Women and Health Learning Package UNWANTED PREGNANCY AND UNSAFE ABORTION

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1 Women and Health Learning Package UNWANTED PREGNANCY AND UNSAFE ABORTION An Educational Resource for Health Professions Students Deyanira González de León Deborah L. Billings Shakuntala Chhabra Todd M. Maja Women and Health Task Force 2015 Global Health through Education, Learning and Service (GHETS) The Network: Towards Unity for Health (The Network: TUFH)

2 UNWANTED PREGNANCY AND UNSAFE ABORTION Women and Health Learning Package Developed by the Women and Health Task Force (WHTF) Third Edition, 2015 Support for the production of the Women and Health Learning Package (WHLP) has been provided by Global Health through Education, Training and Service (GHETS), by the Global Knowledge Partnership (GKP), and by The Network: Towards Unity for Health (The Network: TUFH). WHLP modules and related materials are available on The Network: TUFH and GHETS websites: / ABOUT THE AUTHORS Deyanira González de León Aguirre, MD, MPH Department of Health Care, Division of Biological and Health Sciences, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico Dr González de León graduated from the Faculty of Medicine, National Autonomous University of Mexico and has a Master degree in Public Health from the Institute of Health Development, Havana, Cuba. She has been a full professor at the Metropolitan Autonomous University, Xochimilco Campus, (UAMX) since Her academic interests include health promotion and education, gender studies, and women s health. She teaches subjects related to sexual and reproductive health in both undergraduate and postgraduate university programs. Most of her publications are focused on abortion-related issues. She collaborated in the design of a new curriculum for the Nutrition Program at the UMAX, which incorporated gender issues into several teaching units. Dr González de León served as an external advisor to Ipas Mexico, a non-profit agency working to improve women s lives by focusing on reproductive health. While with Ipas, she collaborated on a project to incorporate reproductive health and abortion care into the curricula of medical and nursing schools; she also worked in a project to create legal abortion services for victims of sexual violence in Mexico City. Dr González de León has been a member of The Network: TUFH Women and Health Task Force (WHTF) since 2002; she has served as Chair of the WHTF since [email protected] / [email protected] Deborah L. Billings, PhD Director, South Carolina Contraceptive Access Campaign, Advocates for Youth; Adjunct Professor, Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, US; Adjunct Associate Professor (Maternal and Child Health) at the University of North Carolina, Gillings School of Global Public Health, North Carolina, USA Dr Billings graduated from the University of Michigan and has a PhD in Sociology. She worked for 15 years to develop research and evaluation strategies to advance Ipas work in Mexico, throughout Latin America and Africa. She served as one of Ipas Mexico s liaisons to the steering committee of the Alianza por el Derecho a Decidir (ANDAR) [Alliance for the Right to Decide] and has been the Co- Principal Investigator on operations research projects related to post-abortion care in Mexico, Bolivia, Ghana, and Kenya. Dr Billings has provided research guidance to Ministries of Health in several countries and has worked on projects in Mexico examining unwanted pregnancy, HIV/AIDS, and unsafe abortion among adolescents. She has led research initiatives in Mexico, Central America and Bolivia,

3 focused on the sexual and reproductive health of adolescents and comprehensive care to survivors of sexual violence. She served as a faculty member in the Arnold School of Public Health, University of South Carolina, where she undertook research on Latino sexual and reproductive health, including the issue of abortion-related stigma. Currently Dr Billings directs the South Carolina Contraceptive Access Campaign, an initiative of Advocates for Youth, as well as consults with agencies including the Pan American Health Organization (PAHO), the United Nations Trust Fund to End Violence against Women (UNTF) and Ipas. [email protected] Shakuntala Chhabra, MD, DGO Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India Dr Chhabra has a Degree in International Maternal Health. Dr Chhabra is the Director of Obstetrics and Gynecology at the Mahatma Gandhi Institute of Medical Sciences. She is a Master Trainer of the Program for the Prevention of HIV Mother to Child Transmission, and Chief Coordinator of the Emergency Obstetric Care Project. She has been chief executive officer in projects to promote women s health, including The Women and Child Project for the Welfare of Unwanted Babies from Unwed Mothers with Advanced Pregnancies. She served as a WHO External Consultant for the Swedish International Development Cooperation Agency, and was a member of the Maternal and Perinatal Health Epidemiology Reference Group of the World Health Organization. Dr Chhabra has received many fellowships and awards, including the Best Teacher Award (Maharashtra University of Health Sciences, India), and the Award for Distinguished Community Services in Emergency Obstetric Care (International Federation of Gynaecology and Obstetrics). She was the President of the Association of Gynaecological Oncology of India. Dr Chhabra has published in many academic journals and is an examiner for undergraduate and postgraduate students at universities in India. Her academic interests are focused in women s reproductive health, gynecological oncology, and health professions education. She has been a member of The Network: TUFH Women and Health Task Force since [email protected] Todd MM Maja, D Litt et Phil (Advanced Nursing Sciences) Faculty of Sciences, Tshwane University of Technology, Pretoria, Republic of South Africa Prof Maja was Associate Dean of the Faculty of Science at Tshwane University of Technology (TUT) in Pretoria, and also Head of the Department of Nursing Sciences at her institution. Prof Maja is retired and collaborates as a supervisor for postgraduate students. She is active in various academic committees, such as the South African Association of Women Graduates from which she received the Women in Research Award in Prof Maja is a member of the Editorial Board for Curationis, an accredited research journal of the Democratic Nursing Organization of South Africa (DENOSA). She also collaborates with the African Journal of Nursing and Midwifery. Her academic interests include women s health, adolescent health and research on HIV/AIDS. She has been actively involved in playing a leadership role in projects with students, staff and community members, and has published a number of papers locally and internationally. In addition to her academic duties, Prof Maja enjoys spending time with women, youth and community members to seek ways to improve their health. She has been a member of The Network: TUFH Women and Health Task Force since [email protected] / [email protected] Thanks are due to colleagues who reviewed drafts of the module and made valuable comments: Judy Lewis, co-editor of the Women and Health Learning Package and founder of the WHTF, and Kamayani Bali Mahabal, Vice-chair of the WHTF.

4 TABLE OF CONTENTS Introduction and Learning Objectives 1 Global Overview 2 Unwanted Pregnancy 5 Unsafe Abortion 8 The Role of Laws 11 Current Standard Methods to Provide Safe Abortions 14 Post-abortion Care 17 Unwanted Pregnancy and Unsafe Abortion Among Adolescents 18 Country Overview: Mexico Case Studies: Mexico Country Overview: India Case Studies: India Country Overview: South Africa Case Studies: South Africa References 48 Appendix I: Additional Suggested Readings Appendix II: Recommended Websites Pre and Post Self-assessment Form 68

5 INTRODUCTION AND LEARNING OBJECTIVES Medical and nursing students often face restrictions in acquiring knowledge about subjects related to women s sexual and reproductive health (SRH). Some topics, such as unwanted pregnancy and abortion, are usually perceived as difficult to address by teachers due to complex ethical and legal issues. Many reasons are cited in developed countries to explain curricular gaps to educate and train future health professionals on issues related to sexuality, contraception and abortion. These include lack of time and competing curricular priorities, lack of trained faculty or adequate training sites, or the idea that these issues are simply less important than others (Shields, 2009). The same reasons are also found at universities in the developing world, where women s access to quality care in SRH is limited and where abortion is, in most countries, restricted by the law (Haslegrave & Olatunbosun, 2003; González de León et al, 2008). Medical and nursing students must receive education and training in a broad range of SRH issues. Evidence has shown that most of these students value having early educational experiences with sexuality and reproduction, contraception and abortion care. In addition, such experiences may have positive effects on their abilities to provide women with quality health care and may also impact on their attitudes toward critical abortion-related issues (Espey et al, 2004; Foster et al, 2006; Association of Reproductive Health Professionals & Medical Students for Choice, 2006; Bennet et al, 2007; Pace et al, 2008; Steinauer et al, 2009). These educational experiences may also have positive effects on students own lives. The third edition of this module has been updated to offer students a wide overview on issues related to unwanted pregnancy and unsafe abortion. The module includes information and case studies from Mexico, India and South Africa, three countries where these issues present particular challenges that medical and nursing students must know about and analyze. It is our hope that the information of this module of the Women and Health Learning Package will help future physicians and nurses to become knowledgeable and empowered advocates for women s sexual and reproductive rights. At the end of this module, students will be able to: Understand how socioeconomic and gender inequalities influence women s experiences with unwanted pregnancy and abortion. Recognize the multiple causes of unwanted pregnancy and identify unsafe abortion as a problem of human rights and social justice. Understand the implications of abortion laws for women s health in their culture, region, and country specific contexts. Understand the special needs of adolescents who have abortions. Identify the best options medical or surgical for a woman requesting an abortion and discuss the role of physicians and nurses in the provision of quality abortion and post-abortion care. Most references cited in the module are available on line. Additional Suggested Readings and a list of recommended websites are presented in Appendixes I and II. It is recommended for tutors to use the Pre and Post Self-assessment Form presented at the end of the module. 1

6 GLOBAL OVERVIEW The adverse effects of unsafe abortion on the health of women are the result of restrictive laws, stigma, poverty, gender inequalities, and lack of access to adequate health care. Access to modern contraception is a key element for the reduction of unwanted pregnancies and the need for abortions. For many reasons, however, not all pregnancies can be prevented and societies should guarantee the right to quality care for all women who decide to terminate their unwanted pregnancies. In almost all developing countries women s access to safe abortion is restricted by the law, which results in high rates of preventable complications and premature deaths. Unsafe abortion continues to be a global persisting, preventable pandemic (Grimes et al, 2006, p.1908) and its consequences have been a serious concern of international organizations. The World Health Organization (WHO) defines unsafe abortion as ( ) a procedure for terminating an unwanted pregnancy carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both (World Health Organization, 1992). The International Conference on Population and Development (ICPD), held in Cairo in 1994, was the first global forum where agreement was reached that unsafe abortion should be recognized as a relevant public health problem. The ICPD gave voice to proposals to improve women s reproductive health that had been held by feminist organizations, physicians, legislators, human rights activists and academics. The recommendations of the ICPD s Program of Action were a starting point to place human rights at the forefront of the debate on population policies in developing countries. The ICPD recognized reproductive rights as part of fundamental women s human rights and ( ) the authenticity of each woman as the central decision-maker in her own life and future, including their reproductive future (Cook, 2006, p.17). The ICPD s Program of Action called for universal access to reproductive health by 2015 and addressed actions that health care systems should follow to eliminate the adverse effects of unsafe abortion on women s health: In no case should abortion be promoted as a method of family planning. All governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women s health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority, and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counseling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counseling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions (United Nations General Assembly, 1994; par. 8.25). 2

7 The Fourth World Conference on Women (FWCW), held in Beijing in 1995, validated the ICPD recommendations about abortion and reproductive rights. The Plan for Action of this forum addressed the need to Recognize and deal with the health impact of unsafe abortion as a major public health concern and called on governments to ( ) consider reviewing laws containing punitive measures against women who have undergone illegal abortions (United Nations, 1995; par. 106). At the five-year review of the ICPD Program of Action, held in New York in 1999, governments reaffirmed their commitment to provide women with safe abortion services and a call was made for health care systems to train health professionals: In circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women s health (United Nations General Assembly, 1999; par. 63iii). Health systems and non-government organizations have implemented programs based on the recommendations of the ICPD, but the influence of conservative forces and the lack of political and financial support have led to an unequal and slow progress in the promotion and protection of women s reproductive health and rights (Langer, 2003a; Stewart et al, 2004; Burke & Shields, 2005; Glasier et al, 2006; Cook, 2006; Fathalla et al, 2006; Center for Reproductive Rights, 2013a). Unsafe abortion is a major obstacle to substantially reduce the high rates of maternal mortality in many developing countries (Crane & Hord-Smith, 2006). One of the Millennium Development Goals, formulated in 2001 by the United Nations General Assembly, called for global efforts to reduce maternal mortality by three quarters in Worldwide, 358,000 maternal deaths occurred in 2008 which means a modest decline of 34% since 1990; the mortality associated with unsafe abortion-related complications which is entirely preventable also declined but accounted for 13% of overall maternal deaths (World Health Organization, 2010). Feminists, advocates for women s reproductive rights and public health researchers have greatly contributed to the political debate about abortion at both global and country levels, and many of the efforts to support women s right to legal abortion have been successful (Hessini, 2005; Grimes et al, 2006; Finer and Fine, 2013; Center for Reproductive Rights, 2013a). At the same time, however, movements to stigmatize abortion have gained political strength throughout the world. Their focus on criminalization and moral religious standpoints has discouraged the debate about abortion in many places. New regulations to limit access to legal abortion have been imposed even in countries with liberal abortion policies and in many others laws continue to be highly restricted. As part of their aggressive campaigns to make legal abortion inaccessible, these movements have disseminated a series of myths to distort abortion facts. Anti-abortion activists have asserted, for example, that restricting or banning abortion is the best way to avoid its practice; that abortion increases the risk for breast cancer; that abortion is always risky and endangers future childbearing; that all women who have abortions experience serious psychiatric disorders; or that emergency contraception is a form of abortion (Center for Reproductive Rights, 2005a; Dudley & Kruse, 2006; Ipas, 2010). Despite its great influence on broad sectors of public opinion, reliable scientific studies have not supported these assertions. Rather, a great amount of scientific evidence and mainstream 3

8 medical opinions show that legal and safe abortion protects the lives of women and has no negative effects on their physical or mental health (Table 1). Table 1: Some Myths and Realities about Abortion Myths Realities Women will have fewer abortions if abortion is prohibited or restricted Women who need to end an unwanted pregnancy will find a way to do so, whether abortion is legally permitted or not. Liberal abortion laws do not prompt women to have abortions. Rather, it is the reality of experiencing unwanted pregnancies that leads women to seek abortions. Access to contraception for all women who want to prevent pregnancy would do more to reduce abortion rates than would restrictive laws. Abortion increases the risk for breast cancer A number of scientific, large scale studies have all concluded that there is no relationship between abortion and breast cancer. The WHO and prestigious medical associations have reached to the same conclusion. Abortion is always risky and endangers future childbearing Early abortion, using manual vacuum aspiration or drugs, is one of the safest medical interventions that a woman may face. Complications from safe, early abortion are less common and less serious than those associated with birth. Reliable scientific studies have not found possible relationships between safe abortion and difficulties to conceive or carrying a pregnancy to term, having ectopic pregnancies, or developing infertility. Women who have abortions experience psychiatric problems otherwise characterized as post-abortion syndrome Studies on the possible effects of abortion on women s mental health have shown that there is no scientific or medical evidence to support the existence of the so-called post-abortion syndrome. The major predictor of a woman s emotional well-being after an abortion is her level of well-being before she becomes pregnant. Some women may experience regret or guilt after an abortion, but evidence show that most women experience positive feelings of relief. Emergency contraception is a form of abortion Emergency contraception (EC) is used to prevent unwanted pregnancies after unprotected sex, while abortion is used to terminate pregnancies. Scientific evidence shows that EC prevents or delays ovulation. It is not effective once the implantation of the fertilized egg in the endometrium has begun, meaning that it cannot interfere with an existing pregnancy. Some countries that permit the use of EC have highly restrictive abortion laws, revealing an understanding of EC as distinct from abortion. Sources: Center for Reproductive Rights, 2005a; Dudley and Kruse, 2006; Ipas,

