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Making abortion law reform happen in Guyana: A success story
Features
Frederick E Nunes and Yvette M Delph On 4 May 1995, after two years ofintense public debate, the National Assembly of Guyana passed the Medical Termination of Pregnancy Bill, making Guyana the second country in the Englishspeaking Caribbean to introduce such legislation. For the entire two years scarcely a day went by without letters or articles in the press, and at least once a week there was a programme on television and radio. This paper describes the history and content of the campaign in support of the new Jaw by the Pro-Reform Group, whose main slogan was ‘Pro-Life, Pro-Choice, ProReform’. This campaign sought common interests with the opposition, theirpublic education was based on research amonghealth and legal professionals, students and the public and on facts about abortion and women’s experiences. It was carried out mainly through the media. The paper ends with a description of the new Jaw and efforts to begin implementing it.
N 1971, four years after the UK passed the 1967 Abortion Act, Guyana became the first Caribbean country to initiate public discussion about abortion law reform. The People’s National Congress (PNC) appointed a Special Select Committee to examine the need to liberalise the law but although they held several hearings, they failed to submit a report. In 1974 Caribbean Common Market (CARICOM) Health Ministers passed a resolution to review legislation essential for improving maternal health. In 1983, a Medical Termination of Pregnancy Act was passed in Barbados. Shortly afterwards, the Health Desk in the Secretariat of CARICOM sent copies to all Permanent Secretaries in Ministries of Health in the English-speaking Caribbean, urging them to use the opportunity to act on the 1974 resolution. Nothing happened. In 1985, the PNC Government in Guyana prepared a draft bill on abortion that was almost identical to the 1983 Barbados Act. In 1988 they began a process of public consultation about the bill. In an effort to respond to concerns raised by various interest groups, the contents were expanded to include clauses on counselling, approval of medical institutions and limiting terminations to 28 weeks. The compact form of the earlier draft had yielded to cumbersome comprehensiveness. Concerns for
administrative control overshadowed the focus on women’s health. Although this Bill was approved by the PNC Cabinet in 1989, it was never advanced to the National Assembly. It was shelved and never voted on, probably in deference to the general election that was expected the following year, and possibly also in response to religious opposition, or both. The PNC had held power continuously from Guyana’s independence in 1966 until they were voted out of office in October 1992 and replaced by the People’s Progressive Party (PPP), the main opposition party. The new PPP Minister of Health demonstrated remarkable courage in the face of this highly controversial subject when, in May 1993, she announced her intention to review the law relating to abortion, which she described as ‘a law which no-one cares to obey and no-one dares to enforce’. She promised an open public debate on the abortion bill which had been left by the previous PNC administration and invited a wide range of interest groups to join in the creation of a Ministerial Committee. A commitment to transparency was manifested in her bold design of this Committee, which included more than 30 members from religious, legal, medical, and women’s organisations and which held public
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hearings around the country. The Committee’s report encountered widespread criticism, so the Cabinet extended the process of consultation by appointing an allparty Special Select Committee in December 1993 to receive views. They recommended removing most of the clauses added to the bill in 1989, once again making it a close replica of the Barbados model. The four sections they retained dealt with counselling, non-liability of physicians except for negligence, statement by guardians and confidentiality of information. Most of the provisions that were removed were then revised and included in the Regulations attached to the law. Existing laws as well as model abortion legislation were used in drafting the exact wording of the text.’ The bill’s social liberalism was balanced by its medical conservatism. It permitted abortion on request up to eight weeks, with no need to show cause, and accommodated a wide range of indications up to 16 weeks. It also made counselling mandatory, with a 48-hour waiting period to facilitate that process. In November 1994 the Select Committee put forward the bill which they had drafted. It was
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laid before the National Assembly in March 1995 and debated and passed by a vote of 32 to 21, without amendment, two months later. This was the first ever non-partisan vote in the history of the Guyanese National Assembly. How did this happen? How is it that after false starts from as far back as the 197Os, Guyana finally succeeded in achieving legal access to medical termination for a wide spectrum of indications? How did a campaign for liberal reform succeed in the face of highly active religious opposition?
THE PRO-REFORM GROUP This paper focuses on the work of the ProReform Group (PRG), who campaigned for the new bill. Members of this group brought skills in research, medicine, theology, law, logic, social work, women’s issues and commu&cation and they invited many others to make contributions within their fields of specialisation. An important feature of the group was their willingness to learn from each other and so to enhance their appreciation of this complex issue. While the core group remained small and
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close-knit, they also had access to many others on whom they could depend for assistance. There was a strong, shared commitment to certain values and objectives: listening carefully to any criticisms, especially those from religious groups; a clear agreement that law reform was essential for improving women’s health; a realisation that the process of the debate itself, as well as a new law, could strengthen family planning; and the prospect of using liberal law reform to help to reduce the incidence of abortion, perhaps the idea that galvanised the group most of all. Guyana has a population of 729,000, of which 51 per cent are East Indian and 43 per cent Black and mixed. The majority of the people are Christian (57 per cent), 33 per cent are Hindu and 9 per cent Muslim. Sensitive to the multireligious nature of Guyana, literature on the theological issues of abortion in Christianity, Hinduism and Islam was collected and studied. Given the particularly strong opposition from activists within the Roman Catholic Church, special effort was made to gather as much information as possible about the Church’s current perspectives, and history and theology on the issues of abortion and contraception. The wealth of information in the publications of Catholics for a Free Choice was invaluable in educating the gro~p.~ Previous attempts to reform the law on abortion were studied to determine why and how the process got bogged down and what might have spurred it forward. The PRG were able to learn which groups and individuals had been active and about the relative strengths of the institutions involved. The perspectives they gained were important for reminding the public not only how much had been done before, but also that nothing of substance had ever come of all that hard work. The message gleaned was one of the need for perpetual vigilance. Data and information from files and newspapers from those years gave authenticity to the long struggle for reform.3 The PRG were committed to honouring the process of consultation proposed by the Minister of Health. They felt that to take to the streets, in spite of such extensive opportunities for
could have undermined and consultation, possibly derailed the process of public dialogue advocated by the Minister. They decided that their strength lay in information, not confrontation, and in public education, not public action. The group were firmly committed to building links and searching for constructive responses to the concerns of the religious opposition, because they realised that the effective implementation of any new law could only benefit from the widespread social organisation and influence of religious bodies. The campaign needed dialogue, not debate. From early on, it was felt to be important to expand the effort beyond Guyana. The PRG turned first to the Caribbean and won support there from chief medical officers, professors of medicine, distinguished Guyanese, epidemiologists, directors of family planning associations, gynaecologists, presidents of medical associations, presidents of nursing associations, theologians, ministers of religion, experts on parliamentary procedure, and so on. The idea was not only to involve them in the campaign in Guyana, but also to initiate a cross-national collective effort. Wider support from people with experience and expertise of changing their laws was also sought from those within the international community who support law reform, including theologians, public health and law professors, physicians, researchers, and a host of leaders of NGOs who communicated their support to decision makers in Guyana and provided technical information or sources for assistance. The group also followed international events such as the murder of a doctor who provided abortions in Florida (USA), the International Conference on Population and Development in Cairo, and the Vatican’s attempt to block accreditation of Catholics for a Free Choice for the 4th World Conference on Women, and referred to these to shed light on the local debate. PRG members kept in close contact with decision makers, who had to be supplied with reliable data. Members of Parliament were provided with fact sheets and videotapes of interviews. Leading columnists and editors were provided with articles and pertinent information and research. PRG members provided back-up information and arguments, monitored the parliamentary process at every stage, and
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learned about administrative and parliamentary procedures and the pitfalls of legal drafting. They stood ready to intervene constructively at every imaginable stage. On one level, the PRG were no match for the organisational strength of the religious opposition, who conducted prayer vigils, marches, and pickets. They had to do nothing but step into the pulpit to find a ready congregation eager to listen. The PRG had to hope to counter their emotionalism with information. Then, during one very large public march against law reform, the zeal of some of the opposition got the better of them. Relying too heavily on technical advice from the USA, they employed tactics alien to Guyanese culture such as picketing doctors’ offices, calling them murderers and holding dismembered dolls smeared in red ink on poles, and even carrying tiny symbolic coffins. This was too much for many in the community. Several people who had until that time kept their peace, spoke out against this conduct and in favour of the Government’s need to address the matter of unsafe abortion. The Anglican Bishop was one of those. The PRG made full use of this event in its letters to the editor. What was intended to be the opposition’s best hour turned out to be an embarrassment.
