Top: A sign in front of a clinic operated by the Planned Parenthood Association of Thailand in northern Bangkok.
BANGKOK — The small clinic has only four sections: a reception area, restrooms, counseling room and an area where the actual procedure is performed.
Located just off busy Vibhavadi Rangsit Road, it’s run by the Planned Parenthood Association of Thailand, an organization that pioneered the concept of family planning, with much success, in the country over 40 years ago.
Speaking next to a bed where patients are examined by ultrasound, a counselor and assistant nurse discuss the steps necessary before getting an abortion. Women are not only screened for their health, counselor Aoy said, but also counseled about the consequences and other options available to them.
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“We ask them if they want to raise the child,” said Aoy, who declined to give her full name because her organization does not allow it. “Some people who come here, after we talk with them, they decide not to do it. Some people go home and think about it … it’s not like we provide the service to anyone without thinking things through.”
Women have been effectively free to end unwanted pregnancies for about a decade under a little-advertised legal amendment. Since then, women’s health advocates say reproductive rights have made gains. Not only has the legal standing improved, but more women than ever have easy access to information about ending pregnancies thanks to the internet – and sustaining services doesn’t depend on unreliable outside support.
New data published Saturday by the health department suggests that most women seek abortions for social and economic reasons. Most of them were in their 20s; many were students.
But the situation is delicate. Health officials are divided in their support for abortion rights, and those who provide the service say they still work semi-secretly, fearing the backlash of a conservative Buddhist society where the practice is routinely stigmatized by the media and religious authorities.
When police last month arrested a 17-year-old woman who ended her late pregnancy by taking abortion pills and dumped the fetus in a garbage bin, yet another round of debates about the morality of abortion dominated talking points on the media.
Open Secret
For many Thais, abortion still conjures images of shady, back-alley operations. Many would be surprised to know that abortion per se is not illegal, albeit with some restrictions. A cursory search online quickly finds a dozen clinics where women can legally have abortions.
One is the small one run by Planned Parenthood, where Aoy works. Some others belong to a foundation set up by Mechai Viravaidya, a family planning activist synonymous with condoms in Thai.
In the past, the laws only allowed termination of a pregnancy that threatened the health of a mother or child, or if it was the result of rape, explained Planned Parenthood Thailand Chairman Montri Pekanan. Abortions not carried out under those exceptions were punishable by up to three years in jail for both the women and their doctors.
But the laws gradually evolved to take into account the high rates of teen pregnancy and women unable to raise children.
“It’s better today. There have been attempts to fix the law itself,” said Montri, who’s worked for Planned Parenthood since 1986.
As a result, the exceptions were expanded in 2005 to broadly include possible physical or mental harm, which has been widely interpreted to mean women who are emotionally distressed at the prospect of having children they cannot raise, Montri said.
In December 2014, two drugs known as the “abortion pill” – Mifepristone and Misoprostol – which had long been in clandestine use, were approved for ending pregnancies in a hospital setting.
Supeecha Baotip, an activist from TamTang, an online-based group providing women information about safely ending pregnancy, said she’s seen much progress in recent years.
“In general, the structure [of providing abortions] in this country is nearly excellent,” Supeecha said. “It’s gone in a good direction.”
But there are limits. For one, abortion pills must be prescribed by doctors at approved hospitals or clinics. Women who terminate pregnancies on their own are liable for punishment under the law.
On Feb. 21, a 17-year-old girl in Bangkok was arrested and charged with performing an unassisted abortion after she allegedly took abortion pills and dumped the dead fetus in a garbage bin. She was eight months pregnant. Police said she decided to end the pregnancy because her husband is in prison for possession of crystal meth, and she didn’t think she could raise the child on her own.
Stigma
That being said, those interviewed for this story say acceptance of abortion by the public has not caught up with its quiet advances under the law.
Supeecha, the activist from TamTang, likened it to advancement in HIV treatment. Although people with HIV can live long, normal lives now, much of society still views them undesirably and shuns them, she said.
“We have had so much success, but the stigma is not going anywhere,” Supeecha said.
One factor might be generational differences, according to the man in charge of Planned Parenthood’s outreach programs.
