Safer Abortion Services – What Has Made The Difference

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Dr. Ian Cooke: “Safer abortion services - how the law can make a difference.  We know that laws affecting clinical care of abortion health system services and women’s empowerment can all affect the ability to make abortion services.  We know that the greater the number of grounds, and the fact that where abortion is legal on extended grounds can have a significant affect on abortion related mortality.  We know that where laws facilitate availability of and access to abortion care can also have a significant impact.  We know that where third party authorizations do not exist women can access care more readily and more safely.  We also know that when women are empowered and know the legal indications for abortion and the human rights relating to the access of abortion, this too can have a huge impact.  In other words, there are three sets of laws; like concentric circles they affect clinical care, health systems delivery, and women’s empowerment, and if properly implemented - and that’s a big if - can make abortion safer.  In the remainder of my time I want to talk about how obstetricians, gynecologists, lawyers, and women’s health advocates can work together to ensure the more effective use of the law in making abortions safer.  I will address this in three ways – clinical care, health systems, and women’s empowerment, and I’ll make two points under each section.  

Clinical care - yes, we need to work together to reform laws to extend the grounds for abortion and to insure abortion is available on request at the earliest possible stage of pregnancy but until that utopia exists, there is much that we can do to operationalize existing indications for abortion as has been so creatively done in Brazil with the 1999 technical norm of the National Ministry of Health for the certification of sexual violence leading to unwanted pregnancy.  That’s a fancy way of saying that in Brazil now there is a Ministry of Health protocol that explains how women can access abortion in cases of rape and sexual abuse.  Lawyers, obstetricians, gynecologists, and women’s health advocates need to work together to operationalize other legal indications as has been done in Brazil and to inform women about them.  Abortion is legal in most countries to save the life of the woman, how can this indication be operationalized?  Through protocols, administrative health regulations, and perhaps ethical guidance to inform healthcare providers, clinics, hospitals, and women on how abortion is legal to save the life of the woman.  Yesterday, I attended the excellent session on malaria and pregnancy and learned the difficult circumstances women face when they are pregnant and with malaria.  They are at a much higher risk of pregnancy.  How can we use this information to develop similar protocols to show women who have malaria that this is an automatic indication for abortion in countries where abortion is legal to save the life of the woman?  There are many other ways that we should work together to insure that abortion is available on other grounds, such as therapeutic grounds.  How can we inform women who are pregnant and have HIV, who are pregnant and have hepatitis, and who are adolescents?  Those risk factors for maternal mortality, how can we use them to explain that where they exist they need the criteria for legal indications to save life and to save health?  

The second point under clinical care is legal conditions for the delivery of clinical care.  We have the general delivery of clinical care such as confidentiality, the scope and limitations of conscientious objection, free and informed choice, including informed consent and informed descent.  What we have not adequately addressed is in this reproductive health field to insure that services are provided confidentially.  I stress the importance of free and informed choice because we have anecdotal information that women who are HIV pregnant are being coerced into abortion all too frequently.  This in the next period is something that we have to address and we have to address it very seriously through clinical guidelines.  For those women who are vulnerable to coerced pregnancy, we need to address those issues and we need to develop some guidance on a free and informed consent in this area.  Insuring access to the safest and most effective care, where the safest and most effective care is not used, for example, where a D&C is used instead of vacuum aspiration when we know vacuum aspiration would be safer, there is a huge utilization gap here.  David Grimes has spoken eloquently on the issue of utilization gap in healthcare generally and how it can apply in the area of reproductive health services including abortion.  Where the utilization gap is wide, this is a denial of women’s rights to the benefits of scientific progress.  We need to train women, healthcare providers, and lawyers to use this language to hold governments accountable to insure that the utilization gap is narrowed and to insure that women have access to the safest and most effective abortion care.  

The secondary thing I want to address is health systems, and the two points I want to make is that excessive requirements such as third party authorization, husband’s authorization, parental authorization, committee authorization, and other excessive requirements for clinical care - excessive clinical licensing requirements, unreasonable doctor certification or health provider certification that don’t reasonably relate to the safety of the care, this is a denial of women’s rights to her health.  Recently we had extremely important developments in international human rights law; it’s called the General Common on the Right to the Highest Attainable Standard of Health issued this summer by the Committee on Economic Social and Cultural Rights.  This is a committee that monitors the implementation of the International Covenant on economic social and cultural rights, and it outlines in very detailed ways how governments are responsible for insuring access to care generally.  We need to take that General Comment 14 which is available on the U.N. Human Rights website and apply it in this context.  Essentially, we can use it to say that where excessive requirements exist in the delivery of healthcare to women that is a denial of their right to healthcare.  

The second point is where governments neglect effective implementation of the law. That too is a denial of women’s rights to healthcare.  Neglecting women’s health needs where abortion is legal is a denial of their right to health.  Neglecting to train healthcare providers in the delivery of healthcare, and neglecting women’s health needs by privatizing health services too is a denial of their right to healthcare.  In other words, governments cannot avoid their obligations under national and international human rights laws by privatizing this issue.  Governments are responsible for health whether it’s delivered through the public or private sector.  There is a whole line of cases that has recently been decided by different courts around the world requiring access to care in emergency situations and requiring access to treatment by AIDS victims.  These cases are from South Africa, India, Venezuela, Brazil, and I know not how many more cases have been decided by other courts.  Courts, in other words, are beginning to recognize health, and women’s health in particular, as a social justice issue that governments have to face.  

Thirdly, and finally, I want to address the issue of women’s empowerment.  We know when women are empowered and know their rights they access care more readily.  We have very important developments in feminist thoughts that also can help the discourse in this area.  The General Comment 24 of the Committee on the Elimination of Discrimination Against Women on Women’s Health says specifically that criminalizing medical procedures that only women need constitutes sex discrimination.  

Finally, the International Covenant on civil and political rights issued a statement on the report of Peru saying that forcing a woman to carry a pregnancy to term contrary to her will, in other words, using women as vessels, is inhumane and degrading treatment.  It is a denial of women’s human rights to be free from inhumane and degrading treatment.  Therefore, denial of necessary care particularly in the area of treatment of incomplete abortion can be characterized as inhumane and degrading treatment.  In discussing the law, let’s think about the law not as technical regulations but as a forest, as a discourse that gives us the language to talk about not only the technical regulations but also how we value women in society.  We need to develop legal avenues in every single country.  We need lawyers, women health advocates, and doctors to diagnose the trees and the forest of the law and to move forward to insure that we hold governments accountable for eliminating laws that are detrimental to women’s health and neglecting women’s health needs.  

Thank you, and congratulations to Ipas for holding this meeting.”