PRO-LIFE, PRO-CHOICE, PRO-REFORM The PRG influenced the language of the debate significantly. In supporting a reform effort emanating from the Ministry of Health, the PRG argued that the fundamental justification for abortion law reform was women’s health. While women’s rights are also an important dimension, women’s health was seen to offer the better tactical tool. The PRG consciously avoided the sabre-rattling of women‘s rights although some in its ranks, and quite rightly so, felt very strongly about that element. They stressed the harm of unsafe abortions, the mortality and, even more, the unquantified morbidity. The group challenged the linguistic dichotomies which are so convenient to those who oppose law reform - anti-abortion and proabortion; pro-life and pro-choice. The PRG rejected the label ‘pro-abortion’ as nonsensical since they knew of no-one who ‘promoted abortion. Instead, they argued that their members were also anti-abortion, that they also
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wanted to see fewer abortions and hoped to educate men and women to that end. The group questioned the notion that a liberal law would encourage more women to have abortions and pointed to the fact that Guyana, with a very strict law, had an abortion rate 70 times as high as the Netherlands, with a very liberal law. The PRG disagreed with the pro-life, prochoice separation. They pointed out that the responsible woman who has an unplanned and unwanted pregnancy and who, after due consideration, decides to have a termination, is doing so out of love and concern for the quality of life - whether her own or that of her children or other dependent relatives, or indeed out of awareness of the limits of her capacity to nurture and care for another child. One of the PRG’s last television advertisements read ‘Pro-Life, ProChoice, Pro-Bill’. Having established that, like their adversaries, the PRG were anti-abortion, the group challenged the notion that the debate was about abortion itself. The difference, they said, between the PRG and Catholics for Life and the AntiAbortion Education Committee, who favoured enforcing the restrictive law, was in their views on how a given law would affect the incidence of abortion. The PRG, therefore, contended that the debate was not about abortion but about the law. On the basis of existing data, the PRG asserted that the strict, prohibitive law in Guyana had done nothing to contain a rampant industry of abortion. They also pointed out how attempts to contain abortion by strict legislation had been dismal failures in Romania and Poland. They could also point to a growing number of countries Barbados, Canada, Tunisia and Turkey- where the introduction of liberal abortion legislation had not resulted in an increase in the number of abortions. This was a major turning point in the campaign. In place of the old labels the PRG put forward new ones - pro-law reform and anti-law reform. This seemed both fair and appropriate since the focus was on the legislation and what it would do. The energies of both parties were directed at influencing the law-making process: The issue was the law. In turn, the PRG were challenged on their use of language. For example, there were objections to their use of the word ‘fetus’ and an appeal that they should use the term ‘unborn child. The group were not reluctant to use a warm, emotive
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word (child) in place of a cold, scientific one (fetus), since they wanted full consideration to be given to the seriousness of abortion. SO they obliged, even though some members argued that by definition, a child had to be born. In adopting the language of the opposition, the aim was to be accommodating, to move away from semantics and to keep the focus on the role of law in
the passage of a new law, but more importantly, the social reform that should attend that law. In any process of social reform, few institutions could prove more valuable allies than the religious bodies which reach into every community in Guyana. Pro-reform advocates therefore resolved to win both respect and support from the country’s religious leaders.
managing abortions. Seeking common interests with the opposition
BUILDING ALLIANCES Placing the issues above party politics A crucial strategy was to place the issue above party politics. This was essential if the newly which had been in elected government, opposition for an entire generation, was to be persuaded to proceed with such a controversial matter. The prospects for doing this were unusually good, since the out-going party had itself formulated and approved the original bill. But that support had to be made manifest and obvious: tacit support was not enough. To this end, the former PNC Minister of Health was helpful at certain very critical stages in the process. He urged the new PPP Minister to benefit from his experience and keep the vociferous religious opposition in perspective, and he urged the formation of a bi-partisan body to consider and refine the bill. Similarly, the PNC Shadow Minister of Health became an outspoken supporter of the drive for reform. On the Government side, this link would be sustained by giving credit to the Opposition for its work in producing the 1989 draft and by continuing to use that document as the basis for further action.
Openness The process of public debate was informed by a clear commitment to openness. Thus, whatever studies were conducted were promptly made available to the opposition. It required a willingness to listen carefully to, respect and learn from others who held opposing or different views. It demanded the humility of being inclusive - of trying to build bridges with one’s adversaries. This process relied on discipline to persist with openness, even when trust and goodwill were abused. The advocates of reform realised that the real victory they sought was not simply
Listening respectfully to their adversaries, the Pro-Reform Group sought and found common interests and amplified those instead of the recognised differences. Divisive language was replaced with a shared interest in enhancing the sanctity of life and finding ways to achieve goals which both sides shared, fewer abortions and stronger families. Information, quiet reason and simple logic were employed against religious dogma, righteous indignation, intense emotionalism, and alarmist claims of grand conspiracies. Rather than confront and denounce the religious opposition, the PRG found allies among liberal Christian and Islamic religious leaders and in doing so destroyed the myth of religious opposition to abortion law reform as monolithic and homogeneous.
RESEARCH: USING THE FACTS TO INFORM POLICY A main weakness of public policy formation in many developing countries is the paucity of factual data and the lack of a tradition of using data to inform decision-making. Instead there is a heavy reliance on values and precedent. The subject of abortion law reform is perhaps the most vexed of all public policy issues and is prone to be conducted in the absence of facts. A major investment was made to ensure that there were data on the local situation to which people could relate. Thus, several studies, including a review of clinical data, were carried out.4 In addition, international data on abortion, maternal mortality and morbidity were gathered.5
Survey of the medical profession The survey of the medical profession examined their views on abortion law reform and their perceptions of the magnitude of the problem. It included 430 medical practitioners, medexes
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(similar to nurse practitioners), nurses and pharmaCiStS. The results were mirrored time and again in most of the subsequent surveys, namely, that when asked a general question ‘Should the law on abortion be liberalised?‘, most respondents would answer in the negative. Yet when the same respondents were asked more specific questions Should legal access to abortion be available if a pregnant woman is mentally incapable of raising the child, or has HIV, or if the fetus is badly deformed, or if the pregnancy is a threat to her physical or mental health, or in cases of rape or incest?’ - a clear majority would answer yes. This was also true for respondents who described themselves as conscientious objectors; the majority supported law reform for these indications. Seventy per cent of the medical respondents felt that the restrictive law on abortion was either totally or largely ignored. There was no consensus among them about how many abortions were taking place in relation to births. The great majority (88 per cent) said that women seeking abortions were mostly 15-24 years old. In general, they showed an openness to legal reform.
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cent by general practitioners. Most of those abortions had been done in private hospitals (54 per cent) and a further 26 per cent in private clinics. For almost two-thirds of those who had had abortions, their first abortion was before their 25th birthday. A disturbing finding, and one that constitutes a major challenge for health educators, is that one in every five women regarded abortion as a form of family planning, and one in six considered abortion to be their preferred method of birth control. Among the men, 34 per cent had contributed to a woman having to have an abortion, 19 per cent had caused the need for abortions in more than one woman, and 17 per cent had caused more than one abortion in the same woman.
Familyplanning records
Surveyof the public and university students
In mid-1993, the medical records of 1,000 women who joined seven family planning clinics in Georgetown in 1992, were examined. Almost half of the women (48 per cent) reported having had at least one abortion and 26 per cent had had more than one. The ratio of births to abortions was high at 422 abortions per 1,000 births, yet informed medical practitioners suggested that the true ratio could be as high as twice that figure or almost 1:l.
Once the debate started, it was essential to gain a sense of general public sentiment as well as objective data on the actual situation of abortion. A stratified cluster sample was taken of workers and professionals in Georgetown and students at the University of Guyana. A questionnaire was administered to 481 people - 289 women and 192 men. There was almost no gender difference in the respondents’ views on the need for law reform though in some questions (for example, should legal abortion be freely available) men were even more liberal than women. There was overwhelming support for most of the specific indications for the proposed law reform, as described above, and significant support for others like contraceptive failure and social and economic conditions. As many as 63 per cent of the women reported having a relative who had had an abortion. What is more, 30 per cent of the women surveyed reported that they themselves had had abortions. As many as 86 per cent reported that their abortions had been done by medical practitioners - 59 per cent by specialists and 27 per
The views of 1,750 students, mostly 13 to 17 years of age, in 60 schools from all over Guyana were polled in early 1994. Because of the high dropout rate of boys after fourth form, almost 60 per cent of the respondents were girls. The great majority (78 per cent) in each form reported that they had no experience of sexual intercourse. The great majority also favoured the introduction of Family Life Education into their school curriculum. When asked to identify a list of methods of birth control, only the condom (89 per cent) was more widely known than abortion (87 per cent). The next best known was the oral contraceptive pill (66 per cent). All other forms of contraception were known by less than half the respondents. Among the girls a considerable &mber had a close relative (33 per cent) or a teenage friend (21 per cent) who had had an abortion. Among the boys, 15 per cent had a male teenage friend who had contributed to a girl needing an abortion, and 14 per cent had a male relative who had contributed to an abortion.
Survey of in-school teenagers
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The notion that teenage girls were more vulnerable than adult women was supported by the fact that among this group, the largest single provider of abortions was nurses (27 per cent). The girls also relied heavily on pharmacists (5 per cent) and ‘others’ (16 per cent). Overall, among the general population of women surveyed, 86 per cent had had abortions performed by medical practitioners, while among the teenagers the corresponding number was only 52 per cent. Although 50 per cent of the students described themselves as conscientious objectors, they did support abortion law reform for several specific reasons, eg.. to save the life of the mother, rape and incest.
Survey of legal profession The views of various members of the legal profession were also sought by questionnaire in May 1994 when the abortion debate was at its height. The results suggest that they had been significantly influenced by the debate. A quarter of those surveyed had changed their views within the first year of the debate, two-thirds of whom moved to more liberal positions. Thus, the legal profession can be a responsive and important ally in the process of law reform.
Personal histories Many people respond less to the abstractions of statistics than to the details of human interest stories. These sometimes proved more compelling in convincing people of the need for reform than research data. The crucial thing was that human interest stories had to be absolutely factual and authentic. The Pro-Reform Group never published the names of any respondents, and used only those stories which they investigated at first hand and where the respondent was willing to sign his or her real name. The newspapers were then asked not to disclose the individual’s identity. All this information provided a compelling empirical basis for the government to take action. It also highlighted the unsatisfactory level of contraceptive education and availability.
