The following translation of our podcast on abortion has been done by Jo Abillama. Fasleh / فاصلة · معلومات عن الإجهاض، وما أدراكِ ما الإجهاض 

Information about abortion, and how well you know abortion.

Nancy: Welcome to a new episode of the podcast Fasleh from The A Project! I am Nancy and today I have with me Haifa and Elissa, and we are going to be talking to you about abortion. This episode is a bit different from episodes we've done before because this time we are going to be talking about abortion in an educational way. We are going to be talking about facts related to abortion since it is a controversial subject in society and around the world, even though it is a subject related to healthcare  but there are a lot of questions around it and there are a lot of myths and rumors that get spread around in society because it is a political subject. Like a lot of things related to women's health, historically a lot of information related to our health and our bodies is not provided to us by healthcare organizations and therefore there are a lot of obstacles before we can reach the information and before we can access the services related to our health, especially our reproductive health. So that's why we wanted to get to know a little about abortion, about the myths surrounding abortion, and about how abortion happens, and who are the people who are asking for this service in society, and we wanted to unravel all the false ideas surrounding abortion bit by bit. First of all, it's essential for us to know that, even though it is a matter of health, the reason why information surrounding abortion is so unavailable to us involves many levels: many political levels, an economical level, a patriarchal level, and a lot of other things like the state we live in, how many inhabitants it has, what's the goal of the state and what is its policy towards foreigners, and at whom certain messages are being directed, about who has the right to have children and who doesn't, and about what and who the state needs, does it need more people or less people depending on the present economy and depending if its in a state of war or invasion or not... So that is why the subject is complicated and we can't talk about it out of context and say that abortion is right or wrong, like that, in general or in a vacuum. First of all, as a simple definition, abortion is the termination of pregnancy. It is a choice that many women make and it is sometimes imposed on a lot of women and it has many reasons behind it, so we can't say that people have an abortion because they don't want to be – because they don't want to continue their pregnancy, or that people have an abortion because their circumstances don't allow them otherwise, so we can't generalize a reason why people ask for an abortion as a service. The reasons could be related to the health of the pregnant person, it could be about the health of the fetus, it could be be about the social and economic circumstances, if they have money or not, it could be about their context, if they are not married and living in a society that doesn't allow them to give birth outside of the institution of marriage, it could be that someone has many children already and can't take care of more people. So the reasons are numerous, and we can't include them all in one podcast of course. But it's really important that we don't have one image of who the person asking for an abortion is. When we think of abortion and how it is depicted in the media, in TV series, and in stories, and how this impacts our image of the person asking for an abortion, in our awareness, we always think of women who aren't married, who aren't mothers, living in circumstances that could lead to their death if they don't continue the pregnancy, unable to give, or unable to build a family or to provide adequate living conditions for their children, so that is the very stereotypical image of who are the people who are asking for abortions and it doesn't really reflect- that is to say, reality is really different. In reality, according to research studies, almost half the women who ask for an abortion are mothers, so they have children, and so all the things and ideas and talks that we have about women who have an abortion, when we say about them that they can't be mothers if they have an abortion, that they can't be mothers or that they are going to be bad mothers to their children, that really banalizes and simplifies a very complicated story and we are eliminating many reasons why someone would choose to have an abortion and at the same time, we are imposing these thoughts about what good motherhood is, and what bad motherhood is. Because some women have an abortion because they are maybe thinking about the children they already have and there are women who have an abortion for reasons unrelated to the children they already have, but in the end, the two things aren't really related, and abortion doesn't take away from how good a mother someone can be. Other than that, it's also important to differentiate between an abortion- which is wanted, so someone goes to ask for an abortion, it is a decision she made, regardless of circumstances- and a miscarriage, which is something that happens to women against their will, so they lose the fetus but they didn't take a pill or had an operation done, it is natural, right. And here we see how society's attitude towards these two matters differs. If someone had a miscarriage, there is sadness and sympathy and if someone has an abortion and there was choice involved, there is shaming and marginalizing and there is talk that this person isn't good and can't be a good mother. And other than that, how much we think of abortion as something that is distant from us contributes to how much we think of it as something imaginary and it becomes difficult for us to talk about the facts related to it and how close to our lives it is. In reality, according to research, 1 in 3 women has an abortion in their life, so it could be once or more than once, so if we are 6 women sitting in a room for example, that means there could be 2 of us who have had an abortion in their lives. And that helps us to recognize and understand how much abortions happen in our families, in our circle of friends, among the people we encounter on the street, and it is not some shameful thing that happens in dark corners and in secret. I mean, of course it is possible for it to happen discreetly depending on the circumstances, but it is not something that is so far from our daily lives, and of course it means that the people who have an abortion aren't necessarily people who support the idea of abortion, or who approve of abortion or love abortion. They can hold different ideas related to abortion. They could be people who believe it is something right and they could be people who believe it is something wrong but felt they had to do it one of those days. So that is why it is very important to stay away from stereotypes about women who have an abortion and about abortion in itself because that makes it harder for us to know the truth about it and the information that we really need and that is available now. We can't say in 2020 that abortion is something mysterious because it is something that we now have a lot of information about and the world has progressed to a point where we now know all the details about abortion, be it the medical and health related details or the details related to psychological and social side effects. I would like to move on now to my colleague Elissa who will talk to us about the legal aspect.

