Reproductive justice and access to abortion in the Czech Republic

1. Introduction

This report presents the results of research on access to abortion on demand in the Czech Republic in 2023. The research was conducted by ASAP (Abortion Support Alliance Prague), an informal activist group.

Our report comes in response to the lack of any publicly available information on the current state of access to abortion in the Czech Republic. Unlike in other countries, there are no institutions monitoring the state of reproductive rights in the Czech Republic. Some organisations working abroad include Federa in Poland, Centrul Filia in Romania, and Možnost’ vol’by in Slovakia,to name just a few. Such organisations play an important role in building local pro-choice movements. The lack of institutional support for reproductive rights in the Czech Republic in particular was one of the driving forces behind the creation of ASAP. The group’s focus is not only research but also organising debates on reproductive justice.

The members of ASAP became acquainted through Ciocia Czesia, an informal collective that helps Polish people obtain legal and safe abortions in the Czech Republic. After almost 3 years of working on the topic of abortion, we have become familiar with the weaknesses and significant issues stemming not only from Czech law itself, but also from hospital habits and practices. We used methods and tools which did not require financial input, as our report was created independently and without any budget. Our guerrilla research was fully carried out by pro-choice activist volunteers.

In our work, we refer to two concepts: reproductive justice and accessibility. These complicate the apparent freedom of choice to terminate one’s pregnancy. Even though abortion is legal in the Czech Republic for the majority of people, not everyone has easy access to it. It is hard to talk about choice if abortion can cost up to 30% of the minimum salary or if medical personnel are trying to influence one’s decision.

SisterSong, an organisation based in the southern USA, defines reproductive justice as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities. ” The movement recognizes the complexity and intersectionality of reproductive health - our diverse identities can cause unequal access to abortion, even when people live in the same country and under the same laws.

The core of reproductive justice is not only keeping abortion legal but also keeping it accessible and affordable for everyone. This idea moves beyond the “choice” model which often excludes marginalised communities. In the context of the Czech Republic, this especially affects foreigners without permanent residence, people with low incomes, and people with disabilities.

2. Methodology

The data used in our research was collected from January to May 2023 and we used both qualitative and quantitative methods.

2.1. Quantitative Method: Surveys

From January to April 2023 we contacted 78 gynaecology departments at state-run hospitals in all regions of the Czech Republic. Our primary means of communication were emails sent either to the head of the department or other personnel, depending on the addresses listed on the website of the medical facility. In cases where we received no response within 2 weeks or after sending a follow-up reminder, we contacted the hospitals by phone.

We did not introduce ourselves as researchers, nor as representatives of any organisations, in order to receive the same answers as a person seeking an abortion would. In each case. We asked the same series of questions about the procedure, following the same scenario: we are contacting the hospital to find out information for a friend, a pregnant foreigner living in Poland, who is approximately 6-7 weeks pregnant and who did not have an abortion or a c-section in the last 6 months. Mentioning an early pregnancy allowed us to receive pricing information for both methods available: surgical as well as medical abortion.

We asked the following questions:

• What are the methods of abortion available?

• Until which week of pregnancy is each of them performed?

• What is the price of each method?

• Does the hospital offer abortions to foreign patients from the EU who do not have permanent residence in the Czech Republic?

2.2. Qualitative Method: Testimony Collection

Since March 2023 we have been collecting anonymous stories from people who have experienced difficulties with abortion access in the Czech Republic. Our anonymous online survey was sent to feminist-oriented organisations, NGOs and groups in order to reach as many people as possible. The survey was accompanied by a short text about our research and information on how the stories would be used. The collected stories have helped us understand problems which are hard to discern from quantitative research - issues caused by the power imbalance between the patient and the doctor and issues connected to abortion stigma. Abortion stigma is closely linked to social expectations and stereotypical gender roles related to motherhood.

3. Legal regulations from 1986 and historical perspective

3.1. Current Legislation

Termination of pregnancy in the Czech Republic is regulated by Act No. 66/1986 Coll., the Act of the Czech National Council on the Artificial Termination of Pregnancy, supplemented by Decree No. 75/1986 Coll. of the Ministry of Health of the Czechoslovak Republic, which entered into force in 1986. Since then, the legislative regulations of artificial termination of pregnancy in the Czech Republic have remained unchanged. Abortion can be performed at the request of a woman without providing a reason until the 12th week of pregnancy (the age is calculated from the first day of the last menstrual period), and for medical reasons up to the 24th week. Abortion up to 12 weeks on request is subject to a fee. The price is determined by each medical facility (Article 3 of Decree No. 467/1992 Coll. of the Ministry of Health, on paid healthcare services). Abortion due to health reasons is covered by public insurance.

