The Long Road to Reproductive Justice

In North Macedonia, abortion law changes when the government does. The practices of the past years vividly demonstrate that abortion is not only a private matter but also a political issue. Depending on whether right or left-wing parties are in power, the law on abortion fluctuates between difficult-to-access and more liberal procedures.

The newly adopted law in 2013 made the procedure harder by requiring a mandatory written request from women, consultative sessions about the advantages of pregnancy, a three-day waiting period, and fines imposed on medical professionals who violated the law’s mandatory steps.

The shift in the political environment in 2017 led to yet another reform in 2019. The 2019 Law on Abortion (Termination of Pregnancy) introduced a number of changes, including the elimination of the requirement for women to go through an approval process in front of the hospital commission, a shift in the legal gestational limit up to the 12^th week, and the introduction of medical abortion, i.e. usage of abortion pills to end a pregnancy.

Yet, at the cultural level, the dominant traditional mentality still stigmatizes women and girls who perform the procedure. Likewise, access, availability, and affordability of reproductive health care services remain problematic, as different categories of women face multiple barriers and there are large disparities in the utilization of reproductive health care services. Contraception needs have not been met, reproductive health care services are unevenly distributed across the country, and sex education is met with resistance from a significant percentage of the population.

How to explain the 2013 Backslide

The step back to a more restrictive regulation of abortion did not come around unannounced: In 2008-2009, posters depicting abortion as murder were displayed in the Macedonian capital Skopje. Simultaneously, a website with the slogan “No to abortion” gained popularity. Parallel to these developments, the actual Christian Democratic government raised the cost of abortion in state-run gynecological clinics and launched a campaign which offered financial incentives to anyone deciding to have a third child. According to the IPPF European Network, the then Government invested millions in an anti-abortion campaign. “Abortion is murder” slogans were not only seen on posters in public places, but also on television in the form of a morbid spot broadcast on national television. The spot was subsequently withdrawn from television programming that aired before midnight and shown in a slightly edited form after midnight when audience ratings were not too high. All of this foreshadowed the new abortion law passed in 2013.

The Law of 2013 was passed after a short procedure without significant public debates and/or consultations with civil society, particularly with women’s rights NGOs. The newly adopted law complicated the procedure by introducing a number of mandatory requirements, including a mandatory written abortion request, a waiting period of three working days before the intervention is performed and approval of the procedure by a hospital commission. The legal gestational limit for having an abortion was shifted back from 12 to 10 weeks. Of particular concern was the reintroduction of the abortion approval procedure, which was abolished in 1969, and meant a serious reversal. Provisions in the newly passed law included fines for medical professionals and abortion service providers who violated the law.

Before the law was passed, many doctors felt that these procedures would traumatize women and complicate the process. Support groups, organizations, and individuals who advocate for choice considered the law to undermine the reproductive freedom of women and promote misleading information in relation to the services provided. The protests in front of the Parliament organized by NGOs and supported by medical professionals, opposition parties, feminists and civic activists demanded that the law be lifted and subject to a broad consultation process. However, the then Government adopted the Law by way of an abridged parliamentary procedure with only one pro-forma public hearing. It was clear that the then Health Minister and the Parliamentary Health Committee had no intention to take into account the NGO’s suggestions and objections. At the same time, NGOs and informal groups and organizations on women’s issues have united on a single platform titled Matka (Uterus) to raise awareness for the impact of the Law. The Declaration for support of abortion rights was signed by 41 NGOs. The struggle over the law continued until the President of the country approved the law. In a final meeting, groups opposing the law tried to persuade the President not to sign the law but were unsuccessful. After the law was signed by the President, the last democratic step left for NGOs to alter the law was to turn to the Constitutional Court. However, this initiative was not successful because, with the exception of one judge, all of the judges thought the law was unproblematic and rejected the initiative.

From transgression to liberalization of women’s sexual and reproductive rights

In 2017, the Social Democrats won the general election. After several consultations with representatives of civil society organizations supporting free abortion the new Minister of Health began the process of changing the law. In addition, the recommendations of the Human Rights Committee, the UN Committee on Cultural and Social Rights, and recommendations of international organizations and the World Health Organization were taken into account. A new law was passed in 2019.

