Hypocrisy holds back use of abortion pills
Here's the good news about women's health in Thailand as the world marks International Safe Abortion Day Wednesday: safe, easy and legal abortions are finally a reality here. And they're also free.
Here's the bad news: It's still very difficult for women to get medication abortion services from state hospitals.
"The problem is not a lack of medical technology. Nor the law. It's the die-hard hypocrisy our society has for women and young girls with unplanned pregnancies," said Kritaya Archavanitkul, a reproductive health activist and associate professor in demography.
Safe and legal abortion services through the use of officially approved abortion pills may still be limited, but the fact that they are available at all is a landmark success for the pro-choice movement to give women safe options and cut abortion-related deaths.
According to the National Health Security Office, more than 300,000 women have sought medical treatment at state hospitals for incomplete abortions in the past decade. Nearly 100,000 of them suffered severe complications and infections. More than 20 of them died each year.
"The real number of women who seek abortions from private or underground sources is certainly much higher than the official figures," said Ms Kritaya. So are the number of women suffering serious and fatal complications.
With abortion pills, things are about to change. And quickly too. "Women's first liberation came with contraceptives in the 60s," said Dr Sanya Patrachai, a gynaecologist from Ramathibodi Hospital at a recent seminar on safe and legal abortion. "Now the second women's liberation has arrived with abortion pills."
The World Health Organisation endorsed the use of mifepristone and misoprostol for early pregnancy termination a decade ago. Thailand's refusal to register them, however, has forced women and young girls with unplanned pregnancies to get the abortion pills from the black market ridden with fake drugs.
In 2014, the Public Health Ministry eventually agreed to register the two medicines for medical abortion of early pregnancies. They were included in the National Essential Medicine List last year despite strict prescription rules.
The reproductive health movement's change of campaign strategy plays a big part in making abortion pills legal in Thailand.
The movement's efforts to amend the archaic Abortion Law dates back four decades. But every time the draft bill reached the House, it was dumped due to fierce resistance from religious groups and politicians' reluctance to support an emotionally-charged legislation.
Subsequently, the safe abortion movement decided there was no point to hit a brick wall when the Medical Council's rules and regulations on abortion already make most abortion requests legal.
Under the abortion law, abortion is legal only when it endangers the mother's physical health or when it results from rape. Under this law, sex with girls under 15 is considered rape regardless of consent.
The Medical Council's regulations, meanwhile, allow "therapeutic" abortion when the pregnancy seriously affects the women's physical and mental health, especially when it involves a defective foetus. These regulations make most abortion requests legal.
At the same time, the WHO's recommended safe abortion pills are already legally available in more than 60 countries around the world.
According to World Health Organisation, the administration of mifepristone followed with misoprostal one or two days later is a highly effective and safe method to terminate pregnancies under nine weeks. They are also safe and effective with pregnancies up to 12 weeks with different dosage and application methods.
"Our challenge then was how to make them legally available in Thailand too," said Ms Kritaya.
Nine years ago, a group of safe abortion activists started working with the Bureau of Reproductive Health, Public Health Ministry, to study the use of mifepristone and misoprostol in Thailand to pave the way for registration. They also started building counselling and referral networks among civic groups and state hospitals to offer legal abortions in accordance with the Medical Council's guidelines.
"I've prescribed these medications for more than 1,000 women. The results are similar to findings around the world. They are nearly 100% safe and effective for pregnancies under nine weeks," confirmed Dr Sanya Patrachai, stressing abortion pills are as safe as today's over-the-counter contraceptives and pain-killers.
At present, however, doctors must record and report every abortion pill prescription to the Public Health Ministry as required by the Food and Drug Administration. But prescription restriction and the red tape involved are not the only thing that stands between women and abortion pills.
A bigger obstacle is many doctors' belief that abortion is a sin, so they refuse to prescribe the pills. "They don't only condemn women or young girls who seek abortions as bad and immoral, they also condemn other doctors who give abortion services bad as immoral too," said Dr Sanya.
But isn't it sinful too to force women to seek illegal and unsafe abortions -- with many ending up on deathbeds -- when help is available, asked Ouyporn Khuengaew, an advocate of Buddhist faminism.
"Society insists abortion is a sin. Yet it cheers on vigorously for soldiers to kill 'enemies' to win wars out of hatred and anger while condemning women and young girls in distress who cannot raise a child out of all kinds of social stigma and pressures."
Why is killing by men and women different? For Ouyporn, this is not a matter of what is sinful or not, but who has the power to say so.
"If women who seek abortions are sinful, so is every party that creates social pressures and stigma on pregnant women and girls unable to raise a child -- from their partners, parents, schools, society, hospitals, to the miserable lack of systematic support for single mothers," she said.
That is what the safe abortion network is set to tackle, said Tasanai Khantiyaporn from the Path2Health Foundation.
The network consists of reproductive health activists and public health personnel to provide counselling, information, and connect them to abortion, prenatal care or adoption services depending on their choices.
Starting with only 10 organisations nine years ago, the network now has 78 member organisations led by the Referral System for Safe Abortion (RSA), a group of pro-choice doctors in different parts of the country. They fill the gap of abortion needs when most doctors still equate unplanned pregnancies with immorality.
Worse, when women came to the hospitals with abortion complications, anti-abortion doctors still use sharp curettes to scrape the walls of the uterus -- a painful and often dangerous procedure -- to give "bad women" a lesson.
"Sadly, this is still a routine practice in hospitals despite recommendations from the World Health Organisation to replace this rudimentary technique with vacuum aspiration," said Dr Sanya.
While the 1663 Hotline and "Women Help Women" e-counselling group help refer the patients to the RSA doctors for safe and legal abortions, they found those who need to continue the pregnancies end up facing a bigger battle.
"There's zero support for single mothers," said Ms Kritaya. "Society opposes abortion but offers no help at all for women who do not or cannot choose abortion. That's hypocrisy."
When women decide to give up their babies for adoption, they are still plagued with guilt for failing to be "good mothers" as society expects from "good women", said Supa-apar Ongsakul from Sahathai Foundation, an adoption agency.
Society needs to dismantle the values and prejudices that punish women and set up a system to support single mothers, she urged. "Otherwise women and young girls with unplanned pregnancies will be forced to seek abortions endlessly."
For high school principal Narakorn Lairang, the choice between abortion and motherhood for teenage students is clear. "Those who ended their pregnancies went on to complete their education and get good jobs," he said. "In short, they succeeded in life."
Those who had to continue their pregnancies, however, became dropouts and struggled as single mothers with no support, facing failure early in life. "That's why abortion pills should be available over the counter to give the girls the future they deserve," he said.
When contraceptives were first introduced, they also faced strict prescription controls and resistance on religious grounds before they were eventually available over the counter, said Ms Tasanai.
"This will happen with abortion pills too. It's just a matter of time."
Former editorial pages editor
Sanitsuda Ekachai is a former editorial pages editor, Bangkok Post. She writes on human rights, gender, and Thai Buddhism.