Politically, abortion is almost always regulated by law.

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Literature Review

Politically, abortion is almost always regulated by law. These laws can vary from complete criminalization to specific circumstances of allowances, all the way to complete legalization. The majority of these regulations exist in the middle area, where abortion is regulated but often permitted when women fall under certain circumstances. In fact, only 6% of the worlds reproductive population live in an area where abortion is completely banned. Regulations of abortion is changing, between 2000 – 2017 33 countries have expanded the allowances in which abortion can take place (Institute, 2018b). However, when we look towards Africa the reality changes drastically. On the continent, 93% of women of reproductive age live in countries with highly restrictive abortion laws and 18% of African countries have an outright ban (Institute, 2018a). Politically, abortion regulation can harmfully criminalize women for reproductive consequences that are unfortunately not completely under their control. 58 million women of reproductive age in Africa have an unmet need for contraception and since Africa has the highest rates of child marriage many women find themselves martially unable to abstain (Walker, 2012).

Culturally, abortion has taken a paramount place in both religious and political identities. A woman’s decision to induce abortion is often as affected by regulation as it is by abortion stigma, which Kumar et al. (2009) describe as “a negative attribute ascribed to women who seek to terminate a pregnancy” (628). Even in contexts where induced abortion is legal, this stigma can often cause women to pursue pathways to abortion that can minimize the stigma, like self-induced abortions or by going to unregulated institutions, often at the severe cost of safety. In Africa, abortion stigma is paramount and has had profound impacts on women’s access to safe abortion. Complexly intertwined in patriarchal and religious norms, male dominance has been normalized in reproductive decisions (Braam & Hessini, 2004). In Malawi, women noted that they viewed their bodies as possession of their husbands, families, and God; therefore, their reproductive decisions were not their own but rather an action to be considered, evaluated, and most importantly judged by the community (Levandowski et al., 2012). In Zambia, which has one of the most liberal abortion laws, women’s pathways to abortion are still significantly affected by stigma and socio-cultural views of patriarchal ownership.  A study conducted by Coast et al. (2016) found that 1/3 of the women they sampled had attempted to induce abortion prior to arriving at the medical facility in order to avoid judgment. Further, a majority of the women were unaware of the legal status of abortion and relied on information from peers – information controlled by social networks that are formed and influenced by both patriarchal and religious norms of abortion (Coast & Murray, 2016).

In addition to being both highly political and personally cultural, abortion is an economic phenomenon that both drives women to seek an abortion and prevents them from accessing it safely. By definition, an induced abortion is a medical procedure and individuals from low-income countries have the lowest levels of access to health care (Peters et al., 2008). The unfortunate consequence of this economic cost of access can drive women to pursue unsafe abortion (Braam & Hessini, 2004). On the other side of the double edge sword, many women likely choose to seek an induced abortion due to the economic costs of supporting another child. Therefore, it is impossible to talk about abortion without talking about the economic realities that surround it.

With the numerous complexities of abortion and the many realms of a woman’s life it affects, the framing of abortion changes often and appears differently in various parts of the word. A prominent example of this comes from the United States where the “pro-life” and “pro-choice” framing emerged in the late 1960’s (Luker, 1985). However, outside of the United States, access to safe abortion is often framed as a human right and as fundamental to one’s own ability to control their bodies and sexuality (Klugman & Budlender, 2001). In the same vein, public health officials and organizations have strived to frame safe abortion and access as pivotal public health issue, especially with its connection to high rates of maternal mortality (Berer, 2000; Organization, 2015).

Regardless of framing, abortion and its regulations have dire consequences for women all over the world. 22,800 women die each year from complications of unsafe abortions, and almost all abortion-related deaths occur in developing countries (Institute, 2018b). Further, Africa has the highest number of abortion-related deaths throughout the world (Institute, 2018a). Unfortunately, complications that result in death due to abortion are often preventable with 97% of related deaths being caused by the reliance on unsafe abortion methods (Sedgh et al., 2012).

In sum, abortion is truly unique in its complexities resulting in numerous and often disjointed agendas to promote access and safety. The majority of which focus on the developing world where the consequences of abortion have been the most severe. There are many actors involved in the promotion of progressive abortion, however, little work has been done looking at one of the key actors in developing countries – women politicians.

