1. Abortion: What Is Happening? ************ Marge Berer Editor, Reproductive Health Matters Chair, International Consortium for Medical Abortion Chair, Voice for Choice

2. Why I am here today  Thank you very much for inviting me.  I have been campaigning for women’s right to safe, legal abortion in the UK and internationally for 30 years.  The Soviet Union was the first country in world to legalise abortion (Kollantai) – this was very influential in Europe and it made a big impression on me as a young woman too.  I hope keeping abortion safe and legal is very important for all of you too.

3. Law and policy

4. Safe, legal abortion: progress  Abortion is on the agenda across the world.  16 countries have liberalised their abortion laws since 1997.  10 others have increased access by speeding up the approval of facilities (India); expanding the cadres of providers (South Africa); expanding the range of methods (Ethiopia) orre-interpreting law to make more abortions legal (Thailand).  10 others have increased access by speeding up the approval of facilities (India); expanding the cadres of providers (South Africa); expanding the range of methods (Ethiopia) or re-interpreting law to make more abortions legal (Thailand). (Boland & Katzive 2008)  6 in 10 women now live in countries where abortion is legal.

5. Abortion: very safe if…  Where it is legal, accessible and provided safely, abortion is one of the safest clinical procedures and also one of the most common.  Abortion deaths are less than 1 per 100,000 live births in North America, western Europe and NZ/Australia.

6. Uruguay 2004  Abortion legally restricted.  Complications of abortion = 29% of maternal deaths, 48% in main maternity hospital in the capital, Montevideo.  Maternity hospital began to offer women with unwanted pregnancy information about how to use misoprostol at home to induce early abortion.  They asked women to return for post- abortion care (+ aspiration in the case of incomplete abortion), and an effective contraceptive method.  After 6 months, no more deaths or complications.  After 6 months, no more deaths or complications. (Briozzo et al, 2006)

7. Nicaragua, El Salvador  Nicaragua and El Salvador have eliminated all legal grounds for abortion.  Maternal deaths are increasing – change of law has made doctors afraid to do abortions, even to save the life of a woman with obstetric emergency.

8. Mexico  Mexico City made abortion on request legal in first trimester of pregnancy and is now providing safe abortions. In the rest of Mexico legal restrictions and abortion complications remain the norm.  Cost (US$) of abortion care (Levin et al): Public hospital: post- abortion care Private clinic: safe abortions D&C (80%) $143 Manual vacuum aspiration $111$53 Medical abortion $79 Treat serious complications $601 − $2,100

9. Victoria, Australia October 2008  In October 2008, abortion was decriminalised by the state of Victoria, Australia, up to 24 weeks of pregnancy. Therapeutic abortion after 24 weeks is also permitted.  Termination of pregnancy will now be regulated like any other medical procedure. (ABC News September 2008, Sydney Morning Herald, October 2008.)

10. Europe: falling fertility Europe: falling fertility  Steady fall in the birth rate since end of 19 th century.  Higher levels of education; more opportunities.  Many women (not just men) working full time.  More young people begin partnerships with cohabitation, marry and become parents later in life, and delay first and second births (Scandanavia late 20s).  Small family norm (1-2 children); more childless women.  Current total fertility rate in Russia almost the same as the average western European level.

11. Pronatalist vs anti-women responses  Pro-natalist: o Reduce mortality in under-60s. o Reduce mortality in under-60s. (Zakharov S) o Improve economic, employment, social and housing/living conditions. o Generous child benefits. o Encourage immigration from other countries.  Anti-women: o Stop women working. o Ban or restrict contraception and abortion.

12. Poland: almost no legal abortion  Women get abortions from: o Private providers in Poland o Travel to Germany, Czech Republic, Austria, Netherlands o Probably also other Eastern European countries (Ukraine, Belarus, Lithuania) if they live close by and have connections there. o Internet ? (Personal communication, Wanda Nowicka)

13. Poland 2008  A woman was refused an abortion by a Polish court, even though it should have been legal because she had a rare condition that affected her sight. She could not afford a private abortion. She had no choice but to continue her pregnancy and went blind. The European Court of Human Rights ruled she had had the right to a legal abortion and granted compensation.  Recently, Poland’s Minister of Health announced a plan to establish a database of all pregnancies in Poland to keep every pregnancy under state surveillance, to prevent terminations. (Romania did this pre-1989)

14. Abortions in Romania pre-1989

15. Romania: before and after 1989  Abortion-related mortality in 1989 accounted for 87% of all maternal mortality (148 per 100,000 live births). In 1993, national health statistics showed a spectacular decline in maternal deaths due almost entirely to the decrease in abortion complications to: o 58 per 100,000 in 1990 o 34 per 100,000 in 1993, and o only 9 per 100,000 live births in 2002.

