Although abortion is a common occurrence throughout the world--46 million or 22% of all pregnancies worldwide end in induced abortion each year (1)--it remains clandestine, stigmatised and unsafe for hundreds of thousands of women. This situation persists due to a lack of awareness in many countries of what the law actually permits and a general unwillingness among policymakers and health professionals to concretise women's reproductive rights.
With only a few exceptions, every country in the world permits abortion under certain circumstances, such as to save a woman's life or to terminate a pregnancy resulting from rape or incest. Tragically, even in these countries, safe abortion is rarely accessible, rarely available and rarely affordable. Around the world, legal and medical professionals in countries with restrictive laws continue to describe abortion as "illegal," rather than acknowledge that women have a legal right to abortion under certain circumstances. As a result, policymakers, health professionals and activists have lost the opportunity to offer safe and legal abortion services to those who need them.
Safe abortion should be made available as part of comprehensive reproductive health care, not in isolation from other necessary health and social services. It is also important that women have access to safe and effective contraceptive methods, screening and treatment for sexually transmitted infections and counselling related to sexual or domestic violence. In many countries, women's need for safe abortion is the reproductive health component that is most ignored by policymakers, health workers and even societies at large. The alternative to providing safe abortion is grim: The World Health Organisation (WHO) estimates that at least 67,900 women die every year from complications of unsafe, and usually clandestine abortions. (2) WHO also estimates that as many as 19 million unsafe abortions take place each year, accounting for 13% of maternal deaths worldwide. (3) However because of methodological constraints inherent in abortion-related research, these estimates may not reflect the full extent of the incidence of unsafe abortion.
Unsafe abortion is a direct cause of maternal mortality in developing countries. Yet, in many developing countries deaths due to unsafe abortion are categorised under maternal mortality, which means the number of deaths due to unsafe abortion are often unknown. (4) Causes of maternal mortality in Indonesia include excessive bleeding (28%); pre-eclampsia (26%); abortion (5%); infection (11%); and others (30%). (5) However, causes of maternal mortality including excessive bleeding, infection and others could also be due to abortion. In Indonesia, the estimates for the percentage of deaths due to unsafe abortion range from 12-17%. (6) Yet, the rate of deaths due to abortion could be higher, mainly due to the ambiguity of the abortion law in Indonesia.
This report aims to provide secondary data on safe and unsafe abortion. In short, this report presents six types of data:
1. Secondary data (or desk research) on published literature and research reports.
2. Primary data from in-depth interviews with women who have undergone abortions, and interviews with health care providers (midwives, physicians and gynaecologists) as well as results from focus group discussions (FGD) in order to unravel why women seek unsafe abortions.
3. Three legal cases in order to locate the existing loopholes in the Indonesian judicial system.
4. Data from monitoring the on-going programme activities of the Ministry of Health in order to look for the implications of the health policies which only focus on preventing unwanted pregnancies and providing post abortion care services.
5. Strategies on advocacy for safe abortion services conducted by other countries.
6. Felt needs and follow-up actions to be taken in the coming months in order to regulate abortion in Indonesia or in one of the regions through a local regulation, which is possible in a decentralised system.
This study will be able to fill a necessary gap as the Indonesian government has neither studied nor estimated the incidence of abortion. In the 1970s and 1980s only sporadic hospital-based induced abortion cases were reported.
FINDINGS FROM THE DESK RESEARCH
ABORTION LAW IN INDONESIA
The law on abortion in Indonesia originates from the Dutch Criminal Code. The Indonesian Criminal Code was enacted in 1918 and made abortion a criminal act. (7) In the mid-1960s discussions between the Indonesian Medical Association and Indonesian Association of Obstetrics & Gynaecology began within Indonesia as to how the law could be amended to allow for abortion. (8) When the publication was released in 1964 the main recommendations included:
1) "Increase the research on the determinants of induced abortion
2) Reform laws on induced abortion to allow for medically indicated pregnancy terminations
3) Include the Medical Code of Ethics in the required course work of all medical schools, which state that abortion is illegal except when on medical grounds
4) Promote the distribution of information on family planning
5) Eliminate illegally induced abortions" (9)
In 1973 the Symposium of the Second Congress of Obstetrics & Gynaecology took place and resulted in support for legalising abortion on medical grounds. During the same year the menstrual regulation method of abortion began to be taught at University of Indonesia, despite the fact that abortion remained illegal. (10) Subsequently, in 1977 an Interdepartmental governmental committee (Ministry of Health, Justice, Police, Attorney General's Office) was set up to formulate the Bill allowing for abortion on medical grounds. This committee's article was drafted into the Bill of Health in 1989.
Around the same time, the political popularity of Soeharto was on the decline and he needed support from other political parties. He sought support from the main Islamic political party (at that time several Islamic parties were united under one umbrella called United Party of Development--Partai Persatuan Pembangunan). Soeharto and his family went to Mecca for a pilgrimage, and upon his return, he stressed the issues of morality and Islamic values.
Towards the end of 1991, a Bill on health that included an article on abortion was submitted to parliament and the debate on it continued well into 1992. Religious leaders made strong statements against abortion. Soeharto, the parliamentarians and the high ranking officials from the Ministry of Health and BKKBN (National Family Planning Coordinating Board) erased the term abortion in the draft of Article 15, replaced it with "tindakan medis tertentu," or "a certain medical procedure" instead. The Bill then specifically stated that "in the case of emergency and with the purpose of saving the life of a pregnant women or her foetus, it is permissible to carry out certain medical procedures." (11) The procedure would be approved if it could save the lives of the woman and the foetus. This ambiguity came up since abortion could only save the mother and not the foetus. This was further debated and in the end the parliamentarians acquiesced to the voice of certain religious leaders who were against the legalisation of abortion. Since the endorsement of the new Health Law No. 23/1992, Article 15 interprets abortion as being illegal. The wording of 'a certain medical procedure' could mean anything, except abortion. A seminar organised by The Institute for Law Development in November 1992 could not reach agreement on this matter either. Then in early December 1992, the Ministry of Health issued a statement, though not directly by the Minister of Health, saying that article 15 was specifically intended to regulate the practice of abortion in the country, even though it could also cover other medical procedures. (12) Abortion in Indonesia must be based on the guidance of a team of experts, have the consent of the woman's husband or family, and must be performed by health workers with the expertise in a "certain structure." A woman must also be referred by some sort of health care clinic, have a letter of reference from a doctor stating that pregnancy threatens her life, the result of her pregnancy test, and her husband's approval if married or the consent of her parents if unmarried, and a statement indicating willingness to use contraception after.
Although eagerly awaited since the early 1960s, this new law did not resolve the legal status of abortion services.
ABORTION PRACTICE IN INDONESIA
Induced abortion is defined as intentional termination of pregnancy prior to foetus reaching the state of viability by mechanical (surgical) means or by drugs. (13) Unsafe abortion is defined as a procedure for terminating an unintended pregnancy either by persons lacking the necessary skills, the minimal medical standards, or both. (14)
As in most countries where abortion is illegal, concrete data concerning its incidence in Indonesia is difficult to find. This situation is compounded due to the sensitivity of the issues surrounding abortion. Nevertheless, from studies using limited samples it can be concluded that abortion is widely practised.
Almost all studies in Indonesia have used hospitals for their principal data source, especially patient records. Many studies were conducted in teaching hospitals. Most hospitals do not process, analyse, and disseminate information on abortion; therefore the known frequency represents only a very small portion of the actual incidence. Further difficulty arises because the use of different diagnostic terms to distinguish between spontaneous and induced abortion is derived indirectly.
In the 1970s there were only a few studies in Indonesia on abortion. Most of the studies, both published and unpublished, describe the characteristics of abortees such as age, parity, number of living children, family planning practices, level of education and socio-economic status. Also described are the methods used for terminating pregnancies, especially induced abortion. Several studies concentrated on the events prior to admission in the clinics.
For measuring risks and for comparison purposes two types of figures are suggested by WHO, i.e., abortion rates and abortion ratios. The frequency of abortion is related to the number of women of reproductive age, while the abortion ratios are measures that relate the number of abortions to the number of births.
Since the complete report of all hospitals is not available, and cases in hospitals represent only a very small fraction of the actual incidence of abortion, no attempts were made to calculate abortion rates. In calculating abortion ratios two types of denominators are used, number of deliveries to the number of pregnancies. The number of pregnancies should be calculated by adding the number of deliveries to the number of abortions plus the number of ob-gyn cases of pregnancy during the period covered in the study.
Jatipura's study (15) conducted in 1978 was one of the first big studies which included 18 general hospitals, representing 85.7% of all hospitals, and 22 maternity hospitals, representing 17.2% of all maternity hospitals in Jakarta. The study found an upward trend from 1972 to 1975 in both the absolute number of abortion cases and number of abortion cases per 100 deliveries.
Jatipura et al. calculated the number of pregnancies by adding up all pregnancies experienced by abortees studied in the last abortion studies. Jatipura used a different technique in calculating the number of pregnancies. Their findings are 31.4 abortions per 100 pregnancies for a random sample of 517 cases admitted to Cipto Mangunkusumo Hospital and 38.1 abortion per 100 pregnancies in PIKMI Maternity Hospitals (all cases were for 1972-1975). If 15-20 pregnancies out of 100 end in spontaneous abortions, as according to WHO, then, they concluded, that about half of the abortions were induced.
There is another study (16) which attempts to measure the frequency of women who have had an abortion. A group of women attending the ob-gyn clinics in Cipto Mangunkusumo Hospital in Jakarta were randomly divided into two subgroups: treatment and control groups. The subgroups were comparable in the terms of age, parity, educational levels, religion, marital status, and family planning practices. With the treatment group a method called "Randomised Response Techniques" was administered, and the control group was interviewed in a conventional manner. Among the women in the treatment group 32.7% (n=355) indicated they had had abortions. The corresponding figure for the control group was 18.7% (n=35). (17)
Between 1972-1980 there were some studies (18) on abortion conducted outside Jakarta, but all were done at general and teaching hospitals. All were retrospective studies using patient records. Studies were conducted at two government hospitals, i.e. Hasan Sadikin and Sanglah, which are located in Bandung, West Java and Denpasar in Bali, where family planning programmes are conducted intensively. The five studies showed that among all abortion cases (spontaneous and induced/illegal,) around 13-35% induced. Up to now, Denpasar in Bali has an atmosphere more conducive for abortion practices (probably due to the influence of Hinduism), although every couple of years the media extensively covers the police invading clinics providing safe abortion services.
The famous gynaecologist in the city of Manado in North Sulawesi, Dr. Rattu, conducted also several studies on abortion. Dr. Rattu had the courage to defend the right of women who needed safe abortion services in Manado and showed that almost 18% of all abortion cases in Manado Hospital were induced abortions. Through the Indonesian Planned Parenthood Association's (IPPA) clinic in Manado, the menstrual regulation method was provided for women who needed safe abortion services. Table 1 below shows the five studies reviewed by Budi Utomo, Sujana Jatipura et al. in 1982 (see table 1).
Menstrual regulation as a contraceptive back-up service in Hasan Sadikin hospital (Bandung/West Java) was again studied by Sastrawinata and et al. in 1976. (19)
Soedigdomarto (20) was one of the first who raised the problem of women needing abortion not only on medical grounds, but also for socio-medical reasons. For example, married women who faced unwanted pregnancies since they still had work contracts with their employers, or had just recently delivered a baby, or had borne too many children and who had experienced contraceptive failure.
Looking for types of abortion, some gynaecologists (21) used different diagnostic terms. In many instances these terms are not interchangeable. The result is that it is almost impossible to make precise comparisons. Several studies classified the frequency of abortion according to stages in the abortion process: complete, incomplete, incipient, imminent, and missed abortion.
From several studies it is apparent that the majority of cases are classified as incomplete abortions, which means that part of the foetal tissue had been expelled prior to examination in the clinic. It can be safely assumed that a significant proportion of those cases are induced abortions.
Terrence Hull, Widyantoro and Sarwono (22) were among the first in the 1990s to write about their concern on the prohibition of menstrual regulation services through the enactment of law No.23/1992 on Health. All the dilatation & curettage (D&C) equipment were taken away from several clinics which provided the MR services. Menstrual regulation is a well-known method of terminating pregnancies. Menstrual regulation is often used in countries with restrictive abortion laws because it is often not viewed as an abortion. Menstrual regulation can be done without a positive pregnancy test and for reasons other than terminating a pregnancy (i.e. uterine biopsy, treatment of incomplete abortion, or to regulate menstruation). Additionally, menstrual regulation is safer, easier, less costly, less traumatic, and can be done early after conception (within 14 days up to 45 days). (23)
In Indonesia, menstrual regulation is tacitly accepted by society and many health care providers. A study which included interviews with Indonesian health care workers found that they did not consider menstrual regulation as a form of abortion, on the basis that Islam states that life begins after 120 days. (24) Acceptance and restrictions on menstrual regulation as a form of abortion vary throughout Indonesia. In areas that are more restrictive, menstrual regulation as a means of terminating a pregnancy can only be used by married women who are acceptors of family planning and have experienced contraceptive failure. In less restrictive areas, menstrual regulation is available to a wider group of recipients, including married women not using contraception, and in some cases for unmarried women (accompanied by counselling). In the least restrictive areas, menstrual regulation is widely available even to unmarried women with menstruation delayed by less than eight weeks. (25)
Right after the introduction of the Health Law No.23/1992, which raised a controversial issue (article 15) on abortion, some scholars started to conduct studies to know about the attitudes of health care providers towards abortion practices in Indonesia. (26) From this research, it was discovered that health care providers could be divided into two groups: one which felt a backlash that menstrual regulation was prohibited after the enactment of Health Law No.23/1992, while the other group was happy with the decision to stop providing abortion services.
In the 1990s, some senior gynaecologists such as Biran Affandi and S. Sarwono (1995) (27) as well as Terence Hull and Ninuk Widyantoro, (28) presented their own research on abortion and tried to estimate the incidence of abortion; but all were certain that it was well-known that hundreds of thousands of abortions took place annually and the need for safe abortion could not be eliminated, since unwanted pregnancies will always exist.
In 2000, more studies on abortion were conducted. It seemed the fall of the Soeharto regime made the atmosphere more democratic and freer. Three large and comprehensive studies on abortion were conducted during 2001-2004.
THREE RECENT AND COMPREHENSIVE STUDIES
The first study, carried out by Utomo, Habsjah, et al. (29) which employed a method combining Service Delivery Points (SDPs) and verification, found that for those women who could pay for abortion services, they could obtain them from several SDPs, (such as some government and private general hospitals, maternity hospitals, family planning clinics, some obstetrician, some general physicians, midwives and traditional birth attendants). Table 3 shows the characteristics of abortion clients, which were collected from all the SDPs, which after verification were included in the study as SDPs which perform abortions.
This study gave a national estimate of 2 million abortion cases per year in the country.
In the cities, more abortions were performed in family planning (FP) clinics, followed by general physicians' practices and then hospitals (government and private); while at the district level, maternity hospitals were the place to get abortion services. At all districts, at the provincial level as well as at the regency level, traditional birth attendants (TBAs) still performed the most abortions. When the clients were asked about their location, more than half were located within the SDP site. Almost three quarters of all the women who had abortions at the provincial level were married. At the city, at the regency level, most were also married women. It was concluded that women who went to TBAs were women with good education (had completed senior high school and/or university education). Many of them had never used contraceptives, some were unmarried, and some had used contraception.
