I Know This Much Is True: Abortion Is A Medical Intervention to Which Women Need Access

@RHRealityCheck

Savita Halappanavar’s death is personal to me.

No one knows for sure yet what happened to Savita Halappanavar. We know that she wanted to be pregnant, that she miscarried, and that the care she received did not save her life. It is important to push for medical accountability in such cases, and to demand a full investigation into whether protocols existed and were followed, and if the patient was subject to discriminatory harassment and remarks, as has been alleged. It is positive that an expert has been appointed to carry out such an investigation.

But we do not have to wait for the investigation to highlight what we already know about abortion in Ireland. For me, this knowledge is weighty and painful.

In 2009, I went to Ireland with a colleague to talk with women, medical providers, and government officials about the impact of Ireland’s restrictive abortion laws on women’s health and lives. No government official agreed to receive us despite multiple requests for meetings. This refusal was the backdrop of the desperation and sadness that was palpable in the voices and testimonies of all the women, doctors, social workers, and community educators we spoke to.

And here is what I learned.

I learned that the Irish government has yet to regulate access to life-saving abortions in Ireland, despite the fact that such medical interventions have been legal in that country for two decades. I learned that the legality of abortion where the pregnant women’s life is in danger was upheld by the Irish Supreme Court in 1992 and supported by a referendum that same year. So while abortion, generally, is criminalized in Ireland, women whose lives are threatened by their pregnancy are constitutionally entitled to have an abortion in Ireland.

And in 2010, I saw that the European Court on Human Rights berated the Irish government for not regulating access to life-saving abortion clearly, creating insecurity for medical providers and patients alike. In 2011 the United Nations Human Rights Council issued various recommendations to the same effect.

My research taught me that many medical providers in Ireland want clarity on when they can intervene and when they cannot. Some asked me how the government proposes they treat a woman who may or may not die as a result of her pregnancy. Should they tell her to come back when she was sure she was going to die? How would she know? And what if it was too late? Who would be responsible for such preventable deaths? In fact, during our research in 2009, and despite the fact that abortion in life-threatening cases had been legal for almost two decades, we were not able to find one single medical provider who had ever heard of a life-saving abortion taking place in Ireland.  

But more than anything, I learned about the pain and fear pregnant women face when something is clearly wrong with their pregnancy and they know they can’t get care near home. I know this because they told me. Some told me with their heads bowed, others sitting straight up. Some told me calmly, others cried. They all spoke with quiet, sad voices about a society that does not see their suffering and a government that does not seem to care.

Savita Halappanavar’s death, however it happened and whomever (if anyone) is responsible for delivering substandard care, should serve as an opportunity for a deeper and more respectful conversation on this topic in Ireland.

Abortion is a medical intervention to which women need access, some to save their lives. This is not an opinion; it is a fact, evidenced by the thousands of women who travel from Ireland to the United Kingdom or mainland Europe to terminate pregnancies every year.

And knowing this, how can we not act?

Deserving vs. Undeserving? Everyone "Deserves" Human Rights

@RHRealityCheck

Most of the issues highlighted during this year’s run-up to the US presidential election are framed in terms of separating the deserving from the undeserving. Abortion for rape victims, but not those who want to have sex. Immigration for the politically persecuted, but not those who move across borders because they need to find a job. Marriage benefits for those who have sex with the right people in the right way.

This debate misses the point in two key ways.

At the most basic level, the issues at hand are basic human rights and not dependent on who "deserves" what: we have a right to access to abortion, health care, work, and freedom and movement because we are humans, not because we deserve it.

But also as a political process, it is ineffectual to focus policy debates on whether or not specific people deserve the services and public goods they clearly need.

I was reminded of this the other day as I was boarding a plane and the flight attendant asked me about the meaning of my t-shirt which read: “Immigration is the sincerest form of flattery.”

"But does that mean you are for it or against it, though,” he asked. I was stumped for words.

Immigration is a reality, just like so many other issues people insist on declaring themselves “for” or “against.” Abortion, adolescent pregnancy, sex outside marriage, sex work, identifying as lesbian, gay, bisexual, transgender, or intersex… the list could go on.

None of these issues is fringe. One in three women in the United States will have an abortion by the age of 45. Every year, 750,000 girls between the age of 15 and 19 get pregnant in the United States. Ninety-five percent of all Americans have sex before they get married (or have sex and may never get married). While it is difficult to estimate the number of sex workers, the National Task Force on Prostitution estimates that over one million people in the United States have worked as sex workers. And a 2011 study shows that almost 9 million adults identify as lesbian, gay, bisexual,transgender, or intersex, i.e. about 4 percent of the US population. As for immigration, very few people in the United States do not trace their ancestry—even their recent ancestry—to immigration.

