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June 15, 2010

More Reflections On The Abortion Debacle

I love today's discussion and lectures. Definitely the type of Global health Course Class I was expecting and waiting for since Day 1. We had many group discussions in the previous days but none as engaging and provocative as this one. Maybe perhaps it is because the topic in itself is already provocative in nature. The issue on abortion, whether it would be legal or not, is always a divisive issue. The topic was all the more made complicated when the proposition was introduced, asking whether as a medical professional, how willing are you to make an illegal abortion safe, given the circumstances. The proposition was made on the contention that worldwide, there are many maternal deaths due to unsafe abortions and most of these unsafe abortions are basically not legalized in their respective countries. Most European nations legalize abortion and the spectrum of qualifications for abortion varies from the most conservative to the most liberal reasons. What was interesting was that the lecturer proposed that in order to minimize or decrease abortion, the best way is to legalize it, citing studies from countries which legalized abortion and saw a decline in their abortion cases and maternal deaths.

During my own small group discussion there was really no agreement as to whether or not make illegal abortion safe. In the first place, we were already divided to some extent on the issue of whether abortion is legal or not. Perhaps for some countries that already has laws that legalize abortion it is easy. Perhaps for some countries whose cultural norms tend to accept the idea of abortion it is already easy to answer. For some countries though whose laws are not in favor of abortion nor are its social norms, it is either difficult to answer or a no-brainer issue.

What was interesting was the fact that some would say that given the circumstances of unwanted pregnancies, it would be "morally" and "ethical" to choose to abort the unwanted child to prevent its dire outcome of not being able to survive due to the probable lack of attention that will be given by the mother. A 14 year-old girl who got pregnant, either by rape of even by engaging in consented sex, may not be able to take care of the unborn considering the limitations that she is in.

Many would agree and I believe it is easy to agree in this contention considering the fact that based on our own observations of the world that we are in, it is really difficult for any child to grow in, much more to grow in a "family" where he or she is not wanted.

However, I find this contention weak. Since when did we doctors become the Dictators of Destiny? How can we confidently say that a child who is probably born in desperate circumstances not be able to survive and therefore not fit to live in this world? I fear that if we have this kind of mentality, we have just granted ourselves a license to control Mankind's Fate, which is not the primary role of doctors.

Besides, many success stories of famous persons born out of poor and almost impossible circumstances can disprove this contention. A popular example would be America's Oprah Winfrey. She was literally born in abject poverty and being a black poor girl made the odds almost overwhelming for her. She even had an abusive father which even made it worse. Now, she is not only popular and influential, she is one of the richest women in the world, with a net worth of 2.9 billion US dollars in 2009.

There are of course so many examples. In The Philippines alone, there are some poor couples who would have many children (half of them may even be unwanted) but were able to become professionals. The key was hard work and access to opportunities, which I think is the key thing in all health problems that we face. Basically we always go back to social determinants of health.

The problem with the issue of abortion is that it makes us medical professionals to only consider the patient and not broaden our view about society. We think in numbers like 800,000 women dying of unsafe abortions every year for example. But then we don't think of how many women in poor circumstances, unable to protect themselves from crimes and abuses of society, making them less empowered, providing little options to survive and make quality living for themselves.

I fear that the contention of making a woman empowered simply by giving her the choice whether to abort her baby or not is a false sense of women empowerment. If a woman in dire circumstances is left with no choice but to abort her baby, then she is not an empowered woman. An empowered woman has more than just one option. She has many. She can opt to take care of her child in a society which provides her the means by which she can do so. And the child she might be taking care of becomes a potential contributor to the development of the society in which she is allowed to grow as a woman. By doing so, she has fulfilled her full potential as a woman, being able not only to generate life (which is by far the most beautiful and noble profession ever) but also ensure the growth of life to its own fullest capacity.

Of course, one must investigate the reasons why some women opt for induced abortion in the first place. The lecture gave numbers as to how many were into abortion but failed to further elucidate why these women are into abortion, so I started researching on some "facts".

