made to ensure that women have access to information, counseling and a full range of high-quality, affordable services. Furthermore, training is not standardized, and different centers and universities use their own curricula. Differences existed in the respondents’ answers to the provision of PAC and elective services for indicators that are legal under the law. Some stated that the family- planning affiliates (FPAs) provide such services while others maintained that the FPAs only offer referrals. Several respondents claimed that medical groups are not aware of the legal status of abortion and that they do not refer to the ICPD in their work.To promote a women’s rights approach and increase access to services, popular education, advocacy tools and manuals for health providers have been developed in Malaysia that explain existing legal codes and procedures in a user-friendly manner.

Working with Muslim scholars and religious leaders is important in Malaysia. Part of these efforts has included consciousness-raising across different constituencies through the use of publications, workshops and seminars.The diversity of Muslim perspectives is evident in Malaysia. For example, respondents mentioned that the Commonwealth Medical Association’s Ethics Conference, held in May 2002, included a discussion of Islam and abortion, and the Malaysian Muslim National Fatwa Council has issued a fatwa3 approving stem-cell research and stating that abortion is legal up until 120 days gestation, at which time the fetus becomes ensouled. Shari’a, however, differs from state to state. Organizations such as Sisters in Islam—a group of Muslim professional women interested in promoting women’s rights within a Muslim framework—are advocating for the standardization of Islamic law across the states. Sisters in Islam organized a workshop in 1998 for Muslim scholars and activists from across the Muslim world to discuss Muslim women’s right to attain the highest standards of sexual and reproductive health.The proceedings from this meeting, Islam, Reproductive Health and Women’s Rights (Sisters in Islam, 2000), have been used to advocate for more supportive policies and programs both in countries that incorporate Islamic law and predominately Muslim countries that use secular legal systems. Several respondents discussed the fine line that exists between

35 raising awareness of a controversial issue and facing possible backlash from conservative forces.

The influences of patriarchy and conservative norms were identified as affecting all women in Malaysia. In particular, addressing the needs of unmarried women and adolescents, who according to traditional perspectives should not need reproductive-health services, was underscored as a major challenge.While a broad range of services exist, it was said that unmarried women seldom, if ever, use public services. Rural women are similarly underserved. The differences that exist in socio-economic status, levels of education, and cultural patterns across various ethnic groups in Malaysia, including Malay, Indian and Chinese women, was also emphasized. In addition, new populations, such as Indonesian women who have migrated to Malaysia due to the economic crisis in the region, have their own specific set of needs.

Financial barriers were discussed as another hindrance for women. Services were said to range from RM 500 to RM 2000 or US$133 to US$530.50.While abortions are said to be more available and safer than in the past, the cost of a safe procedure is too high for many Malaysians. One respondent opined that “time is money”: providers only spend time counseling and providing information on reproductive options to women who have the finances to pay for such services.At the same time, some respondents pointed to national reports that show that adolescent sex, unwanted pregnancies and demand for abortion are all on the rise. Due to women’s inability to access affordable services, respondents stated that forced pregnancies are a reality for some Malaysian women. One women’s group has responded to this need by providing financial support to women who need abortions. In addition,ARROW has recently produced a study examining health-sector reforms and their impact on cost and women’s access to abortion services.

Finally, several respondents drew attention to the fact that ICPD language is important from a macro-level policy perspective; however, it is lacking in regard to concrete recommendations for improving data collection, creating an enabling environment and securing political will.

36 Mark Schlossman / PanosMark Schlossman Pictures

Nepal

“Sex is quite a taboo issue. Sexual education is quite limited . . . It’s very important that people have the right to not want to continue a pregnancy.” – respondent from Nepal Nepal Statistics Nepal has one of the highest maternal mortal- Total population (millions),2001*: 24.1 ity ratios (MMR) in the world.The reproductive risk index is high at 42.4. Studies suggest Population under age 15 (as % of total), that abortion complications are responsible 2001*: 40.5 for anywhere from 5.4% to 30% of all mater- * nal mortalities; up to 50% of all maternal GDP per capita (PPP US$), 2001 : 1,310 deaths in Nepal’s hospitals are attributable to Population living below the national complications of unsafe abortion. poverty line (%), 1995–1996**: 42.0 Abortion policies and services Total debt service (as % of GDP), 2001*: 1.6 Until recently, abortion was widely prohibited in Nepal under its Country Code, first enact- Public expenditure on health (as % of ed in 1854, which combined ancient Hindu GDP), 2000*: 0.9 law, customary law, and common law based on British and Indian codes. It was completely Military expenditure (as % of GDP), revised in 1963 to introduce modern concepts 2001*: 1.1 of equality and non-discrimination into the Nepali legal system.Yet both providers and Physicians (per 100,000 people), women seeking abortions were penalized 1990–2001*: 4 under this code, and a nationwide prison study conducted in 1997 revealed that one- Health expenditure per capita (PPP fifth of women prisoners (about 117 women) US$), 2000*: 64 were imprisoned on charges of abortion or infanticide. Most of these women were poor Total fertility rate (per woman), * and illiterate and had been in prison for three 2000–2005 : 4.3 to five years (CRLP and FWLD, 2002). Contraceptive prevalence rate (%), After years of lobbying by public-health offi- 1995–2001*: 39 cials and women’s groups, the abortion section of the penal code was amended in 2002 to lib- Births attended by skilled health per- * eralize provisions that had in effect prohibited sonnel (%), 1995–2001 : 11