Elissa: The laws around the world that criminalize or legislate abortion differ. There are certain countries where the ability to ask for abortion services is limited to cases where there is a danger to the life of the pregnant person or to the life of the fetus, or also if the fetus has any defects, or it could be that a person can ask for an abortion in the case of rape or sexual violence. And there are countries that allow abortions for social and economic reasons, or for psychological reasons, or for the physical health of the person. And there are countries where the service is just provided when it is asked for. There are a lot of people who think or are afraid that if abortion becomes legal, the number of abortions in the country will rise but that is not true. If we take Romania as an example, in Romania, abortion became legal in 1989, and after it became legal, they noticed a big decrease in the number of maternal deaths. At first, the demand for abortions increased but then the number stabilized, especially after methods of contraception and family planning spread, so they noticed a decrease in the demand for abortions and of course, in unsafe abortions too. If we look around the world, we see that there are only three countries that criminalize abortion even if there is a danger to the health of the pregnant person, and the rest of the countries are like we said, a mix of the cases I mentioned previously. And we notice that in countries where there is a lot of tightening or narrowing of circumstances, a lot of conditions placed on whether a woman can access abortion services, these are usually countries who were colonized for many years and there is still an influence or there are still remnants of this colonization in their constitutions and that is why they continue until now. And in the places where a lot of forced abortions happen like in China with the One Child Policy, we see also that the number of crimes against girls rises, or female infanticide, or the abortion of females, because when people are limited in the number of children that they can have, they choose to have boys.

Haifa: There are also countries where abortion according to sex, or to determine the sex, happens, like India for example. They noticed that there were a lot of abortions happening only with those who were carrying girls or females, so they decided to establish a law to stop that, but that wasn't beneficial for pregnant women because not every woman pregnant with a girl is trying to abort. On the contrary, when they created those laws, that contradicted the laws legislating abortion in India. So that really allowed the state to regain some control on abortion and who can have an abortion and who can't, and in that situation, there were a lot of women who suffered a kind of harassment from doctors and police and security forces who go to doctors and start asking them if they are doing any kind of ultrasound for women pregnant over ten weeks approximately so that they could tell if at that time they could know the sex of the fetus. She's not supposed to have an abortion afterwards. That was very bothersome for women who wanted to have an abortion after ten weeks of pregnancy. That is not against the law in India but because a second law was established to protect girls, it was at the same time harmful to pregnant women or mothers if they had wanted to continue the pregnancy. So yeah, there are a lot of things, mixes. I think we noticed with Elissa on the topic of laws. There is the topic of criminalization, which is talked about a lot of course, to take out criminalization from abortion, and legislation too. I give Canada as an example of one of the only countries who took out criminalization from abortion but didn't legislate it. Why? Because they saw that abortion is a medical operation, not necessary a surgery but something medical. In that case, why should there be laws to criminalize or legislate something that is like any test or any medical procedure or consultation or operation? So for that reason for example- That is working for them in Canada for example. But in other places, when there are arguments between feminist organizations or organizations for women's rights in favor of abortion rights, they fight a lot with the powers that govern, whether they are motivated by something religious or something more moral, or more political, because those three mix together. Those arguments always become about in what aspect it is okay for women to abort. Like Elissa was saying, there are those 6 cases where it is possible for someone to abort, according to the laws generally, whether any kind of sexual harm or rape happened to her, whether the fetus has birth defects, whether her situation is difficult economically or socially. So it is like they are playing with them, it becomes like a game, yes to this, no to that, and what is annoying about that is that it makes it out as if that abortion is good and that abortion is bad and because of that, we talk over here about all the reasons why someone might abort, without saying that some reasons are more valid than others. In the end, everyone has their reasons. Like Nancy was saying in the beginning, there are even people who don't approve of abortion who must have one at the same time. So that really proves that in the end, this is just a medical procedure. So we can talk a bit about the kinds of abortion. There is the surgical kind and the medical kind. By medical, we mean pills. In principle, now we are only talking about safe abortion. There are millions of ways to have unsafe abortions and that is one of the main reasons behind the increase of maternal mortality worldwide. And these are also considered the deaths that could be prevented worldwide; not a single person should die from an unsafe abortion.

