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Seminar on the Socio-Cultural and Political Aspects of Abortion in a Changing World

Trivandrum, India, 25-28 March 1996
Organised by the IUSSP Committee on Anthropological Demography in collaboration with the Centre for Development Studies, Trivandrum

Report

Before the opening ceremonies the death of Bruno Remiche, Executive-Secretary of IUSSP was formally announced to participants, and a minute's silence held in his memory.

In the opening ceremony participants were welcomed by Alaka Basu (Chair of the Committee), Chandan Mukherjee (Director, Centre for Development Studies, Trivandrum) and John C. Caldwell (IUSSP President).

The main objective of the Seminar (the last by the committee during its term) as pointed out by Alaka Basu was to create a forum for scientific and scholarly discussion of an issue that cannot be wished away - the 50 million or so abortions that occur annually worldwide, that take an undue toll on women's and children's health because so many of them are performed illegally and secretly under unsafe conditions, and that reflect the complex interactions between culture, women, religion and the law. This issue is incompletely served by purely statistical analyses, which in any case are far from satisfactory, and needs much more input from micro-level and qualitative studies of the sociocultural and political factors that constrain, facilitate or even encourage abortion.

It was believed that anthropological demography could play a key role in understanding this global phenomenon. As noted by Chandan Mukherjee, this role could be effectively played if demographers and anthropologists come together since this would forge a more in depth understanding of issues pertaining to abortion. This view was further re-enforced by J.C. Caldwell that abortion constituted a great source of worry both in magnitude and particularly due to various statistical deficiencies and re-iterated that Anthropological Demography offered a very basic way of understanding the prevalence of abortion. He applauded the work of the committee through its four-year term.

The programme of the seminar covered five sessions.

1. Changing levels of abortion: the macro and micro evidence

This session included two overview papers that put the subject of abortion in a quantitative perspective. While numbers alone cannot define the abortion problem or suggest the ways in which it can be dealt with, they are essential to provide the frame of reference for the non-qualitative interdisciplinary work that needs to feed more into abortion research. Susheela Singh and Stanley Henshaw's paper (The Incidence of Abortion: a worldwide overview focusing on methodology and on Latin America) suggested that women have always turned to abortion as a last resort to prevent unwanted births even where it was unsafe and forbidden. Quoting WHO's 1990 estimates they indicated that 50 million abortions occurred annually worldwide. About 30 million of these abortions are safe and about 20 million unsafe. Putting this in the perspective of 137 million births worldwide in 1990, it was implicit that induced abortions represent about one-quarter of all pregnancies.

The paper mentions various approaches to the collection of data on abortion and measurement of the incidence of abortion (registration systems, surveys and indirect estimation techniques) and inherent varying degrees of limitations and problems vis-a vis the setting. The paper highlights the implications of unsafe abortion for women's health both in the immediate (haemorrhage physical damage to the reproductive organ, etc) and long term (chronic pelvic pain, obstetric complications, infertility etc.) consequences. Relying on findings of various studies the presenters note that abortion is a significant means of fertility control worldwide notwithstanding difficulties in its estimation.

Alex Mundigo's background paper 'The Challenge of Induced Abortion Research: trans-disciplinary perspectives' relied on case studies on four Latin American countries. He stated that abortion is a social, economic, legal, political, religious and demographic reality. Given this background, he argues that the study of abortion especially where abortion is illegal, remains a major challenge to researchers working on reproductive health and women's right issues. Subsequently he advocates that the study of the determinants of induced abortion should adopt a combination of both qualitative and anthropological approach. He acknowledges that although induced abortion research has the unique characteristic of being at the intersect of several disciplines, researchers are often reluctant to undertake studies largely due to methodological difficulties and strong social and political connotation of the phenomenon. The paper challenges researchers to dare into the areas of abortion service providers, pathways that women follow once they decide to terminate a pregnancy, abortion among adolescents, policy issues regarding induced abortion and innovative approach in the collection of information on induced abortion.

