The Survey looks at the relevant legislation on abortion care in 42 countries, but crucially it also explores how these laws are interpreted by providers and experienced by women and girls. It is designed to provide an overview of women’s and girls’ experience around accessing abortion care, to highlight current threats to their reproductive health and rights, to identify ‘best-fit’ practices and to stimulate further debate and research. The Survey is not a research paper, but rather a synthesis of the expertise and understanding of our Members and Partners working in the field and serving women every day. The report begins by situating abortion care as an essential component of women’s reproductive health, as defined within the broader framework of international human rights law, specifically the Right to the Highest Attainable Standard of Physical and Mental Health. It then examines to what extent current provision within national borders aligns with or deviates from state obligations to care for and value equally women and girls. It covers four key areas: the criminalisation of abortion; the various grounds available to women and girls to access abortion care and the time limits imposed thereon; the additional institutional and procedural hurdles to abortion care; and finally, the significant financial burden inflicted on women and girls when accessing care across the region. For each section, the ‘best’ and ‘worst’ country scenarios have been referenced to highlight how differently a particular barrier to care might be implemented and then experienced by women and girls across Europe and Central Asia.  

Today is a momentous day for women’s rights in Northern Ireland and a day that many thought they’d never see. A day in which an outdated and cruel law has been removed. A law that often silenced, stigmatised and even criminalised women and compromised the care that medical professionals could provide to their patients. In 2001 our chairperson, Dr Audrey Simpson, led the first ever legal challenge into the provision of abortion services in Northern Ireland. The case was taken by FPA NI against the Department of Health and challenged their failure to issue guidance for medical professionals on the termination of pregnancy. At that time Dr Simpson argued that the issue of abortion was surrounded by a wall of silence. Inside the courtroom the judicial review was opposed by five legal teams representing three anti-choice organisations, the Northern Bishops as well as the Government. Outside the court anti-choice protests intensified in their numbers and levels of harassment. While the case took several years to complete it was successful and laid the foundation for the further legal challenges that followed and stimulated a dialogue around women’s reproductive rights in Northern Ireland. This dialogue placed women’s experiences at its centre and it was their voices that were the most powerful in this conversation. As a result people became more educated on the impact of Northern Ireland’s restrictive abortion law and a cross-party coalition of politicians, spearheaded by Stella Creasy MP, actively campaigned and successfully delivered much needed and long overdue change. Previously if a woman made the decision to end a pregnancy she had to begin to think about travel. Who, if anyone, would accompany her? Could she share this experience or did she have to keep it quiet. How would she explain her absence? The law meant women had to deal with a very public, legal judgment, on what is a very private and personal experience. Without exception we have never had a client attend counselling who thought the law was fit for purpose and collectively they felt let down. One of the biggest changes in recent years has been the availability of abortion pills online and the decision to prosecute individuals accessing abortion in this way. No one should ever fear seeking medical or emotional support after ending a pregnancy, and the change that has occurred today will mean that they no longer have to. In the interim period between now and March 31 2020 it is expected that the majority of women seeking an abortion will continue to travel to England through the funded service. Moving forward we must ensure that these journeys cease. Women’s rights should not be dependent on their ability to board a plane. Travel carries stigma. It adds to secrecy and it can take away privacy. Today the wall of silence surrounding abortion has been well and truly demolished. We must never go back to the days of backstreet abortions, criminal prosecutions and lonely journeys across the Irish Sea. Now that abortion is decriminalised it needs to be destigmatised so that we not only remove the wall of silence but also the wall of access. Ruairi Rowan is Director of Advocacy & Policy at Informing Choices NI. Find out more about the fight for reproductive freedom in Northern Ireland. 

