Attitudes towards the legal context of unsafe abortion in Timor-Leste

Abstract

The new Penal Code in 2009 was an opportunity for Timor-Leste to allow some legal grounds for abortion, which was highly restricted under Indonesian rule. Public debate was contentious before ratification of the new code, which allowed abortion to save a woman's life and health. A month later, 13 amendments to the code were passed, highly restricting abortion again. This paper describes the socio-legal context of unsafe abortion in Timor-Leste, based on research in 2006-08 on national laws and policies and interviews with legal professionals, police, doctors and midwives, and community-based focus group discussions. Data on unsafe abortions in Timor-Leste are rarely recorded. A small number of cases of abortion and infanticide are reported but are rarely prosecuted, due to deficiencies in evidence and procedure. While there are voices supporting law reform, the Roman Catholic church heavily influences public policy and opinion. Professional views on when abortion should be legal varied, but in the community people believed that saving women's lives was paramount and came before the law. The revised Penal Code is insufficient to reduce unsafe abortion and maternal mortality. Change will be slow, but access to safe abortion and modern contraception are crucial to women's ability to participate fully as citizens in Timor-Leste.

Full text

©2009 Reproductive Health Matters.
All rights reserved.
Reproductive Health Matters 2009;17(34):55–64
0968-8080/09 $ –see front matter
PII: S0968-8080(09)34470-5
www.rhm-elsevier.com www.rhmjournal.org.uk
Attitudes towards the legal context of
unsafe abortion in Timor-Leste
Suzanne Belton,
a
Andrea Whittaker,
b
Zulmira Fonseca,
c
Tanya Wells-Brown,
d
Patricia Pais
e
a Senior Research Fellow, Graduate School for Health Practice, Institute of Advanced Studies, Charles Darwin
University, Darwin, Northern Territory, Australia. E-mail: Suzanne.belton@cdu.edu.au
b Senior Lecturer, Asia Institute, University of Melbourne, Melbourne, Australia
c Community based Maternal and Child Health Coordinator (Region 1), Alola Foundation, Dili, Timor-Leste
d Health Specialist, World Bank, Dili, Timor-Leste
e Independent lawyer and international legal adviser for development, Matosinhos, Portugal
Abstract: The new Penal Code in 2009 was an opportunity for Timor-Leste to allow some legal
grounds for abortion, which was highly restricted under Indonesian rule. Public debate was
contentious before ratification of the new code, which allowed abortion to save a woman’s life
and health. A month later, 13 amendments to the code were passed, highly restricting abortion
again. This paper describes the socio-legal context of unsafe abortion in Timor-Leste, based
on research in 2006–08 on national laws and policies and interviews with legal professionals, police,
doctors and midwives, and community-based focus group discussions. Data on unsafe abortions
in Timor-Leste are rarely recorded. A small number of cases of abortion and infanticide are reported
but are rarely prosecuted, due to deficiencies in evidence and procedure. While there are voices
supporting law reform, the Roman Catholic church heavily influences public policy and opinion.
Professional views on when abortion should be legal varied, but in the community people believed
that saving women’s lives was paramount and came before the law. The revised Penal Code is
insufficient to reduce unsafe abortion and maternal mortality. Change will be slow, but access
to safe abortion and modern contraception are crucial to women’s ability to participate fully as
citizens in Timor-Leste. ©2009 Reproductive Health Matters. All rights reserved.
Keywords: unsafe abortion, maternal mortality, law and policy, criminalisation, Timor-Leste
TIMOR-LESTE gained independence from
Indonesia in 2002 after 25 years of occupa-
tion, deprivation and human rights abuses.
1
It remains one of the world’s poorest nations.
The population of one million are largely subsis-
tence farmers, live in sub-tropical savannah and
mountainous villages, organised along kinship
and linguistic divisions. Illiteracy is common.
The United Nations and government have worked
to stabilise this fragile nation state, where there is
considerable complexity in forming governance
structures.
2–4
Apart from government and politi-
cal parties, influential powerbrokers include tradi-
tional custodians (liu rai), the Catholic Church, the
United Nations and local and international NGOs.
Despite recent conflict, progress has been made in
forming a democratic system of government, pro-
mulgating law, building infrastructure and nego-
tiating an emerging position in Southeast Asia.
5
Timor-Leste lost much of its health personnel
and infrastructure during the violence that erupted
following the vote for independence in 1999,
which undermined its ability to provide health
services.
6,7
Intermittent post-independence insta-
bility has disrupted service delivery since indepen-
dence in 2002. Two reports on maternal health
services indicate that staff have struggled with a
lack of essential supplies, equipment and running
55

water, as well as some of the basic skills required
for their work.
8,9
Unsafe abortion is the third largest cause of
maternal deaths during pregnancy globally and
contributes to high maternal death rates
10
and
serious morbidity in Timor-Leste. The fertility rate
of eight children per woman is also high. Povey &
Mercer cite a maternal mortality ratio of 890 per
100,000 live births for 2001.
