The acceptability and accessibility of safe abortion - a literature review.

80 Pages·2016·1.03 MB·English

KNOWLEDGE PROGRAMME | 2014

MARIA DE BRUYN

THE ACCEPTABILITY
AND ACCESSIBILITY
OF SAFE ABORTION
A Literature Review
Colophon

First published in December 2014 by the Knowledge Programme

Humanist Institute for Co-operation with Developing Countries
P.O. Box 85565 | 2508 CG The Hague | The Netherlands
www.hivos.net

This review of recent literature was commissioned by Hivos and Rutgers WPF. Both organisations wanted to develop a better
insight into available evidence of effective strategies in the promotion of acceptance of and access to safe abortion. The study
was carried out by Maria de Bruyn.

Design: Tangerine – Design & communicatie advies, Rotterdam, The Netherlands

The publisher encourages fair use of this material provided proper citation is made

This work is licensed under the Creative Commons Attribution-Share alike works 3.0 Netherlands License. To view a copy of
this licens, visit http://creativecommons.org/licences/by-sa/3.0/nl/ or send a letter to Creative Commons, 171 Second Street,
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The Acceptability and
Accessibility of Safe
Abortion

A literature review
Factors in play, research and actions undertaken, research
and action for the coming years
Table of Contents

Preface 5
Abbreviations 6
Executive Summary 8
Introduction 14
1.The Magnitude of Abortion and Issues of Safety 15
2. Socio-economic costs of unsafe abortion 18
3. Laws, policies and human rights 22
4. Abortion acceptability and accessibility 31
5. Lessons learned 46
6. What is needed: research and action 48

Appendix 1
Publications and websites sharing women’s voices
about abortion 54

Appendix 2
NGO/CSO networks collaborating on actions to increase
safe abortion access 57

References 59

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Preface

This paper on the acceptability of abortion and factors influencing girls’ and women’s access to safe
abortion was commissioned by Hivos to serve as resource material for organizations and individuals
who wish to work on increasing access to safe abortion care. The purpose of the commission was to
answer the following questions:

(cid:1) What is the current magnitude and incidence of unsafe abortion generally?
(cid:1) Which safe abortion methods are currently available?
(cid:1) What are the socio-economic costs of unsafe abortions?
(cid:1) Which key factors, barriers as well as enablers, have been identified as influencing ideas about,
acceptability of, and access to, safe abortion?
(cid:1) What do we know about effective strategies to influence opinions and ideas concerning safe
abortion and to promote acceptability and accessibility?
(cid:1) What are key knowledge gaps and research priorities in this area?

To address these questions, a review was carried out of literature published mainly between 2010
and 2014. Much of the resource material was obtained through a search on the PubMed database
using the keywords “abortion and access”, “abortion and success”, “abortion and stigma”, “abortion
and cost” and “abortion and accompaniment”. These search terms called up duplicates of relevant
literature, indicating that important publications were being included.

In addition, Internet searches were done to look for specific topics (e.g., revision of the abortion law in
Uruguay) and to examine publications of key organizations involved in promoting and prohibiting
access to safe abortion in developing countries.

The searches delivered a wealth of information. Due to time and space constraints, not all of the
relevant literature was assessed and some priority was given to documentation from 2013 and 2014.
In addition, some topics were left largely aside (post-abortion care, contraceptive counselling) in
order to focus on safe abortion. Topics that have been increasingly addressed in recent years
(human rights, stigma, conscientious objection, safe abortion outside the legal sphere) were covered
in more depth.

The commission requested an extensive reference list, which has been accommodated. The
references provide numerous resources for readers who would wish to delve more deeply into
various aspects of abortion acceptability and accessibility.

Maria de Bruyn
Abbreviations

CO Conscientious objection
CSO Civil society organization
D&C Dilatation and curettage
D&E Dilatation and evacuation
EU European Union
EVA Electric vacuum aspiration
FIGO International Federation of Gynecology and Obstetrics
GDP Gross domestic product
HCP Health-care provider
ICPD International Conference on Population and Development
LGBTI Lesbian, gay, bisexual, transgender and intersex/inquiring persons
MMM Maternal mortality and morbidity
MVA Manual vacuum aspiration
NGO Non-governmental organization
NWHN Namibian Women’s Health Network
OHCHR Office of the High Commissioner on Human Rights
PAC Post-abortion care
SRHR Sexual and reproductive health and rights
TOP Termination of pregnancy
UN United Nations
UNDP United Nations Development Programme
US United States of America
VC Values clarification
WHO World Health Organization

Executive Summary

Some health issues with which we deal on a daily basis are generally accepted as matters of
importance for which we must ensure appropriate care and treatment. Examples include having high
cholesterol, living with diabetes and providing new-borns with proper nutrition. Other health issues,
however, generate disagreement, dissonance and sometimes denial of care.