Marita (not her real name), 37, was 19 when she got married. She met her husband through a mutual friend. “I was very young, I didn’t have enough education, or awareness at the time. At that age a person is not a full woman yet,” she says.    The couple had their first child at 20, but a year later she was pregnant again. Back then she and her husband were financially dependent on her in-laws. “I didn’t have a university degree [initially] and there were very few opportunities,” she says.   “My mother in law was sick with leukaemia and it was very expensive to treat her. My sister in law, who lived in the house, said they did so much for me, and that now the mother in law needed support.” Due to the circumstances at home she decided against going through a full pregnancy. She had severe complications during the abortion procedure, yet she was sent home the same day. At no point was she offered counselling or support. “It was very difficult and very stressful to leave the hospital on the same day. My cousin was with me because I wasn’t able to walk,” says Marita.   Through all this, and despite her in-law’s best efforts, Marita was determined to complete her university education: “I would stay up at night to study, and at times I would have to take the child along to exams with me. Sometimes my friends would take care of the child while I was sitting the exam.” Her husband offered no support, believing like many in Georgia that childcare is a woman’s responsibility. “[He] would never look after the child… if he knew it was his turn to help out he would not come home for 2-3 days,” she says.   Eventually, with her brother’s support, Marita was able to leave her husband and the shackles of his family. It wasn’t easy: by 26 years old she was a single mum faced with another unintended pregnancy. She was frightened about having to undergo anaesthesia again. Although the surgery was performed without issue, once again she was offered no support after the abortion. “When I awoke from the anaesthesia the doctor was already gone,” she says.   Marita believes counselling should be offered to women after their abortions in the future, as it was so difficult for her to cope. “It is necessary. It’s so important,” she says.  In the future, she hopes women will receive more education to avoid unintended pregnancies and hopes to inspire others with her story: “I think that everyone should have the opportunity to study and I want to help. I often tell my own story to show that once a person falls they may still get up. Something that I thought was unimaginable – leaving my husband’s family, sustaining myself and my child and working – is now real,” she says.   Women in vulnerable situations and who are not financially independent are too often neglected by the system and the State at the expense of their sexual and reproductive safety and dignity.With no access to relationships and sexuality education, access to contraception or any other type of support, women like Marita are left behind.   Click to read our blog series on obstacles to abortion care and women's reproductive safety and dignity in Georgia, and find out how IPPF EN is standing firm against reproductive coercion in Europe and Central Asia. Photo credit: Jon Spaull/IPPF EN

Natela (not her real name) got married a few days after her 16th birthday. She would have preferred to get a job and start out on her own, but when she tried “they asked me about my education and I had none,” she says. She explains that she had no particular wish to be a housewife but did not have any other options.   Her story is similar to many women across Georgia whose life choices are limited because they have been denied a full education, and who get married young and are then expected to raise a family. “All the members of the family are my responsibilities, my mother-in-law, father-in-law and brother-in-law as well as my kids,” she says. Natela is from a rural area near Sighnagi, a tiny town in the eastern region of Georgia. Job opportunities in the region are poor, and access to healthcare, contraception and sexuality education are incredibly restricted for Natela and her community. Due to high costs and lack of public transport, the last time she went to the doctor was 10 years ago, when she faced her third unintended pregnancy and needed to access abortion care. Natela describes her need for abortion care during that period: “My kids were young and I was not working. My mother and father-in-law were old and my brother-in-law was sick at my home,” she says. Not only could she not afford to raise another child, she already faced a huge amount of responsibility caring for the whole family and adding more on her shoulders felt impossible. Like most Georgians, Natela comes from an Orthodox Christian community and she felt conflicted about accessing abortion care because of her faith. “I had to confess a lot,” she says. She feels it is wrong that women like her are placed in this position through government neglect in the first place. Trying to give her children a good life with poor economic opportunities is very difficult, she says. Natela’s experiences are incredibly common. A multitude of reasons, from being denied sex and relationships education to the state’s failure to ensure access to contraception, mean that most of the women Natela knows in her neighbourhood have been confronted with unintended pregnancies. Despite this, Natela says her community still stigmatises and criticises women who have sought abortion care. Natela feels left behind by her government and believes that more needs to be done to provide jobs and education to her community. “We need much more support. There are no jobs. There should be all types of aid from the government but there’s no such thing.” Still unable to access contraceptive care, Natela relies on, “the will of God for me to not get pregnant.” In the future, Natela hopes that instead of taking on family responsibilities, young women will be given more opportunities to continue their education: “I would suggest that no one do the same thing as me. Every woman should finish school, have her own profession and… after that decide her relationships,” she says. IPPF’s Georgian member HERA XXI is working to ensure sexual and reproductive health care and sexuality education for young people and women like Natela across the country. Find out more about their work and the obstacles to women’s reproductive freedom in Georgia in our blog series.   Credits main photo: Jon Spaull/IPPF EN