Nosa Orobaton's paper 'Are unsafe Induced Abortions Contributing to Fertility Decline in Africa? Findings from Egypt and Zimbabwe' was more of test study based on the Target-cost Model developed by The Futures Group. The paper rationalized that the idea of legalizing abortion is highly politicised in many African countries and that governments in Africa were unlikely to change abortion laws without PUBLIC support. The paper argues that the availability of approaches that permit an examination of the effects of induced abortion on the family planning effort could prove to be a very useful tool for policy dialogues on abortions. In the estimation of the paper, the Target-cost Model as utilized in the study shows a proven ability to lay bare macro-level relationships between rising abortion rates, fertility decline and contraceptive use. The model was therefore seen as a potential tool in eliciting policy direction on induced abortion.

Barkat-e-Khuda's paper 'Abortion in Rural Bangladesh: What Do We Know?' used bivariate and multivariate analysis (involving 15,000 women of reproductive age between 1982 and 1995) to examine abortion practices among various socio-economic categories. The paper established increased abortion rates during the study period and found that about four fifths of abortions were performed by untrained Doctors. The paper also noted an increase in spontaneous abortion, the cause of which could probably be attributed to some induced abortions being reported as spontaneous. The paper by Irudaya Rajan et. al 'Role of Abortion in the Fertility Transition in Kerala' notes that fertility decline in Kerala has abortion as an insignificant determinant since only 8% of all pregnancies end in abortion (both induced and spontaneous) which are mostly terminated within 12 weeks of conception. Maternal mortality rates are thus low in Kerala. The last paper for the session 'Induced Abortion and Contraceptive use in Russia; State of the Art and Need for a Micro-approach' was presented by Inge Hunter. The paper relied largely on existing literature and concluded that easy access to legalized induced abortion discouraged the use of contraceptives which were in any case not available. The paper advocated micro study that would enhance understanding of the process of decisions and actions towards induced abortion. At the close of this session participants noted the limited nature of data on induced abortion which did not lend much strength to efforts at soliciting policy change. This largely results from under-reporting.

2. The larger environment : the role of the state, religion and policy

The papers presented in this session examined the issue of abortion within the context of the State, Religion and Policy. Florina Serbanescu et al 'The Impact of Recent Policy Changes on Fertility, Abortion and Contraceptive use in Romania' analysed data from the National Romania Reproductive Health Survey (RRHS) conducted in 1993. The study compared fertility, abortion and pregnancy rates and contraceptive prevalence before and after a change in government policy that legalised abortion and modern contraceptive. Their findings indicate, among others, that the concept of family planning was poorly developed in Romania and that the (liberal) change in legislation did not translate into a significant increase in contraceptive use; and subsequently the extremely high rate of abortion appears to be the principal determinant of the decline in fertility. The paper concludes on the note that since the most common reason for using contraception and abortion is to have no more children, permanent methods of contraception should be promoted. Libor Stloukal 'Eastern Europe's Abortion Culture: puzzles of interpretation' examined several competing explanations for the relatively high abortion levels in Eastern Europe. The paper position was that abortion patterns reflected political developments and their effect on the Institutional sphere; also that the crucial determinant was the prevailing social values of Eastern Europeans as citizens and individuals. Resort to abortion was facilitated by liberal abortion laws and re-enforced by high costs of contraception - these emanating from policies designed to ensure national balance rather than individual needs. For instance monitoring of abortion was the preserve of doctors who were themselves controlled by the state. Susana Lerner and Guadalupe Salas paper was on 'Abortion Legislation in Mexico in the Face of Changing Socio-Demographic and Political Context'. The paper gives an account of the variety of legal measures in effect in the states comprising Mexico. They suggest that in almost all the states, abortion was neither permissible nor prohibitive. They explained that abortion is hardly discussed in Mexico despite a presidential commitment to the contrary, but which however comes against powerful anti-abortion forces like the Catholic Church.