The most commonly used form of intervention (37.5%) was electric or manual vacuum aspiration by physicians. The second most frequently used method (25%) was oral medication and massage. Another 12.5% of the women were administered some form of injectable abortifacient. 8.3% had a foreign object inserted into their uterus. 8.3 % had other preparations inserted into the vagina and 3.7% were treated with acupuncture.
Various traditional methods of abortion are practised. The most common method is to massage the stomach (abdomen) with hands repeatedly and often.
Sometimes two or three massages are necessary. This is extremely painful. The stem of a papaya leaf is rubbed with the sap of certain plants and can be inserted into the uterus, the patient is given herbal potions and is massaged. Post--abortive care consists of drinking herbal potions and antibiotics. Many patients experience complications after an abortion and come to a doctor or hospital for care and medication.
The second study, Counselling-based Safe Termination of Unwanted Pregnancies--Penghentian Kehamilan Tak Diinginkan Yang Aman Berbasis Konseling (30) was conducted in the year 2001-2002 by the Women's Health Foundation in 9 large Indonesian cities: Medan, Batam, Jakarta, Bandung, Yogyakarta, Surabaya, Denpasar, Mataram, and Manado. This study was carried out in collaboration with women's non-government organisations and the Indonesian Society of Obstetrics & Gynaecology (POGI). This study shows that a large proportion of the total number of abortions were performed in the first trimester of pregnancy, that is, within 90 days. According the Islamic view, this is still during the Mudiga Stage, when the soul has not yet begun to reside in the foetus.
Guided by its mission to contribute to the fulfillment of women's rights to adequate health care, the Women's Health Foundation (WHF) has carried out difficult tasks to protect women from the dangers of unsafe abortion. In part, this involves reviewing existing policies and laws that decriminalise information and safe procedures for women who seek early pregnancy termination (under 12 weeks) by trained medical personnel. Surprisingly, support and encouragement has emerged from vital government institutions--including the Supreme Court (Mahkamah Agung), the police force, the Attorney General (Kejaksaan Agung), and the House of Representatives. The findings of this study present a solid groundwork for the process to improve the clause on abortion in the Health Law 23/1992.
Data was collected in 9 clinics and 3 government hospitals. A total of 1446 clients gave consent to undergo the study's standard flow of services, consisting of:
2. Pre-procedure medical examination
3. Pre-procedure counselling
4. Safe abortion procedure
5. Post-procedure counselling (follow-up visit if needed) Carefully designed counselling about risk and rights was given individually to encourage clients to make a follow-up visit.
More than half of the clients (58%) were over 30 years old, with only 3% below 20 years. 87% were married; almost half had at least two children. 54% were high school graduates; 21% academy/university graduates; almost half (47%) were housewives. Among 619 clients who were working, 47% worked in the private sector, while 23% were related to the public sector (including spouses of government officials, the armed and the police forces). 21% of the clients had had an abortion before, with the maximum number of repeated abortions being four.
Reason to terminate the unwanted pregnancy
Psycho-social factors were the main reasons (57.5%) women gave for wanting to terminate their unwanted pregnancy. Around one-third of clients reported having experienced "contraceptive failure." Only 4% of clients stated a reason related to the physical health of the mother (see diagram 1).
Women's efforts before coming the clinic/hospital
As documented by many other studies on abortion, women tried to abort themselves by drinking traditional herbs, toxins, or sought the help of an untrained traditional birth attendant, before deciding to go the clinic/hospital.
Three of the 1289 clients who received safe abortion services experienced bleeding as a complication, but their bleeding was managed by the clinic staff. 80% of the clients decided to use contraceptives after the abortion, with most choosing the intra-uterine device (IUD). Most of the women reported feeling relieved and freed from a burden as a result of the procedure, although 5% of the clients mentioned they still felt guilty. Two-thirds said they do not want to be pregnant again, since they had at least 2 children.
[GRAPHIC 1 OMITTED]
85% of the clients felt satisfied with the services provided by the clinic/hospital, even though they had to travel as far as 23 km to reach the site, wait for one hour on average, and pay Rp.600.000 (US$ 66).
The attitudes of the health providers (doctors, counsellors and nurses) were rated as quite friendly. Clients reported they were satisfied with the information they received on safe abortion procedures and related reproductive health information, including contraception and sexually transmitted infections.
Compliance by the clinic staff in completing the medical records was between 29-60%. This demonstrated that many health workers were still not following the standardised medical recording system.
The study has proven, despite the short period of time (6 months) and small number of health facilities covered, there was a high demand for safe abortion services. It is very clear that in order to prevent unnecessary morbidity or death among women of reproductive age, legal protection for safe and ethical abortion services is needed. Safe and ethical procedures require the following conditions to be met: (1) gestational age less than 12 weeks of pregnancy; (2) procedure performed by trained and certified medical personnel; (3) procedure takes place at a facility that fulfils basic standards of hygiene, equipment, and comfort; (4) process includes pre-and post-procedure counselling by a trained counsellor; and (5) procedure supplied on a non-profit basis designed to meet medical costs while ensuring that fees are affordable for all clients, if necessary, through a system of cross-subsidies.
The third study Retrospective Study on Menstrual Regulation in 9 cities in Indonesia--2000-2003, (31) was conducted by Indonesian Planned Parenthood Association (IPPA). IPPA, which has 40 clinics in 40 cities spread over 25 provinces, provides menstrual regulation services. Menstrual regulation (MR) is often used in countries with restrictive abortion laws because it is not viewed as abortion (see diagram 2). During the 1980s, midwives who were specially trained in dilatation and extraction (D & X), a procedure to regulate women's menstruation could perform MR, but this was banned in the 1990s. This study from IPPA, which gathered data from nine clinics in nine cities, enumerated that 37,685 women received menstrual regulation treatment between 2000-2003.
Figure 1 shows clients served by nine IPPA clinics in nine cities. From these figures, Bali has the highest number of clients 14,965 (39.7%), followed by Yogyakarta 10,056 clients (26.7%), and Semarang 4,239 clients (11.2%). 60% of clients are from the city, while 40% are from out of cities, provinces or out of country.
[FIGURE 1 OMITTED]
Most of the clients (73%) were married women and only 27% were not married while 1 % were either widows or cohabiting. This is shown in Table 4.
Clients' activities in this study were defined as follows: employed, unemployed and still studying--44.1% unemployed, 43.4% employed and 12.5% are still studying at school or college as shown in Table 5.
Clients had many reasons for terminating their pregnancy. The main reasons of unemployed clients were due to economic constraints. Employed clients were either too busy or were still under a signed contract with an employer where it was stipulated that they could not be pregnant within a certain period of time.
In Medan, Bandung, Jakarta, Semarang, Yogya, Manado, and Surabaya the number of unmarried clients is less because those clinics have set the criteria that married women need to provide their marital certificates to obtain MR services and unmarried women need to be accompanied by their parents.
In Denpasar, the number of married and unmarried women seeking to teminate their pregnancies is almost similar. In the previous decade, most clients who asked for menstrual regulation were not married. (32)
In Mataram, the number of unmarried clients is the highest in comparison to other cities, however the number of clients in this study is only 7.7%. The data could not trace where married women seek abortion services. This could be one of the reasons why the maternal mortality rate in Mataram is very high. If safe abortion could be provided, the maternal mortality rate could be decreased.
Most clients who asked for menstrual regulation services had an education level which ranged from senior high school level to college level education (87.4%), while clients who have no education or only elementary school level education were 12.6%. According to SDKI (Indonesian Health and Demography Statistic) 20022003, women who have elementary background or have no education number 63.8% of the population and it would be interesting to follow up where most of these women seek abortion services (see table 6).
This table shows that most clients visiting clinics were accompanied by their husband (65.2%) and this could be proven by showing identity cards or Kartu Keluarga (family cards) or marital certificates. This also indicated that many husbands support women who requested menstrual regulation. Most of the clinics also had procedures where the women and those who accompanied them should sign an informed consent form.
According to Hull, (33) for most Indonesian women, the choice to terminate an unwanted pregnancy is very limited compared to the choices available for the elite and rich women. The only alternative to an unwanted birth was unsafe abortion at the hands of a traditional birth attendant, who used techniques and substances that could cause bleeding and infection.
What is worse, according to him, the bureaucracy used the budget or regulatory tools at its disposal to further inhibit women's access. For example, during the economic crisis during 1997-1999, many women faced unwanted pregnancies since many were delayed in getting their contraceptive injections or IUDs (both which were provided free of charge) and women preferred to use the money for paying their children's school fees and other basic items.
The situation worsened in 2002 when the National Family Planning Coordinating Board (BKKBN) transferred their authority from their own district office to the district government (Pemda) in order to implement decentralisation, which was stipulated by a new decentralisation law in 2000. Continuous contraceptive supplies became a huge problem. Consequently, it is assumed that there was an upward trend in unwanted pregnancy at that time.
Indonesia has committed itself at the international level towards protecting women's sexual and reproductive rights at ICPD and Beijing. However, under the penal code, abortion is a criminal offence. Although the issue of abortion over the years has divided societies, it is interesting and empowering to note the relevant international documents which enshrine women's reproductive rights and advocate access to safe abortion. The Programme of Action adopted at ICPD in 1994 states:
"Governments should make it easier for couples and individuals to take responsibility for their own reproductive health by removing unnecessary legal, medical, clinical, and regulatory barriers to information and access to family planning services and methods."
"Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law."
"Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents ... the promotion of the responsible exercise of these rights for all people should be the fundamental basis for government and community-supported policies and programmes in the area of reproductive health, including family planning."
"In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organisations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion (34) as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services.
Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should already have access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from the abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions."
Amongst the key actions recommended for the further implementation of the Programme of Action of ICPD in 1994 are:
(i) "In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organisations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the resource to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances in which abortion is not against the law, such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from abortion. Post abortion counselling, education and family planning services should be ofered promptly which will also help to avoid repeat abortions.
(ii) Governments should take appropriate steps to help women avoid abortion, which in no case should be promoted as a method of family planning, and in all cases provide for the humane treatment and counselling of women who have had recourse to abortion.
(iii) In recognising and implementing the above, and in circumstances where abortion is not against the law, health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women's health."
The Beijing Declaration from the Fourth World Conference on Women in 1995 states that:
"The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationship between women and men in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behaviour and its consequences."
"Governments, in collaboration with non-governmental organisations and employers ' and workers ' organisations and with support of international institutions (should): a. Recognise and deal with the health impact of unsafe abortion as a major public health concern, as agreed in paragraph 8.25 of the Programme of Action of the International Conference on Population and Development;
b. In the light of paragraph 8.25 of the Programme of Action of the International Conference on Population and Development ... consider reviewing laws containing punitive measures against women who have undergone illegal abortions."
The 'Further Actions and Initiative to Implement the Beijing Declaration and the Platform for Action in 2000' document suggests that:
a. "In light of Paragraph 8.25 of the Programme of Action of the International Conference on Population and Development, (government should) consider reviewing laws containing punitive measures against women who have undergone illegal abortions. "
b. "Design and implement programmes with the full involvement of adolescents, as appropriate, to provide them with education, information and appropriate, specific, user-friendly and accessible services, without discrimination, to address effectively their reproductive and sexual health needs, taking into account their right to privacy, confidentiality, respect and informed consent and the responsibilities, rights and duties of parents and legal guardians to provide in a manner consistent with the evolving capacities of the child appropriate direction and guidance in the exercise by the child of the rights recognized in the Convention on the Rights of the Child and in conformity with CEDAW and ensuring that in all actions concerning children, the best interests of the child are a primary consideration ..."
Indonesia has signed the the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) (with reservations) and the General Recommendation No. 24, Article 12 on Women and Health (1999) states that:
a. Measures to eliminate discrimination against women are considered to be inappropriate if a health care system lacks services to prevent, detect and treat illness specific to women. It is discriminatory for a State party to refuse to legally provide for the performance of certain reproductive health services for women. For instance, if health service providers refuse to perform such services based on conscientious objection, measures should be introduced to ensure that women are referred to alternative health providers.
b. State parties should not restrict women's access to health services or to the clinics that provide those services on the ground that women do not have the authorisation of husbands, partners, parents or health authorities, because they are unmarried or because they are women. Other barriers to women's access to appropriate health care include laws that criminalise medical procedures only needed by women and that punish women who undergo those procedures.
And that nations should also, in particular:
Prioritise the prevention of unwanted pregnancy through family planning and sex education and reduce maternal mortality rates through safe motherhood services and prenatal assistance. When possible, legislation criminalising abortion could be amended to remove punitive provisions on women who undergo abortion."
CULTURAL AND RELIGIOUS VIEWS ON ABORTION
In the last three years, several initiatives were taken by Islamic scholars to interpret abortion according to Islamic laws. Additionally, studies on abortion services performed in religious hospitals were conducted. Whether abortion is forbidden or allowed has long been a topic of debate among experts in Islamic Law, both classical and contemporary. Some experts in Islamic Law agree that the embryo does not yet have a soul, but it has life in it (called "hayati") and is growing and is being prepared to become a new creature with a soul (called "insani")--a human being. There are a number of Islamic principles that influence views on abortion. (35) Firstly, the principle that any action which endangers life is forbidden by Islam. Secondly, the principle that in certain situations, acts that are normally forbidden by religion can take place, out of necessity. If a woman's life is endangered by pregnancy, abortion is allowed based on the premise that it is a greater disadvantage to have a woman die rather than a foetus. Islamic experts generally agree that women must be given priority in this case because, firstly, they are alive and, secondly, her death would be a loss for her husband and any existing children. The death of the foetus is not likely to cause that great a suffering. There is disagreement among ulamas as to when a foetus is considered to become a human being. However, many agree that a foetus is considered to be a human being only after 120 days after conception. Therefore, abortion after 120 days is only permitted to save a woman's life. Some ulamas agree that abortion may be allowed before 120 days for reasons other than to save a woman's life: for example, for economic reasons. Other schools of Islam permit abortion only before 40 days and some do not allow abortion at all.
In Indonesia, social, cultural, political, and religious perspectives on abortion are highly interrelated. The Shafi'i school of Islamic Law predominates in Indonesia and this school rejects the view that abortion is acceptable before 120 or even 40 days after conception and considers abortion at any point a sin. (36) The Shafi'i, represented by Ghazali, also considers abortion a crime; the seriousness of the crime depending on when the abortion is performed. If performed early in the pregnancy, the sin is not so serious, but if performed toward full term, the sin is more serious. Although the Shafi'i view predominates, there is still variation in views among religious groups in Indonesia. For example, within the Nahdlatul Ulama, which is the largest Muslim organisation in Indonesia, abortion is accepted for a "just cause" such as to save a woman's life. The Hanafi school, the oldest school of Islamic thought, represented by Ibnu Abidin considers abortion as being forbidden. However, this prohibition applies when there is no legal basis for the abortion. If there is a legal basis, such as the fact that the mother is still breastfeeding and is less than 120 days pregnant, abortion is allowable, because the mother's breast milk may not be adequate. According to the Hambali school of thought, anyone committing abortion must pay a fine (gurrah). (37) The imposition of a fine is based on the law (sunnah) of Muhammad, who himself paid a fine in the case of a female embryo from the Haudzail family. A few ulama from the Maliki school also accept abortion before 40 days and some ulama agree that it is acceptable before 120 days. (38) Te Maliki school of Islamic thought forbids abortion on any grounds, even when the pregnancy has reached only 40 days. In fact, some adherents of this school are of the opinion that abortion is forbidden from the time of conception. Abortion law in Indonesia remains restrictive because the government is strongly influenced by the predominant Islamic view on abortion. Yet, it is important to note that in the 1950s Islamic organisations in Indonesia were opposed to family planning services, as they seemed to be interfering with the purpose of marriage. However, once government views and policies began to shift, many Islamic organisations began to accept family planning on various grounds. (39)
FINDINGS FROM THE PRIMARY RESEARCH
It is really difficult to be a woman in Indonesia. Even women over the age of 35 who are unmarried still have no control over their bodies. They still need to be accompanied by a close family member should they wish to terminate their pregnancy to sign the consent form. Even a divorcee needs to be accompanied by her father to have an abortion.
