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Rapid Responses: Rapid Responses published:
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Selective abortion: Missing Indian Baby Girls
- Akashdeep Singh, Rupinder kaler (16 November 2007)
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Prevention of abortion needs a more appropriate approach
- Souhail Alouini (17 November 2007)
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Human Rights in Abortion
- Paul F. Vooght (20 November 2007)
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Abortion rate must be lowest where abortion and contraception are illegal.
- Johanna Higgins Barrister at Law (21 November 2007)
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Can abortion laws in India prevent sex-selective foeticide?
- Sudheer Lankappa, Rani Prajwala (22 November 2007)
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Theft of life
- Anne M H Williams (23 November 2007)
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Illegal abortion in El Salvador: no evidence of increase maternal mortality
- Rene Leiva (11 December 2007)
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Psychological Effects of Abortion, Myth or Reality?
- Dr Ravimal Galappaththi, Ms. Chamila S Pathirage (2 January 2008)
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Akashdeep Singh, Assist. Professor Christian Medical College and Hospital Ludhiana,India 141008, Rupinder kaler
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While India’s population rises, the ratio of girls to boys is on steep decline. The sex ratio has become more skewed towards boys in recent decades; in the decennial census,1 the number of girls per 1000 boys aged 0–6 years was 962 in 1981, 945 in 1991, and 933 in 2001, and the discrepancy was more acute in urban areas (from 959 to 906 between 1981 and 2001) than in rural ones (963 to 934). In states such as Haryana, Punjab, and Delhi, this number has sunk below 900; it is a mere 770 in Kurukshetra district in Haryana state. In 2001 alone, the imbalance represented more than 5 million missing Indian baby girls. In India, there is a cultural preference for boys as the male child is considered to continue the family name and bloodline, earn money, look after the family, and take care of parents in their old age as there is no social security scheme in India. To have a daughter is socially and emotionally accepted if there is a son, but a daughter’s arrival is often unwelcome if the couple already has a daughter. Daughters are regarded as a liability due to the wide prevalence of the dowry custom, in spite of Indian legislation prohibiting dowry since 1961. In certain communities the cost of the dowry could be phenomenal and many families are forced to borrow money to fund it. Further , the woman is deemed a culprit if she does not give birth to a boy, although scientifically it is the husband who is responsible for the sex of the child. The cultural preference for male child and pressure from the in- laws succumb the woman to have prenatal sex determination (ultrasonography), which is now available even in rural areas. Sex selection is illegal and punishable in India, and as a result, identifying patients and practitioners who participate is difficult. The solutions to this herculean task lies in change the attitude of the common people through the dissemination of the knowledge that both men and women are equally required to run the family and the society and female foeticide is akin to slaughtering one’s own daughters. References 1 Census of India 2001. Office of registrar general and census commissioner,India http://www.censusindia.gov.in/Census_Data_2001/India_at_glance/fsex.aspx (accessed Nov 16, 2007). Competing interests: None declared |
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Souhail Alouini, Obstetrician and Gynaecologist, M.D. Ph.D. of René Descartes University, Paris 75006
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Brown reported a decrease of abortions number in western countries due to a broader access to contraception contrary to the developing countries (1). We would like to share this optimism thinking that access to contraception and legalisation of abortion in developed countries cause a significant drop in abortion number. The reality is very different. The rate of abortion being a more reliable indicator than abortions number (abortions no./1000 women 15-45 years) remained stable, even increased during the last ten years in many European countries such as France, United Kingdom, Belgium and the Netherlands. This in spite of more accessible and widespread reliable contraceptive means (2, 3). The prevention of the abortion is far from being regulated only by access to contraception. Several factors are implied in the prevention failure (4). The information on contraception (emergency contraception, missing of pill) delivered to women is largely insufficient. The type of contraception proposed by health professionals is not always the same that wished by the patients. The intra-uterine device has a bad image among women although plebiscited by health professionals in repeated abortion. Last generation pills less dosed in hormone, required by young girls are less prescribed as not refunded. The needs for psychological hep are not sufficiently taken into account because of insufficient number of psychologists. The medical discourse is little adapted little to womens’ cultural, religious and ethnic diversity. Finally, the abortion procedure poses little technical but more ethical, moral, or sometimes religious problems for doctors. The desire of patient must be taken into account but abortion may be practised only by volunteer doctors. References 1. Hannah Brown. Maternal Health: Abortion round the world. BMJ 2007;335:1018-1019, doi:10.1136/bmj.39393.491968.94 2. Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet. 2007 ;370:1338-45. 3.Sedgh G, Henshaw SK, Singh S, Bankole A, Drescher J. Legal abortion worldwide: incidence and recent trends. Int Fam Plan Perspect. 2007 Sep;33(3):106-16. 4. Alouini S, Uzan M, Méningaud JP, Hervé C. Knowledge about contraception in women undergoing repeat voluntary abortions, and means of prevention. Eur J Obstet Gynecol Reprod Biol. 2002;104:43-8. Competing interests: None declared |
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Paul F. Vooght, GP Letchworth SG6 3BJ
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The current review of the 1967 Abortion Act by the parliamentary committee wanted to avoid complex ethical issues and so concentrated on scientific and medical developments.You cannot talk about abortion without defining what an abortion is-the destruction of human life at it's earliest stage of development. We are supposed to use evidenced based medicine and yet we aren't consistent when it comes to unborn babies in this country. As doctors we advise pregnant mothers to avoid smoking because it harms their unborn baby but we avoid mentioning the word baby when it comes to talking of an abortion. The evidence is the same in both cases but we choose to ignore it when it comes to abortion.It becomes even more obvious that the unborn baby/embryo(young one)/foetus is a human being when you see the latest 3d ultrasound scans and consider the evidence that the baby is alive and a completely unique new human being who deserves the same human rights as every other human being.Let us be consistent with the evidence and give both mother and baby the care that we give them in the best obstetric tradition Competing interests: None declared |
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Johanna Higgins Barrister at Law, Senior Public Prosecutor PPSNI BT1 3JR
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Hannah Brown states; “One general truth is that abortion rates decline as contraceptive use increases” Historical evidence shows us that this is not in fact true. The above analysis does not take into account those who do not use contraception for moral reasons. Is it likely that people who will not use contraception because they are, say Catholic, will abort children subsequently conceived? It would be interesting to compare the statistics for Ireland in 1975 and England in the same year, where both contraception and abortion were illegal in the former and available in the latter. Further this assertion does not account for the use of abortificients, misleadingly called "emergency contraception", such as the “morning after pill”. Dr Camp states; "Abortion is lowest where contraception and safe, legal, abortions are universally available. What is more, major abortion declines have occurred in countries where abortion is legal but not in countries where abortion is restricted." This claim that abortion is less in countries where it is legal cannot be sustained: 1. The statement is misleading because where abortion is illegal it is likely that abortion figures were already low and therefore their capacity to “decline” is less. It is like saying a person who overeats is more likely to be slim than someone who eats normally because the overeater lost more weight when on a diet that the normal eater. 2. This statistics for the North of Ireland also give lie to this statement: Consider, a) The ratio of abortions in the North of Ireland, where direct abortion is illegal, for the year 2003 (the year of the most recent WHO report on Abortion statistics worldwide)is 3.6 per thousand women between 15 and 44, the lowest in the world. This specific statistic was not in the WHO report but is obtained using the same formula. (Women between the ages of 15 and 44 and abortions figures from the Department of Health in UK) Also there are no instances in the North of Ireland of women dying or suffering health complications due to the want of direct abortion. Competing interests: Co Founder of the Association of Catholic Lawyers of Ireland |
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Sudheer Lankappa, Clinical Lecturer The Longley Centre, Norwood Grange Drive, Sheffield, S5 7JT, Rani Prajwala