The North Macedonian Parliament adopted a law on March 14, 2019, that makes dignified, women-focused abortion care a reality. The new law puts women’s needs at the heart of the system, dismantling many of the obstacles that until now undermined their reproductive autonomy and made it difficult to access basic health care. HERA (IPPF’s member in North Macedonia) has worked tirelessly in a coalition of civil society organisations to make abortion care safe, accessible and dignified for all Macedonian women. “We wholeheartedly welcome this vote for change which makes abortion care safe, legal and accessible. Our legislation now puts women’s well-being and safety on top and makes it possible for health providers to care for their patients when they are at their most vulnerable.” said Bojan Jovanovski, Executive Director of HERA. The previous retrograde law, imposed by the former conservative government, forced women to undergo biased counselling aimed at persuading them to continue through a pregnancy, and then made them wait for 3 days, with no medical justification, before they could access care. Forcing women to jump through these hoops undermines their decision-making abilities. “I did not like the attitude, especially the heartbeat thing and when they tried to persuade me not to have an abortion, that is subtle persuasion.” (Woman from Macedonia, 33 years old) But with the new law in place, these obstacles will be swept away. From now on any information about abortion care will have to be evidenced-based, in line with World Health Organisation standards. A number of other changes in the new law will remove barriers that previously made it difficult to access care. The Parliament shifted the legal gestation limit for having an abortion from 10 to 12 weeks. Women will be able to access abortion care up to 22 weeks of gestation in case of rape, incest, foetal malformation, for socio-economic reasons or in case of crisis pregnancies. They will no longer have to endure an approval process in front of a hospital commission, nor will they have to bring proof from the Public Prosecutor’s office in case of sexual assault. From now on, women and their families will be protected from strangers meddling in their reproductive lives. Increasing access to safe abortion care is at the heart of the new law. Medical abortion pills – recognised by the WHO as being the safest method in early stages of pregnancy - will be introduced for the first time. Medical abortion care will be available at the primary level of health care as well as in hospitals, making it available in more cities and towns. The changes eliminate many of the barriers which put additional financial burden on women, creating more expenses and increasing the time spent away from work and family. The new law also unties doctors’ hands by significantly reducing the penalties and fines they once faced for refusing to make women endure the 3 days waiting period or for providing compassionate counselling rather than biased. These fines were higher for practitioners in this field than for other health care providers in an effort to bully them into delaying abortion care. Doctors can now provide quality and compassionate care to their patients. In a Europe where we are fighting against reproductive coercive movements, North Macedonia now stands out as a defender of reproductive freedom. In a sea of conservatism, the country has managed to become an example of compassion for its neighbours and for Europe as a whole. Bojan added “HERA and our partners are carefully following the timely implementation of this law. We are also fighting to improve language on request for parental/guardian consent for minors above 16 and for people with intellectual disabilities.”  

Dina was just 15 years old when she married her husband, and 16 years old when she had her first child. “It was young. Getting married at this age is bad, because you are still a child,” she says, sitting on the sofa and clutching a teddy bear. Like the majority of Georgians, she is an Orthodox Christian, and the walls of her home are covered in paintings and photographs of religious icons: Jesus, St. Mariam and St. George. Now 32 years old, she describes how after the birth of her first child she discovered she was facing an unintended pregnancy. “Because of financial problems I decided I couldn’t afford to have another child,” she says. Dina lives in a small house just outside of Senaki, a town in western Georgia facing economic hardship according to Nino Shurgaia, a youth leader working with IPPF member HERA XXI to provide sexuality education and sexual and reproductive health care to women in the region. “This is an area for agriculture and subsistence farming: there are few opportunities for income generating activities. People can’t afford to raise children, or to have more children when they already have some to support,” she says. Dina and her husband were using