Theoretical Framework

While the study of abortion, as outlined above, is extensive and touches many aspects of social science, little work has been done in Africa on one of the few actors that can influence abortion legally, culturally, and economically – members of the national and local legislatures. Members of the legislature can most obviously set legislation that both legitimizing’s and legalization abortion, but further can change and promote law that combats the dominance of patriarchal and religious hegemony that prevent women from exercising independence in reproductive decisions (Berkman & O’connor, 1993). Further, they can influence budgets to assist with the economic costs of seeking an induced abortion and change overall healthcare costs and funding (Weikart, Chen, Williams, & Hromic, 2007). Lastly, members of the legislature can work to change the stigma that surrounds abortion by promoting abortion by changing the framing of abortion (Levy, Tien, & Aved, 2001). Therefore, this article surveys members of the national and local legislatures in order to understand their opinions on abortions and the ways in which abortion is framed.

We expect that women will have more liberal opinions on abortion. Studies on women, largely based on work in the Global North, have found that on average women are more liberal than their male peers (Tremblay & Pelletier, 2000) and that women politicians are likely to see themselves as representatives of their gender (Swers, 2002). From work on substantive representation, we know that women’s presence in the legislature progressively changes government policy objectives for women rights (Burnet, 2011; Hanssen, 2005; Tripp, 2006) and that women are more likely to vote for policy on women’s issues (Swers, 1998). Therefore, we expect that among Zambia politicians, both at the national and local level, women will have more liberal opinions on abortion.

H1: Women politicians will have more liberal opinions on abortion than their male colleagues.

We also expect that women will be more affected by the framing of abortion. Studies have found that women engage in discussion surrounding abortion differently often focusing on health ramifications of restricting access to abortion (Levy et al., 2001). Specifically, women politicians root the debate in health where their male peers often rely on arguments of morality or religion to try to combat progressive abortion legislation. More importantly then just women politicians themselves framing the debate on abortion differently, evidence shows that this has impacted the evolution of the framing overtime(Levy et al., 2001). Therefore, we expect that among that among Zambia politicians, both at the national and local level, women will be more supportive of abortion policies when exposed to a health-related framing.

H2: Women will be more supportive of a health-related framing of abortion policy

We will explore these hypotheses by analyzing the results of a survey we conducted in 2017 with members of parliament and ward councilors in Zambia.

 

The case of Zambia

Legal frameworks are recognized as vital for securing the right to health. However, the relationship between the law and access to safe abortion services is complex. Political, economic and social context in which the law are embedded may generate unexpected outcomes (Moland et al. 2017). Unsafe abortion is one of the most neglected sexual and reproductive health issues globally and contribute substantially to maternal mortality. Moreover, abortion-related maternal deaths occur predominantly in  ow-income countries and young women are disproportionately affected. For this reason, the high rate of unsafe abortions is referred to as the “silent pandemic” (Grimes et al. 2006).[1]

Zambia has one of the most liberal abortion laws in Sub Sahara Africa. The Termination of Pregnancy Act of 1972, determines that an abortion may legally take place if the continuation of the pregnancy involves a risk to the pregnant woman’s life, physical or mental health; a risk to the physical or mental health of any existing children; or if there is a substantial risk that the child will be born with birth abnormalities[2]. The Act further specifies that the pregnant woman’s actual or reasonably foreseeable environment may be taken into account. The signatures of three doctors are needed, although this requirement is waived if one doctor believes that the abortion is immediately necessary to protect the woman’s health. The Penal Code was amended in 2005 to explicitly state that abortion is permitted in cases of child rape[3]. In May 2009, the Ministry of Health published a set of standards and guidelines for reducing unsafe abortion; these clarified that a wide range of factors including age, economic situation, social and cultural environment, religion and marital status should be considered in determining whether continuing a pregnancy poses a risk to the woman’s health, including her subjective well-being. If one or more of these conditions are met, then a trained health provider may carry out an abortion based on the woman’s free consent. The guidelines also state that mid-level providers can provide first trimester abortions, which allow services to be decentralized and reduce the distance women need to travel in rural areas.

Despite the relatively liberal legal framework, social attitudes towards abortion remain conservative, and knowledge of safe abortion services remains poor (Onikepe et al. 2017). Troublingly, the law has not advanced safe abortion services, access to safe abortion has been made almost unattainable particularly for young, poor, rural girls (Zulu et al. 2018).  In Zambia, the maternal mortality ratio in Zambia is estimated at 398 maternal deaths per 100 000 live births, with around 30% of maternal deaths thought to be due to unsafe abortion (Cresswell et al. 2016). The Ministry of Health estimates that unsafe abortions accounts for 30 per cent of maternal deaths (MOH 2011, Cresswell et al. 2016).Estimates suggest that approximately 80 per cent of women taken to health facilities for abortion-related complications were adolescents (Muzira and Njelesani 2013).  Survey as well as media reports show that people had strong beliefs regarding the immorality of abortion (Geary et al. 2012). Studies of adolescent women demonstrate that self-induced abortion and traditional healers were considered common methods of abortion, with few participants considering going to a public health facility unless something went wrong. This suggests that many women may not use a trained provider even where they are available (Halwiindi et al. 2016, Cressewell et al. 2016). Health system and human resource constraints mean that, in practice, many Zambian women cannot access safe abortion services. Although abortion in Zambia is legal on medical and social grounds, most women in Zambia resort to illegal abortions because legal abortion services are inaccessible, unacceptable, and because both the population and health workers are unaware of the legal provisions for abortion (Halwiindi et al. 2016). Statistics in Zambia reveal a high induced abortion mortality ration of 120 induced abortion-related deaths per 100 000 live births. Moreover, more than half of the deaths are among school girls. Studies among adolescent girls demonstrate that most female adolescent are not aware of the provision of the law on the termination of pregnancy. Even in urban areas of Lusaka province, only 55% %) of women knew that an abortion could legally take place to save the mother’s life (Cresswell et al 2016).

