Perspectives on Conservative Management and Abortion Legalization as Measures to Reduce Unsafe Abortion Rates

Discussions surrounding the termination of pregnancies in Indonesia remain complex and characterized by various pros and cons. The prevailing fact is that abortion is generally illegal in the country, leading to a significant number of unsafe procedures. Alarmingly, the rate of unwanted pregnancies stands at 40 per 1,000 women of childbearing age in Indonesia, with 63% of these pregnancies culminating in abortion.1 Notably, research conducted in 2018 on the island of Java revealed a striking figure of 42.5 abortions per 1,000 women aged 15-19 years, surpassing the global abortion rate of 39/1000 women reported by the World Health Organization in 2020 (Giorgiona et al., 2020).2  Utomo et al. research aimed to assess the demographic characteristics of women undergoing abortions in Indonesia, conducted across various clinic facilities and government hospitals.[3] The study revealed notable demographic data: approximately two-thirds of the patients were married, with a similar proportion having attained secondary school education. The average age of the patients ranged between 20 to 30 years old, and nearly half of them had at least two children.

According to Utomo's research study, one-third of patients undergoing abortions in Indonesia are married individuals who have experienced contraceptive failure. Interestingly, most of these married women cite reasons related to their desired family size when opting for abortion. The research indicates that the most prevalent cause of abortion among this demographic is unwanted pregnancy resulting from the failure to use contraception effectively.

Most women attempt to induce abortion on their own, often resorting to methods such as using medications or herbal remedies like Jamu. Some may also try traditional massage techniques. If these self-administered methods fail to terminate the pregnancy, then they seek medical assistance for the procedure.[4]

The prevalence of unsafe abortions in Indonesia presents a significant threat to women's health and well-being. Alarmingly, most abortions are conducted in unregulated settings such as with traditional healers or masseuses.5 This situation poses grave risks to maternal health, including complications such as bleeding, infection, genital trauma, and necrotic intestines, all of which can lead to maternal death.[6] Unsafe abortion stands as a significant contributor to both morbidity and mortality among women. Research findings indicate that unsafe abortion accounts for 3.4% of the maternal mortality rate in Indonesia.[7] The high incidence of maternal mortality attributed to unsafe abortion is primarily due to the lack of supervised healthcare facilities equipped to provide safe abortion services, coupled with the absence of comprehensive policies addressing the diverse needs surrounding abortion care.

In general, there are several groups of indications for abortion, encompassing maternal health concerns, severe fetal defects, maternal psychological distress resulting from pregnancy due to rape, and unwanted pregnancies. Abortion is legally protected for the first three indications. Maternal health concerns, severe fetal defects, and maternal psychological distress are recognized as valid reasons for abortion under the law. However there are no regulation regarding abortion when it comes to unwanted pregnancies, the causes typically involve pregnancies within marriage due to failed family planning or pregnancies outside of marriage.

The comprehension and utilization of contraceptives as a means of preventing unwanted pregnancies remain insufficiently widespread. Evidence from various developing nations indicates that approximately 1 in 10 sexually active women of reproductive age do not utilize any contraceptive method, despite not desiring children.[8] Among these women, concerns regarding the potential side effects of contraceptives are prevalent, highlighting the need for comprehensive counseling and education. Providing education on the various contraceptive options is crucial to assist women in identifying and selecting acceptable methods that align with their needs and preferences.[9]

Views regarding unsafe abortion in Indonesia are significantly shaped by a myriad of factors including social, cultural, religious, and political influences.[10] Various perspectives concerning women's reproductive health, as well as social, cultural, moral, and religious beliefs, alongside considerations of human rights, contribute to the complexity and diversity of opinions surrounding this issue.

From the standpoint of women's reproductive health, unsafe abortion practices pose significant risks including severe complications and even death, underscoring the critical need for access to safe abortion services to enhance women's reproductive well-being. From a human rights perspective, it is recognized that every woman possesses the fundamental right to make decisions regarding her own body, including the choice to undergo abortion. However, from sociocultural, moral, and religious viewpoints, abortion is often perceived as a violation of the fetus's right to life. This complex array of perspectives contributes to the multifaceted nature of discussions surrounding abortion. Moreover, from the perspective of women seeking abortion, there is often a reluctance to disclose or openly discuss their decision due to fears of stigma or negative societal attitudes towards them.[11]

From a legal perspective in Indonesia, Minister of Health Regulation No. 3 of 2016 governs the training and implementation of abortion services within the Ministry of Health.[12] ICJR (Institute for Criminal Justice Reform) published a research report in 2020 titled "Implementation of Safe, Quality, and Responsible Abortion Policies by Health Law in Indonesia," highlighting this issue. However, despite the existence of this regulation, which has been in effect since 2016, the Ministry of Health has yet to designate health facilities capable of providing safe abortion services.[13] The government's cautious and conservative approach to regulating safe abortion reflects its efforts to mitigate the prevalence of unsafe abortions.

