By Dr. Tabinda Sarosh | Program Manager, ARROW
We seldom hear the word abortion in conversations people have about their health issues or those of their family. In a global village connected by the Internet, people have access to a lot of health information and we see many people openly talk about their various health problems such as diabetes, hypertension and even invasive procedures such as surgery. In fact having undergone a surgery is often a major life event and is described with much detail and received with sympathetic acknowledgement.
Not so for abortion!
A huge stigma is associated with the word abortion even when it’s being used in a third person scenario. No one wants to say the word “abortion”, it is replaced with more acceptable terminologies like “misfortune”, “incident”, “procedure”, etc. Much like vagina, another word solely associated with a woman’s body is perceived to be a shameful word and heavily stigmatized. So we use other more “acceptable” words that do not offend the sensibilities of people. When I searched the Internet I found a large assortment of words from “twinkie” to “minnie” to “mi-mi”. But that is a discussion for another blog post.
Imagine, if only speaking out the word abortion carries such stigma what would be the stigma of actually having an abortion, particularly an induced abortion? Women have paid for abortion by suffering lifelong social boycotts, isolation, ostracization, humiliation, patronizing attitudes as well as forced marriages, physical violence and diminished socio economic options. This is in stark contrast to treatment meted out to those who have waged, financed and endorsed wars and conflicts that have resulted in tremendous pain, devastation, misery and loss of human lives at a global scale. No stigma seems to be attached to these actions that have caused so many “extra-uterine” deaths.
Sea Change, an organization working on transforming the culture of reproductive stigma, defines abortion stigma as, “as a shared understanding that abortion is morally wrong and/or socially unacceptable”. Naturally, the implications of this stigma are multiple in countries where abortion is prohibited by law. According to data compiled by the Asian-Pacific Resource and Research Centre for Women (ARROW), out of 22 countries examined only 4 have legal provisions for abortion on all grounds. However, this does not prevent women from seeking abortion services, both safe and unsafe. E.g. evidence indicates that often married women resort to abortion as a means of contraception.  In Pakistan alone, where the law around abortion is vague, approximately 800,000 women per year were reported to have availed post abortion care services. In reality however, this figure of 800,000 is only the tip of the iceberg as this data was collected from formal health institutions.
Interestingly, in India where the Medical Termination of Pregnancy Act makes it possible for a woman to access and avail abortion services, unsafe abortions still happen frequently. According to a study 12% of women seeking abortion related services do it for complications caused by unsafe abortion. 63% of these women had an abortion performed by an uncertified provider; a significant 28% reported receiving services from certified providers at a lower-level facility.
Besides the law and/or availability of services, there are other factors that play a decisive role when it comes to women’s reproductive choices. Among various social determinants of health, in this case abortion, are the social constructions of gender, accepted gender roles and the “moral” burden pinned to abortion. The latter has led to the huge stigma related to decision and act of getting an abortion. When it’s socially mandated to be a “hush hush” affair, women would seek services that are “hush, hush”.
In a community setting women naturally gravitate towards services that do not obligate record keeping, and are situated in clandestine locations. These places may not offer a trained service provider or the optimum medical environment for an invasive procedure. An obvious reason behind this risky behavior is to avoid stigmatization by the community and society by keeping it all under the cover. Predictably enough the entire “moral” burden of abortion is on a woman’s shoulders, which implies that the decision then also should be solely hers.
However, choices are not made in a vacuum. Our choices are deeply connected to our lived realities, our social, economic and emotional experiences and challenges. In a Global South scenario this should be viewed in the backdrop of gender disparity, poor quality of health and reproductive health services available to women, stagnating contraceptive prevalence rates, dismal poverty indicators, the widening divide between the rich and the poor of this world, poor work conditions, conflicts and disasters, internal and external displacements, climate change and much more.
On top of the burden of abortion stigma, a woman also has to bear the burden of silence. The burden of not being able to speak about an experience that in all probability must have been a difficult and stressful one. While the introduction of Misoprostol (medical abortion) has given women a safer choice than procedures done in clandestine settings, talking about it or even seeking information still remains a stigma. As a physician I have had women tell me that obtaining Misoprostol from a pharmacy was no mean feat and it took a lot of courage to actually approach a pharmacist or to request a doctor to prescribe it.
September 28th marks the Global Day of Action for Access to Safe and Legal Abortion. In an ideal world we would not need a day dedicated to assuring people that women have reproductive rights and that it’s safe to talk about abortion. But sadly, we do not live in an ideal world. So, let’s start talking about it, about the difficult decisions women have had to make, decisions that cannot be judged by anyone else, decisions often made due to the stigma related to the morality of a woman pinned to issues such as having a baby without getting married. How ironic is that???
 Shirkat Gah Women’s Resource Centre, ICPD + 15 : Investigating Barriers to Achieving Safe Motherhood : A Study in Selected Sites in Rural Sindh and Punjab, 2009
 Bhattacharya S et al., Safe abortion-still a neglected scenario: a study of septic abortions in a tertiary hospital of rural India, Online Journal of Health and Allied Sciences, 2010, 9(2):1–4