Thus, despite relatively liberal laws, Zambian women continue to seek unsafe, illegal abortions. Attitudes remain conservative. Barriers to safe abortions are in part due to the requirement that abortions be performed by a physician, with the consent of an additional two medical practitioners. Another barrier is lack of knowledge about the abortion law in Zambia. Research show that many people believe that abortion is illegal under any circumstance and not available in hospitals or clinics (Geary et al., 2012). Research probing knowledge and attitudes of health personnel, similarly report limited awareness about the legal provision for access to safe abortions.

The case of Zambia, highlights the importance of the religious-moral dimension of abortion. Zambia in 1996 was declared a Christian nation and the churches, the Catholic Church and the independent Pentecostal churches, are increasingly vocal and visible on the issue of abortion. In 2016 a new bill of rights proposed an amendment to the constitution that would have vast implications for abortion had it been passed, stating that “The right to life begins at conception”[4]. In Zambia, the moral-religious discourse has opened for a renewed political dispute over abortion that threaten to stall ongoing public health efforts to simplify access to safe abortion. However, while household surveys indicate that although Zambians hold strong beliefs about the immorality of abortion as a general principle, they are also concerned about women´s health and safety. Based on these findings Geary et al. (2012) suggest that increased awareness about abortion laws in Zambia may be important for encouraging more favorable attitudes. Women with correct knowledge of abortion law in Zambia tended to have more liberal attitudes towards abortion and access to safe abortion services. Poor knowledge and conservative attitudes are important obstacles to accessing safe abortion services. Changing knowledge and attitudes can be challenging for policymakers and public health practitioners alike.

To our knowledge, while attitudes and knowledge-levels have been assessed among adolescent girls (Cresswell et al. 2016), women (Halwiiindi et al. 2016), the general population (Geary et al. 2012), and health workers, [5] (Moland et al. 2017),  no study has analyzed the attitudes of political elites. To what extent are Zambian law makers knowledgeable about the law? To what extent do they support the current law? And, under what circumstances may elected political elites be willing to change attitudes toward abortions?

 

References

(CSO) Central Statistical Office, Ministry of Health (MOH), ICF, 2014: Zambia Demographic and Health Survey 2013-14. Lusaka.

Cresswell, J.  R, Schroeder, M. Dennis O. Owolabi, B. Vwalika, M. Musheke, O. Campbell, V. Filippi, 2016: “Women´s knowledge and attitudes surrounding abortion in Zambia: A cross sectional survey across three provinces”, British Medical Journal https://bmjopen.bmj.com/content/6/3

Grimes, DA, B. J. Singh, 2006: «Unsafe abortion: the preventable pandemic”. Lancet, 368, pp. 1908-19.

Halwiindi, T, Mulenga, D. and S. Siziya, 2016: “Awareness on the availability of legal safe abortions among female adolescents attending secondary school in Ndola district, Zambia” Asian Pac.J. Health Sci, 3 (4), pp. 11-16.

MOH (2011), National Health Strategic Plan 2011-2015.

Moland, KM, H. Haukanes, G. Tadele, A. Blystand, 2017: «The paradox of access- abortion law, policy and misoprostol”. Tidsskr Nor Legeforen

doi: 10.4045/tidsskr.17.0809

Leone,T. E. Coast, D. Parmar,  and B. Vwalika, 2016: “ The individual level cost of pregnancy termination in Zambia: a comparison of safe and unsafe abortion” Health Policy and Planning, 31, 2016, 825–833 doi: 10.1093/heapol/czv138

Geary  CW,  Gebreselassie  H, Awah  P., 2012: “Attitudes toward abortion in Zambia. Int J Gynaecol Obstet 2012;118(, pp 148–51. doi:10.1016/S0020-7292(12)60014-9

Onikepe, O., J. Cresswell, B. Vwalika, D. Osrin, V. Filippi, 2017: “Incidence of abortion-related near-miss complications in Zambia: Cross-sectional study in Central, Copperbelt and Lusaka Provinces”, Contraception, Vol 95, pp. 167-174.