Maria Isabel Balta da Rocha's 'The Abortion Issue in Brazil: a study of the debate in congress' presented an informative review of the debate in the Brazilian Congress which sought to alter existing constitutional provision on abortion. The paper ends is in a tone of suspense. At the centre of the debate is a bill which if passed would slam the door on permission for abortion on grounds of health and rape. If rejected, discussions and debate for further reforms would intensify. Stanley Wijewickrema's paper 'The Roman Catholic Church and Abortion' presented by A. Kukzycki examined the position of the Catholic Church on abortion both in the past and currently. The paper suggested that the Catholic Church in general finds abortion unacceptable. However Roman Catholics do not hold the same position as regards abortion and that the Catholic doctrine itself was not fixed, definite and complete and this opens the door for further debate within the Church.

Maria Consuelo Mejia 'The Role of the Catholic Church in the Abortion Debate' presented by Lucia Rayas examined the central issue in the position of the Catholic Church on Abortion - the hominization of the foetus; that is, the stage at which the foetus acquires a soul. The Catholic Church's view is that abortion is a grave moral fault because it is the deliberate destruction of an innocent human being. She argues that Catholics face a wide range of problems that prevent them from reconciling their daily lives and the church's teachings which they faithfully hold on to. She suggests a lack of scientific and theological consensus in the Catholic Church in labelling abortion as a murder. In a general discussion that followed the presentations, participants concluded that the issues of abortion lie more with legislation rather than the church. It was noted that in general progress on issues concerning women's health and abortion is slow but the increasing opportunities for PUBLIC debate on abortion is reassuring.

3. Constraints and negotiations

Sajeda Amin's paper 'Menstrual Regulation in Bangladesh' examined factors that determine the success of the Menstrual Regulation (MR) Programme - success which appears to be sustained by a maze of ambiguity around the reproductive physiology of pregnancy. The paper defined MR as pregnancy termination by vacuum aspiration in the early stages of pregnancy. The paper suggests that the success of the MR programme among others, was due to a less stigmatized terminology, safer procedure and relatively small cost involved. Ahmet Icduygu's paper 'Correlates of Timing of Induced Abortions in Turkey' used survey data to examine the factors affecting the differences in the gestational age at which abortion occurs. Through bivariate and multivariate analyses, the paper established variations in the timing of abortions found to be related with age, region of residence, education, husband's education, number of living children, agreement with husband on the number of children desired, etc. The paper called for further studies in timing of abortion that would explore the effects of both individual and community-level factors. The work of Chantal Blayo and Yves Blayo 'The Pressure to Abort' centred on France and China. The paper suggested that in France family size is a function of societal expectation which presumably favours a smaller number of children. This puts pressure on women to use contraceptives and to seek abortion in the event of conception. Similarly in China the regulation of one child per couple puts pressure on couples to seek abortion which was considered cheaper than contraceptives.

Elisha P. Renne's 'Changing Assessments of Abortion in a Northern Nigerian Town' used field research to appraise the shift in the practices of abortion in a Muslim Huasa Section of Zaria, Northern Nigeria. The paper suggested that while support for a reassessment of abortion seems unlikely in the present religious and political climate, the actions of young unmarried school girls who attempt abortion even when they know that such behaviour is forbidden according to current strict readings of the Quaran suggest a way that practice may interpolate ideology. John K. Anarfi's paper 'The Role of Local Herbs in the Recent Fertility Decline in Ghana: contraceptives or abortifacient' argued that fertility decline in Ghana in recent years could not be wholly attributed to contraceptive prevalence rates as these did not correlate well with the magnitude of the fertility decline. The paper identifies abortion as the other factor and suggests that this has flourished in the context of proliferation of local herbs potent enough to induce abortion.

The work of Susan Pick et al, 'The Role of Pharmacists and Market Herb Vendors as Abortifacient Providers in Mexico City', covered interviews with 181 pharmacy workers and 41 market herb vendors. The paper established that pharmacy workers and market herb vendors are providers of abortive methods for their clients thus assuming the role of medical providers with regard to abortion but with inadequate training to play such an ascribed role. The paper recommends policy changes, training programmes and further research that should involve wider sample. Andrzej Kulczycki 'Demographic Research and Abortion Policy: the limits to statistics' expressed concern over the limits to using statistical data in advancing knowledge and policy in the area of abortion. The paper argues that relevant statistics may make up a larger part of the background against which the moral as well as the social and health aspects of abortion are discussed. However research reports on many aspects of abortion are flawed or otherwise reduced in value due to deficiencies in the recording of such events. In this respect, he concludes that statistics on abortion lack the credibility needed to address powerful special-interest groups.

