Legal Status of Abortions in Singapore
Abortion is legal in Singapore under certain conditions. Existing legislation provides a framework within which the circumstances under which abortions are permitted, factors taken into account and administrative requirements to be adhered to.
Abortion is presently regulated under the Abortion Act (Cap 4) (the "Act"). The Act empowers doctors registered with the General Medical Council by virtue of having undergone medical training and practicing in selected hospitals in Singapore (designated hospitals) to lawfully perform abortions on women during the first trimester of their pregnancy. In addition, approved doctors may perform abortions on women beyond the first trimester of pregnancy if there are specific statutory grounds for doing so. The doctor is required to consider such circumstances when he decides whether to proceed with the abortion.
The statutory grounds include a medical opinion that the abortion is necessary to save the life of the pregnant woman; the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; the pregnancy is a result of rape , incest or other unlawful carnal intercourse (as set out in the Penal Code) and the continuation of the pregnancy would cause physical or mental injury to the pregnant woman.
If the statutory requirements are not satisfied, a woman who has undergone an illegal abortion would be removed from the government’s subsidised healthcare entitlement-list and private clinics would be allowed to carry out abortions.
An abortion must be performed within a time limit of 24 weeks from the first day of the last period, subject to the statutory grounds. Abortions should not be performed after 24 weeks unless there are compelling medical reasons.
The legislation provides for post-abortion care. Any abortion would be ineffective unless a doctor in his prescribed training and experience provides a post-abortion counselling with the pregnant woman and subsequently certifies that such counselling has been carried out.
In the past few years, there have been calls for further clarification by the government as to the correct interpretation of the current legal framework governing abortions. Singapore’s Health Minister has stated that the government intends to clarify the existing framework and strengthen the law by hardening the guidelines governing abortions. Such changes may be introduced at any time.
Who is eligible to get an abortion?
Certain eligibility requirements must be met before an abortion can be carried out in Singapore.
Age: A woman must be above 16 years old to seek an abortion upon herself. If she is under 16, she must obtain her parent’s consent.
Counseling Sessions: Both before and after a first trimester abortion, the woman may be referred to an approved social service or counseling center. She is obliged by law to attend one counseling session, unless her doctor personally decides that she doesn’t need to undergo counseling. If the pregnancy is a result of incest or rape, the woman is automatically exempted from counseling, but she still needs to sign the necessary paperwork at the hospital.
Consent. Consent must be given by both parents if the woman is below 21 years of age. Her consent is not required if she is married or has previously had a child.
Abortion Procedures and Medical Guidelines
The most common surgical abortion procedure carried out by the Singapore Medical Council (SMC) is a suction curettage (D&C), also known as vacuum aspiration (VA). It involves dilation of the cervix (the canal extending from the upper uterus to the vagina) and scraping inside the uterus. Suction is provided by either a hand-held syringe or an electrically-operated suction machine. A more advanced procedure is electric curettage (D&E), which uses scissors to cut up the tissue in the uterus into smaller pieces before removal. Suction is then used to remove the tissue.
The two medical guidelines of the MOH which apply to abortion clinics are the Abortion Services Clinical Practice Guidelines and the Termination of Pregnancy Clinical Practice Guidelines. The first guideline specifies that there should be an assurance of privacy, dignity and safety for every woman, and respect for her right to make an informed choice and be supported in her decision making process. The second guideline lays out procedures to be generally followed, including details about the referral and counselling system, the abortion procedure itself, and follow-up care. It also states that women terminating their pregnancy at less than 24 weeks should ideally be given general anaesthesia since local anaesthesia is associated with severe complication rates which can be improved by the use of general anaesthesia. After 24 weeks, the only medical abortive method permitted is the procedure of dilatation and evacuation under general anaesthesia.
Abortions Fees and Accessibility
Abortion Accessibility and Costs
In Singapore, abortions performed during the first 12 weeks of pregnancy are classified as "first trimester procedures". Whether a woman can obtain an abortion from a registered clinic performing abortion procedures will depend on whether she meets the following conditions:
1) She must be an adult (between 16 and 50 years old); and
2) She must be a "habitual resident" of Singapore.
In general, registered clinics may only conduct abortions on non-residents of Singapore if there are exceptional circumstances; for instance, emergency cases that require immediate medical attention or repatriation of foreigners after an unwanted pregnancy but where a woman is unable to leave the country due to the pregnancy, etc. Any abortion requests by non-Singapore citizens or permanent residents will generally be referred to the relevant public hospital for assessment instead. Facing an unplanned pregnancy may be a daunting reality for many women and some may choose to undergo their abortions with a private provider. However, a woman should first speak with her doctor, who will be able to advise her on whether an abortion procedure is appropriate and provide her with requisite advice on such matters . There are a variety of private hospitals and clinics providing abortion services, though most doctors will advise one to opt for hospitals as they may be better prepared to deal with the possible complications from abortions.
The costs of obtaining an abortion vary depending on factors such as the type (medical or surgical) and stage of abortion, where the abortion is to be carried out (i.e., private hospital/clinic versus public hospital), individual hospital fees, etc. Medical abortion as well as first trimester surgical abortions are generally cheaper than second trimester procedures. The Ministry of Health has published the fee for the abortion package, which may include pre-abortion consultations, post-abortion follow-up, laboratory tests and certain medication. Generally, the fees for abortions within the public sector are significantly subsidised. Clients may also receive subsidised fees when receiving abortion services from private hospitals that are accredited as Medisave-accredited. Eligible patients who have Medisave accounts may apply for partial payment using the Medisave, though there is a limit on the amount claimable.