Zulu, J., J. Ali, K. Hallez, N. Kass, C. Michelo and A. Hyder, 2018: “Ethical challenges in research on post-abortion care with adolescents: Experiences of researchers in Zambia”, Global Bioethics. Open access https://doi.org/10.1080/11287462.2018.1528657

References

Berer, M. (2000). Making abortions safe: a matter of good public health policy and practice. Bulletin of the World Health Organization, 78, 580-592.

Berkman, M. B., & O’connor, R. E. (1993). Do women legislators matter? Female legislators and state abortion policy. American Politics Quarterly, 21(1), 102-124.

Braam, T., & Hessini, L. (2004). The power dynamics perpetuating unsafe abortion in Africa: A feminist perspective. African Journal of Reproductive Health, 43-51.

Coast, E., & Murray, S. F. (2016). “These things are dangerous”: Understanding induced abortion trajectories in urban Zambia. Social Science & Medicine, 153, 201-209.

Institute, G. (2018a). Abortion in Africa

INCIDENCE AND TRENDS.   Retrieved from (https://www.guttmacher.org/fact-sheet/abortion-africa

Institute, G. (2018b). Induced Abortion Worldwide

GLOBAL INCIDENCE AND TRENDS.   Retrieved from https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide

Klugman, B., & Budlender, D. (2001). Advocating for abortion access: eleven country studies: Women’s Health Project, School of Public Health, University of the Witwatersrand.

Levandowski, B. A., Kalilani‐Phiri, L., Kachale, F., Awah, P., Kangaude, G., & Mhango, C. (2012). Investigating social consequences of unwanted pregnancy and unsafe abortion in Malawi: the role of stigma. International Journal of Gynecology & Obstetrics, 118(S2).

Levy, D., Tien, C., & Aved, R. (2001). Do differences matter? Women members of Congress and the Hyde Amendment. Women & Politics, 23(1-2), 105-127.

Luker, K. (1985). Abortion and the Politics of Motherhood (Vol. 759): Univ of California Press.

Organization, W. H. (2015). Health Worker Role in Providing Safe Abortion Care and Post Abortion Contraception: World Health Organization.

Peters, D. H., Garg, A., Bloom, G., Walker, D. G., Brieger, W. R., & Rahman, M. H. (2008). Poverty and access to health care in developing countries. Annals of the New York Academy of Sciences, 1136(1), 161-171.

Sedgh, G., Singh, S., Shah, I. H., Åhman, E., Henshaw, S. K., & Bankole, A. (2012). Induced abortion: incidence and trends worldwide from 1995 to 2008. The Lancet, 379(9816), 625-632.

Swers, M. L. (1998). Are women more likely to vote for women’s issue bills than their male colleagues? Legislative Studies Quarterly, 435-448.

Swers, M. L. (2002). The difference women make: The policy impact of women in Congress: University of Chicago Press.

Tremblay, M., & Pelletier, R. (2000). More feminists or more women? Descriptive and substantive representations of women in the 1997 Canadian federal elections. International Political Science Review, 21(4), 381-405.

Walker, J.-A. (2012). Early marriage in Africa–Trends, harmful effects and interventions. African Journal of Reproductive Health, 16(2), 231-240.

Weikart, L. A., Chen, G., Williams, D. W., & Hromic, H. (2007). The democratic sex: Gender differences and the exercise of power. Journal of Women, Politics & Policy, 28(1), 119-140.


[1] The Millenium Development Goals (2001) and the Sustainable Development Goals (2015) omitted safe abortion from the agenda of reducing maternal mortality. The highly politicized nature of the abortion issue is further illustrated by the reinstatement of the “Mexico City Policy”, or “the global gag rule” by President D. Trump in 2017 blocking US funds to organizations involved in abortion services or care.

[2] Abortion is regulated the termination of pregnancy Act of Chapter 26 of 1972 and chapter 13 of 1994 of the revised Act.

[3] Section 152 of the Termination Pregnancy Act was amended in 2005 and now provides that where a minor (girlchild) is raped or defiled and becomes pregnant, the pregnancy may be terminated in accordance with the termination of pregnancy act. The provision does not apply to adults, which means that women victims of rape cannot benefit from the provision.

[4] Electoral Commission of Zambia: Understand the 2016 referendum. Lusaka, 2016.

[5] Holo Hachoonda, a clinical director at the Planned Parenthood Association (PPAZ), asserts that many health practitioners did not understand the abortion law, and were reluctant to provide the service.

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