Abortion and fertility regulation

Abstract

SIR—Kulczychi and colleagues’ report (June 15, p 1663) made depressing reading, especially because it was published in The Lancet, which I previously believed addressed global and gender issues in a pragmatic and sensitive way. The article purports to give a public health perspective on abortion and fertility control. Abortion cannot be regarded as a central plank in fertility control, and fertility regulation cannot be considered in isolation from women’s reproductive health; especially with the high prevalence of sexually transmitted diseases (STDs), including HIV infection, in women in countries with less developed economies. Western feminists have scored an own goal by lobbying for abortion rights, rather than for ongoing research for new, safer, and cheap contraceptive methods and securing access and availability of contraceptive services, including emergency contraception. The same mistake should not be repeated in developing countries. Abortion should be part of a range of sexual health services offered to women. Kulczycki et al are, however, naive to think that abortion can become a health-service priority, and therefore a safe intervention for most women, or to assume that women can control their own fertility. Most women lack the social, cultural, political, and economic clout to influence their own fertility. As they point out, in some countries such as India where abortion is legal, poor resources lead to inadequate services with resultant high mortality and morbidity from unsafe abortions. Further, the structural adjustment reforms introduced by donors as a condition of aid to the developing world has had an adverse effect on the health of, especially poor, and rural women: it has made women more vulnerable to economic and social pressures, and to the risk of STDs, including HIV infection. Kulczycki and co-workers ignore the fact that the same activity that puts women at risk of an unintended or unwanted pregnancy also puts women at risk of a reproductive tract infection, and so fail to address the risk of STDs and pelvic infection in women as a result of both unprotected sexual intercourse and repeated abortions. To date women in developing countries have inadequate services for the detection and treatment of STDs. Reproductive tract infections in such women have been termed “the culture of silence”, and Kulczycki’s report reinforces this sentiment. Women with STDs are often symptom-free, suffer more serious sequelae, and face the additional prospect of infecting their children. Also, STDs increase susceptibility and facilitate transmission of other STDs, including HIV infection. STDs cannot be ignored in any strategy for fertility regulation. Kulczycki’s report diverts from the need for urgent health promotion and prevention strategies for women, and men, in lesser developed countries.