37 the legal performance of almost all abortions.

Under the 2002 amendment, a pregnant Nepal Statistics woman may obtain an abortion on request dur- Maternal mortality ratio reported (per ing the first 12 weeks of pregnancy. In cases of 100,000 live births), 1985–2001*: 540 rape and incest, she may obtain an abortion ® during the first 18 weeks of pregnancy. An Women receiving prenatal care (%) : 24 abortion may be legally performed at any time Reproductive risk index®: 62.6 (very during pregnancy with the approval of a physi- high risk) cian if the pregnancy poses a danger to the life of the pregnant woman or to her physical or * UNDP,2003 mental health, or will lead to the birth of a dis- ® PAI, 2001 abled child.A pregnant woman does not need her husband’s consent for an abortion, and the ** World Bank, 2003 law does not distinguish between married and unmarried women.The 2002 amendment also prohibits the performance of amniocentesis in order to carry out an abortion on the basis of sex selection.

In January 2004, the Government of Nepal issued a Procedural Order under the new abortion provisions. Changes since the ICPD Key changes have taken place in the area of reproductive health since the ICPD, including an expansion of family-planning services to rural areas through outreach clinics and efforts to remove targets from family-planning programs.While knowledge of family planning is close to universal, contraceptive prevalence rate (CPR) is low at 39. Since 1994, PAC services have been introduced in 24 hospitals in 17 districts in Nepal, according to respondents.

Through a multifaceted process of underscoring the discriminatory nature of Nepal’s abortion laws, as well as its breach of obligations under international law and policies, Nepalese scholars and women activists lobbied over a period of seven years for the introduction and approval of far-reaching legislation related to women’s overall status and well-being. In particular, language in the ICPD on abortion and the general Recommendation 19 of CEDAW on violence were used to support women’s rights, including the liberalization of the Nepalese abortion law.

In order to ensure implementation of the abortion law, the Technical Committee for Implementation of Comprehensive Abortion Care (TCIC) was formed to plan and implement next steps in the following four areas: training, service delivery, behavioral change communication and advocacy, and monitoring and evaluation.To date, efforts have been made to inform the medical establishment of abortion’s legality. In addition, provider training has been improved with the formation of a training package (reference and training manuals), including standards of care, the development of a national training center with a new comprehensive abortion-care unit, and the actual training of doctors. New training sites are currently being developed at the lower levels of the health-care system, and additional sites in Kathmandu are being examined. NGO and private-sector partnerships and service-delivery approaches are being explored. In addition, behavior change communication activities with individuals who would interface with women seeking abortions are being organized, such as town meetings for communities and sessions with judges, police and taxi drivers.

Nepal now has policies in place that are consistent with international standards, a low- resource program to promote access to abortion in rural as well as urban areas, and a decen-

38 tralized training strategy. Medical providers have been oriented to the law, providers have been trained, and a training-of-trainers program for comprehensive abortion care has been implemented. Since the procedural order, the maternity hospital in Kathmandu has provided services for over 600 women.As part of the liberalization process, a study tour to Vietnam to learn about their model comprehensive abortion care program was conducted.

While the TCIC is well represented by the medical establishment, some respondents report that it has not adequately included the perspectives of women and lawyers. Representatives from the women’s groups also believe that while they were instrumental in advocating for legal change, their input is not being taken in the development of regulations, terms and conditions that will frame how services will be offered. In addition, several of the women’s organizations fear that abortion is being approached purely as a medical procedure instead of as part of a comprehensive set of services.Although policy changes have been made, they have not translated into concrete change for many women. In June 2003, members from the FWLD vis- ited 65 women who were incarcerated under the previous abortion law; to date, 37 have been released.

According to respondents, three of the key challenges in ensuring that women are able to benefit from the new abortion law include: (1) improving women’s status and autonomous decision making, (2) increasing women’s livelihood and reducing poverty, and (3) ensuring that rural women (89% of the female population) also have access to reproductive-health and safe abortion services.