Young, unmarried women often have poor access to family planning information and services. They also have often fewer social contacts and lesser financial means to obtain safe abortion services. In this context, young women and poor women are also more likely to delay pregnancy termination until later stages when the risk of complications is higher.
Te Women's Health Forum established in 1990, consisting of more than ten women NGOs, is still actively monitoring policies and the implementation of programmes on women's health. The Women's Health Forum drafts bills with parliament members and campaigns publicly. This study draws on the strength and experiences of these NGOs and aims to further the gains already made in the field. It was carried out by a team involving 8 non-governmental organisations (NGOs) all of which are members of the Women's Health Forum. These are: Yayasan Melati, Yayasan Pelita Ilmu, Yayasan Kesehatan Perempuan, Yayasan Rahima, Mitra Perempuan, IPPA (IPPF Jakarta), Indonesian Midwives Association, and Women Police. Five of these NGOs are very active at the grassroots level and three of them work in the slum areas of Jakarta. In the short term, the aim was to:
1) consolidate the 8 NGOs;
2) form a research team, with members from the 8 NGOs;
3) design a study framework and a research plan;
4) train the interviewers;
5) conduct interviews, observations in 2 hospitals and 2 clinics (one state owned clinic and one private clinic both of which provided safe abortion services); and
6) conduct focus group discussions.
The research team picked greater Jakarta as the research site. Greater Jakarta meant the inclusion of the outskirts of Jakarta city, which is semi-urban. The residents here are still indigenous natives and have lived there for at least three generations. Jakarta, as the capital city of Indonesia, is the heart of all financial, commercial and industrial activities, and attracts workers from all over the country. These workers settled mainly in the slums located in Central Jakarta, North Jakarta and East Jakarta. In order to gather information from the various levels of the state-owned and private institutions, the following methods were used.
Level One: State level programmes executives such as senior officials of the Ministry of Health, District Health Office and Senior Officials from the National Family Planning Coordinating Board (NFPCB).
Level Two: A senior Gynaecologist, who lectures at the faculty of medicine (about the curriculum of training in abortion procedures) and gynaecologists who worked at state owned hospitals and clinics.
Level Three: Physicians who worked at Emergency Units at state-owned hospitals and private clinics.
Level Four: Senior midwives who worked at the public health centres and midwives who worked in private clinics or their own private practice.
Level Five: Physicians who performed safe abortion services were interviewed about their training and on abortion procedures they followed. All the health providers and professionals were asked about their perceptions and attitudes regarding the necessary policies to provide safe abortion services.
Level Six: The director of a foundation specialising in training midwives.
Level Seven: In-depth interviews with 50 women who had undergone unsafe practices and the ensuing complications from the unsafe practices.
At level seven, the interviews were done to understand and unravel exactly why women resort to unsafe abortion. Fifty women were interviewed. An in-depth interview guide was designed and all members o f the research team tried to find some women who had experienced at least one safe abortion in the last seven years. Two of the research team members managed to find many women who had undergone unsafe abortions since they worked in slum areas. It is usually the poor women who resort to unsafe abortion practices as the cost of safe abortion services is prohibitive. Ironically, if the effort to terminate the pregnancy is unsuccessful they would be forced to go to a hospital. If it was too late the woman would lose her life, and if she was saved, the medical costs would be high. The research team managed to find two instances where women lost their lives after an unsafe abortion. The sisterhood method (40) was used to gain a better understanding of the experiences of these women.
CHARACTERISTICS OF THE INFORMANTS
Of the 50 women, two were a close friend and a relative who witnessed the death of a woman after unsafe abortion services from two different traditional female masseurs. Below are the characteristics of these 50 women:
1). Age at the time of unsafe abortion
Only three informants were below 20 years of age when they had an unsafe abortion; 10 were between 20-24 years old; 12 were between 25-29 years old; 12 were between 30-34 years old; 10 were between 35-39 and three were between 40-45 years old.
2). Age during Interview
Since two of the women interviewed were not the person who underwent the abortion, only 48 women were asked for their age. During the interview, one woman was 23 years old; 15 women were between 25-29 years old; 12 women were between 30-34; 12 women were between 3539 years old and eight women were between 40-45 years old.
3). Marital status
47 women were married when they had unsafe abortions. Tree women were unmarried. Of these three, two died after the abortions while the third survived and married the man, who made her pregnant, a year later. The third had her unsafe abortion by a traditional masseur in Bandung, she was still in the second year of university and was 20 years old at that time. The other two women were 16 and 11 years old when they died.
Half of the women who had unsafe abortions graduated from elementary schools (25 women); eight women had a junior high school diploma; while 15 women were enrolled in senior high school and two women had a university education.
23 women were housewives, 10 women were small entrepreneurs and three were commercial sex workers. 10 women worked as factory workers and five women worked as office employees of which three of the office workers were civil servants. Most of their partners or spouses worked in private companies or factories. In short, half the women in this study belonged to the lower-middle class and earned less than Rupiah (Rp) 800 000 a month; 20 women had a household income between Rp 800 000-Rp 1 500 000; and only five women had a household income above Rp 1 500 000.
6). History of Pregnancy and Contraceptive
30 women had one or two children; 10 women had three children; 5 women had four children; and 5 women had none. The number of live births is usually 1 to 2 children (30 women). Two women had a history of previous abortions, while the others had never had an abortion. Only 16 women can be considered as having a contraceptive failure with pills or injections and one had an IUD-failure. Of these 16, 10 were on contraceptive pills, five used an IUD and 10 used injections. The rest of the women were not using any contraceptive method.
In-depth interviews were also conducted to gauge the attitude of health care providers and health professionals toward abortion services, their experience in performing abortions and the institutions where they worked (i.e. midwives, doctors and gynaecologists). Some focus group discussions (FGDs) were also held involving senior Puskesmas midwives and gynaecologists. Both of these aimed to understand health care providers' concern for women's needs for abortion services; actions for helping women who underwent unsafe abortions; recommendations for women facing unwanted pregnancies; and thoughts on how decentralisation, privatisation and globalisation provide opportunities to use new technologies and new drugs to terminate pregnancies.
Although we tried to find more unmarried women (aged 15-49 years) or adolescents who experienced unsafe abortions, it was very difficult to find respondents. It was only because two researchers had a close rapport with the people in two of the slum areas, did these respondents open up and talk about this very traumatic and sensitive aspect of their lives. During the monitoring activities, the researcher had most difficulties in interviewing officials from the Ministry of Health (MOH). Some were arrogant and some refused to be interviewed. When one researcher interviewed a foreign World Bank consultant at his office in the MOH building, some MOH officials were deeply mistrustful and suspicious.
The entire data consisted of interview notes and tapes of more than eighty-five interviews. Detailed transcripts of the tapes were made. The data was then organised according to the above levels and analysed according to issues.
In carrying out the research activities the members encountered many women who faced unwanted pregnancies. These women openly talked about methods to terminate their unwanted pregnancies. Usually their closest neighbours would tell the women to try different herbs sold by vendors, street pharmacists or female herbalists (ibu jamu gendong) who hawk their self-made herbal drinks door-to-door.
After waiting for a few weeks to see the results of taking the pills and herbal drinks, the women realised these were ineffective. They panicked and looked for abortion services. However, they soon discovered that the services are inaccessible because they are illegal and the few service providers are costly. Most of these low-income women ran for help to female masseurs (tukang urut) and traditional birth attendants (dukun beranak). Not all women successfully terminated their pregnancies. After three days of extremely painful massage, some of them bled heavily and had high fever and had to be hospitalised. At the end, these women had to pay more money for the hospital bill to cover both the curettage and two days of hospitalisation. They were lucky. Two women died tragically after being treated by traditional masseurs. Another woman who underwent unsafe abortion practices by a traditional birth attendant had an infection. Three commercial sex workers in East Jakarta were amongst those who were interviewed about unsafe abortion practices. Some women have even been prosecuted and imprisoned for abortions. A policewoman amongst the researchers was able to visit a woman imprisoned and studied her prosecution file. The prisoner worked daily in a factory and had an unemployed husband and a retarded daughter and had limited options to defend herself in court.
WHO PERFORMED UNSAFE ABORTION SERVICES AND WHAT METHODS WERE USED?
The research findings were:
* Almost all women interviewed tried to expel the foetus by drinking mixed herbal concoctions.
* Many women resorted to traditional birth attendants who used massage as a method, which lasted three days with intervals in between. Some women could not bear the pain during the massage. Some TBAs inserted a leaf or other dangerous objects into the womb.
* Traditional healers tried first with mixed herbal concoctions, but at the same time they often performed massages too.
* Spiritual men, who claimed to have supernatural powers, used these 'powers' to induce an abortion.
* There were some midwives and some GPs who had the courage to provide abortion services by giving the women several medicines or drugs and sometimes combined medicines or drugs with several injections.
* Some acupuncturists provide also abortion services, but this is dangerous since excessive bleeding is the result.
WHAT WAS THE CONDITION OF WOMEN WHO HAD UNDERGONE UNSAFE ABORTIONS? WHAT CARE DID THEY RECEIVE?
From the observation and interviews in the emergency unit of three hospitals it was revealed that:
* Many women were brought to the emergency unit were in a state of incomplete abortion.
* Most of them were victims of unsafe abortion practices.
* Some were in critical condition.
* Most of the staff of the emergency unit still needed to improve their clinical skills since many of them could not perform the first examination of an incomplete abortion. Fortunately, some emergency unit staff, in one of the observed hospitals, were aware of the critical situation of a woman who was suffering excessive bleeding and would send her straight to the maternity ward or operation room.
* The post abortion care was provided by the maternity ward of those hospitals, but the midwives who were in charge told us that they had never received a refresher course in providing quality care.
REASONS FOR UNDERGOING MENSTRUAL REGULATION (MR)
Unmarried young women have abortions for reasons of social shame, unmarried status, fear of parents, continuing study and parental disapproval towards their current partners.
One informant, who was not married to her partner at that moment, stated the following (AP, married, one child):
"I was one month pregnant and I was so confused because my belly started to show. My boyfriend was nervous and scared, and so was I. I was afraid of my parents and embarrassed in front of my friends and other people."
The reasons for married women having an abortion are different: conceived too soon after the birth of a child, had enough children, advanced age of mother, economic reasons and marital problems. Among the economic reasons: income was too small and inadequate to raise children. The woman may like to have the child but is pressured by her husband, as stated by an informant (KR, Married, one child): "My husband is selfish, he demands me to provide his sexual needs but I may not get pregnant, how I can do that? Then he forced me to have abortion. He really doesn't want me to be pregnant; he doesn't want another child, although we've only had one child so far. I personally would like to be pregnant and have another baby. But my husband is really out of line, he only thinks about money all the time because he's an economics major. He only thinks about where to get the money for another child."
Another economic reason is not having enough money for safe abortion services in a clinic and not enough money to use contraception, as stated by a mother (ET, married, three children):
"I went to a midwife for a urine check-up and she said I was positive, two months pregnant. I was using contraceptive injection and I was supposed to get a shot on the 5th of the month but on that day my close neighbour was having celebration. I only had Rp 8000, and I used Rp 5000 of it for my neighbour. I'd feel bad if I didn't because it's my close neighbuor. After that I have no money for the shot, so I didn't get it. Consequently, I got pregnant."
Marital problems such as alcoholism, unemployment, adultery, abuse and husbands who live far away also contribute to the reasons for having an abortion.
IN SEARCH FOR UNSAFE ABORTION SERVICES
Almost all informants said they tried to terminate their pregnancy on their own before they requested help from other people by drinking 'jamu' and certain concoctions, mixed medicine, Chinese pills and fruits, as stated by an informant (DN, married, three children)
"Unripe green pineapple is grated and mixed with yeast and pepper. After that, soak some ashes with water and drink the water."
PROCEDURES OF UNSAFE ABORTION PRACTICES
Procedures of unsafe abortion include the following: drinking certain concoctions, massaging on the belly, hand/finger-scraping inside of the vagina, and putting pressure on the abdomen. One informant who survived explains the detailed process (Ap, married, 1 child):
"First, my belly was massaged, from slow to really hard and painful massage. Then my legs were bent and the witch doctor inserted her fingers into my vagina and scraped the inside all over. When she took her hand out, I felt something coming out from my vagina and I felt so weak. An hour later I was given a concoction and when my stomach felt nauseous, I was given a massage again. It made me scream because I couldn't bear the severe pain. I kept biting on the towel and crying. After 10 minutes, the witch doctor stopped her activity and again I felt something coming out of my vagina. She said it was my baby."
An informant also told a story about her best friend who was unmarried and now dead because of an abortion that she underwent:
"After drinking the concoction from a witchdoctor, she felt a terrible headache. It was so terrible that she knocked her head on the wall repeatedly because she couldn't stand the pain. Then her condition got worse, she was having a fever, a high temperature, and after she was given a massage on her abdomen, blood started to come out and it kept coming out more and more and looked like mashed pieces. She was in pain and getting weaker, then she finally died."
Another woman said that a 'keris'--dagger--was inserted into her uterus and then it was turned around several times. The traditional birth attendants said that the 'keris'--dagger--acted as a purge.
Their feelings after the abortion are mixed: sad, worried, relieved, happy and guilty. Some felt that they had learnt their lesson, as stated by KR, (married, one child):
"My religion (Christianity) forbids it and says that it is a great sin. Even if the foetus is only one hour of age, it already possesses life. So it is clear that abortion is murder, and murder is a violation of God's command. But in a desperate situation like mine, a sin is a sin, what can I do, I don't have any other solutions."
SUGGESTIONS FROM WOMEN
The women interviewed gave suggestions to Indonesian women so that they do not have to experience unsafe abortions: do not have free-sex or sex outside marriage, use contraceptive methods and look after themselves to prevent getting pregnant.
"I hope that teenage girls do not get involved in free sex because it will only hamper their future. I do not want them to experience what happened to me." (AP, married, one child)
"In my opinion, abortion is not good for women, because from the physical aspect, the women might be weak, and from the moral aspect, it is really degrading. What is the benefit of abortion anyway? It hurts you physically and people will think badly of you. Therefore, we should look after ourselves and not face unwanted pregnancies by using contraception." (DN, married, three children)
The government must provide safe abortion services, free contraception, and education and counselling on sex and reproductive health to teenagers.
"The government is supposed to provide abortion services in public health centres for people who already have a lot of children or those who experience contraceptive failure". (Dn, married, 3 children).
THE MOST APPROPRIATE AGENT TO PROVIDE REPRODUCTIVE HEALTH SERVICE FOR WOMEN
Almost all informants said doctors, either general practitioners or specialists, were the most suitable to provide reproductive health services to women. Several doctors interviewed said that midwives' role to perform abortions should be limited because they tend to be reckless and make mistakes. Aside from doctors and midwives, hospitals or clinics, either state or private, with a resident psychologist, charging reasonably, are the most appropriate to provide reproductive health services.
