Dr S.P. Choong,
Asia Safe Abortion
Partnership.
IWAC 2013.
Bangkok, Thailand.
22-25 January 2013.
Defining Stigma, Identifying Effects.
 Stigma lies below the rational
consciousness.
 Entrenched as cultural and religious
‘NORMS’
 Advocates also feel it but not necessarily
understanding ramifications.
Thus there is a NEED to
 Analyze roots of stigma.
 Examining its pervasive effects.
 Exposing irrational historical roots creating
fear and bias
Starting from Home
 Are
we stigmatized? Aware of low
social status; not coming out of the
closet.
 Public
Terminology. What we do women’s health, family planning etc
but not ABORTION?
 Private
Discourse: exploring clients
needs or also unconsciously imposing
our own values?
Sensational trivialized exposes
of sexual ‘offences’ without
mentioning root causes.
 Teen pregnancies,
 baby dumping,
 infanticides
 and ‘illegal’ abortions.
Stigma - Reflected in the Media.
Teen pregnancy and Baby Dumping
attract more attention –
not the marrieds, moral issue again.
Alarming facts – many
strategies but always exclude
abortion access.
Common Advocacy Strategies.
Evidence from health-related stats mortality, morbidity, unmet needs etc.
 Information on 'new' abortion
technology - safer, simpler and cheaper
but still ignored.
 Social effects on poverty, crime,
healthcare costs, population etc.
 Horror stories, personal tragedies
Savita etc.

Making Changes in Laws and Policies.
But is it working?




National Laws - amended to be more
permissive – but few decriminalized.
Health Policies may have been adopted at
ministerial level.
UN International Covenants –
condemned restrictions to abortion from
women's rights perspective; from CEDAW to
ICPD Cairo 1994. Anand Grover report 2011.
Regional human rights bodies in EU and
Inter-American HR Court action on Abortion
Rights. .
Stigma stokers – behind anti-choice





Anti-choice movement continues to
flourish.
Media statements emphasize negative
aspect.
Saving ‘fetal life’ more important than
‘women’s health/life’ - an attractive
ideology?
Hidden Agenda – real prime movers
behind the movement.
Patriarchal traditions and religious
fundamentalism – missing from public
discourse
Not apologetic about pro-choice work.
 Quote historical rationale for controlling
women's reproductive rights - Romania,
Latin America, Philippines, Ireland.
 Link anti-choice movements with failed
states and fundamentalist religion.
 Proven facts on social outcomes –
poverty, crimes, economic development.

Taking the Moral High Ground.
Hidden Forces of Anti-choice.
Anti-contraception as in Catholic
Philippines, after 14 years, RH Bill just
passed but still under threat. (propoverty)
 Anti-education as in Taliban in
Pakistan, Afghanistan - 14 yr old
blogger Malala shot.
 Anti-sex as in FMG practised in
Moslem Africa.
 Anti-individual - confining women
in Burqas in Saudi Arabia.

Equal rights to an embryo/fetus as to an
adult woman? (3cm @ 10weeks)
 Mental incompetence so that ‘moral
counseling’ and a 'cooling off' period
needed before an abortion?
 ‘Liberal’ penal codes - assume a
woman's inability to decide - approval of a
doctor required.

Abortion Stigma -
Assumes Women as a lower life form!
Patriarchal Ideals –
archaic and unrealistic.
Women as Baby factory and Childminders. But also with
 Domestic duties in the kitchen.
 Sexual duties in the bedroom.
 Restrictions in education
imposed
 Often economic roles unpaid
e.g. farming communities.
How Abortion Seekers Stigmatized
Avoiding pregnancy or seeking abortions
is BAD - defies patriachal role models.
 Deciding not to bear (more) children in
preference to other activities is being
selfish, anti-feminine and goes against
the 'natural social order'.
 Having sex without wishing to get
pregnant means women enjoy sex –
they should not!
 Thus abortion seekers are selfish,
avoiding their natural 'god given'
role, sinful etc.

Linking Abortion rights with
outcomes for women.
Anti-choice activists claim to be
feminists by separating abortion rights
from other women's rights.
 But realities in our society show that
.....
Denying women the power to
control her reproductive function in
reality also deprives her of all her
other basic rights; ranging from
access to education, gainful
employment, choices in marriage
etc.