Annika Johansson et. al 'Abortion in Context: a study of induced abortion in two villages in Thai Binh Province, Vietnam' discussed factors that have raised abortion rates in the two villages. The paper suggested that abortion rates reached their highest in the early 1990s during which the annual number of abortions began to exceed the number of births. This was the period when a national two-child family policy became increasingly stringent. Other factors were financially expedient desire for smaller families and inadequate contraceptive service. The paper called for research into the service and social context for women seeking abortion. The last paper for this section by Elsie Levin 'Menstrual Management and Abortion in Guinea, West Africa' described a practice used in a town in rural Guinea in which women by the use of local pharmacopoeia induce menstrual periods that they consider to have been delayed. The practice is locally seen as 'cleaning the belly'. The paper suggests that the importance of not knowing of the presence of a foetus, and of not wanting to know of it when one seeks to 'clean' the belly is part of establishing this activity as apart from abortion. However the paper argues that if this practice also effectively hides some intentional management of fertility, which it almost certainly does by providing an acceptable way of ending an early pregnancy, then there is much more to be learned about intentional fertility management outside of, and before, modern contraception. A lively discussion followed the presentations during which the following consensus were reached - that the papers have satisfactorily explored constraints that women face in seeking abortion; that demographers and anthropologists need to come together to pick several issues discussed for further exploration; that, of particular interest was the efficacy of herbs and non-standard drugs routinely used to induce abortions.

4. unwanted births and unwanted pregnancies

Amy Stambach's paper 'Debates About Schoolgirl Abortion in Northern Tanzania' examined the social and cultural circumstances that compel and motivate girls in secondary school in Machame, Tanzania to seek and sometimes self-induce abortions. The paper explained that these abortions reflect Chagga concerns that educated schoolgirls marry hypergamously and mono-gamously, that they remain economically and socially autonomous from older men and fellow male classmates and that they marry and bear children in ways their families consider appropriate. Barbara D. Miller's paper 'Chasing Equality: the politics of sex-selective abortion in Asia' explored what she believes was an area where long-standing patriarchal structures and values join with the emerging indirect patriarchal mechanisms of new reproductive and medical technology (NRT). The paper submits that economic development and decreased fertility in South Korea, Taiwan and Hong Kong are positively correlated with Female Selective Abortion (FSA). M.E. Khan and Bella C. Patel 'Level of unwanted Pregnancies and Its Consequences' relied on qualitative data to examine the circumstances under which unwanted pregnancies take place. Among others, the paper's findings indicated that as pregnancy order increases the frustration of women experiencing unwanted pregnancies also increase and this exerts pressure on them to abort, especially in the context of lack of control over their sexuality or reproductive goals. In the last presentation Ondina Fachel Leal and Jandyra M.G. Fachel 'Abortion in South Brazil: contraceptive practices and gender negotiation' showed that gender distinctions, tensions and negotiations characterise reproduction and/or abortion in Brazil. The paper indicated that induced abortion through oral procedures are not perceived as abortions but as a contraceptive routine or as menstrual regulation in which the decision involves only the women. The paper showed further that men tend to be more conservative on abortion practices and its legalization.

Discussions that followed the presentations reflected a consensus that the issue of sex selectivity and abortion needs to be appreciated as a more complex one - given the context that men and women operate within a given set of norms that are imposed upon them. Their actions are therefore largely to conform to societal expectations. Participants stressed on the need to combine both anthropological and statistical approaches in analysing issues on abortion.

