Argentina's Slow Tango With Women's Lives

(Originally posted on the Huffington Post)

In five days I will be addressing Argentina's House of Representatives about abortion. The occasion is as deliberately momentous as it is intentionally inconsequential. On the one hand, this is the first time Argentina's national congress has debated the legalization of abortion, and the hearing has been advertised in the national media for weeks. At the same time, the opening of this landmark debate has been scheduled in the last hours of the last legislative session this year, on a day of the week usually reserved for internal meetings.

This "schizophrenic" attitude reflects the way Argentina's government and congress have dealt with sexual and reproductive rights for decades.

On the face of it, Argentina has an impressive array of relatively well-defined and balanced laws and policies on the topic. Comprehensive sex education is mandatory in all schools. Laws stipulate that a spectrum of modern contraceptive methods must be available free through the public health system. The law also says that older adolescents must be allowed access to the medical care they need without parental authorization. And in July, President Christina Fernández de Kirchner took on the Catholic church to make Argentina the first country in Latin America to recognize same-sex marriage. Notably, abortion has been legal for more than a century for women and girls whose lives or health is threatened by their pregnancy, or when the pregnancy is the result of rape or incest.

But the law is one thing. Real access to information, services, and rights is quite a different matter. In 2005 and 2010, Human Rights Watch analyzed women's and girls' effective enjoyment of their human rights as they relate to sex and reproduction. Our conclusions were unfavorable. We found that multiple barriers keep Argentina's women from making independent decisions about their health and lives in the area of reproduction -- lack of information, inaccurate and incomplete information, domestic and sexual violence, and economic restraints the government has not addressed adequately.

We also found that the failure to remove these barriers comes at a real cost. Even today, an estimated 40 percent of pregnancies end in abortions, most of them illegal and unsafe. This in turn contributes to entirely preventable maternal deaths. In fact, unsafe abortion has been a leading cause of maternal mortality in the country for decades. In 2008, according to Argentina's national health ministry, over 20 percent of recorded deaths due to obstetric emergencies were caused by unsafe abortions.

Part of the problem is the politicization of issues related to motherhood, population growth, and, at the most basic level, sex. Argentina was one of the last countries in the Latin America region to abandon a top-down population policy approach that subjected individual decision-making to a nationalist interest in population growth. Until 1985 the sale and use of contraception was entirely prohibited, and even medical service providers still justify actions that curtail women's human rights by referring to a century-old maxim, "to populate is to govern." As recently as 1999, the government declared an annual national "Day of the Unborn Child," which some people still celebrate.

It is also true that any law that labels abortion a crime, even if it allows for exceptions, in practice makes it complicated -- if not impossible -- to get access to life- and health-preserving abortions. This is the situation in Argentina. Often, women are unaware of the circumstances in which they could legally get an abortion. Women who do seek them may be stonewalled by complicated procedures and hostile service providers in the health and justice systems. Many women with crisis pregnancies go directly to underground service providers, though some end up in the courts arguing for their right to health care, with varying success.

Much will be at stake when Argentina's parliament starts debating the legalization of abortion: women's lives, health and rights, as well as Argentina's reputation as a modern democracy respectful of human rights. I am honored to have been invited to take part in this debate. I hope the scheduling of the hearing is an indication of a busy congress rather than a symptom of the same erratic and selectively dismissive attitude that has plagued Argentina's engagement with this topic for years.

Illusions of Care

@The F-Word

In 2004, when I first went to Argentina to research women's reproductive health rights, I didn't expect a rosy picture. Argentina only ended an all-out ban on contraceptives in 1985, and some politicians and some medical providers still talk about women as instruments for population growth rather than as autonomous decision-makers.

But even if I hadn't known all that, the health statistics released by the national health minister told a story of despair. An astounding 40% of pregnancies in the country ended in - mostly illegal and unsafe - abortions. Complications from unsafe abortion have been the leading cause of maternal mortality in Argentina for decades. As a comparison, in most other countries in the region, between 15 and 25% of pregnancies end in abortions. It was obvious that something was very wrong.

