In March 2018, the US-based Guttmacher Institute released its global report on abortion progress and access.¹ The report found that of all abortions performed globally, 55 per cent are safe, meaning they are performed using recommended methods and appropriately trained staff. While it may be heartening to know that more than half of abortions performed worldwide are safe, there are still an estimated 25 million that are not.

The majority of unsafe abortions are, according to the Guttmacher Institute, performed in developing nations, where there may be highly restrictive laws and/or lack of access to adequate health services. However, even in countries where there are more liberal regulations towards abortion, there continues to be a slow ‘chipping away’ at access, driven by predominantly ideological forces.

Abortion has always invoked strong feelings. In most countries, it is considered taboo, subject to criminal proceedings and constant political and social debate. In our region, the procedure is still in the Crimes Act in Queensland, South Australia, New South Wales and New Zealand.

With such controversy surrounding abortion, one could be forgiven for thinking it is a rare occurrence. It is, however, a procedure that will be required by 35 out of every 1000 women of reproductive age.

When it comes to championing safe access to abortion, the role of the clinician, particularly, the O&G, is key². It is this role that has led to the development and application of clinical guidelines, standards and continuous improvement in the training and development of health professionals working in abortion care. This role is broadening beyond clinical and developing into the area of advocacy; a natural evolution given the clinician is in a unique position to see how stigma, law and ideology impact on women seeking an abortion.

Clinician-led advocacy

Successful advocacy requires two essential components: being a respected authority and providing supporting evidence. Doctors are considered one of the most trusted professions³. According to the British Medical Journal, they are considered the third most trustworthy profession in Australia, after nurses and pharmacists. When it comes to women’s health, O&Gs are among the most trusted voices. They are also in a unique position to provide supporting evidence for advocacy efforts. This evidence can be research or more informal methods such as storytelling.

Dr Willie Parker, an O&G from South Carolina, is arguably one of the most well-known clinicians who has taken a lead role in advocating for abortion access and reform. A devout Christian, Parker performs abortions in a number of US states, where access is being reduced through ideologically driven, restrictive legislation. Like many clinicians who perform abortions, Parker knows that each of his patients has experienced judgement, stigma and shame to get to his clinic. ‘By the time a woman arrives at an abortion clinic and places herself in my care,’ writes Parker in his autobiography, Life’s Work: A Moral Argument for Choice, ‘she has faced a world of judgement and found that everyone – her boyfriend, her own mother, her pastor, her best friend – has something to say.’⁴ Parker uses storytelling to build empathy for the women he sees, while at the same time, employing scientific facts to dispel myths that influence poor policy on abortion.

Australia also has advocate clinicians for abortion reform: Prof Caroline de Costa led the successful effort to bring RU486 into Australia; Dr Kirsten Black and Dr Paddy Moore are at the forefront of advocating for better abortion training for budding clinicians; and Dr Philip Goldstone has strongly advocated for the establishment of safe access zones outside abortion clinics.

The move into advocacy

The decision to move into advocacy by a clinician is one that is generally driven by their professional and personal experiences.

Dr Rudy Lopes is an experienced O&G who, until recently, was working in contraception and family planning services in the public and private sectors. He has decided to take on a greater role in abortion advocacy. He will be developing his interest in advocating for equitable and universal access to contraception and family planning services for women worldwide.

Dr Lopes’ story

I’ve always had an interest in contraception and family planning service provision throughout my residency and time in specialist training. After more than 13 years as a consultant in public and private practice, I took these services for granted in a developed country such as Australia. However, I was brought back to earth when I read an ABC article5 about a young woman who fell pregnant and decided to have an abortion, a procedure that is banned in Nigeria. She went to see a traditional ‘healer’, who prescribed a cocktail of traditional medicine, which included spirits, pepper, bark and unnamed herbs, in order to induce a miscarriage. Unfortunately, this failed and she had to pay for an unsafe abortion performed literally in a backyard. She then started haemorrhaging, likely from an incomplete, septic abortion, and was hospitalised. She was lucky to survive. The article goes on to say that 1.25 million illegal abortion procedures are performed in Nigeria annually, and an estimated 30,000–50,000 women die from the procedure. Of those who survive, up to 40 per cent go on to have long-term complications, such as infertility and chronic pain.⁵

The ABC article reports the social complications of having an abortion in Nigeria. This young woman was ostracised from her socially conservative community and forced to work in the sex industry in order to pay off her hospital bills. She had to give up her dreams of studying to be a journalist. Some women who are unable to access a timely abortion are forced to work in brothels, often with their child.⁵ It’s a sad and demoralising picture, which could have been prevented with equitable access to contraception and a reasonable level of school-based sex education.