The act also regulates abortions for foreign women: Article 10:

artificial termination of pregnancy pursuant to Article 4 shall not be performed on foreign women who are in the Czech Socialist Republic only temporarily. This article is further specified in the aforementioned decree: the residence of foreign women shall not be considered temporary in the following cases: residence of women working in organisations based in the Czech Socialist Republic, family members of personnel working in such bodies and organisations, residence of students and other foreigners whose residence is permitted under special regulations and/or international treaties.

3.2. Historical Development

Abortion for non-medical reasons was first legalised in Czechoslovakia in 1957 (Act No. 68/1957 Coll.). This law must be seen in the context of the political situation at the time. Unlike in Western countries, where abortions were legalised as a result of the efforts of feminist movements, in Czechoslovakia it followed similar laws in other countries of the Eastern Bloc (Dudová, 2012). The debate that preceded the adoption of the law was focused mainly on the socioeconomic aspects (eg. the possibility of regulating the size of families in the unfavourable conditions of the post-war period), lack of access to contraception, and the effort to reduce the number of illegal abortions and their adverse health effects. This was reflected in the statutory conditions for performing the procedure. An abortion had to be approved by a committee (which was established by the District

National Committee, and composed of medical experts, party officials and members of the public), and performed in a medical facility. In addition to medical reasons, the law also recognised “other serious reasons” which included: pregnancy resulting from rape, a woman’s age over 40, as well as socioeconomic circumstances or provable marital problems (Dudová, 2012).

In the early 1980s, the topic of abortion returned to the public debate, mainly due to the problematic nature of the abortion committees. From one side, they were criticised by women themselves, who considered it demeaning to confide in strangers about such intimate matters as an unwanted pregnancy. However, the discussion was mainly focused on two different aspects that played major roles in the process. Firstly, a new, safer method called mini-abortion was introduced at the time, but could only be performed up to the 8th week of pregnancy. The necessary approval from an abortion committee prolonged the whole process, and as a result made it impossible to meet the deadline. For this reason, the medical community started to rally for the abolition of the committees. The second important moment that profoundly influenced views on abortion, was the publication of a psychological study about unwanted children (Matějček, Dytrych, Schuller, 1976) which examined the psychology of children born to mothers who were denied abortion by the committee (for more information on the results of the research and its impact on public opinion see Dudová, 2012). These two factors led to the adoption of a new version of the law in 1986, which abolished the abortion committees and remains in effect unchanged to this day.

3.3. Available Methods of Pregnancy Termination

Historically, the method used for abortion was the sharp curettage. This method was gradually replaced by the safer and more gentle vacuum aspiration, or suction evacuation of the uterus. Nowadays, abortions in the Czech Republic are performed surgically using vacuum aspiration (up to the 8th week of pregnancy this method is called mini-abortion because it is an easier procedure) or by administering medications (mifepristone and misoprostol).

4. Results and Analysis

4.1. Access to foreigners from EU

The first matter that our research addressed was the provision of abortions to people with citizenship in countries of the European Union. The 1986 law, which refers to foreign women residing in the Czech Socialist Republic only temporarily, leads to the interpretation that only persons with permanent residency are entitled to receive this healthcare service. However, the Act further specifies that the residence of persons whose stay is permitted under special regulations and/or international treaties will not be considered temporary. Disputes over whether the European Union (which did not exist at the time of the creation of the law) can be considered such an international treaty are based on the unclear interpretation of the law and varying approaches to patients from the EU in different healthcare facilities.

The Ministry of Health, which issued statements confirming the right of EU citizens to abortion in the Czech Republic in 2016 and 2021, has taken the side of a positive interpretation:

We would like to reassure everyone that the Ministry of Health continues to hold the same position as in 2016. The key conclusions published in the statement can be summarised as follows:

The abortion ban does not apply to foreign women whose residence in the Czech Republic is permitted under an international treaty.

One such treaty is the Treaty on the Functioning of the European Union (previously known as the Treaty Establishing the European Community).

Article 21(1) provides clear permission to citizens of the European Union to reside on the territory of the Czech Republic (“Every citizen of the Union shall have the right to move and reside freely within the territory of the Member States, subject to the limitations and conditions laid down in the Treaties and by the measures adopted to give them effect.”).

