1. Contraception and abortion: where are the women’s needs Marcel Vekemans, MD, Ob/Gyn IPPF Central Office, London Moscow 2005

2. Contraception and abortion in Europe Total fertility rate Total abortion rate Russia1.3*2.6* Belgium1.50.2

3. Contraception versus abortion: not a fair dilemma “Until having an abortion is considered as acceptable morally as using contraception, women will not have gained their full reproductive rights”* In some countries, contraception is not favoured. *Løkeland M. Reproductive Health Matters 2004;12(suppl 24):167-173

4. Is the choice between abortion and contraception really based on women’s needs? Choices can be made freely only if: - basic needs are met (shelter, food, clothes, health care, security, basic education, mobility, job) - the options can be accessed - information is complete - no coercion is exerted

5. Contraception versus abortion Abortion – is not a pleasant experience – is stigmatized – entails more health risks than contraception Contraception –is often feared (health? hormonal disturbances, or “foreign body”; leads to promiscuity?)

6. Prevention ? Abstinence Contraception Emergency contraception -------------------------------------------------- Abortion What do the women need? –High quality services –Information

7. Prevention ? Yes, but …1. Abstinence Sex life is part of normal life –hormones, puberty, adulthood, love Peer pressure Societal pressure –media, publicity, literature, … Partner’s pressure Coercion, violence; rape; incest

8. Prevention ? Yes, but …2. Contraception (1) Not so easy ! –Available? (method mix) –Accessible? (geography, transport) –Acceptable? (fears: of side effects, of complications, of low effectiveness, of medical exams and procedures) –Affordable? (costs) –Medical eligibility (WHO criteria) –Side effects, complications –Opposition (parents, partner, educators, physicians – some make a living from abortion - )

9. Prevention ? Yes, but …2. Contraception (2) The adolescent case (1) –Doesn’t know it exists, or what it is –I do not have sex –It’s dangerous –How do you use it? buy it? hide it? –Ethical moral, religious objections … is there, after all, free, informed choice, for all adolescents?

10. Prevention ? Yes, but …2. Contraception (2) The adolescent case (2) Adolescents need friendly services, and correct information Peer counsellors? Sex education Should start at kindergarten (with adequate content) Not limited to anatomy, contraception, STIs Include body changes, masturbation, sexuality, love, feelings, self-confidence, “saying yes or no”, peer pressure, respect, generosity, etc.

11. Prevention ? Yes, but …3. Emergency contraception Not yet widely available, accepted, accessible [Medically: no contra-indications at all with levonorgestrel]

12. Prevention ? Yes, but …3. Requesting or not an abortion (1) Most often, women feel obliged to abort –Pregnancy is unwanted - too soon in life, too late, too soon after previous delivery, too many children; problems with school or job, etc. –Pregnancy is stigmatized - adolescence, older age, single, poor, widow, sick, family problems, etc. –Problems with partner, husband –Coercion, violence, rape, incest –Health problems (woman, foetus) “I’m against” … except for me (or my daughter) ? Sex of foetus ? Embryo reduction after IVF?

13. Prevention ? Contraceptive prevalence (CPR) CPRModern methodsTraditional methods Total% pill%IUD Eastern Europe and Central Asia 624142521 Western Europe 737148103 Awareness is high everywhere. Access differs a lot. Another difference is “contraceptive mentality”, influenced by society, religion, information received (or not received).

14. Contraception: unmet need Russia (DHS) Among all women of reproductive age (15-49) (WRA): –Unmet need is 11% –Met need is 59%- Demand is 70% 30% do not want contraception –Not feeling at risk –Opposed Unmet need for modern contraception is only 3.5% Proportion of unwanted pregnancies: 66%

15. Abortion or not? Specific problems 30% of abortions are repeat abortions. NORMAL: if risk of abortion is 30%, risk for two abortions is 9%, for three, 2.7% etc. Moreover, if you had an abortion you are “less gifted for contraception” Denied abortion results in a statistical increase in bad outcomes, mental illness, asocial behaviour There ARE coerced abortions

16. Is the choice between abortion and contraception really based on women’s needs? A few additional considerations 1.The choice depends on knowledge and services available. These result from an ideological struggle (in which the medical establishment participates) 2.Governments limit access to abortion to claim to moral legitimacy 3.Contraception and abortion have made (young) women’s sexuality visible, independent of marriage, of parental and male leaders’ authority. The patriarchal control over the (young) women’s is lost 4.The real issue is not control over life, is not the (public) health issue, it is CONTROL over sex.

17. THE END Thank you !

18. References www..infoforhealth.org.un.org.guttmacher.org.siecus.org.prb.org.overpopulation.com/faq/.gesis.org mvekemans@ippf.org