Establishing a Referral System for Safe and Legal Abortion Care: A Pilot Project on the Thailand-Burma Border.

The decades-long conflict in Eastern Burma,* and the continued human rights violations and lack of development and economic opportunities there, have led to the displacement of millions of people in the region. Some have been internally displaced, others live in conflictaffected communities in Eastern Burma, and approximately 1.5 million are either residents of nine unofficial refugee camps along the border with Thailand or undocumented migrants concentrated in Tak Province in northern Thailand.1–3 For these displaced populations, the overarching political, development and human rights context has had a significant impact on health in general, and on reproductive and maternal health in particular.4 Individuals in the affected regions of Thailand and Burma face significant barriers to accessing reproductive health services on both sides of the border, and are at an increased risk of rape and sexual exploitation.5–10 Although the maternal mortality ratio for Burma overall has remained relatively constant over the last decade (at 320 deaths per 100,000 live births), it is estimated to be substantially higher (approximately 1,000) in conflictaffected Eastern Burma.11 Limited access to contraceptives and the consequent risk of unintended pregnancy continue to be public health issues for women living in Eastern Burma.5 Although the national contraceptive prevalence rate is only 34%, the rate is likely much lower in conflict-affected areas;12–14 some reports suggest that 80% of women in Eastern Burma have never used a modern method.11,15 Abortion has long been severely legally restricted in Burma. The 1860 Burma Penal Code—incorporated into the law of independent Burma in 1947 and still in effect—is based on British law and prohibits abortion unless the procedure is performed to save the life of the woman; this exception is narrowly interpreted.16 A person who performs an unauthorized abortion and the woman herself may face imprisonment, fines or both; both criminal and civil penalties increase if the abortion takes place after “quickening,”17 an archaic term for when a pregnant woman first perceives fetal movement. Like women in other settings where abortion is legally restricted, women in Burma who want to terminate a pregnancy often resort to unsafe methods.6,7,16,18,19 The national restrictions on abortion, combined with the heightened unintended pregnancy risk, have had