‘Morality above the law’: Thailand’s abortion rights falter despite legal victory

By Teeranai Charuvastra

Photography by Luke Duggleby

Inside the operating room of Vorrachat Clinic in Phimai, Nakhon Ratchasima. Photo: Luke Duggleby/HaRDstories

5 April 2023

Months after abortion is decriminalised in Thailand, women’s rights advocates and sympathetic doctors are still struggling to ensure a truly affordable, safe and convenient access to the service, in the face of push backs from the very heart of the healthcare system.

At a rural clinic in Nakhon Ratchasima’s Phimai district, about 320 kilometres away from Bangkok, a gynaecologist is waging a personal campaign to save women’s lives.

Vorachart Meevasana, M.D., is one of the country’s few doctors willing to perform safe abortions for women who have been turned down by other physicians and hospitals, and who might have otherwise sought out a more dangerous solution: attempting to terminate their pregnancies by themselves.

He and his like-minded colleagues are part of the Referral for Safe Abortion (RSA) network, a coalition working closely with other volunteer groups that assist those with unplanned pregnancies. Their mission is simple: to ensure that women have access to safe and legal abortion services in Thailand, where many medical professionals refuse to provide the procedure on religious grounds.

“It’s very hard to find doctors who perform abortions,” Vorachart, who runs his own clinic and also works at a nearby hospital, said in a phone interview. “Apart from RSA, you wouldn’t be able to find anybody else.”

In February 2020, Thailand made headlines when its high court struck down a ban on abortion as unconstitutional, leading to the decriminalisation of abortion up to 12 weeks a year later. The amendment was expanded to 20 weeks in September 2022, signalling progress in reproductive rights. But abortion rights watchdogs told HaRDstories that little tangible progress has been made since.

They point to a variety of reasons, including bureaucratic inertia, a lack of political will, and perhaps most importantly, widespread objections from members of the medical profession who view abortion as a violation of Buddhist beliefs.

“The law says you can do it, but it doesn’t force you to do it either,” Vorachart said. His clinic embodies this issue – he must carry out abortions at his private practice due to the hospital’s refusal to permit the operation within its facilities.

In a country where up to 95 percent of the population identifies as Buddhist, the religion’s influence in Thai society is undeniable. Even advocates for reproductive rights have found themselves invoking Buddhist language to gain support for their cause. In February, members of the activist group TamTang performed a religious ceremony in honour of the victims of unsafe abortions in front of the health ministry, using symbolism to demand greater access to legal and safe abortions.

Law vs. reality

Under the current law, women can seek an abortion up to 12 weeks into their pregnancy without stating a reason, although girls under 15 years of age must present proof of parental consent. Following the amendment in September, termination of pregnancies between 12 and 20 weeks is also permitted, provided the woman first engages in a consultation with medical professionals.

The relatively open clause is regarded by many as a solution for women who seek abortion for their unplanned pregnancy, especially teenagers – a problem that Thai authorities have been struggling to address in recent years. The procedure is also subsidised at public hospitals by the national healthcare fund.

There is no legal restriction on late-term abortions on various grounds like mental or physical harm to the woman, sexual assaults, and potential birth defects, but the decision rests with the doctors.

Although the law does not mandate doctors to perform abortions upon request, the Medical Council of Thailand has issued a directive stating that physicians who decline to provide the service should refer the cases to those who can “without delays.”

But in reality, only a small number of doctors and hospitals follow that rule, said Sulaiporn Chonwilai, an activist from TamTang, which monitors access to abortion nationwide.

“If they don’t want to do it, then they’re supposed to find someone who can,” Sulaiporn said in exasperation. “But instead they’re giving the women nothing. For them, morality is above the law.”

Krittaya Atchawanitchakun, who leads Choices Network Thailand, a support group for unplanned pregnancies, shares a similar viewpoint: “The problem lies in the lack of a reliable referral system. While there is a referral system in place, it is very limited in scope.”

