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, informa- tion 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 par- ticular, 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 provid- ed 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 aver- age 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 con- cern 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 implementa- tion (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 circum- stances 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