Illegality


http://www.abortionreview.org/index.php/site/article/1323/

31 January 2013

Dr Carlos Morín, the Barcelona abortion doctor facing a possible sentence of 273 years in prison for practising almost a hundred abortions, has been absolved of all charges. Jennie Bristow discusses the circumstances and broader implications of his trial.

Another 10 defendants also faced heavy prison charges for illegal abortion, forgery, conspiracy and professional intrusion; however, the Barcelona court has ruled the abortions were carried out according to the law, and ‘with the consent and under the express request of the pregnant women’, the Spanish newspaper El País reports (1).

With this ruling, notes El País, ‘the Court of Barcelona has closed today an episode that marked a before and after in the Spanish legislation on abortion’. The Morín case attracted attention across Europe because, as the London Times reported back in 2011, ‘hundreds of women from Britain, Spain and other parts of Europe who were seeking late abortions were treated at the Ginemedex and TCB clinics in Barcelona, which were run by Dr Morín’. (2)

In Spain and beyond, the Morín case highlights some unsettling features of the legal and cultural situation surrounding abortion laws in Europe , and their implications for women and doctors. Above all the case shows how quickly, in a febrile cultural climate, countries can shift from being a haven for desperate women who could not be treated elsewhere in Europe into a hell for the doctors who helped them.

Context

Carlos Morín’s Ginemedex clinic in Barcelona has been the focus of attention by anti-abortion groups and media organisations for several years. In 2004, the British newspaper The Sunday Telegraph conducted an undercover investigation into the practice, by the abortion provider British Pregnancy Advisory Service (BPAS), of giving women the Ginemedex clinic’s telephone number when they were too late in the gestation of their pregnancies to be given an abortion under British law. A ‘supplementary report’ published by the Sunday Telegraph one month later ‘alleged that a general practitioner based in the South Birmingham Primary Care Trust had offered to facilitate the referral of a late abortion to the same clinic’. (3)

In Britain, the maximum ‘time limit’ for abortion (except in cases of fetal anomaly or to save the mother’s life and health) is 24 weeks; and pressure on the ‘late’ abortion services at that time meant that a woman presenting for an abortion at gestations over 21 weeks could not always obtain treatment in Britain. In such circumstances, staff at BPAS would sometimes pass on to these women the telephone number of the Ginemedex clinic, where abortions were conducted up to and beyond the 24-week British limit.

The Sunday Telegraph investigations caused significant fall-out in Britain . The Chief Medical Officer (CMO) conducted a thorough investigation of practices at BPAS, and in a report published in September 2005 (3) concluded that, while some of the advice given to the undercover journalist by staff at the BPAS helpline was unacceptable and that training issues should be addressed, BPAS had not broken any laws and continued to run a good service for women needing abortions at later gestations.

The CMO noted that ‘a woman is entitled to travel to another member state of the European Union for a termination of pregnancy’, and that information received from the Catalan Health Authority at the time of writing his report indicated that ‘there is no evidence of the Spanish clinic having acted outside of Spanish abortion law’.

The CMO’s most significant conclusion, for Britain , was that the circumstances leading to women being given the number of the Spanish clinic indicated broader inadequacies in the late abortion service in Britain , where the lack of provision meant that some women were denied access to the abortions to which they would have been legally entitled. The CMO called for an inquiry in the late abortion service in Britain – to date, this has not been acted upon.

Over in Spain , the campaign against Carlos Morín continued. In 2006, a Danish TV company conducted an undercover investigation of the clinic; this prompted another inspection by the health authorities, which found nothing illegal. The ‘ultra-Catholic’ group E-Christians then lodged a complaint about Morín at the Barcelona doctors’ association, which failed. In 2007, following a legal complaint against Morín by an employee, the clinic was searched, documents confiscated, and Morín arrested.

The puzzling thing to arise from this chronology of events is, what changed between 2006 – when the health authorities were apparently satisfied with Morín’s practices – and 2007, when he was arrested and his practice shut down? Again, it is fruitless to speculate on specific details that may emerge over the course of the case. But given broader developments in the Spanish abortion law from 2007, it is necessary to look at the changing cultural, political and legal context in which the Morín case has developed.

The Spanish abortion law, 2004-2007

As things stood in 2004, abortion was permitted under Spanish law for the following reasons:

• The pregnancy is the result of rape – up to 12 weeks gestation;
• The fetus, if carried to term, will suffer from severe physical or mental defects – up to 22 weeks;
• The abortion is necessary to avoid a grave danger to the life of or the physical or mental health of the pregnant woman – no time limit. (4)

In this respect, the Spanish law was similar to the British abortion law: with the exception of rape cases, abortion was not available on request, but it put the onus on the clinician to interpret it according to the woman’s circumstances. Under British law, abortion is legal up to 24 weeks’ gestation on the grounds that the pregnancy risks damage to a women’s mental or physical health; this is interpreted broadly, so that most of those women with an unwanted pregnancy who are motivated to ask for an abortion are considered to be at risk of psychological damage if the abortion is denied.

In a similar fashion, so the Spanish law came to be interpreted in its least restrictive form, and practiced outside of the national healthcare system. As the CMO’s report noted, in Spain in 2005 ‘Nearly all abortions are carried out in private clinics and 97% of abortions are carried out under the last ground shown above. In 2003, 79,800 abortions were carried out; 1.9% of these were at 21 weeks or more.’