No statistics, however, could have prepared me for what I found. Women who had been denied entirely legal abortions to protect their health and who suffered severe health consequences; the women and girls who had been raped and forcefully impregnated by their partners, and still could not get the police to enforce a restraining order; the women who had suffered miscarriages and sought help from a public hospital to contain the bleeding, only to find themselves the focus of police investigations.

But for me, the systematic devaluing of women's lives and decisions was the most jarring. Those using the public health system were stripped of choices: the medical provider would in many cases decide for them what contraceptive method they would use, or even whether they were old enough, married enough, young enough, had children enough (etc) to use contraception at all.

The women I spoke with did not ask for much. Most of them lived in resource-poor communities and expected to work hard for a living. In fact, many even expected abuse. Many articulated their day-to-day choices in terms of how they could best feed their children: a package of condoms cost the same as a liter of milk - you do the maths.

I spent the next five years supporting our Argentine partners as they pushed for legal changes within Argentina, and highlighting with international funders and United Nations bodies just how far the situation on the ground was from guaranteeing a life with dignity. These advocacy efforts paid off, at least on paper: spousal and judicial consent for voluntary sterilisation was declared unnecessary, by law, and sex education was made mandatory.

This year I went back to Argentina to see how much had changed for those women and girls who depend on the public health system for reproductive health care. The answer, depressingly, is not much. Government statistics confirm this. The central question is why.

Part of the explanation is linked to the continued politicisation of issues related to motherhood, population growth, and, at the most basic level, sex. Argentina legalised same-sex marriage last month, meanwhile talking about sex is still taboo.

In July 2010, the national health ministry declared its intention to guarantee access to (already legal) abortion. It immediately backtracked after aggressive questioning in the press.

Laws and policies meant to benefit women and girls go unimplemented - such as the legal exceptions to the general criminalisation of abortion, in cases when the pregnant woman's life or health is in the danger or rape. Key statistics and information are not gathered, not processed, or not shared with existing accountability structures, and when they are not, oversight can't happen. This indicates how little the government cares that laws and promises remain unfulfilled.

The report Human Rights Watch released yesterday in Buenos Aires, Illusions of Care, focuses on this lack of accountability. Or rather, it focuses on the fact that women and girls, more than a hundred years after the Argentine congress allowed for abortion in certain circumstances, and more than a quarter of a century since contraception became legalised, still don't have the power to decide whether, with whom or how often to become mothers. I trust in the transformative power of information and the fact that none of the women and girls I spoke to this time expected to be abused. They expect, deserve, and are entitled to better.

Access to Abortion in Ireland—A Key Human Rights Issue

(Originally published by the National Women's Council of Ireland)

Last week, Human Rights Watch launched our most recent report on women's rights -- "A State of Isolation: Access to Abortion for Women in Ireland". The report was based on interviews and research we conducted in Dublin, Cork, London, Birmingham, and Washington DC in mid 2008. And though the word "abortion" features prominently in the title, the report is about much more than abortion.

It is about the thousands of women who face crisis pregnancies every year in Ireland. And above all, it is about a government that actively sabotages their health.

Through our interviews with women who had traveled abroad for abortions, with medical practitioners, and with social workers, we documented the consistent obstacles women and girls face to independent and responsible decision-making about their pregnancies. They are not allowed to access the services they need within Ireland, they are aggressively discouraged from seeking the care they need abroad, and they cannot trust that the advice they receive is accurate or complete. Indeed, at the most basic level, the report is about information.

And to demonstrate just how important information can be, I want you to imagine a woman with a crisis pregnancy.

Perhaps she is one of the girls who got pregnant as a result of sexual abuse. Perhaps she is a married woman with 3 existing children and cannot afford to feed a fourth. Perhaps she is a student. Or a refugee going through an asylum procedure. Or perhaps she feels that something is not quite right with her pregnancy, health-wise.

Either way, she is a woman who believes she cannot and must not carry her pregnancy to term. But where can she turn?