9 Unwanted Pregnancy Unwanted pregnancy is the most common cause of induced abortions in all societies (Guttmacher Institute, 1999). Unwanted pregnancies are those that occur at an inopportune time, as a result of unfavorable circumstances or among women who do not want to become pregnant or to have more children (Langer, 2002). Women face their unwanted pregnancies depending on their particular conditions and the contexts where they live. While some women will accept their unwanted pregnancies, others will resort to abortion regardless if it is legal or not. Other women will not have access to abortion services and some others will not choose to terminate their pregnancies. Moreover, a woman s decision to have an abortion can change because she adjusts to the desires of others. In some cases, even a planned pregnancy may become unwanted due to unexpected difficult conditions (Bankole et al, 1998). According to evidence from large scale longitudinal studies, an unwanted pregnancy may severely threaten a woman s well-being. Also, denying women the right to abortion may increase the risk for negative effects on emotional development and mental health later in life among children born unwanted (David & Matejcek, 2005). Worldwide, the numbers of unwanted pregnancies that end in abortions or result in unwanted births are high. Estimates for 2008 suggest that more than 40% of pregnancies were unintended; of these, 28% ended in induced abortions in developed countries and 19% in developing countries. The proportion of women who had unwanted births was estimated at 16% (Guttmacher Institute, 2012). Unwanted pregnancies may be substantially reduced when people can plan their pregnancies through effective contraceptive use. However, it must be emphasized that contraception can greatly reduce but never eliminate the need for induced abortions because not all pregnancies can be avoided (David, 1992, 1999; Bankole et al, 1998, 1999; Grimes et al, 2006; Shah & Ahman, 2010). Millions of women in developing countries have an unmet need for modern contraception, which means that they want to avoid pregnancy but are using ineffective methods such as withdrawal and periodic abstinence or any method (Sing & Darroch, 2012; Sedgh & Hussain, 2014). In 2012, the number of sexually active women aged years, both married and unmarried, who were in this condition was 222 million. Globally, the unmet need for modern contraception decreased slightly between 2008 and 2012, but increased in most of Africa reaching 53%, and in some sub-regions of Asia and Latin America and the Caribbean where the figures were 21% and 22% (Singh & Darroch, 2012). In addition, women may not use modern contraceptives for different reasons including concerns about their side effects or health risks, infrequent sex, rejection from their partners, or religious beliefs (Sedgh & Hussain, 2014). Despite international agreements to promote sexual and reproductive health and rights, the implementation of programs to provide comprehensive sex education still remains a great challenge in many parts of the world. Many people especially young people have unprotected sex because they do not receive the most basic sex education and because they have no access to quality counseling in contraception (Boonstra, 2011). 5

10 Equally important is the fact that all contraceptive methods can fail and that no method is 100% effective. Globally, it has been estimated that each year around 27 million unwanted pregnancies occur as a result of method failure or ineffective use; of these pregnancies, nearly 6 million occur every year even when women and couples use contraception correctly and consistently (World Health Organization, 2007). The effective use of contraceptive methods mainly depends on the availability and quality of reproductive health services. These services, however, do not always meet the individual needs of women who want to avoid pregnancy or to control spacing between births. In many settings services do not exist or are underused due to its poor quality, while in others contraceptive choices are limited. Social and gender inequalities also limit women s ability to make their own decisions about sexuality and reproduction. Poor, young and less educated women often find it difficult to gain access to contraception and many get pregnant because their partners reject the use of any kind of contraception. Adolescents and young women are especially vulnerable to experience unwanted pregnancies due to the stigma attached to single women who have sex and use contraceptives. Domestic and sexual violence, a common and often neglected problem, is also an important cause of unwanted pregnancies (Bankole et al, 1999; United Nations Population Fund, 2000; Crane & Hord-Smith, 2006; Glasier et al, 2006; Warriner, 2006; World Health Organization, 2013; Bott et al, 2012; Ipas 2013). Another common cause of unwanted pregnancies is the lack of access to emergency contraceptive pills (ECPs). When used within the first five days after unprotected sex 120 hours, ECPs may substantially reduce a woman s chance of pregnancy. ECPs are a safe, effective recourse for women who have had unprotected sex, which may occur because of rape, unexpected sexual encounters, or accidents and failures when using contraceptives (International Consortium for Emergency Contraception, 2013). ECPs are widely available in most developed countries since the mid-1900s but they are still less known and less used in the developing world (Palermo et al, 2014). In some places, ECPs are the only post-coital contraceptive option that women can obtain without a medical prescription but in many others access to this method is limited. Moreover, obtaining ECPs may be difficult, or impossible, in countries where religiously-based opposition to its use is strong Costa Rica, Honduras, Malta, the Philippines, and some in the Middle East and also in places affected by conflict (International Consortium for Emergency Contraception, 2013). Access to ECPs is important not only for women who have been sexually abused but also for all women and couples that need contraception after having unprotected sex for any reason. ECPs must not be confused with certain medications mifepristone and misoprostol that are used for medical abortion regimes. * A number of reliable studies have shown that ECPs are highly safe and can be used by all women. ECPs prevent unwanted pregnancies and have no abortive properties. Levonorgestrel ECPs or progestin-only pills are currently the gold standard for emergency contraception and are included in the complementary List of Essential Medicines of the WHO (World Health Organization, 2005). The ECPs regime recommended by the WHO is one single dose of levonorgestrel 1.5mg taken within five days after unprotected sex * See the section on Current Methods to Provide Early Safe Abortion 6

11 (International Consortium for Emergency Contraception, 2012; 2013). Some important facts about ECPs are presented in Table 2. Table 2: Facts about Emergency Contraceptive Pills* What are ECPs and how are they administered? ECPs are oral contraceptives to prevent an unwanted pregnancy after unprotected sex. ECPs have a higher dose of the same hormonal active ingredient that regular contraceptive pills contain. The ECPs regime recommended by the WHO is one single dose of levonorgestrel 1.5mg taken within five days after unprotected sex. How do ECPs work? ECPs work by delaying or inhibiting ovulation. They impede follicular development and maturation and/or the release of an egg. ECPs have no effects on the endometrium and will not stop a fertilized egg from implanting in the uterine wall. ECPs cannot interrupt or harm an established pregnancy in any way. Why ECPs are distinct from abortion? A number of reliable scientific studies have concluded that ECPs have no abortive properties. ECPs are often confused with drugs for medical abortion, such as mifepristone and misoprostol. However, the two treatments are quite different: ECPs work after unprotected sex but before pregnancy, while drugs for medical abortion work after pregnancy starts once the fertilized egg is implanted in the uterus. How safe are ECPs? Extensive clinical research and monitoring show that ECPs are highly safe for all women, regardless their age. ECPs may cause minor short-term effects, such as irregular menstruation, but they have no long-term effects. They do not interfere with future fertility or increase the risk of cancer or ectopic pregnancy. According to the WHO, repeated use of ECPs is safe so women can take them as often as needed. ECPs do not protect from sexually transmitted infections, including HIV. How effective are ECPs? ECPs are effective up to 5 days (120 hours) after unprotected sex and are more effective the sooner they are taken. For every 1,000 women who use ECPs after unprotected sex, about 20 will get pregnant; without using ECPs this figure would be about 80. Who should use ECPs? Women who were raped or coerced to have sex. Women whose barrier method failed: a condom broke or slipped, a diaphragm slipped, or a cap dislodged. Women who were late for a hormonal contraceptive injection and women who forgot to take their regular pills. Women using natural contraception who did not abstain from sex at the correct time. Women who were unable to negotiate condom use with their partners. Women who had an unexpected sexual encounters. Any woman who had unprotected sex and does not want to get pregnant. 7

12 *All information presented in this table refers to levonorgestrel (progestin-only) ECPs. Source: International Consortium for Emergency Contraception (2012; 2013). New York: ICEC. 8

13 Unsafe Abortion In all societies women who terminate their unwanted pregnancies give very similar reasons for making their decisions (Bankole et al, 1998, 1999; Guttmacher Institute, 1999): desire to stop or delay childbearing, contraceptive failure, adverse socioeconomic conditions, age, marital status, difficult couple relationships, educational and personal expectations, maternal and fetal health conditions, rape or incest, and sexual partner or parental coercion (Table 3). Table 3: Reasons Why Women Have Abortions To avoid, delay or stop childbearing / Contraceptive failure I have already have as many children as I wanted I do not want to have any children My most recent child is still very young I just want to delay having another child My contraceptive method failed Socio-economic conditions / Educational and personal expectations I cannot afford a baby now I am unemployed I need to work full-time to support my family I want to finish (or continue) my education Difficult couple relationships / Marital status I am having problems with my partner I want my child to grow up with a father I want to be married before having a child Age I am still too young to become a mother I am already too old to have another child Maternal or fetal health conditions The pregnancy will affect my health I have a chronic illness The fetus has malformations I am infected with HIV Rape or incest I have been raped My father (other relative, or stepfather) made me pregnant Coercion My husband (or partner) insists that I must have an abortion My parents are forcing me to have an abortion Source: Guttmacher Institute, 1999 (modified). 9

14 Epidemiological data about abortion-related issues is often difficult to obtain, especially in countries where abortion is legally restricted. However, there is ample evidence that the incidence of induced abortion is high in all regions of the world (World Health Organization, 2011a; Guttmacher Institute, 2012; Sedgh et al, 2012): Almost 42 million abortions were performed in 2008; about 22 million were legal and 20 million were illegal. About 78% of all illegal abortions took place in developing countries in 1995, increasing to 86% in Since 2003, the number of abortions declined by 0.6 million in developed regions but increased by 2.8 million in developing regions. Abortion rates decline unsubstantially between 2003 and 2008, with rates of 28 and 29 abortions per 1,000 women aged years. The reduction in abortion rates was greater in developed countries, from 39 abortions per 1,000 women aged years in 1995 to 26 in In developing countries the decrease was from 34 to 29. The most dramatic decrease took place in Eastern Europe, from 90 to 44, coinciding with a substantial increase in contraceptive use. The rate of induced abortions rose in Africa between 1995 and 2003; the rates for Asia and Latin America showed modest declines. In almost all developed countries most abortions are legal and safe, and are provided at government or other certified health facilities. More than 90% of abortions are performed early in the first trimester of pregnancy by trained providers, using safe methods and in properly equipped settings. Under these conditions the risk for complications and deaths is extremely low (Templeton & Grimes, 2011). By contrast, in most developing countries abortions are usually performed under illegal, clandestine conditions and the numbers of complications and deaths that result from unsafe procedures remain unacceptably high (Berer, 2002; Center for Reproductive Rights, 2005a; Warriner, 2006; Grimes et al, 2006; Singh et al, 2009a;World Health Organization, 2007, 2011a; Sedgh et al, 2012). The most recent global estimates on unsafe abortion (World Health Organization, 2011a; Guttmacher Institute, 2012; Sedgh et al, 2012) show the following facts: The number of unsafe abortions in 2008 was 21.6 million, nearly 2 million more than in Unsafe abortion rates vary widely among world regions, reaching around 30 per 1,000 women aged years in Africa and Latin America, and 11 in Asia. By contrast, in Europe the rate was 2 per 1,000 women and even lower in North America (Table 4). The global rate of unsafe abortion was 14 per 1,000 women aged years in 1995 and did not change between 2003 and Nearly 50% of all abortions worldwide are unsafe, of which 98% occur in developing countries; 56% of all abortions are unsafe in developing regions, compared to 6% in developed regions. More than 95% of abortions in Africa and Latin America were unsafe in 2008, as were 60% in Asia. More than 99% of unsafe abortion-related deaths take place in developing countries. Deaths decreased from 56,000 in 2003 to 47,000 in 2008, but unsafe abortions accounted for 13% of the global annual maternal deaths during this period. 10

15 Data about the age patterns of unsafe abortion are relevant to develop effective strategies to prevent unwanted pregnancies. According to estimates for 2008, 41% of the overall 21.2 million unsafe abortions in developing regions were in women aged years; 15% were in adolescents aged years and 26% in young adults aged years. Two thirds of overall unsafe abortions were in women under-30 years (Shah & Ahman, 2012). Global information also shows that each year 5 million women suffer severe consequences of unsafe abortions, such as hemorrhage, peritonitis, septic shock, and trauma to the uterus and other abdominal organs. An additional 5 million women are affected by temporary or longterm disabilities that result from unsafe abortion including reproductive tract infections, chronic inflammatory disease and infertility (World Health Organization, 2011a). Table 4: Global and Regional Estimates of Number and Rates of Unsafe Abortion, 2008 World / Region Number of unsafe abortions Rate per 1,000 women years World Developed regions Developing regions Africa Asia Europe Latin America and the Caribbean Northern America Oceania Source of data: World Health Organization, 2011a (Table 5, p.19). 1 Japan, Australia and New Zealand are excluded from the regional estimates, but are included in the total for developed regions. 2 No estimates are shown for regions where the incidence of unsafe abortion is negligible. Unsafe abortion-related complications are one of the major causes of hospital admissions in developing countries, which results in a significant drain on the scarce financial resources to provide other reproductive health services (Warriner, 2006; Grimes et al, 2006; Healy et al, 2006; Singh et al, 2009a; Shah & Ahman, 2010; 2012; World Health Organization, 2007; 2011a). In Africa and Latin America, for example, the annual costs of treating women who experience abortion-related complications impose a financial burden equal to more than half of what is spent on obstetric emergencies by government health facilities (Vlassof et al, 2009). See the section on Unwanted Pregnancy and Unsafe Abortion among Adolescents. 11

16 The Role of Laws As shown in Table 5, currently 61% of the world s population lives in countries where abortion is permitted without restriction or under a range of indications: the protection of the woman s life, the preservation of her health and broad socioeconomic grounds. Liberal laws permit abortion during the first trimester of pregnancy and even beyond this limit in cases of rape or incest, to save the woman s life, to protect her physical and mental health, and in cases of fetal impairment. By contrast, more than 25% of people worldwide still live in countries where abortion is only permitted to save the woman s life or ban under any grounds (Center for Reproductive Rights, 2013b). Table 5: Legal Grounds in which Abortion is Permitted, by Percentage of Worlds Population and Number of Countries, 2013 Categories 1 % of world s population Number of countries To save the woman s life or prohibited all together To preserve health (also to save the woman s life) Socioeconomic grounds (also to save the woman s life and preserve health) Without restriction as to reason Categories are defined from the most to least restrictive. Source of data: Center for Reproductive Rights, 2013b. A global trend to the liberalization of abortion laws has been in place over the recent decades. More than 30 countries have recognized women s rights to abortion since the mid-1990 s and many other have amended their laws by adding new circumstances under which abortion could be permitted, by broadening gestational limits or by eliminating parental authorizations in the case of minors (Center for Reproductive Rights, 2013a). In Europe, only four countries Ireland, Andorra, Malta and San Marino maintain their restrictive abortion laws (Center for Reproductive Rights, 2012), and globally only few have made their laws more restrictive. In Latin America, El Salvador and Nicaragua amended their laws to ban abortion under any grounds; in Europe, Poland eliminated socioeconomic reasons as a legal ground for abortion (Singh et al, 2009a). However, even liberal laws may impose restrictions in terms of gestational periods, health facilities and providers, age and consent requirements, counseling and waiting periods, limitations on funding abortion services, or conscience clauses (Cook & Dickens, 2006; Center for Reproductive Rights, 2013a; Finer & Fine, 2013). One example of this is the United States, where at least one half of state-level abortion laws have been 12