11
The UN Develop-
ment Programme quoted a similar figure of 800
per 100,000 for 2006
3
while the World Health
Organization estimated 660 per 100,000 for
2000.
12
In the absence of systematic reporting in
Timor-Leste, such figures remain estimates. The
collection and management of health data are
only just beginning.
This paper describes the socio-legal context of
unsafe abortion in Timor-Leste, based on research
in 2006–08 on national laws and policies and
interviews with legal professionals, doctors and
midwives, and focus group discussions with people
in the community.
National policies on reproductive health
The National Reproductive Health Strategy
(2004–2015),
13
National Family Planning Policy
(2004)
14
and Standard Treatment Guideline for
Primary Health Facilities
15
in Timor-Leste all
obscure the issues of unwanted pregnancy and
abortion. The National Reproductive Health
Strategy categorises reproductive health ser-
vices into “Young people”,“Family planning”,
“Safe motherhood”and “General reproductive
health”. They are progressive policies, but are
patchily implemented due to low capacity in
the Timor health system. Abortion is mentioned
in connection with adolescents, and in terms of
post-abortion care and emergency obstetric care
within safe motherhood. There is no acknow-
ledgement of the illegality of abortion or mention
of access to safe abortion. The Family Planning
Policy promotes modern methods of contracep-
tion, which are free and found in public hospitals
and health posts, but notes that a third of all
women in their 20s and 30s are pregnant in any
one year, and there is a very low acceptance of
modern methods.
14
It does not mention abortion.
Despite the Catholic Church’s position on modern
methods of contraception, members of the Church
participated in formulating this policy although
they do not officially promote modern methods.
New Penal Code, 2009
The Council of Ministers approved the new Penal
Code in April 2009, which included clauses on
abortion. The Indonesian Penal Code (which had
remained in force in Timor-Leste after indepen-
dence) criminalised all abortions. Initial drafts
of the new code, circulated in Dili in Portuguese
and English in 2007 and 2008, made no reference
to abortion at all. Later drafts permitted abortion
on grounds of illness and risk to the life of the
mother and her mental health. In the text as rati-
fied, Article 141 on the Interruption of Pregnancy
had five sections:
•Any person who performs abortion through
whatever means and without the consent of
the pregnant woman shall be sentenced to 2 to
8 years imprisonment.
•Any person who performs abortion through
whatever means and with the consent of the
pregnant woman shall be sentenced to up to
3 years imprisonment.
•Anypregnantwomanwhoconsentstoan
abortion procedure by any other individual or
induces abortion as a result of her own deeds
or those of a third party shall be sentenced to
up to 3 years imprisonment.
•The provisions on the previous paragraphs are
not applicable in cases when the interruption
of pregnancy is the only means to counter the
risk of death or irreversible lesion to the body
and physical or psychological health of the
mother or the fetus, as long as the procedure
is authorised and monitored by a medical
team and performed by a doctor or health
professional in a public health institution with
the consent of the pregnant woman and/or
her life partner.
•The provisions of paragraph 4 of this article
will be the object of a separate regulation.
Article 142 made infanticide punishable with
3–10 years’imprisonment.
Just over a month after ratification, Decree
Law 19/2009 was passed, with 13 amendments
to Article 141, which are highly restrictive. They
say women must be facing imminent death and
have no other medical option other than to ter-
minate the pregnancy. The woman must consent
in writing and her spouse or another person also
sought to give consent. Three doctors need to
agree to the procedure and sign a certificate. A
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
56

fourth doctor, not one of the original three, should
perform the abortion and one of the doctors should
be trained in obstetrics and gynaecology. There
should be a delay where possible of two days
between gaining consent and performing the
procedure. Furthermore, medical practitioners
may conscientiously object to performing an
elective abortion but must refer the woman to
another colleague. Thirty-four parliamentarians
out of 65 voted for the amendments, eight
abstained and one requested the expert advice
of a doctor, as he felt he was not well informed
enough in obstetrics.
These amendments shocked women’shealth
advocates in Timor-Leste. In a letter to the Presi-
dent, calling on him not to sign the amendments
into law, they pointed out that it was not pos-
sible, particularly in rural areas, to have access
to four doctors in Timor-Leste, let alone with
knowledge of abortion or specialism in gynae-
cology and obstetrics. For example, in Atuaro,
there is only one doctor, who is not there every
day. There was little consultation with health
workers, legal personnel or women, who deal with
the consequences of unsafe abortions. The passage
of these amendments takes place in a society
where the Roman Catholic church greatly influ-
ences public opinion and policy.
Methods
We studied the legal and social determinants of
fertility control and unsafe abortion in 2006–08.
Other findings of the study on maternal mortality,
ethno understandings of conception, and post-
abortion care are available in a situational analy-
sis published by UNFPA and Alola Foundation.