condoms to try to prevent pregnancy after the birth of their first child, but they weren’t always able to afford them. The government’s failure to ensure contraceptive care and sexuality education is hugely harmful to vulnerable communities in the region, according to Nino. “People do not have access to contraception and reliable information,” she says. Women in Senaki and the surrounding regions face stigma and discrimination from the local community when they decide not to move through a full pregnancy. This leads to some internalising feelings of shame. “You feel bad, and it was really hard for me to make the decision,” says Dina, who also struggled to reconcile her decision to have an abortion with her faith. On top of that, doctors frequently fail to offer compassionate counselling or support. “There was not even any explanation of the process.” Luckily, Dina was able to rely on a close friend she could talk to. Click to read our blog series on obstacles to abortion care and women's reproductive freedom in Georgia. Photo credit: Jon Spaull/IPPF EN

Tamar (not her real name) was 30 and a mother of two children when she found out she was facing an unintended pregnancy. She and her husband had endured a miserable marriage and were in the process of splitting up, and although employed as a teacher, she couldn’t afford to raise another child alone. “The salary doesn’t pay that well. It’s not enough to meet basic needs. My job is not enough to support my family, no way,” she says. Tamar, now 45, lives in the southwest of Georgia. Poverty levels are high in her region and life for communities can be hard. Women tend to be caregivers, at home raising children, and many people are unemployed. There are many obstacles to women’s sexual and reproductive freedom. IPPF member HERA XXI is one of the few organisations providing sexual and reproductive health care and sexuality education to women and young people in this region, which comprises the city of Akhaltsikhe and surrounding villages. They’re only able to cover a relatively small part of the area according to Marine Sudadze, a community leader and director of HERA XXI's local youth centre. She says a big problem is that the government neglects women’s sexual and reproductive health and rights: “They will claim that they are funding programmes that benefit women, but when it comes to reproductive health we don’t see that support,” she says. One major problem that results in unintended pregnancies is the state’s ongoing failure to equip young people with crucial life skills relating to sexuality and relationships. “Back then I couldn’t even recognise a condom, it was something very alien,” says Tamar, referring to the period before her first unintended pregnancy. As abortion care takes place in private clinics across Georgia, the price of the treatment can vary greatly. Generally, however, it is very expensive for women from smaller cities and rural communities like Tamar. Because of the prohibitive cost, many attempt to take matters into their own hands. “When I found out I was pregnant and I tried to end the pregnancy with a self-administered calcium injection,” says Tamar. The injection caused blood poisoning and proved to be life-threatening. Tamar needed emergency medical treatment. “It was terrible; first of all I was trying to hide what I had done. I was also very angry about not getting support,” says Tamar, who felt abandoned by her government for not providing the health education or affordable care that would have protected her from harm. Only after recovering from this painful experience did Tamar finally receive contraceptive care from the doctors. About five years ago Tamar was faced with another unintended pregnancy during an informal relationship. She describes feeling that her only option was to end the pregnancy. “I was worried what people would think… It wasn’t a problem for me to have a child out of wedlock, but it would have been a problem in my community,” she says. Tamar explains that many elements of a woman’s sexual and reproductive lives are stigmatised in the region. “A woman might be ashamed if someone found contraception in their handbag, they’re worried that they’ll be criticised or mocked. Even if a woman buys a pregnancy test, people have a reaction to that, because during communist times sex was hidden away, it was not openly talked about,” she says. Georgia was part of the Soviet Union from 1921 to 1991, and many values and traditions from this time persist across the country. Stigma and discrimination resulting from patriarchal cultural norms force many Georgian women to travel long distances to other cities, at great financial burden, to preserve their privacy. Shockingly, they are also perpetuated by medical professionals, many of whom deny women compassionate, confidential care. This was the case for Tamar, who had to rely on the help of her family to get the support and treatment she needed. “My brothers had to pay for me to go to the doctor and have the abortion. It was not only about the paying, it was also getting the required attention. It was complicated; they used their connections.” Like many women, Tamar wanted to keep the abortion secret as she was worried about mistreatment from her community, but when she got to the surgery, “I found that the doctors knew my ex-husband. They did not respect my wish to keep it secret,” says Tamar. The doctor violated her right to privacy by sharing her personal information with her ex-husband against her wishes. Five years later, she doesn’t feel much has changed for women in the country: “I can’t guarantee my situation could not happen to somebody else, even in modern times,” she says. Yet, despite her painful history and the longstanding challenges to women’s reproductive rights in Georgia, Tamar still manages to look forward: “Although I have gone through hard times, I try to see positives,” she says. Click to read our blog series on obstacles to abortion care and women's reproductive freedom in Georgia, and find out how IPPF EN is standing firm against reproductive coercion in Europe and Central Asia. Photo credit: Jon Spaull/IPPF EN    