Often, she may not know. The government has made sure that information about the termination of pregnancies remains difficult to access -- even information about how to get information about the termination of a pregnancy.

Those who provide accurate information about abortions abroad cannot advertise broadly and are prevented, by law, from supporting their patients in seeking care.

Meanwhile, those agencies who claim not to provide information about abortion remain unregulated, and therefore free to harass women and girls who are already in distress with harrowing medical claims many of which are completely inaccurate.

In many cases, the agencies that provide accurate information are indistinguishable from those that don't.

Worse still, women who depend on maternity hospitals and GPs for support also cannot be sure to get full information. Despite an exception in the law, clarified by the Supreme Court, that women have a right to an abortion within Ireland if their life is threatened by the pregnancy, there is no official protocol on when abortion might be legally performed in Ireland. Mostly doctors are reluctant to guess, and some, as a result, actively discourage pregnant women with complicated pregnancies from seeking full information about their health status: they can't do anything about it anyway.

Some might say: if the government's intention is to discourage women from having abortions, it looks as if their policy is working.

They would be wrong. Thousands of women and girls travel abroad for abortions every year. They are not prevented by the misleading or scarce information from seeking abortions. They are preventing from seeking abortions in a timely manner. This has a detrimental effect on their health, both physically and mentally.

Abortion, as a medical procedure, is safest when provided within the first 8 weeks of the pregnancy. And the longer a woman with a crisis pregnancy has to wait for the services she needs, the deeper her distress and ordeal. If the woman is suffering through a pregnancy with fatal fetal abnormalities or that has been the result of rape or incest, this is in some cases even more true. By stalling women's access to the care they need, the Irish government is complicit in their distress.

In other words: the government contributes directly to undermining women's health, dignity, and human rights. Because though decisions related to abortion are complicated and deeply personal, they are also a question of human rights. And the Irish government has an obligation to provide women with the support and information they need to navigate those decisions.

Regulating Abortion May Be OK But Not To Avoid Sex-Selection

(Originally posted on the Huffington Post)

Sex-selective abortion raises a multitude of overlapping ethical concerns regarding eugenics, population control, and provider privilege or knowledge. It was also, until recently, an issue we linked mostly to China, Korea, and India. Not anymore. Recent news coverage indicates that the son-preference that has led to sex-selective abortions abroad is alive and well in some ethnic communities within the United States.

This has generated a new discussion about what to do -- indeed, what to think -- about the practice here.

This week, one commentator -- William Saletan -- raised an essential issue in that regard: "Absolutists on both sides need to think carefully. If you're pro-life, how far are you willing to go in regulating abortion? If you're pro-choice, how far are you willing to go in leaving it unregulated?"

Full disclosure: I am a pro-choice European transplant to the United States. I am also a human rights advocate and researcher, and have spoken to dozens of resource-poor women about their reproductive choices. My answer to Mr. Saletan's question is invariably colored by this background and experience. And it falls in two parts.

1. The effect of abortion regulations depends on the context and motivation.

Regulation on abortion, or any other medical procedure for that matter, isn't bad per se. From a human rights perspective, the regulation of medical procedures and interventions is legitimate and indeed often necessary so long as they are based on full respect for the full range of human rights.

In the context of abortion, this, in some cases, has more to do with the context of the regulation than with the regulation itself. Many pro-choice commentators in United States have traditionally criticized the trimester-based regulation on abortion that is the norm in most of Western Europe. Generally, the criticisms are based on the fact that restrictions imposed on access to abortion after the first trimester in those European countries subject female decision-making to medical authority.

I have never had a problem with the European model as such. For one thing, it is, most often, implemented in the context of universal health care, comprehensive sex education, and parental benefits such as leave and childcare support. As a result, women seem to have more control over their parental choices to start with. For another, the social workers and doctors who make up the panels to whom women must apply if they want an abortion in the second or third trimester are generally directed to base their decision on the best interest -- health, life, broadly speaking -- of the woman involved. While there surely is much to criticize about the European model, it is not the fact that regulation exists.