10
The political crisis in 2006 disrupted the
research; we extended the time-line but were
unable to visit all the country’s six hospitals. The
personal and sensitive nature of the topic of
unwanted pregnancy and the illegality of termi-
nation of pregnancy made extreme discretion
necessary. The lack of reliable baseline data is a
difficulty faced by all researchers in Timor-Leste.
We visited two large hospitals and two other
health facilities, which cover 38% of the popu-
lation, and studied data on emergency obstetric
admissions in 2006 and 2007 in the two facili-
ties with these services. The research team inter-
viewed a variety of people knowledgeable about
unwanted pregnancy and abortion. All partici-
pants were assured of anonymity and confi-
dentiality. This is difficult in Timor-Leste, where
many people are related and places easily identi-
fied. We have used pseudonyms throughout and
tried to de-identify people, events and locations.
As there are few health facilities providing these
services, we have limited descriptions of them
for the same reason. Information sheets about
the research and consent procedures were in
English, Tetum and Portuguese. Oral consent
was obtained from those unable to read or write.
Ethical approval was obtained from Charles
Darwin University (#H06092) and the University
of Melbourne (#7125771). The Minister of Health
also approved the research.
Interviews
Fifteen informants from the general community
and governmental and non-government sector,
36 villagers and three traditional midwives gave
information. Twenty-one women admitted for
post-abortion care were interviewed about their
experience and social situation. Thirteen legal
professionals were asked where they were trained,
their areas of expertise and whether they were
aware of cases of manslaughter or murder charges
associated with unwanted pregnancies, their
knowledge and experiences of working with the
Indonesian Penal Code, cases of criminal abortion,
infanticide, sexual assault where pregnancy was
the outcome, or cases involving domestic violence
where abortion was the outcome.
Twenty-one doctors and midwives from four
health facilities in two large urban areas who
provide post-abortion care were interviewed.
They were assured of confidentially and de-
identification of their contribution. Some spoke
English; others were supplied a Tetum inter-
preter. The interview schedule covered clinical
experience and practice, and knowledge and
beliefs in caring for women with post-abortion
complications. Clinicians were asked to recall
specific cases, talk about diagnostics, treatment
procedures, understanding and interpretation of
the law, personal values regarding the provision of
abortion and family planning. They were shown
a visual representation of global abortion laws
16
to elicit discussion of the variation around the
world. Questions were worded slightly differently
depending on the role and seniority of the clini-
cian. Interviews lasted for about an hour. They
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
57

were conducted in the health facilities; handwrit-
ten notes were taken and typed up. Some clini-
cians asked to read their responses (most did not).
The transcripts were thematically analysed.
All respondents were purposively selected. For
example, we only invited doctors who worked
on maternity wards or who had clinics or qualifi-
cations that would attract patients with reproduc-
tive health problems. Midwives were chosen as
they work in gynaecology and obstetric depart-
ments. The legal professionals were those with
experience or exposure to the types of cases we
were interested in. We covered a range of urban
and rural areas. There is a large expatriate com-
munity in Timor-Leste, but the majority of respon-
dents were Timorese. It is difficult to know if those
who consented to provide information were repre-
sentative, but we had few refusals from any group.
Focus group discussions and vignettes
Thirty-six men and women from two villages in
one district responded to vignettes about com-
plicated pregnancies. The district health office of
one of the audited hospitals directed the research
team to the village leaders, who gave permission to
talk with the people. Old and young adults volun-
teered to discuss the cases presented to them, and
village leaders chose gender- and age-similar
groups. People were not directly asked to disclose
experiences of unwanted pregnancy or abortion.
Two vignettes were used
17,18
to generate discussion:
“Maria”about potentially saving a woman’slifeand
“Juana”about socio-economic issues and abortion.
Maria
Maria is 19 years old and is having her first baby.
She is happily married with Antonio. They are in
love and they want this baby. As her pregnancy
grows she becomes increasingly weak. She is
breathless when she has to walk. One day as she
is doing the washing her lips go blue and she can
hardly catch her breath. Antonio quickly takes
her to hospital. As she falls unconscious she says
she wants to live…The doctor and midwife tell
Antonio that she has a serious heart problem
and the pregnancy is too much of a strain on
her weak heart. They say the only thing that will
save Maria’s life is if they stop the pregnancy.
Villagers were asked what the doctor should
do in this situation, what Antonio should do
and what their thoughts were.
Juana
Juana is 30years old andlives fivehours from Dili
in a remote village. She is married to Domingos,
who is an alcoholic and violent. She has had
12 pregnancies and now has six living children.
She is very poor and doesn’t know how to feed all
her children. She worries day and night about
this. She does not want any more children as
she is very tired. She heard about family plan-
ning but Domingos does not agree with this idea.