Nancy: I would like you to explain more since a lot of information is spread around the internet and in society about how abortion happens, so you are saying that there is a medical abortion and a surgical abortion. What is known in society is that the medical abortion, the kind that uses pills, is the kind that is not very successful. What is the difference between a medical abortion and a surgical abortion? I would like to hear from both of you. And in practice, how do these things happen in the body? Because the myths that are widespread online are horrific and they scare people a lot and people feel as if the thing they are doing is very dangerous and very criminal and a lot of feelings come up. It is easy to ignite society's feelings when it comes to abortion, so it is really important that we have medical scientific information on the subject.

Haifa: So surgically, I think that is one of the oldest known methods and it is the one that has the most stigma because it wasn't always done in safe ways so it is known why a lot of people fear surgical abortion, because there really were a lot of infections that happened a long time ago, and there would also be a lot of bleeding that would happen afterwards. But let's start by saying that there are all kinds of abortions and if they are safe, there is nothing to fear from them. They are considered some of the safest medical procedures. Abortions, generally, are safe compared to all the medical and surgical operations that happen too. And that is not clear to a lot of people I think. And it's true that that fear is old, but to be able to give up that fear, we have to know why it is no longer necessary to fear that thing. Surgically for example, a lot of people know the word curettage, right? It is used a lot. There's less talk of vacuum aspiration. In general, there is manual vacuum aspiration and electrical vacuum aspiration. The procedure is not electrical but it happens thanks to electric means while the other kind is by hand. Let's start by saying that curettage is old and that the World Health Organization, the Who, have stated since 2012 that curettage shouldn't be used to terminate a pregnancy, even though it is widely used. Now that doesn't mean that curettage itself is harmful. It depends on how it's done, of course, like anything else. But what is important to know is that curettage is considered a bit excessive. We don't have to use a method that could be harmful to terminate a pregnancy, depending on the practitioner's skill of course, whether it's someone experienced or whether they are gentle. What is curettage? It is the scraping of the uterine lining by means of a sharp tool, and for that reason, a lot of people say that someone might not be able to have children after a curettage. That is not supposed to happen unless the person using these sharp tools is doing it in a very harsh way. That is me saying it in a nice way. So that's one. The vacuum aspiration methods are the best surgical abortion methods. There is manual vacuum aspiration and electrical vacuum aspiration, which is by electric means. Those two can be used up to 14 weeks of pregnancy, so 3 months and a bit, so you can still use it at 3 months. And what's good about them- I think we are going to see what is good and what is bad about each method. What's annoying about it is that it is generally a bit expensive, depending on who the person goes to, but in general, whenever something is criminalized and isn't done in the open, the demand for it differs from one place to another, and the healthcare provider sees a kind of desperation, so sometimes there is an exploitation of that. The tool for a manual vacuum aspiration is a kind of big needle, but without the metal needle part, so it is the syringe, so the plastic. And at the end, there is a kind of straw, a straw that differs in size depending on the duration of the pregnancy. And there is a suction that happens by pulling the air and components in the uterus into the syringe or into the needle. And that's not supposed to be costly, so if you look on the internet, you'll find that its price is maybe 5 or 10 dollars, the cost of all of this, and it is used once and then thrown away. With the electrical vacuum aspiration, it's not used once and thrown away. It's something that is always at the clinic. So all of this doesn't have to happen at hospitals. It can happen in private clinics or external clinics. It doesn't have to be in a hospital, in a surgical operating room, or anything like that. For the electrical method, it's the same tool as the manual one but the difference is that the machine doesn't get thrown away of course. It stays there and only certain components are changed between one patient and another. What should also be said is that we hear a lot of stories about people who spend a night at the hospital to have an abortion by curettage, and that's also considered excessive and there is a lot of money in it, and we can talk about this another time. But those things can be done in a clinic for sure until 14 weeks of pregnancy. So that is about surgical abortion. I don't know if I forgot anything. Oh yes, one more thing! The only things that people are afraid of are infections and bleeding. The good thing about surgical abortions is that in the same 15 minutes, 20 minutes, which is the time needed to end this pregnancy, after that, there is no more bleeding, no more period, so the whole thing is done in those same 20 minutes. What's also good about it is that, depending on the person's life, if she has work outside of the house, if she wants to continue working, or she wants to be done with this situation for some reason, it's also good for that, but like I said, it's expensive. We should also say that with the healthcare provider, if that person or doctor has any kind of stigma attached to abortion, there could be a kind of harassment and that is hard too. And on the topic of infections, that only happens if the tool is not sterilized because the uterus is sterile so the tools we use should be sterile too. But other than that, there shouldn't be any problems. And there shouldn't even be bleeding, unless there are remnants left in the uterus but in any case, and Elissa will talk a bit about this, in any case, if there is bleeding, there is also a solution to that and and it is not necessary for anyone to get hurt or for us to get hurt by that.

