Earlier this year, 28-year old Abigail Agborku became pregnant unexpectedly. Already a struggling mother of three, she sought to terminate her pregnancy. But something went wrong. She didn’t get the right advice, didn’t have adequate access, and didn’t know where to turn. She ended up in the hands of a quack, as too many women do, and died soon after.
Abortion has been legal in Ghana under a wide range of circumstances — including to protect a woman’s mental health — since 1985, making it one of the most progressive laws in Sub-Saharan Africa. Yet unsafe abortion still contributes to nearly one-third of maternal deaths. Access is chronically denied, and knowledge of the abortion law among women and health-care providers alike is scant. In Ghana, the issue of abortion is taboo. In the silence surrounding it, misinformation and stigma thrive.
Nearly 85 percent of the country identifies as Christian, and in a recent survey, almost 90 percent of Ghanaians reported that abortion was morally wrong. Yet abortion stigma must be placed within the context of even broader taboos around sex and sexuality. “In Ghana, we are sort of in denial about contraceptives. If someone is on family planning, for instance, and you ask her, ‘are you on family planning?’ She’ll say no. When you ask her, ‘well how do you space your children?’ She’ll say, ‘It is God’s grace,'” said Rose Asante, a reproductive health worker in Accra.
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“Talking about sex or family planning, or going to get a contraceptive method, people think it means that you are promiscuous,” she continues. “Our society is not a society where you can talk about sex openly. Everybody grows up knowing this is a no-go area. And especially abortion has a lot of stigma and silence around it; nobody wants to talk about it.”
Women in Ghana who seek abortions are seen as more than just promiscuous. They are considered heartless or careless. “People think you must be a really bad woman to have an abortion,” said Richard Oye*, a reproductive health clinic manager in Ghana’s Ashanti Region. “People don’t want to have it, and people who do want to hide it. That’s why the quacks are in good business. They provide services quietly in the back streets.” Though it is impossible to know exactly what role stigma played in Abigail Agborku’s fatal decision to seek an unsafe abortion, it was almost certainly a major contributor.
A confluence of cultural, religious and geographical factors in Ghana create a sensitive environment where issues of sexual and reproductive health, especially abortion, have remained highly taboo for decades. Yet in 1973, the United States Congress put in place a foreign policy that would serve only to reinforce such stigma over the next forty years.
The Helms Amendment to the Foreign Assistance Act, named for the late Senator Jesse Helms (R-NC), prohibits the use of US foreign aid for the “performance of abortion as a method of family planning” or to “motivate or coerce any person to practice abortions.” Essentially, any developing country government or NGO in the world that receives USAID money is prohibited from using those funds to provide abortions, even if it is legal in their country.
The Helms Amendment is an affront to reproductive freedom for several reasons, but perhaps the real peril of the policy is its vague and elusive wording. What is ‘abortion as a method of family planning’? What does it mean to ‘motivate or coerce’? The language is difficult to interpret, and therefore put into practice.
An amendment added in the 1990s was meant to clarify that information and counseling for safe abortion is indeed allowed. But according to recent Ipas research in both Ghana and Nepal, this is largely being ignored in favor of near-universal censorship. NGOs and governments receiving U.S. funding fear for their job and funding security, and as a result often won’t even talk about abortion services.
“Pervasive silence and stigma around abortion is the real damage of the Helms Amendment, not so much from the law itself but as a result of its widespread misapplication,” says Patty Skuster, Ipas senior policy advisor.
While the Helms Amendment doesn’t explicitly foster abortion stigma at the community level, the way it isolates abortion services from the continuum of reproductive health care contributes to an environment of shame. Further, the policy perpetuates an institutionalized stigma at the highest levels — among the ranks of privileged and well-resourced NGO professionals, policymakers, and providers.
“Because of this rule, I don’t dare go near any abortion clinic, because it will look like I’m involved with abortion. Even if I’m just there to talk to the client about family planning — to empower her to make a decision to prevent an unintended pregnancy — because of the rule and my ‘salary,’ I will not ever go there. I don’t want to be part of it and I don’t want to be seen as being part of it,” says one USAID-funded reproductive health professional.
There is a long legacy of institutionalized abortion stigma and censorship in U.S. foreign aid. Before its repeal in 2009, the Mexico City Policy (global gag rule), saw numerous NGOs defunded by USAID for their association with abortion services. At press time, a vote on the permanent repeal of the Mexico City Policy was pending in the U.S. House.
The implications of institutionalized stigma can be disastrous for women at the community level, and for reproductive health advocates working to improve access to safe abortion. While advocates are working at the grassroots level to expand access to safe abortion services, censorship and prejudice is being reflected back to the community from the highest institutional levels. The Helms Amendment prevents doctors who should be providing and NGOs that should be advocating from doing so, both explicitly and implicitly.
Although researchers and advocates are just coming to understand the full effects of abortion stigma in Ghana, there are signs that a sea change, however slow, is possible. Says Rose Asante: “Now it’s changing; 20 years ago it wasn’t like today. At that time you couldn’t even mention ‘abortion,’ but now you can go in, give a talk and even tell people that if you are pregnant and you don’t want to be, don’t take any drug, don’t attempt, just come to the hospital and ask for the service and there are people that can help.”
Abortion stigma is not insurmountable. This, perhaps, is the most empowering thing we can understand as advocates. “Abortion stigma is used to control and punish women. But it’s just a social construct. It simply doesn’t have to be the reality,” says Leila Hessini, director of community access for Ipas. “We as advocates need to reflect on our own contribution to stigma, and how we are all creating it. When we legitimize some abortions — early versus late or those that don’t need public funding versus those that do — we collectively stigmatize abortion. Let’s deconstruct what we’ve learned and create a new paradigm, where women’s rights are upheld.” This, of course, would be a world where Abigail would live happily to see her three children grow.
This post is adapted from an article appearing in the Fall 2011 issue of Because, the Ipas magazine that connects U.S. readers to women around the world, highlighting reproductive health and rights and making connections between U.S. policy and global health. For a free subscription to Because, click here. *All names have been changed.