This interpretation is in line with Article 4(3) of Directive 2011/24/EU of the European Parliament and the Council on the application of patients’ rights in cross-border healthcare, which states: “Patients from other member states shall not be discriminated against on the grounds of nationality.”

The clear conclusion is that citizens of the European Union can legally obtain an abortion in the Czech Republic. This is the case even if they only travel to our country for this purpose and spend only a few days here.1 [Editor’s note]

The Ombudsman expressed a similar view in 2013:

Establishing a law which restricts pregnancy termination as a medical surgical procedure according to whether or not a foreign woman is staying in the Czech Republic only temporarily, violates primary EU law (Article 18 of the Treaty on the Functioning of the European Union) as it constitutes discrimination on the grounds of nationality. 2

However, the Czech Medical Chamber does not share this view. Mgr. Bc. Miloš Máca from the legal office of the Czech Medical Chamber commented on the Ministry’s opinion from 2016 as follows:

In this case, it is only a non-binding opinion of the Deputy of the Ministry of Health of the Czech Republic but in view of a real danger of criminal prosecution resulting from an unauthorised pregnancy termination, we would certainly not follow it in practice. (...) The interpretation that a Czech law and an EU directive can be valid and in effect side by side but the EU directive takes precedence, therefore the law should be ignored, is truly peculiar. Moreover, the opinion of the Deputy of the Ministry of Health is not relevant in practice. The Deputy is not authorised to interpret laws - interpretation of legal regulations falls under the competency of courts. (...) It is still the case that a pregnancy termination can only be performed at the request of those foreign women who have officially registered for permanent residency in the Czech Republic. This is the case even if they hold citizenship in one of the EU countries. „Therefore, we strongly recommend that doctors continue to exercise the same caution as before, and we unequivocally warn against performing abortions on foreigners as a part of their own legal protection in this very sensitive matter“ 3 [Editor’s note]

However, the ombudsman once again responded to this statement in 2021, addressing his comments directly to the CMC. He emphasised that medical personnel do not face any manner of criminal prosecution for performing abortions on EU citizens:

In summary, as evidenced by the Act on Artificial Pregnancy Termination and it’s implementation decree, as well as by relevant European Union laws, abortion can be legally performed on foreigners who are residents of the European Union regardless of whether they are settled here (it is irrelevant here whether they have permanent or temporary

residence, or are only in the Czech Republic for a short period of time). The same applies for third-country nationals if they have any residence permit in the Czech Republic.

Finally, I would like to offer the following reflection on the issue of possible criminal prosecution of health professionals who would perform abortion in accordance with the conclusion of the Ministry of Health. In a case where we admit that several possible interpretations of the law on artificial pregnancy termination exist, and a health professional would follow one of them, which, moreover, has been officially supported by the Ministry of Health as the sponsor of the legislation, I consider it highly unlikely that any criminal proceedings for the offence of unlawful termination of pregnancy would be conducted. Possible conviction in such a situation would be in conflict with the fundamental principle of criminal law which states that an act that is not clearly prohibited by law cannot be considered a crime (nullum crimen sige lege certa). Therefore, I consider the argument of the threat of criminal prosecution, which was made in response to a question in the magazine Tempus Medicorum, as inappropriate.4

Our research confirmed the ambiguity of the legal situation. We approached healthcare facilities via phone or email and introduced ourselves as persons with EU citizenship needing an abortion or inquiring about it for a loved one or a friend. When asked whether they would perform an abortion on a foreigner from the EU without permanent residence in the Czech Republic, out of the 78 healthcare facilities we contacted, 47 % responded yes, 41 % responded no. The remaining 12 % of facilities were unable to provide a clear answer. In several cases the operator referred us to the head of the department or the hospital lawyer. In one of the hospitals, we were first informed that a proof of residence or employment over the last 6 months would be necessary. However, when we approached the head of the department about the matter, he responded positively without requiring any proof of residence. The majority of facilities who responded negatively justified their position referring to the current law: Providing an abortion to a citizen from another EU member state is questionable under the current legal situation. (...) As mentioned above, we do not consider it appropriate to perform an abortion for a woman who is not a Czech citizen (and is from the EU, specifically from Poland) and does not live in the Czech Republic. Another hospital informed us that legally, they would be unable to perform the procedure, but they recommended contacting a private clinic. The lack of knowledge of the medical staff can also be evidenced by another response we received: by law, an abortion can only be performed if abortions are also legal in the person’s home country; or by a case when the head of the gynaecology department was unable to take a clear position on the matter.

