Heng Satha, CWC program director.

The issue of abortion is a controversial one around the world, and Cambodia is no

exception. As in other countries abortions have been performed here for hundreds,

and probably thousands, of years.

This, says one health professional, is easily seen at the 12th century temple of

Angkor Wat, where a bas-relief in the first gallery depicts scenes of heaven and

hell.

Among the carvings is that of a woman being given deep massage treatment, one traditional

method of abortion. The next beautifully sculpted scene of hell shows the woman and

those who helped to terminate the pregnancy condemned to the underworld.

Deep massage has been used for centuries by Cambodian women to induce abortions.

Experts describe it as "very risky" because it can cause severe bleeding.

Across Asia unsafe and illegal abortions occur in high numbers: the World Health

Organization (WHO) estimates 38,000 women die each year from unsafe abortions in

Asia, more than in any part of the world.

Cambodia has taken steps to try to cut down the number of unsafe abortions: the Abortion

Law introduced in 1997 legalizes termination if the fetus is less than 12 weeks old.

Abortion is legal beyond the first trimester if the pregnancy creates a risk to a

woman's life, if a woman has been raped, or if the child will have an incurable disease

once it is delivered.

Yet controversy and secrecy continue to surround the practice, and a number of representatives

from organizations interviewed by the Post were reluctant to discuss the topic publicly.

Many working in the reproductive health field say the social stigma and lack of access

to relevant medical services mean abortion is still very much an underground practice,

and the methods of Angkorian times continue to be used.

Dr Ouk Vong Vathiny, executive director of Reproductive Health Association of Cambodia,

says abortion is seen as socially unacceptable in Cambodia. "Many women don't

want to tell anyone because as Buddhists, the community considers it a sin,"

she says.

That view is supported by Dr Chhun Long, national reproductive health program manager

at the Ministry of Health (MoH).

The instruments for terminating pregnancies are prepared in the theater of a Phnom Penh abortion clinic.

"People view abortion as a dangerous intervention - it is secret because the

Buddhist religion teaches people not to kill, and also because of the honor of women,"

Dr Chhun says. "But at the same time they don't want to have unsafe abortion

services."

The Buddhist religion is uncompromising in its respect for life, a view that carries

over to the abortion debate.

Preah Dhammaudom Youvan-ath Lai, a senior monk from the Thommayut sect, says Buddhist

principles prohibit people killing each other.

"For people abortion is legal, but ... Buddha taught us that we should not kill,"

Lai says. "The unborn babies still love their lives so we should not kill them

- if you kill them you will receive bad karma."

However, societal pressures may in fact be leading young women to terminate unwanted

pregnancies. Dr Chhun says that intercourse before marriage is not respected, but

"having a baby before marriage is even worse than having an abortion. Young

people prefer to have abortions rather than babies."

The social stigma surrounding abortion means that accurate figures are difficult

to obtain. The national Cambodia Demographic and Health Survey 2000 noted that only

5 percent of women aged 15-49 reported having one or more abortions in their lifetime,

and that none between 15-19 had done so.

But the survey's authors say these numbers are underestimates, given the stigma associated

with abortion and the fact that it is "socially unacceptable for an unmarried

woman to admit to having sexual intercourse".

The survey's findings also indicate the abortion rate does not vary significantly

between urban and rural areas and seems unaffected by levels of education.

A more recent report on Phnom Penh, the Intra-Urban Health Survey 2001, puts the

city's figures higher, with 17 percent of poor, married women in slum areas reported

to have had one or more abortions compared with 12 percent for married women classified

as "non-slum, non-poor".

Garment sector employees and sex workers make up over half of the clients seeking

abortions at the Cambodian Women's Clinic (CWC), the only NGO that provides safe

abortion services in Cambodia. Heng Satha, CWC's program director, says the majority

of the clients are single. She feels there should be more openness on the topic.

"I am a Catholic and support abortion 150 percent," she says. "I beg

Cambodian society to be more open and assist women for their lives and rights and

health."

