Almost 50 000 women die every year from complications arising from abortion. There are more abortions and more complications in countries with restrictive legislation. Global debate should focus more on injustice and less on sexual morality
The 100th anniversary of women’s suffrage in Norway gives pause for thought. Two articles in this issue of the Journal of the Norwegian Medical Association remind us of the reality the women who had unwanted pregnancies in Norway faced at the time when women were finally given the vote on equal terms with men (1, 2). But it also reminds us that an unwanted pregnancy is still a catastrophe for women in many parts of the world. Women’s sexuality and fertility are not just important health concerns, they are also fundamental aspects of being human. The ongoing and often heated discussion about extending the right to conscientious objection shows that the abortion issue is not uncomplicated nowadays either. In today’s world there are huge inequalities in the possibilities for women to survive their pregnancies, births and abortions, both within and between different countries.
King Christian V’s Norwegian Act of 1687 did not distinguish between abortion and infanticide. Both entailed the death penalty, and women’s heads were put on stakes to demonstrate their shame and infamy. Extramarital sex was a felony. The woman was often punished, while the man – who could not be unmasked by a growing belly – generally got off scot free. In 1842 the death penalty was replaced by hard labour. From 1902 right up until 1964, women could be sentenced to up to three years’ imprisonment for undergoing an abortion. Dramatic life stories are concealed behind the text of the Act. The expression «unwanted pregnancy» is a weak term to describe the catastrophe that «accidentally falling pregnant» represented for women. Many risked their lives and health through unsafe abortions, or they hid their pregnancies, gave birth in secret and then killed the child. The alternative was to expose oneself to social stigmatisation, moral condemnation and aggravated poverty by having an «illegitimate» child. The topic has been widely explored in fiction down through the years, and demonstrates the explosive social factors inherent in these issues.
Legislation on abortion varies widely in different parts of the world. In countries with the most stringent abortion legislation – a handful of Latin American countries and a few small European ones – any abortion is prohibited, even if it is necessary to save a woman’s life. At the other end of the scale there is Canada, which has completely removed abortion from the penal code. There, the procedure is considered to be a matter between a woman and her doctor. Professional ethics, not legislation, set the guidelines – including for late-term abortions. Between these two extremes there are all manner of shades of grey. In some places abortion is only permitted if it is to save the woman’s life; in others if it is necessary to preserve her physical health. Other countries permit abortion if there is also a risk to mental health, or for socioeconomic reasons, while several countries, like Norway, have abortion on demand up to a certain point in the pregnancy. The general tendency globally is towards liberalising the abortion legislation: more countries are liberalising the criteria for legal abortion rather than curtailing them (3).
We have fairly good knowledge of the consequences of different types of abortion legislation and of what happens when the law is changed. The more stringent the legislation, the more women die from complications of abortion. Liberalisation reduces the mortality rate, sometimes drastically (3). Infanticide continues to be a desperate solution in some countries where women have no access to abortion. The incidence of abortion is practically speaking unrelated to abortion legislation; it is determined in particular by access to contraception. Paradoxically there is a correlation between stringent abortion legislation and high abortion figures, and between liberal legislation and low incidence (3). This is not a causal connection, but is attributable to the fact that countries with stringent abortion legislation generally also have poor access to contraception and the other factors that dictate the incidence (3).
Laws are crucial for access to abortion services and for women’s possibilities of surviving the termination of their pregnancies. However, they also have an effect in setting norms, i.e. for perceptions of what is right and wrong, what is moral and immoral. In many places where abortion legislation is stringent, women who terminate their pregnancies encounter condemnation and receive very poor treatment. It is not unusual for women to wait an unnecessarily long time for treatment, which makes complications such as haemorrhage or infection develop and intensify. They often receive outdated or unsafe treatment and inadequate pain relief (4). Hostile treatment, even abuse, is a significant problem.
Where abortion legislation is stringent, impoverished women resort to unsafe abortions. Treatment of complications from abortion is therefore important in reducing abortion-related morbidity and mortality. There is global cooperation on improved access to and quality of treatment for complications of abortion, for example through the Postabortion Care Consortium, which was started by the US-based organisation Ipas in 1993. When healthcare personnel receive training in this type of treatment, it also opens the door for them to the locked chamber that unsafe, illegal abortions represent.
In recent years it has been emphatically shown that unsafe abortions are something that overwhelmingly affect poorer women (3). Private health services perform safe, illegal abortions for those who can pay, while the complications are generally treated in public hospitals, where they constitute a considerable burden. Even in public hospitals women must frequently pay astronomical sums of money for treatment, which drives them and their families into even deeper poverty (5). I believe that globally there is more to be gained from countering this social injustice than from engaging in debate aimed at achieving a common sexual morality.
