Review article The hidden problems of illegal abortions in Thailand Orawee Chinthakanan, M.D.,1 Roger W. Rochat, M.D.,2 Nuntana Morakote, MPH,1 and Somsak Chaovisitseree, M.D.1 1Department of Obstetrics and Gynecology, Chiang Mai University, 2Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA High rates of unplanned pregnancy and induced abortion were reported among young women in Thailand. Complications from illegal and low standard abortion are a current major health problem in the country. Abortion is considered to be a life-destroying act that counts as a serious bap (sin or demerit) in Thai culture. The current abortion law in Thailand stipulates that abortion is illegal except when performed by a medical practitioner in circumstances considered necessary when the pregnancy endangers the woman’s health or conception had occurred during a sexual offense such as rape or incest. However, most Thai people feel that the abortion law should be amended because Thai society has changed radically in its attitudes over the past decade. The debate over legal reform of this law is still active. Thailand needs a multi-disciplinary approach to reduce and prevent the number of unplanned pregnancies and unsafe abortions, with special attention paid to the most vulnerable group of women. Chiang Mai Medical Journal 2014;53(4):187-91. Keywords: abortion, Thailand, Law, legalized abortion, unplanned pregnancy Introduction The recent revelation of 2,002 dead fetuses port to help with their unplanned and unwanted found in a Buddhist temple in Bangkok enlight- pregnancy. They might have been raped and ened people of the hidden problem of illegal did not seek medical attention or experienced abortion in Thailand. The remains were widely an unexpected pregnancy from failure to use believed to have come from many illegal abor- contraception. They possibly had little or no tion clinics in the city[1]. Complications from money for receiving a standard and safe abor- illegal and low standard abortions are a current tion. Therefore, the attempt to self-induce ter- major health problem in the country. A woman mination of a pregnancy would be dangerous dies every eight minutes worldwide from medi- and probably unsuccessful. On the other hand, cal complications as a consequence of unsafe these women might seek an unqualifi ed surgeon, abortion[2]. These victims were likely young who is relatively inexpensive, to terminate the people, perhaps teenagers, living in rural ar- pregnancy. Sadly, many of these women have eas and having little or no family or social sup- died from medical complications as a result of Address correspondence to: Orawee Chinthakanan, M.D., Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200 Thailand. E-mail: [email protected] Received September 4, 2014, and in revised form December 27, 2014. 188 Chiang Mai Med J 2014;53(4): unsafe abortions. Intervention in order to pre- Problems arising from the Thai abor- vent unwanted pregnancy is the key for solving tion law hidden problems of unsafe abortions, by expand- The current abortion law in Thailand became ing access to modern contraceptive methods, effective in 1956. Section 301-305 of the Crimi- providing safe abortion to the full extent of the nal Code of Thailand stipulates that abortion law, and tackling legal and programmatic barriers is illegal except when performed by a medical against receiving a safe abortion. practitioner in circumstances considered neces- sary when the pregnancy endangers the wom- The situation of abortion in Thailand an’s health or conception had occurred during a A total of 45.5 million induced abortions sexual offense such as rape or incest. A woman accounted for over one-fi fth of approximately also can be criminalized if she allows someone 210 million pregnancies reported worldwide in to perform an illegal abortion on her[10]. Several 1995. These aggregate numbers translated into problems have been raised from the interpreta- a pregnancy rate worldwide of 160 pregnan- tion and implementation of this law. cies per 1,000 women aged between 15 and 44 Firstly, there is no clear defi nition of “health” years old[3]. A high rate of induced abortion was in this law, and the whole range of physical and reported among young women in Thailand as mental health, including social well-being as de- well. Thailand was ranked fi rst for teenage preg- fi ned by the WHO, is not explicit. The courts tend nancy, which accounted for 17.2% of live births to interpret health in the narrow context of physi- in 2009[4,5]. Of those, 40.7% were unintended cal health only. In 2001, the Thai Medical Coun- pregnancies[6]. A study conducted in govern- cil requested an interpretation of the meaning ment hospitals revealed that of 13,090 cases of of health in the law. The Royal Institute there- induced abortion, 47% were in women younger fore provided a