The CMO’s report also cited statistics from the Barcelona newspaper La Vanguardia about the extent of late abortions performed to women from outside Spain: ‘The article also said in 2003, that out of all the patients seen within the 26 centres in Catalunya, 812 patients were foreign and only 14 of these were from the United Kingdom overall. 98.9% of the abortions performed on foreigners were of less than 22 weeks. In three cases it was in the 24th week and in five in the 26th week.’
This detail indicates a number of key points about the legal situation in 2004:

• Abortion in Spain was legal beyond the 24-week British time limit;
• Clinical practice at the Barcelona clinic was above board, in that it was inspected and approved by the Catalunyan health authorities;
• A small proportion of the abortions carried out in Spain were at ‘late’ gestations of only 21 weeks, and an even smaller proportion were carried out beyond the UK time limit of 24 weeks;
• A very small proportion of clients had come from the UK , and most of those were being treated at gestations that were legal in the UK – but presumably, they could not access the procedure here.

In other words, there was no scandal here waiting to be uncovered. The situation in Spain was legal and accepted by the health authorities; and this provided a haven for a small proportion of women travelling from countries where abortion was either illegal or inaccessible. What suddenly seems to have changed in 2007 was not the practice in Spain , but the cultural and political climate in which abortion was provided.

The Spanish abortion law, 2007-date

In 2010, the Sexual and Reproductive Health and Voluntary Termination of Pregnancy Act became law in Spain , replacing the previous legislation. This provides for abortion on request, funded by the state, up until the fourteenth week of gestation; but it is far more restrictive of abortions carried out later on. In this regard, the new Spanish law follows a pattern established in some other European countries, where there has been a ‘trade off’ between liberalisation in the first trimester of pregnancy – abortion on request – against greater restrictions on abortions at later gestations.

The new law seems to have been greeted by abortion providers as a mixed blessing. It was provoked by the bizarre situation in 2007, where a number of abortion clinics were raided by the Guardia Civil, medical records were seized, and clinic staff arrested or investigated. Following this, 40 clinics (over half of those in Spain ) suspended their work because they could no longer guarantee the provision of the service, or the safety of their staff. The situation revealed the fragility of an unclear law in circumstances that can quickly change, and the new abortion law has the merit of clarifying to women what they are allowed to seek, and to doctors what they are allowed to perform.

But at a conference of abortion and contraception providers held in Seville , Southern Spain , in autumn 2010, Eva Rodriguez of the abortion clinics’ association ACAI showed a thought-provoking film examining the new law, and also indicating its negative side. One contributor to the film drew attention to the arbitrariness of the 14-week time limit for abortion on request – why should women be accorded less capacity to decide in week 15, or 20 of their pregnancy? There remained difficulties with the financial and practical aspects of implementing the law, including concerns about regional differences. And of course, for women – in Spain and abroad – who need abortions after 14 weeks’ gestation – things have become that much harder. (5)

This situation indicates a shifting climate of expectation around abortion in Spain . As Ann Furedi, chief executive of BPAS, notes, ‘what has happened in Spain seems less to be a discovery of wrong-doing than a redefinition of wrong-doing’. And it is this notion of wrong-doing that needs to be discussed outside of the court, as a moral and political issue.

The demonisation of ‘late’ abortions

In recent years, and around the world, doctors conducting abortions in later gestations of pregnancy have found themselves in the news headlines, and the reaction is interesting to examine. The murder of the American Dr George Tiller in 2009 shocked those inside and outside the pro-choice movement – it is, thankfully, generally considered to be wrong to murder somebody for going about his lawful business, even if that lawful business is the controversial practice of second-trimester abortion. (6)

On the other hand, the arrest of the rogue Philadelphia doctor Kermit Gosnell in 2010 was shocking to those on both sides of the abortion debate, because of the illegality, brutality and clinically unsound nature of his practices. Those who argue for legal abortion beyond the first trimester do so precisely to protect women – who, when desperate for an abortion, will go to any lengths to obtain one – from charlatans such as these. (7)

As a society – even one like America, which is so polarised around the abortion debate – we set great store by what is legal and clinically safe medical practice, and what is not. This is why advocates of women’s right to abortion seek to make this practice legal, so the woman and her doctors can be safe. It is why the fact that most abortions happen in the first trimester does not mean that women do not need access to abortion beyond that time – as research has amply demonstrated (8), a small proportion of women will always need access to late abortion, and the ‘right to choose’ should not just mean ‘only three months to make your mind up’.

And this is also why abortion advocates and doctors will push for women to have access to safe care to whatever gestation they possibly can within the law. If abortion providers were interested in having an easy life, they a) probably wouldn’t work in abortion services in the first place, and b) would seek to provide women with the cheapest, easiest services they possibly could, even if this meant slamming the door in the face of those women presenting with more challenging conditions or gestations. But they don’t.