Stigma and Attitudes to abortion –
WHO surveys in Malaysia 2011
Pro-choice/Anti-choice positions Stigma shows up in surveys of in
different groups.
Studies on knowledge, attitudes and
practices in three groups;
 a) Medical students,
 b) Consultants and MOs from O&G dept
and
 c) Clients who have experienced an
abortion.
Medical Students
Knowing the law; only 60% were
vaguely aware of the law but 22%
thought abortion illegal.
Attitudes to abortion;
 a) supporting rights to life of fetus
>80%;
 b) unwilling to provide abortion
services. >80%
 c) disapproval of premarital sex >75%
 d) will not give contraceptive to singles
= 36%
Specialists and MOs in O&G
Knowing the law; 80% vaguely aware
abortion permitted under certain
conditions.
 Attitudes; Anti-choice positions expressed
by > 50%
 Practice; Conscientious 'objectors' to
doing abortions > 40%
a) Only ½ of 'objectors' prepared to
refer clients to other abortion providers.
b) Abortion technology; almost 2/3
unaware of safety and indications of MVA
and MA for terminations

Threat to future services
Attitudes and Knowledge of medical
students and especially specialsts and
medical officers in O&G dept alarming!
 Unwillingness to Provide abortions
services falls from 80% in medical
students to 40% in doctors in O&G dept
(objectors)
 Willing to Refer - only 1/2 of objectors;
a serious breach of medical ethics.
 Training/Medical Curricula - lack of
training in medical school, expressed by
90% of students.

Abortion Clients.





Small qualitative study - sampling different
ethnic and age groups –
Objective - insights into clients Knowledge,
Attitudes and Practice.
Legal status - most women considered
abortions illegal, as govt clinics do not
provide them and private sector providers
support this impression.
Attitudes - most express a sense of guilt
related to their religious belief (Bhuddists,
Muslim and Christians).
Practice & justification – despite guilt, most
accepted the decision to abort as necessary
and 'right' for her.
Seeking Help - Stigma prevents any discussion
except with closest relative/friend. Websites
are useful.
Seeking Justification –
 Married women mostly saw financial
constraints as too important to ignore.
 Unmarried status or career plans were
important for younger women.
 Muslim women face threat from Shariah
courts – being charged for sex/pegnancy out
of wedlock.
Overcoming Stigma Justifyinga difficult decision.
Obstacles faced by Abortion
Seekers





Unsympathetic, judgmental doctors and
nurses – common experience..
Inaccurate Information on abortion
services via ‘Grapevine’ info rather than
professional referrals.
Expensive 'clandestine' services; whether
safe/unsafe.
Govt. MOH Services poor reputation for
support e.g. hospitals, welfare dept etc.
(esp low income families)
Religious Authorities- threat of Shariah
court actions for khalwat.




Professional healthcare organizations medical, O&G and Nursing fraternities.
Ministry of Health, enforcement dept for
practice standards (CKAPS) - new rules.
Pharmacy Dept and registration of MA drugs.
Strategies of anti-choice in USA - Targeted
Regulations against Abortion Providers
(TRAP)
Stigma affecting Medical
Community – despite better
laws and policies
Ministry of Health –
law, policy and practice.




Penal Code - in 1989 amendment to
permitted abortion for 'risk of injury' to
'mental or physical health' with one doctors
approval.
Actual Practice - dictated by hospital
directors.
Clients’ Feedback - almost all govt medical
facilities, abortions restricted to treat 'serious
medical complications', requiring 2 doctors
opinions, often including a psychiatrist.
Sector shift - abortion services thus forced
into private sector.
Stigma affecting Services.
Isolation of abortion services from general
practice or gynacological clinics - a
problem.
 ‘Clandestine' abortions in GP clinics kept
very low key – reducing access.
 Integration into FP association clinics –
blocked by stigma, vetoed by committee
in 1970s despite support of IPPF.
‘Open access' clinics thus attract increasing
workload; high demand forces
specialization for efficiency – identifiable
and so more stigma.

TRAP* strategies (in USA)in Malaysia as example




Private Healthcare Facilities & Services Act
enforced in 2006. MOH now regulates private
practice.
Ambulatory Clinics - new regulations now
‘disallow’ abortion procedures by categorizing
them ‘high risk’, restricted to hospitals.
Pharmaceutical division : failure to register
blocks wider use of MA; prosecutions of drs
now.
Effect - Increased costs, Reduced access.
*Targeted Regulations against Abortion Providers
RRAAM and ASAP
New Alliances formed to advocate for
better rights to access safe abortion.
 M'sian based RRAAM in 2007 and Asian
based ASAP in 2008.
 Forums and seminars with health care
personnel focussing on

◦ a) health issues. b) new technology. c) working
within abortion laws – only limited success.
Abortion stigma - an irrational obstacle to
rational discussion.
Experiences and Lessons





Survey on knowledge and attitudes useful baseline data.
New technology imparted – easy part!
Legal status - involves in judgmental
issues when discussing laws.
Traditional Values still rule at the end!
Stigma - analyzing nature and degree of
prejudice in Values Clarification exercises
more successful.
 Values clarification, a useful tool in exploring
roots depth of prejudice.
 Image of services and clinics – start integration.
 'Coming out of closet' for both providers and
clients - en mass. Like HIV/AIDS.
 Celebrities, politicians declaring public
support.
 Socio/economic data – effect on taxpayer
burdens, poverty and crime.
Other Approaches to Stigma.
A losing battle against
STIGMA?
Beyond our International
Campaign –
WHAT ELSE CAN WE DO?





Theoretically, we have a large support
base for our cause.
What can professional organizations do?
What can Individual providers to do?
What can abortion clinics do?
What can our abortion clients do?