4.2. Price Analysis

As a part of the research, we also investigated the affordability of abortion in the Czech Republic. The price of the procedure varies according to the method used (chemical vs. surgical vacuum aspiration) and gestational age (up to 8 weeks, so called mini-abortion is available).

According to the data obtained, the average price of a mini-abortion is 3 913 Kč, 4 755 Kč for an abortion after 8 weeks, and 4 079 Kč for medical abortion.

The lowest average prices are in Královehradecký kraj (mini-abortion: 2 820 CZK, after 8 weeks: 3 620 Kč, medical abortion: 3 680 Kč), the highest in Jihomoravský kraj

(mini-abortion: 5 760 Kč, after 8 weeks: 5 860 Kč, medical abortion: 5 220 Kč) where the average price was increased by two healthcare facilities whose fees for abortion exceeded 8000 Kč. Prices were also higher than the national average in Pardubický kraj (mini-abortion: 5 250Kč, after 8 weeks: 7 675 Kč, medical abortion: 3 500 Kč). This was also the only region where medical abortion was cheaper than mini-abortion and the same for all hospitals surveyed.

We compared the prices with the gross minimum and average wages for 2023.5

The price of abortion after 8 weeks of pregnancy represents up to 27.49 % of the minimum wage (22.62 % for mini-abortion and 23.58 % for medical abortion). This can represent a significant portion of the income of the person in need of an abortion. At the same time, there is no organisation in the Czech Republic that can be contacted for financial assistance. By comparison, in Germany (where abortion on request is also not covered by public health insurance), there is a possibility to claim the cost of the procedure from

the insurer if the person has a low income.6 In some countries (eg. the United Kingdom7 and Spain8), abortion is even entirely covered by public health insurance , and in many EU countries, there are also various non-profit organisations that provide financial support to people who need an abortion, such as the Abortion Support Network.9

4.3. Access to medical abortion

Another issue we focused on in our research was the availability of medical abortion, which has been available in the Czech Republic since 2013 when 3 drugs were registered: Mispregnol (active ingredient is Misoprostol), Mifegyne (active ingredient is Mifepristone) and Medabon (active ingredients are Mifepristone and Misoprostol).10 The use of Mispregnol and Mifegyne was approved for abortion up to 49 days (7 weeks) of pregnancy and Medabon up to 63 days (9 weeks). Currently, only Mispregnol and Mifegyne are available on the market, which limits the availability of medical abortion to 7 weeks. The above-mentioned drugs are prescription drugs that can only be administered by medical personnel at a medical facility providing inpatient care. In practice, this means that the availability of these drugs is limited to gynaecology and obstetrics departments in hospitals. The patient must come to the hospital twice: first for the dose containing Mifepristone, and after 36-48 hours for the second dose, containing Misoprostol.

Our research shows that the price of medical abortion is higher than the price of miniabortion (which is available up to 8 weeks of pregnancy, similarly to medical abortion) in most hospitals: of the 78 facilities surveyed, the cost was lower in only 5 cases, and the same in 14 cases. When asked about the maximum gestational age for abortion pills, most hospitals responded in accordance with the recommended 7 weeks. 4 facilities offered medical abortion up to 8 weeks and 2 up to 9 weeks. Only 4 of the hospitals we surveyed did not offer medical abortion at all.

Although most healthcare facilities offer this method, we identified three main barriers in access: 1) restriction of gestational age to 49 days of pregnancy in most cases, 2) drugs administered in hospitals requiring two visits, and 3) high cost compared to other methods available at this stage of pregnancy. Statistics from the Institute of Health Information and Statistics of the Czech Republic (IHIS CR) from recent years show that mini-abortion is widely preferred over medical abortion.11

Medical abortion is considered by the World Health Organisation (WHO) to be a safe method of pregnancy termination. One of the WHO recommendations, according to