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Infanticide practices have been documented in India since 19th century. British policy makers in India first addressed these issues in 1870 by passing ‘Infanticide Act’. Again in 1961 Government of India passed ‘Female Infanticide Act’ to prevent killing of female infants. Widespread illegal abortion prompted the introduction of ‘The Medical Termination of Pregnancy Act 1971’ (MTP) which was passed in 1973 to legalise the abortion. It was widely acknowledged that this would significantly reduce morbidity and mortality relating to illegal abortions. The act covered wide range of indications for termination including mental illness arising due to continuation of the pregnancy. The act stipulated various requirements to perform the procedure. Unfortunately vast majority of terminations were performed by untrained persons and in poor hygienic conditions. Easy accessibility to newer technologies such as ultrasound scans, amniocentesis and chorionic villi biopsy as led to early determination of foetal sex. Epidemiological studies have shown low male-female sex ratio(1,2). ‘The Prenatal Diagnostic Techniques Regulation and Prevention of Misuse Act 1994’ was passed to prevent abuse of these diagnostic tests. The act clearly stated misuse of test to identify the sex of the foetus would be punishable offence including imprisonment and fine. In spite of above legislations the incidence of the sex selective abortion continued to rise. Further the MPT Act 1971 was amended to ‘Medical Termination of Pregnancy Regulations 2003’. This act imposed regularisation of centres which conducted the procedures. All centres had to maintain a register and obtain a written consent prior to the procedure. There are clear guidelines on storage of this information and provision for accessing the data for inspection by the state health authorities. Any misconduct would lead to revoking the license of the centre and disciplinary action would be imposed on the professionals involved. Social issues predominate more than ethical considerations in India compared to developed countries. Often people live in joint families or nuclear families where the decisions for abortion are made by family members rather than the women. Poverty and poor educational status of girls has compounded the problem. Although the abortion laws have been in existence for a long time they have never achieved the desired objectives. Female infanticide is tip of an iceberg; it reflects social inequalities in society and the financial burden attached to female child. Until these wider issues are addressed, amendments in abortion laws alone will be very futile. References 1. Jha P, Kumar R, Vasa P, Dhingra N, Thiruchelvam D, Moineddin R. Male-to -female sex ratio of children born in India: national survey of 1•1 million households. Lancet 2006; 367: 211-218 2. Varghese J, Aruldas V, Jeemon P. Analysis of trends in sex ratio at birth of hospitalised deliveries in the state of Delhi. Christian Medical Association of India. July, 2005 Competing interests: None declared |
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Anne M H Williams, GP Glasgow G52 2AZ
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This article(1) just proves to me that statistics and 'facts' can be interpreted to suit one particular ethical stance and used to support the agenda of an author(2). Abortion in itself is controversial because no other infringement on human rights, when considered a danger to the perpetrator, has been legalised. When this remedy is considered alongside our response to other crimes such as theft, it appears a strange solution. The human tendency to selfishness has led to the widespread support for asserting abortion as a right, even though it flies in the face of human dignity. When autonomy is adopted as the basis for ethics, the acceptance of this theft of life is perhaps not surprising. The weakness of democracy is that those with the stronger voice seem to attain stronger rights, which become enshrined in law. We humans are influenced by prevailing thoughts and fashions, losing ourselves in the crowd. The peer pressure cannot excuse us from individual responsibility for actions. (1) Original article: http://www.bmj.com/cgi/content/full/335/7628/1018 (2) Any change must be qualified by starting rates. The total abortion rates in western countries are still higher than developing countries. http://www.guttmacher.org/pubs/ib_0599.html http://www.johnstonsarchive.net/policy/abortion/wrjp333pd.html Much of the data were estimates: http://www.who.int/reproductive- health/publications/unsafeabortion_2003/ua_estimates03.pdf Forthcoming conference on Human Dignity - 19 January 2008 Venue: Lister Institute, Hill Square, Edinburgh Speakers: Prof. Kenneth Boyd: The concept of human dignity Prof. Graeme Laurie: How is human dignity protected in law? Prof. Mona Siddiqui: Human dignity and contemporary challenges Dr Mary Ford: Human dignity and postmodern bioethics Download Conference brochure and booking form. http://schb.org.uk/ Competing interests: Director of Scottish Council on Human Bioethics |
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Rene Leiva, Medical Staff Elizabeth Bruyere Health Centre Ottawa ON Canada
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Brown’s hypothesis states that legal and safe abortion leads to lower maternal mortality (1). Epidemiology of abortion and maternal mortality are largely based on statistical estimates that lend themselves to inaccuracies (2). In order to asses objectively this problem, the case of El Salvador might present an interesting real life example that might cast serious doubt on this hypothesis. El Salvador criminalized abortion for all reasons in 1998. Maternal mortality ratio (MMR per 100,000 live birth) prior to 1998 was calculated to be 155 (3). In 2006, the Salvadorian Ministry of Health completed the most comprehensive study carried out so far to evaluate true MMR in the country (3). This study was funded by the U.S. Center of Disease Control (CDC), the WHO, UNICEF, UNFPA and USAID. In addition, technical assistance and supervision was provided by the WHO and U.S. CDC. In short, the study was a prospective reproductive-age mortality study (RAMOS). This approach involved identifying and investigating the causes of all deaths of women of reproductive age (10 to 54) in El Salvador from June 2005 to May 2006 by using multiple sources of data ( interviews of family members, vital registrations, health facility records, burial records, traditional birth attendants). It is recognized that if properly conducted, this approach provides a fairly complete estimation of maternal mortality (3). The study found that the MMR was 71.2. Out of 2,468 all-cause deaths, pregnancy related deaths numbered 100. 