Abstract: Abortion is a woman’s experience. Research is not being conducted from women’s experiential viewpoint. For a woman, it is an experience of physical pain, agony, guilt and shame. Yet, women desire to have it on occasions, when they are not prepared to conceive, or when the family members do not want her to deliver a female baby or when there is social pressure for not to have an “illegal child”. Abortions are often opposed by pro-life movement and some religious groups. Anyway, one thing is certain that it has always been decided by the interest of the dominant cultural group in the society, whereas not much relevance is given to woman’s agency. A woman feels guilty about abortion in a society where motherhood is glorified. In the Kerala context, a cultural change is inevitable to address the moral dilemma of abortion.
Keywords: abortion rights, unsafe abortions, unwanted pregnancy, safe abortion services, contraceptives
Abortion is a woman’s experience. Often the discussions about it take place around public policy issues, family planning, religious issues etc. Research is not being conducted from women’s experiential viewpoint. For a woman, it is an experience of physical pain, agony, guilt and shame. Yet, women desire to have it at occasions, when they are not prepared to conceive, or when the family members do not want her to deliver a baby or when there is social pressure on her not to have an “illegal child”. Now debate is going on about the rights of a woman to have abortions. It is often opposed by pro-life movement and some religious groups. Anyway, one thing is certain, that it has always been decided by the interest of the dominant cultural group in the society, where not much relevance is given to woman’s agency. Women’s experiences are shaped by the socio-cultural factors. In a society where motherhood is glorified, a woman may feel guilty about undergoing an abortion. In media, it is commonly depicted that the woman suffers all pain, defamation and shame to protect the baby and motherhood, even when the father of the baby rejects her. In this situation, taking a stand for abortion or against abortion, is meaningless. On the other hand, we have to analyse the socio-cultural, economic and political factors, which determines a woman’s experience when she undergoes abortion. And also her agency should be considered as a relevant factor. This may leave our debate ‘to have an abortion or not to have an abortion’, open and finally it becomes a woman’s choice rather than a debate; the word ‘choice’ finds meaning in the context of maximum possible freedom. The socio-cultural factors are endless. But they are often masked by the overflow of statistics and urgency of population policies.
The gendered construction of sexual pleasure and its difference between the two genders are some of the socio-cultural factors that determine women’s experience. Sexual pleasure is mainly conceived as that of man’s pleasure in a male dominated society. But often the woman is punished for that pleasure in labour rooms and abortion clinics. The pain experienced by the woman in obstetrics and gynaecology clinics is the repayment given by women for the pleasure experienced by men. This does not mean that women do not experience any sexual pleasure. But the physical pain, mental stress and social pressure as the consequences to the sexual pleasure of the woman, outweigh the latter. Sometimes, either doing an abortion or continuing the pregnancy is painful to the woman, owing to different reasons. In such a situation choosing between them is difficult, but not having a choice is much more suffocating. Hence, the right of the woman to have abortion is not an absolute righteousness, but the righteousness amidst the wrong practices of male dominance.
Women feel guilty about abortion because our society does not easily accept it. Too much importance is given to motherhood and the foetus. Sometimes the foetus is given more importance than the woman. The messages prevailing are that abortion is wrong, women who do it, are selfish and irresponsible, abortion is murder etc. In such surroundings the woman will have traumatic experience associated with guilt and shame. Even in clinics, the health care providers, being insensitive, may communicate the same ideas through their behaviour and talks. The trauma continues for long time.
Abortion is often conceived as an unnecessary evil and the woman is blamed for it. Understanding it scientifically may help us to take it out of the realm of gossips or rumours. Abortion is the result of unwanted pregnancy and it is the consequence of the unmet needs to contraception. The situations may be different. The unwanted pregnancy can happen within marital relations and also pre-marital. Even in marital situations decision-making is very difficult for the woman. Sometimes, the husband or other family members, may not agree with it. Even if they agree, the emotional support the woman may need in that situation is not understood properly by the relatives. In situations where the woman is unmarried, it is a shame for the family members too. The brother of a girl who got pregnant before marriage told me, “ I am thinking of suicide. What is the meaning in life if my sister is rotten like this”. This reflects the severity of the shame and agony experienced by the family members, which augment the difficulties to get an abortion done, because they have to disclose it at least to the clinic staff. So, abortion will be done secretly. People do not mind, even if it is done by untrained people in such a moment. They prefer illegal abortion, irrespective of the available legal remedy, because secrecy is kept. In these situations the family members also will be under stress. So the emotional trauma of the woman is totally neglected. Sometimes she may be punished by the family members, thereby, adding to the trauma. The pregnancy can be the result of rape also. In such situations, there will be sympathy towards the woman. But the specific emotional needs of the woman are not met in the health care institutions. The family members, also, will be upset and they cannot handle the situation properly, unless there is support from the community. Often the family members want to hide it from others. There are instances where the even more community supports the rapist for different reasons. If the girl is a minor, the situation is even more complicated. If the rape is the result of incest, it is further worsened. In all these situations, women become victims of sexual taboo by the patriarchal society. Hence, abortion cannot be seen as a bio-medical problem alone without touching socio-cultural factors.