The many barriers that women in Georgia face in accessing safe care mean many are forced into trying to induce abortion themselves. These attempts are often unsuccessful and can be extremely harmful. Marine Sudadze, community leader and director of IPPF member HERA XXI's youth centre in Akhaltsikhe, speaks of “one woman who tried carrying very heavy items to end the pregnancy because she couldn’t afford the abortion,” while George Tsertsvadze, a gynaecologist at a clinic in Tbilisi, explains that “women take various medicines, and make physical attempts like trying to jump from the top of high furniture.” Desperate methods like these can cause haemorrhaging and the need for urgent medical care. “The longer we delay addressing this trend, the harder it will become to reverse,” cautions Sudadze. Ana Iluridze's Gender Equality team at the Public Defender's Office often share evidenced recommendations with the government on improving the state of women’s sexual and reproductive health in Georgia, but these are rarely implemented. Questioned on this, Deputy Health Minister Maia Lagvilava said that, “We actively cooperate with the Public Defender's Office and if any of their recommendations cannot be taken up, we provide a justified answer to them of why.” Iluridze believes lack of political will to change and lack of representation in government are two of the root causes behind a lot of these issues. “Decision makers… do not view women’s reproductive freedom as important; they don’t see how gender equality is linked to economic growth and development, and how the investment in better sexual and reproductive health can reduce the cost of health care for the country. It’s like gender equality for them is something that is kind of transferred from the West but they can’t connect the issues into the major political decisions,” she says, adding that, “There is 11-13% of women in decision-making positions in government, this is dramatically low to have any kind of influence.” HERA XXI Director Nino Tsuleiskiri says that there is a disparity between women’s legal sexual and reproductive rights and reality: “On the one hand by having a good and solid legislative space we formally recognise women’s rights and gender equality. Legislation stipulates that access to contraception is a means of reducing unintended pregnancies, and it provides for safe abortion care, yet in practice we have a problem with implementing this legislation,” she says. One reason for this, she believes, is widespread ignorance among decision-makers and other stakeholders about sexual and reproductive health and rights and gender equality: “Those who are in politics have inadequate knowledge. So do doctors, lawyers, journalists. None of these groups get sufficient information. A major hurdle to improving general understanding and empathy in Georgian society is the government’s failure to ensure comprehensive sex and relationships education in schools.” One example of how HERA XXI is working to change this and reduce the harm caused to women’s reproductive freedom is through the implementation of a new online training scheme for doctors, aimed at educating them on how to provide women with compassionate abortion care.  Initiatives like this alone will not be enough though, according to Tsuleiskiri. She believes that a change in values across the country is needed to significantly improve things for women in Georgia: “Since becoming a post-Soviet country a lot of developments have taken place, but we need mind-set changes. A lot of the values that were introduced in Georgia after 1991 were a novelty for our society and they are still not fully assimilated.” Recognising the vital importance of reproductive freedom, women’s health, and how these contribute to development, is key for Georgia’s future, says Tsuleiskiri. Photo: Nino Tsuleiskiri is the Executive Director of HERA XXI. She explains that when it comes to abortion care in Georgia, women’s experience shows there is a big disparity between legislation and reality. Credit: Jon Spaull/IPPF EN

In Georgia, it is legal for doctors to deny women abortion care based on their personal beliefs. This remains the case in remote regions where there is only one clinic. Ana Iluridze, Head of the Gender Equality Department at the Public Defender’s Office of Georgia, says, “Even if you are the only medical institution in a mountainous area you can still refuse.” Even in Tbilisi, the capital of the country and home to over 2 million inhabitants, “there are only 5 gynaecologists who perform abortions,” she says. The result is that abortion care is not available in huge swathes of the country. The ultra-conservative views of many medical professionals across the country also mean that, when women do manage to reach a clinic that provides abortion care, doctors tend to focus on dissuading them from going through with it. As one doctor told us, “I personally am against abortions. So we try and get women to change their minds.” Ana Iluridze describes the ordeal many women face: “You are alone with someone you are trusting with your life, who is pretty much persuading you in an aggressive moralistic manner on the harm you are doing to your career, to your health, to your christianity.” For example, Keti, a woman from a region in eastern