By the same token, the relative lack of blanket bans or federal regulation on abortion in the United States does not mean that abortion access is easy, or, indeed, that woman can decide on their fertility without interference. In fact, studies indicate that the United States rate of unintended pregnancies is higher than the world average, and much higher than that in other industrialized nations.

Moreover, despite the apparent illusion that abortion is unregulated in the United States, it is actually already pretty heavily regulated. Many women and girls face serious legal or financial obstacles to accessing safe abortion services because of burdensome regulations, lack of providers, insufficient funding, or political opposition. Also, US restrictions on abortion, whether at the state or federal level, are not motivated by concern for women, and are often implemented in a context in which lack of access to health care generally and to contraceptives specifically make it even harder for women to control their fertility prior to a crisis pregnancy.

2. Regulating sex-selective abortion by banning it would not eliminate the practice.

In the face of news that the gender balance of certain ethnic groups in the United States is starting to tilt, it is perhaps tempting to hope that banning sex-selective abortions would safeguard the gender balance of future generations. However, the criminalization of abortion for whatever reason has in the past led only to underground and unsafe practices. In fact, the criminalization of sex-selective abortion would put the full burden of righting a fundamental wrong--the devaluing of women's lives--on women.

The fact is that many women who choose to abort a fetus because it is female believe they will face violence, exclusion, or stigma if they don't produce a boy. Some--rightly or wrongly--see the financial burden of raising a girl as detrimental to the survival of the rest of the family, a sentiment that can outlast generations even after an ethnic community has been transplanted to the United States.

The solution to the prevalence of sex-selective abortion is to remove the motivation (emotional or real) behind the procedure by advancing women's human rights and their economic and social equality. Choosing the blunt instrument of criminal law over promoting the value of women's lives and rights will only place further burdens on individual women for something that essentially is a social wrong.

So, in short, I support regulation that serves the purpose of furthering the human rights of women to health, physical integrity, equality, as well as the right to decide when and if to become a mother. I also support regulation that brings down the need for (and number of) abortions.

My experience tells me a blanket prohibition of abortion of any kind -- even if to limit a practice as ethically questionable as sex-selective abortion -- would accomplish neither.

True Choices: access to safe and legal abortion is the end rather than the beginning of women's childbearing choices

(Originally published in Conscience Magazine)

FOR AN OUTSIDER, US POLITICS around choice seem oddly divorced from reality. At its most reductionist, choice in this country means merely that a pregnant woman can choose to buy herself an abortion. In a slightly more expansive line of argument, the cost and conditions related to the medical procedure are considered as limitations to choice. But rarely does the debate critically examine the other aspect of choice: whether actually having a child is viable, financially and professionally.

To me, this is the crux of the matter. I have never questioned that women are entitled to free and legal abortion as part of a continuum of necessary health care. But I believe it is tragic when women choose to terminate pregnancies they would have continued if society had provided them with the necessary support. But what would that support look like?

In Latin America there is a popular saying: "Every newborn comes to the world with a loaf of bread in their hand." Anyone who has ever looked at the cost of childrearing knows that this is not true. Apart from the basic supplies such as diapers, food and housing, children need care and education. At a minimum, women and children need access to prenatal health care, childbirth facilities with trained staff and infant health care. And there is a time issue too. Women need time off to give birth, and parents need to spend time with their children, to care for them when they are sick and to participate actively in their rearing and education generally.

The United States provides few legal protections for any of these--largely uncontested--needs. There is no law to guarantee paid sick leave or vacation, and as a result half of the US workforce must pay for their own sick days, and 20 percent for their time off for vacation.

There is no law to protect paid maternity leave, and there are no allowances for time off to breastfeed. Federal law affords 12 weeks of unpaid extended sick leave to be used as parental leave, and only for those who are eligible, which excludes about 40 percent of American workers.

There are no general provisions for health care--not even, in most states, for children. Today, some 8.7 million children in the US have no health insurance.

