Abortion is a Method of Family Planning

Abortion is a Method of Family Planning

Ruth Dixon Mueller
An implied premise in the thinking of much of the international population community is that contraception is somehow very different from, and always preferable to, abortion. Health and family planning professionals frequently consider abortion to be an unfortunate fact of life, or even a necessary evil; some do not consider abortion a method of family planning at all. According to this line of thought, a major goal of the family planning movement is to promote effective contraception in the hope that the demand for abortion will diminish or disappear.
Let us consider an alternative view. First, the sharp distinction between abortion and contraception may be more of an ideological construct than a logical response to women's needs or a recognition of women's diverse realities. Second, many women prefer abortion to contraception because it meets their particular needs at a given time better than contraception does. Third, abortion will always be necessary as a backup for contraceptive failure or nonuse where women or couples are determined to prevent an unwanted birth.
Improvements in the quality and quantity of contraceptive services would undoubtedly help to reduce some women's reliance on abortion. Nevertheless, women will always need to have access to safe and supportive abortion services as an integral element of their reproductive health care.

Are Contraception and Abortion Really Different?
The act of preventing conception is clearly distinguishable in a scientific sense from the act of preventing a birth once conception has occurred. However, the sharp legal and social distinctions that some experts have made between them may be misleading. For many women, the more crucial distinction is not between using a method before or after conception, but between having or not having a surviving child.
Throughout the ages and in virtually all societies, women have tried an array of methods to prevent or destroy unwanted conceptions or births. These include incantations or herbal potions to prevent conception or induce menstruation; abstaining from sexual intercourse during presumably fertile periods; expressing sexuality in ways other than penile-vaginal penetration; suppressing ovulation with breast feeding or synthetic hormones; blocking the passage of sperm by using withdrawal or barrier contraceptives; altering the uterine environment with mechanical devices or contragestive drugs; obtaining surgical sterilization; inducing miscarriage or having an abortion; and killing an unwanted infant or letting a child die.
Why should the distinction between pre- and post-conceptive methods take on such importance in this array? A woman looks, consciously or not, for the method that has the least negative impact on her life. Conception has not always been the "cut-point" in the reproductive cycle in this regard. Women in preindustrial Europe, for example, took their herbal potions before or after a missed period; it was "animation" or "quickening" rather than "conception" that had meaning for them. The technology of contragestive drugs such as RU 486 hours the distinctions even further between contraception and abortion, between "prevention" and "cure." Even a live birth may not be the event that fully defines life: in some societies, a newborn child is not considered a member of society until it has passed through a ritual presentation or naming ceremony some days or months later.
Viewed in this way, contraception and abortion can be considered as complementary and, in some respects, even interchangeable ways of preventing or treating unwanted conceptions. Rather than dichotomizing the two approaches and relegating abortion to the periphery of family planning programming or excluding it entirely, surely it would make sense to try to capture this holistic element by integrating contraception and abortion in service delivery and ensuring the safety of both.

When Abortion is Necessary
A woman may know about and even have access to contraceptives, but use them ineffectively or not at all for quite rational reasons. As international fertility surveys have shown, many couples who are not contracepting do not want to have a child right now. Typically categorized as having an "unmet need" for family planning, many of these women are candidates for abortion if they become pregnant. Some women get pregnant while believing they are safe because they are breast feeding or for other reasons. Others have unexpected or forced and unprotected intercourse. Some are ambivalent about using contraceptives, for health or other reasons, or have discontinued using them because of inaccurate or misunderstood advice, experience with side effects, or fears of future illness or fertility impairment. High rates of contraceptive failure typical of some methods and populations underline the continued need for safe abortion as a backup. Still other women with wanted pregnancies experience a drastic change of economic, social, or personal circumstances in which abortion seems the best-or only-option.

