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Induced Abortion in Thailand: Current Situation in Public Hospitals and Legal Perspectives Suwanna Warakamina Nongluk Boonthaia Viroj Tangcharoensathienb

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Induced Abortion in Thailand: Current Situation in Public Hospitals and Legal Perspectives Suwanna Warakamina Nongluk Boonthaia Viroj Tangcharoensathienb A 2004 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2004;12(24 Supplement):147–156 0968-8080/04 $ – see front matter PII: S0 968 -808 0(0 4)24 018-6 www.rhm-elsevier.com ISBN 0-9531210-2-X www.rhmjournal.org.uk Induced Abortion in Thailand: Current Situation in Public Hospitals and Legal Perspectives Suwanna Warakamina Nongluk Boonthaia Viroj Tangcharoensathienb a Reproductive Health Division, Department of Health, Ministry of Public Health, Thailand b Senior Research Scholar Programme in Health Economics and Financing, International Health Policy Programme, Ministry of Public Health, Nonthaburi, Thailand. E-mail: [email protected] Abstract: Abortion is illegal in Thailand unless the woman’s health is at risk or pregnancy is due to rape. This study, carried out in 1999 in 787 government hospitals, examined the magnitude and profile of abortion in Thailand, using data collected prospectively through a review of 45,990 case records (of which 28.5% were classified as induced and 71.5% as spontaneous abortions) and face-to-face interviews with a sub-set of 1,854 women patients. The estimated induced abortion ratio was 19.5 per 1,000 live births. Almost half the induced abortions were in young women under 25 years of age, many of whom had little or no access to contraception. Socio-economic reasons accounted for 60.2% of abortions. Serious complications were observed in almost a third of cases, especially following abortions performed by non-health personnel. Government physicians’ current provision of induced abortion went beyond the provisions of the law in almost half of cases, most commonly for intrauterine death and for congenital anomalies. The paper proposes a framework for policy discussions of the grey areas of maternal and fetal indications leading to legal reform, in order to facilitate safe abortion. A recommendation to amend the abortion law has been proposed to the Ministry of Public Health and the Thai Medical Council. A 2004 Reproductive Health Matters. All rights reserved. Keywords: unwanted pregnancy and abortion, abortion law and policy, complications of unsafe abortion, Thailand NDUCED, unsafe abortion is a major public prevalence rate 72% in 2000), unmarried women health problem affecting the quality of life of still have difficulties accessing family planning women of reproductive age. This issue was services, and unsafe abortions and complications I 2 given special consideration at the International are still major public health problems. Conference on Population and Development Routine hospital-based reports provide only held in Cairo in 1994. Obtaining accurate data the tip of the iceberg as regards abortion rates.3,4 where abortion remains illegal is difficult. Very Most women do not admit to induced abortion often, abortion rates are derived by means of due to its illegal status and social sanctions. A estimates. Global estimates of 19 million unsafe one-year prospective observational study in abortions and 68,000 deaths annually were made 1984 found that 78% of abortions were induced, for 2000, and unsafe abortions accounted for 13% therapeutic and 65% illegal, and 22% were 13% of all maternal deaths.1 spontaneous. Among the unmarried women who had had therapeutic abortions, the main reasons were in fact socio-economic, e.g. pre- Unwanted pregnancy and induced marital pregnancy, student status and against abortion in Thailand some occupations. Among the married women Though Thailand has a good record in family who had therapeutic abortions, the main reasons planning (total fertility rate 1.9 and contraceptive were socio-economic and contraceptive failure.5 147 S Warakamin et al / Reproductive Health Matters 2004;12(24 Supplement):147–156 Legal perspectives: problems arising from effective prevention of unwanted pregnancies, the Thai abortion law adequate access to safe abortion when needed, The Thai Criminal Code, Sections 301 to 305, prevention of unsafe abortions, minimising the last amended in 1957, defines offences in rela- incidence of complications from induced abor- tion to induced abortion as ‘‘any actions causing tion and proper interventions to achieve these the delivery of a dead fetus’’. Under Article 305, goals. It is therefore also necessary to have data induced abortion can only be performed by a on the magnitude and public health impact of physician for two specific conditions, risk to the induced abortion. woman’s health and pregnancy arising from In the last three decades, there have been rape. Several problems arise in the interpretation a number of dynamic debates and unsuccess- and implementation of this law. ful attempts to reform the Criminal Code in First, there is no definition of ‘‘health’’ or relation to abortion, to specify that health whether it covers the whole range of physical covers physical as well as mental health of the and mental health and social well-being as pregnant woman and to include fetal indica- definedbytheWorldHealthOrganization tions, i.e. severe congenital anomalies and (WHO) Constitution.6 The courts tend to inter- genetic disease incompatible with life. Increas- pret health in the narrow sense of physical ingly, the broader grounds of health and health only, according to several lawyers and fetal indications have gained more acceptance public prosecutors (Personal communication, socially as legitimate reasons for abortion. 