Singlewomens experiences of premarital pregnancy and induced abortion in Lombok.

Eastern Indonesia
LindaRaeBennett
Induced abortion is widely practised in Indonesia by both married and unmarried women. This paper draws on ethnographic research, conducted between 1996 and 1998, which focused on reproductive health and sexuality among young single women on the island of Lombok in Eastern Indonesia. While abortion for married women is tacitly accepted, especially for women with two or more children, premarital pregnancy and abortion remain a highly stigmatised and isolating experience for single women. Government family planning services are not legally permitted to provide contraception to single women and their access to reproductive health care is very limited. Abortion providers were highly critical of unmarried women who sought abortions, despite their willingness to carry out the procedure. The quality of abortion services offered to single women was compromised by the stigma attached to premarital sex and pregnancy. Women who experienced unplanned premarital pregnancy faced personal and familial shame, compromised marriage prospects, abandonment by their partners, single motherhood, a stigmatised child, early cessation of education, and an interrupted income or career, all of which were not desirable options. Young women were only able to legitimately continue premarital pregnancy through marriage. In the absence of an offer of marriage, single women necessarily resorted to abortion to avoid compromising their futures.

Keywords: young women, contraception

abortion, doctor-patient relations,

and unplanned Indonesia

pregnancy,

marital

status, induced

HIS article is concerned with the experience of premarital pregnancy and induced abortion among young, single women in Lombok, Eastern Indonesia. I demonstrate the specificity of single womens experiences of unplanned pregnancy and abortion, and how these are shaped by the social stigma of premarital sex for women. I explore how this stigma results in poor quality of care and increased risk of reproductive morbidity for unmarried women who have unequal access to abortion services,relative to married women. I also discuss how single womens choice to continue a premarital pregnancy is constrained by their lack of social autonomy and the absence of

acceptable alternatives. I draw particularly on one case-study which highlights the narrowness of state and cultural constructions of womens health in Indonesia. National health policy and programmes have conflated the concepts of womens health and reproductive health with maternal health. This can be partially understood as a response to Indonesias persistently high maternal mortality rate (MMR), approximately 425 maternal deaths per 100,000 live births, which compares unfavourably with other ASEAN nations. Regional differences within the country are also great, e.g. the province of Nusa Tenggara Barat, in which Lombok is situated, has an estimated MMR of 750. However, 37

Bennett

the response to this problem has resulted in the neglect of reproductive health concerns that are not perceived as maternal health issues. Moreover, access to maternal health services depends on a womans marital status. Although women who conceive out of wedlock can access maternal health services, it is at the risk of public condemnation. Neglect of single womens reproductive health problems is compounded by the fact that it is illegal to provide family planning services to unmarried women (Indonesian Population Law, 1992: Article 1O).2 This article draws on ethnographic fieldwork conducted with single women and their families, and health care providers in Mataram, the capital city of Lombok, between August 1996 and February 1998. The research focused on sexuality, reproductive health and social change and employed a variety of qualitative methods including participant observation, focus groups discussions, in-depth interviews, life histories and case-studies. The majority of women who acted as key informants were between 16 and 25 years of age and most were Moslem. These women were from different ethnic groups including Sasak, Javanese and Balinese, and were also from a variety of socioeconomic backgrounds, from lower to middle class. Thirty-five women participated in a series of in-depth interviews. Of these, 15 women shared their life-histories and agreed to provide additional information for case-studies. A total of eight focus groups were conducted, in which 58 women participated, and seven educational workshops on reproduction and sexuality were held with participants following the focus groups. Participant observation included both casual observations of women in their every day lives, and more formal observations of women attending health services. Eight abortion providers were interviewed, including four specialists and four GPs, of these four were female and four were male. A total of 18 local health providers were interviewed in the study; however, attitudes towards abortion discussed in this article are drawn only from interviews with abortion providers and reproductive specialists. Four older, married women who had experienced unwanted pregnancy and abortion were also interviewed about their experiences. Pseudonyms have been used throughout to protect the identities of those involved.
38