USINGTHE FACTS FOR PUBLIC EDUCATION With the information from these surveys, the group could speak with confidence about the
great denial in Guyana. They knew that on an issue as contentious as abortion, no research would escape scorching criticism from their opponents but they went ahead anyway, exposing what had been hidden and suppressed. Getting people to listen to information about behaviour which was clandestine, suppressed and stigmatised was a major challenge. The task was to stimulate people to use the data provided to examine whether repressive or liberal legislation would better serve the values they held about individual life, family and society.” The most important messages were very simple: Illegal abortion existed on a very large scale. In Guyana, there was at least one abortion every hour, 24 hours a day, seven days a week. Unsafe abortions were a leading cause of maternal mortality and morbidity, in spite of under-reporting. Septic abortion was third among the leading causes of admission to public hospitals. Prohibitive legislation had failed miserably to contain the practice of abortion. Legislation permitting medical termination was the most effective method of achieving a dramatic improvement in maternal health. Unsafe abortions are 100 to 500 times more risky than terminations carried out in clinical conditions.7 An abortion in the first trimester, under clinical conditions, is about 20 times safer than childbirth at term.7 Liberal abortion legislation, in tandem with improved contraceptive use, could lead to significant reductions (not an increase) in the number of abortions. Fewer abortions would mean fewer fetal deaths as well as fewer women’s deaths. The fear that liberal abortion legislation would lead to a fall of interest in family planning is unfounded. One study after another has documented the fact that women who have had abortions typically become more responsible cont?aceptors.8 Liberal legislation respects the sanctity of life and does not ‘promote’ abortion. In each message, the central focus was women’s health: the main arguments never strayed from that anchor.
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PUTTING
THE MESSAGES
INTO THE
MEDIA A huge investment was made in public education, There is little point in generating and collecting data intended to inform and influence public policy unless it is directed at the decision makers and made available to the general public. The PRG organised a letter writing campaign in the press and developed advertisements for television to ensure that the data it collected became public property. For much of the debate, the only information available was that put together by the PRG; even the adversaries of law reform used it. The reliance on letters in leading newspapers was not accidental. Not the least consideration was that, while time consuming and of limited impact, it was free. Although the editorial pages lacked broad appeal, messages there would be seen by the elite and other influential people. Equally compelling was that writing as a medium is superbly suited to logic, and far less suited to hysteria and scare tactics. Letters were used to challenge and expose some of the emotional appeals of the opponents of reform. Pro-reform advocates knew they had a comparative advantage in the press, and they made optimal use of it. Over the two years of the debate, it was commonplace for them to have as many as three letters in any one paper on a given day; less frequently they had five, and on one occasion as many as seven. Their efforts in the press were not limited to the editorial pages, however. They designed cartoons and hired an artist to craft their messages into attractive advertisements that raised more public discussion than the most poignant letter. The cartoons were not only intended to make more people sensitive to the debate. They aimed also to diffuse confrontation through humour and to suggest that there was vahdhy on both sides: two cartoons with splitimageswere used to convey this to considerable effect. The cartoons helped to keep the debate alive, to keep the public informed of where the Process was and to prod reluctant legislators into action. At the same time, the cartoons took advantage of the public’s interest in sexual relations and gave messages to men about sexual responsibility. Several cartoons involved role reversals, Portraying men pregnant or at risk of pregnancy.
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Television Guyana has seven television stations, one of which seemed particularly disposed to air antireform messages. The opposition made full use of it, often showing films from the USA antiabortion movement. The intense horror of these films was such that few viewers were likely to look at them a second time. What was more, they seemed intent on scaring the viewer into adopting a particular view. Such fright could not endure in the face of the facts. The PRG’s use of television was calculated to stand in marked contrast to these dramas. The people they interviewed spoke with quiet, deliberate reason. First, the PRG filmed interviews with people who had been central to the abortion law reform in Barbados in 1983, eg., the then Minister of Health who had engineered the success of the Act. She not only described the important process of consultation and accommodation, but also expressed her unequivocal support for law reform in full view of the public. Another was of a Guyanese-born medical practitioner, a Catholic and a conscientious objector to abortion, who as a member of the Barbados Association of Medical Practitioners, was involved in the deliberations which led to the 1983 Act. She was able to explain that her worst fears of the new law resulting in increased abortions had been decisively answered instead by the elimination of complications resulting from backstreet abortions. Interviews with two physicians and a minister of religion in Guyana were also taped. In a multi-racial society, the PRG was careful to get an Amerindian Lutheran Minister, an East Indian gynaecologist and a Black physician. Later, they developed a series of ‘abortion facts’ which were written in simple white lettering on a black background with no sound. The idea was to give information, but not to frighten or scare people. This was done at a time when it was felt to be necessary to respond to the runaway advantage of the anti-reform group on television and to move beyond the limited scope of the editorial pages. Next, the Cartoons of pregnant men were televised and dramatised with simple voice-overs. Some of them had children and their parents discussing why these images were being shown. Late in 1994, when the Report of the Select Committee was made public, the PRG put
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together a series of interviews with leading members of the Guyanese public and outstanding individuals in the fight for abortion law reform internationally, on the proposed new Bill. These included the chairwoman ofthe Select Committee and Minister with Responsibility for Women’s Affairs; an outspoken member of the Opposition party who was an ardent supporter of the Bill; the president of the Guyana Human Rights Association; and a prominent gynaecologist. Lastly, advertisements promoting law reform in the name of supporting life, strengthening family life, achieving safe motherhood and reducing the need for abortion (showing loved children, healthy mothers and strong families) were televised on several stations over the last five days before the National Assembly debate. The intent was not so much to influence legislators directly as to place the new Bill in the broad context of positive human and social values, create a climate of sympathy and understanding about the Bill and thereby make it easier for them to vote in support of it.
Radio The Pro-Reform Group’s work in the press and television was not in any way matched by its use of radio. It did use Viewpoint, a sort of radio editorial, to considerable advantage on a few occasions, but not sufficiently. Even though the PRG learned that one good commentary on radio was worth a week’s letters, the group failed to capitalise on that lesson. There were several weekly call-in programmes on radio, but the group made little use of them. As a result, the opposition did a far better job on radio.
THE ACT The Medical Termination of Pregnancy Act in Guyana is unusual in that it claims to be designed to enhance the sanctity of life and unique in its bold promise to reduce the incidence of abortion. These affirmative statements at the beginning of the Act were placed to set the broad frame of the social underpinnings of the legislation. Giving them a place of primacy constituted a sincere intention to reduce the greatest fear of the religious opposition, namely, that making abortion legal would open the floodgates. To ensure that this promise had real political legitimacy, another unusual feature was intro-
duced: an independent Advisory Body to be composed of religious, legal, medical and other representatives. That Body is to be appointed by the Minister to monitor the operation of the law, make proposals to the Minister for improving its effectiveness and suggest corrective action if required. The Select Committee not only amended the Bill, but at the invitation of the Minister of Health, they also drafted the Regulations. This was an astute move, both administratively and politically. Administratively, because laws often suffer for want of enabling regulations, this approach ensured that the Regulations and all the necessary forms would be available from the moment the Bill was approved. Politically, the multi-partisan preparation of the Regulations would give greater credibility to the process of legal and social reform. True to the commitments made repeatedly during the debate, the Act made strong provisions for counselling. In doing so, it contained another unusual feature: in an effort to foster greater male sexual responsibility, the Act made express provision for the inclusion of the pregnant woman’s partner in the counselling process. To stress the importance of counselling to physicians and institutions, a forty-eight hour waiting period was imposed to permit sufficient time for counselling. The details of the subject matter to be covered during pre- and postabortion counselling were also spelled out. The Act is a socially liberal one but medically quite conservative. It permits terminations up to eight weeks with the approval of one physician and without need of cause; these may be done in the physician’s clinic. No matter what their age or marital status all women have direct access to termination services. A woman does not need to inform her partner, and neither parental knowledge nor consent is required for minors. The notion of Government hospitals being automatically approved institutions was removed. Instead, all hospitals are required to meet a set of specified standards to gain approval. All terminations after eight weeks of pregnancy must be done by an authorised medical professional, for a range of indications. Between 12 and 16 weeks, the approval of two physicians is required, while terminations after 16 weeks require the approval of three physicians and are permitted only to save the life of the woman.
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These restrictions were regarded as essential M, safeguard women’s health and intended to acourage women contemplating a termination W seek guidance early in pregnancy. They were made in light of the fact that many cases of septic artion admitted to public hospitals in Guyana irre believed to derive from a small number of private medical practitioners. Those clauses had *e support of both the Guyana Medical Association and the Medical Council of Guyana. The cut-off point of 16 weeks for elective terminations was established in deference to a submission from the Guyana Islamic Trust and wes also recommended by the Ministerial Committee. The range of grounds for which &ortion is legal after eight weeks is broad and mcludes contraceptive failure, socio-economic considerations and HIV infection. The Regulations stipulate the content of counselling which patients must receive before and after a termination; the qualifications or training which physicians must possess for terminations after eight weeks; the staff, facilities and equipment which institutions must provide to be approved for doing terminations after eight weeks; the record keeping requirements; and the Advisory Body. The record keeping requirement is rather detailed for two reasons. First, to be able to design action to reduce the incidence of abortion, as well as monitor the clinical services. Second, as a principal source of information for the Advisory Body which they can use to advise the Minister how better to achieve the goals of the legislation. The conservative provisions of the Act may seem unduly rigid. How can one justify a delay period, staged permission, the burden of seeing two physicians and the even greater weight of Seeing three physicians? First, there was a genuine concern, even among the liberal reformers, for safecniards aaainst the misuse of the h4TP Act. This fear was paramount among those who opposed any liberalisation. These fears were rooted in a major misconception among medical professionals themselves, of whom 75 per cent of those surveyed expected interest in family planning to decline if legal access to abortion was given. The fact that many studies have shown the very opposite -that women who have abortions are disposed to becoming better contraceptors -was not known8 Beyond the fear was the harder social reality, namely, that 17 per cent of the women surveyed in ‘,.