CWC works in partnership with Marie Stopes International and performs 35 abortions

a month. Along with other health professionals, Satha says she has no idea of the

number of pregnant women who succumb to backstreet abortions.

However they agree that the lack of centers such as CWC is likely to be a factor

in the rate of maternal death, which is one of the highest in Asia.

WHO's 1997 figures estimate that unsafe abortions result in around 140 Cambodian

women dying per 100,000 live births.

The MoH's Dr Chhun says abortion is one of the most significant reproductive health

problems for women in Cambodia.

"There are many unsafe abortions and some deaths," he says. "The lack

of trained midwives is increasing the risk of unsafe abortions in rural areas and

that is why we want to introduce safe services."

Other senior officials are aware of the problem. Eng Huot, director-general at the

MoH, says he knows that many women die from unsafe abortions. His ministry is trying

to combat this by increasing the numbers of trained surgeons and midwives across

the country.

Article 6 of the 1997 Abortion Law states that abortions can only be performed in

hospitals, health centers, clinics, or public or private "maternities"

that are authorized by the MoH.

However, since no Prakas has been drawn up to implement the law, none of the service

providers technically have the authority to provide abortion services, says Dr Chhun.

The MoH says it has not implemented the law because it lacks the capacity to control

or regulate abortion centers and so cannot be responsible for any complications or

problems caused by such centers.

"The government has the right to shut [the providers] down and take legal action,"

Dr Chhun says, although that has not happened yet.

Both the CWC's Satha and Mu Sochua, Minister of Women's and Veterans' Affairs, say

the reality is that women continue to have abortions. The lack of sufficient safe

services means their lives are still being put at risk.

Sochua says the MoH has the duty to implement the Prakas, to make abortion services

available and regulate them.

"The longer the Ministry of Health delays the Prakas, the longer the lives of

our women are exposed to danger," warns Sochua. "I want to see full protection

of reproductive rights of women.

"The reality is that women who have no other choices will go to unsafe places

where they are exposed to danger and exploitation from doctors who practice illegally

and with no quality control."

Dr Chhun says the ministry hopes to implement the Prakas within two years, by which

time referral hospitals will have the capacity to do emergency surgery.

"Women have been at risk for a long time, and to reduce risk we will introduce

safe abortion," he says. "If we were rich we would do it tomorrow but we

are poor."

He also says the ministry is not "very strict" and allows women to have

abortions on medical grounds at public providers such as the National Maternal and

Child Health Center in Phnom Penh.

Similarly CWC/Marie Stopes International has an agreement with the MoH to provide

reproductive and sexual health programs and carry out abortions when a woman's health

is at risk.

The ministry focuses heavily on "birth spacing" at almost 900 health centers

throughout the country. It aims to reduce the number of abortions and increase family

planning by providing post-abortion counseling and contraceptive services.

The MoH's Huot says the community's awareness of both birth spacing and up-to-date

contraceptive methods is increasing.

"In 1994, 7 percent of women were using modern contraceptives and now 20 percent

do so," he says.

That is a start, but Sochua says there must be more sex education, and contraceptives

must be made more widely available.

"I think [20 percent] is too low," she says. "Eighty percent means

a lot of women out there have no preventative measures. So even if one percent of

these women don't want the pregnancy, where do they go?"

CWC's Satha says the reality is that, despite social pressures against sex before

marriage, young people do have sex. The best way to reduce unsafe abortions is to

provide sex education from a young age.

"Pre-marital sex is seen as unacceptable but there is plenty of it in the community

and [women] don't know about protection or prevention and how to apply their rights,"

she says.

Regardless of ministerial efforts to authorize safe abortion services and to increase

education and contraceptive use, the issue of abortion will undoubtedly continue

to be contentious for years to come.

And while the methods of terminating unwanted pregnancies should become safer, spiritual

leaders will have nothing to do with the new techniques.

"Monks have a magic spray for pregnant women to reduce difficulties in giving

birth," says senior monk Youvanath Lai, "but we do not have a magic spray

to do abortions."