broader interpretation, including than 25 years old. Also, 21% of these young fe- both physical and mental health, but it had no males were adolescents with little or no access juridical power. Secondly, although incest is not to contraception[7]. The most common reason mentioned in the Code, in practice, medical pro- for induced abortion was the pregnant women’s fessionals consider incest as a form of rape and strong desire to continue their education[8]. abortion is generally provided. Thirdly, in cas- Over 61% of pregnant women were younger es of women seeking abortion because of rape, than 25 years of age, and underwent an abor- physicians are required under the Criminal Code tion performed by providers outside the stand- to obtain proof of the crime and permission for ard health care system. Thirty percent of these an abortion from the police. However, in reali- were teens. Furthermore, only 29% of abortions ty, most women are deterred from reporting rape performed outside the health care system were to the police. Therefore, such women resort to in the hands of qualifi ed health care personnel unsafe abortion or continued pregnancy, due to such as physicians, obstetricians, nurses or mid- the lack of proof and refusal by the physician to wives. Therefore, high numbers of severe medi- operate. Lastly, the law does not cover fetal in- cal complications from illegal abortion carried dications. In 1995, a report stated that a medical out by unqualifi ed personnel were reported[7]. school had been charged with violating the abor- The World Health Organization (WHO) estimat- tion law, as it reportedly terminated 362 preg- ed that the annual incidence of unsafe abortions nancies between 1981 and 1985 for women with in Thailand during 2003 was between 20 and 29 rubella infection, as a result of severe congenital cases per 1,000 women aged between 15 and 44 malformation[11]. years old[9]. The debate over legal reform of this law start- ed in 1973. The reform bill was passed in 1981 in Chinthakanan O, et al. Abortion in Thailand 189 the House of Representatives, but later defeated the Theravada school. Abortion is considered to in the Senate in 1983. Primarily, this was due be a life-destroying act that counts as a serious to lobbying from a leader of a broad-based re- bap (sin or demerit). Many women have cited ligious coalition, who continues to be a central this fear of bap as the main reason for continuing fi gure in the anti-reform movement. The various their unplanned pregnancy. In contrast to Bud- governments that followed this have not taken dhism in Thailand, Buddhists in Japan fi nd abor- up the efforts to legislate reform on this issue[10]. tion more acceptable. The Japanese practice of According to a large-scale hospital-based sur- mizuko rites involves the parents praying for the vey on abortion in Thailand, several indications well-being of the aborted fetuses in their rejected of abortion remain controversial, as to whether “lives”[12]. Following the discovery of 2,002 they should be included in legal reforms. These fetuses dumped in a Bangkok temple, Suan “illegal” indications for abortion are unlikely to Dusit Rajabhat University conducted a survey of be legalized in the near future. Consequently, 1,458 people living in Thailand’s capital and its abortion will remain a politically sensitive issue, neighboring provinces during December 2010. which has been sensationalized in the press in The survey showed that 65.6% of respondents order to counter reform efforts. felt that the abortion law should be amended A recent debatable issue on reproductive because Thai society has changed its attitudes health concerned a law to protect the right to radically over the past decade. More than 62% educate pregnant students. In 2010, the Ministry of participants in the survey said that they could of Public Health introduced a draft law; “Com- not comprehend why there were so many abor- prehensive Reproductive Health”, which aims to tions, and about 15% said abortion was a sin and allow pregnant students to continue their study[5]. should be illegal. However, nearly half of the re- In general, schools lack clear guidelines on spondents (47%) said it was an individual right whether to allow pregnant students to remain in to have an abortion depending on their need. The schools, and decisions depend on the school ex- poll’s margin of error was 5 percent, according ecutives. Within the law, all schools must allow to the survey’s administrators[11]. pregnant students to continue their study, unless they prefer otherwise. In addition, the key con- Voices of Thai Physicians on Abortion tents of the draft law include the rights to access The number of Obstetricians and Gynecolo- reproductive health services, maternal leave, gists (OB/GYN) in Thailand is disproportion- and age-appropriate sex education for students.