From choice, a world of possibilities

Death and Denial: Unsafe Abortion and Poverty

Access to legal and safe abortioncare - as well as to care to treat incomplete abortion orcomplications from unsafeabortion - would help save thelives of thousands of women everyyear. It would also provide a vitalopportunity to ensure women cansubsequently access familyplanning and contraception tohelp avoid repeat abortions.

Punitive legal measures andrestricting access to safe abortiondo not reduce the incidence ofabortion; they just make it moredangerous. The result is that morewomen suffer. Not surprisingly, itis the poorest women - womenleast able to pay for any minimallevel of care - who end up payingthe highest price. I welcome thisreport as an important contributionto dealing with a subject whererational debate and consideredaction are much needed.

Gareth ThomasJanuary 2006

Parliamentary Under-Secretary ofState for International Development

Millions of women have no accessto reproductive health services;many more have little or nocontrol in choosing whether tobecome pregnant. As a result,every year, some 19 millionwomen have no other choice thanto have an unsafe abortion. Manyof these women will die as aresult; many more are permanentlyinjured. Nearly all the women whodie or are injured are poor and livein poor countries.

Preventing these deaths andinjuries will not be achievedwithout stopping unsafe abortionswhich cause around 13 per centof all maternal deaths. Virtually allthe deaths of women from unsafeabortion are in fact preventable. A woman facing an unwantedpregnancy should not have to riskdeath through having an unsafeabortion.

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Foreword by Gareth Thomas MP

“No woman should anywherehave to face death or disabilityfor the want of a safeabortion. Is there anybody whowould disagree with the rightof a woman not to die inpregnancy? Anybody? No.”

The Rt Hon Hilary Benn, MP,Secretary of State for InternationalDevelopment, Countdown 2015,The Global Roundtable, London, 2004.

This year alone, an estimated 19 million women and girls, facedwith unintended and unwantedpregnancies, will face the deadlyconsequences of unsafe abortion.Nearly 70,000 of these women andgirls will die, and hundreds-of-thousands of others will be leftwith debilitating, and frequentlylifelong injuries, as a result. Over 96per cent of these women will comefrom the world’s poorest nations.

For reasons ranging from humanrights to religion, abortiongenerates more political and socialdisagreement than almost anyother subject. It remains a singularlyemotive and complicated issue inmany countries, at times seeminglywithout any room for balanceddiscussion.

This report offers an overview ofthe current situation regardingunsafe abortion around the world.In doing so it seeks to open amuch needed and timely debateamong governments,parliamentarians, public health,development and medical experts,as well as service providers andglobal advocates for legal and safeabortion such as IPPF.

Unsafe abortion is one of thelargest contributors to globalmaternal mortality: a verypreventable human tragedy thathighlights the failure of nationalgovernments and the internationalcommunity to address a publichealth issue that perpetuates oneof the greatest social injusticesseparating rich and poor nations.

Unsafe abortion is a cause andconsequence of poverty; it is alsointimately linked to gender

inequality within societies. It is theinability of women, especiallyyoung women and girls, to fulfiltheir basic sexual and reproductiverights, and to have control overtheir own bodies, which forcesupon them a stark choice - facesocial exclusion or risk their livesand health through unsafe abortion.

During last September’s UnitedNation’s World Summit, worldleaders reaffirmed theircommitment to the MillenniumDevelopment Goals, including thegoal of reducing maternal mortalityand improving maternal health.The Summit also reasserted aprevious global commitment toachieve universal access toreproductive health. The reviewprocess noted that little progresshad been made towards achievingeither since the MillenniumDevelopment Goals were firstadopted five years ago. It furtherhighlighted the fact that unsafeabortion is a major contributor tothese stubbornly high levels,particularly in developing countries.

Extensive independent researchshows that restricting access toabortion does not make it goaway; it only makes it clandestineand unsafe. Health authorities and political leaders in more andmore countries are prepared to re-examine abortion policy whenthey understand how unsafeabortion contributes to maternalmortality and ill health. Moreover,renewed interest in the issue ofpreventing unintended pregnancieshas brought renewed focus on the role family planning andreproductive health services play inpreventing unwanted pregnancies.

Lack of access to moderncontraception as a factor drivingunwanted pregnancies to unsafeabortions cannot be ignored.

There is a pressing need for anopen and informed discussion toaddress the fundamental injusticeof the causes and consequences ofunsafe abortion. There are fewgovernments with the courage totake a leadership position onabortion rights and there areequally few internationalorganisations with such courage.The Government of the UnitedKingdom and IPPF are two of thefew that have both the courageand the resolve to act in a struggleso crucial to women’s well-being.

Through the work of theDepartment for InternationalDevelopment, the United Kingdomhas promoted an approach toaddressing abortion based onsound public health evidence. Indoing so, the UK has establishedan international reputation for bothleadership and wisdom. IPPF isdetermined to play a constructiverole as partner with the Departmentfor International Development inthis undertaking. With upwards of15 per cent of maternal mortalitydirectly attributable to illegal andunsafe abortion – perhaps as muchas 50 per cent in some countries in Africa and South East Asia –tackling head-on the reduction and even the elimination of thispreventable cause of maternaldeath is of paramount importance.

Steven W. SindingDirector-General, International Planned ParenthoodFederation

Introduction

“A straightforward public healthproblem with a known solution hasbeen allowed to become the killingfields of women in developingcountries, particularly Africa.”Fred Sai, Special Adviser to the President of Ghana, speaking on unsafeabortion, Countdown 2015, The Global Roundtable, London, 2004.

complications from unsafe abortionaccount for approximately 70,000,or 13 per cent, of all deaths.

Achieving the MillenniumDevelopment Goals, especially thegoal of improved maternal healthand reduced maternal mortality, willrequire action across a broad front.The causes of maternal mortalityand morbidity are numerous andcomplex, but in countries wherewomen can be responsible for upto 100 per cent of householdincome and for raising a family,death and morbidity from unsafeabortion exacts a heavy economicand societal toll.

Equal access to education for girlsis another key aim of theMillennium Development Goals.The failure to fulfil her educational

Poverty has multiple dimensionswhich include a lack of economicresources, an absence of humanrights, poor health and thedeprivation of choices. At theUnited Nations Millennium Summit,in October 2000, 191 countriesagreed on the imperative ofreducing poverty and inequityworldwide. Improving maternalhealth and reducing by three-quarters the number of maternaldeaths were identified as one ofthe Millennium Development Goalskey to addressing inequality.