One day she thinks she is pregnant again. She
goes to the village midwife and asks for a mas-
sage to bring back her menstruation. The village
midwife says she can do it and she is very suc-
cessful at stopping pregnancies.
Villagers were asked why Juana goes to the
midwife, what does the midwife do and what
should Juana do in this situation.
Findings
Maternal deaths and unsafe abortion
Two health facilities were able to report on
maternal mortality, and records were assessed
where possible. None of the health facilities con-
ducted maternal death reviews, and the number
of obstetric deaths could not be ascertained due
to the absence of complete record systems. The
two hospitals had recorded 1,102 cases of emer-
gency obstetric care in 2006 and 2007. Of these,
470 (42.6%) were women admitted due to com-
plicated abortions, which may have been either
spontaneous or induced.
Women and health workers described how
pregnancies are terminated outside the health
care system: modern and traditional medications/
herbals, pummelling of the pelvic area, applica-
tion of hot water and insertion of objects into
the reproductive organs were all used. One case
study of the introduction of a foreign body fol-
lowed by perforation of the uterus, sepsis, coma,
necrosis of the uterus and hysterectomy was
published in 2009.
19
Legal professionals’view of the law
Only one legal professional had dealt directly
with cases of induced abortion, but many had
worked on cases of infanticide, sexual crimes
resulting in pregnancy, and domestic violence.
“Yes, I worked on 10–15 cases of infanticide
committed mainly in (district name) and (district
name). I remember that one woman was sentenced
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
58

to seven years' imprisonment. It is very difficult
to collect evidence in both crimes –abortion and
infanticide. In many cases the family helps to
conceal the pregnancy until birth and also helps
to kill the baby. They feel shame because the
woman/girl is not married. There are many cases
in the other districts. Women are victims of sexual
abuse; they get pregnant and reject the child.”
(Timorese prosecutor)
Late in 2008 an abortion case entered the judicial
system reported by the Judicial System Monitoring
Programme.
20
According to this account, the man
sourced some traditional medicine to give to his
girlfriend, who took it. This demonstrates one
way unwanted pregnancies are ended, the dan-
gerous nature of unsafe abortion and the legal
complexity of prosecution where evidence is
scant. The prosecution was abandoned due to
insufficient evidence.
Judicial and prison authorities confirmed that
a few women had been investigated for abortion
and some imprisoned for infanticide. The Prose-
cutor's Office reported handling six cases of
abortion crime in 2003, one in 2007 and two in
2008. Prison authorities reported that two women
were in jail for three to four years each for killing
infants less than one month old. The numbers
could not be confirmed by court records, as the
records were misplaced during the 2006 crisis.
Even if someone is charged, most cases do
not reach court as it is difficult to obtain enough
evidence to convict. A police officer said it was
difficult to enforce the law as nobody made
direct complaints to them. Most lawyers com-
mented on the inadequacies of the Indonesian
Penal Code and wanted Timorese legislation on
abortion. Views varied from liberal to conserva-
tive; some said the Code was inadequate in not
making any distinctions regarding length of ges-
tation, or that abortion should not be included in
the Penal Code at all. One Timorese judge spoke
about women’s right to choose and to have pro-
tection in law. Others thought the penalties were
too low, as the issue was about taking a life.
“Our law, religion and culture do not permit us
to induce abortion. In my opinion, if people have
abortions it is because of their own selfish inter-
ests, for example, because they are ashamed that
theyarenotmarriedorbecausetheyhaveno
food or money. If I knew that an abortion had
occurred I would do something.”(Police officer)
“There are cases of abortion where women are
forced by their partners to take medicines to ter-
minate the pregnancy. These cases take place
particularly in the district of [name]. I have seen
more than three. No cases reached court…during
Indonesian times as they suffered from pro-
cedural deficiencies, and could not be judged.”
(Expatriate judge)
“First of all I think the Timorese people need
to be educated, they have no knowledge at all
regarding everything. It is complicated because
of the economic and social situation. Women are
economically weak and uninformed; if they were
[informed] they would protect themselves against
these kinds of situations: abortion, domestic vio-
lence, all. A big issue here is the Catholic Church,
religion. Timorese are very narrow-minded. Only a
few, a very few Timorese have knowledge and they
can’t influence the majority that don’thaveknow-
ledge. The Penal Code is under review and the law
should have exceptions allowing women to have
abortions, namely when they are raped or even
when they can’t raise the kids because they don’t
have money. Women should be able to choose.”