In a study conducted by Uygur and Erkaya on reasons why women have induced abortions in a developing country, they found out that "the desire to postpone a birth or to stop childbearing is a very common reason given by the women seeking abortion. It is seen that despite the women's desire to postpone or stop childbearing, the majority of them were not using an effective contraceptive method." Their conclusion was "reasons women give for why they seek abortion are often far more complex than simply not intending to become pregnant. While improved contraceptive use can help reduce the unintended pregnancy and abortion, some abortions will remain difficult to prevent, because of limits to women's ability to determine and control all circumstances of their lives." (Eur J Obstet Gynecol Reprod Biol. 2001 Jun;96(2):211-4.)

In another study sponsored by the Guttmacher Institute, they also investigated the reasons why women have induced abortions taking into account evidence from 27 countries. The results mirrored the previous research cited above and also identified other secondary reasons such as "...disruption of education or employment; lack of support from the father; desire to provide schooling for existing children; and poverty, unemployment or inability to afford additional children. In addition, relationship problems with a husband or partner and a woman's perception that she is too young constitute other important categories of reasons" (International Family Planning Perspectives Volume 24, Number 3, September 1998)

An American research in 2004 basically almost revealed the same thing. According to the data, 74% of respondents had an abortion because the child might interfere with their education or work. About 73% said they could not afford to raise a baby.

Focusing on these studies alone makes me wonder if what some of us were saying that abortion is okay if the reason is because the "fetus" or "group of cells" is threatening the mother's life is really the primary objective for opting for an abortion.

The reality is, many go into abortions, whether or not this is legal or illegal, safe or unsafe, because of other circumstances beside health reasons. Basically, it is because of the perceived inconvenience. It is harsh however to say that such a mentality would imply that the woman who had an abortion was a bad woman. That is certainly not the immediate conclusion here and that is actually quite an unfair statement. But thinking again in the line of looking health from a social perspective, one must wonder why the woman chose to abort her baby in the first place. Why did she think that a baby would interfere her from doing her work or pursuing an education? Why did she think that she might not be able to afford to raise the baby? Are there elements in the society that would make her think and believe so? Again, I am going back to the argument that, like in all health problems, there are social complexities that contribute to the creation of such conditions in a patient. To see the forest and not just the trees.

What I find hard to consider though is that contention that the woman has the right to her body and therefore she has the right to choose whether or not to abort her child. While this may be correct, I fear that if we agree to this principle, then alcoholic pregnant mothers may be very hard to manage. Let's say a pregnant mother comes to the clinic and with her history of alcoholism tells you that you can't stop her from drinking alcohol even if she is pregnant, what would you do as a medical professional? The argument being, yes, it is my body and it's just a bunch of cells anyway so I can do whatever I want. I can take drugs for all I care. I can drown myself with my alcohol for all I care. This is my body. I have the right to do whatever I can with it.

Well, we all know the effects of alcohol on both the mother and the "fetus". I wonder, though, if someone thought about the right of that "fetus" to be protected against the bad effects of alcoholism. The ethical dilemma now is, whose right is higher? The right of the mother or the right of the baby...or, should I say "fetus"? I do not wish to be placed in this situation for it is definitely a hard choice. You can't sit on the fence on this one.

Unfortunately, we cannot separate ethics from practicalities, more especially among health professionals. In all decisions that we do, we always answer the most basic ethical query: Is this the right choice or the wrong choice? From the most mundane human acts to the more complicated decision-making, we always try to answer this question. And then we rationalize and each approaches his or her rationalization with so many bases. One can approach it from a purely medical or biological stand point. One can approach it from a religious or moral stand point. One can even approach it from a social or epidemiological stand point. It is better that we always look at it from different points of view.