39 Chris Stowers / Panos Stowers Chris Pictures

The Philippines “Now [since the ICPD] there are more groups working on reproductive health, but there are still few who are willing to talk about abortion and women’s reproductive rights to this option . . . Being a relative newcomer on the block, it has been a strategy of women’s rights groups to avoid the topic of abortion. In a sense, by evading, it has actually reinforced how abortion is seen as demonised and negative in the Philippines. People identify many women’s groups as anti-abortion in their position by not speaking up enough on the issue.We need to at least move the discussion up to another level, on a humane level, i.e. women needing [emergency] treatment and needing to prevent unwanted pregnancies.” – respondent from the Philippines Philippines Statistics Abortion policies and services Total population (millions),2001*: 77.2 The Philippines has one of the most restrictive and discriminatory abortion policies in Population under age 15 (as % of total), * the world. Under Articles 256–259 of the 2001 : 37.1 Penal Code, the performance of all abortions GDP per capita (PPP US$), 2001*: 3,840 is prohibited. However, according to general criminal law principles of necessity set forth Population living below the national in Article 11 of the code, it is generally held poverty line (%), 1987–2000*: 36.8 that an abortion can be carried out legally to save the life of the pregnant woman.A person Total debt service (as % of GDP), 2001*: committing the crime of abortion would be 10.9 justified because he or she would be acting to prevent a greater injury—the death of the Public expenditure on health (as % of pregnant woman—than is involved in causing GDP), 2000*: 1.6 the death of the fetus. Military expenditure (as % of GDP), The 1987 Constitution further states that the 2001*: 1.0 government “shall equally protect the life of the mother and the life of the unborn from Physicians (per 100,000 people), conception.” The Filipino constitution is one 1990–2001*: 124 of the few in the world that defines human life as existing from the moment of concep-

40 tion and grants a fetus the same constitutional rights as a pregnant woman. Some respon- Philippines Statistics dents stated, however, that earlier versions of Health expenditure per capita (PPP this constitutional amendment were even US$), 2000*: 167 more discriminatory, excluding altogether the need to protect the life of the mother. Total fertility rate (per woman), 2000–2005*: 3.2 The Government of the Philippines has issued no regulations on the implementation or Contraceptive prevalence rate (%), * interpretation of the abortion provisions of 1995–2001 : 47 the Penal Code. Births attended by skilled health per- * While women’s groups interpreted the above sonnel (%), 1995–2001 : 56 policies as a total ban on abortions in the Maternal mortality ratio reported (per Philippines, medical providers stated that ther- 100,000 live births), 1985–2001*: 170 apeutic abortion was indeed allowed under this law. Women receiving prenatal care (%)®: 77 Changes since the ICPD Reproductive risk index®: 26.4 (low risk) Following the ICPD, the Philippines enacted * UNDP,2003 several policies designed to transition from a ® PAI, 2001 family-planning to a reproductive-health approach.These included: (1) broadening the definition of population, (2) eliminating demographic targets, (3) improving quality of care, and (4) integrating principles of gender equity and women’s empowerment across its programs. This resulted in a reproductive-health program that incorporated 10 key components, including unsafe abortion.

According to respondents, after political changes in 1998, a new group of legislators had to be informed of the gains that were made at the ICPD.This has resulted in a serious backlash in meeting the ICPD commitments due to the political weight of the Catholic Church, which opposes abortion and supports only natural family planning. In fact, one of the key challenges in the Philippines is the lack of separation between church and state.

Numerous changes, mostly leading to fewer reproductive options for Filipino women and increased curtailment of their reproductive rights, have taken place recently. In 2001, the Bureau of Food and Drugs banned Postinor, which is used for emergency contraception, on the grounds that it was an abortifacient and therefore unconstitutional. Government officials have stated that emergency contraceptives and IUDs are abortifacients, and the fear is that this approach could result in the outright ban of all oral contraceptives.The Department of Health has finalized Natural Family Planning Implementation Guidelines which many worry will further reduce the availability of modern methods, especially for low-income Filipino women and men. Moreover, several respondents claimed that the Filipino leadership has explicitly said that it will not fund family-planning and contraceptive supplies.At the same time, USAID will be phasing out its provision of contraceptive methods by the end of 2004 through its Contraceptive Interdependence Initiative and it is not clear who, if anyone, will continue to subsidize modern contraceptive methods for those in need.

Respondents differed in their response to questions about PAC services, which were introduced in the Philippines in 2000. For example, women’s groups highlighted four challenges to the provision of PAC: (1) a great deal of stigma and discrimination exists for women who seek

41 such services; (2) postabortion counseling, education and family planning are practically nonexistent; (3) services are entirely dependent on donor funds; and (4) there is no political will for providing PAC services without outside intervention. A more encouraging response by one of the medical practitioners was that the government is very supportive of PAC and, as a result, providers are trained in quality of care and counseling.