17 amended to impose excessive regulations and where more than 50% of women reside in states with restrictive laws (Guttmacher Institute, 2014). In countries with restrictive laws abortion is defined as a criminal offense and may be either prohibited altogether or permitted only to save the woman s life. In other cases, restrictive laws may permit abortion on the grounds of some additional exceptions risk for the life of the woman, rape and incest, and cases of severe fetal impairment but in most places these exceptions are rarely applied (Cook et al, 2003; Center for Reproductive Rights, 2004, 2009; Singh et al, 2009a; Finer & Fine, 2013). Laws play a crucial role on how women terminate their pregnancies and access to legal abortion largely depends on how laws are interpreted. Restrictive laws are based in obsolete moral concepts and are often difficult to understand for most people including health professionals (Cook et al, 2003). In most developing countries, government abortion facilities are usually scarce and concentrated in urban areas, few professionals are trained or willing to provide abortions, and women are often unaware of their rights. Moreover, legal regulations concerning abortions are unclear, long and bureaucratic. Private safe abortion services do exist in developing countries with abortion restrictive laws, but these services are usually unaffordable for most women. These barriers often force women especially poor, young and rural women to resort to unskilled providers or to perform self-induced abortions using hazardous or ineffective means (Berer, 2002; Cook et al, 2003; Center for Reproductive Rights, 2005a; Warriner, 2006; Grimes et al, 2006; World Health Organization, 2007, 2011a; Singh et al, 2009a). Physicians have greatly contributed to the liberalization of abortion laws in many countries and have also provided women with safe and affordable services in places where abortion laws are highly restricted. However, physicians often play the role of gate keepers to control women s access to abortion services (David, 1992). Studies have shown, for example, that most physicians may accept abortion under broad grounds within the first trimester of pregnancy but their attitudes may significantly shift when asked about abortion in more advanced stages of pregnancy. In other cases physicians may not accept abortion for reasons that are socioeconomic or personal rather than health-related. Where laws are highly restrictive and few medical professionals support and are trained to provide safe abortions, these attitudes generally translate into important barriers for women (David, 1992; 1999; Billings et al, 2002; Cook & Dickens, 2006). The shortage of trained providers may limit women s access to abortion even in developed countries with liberal laws. In the United States, for example, abortion has been legal on broad grounds since 1973 but the number of abortion providers has sharply decreased. The major reasons for this include limited training opportunities, stigma and professional isolation, and harassment and violence against providers and clinics (Physicians for Reproductive Choice and Health, 2009). In 2011, 89% of all counties in the United States where almost 40% of American women reside had no abortion services and 84% of clinics experienced at least one form of antiabortion harassment including picketing and threats through phone calls (Guttmacher Institute, 2014). Laws include conscience clauses through which physicians may abstain from providing abortions based on moral religious objections. The abusive, unregulated use of conscience clauses has greatly undermined women s right to legal abortion in many places (Cook and Dickens, 2006; Finer & Fine, 2013). Therefore, it must be understood that physicians who 13

18 refuse to provide abortions should always refer their patients to non-objecting colleagues. Also, government health facilities must guarantee that all legal medical services are available, that conscience clauses should apply only to individuals and not to institutions, and that objectors should never be exempted from providing post-abortion care to women in need (Cook & Dickens, 2006). There are settings where physicians may not only object abortion. Some physicians may also refuse to prescribe certain types of modern contraceptive methods such as condoms, intrauterine devices or emergency contraceptive pills or to perform sterilizations, denying women their rights to effectively control their fertility and to avoid unwanted pregnancies. The criminalization of abortion may lead health professionals to stigmatize women who are suspected to have an illegal, clandestine abortion. In some Latin American countries like El Salvador or Mexico, many women have been imprisoned under charges of homicide after being denounced to the police by health professionals (Finer & Fine, 2013; Citizens Coalition for the Decriminalization of Abortion, 2014; Paine et al., 2014). These attitudes towards women and the real threat of prosecution often prevent them to seek post-abortion care. Moreover, such attitudes violate women s human rights to health, dignity and confidentiality and reveal how gender-based violence can be perpetrated within obstetric facilities. Women s access to legal and safe abortion is associated with substantial declines in the high rates of complications and deaths that result from unsafe abortion. In Romania, the removal of liberal abortion laws in 1966, along with outlawing contraceptive methods, led to a sharp increase of maternal deaths of which 87% were caused by illegal unsafe abortion. In 1989, restrictions to contraceptive use were remove and abortion laws were liberalized again; in 1990, only one year later, the rate of abortion-related deaths declined to 83 per 100,000 live births, almost one half of the rate in 1989 (Hord et al, 1991). In Nepal, abortion was legalized during the first trimester of pregnancy in Since then, abortion services have been available in most regions of the country and provided by both government and private facilities, with an overall rate of complications of less than 2% (Badahur et al, 2009). The legality of abortion is crucial to prevent unsafe abortion-related deaths but liberal laws do not always guarantee that safe abortion services are available for all women (Cook et al, 2003; Grimes et al, 2006; Sedgh et al, 2012; Benson et al, 2011). Legality may not always coincide with safety, since a liberal abortion law may not translate into real access to affordable safe services (Ganatra & Elul, 2003). In India, for example, abortion has been legal on broad grounds since 1971, but most women have no access to safe services and the number of maternal deaths caused by unsafe abortion remains extremely high (Hirve, 2004; Collumbien et al, 2011). In South Africa unsafe abortion-related complications and deaths decreased sharply after the approval of liberal laws in 1996, but access to safe services continues to be inequitable (Jeukes et al, 2005; Trueman & Magwentshu). ** Experiences from countries with liberal laws Romania, South Africa and Bangladesh show that the mortality associated with unsafe abortion can only be reduced by implementing comprehensive abortion policy reforms. The success of such reforms requires not only a strong political will, but a confluence of coordinated efforts to train physicians and midlevel providers in the provision of safe abortions. Reforms also need to make abortion access See the country overview of Mexico. See the country overview of India. ** See the country overviews of South Africa. 14

19 universal, providing available and affordable services for all women, as well as to expand access to quality reproductive health services and modern contraception, and to improve postabortion care. Furthermore, such policies must be supported by establishing government partnerships with non-government organizations and by maintaining a strong collaboration with international donor agencies (Benson et al, 2011). Current Methods to Provide Early Safe Abortions Manual vacuum aspiration (MVA) and medical abortion (MA) are currently the gold standards to terminate early pregnancies due to its high levels of effectiveness and safety. The use of both methods use has substantially contributed to improve the quality of abortion care (Berer et al, 2005; Grimes et al, 2006; Warriner, 2006; Yarnall et al, 2009; Templeton & Grimes, 2011; World Health Organization, 2012; Lichtenberg & Paul, 2013; Kapp et al, 2013). Before the introduction of MVA in the early 1970s the most common method to perform abortions was sharp curettage, which uses metallic cannula for cervical dilatation followed by metallic sharp curettage (Templeton & Grimes, 2011; Lichtenberg & Paul, 2013). Sharp curettage is still used in many places, but it has been considered by the WHO and prestigious medical associations as an obsolete method for surgical abortion that should be replaced by MVA (World Health Organization, 2012). Vacuum aspiration of which the manual version is the most portable and does not require electricity is the best surgical method for uterine evacuation up to weeks of pregnancy. MVA uses plastic cannula connected to a hand-held aspirator and has several advantages over sharp curettage. MVA is faster, simpler and safer than sharp curettage, and associated with shorter hospital stays and a reduced need for analgesia and anesthesia. MVA has high levels of acceptability among women and providers, and its costs are low especially when performed in outpatient settings (Billings & Benson, 2005; Templeton and Grimes, 2011). MVA is also the safest method for treating complications of both induced abortion and miscarriage (Singh, 2006; World Health Organization, 2011a). Another major advantage of MVA is that it can be performed by midlevel providers including midwives and nurses, clinical officers or physician assistants. This is especially relevant for countries where abortion is legal but access is restricted by a shortage of trained physicians. Given that in most countries only physicians are trained and authorized to perform firsttrimester abortions, training and supporting midwives and nurses to obtain the skills needed to deliver abortion care may benefit both women and health systems. In fact, midwives and nurses are often more likely to provide essential health care in areas where physicians are scarce (Dickson-Tetteh & Billings, 2002; Ipas & IHCAR, 2002; Berer, 2009; Yarnall et al, 2009). Studies in South Africa and Vietnam have found that trained midwives and nurses can perform early abortions using MVA as safely and effectively as physicians do, and that women report equal levels of satisfaction with services from both types of providers (Warriner et al, 2006). Other successful experiences in the provision of early abortions using See the section on Post-abortion Care 15

20 MVA by midwives, nurses, assistant doctors and even paramedics have been reported in Cambodia, Bangladesh, India and Mozambique (Yarnall et al, 2009; Jejeebhoy et al, 2011). Medical abortion (MA) also known as medication abortion consists in the use of drugs to induce an abortion. The combined use of mifepristone and misoprostol is currently the most effective regimen for early MA and is included in the complementary List of Essential Medicines of the WHO (World Health Organization, 2005). Mifepristone also referred to as RU-486 was developed as an abortifacient drug that initiates the abortion by blocking progesterone receptors; it first became available in the late 1980s in France and China and has since been approved in many countries. Misoprostol originally registered to treat gastric ulcers is a prostaglandin analog that causes uterine contractions and increases the efficacy of mifepristone (Berer et al, 2005; 2009; Templeton and Grimes, 2011; Winikoff & Sheldon, 2012). Misoprostol is also used by obstetricians for the treatment of incomplete abortions, to induce labor, to prevent and treat postpartum hemorrhage, or to evacuate death fetuses during the second trimester of pregnancy (Weeks & Faúndes, 2007). Millions of women have used the combination of mifepristone and misoprostol for first trimester abortions and have found it to be highly safe and effective (Berer, 2009; Winikoff & Sheldon, 2012; Zamberlin et al, 2012). MA protocols often require several clinic visits for women to take the drugs under the direct supervision of a physician or nurse. Recent studies, however, suggest that home administration of mifepristone and misoprostol is safe, effective and acceptable for both women and providers, giving women the advantage of privacy during the abortion process (Gynuity Health Projects, 2009; Lorh et al, 2010; Templeton & Grimes, 2011; Swica et al, 2013; Kapp et al, 2013). Mifepristone is expensive and not legally available in most developing countries, so the use of misoprostol alone has become a safe and effective alternative to provide early MA (Winikoff & Sheldon, 2012). The use of misoprostol alone has the potential to avoid a large proportion of complications and deaths associated with unsafe abortion and has gained acceptance among physicians (Harper et al, 2007). Moreover, misoprostol alone has been increasingly self-administered by women to terminate their pregnancies without medical supervision, especially in Latin American and Caribbean countries. Self-administration of misoprostol has also been reported in Africa and by African immigrants in Europe, and even in the United States (Grossman et al, 2010). In several Latin American countries misoprostol is widely available over-the-counter without medical prescription (Billings, 2004; Berer et al, 2005; Lafaurie et al, 2005; Cohen et al, 2005), and in others it can be obtained through the black market or the Internet. In this region, non-government organizations have played a crucial role in providing women with complete information about MA using misoprostol alone (Zamberlin et al, 2012). In some countries Brazil, Peru, the Dominican Republic and Uruguay clinicians have observed that compared to other methods used to induce abortions clandestinely misoprostol alone is safer and associated with fewer complications and deaths (Faúndes et al, 1996; Ferrando, 2002; Miller et al, 2005; Grimes et al, 2006; Briozzo et al, 2006). 16

21 Evidence from Mexico where abortion is highly restricted except for its capital city has shown that obtaining misoprostol directly from pharmacies enables women to access an abortifacient that is safer than other clandestine methods often used. In addition, using misoprostol can be less expensive than seeking care from physicians who provide illegal but safe services. However, most women and pharmacy vendors lack of enough information on the safest and most effective doses of misoprostol, about what to expect during the abortion process or about what to do if the drug fails (Billings, 2009; Lara et al, 2011). By contrast, studies in Mexico and other Latin American countries have shown that most women report positive experiences when misoprostol induced-abortions are provided under the adequate supervision of health professionals (Cohen et al, 2005; Lafaurie et al, 2005). A report on the safe and effective use of misoprostol alone in a Latin American clinic found that women were highly satisfied using misoprostol alone, would use it again if they needed and would recommend it to other women (Billings, 2004). One major advantage of MA either using the combination of mifepristone and misoprostol, or misoprostol alone is that it can be safely and effectively offered not only by physicians, but also by midwives and nurses. In addition, training in the use of this option can be simple and affordable in almost any setting (Gynuity Health Projects, 2009). In some developed countries Sweden, Denmark, France, Great Britain and the United States trained midwives and nurses provide MA; in the developing world, countries such as Nepal, South Africa, Tunisia and Vietnam currently allow midwives and nurses to manage MA (Berer, 2009; Yarnall et al, 2009; Warriner et al, 2011; Winikoff & Sheldon, 2012). MA gives women a safe, non-invasive and effective option to terminate their unwanted pregnancies. However, MA should be offered alongside MVA whenever possible. Health providers must offer comprehensive counselling and unbiased information about MA and MVA (Gynuity Health Projects, 2009; Kapp et al., 2013). Both methods have advantages and disadvantages that women must know about to make their own informed decisions (Table 5). Table 5: Advantages and Disadvantages of Early Abortion Methods, as Cited by Women and Providers Medical abortion Surgical abortion using MVA Advantages Avoids surgery and anesthesia More natural, like a miscarriage More painful to some women Easier emotionally for some women Can be provided by midlevel staff Women can be more in control Quicker and more certain Less painful to some women Easier emotionally for some women Can be provided by midlevel staff Provider controlled Woman can be less involved Disadvantages Bleeding, uterine cramping, nausea Waiting, uncertainty Depending on the protocol, more or longer clinic visits Cost when not provided at public Invasive Small risk of uterine or cervical injury Risk of infection Less privacy and autonomy Cost when not provided at public Mexico has a federal system and each state of the country has its own abortion laws. See the country overview of Mexico. 17