THE ATTITUDE OF FEMALE RELIGIOUS SCHOLARS ON ABORTION
In the last two years some women NGOs have opened up the debate on legalising abortion in Indonesia. Heated debates have centred on when abortions are provided. A group of Muslim scholars gave a time limit of within 40 days, but only with the approval of a panel which should consist of a Muslim ulama, a psychologist and two doctors. A female ulama agreed that the definition of health is not only limited to being free from diseases, but also from psychological tension. Hence it is a woman's right to be released from psychological tension if she had an unwanted pregnancy. She was against abortions performed later in pregnancy. This lady gave her permission to make available the emergency contraception pills, the first medical abortion drug, called Postinor-2, in Indonesia.
THE ATTITUDE OF HEALTHCARE PROVIDERS TOWARD ABORTION
The gynaecologists seem to be still debating. One gynaecologist was of the opinion that abortion services should be provided even in late pregnancy, but before the point of viability, that is, when the foetus can survive outside of the woman's body. According to him, abortion should be banned after viability, except to protect a woman's life and health. The professional association of gynaecologists has not really put its weight behind helping the movement to legalise abortion. Only some individual gynaecologists support the right to abortion and have joined hands with women's NGOs to advocate access to safe abortion services through the passing of constitutional amendments of Health Law No. 23/1992.
Generally, it is easier to gain access to menstrual regulation but the second trimester procedure which is Dilatation and Evacuation (D &E) is often seen as a partial-birth abortion, and still remains a taboo.
However, abortion providers are still extremely afraid to do their work since all abortion is considered criminal. Even their assistants such as doctors, nurses, and midwives felt insecure in their job. They did not know where to seek protection. The privacy of patients and staff members of a reproductive health clinic should be protected, but by whom? Persons seeking to obtain or provide reproductive health services should be protected by law, but there is no law that protects them.
In this study, 12 gynaecologists were interviewed, two female and 10 male. Among the two female gynaecologists, one was very upset when asked about the right of a woman to decide whether she needs abortion services. As a Muslim woman, she is obliged to accept her fate if she got pregnant. It is God's will and she should surrender to it. She was also the female gynaecologist who was very upset and against the introduction of the Post Abortion Care (APK) Programmes in the hospital she worked in. According to her, the APK Programmes could be misused by her colleagues to provide abortion services. She asked "Who will control a gynaecologist who provides abortion services, as all the gynaecologists state in their medical reports that they helped women who were in an incomplete abortion condition?"
The other female gynaecologist, also a Muslim and who worked for a government hospital, was of the opinion that Islam divided the development of a pregnancy into three phases. If it is still in the Mudiga Stage, abortion should be allowed since Mudiga should be considered as blood and seen as a house to be, but did not yet possess a soul. In this period of time, a woman has a right to decide, whether or not to continue her pregnancy. In this situation one has to help a woman by providing safe abortion services. It is her right to decide, as it is also her right to get safe abortion services. The State should protect women from unsafe abortion practices as these have disastrous consequences. "We, as providers, should help women in need of safe abortion services," she said.
Moreover, if every woman knew where she could obtain safe abortion services which are not commercial and were not afraid to be imprisoned, she could decide to have an abortion during the early stages of pregnancy. The illegality of abortion services made women delay their decision to abort earlier. "The implications of refusing to meet the need to terminate a pregnancy are enormous, because the pregnancy then moves into a more advanced stage and any attempted abortion is riskier for the woman. Not only death, but many faced the possibility of having their reproductive organs damaged, perforating the uterus, blocking fallopian tubes, etc." This was the reason why she is one of the gynaecologists who feels that the State should legalise abortion services.
Amongst the male gynaecologists, only one is against the legalisation of abortion services. As a devoted Muslim, he should not be involved in providing abortion services and should also not refer a female patient to an address which provides abortion services. Referring her to someone else is equivalent to providing her with an abortion. Another male gynaecologist was of the opinion that not all abortion cases should immediately be granted. According to him, every woman who would like to have an abortion should first petition a council, consisting of a religious leader, a psychologist and two doctors, and get their approval. When asked about the feasibility of finding a psychologist and two doctors in a rural area, he laughingly said: "In the rural area woman could not get any abortion services and so they just accept their pregnancy."
Many midwives also advised the woman to accept the pregnancy. Some of them gave the address of the government hospital in Jakarta which provided abortion services; but many said that they did not since it would be a sin if they helped the woman gain access to abortion services. According to them, many women came to their practice in an advanced stage of pregnancy and were very surprised to hear they were pregnant. This despite the fact that some had already experienced pregnancy before and already had one or two children. One of the midwives thought that these women were lying about not knowing that they were pregnant and actually wanted to ask the midwife to help them get an abortion. This was also probably because they cried very loudly to be helped for an abortion. If unmarried women asked for abortion services, many midwives would advise the unmarried woman to marry the father of the baby. This is often successful. When we confronted the midwives with the data from an earlier study (44) which stated that some midwives gave cytotec and gynecocyd to help women abort, all of them denied providing such services. All of them were disagreeable to the idea of a midwife performing an abortion. Two midwives who worked at a government hospital in the maternity ward told us that if a woman came in with an incomplete abortion they were only authorised to observe the woman and directly called the gynaecologist to help the woman with the necessary operation or curettage.
TRAINING ON MENSTRUAL REGULATION (MR)
The doctors were asked: "Have you received training in MR?" All obstetric-gynaecologists claimed to have received training, but this was not the case with general practitioners. A doctor in the UGD (emergency unit) never assists with an abortion. Instead he will refer the patient to midwifery polyclinic or to the maternity ward whenever he encounters an unsafe abortion. A general practitioner who is on duty in the emergency unit of a government hospital (ES, general practitioner) said:
"Patients who attempt to have an abortion on their own are present in this hospital but these are relatively not many. It is about 4 or 5 women a month. Usually they claim to suffer excessive bleeding because they slipped and fell; they would not admit to having tried to abort or asked someone else's help to abort. But we would know. There is no special training on MR in emergency unit because there is always one specialist in the maternity ward. So, if there is a case of incomplete abortion, I would refer the patient to that specialist. We are here to handle the emergency part: for example when they came in with bleeding. We could check their haemoglobin count, we would give them intravenous fluid if necessary, and then if curettage is needed, we'd refer them to the specialist."
Almost all physicians interviewed had at least handled one incomplete abortion case in their life:
"A 30-year-old women came to the biggest state owned hospital in Jakarta (RSCM) with an unwanted pregnancy. She was undergoing a divorce process with her husband and intended to have the pregnancy terminated. When being checked, we found that foul smell was coming from her vagina. It turned out that there was an infection because prior to coming to RSCM, she has attempted unsafe abortion by drinking medicines and inserting some kind of plant root into her vagina to cause bleeding. After the bleeding occurred, she went to a midwife. The midwife tried to expel the foetus but she failed and it resulted in an incomplete abortion where some of the foetus was still left in the uterus. She was about 2-3 months pregnant. The incomplete abortion caused an infection of the uterus and she was in a critical condition with breathing difficulty, her blood pressure dropped, and she was unconscious and the uterus had to be removed because it was badly damaged and could cause her death". (AR, a candidate of obstetrics and gynaecology).
"I experienced unsafe abortion among the cases when I worked in Garut. I had just finished my education in medicine. This patient previously went to a traditional birth attendant, to terminate her unwanted pregnancy. But it was unsuccessful so she came to the public health centre where I worked. The public health centre did not have adequate medical equipment so I referred her to the nearest hospital. She was still very young, about high school age, 16-17 years old. There were later also other unwanted pregnancies, but this is the only one who came to me after an abortion by a traditional birth attendant. I have not found such cases in my current work in the city of Jakarta (AT, general practitioner).
"A friend of mine, a doctor, had a patient who had previously undergone an unsafe abortion by massage on her abdomen until her foetus came out in the form of clots. She was 4 months pregnant and the procedure was inaccurate, the equipment used was not sterile because it was cleaned only with hot water. She suffered from continuous bleeding. When she finally came to the clinic, it was too late. After receiving care for some hours, she died. The event created trauma for my friend because before the patient died, she described the procedures of the unsafe abortion, where she witnessed everything because she wasn't given anaesthesia and she could feel the pain. My friend then refused to get married because she thought that marriage lead to sex and result in pregnancy. She finally decided not to get married." (ME, a candidate of ob-gyn).
Unsafe abortion causes not only traumatic to victims but also has an impact on the health care providers who handle them afterwards. Complications suffered by patients who undergo unsafe abortion are, for example, infection and bleeding, as stated by a doctor:
"The most common complication is bleeding, then infection. Patients who came here were usually weak, pale, and suffer from bleeding. "(AL, general practitioner).
Doctors have also given counselling to patients who request to have their pregnancy aborted, but the counselling is given with the purpose of persuading the patients to continue their pregnancy. Doctors regarded this counselling as a waste of time because it takes up to at least 30 minutes to counsel one patient.
"Yes, I give counselling. But it costs me a lot of time if a patient requests for counselling, it will take at least 30 minutes. A check-up will probably take 10-15 minutes only per patient. Counselling can sometimes even take more than half hour. But I will feel satisfied if I can motivate her to continue with her pregnancy and very often it was successful. Not all of course, maybe around 80% were successful. Counselling is not only about motivating, but also includes giving solutions. Motivation is not just with the patient, but also with her family who usually makes it more difficult. The environment makes the problem more difficult, not her. Problems are usually from married women. Maybe because she was made pregnant not by her husband or because of contraceptive failure. These cases are more difficult to motivate. "(GP, obstetric-gynaecologist).
"Of course. We must conduct abortion only with the family's approval. A family's signature must be obtained. We will not do it if it's not approved and now a specialist is required to do it. So if there is no family approval then we will not do it. If the family is not there yet, then we will wait until the family arrives." (ES, general practitioner).
A doctor stated that information given during counselling is usually about the process of abortion and the complications that may be encountered and also to help the patient make a decision.
"During counselling, we give information regarding the procedures in the abortions, the risks, information about birth control, and the explanation that this must be her first and last abortion. The most important thing is to help the patient make a decision, or to motivate her to continue her pregnancy, if possible. Ideally, the counsellor should be her own doctor because naturally the patient would not want to have to talk with many people about her pregnancy since it is a confidential matter." (AR, a candidate of ob gyn).
Counselling on abortion should be a must. A general practitioner stated the need for counselling:
"Using a psychologist might be expensive so I thought a paramedic who was trained in counselling is sufficient. So far during the early counselling period, the paramedic will interview the patient and give all the necessary information so that the client right to obtaining information has been fulfilled. If she understands but still requests for an abortion then she will just have to sign the form. If she changes her mind then she can go home. So the early part ofthe counselling is conducted by paramedic and reinforced again by the doctor or the provider before the intervention is conducted. She will be asked again whether she is sure and has no more doubts. If yes, then the client and doctor both put their signature as a form of responsibility. " (AS, general practitioner).
When asked whether their institutions have Post Abortion Care Programmes (Asuhan Pasca Keguguran = APK) and is experienced in conducting it and handling the obstacles and weakness, doctors seemed to think that the APK is intended to decrease the number of maternal deaths. Specialists usually have obtained APK courses but not general practitioners.
"Yes, there is. APK is intended to decrease the maternal mortality rate and the level of pain that the patients suffer by using standardised equipments and methods that can be performed safely anywhere. Patients do not need to be hospitalised; the cost is low, no anaesthesia, no other medicine is required and more preventive against infection. APK will prevent complications such as bleeding and infection. The equipment is quite simple, cheap and only Rp 500,000 compared to other more expensive equipment. Yes, there should be training. Those who have not received it take it for granted. They excuse themselves saying that 'if it's only like that, we can do it', while in fact, there are several things that they do not understand such as the benefits and methods based on the checklist. There are stages starting from equipment preparation, then sterilisation methods and techniques to prevent infection. All must be performed competently like a pilot. There will be no change in the order of igniting the plane, to land, or to take-off. There are sequences that should not be missed. Same with APK, there are sequences that should not be missed; those who have not received training use their own method. " (GP, obstetric-gynaecologist).
Some obstacles when providing MR services are encountered, for example, in the form of complication, bleeding and infection. Others include coercion from patients' own family or boyfriend to have an abortion.
"If she comes to have abortion on her own wish, she will feel relieved afterwards. The problem is when she still feels doubtful but there are other external factors, such as being told to do it by the family, husband, or boyfriend, afterwards she will feel regretful. This is exactly what has to be dealt with. Therefore, the counselling prior to MR must be really solid until the woman herself makes the decision. So MR is the second most important thing because it may endanger the woman's life. Nowadays, with modern technology, the procedure is simple, it is actually the psychological aspect that has become the main concern." (SAR, obstetric-gynaecologist).
Another obstacle is the presence of pros and cons about abortion and unsupportive laws. Abortion has not been legalised for reasons other than medical; therefore there is no protection for any medical provider who wishes to perform it.
"Actually, abortion without medical reasons is not allowed. But here is the dilemma. If we do not help the patient then she will go and look for services somewhere else, which have more dangerous side effects since it is unsafe. It will result in a high maternal mortality rates. The obstacle is that the practice has not been legalised, although in reality, there have been many who peform it. " (AT, general practitioner).
Besides that, the general obstacle for women themselves is a lack of reproductive health awareness and education, so much so that women do not understand the functioning of their own body, as stated by a general practitioner:
"The obstacle that we encounter for women's health is that their education of anatomy and their understanding of women's reproductive function is zero. There used to be sex education, the term sounds scary, so maybe the use of the words reproductive health education will be more acceptable. If we direct it more towards introduction of women's organs to teenagers so that they will know their own body better, they will know their body functions and be able to look after themselves better. The majority of girls who become victims were the victims of rape and men's flattery or malice. If they understand simple things like their breasts are not supposed to be touched by other people then they will be careful with them." (AS, general practitioner).
IMPLICATIONS FOR WOMEN
Since abortion is criminalised:
* Women did not have the courage to sue for malpractice for being provided unsafe abortion services.
* Family members could not take legal action against the provider of unsafe abortion services. if the women in their family died
* Economic and emotional exploitation by brokers and commercial doctors, of women who desperately need an abortion service.
* Unwanted children were born and since many women tried first to abort by drinking some poisonous herbs some children were born with bodily defects.
* Women suffered excessive bleeding and in the end had to go to the hospital to obtain post-abortion services.
* Many women were put in jail and their children suffered the loss of their mother and had no financial support at all since most of the mothers were the breadwinners.
* The gynaecologists who actually were authorised to perform abortions were reluctant to do it.
* Many medical schools were reluctant to teach abortion techniques.
COMMON REGULATORY AND ADMINISTRATIVE BARRIERS TO OBTAINING SAFE ABORTION
Many barriers exist for women who need to seek abortion services. These barriers can be broadly categorised into two categories--information and access barriers and service delivery barriers. Amongst the information and access barriers are:
* Women and health professionals do not know when abortion is permitted by law or where to obtain legal abortion services.
* Multiple authorisations by doctors or other authorities are required before a woman can obtain an abortion.
* Spousal consent is required for married women while parental notification or consent is required of unmarried women.
* Rape and incest victims are required to press charges against the aggressor, obtain police reports, court authorisation, or complete other medical tests to qualify for abortion.