Almost all maternal mortalityoccurs in developing countries,representing one of the widest,and most unjust, health gapsbetween developed anddeveloping nations. Of the500,000 annual maternal deaths,

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Unsafe abortion:a cause and consequence of poverty

The World Health Organization defines abortions as unsafe when theyare performed by “persons lacking the necessary skills or in an environmentlacking the minimal medical standards or both”. The impact of unsafeabortion casts a spotlight on the gaping social and public healthinequalities between developed and developing nations, as well as withinthose nations where abortion is illegal or severely restricted. There is onesimple truth: unsafe abortion disproportionately affects the poorestwomen in those countries where it occurs.

Unsafe abortion, maternal mortality andthe Millennium Development Goals

potential has an unequivocalimpact on a woman’s ability to playa full economic, social and politicalrole within her community, and is directly linked to poverty. Foryoung women and girls, unintendedand unwanted pregnancy frequentlyforces them to decide betweenrisking their lives and health to havean unsafe abortion or leaving schoolto continue with the pregnancy.

“A poor woman in many partsof Africa is over 200 times morelikely to die as a result ofpregnancy and childbirth than a woman in the UK.”

Department of InternationalDevelopment, UK.

IPPF/Chloe Hall

The EthiopianMember Associationstrives to reduce thenumber of unwantedpregnancies byestablishingcommunity baseddistribution schemesfor contraceptiveservices in rural areas

“Latin Americans are beginningto look at abortion as an issueof maternal mortality, not just maternal morality.”

New York Times, 06 Jan 2006

While the death of a mother,daughter or sister from unsafeabortion has a devastating impacton a family, equally devastating arethe debilitating injuries and illness orlifelong disability hundreds-of-thousands of women suffer as aconsequence of unsafe abortion.

Accessed early, medical care canaddress the complications in manycases, but large numbers of womenhave no reliable access to primaryhealth care facilities. Not all womenare able to get hospital treatmentfor medical complications followingunsafe abortion; however, the datafrom 10 countries indicate the sheerscale of the problem and itssubsequent impact on health care systems.

Health impact caused by unsafe abortion

A WHO study from Nigeria in 2000showed that 75 per cent of womensuffered injury or illness. The studyof 144 women who underwentunsafe abortion in Ilorin, Nigeria,reported typical complications:

Sepsis 27%Anaemia (haemorrhage) 13% Death 9%Cervical tear 5%Injury to gut 4%Chemical vaginitis 4%Sepsis with anaemia 3%

Pelvic abscess 3%Uterine perforation withperitonitis 3%Laceration of vaginal wall 3%Vesicovaginal fistula 1%

A more recent Ipas study fromKenya (The Magnitude of Abortioncomplications in Kenya, InternationalJournal of Obstetrics andGynaecology) supports the Nigeriadata, declaring unsafe abortion as“one of the most neglected healthcare issues in Africa”.

Over 80 per cent of the 809 casestudies from all levels of Kenya’shealth care system hadcomplications as a result of unsafeabortion. Of the seven deathsrecorded, six were due to secondtrimester complications; underliningthe need for safe and accessibleabortion services as early as possibleduring the pregnancy. The studyestimates that annually 20,893Kenyan women will be hospitalizedfrom complications from unsafeabortion.

In countries where abortion is permitted only on narrow grounds,thousands of women are hospitalized each year with serious complicationsfrom unsafe procedures.

HospitalizationsAbortion-related per 1,000 women

Country hospitalizations 15–44

AfricaEgypt, 1996 216,000 15.3Nigeria, 1996 142,200 6.1

AsiaBangladesh, 1995 71,800 2.8Phillipines, 1994 80,100 5.1

Latin AmericaBrazil, 1991 288,700 8.1Chile, 1990 31,900 10.0Colombia, 1989 57,700 7.2Dominican Republic, 1990 16,500 9.8Mexico, 1990 106,500 5.4Peru, 1989 54,200 10.9

Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide

Many women, married orunmarried, simply have no controlover their own sexual lives. Theycannot access, or are not permittedto access, safe family planningservices and as a consequence havelittle choice over when or if theybecome pregnant. The prevailingcultural and religious norms ofmany societies leave women,especially young women and girls,facing death or injury from unsafeabortion, or social exclusion andabandonment.

Many girls and women areprevented from enjoying basicsexual and reproductive rights dueto their unequal status in society.

They lack control over their ownbodies, just as they lack decisionmaking power, mobility and controlof resources within the household.This social, political and economicinequity prevents many womenfrom accessing safe services or fromdemanding the services they desire.

Young women, adolescents andgirls are particularly vulnerable tosexual coercion, abuse andexploitation. Almost 50 per cent of sexual assaults worldwide areagainst adolescent girls of 15 yearsof age or below. They are powerlessin relationships where older mencontrol their lives. This not only putsthem at greater risk of unwanted

pregnancy and unsafe abortion, butit is also a significant factor fuellingHIV infection rates amongst youngwomen in many countries.

Gender inequality, cultural norms,religious practices and poverty areall factors limiting opportunities forwomen and girls to make choicesabout their own sexual andreproductive lives. This leaves girlsand women without the choice tosay ‘no’ to sex, especially if they arepoor or living in marginalizedcommunities. This has direconsequences for many women,especially the very poorest women.

Unsafe abortion:the cost of gender inequality

Millions of women suffer injury or illness from unsafe abortion

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There are approximately 211 millionglobal pregnancies annually; 87million women become pregnantunintentionally, with approximately46 million pregnancies ending ininduced abortion. A further 31million pregnancies miscarry orresult in stillbirths.

Women in all parts of the worldseek to end unwanted pregnancythrough abortion: of the 46 millionwomen who choose to have anabortion each year, 78 per cent arefrom developing countries, 22 percent from developed countries.Annually 19 million abortions areconsidered to be unsafe, over 96per cent of which occur indeveloping countries.

A number of independent studieshave shown that, while there maybe country-to-country differences,

In compiling this report, IPPF has relied on statistical data from a numberof sources, most extensively from the Guttmacher Institute’s landmarkpublication ‘Sharing Responsibility: Women, Society and AbortionWorldwide’, 1999.

across the world women choose to end pregnancies for very similarreasons.

• They choose not to have anymore children

• They are too young or have toofew economic resources to havechildren

• They wish to complete theireducation

• They wish to postponechildbearing to space births

• Their relationship with theirpartner has ended or is unstable

• Childbearing would adverselyaffect their health

• The pregnancy was a result ofrape or incest

• Social or religious beliefs make itimpossible for unmarried womento continue pregnancy

Worldwide unplanned pregnancy and unsafe abortion Unsafe abortion in Europe

Unsafe abortions indeveloping countries

Africa 4.2 millionAmerica and the Caribbean 3.8 millionAsia 10.5 million

All abortions by global region

Africa 11 per centAsia 58 per centEurope 17 per centLatin America and Caribbean 9 per cent

WHO estimates that there arebetween 500,000 – 800,000unsafe abortions in Europe eachyear. Women are still dying inEastern Europe from unsafeabortion, but the situation isimproving. Between 6 and 23per cent of maternal deaths inEastern and Central Europe areas a result of unsafe abortion.