But more to the point, none of these issues will change through declaring them good or bad. The focus for a policy maker should be how to generate policies that most effectively guarantee the maximum level of welfare and human rights-enjoyment for everyone. And from that perspective, whether someone is “deserving” or not is irrelevant.

Abortion and adolescent pregnancy numbers depend on access to comprehensive sex education and contraception. Choices about sex work and immigration to a large extent depend on available work and whether individuals are able to provide for themselves and their families in any other way. And those who believe they can change someone’s sexual orientation or gender identity just by saying they “don’t believe in homosexuality” are more delusional than most. Even those who make a career out of not believing in homosexuality can’t change their own (completely legitimate) sexual orientation.

There is, of course, an enormous difference between the issues high-lighted here: some are medical procedures, some life experiences, some innate traits. However that may be public policy on health, sexuality, immigration, and employment should not be designed to punish us for being who we are or for doing what we feel we need to do, but rather make sure everyone is equally empowered to make the best choices for themselves.

Fatal Consequences: Women, Abortion, and Power in Latin America

Lucila was twenty-two when I spoke with her in 2004 in the mud-floored office of a women’s group on the outskirts of Buenos Aires, while conducting research for a report on reproductive rights in Argentina. During her first pregnancy two years earlier, the doctors at the local public hospital had diagnosed her with a rare heart condition, which converted her otherwise healthy pregnancy into a potentially lethal situation. Lucila was told, in no uncertain terms, that another pregnancy could kill her.

Nevertheless, when Lucila begged these same doctors to sterilize her, they refused the operation, telling her that she was “too young” to stop procreating. Lucila suffered regular beatings and rape at the hands of her husband and was unable to prevent another pregnancy—when I talked to her, she was already showing. And though she qualified for a legal abortion, even under the very strict Argentina law, she was barred from having one due to lack of proper regulation and the extreme stigma attached to abortion.

I later learned Lucila had managed to terminate her life-threatening pregnancy illegally. I did not hear under what conditions, though chances are they were not good. The Argentine health ministry admits that illegal abortions account for approximately one-third of maternal deaths in the country.

(This post is chapter from a newly published book, The Unfinished Revolution: Voices from the Global Fight for Women's Rights)

While Lucila’s situation probably is extreme, it is by no means exceptional. Latin America is home to some of the world’s most restrictive abortion laws. Three countries criminalize abortion in all circumstances, even when the pregnant woman’s life can only be saved through terminating her pregnancy: Chile, El Salvador, and Nicaragua.

Across Latin America, most countries apply an “exceptions” model where abortion generally is outlawed but penalties are waived in specific circumstances, such as if the pregnancy threatens the life or health of the woman, if the pregnancy is the result of rape or incest, or if the fetus is so seriously damaged it is unlikely to survive birth. Only in Mexico City and Cuba is abortion freely available to all women and girls who need the intervention, as long as they seek an early termination.

The restrictions placed on access to legal abortion have not made the practice scarce. In Argentina, an estimated 40 percent of all pregnancies terminate in induced abortions. In Peru, that proportion is 37 percent, and in Chile 35 percent. Most other countries in the region, including Mexico but also the United States, maintain a 20 percent ratio—one induced abortion for every 4 live births.

In fact, if you look at criminal law as only one of many potential policy instruments to affect the social phenomenon that is abortion, it would appear to be a very ineffectual choice: where abortion is illegal, it is equally—if not more—prevalent than in jurisdictions where it is legal. Also where abortion is illegal, it is much more likely to be unsafe. “You get overwhelmed by desperation,” a thirty-five-year-old mother of ten children told me in Argentina. “You seek all the ways out, pills, anything. But if there is no way out, then you take a knife or a knitting needle.”

Despite these facts, there are harsh criminal consequences for abortion in most Latin American countries. When it comes up in political or legislative debate, the criminalization of abortion is justified with reference to a need to protect the right to life of the unborn, and to a reluctance to “promote” abortion, which is considered a moral evil. In Peru, a prominent member of congress reportedly said it is better for a pregnant woman to die—and for her unborn child to die with her—than for her to have an abortion. This same argument was aired in Nicaragua when the parliament in 2007 decided to criminalize so-called therapeutic abortion (to save a woman’s life and health), which had been legal since 1893.