The ambiguous Indonesia

status of abortion

in

While induced abortion is widely and routinely performed throughout Indonesia, it is illegal unless the womans life is at risk.3 By law, abortion can be performed only by an obstetriciangynaecologist or another medical doctor with specialist training. Traditional birth attendants (TBAs), nurses, midwives and many general practitioners (GPs) provide abortions but lack adequate training, and the technical competence of many of these providers cannot be assured. In Mataram, anecdotal and ethnographic data indicate that induced abortion is not uncommon for either single or married women, although there are no quantitative data on prevalence, mortality and morbidity or the characteristics of women who seek abortion.4 In Mataram, as elsewhere in Indonesia, abortions are performed in private practices and family planning clinics, maternity hospitals and womens homes. Abortion methods used in Lombok include traditional and popular methods. Menstrual regulation with vacuum aspiration is now the main method of abortion in Indonesia, especially in urban areas, with fewer reported complications when compared with traditional/popular methods.5 TBAs tend to have close relationships with and obligations to young womens families. Hence, to ensure confidentiality, unmarried women most often present to medical professionals. The cost of menstrual regulation performed by GPs and midwives costs from 60,000 to 300,000 rupiah, 100,000 rupiah from private family planning clinics and around 300,000 rupiah from a specialist.6 Some providers include drug costs in this fee, while others require drugs to be purchased independently. According to providers, follow-up visits are free of charge, though women are rarely aware of this. The most reasonable specialist fee of 100,000 rupiah is beyond the independent financial resources of most single women. However, according to data from focus groups and interviews, financial responsibility for abortion tends to be met by a womans partner, even if he refuses any other form of responsibility. Young women in this study strongly felt that while abortion was a sin, it was also acceptable in certain circumstances. In the focus group discussions, they tended to focus on whether marriage was possible and the wishes of the

Reproductive Health Matters, Vol. 9, No. 17, May 2001

man involved. Many felt that abortion was preferable to continuing a pregnancy if he refused to take responsibility or rejected marriage as a solution. They often argued that causing personal and family shame, having a child out of wedlock and raising a fatherless child were greater sins than abortion. Many women expressed compassion for single friends and peers who had been dip&a aborsi (forced to have an abortion). All thought that the emotional and social consequences of abortion for unmarried women were serious and long-term. These views of abortion reflect a socially embedded morality in which understandings of abortion are compatible with wider social norms and values.7v8 For married women, the acceptability of menstrual regulation accords with the Islamic view that ensoulment takes place at 120 days of pregnancy5 and with state discourses that dictate womens obligation to practise family planning and raise a two-child family. For unmarried women, the immorality of abortion is equated with the immorality of premarital sex, premarital pregnancy and raising children outside wedlock.

abort it. So in one month I had two abortions. Linda: So, since you had the abortions have you been to that doctor again for a check-up? Ishma: No, never, because Im ashamed, here in Lombok things like this are not yet publicly accepted, and Im not married. Im ashamed; Im not brave enough to go there again. At that time my feelings, my thoughts, were regret. But whether I like it or not I have to accept it; its already my destiny.. .Maybe I can ask you something; I o#en have sex with my boyfriend. Sorry ya.. . Can I continue? Linda: Please, dont be embarrassed. Ishma: I have sex with my boyfriend. After we have sex, I often think I am menstruating, I often bleed. It happens before its time for my menstruation, but the blood only comes out after I have sex. I dont think this is normal. Around her 19th birthday, Ishma fell pregnant to Budi, her first boyfriend and sexual partner. When her period was two weeks overdue, she confided in him, hopeful he would suggest marriage. Budi accused her of infidelity and refused responsibility for the pregnancy. Ishma insisted upon her fidelity and pleaded with him to marry her, as he had promised when their relationship began. Budi claimed he was financially unprepared for a wedding and could not trust Ishma unless she proved her faithfulness to him by having an abortion. Ishma was frightened and confused. She desperately wanted to prove her love for Budi and salvage their relationship. She was also afraid she would not be able to find another spouse after having lost her virginity and becoming pregnant. Budi reinforced her insecurity by insisting that if she continued with the pregnancy, she would ruin their lives and shame both their families. He also said that if she continued with the pregnancy, he would publicly deny having had a sexual relationship with her, and she would have to bear the consequences of a damaged reputation and raise the child without his support. Ishma felt she had no choice but to abort her pregnancy. She tried drinking a drug she obtained from a chemist without prescription, twice in one week. She could not recall the name of the drug, but only that it carried the warning not to be taken if pregnant and had been recommended to her by an unmarried girlfriend who had successfully used it to induce an abortion.
39