5. Abortion in South Asia: some determinants and the reproductive health implication*

The papers presented in this session centred mainly on four South Asian countries. M.E. Khan et. al 'Abortion in India: an overview' offered a thorough statistical presentation of the abortion situation in India. The paper indicated that after the legalization of abortion through Medical Termination of Pregnancy (MTP) Act in 1972, approved MTP facilities increased from 1877 in 1976 to 7121 in 1991 and the number of MTP cases rose from 25 in 1972-73 to 632,526 in 1991-92. The paper, argues however, in conclusion that MTP services are not easily accessible to the majority of rural women resulting in about 90 percent of the estimated 6.7 million abortions being performed by untrained village practitioners under unsafe and unhygienic methods and conditions. The paper attributes this largely to slow growth of, and disproportionate distribution of MTP facilities that favour well established states.

W. Indralal De Silva 'The Silent Cry: socio-cultural and political factors influencing induced abortion in Sri Lanka' employed in depth interviews involving abortion service providers, obstetrics consultants and nurses. The paper establishes that despite the technically illegal status of induced abortion, its practice has contributed to fertility reduction. The paper argued that the prevailing socio-economic and cultural environment would facilitate the practice of induced abortion more than the legal position regarding abortion. Drawing comparison with India, the paper concluded that Sri Lanka was lagging behind in legal reformation on abortion. Fariyal F. Fikree et al 'The Emerging Problem of Induced Abortions in Squatter Settlements of Karachi, Pakistan' present the findings of an initial small study and a follow-up in depth study involving 30 women who were known to have undergone induced abortion. The paper establishes that Pakistani women living in low socio-economic settlements of Karachi seek voluntary termination of their pregnancy fully aware of the consequences but in the desire to maintain an economically manageable family size. The paper suggests a more pragmatic government approach that would bring about preventive rather than curative attitude to control of unwanted pregnancies. The paper by M.D. Kapil Ahmed et. al 'Determinants of Induced Abortion in Rural Bangladesh' made use of data from two sources - Demographic Surveillance System (DGS) and Sample Registration System (SRS) to examine trends in induced abortion during 1982-91. The paper established significant increase in induced abortion over the period due to an increased proportion of women not desiring additional children. It was also established that there was an association between contraceptive method use and induced abortion, and that traditional method users and condom and pill users had higher induced abortion. The paper also suggests lower abortion rates when women had access to well-organised and intensive health and family planning programmes.

The session ended with panel discussion 'Is South Asia unique?'. The panel consisted of Pat Caldwell, T.N. Krishnan, Susana Lerner and Nosa Orobaton. Contributions from panelists pointed to consensus that reasons for resort to induced abortion in South Asia were not different from what pertains in other parts of the world and that these were largely social, economic, political and religious within which women have often acted rationally. These same factors tend to shape policy formulation on abortion. The discussion suggested that abortion rates appear to be higher in South Asia - which comparably was seen as being far ahead in terms of availability of data on abortion. In a general discussion that followed, participants anticipated that demographic transition in South Asia would be more dramatic in the next five years. The driving force was seen as economic in which more people are realising that their aspirations cannot be met with large families. It was suggested that quality and efficacy of family planning programmes must involve good counselling on abortion and what to do in case of complications.

Closing session

Conclusions on the seminar were drawn by John C. Caldwell and Pat Caldwell. They submitted that a great deal of abortions are being performed for many women and these abortions should be safe. This was dependent on the creation of situations where abortion is conducted without fear, intimidation or stigmatization. While expressing concern over the reliability of statistics on abortion worldwide, John and Pat Caldwell noted that abortions are relatively safer in sub-Saharan Africa mainly because it has served as additional source of income for providers. They strongly argued that family planning methods can considerably reduce abortions if these methods are introduced early and that abortion and menstrual regulation need not be illegal and clandestine in the context of women's rights. They noted that fear in the fundamental Muslim countries in legalising abortion has to do with fear of increasing individual rights.

Participants were urged to conduct further research especially on women who did not have abortion when they wanted it and the experiences of those who had it. While the Committee on Anthropological Demography may not find it expedient to continue with the abortion issue, it was not to be the end of the topic on abortion. The Committee on Fertility and Family Planning and the Gender and Population Committee were to be encouraged to continue with the abortion debate.

Ernest N. Appiah

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