Such a health issue which is fraught with controversy, conflict and condemnation is termination of
pregnancy. One reason that abortion evokes strong emotions and reactions is that it reflects
women’s need to control their own bodies, a human rights principle that contravenes dominant
patriarchal attitudes and practices and, in some cases, cultural beliefs.

But many other sensitive issues associated with abortion also play a role in impeding women’s
access to safe and legal pregnancy termination. This paper examines those sensitive issues, as well
as other factors that hinder or facilitate the acceptability of safe abortion and girls’ and women’s
access to it.

The magnitude and safety of abortion
Even if all girls and women had access to effective contraception, circumstances would still arise in
which a pregnancy is — or becomes — unwanted and the woman in question will feel the need to
end it. Societies should therefore ensure that all women can voluntarily terminate pregnancies in a
safe manner, including adolescents and young women, women living with HIV, women living with
disabilities, lesbian women, refugees, migrants, indigenous women, and other women in positions of
vulnerability.

Some decades ago, only a few methods using medical instruments (surgical abortion) were practised
in health-care settings to terminate pregnancies safely, including dilatation and curettage (D&C) and
dilatation and evacuation (D&E). Today more methods are available, including surgical methods of
manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA) and abortions using
pharmacological drugs such as mifepristone and misoprostol or misoprostol alone. D&C is no longer
recommended for abortion care and research continues on other abortion methods and post-abortion
care (PAC) with a view to lowering expenses, improving the safety and speed of procedures,
decreasing potential adverse effects and contributing to the acceptability of methods.

Between 1995 and 2003, the number of abortions estimated to take place yearly for every 1,000
women aged 15-44 years (the abortion rate) decreased from 35 to 29. From 2003 to 2008 (the last
year for which estimates are currently available), the rate remained at 28. This is equivalent to 21.6
million abortions per year.

The World Health Organization (WHO) states that unsafe abortions involve pregnancies terminated
by persons who lack the necessary skills to ensure safety, procedures carried out in environments
not conforming to minimal medical standards, or both situations. In 2012, WHO and the Guttmacher
Institute reported that 56% of abortions in developing countries were unsafe; 98% of all unsafe
abortions occurred in developing countries. The youngest group for whom there are estimates, girls
aged 15-19 years, accounted for 22% of unsafe abortions in Africa, 16% in Latin America and the
Caribbean, and 11% in Asia (excluding Eastern Asia).

In 2008, WHO estimated that some 47,000 girls and women died annually due to unsafe abortions.
Available data suggest that some 5 million women are hospitalized yearly due to abortion-related
complications, some of which are quite severe and lead to long-lasting or permanent consequences.

Socio-economic costs of unsafe abortions
Unsafe abortion carries avoidable and preventable socio-economic costs at various social levels: for
individual girls and women and their households and families; for health-care systems; and for the
broader development of communities and societies.

Such costs include morbidity and mortality for the women involved, effects on their personal well-
being (stigmatization, criminalization and attendant costs related to trials, incarceration and other
penalties), and effects for their families and households (days of productivity lost, financial losses,
negative impacts on children, etc.). Some of the social costs also affect health-care providers
(HCPs), including the impact of stigma and criminalization.

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Direct medical costs (equipment, drugs), personnel and overhead costs affect health systems and
national health budgets, with research indicating that provision of safe abortion care and elimination
of all unsafe abortions would ultimately save countries money and enable girls and women to better
contribute to their own and social development. For this reason, pro-choice advocates are making
the case that the new international post-2015 development framework should explicitly mention safe
legal abortion.

Laws, policies and human rights
Because the legal status of abortion is so important for acceptability and accessibility, both anti-
abortion and pro-choice advocates expend tremendous efforts on influencing laws, regulations and
policies.

Anti-abortion groups have primarily worked on constitutional abortion bans and adoption of restrictive
laws and policies; more recently, they have also entered the international human rights arenas in an
effort to influence international law and development policies. On the pro-choice side, recent efforts
have often employed one of three focus areas: contributing to liberalization of laws and enforcement
of legal indications for abortion, promoting abortion as an issue of human rights in international policy
and law, and decriminalization of abortion.

Advocates in Africa are fortunate in that this is the only world region with a human rights treaty which
explicitly mentions abortion. The Protocol to the African Charter on Human and Peoples’ Rights on
the Rights of Women in Africa (the Maputo Protocol) addresses women’s need for safe abortion in
cases of “sexual assault, rape, incest, and where the continued pregnancy endangers the mental and
physical health of the mother or the life of the mother or the foetus.”

More than 30 governments have adopted more liberal laws since 1994, allowing legal procedures for
a greater number of indications than before. No States in Africa adopted (more) restrictions. Latin
America and the Caribbean is the only region where more than one government further restricted
access to abortion at the national level.