Doctors and midwives' views
Most clinicians were unaware of the current
law regulating termination of pregnancy. They
simply “knew”that abortion was forbidden and
when asked who forbade it, they replied “the
Church”. Seeing the World Abortion Law map
engaged them in discussing the variety of laws
regulating abortion and they expressed surprise
at the diversity. They had divergent viewpoints
about what they believed were appropriate grounds
for termination of pregnancy. Nearly all would
want to be able to save the mother’s life and many
understood that physical and mental health rea-
sons were important to consider, as well as fetal
abnormality in making decisions about the via-
bility of a pregnancy. There was less agreement
on social reasons, such as poverty, and clinicians
preferred to offer family planning and support
in these cases. Most acknowledged that incest
and rape were common occurrences, which had
a profound impact on the desirability of a preg-
nancy. Some thought the woman had no choice
but to accept her fate and continue her pregnancy
(with counselling and support); others felt the
woman should be able to end her pregnancy
legally. Many midwives said they would not
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
59

assist a doctor to terminate a pregnancy. One
midwife said: “Although I do not want to assist
the doctor, I would not intervene to stop them as
I know that each person is responsible for their
own sin in the end.”
Only two clinicians, one expatriate and one
Timorese, referred to reproductive rights and
the WHO definition of health. The Timorese
doctor said:
“If an emergency case comes to us, we must save
the woman’s life. We must think about human
rights. In the future, when all Timorese are edu-
cated, we will decide by ourselves. We will respect
all rights and the right to abortion. We need to
understand the definition of health according to
WHO, so mental health is included. This means
that if the woman doesn’t want this pregnancy,
it is her right. Also, in my position, I will use the
WHO definition which includes the mental health
of the woman.”
Villagers’views
In the focus group discussions using the Maria
and Juana vignettes, men and women were
adamant that women deserved to survive preg-
nancy, even if it meant the termination of a
pregnancy. They differed as to when abortion
should be legal, for reasons such as rape, incest,
fetal abnormality, and social and economic rea-
sons. But they had a comprehensive message for
doctors. Doctors should not use their religion to
withhold treatment from women, even abor-
tion. Doctors should try to save two lives but if
they can only save one, then the woman’s life is
paramount, whatever the law may say. During
discussion of the Maria vignette, these views
were expressed:
“As a family member, we are feeling sad but the
important thing is to save Maria’s life and maybe
she can do some good things for the family. Life is
important, not law.”(Village woman)
“We know that religion forbids the termination of
pregnancy but health is also important. If doctors
and midwives let women die because of pregnancy
complications like this one, it is a mistake that
cannot be pardoned by God.”(Village man)
Juana’s story raised other issues. The villagers
said that men and women should control their
fertility and this is possible now. Men especially
should consider their capacity to raise children
and educate them. If women found themselves
in these situations, they should use modern con-
traception even if their husbands did not agree.
Fewer people felt inclined to see abortion as a
solution to Juana's problem, however.
Discussion
While systematic health data are poorly recorded
and illegality continues to obscure the realities
of unsafe abortion, it is unlikely that the full pic-
ture will be known. In neighbouring Indonesia,
with a similarly restrictive legal environment,
and where the stigma of single motherhood is
equally strong, manual vacuum aspiration and
massage are common methods of abortion and
the abortion rate is 37 per 1,000 women of repro-
ductive age.
21,22
Clinicians in Timor-Leste were willing to talk
about abortion and prioritised preserving life,
but they had narrow definitions of health and
were reluctant to consider social and emotional
reasons for abortion. Most health workers con-
flated the Church’s position with the law. Never-
theless, a few clinicians were supportive of reform.
This generation were trained in Indonesia or
Timor-Leste. It will be interesting to see if there
are differences in views among the 600 or so
young Timorese doctors due to return from train-
ing in Cuba. A Timorese member of the Ministry of
Health reflected on the lack of choices women have:
“It is a dilemma to change the people’s ideas in a
day. Perhaps in the next generation people will
approach this differently. It will change. We don’t
want other countries’laws. Maybe in the next five
to ten years we can adapt these laws in our country
but it is difficult. We are a young country, so step
by step…We need to decide together in forums.
To change the law we would invite the doctors…
mostly the doctors know…For myself, I think
when girls or women are not ready there should
be terminations of pregnancy. I can imagine that
a woman does not want the baby; she may neglect
it or abandon it. I even asked the priest about that
and he said family planning and abortion are the
samething.IsaidOKtellmewhatisbetter–to
prevent an unwanted pregnancy, or infanticide or
neglect? These are the real choices for women.”
The judicial system has a very low capacity and
people rely largely on customary law to settle
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
60

disputes.
23,24
Mearns noted in 2002
24
that the
traditional system is functional, highly accessi-
ble and meaningful to many Timorese, but often
disadvantages women and children as interna-
tional human rights standards do not prevail.
There is little protection for women who find
themselves pregnant without a father who will
take responsibility for the baby. Furthermore,
rape is conceptualised as loss of dignity, and
families are financially or materially compen-
sated as though the woman is a spoilt commodity.
Thus, women who have unplanned and unwanted
pregnancies, whether through a consensual rela-
tionship or non-consensual sex, often use tradi-
tional mechanisms (lian nain), such as asking
village leaders to act as mediators. This may result
in the baby being relinquished into the care of
others. Informal family agreements to care for
and raise children may also be arranged. In some
cases, families may hide the pregnancy and kill
the newborn baby. If a baby is abandoned, some
Catholic pastoral services care for them in the
short- or long-term.
