‘Turkey should step up efforts on zero target for mother deaths’

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Professor Ayşe Akın received a United Nations Population Fund (UNFPA) award last week in Nairobi, Kenya at the International Conference on Population and Development (ICDP25) for her contribution to the health of women at the global and national levels since 1994, when the first ICDP took place in Cairo, which she had also attended.

Can you give us an overview of Turkey’s population policies?

The new republic’s population was 13 million at the end of the war of liberation, when a lot of men had lost their lives. Modern Turkey founder Mustafa Kemal Atatürk had endorsed a pro-natal policy, but he has no forceful statement on the record.

In the 1950’s the increase in the number of unsafe abortions because of unwanted pregnancies had led the decision-makers to change the policy. Imagine, the world starts getting interested in population growth in the 60’s, whereas family planning came to the agenda a decade ago in Turkey.

After a decade of efforts, the first population law was endorsed in 1965. The law legalized providing information, use of modern contraception methods like pills, condoms and abortion only on medical grounds.

While the use of modern methods increased, the law could not prevent induced abortion (abortion performed by the pregnant woman herself or with the help of another, without medical assistance.)

In the 1970’s despite its illegality, there were 400,000 induced abortions a year and at least 50,000 of them were self-induced, which became the main cause of the high level of maternal deaths. Women used soap, matches or skewers. I had many patients coming to me, unable to urinate for instance. I had patients die because of self-induced abortion. Unsafe abortion means death.

The woman is poor, she does not have the means to raise a child, but at the time the law did not accept social reasons, as a result she resorts to methods risking death.

So, this has led to an outcry among the medical community and the need to review the law came to the agenda.

We are a people of science, my research took five years, and only after five years we said our last word. Otherwise, we never set on the road by saying let’s legalize abortion. We wanted more efficient family planning, not more abortions.

Our research conducted with the collaboration of World Health Organization (WHO) in five countries showed that the cost of an unsafe abortion is 10 times more than a normal gynecology patient. Another research we conducted showed that midwives and nurses could be trained to insert IUDs (intrauterine device). My work module was approved by WHO and published in English, French and Spanish.

We also worked on training general practitioners (GPs) to provide the termination of pregnancy with atraumatic techniques.

We started explaining our findings to all stake holders including the politicians. And the law endorsed in 1983 authorized nonphysicians to provide IUD services, authorized GPs to terminate pregnancies and legalized abortion up to 10 weeks on request.

As a result, maternal mortalities due to unsafe abortions saw a sharp drop, from 53 percent to 2 percent.

In short, how would you summarize your success?

First of all, leadership is important. The second research was crucial. Third, advocacy. We shared all our findings with decision makers, with the medical community. But most importantly, we did not impose upon them, we explained the reasons, especially to those who were against. You have to convince those who are against.

First of all, you cannot improve the health of a woman by obstructing abortion by request. But most importantly, the message was that we were not advocating murder: On the contrary this is a human right. If a woman wants to continue her pregnancy who can dare to tell her to end it. But if a woman does not want a fourth child for example, we have to respond to her needs.

Forth, intersectoral and interdisciplinary cooperation was also crucial.

Currently, the share of unsafe abortion could drop from 2 percent to 0, if only we uphold this issue as a fundamental human right.

What is your evaluation when you look at the current situation in Turkey?

There is not a problem as far as society is concerned. The society would want to have access to the services it needs. The findings of the last survey (published Nov. 8) are telling us that 12 percent of reproductive women say, “I no longer want a child, but I do not use anything.” This used to be 6 percent in the 2013 survey.

Currently there is a tendency of increasing fertility. There is a sense of alarm about the aging population that feeds the view of “we need a reproductive population.”

But we have a young population. According to our projections, the population of 65 and above will reach 17 percent in 2050. In 2040 it will be 14 percent.

Only when those 65 and above reach 15 percent of the population, that it is considered an old population according to the United Nations.

Second, if our old population is on the rise, why worry? On the contrary be happy. That means healthcare is good in Turkey. But why do we see 12 percent on the unmet need for family planning. Perhaps, society is influenced by the rhetoric of “we are aging we need to have more births.” But honestly, I think our society’s awareness level is high enough not to be influenced by this rhetoric.

A point that I can underline is this. We train nurses and they become certificated to apply family planning methods. But where she goes, she cannot give that service. She is not given the necessary equipment. Or maybe the health personnel don’t want to provide this service because it is not registered in their official “performance record.” I hope I am wrong, but I have the feeling as if there is a tendency to keep a low profile on family planning services.

Currently around 15 of every 100,000 live births end with maternal death and 64 percent are of preventable causes.

With the policies that have been pursued since the 1980’s mother mortalities have gone down sharply. But there is no serious decrease in the last decade. We are not going speedily towards 0 target on maternal mortality. If a mother wants to have her 10th child, she can, there is no problem with that. But if a woman has a heart failure and does not want a child, then the necessary service needs to be given to her. We have the legal ground; the law opens the door wide open. But there seems to be some political barriers.

So it seems there is a group of women who wants to delay pregnancy or who no longer wants a child. They have difficulty in accessing necessary counselling and methods to avoid pregnancy or end pregnancy.

There is difficulty in that group to have access for an efficient method. They use inefficient methods like withdrawal, that then leads to induced abortions. If they cannot have access to abortion services then our people go and find their own ways, women probably did not forget old methods like taking pills or using soap. But we have to look at this issue from a medical point of view.

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