In 2000, a group of over 45 organizations came together to form the Reproductive Health Network (RHN).The coalition’s purpose is to contribute to and advocate for the passage of the Reproductive Health Care Act (RHCA), a bill that would promote women’s access, free from discrimination and coercion, to quality reproductive-health information and services.As part of this process, the Womenlead Foundation, one of the key members of RHN, produced a paper on abortion laws in the Philippines which was presented at a seminar for health-care providers.The RHN’s advocacy efforts have engendered public discussion, resulting in a better understanding by the general public and the Filipino Parliament of women’s primary and reproductive-health care needs. In addition, the RHN was able to provoke public discussion on issues that are considered controversial, such as adolescent reproductive health and PAC, and to discuss the need to attribute budgetary allocations to the RHCA bill.

According to survey respondents, the Catholic Church’s advocacy materials about the bill was purposively misleading and contained the following quote:“If HB41104 is passed, a 13-year-old can have sex, and if she gets pregnant, she can have an abortion without her parents’ permission. If her parents try to stop her, they can be imprisoned.” Other conservative initiatives highlighted by interviewees in the Philippines include calling for prayers and lobbying against draft reproductive-health bills; distributing pastoral letters that are read in all state churches calling reproductive-health laws “anti-family” and those who support them “immoral abortion- ists” (even though the proposed law contains no provision for abortion services); working with the media to further stigmatize abortion; and claiming that any contraceptive method that prohibits implantation is considered an abortifacient, therefore, solely supporting natural family-planning methods.The bill will be considered by the House of Representatives in June 2004. Opposition by the Catholic Church to the reproductive-health agenda in certain countries has been reinforced by the U.S. Bush administration’s own conservative ideological posi- tioning or withdrawal of funds needed to support women’s reproductive options.

To counter conservative strategies, fact sheets and advocacy materials have been produced to challenge the idealized image of motherhood by revealing facts about maternal deaths (Likhaan, 2003a) and to protest the restrictions placed on women’s reproductive options by the Catholic Church in the Philippines (Likhaan, 2003b).A study of PAC and the abortion needs of poor women was also undertaken by Likhaan, an NGO working on issues of women's health and reproductive rights.

42 Liba Taylor / Panos Pictures Thailand

“Directors of each state determine their own internal policy regarding abortion. In some cases, you will find Hospital A with Director A having a policy to provide abortion services in 2002, and when you come back in 2003, Director B is in the position and the policy has changed . . . The ICPD POA should state clearly that women have the right to reproductive choice and that it is a fundamental human right.” – respondent from Thailand Thailand Statistics Abortion policies and services Total population (millions),2001*: 61.6 Abortion in Thailand is governed by the provision of Sections 301–305 of the Penal Code of Population under age 15 (as % of total), * 1956. Under the code, the performance of an 2001 : 25.9 abortion is generally illegal. However, abortion GDP per capita (PPP US$), 2001*: 6,400 is allowed under two conditions: to preserve a woman’s health and in cases of rape. Population living below the national poverty line (%), 1987–2000*: 13.1 There are currently no regulations in Thailand * governing the performance of abortions, but Total debt service (as % of GDP), 2001 : the Ministry of Health is working to address 17.5 this policy void. Public expenditure on health (as % of GDP), 2000*: 2.1 Regarding access to legal abortion services, several of the respondents maintained that Military expenditure (as % of GDP), while enforcement of the law varies across 2001*: 1.4 regions and sectors, it is difficult to obtain abortions for legal indications for a variety of Physicians (per 100,000 people), * reasons.These include a lengthy approval 1990–2001 : 24 process and the absence of centralized, uni- Health expenditure per capita (PPP form policies and procedures—three physi- US$), 2000*: 237 cians need to approve an abortion to preserve a woman’s health. In cases of rape, women Total fertility rate (per woman), must either submit a police statement or a 2000–2005*: 2.9 court verdict in order to access legal abortion Contraceptive prevalence rate (%), services. One respondent also stated that 1995–2001*: 72 women may have to agree to be sterilized before they can obtain a legal abortion. 43 Changes since the ICPD Thailand Statistics In 1997, the Minister of Public Health issued a Births attended by skilled health per- new Reproductive Health Policy which covers sonnel (%), 1995–2001*: 96 the entire life span, stating that,“All Thai citizens, at all ages must have good reproductive Maternal mortality ratio reported (per health throughout their entire lives.” This poli- 100,000 live births), 1985–2001*: 41 cy covers 10 key areas: family planning, mater- Women receiving prenatal care (%)®: 90 nal and child health, HIV/AIDS, reproductive- tract infections, cervical cancer, sex education, Reproductive risk index®: 24.5 (low risk) abortion and its related complications, adolescent reproductive health, infertility, and post- * UNDP,2003 reproductive age and old age care.The ® PAI, 2001 Division of Family Planning and Population was assigned as the governmental unit responsible for research, development, and dissemination about reproductive health, and its name was changed to the Division of Reproductive Health in 2003. In the area of reproductive-health services, several respondents maintained that the key challenges are: (1) providing unbiased information and counseling, (2) focusing on women’s needs and ensuring access to comprehensive services, (3) offering services to adolescents, and (4) decentralizing training and policy changes.