Complex Notions of “Right” and “Wrong”

It is of course true that any government has a vested interest in promoting a civic sense of right and wrong. As human rights activists we routinely expect governments to promote laws that dictate certain morals, such as equality between men and women, the inappropriateness of corporal punishment, and the need to abolish the death penalty. The difference between these issues and abortion is not that abortion is too complicated. There is actually quite broad agreement in most Latin American countries that while abortion is “wrong,” so are blanket bans of the practice.

The difference is that laws that promote equality and ban violence are generally effective in doing just that. Constitutional protections of equality, for example, have led to guarantees of equal pay for equal work. And the effective prosecution of domestic violence and even jaywalking has been proven to deter those practices, at least in part.

By contrast, the morals expressed through the stigmatization and criminalization of abortion are routinely set aside by women and girls who feel they need to terminate their pregnancies. In fact, of the hundreds of women I have interviewed over the years about pregnancy and choice, many have only a rudimentary or confused understanding of the law, but they have a clear sense of what is right. I have spoken to many women from various countries in Latin America who have expressed beliefs about the moral acceptability of abortion in specific circumstances, depending on the financial, marital, or emotional situation of the pregnant woman, and her ability to love the child if he or she were ever born.

“I don’t think [abortion] is really all that criminal during the first month,” Marienela, a thirty-seven-year-old mother of six, confided in me, as we were huddling in the corner of a dark old stable that functioned as a social hall in a slum quarter outside of Santa Fe, Argentina. “But if you already are seven months pregnant, then you have to have it.”

“Sometimes abortion is the best option,” a staunch pro-life activist said to me in 2006. The same woman declared not to believe in the need for modern contraception, but readily conceded the untenable nature of the current setup in her neighborhood, a muddy slum on the outskirts of Tucumán, Argentina: “The most usual form of contraception here is nothing: people either have children or badly done abortion...It’s still something I am thinking through, but I know we have to work on making sure that no one needs to get to that point.” She then looked at me and said quietly, “You cannot even imagine what women end up putting in their uterus.”

The sentiment that abortion is not a moral evil if you didn’t want to be pregnant in the first place is both prevalent and pragmatic in the many women I have spoken to, and also surprisingly clear. “Abortion is necessary,” said one woman in Nicaragua in 2007. “You can’t just bring an undesired child into this world, especially when you didn’t try to have one.” In fact, women and girls already know what they need in order not to need abortions. The vectors that influence real choice are neither fetal rights nor physical autonomy in the abstract. It’s a very concrete sense of what is possible and what makes for a better life—mostly for the child.

Time and time again, women articulate concern about economic stability and the need to feed an existing family. They talk about apprehension with regard to bringing a child into an abusive relationship, often only commenting in passing on their own suffering and pain. They talk at length about difficulties in accessing affordable, easy-to-use, safe, and effective contraception of their choice.

And they always describe variations on a theme that sounds ideologically motivated but happens to be empirically true: that while women in Latin America are socially dependent on men, men are not held responsible for the reproductive disasters that ensue from the unprotected sex they often pressure women into having. “She got herself pregnant” is invariably the response I get from public officials to questions about why a particular woman should suffer through an unwanted pregnancy or unsafe birth. At times it is delivered with a dismissive shrug: “She is responsible for herself.”

Why Legalize Abortion?

These very real experiences should make for excellent public policy: tackling the three issues of violence against women, access to contraception, and gender-based discrimination is what will make abortion less needed. The legalization of abortion will make the practice safe. Most of these facts are undisputed. The real question is why none are adequately addressed in Latin America today.

The short answer is power. Everywhere in the region, proposals to legally limit access to abortion, and even absurd moves to extend the right to child support for all ova fertilized through rape, are used as political chips.

In Nicaragua, a 2006 vote to eliminate access to abortion for women whose lives were threatened by their pregnancy was scheduled a mere ten days before the presidential elections, and most accounts suggest that this was no accident. The fact is that in all of Latin America, churches are powerful players in national politics—in particular the Catholic church—and few candidates want to be seen as “pro-abortion” and thereby lose the support of the church and other politically influential conservative groups. In this particular election, parliamentarians from the Sandinista party were reportedly ordered to vote for the penal code reform so that their candidate, Daniel Ortega, would win, but with an oral promise from the Sandinista party leadership that the issue would be “solved” after the elections. Meanwhile, Ortega went on record saying that “abortion is murder.” More than five years after the blanket ban on abortion went into effect in Nicaragua, it is still in force with disastrous effects on women’s health and lives.

In Mexico, after the Supreme Court in August 2008 upheld a Mexico City law to legalize abortion in the first trimester, several federal states in the country moved to amend their state constitutions to ban it.

