Netherlands

Internet, information and the right to perform your own abortion

Introduction

The Dutch foundation Women on Waves and its sister organisation Women on Web (addressed together as WoW) operate from a core value: that women have a right to their health and a right to access information about safe abortions. Women on Web offers an online abortion consultation service with a licensed doctor through its website.[1] The service is offered in ten languages and the safe abortion information on the website is in twelve languages. The online abortion help service can provide information to women living in countries where safe abortion is not accessible, as well as medical guidance and a medical abortion for pregnancies up to nine weeks. A medical abortion is procured through a combination of drugs, Mifepristone and Misoprostol, and women can administer it themselves. WoW’s claim: it is reducing the number of deaths due to unsafe abortions and making women the primary agents in deciding whether or not to terminate a pregnancy.

In Morocco, 600 to 800 women per day undergo an illegal abortion and at least 90 women per year die as a result. In October 2012, Women on Waves was in Morocco, at the invitation of local rights organisation MALI, to provide safe medical abortions to women in international waters and to launch the Moroccan safe abortion hotline.[2] Warned of their coming, a warship waited at sea, ready to block the entrance to the marina. This did not work as the Women on Waves yacht had already entered the harbour before. Their yacht displayed banners showing the telephone number of the local safe abortion hotline. Police arrived to make the abortion activists leave, which precipitated a media frenzy. Hundreds of photos and film footage of the yacht were taken and disseminated through media channels, effectively launching the hotline through mainstream media. The Moroccan authorities immediately expelled the Women on Waves’ yacht and prevented them from bringing women to international waters and providing them with an early medical abortion.

Policy and political background

The World Health Organization (WHO) estimates that 42 million abortions are induced each year, of which nearly 20 million are performed in unsafe conditions and result in the deaths of an estimated 47,000 girls and women. [3] According to WHO, abortions are as common in countries where they are illegal as in countries where they are legal.

In 29% of all countries, abortions are possible for women who request them. In 71% of the world, abortion law restricts access to abortion; in some countries abortions are illegal under all circumstances. More than one quarter of the world’s people live in these countries.[4]

The Women on Waves sailing vessel is subject to Dutch law. According to Dutch law, a medical practitioner must have a licence to terminate a pregnancy if the woman’s menstrual period is more than 16 days late. For pregnancies of less than 6.5 weeks after the previous menstrual period, no licence is needed to administer an early medical abortion. 

ICTs internationalise the range of influence

Through its campaigns in Morocco, Spain, Portugal, Poland and Ireland, the Women on Waves ship has successfully drawn attention to the availability of safe medical abortions. With global numbers of deaths from unsafely performed abortions so high, and knowing that a self-administered safe medical abortion is possible, Women on Waves wanted to change the way abortion is regulated and performed worldwide. They started by publishing online information on the combination of Mifepristone and Misoprostol, drugs that safely produce an abortion. They also provided detailed information on how to find the drugs and self-administer them.

Taking the potential of the internet a step further, Women on Waves worked with partners to develop the Women on Web website, [5] launching it in 2006. Women on Web facilitates a medical consultation for women who are less than nine weeks pregnant, live in a country where access to a safe abortion is restricted, and have no severe illnesses. Women are advised to do a pregnancy test and an ultrasound before the consultation. A doctor prescribes Mifepristone and Misoprostol and ensures the medical abortion is sent to the woman by post. The service is entirely financed by donations.

Today a help desk operates in 12 languages, all hours of the day, and deals with a stream of 8,000 emails per month. The team closely monitors the use of the website and usefulness of the service.

The online service is now supplemented by safe abortion hotlines, operating in Argentina, Chile, Ecuador, Peru, Venezuela, Poland, Thailand, Pakistan, Indonesia, Morocco and Kenya, most of which have been set up by local partners who invited Women on Waves to train the consultants and/or facilitate the training process.

