Keynote Address by Dr Nafis Sadik

March 24, 2014
World Leaders Consultation on Safe Legal Abortion

Thank you for your generous applause. I am delighted to meet so many old friends – and to make new ones. I am most grateful to Ipas, IPPF and the Center for Reproductive Rights for hosting this important and timely consultation, and for inviting me to make this keynote address.

I know that we all share a deep concern for the health, wellbeing and human rights of women across the world. In my case, it’s been a lifetime pre-occupation, ever since I started out as an ob-gyn in Pakistan. From the very outset, it was clear to me that on the scale of priorities at that time, the women I served came last, even in their own eyes. They were thin, under-nourished, anaemic. They went through too many pregnancies, too close together, and they paid the price in acute suffering, chronic ill-health and early death. And everyone, including the women themselves, thought this was normal.

I set out to change that, first on my own, then in the national family planning agency, and after that for 30 years at UNFPA, the United Nations Population Fund. I suppose I was a bit brash at first – my first job was in a military cantonment, and I just told the commanding officer he had to make sure his men used condoms. He was quite surprised. He wasn't used to being told what to do, especially by a woman, and a very young woman at that. But he did it.

So far so good – but that was only the beginning. Much has changed, including me. I learned over time that things were more complicated that they seemed at first; and that there was more than one way to get what I wanted. I have become, despite myself, a bit of a diplomat. I know some people might not find me very diplomatic, but I can assure you that it is so.

Without some diplomacy, and a lot of very hard work, we would never have succeeded as we did at the International Conference on Population and Development in Cairo 20 years ago this September. We should not forget that the ICPD Programme of Action was 20 years in the making. The 1974 World Population Plan of Action, the first-ever such document, mentions women only twice, both times in the context of fertility. Ten years later, the Mexico City Population Conference adopted 88 recommendations. They included one (Recommendation 11) on the status of women, which says, in its entirety: "Improving the status of women and enhancing their role is an important goal in itself and will influence family life positively." Between Mexico and Cairo, we came a long way. In the process, we found consensus on some old controversies. In particular we made great strides in putting women at the centre of population questions, and at the heart of rights-based development.

What we found, on the whole, was that many of the apparent sensitivities, for example on family planning, arose from misunderstanding; and that once the mental barriers were cleared away, progress was much easier. The result of our diplomacy was that 85% of the Programme of Action was agreed before the ICPD even began. In the event, the Conference took two weeks and two days. The two additional days were spent debating one paragraph, the famous or notorious Paragraph 8.25 on abortion. The final consensus was that abortion should be minimized, notably by promoting family planning; that unsafe abortion is a public health concern; that where it is legal it should be safe and supported, and that legality is a matter for national decision.

Paragraph 8.25 is a compromise, carefully negotiated to achieve consensus among those who opposed abortion in all cases; those who wished for abortion on demand, and the large majority whose position fell somewhere along that spectrum. We were able to extend the reach of Para 8.25 at the Cairo+5 discussions in 1999 to recommend that countries provide humane treatment and counselling of women who have had recourse to abortion; and where abortion is legal that they should train and equip health-service providers and take other measures to ensure that abortion is safe and accessible.

In both cases, the debate over these few sentences was long and hard-fought. The opposition was very determined and firmly entrenched in their position: that is still the case, but the vast majority of countries agree on the broad principles.

I think it’s important to stress this last point – because the opposition on 8.25 came from a small handful of countries, largely led by the Vatican, which for these purposes has the status of an observer state at the United Nations. Without that factor, the wording of 8.25 would have been much more definitive. It would have been much more helpful to the health and wellbeing of women – who are a rather small minority of the population of Vatican City.

Paragraph 8.25, as amended in 1999, remains the international consensus position on abortion. In its time, it was a breakthrough, the first-ever global consensus on abortion – but it is unsatisfactory in many respects. Para. 8.25 approaches abortion as a separate issue, an outlier in the discussion of women’s reproductive health; whereas we know very well that it is an integral concern. Unsafe abortion now kills an estimated 47,000 women every year, and injures millions more. Abortion remains heavily restricted by law in many countries, with severe penalties in some cases for women who seek abortion as well as those who provide it. Even where it is broadly legal, it is often without strong support, even from some service providers, and access is often limited.

I believe that the conditions exist today for a renewed, extensive and enlightened discussion about legalising abortion, as an issue with profound effects on public health, on family life and on the health of women. Compared with 20 or even 15 years ago, countries pay much more attention to maternal health. Contraception to prevent unwanted pregnancy is a matter of routine health care for many women, and over a hundred million more would adopt family planning now, if they could. There is radical and continuing change in the conditions of family and personal life. Women themselves are in a stronger position to speak up: compared with 20 years ago they wield more economic and political power in many countries, and they are very clear that reproductive health is a prime concern.

Abortion remains a highly sensitive matter, and that is quite understandable. But we must also understand that in some cases abortion cannot be avoided. Contraception is neither universal nor perfect, and human beings are fallible; complications of pregnancy can make abortion necessary; an increase in the incidence of gender-based violence, and especially rape, increases the need for intervention. Girls’ education in sexual and reproductive health is still deficient. Even when they marry they often do not know how to protect themselves from unwanted pregnancy and its consequences.

