Daniela Antonovska, MA [Gender Studies]
Skopje, Skopski, North Macedonia; E-mail: dantonovska@gmail.com
Women’s sexual and reproductive rights and healthcare are an integral part of the human rights. However, women worldwide face denials and infringement of their sexual and reproductive rights. These denials erode longstanding efforts and commitments to achieve gender equality. The focus of this opinion piece is on North Macedonia due to 20-years of work in the field of women’s human rights, including women’s sexual and reproductive rights, and due to the frequent change in the context of their availability.
North Macedonia is one of the successor states of the former Yugoslavia that declared independence in 1991. The first decade of independence was marked by the establishment of democratic institutions and practices. After reaching independence the country signed and ratified many human rights international conventions. At the country level, human rights instruments have been incorporated into national laws. Although, laws are adopted a number of difficulties with the practical implementation of these laws remain.
In regard to the right to abortion, North Macedonia adopted by succession the Law on Abortion, dated back from 1977 in ex-Yugoslavia. According to this law, the abortion was legal without any restrictions. However, the ruling conservative party in 2013 voted to support the newly restrictive proposed legislation without wider public debate and consultation with the civic sector. It was a step back and a step towards a potential ban on termination. At cultural level, the still predominant traditional mentality and patriarchal culture stigmatize women and girls who perform the procedure, as well create a perception around abortion as immoral and unlawful. On the other hand, accessibility to the service is interconnected with the socio-economic position of women affecting mostly women from minority and marginalized communities. It is also closely connected to the delivery of sexual and reproductive care services in urban and rural areas. Rural municipalities, inter alia, have challenges with limited access to general healthcare services, which implies to the fact of citizens having limited access to sexual and reproductive healthcare, too. This puts rural women in different situation, compared to the rest.
The 2013 Law on Abortion (Termination of Pregnancy)
The law adopted in 1977 regulating termination of pregnancy was not altered until 2013. In 2013, the Assembly adopted a new Law on Abortion by urgent procedure without any consultation and debates with the public and the civil sector. This initiated street protests by human rights activists and feminist organizations. Women’s NGOs and many others working on human rights, among them many medical professionals, spoke against the lack of transparency and quick adoption of the law. Activists called for protection of women’s right to abortion without promoting the abortion as a birth control but as a right to safe and affordable service for women who need it.
With the newly adopted law, the abortion procedure was made harder by introducing many mandatory requirements, among others, a mandatory written request for an abortion, a three-day period of re-questioning of the decision by the woman and an approval of the procedure by hospital commission. The legal gestation limit for having an abortion was shifted from 12th to 10th week. Of particular concern wаs the re-introduction of the procedure for approval of the abortion request which was scrapped in 1969 and meant a reversal. Among other newly adopted provisions within this law were the fines imposed on medical professionals and abortion service providers who violate the law. New requirements have delayed women’s access to legal abortion and at the same time undermined women’s decision and encouraged misleading information about the service. Many doctors considered that these procedures traumatized women and complicated the process.
At the same time, a campaign called “Choose life” promoting abortion curbs was launched. The slogans such as Abortion is murder were not only present on the posters and put in the visible places in public, but also were screened in a form of a morbid TV spot on the national TV-channel. The spot was accompanied with the statement “Congratulations, your abortion was successful, you just killed your healthy baby who could become a beautiful boy or girl”.1
The law of 2013 was considered as the harshest restriction of the bodily autonomy of women, the denial of women’s rights and freedom to decide on their own. Human rights law is very clear that decisions about women’s bodies have to be made by women.
The 2019 Law on Abortion (Termination of Pregnancy)
The signs and willingness for replacement of the old restrictive law from 2013 come with the change in the country’s political environment in 2017 with the election of the social democrats. In 2019, the law of 2013 was redrawn and a new law was adopted. A number of changes were introduced, such as introducing medical abortion pills for the first time. Although used in a number of European countries as a non-invasive method of termination of pregnancy and as a method along with surgical whereas a woman can decide which type to choose, it was not known and applicable in the country until the adoption of the new law. With the legislative changes in 2019, it finally became recognized as a safe method for termination of pregnancy in early stageup to nine gestational weeks. Medical abortion pills were not only introduced for the first time and available at the primary level of healthcare, but as well as in hospitals. In this way, they became available in many cities and towns reaching diverse groups of women.
The legal gestation limit was shifted from 10th to 12th week with women no longer having to undergo an approval process in front of the hospital commission. Furthermore, women will be able to access abortion up to the 22nd gestational week in case of rape, incest, fetal malformation and socio-economic reasons. The penalties for the medical professionals were reduced thus restoring the dignity of the doctors.2 This law eliminated many of the obstacles which put additional burden on women.
This newly adopted law puts the woman first and does not favor the abortion, but rather prescribes conditions and procedure for safe termination of pregnancy of women who have made such a decision. Laws like this one does not affect in any case women who are willing to give birth.