The Kenyan safe abortion hotline, the first in Africa, was launched in 2012. It pioneers the use of an interactive voice response (IVR) system with a set of pre-recorded messages. In countries where the legal risks are substantial for activists, the IVR hotline has great potential, as it can be anonymous and does not require “live” counsellors. Two different numbers (on different mobile networks to make it cheaper for the callers) are offered and the service is available 24 hours a day in English and Swahili. The hotline provides information about safe abortion, postpartum haemorrhage prevention and other reproductive health matters. Counsellors return the calls of women who leave a voicemail or an SMS.

During the launch of the Kenyan hotline, activists from Kenya, Malawi, Zimbabwe, Nigeria and Tanzania were trained to set up, maintain and replicate an IVR hotline project.

Information strategies

Getting the word out is key to the success of these initiatives. In Morocco, the press helped launch the safe abortion hotline through their articles, photos and video presentations of the news of the boat in the harbour. More than 300 media outlets distributed information on WoW and the safe use of Misoprostol in 2012. Social media is an important part of the WoW information strategy mix, and WoW counted millions of visitors to its websites and social media in 2012.[6] The WoW websites and online system were renewed in 2012 and are now available on multi-platform (mobile and desktop) devices.

As with any information strategy, local presence is key. With its local partners, WoW trains community health workers, youth group leaders and pharmacists in slum communities on how to procure a safe medical abortion. These are the first people women reach out to for help.

Problems faced

The governments of Saudi Arabia and Yemen block access to the WoW website. In response, WoW is looking at the possibility of developing a mobile abortion app for use in those and other countries.

Customs regulations in most countries permit people to receive international shipments of medicines for personal use. Mifepristone and Misoprostol are on the list of essential medicines of the WHO.[7]

WoW has a broad network of organisations willing to honour the intentions of the women who reach out to have a safe abortion in a country where only illegal, unsafe abortions are available.

Legal action in the Netherlands

In 2008 the Dutch Health Inspection requested the public prosecutor to start legal procedures against Women on Waves. The Inspection claimed that Women on Waves did not have a licence to provide women with an early medical abortion in international waters. The public prosecutor declined, saying there is no indication that Women on Waves broke any Dutch law. In 2012 the Dutch Health Inspection and the Ministry for Health, Welfare and Sport again asserted that Women on Waves was not licensed to provide an early medical abortion, in response to the Morocco mission. In doing so it projected a false image that the doctors and staff of Women on Waves were acting outside the law, undermining the credibility of the organisation inside and outside the Netherlands. It failed to protect Women on Waves in the performance of activities that are legal under Dutch law. It failed to defend Women on Waves in the international press and put the lives of the staff of Women on Waves in danger. [8]

Analysis

The sister organisations operate in a newly emerging framework in which harm reduction and human rights merge. The three core principles of harm reduction are neutrality, humanism and pragmatism.

1. Neutrality: Harm reduction strategies ignore legal and social contexts and are concerned only with the risks and health-related harms of an activity. Public health officials have a professional responsibility to provide, as WoW does, information about technologies such as Misoprostol, to minimise women’s personal harms. Public health officials should assure client confidentiality and are not part of the legal apparatus policing a woman’s adherence to the law.

2. Humanism: All individuals have a right to have their health needs understood and addressed, regardless of their assigned moral status or deviance from laws.

3. Pragmatism: Harm reduction recognises that individuals choose to participate in an activity whether it is legal or not. If abortion is illegal, women will seek an abortion by illegal means. Harm reduction is grounded in realistic evidence-based assessments and not moral imperatives.

In addition to promoting the harm reduction framework to save the lives of thousands of women, WoW promotes the concept of women’s agency rather than women’s empowerment. It assumes that the women it communicates with are capable of making their own decisions.

This approach is gender transformative. Where gender transformative approaches typically transform gender roles and promote equitable relationships between women and men, WoW transforms the relationship between women and the state.

As a consequence of the activities of WoW, more and more women who need an abortion consider it as something they themselves regulate, and not as a realm owned by the state and medical institutions. WoW allows them to bypass the patriarchal version of morality-based legislation and act in their own interests – as they would anyway – but now in a way that does not endanger their lives.

