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Anu Kumar Headshot

Abortion, the States and the World Health Organization

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If you're depressed about the daily efforts in the United States to restrict abortion rights -- not to mention the recent court rulings affirming states' rights to lie to women seeking abortions -- maybe you should pick up the new World Health Organization (WHO) guidelines on abortion policy and standards of care.

Or, maybe not. Reading them might make you feel even worse. The new recommendations make it painfully clear that, nearly 40 years after Roe v. Wade, we're doing everything wrong here. Whether it's gestational limits, ultrasounds, counseling or human rights, nearly every policy proposed by anti-abortion legislators directly contradicts the new WHO guidelines, which are based on years of consultation and discussion, incorporating scientific evidence and international human rights standards.

Case in point: One of the most common restrictions introduced in the United States this year is banning termination of pregnancy after 20 weeks, on the false claim that a fetus can feel pain. In fact, Rep. Trent Franks from Arizona liked the ban that his state passed so much that he decided to propose one for the District of Columbia (against the wishes of DC's actual elected representatives). Scientific evidence indicates that this is not true. And women who seek abortions after 20 weeks do so for complex (and often heartrending) reasons. Forcing them to carry pregnancies that could have a devastating impact on their physical or mental health is just cruel and a violation of their human rights.

In contrast, here's what the WHO guidelines say:

Laws or policies that impose time limits on the length of pregnancy for which abortion can be performed may have negative consequences for women who have exceeded the limit. Such policies/laws force some women to seek services from unsafe providers, or self-induce with misoprostol or a less-safe method, or force them to seek services in other countries, which is costly, delays access (thus increasing health risk) and creates social inequities.

Replace "countries" with "states," and you see the impact in the United States.

Compulsory ultrasounds
is another barrier that U.S. legislatures have sought to impose in 12 states. Many health centers do provide ultrasounds to confirm the pregnancy, but it is not always indicated (pregnancy can be confirmed with a lab test, or history of menstrual period and pelvic exam). Nevertheless, in Louisiana, Texas and Mississippi, women not only must undergo an ultrasound before having an abortion, but the doctor must display and describe the image.

Once again, this directly contradicts the WHO document, which states that an ultrasound is not necessary prior to abortion.

But just to be clear, U.S. proponents of ultrasound legislation don't want to require an ultrasound for medical reasons; they say they want to ensure that a woman has all the information she needs to make a complete decision. So it's really about informed consent? Well, not entirely, because 35 states also require a woman to receive counseling before an abortion. However in nine states the "counseling" is in fact a script written by a board of political appointees that includes false and misleading information about the risks associated with abortion, including breast cancer, depression and the ability of a fetus to feel pain (see above).

And what does the WHO have to say about counseling? "Provision of counselling [sic] to women who desire it should be voluntary, confidential, non-directive and by a trained person." In other words, counseling is an important part of abortion care, but only as it meets a client's needs, not a politician's. An ultrasound may be necessary, but only as it meets a clinician's needs. These state-mandated efforts are not intended to ensure women get the best care; they are intended only to shame them for their decision.

What about U.S. laws that force abortion providers to conform to the regulations of an ambulatory surgical center? WHO says, "Both vacuum aspiration and medical abortion can be provided at the primary-care level on an outpatient basis and do not require advanced technical knowledge or skills, expensive equipment such as ultrasound, or a full complement of hospital staff (e.g. anaesthesiologist)."

And as U.S. states try to impose greater barriers to medical abortion, the WHO recognizes the need to increase access to women: "Where medical methods of abortion are registered and available, midlevel health-care providers can also administer and supervise abortion services."

But perhaps the most striking thing is that WHO, in consultation with U.N. bodies and health experts, has determined that access to safe legal abortion is a matter of human rights. And the new document says further that, "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."

To repeat: The state must ensure that abortion care is accessible. If a woman must drive to another state and use her rent money to pay for an abortion, because her insurance refuses to cover abortion, is that accessible? If women are willing to order misoprostol online from unknown providers, is that safe? How do any of these restrictions do anything but shame and degrade women (also a violation of their human rights), and lead them to take more and more extreme measures to have a safe abortion.

In our work, my colleagues see the impact of restrictive laws every day in emergency rooms around the world. In this country, women have been arrested because they have seen no other option than to try to end their pregnancies outside of the restrictive legal setting. How far are we willing to go, against the advice of the world's doctor, before we start fulfilling our duty to women?

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