In order to improve women’s access to safe legal abortion, IPPFEuropean Network, in partnershipwith other organizations, organizeda two-day workshop of staff andvolunteers from the MemberAssociations of Albania, Armenia,Bosnia and Herzegovina, Georgia,Kazakhstan, Poland, Tajikistan andUzbekistan. An additional meetingwas held with other EuropeanMember Associations to assistthem in improving the quality ofabortion services provided.

A law banning abortion waspassed in Romania in 1966.There was a dramatic rise inmaternal mortality from 80deaths per 100,000 live births in 1964 to 180 in 1988. After therepeal of this law in 1989, thematernal mortality ratio fell toaround 40 deaths per 100,000live births in 1992. This fall wasalmost entirely due to womenbeing able to access safeabortion services andconsequently fewer deathscaused by the complications ofunsafe abortion. During theperiod 1966-1988, some 20,000Romanian women are estimatedto have died as a result ofunsafe abortion.

Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide

“In the face of growing conservatism in many parts of the world, aswell as competition for resources, the great challenge is to maintainthe focus of development efforts, as embodied in the MillenniumDevelopment Goals, on the centrality of sexual and reproductivehealth and rights for poverty reduction. This requires that IPPF stepup its advocacy efforts, in partnership with like-minded governmentsand organizations, even as it expands its services in traditionalfamily planning and especially safe abortion.”

Dr. Jacqueline Sharpe, President IPPF.

Unplanned births are common eventsfor women around the world

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% of births in last five years

Unwanted Preferred at later time

Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide

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The causes of unplanned andunwanted pregnancy

• Gender inequality means womenhave less control over their own bodies

• Lack of access to family planningservices

• Lack of information on moderncontraceptive methods andreliance on traditional methods

• The failure of, or irregular use of,contraception

• Stigma surrounding single womenand contraceptive use

• Lack of a woman’s control overthe circumstances of sexualintercourse

• Sexual violence, rape and incest

• Cultural and religious norms meanwomen have less power tonegotiate contraception

Better contraceptive choices

To have full control over the spacingof children and to achieve desiredfamily size, women and men mustuse, correctly and consistently,reliable contraception for themajority of a woman’s fertile years.

Evidence suggests that globally thenumber of married and unmarriedwomen regularly using modernmethods of contraception to avoidunplanned pregnancy is well belowthe numbers who wish to delay orbetter space their pregnancies.

The reasons for this are complex,ranging from ingrained social andcultural attitudes, economiccircumstances and the inability ofwomen to negotiate contraceptiveuse in relationships. Another reasonis that in large parts of the worldthere is an unmet contraceptiveneed, and women and men simplycannot access the family planningservices they want and need. Manycouples are forced to rely ontraditional methods which are noteffective in preventing pregnancy.This inevitably leads to unplannedpregnancies.

Increasingly women desire smaller families. With the exception of sub-Saharan Africa and a handful of other countries this largely means havingtwo or three children. In much of the developed world a small family sizeis the cultural norm. Yet many women throughout the world still havemore children than they would desire.

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Nepal

In Nepal early marriage andmultiple unplanned pregnancieshave lead many women to seeksecret and unsafe abortions.Abortion was legalized underspecific conditions in 2002, and theimplementation of the legislationwas approved in early 2004. Thislegal reform was contained withinthe Pregnancy Protection legislationwhich addressed other rights forwomen. IPPF Member Association,the Family Planning Association ofNepal (FPAN), began providingabortion services in 2004 in threedifferent clinics.

A 14-year old girl arrived atFPAN’s Valley clinic and requestedan abortion. Initially she wasreluctant to speak to the staff,but she eventually revealed thatshe had been involved in a sexualrelationship with a distantrelative and had becomepregnant. A bright student, shewas worried that a pregnancywould affect her forthcomingexams and would prevent herfrom completing her education.

It was the first time that such ayoung person had requested theseservices from the clinic, so staff didnot have a standard procedure tofollow. A meeting was quicklycalled with service providers andsenior staff to discuss the legalimplications and how best to helpthe girl. In Nepal it is illegal toprovide abortion services to anyoneunder the age of 16 unless she hasthe consent of her parents orguardian. The staff decided thatthey would provide safe abortionservices the following day, so longas the girl could return to the clinicthe following morning with aguardian’s consent letter.

The next day, she did not comeback to the clinic and staff becameworried. FPAN field staff madediscreet enquiries, and they metwith the girl in confidence andprovided additional counselling.

They discovered that she had notreturned to the clinic that morningbecause she had been sitting anexam. By now it was the weekend,and although the clinic wasofficially closed for the day, thebranch manager was concernedabout further delays and openedthe clinic especially for the girl, whowas accompanied by her guardian.

A 36 year old pregnant womanwho had learned about theservices of the Family PlanningAssociation of Nepal throughoutreach workers, came to a clinicin mid-2005. She and herhusband, a labourer, were poorand were already struggling tobring up their seven youngchildren. She was clearly distressedthat an eighth child would meanthat none of her children could beprovided for adequately.

Unfortunately, FPAN is unable tooffer free services for all clients, andthe woman could not afford the750 rupee (approximately £6) fee.Realizing that she was in anextremely vulnerable condition,and fearing the woman mightresort to an unsafe, ‘traditional’abortion method, FPAN staffdecided to raise the money for the operation themselves.

For many women, safe abortionsare very expensive andunaffordable, and going into debtis not an option. This is one of themany reasons women resort tounsafe abortion.

The woman received a safeabortion and post-abortioncounselling, including contraceptivecounselling. The woman told staffthat had she known about FPAN’sfamily planning services sooner, shewould have taken steps to havefewer children.

Peru

Carmen, a 19-year-old woman,came to a clinic of IPPF’s PeruvianMember Association, INPPARES,depressed and emotionally upset.She revealed during the conversationthat she had been raped six weeksearlier, but had not reported it orsought medical care because shefelt ashamed. In desperation, shehad attempted to induce anabortion using medication and wassuffering from vaginal bleeding.

Carmen’s boyfriend and motherwere with her during the visit, andshe was able to talk openly aboutwhat had happened and to discussthe options available to her. Inaddition to information on post-abortion care, she was offeredcounselling on testing for HIV andother sexually transmittedinfections. The woman decided tohave a manual vacuum aspiration,which was completed withoutcomplications. When she returnedfor a follow-up visit, she wascounselled on differentcontraceptive methods. She saidthat her boyfriend had left her dueto the stigma associated with rapeand abortion, and that she nolonger needed contraception.