22 facilities facilities Source: Gynuity Health Projects, 2009, p.7. Efficacy rates for early MA up to 9 weeks, or 63 days gestation from the last menstrual period is around 95% and over when the combined regime of mifepristone and misoprostol is used. Efficacy rates for MA using misoprostol alone are lower at 75-90%. In case of MA failure, women will need a surgical abortion using MVA to terminate the pregnancy or to treat complications, such as excessive bleeding (Gynuity Health Projects, 2009; World Health Organization, 2012). MA has a great potential to increase women s access to safe abortion because it can be easily offered in settings where surgical abortion may not be safe or available (Gynuity Health Projects, 2009). This is especially important for places where few physicians are trained or willing to provide abortion services. Given its great potential to save women s lives, training in the current protocols for early MA should be part of both medical and nursing education. Post-abortion Care Post-abortion care (PAC) is the treatment of a woman once she presents to a health facility with complications of an induced abortion or a miscarriage. PAC has a great potential to prevent abortion-related deaths. The provision of PAC is especially relevant in places where abortion is legally restricted, as well as in those where abortion is legal but access to safe services is limited. Models to provide PAC have been successfully implemented in several developing countries. These models have been proven to meet women s needs and reduce the costs of PAC for public health systems (RamaRao et al., 2011; World Health Organization, 2011a). Components of PAC include treatment of incomplete and unsafe abortion complications by using manual vacuum aspiration (MVA); comprehensive counseling to identify and respond to women s emotional and physical needs; provision of contraceptives to help women avoid an unwanted pregnancy or control birth spacing; and referral to other reproductive health facilities. The provision of quality PAC services requires changes in the attitudes and practices of health providers so that women can receive prompt and humane care (Ipas & IHCAR, 2002; Billings & Benson, 2005; Billings et al, 2007; Grimes et al, 2006; World Health Organization, 2011a). The advantages of PAC have been well recognized, but many women still die before they receive any kind of medical care following an induced abortion. Rural women, for example, often face barriers in reaching health facilities due to lack of money or difficulties in accessing transportation. The stigma associated with abortion and fears of prosecution are also common barriers that impede women s access to medical care regardless where they live. The quality of PAC continues to be poor in many places for different reasons: lack of financial resources; the use of obsolete and potentially dangerous surgical methods, such as sharp curettage; shortage of trained personnel to use MVA, which is the safest and most costeffective means for treating complications of both induced abortion and miscarriage; punitive attitudes from health professionals toward women; lack of personnel to provide counseling in 18

23 contraception; and difficulties for referring women to other health facilities (Singh, 2006; Singh et al, 2009a). One major advantage of PAC is that it can be provided safely and effectively by midlevel providers. In some African countries such as Ghana, Kenya, South Africa and Uganda midwives, nurses and other midlevel providers have been successfully trained to provide PAC services using MVA (Brookman-Amissah et al, 1999; Berer, 2009; Yarnall et al, 2011). Additionally, the costs of PAC can substantially decrease when services are provided at primary care facilities (Johnston et al, 2007). Post-abortion contraception is essential to help women avoid another unwanted pregnancy and the risk of another unsafe abortion. Further fertility is not affected by safe abortions either surgical or MA and more than 80% of women will ovulate during the first menstrual cycle following a pregnancy termination. Offering women comprehensive counseling and effective modern contraceptive methods before they leave the facility where they receive medical care should be an essential component of all PAC services (Gemzell et al, 2014). Unwanted Pregnancy and Unsafe Abortion among Adolescents Millions of adolescent girls aged years give birth each year and many others are even younger when they become mothers. The rates of adolescent pregnancy have decreased worldwide but remain high in places where poverty affects large populations. Girls living in marginalized rural and urban areas in developing countries, with limited or no access to education, employment and health care are the most at risk of having early pregnancies (Rowbotton, 2007; World Health Organization, 2011b; United Nations Population Fund, 2013a; Jejeebhoy et al, 2013). Worldwide, 95% of births to adolescents aged years occur in low and middle-income countries. About 19% of young women become pregnant before age 18 and around 20,000 adolescents give birth each day; 90% of births to adolescents occur within marriage or a union. Data on younger adolescents are scarce, but according to some estimates girls aged years account for at least 2 million of the 7.3 million births that occur to adolescents each year (United Nations Population Fund, 2013a). Adolescent pregnancies are also common in wealthy countries, mostly occurring among girls who grow up in low-income households, who live in rural areas or who have less education. Girls who are members of ethnic minorities or immigrant groups are also more likely to become pregnant. Early pregnancies in wealthy countries are currently far more common among single adolescents (United Nations Population Fund, 2013a). Adolescent pregnancies are often accidental and the result of different factors: limited or no access to health care; negative attitudes of health providers toward the use of contraceptives by single adolescents; unexpected sex and lack of knowledge about how to avoid pregnancy; inconsistent use of contraceptives or use of ineffective methods; and rejection of their partners to use condoms or other contraceptive methods. Adolescent pregnancies, however, do not always result from accidents or misinformation. In many places, adolescents often wish and seek to become mothers due to the great influence of traditional cultural values that shape women s gender roles. Early marriage remains common in low and middle-income countries and adolescents are often pressured by their partners and families to prove their 19

24 fertility soon after marriage. Moreover, adolescents are especially vulnerable to sexual abuse and their pregnancies often result from forced sex, rape or incest (Singh, 1998; De Bruyn & Packer, 2004; Center for reproductive Rights, 2005b; Glasier et al, 2006; Bearinger et al, 2007; Rowbotton, 2007; Hindin & Fatusi, 2009; Singh et al, 2009a; World Health Organization, 2011b; United Nations Population Fund, 2013a; Jejeebhoy et al, 2013; Ipas, 2013). Globally, less than 5% of the poorest sexually active adolescents use modern contraceptive methods and among those who are single 10-14% experience unwanted pregnancies each year (Rowbotton, 2007). Data from 41 developing countries show that the proportion of young women aged years reporting an unmet need for contraception remains high; it decreased only modestly between 1995 and 2010, from 27% to 21%. One quarter of young women in sub-saharan Africa and almost 20% in both Southern Asia and Latin America and the Caribbean had an unmet need for contraception (Jejeebhoy et al, 2013). Adolescent pregnancies may be unwanted even among those who are already married and many of them have unwanted births. Under unfavorable conditions such as poverty or being a single mother unwanted births often have long-term social negative consequences for both the young mothers and their children. Adolescents aged years are twice likely to die during pregnancy and childbirth than women in their twenties, and for those under-15 years the risk of death rises five times (Rowbotton, 2007). Adolescents are less likely than older women to obtain skilled health care during pregnancy and childbirth, and about 70,000 of them die annually due to maternal causes (World Health Organization, 2011b; United Nations Population Fund, 2013a). The number of adolescents who have induced abortions has sharply increased in all regions of the world, especially among those who are single (World Health Organization, 2007; 2011b; Rowbotton, 2007). Adolescents reasons to terminate their unwanted pregnancies are varied and some of these reasons differ significantly from those of older women (Table 6). The most common reasons for adolescents to have abortions include contraceptive failure; poverty and lack of social support to care for a child; stigma attached to single mothers and fears of negative family and community reactions; desire to continue their education; fears of expulsion from jobs; unstable sex relationships; already having children; rape or incest; forced marriage and dislike for the man involved in the pregnancy; and partner or parental coercion (Olukoya et al, 2001; Cook et al, 2003; De Bruyn & Packer, 2004; Burket et al, 2008). Adolescents account for a large proportion of unsafe abortions and are especially vulnerable to its negative consequences. In 2008, 15% of all unsafe abortions in developing countries, or 3.2 million, were in women aged years. The highest proportion was in Africa at 22%, followed by Asia and Latin America and the Caribbean at 11% and 16% (Shah & Ahman, 2012). In some places, between 38% and 68% of women who suffer unsafe abortion-related complications are under-20 years (United Nations Population Fund, 2013a). The burden of unsafe abortion-related deaths among adolescents is also high. Worldwide, 18% of overall maternal deaths caused by unsafe abortion in 2003 were in women under-20 years (World Health Organization, 2007; Rowbotton, 2007). The need to assure adolescents access to legal and safe abortion in developing countries has become an important topic of concern among clinicians, public health researchers and advocates for young people s rights. It has been well recognized that adolescents often face 20

25 more barriers than adults in gaining access to abortion and post-abortion care. Also, it has been underlined that models to provide such care to adults must be adapted in order to meet the particular needs of younger women (Olukoya et al, 2001; De Bruyn & Packer, 2004; Postabortion Care Consortium, 2012; Singh et al, 2009a; Ipas, 2013). 21

26 Table 6: Common Reasons Cited by Adolescents for Abortion Reasons Details Education / Work Fear of expulsion from, or interruption of, schooling Fear of expulsion from jobs Economic factors Adolescents have fewer economic resources and other types of support than adults to care for a child Social stigma Adolescents often choose abortion to avoid upsetting their parents and bringing shame on their families Unstable relationships Unstable relationships are more common in adolescents than in adults Contraception failure Contraceptive use among adolescents is lower than in adults. Among those using contraceptives, less effective methods or inconsistent use of methods are more common. Victim of rape or incest A large proportion of rape and sex abuse incidents are perpetuated against girls and adolescents Having a previous child An adolescent may choose abortion when she already has a child Not liking the man involved in the pregnancy Adolescents often seek abortions when married to men that they don t like. The pregnancy may represent the end of any hope of freedom to live with a man of their choice Being forced to terminate the pregnancy Adolescents decisions to have an abortion are often influenced by others. In many cases the decision is rather made by the parents or the partner Source: Olukoya et al., 2001 (modified). Several international agreements and human rights treaties recognize adolescents evolving capacities, a progressive concept that supports the right of minors to make autonomous, responsible decisions about issues affecting their lives and well-being. The recognition of these evolving capacities entitles adolescents to legally exercise their human rights, which include their rights to receive comprehensive sex education and obtain a wide range of services for the protection of their sexual and reproductive health. Regarding abortion, evidence has shown that adolescents may have the same capacities as adults in making their decisions when they have support and all the information they need (Cook & Dickens, 2000; 22

27 De Bruyn & Packer, 2004; Center for Reproductive Rights, 2005b; Ipas, 2013; Clyde et al, 2013). According to this evidence, some important facts about abortion-related issues experienced by adolescents are the following: Legal regulations on abortion often translate into relevant barriers for adolescents access to early safe procedures. Adolescents are often unaware of their rights and laws may not recognize their evolving capacities to make decisions about sexuality and reproduction. Laws often require the consent from parents or guardians, which interferes in their decisions and may lead to delays in seeking an early abortion. Legal barriers may be especially difficult to overcome in places where laws are highly restrictive and regulations regarding minors are unclear. Delaying the decision to have an early abortion is more common in adolescents than in adult women. Adolescents often postpone their abortions due to difficulties in recognizing, admitting or confirming the pregnancy, which greatly increases their risks of complications and death. Other common reasons to postpone an abortion are fears of negative family reactions, fears to die, lack of ability to reach health facilities, difficulties to get money, and lack of support from their partners. Adolescents resort to unskilled providers and use dangerous methods to self-induce an abortion more often than adults do. Given the social disadvantages faced by adolescents in many countries, seeking unskilled providers who perform unsafe abortions at lower costs is far more common among them than among adult women. Also, repeated attempts to self-induce the abortion using ineffective or dangerous methods are more common among adolescents. Delays in seeking post-abortion care services are also more common among adolescents than among adult women. These delays greatly increase their risks of dying or suffering severe long-term consequences associated with unsafe abortion. Common reasons for these delays include lack of support from parents or partners, lack of awareness about where to seek post-abortion care, fears of negative attitudes from health professionals, and lack of money for transportation or to pay for services. The lack of autonomy to make decisions about abortion is more common among adolescents than among adult women. Because of their age and vulnerability to coercion and abuse, adolescents are often excluded from the decision to terminate an unwanted pregnancy. In many cases, the final decision is made by the parents or the partner and physical or emotional violence may be used to force the adolescent to have an abortion. Adolescents are more likely to experience emotional vulnerability when they have an abortion. Social stigma on abortion and the lack of support from parents or partners may seriously affect adolescents emotional conditions. While some girls seek and are supported by their parents, asking for parental support may be harder for those who live in conflictive families, for those who were raped by a family member, for those whose parents hold rigid moral values, and for those who are at risk of physical and emotional abuse. In addition, younger women are more vulnerable to face punitive attitudes from health providers than are older women. 23

28 COUNTRY OVERVIEW: MEXICO Tehuana. Diego Rivera, 1936 (Mexican painter, ) Mexico is considered a middle-income country and is among the most populous in Latin America and the Caribbean with more than 122 million inhabitants in Most Mexicans live today in urban settings (United Nations Population Fund, 2013a). Structural reforms have pushed economic growth but it also increased unemployment and poverty. Deep social and income inequalities result in varying living and health conditions throughout the country. See a general profile of the Mexican population in Table 7. In 2012, Mexico had 53.3 million people living in poverty which means 45.5% of its total population; extreme poverty affected 11.5 million people (Consejo Nacional de Evaluación de la Política Social, 2013). Mexico is a multicultural nation and indigenous groups 18.1 million people, 16% of the total population are more vulnerable to be in poverty and marginalized (Consejo Nacional de Evaluación de la Política Social, 2014). Despite progress in expanding government health care services, in 2012 more than one fifth of the Mexican population had no access to any kind of medical services and only 40% had access to social security medical facilities (Consejo Nacional de Evaluación de la Política Social, 2013). The health of Mexican women differs widely within the country according to geographical regions, income and ethnicity. A variety of factors are still major barriers to improve women s health conditions including poverty, low education levels, deep gender inequalities, a high prevalence of domestic and sexual violence, a weak system of primary health care facilities and poor quality medical services for vast vulnerable populations. 24

29 Table 7: General Profile of the Mexican Population, According to Data from United Nations Agencies Demographic Indicators Total population (millions), Urban population %, Population aged years %, Total fertility rate per women aged ( ) Adolescents currently married/union %, Adolescent birth rate per 1,000 women aged years, Life expectancy at birth, Males Females Infant mortality rate per 1,000 live births Under-5 years children mortality rate by sex Males Females Reproductive Health Maternal mortality ratio per 100,000 live births, Antenatal care coverage at least four times %, Births with skill attendance %, Modern contraception prevalence rate, women aged years %, Unmet need for contraception, women aged years % Primary school attendance %, Males Females Secondary school attendance, Males Females Education Adult literacy rate: females as % of males, Economics and Public Health Gross National Income per capita (USD), ,740 Population bellow international poverty line of US $1.25 per day %, Share of household income %, Lowest Highest Central government expenditure allocated to health %, Use of improved drinking water sources %, Use of improved sanitation facilities %, Source of data: 1 United Nations Population Fund, 2013a; 2 United Nations Children s Fund, The Mexican government ratified the agreements of the 1994 International Conference on Population and Development (ICPD) and reaffirmed its commitment that reproductive health would be addressed as a relevant public health problem during the 1999 ICPD review. However, unwanted pregnancy and unsafe abortion remain relevant public health problems 25