The fact is, those who work in abortion services are motivated by the care of women who come to them in difficult circumstances, and it is frustrating – at times heartbreaking – when the service that is provided cannot meet these women’s needs. For this reason, the British Government’s Department of Health should get on with the task its Chief Medical Office set the country back in 2005, which was never taken up: to review women’s access to abortions in later gestations, and find ways of improving the service. (3)

In Britain , abortion is legal on broad grounds up until the twenty-fourth week of pregnancy. But women are not always able to access abortions at this stage. The burden of ‘late abortion’ provision has been taken on by independent sector clinics, which cannot always accommodate women’s needs; also, delays in the care pathway can mean that by the time a woman is referred to an abortion provider, she is already too close to the gestational limit to be helped. There should be greater collaboration between independent providers and the NHS to ensure these women can be helped, and greater acceptance within the health service that women are entitled to the ‘late abortions’ that they need.

In Spain , Carlos Morín should have been able to expect fair treatment from the courts, and the open-minded support of his international colleagues in the pro-choice world. All those negotiating their way around sometimes unclear, and often changing, abortion laws in the current climate should be aware that those prepared to do the most to help women are also often the most likely to attract the ire of anti-abortion campaigners, media organisations, and politicians. In such cases, the first casualty is the woman who needs her abortion.

(1) Absuelto el doctor Morín en el caso de los abortosEl Pais, 31 January 2013
(2) Doctor charged with 101 illegal abortions. The Times ( London ), 16 September 2011
(3) An Investigation into the British Pregnancy Advisory Service (BPAS) Response to Requests for Late Abortions: A report by the Chief Medical Officer. Department of Health, September 2005
(4) Summarised by An Investigation into the British Pregnancy Advisory Service (BPAS) Response to Requests for Late Abortions: A report by the Chief Medical Officer. Department of Health, September 2005
(5) Achieving Excellence in Abortion Care’: Report on the ninth Congress of FIAPACAbortion Review, 25 October 2010
(6) Comment: One family’s tragedy, not a political indicator. By Jennie Bristow. Abortion Review, 2 June 2009
(7) Late abortion: the new clash in the Choice Wars. By Ann Furedi. spiked, 3 March 2011
(8) See for example Second-Trimester Abortions in England and Wales, by Roger Ingham, Ellie Lee, Steve Clements and Nicole Stone, University of Southampton 2007.

http://www.irishtimes.com/newspaper/ireland/2012/1122/1224326952282.html

 

The Irish Times – Thursday, November 22, 2012

PAUL CULLEN, Health Correspondent

The State has paid substantial compensation to a woman who was forced to travel to Britain for an abortion despite being terminally ill with cancer.

The case was settled in just three months, her solicitor, Michael Boylan, said yesterday.

Michelle Harte, Ardamine, Co Wexford, sued for violation of her human rights last year after a hospital ethics forum had decided against authorising an abortion on the basis that her life was not under “immediate threat”.

“This was resolved very, very quickly, which is unusual in my dealings with the State,” Mr Boylan said. Ms Harte, a former nurse from London, has since died of her cancer.

In 2010, after she became unintentionally pregnant while suffering from a malignant melanoma, doctors at Cork University Hospital advised her to terminate her pregnancy because of the risk to her health.

Mr Boylan said her obstetrician was willing to perform a termination but was “hamstrung” by legal issues. The issue was referred to the hospital’s “ad hoc” ethics committee.

Appalling delay

He said there was an absence of clear guidelines about what to do and an “appalling delay” ensued. After the committee refused the termination, there were further delays because Ms Harte did not have a passport.

“I couldn’t believe the decision [to refuse an abortion in Ireland] when it came,” Ms Harte, who was then 39, told The Irish Times in December 2010. “Apparently my life wasn’t at immediate risk. It just seemed absolutely ridiculous.”

Her condition worsened significantly during this time and she was not able to receive cancer treatment because she was pregnant. She eventually travelled to Britain for an abortion; she had to be helped on to the aircraft due to a deterioration in her condition.

Mr Boylan of Augustus Cullen Law then sued the State on her behalf for infringing her rights under the ABC case, in which the European Court of Human Rights ruled that Ireland had breached the human rights of a woman with cancer who had to travel abroad to get an abortion.

In that case, the woman – “C” – had a rare form of cancer and feared it would relapse when she became unintentionally pregnant. However, the woman said she was unable to find a doctor willing to make a determination as to whether her life would be at risk if she continued to term.

Ms Harte’s lawyers served a statement of claim in May 2011 against the HSE, Ireland and the Attorney General. It was settled by July 2011. Mr Boylan declined to specify the amount but said it was substantial. Ms Harte died that November.

Mr Boylan said his client, a mother of one, was delighted not to have to go through the trauma of a court case and was pleased some compensation was available for her family.

http://www.xojane.co.uk/issues/what-the-death-of-savita-halappanavar-and-canadas-attitude-to-abortion-have-to-teach-us

Savita Halappanavar’s life ended because medics put the life of her unborn child – who they knew would die anyway – before hers, and because those medics were prevented by law from performing a procedure that would have saved her.

 

This week I’ve been thinking a lot about the tragic death of Savita Halappanavar, the 31 year old dentist who passed away in a Galway hospital last month, after being refused an abortion that could have saved her life. By the time this goes live, I’m sure the controversy will have reached Frankenstorm proportions.