Most of these constitutional changes have little effect on women’s real access to legal abortion in those states: it was nearly impossible before and obviously not much better after. However, the fact that state legislatures were willing to spend time and energy on laws that are likely to have little effect on their stated objective is testament to how politically viable anti-choice arguments are, and how little power can be gained by raising the fact that women and girls continue to have abortions—some safe and most unsafe—regardless the legislative framework. And during the presidential campaign in Brazil in 2010, the ruling left-wing party dropped the support of sexual and reproductive rights from its draft human rights plan, perhaps in the hopes that this would ensure the support of the Catholic church which had started publicly referring to then-President Lula as “Herod,” an allusion to the king who, according to biblical accounts, ordered baby boys to be killed. During the Pope’s 2007 visit to Brazil, Lula had already publicly pledged that his government would never propose the legalization of abortion, but this further step was thought necessary to appease the church.

The point is not that morality-based arguments for the criminalization of abortion are always a cheap veneer on actions that are motivated by political gain. In fact, my interaction with activists on both sides of the apparent abortion divide suggests to me that most people who profess to be either staunchly pro-life or staunchly pro-choice in fact are deeply attached to their beliefs and the morality on which they base them. With civility and mutual respect, these beliefs should be aired in public debate.

The point is that the morality of public policy depends on both its intention and its effect. The effect of abortion bans—in particular in the Latin American context of gender inequality and limited access to contraception—is death and suffering for the women who need abortions, with no discernable effect on lowering the number of abortions. As such, abortion bans are both ineffective and immoral.

Unfortunately, the bans continue. Six years after I talked with Lucila, I interviewed another woman in the same impossible situation. Silvia, who suffers from a serious kidney disease that could make another pregnancy near fatal for her, told me she received no help or even sympathy from the doctors who would tell her almost in the same breath, on the one hand, that she couldn’t be pregnant and, on the other, that she had to carry the pregnancy to term: “I said, ‘But you told me that I shouldn’t have it! . . . I am close to needing dialysis as it is.’ . . . I said, ‘Are you going to guarantee that nothing will happen to my health?’ . . . She said, ‘I can’t guarantee that.’”

Winds of Change

Despite this grim state of affairs, there are indications that things are slowly starting to change for the better. In April 2007, abortion was decriminalized in Mexico City, and this law was later upheld as constitutional by Mexico’s Supreme Court. In 2008, Uruguay’s congress approved a law to legalize abortion in the first trimester of the pregnancy. At the time, the law was immediately vetoed by the president, but a similar proposal is currently under consideration with much better prospects. In November 2010, the Argentine Congress also started a series of hearings on the legalization of abortion.

All of these developments are fueled by a growing empathy for the plight of poorer women, in particular. Most people know someone who has had an abortion, and it is increasingly an open secret that the criminalization of abortion mostly affects women who can’t afford to go to the United States or to a private clinic for an illegal but safe intervention. The general rhetoric of the Latin America media on abortion has changed radically, even just over the past five years: questions and comments are now more about why women need abortions, not how to punish them for it.

Indeed, surveys confirm that most people in the region have a much more nuanced understanding of abortion than their elected officers: it must be legal, accessible, and rare. It is only a matter of time before policymakers catch on.



The Dangers of Being Female

@HuffingtonPost

This month was big on bad news for women. First, a family in Canada was convicted for killing four female relatives, then a woman was allegedly strangled by her husband in Afghanistan, and then a high-profile charity in the United States decides to withdraw funds to screen women for breast cancer.

There are two things that struck me as noticeable about these events and their news coverage.

The first is that in all of these cases, different as they may be, women are being punished for being women. The Canada killings were allegedly motivated by the girls' dating and wearing girly clothes. The woman in Afghanistan was supposedly killed because she had given birth to three girls in a row. And it is hard to think of a gesture that more clearly targets women for just being women, in my opinion, than defunding screenings for breast cancer.

The second thing that is noticeable about coverage of these recent events is that many people have expressed their outrage over them, making me feel tentatively optimistic about the future for women's rights. With that in mind, I am hoping that more people will start caring -- and expressing outrage -- about these three very common ways in which women are being punished for being female.

Limited workplace support for pregnancy. Dina Bakst's recent piece in the New York Times put it succinctly: "few people realize that getting pregnant can mean losing your job." Several reports and books describe the devastating effects of limited or weak support for pregnancy on women's careers, health and finances. Contrary to what some might suggest, providing support for pregnant women and new mothers through flex-time, job-protection and paid parental leave is not just good for women: it is good for their families, their employers and ultimately society as a whole. Leaving that aside for a minute, though, regardless of the overall beneficial effects of better work-life policies, women should not be punished for the biological fact that they can get pregnant and men cannot.