30 and significant efforts are still needed to promote women s sexual and reproductive rights. More than 72% of Mexican women living with their partners used some kind of contraception in However, the use of modern methods was lower in certain vulnerable groups: 44.7% in adolescents, 60.5% in women who lacked formal education and 58.3% in women of indigenous minorities (Consejo Nacional de Población, 2009). In addition, 12% of women, or around 2 million, had an unmet need for modern contraception and recent estimates suggest that 55% of pregnancies in Mexico are unplanned or unwanted; 30% of these pregnancies end in abortions and 19% end in unplanned births (Juárez et al., 2013). According to government estimates, 17% of all births occur among women under-20 years; 25% of adolescent pregnancies are unplanned and 10% are unwanted. Fertility rates among women under-20 years increased between 2000 and 2008, from 16 to 17.4 per 100,000 live births (Consejo Nacional de Población, 2011). Emergency contraception (EC) was authorized by the Federal Ministry of Health in EC pills are available over-the-counter and can be prescribed at all government and private health facilities. However, one major problem with EC is that not all women and men are aware of its existence or how to use it properly. In addition, conservative groups have disseminated the myth that emergency contraception is a form of abortion and in some states efforts have been undertaken to ban its use (Cossío, 2010). The maternal mortality ratio (MMR) has declined in Mexico but it remains high when compared to other Latin American and Caribbean countries. In 2012, the MMR was 50 per 100,000 live births, while in Costa Rica and Chile the ratios were 40 and 25 per 100,000 live births (United Nations Population Fund, 2013a). The MMR in Mexico is far behind the Millennium Development Goal target of 22 deaths per 100,000 live births by Recent estimates show that almost 40% of maternal deaths are in women with low or no education and almost 12% in indigenous women; in some largely indigenous states, such as Chiapas, Guerrero and Oaxaca, the MMR is 72.6, 93 and 81 per 100,000 live births. Poor quality of health services is clearly associated with maternal mortality, since more than 70% of all maternal deaths across the country currently occur within government health facilities. Adolescents are especially vulnerable to suffer complications of pregnancy and childbirth, and almost 13% of overall maternal deaths are in women under-19 years (Freyermuth & Luna, 2014). Abortion Legislation The negative consequences of restrictive abortion laws on Mexican women were first recognized by the federal government in the 1970s. However, powerful anti-choice groups and the Catholic Church impeded an open public debate on the issue. For many years, the legalization of abortion had been one of the main political mandates of feminists and the broader women s movement, but it was not until the mid-1990s that abortion became an issue of public interest and gained support from civil society and progressive politicians (Lamas & Bissell, 2000; Ubaldi, 2008). Abortion laws in Mexico vary from one state to another because of the country s federal system. In all states, abortion is permitted in cases of rape and all penal codes have at least 26

31 another condition under which women can obtain a legal abortion. However, among the 32 states of the country only 8 have procedures that explain how the law is to be enforced. In addition, women generally are unaware of their rights and access to legal abortion services at government hospitals is denied in most states (Billings et al, 2002; Lara et al, 2006; Human Rights Watch, 2006; Barraza & Taracena, 2008; Grupo de Información en Reproducción Elegida, 2010; 2013). As such, abortion is a relevant public health and social justice problem because poor women often risk their lives when they choose to terminate an unwanted pregnancy and only poor women eventually face prosecution after having illegal abortions (Ubaldi, 2008). The year 2000 marked a significant change in abortion legislation. In Mexico City the country s federal capital the basis on which abortion could be legally obtained was broadened to include pregnancy resulting from rape, serious risk to the health of the pregnant woman, severe fetal malformation and non-consensual artificial insemination. For the first time, the law clearly defined the responsibilities of the judicial and health sectors in providing safe abortion services. After this reform, some other states passed guidelines to provide legal abortions in cases of rape (Lamas & Bissell, 2000; González de León & Billings, 2001; Grupo de Información en Reproducción Elegida, 2013). The most relevant advance in abortion legislation occurred in April 2007, when a law was passed to decriminalize abortion in Mexico City (Sánchez et al, 2008; Langer, 2011). Since then, abortion on demand is permitted during the first 12 weeks of pregnancy and up to 20 weeks in cases of rape, risk for the health of the woman and fetal impairment. Abortion services are free of charge at facilities governed by the local Ministry of Health for residents of the city and available for moderate fees for women living in other states and for women with social security insurance. Only obstetrician-gynecologists and other trained physicians are authorized to perform the procedures (Asamblea Legislativa del Distrito Federal, 2007). By contrast, in the country s other 31 states, where around three quarters of Mexican women reside, access to safe abortion in cases of rape or any other grounds permitted by state laws continues to be extremely difficult. After the law was passed, private abortion facilities increased sharply in Mexico City and many women continue to use them despite the availability of public safe services. According to the results of one study, based on interviews to 135 physicians, private abortion services vary widely in terms of its quality and are usually expensive. One relevant finding of this study is that the use of manual vacuum aspiration and medical abortion is uncommon among physicians that provide private abortion services in Mexico City, since more than 70% of providers in this sample reported that they used sharp curettage (Schiavon et al, 2010). Challenges to provide quality abortion care at facilities governed by the local Ministry of Health in Mexico City include shortage of trained personnel, lack of resources, existence of numerous conscientious objectors, stigmatization of professionals and heavy workloads due to increasing numbers of women seeking services (Contreras et al, 2011). However, between April 2007 and June 2014, more than 125,000 legal abortions had been performed. More than 80% of abortions were in women with less than 10 weeks of pregnancy and more than 70% were medical abortions (Grupo de Información en Reproducción Elegida, 2014). Misoprostol alone was used until Mifepristone was registered in Mexico in 2011; since then, the In Mexico, the legalization of abortion has been generally described as decriminalization of abortion (Langer, 2011). 27

32 combined regime of mifepristone and misoprostol has been the gold-standard method for medical abortion (Ipas, 2011; Winikoff & Sheldon, 2012). According to qualitative studies, three years after the law was passed women were highly satisfied with services (van Dick et al, 2011) and more physicians working at facilities governed by the local Ministry of Health recognized the benefits of legal and safe abortion (Contreras et al, 2011). Also, public opinion surveys have shown that despite that most of the population in Mexico is Catholic, support for the law and its extension to the rest of the country increased from 51% in 2007 to 83% in 2009 among Mexico City residents (Wilson et al, 2011). Despite its great benefits, one important limitation of the Mexico City s abortion law is that it sets special requirements for women under-18 years. The law does not recognize minors evolving capacities to make informed decisions about abortion and explicitly requires their parental or legal guardians consent (Ubaldi, 2008; van Dick et al, 2011; Clyde et al, 2013). In addition, surgical abortion using manual vacuum aspiration is in general provided only to women with more than 9 weeks of pregnancy and for women who live outside Mexico City (Ipas, 2011). Within a context where few physicians are willing to provide surgical procedures, the use of medical abortion has been the best option to satisfy a high and increasing demand for legal abortion services. In practice, however, this imposes limits for women to choose between surgical and medical abortion. The Mexico City s abortion law is a relevant precedent for abortion liberalization in Latin American and the Caribbean, where only Cuba, Guyana and Uruguay have similar laws. However, the decriminalization of abortion in Mexico City did not lead to a national trend to liberalize abortion laws. Instead, in recent years the legal context of abortion throughout the country has become extremely complex (Langer, 2011; García et al, 2013). Conservative forces have launched an aggressive campaign to prevent other states from decriminalizing abortion. State-level constitutional amendments to grant embryos the right to life have been passed in 16 states since 2008, which may in turn be translated into penal codes reforms to further restrict abortion access. An unknown number of women suspected to have illegal abortions have been imprisoned. Some cases have been documented by lawyers revealing that most women were reported to the police by physicians, nurses and social workers at government hospitals. In all of these cases, health providers and policy officers forced women all of them young and socially disadvantaged to admit that they have had an illegal abortion as the condition to provide them with medical care (Grupo de Información en Reproducción Elegida, 2013; Paine et al., 2014). Abortion-related Facts and Statistics According to recent studies, the incidence of abortion in Mexico is high and has increased over time. The number of women who annually resort to abortion between 1990 and 2006 rose from more than 500,000 to 875,000 (Juárez et al, 2008). In 2009, the number of induced abortions was estimated at around 1 million; 54% of overall unintended and unwanted pregnancies ended in induced abortions. The rate of induced abortion was 38 per 1,000 women aged years, which was higher than the rate of 32 estimated for the Latin American and Caribbean region. Induced abortion in Mexico is more common in urban areas and rates are higher among young women aged years (Juárez et al, 2013). 28

33 Another study found that 44% of all abortions reported in 2006 were induced, of which 16.5% were unsafe. Poorer women were 2.5 times more likely to experience an unsafe abortion, women with more than 13 years of education were less likely to resort to unsafe procedures, and women of indigenous origin were 5 times more likely to have unsafe abortions (Sousa et al, 2009). Abortion-related complications including both induced abortions and miscarriages were the fifth most common cause of hospital stays at all government hospitals throughout the country in 2005 (Secretaría de Salud, 2007). The annual number of women hospitalized at government health facilities for these complications increased by 40% between 1990 and In 2009, around 159,000 women were hospitalized at public facilities due to unsafe abortion-related complications. More than one third of women who have induced abortions experience complications with a higher proportion, of 45%, among women who live in poor rural areas (Juárez et al, 2013). Old national data from federal hospital facilities that provide services to the poorest populations reveal a frightening reality regarding adolescents. In 2002, abortion was the second most common cause of hospital discharge among adolescents aged years and the fifth among girls aged years (Secretaría de Salud, 2003); in addition, 13% of all abortion-related deaths occurred among adolescents between 1990 and 2005 (Schiavon et al, 2007). In Mexico misoprostol is available over-the-counter without medical prescription. Its use to self-induce abortions is common and has increased in the recent years. However, as in other Latin American and Caribbean countries women, pharmacy vendors and even physicians lack enough information about how to use it safely and effectively (Lafaurie et al, 2005; Lara et al, 2008; Billings et al, 2009; Guttmacher Institute, 2012). It has been suggested that the wide use of misoprostol by Mexican women could explain the decrease of severe abortion-related complications septicemia and trauma to the uterus and pelvic organs that has been observed at government hospitals over time (Juárez et al, 2008; Schiavon et al, 2011). Unsafe abortion remains an important cause of maternal mortality in Mexico: 1,537 maternal deaths were attributed to abortion-related complications between 1990 and 2005, accounting for 7.2% of overall maternal deaths. A modest decline in the rate of maternal mortality has been observed during this period, but abortion-related mortality has not changed substantially in terms of its contribution to overall maternal deaths (Schiavon et al, 2007; 2011); in 2012, 8% of maternal deaths were caused by abortion-related complications (Freyermuth y Luna, 2014). Physicians attitudes toward abortion are an important barrier for women s access to safe procedures in Mexico. In general, physicians do not oppose abortion in cases of rape, risk to the woman s life or health, and severe fetal impairment but few are willing to provide abortions and many hold negative attitudes toward women who terminate their pregnancies. However, stigma and the threat of prosecution have not impeded the practice of abortion at private facilities in all big urban areas across the country (González de León & Billings, 2001; Billings et al, 2002; Lara et al, 2004; Silva et al, 2009; García et al, 2013). 29

34 CASE STUDIES: MEXICO *** Case Study 1: Soledad Soledad is a single, 27-year old woman. She was born in San Andrés Tuxtla, a small rural town in the state of Veracruz, and came alone to Mexico City 10 years ago. She did not finish her primary education. Currently, she and her 6 year old daughter live with an aunt in a marginalized area. She lost contact with her daughter s father 4 years ago. Soledad works as a waitress in a restaurant in downtown Mexico City. Soledad began to be sexually active when she was 16 years old and has had two sex partners. She arrives at your private practice with a positive pregnancy test and says that the pregnancy is the result of rape. More than two months ago, she was sexually abused by a man that she met some time ago, and who invited her to go dancing. Afterwards she refused to have sexual intercourse, but he used physical violence and verbal threats to force her to have sex. She did not report the rape to the police. One of her friends recommended her to take some pills to make their period to return, but the pills did not work. Soledad is very worried and says that she cannot afford having another child. She wants to have an abortion. Questions for students 1. What is your legal responsibility to Soledad? 2. What type of information would you offer to this woman regarding the steps required for her to obtain a legal, safe abortion? 3. What type of information would you offer to this woman regarding the possible impact of this pregnancy on her health? 4. Where would you refer Soledad to have a safe abortion? 5. What would you do if you were a conscientious objector to abortion? Case Study 2: Elena Elena, a 33 year-old woman, arrives at the government clinic where you work in Celaya, a small city in the state of Guanajuato. She works as a primary school teacher and has two children. Elena s menstrual cycles are regular and she has never had any serious health problems. Her last period came eight weeks ago, and during the last eight months she and her husband have had sex only sporadically. They have been separated during the last six months and plan to divorce, but approximately four weeks ago she did have unprotected sex with him. Yesterday Elena had a pregnancy exam from a nearby lab. It indicated a positive result. Given her situation, she does not want to have another child and is very worried. She tells you frankly that she wants to have an abortion and asks for your counseling. Elena also tells *** These case studies were developed by Jennifer Unger, Deyanira González de León and Deborah L. Billings. 30

35 you that she knows that it will be quite difficult to find a physician who would help her in Celaya. Questions for students 1. What is your legal responsibility to Elena? 2. What type of information and options would you present to this woman? 3. What would you do if you were a conscientious objector to abortion? Case Study 3: Bertha Bertha is 35 years old. She was born in Cuetzalan, a small town in the state of Puebla where she lived until she moved to Mexico City two months ago. She finished her high school education and married when she was 22 years old. Currently she is a housewife. She has two healthy adolescent daughters and a good relationship with her husband, who is employed in a factory. She arrives alone at your office in a public hospital and reports to you that she is 16 weeks pregnant. Bertha is very sure about the date of her last menstrual period and says that her pregnancy was planned. She had a miscarriage two years ago, when she was 15 weeks pregnant. She has never had any serious health problem. Considering Bertha s age, you decide to request some specific prenatal diagnostic tests: maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol. The lab reports the following results: a high level of alpha-fetoprotein, and normal levels of human chorionic gonadotropin and unconjugated estriol. Given these results, you request an ultrasound scanning which reveals that the fetus has anencephaly. Questions for students 1. How do you classify Bertha s health conditions? 2. What are the legal options for Bertha in this case? 3. What kind of information would you offer to Bertha? 4. If Bertha decides to terminate her pregnancy, where would you refer her to do so? 5. What would you do if you were a conscientious objector to abortion? Case Study 4: Andrea Andrea is 16 years old and a high school student. She was born in Mexico City where she lives with her parents in a middle class neighborhood. Andrea has never been pregnant; she began to be sexually active when she was 14 years old, and has had only one sexual partner. She arrives at the Ministry of Health clinic near Zihuatanejo, Guerrero, where you work as a physician doing your social service. Andrea is accompanied by her boyfriend. They are spending some of their summer vacation here on the beach with some friends. They tell you that they had unprotected sex the night before. Usually, the couple uses condoms on a regular basis but the night before they were on 31

