‘Someone you love has had an abortion’ | Natalie Psaila

Despite being targeted by intense hate-speech (including death-threats), Dr NATALIE PSAILA, of the NGO ‘Doctors For Choice’, argues that people are increasingly beginning to realise that abortion is much more of a ‘social’ and ‘medical’ issue, than a ‘moral’ one

Natalie Psaila
Natalie Psaila

There seems to be a contradiction in the local abortion debate. On the political level, the issue itself is clearly no longer such a ‘red line’ (as evidenced also during the last election campaign). And yet, pro-choice activists continue to receive death threats – in your own case, even targeting your children - suggesting that the situation may actually have worsened, at street-level. How do you feel about this?  Would you agree, for starters, that the political landscape has in fact shifted, since your organization was formed?

In general, yes… but only up to a point. First of all, I do think things are moving forward, on the whole. Since 2019, when Doctors For Choice was launched – together with other NGOs – there has definitely been a change in the way we discuss the issue, on a national level.

Abortion today has become a much more ‘accepted’, as a mainstream topic for political debate. It is clearly no longer the taboo it used to be, just a few years ago. So on that level, at least, we have taken a step in the right direction.

At the same time, however, what Doctors For Choice also argue, is that we [Malta] follow all the international healthcare guidelines, when it comes to every other medical issue… except this one. Diabetes; high blood pressure; cancer treatment; whatever the condition, there are clear international guidelines for how to actually proceed, from a medical point of view.

Yet when it comes to reproductive healthcare… we are not following the same international medical guidelines. In fact, doctors are even told that we cannot follow them: because the law is so strict, that abortion is not allowed even when there is a risk to the mother’s life…

And this also means that we are simply not reaching the accepted international standards, when it comes to reproductive healthcare.

So to come back to your original question: the situation has certainly improved, in terms of how the issue is discussed locally; but in terms of legislation, and accepted medical procedures in hospitals… things haven’t changed at all.

One thing that certainly has changed, though, is (ironically) the number of women seeking abortions in Malta. Recent statistics suggest it may be well over 500 a year: and that only includes abortions in hospitals which publish that sort of data. Meanwhile, Doctors For Choice has been collecting testimonials from quite a few women, who are now clearly willing to go public with their own experiences. Doesn’t this suggest that abortion – legal, or illegal – is already ‘accessible’ in Malta?

Yes, but not to everyone; and not legally, either… which also means, ‘not up to the standards required by international medical procedures’.

And, this only makes the situation worse; not better. Because it’s not just about whether abortion is ‘available in Malta’, or not. As you yourself said… it is. The reality is that people ARE accessing abortion: so long as they have the financial means to do so; if they can afford to travel; or if they have support at home, and so on.

But women whose circumstances, for whatever reason, are different – someone in an abusive relationship, for instance; or who can’t afford to buy pills online; or who just left it too late, because she was surrounded by judgmental people, who made it impossible for her to even think of seeking help… those are the women who are affected by Malta’s total ban on abortion: not the ones who can easily afford to catch a plane.

So there is also a social justice dimension to this issue. It’s ultimately about inequality: some women can access abortion; while others - very simply - can’t. And this is, in fact, why we are arguing that abortion should be made safely accessible, to everyone equally…

Do you think this ‘inequality’ factor might also be the driving force behind changing public attitudes? In other words: that – as was the case with the divorce referendum (albeit on a much smaller scale) – the social problems associated with Malta’s total abortion ban, are now becoming too conspicuous to ignore?

I don’t really think that’s the way most people are looking at it, no. I think that what’s really striking them – and what really made a difference, in the way we talk about abortion here – is… women’s stories.

When people started realising what women are actually being made to go through in Malta, because of the legal status of abortion - and even then, only because some women started speaking out openly on the subject, for the first time -  that, I think, is what really struck a chord with people.

To give you a personal example: an elderly relative of mine recently told me: “I’m against abortion, BUT… I can understand it, in the case of rape, or when the mother’s life is in danger”.  To me, that was an indication of just how much attitudes have changed: because even if a 75-year-old can now see that reality – where, in past generations, it would have been completely unthinkable -  I think it says something, about how far we have come.

But another thing people are also now realizing – even just from those statistics you quoted; and there are other indications - is that they themselves might actually know a lot more women who’ve had abortions, than they ever thought they did.

They might still not know who some of those women ARE – because, despite all the recent changes, there are still those who feel pressured to keep silent: either by their families, or social circles; or by the possible repercussions of ‘speaking out’ on their jobs, or careers…

… and it’s a shame, really: because it also means that those people don’t trust others – not even their own family – to be open about it…

But what has also become clear, from the experiences of those women who did speak out, is that more people today are aware of the realities involved. They know, for instance, that the number of women seeking abortions is much higher than they previously thought; that it will include at least some people they know, and love, themselves – in fact, this is why we use the slogan, “Someone you love has had an abortion”.

