The availability of safe abortion is essential to an individual’s right to reproductive choice and control. In February 2021, Thailand legalised abortion for the first time. However, current legislation remains restrictive. What should follow this constitutional change must be considered next. Looking across Southeast Asia, to offer appropriate reproductive choices in addition to the legalisation of abortion, I find that progress in education, social acceptance, and political representation are needed for systemic change, writes Nicholas Williamson
Sexual and Reproductive Health (SRH) incorporates diverse, nuanced, and intersectional elements. These include sexual wellbeing, reproductive health, sexual pleasure, and abortion service provision. Globally, progress towards the universal provision of safe and accessible abortion services has faced significant advancements and major setbacks. Where countries including Thailand and Argentina legalised abortion for the first time in early 2021, others, including Poland, China, and the USA have dangerously restricted this essential healthcare service.
Making abortion illegal does not reduce its incidence, only its safety.
Almost half of all global abortions are unsafe, and abortion restrictions lead to more unsafe abortions. It is difficult to study on abortion service provision anywhere in the world without considering the current situation in the USA. In September 2021, Texas passed what is currently one of the most restrictive abortion bills in the USA. The “Heartbeat Bill” effectively bans abortion by making it illegal to seek an abortion only six weeks into a pregnancy, earlier than when many – especially those aged under 20 – are even confirmed to be pregnant. Revoking the Roe vs. Wade decision of 1973 is a frightening leap backwards in civil liberties. It echoes a deeply conservative political narrative in the USA and greatly increased restrictions to abortion services throughout 2021. This decision is dangerous. In the wake of Covid-19, the world needs to move towards increased inclusivity and the universal provision of healthcare.
These new restrictive abortion laws disempower millions. Those who are less affluent (and unable to travel elsewhere) from seeking abortion services will be most harmed. Removing the ability to exercise individual reproductive rights by restricting abortion services perpetuates systematic inequalities, discriminates against all individuals who may be able to become pregnant, and can contribute to poverty.
Abortion is a much-discussed topic, but too often communities outside the USA or Europe are overlooked. Consideration of abortion service provision, contraception access and sexual and reproductive health research in other nations illuminates substantial work being done in the Global South on this issue, which heavily influenced my research on abortion frameworks. There is a need to focus on the region-specific barriers to abortion service provision worldwide.
When writing my dissertation at the LSE, supported by the Saw Swee Hock Southeast Asia Centre, I saw that my nations of focus (Timor-Leste, Nepal, Thailand, and Vietnam) shared some similarities that limit access to abortion services. Stigmatisation and conservative norms restrict access even where abortion services are legal. I asked the research question: How can abortion service provision in Southeast Asia be enhanced beyond the formal legalisation of elective abortion on demand? To answer this question, I developed a socio-ecological model for abortion using secondary data derived from demographic and health (DHS) surveys, research publications, and qualitative interview data. A socio-ecological model considers the intersecting and interconnected aspects of health and wellbeing relating to abortion service provision. Models like these are used by institutions such as the WHO to allow, for example, the consideration of myriad public health factors relating to sexual health beyond just the physical. I reached three key conclusions, which I present here. Ultimately, there is a continued need to emphasise that safe abortion access saves lives, and develop policies around this.
Legalisation is only the first step to safe and accessible abortion service provision.
Across Southeast Asia, there is variation in the acceptance of abortion, its legality, service awareness, and provision. In Timor-Leste, abortion remains illegal in almost any context; highly restrictive laws are linked to the Roman Catholic Church’s influence on national policy development, where fear of exclusion from one’s community deters health workers, community members, and potential service users from speaking out in opposition of the restrictive legislation. Consequently, the stigmatisation of service users and providers persists.
In Thailand, the legalisation of abortion took place in 2021. However, abortion is only legal if the pregnancy is terminated in the first 12 weeks of pregnancy. There remains the punishment of incarceration if an abortion is sought outside of this short timeframe. Legalisation in this form is not enough to make abortion services safe and accessible for all.
Education provision and service awareness is the second step to safe and accessible abortion service provision.
In Nepal, abortion in the first 12 weeks of pregnancy for any woman was legalised in 2002. While this move has enabled the expansion of safe abortion services to many parts of the country – particularly access to safe abortion medications – there remains a lack of awareness and knowledge in the general population concerning abortion. DHS findings from 2016 found that 60% of women surveyed are unaware that abortion is legal in the country. Of the 40% that are aware, only 23% know that anybody can seek an abortion up to 12 weeks of gestation. Abortion knowledge among men was not published, so men’s awareness regarding abortion trajectories cannot be considered alongside these figures nor those who do not identify with either gender. Until this narrative changes and abortion is considered a healthcare issue beyond the confines of Women’s Health alone, there will continue to be high rates of clandestine abortions that are often less safe and carry higher risks of complications.
Representing all aspects of a community in government structures is critical to ensure political reflexivity and the consideration of historically excluded people.
Reflexivity considers how an individual’s beliefs are shaped by their situation and experiences. I consider political reflexivity to be a government’s recognition of marginalised stakeholders – communities, groups, and individuals – when developing policy. In Thailand, the fact that abortion is only legal in the first 12 weeks of pregnancy remains a restrictive timeline to access abortion services. Many are not yet aware they are pregnant within this window, and those who are may not be able to seek and utilise abortion facilities in time. Abortion legalisation with a time limit does little to empower individuals. Changes to political leadership are the next crucial steps. A 2008 study found that by increasing the proportion of women in positions of leadership in a country, policies are better designed not just for issues such as abortion and other aspects of SRH but in essentially all aspects of governance. Further, the language of many current laws concerning abortion does not explicitly ensure access to abortion services for those who do not identify as women. Greater and more equal representation of citizens means better region-specific and nation-specific policy development.
These elements are just some of those that, together, will improve access to abortion services systemically. Medicine requires a shift towards treatment and care provision that is intersectional in its approach, factoring sex, ethnicity, culture, gender identity, and many more aspects of our personal lives into healthcare. The reform of abortion service provision, from legalisation to community awareness, is just one component of this shift. Further, the legalisation of abortion provides a platform and opportunity to win advances on other SRH issues and service shortcomings. Examples of these could include improvements to hospital sanitation, contraception dispersal, and education provision.
As someone who identifies as a man, my positionality affects my understanding and interpretation of these areas of healthcare. Further, being of non-Southeast Asian heritage, my research has been informed by guidance and insight from LSE academics, friends with roots from the region, and wide-ranging publications championing local voices and researchers. The objective is to develop an argument that is cognisant of local perspectives and attitudes towards existing and future abortion service frameworks in Thailand and other Southeast Asian countries of interest.
Abortion service provision must be prioritised by policymakers, community leaders, and healthcare providers. Despite abortion being an issue of extreme importance for many women and people who may become pregnant, their voices are often not heard due to historical patriarchal systems that sustain power imbalances today. We must amplify these demands for reform, widespread abortion legalisation, and sexual and reproductive health liberalisation.
A valuable resource for further reading on abortions service provision in Southeast Asia (2020): https://apps.who.int/iris/handle/10665/338768
*This research was supported by the LSE Saw Swee Hock Southeast Asia Centre Student Dissertation Fieldwork Grant 2020-2021.
*The views expressed in the blog are those of the author alone. They do not reflect the position of the Saw Swee Hock Southeast Asia Centre, nor that of the London School of Economics and Political Science.