The formal legal system, the Penal Code of
2009 and the recent amendments to it may pre-
vent pregnant women from receiving emergency
obstetric care if termination of pregnancy is
required to save their lives. Furthermore, there
are no provisions for abortion on grounds of
physical or mental health, or for women who
become pregnant following rape or incest. Civil
society organisations raised these issues publicly
prior to parliamentary debate on the Penal Code,
and the Dili Declaration from the Peace and
Security Conference in March 2009 recom-
mended that Timorese women should have the
right to survive pregnancy and not be discrimi-
nated against.
25
The Code before it was subse-
quently amended went some way to recognising
these issues. However, those who spoke up for
women’s right to reproductive health were
labelled “pro-abortion”by the media.
26
The com-
bined effect of the release of the report and the
new Penal Code generated public debate on abor-
tion. Radio and press media in Timor, Indonesia
and Australia picked up the debate. It was blogged
around the world, as a search on Google demon-
strates. The debate was at times heated, irrational
and polarised. People with little understanding
of the context of Timor wrote in terms of “pro-
choice”or “pro-life”−divisive representations of
reproductive health advocacy which are unhelpful
in a country where women die regularly from
lack of access to reproductive health services.
Considerable social stigma is attached to public
defiance of the Catholic Church’sstanceonabor-
tion, and exclusion from the Church is a fear
for Timorese.
For the majority of Timorese, the Church and
traditional law are the arbiters of moral and
legal viewpoints on abortion. However, in 2005,
as an independent nation state, Timor-Leste
accepted the goals and targets of the Millennium
Development Goals to improve maternal health.
27
The international literature demonstrates that
when access to safe, legal abortion is blocked,
women will continue to end their pregnancies,
suffer permanent health problems, stigma and
sometimes death. The nation has signed and rati-
fied several international conventions that carry
implications for national laws, policies and the
practical delivery of health services to men and
women.
28
The Penal Code does not reflect the spirit
of these international treaties as regards abortion,
and the 2009 observations of CEDAW concur:
“The Committee further calls upon the State
party to review the legislation relating to abor-
tion with a view to removing the punitive provi-
sions imposed on women who undergo abortion in
accordance with the Committee’s general recom-
mendation 24 on women and health and the
Beijing Platform for Action.”
29
Moreover, the Judicial System Monitoring Pro-
gramme, a Timorese NGO with legal expertise,
argue that Article 141 and the 13 amendments
may be unconstitutional.
30
We therefore recom-
mend a review to determine this.
Cook and Ngwena suggest a range of princi-
ples that should guide the development of legal
frameworks on reproductive health: that the law
should be evidence-based rather than reflect per-
sonal morality; legal guidance for women and
health care providers should be clear; and the
law should be applied without discrimination
against women.
31
The international evidence is
clear: criminalisation of abortion contributes
directly to the deaths of women with unwanted
pregnancies and who have no recourse other
than unsafe abortion.
10
Legal reform alone is
insufficient to reduce unsafe abortion, but it is
a necessary step towards making pregnancy safer
for women and reducing maternal mortality,
including in Timor-Leste.
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
61

We recommend the formation of an inter-
sectoral group to advocate for reducing deaths
and morbidity from unsafe abortion. Its mem-
bers could include representatives from the
Ministry of Health, Ministry of Justice, Secre-
tariat of Promotion and Gender Equality, health
professionals, legal professionals, police and
civil society groups who deal most closely with
the consequences of unsafe abortion. Such a
group could study the international evidence
and WHO guidance on making abortion safe,
32
in order to advise government on the medical,
legal and social implications of the current law
and the need for reform. A reliable baseline
survey of maternal mortality and its causes
would provide evidence of the extent of the
problem of unsafe abortion in the country. The
full implementation of current government poli-
cies supportive of increased access to modern
forms of contraception is also crucial. Yet given
the current influence of the Catholic Church
within Timorese social and political life, any
reform is likely to be slow.
Similarly, Timorese civil society groups and
women’s organisations need to be supported by
the media and government in their efforts to
have the issue of access to safe abortion and
modern contraception understood as crucial to
women’s rights and ability to participate and
contribute fully as citizens in Timor-Leste.
Acknowledgements
The Maternal Mortality, Unplanned Pregnancy
and Unsafe Abortion study was led by Suzanne
Belton, Andrea Whittaker and Lesley Barclay.
Permission and support were gained from the
Minister(s)ofHealthandtheMinisterofJus-
tice to conduct the research in Timor-Leste. Many
Alola Foundation staff assisted with cultural
sensitivity, interpreting and logistics. UNFPA
and Charles Darwin University funded the study.