All case studies in this report came from IPPF Member Associations

Case studies: unplanned pregnancies

IPPF/Chloe Hall

Women accesscontraceptiveservices in theNouadhibou clinic of the MauritanianMember Association,these services are fundamental to preventingunwantedpregnancies

IPPF/ChristianSchwetz

The MemberAssociation inThailand ensuresthat women areeducated about different methodsof contraception

The Global Gag Rule

First introduced in 1984 andreintroduced by President GeorgeW. Bush in 2001, the Global GagRule puts non-governmentalorganizations from outside theUnited States in an untenableposition, forcing them to choosebetween carrying out their worksafeguarding the health and rightsof women or losing their fundingfrom the US. The Gag Rule prohibitsorganizations in receipt of US fundsfrom using their own money toprovide abortion information,services and care, or even discussingabortion or criticizing unsafeabortion. It even preventsorganizations from working onthese issues at the request of theirown governments.

The Gag Rule severely restrictsfreedom of speech; it interferes withthe doctor-client relationship; andhinders balanced consideration ofliberalizing abortion laws based onpublic health concerns and human

rights. Around the world this hashad a dramatic impact on the abilityof IPPF Member Associations, andmany other organizations, whichhave rejected the Gag Rule, andconsequently lost much of theirfunding, to provide full sexual andreproductive health services. Thepolicy has restricted the freedom ofspeech and association of thoseorganisations who are bound by itsregulations. However, anti-abortionadvocacy is allowed, underscoringthe ideological nature of the GagRule.

The Gag Rule fails in its stated intent to reduce the globalincidence of abortion. Rather, bydramatically impairing the deliveryof sexual and reproductive healthservices, its actual impact has beento increase the number ofunintended pregnancies and theabortions that inevitably follow.

“It has never been easy to fullyquantify the impact of the GagRule. Its ramifications areinsidious and have occurred overmany years. It is impossible totrack how many deaths havebeen associated with servicesthat could have been providedin the absence of a Gag Rule,how many advocates weresilenced from speaking out abouta devastating public health issue,or how many organizations wereprohibited from working withtheir governments and otherNon-GovernmentalOrganisations to meet theserious health care needs of theirown communities.”

Planned Parenthood Federation ofAmerica, Report on Global GagRule 2003.

At the International Conference onPopulation and Development inCairo in 1994, the internationalcommunity pledged to makeuniversal access to family planningand sexual and reproductive healthservices a reality by 2015. Over adecade later, and despite furtherpledges to deliver universal access,

world leaders are as far away asever from delivering on theircommitment. Indeed, funding forglobal family planning services hasactually fallen during this period.

Non-existent or poor quality familyplanning services, whether frominadequate funding or political and

religious opposition, contributedirectly to unintended andunwanted pregnancies and tosubsequent high levels of maternalmortality and ill health from unsafeabortion.

The global commitment to family planning

IPPF/Chloe Hall

Buzensu walks forseveral hours toattend the marketday outreach servicesin Wondogonet,Ethiopia. TheSaturday clinic is heronly point of accessfor contraceptiveservices

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size and the government’s launchof a national family planningprogramme, Kenya saw a rapiddecline in its birth rate, on averagefrom eight children per woman to slightly over four. Yet maternalmortality hardly declined andabortion rates remained high(estimated at over 300,000 per year).

As abortion is severely restrictedunder Kenyan law, the onlyexception being to save the life ofthe mother, the vast majority ofabortions are illegal and unsafe,accounting for some 30-50 percent of national maternal mortalityrates. The impact on the resourcesof Kenya’s healthcare system isenormous, with as much as 60 per cent of the resources ofKenyatta National Hospital’smaternity ward taken up by victims of unsafe abortions.

Unmet need for family planningthroughout Kenya remains very

Country profile: Kenya

high, with 24 per cent of couplesunable to access the services theydesire, and family planning serviceshave been reduced, largely due tothe imposition of the Global GagRule. Yet the abortion rate remainshigh, indicating that Kenyanwomen continue to turn toabortion to manage their fertility.

Access to contraceptive servicesreduces the number of unplannedpregnancies and subsequently thenumber of abortions. Where thereis an unmet need for familyplanning and contraception, as theKenyan experience demonstrates,women resort to abortion to avoidchildbearing. In countries whereabortion is illegal or restricted, thismeans women put their lives andwell-being at risk by resorting tounsafe abortion. Safe and legalabortion services must existalongside effective family planningand reproductive health services toprevent deaths and tackle thehealth impact of unsafe abortion.

The need to accesscontraceptive services

IPPF is committed to a two-pronged approach to reducing, andeliminating, abortion-relatedmaternal mortality. The first is toprovide those services that reducethe need for abortion; where goodcontraceptive services are providedabortion rates decline. However, nomatter how effectively contraceptiveservices are provided and used,unintended pregnancies will stilloccur.

IPPF’s second goal is to makeabortion legal and safe everywhere.The evidence is clear: only whenwomen have the right to accesssafe abortion services do medicalcomplications from unsafe abortionand maternal mortality becometruly rare.

This approach is dramaticallyhighlighted in Kenya. Between1980 and 2000, driven by demandfrom couples to limit their family

Kenya and the Global Gag Rule

IPPF’s Member Association in Kenya, the Family Planning Association ofKenya (FPAK), provides a significant share of the country’s contraceptiveand reproductive health services. Faced with a choice between losing allits funding and technical aid from the US Agency for InternationalDevelopment and stopping all its work on safe abortion, FPAK chose toforfeit the aid to be free to advocate for the health and well-being ofKenyan women. The resulting loss of funding saw the closure of threeFPAK clinics, the scaling back of services in its remaining clinics and theslashing of funding to outreach programmes. This has made it muchharder for poor Kenyans to access family planning services andinformation, and must inevitably lead to more unwanted pregnanciesand unsafe abortions.

The need to review abortion legislationIn early 2004, a number of Kenyan medical practitioners, accused ofperforming abortions, were put on trial for murder. In response theKenyan Reproductive Health Steering Committee was established,comprising representatives from across Kenyan society, to defend theaccused and to extend reproductive health and rights in Kenya.

Through the Steering Committee’s work, a draft motion to liberalizethe law on abortion will soon be tabled in the Kenyan parliament and a comprehensive national review of abortion is being undertaken. Themobilization of those who support improved access to safe abortionhas lead directly to the challenge to Kenya’s abortion laws. Had thoseorganizations, including FPAK, signed the Gag Rule this challenge couldnot have happened, even at the behest of their own government.

“Continuing unmetcontraceptive need andcontraceptive failure willinvariably be associated withhigh rates of unplanned andunwanted pregnancies, forcingmany women to resort tounsafe termination ofpregnancy with a consequentunacceptably high rate ofcomplications includinginfertility, long term morbidityand death.”

