Abortion in Turkey: women in rural areas and the law MATERNAL DEATHS AND country in the Middle East and one of the This paper aims to emphasise that the UNSAFE ABORTIONS 20 most populous countries in the world. law for safe abortion services may itself Worldwide, an estimated 529 000 girls and Women constitute 36.1 million of the represent a barrier to service provision for women die of pregnancy-related causes population, and half of this number is of all women of reproductive age. each year, about one every minute, and reproductive age. Each year approximately many times that number suffer long-term 1.5 million births take place and 728 –1000 REPRODUCTIVE HEALTH injuries and disabilities. Ninety-nine percent mothers die due to pregnancy-, delivery-, PRIORITIES IN TURKEY of all maternal deaths occur in the and birth-related complications. In Turkey, the reproductive health status of developing world. 1–5 Turkey has made progress in improving the population, particularly women, is low Direct causes of pregnancy-related reproductive health since the 1994 compared to other countries at the same deaths worldwide are: International Conference on Population level of development. In spite of improved and Development (ICPD), and the life expectancy, maternal and infant • severe bleeding, 25%; government has reflected the ICPD targets mortality rates are still above the regional • infection, 15%; and strategies in the country’s averages, as compared with Europe. Some • unsafe abortion, 13%; Development Plan. Furthermore, a National findings of the 2003 Turkish Demographic • hypertensive disorders, 12%; Strategic Plan for Women’s Health and Health Survey (TDHS) may be significant in • obstructed labour, 8%; and Family Planning was developed, which explaining the low status of reproductive • other, 8%. highlights the need to reduce disparities health in the country: the level of unwanted between and within the regions and pregnancies is 11%, nearly one-fifth of Abortion is a sensitive and contentious between different population groups. 9–11 pregnant women do not receive antenatal issue with religious, moral, cultural, and Despite some progress achieved in the care, and one-fifth of births take place political dimensions. It is also a public area of primary mother –child health care outside health facilities. In addition, nearly health concern in many parts of the world. and reproductive health, there are still one-fifth of all births take place without the More than one-quarter of the world’s serious gaps in the availability of healthcare assistance of a doctor or trained health people live in countries where the services, particularly between urban and personnel. The use of modern procedure is prohibited or permitted only rural areas as opposed to towns and cities, contraceptives is low. Condom use among to save the woman’s life. Yet, regardless of and among the regions, especially for those married men is around 11%. 14 legal status, abortions still occur, and living in the poorer eastern part of Turkey Turkey is ranked 94th out of 177 nearly half of them are performed by an rather than in the west. countries according to the Human unskilled practitioner or in less than Induced abortion is a national problem in Development Index for 2005, based on sanitary conditions, or both. women’s health, as it is for the whole 2003 data. 15 The Human Development WHO defines an unsafe abortion as ‘a world, and unsafe abortion is one of the Report also indicates serious regional procedure for terminating an unwanted major causes of death among women of differences within the country. 16 pregnancy either by persons lacking the reproductive age in Turkey. necessary skills or in an environment lacking Despite the liberal nature of the abortion URBAN-RURAL DIFFERENCES IN the minimal medical standards, or both’. law, the number of legal abortions up to WOMEN’S REPRODUCTIVE When abortion is performed by qualified 10 weeks performed in the country has HEALTH SERVICES people using correct techniques in sanitary been sharply restricted by the requirement In Turkey, the proportion of women not conditions, it is very safe. Worldwide, nearly that the procedure be carried out only by or receiving any antenatal care is only 12% in one in 10 pregnancies ends in unsafe under the supervision of gynaecologists. 12,13 urban areas whereas the figure stands at abortion. But this is a global estimate, This factor is especially critical in rural one-third for those living in rural areas. combining countries where abortion is safe Turkey, where medical specialists of any Mothers living in urban settlements are and legal with those where it is restricted type are rare or non-existent. Many rural more likely to receive antenatal care from a and often unsafe. In low-income countries, health facilities that are without a trained doctor than those living in rural areas (84% women have an average of one unsafe specialist are excluded from providing and 58%, respectively). Many women in abortion during their reproductive lives. 