ToI investigates

Easy to access, but hard to stomach, ‘humiliating’ abortion process may soon change

Women seeking to terminate a pregnancy must justify themselves before an impersonal panel, a step reformers want to abolish. After decades, the Health Ministry is now on their side

Carrie Keller-Lynn

Carrie Keller-Lynn is a political and legal correspondent for The Times of Israel

Illustrative image: woman on a hospital bed (iStock by Getty Images)
Illustrative image: woman on a hospital bed (iStock by Getty Images)

Orin’s medical team led her to a small room already cramped with seven strangers — all of whom, like her, came to this Petah Tikvah hospital for a medication-induced abortion. Told she needed to stay for observation, and with the only bed in the room already taken, Orin took a seat and waited for the pill to take effect. Within the hour, she felt “something akin to labor pains.” She was having her abortion, surrounded by strangers, on a chair.

“I was embarrassed to scream. There were strangers there [also experiencing medication-induced abortions]… It reminded me of a cowshed or ‘The Handmaid’s Tale,’” Orin, who declined to be identified by her last name for privacy, recalled. “It was not humane to experience an abortion on a chair.”

The actual abortion was only the last of a series of hurdles that Israel’s public health system had forced Orin to overcome, as part of a regimen under which women are offered fairly open access to abortions, but only after jumping through a bureaucratic hoop seemingly designed to dissuade or even embarrass women seeking to end their pregnancies: the end-of-pregnancy committee.

By Israeli law, women do not have an automatic right to an abortion, but rather must request permission from a legally mandated end-of-pregnancy committee comprising three representatives of the hospital or clinic that would perform the procedure. The two doctors and social worker who form each committee often do not have to have a prior care relationship with the women whose cases they hear.

Orin, a professional woman who ended her relationship with her partner and did not feel emotionally capable of raising a child at that point, had to “humiliatingly” request permission — in person, after a wait of many hours — from the three strangers on her end-of-pregnancy committee.

Women like Orin who have faced end-of-pregnancy decisions in Israel describe a system that seems reasonable at first blush, but in practice is humiliating, invasive, and sometimes obstructionist.

Attempts to reform the system have been stymied for years, but efforts are now being redoubled and have been given a tailwind by the appointment of a progressive health minister, Nitzan Horowitz.

Illustrative: Extra blankets and pads are stored under a bed where women getting abortions rest before and after their procedures, Oct. 9, 2021. (Rebecca Blackwell/AP)

While abortion today is ultimately accessible to women, its gatekeeper is the committee process, which is historically rooted in denying access to the procedure and includes elements smacking of paternalism.

A well-voiced complaint among women who have applied to the committees and abortion access advocates is that the committee’s formal questionnaire includes embarrassing and medically irrelevant questions such as “Why didn’t you use contraception?” where the multiple-choice answers include “forgetfulness/neglect.”

“These questions aren’t relevant. We’re already past that point,” said Nitzan Hacohen, social worker and counseling network director at sexual health organization Open Door, which specializes in counseling young women facing unplanned pregnancies. “And when a woman comes to end a pregnancy, what authority do they have to doubt her about what kind of contraception she did or didn’t use?”

I was disgusted by the fact that I would have to justify my decision in front of a board of people I didn’t know, who would decide what to do with my body

Some women are so “incensed” by their disenfranchisement in making a decision about their own bodies that they refuse to participate in the committee system at all, going so far as to go abroad for treatment.

“I wasn’t willing to have my abortion in Israel because of the review committee,” said a mid-thirties professional woman who fell pregnant while using contraception. “I was disgusted by the fact that I would have to justify my decision in front of a board of people I didn’t know, who would decide what to do with my body.

“I thought Israel would be more progressive about abortion and it was not the case,” she added, comparing it to the United States, where she was born and whose Supreme Court is currently weighing restricting abortion access. “For me it was enough to fly to the US rather than let someone decide what happens with my body for me.

“It’s two years later and the whole thing still makes me absolutely incensed.”