In relation to PAC and elective services, the Thai Ministry of Health produced a handbook for service providers on pre- and postabortion counseling and services, and a training manual on PAC for health personnel. In 2000, the Ministry of Health undertook a nationwide survey that analyzed close to 46,000 abortions and found that the three main reasons for needing abortion services are: (1) economic constraints, (2) improper use of family-planning methods, and (3) pregnancy outside of marriage.

Following a nationwide survey that pointed to 200,000–300,000 annual illegal abortions and the highly publicized case of an 18-year-old girl who was admitted to a hospital with complications from an unsafe, illegal abortion, the Ministry of Health broke its silence on the question of abortion and announced that it would review Thailand’s abortion law. In August 2002, a National Conference on Reproductive Health Issues ended with a resolution to integrate reproductive health and rights into a comprehensive bill on abortion.The Parliamentary Committee on Public Health was subsequently established to discuss the status of women’s reproductive health and rights, and it concluded with the recommendation that Thailand should produce a reproductive-health law to protect women’s reproductive rights; however, this bill has yet to be crafted.

According to some respondents, a group of parliamentarians who support the integration of abortion have developed a draft bill. Others claimed that this process has been stalled, in part due to the lack of understanding of what reproductive health actually consists of and why it is important for women.As a result, an informal group of women’s organizations, medical professionals and legal experts came together to review laws and policies on reproductive laws and rights and to draft a bill.This group seeks to put into place a participatory process to raise awareness and solicit women’s opinions of what should be included in the draft code.

Respondents in the six countries selected for this report differed in what they think the new law should include. Some felt that the two essential new indications for legal abortion should be to preserve a woman’s mental health and in cases of fetal abnormalities; others claimed that HIV-positive women should automatically have access to services. Opinion polls of the general

44 public and health-care providers are currently underway as part of the policy-development process.

The Women’s Health Advocacy Foundation’s study on PAC showed that women with incomplete abortions were only given medical treatment and did not receive counseling or postabortion family planning. D&C is the main method that is used in PAC. One respondent also stated that while Thais benefit from universal insurance coverage, PAC and elective abortions are not covered.

Other laws that have changed since the ICPD include improvements in maternity leave and women’s right to refuse marital sex. In addition, domestic violence against women is increasingly being recognized as another national issue that needs to be addressed.

45 Conclusion The ICPD has served as a catalyst for increased discussion on family planning, reproductive health and women’s status in Asia.This “semantic revolution” (Corrêa, 2000) has contributed to a diversity of approaches developed by women’s groups, medical professionals, government entities and researchers to examine aspects of women’s reproductive health and unsafe abortion, develop advocacy strategies to change restrictive laws and policies, and lobby for programmatic change. New actors are involved in debates around the ICPD, and events have been organized including workshops, national seminars and regional conferences. In addition to national-level activities, several regional initiatives and south-to-south exchanges have been initiated.

While semantic shifts do exist on paper, it is difficult, if not impossible, to assess how increased discussion and policy and legal changes made since the ICPD have affected women’s access to reproductive-heath services. In fact, one of the paradoxes inherent in this study is that the increased mobilization by civil society groups around women’s reproductive rights and abortion is paralleled by the withdrawal of the state from the provision of basic health services.This situation is exacerbated by the fact that donor countries have not met their ICPD commitments and national priorities have shifted.A reprioritization of national budgets to address the gaps in spending around health issues deserves more attention. Incorporating state-of-the-art policy and health-system recommendations, such as those outlined in Safe Abortion: Technical and Policy Guidance for Health Systems (WHO, 2003), is one step toward the efficient use of limited resources. Resource-rich countries should also be held accountable to their ICPD commitments.

With reference to the ICPD recommendations linked to safe abortion care, it is clear that a great deal more needs to be done to ensure that “in circumstances where abortion is not against the law, it should be safe” (8.25) and health systems “train and equip health services providers and take other measures to ensure that abortion is safe and accessible” (63iii).The respondents from the six countries covered in this report provided considerable insight into the areas where these recommendations have not yet been fulfilled.