Public Opinion Surrouding Abortions
Abortion remains a socially divisive issue, not only in Singapore but across the world. The Catholic Church teaches that the unborn child has a right to life, and the European Court of Human Rights has considered abortion "a sensitive moral and ethical issue." But there are those, including a senior Thai Buddhist monk and the Chief Justice of Australia, who have argued in favour of a woman’s right to choose. Suffice it to say that concurrent with the increased freedom of choice surrounding abortion in recent decades, attitudes and opinion toward the practice have shifted from condemnation, to tolerance, to support. In Singapore, from 5 to 24% of respondents to a 1991 Dialogue Singapore Poll survey supported abortion on demand. While the median abortion rate has increased (Data on induced abortions by 1000 women in Singapore from 1981-1992 revealed that the median abortion rate was 10.3 ppm as compared with 17.9 ppm in 1992) the number of women who attended legal abortion services in 1992 is actually lower than that in 1982. The stark facts are that based on 2017 data, only 11% of abortions were performed on Singaporean women. An overwhelming majority were performed on expats. About 96% of the abortions were sought because of ‘gross physical or mental abnormality’ or ‘severe fetal abnormality’ rather than for lifestyle reasons or contraception failure as is sometimes believed. About 20% of those seeking abortions came from another country in Asia and about 37% were from Europe, America and Oceania. Among those, about 25% held Permanent Residence or Employment Pass cards. Religious and cultural influences on public perception of abortion in Singapore include practices and customs from the Chinese, Malay and Indian communities. Dr ElevynTan, former Honorary Secretary, then President of the Aristocrat Group published a book entitled "A Guide to Abortion Practice in Singapore" addressing concerns and misconceptions about abortion which she felt was necessary considering that the leaders of these communities were known to be anti-abortion. She noted that even among these leaders, there is usually an understanding of the necessity of abortion in certain circumstances. Those who feel that religious and cultural arguments should be dominant are probably the minority. The majority are likely to be more tolerant of abortion especially for certain (but not all) reasons related to fetal deformities and maternal health. Given the fact that a majority of abortions in Singapore are performed on non-Singaporeans, the increasing educational and staff opportunities in Singapore as an economic "hotspot" for foreign professionals is likely to have an impact on the total number of legal therapeutic abortions. The so-called "economic migrants" receive benefits of citizenship status which then provides them access to government subsidized health care and hospital services in their area of employment. Given the free service offered, the choice for expatriate women to have an abortion may naturally be reciprocal with the number of foreign women who embrace Singapore for work. As Singapore becomes more cosmopolitan with a broader demographic of Singaporeans that reflect "multicultural" Singapore there is likely to be a continued tolerance for abortion in the community.
The Abortion Laws of Other Nations
Some abortion laws around the world are similar to ours in Singapore, while some are worlds apart. For instance, in the United States where the legality of abortion is a hotly debated issue, the laws there are not uniform nationwide. In some states, there are minimal restrictions, whereas there are very stringent restrictions in others.
Only 13 states currently ban abortion after 20 weeks of gestation (as of May 2016) – these are Arkansas, Georgia, Iowa, Kentucky, Louisiana, Michigan, Mississippi, North Carolina, Ohio, South Carolina, Texas, Utah and Wisconsin. Some of these states allow exceptions for fetal abnormalities, medical emergencies and cases of rape or incest. Interestingly, no state bans abortion prior to 20 weeks, which illustrates how common the current gestation limit is in the US.
Abortion is illegal in most European countries, although it is permitted in some form in some countries. בישראל The law in Israel allows abortion on many grounds. If the judiciaries and doctors approve, abortions may be carried out. The procedure can also be performed on demand if the woman is a minor or mentally challenged. Some religious groups object to abortion on any grounds. Even though abortion is legal, the state does not subsidise the procedure for Israeli women. The Israeli Defence Forces does carry out abortion procedures on IDF soldiers if the procedure was approved by a medical committee.
Canada is one of the countries that allows abortions to be performed on request. In 1988, the Supreme Court of Canada struck down the abortion law after which statutes regarding abortion ceased to exist. Abortion is allowed during the first trimester – the abortion may be performed on request; during the second trimester , the procedure may be performed if there is risk to maternal health, fetal anomalies or other serious emotional, physical or social adverse conditions; later abortions after the second trimester are only performed to protect the life or health of the woman.
In the United Kingdom, if two registered medical practitioners agree that an abortion should be carried out to prevent greater physical or mental injury to the patient, or to prevent serious permanent injury to the physical or mental health of the patient, then the abortion is legal. While it is not a requirement that the two doctors be from the same practice or hospital, at least one of them must be present at the abortion. Otherwise, the procedure can only be carried out in a premises approved for the termination of pregnancy except in a medical emergency.
Abortions cannot be performed on patients who are outside of the gestation limit (24 weeks) on National Health Service hospitals or clinics. In private clinics, abortions can be carried out at any time, although the service must be registered with the Care Quality Commission.
In India, the 1971 Medical Termination of Pregnancy Act regulates the circumstances in which a pregnancy may be terminated. It restricts termination of pregnancies to those that pose a threat to the woman’s physical and mental health, pregnancies caused by contraceptive failure, rape and incest, and hypertensive or diabetic women.
Historically in China, women were permitted to abort a pregnancy at any time. However, domestic law now regards pregnancies as non-viable after 28 weeks. Abortions after 24 weeks are prohibited except when the former law was used to be lenient and discriminate against ethnic minorities.