From restricting access to ‘rubber stamp’

In 2020, the Health Ministry recorded 16,430 abortions legally performed in the Israeli healthcare system, representing 7.7 abortions per thousand women of fertility age and a 5 percent drop from 2019. Since 2001, Israel’s population has increased by one-third, but abortion rates have steadily declined after hitting a peak of 20,000 a year in the mid-2000s.

In each of these abortions, women were forced to plead their case to an end-of-pregnancy committee, first through a questionnaire and then during an in-person interview. Applicants often wait for hours for an audience with the panel, at which point they are expected to explain their decision to terminate their pregnancy. Panelists can probe applicants about contraception use or other deeply personal matters, making an already fraught episode that much more traumatic.

“They were talking to me like I was an idiot,” recalled Orin. “I’m a 30-year-old woman and they asked me if I knew how to use contraception. They didn’t help me. I felt like I had to justify myself.”

Despite the process, the committee rarely rejects abortion requests. In 2020, medical committees approved over 99% of requests, according to the Central Bureau of Statistics.

“There are almost no refusals; that’s an urban legend,” said a gynecologist who performs abortions.

While some point to the approval rating as proof the committees are not a significant burden for women, others see it as a reason to get rid of them altogether.

Sample question from an end of pregnancy committee questionnaire, which asks “why did you not use contraception/a method to prevent pregnancy?” with suggested responses. (Public domain)

“When 99% are approved, I think this is the data point that most speaks to not needing [committees],” said Open Door’s Nitzan Hacohen.

“They’re not a hurdle now; they’re a rubber stamp,” said Ruth Tidhar, a social worker at Efrat, an anti-abortion group that offers payment to women in an attempt to convince them not to terminate pregnancies. The organization claims it wants to prevent abortions rather than limit access.

“The committees are not doing their job,” said Tidhar. “As far as Efrat is concerned, we can do away with them. We don’t think changing laws helps save women from abortion. We believe education does.” Efrat was founded in 1977, the year abortion became permitted in Israel.

The Israeli Medical Association did not respond to a request for comment. Neither did staff from several public and private abortion providers. A spokesperson from one public hospital said that she did not know the facility’s current position on end-of-pregnancy committees, given the ongoing political debate.

The Health Ministry also declined to comment.

Forced to retrofit their condition

Despite the current permissive attitude toward approvals, Israeli abortion law is rooted in restricting access. According to the 1977 Penal Code, abortion is legally framed as criminal, excepting specific circumscribed reasons. Today, the only legally accepted reasons for abortion are if the mother’s age is below 18 or above 40, if the fetus has a serious medical condition, if the pregnancy would physically or mentally damage the mother, or if the pregnancy was conceived out of wedlock or via illegal relations like rape or incest.

According to official statistics, the latter was the most commonly cited reason to the committee, representing 49% of termination requests in 2020.

Because of the penal code, many women seeking to terminate pregnancies must retrofit their condition to fit an accepted narrative.

This problem is especially problematic for married women. “If you’re married, you won’t pass a committee,” said Dina Shalev, director of Ladaat, a sexual health organization that helps women with unexpected pregnancy. “So married women are lying and saying it’s out of wedlock.” But making that claim can complicate their position in divorce proceedings should they arise, so some women opt to find a psychologist to write a note saying that the pregnancy caused them severe emotional distress, another approved reason.

“I don’t like the term ‘lie,’” said Hedva Eyal, activist with Isha L’Isha, one of the organizations supporting reforms that would largely do away with the panel. “It’s the system forcing women to say what they need to say to survive it.”

1988 Health Ministry directive to “prevent unnecessary abortions.” (Screenshot from Health Ministry)

A 1988 directive from the Health Ministry specifically instructed end-of-pregnancy committees to push women to “reconsider” their desire to terminate a pregnancy. Under the heading “Preventing Unnecessary Abortions,” the ministry directed committee members to try to convince women to “reconsider their request” by being a shoulder to lean on and then “explaining” to women why they should consider going to term.

Unapologetically, this directive was framed as a strategy “to improve the state’s demographic situation.” Records on abortion approval rates only start in 1988, but that year over 10 percent of women’s requests were rejected. In the intervening years, the directive was discarded and rejection rates fell to 1%.