In countries like India, where abortions are legal for a broad range of circumstances, the high number of unsafe abortions that still occur signifies a disconnection between the law and women’s experiences and needs.The Indian example reveals that liberalizing abortion laws is not sufficient to reduce abortion-related mortality and morbidity and to ensure that women have access to safe, affordable, quality services. In the five other countries included in this study, services that should be available for legal indicators are often nonexistent. Numerous barriers—medical, political, legal and policy, economic, religious, and international—prohibit implementation of the ICPD recommendations related to abortion care.

For example, respondents claimed that the overmedicalization of the law in many countries results in unnecessary restrictions on women’s access.While these stipulations serve as a legal protection for doctors, they restrict women’s choices and self-determination.The lack of political will was also highlighted as a constraint across the six countries. Until political leaders and policy makers are ready to address women’s needs and interests, deal with gender discrimination, and ensure that women’s perspectives are included in the policy-making process, women will continue to suffer from unsafe abortions.

The legal system exerts power in providing a framework for societal norms and values. Under current laws and policies, women are criminalized for the reproductive choices they make.

46 This is particularly unconscionable as women may not be in control of sexual activities, as demonstrated by the high levels of violence against women across the region. In addition, women may not have the power to decide to adopt contraception, or they may lack the resources to pay for modern methods, especially given escalating prices. Moreover, while abortion in cases of rape is theoretically available in all but one country reviewed in this study, women are often subjected to insurmountable bureaucratic barriers to obtaining legal services.The idea that women may be forced to carry an unwanted pregnancy to term is one of the most blatant violations of women’s basic human rights.

Poverty continues to alienate many women and is a key determinate of unsafe abortion. Poor women have fewer options and suffer disproportionately when abortions are kept illegal and associated costs are exploitatively high. In countries where abortion is heavily restricted and provisions have not been made for safe abortion care, health systems that are already over- burdened must use scarce resources to treat women suffering from abortion-related complications. No woman should be turned away from abortion services because she cannot afford them, and health systems should strive for a more efficient and equitable use of limited resources.

Across the region, religious ideology and patriarchal values coalesce to constrain women’s rights to bodily-integrity, self determination and control over reproduction. Patriarchal norms have helped institutionalize the idea of male dominance in all decision-making, including reproductive decisions. Powerful religious institutions greatly influence government policies and programs, as is the case in the Philippines. In other countries, increasingly fundamentalist approaches to women’s reproductive health and rights serve to promote idealized versions of the family, womanhood and motherhood.

Behind the facile façade of “pro-life” and “pro-family” is a belief system that punishes women’s sexuality and despises equality; a belief system that instead promotes women solely in their roles as mothers and bearers of life.Analyses of the underlying ideologies that contribute to gender discrimination and the continued marginalization of abortion are necessary, including an examination of whose interests are at stake, who suffers, and who benefits when abortion is kept illegal, unsafe and stigmatized (Braam and Hessini, 2004).

In 1994, governments agreed that abortions, in circumstances where they are legal, should be safe, and that all women should benefit from life-saving postabortion care services.Ten years later this commitment is a distant reality for most Asian women.While barriers to implementing the Cairo recommendations are present in all the countries under review, they are not insurmountable. Moreover, the majority of these countries are actually reviewing their abortion-related laws and policies, indicating a move to go beyond the Cairo consensus. Building on the information found in this report, the next section provides recommendations for future action.

47 The Unfinished Agenda: Moving Forward Until 2015 For those countries with liberal abortion laws in Asia, ensuring that the ICPD recommendations are adhered to would include, at a bare minimum, addressing the challenges of moving from policy reform to implementation.This would result in the acknowledgement that: (1) efforts to reform existing abortion laws are essential; however, advocacy efforts should not stop once more liberal laws are in place; (2) if a progressive abortion law is not implemented, it is not an improvement; (3) women must benefit from a continuum of services that are con- fidential, affordable and accessible5, and quality services are essential; and (4) efforts must be taken to address the range of factors that lead to unsafe and unprotected sexual acts and to unwanted pregnancies (adapted from McCall, 2002). India is a good example of legal reforms that have not expanded women’s access; across the region, all countries could do more to address the factors that contribute to unsafe and unwanted pregnancies.

For countries that are in the process of reviewing existing legislation, several lessons can be culled from other countries that have already changed their laws: (1) ensure that flexible definitions of “guardian” are included for adolescents; (2) ensure that laws provide the same access for married and unmarried women; (3) include midlevel professionals as abortion providers; (4) ensure that women have access to the safest and most affordable technologies, including vacuum aspiration and medical abortion; (5) include a wide range of stakeholders in discussions about abortion; and (6) prepare for implementation of the law before the actual change in legislation takes place.