Halappanavar was admitted to hospital miscarrying at 17 weeks. However, abortion is illegal in Ireland, and because the foetal heartbeat was still beating, medics refused to perform the medical abortion she needed and begged for. She miscarried days later, but not before she’d contracted the septicemia that would go on to kill her.

Anti-choice campaigners may rabbit on about the provision under law that states that abortion can be provided when there’s a direct threat to a woman’s life, or claim that the medics looking after Halappanavar should have induced labour in order to save her life.

The reality, as we’ve now seen, is that abortions are just not performed. And as for their suggestion that medics should have induced the birth of her unborn, but dying foetus? It would have been both cruel and totally unnecessary when the foetal heartbeat could have been stopped as the first step of the abortion Halappanavar repeatedly asked for.

The fact is, her baby, sadly, was not going to survive no matter what course of action her doctors took. So why not opt for the one that would have saved her?

Last week, I was contacted by Joyce Arthur, who is the Executive Director of the Abortion Rights Coalition of Canada (ARCC). Arthur emailed members of the British media wanting to talk about Nadine Dorries’ recent attempts to reduce the time limits on abortions in Britain.

She explained that abortion had been fully decriminalised in Canada in 1988 because it was felt that the application of either civil or criminal laws to medicine was inappropriate.

Abortions are seen as a matter for women and their doctors, not law-makers and politicians, and the overall impact has been positive – abortion rates had fallen. Arthur also felt that Dorries, and her strategies, were ‘misguided.’

Happy to talk to anyone who describes Nadine Dorries as ‘misguided,’ I contacted her for an interview.

Who are the Abortion Rights Coalition of Canada, and what do you do?

The Abortion Rights Coalition of Canada is a national advocacy group for abortion rights so we do lobbying and education. We act on various issues, working with MPs, to protect the abortion rights that we have and also try and improve access to abortion in different ways.

What abortion services are freely available in Canada? Are they available on the Canadian National Health Service for free?

We do have universal healthcare [an equivalent to the NHS] so it is fully covered. In 1969, abortion was decriminalised to allow women to go before a therapeutic approval committee of three doctors to get approval before an abortion.

Abortions were available at some hospitals but it turned out that the committees were very arbitrary in how they made decisions so that law was completely struck down by our Supreme Court in 1988.

After that, access improved. Before 1988 abortions were funded [by the health service] and that continued. We had a fight over the next ten years of getting private abortion clinics, which had previously been illegal, funded.

In your email to me you said, “Parliamentary debate led by MP Nadine Dorries on reducing the time limit for abortion is misguided since criminal or civil law is inappropriate in medicine.”

Can you explain to us how the laws surrounding abortion in Canada works?

We don’t actually have any laws. Basically, abortion care is delivered just like any other healthcare. We don’t use civil or criminal law in healthcare normally. Healthcare is delivered by the medical profession and they have their internal policies, they have a code of ethics for doctors around informed consent, all the normal stuff like that.

Really what it comes down to is a decision between a woman and her doctor, and the doctor has discretion over what’s appropriate for each patient and what their own limits are, and so on and so forth. They decide whether they want to perform abortions, to what gestational length and all that kind of thing.

The Canadian Medical Association passed a policy around the time of the Morgenthaller decision in 1988. Briefly, the policy is on induced abortion. It says:

“Abortion on request is recommended up to twenty weeks, and after that under exceptional circumstances.”

It doesn’t really go into [what these “exceptional circumstances” might be]. It just leaves it up to the Doctor’s discretion.

In practice what happens is that very, very few Doctors in Canada perform abortions after twenty weeks. It’s obviously a more complex procedure – it’s more skilled, so not many doctors are trained in it to begin with, meaning it’s only available at a few centres.

In almost all cases, what usually happens, especially later on in pregnancy, an abortion is sought because of lethal foetal abnormalities, where the foetus can’t survive the birth. Other cases most often involve serious health or life endangerment problems for women.

And sometimes a late abortion might be performed in especially socially compelling circumstances, which would be at the discretion of a doctor. For example, if a very young girl was in denial about her pregnancy, or a sexual assault or a domestic abuse survivor sought an abortion. In situations like that though it’s on a case-by-case basis according to the Doctor.

How has the full decriminalisation of abortion affected women in Canada?
The overall effect was that abortion was kind of incorporated into a regular part of healthcare, and even though we also had stand-alone clinics doing abortions, hospitals still were doing the bulk of abortions at the beginning.

They still do almost half so I think having that hospital-based service is important for integrating abortion care into regular healthcare instead of having it so isolated the way it is in the United States, for example.

I think it’s also shown that it’s working – we’ve gone for 25 years without law and nothing bad has happened – women are not presenting for 9 month abortions so they can fit into their prom dress, and so on.

—-

Back to Ireland. Performing or procuring an abortion in Ireland is a criminal act, with persons found guilty of either risking life imprisonment.

Savita Halappanavar’s life ended because medics put the life of her unborn child – who they knew would die anyway – before the life of the woman in front them. Because those medics were prevented by law from performing a procedure that would have saved her, and because the politicians who have the power to legislate so that no woman ever has to go through this again have refused to.

On Wednesday, hundreds of people gathered in protest outside the Dail (Dublin’s equivalent to the House of Commons), to express outrage at this tragedy and, once again, demand the government decriminalize abortion in this country.