Assumptions about female weakness. Despite the fact that many women are the sole or main providers for their families, and despite women's advances as middle managers, women continue to be underrepresented in top leadership roles: in 2010, only 2.8 percent of Fortune 500 companies were led by women. Research repeatedly points to assumptions about women's "nature" as key barriers to promotion: women aren't thought to be as assertive as men, and are seen to lack vision and strength. It is telling that many job adverts suggest that "qualified women" are encouraged to apply. Men, this seems to imply, are qualified just by being male.

Punitive laws related to women's sexuality. Societies have viewed and regulated women's sexuality differently than men's for as long back as we can dig up evidence about. The ancient Greek city-states, for example, expected Greek women to be chaste and demure, and punished or ridiculed those who were not. Today, laws to punish women for having sex with the wrong persons at the wrong time for the wrong reasons persist in almost all countries in the world, ranging from the criminalization of female adultery and of abortion over laws that punish drug use during pregnancy to social services provisions that punish poor unmarried women with more than one child. At the basis of all of these laws is one main thought: Women should not really want to have sex.

All of these three issues are intimately related to the anti-women news items of this month. As long as women are undervalued, expected to bear the entire price of reproduction, and at the same time required to be outwardly asexual, we will see more women and girls killed, maimed and their health needs discarded. Hopefully, we can continue to muster outrage and actually generate change.

The complacency over unsafe abortions must end

@guardian

The results of the latest study on global abortion are no surprise – the shock is policy-makers have ignored such data for decades

The astounding thing about the global abortion debate is not that some people have deeply held views about what a pregnancy is and when a human existence begins. After all, both of these questions are closely related to that most ubiquitous of philosophical questions: what is the meaning of life? The astounding thing is that policy-makers continue to ignore carefully amassed information about the actual outcome of programmes and laws related to sexuality and reproduction.

In that context, one could only wish that the latest figures on induced abortion rates and unsafe abortion came as more of a surprise. The analysis, carried out by the US-based Guttmacher Institute and published in the Lancet, has two main conclusions: first, when governments fail to provide contraception for those who want it, abortion figures stay the same; and second, where abortion is illegal the procedure is predominantly unsafe. The foreseeable consequence – continued high levels of maternal mortality – also plays out in the data.

None of this is new or surprising, and we have, as one health advocate pointedly noted, known it for decades. The aggregate data, however, hides additional details the discerning policy-maker should take into account.

First, overall abortion and fertility rates present the consolidated result of millions of very personal decisions.

It is not an accident that abortion rates are higher and procedures more unsafe in poorer countries generally, and for poorer women everywhere. Because even though decisions about abortion are personal, the context in which they are made is not. In this sense, the frequency with which women and girls need abortions and the conditions in which they feel compelled to access the procedure is in many cases an expression of exclusion, stigma and discrimination.

This is most clearly illustrated by the seeming anomalies in the Guttmacher study. Take a country like India. Abortion is generally legal, and modern contraceptive methods are, in theory, available. Even so, the study found that two thirds of the 6.5m induced abortions that occurred annually in India were unsafe. The reason for this is the combination of available health infrastructure, poverty, moral condemnation of sex outside marriage and severe gender inequities in the labour market. This is the context in which the women and girls make their decisions. Those who are most likely to need an abortion – young or unmarried women, those pursuing education or those engaged in subsistence farming – either cannot afford a legal procedure or fear the stigma attached to going to a recognised clinic for care. As a result, they end up having unsafe abortions, not because the government doesn't allow legal care, but because it does not enable women to effectively access it.

Second, the 70,000 women who die annually as a result of unsafe abortion didn't just die because abortion was illegal in the country they live in. They died because their lives were seen as dispensable by those in charge. Maternal mortality caused by unsafe abortion is, in fact, entirely resource-specific. This is the very reason policy-makers can and do continue to ignore facts: the only women who die as a result of restrictive abortion laws are poor. Case in point: Mississippi, the US state with the highest poverty rate, also has incredibly restrictive abortion access and – not surprisingly – soaring levels of maternal mortality.

Finally, the study hides massive levels of complacency (or resignation), even among those of us who care. How is it that we don't ask for more informed positions from our policy-makers? Regardless of whether we identify as pro-choice or pro-life, or neither, we should all require some sort of plausible explanation for why the suggested solutions actually would generate the change we want. In this sense, if a key goal is lowering the number of abortions, we should not accept policies that police women's sexuality based on particular conceptions of morality.

In fact, we should accept nothing less than what the data for decades has shown to be effective: a policy package of comprehensive sexual and reproductive healthcare, including support for parenting, gender equality and poverty reduction.