* Laws or health system regulations arbitrarily place time limits on when an abortion can be performed in pregnancy.
* Sub-groups of women, such as adolescents or migrant women, are not permitted to have abortions or are discriminated against.
Among the service delivery barriers are:
* A range of methods of abortion is not made available by the health system.
* New abortion methods are not approved by regulatory bodies.
* A narrow range of institutions (such as hospitals, rather than primary care clinics) is approved to perform abortions.
* Only physicians are allowed to perform abortions.
* Health professionals are allowed to exempt themselves from abortion care on the basis of conscientious objection without referring the women to an available and willing provider.
* Confidentiality is not assured to the woman seeking abortion.
* A waiting period is required between the request for and provision of abortion or clients are placed on a waiting list.
* Service delivery standards over-medicalise abortion (for example, by requiring use of ultrasound, inpatient facilities, general anaesthesia, operating theater, etc.).
* Official and 'under-the-table' charges reduce access, especially for poor women and adolescents who do not have access to funds.
THE LEGAL FRAMEWORK: THREE CASES
It is interesting and informative to look at three recent cases in Jakarta which are accusations of abortion crimes against three different people: a native massage practitioner, a practising midwife and a gynaecologist. In the first case, in June 2001, the police arrested a midwife at her private practice under the charge of article 53 which is related to article 349 of the Criminal Code. In the second case, in April 2001, the police arrested a traditional masseur and her 5-month pregnant client under article 346-349 of the Criminal Code. The client asked the masseur to abort her pregnancy as she was fearful of giving birth to a disabled child. In the third case, in November 2000, a senior male gynaecologist, two midwives and two nurses who assisted him, as well as three women and their husbands were detained at the police jail under articles 349, 299 and 55 of the Criminal Code. After being detained for 6 days, the gynaecologist was released. However, the other 10 were detained for 7 days.
THE MIDWIFE'S CASE
On June 15, 2001 the police arrested a female midwife named Ningsih, aged 31 at a clinic in Central Jakarta. A graduate from an academy of midwifery, she was accused of the criminal act of endangering another person's life. The clinic provides services on pregnancy check-ups and the use of contraception. The clinic had been operating with a license for midwifery from the Ministry of Health for one year. During the last 6 months, it had helped patients to abort their babies as long as the pregnancy was under two months, with fees ranging between Rp. 400 000 and Rp. 500 000. The police conducted a thorough search on the clinic and confiscated evidence. Then the police arrested 11 people (5 males and 6 females) who happened to be in the clinic, taking them to the police station by force. Accordingly, the midwife was arrested, and the other eleven were positioned as witnesses. Four of them were employees of the clinic, four others were intermediaries, and the rest were patients.
The midwife was accused of the attempt to conduct abortion and/or possessing psychotropic drugs category IV, type: valium. The codes that put in effect are Section 53, related to 349 of the Penal Code (KUHP) and/or Section 62 of the Law of RI no. 5 year 1997 on psychotropic drugs. The detailed codes are as follows:
a. Section 349 KUHP that states: "If a healer, native midwife (dukun beranak), or expert in medicine helps in crime mentioned in section 346 and 348, the penalty determined in the section shall be added with one-third of it and shall be discharged from the position used to commit crime."
b. Section 53 KUHP that states: (1) to attempt to commit crime shall be penalized, if the intention is obvious from the initiation of the act, and the incompletion of the act is not merely caused by his own wish; (2) the maximum penalty for the primefelony in term of attempt may be reduced with one third of the penalty; (3) if the crime is liable to death sentence and life imprisonment, the penalty to be imposed shall be 15 years of imprisonment; (4) the penalty for the subsidiary felony for the attempt is equal to the penalty for the completed crime.
c. Section 62 of the Law of RI no. 5 year 1997 on psychotropic drugs, that states: "Whoever, without the right, to possess, keep and/or carry psychotropic drugs shall be liable to a maximum imprisonment of 5years and to a maximum fine of Rp. 100,000,000."
The court found the midwife guilty of the crime (section 349 KUHP) and accordingly imprisoned her for 1 year and 6 months.
THE TRADITIONAL MASSEUR'S CASE
On April 10, 2001 the police arrested a female native massage practitioner, Mini, aged 22 years, and a married couple in West Jakarta. Mini has been practising as a masseur and has been helping women have abortions since 2000. The practitioner was accused of helping the 5-month pregnant wife, Yani, to abort for the sum of Rp. 600,000 by inserting a palm leaf rib into the woman's vagina and leaving it there. Then she asked the 'victim' to take some bintang tujuh no. 16' medicine powder with Sprite--a popular carbonated drink. The next day, liquid blood and blood clots came out and she was sent to the hospital. The hospital authorities discovered that the woman had had an abortion and the blood clots were buried by the practitioner's husband, Amin, in their backyard. Yani, who was previously 5 months pregnant, explained that she asked the masseur to help her as she and her husband already have small children to raise, and she was afraid that the baby would be disabled as she had taken drugs to stop the pregnancy. Eventually she was sent to the hospital after suffering from heavy bleeding after the abortion. During the arrest, she brought one of her children aged two years. All three Mini, Yani and Amin were charged under Section 346 KUHP that states: "A woman who deliberately aborts or ends her pregnancy, or asks other persons to do it, is liable to a maximum imprisonment of 4 years" and Section 349 KUHP that states: (1) whoever deliberately aborts or ends a pregnancy of a woman on her approval, is liable to a maximum imprisonment of 5 years and 6 months.
The three were tried in three different courts and were found guilty, and they were liable to different penalties: the native massage practitioner was imprisoned for 1 year and 2 months, the wife who had an abortion was imprisoned for 8 months and the practitioner's husband was imprisoned for 6 months.
THE GYNAECOLOGIST'S CASE
In November 2000, the Police of East Jakarta called on doctor ST who was in the practice room with a 36-week pregnant woman. The police arrested the gynaecologist, 2 midwives, 2 nurses, and 3 married couples in the clinic. Besides, they also made a thorough search and confiscated a number of goods in the clinic. This incident was widely covered by the mass media. 11 people were arrested, detained and accused. Amongst them were a male gynaecologist who has been practising at the clinic for 23 years, two midwives, two nurses and three women with their respective husbands. They were under the doctor's observation after some form of treatment. All were arrested under:
a. Section 349 KUHP that states: "If a healer, traditional midwife, or expert in medicine helps in crime mentioned in section 346 and 348, the penalty determined in the section shall be added with one-third of it and shall be discharged from the position used to commit crime.
b. Section 299 (2) that states:
1) "Whoever deliberately medicated a woman, or told her to be medicated, by informing her or giving her the hope that the medication may cause abortion, is liable to a maximum imprisonment of 4 years or a maximum fine of Rp. 3000,-.
2) If the action of the suspect is committed for a profit, or the action is a way of living or is a habit, or if he is a healer, native midwife, or expert in medicine, 1/3 of the penalty shall be added;
c. Section 55 (1) 1st of the KUHP that states:
"Penalised as the doer of the prime felony, are those who do the crime, those who instruct to do the crime, and those who take part in the crime."
After being detained for 6 days, the doctor was released. However, the other 10 were detained for 7 days. Accordingly, the case failed to be brought to court because of a lack of evidence.
CONCLUSIONS ABOUT THE LEGAL FRAMEWORK
All three cases lead us to certain conclusions about the legal framework which encapsulates the abortion issue:
a. Three persons with different professions and positions were accused for a crime regarding the action of abortion that is regulated in the KUHP, i.e. a gynaecologist, midwife, and native massage practitioner. Also, the female patients and their spouses. They are in the same position and have the potential to be the target of arrest, to be brought to court by the sections in the penal code that forbid abortion as a crime against human life.
b. The experiences of the legal process are quite varied, i.e. those charged may be brought to court, or the process may stop. The legal process does not consider the fact that the perceived 'crime' is actually a professional service or a medical action that follows existing medical standards and procedures.
c. Although Indonesia already has Health Law No 23/1992, which regulates certain medical treatments that may be conducted by doctors (including action of termination of pregnancy), it was not used in the above cases.
d. As long as the sections in the penal code are not yet abrogated, the doctors or other skilled medical practitioners who conduct safe abortions can be charged for crimes.
e. The legal process which works against women who seek abortion services and those who help them professionally, forces women to resort to unsafe abortions.
f. The abrogation of these sections of the penal code needs to be followed by issuing regulations on safe abortion services, coupled with counselling. This also regulates the criteria of the service and the limits on the maximum age of pregnancy.
WHY WOMEN SEEK UNSAFE ABORTION
According to Health Law No. 23/1992, abortions carried out for reasons other than medical grounds are illegal and the Penal Code (KUHP articles 346-349) ban abortion. As a result, many women who faced unwanted pregnancies (including as contraceptive failure, rape, incest, economic and psycho-social reasons) were compelled to seek the assistance of unqualified and unskilled persons to terminate their unwanted pregnancies. Due to the unsafe procedures, many faced untimely deaths. Unsafe abortion is one of the leading causes of maternal death and permanent disability of the reproductive organs, including infertility.
As said earlier and reiterated here: Unsafe abortion is a direct cause of maternal mortality in developing countries. Yet, in many developing countries deaths due to unsafe abortion are categorised under maternal mortality, which means the number of deaths due to unsafe abortion is often unknown. (45) Causes of maternal mortality in Indonesia include excessive bleeding (28%); pre-eclampsia (26%); abortion (5%); infection (11%); and others (30%.)46 However, causes of maternal mortality including excessive bleeding, infection, and others could also be due to abortion. In Indonesia, the estimates for the percentage of deaths due to unsafe abortion range from 12-17%.47 Yet, as is implied above, the rate of deaths due to abortion could be higher, mainly due to the ambiguity of the abortion law in Indonesia.
It seems that many policy makers, law makers and community leaders still lack the perspective of reproductive rights. Most of them still do not recognise the health impact of unsafe abortion and have not seen this as a major public health concern. Although the government has its own National Institute of Health Research and Development (NIHRD), they have never had the courage to conduct a study on the topic of abortion. Selectively ignoring the issue of unsafe abortions leads to never assessing the need for abortion, failure of contraception and never openly discussing this public health concern.
The stigmatisation from the providers compelled women to seek unsafe abortion practices. From several focus group discussions involving midwives it was clear that they regarded referring the woman to a safe abortion provider as equivalent to providing the woman with an abortion and regarded it as a sin. The Ministry of Health has a policy to curb abortion services by doing away with all training on safe abortion for health care providers. Consequently, the provider's competence and skills to help women from abortion-related complications are minimal. There are some midwives who tried to use cytotec or gynaecocid to regulate menstruation, but very often this was unsuccessful. These women soon discovered they were unsuccessful in terminating their pregnancies. In the end, the woman would resort to a traditional masseur to abort.
The government has never conducted research on local conditions and circumstances of victims of unsafe abortions. Several hospital-based studies indicate that the number of women who die of abortion-related complications is 150270 per 1000 live births. Actually, through retrospective research, the causes can be discovered. From these studies, the government should take some emergency measures to lower the high incidence of death among Indonesian women. Many World Bank reports have pointed out that the quality of health personnel were unsatisfactory and unmotivated health care personnel were often seen in the several government health facilities working just until noon and then running off quickly to their private practices. The Fourth World Bank Health Project loan 3905-IND (ended in March 2001) addressed the low quality of health centre services. This project developed and implemented a quality assurance (QA) approach which establishes care standards, and uses peer review to assess compliance. These facility level interventions have been effective in altering provider behaviour. Altering provider behaviour seems to be the most difficult task in Indonesia. It seems that many health providers never felt responsible for the death of women, since most of them still believed that the death of somebody "could not be prevented ... It is fate ... It is Allah's will ... It is already written ... just accept it."
For average women, a midwife is the closest person and so many of them went to a midwife for help, but the government made the midwives helpless. It is hoped that midwives would actively empower women by giving them information on using the now available emergency pills. Indonesian women should be educated and informed on all possible alternatives (new pharmacological technologies) to prevent pregnancy and enable them to control their fertility.
Reliable official data from the government on safe and unsafe abortion is still lacking; it is recognised that to better determine priorities and strategies for optimally dealing with the high maternal mortality issue, the government should have reliable data on the incidence of safe and unsafe abortion. Indonesian women need legal protection from unsafe abortion practices and so need access to safe and affordable abortion services.
The amendment of the Indonesian Constitution of 1945, which stresses the right of women to get access for the needed health care, could be used to frame the needs of women for the protection from unsafe abortion service and to serve the specific needs and rights of women.
The government should recognise and implement additional efforts to ensure women's rights. This includes formulating explicit policies and a strong legislative framework, allocating sufficient budgets and providing access to women's health services.
CHALLENGES AND OPPORTUNITIES
CONCERNS ON THE SUBORDINATION OF THE SOCIAL WELFARE SECTOR INCLUDING HEALTH AND FAMILY PLANNING
While the Hanoi Initiative 20/20 calls upon governments to proportionally allocate 20% of their national budget for social sectors, from 1998 to 2000, Indonesia was in no position to do this as it set its resource allocation priority on recovering its economic "backbone" in the institutional infrastructure of financial sectors (i.e banking restructuring and government's bond payment). The Asian financial crisis was so severe in Indonesia that the nation had to subordinate other social expenditures in the social welfare sector (for example, education, health and family planning programmes) to the economic recovery. In the financial year 1999/2000 the Indonesian government allocated Rp 4.81 trillion or 9.17% of the total budget. The social welfare sector had only 5.43% of the financial year 1998/1999's total budget equivalent to Rp 2.8 trillion, while in the financial year 1999/2000 Rp 3.1 trillion or 6% of the total budget was allocated. In 2004, the health budget, after three decades, was increased to 8% of the annual budget.
Unless public self-initiative and firm political commitment are engaged, it is difficult to find practical and structural funding solutions when an economic crisis and a political transition occur simultaneously. The acquisition of resources through financial intermediation and community mobilisation is an alternative for generating a domestic resource base. The erosion of the existing sources of public finance should be avoided, and public resources should be more effectively secured for social development by tying revenue to outlay, and through fiscal stabilisation.
A UNFPA collaborative project with the Netherlands' Interdisciplinary Demographic Institute indicated that external assistance played a significant role in Indonesia when the country's population programme was in its initial stage. However, external assistance continues to be of vital importance because national NGOs, which are playing a greater role in the provision of services, are highly dependent on external resources. Indeed, 90% of the income of national NGOs comes from international sources, 7% comes from self-generated funding and only 3% from national sources. (48)
It is imperative to fully recognise the vital role of major groups including community-based organisations, NGOs, industry, agriculture and business associations and promote their active participation in social development. The government should encourage and nurture these major groups, particularly because they can deliver social services, often in partnership with the government. The NGOs have long played a positive role in supporting population and poverty alleviation programmes and in complementing government efforts, especially in remote rural areas and urban slums. Reaching under-served populations may be difficult and NGOs, with more flexible, innovative and imaginative programmes may provide pragmatic solutions.