A notable feature, of the experiences of women undergoing abortion, is the diverse socio-cultural situations. The situations are different in developing and developed countries. Religion, race, cultural factors etc also make differences. In countries, where the population growth rate is high, the Governments promote abortion services, whereas it is prohibited in countries where the rate is low. Different standards are taken for different races, in the same country, also. But, even in places where it is legal, the attitude towards abortion has not changed. And no measures are taken successfully to meet the contraceptive needs of women ensuring safety. This contradiction shows that the abortion services are provided with the aim of population control alone, and not as an outcome of women’s struggle to liberate themselves from the sexual control by the male dominated value system.
Women’s movements for abortion rights have much relevance in this context. It can make changes in the attitude of society. In addition to it, health clinics run by women conduct abortions and their experience will contribute much to women’s freedom. They give importance to the uniqueness of each woman’s experience. It can be seen that even in the same cultural context, women have different experiences. Some women may feel positive; others negative, or sometimes they have mixed feelings. Women, often, feel more strength after taking the decision, since they have taken a vital decision. This can be experienced only in an atmosphere of freedom.
The situation in many countries is bad, since abortion is considered a criminal activity. In countries like Nepal, unsafe abortion, is the cause of 50% of maternal deaths. Unsafe abortion is one of the major reasons for maternal mortality in many countries. WHO (1995) defines unsafe abortions as a “procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both”. Abortion becomes unsafe, if it is induced by the woman herself, by nonmedical or unskilled persons in unhygienic conditions. Such abortions, are attempted by administering abortifacient preparations, either orally or by inserting the preparations into the uterus, or by an improperly performed dilation and curettage procedure, ingestion of harmful substances or exertion of external force. In the 1950s, about a million illegal abortions a year were performed in U.S., and thousands died each year as a result. A woman, living in a developing country, faces a risk of death upto 250 times greater, if she has to seek abortion services from an untrained, unskilled abortionist than if she has access to a skilled provider and hygienic conditions. The risk can be reduced, if safe abortion services are available.
There is no point in criminalizing abortion, because it neither reduces the incidences of unwanted pregnancies, nor reduces the number of unsafe abortions. Even, with the wide use of contraceptives, elimination of the need of abortion is not possible. Hence, legal prohibition of abortions is not appropriate. Decriminalisation of abortion is urgent in those countries where it is illegal at present. This will promote safe abortions. Any pregnancy terminated within 12 weeks –(less than 3 months)– of gestation by a trained medical practitioner under clinic situation –(approved government or private health clinics)– can be termed as “safe abortion”. Abortions are unsafe, if any of the three conditions mentioned above, is unfulfilled. However, legal measures alone, will not give results.
In earlier periods, abortions were more or less accepted in all communities. Women helped each other to abort. In developing countries, they still practice it. In the middle of the 19 century, abortion became illegal in U.S., except those necessary to save the life of the woman. In 1969, Pope declared all women having abortions, to be subject to excommunication. Abortion became a sin and crime. Sometimes, it was based on the unsafe aspects of abortions, but it was interesting to note that more unsafe surgical procedures were allowed in the same period for other ailments. So the so-called protection of women was only a way to control women. It was to suppress the women’s movement, for rights of women. Male domination in the modern medical care system also wanted to eliminate the abortion practices of traditional women and midwives. Wherever there was a need for more population, and need for population increase of a particular race, women were not allowed to abort. On the contrary, as a part of the population control programme, wherever there was overpopulation, abortion was promoted. This shows the double standard of states. Thus, abortion, became an issue of the state, controlled by eugenics and population policies. It never considered the woman’s feelings.
It is observed, that even when abortion is illegal, it happens because the need exists. When women are determined, they will do it. But this will be dangerous. Sometimes, women themselves do it using needles, douches or herbal medicines or they seek the help of untrained persons. A recent study, in New York City, showed that over 45 % of women who had legal abortions would have tried to get them, even if they had been illegal. The problems are unnecessary death, costs and also lack of treatment if there is some complication.
