Abortion in Malaysia: legal yet still inaccessible.

Despite the Cairo and Beijing conference agreements 15 years ago,women's access to safe legal abortion services was not widelyrecognised as a human right, reproductive right and public health issuein Malaysia until the Reproductive Rights Advocacy Alliance Malaysia(RRAAM) was set up in 2007. RRAAM believed that in spite of the 1989liberalisation of Malaysia's Penal Code to allow abortion forphysical and mental health reasons, the law was not widely known.

In 2007, RRAAM, a multi-sectoral alliance of women NGOs, theFederation of Reproductive Health Association of Malaysia (FRHAM),gynaecologists, specialists, lawyers and feminist researchers, began tocollect evidence on barriers to abortion service accessibility from bothwithin the health system and from women's experiences. The ARROWICPD+15 monitoring and advocacy project allowed RRAAM and FRHAM togather more evidence and to advocate with policy makers. This articlediscusses the main findings and recommendations from this monitoringstudy. (1)

The RRAAM-FRHAM study found that there is very restrictedaccessibility to legal abortion in most government hospitals. Whenabortions are provided in government hospitals, this is strictly basedon medical reasons and not according to the full permissibility of thePenal Code. (2) Some women who have been raped and women with foetuseswith congenital abnormalities have been reported to have been refusedabortion and referred to other hospitals. In one Kuala Lumpur publichospital, an extreme reluctance to perform any kind of legal abortionwas reported. Furthermore, experiences with women seeking help fromwomen NGOs showed that some low-income, young, unmarried anddisadvantaged women have been refused safe, legal and affordableabortion from government hospitals in Kuala Lumpur.

Meanwhile, abortion services were found to be available in theprivate sector, but services are costly, secretive and unregulated. Thereported cost of an abortion can reach RM2,000 (US$588), when an averagefee for an early abortion is estimated by RRAAM to be around RM300(US$88), thus making the service inaccessible to poor, low-income,migrant and young women.

The study also found that the main barrier restricting access isthe misconception by doctors, nurses, women, the media and the publicthat abortion is not legal. A RRAAM survey found that of 120 doctors andnurses, 43% responded incorrectly about the legalities of abortion.Similarly, a survey of reproductive health clients who had had a legalabortion in a private clinic, found that 41% did not know the correctlegalities on abortion. Inaccurate statements on the legality ofabortion were also found in some government publications and NGO websites, in the Malaysian Medical Council Code of Ethics and in massmedia articles.

Another barrier is the unsympathetic and judgemental attitudes ofmany government doctors and nurses. When asked the RRAAM surveyquestion: "What do you think women who are pregnant due to rapeshould consider doing?" 38% of the 120 doctors and nurses respondedthat such women should continue the pregnancy and either look after thebaby themselves or give it up for adoption rather than consider havingan abortion. Other barriers are the misconception of service providerson Muslim fatwas on abortion and the prohibition of the Vatican onabortion. The fatwa in Malaysia, (3) as in many of the 57 Muslimcountries globally, allow abortion for health and welfare reasons up tofour months. However, this is also not "widely known. Yet,irrespective of personal and religious beliefs, providers need torespect the civil law and women's choices. No guidance exists onthese ethical issues.

Furthermore, there are no Ministry of Health (MOH) clinicalpractice guidelines on the provision of abortion services; thus,availability of abortion services was reported to vary according to theviews of the Heads of the Obstetrics and Gynaecological Departments ingovernment hospitals. Another problem found by the RRAAM-FRHAM study isthat not all types of abortion services are offered in governmenthospitals. The main abortion method used in government hospitals isstill dilation and curettage, which requires anaesthesia andhospitalisation and is costlier, carries comparatively more risks (4)and is less convenient for women, compared to the cheaper, safer andshort out-patient manual vacuum aspiration (MVA) procedure. Medicationabortion is also not offered even though mifepristone and misoprostolhave been available globally for 15 years and have been recentlyincluded by WHO in the essential drugs list. Mifepristone has not yetbeen registered as a drug in Malaysia, while misoprostol has beenregistered for treatment of gastric ulcer and, hence, not used inhospitals for abortions.

