The raging debate over women's reproductive autonomy

Salma Maoulidi examines the link between abortion and women's reproductive autonomy

The first ever Safe Abortion Conference was held in late October 2007 at the Queen Elizabeth II Conference Centre in London bringing together about 800 people from different parts of the world working in different capacities on the issue. The conference was jointly organized by Marie Stopes International, Ipas and Abortion Rights.

Impetus behind the agenda

40years of legal abortion in the UK provided a suitable opportunity to revisit the abortion debate in view of its policy relevance to women's reproductive and sexual health. Indeed in spite of advances in reproductive health sciences and technologies about eighty women, mostly of reproductive age, die every hour from unsafe abortions in countries where it is illegal. One in three women will undergo an abortion at some stage in her life. The World Health Organization (WHO) estimates that 1 in every 16 women in sub-Saharan Africa will die from unsafe abortion as opposed to 1 in 2400 in Europe. Most deaths arise from post abortion complications, deaths that could be prevented if medical abortion were legal.

Deaths resulting from unsafe abortions account for over half of all cases of maternal mortality in most African countries. The continued toll unsafe abortion poses to women's lives worries reproductive health activists and providers. They warn should the current trend continue it will be impossible for most countries in Africa to reach goals 3 and 5 of the Millennium Development Goals (MDGs). The struggle for practitioners and activists is to eliminate unsafe abortions a feat that is complicated by the undue influence the US, backed by conservative quarters, exerts on women's sexual and reproductive health and rights in national and international policy contexts.

Globally the abortion debate is masked in moral and religious terms where the right of the unborn child is put against the right of the woman to choose to bear or abort the child. The public health dimension is rarely underlined and the millions of women who die, or are maimed from unsafe abortions hardly come under scrutiny. Rather, it is the agency of women that is questioned. The purist discourse on the right to life and the guilt of committing a cardinal sin effectively polarizes women and men from engaging with the issue from a political lens where abortion is not only seen to affect some 'immoral' women but is an issue for all women.

The realities on the ground

Abortion politics hold women's reproductive capacity ransom at huge costs to their individual freedom and health. As the Safe Abortion Conference was closing in London, the Morogoro Resident Magistrates Court passed a prison sentence to a 21 year old woman in Tanzania, Faima Hassan, for aborting an eight month old fetus. This case is not a rare occurrence. In recent times abortion has become topical and a major topic for women bashing by parliamentarians in the national legislature. Leading this bashing is the President of Tanzania who, symbolically on the Day of the African Child on June 16, 2007, is reported by the Daily News to have called all women, who opt for an abortion, murderers, a view echoed by the deputy Minister for Health, Hon. Ayisha Kigoda during several Parliamentary sessions. Surely such utterances can be construed to reflect the official position towards women's right to make decisions over their bodies, a position that is in direct conflict to article 14(2) (c) of the Maputo Protocol that recognized a right to medical abortion which Tanzania signed and ratified!

Regrettably it is mostly poor women who cannot afford safe abortion services that will encounter legal and medical problems mainly because they lack resources to benefit from available abortion options that are legal and safe. The bottom line is that back street abortions provide women with an essential service in a context where birth control is not widely and regularly available or where the sexual relationship is unequal and often coerced. Denouncing those who perform illegal abortions could put their lives at risk or make them targets of public and moral recrimination. Faima's double tragedy of carrying a fetus almost to term and being prosecuted is a near impossibility for a woman who is well to do. They can either fly to destinations like South Africa where abortion is available on demand; or solicit the aide of friends in the medical establishment where, in spite of the ban, abortion services continue to be available for a fee.

Significantly the ban on abortion denies women the ability to assert their reproductive autonomy. Prof. Fred Sai, an adviser to the Ghanaian President and a respected personality in women's health in Africa, argues that it is unacceptable that women cannot have a choice in such a personal matter.

What informs my interest in the debate?

While at high school I watched a form two student fight death after a back street abortion. She stank after becoming septic and was delirious. Her state paralyzed anyone from seeking medical attention because either way it spelt trouble incriminating not only the girl but also others who supposedly harboured her: Pregnancy continues to disqualify female students, in most African countries, from enjoying their right to an education. Even if the procedure was successful, it is sufficient grounds to expel a girl from school. In this instance, however, taking her to medical authorities for attention would incriminate her for partaking in a criminal act. In the end, her colleagues smuggled out of the school to undergo another clandestine intervention to save her life.