Georgia, decided to have an abortion after becoming pregnant by her abusive husband. The doctor would only perform the abortion after subjecting her to a long monologue about his personal views, using emotional blackmail to try and bully her into changing her mind. The doctors didn’t ask about the abusive relationship with her husband. Crying, she says, “The experience made me feel very bad.” New legal barriers are also being implemented, further intruding on women’s reproductive freedom. One example is the compulsory, and medically unnecessary, waiting period after an initial consultation, which the government recently increased from three to five days. We spoke to Maia Lagvilava, Deputy Minister of Health, about the reason for making this obstacle even greater. She was not able to provide a clear answer on why the government felt it was necessary, simply saying, “An additional two days have been allowed for consideration and reconsideration of their abortion.” The forced waiting period places an additional financial burden on women, creating more expenses and increasing the time spent away from work and family. Georgia’s Public Defender’s Office has recommended eliminating mandatory waiting periods, and ensuring that any counselling provided to women is unbiased and evidence-based. This has not been implemented. The government has committed to considering the recommendation, but one year later, no steps have been taken. Some women and girls are also confronted with doctors who take it upon themselves to introduce hurdles to compassionate care that are not required by law. For example, although abortion is legal in Georgia from the age of 14 without any requirement for parental consent, a gynaecologist in one clinic in western Georgia explained that her team asks for permission from the parents of any girl under the age of 18 before providing care. When pressed that this an infringement of their legal right, she said, “Parents may complain afterwards, so I prefer to ask for a parental signature.” Research by IPPF member HERA XXI has shown that some clinics have introduced internal regulations that bluntly seek to deny care to women aged between 16 and 18, young women under 16, women with a history of sexually transmitted infections, and other vulnerable groups including sex workers. Read the last blog in our series on obstacles to abortion care and women's reproductive freedom in Georgia. Photo: Ana Iluridze, Head of Gender Equality at the Public Defender’s Office. Research by her department has found that medical professionals openly try to bully women into continuing through full pregnancies. Credit: Jon Spaull/IPPF EN

High costs a major barrier, especially for women in vulnerable situations The cost of abortion can be a major challenge for women in Georgia. “Abortion is quite expensive – between 100 (EUR 33) and 500 lari (EUR 163). The average income in Georgia is 600 - 800 (EUR 196 - 262) lari, so it’s a big chunk of a monthly salary. Some people can’t afford it. Abortion is not covered by the national health care system, not even for socially vulnerable people,” says Ana Iluridze, Head of the Gender Equality Department at the Public Defender's Office of Georgia. Abortion is supposed to be available free of charge to survivors of sexual assault, but bureaucratic measures mean that in reality most aren’t able to access this. Disturbingly, those at the very top of power in women’s sexual and reproductive health do not seem to be aware that affordability is a barrier. When questioned about the cost of abortion care, Georgia’s Deputy Minister of Health Maia Lagvilava appeared to think it was financially accessible to most women: “The services are available… and the population has private insurance as well. The services are offered,” she said, adding the caveat that she wasn’t actually sure if abortion was covered under private insurance in the country. Stigma and discrimination prevent free and safe reproductive lives Stigma and discrimination against women’s reproductive freedom is high in the country, especially for those seeking abortion care. Women are forced to travel great distances, sometimes at crippling expense, to try to keep an abortion secret from their community. One of the major issues is that "women’s sexual and reproductive health is taboo in Georgia,” explains Nino Shurgaia, a youth leader with IPPF member HERA XXI in the city of Senaki. When trying to research access to abortion care in the region she found time and time again that families were not willing to discuss the matter, and many feared what their community would think: “They are afraid that their neighbours or family will find out that they had an abortion. They were worried the information they share with me would be leaked,” she says, adding that often during private interviews she set up as part of the research, a mother-in-law or husband would interrupt and start asking what they were talking about. Indeed, community pressure and social stigma mean that women struggle to live free and safe reproductive lives. One woman described feeling as though ending a pregnancy was her only option because “I was worried what people would think… It wasn’t a problem for me to have a child out of wedlock, but it would have been a problem in my community.”   Read the next blog in our series on obstacles to abortion care and women's reproductive freedom in Georgia. Main photo: Marine is from a small village in southwestern Georgia, near the city of Akhaltsikhe. Affordability was a major challenge when she and her husband needed to access abortion care: “We were still young and my husband’s income wasn’t high. We couldn’t cover the cost of abortion with our salaries.” Credit: Jon Spaull/IPPF EN