Reform of law came in the U.S. gradually, allowing women abortions in certain circumstances –(e.g. pregnancy resulting from rape or incest, being under 15 years of age)– but leaving the decision to doctors and hospitals. It was further liberalized in 1970 so that it can be done on demand if performed under medical facilities by a doctor. It was a continuous fight. There were cases in the Supreme Court urging repeal of all restrictive state laws. Legalisation, though necessary, is not sufficient. The enforcement depends on social movements and social attitude. Even when funds are provided, hospitals hesitate to provide the benefit for women. Experience from Italy shows this. Though, there was a law brought in 1978 in favour of abortion, the doctors themselves, refused to do it by the pressure from religion.
Finally, it came out, that right of privacy, founded in the concept of personal liberty, is broad enough to encompass a woman’s decision whether or not, to terminate her pregnancy. When abortion is illegal, women from low socio-economic class have to suffer more. They cannot afford it. They cannot go to other countries because they cannot meet travel expenses. The illegal abortionists charge very high rates, sometimes even demand sex with them. They want to finish abortion as fast as possible for their own safety, and there will not be any scope for follow up. Other hospitals deny treatment, if there is any complication. Moreover, there is no mechanism to deal with the issue of stress.
Situation in India
Medical Termination of Pregnancy Act was passed in 1971 in India. According to this, termination can be done under 5 conditions. They are:
- Medical- Where continuation of pregnancy might endanger the mother’s life or cause grave injury to her physical or mental health.
- Eugenic- Where there is substantial risk of the child being born with serious handicaps due to physical or mental abnormalities.
- Humanitarian- When pregnancy is the result of rape.
- Socio-economic- Where actual or reasonably foreseeable environments could lead to risk of injury to the health of the mother.
- Failure of contraceptive devices.
At present there is no legal problem for women to seek abortions. But, even now, a large number of unsafe abortions are taking place due to various reasons. The decision making power of a woman, in reproductive matters is minimum, in India. There is lack of awareness and accessibility. A study done by an NGO in rural Uttar Pradesh shows that the husband’s consent was a major factor in the decision to seek abortion. In some cases, the husbands refused consent outright, and the women had to accept the pregnancy. In a few other cases, women attempted abortion without informing or consulting their husbands, mainly out of the fear that they would not consent. Those who wanted to limit their family size were more determined to seek abortion.
When induced abortion was attempted, some women relied more on methods like herbal concoctions, medicines, injections, inserting objects ( sticks)- unskilled providers, like traditional birth attendants and untrained medical practitioners. Then, only half of them, were successful. Women, who did not get support from their husbands, were more likely to try out these methods and turn to unsafe providers, as they wanted to do it secretly. Other factors were, higher costs involved in accessing surgical abortion, women’s fear of the surgical procedure and instruments. This, again, emphasizes that legal measures alone do not help women.
Situation in Kerala
Being a state, where the fertility indicators show high achievement, anybody will expect appropriate use of contraceptives in Kerala. On the contrary, what we see in Kerala, is unmet needs of contraceptives. This is exemplified by the high rate of abortions. The rate is 15/1000 live births. In India, Kerala is the second highest in abortions, the first being Goa. This shows that though fertility rate is low, women do not have much control over their body. If women had choices, and control over their body, unwanted pregnancies could have been avoided. The accepted family planning methods are socially controlled. Tubectomy after two children became a norm, but temporary methods are not practiced effectively. MTP is widely practiced in Kerala. The number of unsafe abortions has come down in the past years. But, the cost of safe abortion is high for poor women in private hospitals. The quality of treatment and counselling should be improved. It is still a taboo area. The medical system has much control over women. The right to information for women is often denied. Even the service of MTP is denied sometimes in Government hospitals due to different reasons. It will depend on the perspective of the doctors. Some doctors insist on the consent of husbands. This makes it difficult for an unmarried woman to get an MTP done.
In Kerala 50% of young women’s (below the age of 24 years) pregnancies are unintended and unwanted. For these women, the need for reproductive health and contraceptives, are not met. The main reason is that child bearing is considered as the main duty of women. Marriages below 20 are high and awareness regarding contraceptives is low. Matters related to sexuality are considered taboo. The decision-making about child bearing is not done by the woman.
The attitude and behaviour of the professionals, is very important to the woman who undergoes abortion. She needs care, affection and kindness. But often the opposite is happening. The medical personnel will be harsh and hostile, because anything related to reproduction and sexuality are considered ugly. In some private hospitals, you can expect a better treatment, but the poor women cannot afford the cost. Legalisation alone is not helpful to women in a cultural milieu, which is against abortion. Anti-abortion propaganda is pervasive in our society. Hence, counselling services are essential in centres providing abortion services. Women should be treated with respect. Each woman, has the right to have painless abortions and treatment meted out with dignity. There is discrimination in choosing anesthesia for the poor and rich women.