36 the beach and they forgot to bring them. The young woman tells you that she has heard her friends talking about some type of pills that can be taken the day after having unprotected sex. The couple would like you to inform them more about this type of medication. Questions for students 1. What is your legal responsibility to this couple? 2. Given her age, do you think that the young woman can make her own decisions about contraception? 3. What information would you offer to the couple? 4. What would you do if this couple returns with the same problem in two weeks? Case Study 5: Lourdes Lourdes is 17 years old and single. She was born in Cuernavaca, Morelos and has lived for the last two years in Ciudad Netzahualcóyotl, State of Mexico, with her aunt. She finished her primary school and currently works as a janitor. Lourdes first had sex at age 15 and has had two sexual partners. She depends on the condom as her contraceptive method but her current partner does not always use it. She has no history of illness or gynecological problems. Lourdes arrived alone to the night shift of the government hospital s emergency room where you are interning. She refers to amenorrhea that has lasted for 8 weeks. She has had vaginal bleeding for two days, accompanied by many clots of blood and intense abdominal pain. She notes that this began spontaneously and without identifiable cause. She is pale and appears to be worried. The gynecological exam reveals that her cervix is dilated to the size of a finger. She describes the headache and chills she has experienced during the last 12 hours. After examining Lourdes, you suspect that she had an induced abortion but you do not say a word. Shortly after her arrival at the hospital, she spontaneously tells you that a neighbor who is a nurse inserted a catheter through her vagina and recommended that she seek care at the hospital immediately after she started to bleed. Questions for students 1. How would you classify Lourdes health status? 2. What are your legal responsibilities to treat this patient? 3. What type of medical care will Lourdes require during her hospital stay? 4. What type of information should you offer Lourdes during her hospital stay and at discharge? Case Study 6: Cristina Cristina is 23 years old. She is a law student and lives in Mexico City with her boyfriend in a middle class neighborhood. Cristina began to be sexually active when she was 17 years old and has had two sex partners. She presents at your private office with a pregnancy at 6 weeks. 32

37 She tells you that she got pregnant because a condom broke when she was by the middle of her menstrual period. She and her boyfriend have a very good relationship, but they do not want to have a child at this point of their lives because they are still too young and have plans to continue their studies in another country. Besides, they both have part-time jobs and do not have enough money. Cristina also refers that she has heard about surgical and medical methods for early abortions and wants to know which would be the best option for her. She also asks whether either method could affect their future reproductive health. Questions for students: 1. Which would be your legal responsibilities to Cristina? 2. Which method would you recommend to Cristina to terminate her pregnancy? 3. What type of information would you give Cristina about condom accidents? 4. What would you do in this case if you were a conscientious objector to abortion? Tutors notes The case studies were designed in order to help students to develop their problem-solving skills, as well as to allow them to put the concepts presented into use. The cases include details of hypothetical situations that students may face in practice. Each one of the cases provides students with the case scenario and a series of questions. The exercise must be carried out with students working together in small groups. The results of each one of the small groups will be shared and discussed in a general session conducted by one or more tutors. Students have to play an active role in presenting and discussing the cases, so tutors must intervene as little as possible in order to allow them to take the leading role in the session. However, tutors must be sure to motivate all students to share their views and queries. Tutors should guide students to focus the discussion on the most relevant elements of the cases. Please keep in mind that the main goal of the session is to help students to understand the underlying social and cultural issues involved in each case. Tutors should be able to discuss the following issues with their students: Statistics on unwanted pregnancy and abortion in Mexico Regulations of Mexican abortion laws throughout the country The role of poverty and gender inequities on women s social status and health conditions in Mexico Current barriers for women s access to quality abortion and post-abortion services Reasons why Mexican women more commonly resort to abortion Adolescents special needs regarding unwanted pregnancy and abortion Common misconceptions and myths regarding induced abortion in Mexico The role of quality abortion and post-abortion care to prevent the adverse effects of unsafe abortion Current methods to provide early safe abortions 33

38 The need to provide accurate information on the use of emergency contraceptive pills among women and men 34

39 COUNTRY OVERVIEW: INDIA Bride s Toilet, Amrita Sher-Gill (Indian artist of Hungarian descent, ). India is the second most populous country of the world with a population of more than 1.25 billion inhabitants in Most Indians live today in rural settings (United Nations Population Fund, 2013a). India is currently considered as a middle-income country and has become one of the fastest-growing economies. However, industrialization and economic growth has not translated into better living conditions for most Indians (McBride, 2012). See a general profile of the Indian population in Table 8. Regarding women, a complex mixture of factors contribute to their low social status and poor health conditions: high levels of social inequalities and extreme poverty, cultural norms that favours extreme discrimination and violence against women, existence of a rigid cast system, and lack of health services for vast vulnerable populations. Despite progress in educational attainment for girls, traditional gender roles and a strong opposition to sex education in schools have had a negative impact on women s sexual and reproductive health. India s maternal mortality ratio is the second highest across the world (Raj, 2011). India was the first country of the world to adopt a population policy in the early 1950s and was also one of the first countries to legalize abortion. In fact, the 1971 Medical Termination of Pregnancy Act was promulgated as part of government strategies to reduce India s fast population growth (McBride, 2012). However, modern contraceptive use in India continues to be low and unsafe abortion is a major cause of maternal mortality and morbidity. Unsafe abortion is not only a relevant public health problem in India but also an issue of social justice and human rights. Data on the prevalence of unintended/unwanted pregnancy are scarce in India, but estimates suggest that 21% of all recent births those in the past three years are not planned. The proportion of unplanned births declined along with total fertility rates, from 29% in 1993 to 22% in 2006, with significant differences among states (Singh et al, 2009b). Between 2005 and 2009, the contraceptive prevalence rate including use of modern and other methods 35

40 among women aged years was estimated at 56% (United Nations Children s Fund, 2011). Table 8: General Profile of the Indian Population, According to Data from United Nations Agencies Demographic Indicators Total population (millions), Urban population %, Population aged years %, Total fertility rate per women aged ( ) Adolescents currently married/union %, Adolescent birth rate per 1,000 women aged years, Life expectancy at birth, Males Females Infant mortality rate per 1,000 live births Under-5 years children mortality rate by sex Males Females Reproductive Health Maternal mortality ratio per 100,000 live births, Antenatal care coverage at least four times %, x Births with skill attendance %, Modern contraception prevalence rate, women aged years %, Unmet need for contraception, women aged years % Primary school attendance %, Males Females Secondary school attendance, Males Females Education - - Adult literacy rate: females as % of males, Economics and Public Health Gross National Income per capita (USD), ,530 Population bellow international poverty line of US $1.25 per day %, Share of household income %, Lowest Highest Central government expenditure allocated to health %, Use of improved drinking water sources %, Use of improved sanitation facilities %, Source of data: 1 United Nations Population Fund, 2013a; 2 United Nations Children s Fund,

41 Since the 1950 s, sterilization has been the most common used method of contraception among Indian women. Despite the government adopted a target-free policy on family planning in 1996, state and local officials continue to set sterilization targets and quotas. In fact, health providers who do not meet established quotas are at risk of losing their jobs. Moreover, sterilization can be dangerous for women due to the low quality of health services; many women are unaware about the health risks associated with sterilization and many also ignore that the method is irreversible (McBride, 2012). Early marriage continues to be common, especially in rural areas. Nearly one in every six adolescents aged years has already had a child or became pregnant, and nearly 50% of India s total fertility rate is attributed to women aged years (Kalyanwala et al, 2010). However, a recent study shows that among married women without children contraceptive use has increased to delay a first birth even in some poorly developed districts. This suggests changes in social gender norms and breaks with the tradition of demonstrating fertility soon after marriage (Collumbien et al, 2011). Surveys have shown very low awareness about emergency contraceptive pills (ECPs) among both urban and rural Indian women, as well as a poor knowledge on the method among general and specialized physicians. The availability of ECPs over-the-counter since 2005 has increased its use, but intensive media campaigns are still needed to inform people about the benefits of the method (Consortium on National Consensus for Emergency Contraception in India, 2001; Mittal, 2008; Palermo et al, 2014). Abortion Legislation Under the 1971 Medical Termination of Pregnancy Act (MTPA), Indian women may have legal access to abortion when the pregnancy threats a woman s physical or mental health, when the pregnancy is the result of rape or incest, in cases of contraceptive failure only for married women, in cases of serious fetal impairment, and because of economic and social reasons. Only physicians are authorized to perform abortions at government certified hospitals and other approved facilities during the first 20 weeks of pregnancy and the law requires a second physician s approval for pregnancies beyond 12 weeks (Santhya & Verma, 2004; Pallikadavath & Stones, 2006; Creanga et al, 2008; Singh et al, 2009b). India s liberal abortion laws, however, do not guarantee access to safe abortion services to all women. Abortion has been legal for decades but unsafe abortions far outnumber legal and safe procedures. A mixture of factors contributes to this: a lack of trained providers and certified services, especially in rural areas; scarce, inadequate and underused facilities; poorly maintained or non-functioning equipment; and legal restrictions on who can provide abortion services that exclude midlevel practitioners. (Khan et al, 1999; Ganatra & Elul, 2003; Hirve, 2004; Santhya & Verma, 2004; Ipas, 2008; Patel et al, 2009; Singh, 2009b). Millions of Indian women remain unaware that abortion services are legal. According to the Abortion Assessment Project, poor and rural women face enormous barriers to access affordable services. Government facilities, in which abortions are free of charge, are not the main providers of services: 75% of abortion-certified facilities are in the private sector and are perceived to offer much better services than those of the government (Creanga et al, 2008). 37

42 Abortion-related Facts and Statistics Despite the lack of reliable statistics on induced abortion in India, it is well known that its incidence remains quite high. According to government data, only about 1 million abortions are performed annually under the MTPA while estimates on those performed outside certified facilities vary between 2 and 6 million per year (Creanga et al, 2008). Unintended and unwanted pregnancy is the main reason for abortion among women in India and studies have shown that most women resort to abortion to limit family size or space pregnancies (Pallikadavath & Stones, 2006). Other less common reasons for abortion include contraceptive failure, pregnancies that occur soon after marriage or outside of marriage, and fetal impairment (Santhya & Verma, 2004; Collumbien et al, 2011). Cultural preference for sons rather than daughters is also among the reasons for Indian women to terminate their pregnancies. Despite that sex selection which is the practice of determining the sex of the unborn fetus and its elimination when found to be female was banned in the mid-1990s, the preference for sons contributes to the demand for abortion in settings where ultrasound technology is widely available (Santhya & Verma, 2004; Singh et al, 2009b; Bali Mahabal, 2012). In May 2011, the Forum against Sex Selection launched a campaign to eliminate sex selective abortions. The child sex ratio has sharply declined in India between 1961 and 2011, from 976 girls/1,000 boys to 914 girls/1,000 boys, which means that over a period of 50 years the sex ratio felt by 63 points. In some parts of the country, like Punjab and Haryana, there are less than 900 girls for every 1,000 boys. The child sex ratio reflects the imbalance between the number of girls and boys, indicating that the practice of sex selection along with other factors such as selective neglect of girls has led to a drastic decrease in the number of girls. Physicians may react to sex selection by denying access to abortion, which results in women seeking clandestine procedures. Pressures to engage in sex selection in a gender discriminatory environment not only directly affect women s reproductive rights and decisions with implications for their health and survival but also put women in a position where they perpetuate the low social status of girls through son preference (Bali Mahabal, 2012). Unsafe abortion-related complications and deaths remain extremely high (Ganatra & Elul, 2006). Data on abortion-related mortality in India are limited and government statistics underestimate the actual dimensions of the problem. However, unsafe abortion is the third leading cause of maternal mortality in the country (Singh et al, 2009b). According to conservative estimates the annual number of women who die after having unsafe abortions ranges from 15,000 to 20,000. Government statistics indicate that unsafe abortion accounted for 9% of maternal deaths in the late 1990s, but data from hospital The Forum against Sex Selection (FASS) was created in May 2011 in Mumbai. The goal of FASS is to renew the campaign against sex selective abortions which is responsible for the country s appallingly skewed sex ratio. FASS is a network with over 50 member including NGOs and individual activists, lawyers and academics. Complete information on the campaign can be found at FASS website: 38

43 facilities suggests that abortion-related complications account for 25-30% of maternal deaths. The risk of experiencing severe abortion-related complications and death is higher for women who seek late abortions and for women who resort to unskilled providers including single adolescents and youth, women with no access to formal education and women who live in rural areas (Santhya & Verma, 2004). It has been estimated that adolescents account for at least 6% of Indian women having abortions (Bankole et al, 1999), but hospital-based studies have shown that adolescents may represent as much as 20-30% (Chhabra, 1988). Most Indian adolescents who seek abortions are married, but delaying a first birth or spacing pregnancies are common reasons for abortion among them. In addition, married adolescents are less likely to accept post-abortion counselling and contraception. Because of rigid cultural norms, coercion from husbands and mothers-in-law often play a major role in adolescents decision making and many are forced to terminate their pregnancies against their will. Changing social norms have led to an increase of both premarital sex and unwanted pregnancies among adolescents. However, pregnancies among single adolescents often result from forced sex and a variety of factors lack of money, limited mobility, fears of stigma, and lack of support from parents or partners lead many young women to have late abortions and resort to unskilled providers (Ganatra & Hirve, 2002; Santhya et al, 2007; Kalyanwala et al, 2010). Access to modern contraception and safe abortion services remains a serious problem in India, especially for younger and single women (Collumbien et al, 2011). One important barrier for adolescents access to legal abortion is that the Indian law requires parental consent for women under-18 years; this legal regulation is further complicated because many adolescents seeking abortions are married, despite the fact that the legal age for marriage is also 18 years (Ganatra & Hirve, 2002). Manual vacuum aspiration (MVA) is used in India to terminate early pregnancies (Santhya & Verma, 2004; Creanga et al, 2008) but the use of sharp curettage is still common and contributes to the high numbers of abortion-related complications and deaths (Singh et al, 2009b). Expanding the use of MVA in India requires amending current legal regulations that impede midlevel practitioners to provide abortion services. According to the findings of one study, carried out in two poorly developed states of India, trained nurses can provide MVA as safely and effectively as physicians do (Jejeebhoy et al, 2011). Therefore, permitting nurses to perform MVA could increase the availability and quality of both abortion and postabortion care in India. In order to expand safe abortion services, the Indian Government approved the combined regimen of mifepristone and misoprostol for early medical abortion (MA) in Evidence has shown that MA is quite acceptable and increasingly requested by Indian women (Santhya & Verma, 2004; Creanga et al, 2008). However, the availability of MA is still limited in most government health facilities and few physicians are trained in its use (Winikoff & Sheldon, 2012). Permitting nurses to perform MA at primary health facilities could greatly contribute to prevent a large proportion of abortion-related complications and deaths in India (Patel et al, 2011). 39

44 CASE STUDIES: INDIA Case Study 1: Priyani Priyani is 19 years old. She is married, with her third pregnancy. She lives with her husband and two children in a rural area in a small house made of mud and hay. She was admitted at the emergency room with complaints of high fever, excessive vaginal bleeding and abdominal distension. Her last menstrual period was 4 months prior to the hospital admission. At admission Priyani s general condition was poor. She had tachycardia, hypotension and was very pale. Abdominal examination revealed a tense and distended abdomen. Priyani received 3 units of blood and antibiotics. An exploratory laparotomy was done. The peritoneal cavity was full of pus and a uterine perforation and intestinal adhesions were found. After surgery, Priyani s condition became worst. She was given two more units of blood and antibiotics. Four days later she became unconscious and died 2 hours later despite of aggressive resuscitation management. Questions for students: 1. What was the cause of Priyani s death? 2. What are the socioeconomic and gender-based cultural factors that led Priyani to death? 3. How could Priyani s death could be prevented? 4. What needs to be done to eliminate the adverse effects of unsafe abortion in India, a country where abortion is legal? Case Study 2: Susmita Susmita is a 42 years-old unmarried woman. She lives in a marginalized community in Mumbai. She has been pregnant twice and has had one induced abortion and one miscarriage. Her first abortion took place when she was 15 years old and resulted in a severe infection after a catheter was used to terminate the pregnancy. She was ostracized from her community since she was not married when she became pregnant. She runs a small food store and earns enough to pay her rent and food each month. Susmita has occasional sex intercourse with a man who lives in a village near the city. Susmita was admitted at the emergency room with complaints of excessive vaginal bleeding and abdominal distension. Her last menstrual period was 6 weeks prior to admission. She is known to be diabetic. At admission Susmita s general condition was good, though she was pale. Abdominal examination revealed generalized distension and the cervix admitted the tip of a finger. Abdominal and pelvic ultrasound showed a bilateral septic uterus. Susmita received 2 units of blood and antibiotics, as well as medications to control her diabetes. The pregnancy was at 10 weeks and a sharp curettage was done. Susmita was quite well on discharge and she was referred to a community family planning clinic. Case studies 1 to 3 were developed by Shakuntala Chhabra. Case study 4 was developed by Kamayani Bali Mahabal. 40