It should be noted that not only abortion laws per se may be invoked to penalize persons involved in
abortions. Women and others involved in abortions (HCPs, family members) have been charged with
homicide, aggravated homicide, criminal murder, manslaughter, foetal murder and child
endangerment. Advocates concerned with abortion laws and criminalization should therefore also
examine other national laws to determine their possible impact if used by anti-abortion advocates to
pursue legal cases against women and HCPs.

Abortion acceptability and accessibility
For this overview, abortion acceptability is defined as agreement that safe abortion is a legitimate
health-care need which governments are obliged to fulfil for girls and women who voluntarily choose
this during the course of pregnancy. It may also refer to women’s and HCPs’ satisfaction with, and
willingness to use, specific abortion methods. Abortion accessibility refers to the availability of means
to carry out abortions in a timely and safe manner. Acceptability and accessibility are also both
important for ensuring that women can obtain PAC in a timely, safe and satisfactory manner.

A multitude of factors have an impact on the acceptability and accessibility of abortion care. Some of
these may have either a negative or positive impact. For example, gatekeepers may either facilitate
or block women’s decisions and ability to obtain safe abortions.

Factors that affect both acceptability and accessibility include:

Knowledge and information about abortion legality
HCPs, law enforcement officials and the general public often lack knowledge about the legality of
abortion; when laws are liberalized, it may take quite some time for people to learn about the new
conditions under which abortion is legal. Governments may also be remiss in ensuring that HCPs
and others have guidance on implementing abortion care and some anti-abortion advocates may
misinform women, preventing them from obtaining legal services.

Gatekeepers
are individuals who can influence a woman’s reproductive decisions and ability to implement her
decisions. These people — partners, in-laws, parents, siblings, friends, teachers, employers —
may serve as either enablers or barriers to women’s reproductive choice. When women perceive
that certain people in their social networks will prevent them from ending a pregnancy, they may
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keep their desire for an abortion secret or involve others in their decision-making whom they feel
will be more apt to help rather than control the decision. While anti-abortion groups have targeted
men in their advocacy, pro-choice advocates have done much less to involve men

Association of abortion with other sensitive issues is common
such as lack of protection of human life; foetal and baby dumping; child abuse; foetal pain and
infanticide; gender-based discrimination; coerced abortion; discrimination of disabled persons;
coercive population control; and profiteering in the health sector. Acknowledging and addressing
some of the sensitive issues that trouble community members — both through mass media and
targeted smaller-group interventions — could perhaps help promote acceptance, or at least more
tolerance for, safe abortion.

Stigmatization of abortion
is said to be associated with presumed transgression of widely endorsed social norms: women
should engage in sexuality for the purpose of procreation, should fulfil the normative role of
motherhood, and should express the feminine ideal by nurturing family members. Abortion stigma
has multiple negative effects for women and HCPs (e.g., isolation, discrimination, harassment and
violence, criminal prosecution and internalization of such stigma). Pro-choice efforts to counter-act
stigma include an intensified research agenda on stigma and abortion, mass media and
community work to highlight the consequences of unsafe abortions, campaigns to “give a face” to
those who undergo and support safe abortion, accompaniment and support programmes for
women undergoing abortions, and mentoring and support programmes for HCPs.

Collaborative action to strengthen advocacy for safe abortion
is supported through dedicated listservs and joint actions at the international and national levels.

Numerous factors can influence the accessibility of safe abortions:

Service qualities and characteristics
Even where legal abortions are permitted for several indications, women still have unsafe abortions
or carry unwanted pregnancies to term because of administrative and logistical inadequacies of
abortion facilities and services. These include: sparse geographical distribution, lack of privacy and
confidentiality, long waiting times, unnecessary authorization requirements and unaffordable costs.
Poor and stigmatizing attitudes on the part of HCPs involved in abortion care also drive women
away from legal services.

The availability of legal abortion
can be increased by eliminating unnecessary requirements, expanding the number and range of
HCPs and facilities involved, and increasing the range and number of venues where women can
obtain factual information and good-quality care. Measures used involve: training (including values
clarification exercises); task shifting; dissemination of protocols and guidelines, and monitoring of
their application; and ensuring continuous supplies of needed equipment and drugs.

Strategies to enable women to self-induce medical abortion
are promoted as a means of providing safe abortion care to women living in areas with severe
abortion restrictions and/or to accommodate the needs of women who cannot or do not want to use
legal facility-based care. This option is said to be indistinguishable from a miscarriage (if the pills
are administered by mouth rather than vaginally). This is important in case a woman needs to seek
PAC since she might risk being reported to the police for illegal abortion if HCPS find remnants of
the drug in her vagina. Various models are being assessed in this regard, including telemedicine
using the Internet, hotlines and community-based programmes. Research is investigating the
strengths and weaknesses of these programmes.

Conscientious objection (CO)
is a serious obstacle to women’s access to safe abortion, and it is now invoked both by individual
HCPs as well as medical facilities. Courts have confirmed that CO may not be used to prevent
patients from receiving proper medical care; objectors are obliged to refer patients in a timely
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