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Laws aside: the reality of unequal abortion access

“One woman, she was brought from a remote village and she was in very severe condition… She’d tried to induce an abortion by herself,” recalled Nuriye Ortayli, who worked as an obstetrician and gynaecologist in Turkey in the 1980s and 1990s. “Everybody, younger residents, more senior people, tried for more than 12 hours, close to 24 hours. We tried everything we could. But she died.”

Yet Dr. Ortayli’s story is not about an illegal, back-alley abortion. Safe abortion services were legally available in Turkey at the time. “If she had been able to come to the hospital… you could do it under local anaesthesia,” she said. Instead, her story is about a reality facing women and health providers around the world: abortions happen, frequently, even in places where the procedure is highly restricted or illegal, and women are regularly denied access to safe abortion even in places where it is legally permitted. No matter the law, then, it is often other factors—such as economic resources, distance from services or social norms—that determine whether a woman will be able to access a safe abortion.

Dr. Ortayli saw this phenomenon play out both as a physician in Turkey and as a programme manager and reproductive health adviser for health organizations, including UNFPA, in Eastern Europe, the Middle East, West Africa and the Americas. “We see it again and again. Independent of the legal status of abortion in a country, women make those decisions and they find a way,” she said. “Those who are affluent, somehow they manage to have better health than others, because they have opportunities, they have money, they have networks. Those who are disadvantaged economically or socially or culturally, they suffer more.”

By contrast, even when abortion was strictly banned in almost all circumstances in Ireland, large numbers of women who wanted the procedure were able to travel overseas to obtain it. “In an awful lot of cases, if women were determined to have an abortion, they would eventually manage to do it,” said Caitríona Henchion, the medical director at the Irish Family Planning Association.

For many—even most— women, the law did not prevent abortion, but it “often might result in a long delay in actually being able to get it,” Dr. Henchion said. “All of the time that they were waiting is a period of great stress and anxiety… [and] there would have obviously been the higher risk attached to the procedure that they were then having.”

Those who were unable to obtain an abortion by travelling internationally were “a, relatively speaking, small group,” she said, “particularly women who had either poor English or who didn’t have full citizenship and those rights that would go with it”—such as the ability to easily leave the country and return—“teenagers who might’ve required parental consent, people who didn’t have the money to travel at all… or people who did not have anybody that they could disclose [the pregnancy] to or nobody that could have helped them.”

Though Dr. Henchion could not provide abortions at the time, she could and did perform post-abortion care, typically after women illegally obtained pills to induce a medical abortion. “In most cases, it is safe and straightforward and people won’t have problems or complications,” so only a fraction of abortions performed this way came to the attention of the health system, she explained. Still, it was “regular enough” to receive patients with heavy or prolonged bleeding and “women who maybe took abortion pills at home at a more advanced gestation than either they thought they were, or than they should have been if they were going to use that method.”

These circumstances were challenging for doctors, Dr. Henchion recalled. Sometimes, patients literally begged for abortion information or referrals she legally could not provide. In the end, the rules seemed to create one outcome for people with money and resources, and another outcome for those without. ”That’s how I always felt,” she said. She was a leading proponent for the legalization of abortion in Ireland, a change that took place following a referendum in 2018.

But even today, those who are most disadvantaged continue to experience higher barriers and greater risks. “There are some parts of the country that really have almost no access in terms of providers,” Dr. Henchion said. Some women still have to travel to access safe abortion, incurring all the associated delays and costs. Undocumented immigrants and people who do not speak English also continue to face challenges.

Dr. Ortayli described a similar frustration. “I had a private practice for seven or eight years in Istanbul, and I had many clients coming from the Gulf, where [abortion] is more restricted. Of course, these women were women who could afford it.” At the same time, she knew that vulnerable women in her own country were struggling to receive the same level of care, whether because of distance to services or spousal permission rules. “I have seen men sometimes use this as a weapon towards women. For example, if a woman wants a divorce, but she gets pregnant, and he doesn’t let her have an abortion in order to tie her up.”

Still, she was glad the option to terminate a pregnancy was available in Turkey, even if access was uneven. She remembers being bereft when her patient died following the unsafe abortion. A more senior physician told her it used to be worse. “He said, before the liberalization of the [abortion] law, in the same ward, we lost women like her, maybe two or three of them every week.”

And paradoxically, Dr. Henchion says, the legalization of abortion in Ireland has given many women one more option: the choice to change their minds. Before, when women had to travel internationally for an abortion, they might feel compelled to undergo the procedure after spending the time and resources to arrange it. “The pressure on them to actually make the decision was huge… This is your only chance either to have it, or don’t.” But today, she says, “you can actually give people all of the information and give them space and time.” 

She says these changes make an even bigger difference now during the COVID-19 pandemic. “When you think about the [pandemic-related] limitations on travel, we would be looking at a really, really serious situation if we hadn’t legalized when we did… There have been a lot of crisis pregnancies because of COVID, people who maybe have lost jobs or their situations have totally changed, and they can still access this care.”

This story was published as part of the global UNFPA State of World Population report, My body is my own: Claiming the right to autonomy and self-determination.