Childcare options are mostly private, at least until the child is four years old, and private infant-care options are limited. "The infant-care shortage in this country is amazing," says Veronica Arrealo, co-chair of the Now Mothers/Caregivers Economic Rights Committee. "As soon as that pregnancy test comes in with two lines, the first call you should be making really is to the infant-care facility, because it is generally about a nine-month wait to get a slot."

Money and time are probably two of the main concerns of those thinking of expanding their families. In most high-income countries, public policies recognize and support that. A 2008 publication from the Institute for Women's Policy Research (IWPR) in Washington, compares legislative frameworks on these issues in high-income countries to the United States, and looks briefly at their impact on key equality indicators. (Ariane Hegewisch and Janet C. Gornick, "Statutory Routes to Workplace Flexibility in Cross-National Perspective," Institute for Women's Policy Research, 2008)

The contrasts are sharp. In all countries examined--Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, the United Kingdom and the United States--only the United States does not provide for paid parental leave. Most allow the right to a gradual return to work on a part-time basis. Many countries entitle parents to tailor the parental leave to their needs, with options such as taking the leave in one block with an allowance, or working part-time over a longer period; reducing the working day during a set time period or extending the paid leave period into unpaid leave, with job guarantees.

Not surprisingly, parents in these other high-income countries tend to spend more time with their children. Ariane Hegewisch, one of the authors of the IWPR report, notes that the proportion of married couples with children in the United States who work 80 hours a week or more is twice as high as in the next European country. "The question of choice really is a question of whether you have time to combine work with having a family," she says, "which is not really something you have in the United States."

Legislative protections for paid parental leave and part-time options, in fact, have a direct impact on women's choices because they don't force women to "choose" between being a mother and being a professional. The IWPR study shows that women with college degrees in the United States are less likely to have paid employment than women in any of the other 20 surveyed countries, implying at least in part that where more legislative protections are in place, more women get to take advantage of their education in formal employment.

What is perhaps less well-known is that many lower-income countries have much stronger legal protections for paid parental leave and options than the United States. Costa Rican and Salvadoran law, for example, provides for three months leave after an infant is born, at 80 percent and 75 percent pay respectively. Most Latin American countries require employers to allow breastfeeding mothers the time and physical space to nurse their children generally for at least a year after childbirth. And paid vacation and sick leave are protected by law almost everywhere in the region.

Having parental rights protections enshrined in law is no guarantee of time and support. For one thing, the protections are generally linked to continuous, fulltime employment, which has always been more common for men than for women. Perhaps more importantly, more and more workers--men and women alike--find themselves in more precarious situations, in part-time or temporary contracts, or are otherwise excluded from the statutory provisions that might protect their choices.

But in terms of societal understanding and support of parenting, the question is not to what extent legal protections are properly implemented, but rather if they exist at all. Few would contest that time and quality child- and health-care options are necessary for good parenting. The question is who we, as a society, believe should pay for them. It is this societal understanding of parenting responsibilities that is expressed in the law.

In the United States, the main cost of childrearing falls to the individual family or woman, because, in general, Americans think of parenting exclusively as a personal choice whereas European and Latin Americans do not. This fundamental difference in the way people think about children and families is what determines what real choice means.

Paradoxically, it may be precisely the culturally ingrained respect for seemingly free individual choices in the United States, without reference to contextual limitation such as money and time, which has led to a lack of political support for legally sanctioned parenting options. In her book, The Price of Motherhood, former New York Times writer Ann Crittenden exposes the myth of choice as one of the main reasons for the prevailing "hands-off parenting" policies in the United States: "The sidelined ambitions, the compromises mothers live with that their husbands never had to make, all justified on the grounds of women's choice ... It's their choice. No one 'made them do it,' so no one has to do anything about it."

But if you dig a bit deeper, perhaps the real opposition or political discomfort with regard to the provision of childcare and parental work flexibility options in the United States is linked to perceptions of who is seen to benefit from a stronger support network. And this, again, is closely related to how welfare policies and parenting choices are covered in the mainstream media.