3,6 –8 services. Consequently, a rural Turkish Turkey are aware of the importance of an woman seeking an abortion within the first early visit for antenatal care. More women COUNTRY PROFILE 10 weeks of pregnancy may not be able to in urban areas (80%) seek antenatal care Turkey is currently the most populous obtain one. before the sixth month of pregnancy 370 British Journal of General Practice, May 2008 Essay compared to women in rural areas (52%). primary prevention of complications in where mid-level providers are government Antenatal care coverage exceeds 80% in developing countries. This technology trained and accredited to do first-trimester all regions except the east, where it was relies on the use of a simple syringe with a abortions. It was found that with received by 61% of mothers for the most plunger to generate negative pressure for appropriate government training, mid-level recent births in the 5 years prior to the uterine evacuation, and plastic cannulas of healthcare providers can provide first survey. Reflecting the greater tendency varying sizes. The amount of negative trimester MVA abortions as safely as among rural women to delay seeking care, pressure obtained with manual vacuum doctors can. 31 –36 the median duration of pregnancy at the aspiration (MVA) is similar to that generated In Turkey, induced abortion has always first antenatal visit is 2.6 months in urban with large, expensive, electrical pumps, been important in fertility regulation, even areas and 3.5 months in rural areas. which makes this method especially suited preceding it’s legalisation on socioeconomic This unmet need for family planning in for use in clinics, offices, and low-resource grounds in 1983 with the enactment of the Turkey fell from 10% in 1998 to 6% in settings. MVA also has the advantage that new Population Planning Law. In the early 2003, but this is higher among women the syringe can be cleaned, disinfected to a 1980s, the growing incidence of unsafe aged 15 –29 years and women living in rural high level, or sterilised and used repeatedly; abortion in Turkey and the resulting accommodation. Unmet need by region similarly, cannulas can be discarded or re- morbidity and mortality rates led the varies from 3% of women in the west to used after appropriate disinfection or government to liberalise the law further and 15% of women in the east. 14 sterilisation. Vacuum aspiration is safer make abortion widely available. The Limited access to and low utilisation of than sharp curettage, and the WHO Population Planning Law in 1983 provided health services in the eastern and south- recommends vacuum aspiration as the safe abortion on request during the first eastern regions and rural areas throughout preferred method for uterine evacuation 10 weeks of gestation for every woman who the country is often related to the low before 12 weeks of pregnancy. 20,21 needed the service. 12 social status of families, especially of The vacuum aspiration method is also a Under this law, trained nurses and women. safe, effective, and acceptable treatment midwives are authorised to insert IUDs, for the treatment of first-trimester and GPs and family physicians with special SCOPE OF INDUCED uncomplicated incomplete abortion, as is training are allowed to provide abortions by ABORTIONS 600 µg oral misoprostol. 22 –24 vacuum aspiration, under the supervision The international health community and MVA is faster, safer, more comfortable, of obstetrician –gynaecologists. 13,37,38 governments worldwide have repeatedly and associated with shorter hospital stay In rural areas of Turkey in particular, agreed that reducing deaths and injuries for induced abortion than sharp primary sometimes second-level from unsafe abortion is a high priority. 17 curettage. 25,26 Additional advantages healthcare facilities without obstetricians Although specific commitments have compared with sharp curettage are its ease have to refer their abortion cases, even been made toward achieving this of use as an outpatient procedure, the need those with severe bleeding, to a higher objective, progress to date has been for less analgesia and anaesthesia, 27 and its level facility, leaving most women unable to wholly inadequate. Significant progress lower cost per procedure, especially if done obtain emergency care in time. 39 cannot occur until all women of on an outpatient basis. 28 In countries with a Although the percentage of pregnancies reproductive age have much better access small number of physicians, vacuum that are ended through induced and unsafe to safe abortion care in their communities. aspiration can be safely and effectively abortion in Turkey have reduced, the level Abortion is safest when performed early in used by mid-level health service providers, remains high due to this legal obligation. a pregnancy. Menstrual regulation is such as midwives.