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Denial of Abortion in Legal Settings

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Denial of Abortion in Legal Settings COMMENTARY Denial of abortion in legal settings Caitlin Gerdts,1 Teresa DePiñeres,2 Selma Hajri,3 Jane Harries,4 Altaf Hossain,5 Mahesh Puri,6 Divya Vohra,7 Diana Greene Foster8 For numbered affiliations see ABSTRACT end of article. Background Factors such as poverty, stigma, Key message points Correspondence to lack of knowledge about the legal status of Dr Caitlin Gerdts, Advancing abortion, and geographical distance from a ▸ Legal restrictions on abortion are often New Standards in Reproductive provider may prevent women from accessing safe the cause of abortion denial. Health, University of California, abortion services, even where abortion is legal. San Francisco, 1330 Broadway ▸ Abortion denial is common, though St, Suite 1100, Oakland, Data on the consequences of abortion denial incidence varies by country. CA 94612, USA; outside of the US, however, are scarce. ▸ The denial of legal abortion services [email protected] Methods In this article we present data from may have serious consequences for the Received 10 June 2014 studies among women seeking legal abortion health and wellbeing of women and Revised 30 August 2014 services in four countries (Colombia, Nepal, their families. Accepted 7 November 2014 South Africa and Tunisia) to assess Published Online First sociodemographic characteristics of legal 15 December 2014 abortion seekers, as well as the frequency and reasons that women are denied abortion care. becomes more widely available, women Results The proportion of women denied may be able to access safe abortions 3 abortion services and the reasons for which they outside legal systems. Whileevidenceis were denied varied widely by country. In limited, it is likely that factors such as Colombia, 2% of women surveyed did not poverty, stigma, geographical distance from receive the abortions they were seeking; in South a provider and lack of knowledge about Africa, 45% of women did not receive abortions the legal status of abortion on the part of on the day they were seeking abortion services. women and potential providers, prevent In both Tunisia and Nepal, 26% of women were many women from accessing safe abortion 4 denied their wanted abortions. services, even where abortion is legal. Conclusions The denial of legal abortion Both in contexts where abortion is services may have serious consequences for legally restricted and where it is available, women’s health and wellbeing. Additional widespread stigma about unwanted preg- evidence on the risk factors for presenting later nancy and abortion lead to substantial 5 in pregnancy, predictors of seeking unsafe illegal bias in data collected about abortion. abortion, and the health consequences of illegal The lack of reliable data makes it difficult abortion and childbirth after an unwanted to gain a broader understanding of abor- pregnancy is needed. Such data would assist the tion safety and access in legal contexts, or development of programmes and policies aimed to fully understand the role of misoprostol at increasing access to and utilisation of safe in making abortions safer and more Open Access 3 Scan to access more abortion services where abortion is legal, and accessible in any context. The availability free content harm reduction models for women who are of new data from four countries sheds unable to access legal abortion services. light on the extent of abortion denial in legal settings and sets the stage for study- ing the health and socioeconomic conse- BACKGROUND quences of not receiving a wanted The legal status of induced abortion has abortion. long been seen as a proxy for ease of access Legal restrictions on abortion are often to safe abortion services.1 The notion that the cause of abortion denial. In Nepal, the legality equals safety is simplistic; some law permits abortion on request up to a illegal abortions are safe and even where gestational age of 12 weeks. In South abortion is legal, many women are unable Africa, the law allows legal termination of To cite: Gerdts C, 2 DePiñeres T, Hajri S, et al. J to access these services. As misoprostol – pregnancy on request up until 12 weeks Fam Plann Reprod Health an abortifacient that women can use to gestation, and for socioeconomic or Care 2015;41:161–163. safely terminate their own pregnancies – medical reasons from 13 to 20 weeks. In Gerdts C, et al. J Fam Plann Reprod Health Care 2015;41:161–163. doi:10.1136/jfprhc-2014-100999 161 Commentary Tunisia, abortion is legal on request during the first clinic to have an ultrasound scan prior to the procedure 12 weeks of pregnancy. In Colombia, abortion is per- or were referred to other providers. In Nepal, 26% of mitted by law when the pregnancy endangers the life women did not receive the abortions they sought; 14% or health of the woman, the pregnancy is the result of were turned away for gestational age reasons and 12% rape or incest, or if the fetus has a life-threatening were turned away for