Ishmas story
lshma is a young, single, Muslim woman who was 20 years old when I met her in 1996. She lived with her natal family and worked in paid employment in a local print shop. Her family was of medium to low socio-economic status and depended upon the income generated by both of Ishmas parents and several of the children, including Ishma. During an interview, I asked Ishma if she had ever experienced any reproductive health problems. She responded with an elaborate narrative of her experiences of premarital pregnancy and abortion: Ishma: I have some experience - ya, once I.. . Ill just be honest - ya, I had an abortion with Dr Anu. Since then Ive had keputihan (white discharge), before then I never had it like this.. . Maybe I have keputihan because I had two abortions in one month, ya? The first time I did it I felt I was already clean, but it turned out that my baby was still there, my babys soul was too strong. I was forced to abort again because I was scared my baby would be deformed because I had already attempted to

Bennett

A week later lshma had not experienced any bleeding and was certain that she was still pregnant. She decided to approach a local doctor known to perform abortions, Dr Arm, and made an appointment with him. Accompanied by her closest girlfriend Rapita, lshma saw Dr Arm around midnight, after his routine consultation hours. He examined her, requested a urine test, and confirmed that she was about six weeks pregnant. He then proceeded to lecture her on the immorality of her behaviour and warned her against having sex outside marriage. lshma felt extremely embarrassed and guilty, but was relieved when Dr Arm agreed to perform the abortion the following afternoon for a fee of 300,000 rupiah, payable on the day. He also gave her a prescription for a sedative, a painkiller and an antibiotic, which she had to buy. He did not offer her any information about contraception, the risks of unprotected sex or any information about abortion. His only advice was to refrain from premarital sex in the future. Early the following morning, lshma informed Budi of her appointment and the costs. Although he was outraged at the high fee, which represented two months wages for him, and despite lshmas obvious distress and reluctance to proceed with the abortion, Budi insisted she keep the appointment and borrowed the money from his elder brother. He refused to accompany her to the doctor to avoid public suspicion if they were seen at the maternity hospital together, but he promised to visit her at home that evening. lshma pretended to leave for work as usual; instead she went to Rapitas house where they waited for the appointment, so as not to be seen in public during work hours. lshma remembers crying all morning, hoping that Budi would come and stop her from having the abortion. lshma kept her appointment with Dr Anu. She was given three injections and remembered nothing of what happened after that. She awoke in the recovery room with Rapita at her side. They waited until lshma was due to return from work, and Rapita escorted her home. lshma told her mother that she had severe menstrual pain and went to bed. She took the next day off work with the same excuse. lshma felt confident that she had been able to hide her condition from her mother. In the days and weeks following the abortion, Budi failed to visit her. lshma was 40