Alas this is not the only abortion incident I would encounter. During my undergrad years at the University of Dar es Salaam, a dorm mate died after attempting to end a pregnancy her boyfriend refused to acknowledge. She swallowed a handful of pills. Her family found her and sought medical attention but the process attracted delays such that by the time doctors attended to her she was already cold. Also in the course of my work I have met young and older couples pushed by economic considerations to end unintended pregnancies: In view of the harsh economic realities they cannot afford another child since, in a cost sharing set up, the question is not just about an extra mouth to feed but also about an extra body to shelter, dress, treat and to educate. Women also end a pregnancy because it was forced; or there is a bigger threat militating against having the baby such as marital discordance or a health risk like seropositivity. Rarely is the intent to pursue a hobby of killing fetuses or as alternative a FP method.

Origins of the prohibition

Abortion is challenged on a number of grounds chief being preserving the sanctity of (all forms of) life. Religious scriptures are often cited to challenge the practice. In addition to religious arguments human rights arguments are deployed to delegitimize any moral basis to the practice, similar to those employed to oppose the death penalty. Yet abortion laws, per se, are not indigenous to local cultures and prior to their adoption there existed practices in local communities to get rid of unwanted fetuses or children.

The prohibition against abortion came as a result of British laws and missionary interventions in African colonies. The context such a law came to be is underemphasized. Prof. Said explains that when abortion was criminalized in Victorian England it was to protect women from "barber surgeons" whom, women frequented to end unintended pregnancies. Abortion services at that period were not safe and more women died undergoing abortions than during child birth, requiring urgent measures to safeguard women lives and health.

Lord Steel, the Architect of the UK 1967 Abortion Act notes the tremendous advances in the sciences since the passage of the Act necessitating a fresh look at the 1967 Act which working within the confines of possibilities of science at the time mainly confined it self to surgical abortions. But today medical technology is so advanced women can induce abortions at home by taking a pill requiring minimal medical intervention as was the case four decades ago.

How then is it that while imperialist forces that abortion law have adapted to the progress made in reproductive technologies the law is fervently retained in most former colonies? Surely abortion legislation reflecting an antiquated approach to safeguarding women's health and lives, can only be understood as a remnant of the imperialist project in Africa, a project increasingly manifested through the undue control of women via criminal and personal laws while all else on which livelihood depends is liberalized.

What is implicit in the anti-abortion debate?

All types of women have abortions and they do so for various reasons. Few women make the decision to have an abortion lightly (or while emotionally possessed) as is suggested by those who question women's state of mind and motives for wanting an abortion. In most cases an abortion is a desperate act to control one's fertility where that ability to do so has been denied. And while undue attention is on the woman and her 'immoral' and 'criminal' rarely is the behaviour of men who impregnate women against their will, either by force or deceit, brought under scrutiny.

Is the ban on abortion about the sanctity of life or about patriarchy and the obsession to control women via the womb? Indeed the most effective way to control women has historically been via her reproductive function. Also some arguments against abortion express conservative notions about the sexual hierarchy. In many ways family planning technologies revolutionized power in the sexual relationship. Anti choice arguments imply that a woman cannot make decisions over her own person and body and further the assumption that women are not rational beings and impliedly cannot make decisions over their own bodies let alone over others.

Possibly the high abortion death rates are tolerated because women are deemed replaceable should they die; become maimed; or rendered infertile as a result of unsafe abortion. In contrast the same jurisdictions place few prohibitions on men's sexual and reproductive practices (or the consequences thereof) as are placed on women. While the law and pro-life opinion compel the woman to have the child, few laws oblige a father to look after issues fathered; the responsibility largely rests with the mother. Presently the official maintenance rate in Tanzania is 100 shillings (about 8 cents US) nor is there a mechanism to enforce maintenance awards. A mother knows what carrying a pregnancy to term will mean. Yet, those opposing women's right to choose are not willing to offer women the institutional support to raise an unintended child; or to advocate the necessary reforms that would put women in a more egalitarian footing in the sexual and reproductive relationship.

The abortion debate reflects a desire to perpetuate gender dominance at one level and power inequalities in development prescriptions on the other. The control of poor women's reproduction features prominently in development strategies but no where is the intent as contentious as in the case of abortion. Indeed long before the Gag Rule abortion was high in the US development agenda leading the Centre for Disease Control (CDC) to have an abortion branch. A few years later the priorities have changed impacting significantly on local reproductive health politics where the services are most crucial to reduce unnecessary deaths.

Medical dimensions of the debate

In view of the advances in reproductive heath technologies abortion deaths should be history in the 21st century not a public health issue. Sadly this is far from the reality such that women are forced to adopt extreme measures to get rid of pregnancies they had not planned. This may involve taking toxic potions and drugs; inserting crude objects in the uterus; and subjecting themselves to falls or blows to induce abortion.

Surely, confining the abortion debate to the 'appropriateness' of ending the life of an unborn child fails to take into account the circumstances in which the child came to be.
WHO estimates that one in every three pregnancies is unintended. Questions should therefore be posed about how women became pregnant and not why they want to rid themselves of a pregnancy they do not want.

