Dr Sim-Poey Choong Chair, ASAP

Malaysia in the Asian context
The Malaysian situation clearly doesn’t have the urgency that is seen in other countries in Asia in such as India, Nepal, Indonesia or the Philippines where the high mortality and morbidity rates from unsafe abortions provide a dramatic argument for change.

This is seen for example, in our low MMR (<15/100,000) and our low mortality rates for abortion complications (2-5/year).

Malaysia is seen as a very progressive nation with good living standards, health care, and infrastructure; the iconic Petronas Twin Towers stands in the heart of KL, our capital city. Women have free access to education and high career achievements as ministers and CEOs which says a lot for the progress we have made in social development.

Other indicators are however a matter of concern –e.g. the incidence of teen pregnancies remains high, and contraceptive prevalence rate is low. As pointed out by Prof. Low in her article, social changes taking place in Malaysia has made teen pregnancies a very visible problem. This has resulted in the recent media hype over teen pregnancies and baby ‘dumping’.

But, like many economically developed countries, as in the USA, the stigma attached to abortion makes it the last ‘right’ for women to achieve in terms of equality in decision making and control of her own bodies and their sexuality.

Abortion within the Medical Fraternity
As a young doctor, I was truly puzzled over the medical profession’s irrational attitude to women’s sexual and reproductive health issues; evident from their early objections to the pill and IUCD as posing a danger to women ‘abusing their freedom’. A similar situation has now arisen over the introduction of medical abortion with mifepristone and misoprostol.

The stigmatization of abortion has made efforts to open up this issue, a long and difficult journey. Trying to bring up the subject for rational discussion, until recently, was virtually impossible, even within medical circles. This is despite the overwhelming evidence that abortion is widely available and practiced here.

Surprisingly, even doctors who provided abortions ‘on the quiet’ were ignorant of the penal code on abortion, amended in 1989. A survey done by RRAAM in 2008 revealed that only 57% of doctors and nurses knew the law and while a survey of client seeking abortions, more than half thought it was illegal.

A recent experience with a colleague illustrated this point dramatically; an O&G in charge of a local maternity home who performed occasional abortions came to me in great distress; he had dismissed a nurse for misconduct and she had then threatened to ‘expose’ him. I was surprised he had never bothered to examine the penal code on abortion until I brought it up!

Situation in the 70’s
In the 70s, the concern for abortion access came not from statistics (there were none) but from grassroots healthcare providers who meet women faced with unwanted pregnancies daily. Those facts were evident in my early years as a family planning volunteer. But somehow most women then found a way out, often by accessing competent abortion providers which presumably accounted for the relatively low complication rates.

Exploitation by the profession
At that time, the penal code permitted abortion only ’to save the mother’s life’ (1971). However, as happens everywhere else, it was available for anyone who could afford it, often at exorbitant fees. While working as a consultant anaesthetist in private hospitals it became obvious to me that fees for abortions were often ‘disproportionate’ in relation to other similar procedure. (That was my main occupation for the 8 years of my professional life). At that time all abortions were D&Cs performed under a general anaesthetic.

Sneaking in Abortion Services via MR
In the 60s, the Karman Cannula had been established as a cheaper safer method for abortion under local anaesthetic, but it remained untapped in Malaysia until in the mid 70s, when the late Prof I. S. Puvan of University Malaya had the vision to see its potential and decided to introduce it as ‘menstrual regulation’ (called MR) thus by-passing the penal code by performing the procedure in early pregnancy without confirming it with a urine pregnancy test.

Thus in the mid 70s, as a result of his position and influence, MR gained some acceptance as a legal way of providing abortions. It was even practiced at certain government clinics officially for a time. Sadly, it was not taken up in a big way but MRs remained a low key service provided by some private clinics with charges remaining high.

FFPAM1 and Abortion services in Penang
Although the IPPF supported this move and introduced it to the Family Planning Associations of Malaysia (FFPAM), it was never taken up because of the sentiment of the grass roots members. However, on Prof Puvan’s advice, I agreed to set up a service in my group GP practice in Penang for the equivalent of US$20/- when the standard charge was then US$100/-.

As it happened, the demand for MR services raised so quickly that within a year my GP services were discontinued to focus on abortions for unintended pregnancies and post abortion contraception. Some government objections to my ‘open’ concept abortion clinic were expected, but none came. Actually, from the legal records, no doctor in Malaysia had ever been charged for performing an uncomplicated early abortion, even though, under the 1971 penal code, they clearly breached the law.

Legal Reform and after
There was a breakthrough in legal reform in 1989, when more abortion complications surfaced through the media, possibly one effect of urbanization and the need for smaller families. The clause added in was in line with the British Penal Code that they had amended in 1957 which is to allow abortion for threat of injury to the ‘mental or physical health of the woman’.

Many of us heaved a sigh of relief and I had hoped this was the cue for the family planning associations to take a leading role in providing this service; at that time I was in the executive council of the Federation of FPAs Malaysia, later becoming chairman (1992-6). Despite all my efforts, this never came through; such was the conservative sentiment amongst members at the time.

New Players in Abortion Advocacy
From FIGO, Ipas to RRAAM

There were few developments in advocacy in Malaysia until the FIGO conference took place in Malaysia in 2006 and the APCRSH/FFPAM conference a year later. Prof Anibal Faundes, a past president of FIGO, made a strong stand on the blight of unsafe abortions and the absolute need to recognize it as a major factor in women’s health, in consonance with her basic human rights. At those conferences, Ipas was promoting their safe abortion initiatives while the Asian-pacific Research and Resource centre for Women (ARROW), through an initiative by Ms Rashidah Abdullah, had put up a side symposium to address unmet needs in Malaysia.

All this together created an opportunity to discuss with Ipas the possibility of a project to address the abortion issue; the coalition was formally started in 2007 drawing members who had been activists working directly or indirectly with the family planning associations. Called the Reproductive Rights Advocacy Alliance Malaysia (RRAAM), it was committed to promoting women’s reproductive rights and services (particularly, to contraceptive access for youths and marginalized groups and to safe abortions).

Further developments were initiated in 2008 when International Consortium on Medical Abortion (ICMA) and IPPF (ESEAOR) organized a regional forum on abortion access in Kuala Lumpur. Major players in reproductive health from 15 countries attended including some donor agencies to discuss and share ideas on the situation in Asia.

The members at the meeting concluded that while different countries faced different obstacles in making safe abortion assessable, there were many individual activists and agencies promoting the same cause in each country. However, there was no central coordinating group that could harness the different experiences to help each other. This became the rationale for creating the new coalition. The Asia Safe Abortion Partnership (ASAP) was thus formed to provide an active network of advocates.

For RRAAM, this provided us opportunity to become part of a regional and global movement. The network has obviously benefited members through it regular email forums, organizing workshops in abortion technology, advocacy strategies and values clarification. But apart from this, the realization of being members of an international movement has significant internal and external impacts.

Speaking for RRAAM members, we have broken out of a shell that labeled us as an isolated ‘eccentric non-conformist group’ and for the general public, RRAAM is now seen as part of an international movement in sync with the efforts of international agencies like IPPF, ICMA, Ipas, Gynuity, etc. and prominent regional players from Vietnam to Nepal. The gratifying response to the joint ASAP/RRAAM seminar on Abortion Access in January 2011 in Kuala Lumpur is, I believe, a testimony to this.

1. Now changed to Federation of Reproductive Health Associations Malaysia (FRHAM)