Protect Women’s Sexual and Reproductive Health and Rights
Access to sexuality education: Access to sexuality education play a pivotal role in ensuring women’s sexual and reproductive rights. Women and girls as well as boys and men, must have access to education and to appropriate information about family planning and contraception. However, comprehensive sexuality education in the country is still not introduced and is met with resistance by part of the population. There are plans for it to be introduced as of September 2021, as a pilot project in few schools from urban and rural country areas.3
The access to contraception: The access to contraception is an important part for reducing unintended pregnancies and abortions. However, in the country the access to contraception is still low. Conducted researches showed that only 13% of couples in North Macedonia use modern contraceptives and only 1.6% of young people use oral contraceptives.4 There is no quality sexual and reproductive health without contraception. The country has one of the lowest rates of usage of modern contraception compared to other countries in Europe. Contraceptives are still not listed as medications which the insured persons can take at the expense of the Health Insurance Fund of North Macedonia. This represents such an obstacle for women coming from poor, marginalized and vulnerable groups. Many women of them cannot afford to buy contraceptives. On the other hand, some women, particularly those from rural areas and from traditional families, besides prices as an obstacle, face shame and stigma in contraceptive usage. Economic situation and traditional mentality are still among the factors that hinder women from discussing and using contraceptives.
Although, the country made significant efforts in educating family physicians and gynecologist about the importance of the modern concept of family planning still some doctors are reluctant to embracing modern concept and novelties in family planning. Since 2016, over 200 family doctors were trained and WHO’s guideline for family planning was translated into local languages. Primary healthcare is a key starting point to expand access to family planning services and to move towards universal health coverage in the country.5
Ensuring Access to Safe and Legal Abortion
Legal and regulatory framework is a key to access to safe and legal abortion. However, the accessibility of the national abortion services is not proportionally distributed through the whole country. Women, particularly those living in small towns and rural areas, have to travel to the nearest hospital to provide abortion care. The nearest hospital, actually, may be not so near and this is such a procedure for obtaining a basic healthcare.
The rate of abortion is relatively stable in the last few years. In 2018 the rate was at 18.5 per 100 live births, in 2019 the rate slightly increased to 19.5 per 100 live births. In 2014, the rate was at 20.5 per 100 live births whilst in 2015, the rate stood at 19.9 per 100 live. There is no significant trend of increasing or decreasing of abortions.6
However, cultural issues such as harmful gender stereotypes, stigma, social norms, they still have a significant influence on women’s decision on performing abortion. The stigmatization is particularly present in vulnerable and marginalized groups of women with low educational attainment and poor socio-economic background. Roma women and rural women face more limitation in access to safe and timely sexual and reproductive healthcare.
The Way Forward
Equality comes in many forms, including equal and equitable treatment and personal autonomy for all. Personal autonomy involves independent decision-making by women and men, without imposing barriers that would hinder or direct their decision-making.
Safe abortion should be available to all and both forms, medical and surgical, should be accessible. Women who have decided to have an abortion must in no case be discriminated against, convicted, labeled in any way or on any grounds.
The state should ensure that all women and girls have access to sexual and reproductive health services and facilities. Accessibility means not only being physically, but as well as economically accessible.
Sexual and reproductive health information, including comprehensive sexuality education should be taught in schools.
Any kind of barriers in access to contraception, including economic barriers, should be removed.
A country that wants to improve the quality of life of its citizens should not ban or restrict abortion because that leads to forcing women and girls to look for unsafe abortions which may have fatal consequences.
An attempt to ban or restrict abortion does not mean that the numbers of abortions will reduce. On the contrary, it will force women and girls to look for unsafe abortions which may bring unwanted consequences. Women should have the right to professional and non-biased information and counseling before and after the procedure. The country and the government need to increase the availability of integrated sexual and reproductive health services that are gender responsive and meet human rights standards for equal access and quality of care. The geographical distribution of obstetricians and gynecological services should be improved and equal access to every woman should be ensured.
1. Antonovska D, Conservative mobilization against progressive gender equality policies. CA, USA: LAP Lambert Academic Publishing; 2017: 76.
2. International Planned Parenthood Federation, North Macedonia’s abortion care law signals new dawn for reproductive freedom. Website. https://www.ippfen.org/blogs/north-macedonias-abortion-care-law-signals-new-dawn-reproductive-freedom-0. Updated April 4, 2019. Accessed December 22, 2020.
3. HERA. Comprehensive sexuality education. Website. https://hera.org.mk/shto-rabotime/seopfatno-seksualno-obrazovanie/?lang=en. Accessed December 22, 2020.
4. HERA. Contraception. Website. https://hera.org.mk/shto-rabotime/kontraczepczija/?lang=en. Accessed December 22, 2020.
5. World Health Organization (WHO). Primary health care helps extend sexual and reproductive health services in North Macedonia. Website. https://www.euro.who.int/en/media-centre/events/ events/2019/04/world-health-day-2019/news/news/2019/04/ primary-health-care-helps-extend-sexual-and-reproductive-health-services-in-north-macedonia. Updated April 5, 2019. Accessed December 22, 2020.
6. State Statistical Office. Women and men in Macedonia. 2017. Website. http://www.stat.gov.mk/Publikacii/Gender2019.pdf. Accessed December 22, 2020.
10.17140/CTPOJ-7-125
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