50 cases related directly to pregnancy complications, 32 cases indirectly to the pregnancy, and 18 non- related to the pregnancy. Out of the 32 indirect cases, 13 were due to suicide related to the pregnancy. Out of the 50 direct cases, 6 deaths were related to abortion as follows: 1 septic abortion, 2 ectopic pregnancies, and 3 indirect deaths after having completed the induced abortion. 5 out of these 6 cases were handled in tertiary care centers. Concluding, there seems to be no evidence that overall maternal mortality has worsen in El Salvador since the criminalization of abortion. Second, most of cases of maternal deaths in El Salvador are due to common preventable medical complications. Third, it is unfortunate that a significant mortality is due to suicide. No clear connection can be drawn here since suicide and maternal psychiatric morbidity seems to be increased specially with induced abortions (4). 1. Brown H. Abortion round the world. BMJ. 2007 Nov 17;335(7628):1018-9 2. WHO. Maternal Mortality in 2005 Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization, 2007. 3. Gerencia de Atención Integral en Salud a la Mujer. Linea de Base de Mortalidad Materna en El Salvador. Junio 2005-Mayo 2006. Ministry of Public Health and Social Assistance. San Salvador. El Salvador. 2006. http://www.mspas.gob.sv/p_attmujer.asp (Accessed December 7, 2007) 4. Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. Eur J Public Health. 2005 Oct;15(5):459-63. Competing interests: None declared |
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Dr Ravimal Galappaththi, Staff Grade Psychiatrist, Crisis Assessment Service Pilgrim Hospital, Boston, Lincolnshire, UK, PE21 9QS, Ms. Chamila S Pathirage
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I read this timely debate on issues on abortion with enthusiasm. In summery abortion has number of important aspects which needs to be addressed. There appears to be a wider disagreement on these technical, medical, legislative, ethical and spiritual aspects of abortion, across countries and cultures. Some of these areas remain minimaly researched and the lack of evidence hinders the implimentation of sensible policies. My forcus is on psychological impact of abortion on womans life, which in many ways ignored by health care professionals. Undoubtedly abortion is a loss to a woman’s life no matter the timing, the reasons either medical or social or whether a concious decision was taken after weighing the pros and cons. In clinical practice many women suffer adjustment reactions, grief and clinical deppression following abortion. Abortion as a life event act as a significant trigger to bring about mental illness in already vulnerable majority. It is important to understand that each woman is diffrent and so do the likelyhood of her reaction to abortion. Many clients commonly describe feelings of guilt, shame, anxiety, helplessness, grief, remorse, uncontrollable crying, feelings of anger, distrust, bitterness and resentment. Later they may present with lowered self-esteem and behaviors such as avoidance of babies, small children, and fear of future pregnancies. There has been reports of clients desire to have a "replacement" baby; flashbacks to the abortion experience; nightmares and persistent sleeping disorders. Sexual dysfunction, perception of negative aspects of relationship even in previously positive one has also been documented. Many such clients let them selves to unhelpful coping strategies such as using illicit drugs or alcohol, self- destructive behavior and restricted eating. Further consequences include problems bonding with future offspring and continued negative ruminations and suicidal thoughts or tendencies. It’s unfortunate that these areas are far fewer researched and lack of evidence results in poor policies either based only on political and social agendas. In many parts of the world especially in developing nations, woman’s voice and concerns are never taken in to consideration by policy makers and health professionals and the issues are unaddressed while clients silently suffer. Good quality qualitative and quantitative research is needed, so health professionals are better equipped with information to women and also to arrange pre and post abortion counseling. References: 1. Los Angeles Times Poll, March 19, 1989. See also Zimmerman, M., Passage Through Abortion (New York: Praeger Publishers, 1977) and Reardon, D., Aborted Women: Silent No More (Chicago: Loyola University Press, 1987). 2. "Revisiting the Koop Report," The Post Abortion Review, Summer 1995, 1- 3. See also "Surgeon General C. Everett Koop's Statement on Post-Abortion Syndrome," Life Cycle, September 1989, 2. 3. Dr. Martha Shuping, M.D, Experience in helping women with post-abortion issues. Competing interests: None declared |
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