other reasons including lack of anomaly. While there is no legal gestational limit in availability of abortion medications at the facility, Colombia, the largest provider of abortions in the undetectable pregnancy, and medical contraindications. country has a gestational age limit of 15 weeks.6 In Colombia, 2% of women surveyed did not receive the abortions they sought, all due to gestational age STUDY FINDINGS restrictions. We interviewed all women presenting for abortion at The findings in Nepal, South Africa and Tunisia that two clinics in each of four cities: Katmandu, Nepal; a large proportion of women seeking abortions are Cape Town, South Africa; Tunis, Tunisia; and Bogota, turned away are similar to results of a recent study Colombia over a span of 1–6 weeks between 2012 and among women seeking menstrual regulation services in 7 2013. We administered questionnaires and documen- Bangladesh, where one-quarter of women seeking ted each participant’s gestational age at the time of the menstrual regulation services in 2010 were turned visit, whether she received the abortion she was away. The study found that health facilities denied ser- seeking, and, in the case of denial of services, the vices to women because too much time had elapsed reason for denial. since the last missed period or for other medical con- Women seeking abortion ranged in age from a mean cerns. However, consistent with our findings in Tunisia of 26.4 years in Colombia to 30.6 years in Tunisia. The where clinics required unnecessary tests, facilities also mean gestational age ranged from 6.1 weeks in reported turning women away for reasons that were Colombia to 9.9 weeks in South Africa, and the propor- not legally required or medically necessary, such as tion of women presenting for abortions after 12 weeks’ being unmarried or not having the husband’s consent. gestation ranged from 2% in Colombia to 20% in South Africa (Ta b l e 1 ). ILLEGAL ABORTIONS The incidence of abortion denial was overall much What happens to women who are denied the abortion higher than we expected and varied significantly by services they seek? Researchers have hypothesised that country. In South Africa, 45% of women in our survey in some settings women who are denied abortions did not receive the abortions they sought at the clinic: because of gestational age limits may go on to seek 20% of all women interviewed were turned away for illegal abortions elsewhere.8 In each of the countries advanced gestational age, 20% because the clinic did some women received referrals to other legal provi- not have the staff to perform their abortions that day, ders. It is, however, unknown whether women were and 5% because of an inability to pay for their abor- able to pursue those referrals and receive a legal abor- tions. In Tunisia and Nepal, approximately one-quarter tion, whether they sought illegal abortions, or whether of women were denied wanted abortions. In Tunisia, they continued with their pregnancies. 26% did not receive the abortions they sought; 7% of Evidence suggests that with increased access to women were turned away for gestational age reasons, misoprostol, women seeking abortions outside legal 15% were required by the clinic to undergo laboratory systemsmayhaveasaferalternativetoinvasiveand tests not required by law prior to receiving the abortion potentially life-threatening methods of self-termination.3 they requested, and 4% were either required by the Data from Latin America indicate that misoprostol has Table 1 Characteristics of women seeking abortions in four countries Selected characteristics Tunisia* (n=85) South Africa* (n=60) Colombia† (n=225) Nepal* (n=311) Sociodemographic characteristics (mean) Age (years) 30.6 28.2 26.4 28.6 Gestational age by ultrasound (weeks) 7.6 9.9 6.1 8.8 Education (%) None/primary school 47 8 5 40 Secondary school 39 57 49 40 Beyond secondary school 14 35 46 20 Receipt of abortion (%) Received abortion 74 55 98 74 Turned away due to gestational age 7 20 2 14 Turned away for other reasons 19 25 0 12 *Gestational limit 12 weeks. †Gestational limit 15 weeks. 162 Gerdts C, et al. J Fam Plann Reprod Health Care 2015;41:161–163. doi:10.1136/jfprhc-2014-100999 Commentary contributed to a decrease in the mortality and morbidity 8Associate Professor, Advancing New Standards in associated with illegal abortion,9 but that it may also be Reproductive Health, University of California, contributing to a higher rate of facility visits for San Francisco, CA, USA abortion-related complications as women seek services to complete the abortion once it is started with miso- Acknowledgements The authors thank Rana Barar, Heather prostol.10 Outcomes associated with misoprostol use Gould, Alison Swiatlo, Debbie Nguyen and Elisette Weiss. Funding Funding for these studies was provided by the University for self-induced abortions outside legal systems have ’ 3 of California, San Francisco s Research Allocations Program, and been challenging to document, and how women access through a crowdfunding campaign hosted on IndieGoGo.
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