women in Poland

Sexual and Reproductive Health and Rights

INDEPENDENT REPORT SUBMITTED
TO THE UNITED NATIONS HUMAN RIGHTS COMMITTEE  

September 2004

Federation for Women and Family Planning
NGO in SPECIAL Consultative Status with 
the Economic and Social Council of the United Nations

Sexual and reproductive rights (SRR) of women in Poland continue to be neglected and, at times, blatantly violated.  No steps have been taken to improve the situation of women in the area of reproductive and sexual health since 1999 despite concluding observations of the UN Human Rights Committee and other Treaty Monitoring Bodies which reviewed government’s reports on the implementation of the human rights conventions. In 1998 and 2002 the Polish Government was reporting to the Committee on Economic, Social and Cultural Rights and in 1999 it was reporting to the Human Rights Committee. The Committees noted with concern the following issues:

• strict laws on abortion resulting in high number of clandestine abortions and attendant risk to women's life and health,

• the lack of family planning programs and services and limited access to contraceptives due to high prices and restricted access to prescriptions,

•  the lack of sex education in schools.

Also the UN Committee on the Rights of the Child expressed its concern (2002) about the limited access of adolescents to reproductive health education and services.  

Article 3 of the International Covenant on Civil and Political Rights implies that women and men will equally enjoy all the rights provided for in the Covenant. However, prevalent  gender-based discrimination in Poland continues to affect specifically sexual and reproductive rights of women. As a result, women continue to be deprived of laws and policies that only women need in order  to be equal partners in the society. Discrimination of women in the area of SRR has disempowering impact on their capability to realize other rights provided for in the Covenant.

In this report the Federation will focus on three aspects of SRR in which gender discrimination is the most striking and the situation has systematically worsened in the last 12 years i.e on the right to safe abortion, right to family planning and right to sex education. Restricted access to these basic rights recognized in the UN ICPD PoA ( Cairo , 1994) and FWCW PfA ( Beijing 1995) has negative impact on women. Without access to them women are not empowered and cannot fully exercise their other human rights. 

Right to Safe Abortion Services 

Unsafe abortion poses a major threat to women’s health in Poland . Because women have a very limited access to legal abortion services under current legislation, they often risk  undergoing illegal and unsafe abortions.  The Family Planning, Protection of the Human Fetus and Conditions for Termination of Pregnancy Act of 1993 (Anti-Abortion Act) restricts the right to abortion to cases where a pregnancy endangers the life or health of the woman; the embryo is irreparably damaged; or has an incurable, life-threatening illness, or the pregnancy is probably the result of a criminal act.

 The Federation for Women and Family Planning has been monitoring the implementation of the law since its inception. Studies conducted by the Federation in 1999 and 2000 confirm the results of research conducted by the organisation in 1993 and 1996. The main findings are as follows:

§          The anti-abortion law did not eliminate and probably did not diminish the phenomenon of abortion. Illegal terminations are still common. The scale of the phenomenon can be estimated at between 80,000 and 200,000 abortions per year.
§          Most illegal abortions are conducted by doctors are relatively safe although very expensive. The phenomenon is known as the ‘abortion underground’. Many women due to economic constraints cannot afford services of good quality.
§          Some women travel abroad to have an abortion. This phenomenon is known as ‘abortion tourism’. The number of women traveling abroad is not known although many foreign clinics report having Polish women as their patients. 
§          Restrictive regulations have not eliminated abortions on social grounds. Instead, they have resulted in serious limitations on access to legal abortion. Public hospitals terminate very few pregnancies. Many women who have a right to abortion according to the law, but for various reasons cannot exercise this right, are increasingly turning to the abortion underground for solutions or are forced to continue pregnancy in spite of medical or social contraindications.
§          Knowledge about conditions for lawful termination of pregnancy is highly unsatisfactory, both in the society in general, as well as among medical staff. This general ignorance makes women even more vulnerable and dependant on negative attitudes of medical personnel. 
§          The anti-abortion law results in personal dramas  and causes substantial health problems for hundreds of thousands of women in Poland every year.

 The anti-abortion law is much stricter de facto that it is de jure. Women who are entitled to legal abortion under the Act are very often denied the termination. Since 1993 the accessibility of legal abortions in public hospitals has deteriorated, with some hospitals publicly admitting that they do not conduct abortions. The numbers of legal abortions are: 1998 - 310, 1999 - 151, 2000 - 138, 2001 - 124, 2002 – 159. Official numbers by no means represent real needs of women providing 10 mln. of women in reproductive age.