There is a strong link between abortion and women's reproductive autonomy. Many women have sex in circumstances that are equal to forced sex or rape putting her at risk of becoming pregnant and becoming infected with sexually transmitted diseases. It is, therefore, important to vigorously link the public health aspects in the ongoing debate. Likewise, advocacy initiatives should emphasize facts with regards conceptions. Indeed about a quarter of all conceptions (about 240 million annually) will lead to early pregnancy wastage a figure twice higher than that pertaining to induced abortions estimated at 42 million, only 20 million of which are illegal. Perhaps such truths will mitigate residues of ambivalence abortion evokes especially among conscientious women and men.

Opportunities for decriminalization

Increasingly abortion is not solely seen as a feminist agenda but as an agenda that is embraced by a wider spectrum of actors from the reproductive health sector and medical professionals. For instance the medical community in India made safe abortion a health agenda and actively lobbied the government under the banner 'Safe abortion saves lives'. While doctors elsewhere are spearheading safe abortion, one wonders why the medical community in Tanzania and in other Africa countries remains silent lest the status quo benefits individual practice.

Decriminalization is easier when safe abortion is part of national population or health policies as is the case in India and China. Even so in societies where women feel compelled to produce male heirs there is a risk of abuse to facilitate sex selection. In any case safe abortion is more cost effective since more money is spent treating complications arising from illegal and unsafe abortions. In a context where health services are severely constrained and fewer allocations in the health budget are made to reproductive health services, liberalizing medical abortion and post abortion services may be the logical policy intervention.

Some activists believe the Maputo Protocol has a potential to advance African women's sexual and reproductive rights via test in line with regional and international instruments. Alas, courts on the continent, continue fail women, willingly preserving the status quo while stifling any attempt towards a progressive appreciation of women's human rights. Moreover although new judicial regimes like the East African Court present a huge potential in furthering existing human rights interpretation, their mandate is confined to issuing opinions effectively limiting their influence in obliging states to reform. Surely this is an area for future advocacy.

Is there strong policy commitment to safe abortion?

Presently there is a deep realization within the activist community that legalizing abortion may not be enough. Abortion activists in the US express concern with the April 2007 Supreme Court decision which though on later term is interpreted as dispensing with the requirement to protect women's health asserted in the 1973 landmark Roe v. Wade that explicitly recognized a woman's right to choose.

Thus while abortion remains legal in the US conservative forces have used sophisticated means to ensure that a woman's right to choose is thwarted by raising legal challenges and placing procedural restrictions, at the state level, all designed to limit a woman's ability to access abortion on demand e.g. mandatory waiting periods. Moreover as fewer clinics in the US provide the services, women are forced to go further distances, at times out of state, to obtain an abortion placing undue economic and social burdens.

The Dutch Minister for Development Cooperation, Bert Koenders, offered an optimistic assessment of donor practice with regard development assistance in the area of maternal health including reducing deaths from unsafe abortions. The assertion while laudable must be evaluated against current practice with regard development funding where increasing partnership with governments to the exclusion of civil society organizations may limit meaningful interventions in sexual and reproductive health and rights. Moreover greater activism in countries where abortion is not legal may further restrict the mandate of civil society organizations supposedly for engaging in illegal activities.

The conference came to a realization that civil society organizations and health practitioners in Africa can agitate for the politicization of the abortion issue e.g. as part of Peer Review Mechanism to monitor progress of national and regional instruments. Sadly there remains in Africa a reluctance to approach abortion as a policy issue it is therefore not surprising that maternal health dominates different forums on women's health instead of reproductive health, the latter recognizing more forthrightly the biological role women play in conception but also her agency in the sexual relationship.

Towards meeting key policy commitments on sexual and reproductive health rights.

WHO and ICPD define health and wellbeing to include the right to decide one's fertility; and to enjoy a satisfying sexual life free from violence and risk of disease. The MDGs reiterate the centrality of maternal and reproductive health and rights to the development agenda. Health Ministers acknowledge the link between unsafe abortion and maternal deaths and the African Union (AU) has sought to address this aspect in article 14 of the Maputo Protocol and Plan of Action.

How can the legal framework and reproductive health services locally reflect the accepted global standard? Undoubtedly the ideal is a situation where women don't have to resort to abortion as a way to get rid of unwanted pregnancies; or to regulate births. This implies empowering women to exercise sexual and reproductive choices. Clearly it makes no sense denying a service that is medically and economically efficient. Rather than moralizing on the issue policy makers ought to engage more effectively with evidence gathered by different actors including the WHO to guide policy interventions with respect to curbing maternal deaths.

* Salma Maoulidi is an Activist/Executive Director of the Sahiba Sisters Foundation in Dar es Salaam, Tanzania.

* Please send comments to or comment online at www.pambazuka.org