The bury-one's-head-in-the-sand approach to abortion that is all too prevalent around the world is causing a public health disaster for women. The classic head-in-the-sand approach assumes that, if one makes abortion illegal, abortion will disappear. The new revised head-in-the-sand approach of the Bush Administration seeks to get to this goal more rapidly by defunding any organization that so much as talks about making abortion legal. It has been conclusively demonstrated once again, this time by the Global Health Council, that making abortion illegal and prohibiting speech about it does indeed make it disappear, but only from public view and, more dangerously, from public regulation and oversight. Abortion still happens, privately, unsafely, more expensively and with calamitous health consequences for women.

The recent Global Health Council report entitled "Promises to Keep: The Toll of Unintended Pregnancies on Women's Lives in the Developing World" calculated that there were more than 300 million unintended pregnancies in the developing world during the six-year period from 1995 to 2000, which resulted in the deaths of 700,000 women from complications during childbearing and from unsafe abortion.

There are two levels of intervention that could save these women's lives. First, the provision of family planning services, broadly defined both before and after pregnancy, is vital for ensuring that every pregnancy be wanted and planned, and occur at the optimum time for the mother and the family. Proper prenatal and delivery care can minimize the risk of death and injury to mother and baby. There are no laws that prevent the allocation of resources to this type of medical intervention. There is only the lack of political will. These health services can be provided without any concomitant political will to alleviate poverty or gender discrimination or racism. Furthermore, the provision of basic reproductive health services for women can be done without a huge investment in a nation's infrastructure.

The International Conference on Population and Development in Cairo in 1994 called for increased investment by developed and developing nations in the reproductive health of the world's women. Both groups of nations have failed woefully to meet this challenge. The United States and other Western governments have not increased their foreign assistance for women's health sufficiently to meet their Cairo obligations, nor have the developing countries. During the six years after Cairo, 1995-2000, the world's 1.3 billion women of childbearing age had 1.2 billion pregnancies. One-quarter of these, 300 million, were unintended, as opposed to just being mistimed. It is in this group of pregnancies that the disastrous health consequences occurred and where the Cairo investment could have made a difference. About one-third of these women died from complications during labor, and about 400,000 died from unsafe abortion.

The elimination of unsafe abortion is thus the second area for intervention to save women's lives. This was too politically explosive for the Cairo conference to deal with--the final report merely called for abortion to be made safe, where legal. Abortion is legal in whole or in part in many countries of the world, including India, China, Russia and South Africa. Only in a few countries, such as Chile, is abortion totally banned. Thus, in most of the world there is legal opportunity for action under the Cairo Accord to make abortion safer. Since Cairo, only a few countries like South Africa and Nepal have revised their abortion laws to remove abortion as a criminal offense.

The need for revision of the world's abortion laws is huge. Three-quarters of unintended pregnancies worldwide were terminated by abortion during the 1995-2000 period, resulting in more than 250 million abortions. In Latin America, which has some of the strictest abortion laws, one-quarter of all pregnancies ended in abortion. Legal, cultural and religious strictures have little effect on the abortion rate.

The provision of abortion services does not necessarily need a major investment in a country's infrastructure. Early abortions can be performed with pills or manual vacuum aspiration, although surgical backup is advisable. Personnel need to be trained and continuing care needs to be provided for the patients. This is not insurmountable. The cost of doing this is less than the cost in lost and damaged lives.

In Latin America and the Caribbean, almost 42 million of the region's 114 million pregnancies between 1995 and 2000 were unintended. There were 28 million abortions, 27,000 deaths from abortion and 129,000 maternal deaths. In Peru, for example, of the 7 million pregnancies during that period, 2 million ended in abortion, with 1,900 deaths from abortion and 9,700 maternal deaths.

The Peruvian figures have the potential to get worse very quickly. The new government has appointed conservatives to key health posts who have made it known that they do not favor contraception, much less abortion. The health ministry is using the excuse of sterilization abuses during the tenure of the previous government of Alberto Fujimori to try to reduce government funding of contraceptives. The ministry has indicated that it considers emergency contraception (EC) to be the same as abortion. It has said the same for the IUD. It has also called for outlawing sterilization entirely, even when it is the informed choice of the man or woman. It seems that the rhythm method will be the only approved method of contraception in Peru. Since sterilization and the IUD are the most common methods of contraception in Peru, as they are in many countries in Latin America and elsewhere, one wonders what the women of Peru will do for contraception if there is no funding for other methods.

INPPARES, the Peruvian member association of the International Planned Parenthood Federation, Western Hemisphere Region, and various women's groups are fighting these proposed changes and so far have forestalled any changes to the methods offered by the government. But emergency contraception is still not available through public health services. USAID, too, is hiding its head in the sand on EC, refusing to pressure the government to offer a full range of contraceptive options. INPPARES is offering emergency contraception at its clinics, but it cannot reach all the women who may need it.

The results of this kind of head-in-the-sand approach are clear. The Global Health Council report makes it clear. Women die. Unwanted children are born, damaging the life prospects of their siblings and parents. When will we learn?

Alex Sanger
11/11/02