Earlier, as a student, and now a practitioner, of public health, I always wonder why opinions about abortions are so polarized. Why is it that most people prefer not to talk about abortion? After all, it is one of the most widely conducted surgical procedure in the medical field. From Chinese literature of Emperor Shen Nung’s time to the Ebers Papyrus of Egypt and later, the 10th-century Persian physician Al-Rasi, all talk about abortion and contraception. Some historical figures like the Roman satirist Juvenal have gone as far as explicitly writing about “our skilled abortionists”. Over the years, these voices have been silenced by conservatism in religion, politics and by hegemonic gender roles. As a young working woman, I find the silence hypocritical and stifling. Conservatism, in development and public health, specifically in abortions, is a huge challenge.
Several international laws explicitly state that young girls and women have the right to demand and access credible and relevant sexual and reproductive health information. These documents strongly support health as a human right, to be enjoyed by all, irrespective of differences and social classifications. Article 12.2 (a) of the International Covenant on Economic, Social and Cultural Rights, The Convention on the Elimination of All Forms of Discrimination against Women, Article 24 of the Convention on the Rights of the Child, the 1995 Beijing Platform for Action and the Millenium Development Goals, in addition to the most commonly quoted Programme of Action of the 1994 International Conference on Population and Development- all comprehensively and explicitly state that the right to sexual and reproductive health for every young person, girl and woman is all encompassing. The rights elicited in these Declarations not only state those aspects of health that need to be prioritised but also note the obstacles that hinder the furtherance of the right to health from a gendered perspective.
Encouraging agency for girls and women (Covenant on Economic, Social and Cultural Rights); the dynamic of relationships that women must navigate in families, marriage and associated vulnerabilities (discrimination), and a woman’s right to determine her fertility are some of the perspectives considered in these Declarations. The comprehensiveness of some of these is evident as they urge nations against criminalising aspects of sexual and reproductive health, as stated in the Beijing Platform for Action. These documents embolden young girls and women to experience sexuality and reproductive health, not only as ‘fertility’ but as being sex positive. They advocate for an understanding of relationships and pleasure through the implementation of valid sexuality and reproduction related education programmes.
While researching for this article, I was appalled at my ignorance of the scope of these texts, and at the same time pleasantly surprised to know that there are voices speaking in support of the agency of women. And the questions, why are we still scared to talk about it? Why do my friends and family still believe that to get an abortion would be a scene from their worst nightmare? Why am I told never to tell anyone? loom larger than ever.
Besides religious arm wringing, lack of awareness, criminalisation and stigma have furthered the pro-life cause. When abortion or aspects of it are a crime, it not only forces women to resort to unsafe methods and service providers, but it perpetuates stigma as well. Interestingly, the perceived stigma of legal abortion dissuades professionals from choosing to train in the procedure. In countries like India, physicians are not always aware of the country’s liberal abortion laws. And medical professionals, who are unaware contribute to the already existing prejudice. Thus the vicious circle continues. Unsafe abortions, though, whether a high or low concern, remain a public health issue. Beyond religion and politics, medical and international development fraternities also have a role to play in normalizing abortion in communities and clinics.
The experiences of girls and women cannot be explained in terms of religion, and that a ‘man’ always knows best. ‘Viability’ is not a universal term, it is a personal philosophy. The choice to end a pregnancy is as noble and as brave as the choice to care for a physically challenged baby. But this is a choice and a personal one at that. If you are to practice choice and faith with relation to safe abortions, choose to support the girls and women in your life. Talk to them about contraception- the right way to use them, where you can find one, how you can ask for one and the like. Have faith that, armed with the correct information, she will be capable of choosing what she believes is best for her. And should you have to deal with a spiritual dilemma- non-violent dialogue/protest is your safest bet to heaven.
The central message is that a safe abortion can not only save a life in the most straight-forward reality of decreased maternal mortality and morbidity but, if performed legally and safely, it allows the young woman to fulfill her aspirations. These will include one of these or a combination of the following: going back to school/college/university, earning a livelihood and improve her social mobility. Programmes like the NIKE Girl Hub and Gapminder’s Hans Rosling have all provided credible evidence that education leads to better reproductive health in young girls. By disallowing her fundamental right to choose, you simply stop her from ever moving out of the ‘vicious’ cycle of poverty, illiteracy and gender-based violence you often ‘quote’ as the evils of this millennium.
Reporting on abortion needs to be brought into the mainstream as it is fundamental to maternal health, by involving the medical as well as the international development fraternity. The Human Rights discourse has provided a good foundation for advocacy efforts by the two groups. The biggest hurdle in the implementation will be that of criminalisation. However, initiatives have shown that even in settings where abortion is criminal, both clinicians and advocates have initiated programmes to ensure that women have access to information on medically safe and successful procedures.
At the medical level, doctors must be encouraged to train for providing a safe procedure, irrespective of its social implications in a legal or restricted setting. Licensing procedures in restricted settings should be made easier to generate demand for the service. Abortion-related complications should be reported, and governments should ensure that providers and clients are protected from non-state aggression. The medical abortion method is very beneficial as, in severely restricted settings it allows for harm reduction strategies, which protect both the clinician and the client, without hampering access to evidence-based information. This has been the experience of initiatives such as Women on Waves and the Uruguay model, both of which have successfully helped women undergo a medical abortion.
The development sector needs to de-medicalise and demystify abortion to align with equality, equity and health as human rights, enshrined in the laws mentioned above. In legalized and restricted settings abortion counseling can be implemented by intermediate service providers such as pharmacists and paramedics. Medical abortions are often mistaken to be a surgical procedure when in reality it is medically induced through pills. Providers of herbal abortifacients can also be trained to provide the medicines. International non-governmental and advocacy organisations need to work towards decriminalizing and destigmatising abortions, especially in very religious communities and also within their institutional structures (commonly known as ‘Value Clarifications’). They must encourage greater acceptance of modern contraceptives to reduce the demand for clandestine procedures.
My parents often told me that the two things you should ‘avoid’ discussing in a crowd were politics and religion. How ironic that outside the pages of public health, human rights and popular wisdom, the laws on abortion are nothing but a poisonous concoction of religion and politics, one always trying to outdo the other!
Stories have an impact. Whether it is your own or that of a friend, acquaintance; or mere hearsay – even a myth says something about the individual, community, or a school of thought. Abortion too is a part of many stories. Some are of brave and angry women demanding a greater place in our world for women’s choices; some are that of priests and clergyman for recognition and redemption rather than termination. Some are of advocates at parliaments, international organisations and community movements. But most stories are that of your friends, maybe even yourself. And they often go unheard. Maybe you don’t think that it’s important to talk about it, or you are afraid to talk about it, for fear of being judged or incarcerated. For many, it is now just a memory. The voices of others are silent if your voice is not heard, if it is not articulated. They are silent until promises are kept and memories turn empowering not embarrassing.