45 Questions for students: 1. How do you classify Susmita s health condition at hospital admission? 2. What are the socioeconomic and gender-based cultural factors that led Susmita to have an abortion? 3. What is your opinion about the treatment that she received at the hospital? What other options could be used in Susmita s case? 4. What type of contraceptive method would you prescribe to Susmita? Case Study 3: Anamika Anamika, a 14 years old girl was brought to a government hospital in Delhi by her mother due to abdominal distension. The mother informed that Anamika had suffered from some illness by the age of 3-4 years after which she became mentally retarded. She was the oldest daughter in the family, having two more male siblings. Both parents were employed in clothes factories. Anamika was admitted at a residential school for mentally retarded children, where she was in 5 th standard grade. While in school, she was raped by employees. She got pregnant but given her condition she did not realize about it. Her parents also did not know about Anamika s pregnancy until the mother brought her to the hospital for abdominal distension. After examination and ultrasound, the doctors found that the pregnancy was at 26 weeks so it was too late to authorizing an abortion. The police was informed and she was admitted in the hospital. A psychiatrist was consulted and it was decided to sterilize Anamika after the birth of the baby. Her parents left her alone in the hospital and there was nobody to look after her. In view of the problem, the mother was called to take her daughter home with the advice of bringing her back to the hospital two weeks before the date for her birth and sterilization. Questions for students: 1. What should government institutions do to protect the human and reproductive rights of girls like Anamika? 2. What are the socioeconomic and gender-based cultural factors that led to the rape of this girl? 3. Why Anamika was not a candidate for a late abortion? What are the legal restrictions in this case? 4. What is your opinion about Anamika s mother attitude? What do you think that will happened to Anamika s baby? Case Study 4: Shabana Shabana was a 26 years old Muslim woman. She lives with a large extended family with 11 brothers and their families in the Village of Sahebganj, in Muzzafarpur District in Bihar. The family is not poor and has many small scale business ventures. Shabana was pregnant for the 41

46 fifth time. She already had 4 daughters but she desperately wanted a son. She went with her husband to a famous obstetrician in the city. An ultra sound was done and Shabana was told that the fetus was a female. The pregnancy was at 13 weeks. She and her husband returned to the doctor the next day for an abortion. A sharp curettage was done and the doctor told Shabana to come back for check-up after one week. When Shabana and her husband returned home, her in-laws all came to know what they had been doing in the city. She faced much verbal abuse from them. They said that whatever the case she should not have had an abortion. She did not return to the doctor although the bleeding had not stopped. She bled for 18 days. One day she went to the pond for a bath and collapsed. The husband took her to a private hospital in the city, where the doctors told him that Shabana s condition was extremely serious. She died two hours later. This story was told by an old woman of the village. The family gave a different story, saying that Shabana was bleeding and was taken by her husband to the hospital for the treatment of a miscarriage. They did not mention anything about the ultrasound. Her husband married again 8 months after Shabana s death. Questions for students: 1. What are the socioeconomic and gender-based cultural factors that led Shabana to death? How could this death could be prevented? 2. What needs to be done to eliminate the adverse effects of unsafe abortion in India, a country where abortion is legal? 3. What is your opinion about sex-selection abortions in India? 5. What is your opinion about the treatment that this woman received? What other options could be used in Shabana s case? Tutors notes Tutors should be able to discuss the following issues with their students: The role of poverty and gender inequities on women s social status and health conditions in India. Current barriers to decrease the high incidence of unwanted pregnancies in India. The importance of proper understanding and adequate implementation of abortion laws. Statistics on unwanted pregnancy and unsafe abortion in India. Unsafe abortion as one of the major causes of maternal morbidity and mortality among Indian women. Disparities in access to abortion services according to women s age, marital status and place of residence. The role of preference for sons and sex selection on a woman s decisions to terminate a pregnancy. The need to expand the use of manual vacuum aspiration and medical abortion in all abortion facilities. The role of quality abortion and post-abortion care services to prevent the adverse effects of unsafe abortions. 42

47 The need to expand the provision of quality abortion and post-abortion services by well-trained midlevel providers. 43

48 COUNTRY OVERVIEW: SOUTH AFRICA Marcella de Boom. South African artist ( ) The Republic of South Africa (RSA) is a middle-income country with a population of 52.8 million in The population is composed of multiple tribal groups and is 79% black African. There are eleven official languages. The RSA has an increasingly urban population, currently at 62%, and very high unemployment at 23%. The RSA has vast social and health inequities rooted in its long history of apartheid and discrimination by the white immigrants primarily Dutch and English against the indigenous, mixed-race and Asian populations (World Bank South Africa, 2012). See a general profile of the South African population on Table 9. The constitution of the RSA is very progressive on women s rights and reproductive health. It outlawed discrimination on the basis of sex, gender and sexual orientation and ratified the United Nations Convention on the Elimination of All Forms of Discrimination against Women (Cooper et al, 2004; Jewkes and Abrahams, 2002). South Africa is in the top of countries in terms of the number of women participating in parliament, but there has been limited progress in bringing women s rights into practice (Björnberg, 2012). Violence against women is a major social problem in South Africa and the country has the highest rate of reported rape cases in the world 240/100,000 women in 1997, primarily occurring in low-income black African communities (Jewkes & Abrahams, 2002; Cooper et al, 2004). As a consequence, many women become pregnant because of sexual violence. This increases the need for accessible and safe abortion. The maternal mortality ratio was 310 deaths per 100,000 live births in The HIV epidemic in South Africa the largest in the world and challenges to improve the quality of maternal health care have led to a rising number of women dying during pregnancy and 44

49 childbirth. HIV infection complicated by tuberculosis and pneumonia is currently the major cause of maternal mortality, accounting for more than 40% of deaths. In addition, most births occur in health facilities but failure to follow standard protocols accounts for 38.4% of overall maternal deaths (United Nations Population Fund, 2013b). Table 9: General Profile of the South African Population, According to Data from United Nations Agencies Demographic Indicators Total population (millions), Urban population %, Population aged years %, Total fertility rate per women aged ( ) Adolescents currently married/union %, x Adolescent birth rate per 1,000 women aged years, Life expectancy at birth, Males Females Infant mortality rate per 1,000 live births Under-5 years children mortality rate by sex Males Females Reproductive Health Maternal mortality ratio per 100,000 live births, Antenatal care coverage at least four times %, Births with skill attendance %, x Modern contraception prevalence rate, women aged years %, Unmet need for contraception, women aged years % Primary school attendance %, Males Females Secondary school attendance, Males Females Education Adult literacy rate: females as % of males, Economics and Public Health Gross National Income per capita (USD), ,610 Population bellow international poverty line of US $1.25 per day %, Share of household income %, Lowest Highest Central government expenditure allocated to health %, Use of improved drinking water sources %, Use of improved sanitation facilities %, Source of data: 1 United Nations Population Fund, 2013a; 2 United Nations Children s Fund,

50 Access to contraception in South Africa has improved and 60% of women use modern contraception including injectables, pills, male condoms and sterilization. However, 14% of women still have an unmet need for contraception. The total fertility rate declined from 2.92 children per woman in 2001 to 2.35 in 2011, and is among the lowest in Africa. The adolescent birth rate is 54 per 1,000 women aged 15-19, which is higher than the global average of 49 (United Nations Population Fund, 2013). Despite an increasing use of modern contraception, around one quarter of births is mistimed or unwanted. More than 40% of all births to women under-20 years are reported as mistimed (Department of Health, 2007). Emergency contraceptive pills (ECPs) are available at no cost in government health facilities and also over-the-counter in pharmacies across the country. However, knowledge about ECPs availability is poor among women and men. Reasons for this are providers concerns about women discontinuing more reliable contraceptive methods in favor of using ECPs and concerns that the method causes abortions. Few community-based educational programs provide information about the benefits of ECPs (Department of Health, 2007). Abortion Legislation In South Africa, the Choice on Termination of Pregnancy Act (TOP Act) was passed in The law ushered in a new era in addressing the plight of women. This Act was passed to reduce and ultimately eradicate the burden of morbidity and mortality resulting from unsafe abortion and to enable women to exercise their sexual and reproductive rights. Abortion is permitted on request through 12 weeks of pregnancy, and up to 20 weeks when the pregnancy presents risks to the woman s social, economic or psychological well-being. After 20 weeks of pregnancy, abortion is permitted on limited grounds including rape, grave risk for the life of the woman and fetal impairment (Ipas & IHCAR, 2002). The TOP Act enables women from the age of 12 to decide on the termination of a pregnancy during the first trimester of pregnancy and without the consent of their partners or parents. This regulation had immediate positive effects on morbidity and mortality, especially among younger women (Elhers et al, 2000; Elhers, 2003; Potgieter & Andrews, 2004; Jewkes et al, 2005; Benson et al, 2011). Before 1996 abortion was only permitted to save the life of the woman, so there was little resistance to the law from Christian anti-abortion groups. After the passing of the TOP Act, some organizations the Planned Parenthood Association of South Africa, the Reproductive Health Research Unit and the Reproductive Rights Alliance conducted values clarification workshops aimed at educating health care professionals about the provisions of the new Act, encouraging them not to be judgmental when providing abortion services and to treat women with dignity and respect (Ipas & IHCAR, 2002; Dickson-Tetteh & Billings 2002; Benson et al, 2011). The Choice on Termination of Pregnancy Amendment Act of 2003 allows any health facility with a 24-hour maternity service to provide first trimester abortion services without a health ministry approval. According to this Act, midwives and nurses, especially those who work at the primary care level and complete the training program, can perform abortions up to 12 weeks of pregnancy using both manual vacuum aspiration and medical abortion. Second 46

51 trimester services are provided by trained physicians (Cooper et al, 2004; Warriner et al, 2006; Blanchard et al, 2006; Berer, 2009). Abortion Related Issues and Statistics Before the liberalization of abortion laws about 1,000 legal abortions were performed each year in the country, mostly to middle and upper class women. Annually, an estimated 200,000 unsafe abortions occurred among poor disadvantaged women causing 45,000 hospital admissions and over 400 deaths from septic abortions (Dickson et al, 2003). After the TOP Act was passed abortion-related morbidity declined to one half and deaths dropped 91% between 1994 and 2001 (Jewkes et al, 2005). In 1994, the estimated rate of unsafe abortion-related complications was 32.6 deaths per 1,000 abortions, declining to 0.8% in Between 2005 and 2007, only 3.3% of maternal deaths were attributed to unsafe abortions (Benson et al, 2011; Trueman & Magwentshu, 2013). Midlevel providers are essential for South Africa s health system and the successful implementation of the TOP Act depends on increasing the number of trained midwives and nurses to ensure the full provision of services at designated facilities. All abortion facilities are certified by the National Department of Health. By the year 2000, 289 hospitals and clinics were certified to provide abortions but only one fifth had well trained personnel; this improved by 2003, when 62% of facilities had trained midlevel staff (Potgieter et al, 2004; Buchmann, et al, 2007). In 2006, all community health clinics throughout the country were authorized to provide abortion services (Benson et al, 2011). In 1998, the government established the Midwifery Abortion Care Training Programme. The Reproductive Health Research Unit was responsible for coordinating the program, which was carried out through a partnership with the Maternal, Child and Women s Health Directorate of the Department of Health, the provincial health departments and universities. An international non-government organization collaborated in this process including the assessment of midwives and nurses skills to provide abortion care. The aim of the program was to expand the capacity of government facilities to offer high quality abortion care and to provide comprehensive reproductive health services (Dickson-Tetteh & Billings, 2002). Today, 76% of abortions are performed within public health facilities by trained midwives and nurses (Trueman & Magwentshu, 2013). According to a recent critical review, South Africa has one of the most progressive and developed government systems for the provision of abortion care in Africa. However, since the approval of the TOP Act conservative groups with strong political influence have not stopped in launching aggressive campaigns against abortion and hostility towards its practice has risen. In recent years, the government has made concessions to these groups and inequities in the provision of safe services persist. Currently, major barriers for universal access to abortion include an abusive use of conscientious objections by physicians to perform second trimester abortions; heavy workloads for midwives and nurses that provide early abortion services at primary health facilities; financial constraints; community-based stigma and poor awareness about abortion s legality. The lack of political will to defend the TOP Act threatens to turn back relevant achievements made during the first ten years after its approval and has left many women especially poor, young and rural women without access to safe procedures (Trueman & Magwentshu, 2013). 47

52 CASE STUDIES: SOUTH AFRICA Case Study 1: Moipone Moipone, aged 41 years, and Mogale, aged 47 years, had six children aged between 19 years and 2. Mogale lost his job three years ago and has not been able to find another one. The family relied on Moipone s salary from work as a general assistant at a local clinic in Mahwelereng. Moipone was still breastfeeding her two year old daughter and was not using any contraceptive method. She believed that she had enough children and could not become pregnant while breastfeeding. One morning she felt exhausted and could not continue with her work. A nurse then did a physical assessment including a pregnancy test, which indicated that she was 22 weeks pregnant. This came as a surprise to her and when she told to her husband, he was disappointed and responded that the only remedy would be to terminate the pregnancy as they would not afford to raise another child. Three of their elder children had dropped out of school and were just doing household chores. Moipone was worried but she finally went to the hospital to request a termination of pregnancy. Her pregnancy was 24 weeks and the nurse at the unit explained to her that it was against the law to terminate a pregnancy after 12 weeks. Moipone admitted that she could also feel the fetal movements but was scared of her husband who was adamant that she should terminate the pregnancy. The nurse advised her to attend antenatal care. After another week, Mogale insisted that his wife should terminate the pregnancy and escorted her to a back-yard midwife, adding that the process would be done immediately without other people knowing about it. The procedure was done at the backyard place with a cost of R450 ($55 USD). Moipone bled severely and had to be transported to the hospital by taxi. She was treated for two weeks and was finally discharged. Although she survived, Moipone is now being treated for a vesico-vaginal fistula. Questions for Students 1. What would you recommend to Moipone and her husband about contraception? 2. What information would you provide about the couple s legal rights to termination of pregnancy? 3. What are your perceptions about abortion? Should the termination of pregnancy be used as a contraceptive measure? Justify your statements. 4. How would you discuss Moipone s options, including the role of backyard midwives? Tutors Notes Tutors should be able to discuss the following issues with their students: Consistent contraceptive use Current South African laws governing the termination of pregnancy Access to legalized termination of pregnancy services Early identification of signs and symptoms of pregnancy Dangers of illegal terminations of pregnancy These case studies were developed by Todd Maja. 48

