Abortion: Abortion: What Is Happening?What Is Happening?

************************Marge BererMarge Berer

Editor, Reproductive Health MattersEditor, Reproductive Health Matters

Chair, International Consortium for Chair, International Consortium for Medical AbortionMedical Abortion

Chair, Voice for ChoiceChair, Voice for Choice

Why I am here todayWhy I am here today

Thank you very much for inviting me. Thank you very much for inviting me.

I have been campaigning for women’s right I have been campaigning for women’s right to safe, legal abortion in the UK and to safe, legal abortion in the UK and internationally for 30 years. internationally for 30 years.

The Soviet Union was the first country in The Soviet Union was the first country in world to legalise abortion world to legalise abortion (Kollantai)(Kollantai) – this – this was very influential in Europe and it made a was very influential in Europe and it made a big impression on me as a young woman big impression on me as a young woman too.too.

I hope keeping abortion safe and legal is I hope keeping abortion safe and legal is very important for all of you too.very important for all of you too.

Law and policyLaw and policy

Safe, legal abortion: progressSafe, legal abortion: progress

Abortion is on the agenda across the world.Abortion is on the agenda across the world.

16 countries have liberalised their abortion 16 countries have liberalised their abortion laws since 1997.laws since 1997.

10 o10 others have increased access by thers have increased access by speeding up the approval of facilitiesspeeding up the approval of facilities (India); (India);

expanding the cadres of providersexpanding the cadres of providers (South (South

Africa); Africa); expanding the range of methods expanding the range of methods (Ethiopia) (Ethiopia) oror re-interpreting law to make more re-interpreting law to make more abortions legal abortions legal (Thailand).(Thailand). (Boland & Katzive 2008)

6 in 10 women now live in countries where 6 in 10 women now live in countries where abortion is legal.abortion is legal.

Abortion: very safe if…Abortion: very safe if…

Where it is legal, accessible and Where it is legal, accessible and provided safely, abortion is one of the provided safely, abortion is one of the safest clinical procedures and also safest clinical procedures and also one of the most common.one of the most common.

Abortion deaths are less than 1 per Abortion deaths are less than 1 per 100,000 live births in North America, 100,000 live births in North America, western Europe and NZ/Australia.western Europe and NZ/Australia.

Uruguay 2004Uruguay 2004 Abortion legally restricted. Abortion legally restricted.

Complications of abortion = 29% of maternal Complications of abortion = 29% of maternal deaths, 48% in main maternity hospital in deaths, 48% in main maternity hospital in the capital, Montevideo. the capital, Montevideo.

Maternity hospital began to offer women Maternity hospital began to offer women with unwanted pregnancy information about with unwanted pregnancy information about how to use misoprostol at home to induce how to use misoprostol at home to induce early abortion.early abortion.

They asked women to return for post-They asked women to return for post-abortion care (+ aspiration in the case of abortion care (+ aspiration in the case of incomplete abortion), and an effective incomplete abortion), and an effective contraceptive method. contraceptive method.

After 6 months, no more deaths or After 6 months, no more deaths or complications. complications. (Briozzo et al, 2006)

Nicaragua, El SalvadorNicaragua, El Salvador

Nicaragua and El SalvadorNicaragua and El Salvador have have eliminated all legal grounds for eliminated all legal grounds for abortion. abortion.

Maternal deaths are increasing – Maternal deaths are increasing – change of law has made doctors change of law has made doctors afraid to do abortions, even to save afraid to do abortions, even to save the life of a woman with obstetric the life of a woman with obstetric emergency.emergency.

MexicoMexico Mexico City made abortion on request legal Mexico City made abortion on request legal

in first trimester of pregnancy and is now in first trimester of pregnancy and is now providing safe abortions. In the rest of providing safe abortions. In the rest of Mexico legal restrictions and abortion Mexico legal restrictions and abortion complications remain the normcomplications remain the norm..

