Abstract
Reviewed by: Darshi Thoradeniya, Colombo Branch, South Asia Institute, University of Heidelberg, Germany
According to 2015 statistics provided by the Centre of Reproductive Rights in New York, abortion is completely prohibited by law in only three countries in Asia: Iraq, Laos, and the Phillipines. In other words, most Asian countries permit abortion under various circumstances, such as to save the life of the woman, to preserve the physical health of the woman, to preserve the mental health of the woman, or on socio-economic grounds. Seventeen Asian countries permit abortion without restriction as to reason, but impose gestational limitations. Three countries, namely China, North Korea, and Vietnam, have different regulatory mechanisms. However, at least 6 percent (5400) of all maternal deaths in Asia each year occur due to unsafe abortions and 4.6 million women in Asia are hospitalized annually for treatment of complications from unsafe abortions (Guttmacher Institute, 2015). What do these statistics tell us? Although abortion is rarely entirely prohibited in Asia, there is a high prevalence of women receiving illegal abortions. This illustrates that laws alone do not ensure safe abortion services in Asia; there are multifaceted reasons for women to seek illegal – and potentially unsafe – abortion services. These statistics not only shed light on the severity of the problem of access to safe abortion but also make us wonder (as Andrea Whittaker inquires) why so little has been written on abortion in Asia.
Andrea Whittaker’s efforts to address this lacuna are commendable. This edited volume contains 11 chapters covering seven countries in the region and attempts to understand abortion in Asia through a myriad of lenses. These include a reproductive rights perspective; a religious perspective; moral, ethical, and cultural perspectives; a public health perspective; political and legal perspectives; and the perspective afforded by examining poverty, violence, and accessibility. Contributors to the volume are a mixture of Asian and western researchers and activists from different fields such as anthropology, demography, women’s studies, public health, and development studies. Certainly, the strongest part of the volume is the introductory chapter by Whittaker, in which she gives an overview of abortion in Asia. Whittaker is an associate professor at the School of Social Sciences, University of Melbourne, Australia. By training she is a medical anthropologist focusing on international public health, Asian studies, and gender studies. She has done extensive research on abortion in rural Thailand and is currently working on infertility and reproductive tourism in the Asia Pacific region. Her anthropological background leads her to probe the silent and fuzzy edges of statistics in order to explore socio-economic, political, religious, moral, and cultural reasons for women to resort to abortion.
Whittaker provides country profiles that give an account of current capacity of women to access safe abortion services in selected countries in Southeast Asia. Through these profiles, she takes the reader by the hand to explore the diversity of approaches to abortion across the region, a diversity that is shaped for better or worse by “social changes such as industrialization, increased education for women, rural–urban migration and increased participation in the workforce, the effects of conflict, and state policies” (p. 9). As Whittaker says, this volume is intended to be a dialogue between academics and advocates and between anthropology and public health, offering a certain degree of optimism about ‘possibilities for change’ (p. 5). This dialogue was possible as the chapter authors are a mix of advocates and academics, studying on one hand structural issues of abortion in Asia and on the other hand the micro-politics of gender relations and the lived experiences of abortion decision-making.
Whittaker argues that women’s advocacy strategies for abortion rights have developed around two major approaches: a “health rationale” and a “rights rationale.” A health rationale frames abortion “as a major contributing factor in women’s mortality” while a rights rationale asserts that “the right to terminate a pregnancy is one protected by fundamental principles of human rights” (p. 24). However, the essays in this volume prove how fuzzy the boundary between these two strategies becomes when dealing with marginalized (e.g., under-privileged, migrant, rural or minoritized) women’s day-to-day lives, their negotiations with public health services provided by the state, cultural values (such as moral motherhood), and religious doctrines (for example, beliefs about the afterlife of the fetus). Anthropological accounts (e.g., Chapters 2, 3, 4, and 5) convincingly bring out the difficulty of separating a rights rationale from a health rationale. For example, in Chapter 5, Sabina Faiz Rashid explores how the provision of “Menstrual Regulation” (MR) is practiced in a slum in Dhaka, Bangladesh. In 1979, the government of Bangladesh introduced MR into the national family planning program as an “interim method of establishing non-pregnancy.” MR can legally be performed up to 10 weeks following a missed period (Huda, Chowdhuri et al., 2013). Quoting the WHO definition of MR, Rashid defines MR as “early uterine evacuation without laboratory or ultrasound confirmation of pregnancy for women who report delayed menses” (p. 102). However, the term MR is used by professionals and lay people in Bangladesh in a very loose sense to refer to a broad range of procedures, including abortions, performed long after the 10-week limit set by the government. These procedures can cause serious complications that are not adequately attended to by the health sector. Even though the approval of MR in 1979 was intended to reduce female mortality due to abortion (a health rationale), it also gave women the right to terminate a pregnancy or to have an abortion (a rights rationale). However, as Rashid points out, many women are too poor to afford MR services provided by trained people, which cost 290 Taka (US$ 7.25). Because MR is out of reach for many women, the approval of MR has not effectively expanded women’s reproductive rights. This shows how the rights rationale is absorbed into the health rationale by making abortion seem purely a health/medical issue.