To sustain the social programmes, all existing donors including traditional bilateral donors and cooperation partners need to be maintained and where possible to increase the level of their extra-budgetary contributions for the implementation of technical cooperation activities on population-poverty fields become crucial. In this context, Indonesia certainly urges donor countries and international financial institutions to take an active part to enhance their commitments and financial assistance for the implementation of projects and follow-up actions in the population and poverty fields. It is hoped the donors would earmark some of their respective annual funding programmes for conducting impact evaluations of selected technical cooperation projects implemented either completely or partially with their funds. This would basically strengthen the project sustainability and build national capacity. An updated comparison of the contribution of external funding assistance to government social programmes is shown here: (49)
In the midst of international resource scarcity, the Indonesian government proposed that international organisations and government were going to further initiate innovative pilot projects and partnership arrangements that encourage the private sector and other major groups to finance population-related programmes. Action at local, national and global levels are often interrelated and, in a number of cases, a link between national and international action would be beneficial. While underscoring the significance of NGO participation on financing population-poverty related activities in the scheme of collaborative programmes, the Indonesian government has encouraged the private sector to participate by selectively channelling resources to "end-users" at the local level. By such exertion, a number of civil society organisations will develop into active agents of community empowerment in the specific field of population (e.g. through family planning programmes).
Moreover, to avoid duplication or inappropriate use of funds, it is important to identify ways and means of integrating the themes of population and poverty into national development strategies and planning. Both ESCAP and UNFPA can facilitate the sharing of experiences in poverty reduction in the region by formulating appropriate population policies through the identification, documentation, dissemination and replication of best practices of certain sensitised pilot projects or in-country consultations. These bodies can also ultimately function as a bridge between member countries and donors. It is said that 15-20% of core UNDP allocations (at the global, regional and country levels) are used for work on gender. This includes the advancement of women in the political area. If gender issues could be interpreted in a broader framework it might be included to protect women from unsafe practices and those funds can also be accessed.
SHORTCOMINGS OF SUPPLY OF SERVICES
There are many on-going Safe Motherhood Interventions to improve quantity, quality and access of reproductive health services, which have been identified as key constraints for safe motherhood interventions, especially at the Puskesmas level. However, policy makers, programme managers and providers at all levels still have to make services more available and increase awareness and commitment to reproductive health services by expanding current human resources allocated and providing better managerial and technical skills. The most important constraint on the supply side is that most providers need to improve their clinical skills and experiences, their counselling abilities and community-relations capacities.
Health providers should be capable of preventing and managing problems that arise among adolescents and youth, during pregnancy and complications of delivery, and the post-reproductive ages. There is a great need for competency-based training that moves away from supply driven, quantity based training programmes to one that stresses quality and competency of the Reproductive Health providers. Another constraint relates to referral systems that do not function properly at every level of service. For example, referral facilities are lacking the necessary staff" and medicines required for managing complications of high-risk pregnancy even when they are referred to a better hospital. This will seriously undermine consumer confidence in the Reproductive Health Centre system.
On the supply side, private providers (doctors and midwives practising individually, in groups, or as members of non-governmental organisations) are still an underutilised resource. There is still a need to improve both quality and the accessibility of private reproductive health services. In addition, because new innovation is lacking in Reproductive Health Centre services, efforts should be made to conduct experiments with innovative approaches for the management of complications of pregnancy and delivery.
SHORTCOMINGS OF BKKBN QUALITY OF FAMILY
The country report for ESCAP in October 2002 mentions that the National Family Planning Coordinating Board (BKKBN) had developed strategies to improve quality of family planning programmes, which includes the provision of a broader range of contraceptive choices. What happened? In the field, our interviews indicated that there are no choices at all. Due to limited external (foreign) funding, BKKBN's strategy for the coming years is providing only 'effective' contraceptives: IUDs and implants. But the poor urban women of Jakarta still had no access to affordable contraceptives since IUDs are too expensive. A representative of the BKKBN (National Family Planning Coordinating Board) informed us that since no donors were helping out in the supply of contraceptives, the BKKBN made a policy switch to supply only non-hormonal contraceptives, i.e. IUD, but for a fee.
DECENTRALISATION OF THE FAMILY PLANNING PROGRAMMES
The Presidential Decree No. 103/2001 on Position, Tasks, Function, Authority, Organisational Order and Work Procedure on Non-Departmental Government Institutions (especially Article 114 section 2) states that some governance duties conducted by the BKKBN head office will be transferred to the provincial governments in accordance with the provisions of established law by 31 December 2000 at the latest. By doing this, the family planning programmes will experience changes because the implementation of family planning service will greatly depend on the condition that prevails in that area.
By the implementation of regional autonomy and decentralisation of the family planning programmes, the regency/city is expected to work independently in handling family planning issues including the issue of reproductive health in its own area. Before decentralisation, policies and planning regarding family planning are still characterised by a 'top down' nature. However, after decentralisation development planning especially in the field of family planning has shifted towards a 'bottom up' nature. The regency/city must design its own family planning (FP)/ reproductive health (RH) programmes. Theoretically, the regency/city is in a more advantageous position compared to the central government or provincial government because it is closer to the target community. This closeness explains why the regency is considered more capable of identifying the area's specific problem and adapting its local resources in accordance with its needs.
Nevertheless, the ways in which and to what extent the regency/city translates this advantage into realistic programmes which will benefit the community still need to be sharpened. Experiences in other countries show that a lack of preparation in implementing decentralisation will worsen the existing service programmes. Field research on the identification of community and regional governments' potential capacity in funding for FP/RH activities in the Safe Motherhood Project 2001 shows that the regional governments' commitment to FP/RH programmes is still low. FP/RH programmes were not prioritised in regional development policies, since they were not provided with sufficient funding even though they are included in the region's basic pattern and strategic plan. FP programmes are not yet perceived as a form of investment for regional human resources development. Furthermore, the regional government is still incapable of exploring the existing potential to support FP/RH programmes.
Several economic and demographic experts have calculated that investing in family planning is very important and is a dominant factor in dealing with demographic problems arising from fast population growth. A detailed calculation is available on the cost of the programmes, the number of births prevented, and the economic advantages achieved by this prevention on macro and micro levels, both in the short term and in the long term.
With decentralisation, the FP programmes implementation is hampered by several interregional issues. This is due to the variation in the preparedness of the regional government and its community in the present situation. FP programmes in a regional city take the form of various organisations such as one whole office, agency, merged office, etc. W. Parker Mauldin and Steven W. Sinding mentioned several important factors that can influence the success of a FP programme, such as: (a) Strong commitment from the government; (b) Administrative structure, whether it is under a department or Coordinating Agency; (c) Civil Bureaucratic involvement from the centre to the village; (d) Easy access to contraception; (e) Service systems such as hospitals, clinic, travelling (mobile) service, pharmacy, community-based distribution such as FP posts, social marketing, etc; (f) The involvement of non-government organisations (NGOs/LSM); (g) The effectiveness of communication, information and education.
Positive support from the head of the local governments and officials in the FP programmes will affect the provision of human resources, facilities and infrastructure for the service. In turn, it will contribute to the sustainability of FP services in the region so that the contraceptive prevalence rate can be sustained to reduce birth rates. This will definitely have implications for abortion services.
ACCOUNTABILITY OF HEALTH SERVICES
So far, it seems that there is no effort toward promoting accountability for health services. NGOs in Indonesia work on transparency in state owned enterprises and in the banking sector, but so far as we know there are no NGOs which specifically monitor the accountability of health services in both private and state owned health institutions. A credible and accountable social safety net needs to be set up in the health sector which is capable of providing effective health insurance for women.
The existing social safety net for health care should be expanded and there is a need for many improvements in the implementation. In particular, in targeting the beneficiaries, i.e. vulnerable women, and raising coverage within the target group. At this moment, only 1/4 of the poorest families received a 'health card' (kartu sehat) which enables them to access the kind of health services provided. But this does not include obstetric and gynaecology care.
The programmes' implementation should be improved to better target those most in need. This can be done through extensive information dissemination and intensive monitoring. The 'kartu sehat' should reach the most needy and it should cover contraceptives and abortion services. Perhaps the solution would be to involve women NGOs who work in the area to help disseminate the health cards since they would be able to identify exactly the poorest women who need health services.
MOVEMENT ON PATIENT RIGHTS
The Consumer Association (YLKI--Yayasan Lembaga Konsumen Indonesia), established 30 years ago, which has branches in 7 provinces, was the first organisation to represent the Indonesian consumers. One of their main concerns has been about family planning acceptors, mostly women. They are not only active in monitoring the well-being of FP acceptors, but they also do advocacy work, such as conduct training to raise awareness of the general public about their rights as patients. They publish books such as " Knowing Our Body," "Reproductive Health," "Occupational Health" and "HIV/AIDS" as well.
POLITICAL PARADIGM CHANGES
With the political paradigm shifting, from the "New Order Regime" to the "Reform era" and with the decentralised government and the stronger role of parliament, political parties, and other elements of civil society in policy making, legal reform and resource allocation and control, there are new ways to succeed in amending the Health Law which will enable women to gain their rights to access safe abortion services. In the "Reform era" many women NGOs are actively advocating for women's rights, including the right to have access to safe abortion services.
Efforts to enhance a programme's equality, sustainability and efficiency are very important. Special attention should be paid to planning better policies, monitoring and evaluation of RH services so that the demand and supply sides of RH services can be equalised. The most urgent steps are building full awareness, a strong commitment and better coordinating among political leaders, policy makers, programme managers, and health providers, family, community, professionals, and non-governmental organisations in order to effect change. On RH promotion and improvement, better monitoring and evaluation indicators are needed. Important steps taken include policy and efforts to increase the private sector's role and NGOs. The public sector efforts include focusing on hard-to-reach areas and the poor. To strengthen programme sustainability, a policy to improve quality of services and increase private sector involvement is being implemented carefully, keeping in mind those below the poverty line. Decentralisation will encourage district and community-level initiatives and responsibilities and will increase local specificity of RH programmes and, subsequently, their effectiveness.
FINANCING HEALTH CARE FOR POOR WOMEN
The Ministry of Health conducted a pertinent study --Social Safety Net for the Health Care of Poor Families--in 2003. The study noted that obstetric and gynaecology care at the public health centres (Puskesmas) provide only maternal health care, i.e. antenatal care for pregnant mothers, deliveries and postnatal care. The number of incomplete abortion cases and the number of referrals were not stated in their monthly medical reports.
The government has set up a PKPS-BBM subsidy--which uses funds gained from the fluctuating price of fuel--to subsidise poor families' access to health care facilities. But this subsidy does not cover abortion cases. The poor families could have access to certain subsidised medicines but never those medicines and services needed during or after abortions. These include laboratory services and USG or blood transfusion services which were almost never provided free for the poor women in need. This study also indicated that the distribution of the health card was not well targeted. It is still confusing as to who should be responsible for the distribution and the criteria for eligibility are still unknown. Besides, the funds for the health card came too late, some three months later. In this report it was recommended that the social safety net for the health care of the poor families should be incorporated in the local Askes (state-owned insurance company) office and the unit cost of the subsidy should be the same as the premium required by Askes.
Chapter 7 of the ICPD Programme of Action states that governments are asked to remove unnecessary legal, medical, clinical and regulatory barriers to family planning services, and to try to identify and remove all the major barriers to the use of services, such as inadequacy, cost and poor quality. The document asks governments to assess the extent of unmet need for quality family planning services nationally, paying special attention to the needs of the underserved and vulnerable groups, including the rural and urban poor, indigenous people, people with disabilities, migrants and refugees.
From our research and monitoring activities in Jakarta it is clear that programmes that address the unmet need for quality family planning services, particularly for the urban poor women, have not yet been implemented since many women tried to get an IUD but it was too expensive. In the two slum areas studied, no one received a health card 'kartu sehat' in order to get free health care services. Many of them have never even heard about the 'kartu sehat'. Those who know of the health card system, tried to obtain it but were refused by the neighbourhood head because they were categorised as migrants (or people who had no Jakarta Identity Card), although they have been residing in Jakarta for at least 1015 years. The neighbourhood head made it clear that only legal residents are eligible for the health card and people who either commute between the neighbourhood and villages were considered migrants. Migrants in Jakarta were not eligible for the health card.
It is interesting to note that some developing countries have adopted the following approaches:
* Thailand has abandoned its health-card policy and has switched to a 30-Baht policy. This means that every Thai citizen who obtains health care service from the government's health facilities will be charged only 30Baht. The government will subsidise the rest.
* In Singapore, low-income citizens are directed towards using in-patient facilities in C-class wards, which are occupied by around 20 patients. C-class patients receive 80% subsidiary of their total cost from the government so that they have to pay only S $30 per day. Those who are really incapable of paying get the treatment and service free.
The monitoring and evaluation study of the HNSDP (funded by the World Bank under the name Provincial Health Project II) was conducted by ACIL Australia along with the Ministry of Health, Republic of Indonesia. The indicators used were: 1) Programmes and financial management; 2) Health insurance; 3) Health cards (kartu sehat); 4) The accuracy of target population; 5) Cost effectiveness 6) Impact on the basic health service and obstetric services; 7) Health care providers' behaviour.
The study found that it was difficult to target the poor. The different social groups were difficult to compare. The poor in the big cities, such as Jakarta, lived between and squeezed among the better houses. In this situation, the targeting should be based on individual income levels and not social groups, since within a social group there are gaps in economic status. The health cards (kartu sehat) should be provided very selectively based on individual conditions. Categorising a group according to geographical areas is misleading, not all those who live in a slum in Jakarta can be considered poor. The health card does not cover the cost for abortion services
THE IMPACT OF HEALTH SECTOR REFORM
Health sector reform greatly stresses privatisation and this has encouraged doctors and midwives to open up private practices. However this did not result in improving the performance of those health care personnel. Moreover, women who came to the public health centres were not given the necessary treatment. The Fifth Health Project of the World Bank (HP V, Loan 4373--IND) aims to improve the distribution, utilisation and quality of the health work force. Health Project V anticipated the Indonesian government's decentralisation initiatives in its focus on improving the capacity of province and district health staff, and introducing methods for workload assessment, performance review, and service quality assurance. The project also encourages piloting of innovations in staff deployment and financial autonomy of health facilities. In the next stage, district level service reform will be introduced by providing a strong foundation for eliciting local commitment. The Safe Motherhood Project (Loan 4207 --IND) has used different instruments to establish attractive and sustainable work conditions for 'village midwives', who are key providers of services potentially beneficial to poor women. One of the measures piloted has been performance contracts, which are effective in improving the quantity and quality of services reaching poor clients. The project has also used different means to promote the acceptance of these front line providers in local communities. For example, use of coupons for poor households can be effective in generating service demand and empowering poor clients. These achievements are relevant to challenges faced by budget-constrained districts, which through Law 22 in 1999, are responsible for services intended for the poor. Despite introducing many projects at the provincial and district levels, new roles, structures and organisational responsibilities have not been introduced to prevent irregularities. In designing service delivery, safe abortion services should be included and health promotion activities should include emergency pills as prevention measures.
This section describes programmes related to health, particularly to monitor whether all the on-going programmes are reaching their targets.
a) Women's Health Foundation / YKP
The ICPD Programme of Action stipulated that in a country which has a restricted law on abortion, there should be efforts to compile data on practices of abortion in the country. Women's Health Foundation (YKP) succeeded in conducting a study on counselling-based safe pregnancy termination. It began in January 2002 and ended in January 2003. Nine outstanding hospitals/clinics throughout Indonesia voluntarily joined the study, despite the unsupportive legal situation for safe abortion services. YKP was also successful in persuading the Department of Police to protect the research activity so that the research team faced no serious problems. On the contrary, the health providers themselves were usually not very supportive to this study due to various reasons. The research team found that even the doctors who were participating in the study had to be encouraged to complete the client's form in order to improve medical services. The findings were shared with a variety of stakeholders in 9 cities, involving NGOs, universities, legal professionals, professional institutions/ organisations, MOH, BKKBN (NPFCB), The Ministry of Religious Affairs, The Ministry of Women's Empowerment, the Parliament, MUI (Indonesian Council of Moeslem Leaders) and the mass media.
