Safer Abortions – What’s Made the Difference?

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Dr. Kaham Rogo: “Mine is a fairly simple task of trying to summarize in context what my very illustrious colleagues have already given you.  The topic really was safe abortion services what has made the difference and what can make the difference?  I think it’s important that a call for action is made to obstetricians and gynecologists who are at this Conference.  I chose this statement before I knew that Nafiz Sadik would be on this last Sunday here in our August gathering.  It’s a statement that Nafiz made during the Women’s Conference in Beijing, you will agree with me that it was extremely relevant then, five years ago, but it shocked me at how relevant it still is, particularly, to this meeting five years later.  She was talking to women but this is a statement that is extremely critical if she were here today and made the statement to obstetricians and gynecologists.  It strikes me that a statement that’s so relevant to women is even more relevant to obstetricians and gynecologists, and to me, this is where the conference’s one interest comes into focus.  

The big question, though, is to what extent have obstetrics and gynecologic societies responded in the way that Nafiz Sadik wanted women to respond?  You probably know, particularly the obstetricians and gynecologists who are here, that the FIGO Committee for the Ethical Aspects of Human Reproduction in Women’s Health came out with ethical guidelines regarding induced abortion for non-medical reasons.  It was formulated in 1998 in Cairo, published in 1999 in the International Journal of Gynecology and Obstetrics, and it’s also contained in one of the ethical guideline books, a blue one that I believe has been distributed to everybody starting this conference.  At Ipas, we decided early this year to send out a questionnaire and the objective was to try and assess the extent to which the obstetric and gynecologic society is more knowledgeable of these guidelines that come from FIGO, and whether they accept the guidelines or not, and much more important, to determine the extent to which they’re being utilized, to shift national policies and service deliverers in countries in which we can.  It was a very, very simple survey.  We sent a one-page questionnaire to 101 obstetric and gynecologic societies who are officially registered and paid up members of FIGO.  We got a surprise – fifty-seven responses, that’s 56%, which the older members of FIGO tell me is extremely good.  We analyzed fifty-five, two we did not analyze because the response from those societies were that our laws are clear on this so that is not a response that we can give you.  But the fifty-six that were analyzed had very interesting responses, one is that the obstetric and gynecologic society is generally well aware, as you’ll see there; awareness was the first question and is implicit.  How many have acted - that is a lot lower, less than 40%.  How many accept - extremely high, going nearly to 100%.  Interestingly too, is how we made the Ministers of Health aware of these things and, again, we come way down to just about 30%.  

What we see here clearly is that when it comes to knowledge, awareness, and acceptance our societies are knowledgeable, they are aware, and they accept but when it comes to acting and doing something about it either themselves or through their Ministers of Health, then we start finding a major problem.  We’ve analyzed this further as shown in this slide to differentiate between the societies from counties where maternal mortality is high and where maternal mortality is low.  We did this because we thought that probably some of the responses of not acting was because those societies were in countries where the laws and everything was already so good that they would not do anything despite the fact that last year this thing was sent to them.  But what you see here is a similar pattern, even in countries where maternal mortality is still high; we know too that those are countries where abortion is still a major killer.  Look at the second question and the fifth response there, you see the same thing happen in question one, three, and definitely question six, knowledge and acceptance great but action either by societies themselves or with the Minister of Health is extremely low.  We believe that this is an important finding for FIGO because often times at international meetings it will be quoted that the obstetric and gynecologic societies and FIGO has already made this statement but everywhere that we go in the country that we come from women still continue to die of the very things upon which we make that great statement.  

Our plenary conclusion is clear that there seems to be very, very strong support for the recommendations on this issue that come from FIGO but a very, very significant gap between acceptance and action.  Action, I believe, is an issue that Mahmoud Fathalla has raised, and let’s talk about it but in acts.  This to me is the issue that we have to put in context that, yes, over the last one hundred years differences have been made because of the laws and laws have helped us because of technologies.  Yes, they’ve helped us and to some extent because they have been providers, members of obstetric and gynecologic societies and members of the medical profession that have committed themselves to doing something.  Therefore, I propose, and this is something we’re bringing from Ipas, there may be room for us to start thinking of some six cardinal rules and responsibilities that all obstetric and gynecologic societies and the gynecologists should be able to undertake if we are to make bigger strides in the next millennium.  The first is that we must commit ourselves to expanding services, geographic, economic, and cost has been an issue that Rebecca touched on, and even more important is the level of providers.  

We are not enough as obstetricians, gynecologists, medical practitioners, and physicians, so going down to a midlevel provider becomes an imperative.  Second is the commitment and the role of creating awareness amongst women in communities and amongst men.  Rebecca mentioned very clearly that where women are empowered with knowledge they tend to access the services better, safer, and earlier.  This is a responsibility of providers as much as everybody else.  Third is improving the quality of care, in terms of the skills for the providers, a key area for us because members of obstetric and gynecologic societies are the biggest trainers, teachers, and professors in reproductive areas in their countries, in terms of the other areas such as attitude, which again, we’ll say that attitudes still remains a major problem for us.  In terms of technology, yes, we have not tried enough of that but we’ll mention that technology did come and has made a difference but cannot do it on its own.  In terms of treatment protocols, they are not there in places where they’re supposed to be.  Fourth, is simplifying guidelines and regulations for access to service and, again, Rebecca touched on this quite amply in terms of who is to give consent.  Three physicians to give consent in a country where there is probably less than one-hundred physicians in total - is that really realistic?  All the relatives to give consent when the person, the victim, does not want any relative to know - is that realistic?  Look at it in terms of planned flow, how many stops do you have before you eventually get your service, and how many people laugh at you and do not keep the secret?  In terms of waiting time, that makes you move from the first trimester when it is safe to the second trimester or even beyond the second trimester and, therefore, you have to deliver the baby.  Fifth, a responsibility is our support for legislative change.  Teamwork is a key here, we cannot do it on our own but, again, Rebecca stated clearly that the law is not just what is written there, there’s much more to it that needs to be put in place, and in our country where laws are not changed, our voices have not been heard enough.  The sixth one of these responsibilities is the protection of preservation of existing legal and solvate opportunities because we know that even in countries where there have been changes, the goal is a threat for reversal.  The threats are here in the United States, the threats have been in Poland, I believe they’re reversed and moving one way or the other.  They are having resistance in South Africa, and it has been there in India.  So those opportunities are important that when they’re there you take care of them.  

The big question still is - will we be able to do this thing so that we make a difference?  I seriously believe that deserving as every other honoree was that was given the honor on Sunday evening by FIGO, one thing was glaringly missing.  We did not even mention a name of a colleague or a provider who lost his or her life in the line of duty.  If this had been a military gathering, and it could have been extremely relevant in this country where our colleagues have died simply because they are providing a service, those names would have been there on a role of honor, even posthumously.  To me, that would probably be the biggest statement that FIGO could make in their commitment to the lives and dignity of women if before we leave this conference, we did mention the names of those people who have died in this country for no reason other than doing what the military people call ‘died in the line of duty.’  

Thank you.”