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Georgetown considered abortion their preferred method of birth control. Given the low level of contraceptive prevalence, the high incidence of abortion, and the common feature of repeat abortion, there was good reason for staged controls and mandatory counselling. This was not only believed to be in the best interest of women’s health, but also reflected a genuine concern about the sanctity of life. The proponents of reform did not want to appear to be giving pregnant women an unrestricted license. It is entirely possible that as sexual responsibility and contraceptive prevalence increase and recourse to abortion declines, the need for such controls may diminish. That is a matter for the Advisory Body.
MAKING THE LAW WORK Following the successful passage of the Bill through a tempestuous and emotional debate and an historical non-partisan vote, the PRG moved quickly to inform the public about the new law and to explain its merits. They knew that the passage of the bill merely meant the beginning of the real task of demonstrating that a liberal law could do much more than improve maternal health - it could also reduce abortions. They also knew that opposition to the bill would not vanish, but sharpen, and that they had little time to lose. The day after the bill was passed, two women went to the Public Hospital Georgetown (PHG), the country’s main public hospital, seeking terminations. They were turned away partly because there was no capacity to meet their needs and partly because the leadership of the institution was unsure of its legal position. At that time, the President had not yet assented to the law and the hospital had not received any instruction from the Slinistry of Health. The PRG prepared scripts for six 60-second radio advertisements. Generally, they involved a parent and a teenager speakmy ~UUULL~LC’ ~a,\. ~11 each one a teenage girl would express one of the misgivings and fears of those who opposed the law, and her father would give simple, well informed responses. The idea was to reach a fa’r wider audience than was possible through the editorial pages. Each advertisement would end with a statement from a narrator encouraging listeners to seek further information from a doctor they trusted or their health centre. The advertisements were run twice daily on
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Guyana’s two radio stations for several months. Where to establish abortion services was not immediately clear. One possibility was the West Demerara Regional Hospital (WDRH) just across the river from Georgetown. That hospital had a lot of vacant space which could easily be brought into service. Providing the floating pontoon bridge across the river was working, it was only about half an hour away by public transport. If the bridge were opened for ships to pass, there could be an irritating delay. If the bridge were not operational, given the overload the ferry service would face, any facility at the WDRH would be virtually inaccessible. Another was the Public Hospital Georgetown, which would be far more easily accessible to the majority of the population. Unfortunately, many of the worst tales of poor medical care have been associated with the overcrowded and unsatisfactory state of services at PHG. Still, the senior staff were keen to make the effort to offer a service. They felt that offering a conveniently available service was essential if women were to be discouraged from continuing to use unsafe sources. Training was provided to the staff at both hospitals. This included an explanation of the law itself, the social need for it, and its objectives of improving maternal health and reducing abortions. The central importance of the nurse in counselling was emphasised, especially if there was to be any real hope of attaining the goal of reducing abortions. In each of these sessions, nurses’ concerns were aired and discussed and staff appreciated that the law was addressing a social and medical problem - not promoting promiscuity or degrading the value of life. In almost every session, once a simple schema explaining the social context of the law and how it was designed to work was shown and discussed with the nurses, one of them would ask ‘Why weren’t we told this before? This makes it so easy to understand why we need the law and how we can help.’ The Pro-Reform Group were concerned about reaching teenagers. They decided that what teenagers needed was access to reliable information in a way that safeguarded their privacy. They decided to explore the establishment of a hotline with automated answers regarding moral guidance, information on STDs, contraceptives, pregnancy tests, abortion, the
new law and how it affects teenagers. The software is being developed and the telephone company has been approached to contribute a number of lines for an experimental period. The Pan American Health Organization (PAHOWHO) conducted two workshops on reproductive responsibility, one for teachers and nurses, and another which also included parents and teenagers. This was the first time that teachers and nurses had worked together on any matter of reproductive health. The programme covered the MTP Act, contraceptive methods, male responsibility, sexually transmitted diseases, and stressed communication and counselling skills. A leading member of the local Catholic Church, who teaches the Billings Method, explained that method of natural family planning. Information from the surveys was also shared. Another critical initiative was the development of a basic counselling video. With the support of the Ministry of Health, the Adoption Board, religious leaders, family life educators, physicians, medical social workers, and the director of the STD clinic, a video was prepared on the range of issues that must be covered during counselling by physicians and institutions that intend to offer terminations. The video will ensure that throughout the country, clients will have access to the same standard of basic information prepared for them by leading national authorities.
CONCLUSION The 1993-95 movement for abortion law reform in Guyana succeeded. The particular course of events may be unique but the lessons are portable. The experience can be replicated. In the interests of women’s health and family values, it must be. s
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References and Notes Cook R J and Dickens B M, 1979. Abortion Laws in Commonwealth Countries. WHO, Geneva. And Emerging Issues in Commonwealth Abortion Laws (1985) by the same authors. For example Conscience, a news journal of prochoice Catholic opinion. CFFC’s publications, which advocate dialogue within the Church, are very well researched. Another very helpful source was Women, Religion and Sexuality: Studies of the Impact of Religious Teachings on Women. J Becher (ed). World Council of Churches, 1990. Advocates of reform should not underestimate the importance of the historical perspective, both locally and elsewhere. A useful view of the experience in the UK may be found in Grubb A, 1990. Abortion law in England: the
RBSUMB Le 4 mai 1995, discussions, adoptait
medicalization of a crime. Law, Medicine and Health Care. 18(1-2):146-61. 4. These included: -Medical Opinion on Abortion in Guyana: A National Survey of Physicians, Medex, Nurses and Pharmacists, 1993; -Abortion: A Survey of Public Opinion and Experience in Georgetown, 1993; -An Assessment of the Prevalence of Abortion in Seven Urban Clinics in Georgetown, 1993; - Teenagers’ Views on Reforming the Law of Abortion in Guyana, 1994; and -Legal Opinion on Abortion Law Reform in Guyana, 1994. These unpublished surveys are available in the Health Statistics Unit, Ministry of Health, Guyana. 5. A principal source of information on abortion and
RESUMEN apres
1’Assemblee
deux
an&es
nationale
une loi sur l’interruption
d’intenses guyanaise
medicale
de la
du Guyana le second pays des Cara’ibes anglophones & avoir pareille legislation. Durant ces deux annees, des lettres ou des articles avaient paru a peu pres chaque jour dans la presse, et il y avait eu une emission a la radio ou la television au moms une fois par semaine. Cet article retrace les Cvenements qui ont amen6 - en plus de 20 ans - la reforme legislative, et les arguments present& en faveur de la campagne pour la nouvelle loi par le Pro-Reform Group, dont le principal mot d’ordre Ctait “Pour la vie, pour le choix, pour la reforme”. La campagne, me&e essentiellement au travers des m&as, reposait sur l’education du public, grace aux resultats d’enquetes effect&es dans divers groupes: professionnels de la Sante, juristes, etudiants, adolescents, clientele des dispensaires de planification familiale. Les donnees relatives aux avortements clandestins etaient completees par le &it des experiences de femmes a cet egard. L’article s’acheve sur un expose des nouvelles dispositions legales et des efforts deploy& pour leur donner un commencement d’execution. grossesse,
maternal mortality was the Alan Guttmacher Institute in New York. Especially useful was: Tietze C and Henshaw S K, 1986. Induced Abortion: A World Review, 6th edition, and Clandestine Abortion: A Latin American Reality, 1994. 6. Muller J 2,1995. The conservative case for abortion: why the pro-life movement is the enemy of family values. New Republic. 21 and 28 August. 7. Royston E and Armstrong S, 1989. PreventingMaternal Deaths. WHO, Geneva. 8. Chhabra S, Gupte N, Mehta A et al, 1988. Medical termination of pregnancy and current contraceptive adoption in rural India. Studies in Family Planning. 19(4):244-47. Contains references to other studies which report this phenomenon.
ce qui faisait
El 4 de Mayo de 1995, tras dos atios de intenso debate publico, la Asamblea National de Guyana aprobo el proyecto de ley de Termination MCdica de1 Embarazo, que convirtio a Guyana en el Segundo pais de1 Caribe angloparlante en introducir dicha legislation. Durante esos dos aiios, raro fue el dia sin cartas 0 articulos en la prensa, y hubo programas en television y radio al menos tma vez por semana. Este ensayo describe 10s mas de 20 adios de historia que condujeron a la reforma de la ley, y el contenido de la campaiia de apoyo a la nueva ley llevada a cabo por el Grupo Pro-Reforma, cuyo lema principal fue “Pro-Vida, Pro-Election, Pro-Reforma”. Su campaiia se realize principalmente a traves de 10s medios y fue basada en education al publico, utilization de 10s resultados de encuestas realizadas entre profesionales de la medicina, abogados, estudiantes, adolescentes y mujeres usuarias de las clinicas de planificacion familiar. El grupo dio a conocer 10s hechos relacionados con el abort0 ilegal en Guyana y las experiencias que las mujeres han tenido de1 mismo. El ensayo concluye con una description de la nueva ley y de 10s esfuerzos para iniciar el proceso de implementation.
