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Abortion: Stigma and Inertia

(by Dr Fred Nunes)

Several readers have already turned away from this article in a strong, negative reaction to the first word of the title. Very few persons have any appetite for learning about an issue that we have made into such an ‘awful’ topic.

Yet that reaction, while perfectly understandable, is also profoundly foolish.

We like to think of ourselves as rational and informed. On the issue of abortion, we are terribly misinformed and driven more by our values than the facts.   We have firm beliefs and flimsy data.

The stigma of abortion prevents discussion. An absence of discussion fosters rumours. Rumours develop into myths. And myths nurture our values. The net outcome is a paralysis of action on all sides among leaders, victims and even advocates. That is why the Medical Termination of Pregnancy Act passed in 1994 has not been implemented 20 years later.

Abortion is commonplace. In Guyana, about 70 per cent (7 of every 10) women will have at least one abortion by age 44.( *In the United States, that figure is about 40%, due to much higher access to contraceptive methods. )

In other words, most adult women and most adult men in our country will have personal experience with an abortion.   Having an abortion is a question of when – not whether. You have to be lucky to avoid causing or having an abortion. Those few who do are the distinct minority. Almost no family in Guyana has not had and caused abortions.

But the enormous burden of the stigma we attach to abortion leaves each of these persons feeling lonely and vulnerable. Abortion remains a subject that is never discussed. At a personal level, we deny and we suppress. And more broadly, we avoid the topic.

An unwanted pregnancy is a natural consequence of sexual activity. While men bear at least half the risk of every unwanted pregnancy they are totally absolved of the stigma of abortion. How rational is that? How fair is that? Indeed we talk glibly of ‘teenage pregnancy’; but 74% of teenage pregnancies are caused by men 20 years or older. The power is with the men; they should be our focus.

None of the denial, suppression, avoidance and stigmatisation of abortion has changed since Guyana expanded the ground for legal abortion in 1995.   And we need to ask why.

The explanation is the same as it is for any social prejudice – whether tuberculosis, cancer, race, gender, or homosexuality: it takes an enormous investment in education, in public discussion and a monumental measure of personal courage from individuals to change stigma. It requires courage and leadership in all quarters — teachers, artists, religious institutions, business, politics, sport. People have to take risks.

The law is both helpful and necessary; but it is not sufficient. Where our values lead us to shame others, to call them names, to exclude them, to treat them with contempt, to regard them as inferior, and to make them ‘wrong’ we foster division. This same behaviour makes it very difficult for leaders to stand up for fairness. In other words, we intimidate those who should lead.   They become fearful and they do nothing. So we create a culture of inertia. Nothing happens, nothing changes.

This phenomenon can take quite pernicious forms. During the campaign for law reform in 1992-94, there was a large street march, inspired and influenced by anti-choice groups from the U.S. At one point some persons gathered outside of the late Dr. M.Y Bacchus’s clinic and chanted ‘Murderer, Murderer!” He was furious. More than a few of the women in that crowd had been patients who had sought and received abortions from him.

In other words, in order to distinguish ourselves from what our community holds as negative (abortion, homosexuality, etc.) we have to make a loud public showing of being on the ‘other’ side. It is easy to describe this as hypocritical. It is in fact the price we pay for social inclusion – for espousing or ‘advertising’ our values to ensure that we are not ourselves at risk of being stigmatised, labelled, tarnished and excluded. We wear a cloak of protection.

More than 22 years ago, in 1992, the main drive for law reform was the fact that septic abortion was the third highest cause of admission to public hospitals. Worse: incomplete abortion was the eighth highest cause. Given the under-reporting associated with the shame of abortion, we contend that unsafe abortion was arguably the single leading cause of hospitalisation.

All of this was entirely avoidable. Totally. This very expensive situation was unnecessary and could be completely eradicated. That is what propelled Gail Teixeira, then Minister of Health, to take the charge and announce her intention to change the law. That was a highly courageous stance.

But who were these women being admitted in their thousands year after year? They were all poor. And thereby hangs the tale.

Unsafe abortion is not uniformly spread across our society. Unsafe abortion was and remains largely a problem of poor women who cannot afford access to doctors. It is the experience of poor women. This is so widespread in the Caribbean that almost every large public hospital has a ‘Slip and Fell Ward’. They are so named to hide any attempt at an abortion and to pretend that their condition is the result of an accident. Women die rather than admit an attempt at an unsafe abortion. Such is the force of stigma.

It costs us tax payers far more to treat unsafe abortions than to provide safe ones, in the order of 5-10 times as much. This is madness.

Abortion is the most commonly performed surgical procedure in Guyana. In early pregnancy, it is a simple procedure. And some 85-90% of abortions in Guyana are done early, taking place in the first trimester. Every few years the technology of safe abortion improves. Today with manual vacuum abortion (MVA) and even more, with medication abortion (MA), the procedure is even safer.

If the public problem is the power of stigma, the real problem is one of social power. The poor women who face the risk of unsafe abortion have no power to change their situation; the women who have the economic and social power to change the situation, have no need to do so – they have ready access to safe, private medical services. And the certainly don’t want the ugly stigma of being ‘pro-abortion’.

Only leaders, from whatever realm, with real conviction and courage would step into this controversy. Clearly we are terribly short of such persons of character. It is safer to be popular than to lead. The end result is that we have a law that has not been enforced – ever.   Various Ministers of Health, all well-meaning, have found one excuse after another – lack of resources, lack of equipment, resistance among nursing staff, reluctance of hospital leadership, the pressure of other priorities, fear of overcrowding if we offer the service, etc.

This May 2014, that law will turn 20 years. In the first six months of the law the number of women admitted to Georgetown Hospital with unsafe abortions fell by 41%. The law forced doctors to improve their quality of service. But the Government failed to require public hospitals to provide abortion services. And that has not changed. This is shocking, shameful and sad.

The problem is not resources. The problem is one of values vs prejudice, courage vs fear. The problem is one of leadership. We change stigma by speaking out. By standing up. By taking on the agents of the stigma. There is a need for investment in education in values clarification workshops for service providers and in sheer education for political leaders. Journalists need to wake up and climb above their inertia. Professional associations need to face their responsibilities as attorneys, doctors, midwives, nurses, social workers, etc.

We need to put a face to abortion, literally. We need to come out of the closet. That is how we challenge and end stigma. Imagine 100 upper and middle class women taking snaps of their faces, giving their names and agreeing on a full page newspaper advertisement: “This is what abortion looks like.” Then imagine another 100 upper and middle class men doing the same.

Twenty years of excuses are far too many. We need a sense of urgency. Real change is long overdue.

Dr. Fred Nunes is a life member of the Family Planning Association of Guyana. Dr. Nunes was integrally involved in the drafting of the Medical Termination of Pregnancy Act during his tenure at Pan American Health Organisation here in Guyana.

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