Nancy: Thanks a lot, Haifa.

Haifa: Sorry, did I take too long? I didn't mean to.

Nancy: No. So as you clarified now, there are a lot of myths present about surgical abortions. But there are even more myths and more false information about medical abortions, not just that medical abortions and pills don't work, aren't any good, don't have the same efficiency as surgical abortions, but also about if we can trust women to take pills and deal with abortions in their homes instead of it happening inside a hospital, which of course has more legitimacy because we can have operations related to our bodies there, even though we know that historically, women had abortions in their own private spaces, in their homes, without relying on the medical institution. Elissa, if you could talk to us more about medical abortions and clarify the false ideas surrounding them.

Elissa: Yes of course. As you mentioned, Nancy, there are a lot of false ideas surrounding this subject. And the myths don't only come from us and what we hear and the internet. They also come from doctors and what we hear them telling us about medical abortion. Medical abortion happens through pills. There are two kinds of medications available under different names depending on the country, but their medical names are Misoprostol and Mifepristone and you take them. There are some countries where only one of them is available and that is Misoprostol, which can be taken in a specific way. And  if both medications are available in the country and women can get them, that increases their effectiveness.

Nancy: Is Misoprostol the same thing as Cytotec?

Elissa: Yes, it's the same thing.

Nancy: Okay.

Elissa: So the effectiveness of these methods varies between 85 % if it's just Misoprostol and 95% if Mifepristone is present. And the World Health Organization even publishes every once in a while the best ways to use those two medications, and how to take them, depending on what's available, and the details are available on their website too.

Haifa: Let's just say that the advice on how to use those pills changed a lot recently. In the last 10 years alone, the methods changed a lot. That's why, a lot of times, we find a lot of people using the pills wrong, and raising awareness on how to use those pills differs a lot because the research is changing and the best ways of using them are still being discovered. But I think in the last 5years, we focused on a few ways. Sorry I interrupted you, Elissa. I didn't mean to.

Elissa: No, no, it's fine. Yes, and even sometimes we get the wrong information or the wrong methods on how to use them by some doctors, either because they are not up to date on recent research, or like Haifa was saying, because there is money involved, and there is more payment with surgical methods so sometimes there is the promotion of one kind of abortion not because it's safer or more effective but because it'll make women pay more for a service that they can do in their own homes with more security and privacy.