6 See: https://www.profamilia.de/en/topics/abortion

7 See: https://www.nhs.uk/conditions/abortion/

8 See: https://quieroabortar.org/como-abortar/

9 See: https://www.asn.org.uk/get-help/

10 See: https://www.sukl.cz/sukl/sukl-zaregistroval-pripravky-urcene-k-umelemu-ukonceni

11 See: https://www2.hse.ie/conditions/abortion/methods/medical/

the latest 2022 guidelines, is telemedicine as a method of delivering medical abortion care (recommendation 48) and self-managed abortion (recommendation 50). These practices have had a major impact on expanding access to abortion. In some European countries, medical abortion is available without the necessity to visit a healthcare facility. In the UK, this is possible up to 10 weeks of pregnancy: after a phone consultation the patient receives a shipment of medication containing Mifepristone and Misoprostol, as well as some painkillers, from the pharmacy within 3 working days.12 A similar procedure also exists in Ireland: here it is possible to undergo a medical abortion at home until the end of the 9th week (after 9 weeks the first dose must be taken under supervision in a healthcare facility). Other countries, such as Spain13 and Moldova14 (both of which have medical abortion available up to 9 weeks) require a visit to a healthcare facility only for the first dose. WHO also recognizes that ending a pregnancy outside a medical facility (for example at home) is not only safe and efficient but also empowering. Eliminating or reducing the necessity of hospital or clinic visits greatly increases the availability of the medical abortion method.

5. Abortion Testimonials

5.1. Introduction

In addition to the research on the availability of abortion in terms of cost and country of origin, we also focused on the experiences of people who had or sought abortions in the Czech Republic. We concentrated mainly on the problematic points and barriers that people encountered.

We shared a graphic in Czech and English through ASAP social media and through other allied feminist organisations and initiatives in the Czech Republic.

The graphic was accompanied by the following additional questions:

Have you or someone close to you experienced unequal access to reproductive rights in the Czech Republic?

Have you encountered coercion, questioning or other forms of manipulative behaviour?

Have you heard about the refusal of medical help/abortion in your area? We will be very grateful if you share similar experiences with us. It will be a valuable source of information for us and will contribute to our research on access to abortion in the CZ that we’re currently working on. It will also show us the most burning issues and help us plan our future activities. We will evaluate them completely anonymously and try to approach them as sensitively as possible.

Of course, the testimonies that we have received in response to our survey represent only a small part of the general experience with abortion in the Czech Republic. Nevertheless, we believe that the problems that we have identified thanks to these testimonies cannot be ignored.

5.2. Personal Experience

Between March and June 2023 we received 18 personal stories, from which we identified several recurring problems: stigmatising comments and shaming, coercion, accusations of irresponsibility, moralising, inadequate hospital conditions, unwillingness of medical staff and refusal to help, unprofessional approach, projection of own opinions into the delivery of medical care, and unsolicited advice and information. Due to the wording of our questions, we did not encounter financial (un)availability in the responses. Below are specific examples from each story illustrating the issues mentioned above. (emphasised in the examples - ASAP).

a. stigmatising comments / shaming

Stigmatizing comments that people encountered were aimed either at the decision to have an abortion or their sex life. In the case of the stigmatisation of abortion itself, the problem was often linked to the doctors projecting their own views into the provision of health care or to moralising or accusations of irresponsible behaviour (see next points b) and c)).

Examples:

I called my gynaecologist right away that I didn’t want it. Honestly, I’m not okay with just myself, let alone have a little bundle next to me. At my gyno, at 30 years of age, I got absolutely roasted about only hormonal contraception saving me, no condom, only HC. And basically that it’s awful, what I’m about to do. That some women wait for this for years.

I felt physically and mentally sick, the doctor was being arrogant and condescending to me, kept asking me about my sex life and said that without more checks, this wouldn’t work. I had to agree, I wasn’t in a state to be going around doctors or waiting until someone who would better suit me take me in. I had zero experience.

b. projecting one’s own views into the delivery of medical care

This problem came up in personal stories most often, and from female doctors, during the gynaecological exam which the persons concerned underwent to obtain an approval for the procedure. We often see the argument that many women try to get pregnant for a long time, while this person is simply deciding to terminate their pregnancy. Gynaecologists do not hide their anti-abortion views and try to talk patients out of their decision.

Examples:

I was told I was young which is ideal for pregnancy. Overall she didn’t try to hide that she didn’t approve, she played the foetal heartbeat for me. .

The gynaecologist’s reaction was completely inhumane, immoral and unprofessional. On her own, she started telling me and even scaring me that she got a lot of women who wanted a baby but couldn’t get pregnant. That this is the problem and I’m doing the opposite. It was absolutely disgusting, insensitive and useless.

Yes, my gynaecologist tried to convince me not to go. He said that I was at the ideal age to have a baby, that my own body was telling me that it’s at its most fertile age.

In the end, he tried to convince me to keep it and I had to explain reasons why I didn’t want it and why it really wasn’t appropriate and that I was satisfied with my life as it was. (...) The communication was awful so after one interview, I have completely wrong information in my file, he just kept lecturing me.