Medical education curricula for undergraduates in three publicuniversities, which are also teaching hospitals, are not up-to-date onthe legality of abortion. Practical training on abortion is also notavailable for undergraduates due to the very few abortions being carriedout in government hospitals.

The study points to Malaysian women's high need for betteraccess to legal abortion, particularly due to several factors. Womenhave a high unmet need for contraceptives. Twenty-four percent ofmarried women in 2004 did not want more children but were not using anykind of contraceptives, according to the most recent national populationand family study. (5) Additionally, young people (who are not includedin these surveys) are increasingly sexually active but their use ofcontraceptives is low. Indeed, the use of contraception in Malaysia hasstagnated for 20 years at around 50% for married couples, which is anindication of low policy priority. Moreover, in 2004, only 32% usedmodern contraceptive methods. The need for abortion is known to behigher in countries "with low use of contraceptives. Access tosafe, legal abortion and to a "wide-range of contraceptives areboth necessary to ensure women's reproductive rights.

The combination of low contraceptive use and limited abortionaccess has several mortality and morbidity outcomes, including deathsdue to unsafe abortions, suicide of young people and abandoning ofbabies. Morbidity includes psychological suffering due to havingunwanted babies, abandoning babies and being forced to bear children asan outcome of rape and incest and children "with congenitalabnormalities. While morbidity has not yet been quantified, RRAAM hasbeen gathering evidence for this.

Recommendations based on the evidence gathered from the study arealready being acted upon. The Ministry of Health is now working on anabortion policy and guidelines. In 2009, the MOH joined RRAAM in aseries of state-level seminars educating all private and public sectorservice providers on abortion law and rights-based women-centredabortion services. The Obstetrics and Gynaecological Association ofMalaysia is also on-board and invited RRAAM in 2009 to present afirst-ever symposium on abortion and reproductive rights at their annualcongress. Meanwhile, RRAAM submitted updated content on abortionlegality at the end of 2009 for the review of the Malaysian MedicalCouncil Code of Ethics, as the legal inaccuracies confuse doctors.

Recommendations that still need to be addressed are obtaining highpolicy priority for increasing contraceptive use, updating the medicalcurriculum with accurate legal content on abortion and training onrights-based and ethical abortion services, and education of the media.

Endnotes

(1) Abdullah, Rashidah (with input from FRHAM). 2009. ICPD+15 NGOCountry Monitoring Report. Malaysia: ARRO W. [unpublished]. Emailarrow@arrow.org.my for the copy.

(2) "In Malaysia, abortion is permitted under the followingcircumstances according to the Penal Code 312 (Amendment) Act 1989 inMalaysia: a) to save the woman's life, b) to protect thewoman's physical health, and c) to protect the woman's mentalhealth." RRAAM. 2010. "Top 10 Myths about Abortion."

(3) "In 2002, the national Fatwa Committee in Malaysia issueda fatwa (legal advisory under syariah law) declaring that an abortionafter 120 days gestation is considered murder unless the mother'slife is in danger or there is fetal impairment." RRAAM. 2010."Top 10 Myths about Abortion."

(4) Abortion is actually safer than childbirth. RRAAM. 2010."Top 10 Myths about Abortion."

(5) Lembaga Penduduk and Pembangunan Keluarga Negara (LPPKN). 2009.Laporan Kajian Penduduk Dan Keluarga Malaysia 2004. Malaysia: LPPKN,Kementarian Pembangunan Wanita & Keluarga dan Masyarakat. [NationalPopulation and Family Development Board (NPFDB). 2009. MalaysianPopulation and Family Study 2004. Malaysia: NPFDB, Ministry of Women,Family and Community.]

By Rashidah Abdullah, Co-Chair, RRAAM.

Email: rashidahabd@yahoo.com