Being pregnant when you want to be can be a wonderful experience. Being pregnant when you have been raped or coerced into sex or unready or unable to care for a child is one of the worst and most dangerous experiences a woman can have. Women in these circumstances feel so strongly about not wanting to be pregnant, that they will take extreme measures to avoid it, often risking their lives and health. Women will not have control over their health and their destinies, and maternal mortality rates in poorer countries will remain high until universal access to inexpensive safe abortion is available around the globe. Abortion is sometimes avoided as an issue because of its controversial nature and because the debate so rarely changes people's minds on the subject. But access to safe, legal, and affordable termination is vital for several reasons that are discussed on pages 112 to 118 of the text. We also have a video of Caitlin Gerdts, an epidemiologist and expert on reproductive health, speaking about these issues. >> Was it your interest in inequality that led you to focus, as you have? >> Yeah. >> And let's here more about that focus. >> That's a great question. So as I said, I think that what has brought me to the field of reproductive health has indeed been issues of inequality, both in our own country, but globally has always been more of my focus. And again, because I study contraception, and specifically abortion, thinking about inequality and inequality in access to services and access to rights is a big question around the world. And it varies from country to country what the issues of inequality are. But I think that as someone who has been committed to women's rights and reproductive rights, thinking about the choices that women are making and the choices that women have in various limited or more expansive contexts has always been of interest to me. >> Could you give us an example, a very specific example, perhaps from Ecuador or other, wherever you may have traveled or lived. >> So after I left Stanford, I spent some time in the Peace Corps in Ecuador. And much of my work there focused on education around family planning. And something that I saw very commonly among women in the community that I was living in was an interaction between gender-based violence and access to family planning. And it took me quite some time to understand this interaction and where it was coming from. But the patriarchal establishment in the country where I was living certainly condoned gender-based violence as a norm, as something that women were expected to tolerate. But that experience for women was so disempowering and was so, I think, harmful to their own image of themselves and their own ability to control their lives broadly that their interest in or information about or access to information about family planning was in turn very limited. Whether it was because they themselves didn't recognize their own ability to go and seek information or simply because their partners would forbid it. And thinking about the way that these women were living their lives, just talking with them and presenting them all of the options in terms of family planning was a fascinating conversation. Most women in the community I was living in were having four or five kids. But if you asked them how many kids they would like to have, they would say two or three, which means they're having two or three more children than they ideally would want. And there certainly were some interesting interactions with religion that I encountered while I was in Ecuador. But I did find even the Catholic priests in the community were relatively open to women using modern methods of family planning. But one thing that I kept encountering over and over was that despite the fact that women wanted to be able to control their own fertility and might even know about some of the methods of contraception. They weren't willing to go to the one place where they could have gotten it in their community, which was the health center and surmounting those kinds of hurdles. And thinking about the fact that this was, it's certainly the only place they could go in their own town. And if they wanted to go somewhere else, it would be 45 minutes to one hour and a half walk to get to a different health center in a different town. But women don't have that kind of time freely, and they would often have to justify it to a partner or to other members of the community if they saw them walking in one direction. And thinking about how to increase women's ability to access these services without putting themselves at jeopardy certainly peaked my interest and Brought me even closer and made me want to study these issues even more Another example that I could give is access to abortion services in Ethiopia. Similarly, gender norms and centuries of patriarchy leaves women faced with similarly difficult choices in Ethiopia. There's a fascinating program in one region of the country where traditional birth attendants have been trained to give women Depo Provera injections. Which is a very covert method of birth control, and it's something that women don't even have to leave their house. To receive in a visit from a traditional birth attendant is a very common occurrence. So, it's not particularly suspicious. So, I think that kind of methodology is certainly interesting. Depending on the trust that the woman has with her birth attendant. But despite the fact the contraception is perhaps even more readily available in Ethiopia then it was in Ecuador, in 2005, the Ethiopian parliament changed