Surely this time, now that Ireland and its abortion laws are under international scrutiny, something has got to give.

I’m tweeting angrily about Savita, Dorries and the state of reproductive rights in Ireland @AlisandeF

To make donations to ARCC or show your support, check out their website, or follow them on Twitter @abortionrights

SOLIDARITY REQUEST:

 

Protest the death of Savita Halappanavar in Ireland

 

PLEASE SIGN AND SEND THE E-MAIL BELOW TO THE FOLLOWING:

 

To: Taoiseach Enda Kenny (Irish Prime Minister)

cc: Tánaiste Eamon Gilmore (Irish Deputy Prime Minister and Minister of Foreign Affairs)

 

E-mails:

taoiseach@taoiseach.gov.ie

enda.kenny@oireachtas.ie

eamon.gilmore@oir.ie

 

Copy also to the Irish Embassy in your country. Find contact details here: http://www.dfa.ie/home/index.aspx?id=285

   

 

Re: Death of Savita Halappanavar in Galway

 

Honourable Taoiseach,

 

We are writing to you to express our concern about the recent death of Savita Halappanavar, who was repeatedly denied an abortion in Galway. This tragic case demonstrates once again that the prohibition of abortion in Ireland is not just undermining the autonomy of the women across the country, it is leading to unacceptable suffering and even death.

 

Savita Halappanavar made repeated requests for an abortion after presenting at University Hospital Galway on 21 October while miscarrying during the 17th week of her pregnancy. Her requests were refused, and she died one week later after several days in agonising pain and distress.

 

The situation of Savita Halappanavar provides the clearest possible evidence that laws that permit abortion only to save the life of a woman, such as the Irish law, are clinically unworkable and ethically unacceptable. There are numerous clinical situations in which a serious risk posed to a pregnant woman’s health may become a risk to her life, and delaying emergency action only increases that risk. There is only one way to know if a woman’s life is at risk: wait until she has died. Medical practitioners must be empowered by law to intervene on the grounds of risk to life and health, rather than wait for a situation to deteriorate.

 

You will be aware that the European Court of Human Rights, as well as a number of United Nations human rights bodies, have called upon the Irish government to bring its abortion law in line with international human rights standards. Had these calls been heeded before now, the death of Savita Halappanavar would have been prevented.

 

With the death of Savita Halappanavar, Ireland joins the ranks of countries worldwide where abortion is denied to women and leads to their deaths.

 

We call on your government to take urgent and decisive steps to reform the legislation that led to the death of Savita Halappanavar. Until the Irish legal system is reformed the lives, health and autonomy of women across Ireland are in jeopardy.

 

Yours faithfully,

By Selcan Hacaoglu on November 06, 2012

Four Turkish women went on trial today for staging an unauthorized protest outside the office of Prime Minister Recep Tayyip Erdogan against government plans to curb abortion, the Halkevleri activist group said.

The protesters face a maximum three years in prison if convicted by the court for the protest in Istanbul, said Sevinc Hocaogullari, an official at the group. More than 80 of its members are on trial for similar protests in the capital Ankara and the western city of Eskisehir, she said.

Thousands of demonstrators took to the streets in June after Erdogan called abortion “murder.” Abortion is legal in predominantly Muslim Turkey until a maximum 10 weeks from conception, and Erdogan’s government said it was considering a proposal to ban the operation after four weeks except in emergencies. Parliament in July barred Caesarean sections unless women can prove there is a medical condition preventing them from giving birth naturally.

“It is our body, our choice, not the prime minister’s, the family’s or the husband’s,” Hocaogullari said, accusing the ruling Justice and Development Party of attempting to ban abortion.

Health Minister Recep Akdag drew an angry response from women’s groups in June when he said the government could even take care of the babies of rape victims.

‘Cheap Labor’

Erdogan has repeatedly said that Turkish families should have at least three children, and has argued that a large population will enable Turkey to provide a workforce for an ageing Europe if it’s granted European Union membership. Turkey’s current population is about 75 million, and its birth rate fell from 1.5 percent in 2010 to 1.3 percent in 2011, according to the official statistics agency.

“The prime minister wants cheap labor to compete with China,” said Hocaogullari.

Erdogan may also be concerned to balance the country’s ethnic demographics. Mothers in the largely Kurdish southeast of Turkey have an average of 3.4 children, higher than the national average of 2. The government has been fighting autonomy-seeking Kurdish militants for decades in a war that has killed nearly 40,000 people.

To contact the reporter on this story: Selcan Hacaoglu in Ankara at shacaoglu@bloomberg.net

To contact the editor responsible for this story: Andrew J. Barden at barden@bloomberg.net

by Jennifer Daw Holloway, Ipas

11 October 2012 

http://www.rhrealitycheck.org/article/2012/10/11/an-unmet-need-world%E2%80%99s-women-provider-stories-second-trimester-abortion

 

If you work in reproductive health or public health you often hear people talking about the “unmet need for contraception” in a certain country or region. But here’s an unmet need that never gets discussed outside of small circles: second-trimester abortion.

 

Millions of women die or are disabled every year from unsafe abortion. Two-thirds of the women who suffer or even die are those who had an unsafe second-trimester abortion. No one really wants to talk about it but second-trimester abortions are often a medical emergency. And if they’re performed unsafely, women die. But with appropriate provider training, we can save women’s lives.

