Abortion in Malaysia: legal yet still inaccessible.
In 2007, RRAAM, a multi-sectoral alliance of women NGOs, the Federation of Reproductive Health Association of Malaysia (FRHAM), gynaecologists, specialists, lawyers and feminist researchers, began to collect evidence on barriers to abortion service accessibility from both within the health system and from women's experiences. The ARROW ICPD+15 monitoring and advocacy project allowed RRAAM and FRHAM to gather more evidence and to advocate with policy makers. This article discusses the main findings and recommendations from this monitoring study. (1)
The RRAAM-FRHAM study found that there is very restricted accessibility to legal abortion in most government hospitals. When abortions are provided in government hospitals, this is strictly based on medical reasons and not according to the full permissibility of the Penal Code. (2) Some women who have been raped and women with foetuses with congenital abnormalities have been reported to have been refused abortion and referred to other hospitals. In one Kuala Lumpur public hospital, an extreme reluctance to perform any kind of legal abortion was reported. Furthermore, experiences with women seeking help from women NGOs showed that some low-income, young, unmarried and disadvantaged women have been refused safe, legal and affordable abortion from government hospitals in Kuala Lumpur.
Meanwhile, abortion services were found to be available in the private sector, but services are costly, secretive and unregulated. The reported cost of an abortion can reach RM2,000 (US$588), when an average fee for an early abortion is estimated by RRAAM to be around RM300 (US$88), thus making the service inaccessible to poor, low-income, migrant and young women.
The study also found that the main barrier restricting access is the misconception by doctors, nurses, women, the media and the public that abortion is not legal. A RRAAM survey found that of 120 doctors and nurses, 43% responded incorrectly about the legalities of abortion. Similarly, a survey of reproductive health clients who had had a legal abortion in a private clinic, found that 41% did not know the correct legalities on abortion. Inaccurate statements on the legality of abortion were also found in some government publications and NGO websites, in the Malaysian Medical Council Code of Ethics and in mass media articles.
Another barrier is the unsympathetic and judgemental attitudes of many government doctors and nurses. When asked the RRAAM survey question: "What do you think women who are pregnant due to rape should consider doing?" 38% of the 120 doctors and nurses responded that such women should continue the pregnancy and either look after the baby themselves or give it up for adoption rather than consider having an abortion. Other barriers are the misconception of service providers on Muslim fatwas on abortion and the prohibition of the Vatican on abortion. The fatwa in Malaysia, (3) as in many of the 57 Muslim countries globally, allow abortion for health and welfare reasons up to four months. However, this is also not "widely known. Yet, irrespective of personal and religious beliefs, providers need to respect the civil law and women's choices. No guidance exists on these ethical issues.
Furthermore, there are no Ministry of Health (MOH) clinical practice guidelines on the provision of abortion services; thus, availability of abortion services was reported to vary according to the views of the Heads of the Obstetrics and Gynaecological Departments in government hospitals. Another problem found by the RRAAM-FRHAM study is that not all types of abortion services are offered in government hospitals. The main abortion method used in government hospitals is still dilation and curettage, which requires anaesthesia and hospitalisation and is costlier, carries comparatively more risks (4) and is less convenient for women, compared to the cheaper, safer and short out-patient manual vacuum aspiration (MVA) procedure. Medication abortion is also not offered even though mifepristone and misoprostol have been available globally for 15 years and have been recently included by WHO in the essential drugs list. Mifepristone has not yet been registered as a drug in Malaysia, while misoprostol has been registered for treatment of gastric ulcer and, hence, not used in hospitals for abortions.
Medical education curricula for undergraduates in three public universities, which are also teaching hospitals, are not up-to-date on the legality of abortion. Practical training on abortion is also not available for undergraduates due to the very few abortions being carried out in government hospitals.
The study points to Malaysian women's high need for better access to legal abortion, particularly due to several factors. Women have a high unmet need for contraceptives. Twenty-four percent of married women in 2004 did not want more children but were not using any kind of contraceptives, according to the most recent national population and family study. (5) Additionally, young people (who are not included in these surveys) are increasingly sexually active but their use of contraceptives is low. Indeed, the use of contraception in Malaysia has stagnated for 20 years at around 50% for married couples, which is an indication of low policy priority. Moreover, in 2004, only 32% used modern contraceptive methods. The need for abortion is known to be higher in countries "with low use of contraceptives. Access to safe, legal abortion and to a "wide-range of contraceptives are both necessary to ensure women's reproductive rights.
The combination of low contraceptive use and limited abortion access has several mortality and morbidity outcomes, including deaths due to unsafe abortions, suicide of young people and abandoning of babies. Morbidity includes psychological suffering due to having unwanted babies, abandoning babies and being forced to bear children as an outcome of rape and incest and children "with congenital abnormalities. While morbidity has not yet been quantified, RRAAM has been gathering evidence for this.
Recommendations based on the evidence gathered from the study are already being acted upon. The Ministry of Health is now working on an abortion policy and guidelines. In 2009, the MOH joined RRAAM in a series of state-level seminars educating all private and public sector service providers on abortion law and rights-based women-centred abortion services. The Obstetrics and Gynaecological Association of Malaysia is also on-board and invited RRAAM in 2009 to present a first-ever symposium on abortion and reproductive rights at their annual congress. Meanwhile, RRAAM submitted updated content on abortion legality at the end of 2009 for the review of the Malaysian Medical Council Code of Ethics, as the legal inaccuracies confuse doctors.
Recommendations that still need to be addressed are obtaining high policy priority for increasing contraceptive use, updating the medical curriculum with accurate legal content on abortion and training on rights-based and ethical abortion services, and education of the media.
(1) Abdullah, Rashidah (with input from FRHAM). 2009. ICPD+15 NGO Country Monitoring Report. Malaysia: ARRO W. [unpublished]. Email email@example.com for the copy.
(2) "In Malaysia, abortion is permitted under the following circumstances according to the Penal Code 312 (Amendment) Act 1989 in Malaysia: a) to save the woman's life, b) to protect the woman's physical health, and c) to protect the woman's mental health." RRAAM. 2010. "Top 10 Myths about Abortion."
(3) "In 2002, the national Fatwa Committee in Malaysia issued a fatwa (legal advisory under syariah law) declaring that an abortion after 120 days gestation is considered murder unless the mother's life is in danger or there is fetal impairment." RRAAM. 2010. "Top 10 Myths about Abortion."
(4) Abortion is actually safer than childbirth. RRAAM. 2010. "Top 10 Myths about Abortion."
(5) Lembaga Penduduk and Pembangunan Keluarga Negara (LPPKN). 2009. Laporan Kajian Penduduk Dan Keluarga Malaysia 2004. Malaysia: LPPKN, Kementarian Pembangunan Wanita & Keluarga dan Masyarakat. [National Population and Family Development Board (NPFDB). 2009. Malaysian Population and Family Study 2004. Malaysia: NPFDB, Ministry of Women, Family and Community.]
By Rashidah Abdullah, Co-Chair, RRAAM.
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|Publication:||Arrows For Change|
|Date:||Sep 1, 2009|
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