Consider the case of Nadya Suleman. Ms. Suleman, already a mother of six children under the age of 7, gave birth to octuplets in January 2009 after in-vitro fertilization. Ms. Suleman's octuplets were the second full set of octuplets to be born alive in the United States and the birth was newsworthy because of that.

What is interesting is that the media coverage about the case, in particular as expressed in opinion pages and editorials, pits choice against choice. For some, Ms. Suleman is seen as epitomizing "good motherhood," making a disinterested choice to continue a multiple pregnancy that could have seriously and permanently damaged her health. For others, her choice is based on individual greed and an alleged desire to leech on society by having children she clearly can't afford to feed, clothe and house without support.

In contrast, the explicit reasoning behind European welfare policies that affect parental choice is rarely individual. Often, there is reference to a broader macroeconomic argument--that all economies need to produce the next generation of workers. At times, this argument is expressed as nationalism or poorly veiled racism: one way to reverse falling birth rates and prevent diversity in the workforce is to promote parenting through tax breaks, work-time flexibility and childcare options.

Interestingly, though, many of the basic parental support policies in Europe such as paid sick leave, paid paternity leave and caps on work hours precede the falling birthrates in the 1990s, and the corresponding concern with population composition and growth. Commentators link the motivation for these policy changes to a European notion of collective responsibility and to industry-wide union organizing that focused on establishing a social floor through permanent legislation instead of, as in the United States, through bilateral contractual obligations that can be and often are renegotiated in times of economic difficulties.

Which brings us back to the overwhelming American focus on individuality, and the resulting limited understanding of parenting as separate from a national interest in the new generation. Women's organizations in the United States have, in fact, long challenged the notion of Americans as naturally individualist. "I struggle with the word 'choice'," says Erin Mahoney, chair of the Women's Liberation Social Wage Committee. "When we emphasize the individual choice of parenting, we take away the fact that we, as women, are doing real work to rebuild society. Every child that's raised in this country is the next mailman, the next nurse. It's not the responsibility of individual women to do that work alone."

There have been times in American history where the national interest has superseded individualism, with direct consequences for the provision of childcare. In the 1930s, the federal government sponsored nursery schools under the Works Progress Administration program, which was expanded to cover daycare as a war-time necessity during World War II. Even now, women employed by the US military enjoy access to legally mandated quality childcare, a provision that, to a large extent, was motivated by a need to maintain trained personnel and prevent turnover in the military in the interest of national security.

Generally, though, in the United States children remain the exclusive concern and responsibility of their parents. And choice remains a codeword for legal but often inaccessible abortion services. Logically, one would therefore expect women in the United States to choose to have smaller families than in Europe. This is not the case. Though the birthrate has been declining in the United States, it remains higher than in most European countries. In fact, Japan and about 20 countries in Central and Eastern Europe are experiencing negative population growth (when we exclude the impact of immigration and emigration).

"The central question is why people continue to have children when it is so hard," muses Ariane Hegewisch. "And conversely, there is no evidence that everyone in Europe has 16 kids, just because they can."

One reason may be that while politics in the United States is traditionally unconcerned with women and equality, children are, at least in political rhetoric, a strong motivator for change. Just recently, the corporate bailouts and economic rescue plan, while seemingly inconsistent with American individualism, have been justified by reference to the next generation.

Perhaps the policies that protect women's choices as mothers would be more palatable to American policymakers and to the public at large if they were articulated as necessary for children. "When you deny support to mothers, you punish the children," says Hegewisch. Veronica Arreola from now agrees: "All of the things we advocate for: childcare, infant care, health care, sick leave, etc. All are things that, when it comes right down to it, are about caring for our children."

In my experience interviewing hundreds of women about their childbearing choices, access to safe and legal abortion is the end rather than the beginning of that choice. Women talk to me about food for their children, time to play and concern with paying for their children's education. They talk about expensive birth control and childcare and about limited healthcare options. They talk about how difficult it is to decide when and if to become a mother. And they talk about abortion as an option where other options have failed. Public policy on choice should reflect all of these essential concerns.