As a case study for examining regulatory transformations towards safe abortion, Serbia presents a compelling example. Historically, Serbia has grappled with high abortion rates, with official data from the Belgrade Institute of Public Health in the 1930s indicating a staggering number of both legal and illegal abortions annually.[14] The prevalence of illegal abortions led to numerous complications, including severe bleeding and inflammation, necessitating medical intervention. However, beginning in the 1960s, there was a notable shift towards conducting abortions within medical institutions, coupled with a gradual legalization of abortion rights.[15] Women aged 20-39 comprised the majority of those seeking abortions, with the primary reason being the desire to control the number of births, given the limited availability of contraception during that era. Importantly, records indicate a significant reduction in maternal mortality attributed to abortion complications following the legalization of abortion. Consequently, in 1977, Serbia legalized abortion, permitting the procedure upon a woman's request for pregnancies of less than 10 weeks gestation. [16]

In tandem with the legalization of abortion in Serbia, there has been a notable uptick in the number of abortions performed, as some women opt for abortion to control pregnancy rather than relying on contraception. This trend has had adverse implications for women's health and has led to a significant decline in the fertility rate. Notably, in 1989, Serbia experienced its highest abortion rate, reaching a staggering 63%.14 This surge in abortion rates can be attributed to several factors, including inadequate sexual education, limited knowledge about contraceptive methods, and a substantial number of unwanted pregnancies.[14]

Several positive lessons can be gleaned to prevent unsafe abortions, particularly concerning the abortion regulations outlined in the law on procedures for terminating pregnancy within Serbian state institutions.16 Notably, Article 6 of the law stipulates that abortion, up to 10 weeks of pregnancy, can be performed at the patient's request by a specialist obstetrician at a stateappointed health institution.

Healthcare providers have the option to exercise conscientious objection regarding abortion procedures, but they are obligated to refer the woman to another abortion provider. However, conscientious objectors cannot use this claim to refuse emergency medical assistance. Additionally, it is required that the doctor performing the abortion be specialized in obstetrics and gynecology, ensuring that the procedure is conducted by a qualified and trained medical professional.[17]

Article 6 specifies that indications for terminating pregnancy after 10 weeks are medically indicated, encompassing pregnancies that pose a threat to the mother's health, pregnancies involving fetuses with serious defects, and pregnancies resulting from rape. [16]

Between 10 to 20 weeks of pregnancy, the termination decision is made by a panel of doctors within the relevant health institution. For pregnancies beyond 20 weeks, the decision falls under the purview of the ethics committee of the state health institution. According to Article 8, the chairman and members of the ethics committee are appointed for a two-year term by the Ministry and are accountable for reviewing proposals from the respective health institutions. The termination of pregnancy takes place in a hospital, overseen by a team of doctors designated by the health service institution. Article 12 stipulates that health institutions are obligated to maintain medical records of pregnancy termination and submit reports to the designated Health Institution as mandated by law while ensuring the confidentiality of documentation data.[16]

From the findings of a literature review concerning abortion legalization regulations, it becomes evident that early in the history of abortion, unsafe practices were widespread, leading to significant health risks. In response, regulations governing the implementation of abortion were introduced to establish government oversight. This state supervision involves the designation of health workers and health institutions authorized to carry out abortions, ensuring a controlled and safe environment for the procedure. Additionally, the existence of an ethics board is crucial in decision-making processes related to abortion, further ensuring accountability and ethical considerations in the provision of abortion services.

On one hand, the legalization of abortion, particularly for pregnancies of less than 10 weeks where abortions can be requested by the patient, has led to a significant rise in the number of individuals seeking abortion services due to unwanted pregnancies. This surge in demand has implications for women's reproductive health, as multiple abortions can have adverse effects on their well-being. Additionally, the decreasing fertility rates reflect a societal shift where many families are actively avoiding pregnancy. Unfortunately, this normalization of abortion as a means of contraception signifies a departure from its original intent as an emergency measure. This shift is exacerbated by inadequate sexual education and limited knowledge about contraceptive methods and healthy reproduction, contributing to unhealthy sexual behaviors.