 

In the United States, most women who end up seeking a second-trimester abortion are disproportionately young and poor. They may not recognize signs of pregnancy early on, or they may delay seeking care for financial reasons. And then there are health reasons for later abortion, such as in cases where a wanted pregnancy goes horribly wrong and either fetal abnormalities or the woman’s health make the procedure necessary.

 

In the rest of the world, the picture is much the same. There is one difference, however: As many barriers to safe second trimester abortion as exist in the United States, barriers are that much greater in the global south. Many women facing complications from unsafe procedures have nowhere to get follow up care. And many women don’t make it.

 

At the World Congress of Obstetrics and Gynecology (FIGO 2012), now underway in Rome, Italy, Ipas and the FIGO Working Group on the Prevention of Unsafe Abortion sponsored sessions on second-trimester abortion in low-resource settings. In Nepal, for example, where safe abortion-including second-trimester abortion-is integrated into the national health system, providers have to turn some women away for various reasons… only to find that despite warnings and counseling, the woman sought an unsafe procedure and was seriously injured or even killed. Providers remember these women’s faces and their stories; they recall the woman’s fear and emotional pain like it was just yesterday.

 

Dr. Alfonso Carrera, a Mexican gynecologist, says in the last year he has seen 160 second-trimester abortion cases. Why? The health system failed these women. Some have been raped, he says. Some are just teenagers. With few options and few resources, they come to him because other health facilities won’t see them. “One woman said if I couldn’t help her she would kill herself,” he says with tears in his eyes.

 

Another doctor in Africa says he only knows of a handful of providers in his country who will perform a second-trimester abortion-and all are in a major city, hundreds of miles from women in rural provinces.

 

In Ethiopia, 20 to 40 percent of women seeking abortion are second-trimester cases. In South Africa, roughly 25 percent of abortions are performed in the second trimester. Like in other countries, despite the law allowing for abortion up to a certain point in second trimester, some facilities set their own guidelines, shortening the time period during which they’ll perform a second-trimester abortion. Providers are often reluctant to perform these abortions because of stigma. A nurse in South Africa said “other professionals call you a murderer.”

 

And don’t forget the stigma women face. In Colombia, women are sometimes given the fetal remains in a plastic bag, or are put in the labor ward-seemingly as punishment for their decision to terminate a difficult pregnancy.

 

But, second-trimester abortion services are achievable even in low-resource settings. Providers need clinical and networking support from colleagues. In Nepal, providers have developed an exchange program with providers in Ethiopia, another country where second-trimester abortion care has been improved with legal reform and buy-in from the government. The World Health Organization’s most recent safe abortion guidance includes recommendations on abortion after 12 and 14 weeks.

 

Providers around the world who are willing to perform second-trimester abortion care all agree: The challenges and barriers are great. They call for more training, particularly for whole-site training to sensitize all staff, even those working in reception or in janitorial positions.

 

For both women and providers, this is no easy decision. As advocates for women’s sexual health and rights, should we dismiss this population’s rights? Safe abortion is part of the spectrum of reproductive health care. How can we ignore this unmet need for safe second-trimester abortion services?

Author image

by Emily Anne, Lesbians and Feminists for the Right to Information

 

http://www.rhrealitycheck.org/files/imagecache/Teaser-Image/teaser-images/2012-10-16-anne2.jpg

The phone buzzes insistently and I scramble to answer it. Nervously, the woman on the other end explains that she has six pills of misoprostol, and wants to know how to use them to induce an abortion. I explain that according to the World Health Organization (WHO) the recommended dose is 12 pills spread over nine hours, dissolved under the tongue. I explain the symptoms, and how to recognize problematic bleeding or infection. But I can’t say much more, or ask her any questions about her health, because helping a woman to get an abortion is illegal in Chile, and if we were caught openly discussing it, both of us could be arrested.

After I finish explaining, there’s a long pause. Finally, she asks if there’s a doctor she can call if there’s a problem. This is perhaps the biggest concern for women who have abortions in Chile: a misoprostol abortion is very safe, but if something does go wrong, women may hesitate to seek treatment because they face up to three years in prison if they’re reported to the police. I assure her that as long as a woman puts the pills under her tongue, she’s safe—in an emergency room, a misoprostol abortion looks exactly like a miscarriage.

As part of Chile’s only abortion hotline, most of my conversations with women are like this. I have to follow a lawyer-approved script that keeps us just on the right side of the law. While it’s impersonal, it’s the only way we can actually reach women without putting our callers and ourselves at risk.

Chile is estimated to have one of the highest abortion rates in all of Latin America, but it has one of the strictest anti-abortion laws in the world. Abortions are banned under all circumstances, including saving the woman’s life. Naturally, this has forced women to seek abortions outside of the law—with varying levels of safety.

That’s why the Chilean safe abortion hotline was launched in 2009. It’s run by a national network known as Lesbians and Feminists for the Right to Information. The hotline is open 365 days a year, for four hours a day, on a completely volunteer basis. Women call from all over Chile, and they are offered information on the correct dosage and administration of misoprostol, its contraindications and side effects, as well as information on abortion law and legal rights. Since its launch, it has received more than 10,000 calls, up to 15 a day.