Practical interpretation of the provisions that create exceptions to the ban on abortion is very restrictive, doctors in most cases  deny the certification required for a legal abortion, even when there are genuine grounds for issuing such referral. There are no guidelines as to what constitutes a threat to a woman’s health or safety and it appears that some doctors discount any threat to a woman’s health as long as she is likely to survive delivery. For example, most doctors ignore health risks related to teenage pregnancy and do not see it as sufficient indication for abortion.

Therefore, abortion on the health grounds is difficult to obtain. In one of the hospitals in Warsaw a woman with AIDS was denied the right to legal abortion on the argument that HIV positive mothers can have healthy children. Her right to health was not respected.[1] As in this case, hospital directors can refuse to allow abortions in their hospitals, and doctors often refuse to perform abortions without referring the patient to another doctor who is willing to provide the service, although according to the Polish law doctors are obliged to refer. 

Although abortion on any legal grounds is difficult to obtain, it is particularly evident by yearly number of legal abortions due to rape. Every year no more than  2-3 abortions are performed on this ground while highly unreported rape statistics indicate several thousands rapes per year. Media reported cases of women who were denied to receive necessary referral for abortion services from a persecutor who objected on religious grounds. Moreover, long procedures  make difficult for a women to receive legal abortion before the deadline which is 12 weeks of pregnancy.

The State failed to introduce legal mechanisms to ensure that conscience clause practiced by healthcare providers guaranteed by law, would not hinder women’s right to legal abortion services. More on more public hospitals  refuse to perform legal abortions although the right to conscientious objection applies to individual doctors not the entire  hospitals. It is important to note that these hospitals often are paid by the National Health Fund for the whole package of ob/gyn. services without any exceptions.

Restrictions to abortion affect negatively access to other reproductive health services. Pregnant women quite often experience difficulties in receiving prenatal tests in public  healthcare. Some clinics refuse to issue necessary referral on the grounds that it may lead to abortion. One woman from Lomza who was denied prenatal tests in spite of clear indications and, as a result, forced to give birth to the second baby (1999) with the same serious genetic disease as her first child, sued  the doctor to the court.[2] The Prosecutor did not found the doctor guilty and abandoned the case. Finally (2004), the Civil Court found the doctor guilty and she was received a symbolic compensation.[3] 

It should be stressed that there is no system of social support for women forced against the law to continue pregnancy. Women's experience prove that the only way to get some compensation for being illegally forced to give birth to a child is to sue people or institutions responsible for not providing the needed services in time (abortion or prenatal exams). But this way is time-consuming and does not guarantee success. Meanwhile women and their families are left on their own - very often with no means to take care of their health, to raise the children and to cover the needs of their often disabled or seriously ill children.

The abortion underground in Poland is well developed. Accessing a private clinic in which one can obtain an illegal termination is easy in big cities and towns - it simply requires the woman to find the relevant press-announcement. In small towns and villages, however, doctors are not anonymous and are afraid of stigmatisation. Further, even if it were possible to find a local doctor who performs abortions, women prefer to travel outside of their community to be sure that the procedure remains confidential.

Since illegal abortion services provided in so-called abortion underground are extremely expensive, women may not be able to overcome the serious obstacles to getting an abortion. As a result, some women may undergo risky, illegal abortions or attempt to induce abortions themselves.  Fatal consequences of these abortions are occasionally reported in the media.  For example, a 20 years old – mother of a one child – died during illegal abortion.[4]

The price for an illegal abortion is usually between 1,500 PLN (US$330) and 3,000 PLN (US$675). The abortion pill, which has not been registered for sale, is offered for about 1,000 PLN (USD 220). Without any medical supervision there is no clarity what is offered to women as abortifacient. Recently it is being offered via internet by non-doctors.