the criminal code to make abortion more legal on broader grounds in Ethiopia. And a big driver for the legal change was a discrepancy, a real inequality, in the maternal mortality ratio for young women, for women under the age of 18. And much testimony was offered by obstetricians and gynecologists, by the society of midwives, by a group of female lawyers, that was incredibly compelling. Suggesting that much of the maternal mortality in younger woman in Ethiopia was being driven by unsafe abortion. And the millennium development goals that the United Nations established in the year 2000, despite many of their shortcomings, have certainly encouraged governments around the world to attempt to reach their targets. One of the targets of the millennium development goals is to reduce maternal mortality from 1990 levels by three-quarters. That's a challenging goal and very few countries, indeed, are on track. But Ethiopia are one of the five largest contributors to maternal mortality on the planet. And they were a long way off. And when the parliament saw this compelling evidence suggesting that so much of maternal mortality was being driven by complications from unsafe abortion, there was a real sea change in terms of attitudes about abortion and legalization. So now in Ethiopia, if you're under the age of 18, you can get an abortion on demand. There are also broad provisions for health exceptions. When the life, or health of a woman is in danger. There are mental health exceptions. There's an exception for rape, and incest. All things which were not permissible before 2005. And while Ethiopia now has one of the most liberal laws on the African continent, and abortion is readily available in the capital city, the law has not, there has not been a concerted effort by the Ethiopian government to roll it out and to actually implement the law equally throughout the country. So still, especially in some of the poorest, most rural districts of Ethiopia, women are facing access problems. Abortion is for all intents and purposes legal, but women in many parts of the country are unaware of the law. There has been no real public education campaign. And clinicians, obstetricians and gynecologists are few and far between in that country. And registered nurses, and midwives, and even lower level health providers have in some parts of the country been trained to provide abortion. But for most of the country, there is simply no one who can safely provide abortions. And as we know, women who experience an unwanted pregnancy, whether in marriage, out of marriage, accidental or no for whatever reason, if the pregnancy is unwanted, we know that women will terminate that pregnancy. And the only difference that a law makes is that those terminations will either be safe or they'll be unsafe. And the maternal mortality and we were seeing in Ethiopia pre 2005 driven by unsafe abortion, is certainly women who need this service and need access to safe method of termination and simply don't have it. And if the law has changed, but has essentially not been implemented, the actual change in maternal mortality is going to be negligible. >> We don't have too much time left, but I would like you to speak a little bit about how can we get into it? Well the choice you made in your career. You could've gone in medicine, I mean you took a public health degree, you ended up being an epidemiologist. And I'm interested and people might be interested, as to know by going that route, what specifically are you actually working on now? But I also think people would be interested in some commentary that, as you were speaking about Ethiopia, is very reminiscent of the United States where we have the law that allows access to abortion but access is the problem. >> Yeah. >> And I wonder if you could make some commentary about that. >> To bring it back, not that this course is about the United States necessarily. But a general point that I'll probably make at some point is that I think there are about three issues that really unite women across borders, this is one of them. Reproductive freedom, access. And another is violence and I think the third is access to the paid economy. But in this case, I think it unites women. And so I'm wondering if you could comment on the United States, the situation particularly having to do with access. And then a little bit about maybe even taking up the issue of people who are uncomfortable with the idea of abortion. >> Yeah, okay. So, let me go back, I guess to where I said that issues of inequality are what brought me to this field. And it is certainly true that there are many issues of inequality that one could focus on. And I think there are many elements of reproductive health that are less controversial. We see, in fact, that the Gates Foundation, which is largely driven by Melinda Gates who is a Catholic is finally, after many, many years, investing enormous amount of money in contraception with the ultimate goal of reducing unmet need. But they are also making the claim that by providing women with access to contraception, they will inevitably reduce maternal mortality. And my take on that is that it's fabulous. That we should certainly provide women who want it with access to every form of contraception that is available on the market. Every woman should have that choice. But even if we reduced unmet need for contraception completely, we would still have 14 million abortions every year. That's because not all contraception is perfect. That's because women are not always empowered to be able to get their partners to