With Israeli women currently living under a disempowering, yet permissive, abortion climate, it’s a stark reminder that the legal machinery in place can be used to curtail access.

A window opens

In December, Health Minister Nitzan Horowitz announced plans to push legislative reforms that would return much of the decision-making power to women. His effort is backed by fellow Meretz party MKs as well as members of the Knesset Committee for the Advancement of the Status of Women and Gender Equality.

The envisioned legislation would eliminate medical committees for the first trimester, make them advisory for the second trimester, and maintain their decisive role for the third trimester. A spokesman for Horowitz said the legislation would be drafted by Meretz MK Michal Rozen, in consultation with the Health Ministry.

A parallel effort is also in play within the Horowitz-led Health Ministry, which is currently trying to move the end-of-pregnancy questionnaire online, to remove the in-person prodding into a women’s personal and sexual history as a barrier to obtaining the procedure. Even if that happens, however, some women may still need to physically appear for the committee.

The ministry is also looking to eliminate certain medically unnecessary and humiliating questions, such as scrutiny of contraception practice, that do not have bearing on the moment of pregnancy termination. It is also attempting to end the need to appear in person before a committee for women who unequivocally fit the legal criteria for an abortion, such as unmarried women or women younger than 18 or older than 40.

“The Health Ministry is trying to do the maximum within its power with respect to end-of-pregnancy committees to make things easier for women,” said Shalev. Currently, online forms and ending in-person appearances for women who prima facie qualify is the “most radical thing they can do” without getting Knesset approval, she said.

United Torah Judaism MK Yaakov Litzman at the Knesset, November 2, 2021. (Olivier Fitoussi/Flash90)

Ladaat is part of a coalition of activists and organizations that have been working to end the state’s say over a woman’s end-of-pregnancy decision. A previous attempt to introduce similar legislation in 2015 failed, with the Health Ministry, at the time controlled by ultra-Orthodox United Torah Judaism MK Yaakov Litzman, unwilling to back legislation easing access to abortions.

“Up until now there was no Health Ministry that was worth trying to work with,” Shalev said. “The minute we knew that Nitzan Horowitz would be the health minister, we got together and started promoting this law again.”

Even with Horowitz backing the measure, the legislation is expected to face an uphill battle, making the internal Health Ministry changes all the more important, Shalev noted.

“We still have a conservative coalition and government in general,” she said.

Horowitz’s Meretz is the most progressive constituent of the governing coalition, which comprises eight parties, some of them staunchly conservative. With the coalition enjoying only a single seat-majority over the opposition, all eight parties must back a bill if it is to have any chance of passing. The Islamist Ra’am party in particular has shown itself unwilling to back progressive social measures, such as cannabis legalization.

Rather than do away with the committees, some conservatives have sought to bolster them. In 2017, conservative Knesset members raised the idea of adding a rabbi, qadi, or a priest to end-of-pregnancy committees, but it was never advanced.

Meretz MK Gaby Lasky attends a meeting at the Knesset on June 21, 2021 (Yonatan Sindel/Flash90)

MK Gaby Lasky (Meretz) told The Times of Israel that she expects the changes to enjoy wide but by no means universal backing. “I estimate that there will be broad support from MKs from all Knesset factions for these moves, and those who won’t support this probably do not understand how a woman in a complex situation feels when she is required to explain her decision and answer abusive and humiliating questions,” Lasky said.

In early December, Religious Zionist party chairman MK Betzalel Smotrich said in response to a tweet by women’s rights advocate Transportation Minister Merav Michaeli (Labor), in which she announced the government’s intention to reform abortion law, that “at a certain stage of pregnancy, abortion is murder” and “we will do everything to topple this government.” Smotrich invoked “Jewish values” in his criticism, leading to a Twitter debate on whether or not Judaism actually forbids the procedure.

The offices of MK Litzman, MK Smotrich, and Ra’am chairman MK Mansour Abbas did not respond to a request for comment on how they would receive an abortion reform bill.