overwhelmed with grief and sorrow; she was hardly able to eat and lost the desire to speak. Dr Anu had advised lshma that she would menstruate two to four weeks after the abortion. When this did not happen and she still felt nauseous, she suspected that she was still pregnant. One lunch hour, she went for a pregnancy test. The test was positive. She immediately contacted Dr Arm, who agreed to see her that evening and confirmed that she was still pregnant. Although he offered no explanation as to why the procedure had failed, he did agree to perform a second abortion immediately, at no cost. When lshma came to from the second abortion, she had severe abdominal pain and knew instantly that she was no longer pregnant. The following morning, when lshma told her mother she was taking the day off work again, her mother disclosed that lshmas cousin had seen her enter the pathology lab where she had had the pregnancy test. In her vulnerable emotional state, lshma broke down and confided in her mother, who comforted her and condemned Budis cruelty. She also instructed lshma never to speak of the experience again and to keep it a secret from the rest of the family, especially her father. She forbade lshma to see Budi again and warned that she would never be able to marry if she did not protect her reputation. lshma felt relieved that her mother had accepted her wrong-doing, yet she also felt more isolated knowing that she must grieve in solitude. lshma experienced post-operative bleeding for a week and a heavy period two weeks later. Dr Anu had asked her to return in a month for a check-up, but she did not attend due to her feelings of shame and fear of exposure. A year later, when I first met her, she had recurrent thrush and was experiencing severe dysmenorrhoea, which she was self-treating with antibiotics purchased over the counter - the same brand prescribed by Dr Anu for the abortion. She was also having unprotected sex with a new boyfriend, and suspected that she was infertile due to the two abortions and regular bleeding she experienced with intercourse. Despite her constant discomfort and my encouragement, Ishma could not be persuaded to see a doctor. The only advice she was willing to accept was to use an appropriate painkiller for dysmenorrhoea and to stop using antibiotics on a regular basis.

Reproductive

Health Matters, Vol. 9, No. 77, May 2001

The impact of premarital abortion

pregnancy

and

Ishmasstory provides critical insight into the experience, and the social and emotional consequencesof premarital pregnancy and abortion for young women in Mataram. Other young women who shared stories similar to Ishmas, during in-depth interviews and life histories, spoke at length of the grief, shame and guilt surrounding their experiences. They alsodescribed the fear of karma (divine retribution), of public exposure, loss of the companionship of girlfriends, emotional, verbal and physical abuse from partners and families, fear of abandonment by their boyfriends, the possibility of infertility, of raising a child alone and of compromised marriage prospects. The emotional and psychological impact of abortion for young women also manifests itself in low selfesteem, feelings of social isolation due to the need for secrecy and feelings of powerlessness. Furthermore, women who experience premarital abortion may be more likely to enter into or endure abusive and unrewarding relationships. One young woman who had terminated a premarital pregnancy explained: 1 deserve to be treated badly, no decent man would want me after what I have done. If my boyfriend hits me.. . so that I can see the bruises on my body, this is a sign of my shame. We both know it. lshmas experience illustrates the poor quality of care available to young, single women in Lombok. In this instance, and other cases collected in the course of fieldwork, no attempt was made to explain the abortion procedure, possiblecomplications and the importance of a follow-up appointment, nor to provide information about preventing pregnancy and using contraception. Provider/client communication was characterised by the doctors moralistic and judgemental attitude. The lecture to which lshma was subjected was commonplace, and no counselling support was made available, which might have assisted Ishma in dealing with her decision to have the abortion and the negative feelings she experienced as a result. Ishma considered it shametil that she had to have a vaginal examination to establish pregnancy, due to the violation of her personal modesty and because it emphasised her non-

virgin status. The social value of virginity remains a critical factor in single womens lack of access to reproductive health care in Indonesia, regardless of whether their status as virgins is being protected in a physical or social sense. The imperative of secrecy for single women meant that Ishma attempted an abortion without her familys knowledge and with very little information about appropriate care. The reproductive health of unmarried women who have abortions is further compromised by the difficulty of ensuring that follow-up appointments are kept. Women themselves are reluctant to attend, and providers are unable to contact them with reminders because of the need for secrecy. The technical competence of providers is also questionable, as implied by the failure of Ishmas first abortion, and my observations of other womens consultations with reproductive specialists. The chronic reproductive morbidity Ishma suffers from is also likely to be a wider problem that remains unrecognised because it is undiagnosed and untreated. The inflated fees, uncontrolled because abortion procedures are clandestine, also represent a significant barrier to young women trying to access safe abortion services. Several of the young women interviewed confided that they had delayed consulting a medically qualified provider when they suspected unwanted pregnancy, due to the cost.

