Ms Alberte Verwohlt Hansen
Alberte Verwohlt Hansen is a researcher at the Programme for Studies on Human Rights in Context. She is a member of the IMPACTUM team and works under the supervision of Prof. Dr Clara Burbano Herrera. Recently she graduated from the University of Kent and the Erasmus University Rotterdam. For her master's thesis, for which she obtained a UK distinction, she focused on barriers to abortion care in Belgium from the perspective of healthcare providers.
Abortion in Belgium
After a long struggle, Belgium was in 1990 one of the last European countries to legalise first trimester abortions. Nevertheless, the abortion debate has continued to exist, albeit to varying degrees, with 2018 seeing an amendment to the 1990 abortion law. The result was a predominantly symbolic change, where abortion is no longer legally considered a crime against the family order and public morality, but rather a right falling under the protection of the person. Other changes were also made such as including the mandatory waiting period in the gestational age limit, resulting in the gestational age limit being prolonged by a week should someone discover their pregnancy at the end of the first trimester. Moreover, doctors who conscientiously object to performing an abortion are since then legally obliged to refer the person to somewhere they can get the care they need.
The amendments regarding prolonging the gestational age limit, which is currently twelve weeks, and eliminating the mandatory waiting period, which is now six days, were not passed but continued to be discussed. These changes are supported by the majority of the political parties, doctors, feminist organisations, research and substantiated by testimonies of people who had abortions and abortion care providers. However, the topic continues to cause division, with the discussion eventually provoking the opposing parties to obstruct the formation of the federal government in 2020. Subsequently, a scientific committee was formed to analyse the Belgian abortion law and related practices. Briefly summarized, the final report of March 2023 included numerous recommendations, but related to the previous topics it stated full support for prolonging the gestational age limit to eighteen weeks and removing the mandatory waiting period. However, these changes are yet to be approved, and are causing turmoil for the upcoming elections of June 2024 as the Flemish Christian party is still opposing the prolongation of the gestational age limit.
Following the contested abortion legislation, my master’s thesis set out to analyse the legitimisation of the Belgian abortion law from the perspective of abortion care providers. To gain further insight into the legitimacy and the functioning of the law in practice three socially relevant themes were selected to analyse the effects of the law: abortion travel, the COVID-19 pandemic, and abortion stigma. Moreover, these subthemes were selected to understand how they organise their work within the legal framework and how their experience is shaped by the law.
Research has shown that not only people living in areas with heavily restrictive abortion regulations travel for abortion care, but restrictions in areas generally considered more liberal, also result in people seeking abortion care elsewhere. One main reason people from more liberal areas travel is gestational age limits. This is also the case in Belgium; it is estimated that every year between 300 and 800 women have an abortion past the first trimester in Belgium. This is 3% of the total number of abortions. This results in a yearly estimation of 400 to 500 people residing in Belgium seeking an abortion abroad.
Accessing abortion care by travelling, is not available to everyone. Travel is costly, time-consuming and can be physically and mentally burdening. Therefore, having to travel can be especially challenging for women in abusive households, people who have children, people with disabilities, and people with less financial means. This creates unequal access to abortion care. Moreover, gestational age limits fail to acknowledge circumstances in people’s lives which can delay the process of noticing the pregnancy and seeking care. Examples of reasons include being on hormonal birth control, overwhelming events, and receiving incorrect medical information.
COVID-19 pandemic & telemedicine
The outbreak of the COVID-19 pandemic drastically restricted movement and overwhelmed healthcare systems worldwide, making it increasingly problematic to seek abortion care. Within Belgium, the response depended on the facility type and region. All outpatient abortion centres continued to provide abortion care; however, the response differed between French- and Flemish-speaking abortion facilities, and the approach further varied depending on the centre. Besides general guidelines for all sectors, the government did not provide specific assistance for abortion care. On initiative from abortion providers, abortion care was facilitated during the COVID-19 pandemic in Belgium through phone consultations and medical abortions at home. Prior to the COVID-19 pandemic, abortion by telemedicine was not widely available, but abortion providers would now like to continue this because of the positive experiences.