Cost (US$) of abortion care Cost (US$) of abortion care (Levin et al):(Levin et al):

Public Public hospital: post-hospital: post-abortion careabortion care

Private Private clinic: safe clinic: safe abortionsabortions

D&C (80%)D&C (80%) $143$143

Manual vacuum aspirationManual vacuum aspiration $111$111 $53$53

Medical abortionMedical abortion $79$79

Treat serious complicationsTreat serious complications $601 − $2,100$601 − $2,100

Victoria, Australia October 2008Victoria, Australia October 2008

In October 2008, abortion was In October 2008, abortion was decriminalised by the state of decriminalised by the state of Victoria, Australia, up to 24 weeks of Victoria, Australia, up to 24 weeks of pregnancy. Therapeutic abortion after pregnancy. Therapeutic abortion after 24 weeks is also permitted.24 weeks is also permitted.

Termination of pregnancy will now be Termination of pregnancy will now be regulated like any other medical regulated like any other medical procedure.procedure.

(ABC News September 2008, Sydney Morning Herald, October 2008.)

Europe: falling fertilityEurope: falling fertility Steady fall in the birth rate since end of 19Steady fall in the birth rate since end of 19 thth

century.century. Higher levels of education; more Higher levels of education; more

opportunities.opportunities. Many women (not just men) working full Many women (not just men) working full

time.time. More young people begin partnerships with More young people begin partnerships with

cohabitation, marry and become parents cohabitation, marry and become parents later in life, and delay first and second later in life, and delay first and second births births (Scandanavia late 20s)(Scandanavia late 20s)..

Small family norm (1-2 children); more Small family norm (1-2 children); more childless women. childless women.

Current total fertility rate in Russia almost Current total fertility rate in Russia almost the same as the average western European the same as the average western European level.level.

Pronatalist vs anti-women responsesPronatalist vs anti-women responses

Pro-natalist:Pro-natalist:o Reduce mortality in under-60s. Reduce mortality in under-60s. (Zakharov S)

o Improve economic, employment, social and Improve economic, employment, social and housing/living conditions.housing/living conditions.

o Generous child benefits.Generous child benefits.o Encourage immigration from other countries.Encourage immigration from other countries.

Anti-women:Anti-women:o Stop women working.Stop women working.o Ban or restrict contraception and abortion.Ban or restrict contraception and abortion.

Poland: almost no legal abortionPoland: almost no legal abortion

Women get abortions from:Women get abortions from:

o Private providers in PolandPrivate providers in Poland

o Travel to Germany, Czech Republic, Travel to Germany, Czech Republic, Austria, NetherlandsAustria, Netherlands

o Probably also other Eastern European Probably also other Eastern European countries (Ukraine, Belarus, Lithuania) if countries (Ukraine, Belarus, Lithuania) if they live close by and have connections they live close by and have connections there. there.

o Internet ?Internet ?

(Personal communication, Wanda Nowicka)(Personal communication, Wanda Nowicka)

Poland 2008Poland 2008

A woman was refused an abortion by a A woman was refused an abortion by a Polish court, even though it should have Polish court, even though it should have been legal because she had a rare been legal because she had a rare condition that affected her sight. She could condition that affected her sight. She could not afford a private abortion. She had no not afford a private abortion. She had no choice but to continue her pregnancy and choice but to continue her pregnancy and went blind. The European Court of Human went blind. The European Court of Human Rights ruled she had had the right to a Rights ruled she had had the right to a legal abortion and granted compensation.legal abortion and granted compensation.

Recently, Poland’s Minister of Health Recently, Poland’s Minister of Health announced a plan to establish a database announced a plan to establish a database of all pregnancies in Poland to keep every of all pregnancies in Poland to keep every pregnancy under state surveillance, to pregnancy under state surveillance, to prevent terminations. (Romania did this prevent terminations. (Romania did this pre-1989)pre-1989)

Abortions in Romania pre-1989Abortions in Romania pre-1989

Romania: before and after 1989Romania: before and after 1989

Abortion-related mortality in 1989 Abortion-related mortality in 1989 accounted for 87% of all maternal accounted for 87% of all maternal mortality (mortality (148 per 100,000 live births)148 per 100,000 live births). . In In 1993, national health statistics showed a 1993, national health statistics showed a spectacular decline inspectacular decline in maternal deaths maternal deaths due almost entirely to the decrease in due almost entirely to the decrease in abortion complications to:abortion complications to:

o 58 per 100,000 in 199058 per 100,000 in 1990o 34 per 100,000 in 1993, and34 per 100,000 in 1993, ando onlyonly 9 per 100,000 live births in 2002. 9 per 100,000 live births in 2002.