Providers attitudes

towards

abortion

Interviews conducted with eight providers in Mataram indicated a remarkable consistency in their attitudes towards abortion. They expressed a degree of compassion for married women who requested an abortion, but not for single women. Abortion for married women was considered most justifiable if the woman had two or more children and the pregnancy was the result of contraceptive failure. Providers typically invoked the official ideal of the small and prosperous family and the notion that the first priority of good women was the welfare of their families. Married women with children who chose abortion were perceived by providers as putting their familys welfare first, by limiting family size in accordance with state directives.
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Bennett

In contrast, while they were willing to perform abortions for unmarried women, they frequently lectured them on the immorality of premarital sex and abortion. One provider stated that he believed that premarital pregnancy and abortion were karma for the sin of premarital sex. Doctors routinely warned single women not to engage in premarital sex in the future and that an abortion would not be performed a second time. Overwhelmingly, they thought single women who sought abortions were immoral or bad, reinforcing young womens feelings of shame, helplessness and guilt. Although all the providers agreed that reproductive health/sex education was the key to the prevention of premarital pregnancy and abortion, many refused to provide information about contraception to unmarried women, including those engaged in community-based reproductive health/sex education for youth. Their contradictory behaviour suggests a divergence between public and private moralities of many health professionals in Indonesia today.

What kind of choice is abortion women?

for single

Ishma explained that she felt she had no choice other than abortion. Other young women interviewed also repeatedly expressed feelings of powerlessness when sharing their experiences of abortion. If choice implies the existence of viable options, unmarried, sexually active women in Mataram did not perceive themselves to have a choice, either to protect themselves from pregnancy, to continue an unintended pregnancy or to have a safe abortion. Although Ishmas story may not be typical in terms of the severity of her reproductive morbidity after the abortion, her experience of pregnancy and abortion does reflect that of other single women living in Mataram. The social and cultural regulation of female sexuality is also remarkably consistent for young single women, who face similar constraints on personal autonomy and mobility as Ishma did, when negotiating their premarital relationships. As long as access to contraception for unmarried people is restricted by law, the most realistic option for sexually active single women and men is to use condoms. However, 42

young women will not purchase condoms due to their association with commercial sex and other deviant sexual behaviour. Single women are therefore dependent on their boyfriends to purchase condoms and to use them.g Many women find it difficult to negotiate condom use, given mens reluctance, and are often persuaded to have unprotected sex by the promise of marriage. Young womens knowledge of how pregnancy occurs is commonly inaccurate and incomplete, and so they take risks without fully understanding the consequences of pregnancy or infectionlO A young womans decision to continue a premarital pregnancy is highly contingent on her partners willingness to take responsibility. The young women I met who continued their unplanned pregnancies were all supported by their partners and were married before their children were born. The women in this study who terminated their pregnancies were asked or pressured to do so by their boyfriends and/or families. Forced marriage, social ridicule, compromised marriage prospects, abandonment by their partner, single motherhood, a stigmatised child, early cessation of education, and an interrupted income or career were clearly not desirable options. For single women who lacked the choice of marriage, only abortion allowed them to maintain their status as good women and to avoid compromising their futures.

Acknowledgements
Many thanks to the young women who participated in this research for their generosity in sharing their personal experiences of sexuality and reproduction. Thanks also to Andrea Whittaker, who provided intellectual inspiration through her work on abortion in Thailand, Lenore Manderson for helpful editorial comments and Christina Hall for assistance with formatting. An earlier version of this paper was presented at the Asian Studies of Australia Association conference, Melbourne, 4-7 July 2000.

Correspondence
Linda Rae Bennett, Key Centre for Womens Health in Society, School of Population Health, University of Melbourne, Victoria 3010, Australia. Fax: 61-3-9347-9824. Email: lindab@unimelb.edu.au