Haifa: There's also something about pills. Pills, like you were saying, are cheaper, much cheaper, so pills- so a box of Cytotec in Lebanon costs maybe 13,000, that's I think before they increased the prices, but 13,000 and it has 28 pills, and those 28 pills are enough for two abortions even. But the idea is that it's considered cheap. Now the Mifepristone pill is not registered and not available in Lebanon. It's generally more expensive but it's not available here in any case because its only use is for safe abortion. But Cytotec or Misoprostol are used for other things so that's why it's available. Misoprostol is even considered one of the essential medications and is also on the World Health Organization list of essential medications, during birth or after birth or with any problems, especially in countries where there aren't many dispensaries or health care centers for long distances. Most midwives or people who are with women when they are giving birth have Misoprostol or Cytotec because it really does save women's lives when they are bleeding. And bleeding happens- maybe we should have said that at the beginning, Nancy- bleeding happens often. A lot of people are very afraid of bleeding during an abortion but it happens more during births. So births, medically, are considered much more dangerous than safe abortions. We always say safe abortions. I am not sure of the exact number but it's around 150 times more dangerous for someone to give birth than to have an abortion, if they are both in a safe place and all that. Because of course during birth, the fetus is complete and in its full size and there could be bleeding; it's one of those things that we can't predict much earlier. But during abortion, in most cases, it's still early in the pregnancy. A lot of people think: oh abortion! And abortion is forbidden! And it happens at an advanced stage. But in reality, 80 or 85 % of all abortions are in the first stage of pregnancy, which is 3 months, not after, and that's I think one of the big myths on abortions, that it happens at the end, as if someone was giving birth and decided: I either give birth or I abort. That's not true at all.

Nancy: That's how the videos that they show you online are, a 9 months fetus that is being cut up.

Haifa: Yes, that's true. It's true that there is a lot of propaganda on this subject, but the means are much safer than people think, and... yeah.

Elissa: The pills themselves are very safe on women's health; there aren't any complications afterwards. While you are taking them, there is bleeding and pain and symptoms that women experience while they are going through this stage but afterwards there aren't any effects on their chances to get pregnant in the future or on their sexual and reproductive health, so that's also-

Haifa: That's also one of the myths, that if you abort, that's going to impact your fertility. But sometimes, I am not sure if this is a complete myth, because a long time ago, when surgeries really weren't safe, it's possible of course that curettage was done in a brutal way, so of course that could have led to sterility, because it would have been very harmful or there would have been a lot of bleeding so she had to have an operation, or many times, in other countries, while women were having an abortion, a sterilization was imposed on them, like in Brazil for example, there were women who were giving birth, not having an abortion but after giving birth. So what I am saying is it's true it's a myth but a lot of people are afraid, not just medically. They think that, if I abort, I will be punished and I won't be able to have children, so there is something like that and you don't know where it's coming from, morally, religiously, cosmologically, that there is a wrath that will come down on us, or medically. But of course everything has real dimensions. But for now let's say that all this is no longer true. Sorry, did you want to say anything, Nancy?

Nancy: I wanted to add that apart from the medical aspect, some of the consequences of abortion that we also talk about have to do with the psychological aspect, so we always say that women who have abortions are going to get depressed and they are going to enter a period that is very sad and painful and psychologically difficult. And it's true that there are a lot of women that go through these things, especially if it was a pregnancy that they wanted but their circumstances didn't allow them to continue with it and that is why they decided to abort, or maybe they are living in particular circumstances. It doesn't have to be a wanted pregnancy but it can be because of factors present in society, how much the idea of motherhood is imposed on us since we're little and that any abortion is the loss of an opportunity to become a mother. And if we already have children, we are thinking of how this affects us and our understanding of how good we are as mothers. Of course this affects us psychologically. At the same time, it's important for us to know that, apart from the difficult situations and the difficult impact of abortion on a lot of women, research shows us that the feeling that most women get after abortion is a feeling of relief. And that relief can be explained in many ways, whether we are relieved from a pregnancy we weren't comfortable with, or we are out of a certain predicament, if we had continued with the pregnancy, we would have been in some danger, or the idea that we are hiding this from society and we doing it in secret and in circumstances that are sometimes very hard, whether financially or the ways doctors treated you was bad and anxiety provoking, so all those are things that lead women to feel, after an abortion, that they are relieved from something very difficult they were going through, because of its effects. So that's why it's important that we know what the numbers are telling us on how much relief there is, and to also listen to the stories of women when they express how much pain they are going through psychologically afterwards, and not say that one feeling is better than another. In reality, this really depends on the person who is having an abortion and what are the circumstances surrounding their pregnancy.