A number of changes have been introduced, including the abolition of forced and biased consultations and a three-day waiting period after consultations. The legal gestational limit was shifted yet again – from 10 to 12 weeks. In case of rape, incest, fetal malformation or for socio-economic reasons, accessing abortion was extended up to the 22^nd gestational week. The termination of the pregnancy between the 12^th and  22^nd gestational week can be undertaken upon written request of the pregnant woman or the parent as guardian if the woman is a minor or deprived of business capacity. The fines for the medical professionals/doctors were removed, thus restoring their professional reputation. For the first time ever, the Law introduced medical abortion, i.e. usage of abortion pills as a non-invasive method along with the surgical one. With the adoption of the 2019 Law, women’s NGOs considered that women are provided with complete, objective and accurate information regarding the method of performing an intervention. At the same time, administrative barriers were removed and women were again allowed to make a decision. Pro-Choice activists said the new law of 2019 puts women first and doesn’t affect women willing to give birth.

The 2019 Law in Action: We need to talk about Reproductive Justice

“With the new law, abortion is available to everyone, but not to Roma women,” stated representatives of a Roma women’s organization in Skopje. Although the 2019 Law included the requested changes by NGOs and women’s activists, abortion is not covered by health insurance if it is a question of choice. The health insurance only covers abortion services if the health is jeopardized during the pregnancy. Roma women who are at social risk and live in extreme poverty cannot have an abortion because of the high costs of the procedure. Prices range from 6000-9000 MK denars, i.e. 100-150 euros. Many Roma women who are at social risk, unemployed, and already have children, are forced to perform illegal abortion in private gynaecological clinics, where the procedure is less expensive but not as safe as in state hospitals. The program for active health care of mothers and children also does not offer financial compensation for abortion costs. In the country it is well known that vulnerable groups of women are exposed to the risk of unsafe abortion in some private gynecological clinics where the service is offered by lower prices. Everyone knows, but no one is doing anything to guarantee real reproductive justice.

Medical abortion is still far away from being available countrywide and to all groups of people. There are a few attempts to reduce access problems: Through a donation of the IPPF a room to inform and advise women about medical abortion has been set up at the University Clinic for Gynecology and Obstetrics. In addition, within the framework of the Preventive Program for the Health of Mothers and Children for 2021, the Ministry provided a certain budget for the purchase of drugs for medical abortion for the Clinic. However, this service is only available at the Clinic for Gynecology and Obstetrics in the capital and there is still a lack of drugs on the market. Likewise, sufficiently trained medical staff is lacking, posing another challenge for the country-wide availability of medical abortion.

In addition, reproductive health care services and gynecological ambulances are unevenly distributed among the country. Rural municipalities lack doctors, particularly gynecologists. Therefore, women in rural areas who want to have an abortion or undergo a gynecological examination have to travel dozens or even hundreds of kilometers.

Comprehensive sex education and contraception

Sex education and contraception could be one preventive way to address the issue. However, sex education is still frowned upon in the country, with only 13% of students learning about condoms and barely 2% learning about oral contraception. Since 2009, many NGОs have advocated for comprehensive sexual education. The so-called Framework for Comprehensive Sexual Education was adopted in 2011, proposing principles and providing guideline for the implementation of a comprehensive sexual education curriculum program. The Framework was followed by a request in the form of a written Declaration signed by 47 civil society organizations emphasizing the need and importance of introducing sexual education in accordance with the Framework’s principles.

During the 2016 pre-election campaign, ten political parties pledged to support the issue in formal education. At the end of 2019, four primary schools in the ninth grade began with comprehensive sexual education as an optional subject.

However, this was met with strong opposition from some civic organizations opposing educational reforms. Attacks on social media and even physical attacks have been reported against NGO activists –advocates for formal comprehensive sexual education. According to the research only 14% of women in relationships or married in the country use contraception. Since 2017, the Government of the Republic of North Macedonia has promised to add at least one modern contraceptive under the burden of the state health insurance but its implementation has not yet taken place. Only a very small number of women from socially vulnerable and marginalized groups has been provided with oral contraception, spirals etc. As an example, while 150 women have received free contraception in 2018, this number was reduced to 50 in 2021. The lack of sexual education in schools has led to high underage pregnancy rates, with 790 women between the ages of 15 and 19 pregnant in 2022, including 20 women under the age of 15, which is a high rate for a country with nearly 2.000,000 inhabitants.

Reproductive justice for all human beings

Clearly, abortion is a very sensitive issue for a large portion of the population.

However, it is not as simple as “pro-life” versus “pro-choice.” Beyond reproductive rights, a holistic approach is required to discuss reproductive justice. Reproductive justice is about people having control over their own bodies, making the decision to have children or not, choosing when and how to have children, and having access to healthy and safe services. Everyone should be able to make their own decisions. If abortion is prohibited, it does not mean that it will cease to exist. On the contrary the practice shows it will increase and become more unsafe. Comprehensive sex education is one way to reduce abortion rates among minors. The access to abortion services should be available to everyone, to people from marginalized groups, to people from rural areas and to people of all ethnic communities.