Reproductive Health Matters, Vol. 9, No. 17, May 2001

References and Notes

I. World Bank, 2001. Reproductive HealthTable 2.16 accessed at: http://www.worldbank.org/data/ wdi2OOO/pdfs/tab2~16.pdf 2. Situmorang A, 1999. Family planning for Indonesian unmarried youth: views from Medan, North Sumatra. DevelopmentBulletin. 47:33-35. 3. 1992 Health Law (Section 2, Articlesl5 and 80). For an extensive discussionof the ambiguity of Indonesian abortion legislation, seeHull T et al, 1993. Induced abortion in Indonesia. Studies in Family Planning. 4:241-51. 4. This lack of information also existsat national level. There have been some attemptsto estimate the prevalence of abortion indirectly by calculating the number of abortion providers nationally, but these estimates are not reliable. See Hull et al, 1993 [3 above] for a discussion of various estimates of prevalence made in the early 1990s. 5. Djohan E, lndrawasih R, Adenan M et al, 1993. The attitude of health providers towards abortion in Indonesia. Reproductive Health Matters. 1(2):32-40. 6. At the time this research was conducted (1996-98) 6,000 rupiah was approximately one Australian dollar, and the average monthly wage in Mataram was around 150,000 mpiah. 7. Georges E, 1996. Abortion policy and practice in Greece. Social Science and Medicine. 42(4): 509-

20. 8. Whittaker A, 2000. Intimate Thailand. Allen 8 Unwin, St Leonards. 9. Bennett LR, 1997. A preliminary analysis of reproductive health among young women in Mataram, Lombok. Paper presented at Seminar lntemasional: Bahasa dan Budaya di Dunia Melayu, 2 l23 July. University of Mataram, Mataram. 10. Widyantoro N, 1989. Complete reproductive health care. People. 16(4):21-23.
Knowledge: Women Health in North-East and Their

R&urn4
Lavortement provoque est frequent en Indonesie chez les femmes mariees et celibataires. Cet articlesinspire dune etude de cas portant sur la grossesseet lavortement dune jeune femme celibataire,time dune recherche ethnographique meneeentre 1996 et 1998 sur lile de Lombok en lndonesie orientale. Si lavortement est accept6 pour les femmes mariees, conformement a la politique officielle de planification famihale, particulierement pour les meres de plus de deux enfants ayant connu un echec contraceptif, la grossesse et lavortement avant le mariage isolent les femmes et les stigmatisent. Les services de planification familiale ne sont pas autorises a foumir une contraception aux femmes celibataires et leur acces aux soins de Sante genesique est tres limit& Les praticiens jugeaient durement les femmes celibataires demandant un avortement, tout en Ptant prets a le pratiquer, souvent au prix fort. Pour continuer une grossesse premaritale, les jeunes femmes devaient se marier, sous peine de sexposer aux railleriesde la societe, de voir echouer leurs projets matrimoniaux, detre abandonnees par leurs fiances, delever seules un enfant mis a lindex, dabandonner leurs etudes, et dinterrompre leur car&e ou leur revenu. Les femmes celibataires pour lesquelles le mariage etait impossible navaient dautre choix que lavortement pour eviter de compromettre leur avenir.

1 Resumen
El abort0 inducido es practicado ampliamente en Indonesia entre mujeres casadas y solteras. El presente trabajo esta basado en un estudio de case de embarazo y abort0 de una soltera joven, tornado de una investigation etnografica realizada entre 1996 y 1998 en la isla de Lombok en Indonesia Oriental. El abort0 es aceptado para las mujeres casadas, en concordancia con la politica de planificacion familiar estatal, especialmente en cases de mujeres con mas de dos hijos que han experimentado una falla anticonceptiva. Sin embargo, el embarazo y el abort0 extraconyugales estan cargados de estigma y aislamiento para las mujeres jovenes. No se permiten a 10s servicios de planificacion familiar proveer anticonceptivos a las solteras jovenes, cuyo acceso a atencion de salud reproductiva es muy limitado. Los proveedores de abort0 criticaban fuertemente a las solteras que buscaban abortar, aun cuando estaban dispuestos a practicarlo por un precio muy alto. La unica forma de continuar con un embarazo extraconyugal era a travts de1 matrimonio. De otra manera, las jovenes debian enfrentar la burla social y el abandon0 de sus novios, comprometian la posibilidad de matrimonio y se arriesgaban a convert&e en madres solteras y a tener un vastago estigmatizado. Debian abandonar 10s estudios e interrumpir 10s ingresos 0 sus carreras. Para las solteras sin posibilidad de casarse, el abort0 era la unica option que no comprometia sus futuros.
43