The pain woke Gema before morning prayers. She had felt it the day before but it was much worse now. It had been less than 24 hours since she travelled by motorcycle in the pouring rain to the clinic in Indonesia's East Java province for the abortion her boyfriend had bartered down to Rp3.5 million ($A360). The midwife had told her the procedure could take up to three days to take effect.
Fluid ran between her legs and on to the bed before she stumbled to the toilet, cradling the contents of an oversized plastic nappy. Alone on the bathroom floor in her parents' home and five months pregnant, the 18-year-old student gave birth to a tiny girl. Gema watched as the baby gasped for air then died a few minutes later. "She looked beautiful," she recalls. "Her eyes, nose, eyebrows, mouth, fingers, toes were perfect."
Gema cut the umbilical cord, bathed the body and cried before quietly leaving the bathroom. She was relieved that her parents, who had always been proud of her academic achievements, would never know she had been carrying a baby. Later that day, Gema and her boyfriend buried the tiny body, along with any evidence she had ever been pregnant.
Gema's was one of at least one million induced abortions, most illegal, performed each year in Indonesia. According to 2008 figures from s-xual health advocates at the US-based Guttmacher Institute, 37 abortions occur for every 1000 Indonesian women of reproductive age. The figure is almost 30% higher than for the rest of Asia and nearly double the number in Australia. What is not known is how many women die every year as a result of septic abortions.
Australia's overseas aid program AusAid pours almost $560 million into Indonesia each year. In the 2011-12 financial year, about $16.6 million aid funded maternal and neonatal health programs -- including post-abortion care and the provision of contraceptive training -- in the East Nusa Tenggara province. The government's international assistance arm has also committed $139 million in maternal health grants to the country, one of Australia's closest neighbours, between 2010 and 2014.
But the focus is on prenatal and postnatal health rather than on reducing the number of septic abortions. This is despite an acknowledgement that the country is struggling to cut maternal mortality rates. The latest UNICEF figures put the chance of an Indonesian woman dying as a result of complications during pregnancy at one in 90. In Australia, the figure is one in 7400. "Australia's family planning programs in Indonesia focus on the prevention of unwanted pregnancies, but do not fund abortions," an AusAid spokeswoman said.
Abortion was made illegal in Indonesia in 1918 and since then political debate about the issue has been influenced largely by conservative Islamic groups concerned about the moral implications of family planning. The collision of religion and governance in the predominantly Muslim country of 240 million people has led to restrictive abortion laws and a flourishing illegal industry.
Gema was left alone at times during the eight-hour procedure. At one point the midwife left her to attend a church service. She was not allowed to drink water. She suffered unbearable pain and for hours she bled. "Tears, regret, hate, nightmares, hallucinations, physical pain. That is how my life has changed," she says now.
According to Australian National University professor Terence Hull, who has researched s-xual health in Indonesia, two centuries of debate over abortion law have failed to clarify women's reproductive rights. "They continue to die due to unsafe abortions," he said. "If students become pregnant, they are expelled from schools. If workers experience a contraceptive failure, they face the unenviable choice of leaving their job or having an illegal pregnancy termination. Poor couples attempting to limit their family size are denied the option of safe abortion in a cultural context that condemns the practice."
"One of the key points is that 'illegal' is a very fraught concept in Indonesia. The laws are terribly contradictory ..."
Despite recognition in the 1960s and '70s that septic abortions were straining the health system and were a major cause of maternal mortality in the region, legalising the procedure is still widely opposed. The resulting Health Law is confusing at best. Drafted in 1992 and revised in 2009, the law refers to abortion as "a certain medical procedure". It allows abortions up to six weeks gestation, but generally only in r-pe cases or where there is serious risk to the mother's health. In life-threatening emergencies, the woman's husband is required to give consent. For a woman who does not satisfy the strict criteria, an illegal abortion is her only option. If caught, she faces four years in jail. Her doctor risks up to 10.
In fact, says Hull, criminal proceedings against practitioners and clients are so rare that the law acts more as a "moral statement". The law, he says, provides loopholes for doctors and opportunities for bribery by police. "You would think that any organised society interested in eliminating unsafe abortion would be able to prosecute the perpetrators of these crimes. But they go unacknowledged, unreported and unimpeded, protected by the secrecy in which both the pregnancy and the termination are set," he told Crikey
"Considering that government officials quote the numbers of abortions in terms of millions of cases annually, it is strange to think that the number of arrests and prosecutions amounts to no more than a handful each year. One of the key points is that 'illegal' is a very fraught concept in Indonesia. The laws are terribly contradictory and the practice of abortion is widespread and generally hidden, with little involvement of law enforcement."