Reasons for abortion: RussiaReasons for abortion: Russia

Reasons for abortion among 352 Reasons for abortion among 352 urban and rural women: cannot afford urban and rural women: cannot afford another child, poor health status of another child, poor health status of woman or her husband.woman or her husband. (Vikhlayeva EM, (Vikhlayeva EM, Nikolaeva E, 1996)Nikolaeva E, 1996)

Reasons for non-use of Reasons for non-use of contraception: irregular sex contraception: irregular sex (29%)(29%), , desire for pregnancy desire for pregnancy (22%)(22%), perceived , perceived infertility infertility (15%)(15%), methods unpleasant , methods unpleasant (15%)(15%), health problems , health problems (11%)(11%), abortion , abortion available available (6%)(6%). . (Perlman F, McKee M, 2009)(Perlman F, McKee M, 2009)

Trends re abortion Trends re abortion methods and providersmethods and providers

Trends: abortion methodsTrends: abortion methods

Trend towards abortions taking place Trend towards abortions taking place very early in pregnancy very early in pregnancy (positive pregnancy (positive pregnancy test)test) where manual vacuum aspiration where manual vacuum aspiration or/and medical abortion are offered very or/and medical abortion are offered very early. early. (Western Europe)(Western Europe)

D&E for second trimester abortion is D&E for second trimester abortion is main method in USA but declining in main method in USA but declining in Europe. Europe.

Almost all 2nd trimester abortions in Almost all 2nd trimester abortions in Scandanavia are medical abortions Scandanavia are medical abortions (too (too few late abortions to maintain D&E skills)few late abortions to maintain D&E skills). Both . Both are safe and effectiveare safe and effective..

Dilatation and evacuation (D&C)Dilatation and evacuation (D&C)

Dilatation and evacuation (D&C) as a Dilatation and evacuation (D&C) as a method of first trimester abortion is no method of first trimester abortion is no longer recommended by World Health longer recommended by World Health Organization because it has a higher Organization because it has a higher complication rate. Yet it is still very complication rate. Yet it is still very commonly used for abortions and commonly used for abortions and treatment of incomplete abortion.treatment of incomplete abortion.

Second trimester methods such as Second trimester methods such as instillation also no longer recommended instillation also no longer recommended because of higher complication rates because of higher complication rates but are still used.but are still used.

Changes due to medical abortionChanges due to medical abortion

Medical abortion is changing abortion Medical abortion is changing abortion practice all over the world. practice all over the world.

Where abortion is legal, use of medical Where abortion is legal, use of medical abortion is steadily increasing.abortion is steadily increasing.

Where abortion is illegal, self-Where abortion is illegal, self-medication with misoprostol is the medication with misoprostol is the reality of first trimester abortion. Drug reality of first trimester abortion. Drug sources sources (drug sellers, internet, wide range of (drug sellers, internet, wide range of providers) providers)

Growing number of pharmaceutical Growing number of pharmaceutical companies producing the two drugs companies producing the two drugs globally globally (USA, France, India, China)(USA, France, India, China)..

WHO safe abortion guidance 2003WHO safe abortion guidance 2003

Abortion services should be provided at the Abortion services should be provided at the lowest appropriate level of the health care lowest appropriate level of the health care system.system.

Vacuum aspiration can be provided at Vacuum aspiration can be provided at primary care level up to 12 completed primary care level up to 12 completed weeks of pregnancy and medical abortion weeks of pregnancy and medical abortion up to 9 completed weeks of pregnancy. up to 9 completed weeks of pregnancy.

