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June 14, 2010

Women's Health: Day 9, 7th Global health Course

Today's topic focused on Women's Health and when we talk about women's health, we usually talk about sexual and reproductive health mainly for obvious reasons. A woman is in a special biological privilege to bear children. But when one talks about Women's Health, one cannot also avoid talking about gender inequality, injustice towards women and poverty. Topics on overpopulation, birth control and even abortion are only the surface of a murky water where in its depths are primordially the most basic causes of these maternal illnesses. The lecture brought new perspectives regarding population control, sexual and reproductive health and rights. One major question proposed during the lecture was, "What is the best contraceptive of all times?"

The answer is child survival. The more we improve the survival outcome of children, the more mothers will choose not to bear more children. In other words, the lecture was touching on the so many social determinants of women's health. Overpopulation has become an easy excuse for proponents of "birth control". Such a perspective is referred to in the lecture as the "Helicopter" perspective, which means, looking at the problem from a bird's eye view. From a distance, we see that the root cause of the problem on maternal deaths is poverty, and thus the choice is to do population control, making contraception a first priority. But this is a narrow-minded perspective. If we take the "Grassroots" Perspective, which means, seeing all things at ground level, then we can understand that the root cause is impoverishment, which is entirely different from poverty.

Impoverishment is the act of making someone poor. Thus, when we make others poor, through inequitable distribution of wealth and rights, we make them powerless. If one is powerless, there is definitely no chance of survival. Thus, the policy from the grassroots level must be survival first. Through improving health conditions, one's survival chances are improved as well.

The lecture pursued the many factors that contribute to poor maternal conditions in the world. Among the many factors include basically the lack of attention by the community of nations to take maternal health seriously. The lack of attention is manifested in the lack of human resources that would attend to maternal health care.

The lecture further progressed to unsafe abortions. Basically the contention was, unsafe abortions contribute to 15% of maternal deaths globally, therefore, it would be better if we legalize safe abortion in order to save mothers from dying.

I could not argue with facts. However, what I feel must be addressed is the cause of the first cause. Why are some women going for induced abortion in the first place? Who are these women who go for induced abortion?

Basically, the lecture mentioned about unwanted pregnancies as the cause for these abortions. Now, I think that I must pursue the question of what caused these unwanted pregnancies. How much percentage of these unwanted pregnancies are due to abuses against women (rape) or cultural norms (early or arranged marriages) or teenage pregnancies (extra or pre-marital sex).

One study conducted by Guttmacher Institute published in 1998 entitled, "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries" concluded that: "Worldwide, the most commonly reported reason women cite for having an abortion is to postpone or stop childbearing. The second most common reason—socioeconomic concerns—includes 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. Women's characteristics are associated with their reasons for having an abortion: With few exceptions, older women and married women are the most likely to identify limiting childbearing as their main reason for abortion." (Guttmacher Institute)

In the United States, "Women who have never married and are not cohabiting account for 45% of all abortions"(Jones RK, Finer LB and Singh S, Characteristics of U.S. Abortion Patients, 2008, New York: Guttmacher Institute, 2010).

At the same time, "Eighteen percent of U.S. women obtaining abortions are teenagers; those aged 15-17 obtain 6% of all abortions, teens aged 18-19 obtain 11%, and teens under age 15 obtain 0.4%." (Jones RK, Finer LB and Singh S, Characteristics of U.S. Abortion Patients, 2008, New York: Guttmacher Institute, 2010).

My opinion is perhaps we have again missed the point. If we have therefore identified the reasons for these unwanted pregnancies, then shouldn't we be focusing on addressing these causes instead of heavily depending on legalizing abortion as an answer?

If the reason for unwanted pregnancy is crime against women (rape), then shouldn't we be more aggressive in the implementation of our laws against crime against women and children? If the reason for unwanted pregnancy is cultural, which is mostly grounded on gender inequality, shouldn't we be more focusing on the protection of women's rights, such as the right to choose her groom or own property? If the reason for unwanted pregnancy is the rate of teenage pregnancies or extramarital or premarital sex, shouldn't we be addressing this issue by changing attitudes with regards to sexual responsibility?

I wasn't comfortable about the question posed by the lecturer in the end. He said, "The question is not if you are against or in favour of legal, safe abortion. Rather, if you can accept ongoing slaughter of 90,000 women, dying from unsafe, illegal abortions, each year."

Then he continued the slide with: "The right to life?" with a picture of a tombstone engraved with the words, "In Memory of all the women who have died from illegal unsafe abortions because they had no choice."

Now, my opinion is I think this is a false choice.

We must remember that we are talking about TWO lives here: the life of the mother and the unborn child. Unfortunately, many proponents of "pro-choice" would use terms as fetus or embryos as if such are just extensions of the mother's tissue, sort of like an outgrowth that can be taken out anytime.

The right to life indeed. But whose right to life are we trying to protect here?

While the lecturer avoided the ethical question with regards to abortion, I feel that as a physician, we must always deal with ethical questions. In any action we take as medical professionals but we always consider the ethics of every action or decision that we take. That includes abortion as well.

Another easy excuse would be to blame it on the influence of religion contributing to the maternal deaths due to its opposition against "safe" and "legal" abortion.

The ethical question of "whose life to choose" deals on the ethical concept of Double Effect. According to the principle of double effect, an action having foreseen harmful effects practically inseparable from the good effect is justifiable if upon satisfaction of the following:

1. the nature of the act is itself good, or at least morally neutral;
2. the agent intends the good effect and not the bad either as a means to the good or as an end itself.
3. the good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm.

Applying that therefore to a situation wherein a medical professional is made to choose between the life of the "fetus" and the mother, one must therefore answer these questions stated by the criteria.

An example would be when a doctor who believes abortion is always morally wrong may nevertheless remove the uterus or fallopian tubes of a pregnant woman, knowing the procedure will cause the death of the embryo or fetus, in cases in which the woman is certain to die without the procedure (examples cited include aggressive uterine cancer and ectopic pregnancy). In these cases, the intended effect is to save the woman's life, not to terminate the pregnancy, and the effect of not performing the procedure would result in the greater evil of the death of both the mother and the fetus.

It is therefore always and will be an ethical dilemma and should never just be an epidemiologic issue.

The issue of abortion is ageless and it is nothing to do basically with one's affiliation with any particular religion. In fact, the Original Hippocratic Oath states that,
"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement.........I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion."

It is a sad fact that many women die of Unsafe Abortions but the solution of legalizing abortion is just a mere scratch on the surface. It does not answer the social determinants that cause these women to seek abortion (safe or unsafe) in the first place. The danger here is that if we allow legalization of abortion to initially address maternal welfare, there will come a point, and it has indeed come to certain countries, that women will seek abortion solely because they want to terminate the pregnancy for many reasons and may not necessarily be life-threatening reasons.

Reasons such as congenital malformation like Down Syndrome for example. Are we in the position therefore to choose which type of "human beings" we would like to live in our world? If that is so, what difference is there between such act and Nazism which strived for the eradication of perceived lower forms of race such as Jews?

I may not be a spokesperson for any Church but as a doctor and as a public health officer, I feel it more worthwhile and productive, not to mention cost effective, to address the root causes of unwanted pregnancies.

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