History has proven that the legal status of abortion is fundamental to ensuring patients' safety. Almost 43 years ago to the day, the US Supreme Court voted to legalise abortion. In the decade that followed the historic ruling, the risk of life-threatening complications dropped dramatically. Today, in the US, both medical and surgical abortions provided by trained doctors and nurses hold an enviable safety record, with less than 0.5% of women who choose abortion experiencing any major complications.
In Thailand, abortion has been legal since the 1950s. The law states that a doctor may perform an abortion if it is necessary to protect a woman's health, when the woman is a survivor of rape, or if she is under the age of 15. The most recent regulations regarding laws on abortion were adopted in 2005. These explicitly state that a woman may seek an abortion for protection of either physical or mental health; however in the latter case two doctors must agree that the procedure is necessary.
Although these laws have been in effect for decades, women in Thailand continue to die from complications of unsafe abortions at a rate mirroring countries where abortion is heavily restricted. In 2011, the Ministry of Health estimated Thailand's abortion mortality rate to be more than 130 times higher than the rate in the US. As obstetrician-gynaecologists (OBGYNs) dedicated to improving the health and lives of women and their families, we find these numbers shocking.
Doctors and nurses who provide reproductive healthcare to women in Thailand have access to the medications and medical equipment they need to provide safe abortions. Many have the knowledge and skills required to provide both medical and surgical options. Most importantly, regulations within the law give doctors -- and doctors alone -- extraordinary discretionary power to grant women access to this vital medical service. What is grossly lacking among many of our physician colleagues is the will to provide this care. By invoking personal objections to abortion, many doctors have been complicit in causing the harm women in this country have suffered as a result of unsafe abortions.
The Women's Health and Reproductive Rights Foundation (WHRRF) was established in 2007 with the aim of increasing access to safe abortion in Thailand. In addition to contributing expert opinion to abortion legislation and training healthcare providers on simple outpatient abortion techniques, the staff of the non-profit organisation conducts workshops aimed at de-stigmatising abortion care.
These workshops have provided incredible insight into professional medical culture. Doctors and nurses almost always state that their reason for refusing to provide abortions is because "it is a sin". They express concern for their own spiritual fate as well as the spiritual fate of their family members. These healthcare providers believe they are protecting their spiritual well-being by denying women this procedure.
We urge doctors to take a patient-centred approach to the medical care they have been asked to provide. We ask them to serve the needs of the women who seek their services before serving their own. Consider this: Is it not a sin to refuse a woman a safe abortion procedure knowing that she would otherwise likely choose to undergo an unsafe abortion? For women who cannot find another abortion provider and who continue the pregnancy, is it not a sin to play a part in forcing a woman to raise a child when she does not have the means to feed, clothe or educate the child?
Is it not a violation of the ethical code of physicians to refuse treatment to those in need? OBGYNs have the responsibility to care for women during some of the most vulnerable times in their lives. They have a duty to improve health and well-being and avoid inflicting harm while doing so. They have a duty to provide care with compassion, which means acknowledging that the conditions faced by their patients may also be suffered by their patients' families. Therefore, these related problems should also be the doctor's concerns. Doctors have a duty to instil these values in generations of learners that follow. When OBGYNs fully honour their duties to women, they will surely find peace of mind.
The Health Ministry estimates there are up to 400,000 abortions in Thailand every year with over 90% being performed in potentially unsafe settings. We are aware of a few dozen doctors and nurses who provide abortion care for all indications permitted under Thai law. We could not expect these few brave providers to meet the needs of all women who seek abortion services. In order to reduce maternal death and disability, Thailand needs more trained and empathic abortion providers.
As women's health experts gather at the Third International Congress on Women's Health and Safe Abortion (IWAC) this week in Bangkok, we hope they will tackle the age-old problem of recognising that all contraceptive methods can fail. Multiple effective and safe treatments are available for women who choose to end an unintended, unwanted or medically doomed pregnancy. Abortion is legal in Thailand. What the country lacks is physician will -- will to invoke the law, to honour their duty to protect and promote women's health, and to provide true patient-centred care. Change is long overdue. Thai women's lives depend on it.
Piyapa Praditpan, MD, MPH, is obstetrician-gynecologist who practises in New York City. Kamheang Chaturachinda MB.ChB, is President of the Women's Health and Reproductive Rights Foundation of Thailand.