And I think (or at least, hope) that more and more of them are realizing that this is a situation that needs to be changed.   

On the subject of ‘women’s stories’: so far, the pro-choice argument has been mostly limited to legalizing abortion in certain very specific circumstances (e.g., risk to the mother’s life). But we also hear of cases where the mother’s life would not be in any imminent danger; yet she might end up being denied treatment, on the basis of how the unborn child is affected. As a practitioner, do you encounter such complications yourself?

Yes; and again, much more frequently than most people probably imagine. The most drastic cases, of course, are the ones where the mother’s life is actually threatened - where she really could die – but that’s not the only medical indication that exists.

There are some conditions where the mother would not be in any direct danger of dying; but which could still have severe, long-term effects on her health. For example: a pregnant woman, who suffers from certain heart conditions, would be at a much higher risk of heart failure, than before she got pregnant.  And it’s a risk that she will then have to carry for the rest of her life.

Another example would be when children get pregnant.  Young girls cannot be expected to give birth. It is too stressful on their health; and even the baby itself – if it is born – will have a much higher chance of developing serious health conditions. It is, in a nutshell, far too dangerous to allow a young girl to carry a pregnancy to full-term. Yet legally speaking, that is precisely what the law expects them to do.

Then, there’s the issue of ‘fatal foetal anomalies’. There are cases where women are told they have to go through with their pregnancy: even when they know from beforehand that the baby will die just a few hours after birth; or where the foetus would die, only a few weeks into the pregnancy…

And those are just a few examples. There are many more…

And yet, you also get other doctors (for instance, your counterparts: ‘Doctors For Life’) who argue that all these cases ARE, in fact, regulated by standard medical procedure. For instance, the ‘double-effect’ principle: whereby abortion is permissible, if the primary intention is to save the mother’s life. How do you respond to that?

The problem with the double-effect doctrine is that: it’s a religious principle - or a ‘moral’, or ‘philosophical’ principle; call it what you will - but it is not a legal principle. It’s not mentioned anywhere in the law; and not in the medical guidelines in hospitals, either.

There is, in fact, nothing in the guidelines that we use, that specifies at which precise point it suddenly becomes permissible – according to the double-effect principle – to terminate a pregnancy, in order to save the mother’s life.  We have very detailed guidelines on all other medical procedures… but not this one. It just doesn’t exist.

So in practical terms, doctors still face the same dilemma. How long do you have to wait, exactly, before the mother is in such danger of losing her life, that intervention becomes necessary? And what if, by that time, it is too late?

That’s where the problem really lies. And it has to be addressed at the political level: because that is the only level at which the law can be changed…

That doesn’t look very likely, though: when Prime Ministers like Robert Abela (and all his predecessors, from both parties) keep saying things like: ‘abortion is a red line that cannot be crossed’. What options does that even leave you with, as an NGO campaigning for legislative change?

Well, it does make you feel a little disheartened, obviously. But even here, the situation has at least improved a little. In the past, we used to have ministers like Tonio Fenech saying that we shouldn’t be allowed to even discuss abortion at all!

But, then as now, we ignore these things. Because – regardless of what politicians might say – the debate IS happening; we are promoting the discussion; and we are more interested in bringing women’s stories to light, and revealing what they are actually going through…

At the risk of a devil’s advocate question: the changes you are proposing are not entirely clear, though. Initially, the Women’s Rights Organisation requested ‘safe access to abortion’ only in four specific circumstances: risk to mother’s life; rape; incest; and fatal foetal anomalies. But now, the discussion seems to have broadened to ‘abortion on demand’, in all circumstances. What do you really want, at the end of the day? An abortion law that is tailored to our specific circumstances? Or a recognition of abortion, as a ‘fundamental right’?

All I can say to that is: we are not going to be the ones to put any ‘limits’, on how abortion is accessed in this country. We’re not going to do that, ourselves. But it is something that policy-makers can do; and it’s what all other countries which have legalized abortion, have already done in the past.

If you look at legislation in the rest of Europe, for instance: each country has set its own limits and specific regulations, however they saw fit. In Italy, for instance, abortion is legal only up to a minimum of 10 or 12 weeks. In the UK, on the other hand, it goes up to 24 weeks… and even to late-term pregnancy, in cases of risk-to-life. And in Poland, abortion is only legally permitted, in cases of rape, incest, and so on.

So it ultimately depends on what the policy-makers decide; and which model they choose to look at.

As for myself, however: I think that – at the very minimum – abortion should be made safely available here, at least for healthcare reasons. At the very minimum…