These are all hard facts, and they are hard for any policymaker or public health professional to confront. But we must confront them, just as women confront them every day. We must do whatever is possible, for women in an impossible situation.

It is also a fact that many of the barriers to a frank and open discussion are in people’s minds. When I started my career in public health, many people, even some women, opposed family planning. It was said to be dangerous, unhealthy, unnatural, an interference with the will of God, a Western imposition, a tool of neo-colonialism, and all sorts of claptrap. Some people still oppose family planning on these grounds, but they are very few, and most of them feel threatened in one way or another by the idea of a woman who is able to make crucial life decisions for herself.

A particularly revealing argument against contraception was that poor and illiterate women would not accept it, or would be easily deceived by people wishing to impose it on them, or would be vulnerable to coercion. Considering the enormous reach of voluntary family planning today, we can see that deception and coercion are self-defeating. It turns out that poor and illiterate women, just like their more affluent or educated sisters, can make their own rational choices, if they are free to do so. The question is not about women’s ability to make choices, but of women’s freedom to make them. Of course, education helps to make women free, and we must ensure that tomorrow’s women are free by educating today’s girls. The human right to education and the human right to health are part of the same discussion.

As at ICPD, we agree on most of the questions. We agree, first of all, that contraception is much to be preferred, but that even if contraception is universally available, some pregnancies will inevitably end in abortion. We agree, second, in our concern for public health and women’s wellbeing: We are all determined to ensure that maternal death and disability rates continue to fall, and that pregnancy does not entail an avoidable risk of death. Finally, we agree that illegal abortion increases women’s risks. A practice that is underground, unregulated, unsupported by emergency services, where practitioner and patient alike feel threatened by the law – that is a formula for ensuring increased death and disability.

Faced with these realities, what should policymakers do? First, I would say, let us practice diplomacy. Many people who apparently oppose legal abortion, including some reluctant health service providers, are open to persuasion. Presented with the facts as I have outlined them here, who can disagree? Many people are influenced by so-called cultural values – but all cultures celebrate life; and no culture worth the name drives women to desperate, life-threatening measures.

Merely opening a discussion will help to change peoples’ minds. All of us in this room, without exception, know a woman who has had an abortion – but we may not know it, because the matter is hidden from sight. Some will say "But I don’t know any women like that." But I say you do – women like that are women like us. Once we start a real, open, frank discussion, we discover that abortion is not the recourse of unfaithful wives, loose women or careless girls. It is not the result of an immoral life. We discover that mothers, sisters, wives, daughters, ordinary women from all states and stages of life, are forced to choose between a pregnancy they cannot continue and an abortion they cannot avoid. It is an agonising choice. The law should make it easier, not harder, for women to make that choice.

Looking at the literature, we find that countries have taken very different stances on abortion policy, depending on their national and local histories and cultures. Changing circumstances now demand that all countries engage in informed and serious debate about the future of abortion. Medical science has shortened the period between conception and viability, raising questions that must be addressed. Family structures are changing; economic conditions are driving decisions. Every country is different, and every country must come to its own conclusion. But no country can avoid the decision, and it is best that the decision be made openly and with the full participation of every woman and man. At the other end of the spectrum, outcomes are worst where interest groups and extremists dominate the discussion, or prevent it altogether.

There will always be opposition, from what I call "the usual suspects," people who for their own reasons cannot or will not recognize, understand or accept that women have a right to make the decisions that will shape their lives. I do not waste time on debating such people. We are rational human beings who live in a rich and varied world, and we cannot allow narrow-minded, backward-looking individuals and institutions to dominate our political and personal life. Diplomacy has its limits!

But diplomacy on sensitive questions has been very successful up to now. Let us look at the successes:

  • Voluntary family planning is universally accepted as a normal part of life, even in countries where it was outlawed only a few years ago;
  • HIV and AIDS does not bear the stigma that held back prevention and treatment in so many places for so many years;
  • Many countries, with some unfortunate exceptions, recognise that human gender and sexuality comes in many flavours;
  • Female genital mutilation or cutting is no longer defended as some sort of religious or cultural value, and in many places is on the decline;
  • All countries recognize girls’ right to education to help them protect their sexual and reproductive health.

None of these successes were easily won, and it took many people and many institutions, including the global consensus-building process of the United Nations, to make the difference. Debates continue in all countries on all these issues, and that is how it should be. Life changes and we, individuals and countries, must change with it. But we should remember that everything started with individual people taking action, individual voices speaking up. It started with a few courageous people, and built from there. And today our voices and our actions are world-wide.

Of course, the hands-on diplomacy I am suggesting calls for courage. It calls for leadership. It calls for a passion on behalf of the health and well-being of women. But that is why we are here: to express our solidarity and our determination to do whatever it takes. Our mission is to ensure that this generation and our daughters’ and grand-daughters’ generations will have the health care they deserve; that they should not have to accept the risk of suffering and death as a normal part of daily life. For me, today, that means opening a discussion about safe and legal abortion, in every part of every country, for the health and wellbeing of every woman.

Thank you.