In order to prepare for reviews of legislation, various steps need to be taken. It is necessary to document the social costs of unsafe procedures: the negative impact on women, families, existing children and community members; the loss of health, work and income; and the drain on scarce medical resources that are being consumed treating abortion complications. Prompting debate with informed, balanced and unbiased information on the impact of unsafe abortion is critical. Deconstructing the myths—for example, the myths that religious leaders do not support abortion, that women who choose abortion are irresponsible, or that pregnancy does not lead to death for some women—is critical, as witnessed in the Filipino, Indonesian and Malaysian contexts. Situating abortion within a broader health, rights and social justice framework, as was done in Nepal, is also important. Several respondents stated that women’s groups have been reluctant to address the issue of abortion.While the risks of dealing with a subject that is so stigmatized are very real, a proactive approach that is unapolo- getic and women-centered is necessary. Such an approach is critical as it situates women’s need to end unwanted pregnancies in the larger context of the reality of women’s lives and identifies the gender constructs and social and cultural norms that limit women’s reproductive options.

While every woman on average will experience one abortion in her lifetime (AGI, 1999), women’s experiences differ greatly and depend on the options that they have when faced with an unwanted pregnancy. In cases where pregnancy is not socially acceptable, for example, girls and women may consciously choose to end their own life instead of continuing what is perceived as an undesired pregnancy (Ganatra, 2003).Therefore, abortion must be included as part of a continuum of needs experienced by women. It is indispensable in that women are unable to benefit from other rights—social, political, economic and cultural—if they do not benefit from the basic rights to health, livelihood and self-determination.

48 New strategies need to be developed to mainstream abortion and to develop strategic partnerships with other social movements, in particular those working in the areas of HIV/AIDS, social justice, globalization, poverty eradication, and economic, cultural and social rights. It is critical that the sexual and reproductive rights and health movements become more engaged with the World Bank/International Monetary Fund, the World Trade Organization, and other international financial institutions in order to influence key anti-poverty events, debates on the Millennium Development Goals and relevant programming decisions of these institutions.The social injustice of unsafe abortion and the fact that countless women opt for unsafe abortions due to economic hardship must be addressed by actors outside the reproductive-health field.

All countries in this report have signed and ratified the major human rights treaties that recognize and support women’s right to life and health.All are signatories to CEDAW and have thus agreed to eliminate all forms of discrimination against women in the civil, political, economic, social and cultural areas, including health care and family planning, pregnancy, childbirth, and the postnatal period.The right to equality and non-discrimination means that gender discrimination must be eliminated; a woman should not be discriminated against simply because she is a woman.As unsafe abortions only impact women directly, denying them access to abortion can be interpreted as a violation of their basic rights.Approaching health as a human right and recognizing the role of the public sector in providing safe, affordable, and accessible abortion and postabortion care services is therefore critical.

Access to safe abortion services is a social good that benefits women, children, families and entire countries. By recognizing abortion as a social need, we are obliged to also recognize abortion as a right and as a positive social value.As history demonstrates, long-term transfor- mations are the most sustainable when those who have the most at stake are involved in the process of change. It is thus essential to engender broader participation in efforts to influence abortion reform and include a diversity of women’s perspectives as we strive to ensure that women do not needlessly die because they lack reproductive options.

49 Notes 1. Unsafe abortion is defined by the World Health Organization as a procedure for terminat- ing an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both (WHO, 1992). 2. Abortion laws were liberalized in Tunisia and Turkey in 1973 and 1983 respectively. 3. A fatwa is a religious decree.When issued in the national gazette, a fatwa is equal to law.This is the case for the fatwa that prohibits male sterilization in Malaysia.According to respondents, however, the fatwa on abortion seems to serve as a broad guideline in lieu of a law. 4. Also known as the Reproductive Health Care Act. 5. Ensure that services are as close as possible to women’s homes or, since access is not always measured in distance, ensure that physical access is easy regardless of where the site is. Statistical Definitions Abortions: Calculated from abortion rate and number of women aged 15–44. Annual population growth rate (%): Refers to the average annual exponential growth rate for the period indicated. See total population. Births attended by skilled health personnel (%): The percentage of deliveries attended by personnel (including doctors, nurses and midwives) trained to give the necessary care, supervision and advice to women during pregnancy, labor and the postpartum period; to conduct deliveries on their own; and to care for newborns. Births: Calculated from population and birth rate. Contraceptive prevalence rate (%): The percentage of married women (including women in union) aged 15–49 who are using, or whose partners are using, any form of contraception whether modern or traditional. Deaths due to unintended pregnancies (total): Maternal deaths from unintended pregnancies not aborted + number of maternal abortion deaths. Health expenditure per capita (PPP US$): The sum of public and private expenditure (in PPP US$), divided by the population. Health expenditure includes the provision of health services (preventive and curative), family-planning activities, nutrition activities and emergency aid designated for health, but excludes the provision of water and sanitation. See public expenditure on health. Infant mortality rate (per 1,000 live births): The probability of dying between birth and exactly one year of age, expressed per 1,000 live births. Maternal abortion deaths: Calculated from births and unsafe abortion mortality ratio per 100,000 live births. Maternal deaths: Calculated from births and maternal mortality ratio (MMR). Maternal mortality ratio (MMR) (per 100,000 live births): The annual number of deaths of women from pregnancy-related causes per 100,000 live births. Data are estimates based on available national data and adjusted for the well-documented problems of underre- porting and misclassification of maternal deaths or, where national data are unavailable, model- based estimates.

