Abortion in Asia

Local Dilemmas, Global Politics

Andrea Whittaker

• Publisher: Berghahn Books
• Year: 2010
• Print ISBN: 9780857457950, 9781845457341
• eBook ISBN: 9781845459758
• Edition: 1
• Topic: Social Sciences
• Subtopic: Gynecology, Obstetrics & Midwifery
• Index: Social Sciences

The issue of abortion forces a confrontation with the effects of poverty and economic inequalities, local moral worlds, and the cultural and social perceptions of the female body, gender, and reproduction. Based on extensive original field research, this provocative collection presents case studies from Thailand, Cambodia, Burma, Vietnam, Bangladesh, Indonesia, and India. It includes powerful insight into the conditions and hard choices faced by women and the circumstances surrounding unplanned pregnancies. It explores the connections among poverty, violence, barriers to access, and the politics and strategies involved in abortion law reform. The contributors analyze these issues within the broader conflicts surrounding women's status, gender roles, religion, nationalism and modernity, as well as the global politics of reproductive health.

Chapter One

ABORTION IN ASIA

AN OVERVIEW

Andrea Whittaker

Aunty Phim

At my age [forty-five years old] it’s not normal [to be pregnant] is it? . . . I’m not young and strong any more. There’s no way I’d be able to raise it. So I went to Bangkok. My younger sister is in Bangkok so she took me . . . They injected some medicine in. Made my stomach hurt. I gave birth just the same as you’d give birth to a child. I didn’t know how they did it, I just lay down. Lay down on a bed and gave birth there on the bed itself. I could see young people, they were crying, it wasn’t just me who was there. They had nurses, but the doctors, they did their work. But they looked after me. Once they had gotten the tua [body] to come out, a luuk [child] came out, see. But it wasn’t very big, quite small, just over two months. When it came out the pain went away just like giving birth to a child. They had me lie in the hospital for a night . . .

And Auntie when they injected you, did they give you saline?

They didn’t inject me. They gave it [the medicine] to me by way of the nam kleua [saline intravenous drip]. Once the saline and the medicine had gone in I had stomach pain straight away. Then it was just one lump. It was just the same as giving birth to a child . . .

Did you lose a lot of blood?

No, no I didn’t lose a lot, normal. I’d have to tell you straight that it was comfortable. But the young girls who went to do it, three months’ [gestation], five months’, dangerous. But the doctors took good care of them. But they were in a lot of pain. I saw kids, they’d be all bent up, Wooh! crying. . . .

Aunty Phim is a rice farmer with four years of education and lives in a village in Roi Et province in northeast Thailand. She has two daughters. One daughter (twenty years old) is already married and the other (fourteen years old) is still in school. The abortion cost five thousand baht (approximately US$ 100), or two thousand baht per month of gestation – nearly a third of her yearly family income. Following the abortion she was given medicine to treat infection, vitamins and pain killers.

What sort of feelings do you have now that you have gone to do it?

I’ve been to do it. There. I feel that we won’t have any obligation to feel anxious over that child. I won’t have to think about lots of different things and try to be happy that I have to raise a child, anything like that. I’m old already. We could raise them but not well enough. Now the thinking has gone away, I don’t have to think any more. I just think it was born just thus far and I’ll let it go according to merit [the Buddhist understanding of the balance of good and bad deeds during one’s life]. Some people, they say to correct it I should make merit.

Aunty Laem

Aunty Laem is thirty-six years old and married with two children, one son aged three and one daughter aged four. She has had four years of education. She is also a rice farmer with more debt than income. Last year she had an abortion when she was approximately three months’ pregnant. She hadn’t been using contraceptives. She went to a local woman’s house who gave her an injection per vagina. The abortion cost her two thousand baht [US$ 40]:

She put medicine into a syringe and injected it into my vagina. It was black medicine, black but not very strong so I had no problem and no symptoms, it was just normal. Then I returned home and on the second day it [the pregnancy] came out. It came out normally like I had my periods but the last lump was big – then I had cramps and didn’t feel very good. When the last lump came out I was OK. She said what she would do for me and she said that if I died or anything she wouldn’t take responsibility and I said that I needed it and accepted that. But lots of people go. Lots of people from our village and [they] don’t have any problem . . . She said it was bap [Buddhist sin] but only a small sin and not really a problem . . .

My child was still breastfeeding so I wasn’t ready and so I decided . . . I spoke with my friends and I decided we lacked any other path. So I forced myself to do it. We weren’t ready to have another child and so what can you do? We didn’t have any money and so it was a necessity.

Following the abortion, Aunty Laem started using injectable contraception and now is using the contraceptive pill. She has had a number of women come to ask her about her experience of abortion and has referred them to the woman.

Now I think about it and I am not happy. I’m scared I will catch something. I am scared it will become something like cancer. Scared I may have caught AIDS or something. Five people went to do it [abortions when she was there]. That’s how I think in my heart. But before I went I didn’t think about that . . . But I hope I didn’t catch anything. But I saw lots of people being done. No one had anything.