The Magnitude of Abortioncomplications in Kenya, RCOGInternational Journal of Obstetricsand Gynaecology

South America has longexperienced the ravages of severerestrictions on abortion with someof the highest maternal mortalityrates from unsafe abortion in the world. In Venezuela, abortionis legal only to save the life of a woman, and there are noexceptions for rape, incest or to preserve a woman’s health.Additionally, the law prescribes upto two year’s imprisonment for awoman who undergoes anabortion and up to 30 months’imprisonment for the provider.

On 1 December 2004, a proposalto decriminalize abortion waspresented publicly before theNational Assembly. For healthprofessionals, weary of seeingwomen die from complicationsresulting from unsafe abortion,this was a momentous event.The bill represented the efforts ofmany women’s organisations,universities, obstetrics andgynaecological societies, theMinistry of Health andreproductive health providers,including the IPPF MemberAssociation in Venezuela,

Asociación Civil de PlanificaciónFamiliar. In a country where theCatholic Church exerts a powerfulinfluence over society, theproposal for decriminalization is afirst step in opening up a muchneeded public and legislativediscussion on abortion.

The Asociación Civil dePlanificación Familiar helped draftthe proposals and presented thepublic health concerns of unsafeabortion to the CongressionalCommission on Women, Familyand Youth, which now supportsthe proposals. The Commissionchanged its position significantlyonce members heard the stories of women who needed access tosafe abortion facilities, and sawfirst hand the impact of maternalmortality and morbidity. Theyrecognized that criminalizingabortion was neither preventing itfrom taking place nor reducing thedemand for it, but only makingwomen suffer; they subsequentlyagreed that current legislationneeded to be reformed.

Abortion law reform efforts in Venezuela 29 Countries have liberalizedtheir abortion laws despitethe imposition of the GlobalGag Rule in 1984

Albania - 1996Algeria - 1985Australia - 2002 (two States)Belgium - 1990Benin - 2003Botswana - 1991Bulgaria - 1990Burkina Faso - 1996Cambodia - 1997Canada - 1988Chad - 2002Czech Republic - 1986Ethiopia - 2004France - 2001Ghana - 1985Guinea - 2000Greece - 1986Iran - 2005Malaysia - 1989Mali - 2002Mexico - 2000 (two States)Mongolia - 1989Nepal - 2000Pakistan - 1990Romania - 1989Slovakia - 1986South Africa - 1996Spain - 1985Switzerland - 2002

IPPF/Asociación Civilde Planificación

The VenezuelanMember Associationand their volunteersare key players in the campaign to decriminalizeabortion inVenezuela

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IPPF/Chloe Hall

The free familyplanning servicesoffered by the MemberAssociation clinicin Nouakchott,Mauritania arefundamental toensuring thatwomen likeMimoona do notbecome anothermaternal mortalitystatistic.

“Accessible, effective familyplanning services may avert upto 35% of maternal deaths”Reducing Maternal Death:Evidence and Action, A Strategyfor DfID, September 2004.

A study of 15 West Africancountries found that those withthe highest contraceptiveprevalence had the lowestmaternal mortality rates, andvice versa.

The sexual and reproductive health and rights community faces increasingly hostile politicalopposition from the United States,the Vatican and other conservativegovernments and religious leaders.This has ensured that universalaccess to reproductive healthservices remains a distant hope forthe majority of the world’s poor.The direct result is that womenand girls across the globe continueto bear the brunt of policies thatfail to address the nature andscale of maternal mortality andunsafe abortion.

Opposition to family planning undermines efforts toreduce unwanted pregnancy and unsafe abortion

Where access tocomprehensive familyplanning services andinformation is availableabortion levels have fallen:

The number of abortions inArmenia, Kazakhstan, KyrgyzRepublic, and Uzbekistan couldbe halved if women who donot use contraceptives or usetraditional methods switchedto modern contraceptives.

Bangladeshi women with good access to high qualityfamily planning services havean abortion rate of 2.3 per1000 compared with 6.8 forwomen without access. (DuffGillespie, The Lancet, Vol. 363,January 2004).

The ideological debate surroundingabortion masks an unspoken truth:when faced with an unwantedpregnancy many women will seekan abortion regardless of its legalityor safety. The deadly consequencesof this are all too evident; women’slives are put at risk and all toooften they die or suffer lifelongdisability. The illegality and thestigma attached to abortion makeevidence difficult to find. However,when research is undertaken andthe facts are analyzed, the case for

liberalizing abortion laws andsimultaneously increasing access tosafe services is compelling.

Proof that criminalizing abortiondoes not reduce abortion rates, butinstead endangers women’s lives,can be seen across all globalregions. In Latin America abortionis illegal or severely restricted invirtually every country, yet theabortion rate is one of the highestin the world, far exceeding that ofWestern Europe or North America.

Colombia, which prohibits abortioneven to save a woman’s life,averages one abortion per womanthroughout her reproductive years.In Peru, this rises to an average oftwo abortions per woman. Forpoor women, unable to afford safetreatment, this means resorting toillegal unsafe abortion at the handsof unqualified people in unsanitaryconditions.

Creating the platform for change: evidence-based interventions

The controversy surrounding whenand how abortion should be legalin Uganda hides a vicious reality forwomen. Currently abortion is illegalwith the exception of saving awoman’s life, or to preserve herphysical and mental health.However, additional administrativebarriers exist as an abortion has tobe performed by a registeredphysician, and the consent of twoadditional doctors is usually sought.Under the Ugandan penal code,performing an illegal abortion ispunishable by up to seven years inprison for both the woman and thedoctor, yet this has done little toreduce the level of unsafe illegalabortions.

Uganda is one of the world’spoorest countries, with nearly 40per cent of people living below thepoverty line. DfID funded researchreleased in 2005 has shown thatone third of Ugandan women aredenied contraception because theyhave no access to services. Thissupports evidence from the FamilyPlanning Association of Ugandaand builds a real and tangibleargument to generate public

support and political commitmentfor legal reform of abortion laws.

The result of restricted access tofamily planning services is that theaverage Ugandan woman givesbirth to seven children during herlifetime, two more than she wouldprefer. Many women break the lawto end unwanted pregnancies inunsafe and unhygienic conditions.The greatest impact of this is felt bythe poorest women in Ugandansociety, especially those living inrural areas who are driven to usingsharp instruments and herbs in adesperate attempt to end anunwanted pregnancy. Upwards ofseventy-five per cent will sufferhealth complications, and unsafeabortion now accounts for onethird of all maternal deaths inUganda.