When Abortion is Preferred
Abortion is not only necessary, it is sometimes a preferred method of family planning for some women. Depending on a woman's personal circumstances, abortion can offer several advantages over contraception. Abortion permits the greatest control over the timing of childbearing, for example: it allows a woman to decide about a pregnancy if and when she is actually pregnant. As a curative rather than preventive method, its outcome is more certain than a contraceptive that may or may not be effective or even necessary. Moreover, abortion can in theory be used by a woman without the knowledge of her sexual partner, which is not true of all contraceptive methods.
Some women may also prefer abortion if they are afraid to contracept or are afraid to ask their partner to do so. Inducing a miscarriage can seem more natural to some women than taking a pill every day, getting periodic injections, having a device inserted into the uterus or under the skin, or being surgically sterilized. Estimates on the incidence of abortion in Southern countries-38 million per year, with only an estimated 17.6 million performed legally-suggest that such preferences may prevail not only where abortion is done in a safe and sensitive manner, but also where it is costly or dangerous. Where abortion is properly performed within the first 12 weeks of pregnancy, the resulting mortality rate is lower than for other family planning methods, such as the IUD, tubal ligation, or hormonal pills. A sexually active woman might rationally choose a barrier method with early abortion by trained providers as a backup, because in combination they offer the safest method of prevention an unwanted birth.
Many women also prefer abortion over contraception at certain points in their lives because of conflicting social norms and sexual relationships. For example, some young single women want to avoid the dilemma of being contraceptively "prepared" for sexual encounters that they or others may consider immoral. Getting pregnant with the option of safe termination enables a woman to test her partner's commitment to maintaining the relationship and raising a child. A woman who is uncertain about her fecundity can demonstrate to herself or to others that she can get pregnant, which may be important to her marriage ability or to her status within a marital or non-marital relationship even if she does not intend to have a child right away.
Whereas an unsafe, clandestine abortion, or even an impersonal medical procedure, can be physically and emotionally traumatic, supportive counseling in the context of safe services can encourage women to construct or reconstruct their social identities and clarify their goals. More clearly than contraception, the abortion experience for some women can illuminate and perhaps help to resolve conflicting relationships and responsibilities in concrete ways.
For all of these reasons, some women will continue to prefer abortion, at least at some point in their lives, unless the circumstances that favor abortion over contraception are radically altered. Some of these circumstances derive from a woman's particular social or personal situations, some from the inadequacies of particular contraceptive methods or delivery systems. While some elements can be altered through programmatic interventions, others are embedded in social structures and gender relations that will require far broader and deeper social transformations.

Altering the Cost-Benefit Balance of Contraception and Abortion
Some critics contend that the majority of contraceptive programs are not effective in preventing abortions because they respond not to the "definition of the situation" experienced by women themselves, but to institutional needs instead. Is it possible to transform contraceptive delivery systems so that they have a better "fit" with women's own needs and experiences?
Proposals for improving contraceptive service delivery and quality of care include raising providers' interpersonal skills and sensitivity, guaranteeing clients fully informed choice among a wide range of birth control methods, assuring clients of careful follow-up and continuity of care, creating positive and trusting client-provider relationships, and offering an appropriate constellation of services to meet women's comprehensive sexual and reproductive health needs. At the heart of these proposals lies the transformation of modes of exchange so that technical information is offered in a way that builds on what women already know and helps them gain control over their fertility and sexuality. Family planning workers would be trained not only to convey respect and caring for clients, but also to explore women's feelings and values, provide information effectively, and help to clarify clients' options in their sexual and reproductive lives.

Safe Abortion as Necessary and Good
Improving the quality as well as the distribution of contraceptive and other reproductive health services could go along way toward altering the reliance on abortion as a primary method of fertility regulation among women whose contraceptive and counseling needs are not currently being met. For many women however abortion will continue to be a preferred method of family planning while for others it will be a necessity. The demand for abortion remains high in most industrial countries and is likely to rise in many Southern countries even with rising rates of contraceptive practice, as women and men try to adapt their fertility to changing preferences. Eliminating dangerous, clandestine abortion is clearly a matter of utmost urgency. The availability of safe, supportive abortion services as a basic component of women's comprehensive reproductive health care is thus neither an unfortunate fact nor a necessary evil. Like all family planning, it is a woman's right, a social entitlement, and a positive social good.

This essay draws in part from a paper by, and with the permission of, Deborah Rogow, IWHC Consultant, "From Abortion to Contraception: Getting to the Emerald City," written for a meeting sponsored by The World Health Organization, Regional Office for Europe, on the topic "From Abortion to Contraception: Public Health Approaches to Reducing Unwanted Pregnancy and Abortion Through Improved Family Planning Services," held in Tbilisi, USSR, October 1-13, 1990.

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