“The Baby Boomer generation was raised with the understanding that no matter how many children [their] parents had, they still managed to take care of them all,” Somchai Kamthong said, citing a well-known saying. “They think quantity over quality. But younger generations see it [abortion] as a solution.”
Other dominant factors are conservative messages repeated by religious authorities. Nearly all experts and monks in Buddhism, the religion of the vast majority, view abortion as sinful and a source of bad karma that will haunt the “sinner” for many lifetimes.
There are even supernatural pressures. In 2010, an undertaker at a Buddhist temple in Bangkok was arrested after police found he was paid by illegal abortion clinics to bury 2,000 aborted fetuses in the graveyard. Major newspapers soon ran stories about child ghosts being heard weeping near the temple for their “evil mothers.”
Terms like ”evil mothers” and “immoral promiscuous teens” are routinely used by newspaper editors – mostly men – to describe raids on illegal abortion clinics and other stories.
Supeecha, the activist from TamTang group, said such media coverage personally offends her.
“They denounce women who had abortions. I was one of those women too. It’s like they denounce me personally, too. Women like us didn’t have any space to speak up at all,” Supeecha said.
She started her website two years later, in 2012, partly to give women a platform. The group’s name means “finding a way,” but also sounds similar to the word “abortion.”
Aoy, the Planned Parenthood counselor, said she felt the media is unsympathetic toward their work.
“I feel like the media is hostile toward us,” Aoy said. “A majority of them don’t understand us, and they oppose us.”
Private clinics like the Planned Parenthood are prefered to state hospitals because the latter tend to make patients uncomfortable by giving them a series of intrusive questionnaires, association director Montri said. Many doctors at public hospitals also decline to perform abortions on religious grounds, he said.
Difficult Decisions
At Planned Parenthood’s Vibhavadi clinic, Aoy went through the process a woman goes through if she requests to undergo an abortion there.
Most make contact via social media messages, which are read and replied by Somchai, the organization’s media and publicity officer. He asks them a set of routine questions, such as whether they have had a pregnancy test, why they want to have an abortion, and whether they have any health conditions.
Patients then come in for ultrasound and a counseling session. Children under 15 must acquire consent from their guardians. Those seeking services are asked whether they are being forced to do it.
Aoy said she once had to sit through a long argument between a woman who wanted to terminate her pregnancy and her husband, who objected.
“Whenever I see this kind of case, I tell them to settle the issue with each other first,” she said.
If the woman follows through, she is given an abortion consent form distributed to all clinics and hospitals by the Medical Council. Doctors at the clinic decide how to perform the procedure, whether by prescribing pills or using vacuum aspiration. The entire process lasts about three hours, and women can go home right away.
Per state regulations, clinics like those operated by Planned Parenthood can only provide abortions to women in their first trimester of pregnancy. Those seeking to end second-trimester pregnancies must do so at a hospital. Abortions cannot be performed after 28 weeks.
Public Health Issues
Although teen pregnancy remains a serious national health problem, there’s little family planning service providers can do but encourage responsible behavior.
When Somchai and his boss Montri talk to students at schools about safe sex, they don’t promote termination services because of the issue’s sensitivity and ambient antipathy toward sex education.
“When we tried to just install condom vending machines, school directors opposed us. They said we damaged their schools’ reputations,” Montri said, adding that while some administrators understand and welcome their teaching about contraceptives, “many places just shoo us away.”
Since he cannot directly mention abortion in these outreach programs, Somchai said the best he can do is tell students not to seek out illegal clinics or take pills on their own, as they could be placed in danger. Instead, he told them, they should seek advice from doctors and family planning groups, such as the one for which he works.
Somchai said his organization once thought about publicly advertising its services by putting up a billboard to save women and girls from unsafe abortions, but it was slapped down by puu yai who feared a backlash from society and fell back on discredited arguments about behavioral inducement.
“They said it would be like encouraging people to be irresponsible,” Somchai said.
Advocates like Somchai and Montri are visibly concerned their work could be portrayed as promoting abortion. They stressed pregnancy termination is a fraction of Planned Parenthood’s mission. Distributing contraceptives, they said, along with providing counseling on safe sex, family planning and teen pregnancy, account for the majority of their efforts.