Aunty Phim and Aunty Laem shared their stories with me in 1997 during fieldwork in Thailand. At that time Thailand had one of the most restrictive abortion laws in the region, allowing legal abortion only in the case of rape, incest and a threat to the health of the mother, which was usually interpreted very narrowly. Debate over Thailand’s abortion laws has raged publicly since 1980, pitting Thai women’s groups and public health advocates against popular conservative politicians, a Buddhist religious sect and a sensationalist media. In these debates, abortion became a metaphor for westernisation, changing gender roles, and political corruption – a threat to cherished notions of what it means to be Thai and to be a Buddhist (Whittaker 2004). Within that debate the experience of women was rarely voiced. Faced with their personal dilemmas of unplanned pregnancies and uncertain futures, women acted with pragmatism to address their situations. But their choices were structured within the broader political-economic and legal context. For Aunty Phim that involved a technically illegal abortion under medical supervision but in conditions that fell short of high-quality care. After unsuccessful attempts with ‘hot women’s medicines’ (local herbal mixtures said to act as abortifacients), Aunty Laem resorted to the services of a local injection abortionist. Both women were aware of the illegality of their act and possible risks. They were fortunate they did not suffer adverse complications, although they knew women who had. Aunty Phim looks back with relief and few regrets. Aunty Laem still worries about the unknown karmic consequences of her act but also fears long-term problems – AIDS from the use of shared equipment, or uterine cancer believed to derive from the disruption to the womb.

ILLUSTRATION 1.1 Small village stores in Thailand often stock herbal medicines and other patent drugs purchased by women in attempts to induce abortions (Photograph: A. Whittaker)

Raising the Issue

Writing about abortion forces us to confront the effects of poverty and economic inequalities, the configurations and expectations of gender relations, the meanings attributed to motherhood, the value of children, local moral worlds and understandings of women’s bodies. The authors in this book articulate the conditions and hard choices faced by women throughout Asia. We relate stories of women’s experiences with abortion as well as the politics surrounding abortion reforms. We describe how structural factors such as the distribution of economic, political and institutional resources are fundamental to the degree of control women and men have over reproductive decision-making and how cultural processes shape the contexts and meanings of their reproductive decisions. This draws attention to state interventions into their citizens’ reproductive lives and the macro and micro relations of power, class and gender politics influencing reproductive experiences.

This book is also about the progress and possibilities for change. Despite the vociferous debate in Thailand, reform to the medical regulations governing abortion occurred in 2006 through the patient lobbying and quiet determination of a group of public health advocates and women’s advocates working within existing bureaucratic and legal systems (see Nongluk Boonthai et al. this volume). This has made pregnancy terminations permissible under some circumstances such as for certain foetal conditions and mental health reasons, easing access to safe abortion services for some women. Despite this progress, abortion remains in the Thai Criminal Code and remains illegal for social and economic reasons as described by Aunty Phen and Aunty Laem. Work towards reform continues.

My ethnographic work in Thailand alerted me to the need for a volume bringing together current social research on abortion in Asia, in order to bring the diverse perspectives and insights from this region to a wider audience and to encourage further research of the consequences and implications of unsafe abortion in the region and the need for access to quality services. To date, relatively few books have addressed abortion in Asia.¹ This is surprising, given that the majority of the world’s population lives in Asia and that over half of the world’s deaths due to unsafe abortion take place in Asia.

This book aims to present a set of chapters detailing current work in Asia on abortion that reflect the diversity of experiences and perspectives from parts of the region usually under-represented in academic work, and to provide commentary on contemporary developments and understandings of the issue. The authors present cases ranging from nations with liberal abortion laws to those with strict restrictions, and highlight the fact that liberal laws alone do not ensure safe abortion services. Written by a mixture of Asian and Western researchers and activists, the book is comprised of eleven chapters that juxtapose anthropological descriptions of the lived experience of abortions with overviews of policy development and legal reform in the region. The contributors in this volume draw upon anthropology, demography, women’s studies, public health and development studies in their approaches, and so the chapters require reading across disciplines but also across language written for different purposes. This book is intended to be a dialogue between academics and advocates and between anthropology and public health. The chapters are linked by their common attention to the cultural and historical specificities of abortion in each setting and their common underlying advocacy of the reproductive rights and entitlements of women and men to control their fertility.

The authors address a range of issues of importance in approaches to abortion, such as the difficulties faced by providers of reproductive health services to vulnerable populations; the linkages between violence and abortion; patients’ assessment of quality of care versus costs of abortions; the sensitivity and care required of health providers for women experiencing mid-trimester or later term abortions for medical reasons; and the necessary collaboration with government ministries and other strategies employed for policy and legal reform. Through the use of anthropological methods, a number of authors are able to present insights into the micro-politics of gender relations and the lived experiences of abortion decisionmaking with a depth not possible through other, more quantitative means. The final chapters remind us of the dogged persistence and negotiations required to implement legal and policy reforms and the need to defend hard-won successes in reproductive rights. The book is ambitious in that it attempts to provide insights into the diversity of Asian countries, cultures, religions and historical experience. It will quickly become clear to readers that one cannot necessarily assume commonalities between ‘Asian’ countries and their approaches to the issue of abortion. As the essays in this book demonstrate, across the region different political systems, religious groups, colonial and postcolonial histories and legal developments have all influenced the nature of women’s access to abortion.