On the one hand, research on abortion care through telemedicine has shown that women are able to identify complications and seek the necessary medical attention themselves, there are high satisfaction rates amongst women who choose this abortion method, and high effectiveness rates. In addition, research suggests that making abortion more broadly available could reduce abortion stigma and give women more independence over their bodies. However, on the other hand, studies also show that some people – for example, younger patients – might prefer face-to-face communication over telemedicine, and that economically precarious women are at a higher risk of lacking emotional support when terminating their pregnancy through telemedicine. Providing abortion through telemedicine at the national level would also radically challenge the medicalised perspective on abortion. To conclude, telemedicine could be an advantage in abortion care provision, but it might not work for everyone, especially people in vulnerable situations.
Abortion stigma and misinformation
The law plays an important role in portraying abortion, since criminalising abortion and/or imposing taxing requirements reinforced the idea that abortion is morally wrong and/or should be controlled. Additionally, studies indicate that it can be challenging to find correct information on abortion, because deceptive ‘medical’ studies persist. This false medical narrative is dangerous as it fuels strict abortion legislation, misinformation, and stigma.
Moreover, abortion stigma can hinder quality abortion care and shape the environment of abortion procedures. Concretely, abortion stigma can lead to (1) poor treatment of patients; (2) the obstruction of adequate care through either a lack of resources to provide abortion care or deliberately failing to provide correct information; (3) and punishment and/or threats to people who provide and/or seek abortions. All factors contribute to delaying abortion care and negatively conceptualising abortion. In addition, it can lead to improper education on abortion for healthcare providers, potentially resulting in medical personnel’s misunderstanding and ignorance about abortion, and medical personnel expressing judgment for people who have abortions, potentially resulting in doctors providing incorrect information and offering below standard care. The lack of properly educated providers consequently can lead to a deficit of abortion care providers, making a small number of doctors responsible for abortion care. Lastly, while separate clinics for abortion care might have been initially positive to ensure sensitive- and women-controlled care, the separation of abortion from mainstream health care can marginalise abortion and providers.
This study included sixteen interviews with seventeen people providing abortion care in Brussels, Flanders, and Wallonia. Abortion care in this study encapsulated physical and mental well-being, and thus the care provided by the interviewees ranged from medical to psychosocial and/or psychological care. Furthermore, there was a large variety in the participants’ backgrounds and tasks. Of those seventeen participants 3 people from 3 different Flemish centres, 6 people from 5 different family planning centres in Brussels and 8 people from 7 different family planning centres in Wallonia were interviewed. As most abortions in Belgium are performed outside of the hospital setting, the focus of this study was on the outpatient centres.
Regarding the current abortion regulations in Belgium, all participants highlighted key elements that could be improved in their opinion. Regarding the law, all of them but one, mentioned specific legal changes they would like to see. Most often, the law was said to be outdated and/or vague, in combination with an emphasis on some positive aspects. Significantly, the discussions on the mandatory waiting period showed that some participants prefer to adapt the care to the needs of the patients, but are therefore breaking the law by not always respecting the mandatory waiting period.
Continuing, the questions on the pandemic showed how legally separating abortion from other healthcare procedures led to the abortion care providers being solely responsible for ensuring access to abortion during the pandemic. Moreover, the changes initiated by the abortion care providers during the pandemic, most notably the possibility of having a medical abortion at home, were at the time of the study still not integrated into the legal or financial framework. Most of the participants accordingly mentioned that the organisation of abortion was cumbersome and/or stressful during the pandemic.
The opinions on telemedicine varied greatly, as did the access provided during the pandemic throughout the country. Generally, the opinion was that telemedicine could be used in certain circumstances if it was for the benefit of the person seeking an abortion, but telemedicine should not become the sole method of abortion care, partly because of a fear of neglecting the human aspect of medicine. These results show that from the perspective of abortion care providers in the Belgian setting, there was a potential benefit for providing abortion through telemedicine. However, the in-person availability of abortion was deemed indispensable for people in specific situations because of the desire of healthcare professionals to continue working with people face-to-face. While previous studies on abortion telemedicine in restricted areas highlight the importance of ensuring a safe, efficient, and adequate experience for the users, further studies should focus on how to incorporate access to abortion via telemedicine from the national healthcare perspective in legal settings.