It is an enigma that in the so-called developed countries where women’s liberation is proclaimed, they did not have abortion rights. Still in some of the countries like Italy, it is illegal. In the U.S. also, the progressive legislations are slowly reverted, irrespective of the strong movements for abortion rights. The women who got opportunity to have abortion when they wanted it, feel that these options should be available to all women. They are not seeing it in isolation, but they want it along with other factors like positive environment for childcare, decent incomes, housing and education, elimination of racism etc. These movements have contributed much to women’s assertion of their rights.
Though, abortions became illegal at one point of time in U.S, there had been a strong movement for abortion rights. Most of the women in the democratic world think that no one else has any right to interfere with a woman doing what she needs to do with her body, according to her own wisdom and judgement. For a woman who decides to have an abortion, it is not a difficult task. But, they get confused and feel guilty, when others interfere. Then they question themselves and wonder whether it is a crime if she is not getting upset with abortion.
It can be understood that it is the wrong practices of society that makes it a dilemma to have an abortion. A woman who chooses to have abortion need not feel guilty about it, if she has the right to choose. In such a period, a woman can have the desire to continue the pregnancy, valuing the new life, even if there is an uncomfortable situation. Here, taking the risk is the woman’s choice. No one else has the right to ask her to do what others desire.
If there are abortion clinics run by sensitive women, emotional support can be given to the women who attend the clinic. There are examples of feminist health centres in countries like U.S., where trained counsellors give support to women and help them to sort out their feelings before and after the procedure. At the same time, if a woman needs privacy, that also should be accepted. If a woman does not want to share her feelings, that is also accepted. Also, the women themselves, can share and support each other. Detailed and correct information should be given to the women about the abortion procedure. A friend of the woman should be allowed to stay with her, if she wants it. Woman should have a major participation in decision-making. It is the right of the woman to get a respectful treatment, and women need not feel always thankful to the institution if they are treated well.
There are instances in other countries, where women’s health centres provide affordable services, sometimes even free services to poor women, even when it is considered a crime by the state. In these clinics, trained non-medical women provide services. Everything is done keeping the anonymity and security. Follow-up services are also rendered, such services including emotional support and reassurance. At the same time, awareness is given to women so that they can avoid dangerous measures like herbal medicines, chemicals, introducing crude instruments etc.
In India, women’s groups recommend IEC programmes to promote community awareness on women’s health issues, consequences of repeated pregnancies and abortion, the importance of seeking abortions early and from trained providers, the risks associated with home-based, traditional, trial-and- error methods. Availability of safe abortion services must be ensured, and male responsibility should be considered. More information, regarding contraceptives, should be given.
In the Kerala context, a cultural change is inevitable, to address the moral dilemma of abortion. In Kerala, safe abortion facility and information regarding contraceptive practices are not lacking. But, women’s power to control their own body, is lacking here. We should be sensitive enough to understand the risks taken by women in other countries to help their sisters, even when it is illegal. Here, it is legalised, but it is done with shame and guilt. Even if there is no shame and guilt, the woman’s stress is not properly addressed by others, because sexuality and related things are still not open. And, also, the legalisation of abortion was not the result of the assertion of rights of women. It was part of the population policy. If women have proper access to contraceptives and control over their body, the incidents of abortion itself can be reduced. But, it is entirely different from legal control. The number is reduced through autonomy and choice of women in the former situation, and therefore, safety is ensured. In the latter situation, rights of women are denied and it will lead to unsafe procedure. Here, the number of abortions are more, because women are not allowed to have control over their body, not allowed to decide their role in sexual interaction, not allowed to choose contraceptives which is not harmful to her body. So, the rights are essential to correct the wrongs in our society. Legal sanction alone is not enough. A pro-choice movement can make a difference.
JAYASREE AK. Medical doctor with M.D. Noted feminist activist. Chairperson, Foundation for Integrated Research in Mental Health; Guest Lecturer in Sree Chitra Thirunal Institute of Medical Science and Technology, Thiruvananthapuram and Mahatma Gandhi University, Kottayam. Resource person for State AIDS Control Society, Kerala; Member, Task Force on Health and Family Welfare, Kerala State Planning Board, Monitoring Committee on Women’s Development in Kerala, Advisory Committee SAKHI Resource Center for Women, Kerala Sasthra SahityaParishad and Stree Vedi. Presented papers in national and international seminars and conferences. Published articles in scientific journals, magazines and newspapers.