ILLUSTRATION 1.2 Northeast Thai village women gathered for a focus group (Photograph: A. Whittaker).

Counting the Costs

It has become a public health mantra to cite the International Conference on Population and Development (ICPD) 1994 statement that in circumstances where they are legal, abortions should be safe, and that all women should have access to life-saving post-abortion care (PAC) services. The Fourth World Conference on Women (FWCW) further called upon governments to consider reviewing laws containing punitive measures against women who have undergone illegal abortions (United Nations 1996, paragraph 106) and reaffirmed the human rights of women in the area of sexual and reproductive health, including their right to ‘decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and their right to attain the highest standard of sexual and reproductive health’ (United Nations 1995, paragraph 7.3). Despite much activity and rhetoric over reproductive health rights, over a decade later this commitment remains a distant goal for most countries in the Asian region.

The statistics speak for themselves. Approximately 10.5 million unsafe abortions take place in Asia each year, almost one for every seven live births. An unsafe abortion is one ‘either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both’ (WHO 2003: 12). Thirty per cent of unsafe abortions in Asia are performed on women under twenty-five years of age and 60 per cent are obtained by women aged under thirty (Aahman and Shah 2004). It is estimated that each year 35,000 women in Asia lose their lives due to unsafe abortions, around half of the global deaths from unsafe abortion (Shah 2004). Apart from maternal death, at least one in five women suffer reproductive tract infections causing infertility as a result of their unsafe abortions (WHO 2003: 14). Complications from abortions are also costly to health services; it is estimated that in 2005, five million women across the world were admitted to hospitals due to complications caused by unsafe abortions (Singh 2006).

For many women in Asia, abortion and its consequences remain a common threat to their sexual and reproductive health. Many women do not yet have access to basic safe abortion services or postabortion care. Instead, many women such as Aunty Phim and Aunty Laem face induced abortions in fear, pain and insecurity, seeking treatment wherever it is available, often at high cost to themselves and their families. ‘Deciding freely’ or ‘choice’ as it is articulated within the international human rights documents is bound up with Western notions of the autonomous rational individual subject who rationally selects between the available options. As the chapters of this book reveal, the ‘right to choose’ is not a mere question of the legality of abortion, but depends upon questions of culture, political economy, class and gender relations.

Regional Overview

In almost all countries in Asia laws permit abortion to save a woman’s life. However, considerable variation exists in the legal permissibility in other circumstances. Debates have taken place over the relationship between the legalisation of abortion and rates of maternal mortality. A study of 160 countries found that, in general, those with liberal abortion laws had a lower incidence of unsafe abortion and lower mortality from unsafe abortions when compared to those countries where abortion is restricted (Berer 2004). The countries with the most restricted abortion laws in Asia include Sri Lanka, Pakistan and the Philippines. Those with the least restrictions include Cambodia, Vietnam and China. It must be noted that this refers to the legality of abortion in various states’ Criminal or Penal codes and may accurately reflect neither the ‘grey law’ regulatory frameworks which operate in various locations, nor the enforcement of that law. As will become evident below in the selected national profiles, a range of administrative and regulatory barriers restricting women’s access to abortion services may operate even in states with liberal laws. The overview also illustrates that access to safe abortion services remains limited in most localities, whether because of economic or social barriers, the negative attitudes of health providers, or the failure of health systems to provide quality comprehensive reproductive health services. For example, in India, where abortion has been legalised for three decades, the high rate of unsafe abortion continues to be an issue (Ramachandar and Pelto 2002; Pallikadavath and Stones 2006). As the overview also reveals, there is a lack of comprehensiv...

Table of contents

• Cover
• Half title
• Title
• Copyright
• Contents
• List of Figures
• Acknowledgements
• Contributors
• 1. Abortion in Asia: An overview
• 2. Contraceptive use and unsafe abortion in rural Cambodia
• 3. Between remembering and forgetting: Maintaining moral motherhood after late-term abortion
• 4. Violence, poverty and ‘weakness’– Interpersonal and institutional reasons why Burmese women on the Thai border utilise abortion
• 5. Quality of care and pregnancy terminations for adolescent women in urban slums, Bangladesh
• 6. Choosing abortion providers in rural Tamil Nadu: Balancing costs and quality of care
• 7. Abortion in Vietnam: History, culture and politics collide in the era of doi moi
• 8. Abortion and politics in Indonesia
• 9. Access to abortion services in Malaysia: A rights-based approach
• 10. Improving access to safe termination of pregnancy in Thailand: An analysis of policy developments from 1999 to 2006
• 11. Epilogue: Further challenges
• Glossary
• Index