Haifa: Yeah but I think a lot of people used to- I mean, the idea that a woman should be sad after she aborts was very common because there also were a lot- there are a lot of people who fight against abortion. They would posit this a lot, they would tell people that of course, there is a feeling of guilt and all that. Actually, there was very little room for people who didn't feel that- who felt that they made the right choice. They didn't really have a space to talk about this. Like you said Nancy, they might feel that people will look at them differently or they might think: I am not sad, what's wrong with me that I am not sad? This of course goes back to the situation of each person and how difficult it was for them to find that service because in a lot of countries- In Lebanon, for example, most abortions are considered criminalized. It's only legalized in cases where the woman's life is in danger so here of course, a lot of people find it difficult to find this service so if someone has been going from provider to provider, from healthcare provider to pharmacies and is looking around, and people are talking to her, and friends are hearing things about her, or if she is hiding this from her partner or her parents or anything, in any situation she is in, this of course creates a lot of kinds of psychological exhaustion and fear and anxiety. So of course there will be relief in the end, even if the abortion was difficult, very painful I mean or with many side effects. You'll still find that after they overcome all the difficulties, they'll still feel that they have to hide it. It's- like I said in the beginning, 1 in 3 women will have an abortion in her life, so so that's not a small number. It's a very big number for something that is very hidden, I think.

Nancy: True.

Haifa: There are a lot of people who think that pills don't work. I forgot to say at the beginning that the surgical way is very successful, around 99% of the time, so that's why there is a difference between the surgical way and the medical way. Still, the medical way is very successful, it's between 85% and 95% with only Cytotec. If it's Cytotec with Mifepristone, which isn't available in Lebanon, its effectiveness goes up to 98%. That's a very high effectiveness but there are a lot of people here who say no, it's half and half, a 50% chance it'll work and a 50% chance it won't work, and that is because the medication is being given in the wrong way. They are not taking 4 pills of Cytotec, which is 200 milligrams, under the tongue, every 3 hours, until bleeding starts. A natural bleeding, not an unnatural bleeding, of course. They are not taking it in that manner. They are taking it in a different way, that is not very safe. And for the pain, there are very few people, while they are taking the medication, they take pain killers. No one tells them that taking the pain killers before they take the abortion pills makes a big big difference. There are a lot of studies that showed that if they took the pills, not the- never Ponstan, never Spasphon, because those stop contractions and prevent abortions. No, I mean the painkillers that really work on the pain nerves, which are Ibuprofen and Panadol and those are the ones that decrease the pain, Ibuprofen much more than Panadol. No one starts with Panadol, I think. But in any case, I think it's important for those things to be clarified and we should know, of course, that those who are having an abortion at home especially should have someone with them. So if there is someone she can trust or talk to. So she shouldn't be alone. And even though there are a lot of people who scare you about bleeding or side effects, so there are a lot of women who feel that if they experience any side effects, they should run to the emergency room, but they are normal. It's normal for Misoprostol to bring about many side effects, such as diarrhea, nausea, vomiting, cold chills, so your temperature rises a little. Those are when you are taking the medications; they don't stay for 5 or 6 days. And I think when people know that those side effects might happen, that lessens the fear, and it also takes away from that myth that this is something very harmful and scary and all that. So that's about the medical means. Now there's the needle that we haven't talked about a lot, but it's not used much anymore. It used to be given when there was a pregnancy outside of the uterus. The injection is given, the same kind that is used sometimes in the treatment of some cancers. It's called Methotrexate and it's used to shrink the cancer tumors and in this case, it shrinks the cells that are still multiplying because they would still be at the beginning of the pregnancy, so it's used if the pregnancy is outside the uterus. But that can show on an ultrasound, if the pregnancy is outside or inside the uterus. Methotrexate isn't really needed. Cytotec is still more active. Yeah, I don't know if there is still anything. Is there anything else about abortion we haven't talked about?

Nancy: I feel like we've covered a lot and we might need a part 2, after a while.

Haifa: Nice.

Nancy: I was really pleased by the information and I learned new things, and I hope the listeners benefited from specific things, and of course we are going to be linking some sources that we rely on in the podcast below. If you liked the information and you found it useful to you, I hope that you'll share with your friends. Thank you for listening to the Fasleh Podcast and I hope you'll join us for the next episode. You were listening to Nancy and Elissa and Haifa.