This limited referral system results in women seeking abortions being turned away from public hospitals on baseless grounds and sometimes even being shamed by hospital staff, Krittaya said. Those who still wish to terminate their pregnancy have few options: they must either pay up thousands of baht to private hospitals and clinics – a considerable amount for Thai salaries – or travel far from their homes to find a physician who is willing to provide the service.

According to Sulaiporn and other advocates, the lack of abortion availability puts women at greater risk. As the pregnancy continues, the abortion procedure becomes more complicated, which increases the likelihood of health complications. Additionally, women would have to bear the emotional and financial costs associated with the procedure.

“It reflects that even though we now have the law, it doesn’t solve the problems. It’s almost pointless,” Sulaiporn said. “They say we have rights, but there’s no way we can exercise those rights.”

Making their own rules

Khiri was a recent graduate who had just started her first job when she discovered that she was pregnant – just a few months before Thailand legalised abortion in early 2021.

Her experience was representative of what many women went through in the pre-decriminalization era. She called 1663, a hotline run by volunteers for unplanned pregnancies, where she was given the code name Khiri (“mountain”) and referred to the nearest provider in the RSA network. The clinic was located in Singburi, as no other public hospital in the capital was willing to take her case.

Once she arrived at the clinic, she was able to obtain the service by using a well-known loophole that permitted abortion when a woman’s “mental wellbeing” was at risk. To finally receive the abortion pills, Khiri was encouraged to identify herself as suffering from depression.

The ordeal inspired Khiri to later volunteer with TamTang and campaign for better access to abortions. Reflecting on her past and the current situation, Khiri said she’s struck by how little progress has been made after the law was changed beyond a symbolic affirmation of women’s autonomy over their own bodies.

“The law got better, but it hasn’t yet translated into actions,” she said.

According to assessments by TamTang and other abortion support groups, the service is still out of reach for many women, especially those from poorer backgrounds who depend on the universal healthcare system.

Abortion costs are covered by the National Health Security Office at public hospitals that provide the service, while the fees at private hospitals and clinics generally start at 3,000 – 4,000 baht (86 – 115 USD), and it is not unknown for some late term abortion to cost up to 20,000 baht, according to TamTang.

As of the latest available figures released by the government, hospitals in only 39 out of 77 provinces are registered as abortion providers – and even fewer actually offer the service. For instance, some have registered, but have since changed their policies due to a lack of willing physicians. Vorachart recalled abortion seekers coming to his clinic from as far afield as Songkhla province.

The situation is dire even in the capital, activists like Krittaya and Sulaiporn say. None of the hospitals governed by the Bangkok Metropolitan Administration provide abortions, and while some public hospitals do offer the service, inquiries made by HaRDstories discovered that they tend to set up their own criteria that filter out many women, contrary to the law’s wording.

To test how ordinary members of the public would fare when requesting abortions, a reporter for HaRDstories made phone calls to a number of public hospitals in Bangkok asking for an abortion on behalf of a woman with a 10-week unplanned pregnancy – well within the legal boundary.

But nurses and staffers at hospitals contacted by HaRDstories either said that unplanned pregnancies are not eligible for abortions, or that they’d only be willing to perform abortions in cases that involve sexual assault or deformities.

“If it’s an unplanned pregnancy, we don’t accept it. We don’t accept this category,” a nurse at a hospital on Ratchawithi Road said by phone. “It’s up to the hospital to set the conditions.”

Only one hospital, located in the Thonburi side, made the slightest effort of referring a reporter to another abortion provider after declining the service, while the rejection at a certain hospital in the northern suburbs is also the most telling. “The doctors here won’t accept it, and so we can’t accept the case either,” a nurse there said, her tone final.

First, Do No Harm?

Despite the changes in the law and the attitude of wider society, many physicians remain convinced that abortion amounts to committing sin or murder, and therefore an affront to the medical profession’s commitment to saving lives, said Vorachart, the RSA doctor. The belief is especially prevalent among the senior doctors in positions responsible for shaping policies and practices.