There have even been reported cases of doctors who work at state-run or private clinics also working at illegal outfits, highlighting the divide between law and enforcement.
The Indonesian Planned Parenthood Association, a not-for-profit organisation providing abortion under the guise of "menstrual regulation" at 13 clinics across Indonesia, is an example of how widespread the practice is. Chairman Budi Wahyuni says that more than half of the 3000 women attending the association's Jogjakarta clinic each year receive abortions at up to 10 weeks' gestation. Its clients are a mix of unmarried adolescents, married women who do not want more children or who have experienced a contraceptive failure, and women who have been r-ped.
Wahyuni says about 40% of those who attend the association's clinics are turned away for reasons such as not providing their husband's consent or being more than 10 weeks' pregnant. "This means that the rest of them will be forced to continue [with the pregnancy] or go to the unsafe services," Wahyuni says. “If abortion is not legalised, women who need help will seek the unsafe help from traditional birth attendants." These women risk infection, infertility and even death.
Sarah was studying for her masters in psychology in Jogjakarta when she became pregnant after being r-ped on campus. Consumed by guilt and shame, the 21-year-old had an abortion in secret. Over the following years, Sarah became pregnant twice more. She was not married and, like two-thirds of women in developing countries who fall pregnant, was not using contraception. Both pregnancies ended in abortions at illegal clinics.
"I almost committed suicide," she recalled. "I had a desire to be a housewife, to take care of my child and the family. But I couldn't disgrace my family." Sarah suffered side effects for many months after the abortions, including persistent stomach cramps, hallucinations and a discoloured discharge.
A 2008 Guttmacher study at clinics in six regions across Indonesia found the conditions under which abortions are performed were often unsafe. While researchers estimated family planning staff, obstetricians and midwives performed about 85% of procedures in urban areas, in rural regions 80% of women turn to traditional healers known as dukun.
Their method, like the one Gema experienced, consists of rough abdominal massage, the consumption of toxic herbal mixtures and the insertion of poisonous roots and leaves or chemicals into the uterus. The results can be deadly. In one instance, a woman who consumed a herbal concoction was in so much pain that she smashed her head against a wall. She died soon after, according to the Guttmacher Study.
It is not clear how many Indonesian women die from botched abortions. The government estimates anywhere between five and 11% of maternal deaths are caused by the procedure. The World Health Organisation conservatively puts the figure at 13%.
Psychologist and activist Ninuk Widyantoro, a former counsellor at the Indonesian Planned Parenthood Association, says women continue to die as a result of illegal abortions. "It happens every single day in Indonesia," she said. After leaving the IPPA, Dr Widyantoro founded the not-for-profit Women's Health Foundation to defend women's reproductive rights. She has spent the past two decades lobbying for safe abortion in Indonesia and has come under pressure from Islamic and Christian groups.
The Indonesian government’
s health ministry invited Dr Widyantoro to help draft changes in the reproductive health guidelines to the country’s 2009 revised Health Law. But more needs to be done, she says. "There is a difference between what we drafted originally and what is now law. We want every woman to have the right to access safe abortion services. Under the current law there are only two reasons why women can have an abortion: they are in physical danger or have been raped. Then it is only within six weeks."
Dr Widyantoro says it is common for doctors working at state-run or private clinics to also work at illegal outfits. "Sometimes the police raid a clinic and bring the doctor to court, but this is rare. There is a lot of corruption," she said.
Gilda Sedgh, a senior research associate at the Guttmacher Institute, says that for the past decade the use of contraceptives in Indonesia has remained static. "It is currently illegal to provide contraceptive services to unmarried women, and this puts [women] for whom the consequences of unwanted childbearing might be especially dire at great risk of unintended pregnancy."
In July, Australia's Foreign Minister Bob Carr announced a $60 million aid package over four years aimed at helping 3 million Indonesian women, particularly in rural areas. The program, to be rolled out this year, will focus on maternal and reproductive health, employment, domestic violence and education.
It is little consolation for Gema, who says she will never forget the secret procedure that begun in the back room of a house and lasted almost 24 hours. "She told me to lie down on the in bed and put my feet in straddle position. And then the process started," she said. "She put cream on her finger and inserted it inside my uterus. I was a little startled and began to feel pain in the back waist. She continued the process three times and then took three stems of plants that I didn't know, about 35cm in length, and entered them one by one into my uterus.
"Since then I often get angry out of control and always cry when I see a small child. I hate myself and will never forget that when she was born she was still alive. She weighed about two kilograms. It breaks my heart to remember it."
Indonesia’s new health minister Dr Nafsiah Mboi declined repeated requests for an interview.
*Names have been changed