Such strong factual evidencecannot be ignored. There is alreadya groundswell of support forchange. In September 2005, IPPFand the Family Planning Associationof Uganda facilitated a fact-findingmission by some NorwegianMembers of Parliament. The

Country profile: Uganda

findings led the delegation to makea declaration that stressed theimportance of increasing access tosafe, legal abortion, particularly forpoor, vulnerable and rural women.This declaration was publiclydiscussed with Ugandan Membersof Parliament, Ministry of Healthofficials and the media whichstimulated considerable publicdebate. This has lead the Head of the Reproductive HealthProgramme to acknowledgepublicly that legal abortion wouldreduce the maternal death rate.The Ministry of Health is planningto review the abortion law and is considering how the currentabortion law can be betterinterpreted so as to prevent furtherunnecessary mortality andmorbidity from unsafe abortioncomplications.

Using evidence to support the casefor reducing rates of unwantedpregnancy through improvedaccess to safe abortion, IPPF’sMember Association has appealedto the Government for repeal ofthe current restrictive abortion lawson public health grounds –something that could not havehappened had the Family PlanningAssociation of Uganda signed theGlobal Gag Rule.

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Abortion is legal in Mongolia,although government policy does not always translate intoconcrete services to decreaseunsafe abortion. The strict rulesfor service provision state thatabortions must be carried out at a medical facility certified by the government. While this mayensure high quality services, thereality for women is that few legaloptions are available apart fromthe services at governmenthospitals. This situation serves torestrict access to services.

Long queues and bureaucraticprocedures force many women togo to private uncertified clinicswhere abortions can be procuredquickly, but there are higher feesand they operate illegally. Access,particularly in rural areas, remainspoor. Because of this situation,IPPF’s Member Association theMongolian Family WelfareAssociation (MFWA) is advocatingfor an alternative system wheresimpler clinics could also providesafe legal abortion, with measuresin place to ensure that health andsafety standards remain high.

Country profile: Mongolia

As a first step in this process,MFWA undertook a survey of over1,700 people to find out moreabout public opinion andexperiences around abortion. A cross-section of the public was interviewed, which revealed thatmost of the respondents had highawareness of abortion availabilityand eligibility. Residents in ruralareas, where there are no privateclinics or public hospitals withineasy reach, supported plans tomake abortion services moreaccessible, indicating that therewas a significant demand foraccess to safe abortion services.

• Prior to 1950 safe abortion wasillegal or severely restricted invirtually every country worldwide

• Growing concerns about theimpact of unsafe abortion saw arapid increase in the number ofcountries liberalizing or legalizingabortion, primarily in thedeveloped world but also in othercountries

• This trend slowed after 1984when the Global Gag Rule wasfirst introduced

• Between 1985 and 1997 another19 countries eased abortion laws

• More recently, another 11countries have liberalized theirabortion laws

• At the same time five countrieshave tightened their laws

• 25 per cent of the world’spopulation continue to live incountries where abortion is illegalor severely restricted

• In other countries, access toservices and information is beingseverely restricted while abortionremains legal under certainconditions

• The interpretation andenforcement of national laws, and the attitude of the medicalcommunity towards abortion,critically affect access to services

• Studies have proven thatlegalizing or liberalizing abortionlaws does not lead to an increasein the over all abortion rate

Worldwide abortion law: A public health concern

Ensuring adequate informationabout abortion and access to safeand affordable abortion servicesare as important as legalizingabortion; unless these things areconcurrent, unsafe abortion willcontinue to devastate the lives ofmillions of women worldwide.

In countries where abortion isallowed, legal barriers cansignificantly delay access to safeservices which can have negativeconsequences for a woman’s well-being. Mandatory waiting periods,the need for spousal or guardianconsent and the need to travellong distances to an authorizedprovider all act as impediments toaccessing safe abortion.

This is equally true of affordability.High costs involved in acquiring asafe abortion affect poor womenthe most and can lead to womendelaying an abortion until a later,more dangerous stage of pregnancy.

In India, despite 30 years of legalprovision of abortion services, therecontinues to be a ratio ofapproximately 6:1 of illegal to legalabortions, contributing to over 15per cent of the maternal death rate.This is largely due to lack ofawareness of the legal status ofabortion, a lack of access to safe,hygienic abortion services and ashortage of skilled medicalpersonnel, especially in rural areas.

Access to safe and legal abortion services

Grounds on which abortion is permitted around the world

To save the woman’s life

Also to preserve physical and mental health

Also in cases of rape or incest

Also in cases of fetal impairment

Also economic or social reasons

Also on request

Population concerned (millions) Number of countries

The World Health Report 2005, WHO

Gete (not her real name), a 22year old Ethiopian woman, cameinto a Family Guidance Associationclinic in Addis Ababa because shehad been raped. She originallycame from Gondor in the northbut moved to Addis to find work,living with her aunt and unclesince 2004.

Gete was raped by a friend of hercousin. At the time abortion wasillegal in Ethiopia other than incases of rape and incest, and toaccess abortion services a womanneeded to obtain a police reportconfirming rape (this law hasrecently been liberalised). Thestigma surrounding rape andabortion is great and she wasreluctant to go to the police,thinking they would not believeher. When she told her uncle shehad been raped he threw her out.

When she found out she waspregnant Gete decided shewanted an abortion and,overcoming her fears, she went tothe police. They sent her to theclinic to get confirmation, butbecause she was already fourmonths pregnant clinic staff wereunable to confirm whether shehad been raped and were limitedto providing counselling andconfirming pregnancy for thepolice.

“If the woman does not receivethe correct documentation fromthe police, the clinic will be unableto refer her for a safe abortion. Incases like this it is common forwomen to visit illegalabortionists.”

Sister Mekele, head nurse of theAddis Ababa model clinic.

Country profile: Ethiopia

Medical abortion, a combination ofmedications, is a safe and highlyeffective method for ending anunwanted pregnancy, and isincreasingly the preferred methodin many developed and somedeveloping countries. At present itis largely unavailable to womenliving in the latter. Provided bytrained personnel, complicationsare rare.

Using the antiprogestogen,mifepristone, in conjunction with asynthetic prostaglandin analogue,the effects of medical abortion aresimilar to those of spontaneousabortion. In countries wheresurgical abortion presents severemedical or financial difficulties forprimary healthcare systems,medical abortion has proved to beeffective and user friendly, andoffers real hope of making safeabortion much more accessible tothose women who need it most.

Medical abortion up to nine weeks’gestation requires two clinical visitsto administer two separate drugs,but can also be administered athome which is increasingly the casefor its second administration.Following administration of theprostaglandin on the second visit,90 per cent of women will abortwithin 4-6 hours.The procedure hasa 98 per cent efficacy rate. Beyondthe nine week period there is arequirement for additionaltreatment, although never asinvasive as surgical abortion, and ithas a 97 per cent efficacy rate.