The management of abortion in Indonesia continues to grapple with the challenge of reducing the high prevalence of unsafe abortions. The factors contributing to this issue are multifaceted and complex, encompassing various considerations from the perspectives of patients, medical professionals, and regulatory authorities.

From the perspective of patients, undergoing an abortion remains heavily stigmatized and taboo within society, prompting individuals to conceal their circumstances and seek abortion services discreetly. Furthermore, there persists a notable lack of understanding among patients regarding healthy sexual behavior, contraception, and pregnancy preparation. This deficiency in knowledge stems from the inadequate provision of comprehensive sexual education, which is not universally incorporated into school curriculums.

In the realm of medical personnel and healthcare services, there remains a lack of legal understanding and protection concerning the provision of abortion services. Religious and sociocultural beliefs contribute to a significant number of doctors refusing to perform abortions, often aligning with pro-life stances. Additionally, within the realm of reproductive health regulations, the government appears hesitant to enact changes that could broaden the indications for abortion or implement licensing or legalization processes akin to those observed in European countries.

The literature review on abortion legalization systems highlights several positive elements aimed at safeguarding women's reproductive health. These include designating government health services as the authorized facilities for performing abortions and ensuring a controlled and regulated environment for the procedure. Moreover, the presence of trained obstetrician specialists appointed to carry out abortions enhances the quality and safety of the procedure, minimizing potential risks to women's health. Additionally, the establishment of an ethics committee responsible for deliberating on abortion decisions ensures that ethical considerations are taken into account, further protecting women's rights and well-being. Importantly, all these regulations are enshrined in the law governing the termination of pregnancy in health institutions, underscoring the commitment to comprehensive reproductive healthcare within the legal framework.

The health protection system aimed at combating unsafe abortions has indeed yielded positive outcomes by reducing the incidence of unsafe abortions. However, it has also inadvertently led to a shift in the indications for abortion, transforming it into a means to facilitate the termination of unwanted pregnancies. This shift is notably influenced by Article 6 of the health law, which legalizes abortion up to the tenth week of pregnancy, allowing it to be performed at the patient's request. As a result, abortions have increasingly become a recourse for individuals seeking to end pregnancies they deem undesirable, rather than solely for medical or health-related reasons.

Based on the literature studies outlined above, several suggestions can be proposed to inform abortion regulations in Indonesia, considering the perspectives of patients, medical personnel, and regulatory frameworks.

To address issues such as pregnancies from unhealthy mothers, pregnancies with fetal defects, and unwanted pregnancies, prioritizing reproductive health and promoting healthy pregnancies becomes imperative. One effective strategy involves collaboration with the Department of Education to integrate comprehensive reproductive health education into the mandatory school curriculum, starting from the elementary school level up to higher education. This initiative ensures that individuals receive essential knowledge about reproductive health, contraception, pregnancy prevention, and the importance of preconception health care from an early age. Additionally, health authorities at the district and sub-district levels should take proactive measures to register adolescents of reproductive age and ensure they receive targeted reproductive health education.

From a regulatory standpoint, the Ministry of Health plays a crucial role in facilitating reproductive health services, particularly safe pregnancy termination services, across government hospitals. These services are governed by clear legal regulations aimed at ensuring the safety and well-being of patients. Collaboration among doctors, psychologists, and the hospital ethics committee is essential to provide comprehensive care while prioritizing patient privacy rights. Moreover, it is imperative to communicate these services comprehensively and continuously to the community, ensuring that women facing pregnancy-related issues are aware of where to seek help and can avoid resorting to covert and potentially unsafe actions.

The government appoints a central coordinator responsible for overseeing all pregnancy termination services within government agencies. This individual is tasked with coordinating, recording, and evaluating these services, as well as serving as a liaison with relevant organizations such as the Women's Protection Agency and Security Forces. This regulatory framework ensures effective coordination and collaboration across sectors to provide comprehensive support for individuals seeking pregnancy termination services. Moreover, the government has taken proactive steps to socialize this regulation and incorporate it into the curriculum for health workers, thereby fostering a clear understanding of the Pregnancy Termination Services policy among healthcare professionals.