Frederick E Nunes and Yvette M Delph On 4 May 1995, after two years ofintense public debate, the National Assembly of Guyana passed the Medical Termination of Pregnancy Bill, making Guyana the second country in the Englishspeaking Caribbean to introduce such legislation. For the entire two years scarcely a day went by without letters or articles in the press, and at least once a week there was a programme on television and radio. This paper describes the history and content of the campaign in support of the new Jaw by the Pro-Reform Group, whose main slogan was ‘Pro-Life, Pro-Choice, ProReform’. This campaign sought common interests with the opposition, theirpublic education was based on research amonghealth and legal professionals, students and the public and on facts about abortion and women’s experiences. It was carried out mainly through the media. The paper ends with a description of the new Jaw and efforts to begin implementing it.
N 1971, four years after the UK passed the 1967 Abortion Act, Guyana became the first Caribbean country to initiate public discussion about abortion law reform. The People’s National Congress (PNC) appointed a Special Select Committee to examine the need to liberalise the law but although they held several hearings, they failed to submit a report. In 1974 Caribbean Common Market (CARICOM) Health Ministers passed a resolution to review legislation essential for improving maternal health. In 1983, a Medical Termination of Pregnancy Act was passed in Barbados. Shortly afterwards, the Health Desk in the Secretariat of CARICOM sent copies to all Permanent Secretaries in Ministries of Health in the English-speaking Caribbean, urging them to use the opportunity to act on the 1974 resolution. Nothing happened. In 1985, the PNC Government in Guyana prepared a draft bill on abortion that was almost identical to the 1983 Barbados Act. In 1988 they began a process of public consultation about the bill. In an effort to respond to concerns raised by various interest groups, the contents were expanded to include clauses on counselling, approval of medical institutions and limiting terminations to 28 weeks. The compact form of the earlier draft had yielded to cumbersome comprehensiveness. Concerns for
administrative control overshadowed the focus on women’s health. Although this Bill was approved by the PNC Cabinet in 1989, it was never advanced to the National Assembly. It was shelved and never voted on, probably in deference to the general election that was expected the following year, and possibly also in response to religious opposition, or both. The PNC had held power continuously from Guyana’s independence in 1966 until they were voted out of office in October 1992 and replaced by the People’s Progressive Party (PPP), the main opposition party. The new PPP Minister of Health demonstrated remarkable courage in the face of this highly controversial subject when, in May 1993, she announced her intention to review the law relating to abortion, which she described as ‘a law which no-one cares to obey and no-one dares to enforce’. She promised an open public debate on the abortion bill which had been left by the previous PNC administration and invited a wide range of interest groups to join in the creation of a Ministerial Committee. A commitment to transparency was manifested in her bold design of this Committee, which included more than 30 members from religious, legal, medical, and women’s organisations and which held public
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hearings around the country. The Committee’s report encountered widespread criticism, so the Cabinet extended the process of consultation by appointing an allparty Special Select Committee in December 1993 to receive views. They recommended removing most of the clauses added to the bill in 1989, once again making it a close replica of the Barbados model. The four sections they retained dealt with counselling, non-liability of physicians except for negligence, statement by guardians and confidentiality of information. Most of the provisions that were removed were then revised and included in the Regulations attached to the law. Existing laws as well as model abortion legislation were used in drafting the exact wording of the text.’ The bill’s social liberalism was balanced by its medical conservatism. It permitted abortion on request up to eight weeks, with no need to show cause, and accommodated a wide range of indications up to 16 weeks. It also made counselling mandatory, with a 48-hour waiting period to facilitate that process. In November 1994 the Select Committee put forward the bill which they had drafted. It was
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laid before the National Assembly in March 1995 and debated and passed by a vote of 32 to 21, without amendment, two months later. This was the first ever non-partisan vote in the history of the Guyanese National Assembly. How did this happen? How is it that after false starts from as far back as the 197Os, Guyana finally succeeded in achieving legal access to medical termination for a wide spectrum of indications? How did a campaign for liberal reform succeed in the face of highly active religious opposition?
THE PRO-REFORM GROUP This paper focuses on the work of the ProReform Group (PRG), who campaigned for the new bill. Members of this group brought skills in research, medicine, theology, law, logic, social work, women’s issues and commu&cation and they invited many others to make contributions within their fields of specialisation. An important feature of the group was their willingness to learn from each other and so to enhance their appreciation of this complex issue. While the core group remained small and
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close-knit, they also had access to many others on whom they could depend for assistance. There was a strong, shared commitment to certain values and objectives: listening carefully to any criticisms, especially those from religious groups; a clear agreement that law reform was essential for improving women’s health; a realisation that the process of the debate itself, as well as a new law, could strengthen family planning; and the prospect of using liberal law reform to help to reduce the incidence of abortion, perhaps the idea that galvanised the group most of all. Guyana has a population of 729,000, of which 51 per cent are East Indian and 43 per cent Black and mixed. The majority of the people are Christian (57 per cent), 33 per cent are Hindu and 9 per cent Muslim. Sensitive to the multireligious nature of Guyana, literature on the theological issues of abortion in Christianity, Hinduism and Islam was collected and studied. Given the particularly strong opposition from activists within the Roman Catholic Church, special effort was made to gather as much information as possible about the Church’s current perspectives, and history and theology on the issues of abortion and contraception. The wealth of information in the publications of Catholics for a Free Choice was invaluable in educating the gro~p.~ Previous attempts to reform the law on abortion were studied to determine why and how the process got bogged down and what might have spurred it forward. The PRG were able to learn which groups and individuals had been active and about the relative strengths of the institutions involved. The perspectives they gained were important for reminding the public not only how much had been done before, but also that nothing of substance had ever come of all that hard work. The message gleaned was one of the need for perpetual vigilance. Data and information from files and newspapers from those years gave authenticity to the long struggle for reform.3 The PRG were committed to honouring the process of consultation proposed by the Minister of Health. They felt that to take to the streets, in spite of such extensive opportunities for
could have undermined and consultation, possibly derailed the process of public dialogue advocated by the Minister. They decided that their strength lay in information, not confrontation, and in public education, not public action. The group were firmly committed to building links and searching for constructive responses to the concerns of the religious opposition, because they realised that the effective implementation of any new law could only benefit from the widespread social organisation and influence of religious bodies. The campaign needed dialogue, not debate. From early on, it was felt to be important to expand the effort beyond Guyana. The PRG turned first to the Caribbean and won support there from chief medical officers, professors of medicine, distinguished Guyanese, epidemiologists, directors of family planning associations, gynaecologists, presidents of medical associations, presidents of nursing associations, theologians, ministers of religion, experts on parliamentary procedure, and so on. The idea was not only to involve them in the campaign in Guyana, but also to initiate a cross-national collective effort. Wider support from people with experience and expertise of changing their laws was also sought from those within the international community who support law reform, including theologians, public health and law professors, physicians, researchers, and a host of leaders of NGOs who communicated their support to decision makers in Guyana and provided technical information or sources for assistance. The group also followed international events such as the murder of a doctor who provided abortions in Florida (USA), the International Conference on Population and Development in Cairo, and the Vatican’s attempt to block accreditation of Catholics for a Free Choice for the 4th World Conference on Women, and referred to these to shed light on the local debate. PRG members kept in close contact with decision makers, who had to be supplied with reliable data. Members of Parliament were provided with fact sheets and videotapes of interviews. Leading columnists and editors were provided with articles and pertinent information and research. PRG members provided back-up information and arguments, monitored the parliamentary process at every stage, and
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learned about administrative and parliamentary procedures and the pitfalls of legal drafting. They stood ready to intervene constructively at every imaginable stage. On one level, the PRG were no match for the organisational strength of the religious opposition, who conducted prayer vigils, marches, and pickets. They had to do nothing but step into the pulpit to find a ready congregation eager to listen. The PRG had to hope to counter their emotionalism with information. Then, during one very large public march against law reform, the zeal of some of the opposition got the better of them. Relying too heavily on technical advice from the USA, they employed tactics alien to Guyanese culture such as picketing doctors’ offices, calling them murderers and holding dismembered dolls smeared in red ink on poles, and even carrying tiny symbolic coffins. This was too much for many in the community. Several people who had until that time kept their peace, spoke out against this conduct and in favour of the Government’s need to address the matter of unsafe abortion. The Anglican Bishop was one of those. The PRG made full use of this event in its letters to the editor. What was intended to be the opposition’s best hour turned out to be an embarrassment.