The study involved 1,446 clients. Each client was put through a standard flow of services: 1) registration; 2) pre-procedure medical examination; 3) pre-counselling; 4) safe abortion procedure; and 5) post-counselling and follow-up
The findings were reorganised into presentation kits to be used for advocacy activities. The targets of the advocacy activities were parliamentarians, journalists and health care providers including MOH officials. The long and arduous process of advocacy and lobbying to the policy makers, partners and media has been ongoing since the year 2000, and since then has met with some success. Support and approval were gained from all 9 political parties in the Parliament, with more than 51% votes to amend the 1992 Health Law and to add a special chapter on reproductive health. Women's Health Foundation with support from many individuals and NGOs, have proven that a smart strategy combined with persistent persuasion on human-right based ideology, can successfully achieve a goal previously thought of as an impossible task. This success had a great impact in gaining recognition from the senior members of POGI (Indonesian Society of Obstetricians and Gynaecologists). They decided to take the initiative to persuade both the chair of Commission 7 of the parliament and the Ministry of Health, to speed up the process. The bill of the revised Health Law was drafted together with the members of the Commission and the Foundation successfully inserted two paragraphs: the government should protect women from unsafe abortion. However, further efforts are still needed to put forth the bill in the plenary session of the parliament and to pass it.
The advocacy activities will continue until the main goals are reached, namely:
1) to gain local recognition of reproductive rights through the amendment of 1992 Health Law or replace it with a new health law which protects and meets women's need for humane and comprehensive sexual and reproductive health services, including safe abortion;
2) to promote the need for a rational health policy both at national and local levels which favours the realisation of women's reproductive and health rights;
3) to conduct training for physicians, midwives and prospective counsellors;
4) to design modules on counselling and practical guides for physicians to perform safe abortion;
5) to develop advocacy strategies in collaboration with other organisations whose activities aim to improve the status of women's health, such as the Indonesian Planned Parenthood Association (IPPA), Education for Health Providers Foundation and other community based organisations (for example, Islamic Women Organisation --Fatayat) and the professional associations of midwives and gynaecologists).
Based on the strong belief that the education of health providers is very crucial in the implementation of comprehensive SRH (Sexual Reproductive Health) services, three members of Women's Health Foundation were actively involved. They helped modify the midwife education curriculum, including drafting the student's manual and teacher's guide book, and also participating in the training of trainers for applying the new curriculum.
b) The Indonesian Planned Parenthood Association (IPPA)
IPPA or Perkumpulan Keluarga Berencana Indonesia, established in 1957, was founded with the main aim of reducing the high maternal mortality rate during the 1950s and to prevent unwanted pregnancies. Despite the hostile social environment, IPPA managed to organise their first national congress in 1967. At that time IPPA launched its five-year family planning programmes and prepared all levels of the association to be the partners of the government in implementing family planning programmes. At the same time, IPPA became a member of the International Planned Parenthood Federation (IPPF).
In 1970, the Government of Indonesia declared family planning as a national concern and established the National Family Planning Coordinating Board (NPFCB/ BKKBN). This meant that the government accepted the IPPA's struggle as a national one. IPPA was not alone, and became one of many family planning implementing units within the national family planning programmes. IPPA has since then extended its activities beyond family planning and into the family welfare sphere, known as responsible parenthood. In 2004, IPPA had 200 branches spread out through 25 provinces.
The new strategic plan which spans from 2001 to 2010 was developed from strategic issues identified in the field of reproductive health. IPPA also has adapted itself to the environmental changes and challenges by turning its focus from family planning to sexual and reproductive health and rights. This is mainly due to the IPPF Vision 2000 policy and also the International Conference on Population and Development (ICPD) in Cairo, 1994. IPPA's commitment to the ICPD Programme of Action resulted in IPPA changing its programmes to tackle broader strategic issues such as sexual and reproductive health and rights. IPPA's mission is to struggle for the acceptance and realisation of responsible parenthood in Indonesia by developing programmes, networks, partnerships, and community empowerment within the population, with particular attention to sexual and reproductive health.
c) Comprehensive Reproductive Health Package
Indonesian policy with regard to reproductive health has changed little as a result of the ICPD Programme Of Action. Population policies, which talk about a "Target Free Approach to Family Planning", continue to target the poorest women as implant users.
The Ministry of Health has introduced some new programmes called the "Comprehensive Reproductive Health Package", which includes: MCH, family planning, adolescent reproductive health and reproductive health for the elderly. However, in the organisational structure of the Ministry of Health and at the district level there were no significant changes.
d) USAID Projects
From 1999 to 2004, the Department of Maternal and Neonatal Health (MNH) based in Jakarta conducted several projects which were part of the safe motherhood project. The pilot project, which aimed to empower the midwives, was tested in South Kalimantan. A training centre for midwives was set up in South Kalimantan with the objective of training all the midwives from the regions of Kalimantan and Sulawesi. However, safe and accessible abortion services were never mentioned in the curriculum of the project.
e) Ford Foundation Funded Projects
In 2003, Women's Health Foundation took the initiative to develop a new curriculum for prospective midwives. They were assisted by a team of experts from the Philippines. Out of the 40 subjects there are 23 new subjects which used a gender perspective. All the prospective midwives will be trained to be gender-sensitive and be able to identify domestic violence cases. Safe and accessible abortion services will be one of the subjects taught. Ford Foundation will also provide scholarships for certification of D-3 midwifery for a limited period. Close relatives of traditional birth attendants (daughters, nieces, helpers, etc.) are eligible.
f) The Post abortion Care Programme of the Islamic Hospital
The Islamic Hospital was set up based on common Muslim interests to provide health services. For the poor, the hospital provided a special ward (called the third class ward) which is subsidised. The source of the funding was the 'infaq' account.
All cases in the third class ward are covered by the infaq account. Since many Islamic Hospitals have a post abortion care programme, the incomplete abortion cases for the poor were covered by the fund.
g) Movement to amend the Health Law No. 23/1992
An attempt to amend the abortion law in the Penal Code of Indonesia is still unsuccessful, but members of commission VII (after 2004) of the Indonesian Parliament and some women NGOs tried to amend the Health Law No.23/1992 at the end of 2003. All the nine factions of the parliament agreed to submit a draft bill of the Health Law to the chairman of the parliament. The chairman of the parliament was requested to write a letter to the president asking him to appoint a lead department to finish drafting the bill into a law. Women's Health Foundation (YKP) is actively counter attacking the conservative religious and political opinions against women's right to control their sexuality and reproductive health by working together with religious leaders and scholars who support women's rights.
Several journalists were trained in reproductive health issues to create exposure for these issues. The aim of the training was to broaden their knowledge on reproductive health and rights; to understand the decriminalisation of abortion; to understand government commitments; and to be aware of women's specific needs enabling them to write more women-friendly articles.
h) Women's Health Foundation and the Media
Women's Health Foundation has worked closely with other NGOs to advocate to political parties and parliamentarians the need to incorporate women's health issues in their policy agendas. It is building a stronger partnership with the media for gaining public support towards the much needed amendments of the Health Law and the Penal Code in order to save women's lives. Fostering interest among journalist groups is very important, since the media helps form public opinion.
Abortion still continues to be a controversial issue and antiabortion activists have borrowed language and tactics from the United States. Some media sensationalise the issue and create a sense of moral panic by equating abortion with infanticide. Infanticide is not identical with abortion. However, some of the largest newspapers in the country have been presenting a balanced view on women's rights for abortion services. More radio programmes are also covering the issue. Through interactive radio programmes, people have started talking about the issue and, in time, they will realise the need for access to safe abortion. If a woman is empowered she knows directly when she should act to prevent pregnancy, prevent conception (right after intercourse) or terminate her pregnancy.
i) Islamic-based Organisations
There are women NGOs based on Islamic values which have tried to look for new ways to legitimise abortion under some circumstances such as 1) less than 40 days gestation and/or 2) women's state of mental health during the pregnancy. This is based on the definition of health which includes complete physical, mental and social well-being, and not merely the absence of diseases or infirmity.
Inherent contradictions with prevailing religious teaching also complicate the formulation and implementation of women's health related legislation. We hope that in the near future a more comprehensive women's health law would be released which could address the needs of women.
ACTIONS TO BE TAKEN
With the current situation, we should determine what is needed to make abortion services legal and more accessible. The IPAS Publication (2001) (50) suggests we think comprehensively and expansively to develop the fullest possible picture of how abortion services should be provided for women. Their motto is: "Don't let current political or cultural movements limit your vision! Think about other groups or individuals who could help make the changes envisioned happen!"
The following strategic elements for addressing safe and accessible abortion service should be considered.
Crafting an Abortion Law That Respects Women's Rights
NGOs can effect health policy changes (IPAS Publication, 2001). Women's Health Foundation (Yayasan Kesehatan Perempuan) started to draft an Abortion Law that respects women's rights. By doing this, the members of Commission VII of the Indonesian Parliament who took the initiative to amend the Health Law No.23/1992 felt secure to have a professional partner in drafting the amendment. The Women's Health Foundation also actively contributed to and influenced the debate on this draft in the parliament. Special training on reproductive health and rights were conducted for some parliament members which included a study tour to Turkey. There, the parliament members were impressed to see the organisation of safe abortion services performed in the earlier weeks of pregnancies and adhering to high standards.
Listen to Women's Voices
As women NGOs advocating for the legalisation of abortion services, our general experience was that institutions which were mostly led by men did not want to listen to women's voices. If we brought examples of women's sufferings from social-psychological problems which ended by a decision to terminate their pregnancies, most men would sermonise on a good woman's behaviour and the immorality of abortion. They did not seem to really understand the meaning of reproductive rights--where a woman should be respected for her decisions about her own body. Men seemed to be embarrassed by women who need abortion services, not understanding that many women were victims and unwanted pregnancies were the consequences of irresponsible male behaviour. Family honour was very often used to prevent a woman having access to abortion services. Women were expected to be passive and helpless, accept their fate and allow other people to make the decisions about their bodies. Many men interviewed feared legalising abortion because they confused legalisation with liberalisation of abortion and opposed liberalism because it is a belief in individual freedom or solution. The feminist strategy of employing women's personal narratives as primary sources is one way of making visible women's experiences.
Establishing Working Partnerships
Addressing abortion requires a multidisciplinary approach. Developing a map of key constituencies and setting-up a coalition which represents women should be beneficial. So far, this research team consists of eight NGOs, each of whom is specialised in a certain area. Each NGO also has its own network of contacts, such as the Muslim Women's Organisation (Fatayat NU). The Melati Foundation has contact with government officials from the Ministry of Health and the National Coordinating Board for Family Planning. The Indonesian Midwives Association and the Women Police Association have other contacts needed during advocacy.
Women's Health Foundation works closely with PKBI (affiliated with the IPPF) on project formulation and implementation and provides information and technical expertise to assist some reproductive health clinics to systematically incorporate women's interests in all aspects of programmes. Policy ideas from other countries have been carefully considered to help draft the content of the abortion law. By studying other countries' policy experiences, all negative effects of legalising abortion services can be anticipated. High quality abortion services should be achieved which should prioritise women's needs and create at least one avenue for them to exercise reproductive choice.
Some highly respected ob-gyns supported the advocacy work to amend the Health Law No.23/1992 and held several talks and exchanged ideas with parliamentarians. It seems that parliament members who two years ago still opposed efforts to insert an article in the draft bill on abortion have now changed their minds. All parties who have some stake in the abortion issue should be included in the partnership.
Bringing Health Providers on Board
One of the difficulties is that the barrier to service provision may not be somewhere in the system that can be targeted for advocacy. It may be at the level of the individual providers. Whatever the law, health professionals play a critical role in its interpretation. Despite the fact that abortion is legal in South Africa, India or Kenya, certain health professionals do not provide abortion. Some use the conscience clause to refuse abortions when they are overwhelmed by demand. In India, the problem was solved by identifying obstacles in the effort to improve the quality of women's health care by both health providers and the state administrators. One of the crucial obstacles was the refusal to do abortions. This type of advocacy intervention based on research is very effective. The dissemination of the findings--which showed many health providers refusing abortions and not referring the woman to other providers--left the health providers unable to defend themselves to state administrators.
The private sector which runs a chain of hospitals and clinics should be included as partners. Through the providers' network, the coalition of women NGOs can get support for changing policies and regulations at the provincial or city level. So far, the Regional Health Office of Jakarta has already trained medical doctors and senior midwives in post abortion care in all Public Health Centres and some district hospitals. Some hospitals have been appointed as the centres of postabortion care. In this way, an initiative has impacted the system as a whole.
A Mass--Based Approach is Effective
The context of the movement to make abortion services more accessible should be clear. In Italy, it took a decade: it started by legalising contraceptive advertisements, then making contraceptives available, setting up family health counselling centres everywhere and, finally, legalising voluntary termination of pregnancy. Because the power impacts directly on legislation, it depends on its depth and tenacity. Demonstrating popular support for the legalisation of abortion services by collecting enough signatures to bring abortion reform bills to parliament is an effective way to reach the goal. We should build a support base amongst the majority of women and involve women's organisations and networks at the grassroots level if we want to mainstream abortion.
Framing a Message
With advocacy work, the first question to be raised is: "How should the issue be framed?" The pro-choice position argues women's right to control their fertility and thus makes access to abortion an issue of human rights and choice. The advocacy movement for abortion reform in other countries used high maternal mortality and morbidity as a public health concern. In Turkey, the message which was used everywhere was: "We do not want our women to die due to unsafe abortion!" Activists frequently assume that mass mobilisation is a requirement for success. In the case of Turkey, it was charismatic leadership who provided the catalytic role.
Moral Debate Versus Data Driven Public Health Debate
In some countries, like India and Poland, the religious sector did not raise any objections to the passing of a liberal health law or an abortion act. Historically, the abortion issue in Indonesia was very often politicised in order to gain political support from religious leaders. In the early 1990s, when the power of Soeharto started to decline, his party members in parliament opposed the draft of the health law which allowed health professionals to perform abortions. Due to this strategy, he succeeded to hold on to power because he has garnered the support of religious leaders until 1998. In Indonesia, many religious leaders still have supporters in key institutions of state and the media and can undermine access to abortion. In Italy, the ideological force of feminism and socialism, coupled with women's limited access to contraception and their increased desire to control fertility, collectively undermined the power of the Catholic Church. Pro-choice activists can thus try to influence the cultural and ideological context.
Change of Power is an Opportunity for Change
A number of case studies illustrate how major social upheavals or specific moments in history can play a significant role in facilitating abortion access. In South Africa, the arrival of democracy created a moment in time when politicians wanted to demonstrate their commitment to gender equality, to ending race discrimination and to public health. A new bill of rights was developed which insists on gender equality and on the right to health, including reproductive health.
In Bangladesh, the mass rape of women by the army during the War of Liberation led the government to facilitate access to abortion despite its illegality. By doing so, it shifted the national approach to abortion and laid a foundation for activists to introduce services that continue until today.
In Sau Paulo, Brazil a strong public pro-choice movement helped a candidate on an abortion rights platform win the city elections. It also led some activists to focus on abortion as an issue for a political platform in other cities.
