Introduction by Croakey: This International Women’s Day (March 8), Médecins Sans Frontières (MSF) is highlighting the crucial role of safe abortion care in preventing maternal mortality.
Globally, this is a huge issue, and one on which, as MSF Australia’s Medical Advisor for Obstetrics and Gynaecology, Dr Claire Fotheringham, writes below, there has been frustratingly slow progress.
Australian women are not forced into some of the drastic measures Fotheringham has encountered in her work, but problems with uneven access to abortion and affordable contraception persist.
Debate about these issues was reignited by opposition spokeswoman for women, Tanya Plibersek’s, announcement yesterday that, if elected later this year, a Labor government will make contraception and medical abortion cheaper and more readily accessible, and work with state governments to ensure public hospitals offer surgical abortion.
While the planned suite of policies was welcomed by many, Prime Minister Scott Morrison responded, saying the issue was too divisive to be decided federally, and should be left up to state government legislation.
In NSW, where a state election will be held later this month, the future of abortion legislation is far from certain, with a conscience vote on decriminalisation a possible outcome in the next parliamentary term, whichever party is elected. Women might well be left wondering, along with the Guardian’s Brenda The Civil Disobedience Penguin, why our reproductive rights are still so heavily politicised.
One global political influence on women’s reproductive rights is the “Global Gag Rule,” whereby the US government in 2017, cut off all funding for organisations and programs overseas that are involved in abortion-related activities, including counselling and informing women about their reproductive choices.
Recent research, highlighted in this article in the Conversation, shows that when the Global Gag Rule was applied by a past Republican administration, abortion rates rose in countries whose aid was cut off – especially in Africa and Latin America, where the majority of abortions were likely to have been unsafe.
The author writes that the Trump administration has now announced that it will defund domestic organisations, such as Planned Parenthood, that have any links to abortion services, with the expected but paradoxical outcome that demand for abortion will increase.
MSF told Croakey that, as it is funded independently and receives no money from the government, the Global Gag Rule does not affect the organisation’s ability to continue providing care where the needs are greatest. But in the international aid world, MSF is an exception.
Claire Fotheringham writes:
It was September 2011 and I was on my first assignment with Médecins Sans Frontières/Doctors Without Borders (MSF). Setting foot in the busy maternity hospital in West Africa, I was completely unprepared for what I found: women arriving on death’s door, with complications like heavy bleeding and septic shock.
In the operating theatre, examining many of these women, I found trauma marks on the cervix, caused by objects such as sticks that had been inserted to terminate their pregnancies. Examples of unsafe abortion that had resulted in horrific injury.
I realised the sheer desperation that must have driven these women to do this, and how limited their options must have been. They were willing to resort to any means to terminate their pregnancy, even while knowing the huge risk to their own lives.
Some of these women needed antibiotics or a tetanus injection for infection. Others required blood transfusions for life-threatening bleeding, or major surgery to repair perforations to their bladder, bowel or abdomen, or to remove infected tissue caused by peritonitis or an abdominal abscess.
Even if these initial complications could be rectified, I knew these women faced the danger of long-term impacts, including chronic pain, anaemia and infertility. Even if a woman did not want to continue this one pregnancy, she may never be able to have children again.
The health effects didn’t stop when these women left the hospital. Unsafe abortion—and unwanted pregnancy—can bring shame and stigma with wide consequences such as being ostracised from the community, or finding it harder to get married or complete schooling. This meant the women could face secondary mental health consequences as well.
Encountering this sort of medical emergency was shocking. But I shouldn’t have been surprised; I now know that unsafe abortion represents a major public health issue worldwide. At least 22,000 women and girls die from unsafe abortion each year, making it one of the top five direct causes of maternal mortality.
On top of this number, an estimated 7 million women and girls suffer long-term consequences from unsafe abortion, including serious side effects and lifelong disability. Sadly, these numbers are likely to be an under-estimate –many unsafe abortions, just like the pregnancies, are not disclosed, either by the women themselves, their families, or those who provided the abortion.
Every day, MSF witnesses the consequences of unsafe abortion. In some of our hospitals, it is the cause of up to 30 percent of obstetric emergencies. Yet this devastating cost to the health and lives of women and girls is completely preventable.
Safe abortion care is recognised as a medical necessity, established as part of the package of sexual and reproductive health that is considered worldwide to be beneficial to preventing mortality in women.
Termination of pregnancy is a safe, effective procedure that can be accomplished surgically or with medication. These tablets, a two-stage, five-pill therapy known as medical abortion, are increasingly used in MSF fields and can be dispensed as part of our outpatient care. Every safe abortion provided is an unsafe abortion averted.
Yet barriers to safe abortion care do not stop at shame and stigma in many societies, including Australia – and tend to be especially prominent in the settings where MSF works.
They include legal restrictions, economic and social obstacles and administrative hurdles; institutional decision-makers and medical providers may also lack knowledge, fear repercussions, or object on personal grounds. But even where abortion is restricted, women, for many reasons and despite the risks, will still want to terminate their pregnancy, and will resort to any means available to them to do it.
Since 1990, the baseline for the Millennium Development Goals, we have seen reductions in maternal mortality in many countries, including where MSF works – but deaths from unsafe abortion are where we’ve seen the least change. This is simply unacceptable.
Even in MSF, we haven’t seen the progress we’ve wanted. Although safe abortion care has been part of our policy since 2004, we saw minimal change in the extent of the provision of care from 2007 to 2016. But, in the past three years, with a renewed focus on the issue, we are starting to see real change.
I hold the hope that the next young obstetrician who goes on assignment will not be confronted with the tragedy of post-abortion complications like I was.
MSF is working with its staff, with local communities and departments and ministries of health and other non-governmental healthcare providers to improve access to contraceptives, to post abortion care and to safe termination of pregnancy for women and girls lacking access to healthcare or caught in a humanitarian crisis.
We must continue to push for more progress on safe abortion care worldwide: women’s and girls’ lives depend on it.
Dr Claire Fotheringham is Medical Advisor for Obstetrics and Gynaecology, Médecins Sans Frontières Australia