There are five hotlines like ours in Latin America (Chile, ArgentinaEcuadorPeru and Venezuela), and others around the world. Some are independent, and others work closely with organizations such as Women on Waves, which uses tele-medicine  to provide medical abortions to women in countries where it’s illegal.

Of the five Latin American hotlines, Chile’s faces the most constraints. We do have the right to share public information with the women who call us—but that’s about it. That means addressing women in the third person (“According to the WHO, a woman can….”), and not asking any questions. Cell phone minutes are expensive, and sometimes women run out of minutes before we finish explaining the procedure. If the line does go dead, we have no way of knowing if we’ll ever be in touch again. We also can’t provide any kind of counseling, and there’s not much we can do to address the social stigma of abortion. And as far as the pill itself is concerned, women are on their own.

Some women who call are already very informed about misoprostol, and looking for answers to very specific questions. Some are surprising: one woman called to ask if she could eat watermelon during the abortion (answer: yes!). Others have never even heard of misoprostol. Some have the full support of their partner, a family member, or a friend. But others call us in the midst of the abortion, because they are alone and are terrified that something will go wrong.

Some women are confident and matter-of-fact about their decision. Others call in tears, explaining that they can’t have a baby because they are already mothers, or are students, or have no support from their partner. Those are the calls that stick with us, because although we may believe that any reason not to have a baby is a legitimate reason, we can’t remove a lifetime of stigma and guilt in a five-minute phone call.

We can offer the information we do because it’s already available online from organizations such as the WHOInternational Consortium for Medical Abortion,Ipas, and Women on Waves. Of course, for most women it’s not obvious where to find it, and there’s no guarantee they’ll understand the medical terms if they do. As an organization we have much more access to these resources. Some of us have been trained in misoprostol use by these international organizations. Some of us are health professionals. Some are involved in extensive activist networks, and have been able to share information and strategies with women around the world. These experiences allow us to take this public information, and present it in a way that’s accessible to as many Chilean women as possible.

Each of us has our own reasons for joining the hotline. Some of us have personal experiences with abortion—both good and bad. One hotline member saw her roommate hospitalized—and then jailed for two years—after an abortion with a TV antenna. Another woman watched her cousin be denied an abortion after discovering that the fetus had severe genetic defects, only to give birth and watch her child struggle to survive for more than a year before dying. Others are lifetime activists, who were frustrated with the lack of progress in decriminalizing abortion. But whatever our motivations for joining, once we do, few think of quitting. Answering the hotline is a radicalizing experience. It’s impossible not to listen, night after night, to the injustice that these women face, and not be moved to take action.

Misoprostol has indeed revolutionized the way women have abortions—especially illegal abortions. Throughout history, women have had their methods for inducing abortion, some safer than others. Likewise, throughout the world there have probably always been networks of women to help each other get abortions (the Jane Collective in Chicago in the early seventies is a famous example).

But for the first time, a safe method is available for women to use themselves, in the privacy of their own homes. Originally invented as an ulcer drug, today misoprostol is used around the world (including the United States) to provide first trimester abortions, along with the drug mifepristone (RU-486).  Although the mifepristone-misoprostol combination is more effective, misoprostol alone is also recommended by WHO, as a safe alternative where mifepristone is not available. In Latin America, misoprostol use for self-abortion care was first documented in Brazil in 1986; today, in Chile it’s sold on the black market for about $250 for the full dose of 12 pills.

Unlike an illegal surgical abortion, a woman doesn’t have to put herself at the mercy of an illegal abortionist- who is likely someone she doesn’t know, may or may not be trained, will probably charge her exorbitant amounts of money for what is a relatively simple procedure, and may submit her to verbal or sexual abuse. The lack of training of many illegal abortion providers not only puts women’s health at risk, but also their security in an emergency room, a badly preformed surgical abortion is very easy to identify, which increases the chances of being sent to prison. And even in cases where the practitioner is well trained, the additional people that may be involved- the practitioner themself, assistants and contact persons—also may make it more likely to get caught.

But with misoprostol, the practitioner is often the woman herself. She doesn’t have to put her life in the hands of a total stranger. She can choose when, and where, to have the abortion, and she has much more control over who knows about it. A woman in an abusive relationship doesn’t have to tell her partner. A teenager doesn’t have to tell her parents. An emergency room doctor doesn’t need to know she used misoprostol, because the treatment for complications is identical to the treatment for miscarriage.

Perhaps most importantly, illegal misoprostol abortion is inherently safer than illegal surgical abortion, because there are fewer things that can go wrong. Since no foreign objects are introduced into the vagina, there is very little chance of infection, and therefore little chance of long-term consequences such as infertility. Problematic bleeding is uncommon. Uterine rupture (often incorrectly cited as a risk) is extremely rare, even in second trimester abortions when the uterine walls get thinner. Because no technical skills are needed, it is very easy to learn to do a misoprostol abortion; essentially, one must learn the timing of misoprostol administration, and what warning signs to look for.