Link Abortion Rights to Broader Demands
In some countries, safe abortion services were provided outside of a public health system, namely at the private "for profit" health sector. These are often referred to as "underground" abortions. In Indonesia, this has already happened, where women through some networks access information (and in some cases, even funds) on safe abortion services. The demand to control the number of children so that each child is a wanted child could be used as a starting point to influence policy makers to understand the need of women for abortion service. Giving adequate information to the various groups in a community helps design appropriate policy responses, and provides feedback on the impact of the policies which allows corrections if the desired impact does not materialise. At a national level, it is important to support well-informed debate on the issue (i.e. high death rates caused by unsafe abortion) and its impacts and solutions.
We, as women advocates, will work continuously to advocate for regulating abortion. Public education about the health implications of unsafe abortion should be conducted in several regions to help educate the public and elucidate a positive public opinion. Through new local regulations and an enabling environment women would be able to exercise their rights to get safe abortion services as part of a comprehensive reproductive health package.
Healthcare providers at the public health centres need to be trained to perform safe and affordable menstrual regulation services (below 8-10 weeks,) which will help stem the tide of the commercialisation of abortion services. When safe abortion services are commercialised, they become out of reach for poor and marginalised women who may need them. The government is already beginning to introduce the post abortion care (PAC) programme, and in Jakarta almost all district public health centres are trained in PAC. Information on the availability of this service should be extensively disseminated to every woman without discrimination based on age, socio-economic status or marital status.
The stigma associated with abortion means that women may be reluctant to go to a public hospital or public health centre, and may prefer to go to a back street doctor or masseur, even if the service is unsafe. If a woman knows that indeed it is her right to choose how many children she should bear and when she should bear them, she would be brave enough to take the necessary steps. Such as asking a healthcare provider for emergency contraception after having unprotected sex. Or requesting for menstrual regulation services early on in the pregnancy.
Addressing the stigmas towards abortion services should be the first priority to empower women to take charge of their own bodies.
Accurate information on all methods of preventing unintended pregnancies and empathy should be conveyed to women who are facing unintended pregnancies. This is the main reason why the Women's Health Foundation (Yayasan Kesehatan Perempuan) made counselling services as a prerequisite. During the counselling sessions, every woman is empowered with information and understanding so that the atmosphere is conducive to her making the best decision for herself. If at the end she decides not to terminate her pregnancy and instead needs a shelter to be protected from her angry family members, the counsellor directs her to a safe haven.
Post-counselling after an abortion is also just as important especially to prevent another unintended pregnancy. Many abortions can be prevented through effective contraception. Through post counselling sessions, the women will be empowered in making decisions to prevent another pregnancy. During the second counselling, her partner should also be assisted in understanding that both of them are responsible for pregnancy and both are equally responsible in prevention.
The healthcare providers not only at the hospitals and clinics, but also the public health centres, should listen with empathy and get to know the needs of every woman who walks into their examination rooms. They should get training to ensure they understand the need for confidentiality and the services are set up in such a way that they support this. Women who need abortion services should go through confidential registration and then go to the counselling room. The fee for all services should be affordable and women who are too poor to pay should receive subsidised service.
The Ministry of Health's p olicy to disseminate information on modern methods of contraception and to provide post abortion care needs to be complemented by providing safe abortion services. Currently only incomplete abortion cases are eligible to be treated. The Ministry of Health needs to provide safe abortion services in order to alleviate the pain and suffering of so many women.
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(26) Utomo, B. Habsjah, A. et al. 2001. Incidence and Socio-Psychological Aspects of Abortion in Indonesia: A Community - Based Survey in 10 Major Cities and 6 Districts, Year 2000. Jakarta: Center for Health Research University of Indonesia.
(27) Affandi, Biran and S. Sarwono "Keluarga Berencana dan Aborsi", in YLKI: Keluarga Berencana dari Perspektif Perempuan. Jakarta: YLKI and Ford Foundation, 1995.
(28) Hull, T.H, S.W. Sarwono, and N. Widyantoro. "Induced Abortion Indonesia" in Studies in Family Planning 1993; 24(4):241-251
(29) Utomo, B. Habsjah, A.et al. 2002. Incidence and Socio-Psychological Aspects of Abortion in Indonesia: A Community Based Survey in 10 Major Cities and 6 Districts, Year 2000. Jakarta: Center for Health Research University of Indonesia.
(30) Widyantoro, N and Lestari, H. 2004. "Penghentian Kehamilan Tak Diinginkan Yang Aman Berbasis Konseling". Penelitian di 9 Kota Besar, Jakarta.
(31) IPPA. 2005. "Retrospective Study on Menstrual Regulation in 9 cities in Indonesia: 2000-2003.
(32) I.B. Artha and I.B. Tjitarsa. 1994. "Characteristic of women come to ask for menstrual regulation". Report Denpasar.
(33) Hull, Terence H. 2005. People, Population, andPolicy in Indonesia. Jakarta, Equimax Publishing (Asia) Pte.Ltd.
(34) Unsafe abortion is defined as a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both. (WHO)
(35) Mas'udi, M.F. (ed.) 1996. Islam and Women's Reproductive Rights. Indonesian Society for Pesantren and Community Development.
(36) Djohan, E., Indrawasih, R. Ademan, M. Yudomustopo, H., and Tan, M. 1999. "The Attitudes of Health Care Providers Towards Abortion in Indonesia". In Abortion in the Developing World. Ed. Mundigo, A.I., and Indriso, C. Vistaar Publications, New Delhi.
(37) "Ghurrah" means payment for a male or female slave or some equivalent. In contemporary life it is more accurate to consider ghurrah to be equivalent to half the value of diyat as the practice of slavery has been abolished and the penalty is imposed on those who are free.
(38) Sciortino, R., Natsir, L.M., and Mas'udi, M.F. (1996) "Learning from Islam: Advocacy of Reproductive Rights in Indonesian Pesantren" in Reproductive Health Matters. Nov. No. 8.
(39) Sciortino, R., Natsir, L.M., and Mas'udi, M.F. (1996) "Learning from Islam: Advocacy of Reproductive Rights in Indonesian Pesantren" in Reproductive Health Matters. Nov. No. 8.
(40) "The sisterhood method was originally developed during the late 1980s. The approach was designed to overcome the problem of large sample sizes and thus reduce costs. It is an indirect measurement technique of the kind frequently used to measure a variety of demographic parameters (such as child or adult mortality), which has been adapted for the measurement of maternal mortality." World Health Organization and United Nations Children's Fund. 1997. The Sisterhood Method for Estimating Maternal Mortality: Guidance Notes for Potential Users. Geneva: World Health Organization. Pp. 5.
(41) Abdullah, R. 2004. "Break the Silence", in Sjodahl, S. (ed.) Respect Choice Safe Abortion a Prerequisite for Safe Motherhood. Stockholm: Swedish Association for Sexuality Education. Pp. 14-15.
(42) Asian Pacific Resource and Research Centre for Women. 2005. Monitoring Ten Years of ICPD Implementation The Way Forward to 2015: Asian Country Reports. Kuala Lumpur: Asian Pacific Resource and Research Centre for Women. Pp 330.
(43) Asian Pacific Resource and Research Centre for Women. 2005. Monitoring Ten Years of ICPD Implementation The Way Forward to 2015: Asian Country Reports. Kuala Lumpur: Asian Pacific Resource and Research Centre for Women. Pp 331.
(44) United Nations Economic and Social Comission for Asia and the Pacific. 1998. XI. Resource Mobilization: Current Situation and Future Requirments. Technical and Policy Division, UNFPA". Available at http://www.unescap.org/esid/psis/population/icpd/ sec11.asp
(45) UNFPA, Asian Population Studies Series No. 153
(46) IPAS. 2001. A Guide to Providing Abortion Care. Chapel Hill: IPAS.
Table 1: Hospital--based studies on abortion, conducted between 1973-1980. Author(s) Abortion Period Location Cases 1. Rattu (1973) 663 1972 Manado Hospital 2. Sopachua (1974) 449 1972-73 Ujungpandang Hospital (South Sulawesi) 3. Manuaba (1979) 1068 1975-78 Sanglah Hospital Denpasar 4. Effendi (1980) 2417 1977-79 Hasan Sadikin Hospital Bandung 5. Surya & Manuaba 1000 1979-80 Sanglah Hospital Denpasar (1980) Author(s) Types of Abortion Sponta Legal Illegal Neous 1. Rattu (1973) 81.6% ... 18.4% 2. Sopachua (1974) 86.2% ... 13.8% 3. Manuaba (1979) 64.8% ... 35.2% 4. Effendi (1980) 90.2% 1.9% 7.9% 5. Surya & Manuaba 74.2% ... 25.8% (1980) Source: Utomo, B; Sujana Jatiputra, and Arjatmo Tjokronegoro. "Abortion in Indonesia: A Review ofthe Literature. Jakarta: 1982. Note: Effendi's definition oflegal abortions (1.9%) means that the induced abortions were performed on medical grounds. Table 2: Frequency of Abortion According to Stages of Abortion Stages Authors Lim Wiharto Surya & (1969) (***) Manuaba(1980) 1. Imminent 14.1% 23.6% 15.7% 2. Incipient 11.3% ... 5.9% 3. Incomplete 64.8% ... 74.7% 4. Complete ... ... 0.2% 5. Missed Abortion ... ... 0.9% 6. Other 9.8% ... ... Total 100% * 97.4% N=1188 N=2205 N=1000 Source: Utomo, B; Sujana Jatiputra and Arjatmo Tjokronegoro. "Abortion in Indonesia: A Review of the Literature". Jakarta: 1982. Faculty of Public Health, University of Indonesia. Table 3: Characteristics of abortion clients All Clients Total City District N 1302 261 1563 Types of SDP Government General Hospital 15.4 8.0 14.1 Private General Hospital 15.4 5.0 13.7 Maternity Hospital 1.0 51.0 9.3 FP Clinic 39.5 0.0 32.9 Obstetrician 1.2 0.0 1.0 General Physician 22.2 4.6 19.3 Midwife 4.2 0.4 3.6 TBA 1.1 31.0 6.1 Address Outside the SDP site 36.0 12.6 32.1 Within the SDP site 64.0 87.4 67.9 Age (year) <20 6.6 9.6 7.1 20-29 46.0 49.0 46.5 30-39 38.1 29.9 36.7 40+ 9.3 11.5 9.7 Marital Status Married 77.2 73.9 76.6 Unmarried 21.9 24.9 22.4 Divorced 0.9 1.1 1.0 Education Not yet completed primary 12.5 16.5 13.2 Completed Primary 16.2 8.0 14.8 Completed Junior 15.5 13.4 15.2 Completed Senior 39.9 42.1 40.2 Completed academy/university 15.9 19.9 16.6 Number of Pregnancies 1 32.9 43.6 34.7 2 16.9 16.2 16.8 3+ 50.2 40.2 48.5 Number of live births 0 34.4 45.2 36.6 1 17.7 16.5 17.5 2 24.3 19.5 23.5 3+ 23.6 18.8 22.8 Contraceptive Use Never used 52.4 60.2 53.7 Had used 32.6 33.3 32.8 Currently using 15.0 6.5 13.6 Total City District N 930 101 1031 Types of SDP Government General Hospital 6.9 3.0 6.5 Private General Hospital 7.1 2.0 6.6 Maternity Hospital 0.4 6.9 1.1 FP Clinic 47.1 0.0 42.5 Obstetrician 1.7 0.0 1.6 General Physician 31.0 10.9 29.0 Midwife 4.3 0.0 3.9 TBA 1.5 77.2 8.9 Address Outside the SDP site 43.4 10.9 40.3 Within the SDP site 56.6 89.1 59.7 Age (year) <20 7.1 14.9 7.9 20-29 45.4 51.5 46.0 30-39 37.7 26.7 36.7 40+ 9.8 6.9 9.5 Marital Status Married 68.9 36.6 65.8 Unmarried 29.9 60.4 32.9 Divorced 1.2 3.0 1.4 Education Not yet completed primary 5.4 11.9 6.0 Completed Primary 16.6 9.9 15.9 Completed Junior 14.3 11.9 14.1 Completed Senior 44.5 25.7 42.7 Completed academy/university 19.2 40.6 21.3 Number of Pregnancies 1 32.9 58.4 35.4 2 14.8 9.9 14.3 3+ 52.3 31.7 50.3 Number of live births 0 34.6 64.4 37.5 1 14.0 5.9 13.2 2 25.9 10.9 24.4 3+ 25.5 18.8 24.8 Contraceptive Use Never used 46.8 78.2 49.9 Had used 34.5 14.9 32.6 Currently using 18.7 6.9 17.6 Source: Utomo, B. Habsjah, A. et al.2001. Incidence and Socio-Psychological Aspects of Abortion in Indonesia: A Community Based Survey in 10 Major Cities and 6 Districts, Year 2000. Jakarta: Center for Health Research University of Indonesia. Table 4: Status of Clients' Marriage Status of Marriage Frequency % Married 27,379 73 Unmarried 10,042 27 Others 264 1 Total 37,685 100.0 Source: Widyantoro, N and Lestari, H "Penghentian Kehamilan Tak Diinginkan Yang Aman Berbasis Konseling".Penelitian di 9 Kota Besar, Jakarta: 2004 Table 5: Clients' Activities Status of Marriage Frequency % Employed 16,352 43.4 Unemployed 16,615 44.1 Student/College 4,718 12.5 Total 37,685 100.0 Source: IPPA (2005) "Retrospective Study on Menstrual Regulation in 9 Cities in Indonesia year 2000-2003" Table 6: Client's educational background and who they visited the clinic with (%) Education Who accompanied them to the Clinic Sub Total With With With Alone husband family friend Kindergarten- Elementary-other 0.4 10.0 1.0 1.2 12.6 Junior High-Senior High 3.0 43.5 4.9 13.7 65.1 College 1.5 11.8 1.5 7.6 22.3 Sub Total 5.0 65.2 7.4 22.5 100.0 Source: IPPA (2005) "Retrospective Study on Menstrual Regulation in 9 Cities in Indonesia year 2000-2003" Table 7: The composition Of Internal--External Resources in Year 2002 Proposed Per Sub/Sector Government Budget Allocationl (in Billion Rupiah/Rp) No Sub-sector National External Total Funding Assistance 1 Agriculture 1,085.8 1,068.4 2,153.9 2 Marine and Fishery 618.2 270.2 888.4 3 Manpower 127.8 22.1 149.9 4 Cooperative and SMEs 333.4 100.0 433.4 5 Regional Development and 637.4 2,661.3 3,298.7 Community Empowerment 6 Education 6,803.0 4,393.6 11,196.6 7 Extra-Curricular Education 215.0 10.0 225.0 8 Population and Family 248.8 62.6 311.4 9 Social Welfare 1,056.0 0.0 1,056.0 10 Health 2,140.5 1,073.3 3,213.8 11 Women Empowerment 26.6 7.7 34.3 12 Housing 222.1 0.0 222.1 13 Human Settlement 516.6 268.3 784.9 14,030.9 9,937.5 23,968.4 Diagram 2. Reason to terminate the unwanted pregnancy Medical Indication 3.9% FP failure 36% Psychosocial 58% Others 2% Note: Table made from pie chart.
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|Title Annotation:||Chapter 2|
|Publication:||Rights and Realities: Monitoring Reports on the Status of Indonesian Women's Sexual and Reproductive|
|Date:||Jan 1, 2008|
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