“Doctors have their convictions, too. If they think something is wrong, they won’t do it,” Vorachart explained. “They were taught that abortion is wrong. They were taught that it’s about morality.”

He also lamented that many of his peers seem to operate on the ” mindset – turning down abortion requests, telling the women to find some other doctor, and consider their work done.

“Sure, there’s a clause that if doctors won’t do it, they must ‘refer the cases without delay,’ but refer them to where? There’s no place the patients can go!” Vorachart said.

Krittaya from Choices Network Thailand said doctors play a significant role in abortion access because if the resident physicians refuse to perform it, there’s nothing the hospital administration can do.

She recalled a case at a certain public hospital where abortion was not possible because it lacked a gynaecologist, so hospital staff had to refer abortion requests to other facilities. Once a gynaecologist was dispatched there, the staff rejoiced, thinking that abortion would now be available. They were mistaken. The new doctor made his objection to abortion known to all, and banned the staff from even referring cases to other hospitals.

“People working in the healthcare system don’t like to challenge doctors,” Krittaya said. She added that the culture of shrugging responsibilities also led to smaller hospitals having to bear the costs of abortion because larger ones refuse to perform the procedure.

But antagonism toward abortion may also stem from nursing staff. In fact, Dr. Vorachart’s need to perform abortions at his clinic arises from the refusal of the hospital staff to participate in the procedure in any capacity.

“They wouldn’t even touch the IV syringe,” Vorachart said. “They wanted nothing to do with abortion.”

More troubling, perhaps, is the impact on the patients. Natakamon Siwasilp, a legal officer at TamTang, has been tracking abortion access since April 2021. Based on testimonies from about 60 women, Natakamon said many women seeking or inquiring about abortion at public hospitals often had to go through humiliating procedures.

“The nurses would talk to them in an embarrassing way, or call their names loudly in the hallway as women who want abortion. They don’t respect the privacy of people who sought the service” Natakamorn said. “We can only guess what they were trying to achieve. But I think it was meant to turn them away in shame.”

‘Even a person like me can change’

Advocates interviewed for this story urge the government and the leadership of the healthcare authorities to take a more proactive approach to abortion rights, beyond writing the law without enforcing it.

They suggest including abortion access as part of hospital accreditation requirements to build incentives, ensuring that at least one state-funded abortion provider exists in every province, and instructing hospitals to implement an effective referral system that helps connect women with the service providers, instead of obfuscating them.

“Abortion has to be truly accessible. Otherwise, only people with money would have access to abortion,” Sulaiporn of TamTang said. “It has to be available, and free.”

Other solutions include training hospital staff and new generations of doctors to keep up with the recent changes in the law and respect women’s rights to choose for themselves.

“When contraceptive pills were first available, people said it would make women promiscuous,” Dr. Vorachart said. “Society later changed its views on the pills. And I hope one day it’ll change its mind about abortions, too. It just takes time.”

The gynaecologist said he understood firsthand the power of conversations to change one’s mind because it worked on him, too.

“I used to oppose abortion as well. Back then, abortion had to be done through dilation and curettage, it was really painful to the uterus, and I took delight in knowing that. I was thinking, these women deserved it for killing their babies. But even a person like me could change,” he recalled.

“I learned that people have their own reasons … and what right do I have to judge them? So I told myself I’d live by a simple rule: if women want to continue their pregnancy, the childbirth must have quality care. If they want to end it, it must be safe. Simple as that.”

Teeranai Charuvastra is a feature writer at Prachatai English, where he covers politics, freedom of expression, and human rights. He also serves in the Thai Journalists Association as its vice president for Press Freedom and Media Reform.

Luke Duggleby is a Bangkok based documentary photographer. He regularly works on stories related to social issues, the environment and the impact of pollution and development on local communities.