Safer Abortion Services - What Makes The Difference?

September 8, 2006

OBGYN.net Conference CoverageINTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

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Dr. Jose Barzelatto: "Thank you very much for your very kind words. Since we only have ten minutes each, I'm going to make three points and let me also say that I understand the spirit of safer abortions. The spirit of this meeting is to see how we can do even better in the future. The first point I want to make is that abortion nowadays is one of the safest surgical procedures that can be done and, of course, the earlier the safer. This is important because I understand that the legal history of giving authorization for abortion was in order to protect women from dying during the dangers that this procedure had when this legislation started. So at least the origin of the law is not valid any longer. Now, why is it safe? It's safe now because we have good technology. Good technology also means that you have well trained providers and good facilities to perform the procedure at. Now if we have the technology and we can do it safe, why is abortion killing so many women every day? Of course, it's because good technology and good procedures are not being followed. Why are they not being followed? Basically, for two reasons - one, it's illegal in so many countries or it's so restricted so it's not available, and the other one is because there are poor services and not enough resources are being allowed for this purpose. That's my first point; the second one is that safe abortion services are not the same thing as safe technology. If you remember the definition of health is - physical, mental, and social well-being. The physical part is matched by good technology. The mental part is matched by good quality of services. 

We have very good technology, but the quality of services sometimes is excellent and sometimes it's very poor and we have everything in between. What is the essence of good quality? I would say that first is to listen to women, second is to empathize with them, and thirdly is to help them not only in the interruption of the pregnancy but help them beyond that in trying to help the circumstances that brought the woman to the decision to seek an abortion. This is generally referred to as counseling but truly the word counseling is too restrictive, for example, it's not just giving them counseling for contraception to try to avoid another pregnancy, yes, that's mandatory but it's more than that. The service is looking into the circumstances and providing other kinds of support but it's something even referred sometimes according to the circumstance. We don't have time to go into detail but you understand what I'm trying to say. 

The third element of health, the social part, this is where we are still far away from having. The social well-being means that there is this social approval, that there is a social understanding and acceptance of abortion. This is not the case, although the information progress the trend is progressing the end, I won't take time, Rebecca will be talking about this. The cultural respect and acceptance of abortion is far from being a reality, and this is reflected in the way that women are treated when they come to have an abortion in most places or to when they come with complications of an abortion. The way they are treated from the receptionist to the provider is unfortunately frequently very bad. In order to change this cultural rejection, you first have to eliminate the stigma that our culture has around abortion. Stigma not just from society in general but it's also in the medical profession and even many obstetricians and gynecologists. Unless we eliminate this stigma, we are not going to be able to provide good quality services. So my third point is how to build a social consensus that would allow us to round up a really good quality of services. I would submit to you that this can be done, it's not easy but it can be done. I think the way to start this is by accepting publicly two facts, number one - that the number of abortions that are done today in the world is a public scandal. It should not be that there are so many abortions and, of course, the consequence is mortality, which is the second part of the scandal but even if they were all legal, there are too many, and I think that this is something that practically everybody can accept. 

The second point is that the world is not divided between those who are in favor of abortion and those who are against abortion. In fact, there's nobody in these extremes or practically nobody, and this I realize is a little more controversial but I would say that everybody would accept the first point that there are too many abortions. The second one I would say that practically everybody accepts, let me put it this way, everybody or practically everybody will accept that abortion is a necessary, let's call it 'lesser evil' under certain circumstances. I don't know anybody who doesn't accept that. I want to remind you that when a woman with an ectopic pregnancy is operated on, that's performing an abortion to save the life of the pregnant woman. Technically speaking and religiously speaking, that is an abortion. I don't know anyone, no matter what the law says, that opposes that so if we start with these two acceptable principles, we have a very narrow consensus but we have some consensus to start the discussion. If we start from the confrontation that everybody has to be either totally in favor or totally against, there is no way to establish a dialogue and to make this consensus grow. If this is the case, what is the debate, why are people so emotionally involved in fighting about abortion? Really what the debate is all about is values and respect of what can be done to decrease the number of abortions and which circumstances are permissible for abortions. We all know here is where the difference is from someone saying you have to forbid abortion and that will make it disappear to someone saying you have to accept abortion on demand and that will make it disappear in terms of numbers, in terms of procedures. You can, again, go on a very wide way when you consider in terms of when it's permissible. You can go from some people who'd say whenever in good conscience a woman decides to have one to clearly the most restricted position, which is the one of the Catholic church that says abortion is permissible under two circumstances. One is ectopic pregnancy and the second one is when the pregnancy coexists with the cancer of the genital tract. This is in the Canonical code, it's accepted by the Vatican so even the Catholic church which appears as the most negative position in respect to abortion is accepting it under two circumstances. They call it secondary abortion, they apply what they call the double effect, the intention is not abortion, the intention is to save the life of the woman but all that can be discussed because it's not at all clear why under those two circumstances this principle applies and not if the woman has others types of pathology. That's what's considered a rational dialogue respecting intellectual integrity and that I think is the basis under which we could start a dialogue but we have to reject this position that you have to be either in favor or either against and to assume that the other one is either your friend or your enemy. That's all that I wanted to say in my ten minutes. 

Thank you very much. " 

Dr. Mahmoud Fathalla:  "Thank you very much Jose, you really have set the stage for this important session and we thank you very much for your clear presentation on a difficult and sensitive subject. It reminds me of the old days when we had the pleasure of working together on such important issues. Now it's my pleasure to introduce the next speaker, Professor Rebecca Cook. There are two ways to introduce Rebecca, an easy way and a difficult way. The easy way is just to say, 'This is Rebecca Cook,' and if anyone in the audience does not know of Rebecca, she or he has a problem. You'll have to do something about it. The difficult way is to try to introduce Rebecca, her background, and her achievements and the whole time period of this session would not be enough to do that in but Rebecca's strength is that she combines the scientific knowledge, the solid science, together with putting her heart in the strong advocacy efforts for women's health."