Elizabeth Hoban, Tung Rathavy, and Phirun Lam (Chapter 2) present the difficulty of pursuing a rights rationale in Cambodia due to lack of access to abortion services (despite reasonably liberal abortion laws), as well as lack of awareness of the legality of abortions among government healthcare providers and women. The authors explore the interrelationships between contraceptive use, unwanted pregnancy, and unsafe abortion to understand why Cambodian women continue to utilize local midwives rather than state healthcare providers, despite having relatively liberal abortion laws. The chapter is based on Hoban’s 15-month ethnographic study in northwest Cambodia. The distance between women and the state is clearly seen in the interviews with women, but the authors have not brought out this effectively in the analysis. Despite the state apparatus (e.g., public health services, abortion laws) in place, a dialogue has not yet developed between the state and women to make women aware of the legality of abortion and of how to access “safe” abortions. Were women mere beneficiaries of state welfare? Given the situation, it is not surprising that women seek abortion services from village midwives, who are their most accessible and trustworthy source. Situations like this in which many women do not avail themselves of abortion services that are legal and legally available raise important questions for both activists and academics/researchers. One wishes that these questions had been critically examined in this chapter or elsewhere in the volume. However, in light of the obstacles to doing abortion research in Asia (such as the difficulty in obtaining statistics, the reluctance of traditional abortion providers to participate in research, and the reluctance of women who have undergone abortions to come forward), it seems unfair to criticize the contributors on this score.
Chapter 6 by Lakshmi Ramachandar and Pertti Pelto on Tamil Nadu (a state in the south of India) stands out as a longitudinal study of several cohorts of rural women concerning experiences of abortion. The chapter explores the “decision-making processes of rural women in their choices of providers for termination of unwanted pregnancy.” The authors examined the “interactions of cost factors with other criteria and situational factors that affect women’s choices of abortion providers” (p. 127). The chapter would have been stronger, however, if the authors had critically engaged with the term “unsafe” abortion; instead, they assume that “safe” abortions are possible only in hospitals/clinics staffed by providers trained in western medicine. This conceptualization is problematic because it ignores the “unknown number of ‘informal providers’” (p. 124). The authors seem to have an unwavering faith in western medically trained abortion providers as opposed to “informal providers” trained in indigenous medical practice. It seems wiser to conceptualize abortion and abortion providers more broadly to encompass the full range of possibilities available to women seeking to terminate a pregnancy.
Chapters 7 to 10 broadly deal with the tensions between formation of local policies, global developments, and national politics, and how these are translated into practice, especially in day-to-day living (within social, economic, gender, culture and religious beliefs). These chapters illustrate the power of the state to intervene in the private reproductive lives and the bodies of its citizens.
Whittaker has done justice to the topic (abortion) and the region (Asia) by including chapters by both western and Asian activists and researchers. She was also able to bring out the challenges faced by disadvantaged women in Asia, service providers (particularly in the public health sector), and policy makers within the region. These challenges were further problematized through discussions of concepts such as “moral motherhood” and “wanted child/wanted pregnancy” in Gammeltoft’s chapter on Vietnam, “menstrual regulation” in Hull and Widyantoro’s chapter on Indonesia, “termination of pregnancy” and “clot of blood” in Abdullah and Wong’s chapter on Malaysia, “weakness” in Belton’s chapter on Burmese women on the Thai border and “unsafe abortion” in Hoban et al.’s chapter on Cambodia. By doing so, these chapters point toward the complex nature of abortion in Asia.
At the end of the volume, Whittaker suggests additional research topics, including women with HIV/AIDS, disabled women, unmarried adolescents, migrant women, and displaced women in conflict zones. She also points to a need for research on the effects of biotechnology in reproductive regimes and on the trade in and movement of drugs for medical abortions. Some additional topics that were not addressed are the use of “hot” medicines (self-administered medicines as abortifacients and menstrual regulators, p. 28); herbal abortifacients; women’s medicines (herbal and traditional abortifacients); and assorted contraceptives, all of which have a long history and a huge market in the region.
This volume rests on an ideology of modern capitalist development in which western medical/health technology and practice are presumed to improve on traditional medical knowledge and practice. For example, a dichotomy between safe abortion via registered medical doctors and unsafe abortion via local midwives and traditional medical practitioners is put forward throughout the volume as if it were unproblematic. Who is unsafe in an “unsafe abortion”? What is unsafe about an “unsafe abortion”? Are abortions carried out by registered medical providers always necessarily safe? Are abortions carried out by traditional practitioners necessarily unsafe? A more critical stance toward the modern state and governmentality would open the way to new questions about both the health rationale and the rights rationale for abortion.
Considering the gamut of issues raised and the breadth of its policy discussions, this volume is recommended for graduate-level courses on reproductive health and rights.