For women who use misoprostol, information is key; it can be the difference between a safe abortion, and one that ends in an emergency room, or in jail. If they do have to go to a hospital, women who don’t know their rights may be pressured to confess by hospital staff. And there are plenty of myths about misoprostol use, some of which come from doctors themselves. Because there are no circumstances in which they can legally perform abortions, Chilean doctors only receive training on post-abortion care, not abortion itself, and will often prescribe the wrong dose. The problem is that misoprostol dosage is very counterintuitive—the further along the pregnancy is, the lower the dosage that is needed. So 12 pills may seem like a lot, both to women, and to doctors who are used to using smaller doses of the drug (for example, in induction of labor).

Many people don’t realize that in a legal medication abortion, the actual abortion takes places in the woman’s home. According to clinical guidelines published by the WHO, ICMA, and Ipas, the practitioner (who may be a doctor, nurse, midwife, or physician’s assistant) begins by confirming the length of the pregnancy and ruling out contraindications, of which there are few.  Next, the women is told how to take the pills and how to recognize signs of hemorrhage and infection, and then sent home to take the pills at her convenience. She would need to return to the clinic in two weeks, and if the abortion was incomplete it can be taken care of at that point; unless there are signs of infection, an incomplete abortion is not a life threatening situation.

So in a country like Chile- where almost 90 percent of the population lives in urban areas, with easy access to hospitals and post-abortion care, women are able to mimic clinical procedures, and safely induce their own abortions. Chilean reproductive health specialists have publically stated that misoprostol use hasgreatly reduced the number of abortion complications they see in their practice, a phenomenon that has been documented in other countries as well.

Unfortunately, most press coverage of illegal misoprostol use is sensationalist and misinformed. The image of a woman taking pills in the privacy of her home is quite different from what most people imagine that illegal abortion is like. The image of a “back-alley” abortion is a powerful one for Americans and Chileans alike. Gruesome images, such as that of Geri Santoro, dead in her hotel room 1973, played an important role in the struggle to legalize abortion in the United States. But they don’t accurately represent the reality of illegal abortion today.

In today’s United States, we have women Jennie Linn McCormack, an Idaho woman who bought the abortion pill over the internet because she didn’t have the money to obtain a legal abortion in Salt Lake City, three hours from her home. She underestimated the length of her pregnancy, and was surprised by the size of the fetus. When she called a friend for help, the friend’s sister called the police. McCormack had no complications, and her case was later dismissed, but she still had to suffer abuses at the hands of the police, media attention, and ostracism by her neighbors.

Of course, McCormack’s case represents a huge failure on the part of the US healthcare system. Even though she lives in a country where abortion is a constitutional right, a safe abortion was no more accessible to her that it is to her Chilean counterparts. It’s unclear how often American women have to resort to inducing their own abortions. But in other countries, stories like hers are all too common.

Chile is one of 5 countries in the world with a total abortion ban; the others are El Salvador, Nicaragua, Malta, and the Vatican. There are no reliable statistics that tell us how many abortions there are in Chile each year, and even less information on the number of misoprostol abortions. Estimates range from 60,000 to 200,000  abortions per year, in a country of 17 million people.

So-called “therapeutic” abortion, permitted only if the woman’s life or health is in danger, was legal from 1939 to 1989. It was legalized in part to bring down the high maternal mortality rate. Its prohibition was one of dictator Augusto Pinochet’s last acts in office.
Pinochet’s 17 year reign ended not with a counter-coup, but rather a plebiscite. In exchange for a bloodless “transition to democracy,” the country maintained the dictatorship’s constitution and many of its legislators. Because of this and related social processes, there have been no changes to the abortion law since 1989. The most recent bill, which would restore the therapeutic abortion law, was proposed in March of this year, but Congress refused to even open discussion.

For many Chileans, abortion is a non-issue. It is rarely even mentioned in the press, and when it is, coverage is invariably anti-choice. As in most countries with restrictive laws, there is little political will among the legislators. That may be in part because most come from the upper class, and safe abortion has always been available to those who can pay for it. Some thought that the government of Michelle Bachelet—a female, socialist, physician who was president from 2006-2010—would make more progress. But in fact, it was during her government that misoprostol was pulled from pharmacies (where it had been available with a prescription), leaving women to try their luck on the black market.

Another reason may have to do with Chile’s low maternal mortality rate. Abortion has long been established as an important cause of maternal mortality, and in many countries where some form of abortion is now legal, legislators were moved to lift the abortion ban because they wanted to protect women’s lives. But Chile has one of the lowest rates in Latin America– 26 per 100,000 live births, comparable to the US rate of 24 per 100,000.  There are probably many reasons why maternal mortality has declined, but some of the most important factors are likely government subsidized birth control and post-abortion care, and access to safer illegal abortions using misoprostol.  But increasingly safer abortions means there hasn’t public outcry to remove the ban.

In 22 years of democratic government, there has been zero progress towards decriminalizing abortion. Another 20 years could easily pass before any action is taken at the national level. Chile has shown itself incapable of protecting women’s reproductive rights. And if current trends are any indication, the United States is not much better. But meanwhile, women still need abortions. So we have no other choice than to organize ourselves, and empower women to have the safest, most positive abortion experience they can. Someday, women in the United States and Chile alike will have access to affordable, legal abortion offered by a trained practitioner. But until then? We’ll be here. Give us a call.

 

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