Supeecha, the TamTang activist, lamented that reluctance to speak publicly about abortion results in a vicious cycle that only perpetuates the danger of unsafe abortions and the stigma of those seeking legal abortion.
“The problem isn’t teens being immoral and promiscuous, it’s the government and society being thin-skinned,” she said. “People don’t know about this because the government doesn’t tell them. The government doesn’t tell them because it’s afraid people will denounce them.”
Aoy, the Planned Parenthood counselor, wishes for an open conversation.
“I want the government to be more open than this, instead of just hiding things,” Aoy said. “If we don’t speak frankly, people will have illegal abortions, and they will suffer from complications. In the end, they will have to go to state hospitals for help, and the state will end up having to pay more anyway.”
Data-Riven Decisions
Because of this arrangement, in which abortion rights expand without being openly acknowledged, quantifying the number performed is difficult.
The numbers are not made public. A 2012 report published by the Bureau of Reproductive Health said state hospitals don’t differentiate between elective abortion, abortion for health reasons and miscarriage.
“Therefore, there has never been any official report on the ratio of induced abortions to the number of abortions overall in Thailand,” the paper said.
Reached by telephone Wednesday, bureau director Kittipong Saejeng said there’s still no centralized data on abortion numbers in Thailand. Apart from the reasons mentioned in the 2012 report, Kittipong said private clinics do not send data about their operations to the department, citing confidentiality, while illicit abortions are impossible to track.
“I wish I could have the total number of abortions requested [for economic or social reasons], but I simply don’t have the data,” Kittipong said.
He also declined to estimate the number of abortions carried out each year nationwide.
“No one in this country knows the overall number of abortions,” Kittipong said. “I cannot give any estimate to you, because I don’t know what I can use to estimate for you.”
Because of the lack of national data, Kittipong said his bureau resorted to conducting a survey called the Abortion Surveillance Report every year that samples cases of abortion from a number of provinces to gauge the background and motivations of those who request the service.
For example, in 2014, the department interviewed 689 people who went through induced abortions (as opposed to miscarriages) at clinics and hospitals in 13 provinces.
It found one in four were students. Seventy percent cited “economic, social or family reasons” for seeking an abortion. The rest requested it for health reasons. Numbers from previous studies in 2011 to 2013 tell a similar story.
Planned Parenthood’s Somchai said his organization does not keep data about its patients. Making the numbers public, he suggested, could spark a backlash.
“Suppose they said, ‘30,000 people had abortions.’ Then society might go, ‘Whoa, 30,000 people had an abortion!’” Somchai said.
He estimated that most people who visit the clinic are working age – 20 and up. Teenagers rarely show up, perhaps because they cannot not afford the cost, which runs between 4,000 baht and 5,000 baht. Director Montri said the clinic, like state hospitals, charge women for abortion services, except for rape victims or economically disadvantaged women.
Normalization
Although it’s difficult to quantify how the extent to which abortion has increased or decreased, its expansion has pushed the needle from privilege toward right.
Despite not advertising itself openly, Somchai said people easily find their way to the Planned Parenthood clinic using Google.
More and more people also have access to safe abortion. Numerous groups have been formed to raise awareness about reproductive rights, such as Supeecha’s TamTang. There’s also Referral System for Safe Abortion, or RSA, a network of health workers and doctors dedicated to providing the service to women who request it.
A landmark bill designed to combat the number of teen pregnancy, which was passed by the interim parliament just last year, stated that teenagers have the rights to “all” aspects of reproductive health
But, as Montri said, abortion rights still hang by a thread. For every progressive thinker in state health agencies pushing for more access, there’s a conservative opponent who wants to roll back the progress.
“I don’t want to blame anyone about this issue, really,” he said. “When it comes to educating people, we must take it step by step. If they do it too much, they will be criticized.”
Aoy, the counselor, said she’s hopeful that will change for the better. She’s also content with the fact that, despite all the preaching against reproductive rights, there are no militant groups threatening to attack her workplace, like in the stories she hears from the United States.
“We don’t have hardcore opponents like in America. We Asians are kind-hearted. We only talk a lot, but don’t actually do anything,” she said, laughing.
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