PRO-LIFE, PRO-CHOICE, PRO-REFORM The PRG influenced the language of the debate significantly. In supporting a reform effort emanating from the Ministry of Health, the PRG argued that the fundamental justification for abortion law reform was women’s health. While women’s rights are also an important dimension, women’s health was seen to offer the better tactical tool. The PRG consciously avoided the sabre-rattling of women‘s rights although some in its ranks, and quite rightly so, felt very strongly about that element. They stressed the harm of unsafe abortions, the mortality and, even more, the unquantified morbidity. The group challenged the linguistic dichotomies which are so convenient to those who oppose law reform - anti-abortion and proabortion; pro-life and pro-choice. The PRG rejected the label ‘pro-abortion’ as nonsensical since they knew of no-one who ‘promoted abortion. Instead, they argued that their members were also anti-abortion, that they also
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wanted to see fewer abortions and hoped to educate men and women to that end. The group questioned the notion that a liberal law would encourage more women to have abortions and pointed to the fact that Guyana, with a very strict law, had an abortion rate 70 times as high as the Netherlands, with a very liberal law. The PRG disagreed with the pro-life, prochoice separation. They pointed out that the responsible woman who has an unplanned and unwanted pregnancy and who, after due consideration, decides to have a termination, is doing so out of love and concern for the quality of life - whether her own or that of her children or other dependent relatives, or indeed out of awareness of the limits of her capacity to nurture and care for another child. One of the PRG’s last television advertisements read ‘Pro-Life, ProChoice, Pro-Bill’. Having established that, like their adversaries, the PRG were anti-abortion, the group challenged the notion that the debate was about abortion itself. The difference, they said, between the PRG and Catholics for Life and the AntiAbortion Education Committee, who favoured enforcing the restrictive law, was in their views on how a given law would affect the incidence of abortion. The PRG, therefore, contended that the debate was not about abortion but about the law. On the basis of existing data, the PRG asserted that the strict, prohibitive law in Guyana had done nothing to contain a rampant industry of abortion. They also pointed out how attempts to contain abortion by strict legislation had been dismal failures in Romania and Poland. They could also point to a growing number of countries Barbados, Canada, Tunisia and Turkey- where the introduction of liberal abortion legislation had not resulted in an increase in the number of abortions. This was a major turning point in the campaign. In place of the old labels the PRG put forward new ones - pro-law reform and anti-law reform. This seemed both fair and appropriate since the focus was on the legislation and what it would do. The energies of both parties were directed at influencing the law-making process: The issue was the law. In turn, the PRG were challenged on their use of language. For example, there were objections to their use of the word ‘fetus’ and an appeal that they should use the term ‘unborn child. The group were not reluctant to use a warm, emotive
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word (child) in place of a cold, scientific one (fetus), since they wanted full consideration to be given to the seriousness of abortion. SO they obliged, even though some members argued that by definition, a child had to be born. In adopting the language of the opposition, the aim was to be accommodating, to move away from semantics and to keep the focus on the role of law in
the passage of a new law, but more importantly, the social reform that should attend that law. In any process of social reform, few institutions could prove more valuable allies than the religious bodies which reach into every community in Guyana. Pro-reform advocates therefore resolved to win both respect and support from the country’s religious leaders.
managing abortions. Seeking common interests with the opposition
BUILDING ALLIANCES Placing the issues above party politics A crucial strategy was to place the issue above party politics. This was essential if the newly which had been in elected government, opposition for an entire generation, was to be persuaded to proceed with such a controversial matter. The prospects for doing this were unusually good, since the out-going party had itself formulated and approved the original bill. But that support had to be made manifest and obvious: tacit support was not enough. To this end, the former PNC Minister of Health was helpful at certain very critical stages in the process. He urged the new PPP Minister to benefit from his experience and keep the vociferous religious opposition in perspective, and he urged the formation of a bi-partisan body to consider and refine the bill. Similarly, the PNC Shadow Minister of Health became an outspoken supporter of the drive for reform. On the Government side, this link would be sustained by giving credit to the Opposition for its work in producing the 1989 draft and by continuing to use that document as the basis for further action.
Openness The process of public debate was informed by a clear commitment to openness. Thus, whatever studies were conducted were promptly made available to the opposition. It required a willingness to listen carefully to, respect and learn from others who held opposing or different views. It demanded the humility of being inclusive - of trying to build bridges with one’s adversaries. This process relied on discipline to persist with openness, even when trust and goodwill were abused. The advocates of reform realised that the real victory they sought was not simply
Listening respectfully to their adversaries, the Pro-Reform Group sought and found common interests and amplified those instead of the recognised differences. Divisive language was replaced with a shared interest in enhancing the sanctity of life and finding ways to achieve goals which both sides shared, fewer abortions and stronger families. Information, quiet reason and simple logic were employed against religious dogma, righteous indignation, intense emotionalism, and alarmist claims of grand conspiracies. Rather than confront and denounce the religious opposition, the PRG found allies among liberal Christian and Islamic religious leaders and in doing so destroyed the myth of religious opposition to abortion law reform as monolithic and homogeneous.
RESEARCH: USING THE FACTS TO INFORM POLICY A main weakness of public policy formation in many developing countries is the paucity of factual data and the lack of a tradition of using data to inform decision-making. Instead there is a heavy reliance on values and precedent. The subject of abortion law reform is perhaps the most vexed of all public policy issues and is prone to be conducted in the absence of facts. A major investment was made to ensure that there were data on the local situation to which people could relate. Thus, several studies, including a review of clinical data, were carried out.4 In addition, international data on abortion, maternal mortality and morbidity were gathered.5
Survey of the medical profession The survey of the medical profession examined their views on abortion law reform and their perceptions of the magnitude of the problem. It included 430 medical practitioners, medexes
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(similar to nurse practitioners), nurses and pharmaCiStS. The results were mirrored time and again in most of the subsequent surveys, namely, that when asked a general question ‘Should the law on abortion be liberalised?‘, most respondents would answer in the negative. Yet when the same respondents were asked more specific questions Should legal access to abortion be available if a pregnant woman is mentally incapable of raising the child, or has HIV, or if the fetus is badly deformed, or if the pregnancy is a threat to her physical or mental health, or in cases of rape or incest?’ - a clear majority would answer yes. This was also true for respondents who described themselves as conscientious objectors; the majority supported law reform for these indications. Seventy per cent of the medical respondents felt that the restrictive law on abortion was either totally or largely ignored. There was no consensus among them about how many abortions were taking place in relation to births. The great majority (88 per cent) said that women seeking abortions were mostly 15-24 years old. In general, they showed an openness to legal reform.
1995
cent by general practitioners. Most of those abortions had been done in private hospitals (54 per cent) and a further 26 per cent in private clinics. For almost two-thirds of those who had had abortions, their first abortion was before their 25th birthday. A disturbing finding, and one that constitutes a major challenge for health educators, is that one in every five women regarded abortion as a form of family planning, and one in six considered abortion to be their preferred method of birth control. Among the men, 34 per cent had contributed to a woman having to have an abortion, 19 per cent had caused the need for abortions in more than one woman, and 17 per cent had caused more than one abortion in the same woman.
Familyplanning records
Surveyof the public and university students
In mid-1993, the medical records of 1,000 women who joined seven family planning clinics in Georgetown in 1992, were examined. Almost half of the women (48 per cent) reported having had at least one abortion and 26 per cent had had more than one. The ratio of births to abortions was high at 422 abortions per 1,000 births, yet informed medical practitioners suggested that the true ratio could be as high as twice that figure or almost 1:l.
Once the debate started, it was essential to gain a sense of general public sentiment as well as objective data on the actual situation of abortion. A stratified cluster sample was taken of workers and professionals in Georgetown and students at the University of Guyana. A questionnaire was administered to 481 people - 289 women and 192 men. There was almost no gender difference in the respondents’ views on the need for law reform though in some questions (for example, should legal abortion be freely available) men were even more liberal than women. There was overwhelming support for most of the specific indications for the proposed law reform, as described above, and significant support for others like contraceptive failure and social and economic conditions. As many as 63 per cent of the women reported having a relative who had had an abortion. What is more, 30 per cent of the women surveyed reported that they themselves had had abortions. As many as 86 per cent reported that their abortions had been done by medical practitioners - 59 per cent by specialists and 27 per
The views of 1,750 students, mostly 13 to 17 years of age, in 60 schools from all over Guyana were polled in early 1994. Because of the high dropout rate of boys after fourth form, almost 60 per cent of the respondents were girls. The great majority (78 per cent) in each form reported that they had no experience of sexual intercourse. The great majority also favoured the introduction of Family Life Education into their school curriculum. When asked to identify a list of methods of birth control, only the condom (89 per cent) was more widely known than abortion (87 per cent). The next best known was the oral contraceptive pill (66 per cent). All other forms of contraception were known by less than half the respondents. Among the girls a considerable &mber had a close relative (33 per cent) or a teenage friend (21 per cent) who had had an abortion. Among the boys, 15 per cent had a male teenage friend who had contributed to a girl needing an abortion, and 14 per cent had a male relative who had contributed to an abortion.
Survey of in-school teenagers
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The notion that teenage girls were more vulnerable than adult women was supported by the fact that among this group, the largest single provider of abortions was nurses (27 per cent). The girls also relied heavily on pharmacists (5 per cent) and ‘others’ (16 per cent). Overall, among the general population of women surveyed, 86 per cent had had abortions performed by medical practitioners, while among the teenagers the corresponding number was only 52 per cent. Although 50 per cent of the students described themselves as conscientious objectors, they did support abortion law reform for several specific reasons, eg.. to save the life of the mother, rape and incest.
Survey of legal profession The views of various members of the legal profession were also sought by questionnaire in May 1994 when the abortion debate was at its height. The results suggest that they had been significantly influenced by the debate. A quarter of those surveyed had changed their views within the first year of the debate, two-thirds of whom moved to more liberal positions. Thus, the legal profession can be a responsive and important ally in the process of law reform.
Personal histories Many people respond less to the abstractions of statistics than to the details of human interest stories. These sometimes proved more compelling in convincing people of the need for reform than research data. The crucial thing was that human interest stories had to be absolutely factual and authentic. The Pro-Reform Group never published the names of any respondents, and used only those stories which they investigated at first hand and where the respondent was willing to sign his or her real name. The newspapers were then asked not to disclose the individual’s identity. All this information provided a compelling empirical basis for the government to take action. It also highlighted the unsatisfactory level of contraceptive education and availability.