I came in for support for my decision and I left pretty devastated. After my gynaecologist tried to convince me to keep the baby and then give it up for adoption, that it was really a heroic act which is underestimated, she finally, unwillingly, gave me the papers. obrovolně vydala.

c. accusations of irresponsibility / inappropriate moralising

The root of the problem is the idea that a person seeking abortion is behaving “irresponsibly” - it is also a case of stigmatisation of sexual behaviour. Respondents mainly encountered questions about whether they were using protection during sex at all, and comments about choosing the wrong kind of contraception. The preference of gynaecologists for hormonal contraceptives in particular is evident here

Examples:

(...) I got a few stigmatising comments, both from the doctor at the hospital (“for my own moral peace of mind, do you really want to do this?”) and my gynaecologist (shaming me for not wanting to use an IUD anymore because I got pregnant anyway - apparently I was irresponsible).

(...) At my gyno, at 30 years of age, I got absolutely roasted about only [hormonal contraception] saving me, no condoms, only HC.

I had 2 abortions, one for genetic reasons, everyone was considerate then. The second time was a mini-abortion by choice. I intentionally went to a private clinic to avoid unpleasant treatment but even that didn’t help. As if no one took into account that the situation was

awful, that the choice was painful for me and that I had feelings towards this embryo. The nurses and doctors approached my tears by commenting “well, you should have thought about this before.” As if I came there because I had random sex with the first guy I met at a party and deliberately gave up protection.

She told me it was shameful to have an abortion at 28 and that at my age I should know how sex goes and what risks there are. She asked me if I even knew how to use contraception... On the other hand, she didn’t give me any information about what to do after the procedure.

I don’t have personal experience but I’m passing on my friend’s experience... at 15 she got pregnant and after a long discussion at home they settled on abortion. The gynaecologist made deranged remarks like “pregnant at 15, that’s awful. Well, it’s terrible, these young people nowadays. They make a baby and hurry to get rid of it.”

I had an abortion at 19 based on my own decision (...). After the fact I was subtly forced and pushed into hormonal contraception (not by my gynaecologist but by the doctor who performed the procedure) which I didn’t want because I was worried about side effects. But eventually I got persuaded anyway and started using it. After three years I got pulmonary embolism from it. That caused me to develop a panic and anxiety disorder which I’ve been battling for the last 4 years.

d. coercion

Coercion is primarily understood as manipulative behaviour intended to affect the emotions of a person and influence or question their behaviour to have an abortion. One of the most common forms of coercion is forcing a person to listen to the foetal heartbeat or showing them ultrasound images. Respondents encountered this both at their gynaecologist checkups and during preoperative examination before the procedure, and they perceived it as an attempt to change their decision.

Examples:

I was told I was young which is ideal for pregnancy. Overall she didn’t try to hide that she didn’t approve, she played the foetal heartbeat for me.

My friend had an abortion at 18. Not only was she told by the doctor that she was “expecting twin babies,” and what stage of development they were but he also forced her to look at the ultrasound. She had already made up her mind, she just wanted him to do the surgery.

In the end, I had my abortion at Bulovka hospital but the process of it, that’s a completely different story. Listening to the heartbeat, examining the size of the foetus despite the fact that I went to the polyclinic with a clear goal and an approval form.

She made an appointment for an abortion but then she got the flu and had to reschedule. At the clinic they told her the flu was a sign to cancel the abortion.

e. reluctance and refusal of assistance

Another common problem that emerged in the testimonials was reluctance on the part of gynaecology office staff. In the stories, this was directly or indirectly linked to the personal opinions of the doctors about abortions (point b) This was presented through unwillingness to issue an approval for the procedure, sending patients for additional tests and examinations (and thus delaying the abortion date and jeopardising the possibility to undergo the procedure within the legal limit), and through unwillingness to provide more detailed information about the procedure. We have encountered two cases of direct refusal of assistance, both on the basis of nationality: the first woman was able to undergo an abortion (as an EU citizen), the second opted for an at-home medical abortion.

Examples:

When the doctor confirmed the pregnancy, she basically said she’d see me at the next check up (I don’t know when it was supposed to be but definitely after the legal limit for abortion). She was very surprised when I said that I wanted an abortion, and I had to drag all the information from her.

I was 28 and I was more than sure I wanted an abortion which I made clear to the doctor. Yet she questioned my decision, and she told me she’d let me sign the documents only in a few days, after I had justified my decision.