17. Reasons for abortion: Russia  Reasons for abortion among 352 urban and rural women: cannot afford another child, poor health status of woman or her husband. (Vikhlayeva EM, Nikolaeva E, 1996)  Reasons for non-use of contraception: irregular sex (29%), desire for pregnancy (22%), perceived infertility (15%), methods unpleasant (15%), health problems (11%), abortion available (6%). (Perlman F, McKee M, 2009)

18. Trends re abortion methods and providers

19. Trends: abortion methods  Trend towards abortions taking place very early in pregnancy (positive pregnancy test) where manual vacuum aspiration or/and medical abortion are offered very early. (Western Europe)  D&E for second trimester abortion is main method in USA but declining in Europe.  Almost all 2nd trimester abortions in Scandanavia are medical abortions (too few late abortions to maintain D&E skills). Both are safe and effective.

20. Dilatation and evacuation (D&C)  Dilatation and evacuation (D&C) as a method of first trimester abortion is no longer recommended by World Health Organization because it has a higher complication rate. Yet it is still very commonly used for abortions and treatment of incomplete abortion.  Second trimester methods such as instillation also no longer recommended because of higher complication rates but are still used.

21. Changes due to medical abortion  Medical abortion is changing abortion practice all over the world.  Where abortion is legal, use of medical abortion is steadily increasing.  Where abortion is illegal, self- medication with misoprostol is the reality of first trimester abortion. Drug sources (drug sellers, internet, wide range of providers)  Growing number of pharmaceutical companies producing the two drugs globally (USA, France, India, China).

22. WHO safe abortion guidance 2003  Abortion services should be provided at the lowest appropriate level of the health care system.  Vacuum aspiration can be provided at primary care level up to 12 completed weeks of pregnancy and medical abortion up to 9 completed weeks of pregnancy.  Mid-level health workers can be trained to provide safe, early abortion without compromising safety.

23. Increasing role of non-physicians  Both surgical and medical abortion can be carried out / managed by trained GPs, clinical officers, nurses and midwives.  France: with medical abortion, physicians confirm pregnancy and conduct follow-up visit. Nurses do the rest.  France: with medical abortion, physicians confirm pregnancy and conduct follow-up visit. Nurses do the rest. (Hassoun 2001)  South Africa, Viet Nam, USA: nurse practitioners legally permitted to manage vacuum aspiration and medical abortions themselves.  South Africa, Viet Nam, USA: nurse practitioners legally permitted to manage vacuum aspiration and medical abortions themselves. (Warriner et al 2006; Berer 2009)

24. Second trimester abortion

25. Why focus on second trimester abortions?  Only the most dedicated providers do them.  The women who need them are often young and the most vulnerable.  Women ’ s lives are at greater risk if they are unsafe.  Subject of anti-abortion attacks as if they are “ more wrong ” than first trimester abortion (Britain, Spain, Netherlands, Russia, Germany, USA)

26. How many women have them?  Britain 2007* o 13-19 weeks8.8% o >20 weeks 1.5%  Netherlands 2006* o >12 weeks 6.6%  Sweden o >18 weeks very few   South Africa o o 1997 >12 weeks33%+ o o 2007 >12 weeks20% (Ingham et al 2008; Loeber & Wijsen 2008; M Bygdeman 2008)

27. Reasons: Britain  Five stages of delay: o suspecting pregnancy o confirming pregnancy o deciding on abortion o seeking abortion o obtaining abortion  Interventions of better sexuality education and access to supportive counselling first 3 stages; improving services can only help at last 2 stages. (Ingham et al 2008)

28. Netherlands: early and late  Early medical abortion and MVA do not appear to have an influence on the number of second trimester abortions in the Netherlands.  Delays are due to relationship problems (no partner, partner left, partner aggressive),.  Delays are due to relationship problems (no partner, partner left, partner aggressive), young age (pregnancy too early), inability to recognise pregnancy, ambivalence towards pregnancy, having to travel to Netherlands for abortion. (Loeber & Wijsen 2008)

29. Fetal anomalies  Wanted pregnancies  Screening becoming universal for all pregnancies.  Potentially more anomalies detected.  Potentially more second trimester abortions.  Physician skills important.

30. Ideal abortion law and policy  Abortion available at the woman’s request to 24 weeks and no limit for therapeutic reasons.  Public health services provide, or at least fund, all abortions. ******* Thank you very much!