USINGTHE FACTS FOR PUBLIC EDUCATION With the information from these surveys, the group could speak with confidence about the
great denial in Guyana. They knew that on an issue as contentious as abortion, no research would escape scorching criticism from their opponents but they went ahead anyway, exposing what had been hidden and suppressed. Getting people to listen to information about behaviour which was clandestine, suppressed and stigmatised was a major challenge. The task was to stimulate people to use the data provided to examine whether repressive or liberal legislation would better serve the values they held about individual life, family and society.” The most important messages were very simple: Illegal abortion existed on a very large scale. In Guyana, there was at least one abortion every hour, 24 hours a day, seven days a week. Unsafe abortions were a leading cause of maternal mortality and morbidity, in spite of under-reporting. Septic abortion was third among the leading causes of admission to public hospitals. Prohibitive legislation had failed miserably to contain the practice of abortion. Legislation permitting medical termination was the most effective method of achieving a dramatic improvement in maternal health. Unsafe abortions are 100 to 500 times more risky than terminations carried out in clinical conditions.7 An abortion in the first trimester, under clinical conditions, is about 20 times safer than childbirth at term.7 Liberal abortion legislation, in tandem with improved contraceptive use, could lead to significant reductions (not an increase) in the number of abortions. Fewer abortions would mean fewer fetal deaths as well as fewer women’s deaths. The fear that liberal abortion legislation would lead to a fall of interest in family planning is unfounded. One study after another has documented the fact that women who have had abortions typically become more responsible cont?aceptors.8 Liberal legislation respects the sanctity of life and does not ‘promote’ abortion. In each message, the central focus was women’s health: the main arguments never strayed from that anchor.
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PUTTING
THE MESSAGES
INTO THE
MEDIA A huge investment was made in public education, There is little point in generating and collecting data intended to inform and influence public policy unless it is directed at the decision makers and made available to the general public. The PRG organised a letter writing campaign in the press and developed advertisements for television to ensure that the data it collected became public property. For much of the debate, the only information available was that put together by the PRG; even the adversaries of law reform used it. The reliance on letters in leading newspapers was not accidental. Not the least consideration was that, while time consuming and of limited impact, it was free. Although the editorial pages lacked broad appeal, messages there would be seen by the elite and other influential people. Equally compelling was that writing as a medium is superbly suited to logic, and far less suited to hysteria and scare tactics. Letters were used to challenge and expose some of the emotional appeals of the opponents of reform. Pro-reform advocates knew they had a comparative advantage in the press, and they made optimal use of it. Over the two years of the debate, it was commonplace for them to have as many as three letters in any one paper on a given day; less frequently they had five, and on one occasion as many as seven. Their efforts in the press were not limited to the editorial pages, however. They designed cartoons and hired an artist to craft their messages into attractive advertisements that raised more public discussion than the most poignant letter. The cartoons were not only intended to make more people sensitive to the debate. They aimed also to diffuse confrontation through humour and to suggest that there was vahdhy on both sides: two cartoons with splitimageswere used to convey this to considerable effect. The cartoons helped to keep the debate alive, to keep the public informed of where the Process was and to prod reluctant legislators into action. At the same time, the cartoons took advantage of the public’s interest in sexual relations and gave messages to men about sexual responsibility. Several cartoons involved role reversals, Portraying men pregnant or at risk of pregnancy.
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Television Guyana has seven television stations, one of which seemed particularly disposed to air antireform messages. The opposition made full use of it, often showing films from the USA antiabortion movement. The intense horror of these films was such that few viewers were likely to look at them a second time. What was more, they seemed intent on scaring the viewer into adopting a particular view. Such fright could not endure in the face of the facts. The PRG’s use of television was calculated to stand in marked contrast to these dramas. The people they interviewed spoke with quiet, deliberate reason. First, the PRG filmed interviews with people who had been central to the abortion law reform in Barbados in 1983, eg., the then Minister of Health who had engineered the success of the Act. She not only described the important process of consultation and accommodation, but also expressed her unequivocal support for law reform in full view of the public. Another was of a Guyanese-born medical practitioner, a Catholic and a conscientious objector to abortion, who as a member of the Barbados Association of Medical Practitioners, was involved in the deliberations which led to the 1983 Act. She was able to explain that her worst fears of the new law resulting in increased abortions had been decisively answered instead by the elimination of complications resulting from backstreet abortions. Interviews with two physicians and a minister of religion in Guyana were also taped. In a multi-racial society, the PRG was careful to get an Amerindian Lutheran Minister, an East Indian gynaecologist and a Black physician. Later, they developed a series of ‘abortion facts’ which were written in simple white lettering on a black background with no sound. The idea was to give information, but not to frighten or scare people. This was done at a time when it was felt to be necessary to respond to the runaway advantage of the anti-reform group on television and to move beyond the limited scope of the editorial pages. Next, the Cartoons of pregnant men were televised and dramatised with simple voice-overs. Some of them had children and their parents discussing why these images were being shown. Late in 1994, when the Report of the Select Committee was made public, the PRG put
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together a series of interviews with leading members of the Guyanese public and outstanding individuals in the fight for abortion law reform internationally, on the proposed new Bill. These included the chairwoman ofthe Select Committee and Minister with Responsibility for Women’s Affairs; an outspoken member of the Opposition party who was an ardent supporter of the Bill; the president of the Guyana Human Rights Association; and a prominent gynaecologist. Lastly, advertisements promoting law reform in the name of supporting life, strengthening family life, achieving safe motherhood and reducing the need for abortion (showing loved children, healthy mothers and strong families) were televised on several stations over the last five days before the National Assembly debate. The intent was not so much to influence legislators directly as to place the new Bill in the broad context of positive human and social values, create a climate of sympathy and understanding about the Bill and thereby make it easier for them to vote in support of it.
Radio The Pro-Reform Group’s work in the press and television was not in any way matched by its use of radio. It did use Viewpoint, a sort of radio editorial, to considerable advantage on a few occasions, but not sufficiently. Even though the PRG learned that one good commentary on radio was worth a week’s letters, the group failed to capitalise on that lesson. There were several weekly call-in programmes on radio, but the group made little use of them. As a result, the opposition did a far better job on radio.
THE ACT The Medical Termination of Pregnancy Act in Guyana is unusual in that it claims to be designed to enhance the sanctity of life and unique in its bold promise to reduce the incidence of abortion. These affirmative statements at the beginning of the Act were placed to set the broad frame of the social underpinnings of the legislation. Giving them a place of primacy constituted a sincere intention to reduce the greatest fear of the religious opposition, namely, that making abortion legal would open the floodgates. To ensure that this promise had real political legitimacy, another unusual feature was intro-
duced: an independent Advisory Body to be composed of religious, legal, medical and other representatives. That Body is to be appointed by the Minister to monitor the operation of the law, make proposals to the Minister for improving its effectiveness and suggest corrective action if required. The Select Committee not only amended the Bill, but at the invitation of the Minister of Health, they also drafted the Regulations. This was an astute move, both administratively and politically. Administratively, because laws often suffer for want of enabling regulations, this approach ensured that the Regulations and all the necessary forms would be available from the moment the Bill was approved. Politically, the multi-partisan preparation of the Regulations would give greater credibility to the process of legal and social reform. True to the commitments made repeatedly during the debate, the Act made strong provisions for counselling. In doing so, it contained another unusual feature: in an effort to foster greater male sexual responsibility, the Act made express provision for the inclusion of the pregnant woman’s partner in the counselling process. To stress the importance of counselling to physicians and institutions, a forty-eight hour waiting period was imposed to permit sufficient time for counselling. The details of the subject matter to be covered during pre- and postabortion counselling were also spelled out. The Act is a socially liberal one but medically quite conservative. It permits terminations up to eight weeks with the approval of one physician and without need of cause; these may be done in the physician’s clinic. No matter what their age or marital status all women have direct access to termination services. A woman does not need to inform her partner, and neither parental knowledge nor consent is required for minors. The notion of Government hospitals being automatically approved institutions was removed. Instead, all hospitals are required to meet a set of specified standards to gain approval. All terminations after eight weeks of pregnancy must be done by an authorised medical professional, for a range of indications. Between 12 and 16 weeks, the approval of two physicians is required, while terminations after 16 weeks require the approval of three physicians and are permitted only to save the life of the woman.
Reproductive
These restrictions were regarded as essential M, safeguard women’s health and intended to acourage women contemplating a termination W seek guidance early in pregnancy. They were made in light of the fact that many cases of septic artion admitted to public hospitals in Guyana irre believed to derive from a small number of private medical practitioners. Those clauses had *e support of both the Guyana Medical Association and the Medical Council of Guyana. The cut-off point of 16 weeks for elective terminations was established in deference to a submission from the Guyana Islamic Trust and wes also recommended by the Ministerial Committee. The range of grounds for which &ortion is legal after eight weeks is broad and mcludes contraceptive failure, socio-economic considerations and HIV infection. The Regulations stipulate the content of counselling which patients must receive before and after a termination; the qualifications or training which physicians must possess for terminations after eight weeks; the staff, facilities and equipment which institutions must provide to be approved for doing terminations after eight weeks; the record keeping requirements; and the Advisory Body. The record keeping requirement is rather detailed for two reasons. First, to be able to design action to reduce the incidence of abortion, as well as monitor the clinical services. Second, as a principal source of information for the Advisory Body which they can use to advise the Minister how better to achieve the goals of the legislation. The conservative provisions of the Act may seem unduly rigid. How can one justify a delay period, staged permission, the burden of seeing two physicians and the even greater weight of Seeing three physicians? First, there was a genuine concern, even among the liberal reformers, for safecniards aaainst the misuse of the h4TP Act. This fear was paramount among those who opposed any liberalisation. These fears were rooted in a major misconception among medical professionals themselves, of whom 75 per cent of those surveyed expected interest in family planning to decline if legal access to abortion was given. The fact that many studies have shown the very opposite -that women who have abortions are disposed to becoming better contraceptors -was not known8 Beyond the fear was the harder social reality, namely, that 17 per cent of the women surveyed in ‘,.