‘Delays health’

Moving the questionnaire online and streamlining the process would not only remove one of the more humiliating aspects of the process, but also address the system’s tendency to drag out the process for up to three weeks, affecting treatment options and delaying a woman’s ability to recover from a potentially traumatic event.

“This is supposed to be a process for women’s health, but it delays health,” said Eyal of Isha’ L’isha.

Until the ninth week of pregnancy, women in Israel can opt to terminate pregnancy with a pill that induces a miscarriage. This obviates the need for an invasive surgical procedure, which would either be suction or scraping the uterine lining, depending on the level of advancement.

Medical committees have different schedules across hospitals, and many public hospitals only convene them once a week. The one to three weeks that go by after discovering pregnancy — for scheduling and attending a committee session, receiving approval, and then being booked for treatment — can be the critical delta between a non-surgical and a surgical intervention.

“Time is of the essence in this situation,” said Open Door’s Nitzan Hacohen.

Illustrative: Bottles of abortion pill mifepristone at an American abortion clinic. (Charlie Neibergall/AP)

Since 2014, abortion has been covered by national health insurance for all women until age 33, and in all cases with a health issue involved.

But women who want to avoid the wait and the appearance before a committee can look to the private sector, paying NIS 3,000-4,000 ($950 to $1,300). Both private and public abortion providers are state-approved, but private providers offer a higher level of service as a trade-off for out-of-pocket cost.

“If you pay money, you can get it done the same day — committee and abortion,” said Shalev. “This creates a lot of inequality between women. If you can afford it, you can have a faster, painless procedure, versus if you need the funding, you have to go through this ordeal.”

A Tel Aviv woman who asked not to be named said she chose a private clinic to avoid the unpleasantness of a committee. Although a committee technically met in absentia to approve her, the procedure was lax, requiring her only to sign a committee consent form with a secretary, pay her fee, and book a procedure date.

Experts in 2017 cited the illegal abortion market at some 15,000 procedures a year, which if accurate, would rival the number of legal abortions

“I just didn’t want to deal with it,” she said. “It was worth paying a few thousand shekels.”

A request to the clinic for comment was unanswered.

Shalev also said that avoiding the committee process pushes some women to the illegal abortion market, which can run the gamut from private visits with a physician to unsafe, unregulated methods. Experts in 2017 cited the illegal abortion market at some 15,000 procedures a year, which if accurate, would rival the number of legal abortions.

“Changing this law is a needed correction,” said Eyal. “What happens in the committees is an injustice.”

What happens after (and before)

Practitioners who guide women through pregnancy termination say the proposed reforms should only be considered the first step in a total rethinking of Israel’s approach to the topic.

While much emphasis is placed on abortion and managing unplanned pregnancies, the state does not invest in sexual health education and resources that could provide tools to prevent them.

According to Shalev, Israeli public schools do not have mandated sexual health education, relying instead on organizations like Ladaat to provide workshops to students on fundamental sexual health information.

“And we only do secular schools. In the religious schools there’s almost nothing,” Shalev noted.

Additionally, contraceptive methods like birth control pills and intrauterine devices are not covered by health insurance.

Birth control pill (Photo credit: Public domain)
Illustrative photo of birth control pills (Public domain)

While women are largely able to obtain abortions, the health system does not provide emotional support for women aside from whatever interaction they have with the social workers on the end-of-pregnancy committee.

Emotional support “is not something that really broadly exists,” said Open Door’s Hacohen. “There’s a lot of focus on the abortion and very little on processing after.”

Orin said nobody from her hospital care team ever reached out, leaving her to turn to a private counselor to help her process her abortion.

“From the beginning to the end, there’s ignoring of the whole emotional side of this thing. It’s not even a factor,” she said. “I really became depressed. I cried whole days. I couldn’t leave the house. It was hard for me to shower. Everything hurt, 24/7.”

“‘You made a mistake and let’s get past it as quickly as possible’ — that’s the feeling [I got],” Orin added. “I wasn’t prepared, and it made it so traumatic.”

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