50 National poverty line: The poverty line deemed appropriate for a country by its authori- ties. National estimates are based on population-weighted subgroup estimates from household surveys. Physicians (per 100,000 people): Includes graduates of a faculty or school of medicine who are working in any medical field (including teaching, research and practice). Population living below the national poverty line (%): The percentage of the population living below the specified poverty line. Pregnancies: Abortions + fetal wastage + births. Public expenditure on health (as % of GDP): Current and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations), and social (or compulsory) health insurance funds.Together with private health expenditure, it makes up total health expenditure. See health expenditure per capita (PPP US$). Reproductive risk index: Lifetime risk of dying during pregnancy and childbirth.This index is determined by both the risk of dying during a given pregnancy, and the frequency of expo- sure to that risk, so it includes both the maternal mortality ratio (maternal deaths per 100,000 live births) and total fertility rate (average number of live births per woman) as indicators (PAI, 2001). Total fertility rate (per woman): The number of children that would be born to each woman if she were to live to the end of her child-bearing years and bear children at each age in accordance with prevailing age-specific fertility rates. Total population (millions): Refers to the de facto population, which includes all people actually present in a given area at a given time. Unintended births: Births x percentage of unintended births. Unintended pregnancies: Unintended births + abortions. Acronyms AAP: Abortion Assessment Project, India AGI: Alan Guttmacher Institute, United States AIDS: acquired immune deficiency syndrome ARROW: Asian Pacific Resource and Research Center for Women, Malaysia ATF: Abortion Task Force, Nepal CAC: comprehensive abortion care CEDAW: Convention on the Elimination of all Forms of Discrimination Against Women CEHAT: Center for Enquiry into Health and Allied Themes, India CPR: contraceptive prevalence rate CREHPA: Center for Research on Environment, Health & Population Activities, Nepal CRR: Center for Reproductive Rights, United States D&C: dilatation and curettage EC: emergency contraception FHD: Family Health Division, Nepal FIGO: The International Federation of Gynecology and Obstetrics

51 FOGSI: Federation of Obstetric and Gynecological Society of India FPAN: Family Planning Association of Nepal FPAs: family planning affiliates FWLD: Forum for Women, Law and Development, Nepal GGR: Global Gag Rule GIDR: Gujarat Institute for Development Research GTZ: The Deutsche Gesellschaft für Technische Zusammenarbeit,Germany HAWA: Women’s Development Division, Malaysia IPPF - ESEAOR: International Planned Parenthood Federation, East and Southeast Asia and Oceanic Region LPPKN: Population and Family Development Board, Malaysia MOH: Ministry of Health MTP: Medical Termination of Pregnancy Act, India MUI: Ulemas Council, Indonesia MVA: manual vacuum aspiration NGO: nongovernmental organization NSMP: Nepal Safer Motherhood Project NSOG: Nepal Society of Obstetricians and Gynaecologists Ob-Gyn: obstetrician/gynecologist PAC: postabortion care PAI: Population Action International, United States PEA: Public Education and Advocacy Project, Nepal PND: Pre Natal Diagnostic Techniques Act, India PNGOC: Philippine NGO Council on Population, Health and Welfare, Inc. PKBI: Perkumpulan Keluarga Berencana Nacional PPAT: Planned Parenthood Association of Thailand RHCA: The Reproductive Health Care Act, the Philippines RHN: The Reproductive Health Network, the Philippines RUNDUC: Rural Women’s Development and Unity Center STIs: sexually transmitted infections TCIC: Technical Committee for Implementation of Comprehensive Abortion Care, Nepal UNFPA: United Nations Population Fund USAID: United States Agency for International Development WHAF: Women’s Health Advocacy Foundation,Thailand WHF: Women’s Health Foundation, Indonesia WHO: World Health Organization WHRAD: Women’s Health Rights and Advocacy

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