International human rights law can be said to have evolved to the point where it now imposes obligations on governments to provide, and to refrain from interfering with the communication of, information that is necessary for the protection and promotion of reproductive health and choice.[9]

International human rights jurisprudence is increasingly taking abortion as a major cause of death as its starting point. [10] In the face of known and avoidable suffering and death in countries where there are legal restraints on safe abortions, international human rights jurisprudence holds that states are legally accountable to do more than nothing. States that omit or fail to act breach human rights law.[11] This raises the question of whether the Dutch state infringed its obligation to reduce the harms of unsafe abortions when it publicly and falsely claimed that Women on Waves was operating without a licence in Morocco.

Even social media sites are baffled by WoW. Nothing in Facebook’s Community Standards states that one may not post information on how to procure a legal abortion, yet Facebook closed the account of Dr. Rebecca Gomperts, director of Women on Waves in the Netherlands, for doing just this. Recently YouTube blocked a WoW information video on the best use of Misoprostol to induce a safe abortion. There are laws governing appropriate behaviour and courts that uphold these laws, and WoW operates within these laws, yet social media sites are using their power to mould society into an expression of what they think is acceptable. The behaviour of the social media sites exemplifies how the dominant normative order [12] is confronted by WoW and its commitment to realising the human right of women to safe abortions.

Conclusions

ICTs have enabled Women on Waves to radically expand its ability to provide safe abortions and inform women on how to access safe medical abortions. The organisation is committed to using innovative strategies and links to issues of autonomy and social justice in order to change the public discourse around abortion. Its commitment to harm reduction and human rights is a global commitment. It operates in a patchwork of national conversations, working with women who live in countries that restrict the autonomy of women and curtail their right to terminate a pregnancy.

Action steps

Women on Web and Women on Waves will lobby for support and recognition of the work of the smaller organisations by the big international networks and for the creation of a good database and communication platform to exchange information about outreach efforts.

Women on Web will continue to invite women to share their stories on the “I had an abortion” section of the website, [13] to remove the taboo on talking about abortion. It will continue to encourage people to donate money, to ensure that the service remains available as long as it is needed. It will continue to train local leaders to provide information on how to procure an abortion safely, even in countries where abortions are legally restricted.

In 2014 WoW will expand its ICT offerings with games, videos and audio abortion testimonies.

There is a women’s human rights dimension to this story, and a dimension that is relevant to any activist operating on the global stage. ICTs make it possible to ignore political borders. Our only limitation is our imagination and our willingness to act.

References

[1] www.womenonweb.org

[2] www.womenonwaves.org/en/page/3416/in-collection/2604/safe-abortion-camp…

[3] World Health Organization (2007) Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2003, 5th edition.

[4] www.prb.org/pdf11/abortion-facts-and-figures-2011.pdf

[5] www.womenonweb.org

[6] Conversation with coordinator at Women on Web, 25 May 2013.

[7] Misoprostol can be used as a morning-after pill, for the cure of depression, and as a treatment for gastric ulcers and breast cancer.

[8] Kleiverda, G., Gomperts, R. and Swaab, E. H. (2012) Women on Waves volkomen legaal, Medisch Contact, November. www.womenonwaves.org/en/page/4030/publicatie-medisch-contact-november-2…

[9] Coliver, S. (1995) The Right to Information Necessary for Reproductive Health and Choice under International Law, in Coliver, S. (ed.) The Right to Know: Human Rights and Access to Reproductive Health Information, University of Pennsylvania Press.

[10] Erdman, J. N. (2011) Access to Information on Safe Abortion: A Harm Reduction and Human Rights Approach, Harvard Journal of Law and Gender, 34, p. 413-462, footnote 77.

[11] Commission on Economic, Social and Cultural Rights (2000) General Comment 14: The Right to the Highest Attainable Standards of Health, Article 12, UN Doc. HRI/GEN/Rev.9, quoted in Erdman (2011) Op. cit.

[12] Erdman (2011) Op. cit.

[13] www.womenonweb.org/en/page/864/about-the-i-had-an-abortion-project and www.womenonweb.org/en/page/488/i-had-an-abortion#lang=all