When discussing the gestational age limit and abortion travel all participants discussed how they had helped people travel for abortion care, to either the United Kingdom, The Netherlands, Spain, or France, if the pregnant person seeking an abortion had passed the legal limit in Belgium. Some of them discussed how the pandemic made this situation considerably more difficult. Several also discussed how it was difficult for them to not be able to provide the proper care for the people in need, and to not know what eventually happened to the people requesting an abortion. The assistance provided to people travelling abroad ranged from providing information on abortion abroad, offering guidance before and after the abortion, to providing financial help, and in one case even physical support to someone unable to go alone. In line with previous research on gestational age limits, this study confirms that in Belgium the gestational age limit is specifically harmful to people in vulnerable positions and fails to take into consideration reasonable causes for discovering the pregnancy at a later stage or asking for an abortion at a later stage. In other words, it shows that the law fails to take into consideration the most vulnerable people in need of abortion care, leaving the abortion care providers to navigate legal ambiguity and/or to find the best solutions for difficult situations. In the worst case, this can result in having to deny a person abortion care or providing abortions illegally past the legal limit.
There was no unanimity on when the gestational age limit should be. However, none were against prolonging it. Several interviewees underline the need to discuss the organisation of second trimester abortions, should they become legalised. While many of the participants agreed that the best abortion care is provided outside of the hospital setting, various also said that second trimester abortion could not be organised in out-of-hospital centres. Though there are extremely valid and important considerations to be made regarding the organisation, we should be mindful to not extend the stigmatisation of abortion by separating second trimester abortions from other abortion care, resulting in stigmatisation and exclusion of people providing and having second trimester abortions.
Finally, experiences with abortion stigma and/or misinformation were very common. The stigma and/or misinformation can be categorised into three groups: coming from the people needing abortion care, from medical personnel, or being generally present in society. As research suggests, many of the participants mentioned how they thought the law played a significant role in causing and continuing the stigma around abortion. Moreover, many participants critiqued the way abortion is discussed legally and publicly. This study found that consequently neither people who are happy with their abortion, nor people who experience difficulties can openly discuss their thoughts. Lastly, all the risks of abortion stigma to obstruct the best abortion care described in the study by Sorhaindo and Lavelanet (2022) were present in Belgium. For abortion care providers, abortion stigma and misinformation result in a time-consuming practice of explaining what abortion actually is. Therefore, many of the participants underlined the importance of the first consultation. The misinformation and stigma coming from other healthcare personnel, is also in line with research on the effects of abortion stigma. Abortion stigma and misinformation can thus contribute to delaying abortion and the lack of health care providers providing abortions.
These societally and currently relevant topics substantiate the majoritarian feeling of an outdated and vague legal framework to provide the best abortion care in Belgium. They show how the Belgian abortion law in practice fails to take into consideration the different needs of people, and leaves abortion care providers with an enormous responsibility of providing the best care possible within an inadequate framework. Moreover, some participants found that the current law places mistrust in abortion care providers. Consequently, many people did not know how to envision the future of abortion care in Belgium. The future was described as unsure (e.g.: “we will always have to fight for abortion rights”), positive (e.g.: “many young doctors are motivated to learn about abortion”), and fearful (e.g.: fear of abortion rights declining such as in other countries). All the participants stressed their dedication to providing the best care they could for the person in need of an abortion, and that they always do what is best for the function of that person.
While there are several positive aspects to the abortion law in Belgium, access to abortion has historically been and continues to be an arduous journey. Unfortunately, the future continues to look legally ambiguous and research on abortion therefore remains crucial. By means of three societally relevant situations, abortion travel, abortion stigma, and the COVID-19 pandemic, this study showed how the Belgian abortion legislation fails to take into consideration the reality of seeking abortion, and consequently burdens abortion care providers with finding solutions in a deficient system. I would like to end by stating that all compromises to abortion care have real consequences for abortion care providers and people seeking abortions. There are therefore no compromises when it comes to abortion care.
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