use effective methods of contraception. Rape and incest still happens, accidents happen. We would still have a great need for safe abortion services all over the world. And in order the address the issue of maternal mortality, ignoring abortion is a non-starter. We can't do it. Unsafe abortion kills tens of thousands of women every year. We don't have good enough data on it, partly because women are terrified to talk about it. And I think in terms of the career choice that I made, and the decision to study a field that federal government is loathe to fund, [LAUGH] that the Gates Foundation will never touch, has as much to do with inequality and access to services as it does with the treatment that abortion gets in general discourse, both in the United States and globally. And I think this is where reproductive health and human rights intersect in a deeply intimate way. We talk so much about choice and that has certainly been the common rhetoric in the United States. But I think that we often forget that women have a right to control their fertility. Women have a right to make decisions for themselves about what is right for their lives and for their families. And when you ask women why they are seeking abortions, in the United States, more than half of women who have abortions already have children. That's true all over the world. And women are making decisions not to have another child often for the well-being of the families that they already have. Because they simply don't have the resources or the ability to care for another child. These are not selfish choices. These are choices that women are making for their lives and for the lives that the people that they love. And that is every woman's right. And it concerns me a bit that we focus so much internationally on unsafe abortion and on the health consequences of women not having access to safe abortion services, when I think the conversation should also very much be about what happens when women don't have the right to make the choices that they know are good and right for their lives. It's interesting, as someone who has focused primarily on global abortion issues, I often present a pie chart that shows the proportion of the world's population that lives in countries where abortion is restricted for a variety of different reasons. There are a handful of countries where abortion is completely illegal for no reason. Even to save a mother's life, would abortion be committed. Very few countries. Then there is another chunk of countries where abortion is permitted, only to save a woman's life, then for health reasons, then for mental health reasons, then more broadly expanded to socioeconomic reasons. And then there's about 40% of the world's population who live in countries where abortion is quote, unquote unrestricted. But in that 40% falls the United States of America. And we know very well that while, up until now, a woman has not had to state a reason for seeking abortion, there is a gestational age limit that has been established by the decision Planned Parenthood versus Casey, which essentially says that viability is the line up until which a women can receive an abortion. Now, most doctors, most obstetricians and gynecologists interpret that as 24 weeks but that is entirely up to the medical establishment. There are other exceptions for which women can get abortions later on in their pregnancies for fetal anomalies and for health and life exceptions in some places. But even in states where 24 weeks is the viability interpretation, as we have seen over the last decade, more and more states are restricting access to abortion using a myriad of techniques. Whether it's restricting doctors from performing abortions unless they have admitting privileges to hospitals. Whether it's regulations on abortion facilities. Waiting periods. We have [COUGH] anything from a 24 to a 72-hour waiting period in Utah. And the rhetoric from the lawmakers and the advocates who are pushing for these restrictions is that they only want to make abortion safer. But we have incredibly compelling evidence that, at any stage in pregnancy, abortion is far safer than childbirth. Across the board in the United States, it doesnt matter when. And we also know that women who are forced to wait 24 hours, 36 hours, up to 72 hours. That means, if you've had a difficult time getting to an abortion clinic the first time, and then you're told you have to wait another three days, that means finding child care. That means figuring out somewhere to stay. That means transportation costs. This is not about safety. This is about putting an undue burden on women. A burden that is so heavy that they will be unable to get the abortion that they're seeking. This really is about restricting women's access and restricting women's right to an abortion. And we've seen that play out over and over again in states that try to pass gestational limits that are lower, that try to pass waiting periods and track laws. And I do think that access issues in the United States, despite the fact that it falls in that category of without restriction, are becoming more and more real. I haven't at all talked about the fact that medication abortion and Misoprostol, which is a safe medication that can safely terminate a woman's pregnancy, has dramatically reduced maternal mortality all over the world. And I think, as we see access being restricted in the United States, we will see more and more women using Misoprostol to terminate their own pregnancies, safely, and outside the medical system. >> Thanks so much, Caitlin.