2002). Upon official requests by the Medical Social reasons, on the other hand, such as con- Council in 2001 to interpret the meaning of traceptive failure, have not. Indeed, a proposal to include the latter led to strong opposition to health in the law, the Royal Institute replied 8 that a broader interpretation, including phys- reform in 1981. ical and mental health, was correct. However, The objective of this study, carried out over a the Royal Institute has no juridical power. period of one year in 1999, was to estimate the Second, although incest is not mentioned magnitude and profile of induced abortion in in the Code, in practice medical professionals Thailand through a prospective study in sentinel consider incest a form of rape and abortions public hospitals, and to make policy recommen- are generally provided (Personal communica- dations on how to reduce unsafe abortion. We tion, obstetricians and general practitioners). intended to include all 830 public and approxi- Third, in cases where women seek abortion as mately 400 private hospitals in the country,* a result of rape, physicians are required under but the private sector declined due to legal the Criminal Code to obtain proof from the restrictions and the illegal nature of many police. However, in practice, most women are abortions. Only the public hospitals were willing deterred from reporting rape to the police. to participate. Lack of proof and refusal by physicians force women to resort to unsafe abortion or con- Methodology and participants tinuing the pregnancy. Lastly, although the law does not cover fetal Two main research methods were used, case indications, abortions are carried out by medi- record review and face-to-face patient inter- cal professionals on these grounds. In 1995 views. In the case record reviews, all ambulatory a teaching hospital was reported to have been abortion visits and admissions were examined charged with violating Articles 301 and 302 for the whole of 1999. The diagnosis of sponta- of the Criminal Code as it had terminated neous vs. induced abortion recorded by the physicians was to be based on the following 362 pregnancies during 1981–85 of women 9 with rubella infection, because it causes severe WHO case definition criteria: congenital malformations.7 *The public health care system in Thailand includes more than 700 district hospitals, covering all districts, and 92 The reproductive health policy context provincial/regional hospitals in all 75 provinces. Private The policy goals of reproductive health, as stipu- hospitals have less than 20% of the total number of lated by the Ministry of Public Health, are the beds nationally. 148 S Warakamin et al / Reproductive Health Matters 2004;12(24 Supplement):147–156 Certainly induced abortion – when the woman conducted using a structured questionnaire. herself has admitted it, or has told a health Hospital staff designated to do the interviews worker or relative (in the case of the woman received one day of training from the researchers. dying), or there is evidence of trauma or of a We aimed to interview a total of 2,000 women. foreign body in the genital tract; Patients were interviewed until a quota of 20 Probably induced abortion – when the woman (for district hospitals) and 40 (for provincial or has signs of induced abortion accompanied teaching hospitals) was achieved. To prevent bias, by sepsis or peritonitis, and the woman states we applied the principle that every consecutive that the pregnancy was unplanned; induced abortion patient would be interviewed. Possibly induced abortion – if only one of the Almost all the women concerned agreed to par- ‘‘probably induced’’ conditions is present; ticipate in the interviews. Note that the women Spontaneous abortion – if none of the con- interviewed were a sub-set of those in the case ditions listed above is present, or if the record review. woman states that the pregnancy was planned Participating patients and hospitals were pro- and desired. tected for data confidentiality. The interviews were conducted during the second half of 1999 For the purposes of this study, the first three on the hospitals’ premises in a private room in case definitions (certainly, probably and possibly) the gynaecology ward. were all classified as induced abortion. The pregnancies of the women who comprised Information about each abortion case was the study sample were terminated at less than retrieved from the medical records by a desig- 28 weeks of pregnancy. The women had either nated hospital staff person and sent to the been admitted to hospital with symptoms related researchers each month, with a copy retained in to spontaneous or induced abortion, or had had the participating hospital for verification in case therapeutic abortions conducted in the hospital.
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