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Print version ISSN 0042-9686
Bull World Health Organ vol.78 n.8 Genebra Aug. 2000
BOOKS & ELECTRONIC MEDIA
Founder and co-ordinator of the Pro-Choice, Centre for Womens Studies, The University of Kent at Canterbury, Canterbury CT2 7NS, England
Abortion in the developing world
edited by Axel I. Mundigo and Cynthia Indriso. Published by Zed Books, London and New York, ISBN 1 85649 649 X, 480 pages, price £49.95 (US$ 69.95) hardback
In March 2000, the British Royal College of Obstetricians and Gynaecologists, with the support of the Department of Health in the United Kingdom, produced a guideline for its members on the care of women seeking abortion. It states that abortion should be considered a health care need, and that all British women should have access to a service of a uniformly high quality. In such a context it is easy to forget just how contentious an issue abortion remains in some parts of the world, and how devastating the consequences are for women in societies where it remains illegal, or where need far outstrips the capacity of existing facilities to provide abortion safely.
Abortion in the developing world provides a clear and graphic picture of the problem. In the introduction we are reminded that 70 000 abortions each year result in death. The risk of dying from unsafe abortion in the developing world is 1 in 250 procedures (1 in 3700 in the developed world), with many more abortion procedures resulting in severe complications, including sepsis and uterine perforation. It is against this background that Mundigo and Indriso present a collection of 22 research reports, the aim of which is ...to provide information useful for policy-makers...in countries where womens health advocates are working towards legal reform and normative change in the health codes to depenalize abortion.
The reports are the result of a research project commissioned in 1989 by the Social Science Research Unit of the Special Programme of Research, Development and Research Training in Human Reproduction at the World Health Organization. They provide data on a range of developing countries, where the availability of safe abortion is restricted because of legal prohibitions, or lack of availability of services. The starting point for the research was the recognition that in this context, induced abortion is an ...important contributor to reproductive ill-health and to maternal deaths. Researchers aimed to find out why women resort to abortion, including in situations where contraception is available.
The countries covered are Chile, China, Cuba, the Dominican Republic, Mauritius, Nepal, Turkey, Brazil, Mexico, Indonesia, the Philippines, Sri Lanka, the Republic of Korea, the United Republic of Tanzania, Colombia and Slovenia. Researchers have considered three main issues: the relationship between abortion and contraception, the quality of abortion care, and adolescent sexuality and abortion. In all cases, the findings make fascinating reading, but perhaps the most novel and striking aspect of the research is the attention paid to the motivations, opinions and needs of women themselves. This focus makes the collection both refreshing and innovative, but most of all challenges the reader to rethink their assumptions, since findings sometimes contradict preconceived ideas.
The challenging aspects of the research are perhaps most apparent where the relationship between abortion and contraception is considered. For example, the studies reveal that abortion is frequently not the result of a lack of knowledge and experience of contraception, or a lack of desire to regulate fertility. Rather, there can be a significant disparity between what policy-makers and others involved in providing contraception might consider effective, and the views of women themselves. The widespread use of withdrawal as the chosen form of fertility regulation is the clearest example of this disparity. For many, it is highly valued as a flexible, free method, which is not considered detrimental to health, and which perhaps most importantly is confidential and does not require contact with clinic or pharmacy.
In this context it would be both impractical and unethical to consider an unplanned pregnancy that may result as a symptom of a lack of knowledge which requires intervention on this basis. A further laudable aspect of the studies which considered the relationship between abortion and contraception was the attention they have drawn to the need for more research into gender (the differences between men and women in their approach to contraception), and emergency contraception.
In the section on abortion care, attention again focuses on the importance of starting with and prioritizing womens needs. Research reveals that, in order to improve services, providers need to ask questions including what is the level of knowledge about abortion, possible risks and complications amongst women who use it? What does the experience of unwanted pregnancy constitute for the woman concerned? What can be done to minimize levels of pain for women who have abortion? How can a desire for access to medical abortion be better met? How can services address the need for family planning and abortion services to be better linked? Emphasis is placed on the need for better facilities and more compassionate, well-trained staff: in summary, ...where abortion is provided, all who seek abortion should have their concerns and situations as individuals addressed.
The final section, on adolescent sexuality and abortion, graphically re-emphasizes some themes which are becoming more familiar. Whilst the needs of adolescents are now rightly on the agenda as a key issue for reproductive health services, the needs remain under-researched, and must be a central priority for the future. Research findings in this collection again indicate that there is a lack of access to sex education and family planning services, and that low levels of knowledge about sex and sexuality remains a major issue in adolescent sexual and reproductive health.
Perhaps above all, this volume emphasizes a lesson familiar to those of us in the developed world, that however perfect contraceptive services become, there will always be a need for abortion. Experience indicates that even where efficient and effective methods of contraception are increasingly easily available, and widely used, abortion remains a fact of life. Those involved with the provision of contraceptive services must work hard to ensure their services meet the needs and aspirations of their clients. But part of the alternative to the current scourge of unsafe abortion in the developing world is the provision of an inexpensive procedure, that, as experience in the developed world shows, poses no risk to health when performed under safe conditions.
Centre for Womens Studies
The University of Kent at Canterbury
Canterbury CT2 7NS England