53 Medical care after a termination of pregnancy Issues to be highlighted in the discussion of the case Failure to use contraception may lead to an unintended pregnancy Unintended pregnancy increases women s risk for unsafe TOP Women s powerlessness regarding the control of their own bodies Insistence of the husband to terminate the pregnancy even in late stages of gestation Unsafe TOP often leads to complications and even death Case 2: Raisibe s pregnancy problems Raisibe had a child when she was 16 years old. Her parents were disappointed as they were well known and respected by their community. She went back to school and continued in Grade 12. Before she could write her final examination, she became pregnant again when her baby was 1 year 3 months old. She was afraid to tell her parents that she was pregnant again. She talked about her situation to a friend, who advised her to terminate the pregnancy under the new law of the country. She went to the neighboring hospital which was designated to provide termination of pregnancies (TOP). Raisibe obtained the Act online and was relieved to learn that she did not need her parents nor partner s permission to terminate her pregnancy. She did not inform her parents that her pregnancy had terminated successfully. The nurse gave Raisibe a thorough lesson about postabortion. Raisibe recovered without her parents noticing what had happened although she regretted and had guilt feelings. Not long after, Raisibe met an older man who promised her all the material things that she needed. She was using the pill but had weight problems and discontinued its use without informing the nurse at the clinic. She depended on male condoms which were used inconsistently as she was afraid to remind her partner to use a condom. She became pregnant 6 months into the affair, and one year after her last abortion. She quickly decided to terminate the pregnancy and went to another health centre due to fear of being noticed. One of her neighbors who worked at the centre saw Raisibe and was informed that she had a TOP. Raisibe s mother ultimately heard about her daughter s abortion and was further disappointed when Raisibe left school without completing Grade 12 because her neighbors and classmates were gossiping about her abortion. This caused more friction in the family. Questions for students 1. Why are adolescents at greater risk for pregnancy? 2. What information does Raisibe need regarding protection to avoid an unwanted pregnancy? 3. Could Raisibe s pregnancies have been prevented? 4. Should you involve Raisibe s family? Tutors Notes 49

54 Tutors should be able to discuss the following issues with their students: Importance of preventing risky sexual behaviors that leads to unplanned pregnancy among adolescents. Benefits of adequate, consistent contraceptive use among adolescents Regulations of current South African laws regarding adolescents and importance of proper understanding and correct implementation of laws Importance of assuring health providers confidentiality to all women having abortions Issues to be highlighted in the discussion of the case Poor communication between parents and children regarding sexuality issues Poor information about sexuality and contraception among parents and adolescents Vulnerability of young girls to risky sexual behaviors Powerlessness and lack of skills to make informed decisions to avoid unwanted pregnancies and sexually transmitted infections, including HIV Case 3: Tumelo Tumelo, a 36 year old woman, had a 2 year old son and then realized that she was pregnant. She did not inform her husband Tiego as their relations were strained and she was not in a position to bring up a child alone. She concluded that the termination of her pregnancy would be the best solution. She consulted a termination of pregnancy unit at the neighboring health facility, where she was informed that her pregnancy was at 10 weeks. During the counseling session, the nurse listened carefully to Tumelo s reasons to terminate her pregnancy. Tumelo felt much better after the counseling and told the nurse that she would come back after thinking about her situation. One week later, Tumelo remembered the nurse s supporting words about respecting her decision. But she finally decided to continue her pregnancy and went to antenatal care at the same health care facility. Tumelo was informed of her good progress regarding the pregnancy. Then she informed Tiego about the pregnancy, who accused her of telling him when it was already advanced. He said that the pregnancy was not his, so Tumelo should leave their home. She remained calm and as time passed Tiego became apologetic and more caring. He even said that the new baby would bring happiness to the family and that the baby s name would be Kgotso, which means peace. Question for Students: What should be done by health professionals to help women to make their own decisions regarding an unplanned pregnancy? How can women be guided to use contraceptives consistently to avoid unplanned pregnancies? What kind of information will you give women during pre-termination counseling to make their own decisions? What lessons can be learnt from Tumelo s case? 50

55 Tutor s notes Tutors should be able to discuss the following issues with their students: Consistent use of contraceptives Involvement of men in promoting reproductive health Early identification of signs and symptoms of pregnancy Adequate counseling Informed decisions by women regarding abortion Issues to be highlighted in the discussion of the case Importance of correct and consistent use of contraceptives to avoid unplanned and unwanted pregnancies. Communication with partner about contraception and other sexual and reproductive health issues. Supporting women to make their own decisions about their pregnancies. Encouraging the use of emergency contraceptive pills in cases of unprotected sex. 51

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68 United Nations General Assembly. (1994). Program of Action of the International Conference on Population and Development. New York: UN. United Nations General Assembly. (1999). Key actions for the future implementation of the program of action of the ICPD. New York: UN. United Nations Population Fund. (2000). State of world population 2000: Lives together, worlds apart: men and women in a time of change. New York: UNFPA. United Nations Population Fund. (2002). State of world population 2002: People, poverty and possibilities. New York: UNFPA. United Nations Population Fund. (2003). State of world population 2003: Making 1 billion counts. Investing in adolescents health and rights. New York: UNFPA. United Nations Population Fund. (2004). State of world population 2004: The Cairo consensus at ten. Population, reproductive health and the global effort to end poverty. New York: UNFPA. United Nations Population Fund. (2005). State of world population 2005: The promise of equality. Gender equality, reproductive health and the Millennium Development Goals. New York: UNFPA. United Nations Population Fund. (2010). State of world population From conflict and crisis to renewal: generations of change. New York: UNFPA. United Nations Population Fund. (2013a). State of world population Motherhood in childhood. Facing the challenge of adolescent pregnancy. New York: UNFPA. United Nations Population Fund. (2013b). South Africa annual report Pretoria: UNFPA South Africa Country Office. Van Dick MG, Arellano LJ, Aranguren AG, Toriz AA, Krumholz A & Yam EA. (2011). Women s experiences with legal abortion in Mexico City: A qualitative study. Studies in Family Planning, 42(3): Vlassof M, Walker D, Shearer J, Newlands D & Singh S. (2009). Estimates of health care system costs of unsafe abortion in Africa and Latin America. International Perspectives on Sexual and Reproductive Health, 35(3): Warriner IK. (2006). Unsafe abortion: An overview of priorities and needs. In: Warriner IK & Shah IH (Editors). Preventing unsafe abortion and its consequences. Priorities for research and action. New York: Guttmacher Institute. Warriner IK, Meirik O, Hoffman M, Morroni C, Harries J, My Huong NT, Vy ND & Seuc AH. (2006). Rates of complications in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: A randomized controlled equivalence trial. Lancet, 368:

69 Warriner IK, Wang D, My Huong NT, Thapa K, Tamang A, Shah I, Baird DT & Merik O. (2011). Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomized controlled equivalence trial in Nepal. Lancet, 377: Weeks A & Faúndes A. (2007). Misoprostol in obstetrics and gynecology. International Journal of Gynecology and Obstetrics, 99: S156-S197. Wilson KS, García SG, Díaz C, Villalobos A, Rodríguez JV, Smith PS & Burks C. (2011). Public opinion on abortion in Mexico City after the landmark reform. Studies in family Planning, 42(3): Winikoff B. & Sheldon W. Use of medicines changing the face of abortion. Comment. International Perspectives on Sexual and Reproductive Health, 38(3): World Bank South Africa Country webpage. Accessed July 30, World Health Organization. (1992). The prevention and management of unsafe abortion. Report of a technical working group. Geneva: WHO/MSM. World Health Organization. (2005). Essential medicines. WHO model list (revised March 2005). Explanatory notes. 14 th edition. Geneva: WHO. World Health Organization. (2007). Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion and associated mortality in th Edition, Geneva: WHO. World Health Organization. (2010). Trends in maternal mortality: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: WHO. World Health Organization. (2011a). Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion and associated mortality in th Edition, Geneva: WHO. World Health Organization. (2011b). WHO guidelines on preventing early pregnancy and poor reproductive health outcomes among adolescents in developing countries. Geneva: WHO. World Health Organization. (2012). Safe abortion: Technical and policy guidance for health systems. 2nd Edition, Geneva: WHO. World Health Organization. (2013). Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO / London School of Hygiene and Tropical Medicine / South African Medical Research Council. Yarnall J, Swica Y & Winikoff B. (2009). Non-physician clinicians can safely provide first trimester medical abortion. Reproductive Health Matters, 17(33):

70 Zamberlin N, Romero M & Ramos S. (2012). Latin American women experiences with medical abortion in settings where abortion is legally restricted. Reproductive Health, 9:

71 APPENDIX I: ADDITIONAL SUGGESTED READINGS Association of Reproductive Health Professionals. (2000). Reproductive health model curriculum. Second edition. Washington: ARHP. Association of Reproductive Health Professionals. (2008). Position statement on emergency contraception. Washington, DC: ARHP. Crane BB & Hord-Smith C. (2006). Access to safe abortion: An essential strategy for achieving the Millennium Development Goals to improve maternal health, promote gender equality, and reduce poverty. Chapel Hill, NC: Ipas / Millennium Project. Center for Reproductive Rights. (2004). Emergency contraception (EC): An affirmative agenda to improve access. New York: CRR. De Bruyn M. (2002). Human rights, unwanted pregnancy & abortion related care: Reference information and illustrative cases. Chapel Hill, NC: Ipas. De Bruyn M Violence, pregnancy and abortion. Issues of women s rights and public health. A review of worldwide data and resources for action. Chapel Hill, NC: Ipas. Dixon D. (2001). Preventing unsafe abortion: A call to action for health providers. Chapel Hill, NC: Ipas. Freedman L, Landy U, Darney P & Steinauer J. (2010). Obstacles to the integration of abortion into obstetrics and gynecology practice. Perspectives on Sexual and Reproductive Health, 42(3): Guttmacher Institute. (1998). Into a new world: Young women s sexual and reproductive lives. New York: AGI. Hessini L. (2004). Advancing reproductive health as a human right: progress toward safe abortion care in selected Asian countries since ICPD. Chapel Hill, NC: Ipas. Hord C, Baird T & Billings D. (1999). Advancing the role of midlevel providers in abortion and post-abortion care. Issues in Abortion Care 6. Chapel Hill, NC, USA: Ipas. Hyman A. (2003). What is woman-centered comprehensive abortion care? Chapel Hill, NC, USA: Ipas. International Planned Parenthood Association & Forum on Marriage and the Rights of Women and Girls. (2006). Ending child marriage. A guide for global policy action. London: IPPF. International Planned Parenthood Federation. (2006). Death and denial: Unsafe abortion and poverty. London: IPPF. 67

72 Ipas. (2009). Misoprostol and medical abortion in Africa (fact sheet). Chapel Hill, NC, USA: Ipas. Joffe C. (2006). Morality and the abortion provider (Editorial). Contraception, 74, Radhakrishna A, Gringle RE & Greenslade FC. (1997). Identifying the intersection: adolescents, unwanted pregnancy, HIV / AIDS and unsafe abortion. Chapel Hill, NC, USA: Ipas. Rodríguez P & Shields WC. (2005). Religion and medicine (Editorial). Contraception, 71, Stewart FH, Wells E, Flinn SK & Weitz TA. (2001). Early medical abortion: Issues for practice. San Francisco: Center for Reproductive Health Research & Policy, University of California. Turner K, Wegs C & Randall-David B. (2003). Effective training in reproductive health: Course design and delivery. Trainer s manual. Chapel Hill, NC, USA: Ipas. Villarreal J. (1989). Commentary on unwanted pregnancy, induced abortion and professional ethics: a concerned physician s point of view. International Journal of Gynaecology and Obstetrics, 3 (Sup.): Warriner IK & Shah IH. (2006). Preventing unsafe abortion and its consequences. Priorities for action. New York: Guttmacher Institute. Wolf M. (2002). Deciding women s lives are worth saving: Expanding the role of midlevel professionals. Issues in Abortion Care, number 7. Chapel Hill, NC: Ipas/IHCAR. 68

73 APPENDIX II: RECOMMENDED WEBSITES Advocates for Youth American Medical Women s Association Association of Professors of Gynecology and Obstetrics Association of Reproductive Health Professionals Center for Reproductive Health Research & Policy Center for Reproductive Rights Centro de Información en Reproducción Elegida Education for Choice: Supporting Young People s Right to Informed Choice on Abortion Engender Health Family Care International Family Health International Feminist Majority Foundation Forum against Sex Selection (FASS, India) Global Health Council Grupo de Información en Reproducción Elegida (México) Guttmacher Institute Gynuity Health Projects 69

74 Human Rights Watch Ibis Reproductive Health International Center for Research on Women International Consortium for Emergency Contraception International Consortium for Medical Abortion International Federation of Gynecology and Obstetrics International Women s Health Coalition Ipas Ipas Ideas, International Data for Evaluation of Abortion Services Latin American and Caribbean Committee for the Defense of Women s Rights María, Fondo de Aborto para la Justicia Social (México) Medical Abortion Consortium Medical Students for Choice National Abortion Federation National Association of Nurse Practitioners in Women s Health Pacific Institute for Women s Health Pan American Health Organization Pathfinder International 70

75 Postabortion Care Consortium Physicians for Reproductive Choice and Health Planned Parenthood Federation of America Population Action International Population Council Population Reference Bureau Red de Salud de las Mujeres Latinoamericanas y del Caribe Reproductive Health Gateway Reproductive Health Outlook Safe Motherhood Initiative The Access Project United Nations United Nations Population Fund, Reproductive Health Women Care Global Women s Global Network for Reproductive Rights Women s Health Project Women on Waves Women Watch 71

76 World Health Organization, Reproductive Health and Research World Health Organization, Gender and Women s Health 72

77 PRE AND POST SELF ASSESSMENT FORM Please read each statement carefully and indicate your response by marking (X) in the appropriate column: agree, not sure, or disagree Statement Agree Not sure Disagree 1 Unwanted pregnancy is the most common cause of induced abortions 2 The only way to prevent unwanted pregnancies is by providing women with modern contraceptive methods 3 Unsafe abortion is a major cause of maternal mortality in developing countries 4 Banning abortion is the best way to avoid its practice 5 All women who have induced abortions experience serious psychiatric problems 6 Induced abortion increases a woman s risk for breast cancer 7 Emergency contraceptive pills cause abortions 8 Sharp curettage is the best option for treating women with abortionrelated complications 9 Girls who have been raped should have the right to have an abortion 10 Abortion is morally wrong and should not be permitted under any grounds 11 Health providers should always discourage women to have abortions 12 All women should have the right to terminate an unwanted pregnancy 13 An adolescent must have her parents consent to have an abortion 14 All unwanted pregnancies can be prevented 15 Most unsafe abortion-related deaths occur among poor women 16 Only physicians should be trained to provide abortions services 17 Nurses and midwives should not provide abortion services 18 Women who have abortions should be in prison 19 Physicians who provide abortions should be in prison 20 Adolescents should not use emergency contraceptive pills 73