Access to and reality of abortion in Europe
Marcel Vekemans, MD, Ob/Gyn, Medical Advisor, IPPF, London, UK.
In Europe, access to safe abortion is much easier than in the developing world, de jure and de facto. Legally, 81% of 59 developed countries (10%, in underdeveloped countries) allow induced abortion without restriction as to reason. Only 12% of the European countries (very small ones, except IRL and PL) restrict abortion to “physical risk to the pregnant wife”. Illegal abortion is not necessarily unsafe, or difficult of access, or entailing prosecution. And “legal” does not mean “safe”, or “easy to obtain” (P). Many European women still recourse to “abortion tourism” for discrete or second trimester abortions. But, de facto, Europeans are not equal concerning access to safe abortion, which depends on other than legal variables: availability of trained staff, restrictions on types of providers and facilities (in-, out-patient), dissuasive counselling, “experts” commissions, waiting periods (UK), permission from parents (I, DK) or husband (Turk), negative cultural/religious influences causing delays in care seeking, lack of trust in confidentiality, costs involved (social security reimbursement?), providers’ “conscientious objection” (I, D, Ö). Abortion services up to the full extent of the law should be accessible everywhere: health care providers are legally bound to this be it through referral. “Underserved groups” (adolescents, refugees, illegal immigrants) are targets for expanding our social role. Legal and other restrictions (and popes’ admonishments) do not eradicate induced abortion, as shown all over the world and throughout human history. Nor do prevention, such as modern and emergency contraception, sex education, abstinence vows and ignorance-only education. In the US, 60% of 1.3 million abortions per year are contraceptive failures. The 1991 Tbilissi recommendation “From Abortion to Contraception” has not been fully implemented.
A lack of staff trained in abortion techniques (medical, counselling) is alarming. Young professionals might be less motivated. Most have not seen women die after induced abortion. Training is not given enough attention. Also, better pain control and post-abortion contraception, and more humane attitudes, are needed. More training “Centres of Excellence” could be developed (and train providers from the underdeveloped world, where 13% of the maternal mortality, 220 deaths every day, is due to unsafe abortion). In (mainly Eastern) Europe, there remain 600 deaths/year after unsafe abortion, related to high incidence of abortion in some countries, use of less safe techniques (vacuum should replace curettage), and, at times, poor quality of care.
Advocacy for less restrictive laws and for keeping alive adequate laws remains necessary, in front of the anti-choice movement. The battle is never won for ever. Decriminalization (“l’avortement hors du code pénal!”) is an option: leave this medical issue to the private sphere, abortion being a normal, natural part of reproductive life.
Thanks to the commitment of governments, NGOs, and international organizations (the European Union has shown commitment to the respect of the women’s rights), access to safe abortion is quite satisfactory in Europe, but not everywhere and not for everybody. Continuous efforts are needed to improve the situation and to defend the progress made.
Who is afraid of a woman’s right to self-determination?
Marcel Vekemans, MD, Ob/Gyn, IPPF Central Office, London, UK
For the species survival, new human life has to be protected: we all are “pro-life”.
However, humans can interfere with procreation, using abstinence, contraception,
abortion, infanticide, assisted reproduction. Decisions have to be made; limits have to be
set for health, financial, and ethical considerations. Societal organizations, religions and
individuals all want to interfere and take decisions based on tradition, cultural values and
beliefs, family and community goals, legality, religion, morality, philosophy, power, and
ambiguous “natural laws”. By definition, those who set limitative norms are opposed to, or
concerned by, a woman’s right to self-determination. With regard to abortion, the issue is
not about protecting life. This is easy to show: most so-called “pro-lifers” do not actively
oppose the death penalty, war, or environmental degradation, nor do they support
contraception and universal access to health care, or do they fight neonatal death (4
million mostly preventable deaths yearly, globally), or infant killing diseases such as
The issue in patriarchal societies is to guarantee a man’s paternity (“sola mater certa est”)
by controlling the female reproductive function and sexuality, imposing prenuptial virginity,
arranged marriages, dowry systems (a reason for sex selection), absolute fidelity and
harsh punishment of female adultery, confinement of women in-house, and abstinence-
only education. Contraception is made difficult accessing, violence against women (up to
“honour killing”) is used, women are humiliated by lower wages, genital cut-ting, denial of
general education. Traditional patriarchal systems are still protected by laws,
governments, judicial systems, religions, and by most men and women. However, more
and more leaders and governments understand that the death toll related to unsafe
abortion is not acceptable, and that imposed child-bearing is a serious denial of women’s
rights. Traditions being slow to reverse, many governments, parliamentarians, judges,
international and professional organizations, and most men and women, are still afraid of a
woman’s self-determination. Only for one-self, if confidentiality is ensured, is the right to
self-determination almost universally accepted.
Why safe abortion and contraception is a necessity for society
Marcel Vekemans (IPPF)
IPPF, London, United Kingdom
In traditional medicine, doctors know best. In the field of contraception and abortion, we health care providers indeed can easily prove that safe abortion is better than unsafe abortion, that contraception is better than unwanted pregnancy, that high contraceptive use decreases abortion rates, that access to safe legal abortion decreases maternal mortality and morbidity, and that huge cost savings for health systems can be made by eliminating unsafe abortion. Have we been able to convince all societies?
Societies are a heterogeneous mix of formal and informal groups, of diverse “communities”, and of individuals with divergent opinions. Forces are exerted in various directions. Concerning abortion and contraception, opposition to liberal attitudes comes from different sides, as influenced by traditions, social and economic pressures, convictions, religions, patriarchy, conservatism, fundamentalism, etc… As a result attitudes, behaviours and legislations vary hugely between countries, and over time. The claim that safe abortion is unacceptable in a society as a whole is a myth, as shown by the fact that abortions occur everywhere. But countries with restrictive abortion laws and/or limited access to contraception are evidence that significant parts of a society can refuse to accept or endorse our simple truth that “access to contraception and safe legal abortion is best”.
Demographic concerns also intervene: governments favour population expansion (to be strong, politically and economically; to have a powerful army; to avoid ageing of the population) or limitation (to avoid famine, impoverishment, exhausted resources, pollution), or remain unconcerned.
Pro-choice activists need to harness two opportunities: the diversity of societies and the ability to influence the development of laws and policies.
Access to safe legal abortion and to contraception is a basic human right, but very often essential prerequisites to exert these rights are lacking. Most importantly, almost everywhere education about reproductive health and sexuality remains problematic, despite efforts started a century ago. We still need to ensure, especially in the developing world, easy access to a well-developed health care system, equal status of women and men (a fundamental prerequisite for exerting women’s rights), and the elimination of gender exploitation and violence (zero tolerance).
We still need to convince many societies of the importance of contraception and safe abortion, and/or of taking action to make the services accessible.