Some women are often forced to continue unwanted pregnancies to term what leads sometimes to tragedies of abandoned children or even infanticide. The data on life conditions of such women is scarce and anecdotal, presented by the media in sensational and stigmatized way. Among cases of infanticide and abandoned children young mothers constitute a significant portion. Almost every week report on such cases.  For example, 19-years-old woman killed her new born baby. [5] Another 17-years-old adolescent girl was arrested for infanticide.[6] Recently the 14-years old girl from a small village Plaszcyca delivered a baby in her bathroom.[7] The baby died during or after delivery. No family member noticed she was pregnant. Root causes of such tragedies are completely ignored by social policies. Women are the only ones to blame for such tragedies, which may be caused by variety of socio-cultural factors which include:

• social stigma around premature motherhood forcing pregnant adolescents to hide pregnancy until last moment and sometimes leave their homes;

• lack of satisfactory financial support from the state to poor mothers. The support if at all is only symbolic;

•  lack of sufficient net of shelters and other social institutions helping mothers become financially independent and/or continue education;

Restrictions to abortion affect also the quality of abortion services and access to modern technologies. In Poland old fashioned D&C method is still practiced in public hospitals. Vacuum aspiration is not introduced to the Polish healthcare system which cannot be not justified by medical nor financial constraints. The abortion pill is no registered which results in increased number of cases when women are offered unknown tablets outside of medical settings.

The government has taken no measures to liberalize the abortion law or make it less restrictive for women in practice. The effects abortion underground has on the situation of women and on their health has not been evaluated. None of government's reports address this issue as well as social consequences of the abortion law.

Restrictions imposed on abortions:

Questions:

1) Has the government taken any measures to liberalize the restrictive abortion law?
2) What measures has the government taken to make legal abortions accessible for women?
3) What measures has the government undertaken to assess the situation of women forced to use backstreet abortions? 
4) What measures has the government undertaken to improve access to genetic prenatal tests?

The Right to Family Planning Services

The anti-abortion law obliges relevant state authorities to provide people with full access to contraceptive methods in order to help them prevent unwanted pregnancies. However, the Government fails to meet this obligation. In 1999 five contraceptives have been withdrawn from the list of refunded medicines. Since then any action  taken to introduce contraceptives on the lists of subsidized medicines has failed. 
In the years 1998-2002 the public health care system focused on "natural" family planning methods; modern contraceptive methods were completely neglected. The fictional National Team for Family Planning Promotion that was established in 2002 (mentioned in the governmental report) does not have practical means and ability to solve the problem of the lack of a system of family planning services and in fact has not been functioning for last two years.

 Social and economic barriers often prevent women and girls from obtaining contraception which can be bought on the basis of medical prescription. Contraceptive counseling is not integrated into primary health care system. Moreover, some regional branches of the National Health Fund  do not refund contraceptive counseling[8]. Private gynecological visits, which  are quite often the only option for women, are expensive, and some doctors require patients to visit the clinic every month to get a prescription for a monthly packet of the Pill.[9]  Many women report that doctors quite often do not know modern forms of contraceptives (e.g. emergency contraception) or impose some religiously-based biases on women during medical counseling what constitutes a serious barrier in access. The cost and time required to visit a clinic every month can be prohibitive for any woman, but is especially burdensome for adolescent girls.   

Oral contraceptives may be practically inaccessible because they are so expensive relative to income.  On average, oral contraceptives cost $5 a month, while minimum monthly income in Poland is less than 200 USD. Furthermore, four medicines with contraceptive power are on the list only due to their curing hormonal disorder functions not contraceptive functions are subsidized by the state.  The government’s limited offerings further lowers the number of women who are able to use oral contraceptives. Since 2005 even those might be withdrawn from the list. In the debate on subsidizing contraception key decision-makers say that since contraception is not curing any illness, it is not a real medicine and as such cannot be subsidized by the state. By promoting such a perception of contraception they ignore the WHO list of essential medicines.

 Adolescents are also denied access to contraceptives because cultural and religious values deny teenage sexuality.  Many doctors are unwilling to provide contraceptives to adolescent girls or write a prescription for oral contraceptives.  Because doctors are not compelled to provide contraceptives, adolescents may be left without any means to access modern forms of birth control.  

Due to the old law which is in force since 1932, voluntary sterilization is illegal in Poland. Often the law is being interpreted so restrictively that even women with serious health contraindications for pregnancy are denied access to sterilization. The consequences are dramatic - if they got pregnant they are also denied the possibility to terminate pregnancy, although they are entitled to legal abortion.

 Questions:

1) Why has the  government not taken measures to adopt or amend the law so that it would allow to subsidize oral contraceptives?
2) Why Polish law does not recognize WHO medical standards related to contraception, such as WHO model list of essential medicines? 
3) What steps have been taken to create a system of family planning services which would provide high quality counseling and modern methods of family planning?
4) Voluntary sterilization is not legal in Poland due to the seventy-year-old law - what steps have been taken by the government to make all methods of contraception accepted by WHO accessible for women and men in Poland?