Mid-level health workers can be trained to Mid-level health workers can be trained to provide safe, early abortion without provide safe, early abortion without compromising safety.compromising safety.

Increasing role of non-physiciansIncreasing role of non-physicians

Both surgical and medical abortion can be Both surgical and medical abortion can be carried out / managedcarried out / managed by trained GPs, by trained GPs, clinical officers, nurses and midwives.clinical officers, nurses and midwives.

France: with medical abortion, physicians France: with medical abortion, physicians confirm pregnancy and conduct follow-up confirm pregnancy and conduct follow-up visit. Nurses do the rest. visit. Nurses do the rest. (Hassoun 2001)

South Africa, Viet Nam, USA: nurse South Africa, Viet Nam, USA: nurse practitioners legally permitted to manage practitioners legally permitted to manage vacuum aspiration and medical abortions vacuum aspiration and medical abortions themselves. themselves. (Warriner et al 2006; Berer 2009)

Second trimester abortion Second trimester abortion

Why focus on second trimester Why focus on second trimester abortions?abortions?

Only the most dedicated providers do Only the most dedicated providers do them.them.

The women who need them are The women who need them are often often young and the most vulnerable.young and the most vulnerable.

Women’s lives are at greater risk if they Women’s lives are at greater risk if they are unsafeare unsafe..

Subject of anti-abortion attacks as if they Subject of anti-abortion attacks as if they are “more wrong” than first trimester are “more wrong” than first trimester abortion abortion (Britain, Spain, Netherlands, Russia, (Britain, Spain, Netherlands, Russia, Germany, USA)Germany, USA)

How many women have them?How many women have them?

Britain 2007*Britain 2007*o 13-19 weeks13-19 weeks 8.8%8.8%o >20 weeks>20 weeks 1.5%1.5%

Netherlands 2006*Netherlands 2006*o >12 weeks >12 weeks 6.6% 6.6%

SwedenSwedeno >18 weeks >18 weeks very fewvery few

South Africao 1997 >12 weeks 33%+o 2007 >12 weeks 20%

(Ingham et al 2008; Loeber & Wijsen 2008; M Bygdeman 2008)

Reasons: BritainReasons: Britain

Five stages of delay: Five stages of delay: o suspecting pregnancy suspecting pregnancy o confirming pregnancy confirming pregnancy o deciding on abortion deciding on abortion o seeking abortion seeking abortion o obtaining abortionobtaining abortion

Interventions of better sexuality Interventions of better sexuality education and access to supportive education and access to supportive counselling first 3 stages; improving counselling first 3 stages; improving services can only help at last 2 stages.services can only help at last 2 stages.

(Ingham et al 2008)

Netherlands: early and lateNetherlands: early and late

Early medical abortion and MVA do not Early medical abortion and MVA do not appear to have an influence on the appear to have an influence on the number of second trimester abortions number of second trimester abortions in the Netherlands. in the Netherlands.

Delays are due to relationship Delays are due to relationship problems problems (no partner, partner left, partner (no partner, partner left, partner

aggressive)aggressive), , young age (pregnancy too early), inability to recognise pregnancy, ambivalence towards pregnancy, having to travel to Netherlands for abortion. . (Loeber & Wijsen 2008)

Fetal anomaliesFetal anomalies

Wanted pregnanciesWanted pregnancies

Screening becoming universal for all Screening becoming universal for all pregnancies.pregnancies.

Potentially more anomalies detected.Potentially more anomalies detected.

Potentially more second trimester Potentially more second trimester abortions.abortions.

Physician skills important.Physician skills important.

Ideal abortion law and policyIdeal abortion law and policy

Abortion available at the woman’s Abortion available at the woman’s request to 24 weeks and no limit for request to 24 weeks and no limit for therapeutic reasons.therapeutic reasons.

Public health services provide, or at Public health services provide, or at least fund, all abortions.least fund, all abortions.

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Thank you very much!Thank you very much!