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Georgetown considered abortion their preferred method of birth control. Given the low level of contraceptive prevalence, the high incidence of abortion, and the common feature of repeat abortion, there was good reason for staged controls and mandatory counselling. This was not only believed to be in the best interest of women’s health, but also reflected a genuine concern about the sanctity of life. The proponents of reform did not want to appear to be giving pregnant women an unrestricted license. It is entirely possible that as sexual responsibility and contraceptive prevalence increase and recourse to abortion declines, the need for such controls may diminish. That is a matter for the Advisory Body.
MAKING THE LAW WORK Following the successful passage of the Bill through a tempestuous and emotional debate and an historical non-partisan vote, the PRG moved quickly to inform the public about the new law and to explain its merits. They knew that the passage of the bill merely meant the beginning of the real task of demonstrating that a liberal law could do much more than improve maternal health - it could also reduce abortions. They also knew that opposition to the bill would not vanish, but sharpen, and that they had little time to lose. The day after the bill was passed, two women went to the Public Hospital Georgetown (PHG), the country’s main public hospital, seeking terminations. They were turned away partly because there was no capacity to meet their needs and partly because the leadership of the institution was unsure of its legal position. At that time, the President had not yet assented to the law and the hospital had not received any instruction from the Slinistry of Health. The PRG prepared scripts for six 60-second radio advertisements. Generally, they involved a parent and a teenager speakmy ~UUULL~LC’ ~a,\. ~11 each one a teenage girl would express one of the misgivings and fears of those who opposed the law, and her father would give simple, well informed responses. The idea was to reach a fa’r wider audience than was possible through the editorial pages. Each advertisement would end with a statement from a narrator encouraging listeners to seek further information from a doctor they trusted or their health centre. The advertisements were run twice daily on
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Guyana’s two radio stations for several months. Where to establish abortion services was not immediately clear. One possibility was the West Demerara Regional Hospital (WDRH) just across the river from Georgetown. That hospital had a lot of vacant space which could easily be brought into service. Providing the floating pontoon bridge across the river was working, it was only about half an hour away by public transport. If the bridge were opened for ships to pass, there could be an irritating delay. If the bridge were not operational, given the overload the ferry service would face, any facility at the WDRH would be virtually inaccessible. Another was the Public Hospital Georgetown, which would be far more easily accessible to the majority of the population. Unfortunately, many of the worst tales of poor medical care have been associated with the overcrowded and unsatisfactory state of services at PHG. Still, the senior staff were keen to make the effort to offer a service. They felt that offering a conveniently available service was essential if women were to be discouraged from continuing to use unsafe sources. Training was provided to the staff at both hospitals. This included an explanation of the law itself, the social need for it, and its objectives of improving maternal health and reducing abortions. The central importance of the nurse in counselling was emphasised, especially if there was to be any real hope of attaining the goal of reducing abortions. In each of these sessions, nurses’ concerns were aired and discussed and staff appreciated that the law was addressing a social and medical problem - not promoting promiscuity or degrading the value of life. In almost every session, once a simple schema explaining the social context of the law and how it was designed to work was shown and discussed with the nurses, one of them would ask ‘Why weren’t we told this before? This makes it so easy to understand why we need the law and how we can help.’ The Pro-Reform Group were concerned about reaching teenagers. They decided that what teenagers needed was access to reliable information in a way that safeguarded their privacy. They decided to explore the establishment of a hotline with automated answers regarding moral guidance, information on STDs, contraceptives, pregnancy tests, abortion, the
new law and how it affects teenagers. The software is being developed and the telephone company has been approached to contribute a number of lines for an experimental period. The Pan American Health Organization (PAHOWHO) conducted two workshops on reproductive responsibility, one for teachers and nurses, and another which also included parents and teenagers. This was the first time that teachers and nurses had worked together on any matter of reproductive health. The programme covered the MTP Act, contraceptive methods, male responsibility, sexually transmitted diseases, and stressed communication and counselling skills. A leading member of the local Catholic Church, who teaches the Billings Method, explained that method of natural family planning. Information from the surveys was also shared. Another critical initiative was the development of a basic counselling video. With the support of the Ministry of Health, the Adoption Board, religious leaders, family life educators, physicians, medical social workers, and the director of the STD clinic, a video was prepared on the range of issues that must be covered during counselling by physicians and institutions that intend to offer terminations. The video will ensure that throughout the country, clients will have access to the same standard of basic information prepared for them by leading national authorities.
CONCLUSION The 1993-95 movement for abortion law reform in Guyana succeeded. The particular course of events may be unique but the lessons are portable. The experience can be replicated. In the interests of women’s health and family values, it must be. s
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References and Notes Cook R J and Dickens B M, 1979. Abortion Laws in Commonwealth Countries. WHO, Geneva. And Emerging Issues in Commonwealth Abortion Laws (1985) by the same authors. For example Conscience, a news journal of prochoice Catholic opinion. CFFC’s publications, which advocate dialogue within the Church, are very well researched. Another very helpful source was Women, Religion and Sexuality: Studies of the Impact of Religious Teachings on Women. J Becher (ed). World Council of Churches, 1990. Advocates of reform should not underestimate the importance of the historical perspective, both locally and elsewhere. A useful view of the experience in the UK may be found in Grubb A, 1990. Abortion law in England: the
RBSUMB Le 4 mai 1995, discussions, adoptait
medicalization of a crime. Law, Medicine and Health Care. 18(1-2):146-61. 4. These included: -Medical Opinion on Abortion in Guyana: A National Survey of Physicians, Medex, Nurses and Pharmacists, 1993; -Abortion: A Survey of Public Opinion and Experience in Georgetown, 1993; -An Assessment of the Prevalence of Abortion in Seven Urban Clinics in Georgetown, 1993; - Teenagers’ Views on Reforming the Law of Abortion in Guyana, 1994; and -Legal Opinion on Abortion Law Reform in Guyana, 1994. These unpublished surveys are available in the Health Statistics Unit, Ministry of Health, Guyana. 5. A principal source of information on abortion and
RESUMEN apres
1’Assemblee
deux
an&es
nationale
une loi sur l’interruption
d’intenses guyanaise
medicale
de la
du Guyana le second pays des Cara’ibes anglophones & avoir pareille legislation. Durant ces deux annees, des lettres ou des articles avaient paru a peu pres chaque jour dans la presse, et il y avait eu une emission a la radio ou la television au moms une fois par semaine. Cet article retrace les Cvenements qui ont amen6 - en plus de 20 ans - la reforme legislative, et les arguments present& en faveur de la campagne pour la nouvelle loi par le Pro-Reform Group, dont le principal mot d’ordre Ctait “Pour la vie, pour le choix, pour la reforme”. La campagne, me&e essentiellement au travers des m&as, reposait sur l’education du public, grace aux resultats d’enquetes effect&es dans divers groupes: professionnels de la Sante, juristes, etudiants, adolescents, clientele des dispensaires de planification familiale. Les donnees relatives aux avortements clandestins etaient completees par le &it des experiences de femmes a cet egard. L’article s’acheve sur un expose des nouvelles dispositions legales et des efforts deploy& pour leur donner un commencement d’execution. grossesse,
maternal mortality was the Alan Guttmacher Institute in New York. Especially useful was: Tietze C and Henshaw S K, 1986. Induced Abortion: A World Review, 6th edition, and Clandestine Abortion: A Latin American Reality, 1994. 6. Muller J 2,1995. The conservative case for abortion: why the pro-life movement is the enemy of family values. New Republic. 21 and 28 August. 7. Royston E and Armstrong S, 1989. PreventingMaternal Deaths. WHO, Geneva. 8. Chhabra S, Gupte N, Mehta A et al, 1988. Medical termination of pregnancy and current contraceptive adoption in rural India. Studies in Family Planning. 19(4):244-47. Contains references to other studies which report this phenomenon.
ce qui faisait
El 4 de Mayo de 1995, tras dos atios de intenso debate publico, la Asamblea National de Guyana aprobo el proyecto de ley de Termination MCdica de1 Embarazo, que convirtio a Guyana en el Segundo pais de1 Caribe angloparlante en introducir dicha legislation. Durante esos dos aiios, raro fue el dia sin cartas 0 articulos en la prensa, y hubo programas en television y radio al menos tma vez por semana. Este ensayo describe 10s mas de 20 adios de historia que condujeron a la reforma de la ley, y el contenido de la campaiia de apoyo a la nueva ley llevada a cabo por el Grupo Pro-Reforma, cuyo lema principal fue “Pro-Vida, Pro-Election, Pro-Reforma”. Su campaiia se realize principalmente a traves de 10s medios y fue basada en education al publico, utilization de 10s resultados de encuestas realizadas entre profesionales de la medicina, abogados, estudiantes, adolescentes y mujeres usuarias de las clinicas de planificacion familiar. El grupo dio a conocer 10s hechos relacionados con el abort0 ilegal en Guyana y las experiencias que las mujeres han tenido de1 mismo. El ensayo concluye con una description de la nueva ley y de 10s esfuerzos para iniciar el proceso de implementation.