The authors thank Professor Rebecca Cook, Chair
in International Human Rights Law, Faculty of
Law, University of Toronto, Canada; Professor
George Nwenga, Department of Constitutional
Law, University of the Free State, South Africa;
Fred Nunes; and Charlotte Hord Smith, Director
of Policy, Ipas, USA, for their insightful com-
ments. Karen Otsea was particularly helpful
and supportive. The complete study is published
as a report entitled Maternal Mortality, Unplanned
Pregnancy and Unsafe Abortion in Timor-Leste:
A Situational Analysis, by UNFPA (Dili) and
Alola Foundation at <www.alolafoundation.org/
index.php>.
References
1. Dunn J. East Timor: a rough
passage to independence.
Double Bay: Longueville
Books; 2003.
2. Kingsbury D. South-East Asia:
A Political Profile. 2nd ed.
Melbourne: Oxford University
Press; 2005.
3. United Nations Development
Programme. Timor-Leste
Human Development Report:
Path Out of Poverty, Integrated
Rural Development. Dili:
UNDP; 2006.
4. Shoesmith D. The crisis in
Timor-Leste: understanding
the past, imagining the future.
Darwin: Charles Darwin
University Press; 2007.
5. Internal Displacement
Monitoring Centre. Countries:
Asia Pacific: Timor-Leste
Country Statistics 2008. 2008.
At: <www.internal-
displacement.org/
8025708F004CE90B/
(httpCountries)/
3FF6A63FDDF45BD6C1257
1780029F4AB?opendocument&
count=10000>.
6. Galvin GM. Establishing
rudimentary health-care
facilities in East Timor.
Emergency Medicine 2000;12:
207–11.
7. McAuliffe AV, Grootjans J.
Hasten slowly: a needs analysis
for nurse and village health
worker education in East Timor.
International Nursing Review.
2002;49:47–53.
8. Revilla JJ, Bucens I,
Husenynzada S. Basic
Emergency Obstetrical and
Neonatal Care Training
for Health Providers at
National and Referral Hospitals.
Dili: Ministry of Health,
UNFPA; 2006.
9. Sullivan S. Evaluation of the
Safe and Clean Delivery
Training Program. Timor-Leste:
UNICEF; 2006.
10. Berer M. National laws and
unsafe abortion: the parameters
of change. Reproductive Health
Matters 2004;12(24 Suppl):1–8.
11. Povey G, Mercer MA. East Timor
in transition: health and health
care-report from East Timor.
International Journal of Health
Services 2002;32(3):607–23.
12. World Health Organization.
Maternal mortality in 2000:
estimates developed by
WHO, UNICEF and UNFPA.
Geneva: WHO Department
of Reproductive Health and
Research; 2004.
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
62

13. Democratic Republic of
East Timor. National
Reproductive Health Strategy
2004–2015. Timor-Leste:
Ministry of Health, UNFPA,
WHO; 2004. p.64.
14. Ministry of Health, Democratic
Republic of Timor-Leste.
National Family Planning
Policy. Dili: MoH; 2004.
15. Ministry of Health, Democratic
Republic of East Timor.
Standard Treatment Guidelines
for Primary Health Care
Facilities in East Timor. Dili:
MoH; 2004. p.250.
16. Centre for Reproductive Rights.
World Abortion Laws Fact
Sheet 2008. 2008. At: <http://
reproductiverights.org/en/
document/world-abortion-
laws-2008-fact-sheet>.
17. Mitchell EMH, Halpern CT,
Kamathi EM, et al. Social scripts
and stark realities: Kenyan
adolescents' abortion discourse.
Culture, Health &Sexuality
2006;8(6):515–28.
18. Whittaker A. Eliciting
qualitative information about
induced abortion: lessons from
Northeast Thailand. Health Care
for Women International 2002;
23(6–7):631–41.
19. Ondrej S, Martin P, Sevinj HZ,
et al. Abortion induced by a
foreign body with artificial
perforation of the uterus,
followed by sepsis, coma,
necrosis of the uterus and
hysterectomy. A case report.
Australian and New Zealand
Journal of Obstetrics and
Gynaecology 2009;49(3):337–38.
20. Judicial System Monitoring
Programme. Victim and fetus
die from abortion. Press release.
At: <www.jsmp.minihub.org/
index2.htm>. November, 2008.
21. Bennett LR. Single women's
experiences of premarital
pregnancy and induced
abortion in Lombok, Eastern
Indonesia. Reproductive Health
Matters 2001;9(17):37–43.
22. Sedgh G, Ball H. Abortion in
Indonesia. New York: Alan
Guttmacher InstItute; 2008.
23. Hohe T, Nixon R. Reconciling
justice, “traditional”law and
state judiciary in East Timor.
City unknown: United States
Institute of Peace; 2003.
24. Mearns D. Looking both ways:
models for justice in East Timor.
City unknown: Australian Legal
Resources International; 2002.