One of the major benefits ofmedical abortion in developingcountries is that, for the vastmajority of women, the procedurecan be carried out on an outpatientbasis, requiring far fewer medicalresources.

Medical abortion: Saving lives in resource poor settings

Sarawati, a 37 year old healthcare worker from India said

“I wish this method [medicalabortion] was available when Iwas young and had anunwanted pregnancy. I went toa Dai [traditional healer]because I did not want to havesurgery done by the maledoctor; I had pain and fever formany days. I never could getpregnant after that, and myhusband left me.”

Medical abortion has beenused for over a decade in manyEuropean countries. In somecountries it now accounts forover 50 per cent of abortionsundertaken (Sweden 51 percent; France 56 per cent;Scotland 61 per cent).

IPPF/Chloe Hall

Gette preferred not to have heridentity revealed inthis photograph

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IPPF/Chloe Hall

Itenesh is HIVpositive and visitsYouth Centresrun by the FamilyGuidanceAssociation ofEthiopia to talk toyoung peopleabout what beingpositive meansfor their futurereproductivehealth

access to comprehensiveprevention of mother-to-childtransmission programs, HIVpositive women who give birth to HIV positive children are oftenblamed.

The right to have a family anddecide whether and when to havechildren is a fundamental part of awoman’s sexual and reproductivefreedom. Yet, women living withHIV are frequently denied thisright because society and serviceproviders do not believe that HIVpositive women should havechildren, or should even besexually active.

This is a tragic picture, whichpaints HIV positive women as bothculprits and victims, and implies adegree of coercion in the decision-making process. To date, fewstudies have explored how HIVpositive women make childbearing

Women of childbearing age livingwith HIV are as likely to have anunplanned pregnancy as thosewho are HIV negative, and areequally faced with the question ofwhether to have a child or not.However, in the case of the HIVpositive woman, the issue is morecomplex, for personal, familial,social, cultural, religious andmedical reasons.

Women living with HIV are oftenstigmatized for being HIV positiveand, if pregnant, for irresponsiblybeing sexually active andbecoming pregnant while HIVpositive. Sometimes they areunder pressure by family or healthworkers to have their pregnancyterminated, while in other casesthey are pressured by partners andsociety to have children. Womenliving with HIV can also bedemonized for seeking or havingan abortion. In the absence of

HIV-positive women and their right to choose

decisions. However, whatemerges from current research is the lack of respect and valueplaced on HIV positive women’slives.

It is clear that provision ofservices needs to be based onthe respect for the woman’ssexual and reproductive rightsand decisions, including, ifneeded, the right to safe andlegal abortion. Making availablesafe abortion services isextremely important for HIVpositive women as unsafeabortions become significantlyless safe due to the greater risksHIV positive women face ofsuffering complications such assepsis and haemorrhage.

No matter what their statuswomen should have the right todecide for themselves whetheror not to bear a child.

Every week at the Hospital dasClinicas in Sao Paulo, Brazil’slargest public hospital, women arerushed to the emergency roomwith severe vaginal bleeding.

Most are in their teens or early20s and live in the dirt-poor slumsthat encircle South America’sbiggest city. Some say they haveno idea what caused the bleeding.Others tell elaborate stories ofmenstruation gone awry.

But hardly any own up to thetruth; scared of being turned in tothe authorities in a country whereabortion is illegal, they are reluctantto admit they induced miscarriageby inserting a black-market ulcermedication into their vaginas.

Although abortion is outlawed inBrazil except in rare circumstances,the country has one of the highestabortion rates in the developingworld. The Health Ministryestimates that 31 percent of allpregnancies end in abortion. Thatworks out to about 1.4 millionabortions a year, mostly clandestine.

In the United States, whereabortion was legalized in 1973,about 25 per cent of allpregnancies end in abortion. Inthe Netherlands, a country withsome of the world’s most liberalabortion laws, the ratio is closer to 10 per cent.

Despite its prevalence, abortionlargely remains a taboo subject inBrazil, the world’s biggest RomanCatholic country. But that is nowchanging as civic groups and somemedical professionals prompt apublic debate on abortion bychampioning a woman’s right toend an unwanted pregnancy. Theywant to prevent women fromdying from clandestine abortions.

Currently, abortion is only allowedin cases of rape or when themother’s life is in danger. But eventhen, getting a judge to authorizethe procedure can be difficult, andsome doctors refuse to performabortions on religious grounds.

Botched abortions are the fourth-leading cause of maternal deaths

in Brazil. In 2004, some 244,000women were treated forcomplications from clandestineabortions in public hospitals,costing the government 35 millionreals (£9 million).

Brazil’s abortion laws alsohighlight its gaping socialinequalities. Well-to-do womenresort to clandestine but safeclinics to end their pregnancies,paying as much as 1,500 reals(£400) - five times the monthlyminimum wage - for an abortion.

Most poor women, by contrast,turn to an ulcer drug calledmisoprostol, better known by thebrand name Cytotec. Wheninserted into the vagina Cytoteccauses the uterus to contract,expelling the embryo or fetus.

Reuters news agency report, 10 January 2006

Country profile: Brazil

IPPF/JennyMatthews

Although abortionin Nepal has beendecriminalised and many womenimprisoned forillegal abortionhave beenreleased, they arestill aware of thepotential stigmasurroundingabortion

“That’s how so many women confrontthe problem: ALONE.”Dr. Gladys Bazan – Gynaecologist, IPPF Member Association in Peru.

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A future free from death and denial?

IPPF advocates for: “A universal recognition ofa woman’s right to chooseand have access to safeabortion, and a reduction inthe risk of unsafe abortion.”IPPF Strategic Framework

When abortion is legal and servicesare both accessible and safe, thechance of a woman dying or beingphysically harmed from eithersurgical or medical abortion isnegligible. Indeed, abortion is oneof the safest medical procedures. Itis a public health tragedy then thatalmost 200 women around theworld continue to die each andevery day due to complicationsfrom unsafe abortion, virtually all ofthem living in the developing world.

Women who are already facing afuture of limited opportunities andsocial inequalities, who findthemselves with an undesiredpregnancy, must also encounter the often deadly risk of an abortionperformed by someone withoutany medical training in unsanitaryconditions, or by attempting to endan unwanted pregnancy themselveswith traditional methods.

This report has sought to highlightsome of the key issues related toabortion in countries where it iseither illegal or severely restricted.Our hope is that one day womenwill no longer have to put theirlives and health at risk from unsafeabortion; for this to be a realityabortion must be both legal andsafe everywhere. It is IPPF’s beliefthat a woman’s right to choosewhether to have an abortionshould never be compromised byunwarranted intrusion from thelaw, or the very real risk of deathdue to the lack of minimal medicalstandards and skills.