As mentioned in the lecture, an abortion simply implies a failure. It is a failure of society for having prevented the circumstances that led to the abortion. If it is so, then shouldn't we be focusing on the circumstances that led to the failure, rather than condoning the failure? I cannot seem to see the logic here. The contention is since it has been there for ages and we seem to unable to eradicate abortion despite the restrictive laws of anti-abortion, we might as well legalize it.

I don't know if it will work in The Philippines though. For example, in our case of illegal gambling or jueteng. No matter how many laws the Philippine government passed in order to eradicate jueteng, it seems jeuteng is still rampant. Thus, there was a move to propose the legalization of jueteng. In Philippine society, gambling is always a manifestation of society's impoverished state. When one results to small-town lotteries such as jueteng, it does not only reflect the issue of poverty in our country but at the same time compounds the problem of poverty like a vicious cycle. To some degree, gambling can destroy a family. I am not sure of the numbers but there is a correlation between gambling members of the family and the steady decline into poverty of the said family. In efforts to curtail illegal gambling, the government "legalized" it through STL or Small-Town-Lottery. Sure, it did solve the gambling issue since there are no more illegal gamblers (they were all "legally" gambling), but it still did not solve the root cause of the problem. A local councilman was quoted as saying, ""As long as there is poverty and there is corruption in the government, people will gamble,"

But gambling is different from abortion, one would say. Abortion here is meant to save a life: the mother's life. True, however, one fails to note how many lives were ruined as well due to excessive gambling.

As a public health officer, it is I think more cost-effective to address the issues that led to the choice of abortion rather than to invest much on the provision of abortion. After all, addressing social determinants that lead to "unwanted" pregnancies not only answers the issue of abortion but other health problems as well such as TB, HIV, Under-five mortality, Infant Mortality, etc.

I came upon an interesting essay written by Thomas W. Strahan, J.D. stating that induced abortion may increase the feminization of poverty. According to him "abortion may instead actually be a contributing factor. Through an increase in broken relationships, psychological difficulties, and substance abuse, a practice which is done exclusively on women may put them at greater economic disadvantage". He cited in his essay that "Researchers have found that the socioeconomic status of women tends to deteriorate as abortion is repeated. In one study at Yale Medical School, researchers reviewed the records of the abortion clinic at Yale-New Haven Hospital of 886 women having a first or repeat abortion at the clinic during 1974-75. It was determined that women having first abortions were similar both in age (22.7 versus 24.0) and in years of completed education (11.8 years versus 12.1 years) to those having repeat abortions. Women in the repeat abortion group were significantly more likely to be divorced (11.9% versus 6.1%), less likely to be a student (15.7% versus 27.7%), and more likely to be a welfare recipient (38.2% versus 25.8%). Among black women 55.6% of the first abortion group were on welfare versus 65.6% of those having repeat abortions. The respective figures for white women on welfare were 12.3% for first-abortion women and 19.3% for repeat abortions. Among those repeating abortion, an average of approximately two years had elapsed since the previous abortion, but 42% had repeated abortions within the last 12 months. Women on welfare were found to be particularly likely to engage in unprotected sexual intercourse and appeared to remain susceptible to repeat abortion" (Strahan). What this guy was trying to say was "this increased feminization of poverty coincides remarkably closely to the period of increasingly legalized abortion. Arguments have been made that the availability of abortion should help avoid this trend, because job loss due to childbirth would be avoided, as would the burdens of child care which so clearly contribute to povertization. The fact that the pattern has worsened precisely during the period when there was an upsurge in abortions suggests that, at the very least, abortion has been an inadequate solution to this poverty trend." This essay was written many years ago and I wonder how the numbers are today.

There is no simple answer to this complex issue. It is not as simple as Yes and No. There is always a gray area, even in situations which require ethical analysis. To answer a Yes may mean disagreeing with other dimensions of the issue. To answer a No may mean denying other realities that contribute to the complexities of the issue.

What can be agreed upon is this, that the issue of abortion will always be an eternal issue unless we solve the social determinants of health that hound as since disease and illness were introduced to mankind.

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