I live in Prague but I have my doctor close to the border, where I come from. I somehow expected to leave with an approval form but instead I left with an ultrasound image and instructions to arrange tests with my GP to see how well I would tolerate anaesthesia. And thus began my never ending circle. My GP in Prague couldn’t understand why my gynaecologist was requiring such a thing but he made an appointment at another doctor for blood work. Then I waited for the results, I went back to my gynaecologist who told me he had to do a test for the Rh factor (I know what mine is but I understand why they need to be certain instead of just relying on what I say) and sent me back home to Prague. Then I had to come back to my hometown for the results and weeks went by. (...) When the gynaecologist finally had no more tests to run, I got the approval and rushed to Apolinář hospital. I arrived just late enough that I couldn’t take the abortion pills and had to have

a surgery. The doctor at Apolinář shook her head wondering why my doctor was forcing me to do all these tests which, if I understood correctly, they could have done themselves, compared to what I went through, in a moment. (...) I think it took me a few years before I understood what my doctor was subtly pushing me to do. The only thing that makes sense is that he was trying to get me to change my mind about the abortion.

Then I searched for a place to go, there’s not much information about this out there. I called a few private offices, one receptionist lady said “well we don’t really do this here, goodbye!” very unpleasantly and full of contempt.

I’m Slovak, I’ve been living in the Czech Republic for 6 years - I work here and have been functioning here since university… While trying to arrange an abortion, despite having been here for several years, they refused to perform it because I didn’t have permanent residence.

I just arrived in Prague in February 2020 and then obviously everything got locked down. I found out I was pregnant in March 2020, where I just got a job but couldn’t leave the country as I wouldn’t get back in. (...) I went to the women’s hospital in Prague 4. I could not speak czech, I used Google translate to indicate I wanted an abortion and the woman told me go to a desk I handed over my passport and she just shouted at me in czech over and over again. I couldn’t make sense of what was going on, there was no one that could speak English and everyone was so afraid of covid they didn’t touch my phone to use Google translate. I cried and the woman shouted some more. I couldn’t take the stress anymore I ran away.

f. inadequate conditions in hospitals

S nevyhovujícími podmínkami v nemocnici se setkaly osoby, které se rozhodly pro farmakologickou interrupci. Jedna z nich popisuje, že po podání první dávky léku musela povinnou observaci strávit v čekárně spolu s těhotnými pacientkami, čekajícími na kontrolní vyšetření. Druhým problémem je neinformování pacientek o tom, že první dávku léku při farmakologické interrupci nemocnice podávají většinou v první půlce týdne, aby se během pracovních dnů stihla i druhá dávka. Z toho důvodu může pacientka promeškat povolenou lhůtu pro tuto metodu.

Examples:

The cherry on the cake was probably the waiting room for patients who want to continue their pregnancies connected with the waiting area for those waiting the obligatory hour after their pill and who are starting to bleed. Depressing and awful feeling both for me and the lady waiting for her ultrasound.

In the end they let me go and the doctor said that we wouldn’t manage today, that I had to get my bloodwork done and that they only administered pill until Wednesday cause there wouldn’t be anyone here on Saturday to mind me after my second dose.... but no one had told me about this...

Because it was Friday, they couldn’t give me my first dose. I was supposed to come for it next week. Again, I got a date when I was supposed to come. I came that day on time (quite early in the morning.... And as instructed, with an escort). And the nurse began to inform me that they’d run out of the pills. (Good joke, right?) Thankfully, even though she was quite unpleasant, she was at least helpful and promised that they’d get the pills delivered from the hospital pharmacy and as soon as they’d get there, they would call me to come. Well... so I waited impatiently all day on alert just for them to call me an hour before the end of office hours when I was sufficiently stressed and had twice called my friend who worked in the clinic to find out what was up.

g. unprofessional attitude

People needing abortions experience unprofessional attitudes from all groups of healthcare staff - both from doctors and nurses. Staff are often unpleasant, treat patients insensitively despite their vulnerable position, and make inappropriate remarks. A recurring issue is medical students and trainees being called in for examinations without patient consent.

Examples:

The nurses treated me quite badly, the doctor didn’t even say hello. I waited for a very long time. Finally the doctor admitted me, and medical students came in to observe... And no one asked me if I was okay with it. The doctor pointed at me and said a lot of things. It was long and it really hurt, I started crying but no one even cared... (...) When getting my blood taken, the nurses yelled artificial termination of pregnancy all around and gave me nasty looks...