25. Recommendations Second
International Conference
Women for Peace, Dili,
5–6 March 2009. At:<www.
alolafoundation.org/peace_
conference_speeches/
Conference%
20Recommendation09%
20[Compatibility%
20Mode].pdf>.
26. Tozzi PA. Feisty Timor-Leste
bucks abortion lobby, upholds
right to life. Catholic Family
and Human Rights Institute;
June 11 2009. <http://www.
c-fam.org/publications/id.1228/
pub_detail.asp>.
27. United Nations. Millennium
Development Goals 2000.
At: <www.un.org/
millenniumgoals/>.
28. University of Minnesota.
Ratification of International
Human Rights Treaties -
Timor-Leste. 2007. At: <www1.
umn.edu/humanrts/research/
ratification-timor.html>.
29. Committee on the Elimination
of All Forms of Discrimination
against Women. Concluding
observations of CEDAW,
Timor-Leste. Section 38.
New York: United Nations;
July–August 2009.
30. Judicial System Monitoring
Programme. Abortion reform
still needed: Article 141 of
East Timor penal code must
comply with constitution and
international law. 28 April
2009. At: <www.jsmp.minihub.
org/English/webpage/publica/
Abortion%20Report%2020%
20April_e.pdf>.
31. Cook RJ, Ngwena CG. Women's
access to health care: the legal
framework. International
Journal of Gynecology &
Obstetrics 2006;94(3):216–25.
32. World Health Organization. Safe
Abortion: Technical and Policy
Guidance for Health Systems.
Geneva: WHO; 2003.
Résumé
En 2008, le nouveau code pénal était l’occasion
pour le Timor–Leste d’autoriser dans certains cas
l’avortement, qui était strictement limité sous
le régime indonésien. Le débat public a fait
rage avant la ratification du nouveau code, qui
permettait à la femme d’avorter pour sauver sa
vie et sa santé. Un mois après, 13 amendements
au code étaient adoptés, restreignant de nouveau
sévèrement l’avortement. L’article décrit le
contexte socio-juridique de l’avortement à risque
au Timor-Leste, sur la base de recherches en
2006–2008 sur les législations et les politiques
nationales et d’entretiens avec des juristes, des
Resumen
El nuevo Código Penal de 2009 fue la oportunidad
deTimor-Lestedepermitircausalesparael
aborto, que era muy restringido bajo el gobierno
de Indonesia. El debate público era polémico
antes de la ratificación del nuevo código, que
permitió el aborto para salvar la vida y la salud
de la mujer. Un mes después, se aprobaron 13
enmiendas al código, que volvieron a restringir
elaborto.Enesteartículosedescribeelcontexto
socio-jurídico del aborto inseguro en Timor-
Leste, de acuerdo con investigaciones realizadas
en 2006–08 sobre las leyes y políticas nacionales
y entrevistas con profesionales jurídicos, policías,
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
63

officiers de police, des médecins et des sages-
femmes,ainsiquedediscussionsdegroupeà
assise communautaire. Au Timor-Leste, les
données sur les avortements à risque ne sont
guère enregistrées. Un petit nombre d’avortements
et d’infanticides sont notifiés, mais ils font rarement
l’objet de poursuites, par manque de preuves et de
procédures efficaces. Des voix soutiennent la
réforme législative, mais l’Église catholique
romaine influence profondément la politique
publique et l’opinion. Les avis professionnels
divergeaient sur les motifs légaux d’avortement,
mais l’opinion estimait que sauver la vie de la
femme était primordial et passait avant la loi. Le
code pénal révisé est insuffisant pour réduire les
avortements à risque et la mortalité maternelle.
Les changements seront lents, mais l’accès à
l’avortementsansrisqueetàlacontraception
moderne est capital pour que les femmes participent
pleinement en qualité de citoyennes du Timor-Leste.
médicos y parteras profesionales, y discusiones en
grupos focales comunitarios. Rara vez se registran
datos sobre el aborto inseguro en Timor-Leste. Un
pequeño número de casos de aborto e infanticidio
son denunciados pero rara vez enjuiciados, debido
a deficiencias en evidencia y procesos. Aunque
hay voces que apoyan la reforma de ley, la Iglesia
romana católica tiene una gran influencia sobre
la política y opinión pública. Los puntos de vista
profesionales en cuanto a cuándo el aborto
debería ser legal variaban, pero en la comunidad
la gente creía que salvar la vida de las mujeres
es lo primordial y se debe anteponer a la ley.
ElCódigoPenalrevisadonoessuficientepara
disminuir las tasas de aborto inseguro y mortalidad
materna. Los cambios serán lentos, pero el acceso
al aborto seguro y anticonceptivos modernos es
imperativo para que las mujeres puedan participar
plenamente como ciudadanas de Timor-Leste.
S Belton et al / Reproductive Health Matters 2009;17(34):55–64
64