Right to sex education

Right to sexuality education is a precondition of the realisation by adolescents their right to health. It has also been recognized in consensus documents such as ICPD Programme of Action, FWCW Platform for Action and their 5 years later reviews (Cairo+5 and Beijing+5). Especially adolescent girls are affected by the lack of adequate sex education due to the threat of premature pregnancy and higher risk of getting Sexually Transmitted Infections incl. HIV/AIDS.

In Poland there has been no national compulsory sex education program in schools since 1999. Instead, secondary schools are required to offer “preparation for family life” programs focused on preparing adolescents for marriage and family, with little focus on information about sexuality and reproductive health.  Most teachers lack the qualifications to teach the subject since courses for teachers provided by institutions supported by the Ministry of Education promote similar approach i.e. the manuals reflect stereotypical gender roles and do not present accurate information about modern contraceptives. The structure and content of the “family life program” is heavily influenced by the Roman Catholic Church, which has played a major role in ensuring that school programs reflect its official view against modern family planning and in favor of traditional roles for men and women in the family. They quite often discourage from using contraceptives, including the Pill and condom, promoting only so called natural methods as highly effective. A great part of recommended manuals also promote such approach. The test books are full of gender stereotypes and give biased information about modern contraception. (e.g. "contraception means something more than damaging physical health, it damages the relationship or "just" does not allow it to develop" - Ryś M., Wychowanie do życia w rodzinie. Książka dla młodzieży, CMPP-Ped MEN, Warszawa (1999) - the book is still on the list of recommended manuals which can be found on the website of Ministry of Education and Sport).

 The traditional approach to sexuality and education conflicts with the expressed preferences of the majority of Poles.  A survey in 1997 found that 88% of respondents wanted to see a sex education program in public schools that included lessons on avoiding STIs and unwanted pregnancy.[10]

According to the research conducted by Gdańsk University in 2000 it is often difficult for school directors to introduce sex education programs. The reasons they pointed at are as follows: lack of teachers with adequate qualifications, parents disagreement, lack of financial resources. The research showed that young people are interested in the subject (in 77% of schools examined almost all students attended the classes, in 19% - majority of them). Nevertheless the subject is rarely given adequate position in school programs - only in 28% of schools sex education was included in regular agenda, in 45% of schools it was treated as overtime classes and in 23% of schools it was organized instead of other classes, when other teachers were absent.

Adolescent mothers represent a high percentage of women giving birth, up 7% of all births. For example, in 2001 26,126 adolescent girls from 12 years old till 19 years old had babies. In order to decrease the teenage pregnancy rates and prevent the spread of disease among adolescents, accurate and comprehensive sex education in schools is critical.  Sexual education programs are woefully inadequate in their present form.

The issue of adolescent reproductive and sexual health is not treated with adequate seriousness by the government which has been in power since September 2001. In spite of promises made by present decision-makers during parliamentary elections to introduce modern sex education, three years later no positive changes can be observed. It is truly unfortunate that the issue of adolescents’ sexual health has become highly politicized and subsequent governments fail to address it in a way that would protect young people more efficiently against potential sexuality-related dangers.

New elections due in 2005 will certainly bring even worse political forces in power. Radical right will certainly win so we can expect even more backlash in the area of sexual and reproductive health.

Questions:

1) What measures have been taken by the government to motivate and support the school directors to introduce high quality sex education programs?   
2) When will the Government withdraw recommendations for the sex education manuals which inform adolescents that modern contraception "damages physical health and relationship between spouses"?
3) Does the government considered establishment of the system monitoring the status and quality of sex education programs?

 Conclusion

In spite of  women’s movement efforts to improve sexual and reproductive health and rights of women in Poland the situation remains very bad. The Roman Catholic Church together with minority but violent religious fundamentalists and extremely conservative politicians hinder  every initiative to liberalize restrictive anti-abortion law or improve access to contraception and sex education. Recently the Parliament rejected the possibility of subsidizing contraception by the state. Even integration of Poland with the European Union will not improve sexual and reproductive rights since the EU law does not interfere with national legislation. Expected victory of the Right in parliamentary elections in 2005 makes women’s groups very concerned about the status of SRHR of Polish women in coming years.

Wanda Nowicka
President
Federation for Women and Family Planning
Ul. Nowolipie 13/15, 00-150 Warsaw, Poland
Ph/fax 48.22.635 93 95
e-mail: nwanda@federa.org.pl