Unfortunately, Nigeria is not alone in its stance against contraception and abortion. Unsafe abortion has been described as, ‘one of the most neglected sexual and reproductive health problems in the world today,’⁶ and is a major public health crisis in many developing countries. The World Health Organization (WHO) defines unsafe abortion as a procedure that results in complications or death due to inadequate skills of the provider, harmful techniques and/or unsanitary conditions.

There are a number of nations that are, through legislation and regulation, driving women to seek unsafe abortion. The Timorese Government is considering draft legislation seeking to ban contraception.⁷ Unplanned pregnancy continues to be problematic in Latin America, particularly among the indigenous, rural and remote populations. In Haiti, Médecins Sans Frontières (MSF) reports high rates of complications with unsafe abortion, requiring hospital treatment.⁸ A pre-teen girl in India gave birth after being raped.⁹ A teenage rape victim in Paraguay died giving birth to a macrosomic infant, possibly due to a pulmonary or amniotic fluid embolism.¹⁰ Maternal death is a possible consequence of unintended pregnancy.

As clinicians, we should be at the forefront of advocating for equitable access. The Guttmacher Institute specifically references the power that reform-minded champions have in changing public opinions. National associations of O&Gs and medical councils have used evidence on high maternal mortality linked to unsafe abortion to advocate for reform.

I have joined the fight against these restrictive policies, and to this end, have enrolled in a Masters in Public Health, in order to gain more knowledge and become more effective in my role as an advocate for women in underprivileged areas. If we can look after the reproductive rights of women throughout the world, this will improve the current rates of morbidity and mortality caused by lack of contraception and access to safe family planning services. If I can stop one unnecessary maternal death from unsafe abortion or lack of contraception, then I will have done something worthwhile. As individuals, clinicians are powerful advocates. It is, however, when we act collectively that our power is amplified.

Across the globe, access to safe abortion is unfinished business, even in developed nations such as Australia and New Zealand. Advocacy requires a chorus of voices from the medical community. I became a doctor because I wanted to help people. Women need access to adequate contraception and safe family planning services. Yet, in many cases, women are unable to speak up about their experiences in being denied this access. It is our responsibility, as carers, to speak on their behalf, to advocate for them, and to use our influence to advance their cause. We must be the voice for change on the issue of access to safe termination of pregnancy.

Find out how you can get involved in abortion advocacy: www.mariestopes.org.au/advocacy-policy.

Further reading

Ganatra B, Tunçalp O, et al. From concept to measurement: operationalizing WHO’s definition of unsafe abortion. WHO Online Bulletin. 2014 Available from: http://dx.doi.org/10.2471/BLT.14.136333.

1. Guttmacher Institute. Abortion Worldwide 2017: Uneven Progress & Unequal Access. New York 2018.
2. Luft LM. The essential role of physician as advocate: how and why we pass it on. Canadian Medical Education Journal 2017 June 30;8(3):e109-e116.
3. Kmietovicz Z. R.E.S.P.E.C.T – why doctors are still getting enough of it. BMJ 2002 January 2; Vol 324. 11p.
4. Parker W. Life’s Work: A Moral Argument for Choice. Kindle Edition. New York. Simon & Schuster, 2017.
5. Cooley D. Quacks are killing our women: Nigeria’s abortion ban pushes women to drastic measures. ABC. 2018 February. Available from: www.abc.net.au/news/2018-02-10/nigerias-abortion-ban-pushes-women-to-drastic-measures/9416164.
6. Grimes DA, Benson J, et al. Unsafe abortion: The preventable pandemic. Lancet 2006;368(9550):1908-1919.
7. Barker A. East Timor considering contraceptives ban for unmarried women and girls. ABC. 2017 December. Available from: www.abc.net.au/news/2017-12-12/east-timor-might-ban-contraceptives-for-unmarried-women-girls/9247490.
8. Charles J. Unsafe abortions: Haiti’s abortion crisis. Miami Herald. 2013 November. Available from: www.miamiherald.com/news/nation-world/world/americas/haiti/article1957812.html.
9. 11-year-old girl gives birth after alleged gang rape by six men. News Ltd. 2018 March. Available from: www.news.com.au/lifestyle/real-life/news-life/11yearold-girl-gives-birth-after-alleged-gang-rape-by-six-men/news-story/ec927e24fef9128fa5256e5c585330fc.
10. Rape victim, 14, dies in childbirth in Paraguay. Nine News Digital. 2018 March. Available from: www.9news.com.au/national/2018/03/23/13/23/rape-victim-14-dies-in-childbirth-in-paraguay?app=applenews.