It has been shown that by makingfamily planning and reproductivehealth services available, the rate of unintended pregnancy dropssignificantly, thus decreasing theneed for abortion.

However, even with the mostefficient use of contraceptionunwanted pregnancies will stilloccur.

The most important message fromthis report for governments tounderstand is that by criminalizingabortion the issue does not goaway; women will continue to seekabortions for all the reasons outlinedin this document, and women willcontinue to die. We therefore needto make sure that if a womanchooses to have an abortion, it isboth safe and legal.

This report has highlighted that weneed to create the political will to:

1.Reduce unwantedpregnancies

•Build upon past gains in sexualand reproductive health

•Increase access to familyplanning

•Focus on the needs of poor and rural women and men

•Promote women’s status and rights

2.Make safe and legalabortion available to everywoman who wants it

3.Address gender inequality•Create the circumstances in

which women are socially,politically and economicallyempowered

4.Ensure that post abortioncare services to womenwho have incompleteabortions or medicalcomplications following anabortion are included inboth public and privatehealth services

5.Eradicate unsafe abortion

•Increase access to safe andlegal abortion

•Reduce legal and socialbarriers to safe abortion

6.Hold governments in bothdeveloped and developingcountries accountable forprogress

•Document the impact ofunsafe abortion on women,families and society

•Educate the public about theconsequences, the costs andthe social injustice of unsafeabortion

7.Tackle the stigma anddiscrimination attached toabortion and promote theopen and frank discussionof abortion and its impacton women

The commitment of theDepartment for InternationalDevelopment means that theUnited Kingdom continues topromote a global approach tolegalizing abortion based onpublic health evidence. IPPFstrongly supports this approachand will continue to work withthe Government of the UnitedKingdom, as well as otherdonors, to spearhead thisundertaking.

Without the hard work of so manyof our Member Associations whohave refused funding from theUnited States due to their belief insafe, legal abortion, and whocontinue to confront policy makersaround the world, the future forwomen in many countries wouldremain unchanged.

There is a gradual shift in theabortion paradigm and amovement towards liberalizingabortion laws. This report shouldhelp to keep up this momentum.By providing real evidencedemonstrating the public healthimpact of unsafe abortion,particularly its links to socialinequality and poverty, we canhope to persuade governments tomake abortion both legal and safe.We must continue to make thearguments for a woman’s right tochoose whether to have anabortion and to ensure that, if shedoes, she is not putting her life orhealth in jeopardy. Only then canwe look towards a brighter futurewhere women no longer face therisk of death and denial.

BibliographyAccess Denied. (2005) The Impactof the Global Gag Rule in Kenya.(http://www.globalgagrule.org/)

Access Denied. (2005) The Impactof the Global Gag Rule in Nepal.(http://www.globalgagrule.org/)

Alan Guttmacher Institute. (1999)Sharing Responsibility: WomenSociety and Abortion Worldwide.Alan Guttmacher Institute,Washington DC, USA.

Bradford, Carol and Holmes, Sue.(2005) Joint Output to PurposeReview of DFID Funded Projects onAccess to Safe Abortion.Department for InternationalDevelopment, London UK.

Centre for Reproductive Rights.(2004) Making Abortion Safe, Legaland Accessible: A Toolkit forAction. Centre for ReproductiveRights, New York, USA.

Department for InternationalDevelopment. (2004) ReducingMaternal Deaths: Evidence andAction. Department for InternationalDevelopment, London UK.

Gillespie, Duff. (2004) MakingAbortion Rare and Safe. TheLancet, 363:74.

Global Health Council. (2002)Promises to Keep: The Toll ofUnintended Pregnancies onWomen’s Lives in the DevelopingWorld. Global Health Council,Washington DC, USA.

International Centre for Researchon Women. (2005) TowardAchieving Gender Equality andEmpowering Women. InternationalCentre for Research on Women,Washington DC, USA.

Ipas, (1995) Ten Ways to EffectivelyAddress Unsafe Abortion, Ipas,Chapel Hill, USA.

Ipas. (2003) 5 Portraits, Many Lives:How Unsafe Abortion AffectsWomen Everywhere. Ipas, ChapelHill, USA.

Ipas. (2005) Global Abortion News Update.

Nerquaaye-Tetteh, Joana. (no date)Access to Reproductive HealthServices: Political Reality in Africa.Planned Parenthood Association ofGhana, Ghana.

Planned Parenthood Federation ofAmerica. (2003) The BushAdministration, The Global GagRule, and HIV/AIDS Funding.Planned Parenthood Federation ofAmerica, Washington DC, USA.

Vekemans, M and De Silva U.(2005) HIV Positive Women andTheir Right to Choose. Entre Nous,No. 59.

United Nations Population Fund.(2005) The State of WorldPopulation 2005. United NationsPopulation Fund, New York, USA.

World Health Organization. (2003)Safe Abortion: Technical and PolicyGuidance for Health Systems.World Health Organization,Geneva, Switzerland.

World Health Organization. (2004)Unsafe Abortion: Global andRegional Estimates of Incidence ofUnsafe Abortion and AssociatedMortality, 4th Ed. World HealthOrganization, Geneva, Switzerland.

World Health Organization. (2005)World Health Report 2005: MakeEvery Mother and Child Count.World Health Organization,Geneva, Switzerland

Deliver. 2003. “No Product? NoProgram! Reproductive HealthCommodity Security for ImprovedMaternal and Child Health.” Paperpresented at the Fourth OrdinaryMeeting of the West African HealthOrganization, Banjul, Gambia,14–18 July

Who we are

The International Planned Parenthood Federation(IPPF) is the strongest global voice safeguarding sexualand reproductive health and rights for peopleeverywhere. Today, as these important choices andfreedoms are seriously threatened, we are needednow more than ever.

What we do

IPPF is both a provider and an advocate of sexual andreproductive health and rights. Our voluntary, non-governmental organization has a worldwide networkof 151 Member Associations in 183 countries.

Our visionWe see a world where women and men everywherehave control over their own bodies, and thereforetheir destinies. A world where they are free to chooseparenthood or not; free to decide how many childrenthey’ll have and when; free to pursue healthy sexuallives without fear of unwanted pregnancies andsexually transmitted infections, including HIV.

We will not retreat from doing everything we can tosafeguard these important choices and rights forcurrent and future generations.

International Planned Parenthood Federation 4 Newhams Row, London, SE1 3UZ, United Kingdom

Tel +44 20 7939 8200Fax +44 20 7939 8300

Email info@ippf.org www.ippf.org

Cover photo: IPPF/Jenny Matthews

Published in January 2006, London, United Kingdom© 2006 International Planned Parenthood Federation