After my gynaecologist did the checkup and confirmed I was pregnant, I was relieved because her attitude was absolutely professional and wonderful. (...) The very next day I went to the outpatient clinic of gynaecology and obstetrics. After about two hours of waiting (even though I was given a time to come in), in a waiting room full of pregnant women, the doctor admitted me. I explained what happened and why I was there. He opened the documents from my doctor and read through the form I had filled in. He came across the line about the number of children I had and he couldn’t resist a comment: “You have no children? At 24? Well, you made your mind up fast about not wanting any...”

I just sat there flabbergasted, not knowing what to say. Considering that the line above said I became pregnant despite using birth control (IUD for 5 years!!!), which by itself implied that I didn’t want any children, it was insensitive and inappropriate to make such comments, despite not knowing what the whole situation was and how I came about my decision (which he didn’t care about at all - I wasn’t expecting he would but at the same time, he should have kept his stupid comments to himself). I was sure about my decision and yet it hit me (after all, I just felt sorry about the whole situation, I was confused and had no support apart from my partner). It was my turn and I got more awfully funny comments. At one point he asked: “so what shall we do with this IUD? Well I guess we’ll take it out... what else, am I right.” He took out the IUD, waved it around in my face and said: “do you want to keep it as a souvenir?” After the foetus was expelled, I had a checkup after 14 days to see if all was well. There was a different doctor at the clinic and at first I thought he was nice. Which he probably was. But then he called in an intern from university and told her she would do my exam. She looked absolutely terrified and during the whole ultrasound check she seemed to not know what she was looking for and the doctor kept correcting her. In principle, I don’t mind, after all new doctors have to learn on someone. But I was somewhat concerned that he didn’t even ask me or assure me that he would double check.

5.3. Comments

The personal experiences suggest that despite having been legal in the Czech Republic for over 70 years, abortion is still a taboo subject and is often stigmatised, even by medical staff. They also show an unequal relationship between the doctors and patients: people undergoing abortions are being confronted with the personal opinions of gynaecologists and are forced to defend their decisions. There is also a clear lack of reliable and accessible information on the available methods of abortion, and the overall process of seeking this healthcare service. It is important to mention that most of the stories that reached us are from people with Czech citizenship - the problems they encountered were therefore not the result of unclear legislation or a language barrier.

The question of abortion and issues associated with it does not exist in a vacuum, but is related to reproductive health and reproductive rights in general. Another example worth mentioning is abuse during childbirth. Organisations concentrating on preventing this are: Rodím v klidu a bez násilí (Giving Birth Peacefully without Violence), Unie porodních asistentek (Czech Union of Midwives), Liga lidských práv (League of Human Rights) and Asociace pro porodní domy a centra (Association for Birth Houses Centers). Thanks to the efforts of these organisations, the topic of childbirth and the respectful treatment of women during pregnancy has become more widely known and the subject of public debate. Abortions need the same attention.

6. Conclusion

Abortion is not only a matter of individual choice, but access to it is influenced by many different factors which are often beyond the control of individuals. Movements, organisations and collectives fighting for reproductive justice seek to address and resolve these systemic issues. As ASAP, we uphold these values. Abortion should be part of basic healthcare and available to all who require it. Below we attach a list of recommendations for institutions and organisations that can help make abortion more accessible.

To the Ministry of Health:

• Create a reliable platform on abortion in the Czech Republic that provides information on pregnancy termination, both on request and for health reasons.

• Establish a protocol on abortion for foreigners with EU nationality that clearly describes when abortion is and is not possible.

• Extend the time limit for medical abortion beyond 7 to 8 weeks of pregnancy. Ideally, follow the World Health Organisation recommendations and allow medical abortion up to 12 weeks of pregnancy.

To the Czech Medical Chamber:

• Issue a clear stance on the interpretation of the existing abortion law, taking into account the recommendation of the Ombudsman JUDr. Stanislav Křeček from July 27, 2021, where he clearly establishes that from a legal standpoint, it is perfectly legal to perform abortions on foreigners.

To the ASAP collective and other feminist organisations in the Czech Republic:

• Create a platform with reliable information on abortion, independent of the Ministry of Health.

• Continue to spread information about abortions on social media.

• Establish a fund (taking an example from foreign organisations) from which it would be possible to contribute to abortion for people who cannot afford the procedure or whose income would be significantly affected.

• Research writer: Anna Militz

• Data collection: Dominika Ginter, Jolanta Nowaczyk

• English translation: Eva Ptašková

• Proofreading : Jack Stevens

• Graphic design: Natasza Kornobis

If you have any questions or comments please do not hesitate to contact us: asap.praha@gmail.com.