Between a Rock and a Hard Place: Abortion, Catholicism, the Populist Right and Public Health Threats in Poland

Abstract

This article analyzes how and why a near-total abortion ban was recently secured by a populist ruling party with support from Catholic Church leaders and lay groups following earlier passage of one of the most restrictive abortion laws in Europe. The paper further examines the public health threats posed by these measures, which have long been under-researched. These policy shifts are situated within the deeply embedded context of Poland’s abortion conflict and a setting that has long been challenging for reproductive health. The 1993 ban led to the resurgence of clandestine abortions, a near-total privatization of abortion services, and more women seeking abortion services overseas. In late 2020, the exemption for severe fetal anomalies that made up 97% of all legal abortion cases in prior years was eliminated. Neither ban has significantly reduced the number of women obtaining abortions, nor have they increased birth rates as anticipated by proponents who championed traditional family values that they equated with Catholicism and Polish national identity. The new blanket ban on abortion constitutes a health risk and a punitive measure achieved via a judgement of the Constitutional Tribunal stacked with loyalists by the ruling party. It did not reflect popular will, although societal attitudes on abortion are markedly less permissive than in much of Europe. Although the populist and religious right have realized their long-held goal of further restricting, if not eliminating, women’s access to abortion services, compelling criticisms have been raised about how this move compromises women’s health and autonomy. Ironically, the realization of this goal, which many Poles view as unduly extreme, may also undermine long-term support for both the political right and the Church. The wisdom of their move was widely questioned, sparked the largest protests since the end of Communist rule, and drew international criticism. It proved a polarizing action that alienated many young adults and may have accentuated a secularizing shift. Women and their partners are finding new ways to navigate many public health threats by increasingly traveling beyond Poland for safe abortion care and resorting to newly available medication abortion methods.

1. Introduction

For close to a century, abortion has been a touchtone issue in Poland that has sparked episodic periods of potent controversy. Notably, it has never disappeared from the agenda of many Catholic Church leaders, their political partners, and lay groups, who have long championed a legislative ban on abortion, emphasized traditional family and religious values, and sought to crowd out other ways to frame debate about this issue. Following a protracted struggle during the democratic transition, this social conservative alliance secured passage of a law severely restricting abortion services. Almost three decades later, similar groups used judicial channels to enforce additional restrictions after seeing their legislative attempts contested and put on hold. In the process, they ignited a social protest movement not seen in Poland since the momentous democratic transformation. This paper examines this longstanding debate with a focus on its more recent phases, including how and why these bans were adopted, how public health threats were again sidelined, and the consequences of their oversight.

Poland has been at the center of regional attempts to change abortion policy. It is the largest country in East–Central Europe and occupies an increasingly important role in European Union (EU) matters. About 85% of Poles have been baptized Catholic (ISKK 2015; Statistics Poland 2014), the highest percentage in any European country (Pew Research Center 2013); most still identify as Catholic, but substantially fewer are routinely practicing adherents of their faith tradition. Beyond its central religious role, the Catholic Church has long been influential culturally, socially, and politically. As is discussed further in this paper, it was marginalized when abortion was legalized under Communist rule in 1956 and made available upon the request of a pregnant woman. Once the Communists lost power, restricting abortion became a top priority for the country’s bishops and their new political partners. Efforts to restrict abortion and other aspects of reproductive rights in several other post-Communist countries were unsuccessful in the early 1990s (David 1999; Gal and Kligman 2000). However, the situation played out differently in Poland, where commitment to liberal democracy became conflated with protecting life from the moment of conception. Successive moves to enact legal abortion bans have also been used as mobilization vehicles and profoundly threatened public health and women’s agency and rights.

Legislators criminalized abortion in 1993, and controversy simmered thereafter. This legal ban was overturned in 1996 and reinstated a year later. The conflict intensified after the staunchly conservative Law and Justice Party (PiS) came into power in 2015 and sought to restrict abortion services further. After their initial attempts to do so were rebuffed, the country’s highest court ruled in late 2020 that fetal abnormalities were unconstitutional grounds for permitting abortion to occur. Despite nationwide protests, in early 2021, the ruling went into effect, eliminating fetal malformations as the last significant exception permitting the procedure. Poland is now the only large EU country where a woman is permitted to terminate a pregnancy only if it results from rape or incest or if her health or life is at risk, with these exemptions not always available in practice. Poland’s de facto blanket ban on abortion, first imposed in 1993 and reinforced in 2020, carries major public health threats, especially to reproductive health and rights. The situation is complicated further by the lack of ready access to effective methods of modern contraception, with widespread ignorance and poor communication about family planning.

This paper has three objectives. Firstly, it examines the interplay between the Polish Catholic Church and allied politicians, particularly from the populist right, to assess how and why a near complete ban on abortion services was secured—after having earlier passed one of the most restrictive statutes in the former Soviet Bloc countries of East–Central Europe. The new ban was arguably achieved via the sidelining of normal democratic channels, public opinion, and the voices of women outside of their traditionally prescribed roles as mothers and caretakers. The earlier ban had replaced a broadly permissive statute in Poland similar to the legislation adopted in all these countries in the mid-1950s that at the time was among the most liberal in the world. The critical junctures in the recent phases of this conflict are analyzed, including the strategies advanced by its main protagonists and the shifts in abortion policy that occurred, set within their evolving public health context that remains understudied. Secondly, it updates earlier analyses of the Polish abortion debate and the roles played by its key actors via consideration of the longer-term evolution of the ensuing conflict up to the present day. This shows that despite some notable differences, many aspects of modern-day conflict are rooted in past phases of this longstanding controversy. Thirdly, it discusses the implications of these developments, especially for public health, and attempts to navigate the new realities that have emerged.

2. Materials and Methods

To accomplish these objectives, we employ a blended political economy and policy analysis framework focused on the contexts, processes, interests, systems of power, and main actors involved in this conflict, embedded within a public health perspective. The paper is firmly rooted in empirical research and within the tradition of policy analysis found in public health and health policy. Policy analysis seeks to understand, describe, and explain what is defined as a public problem worthy of policymakers’ attention—including by whom, when, why, by what means and in what ways—and how such problems are articulated, with policy options formulated, decided upon, and implemented. These are inherently political processes, although many other considerations come into play. Policy scholarship critically evaluates contested policies, their varied origins and impacts, and relevant aspects of policy making. Policies manifest when there is a convergence of issues. Health policy analysis seeks to understand and explain the interactions between institutions, interests, and ideas in the policy process, including the evaluation of past and present policy failures and successes, and it assesses plans for future policy implementation and health reforms. The multi-dimensional frame adopted is critically informed by public health.

Several data collection instruments were used, including documentary analysis, interview data conducted by the author at different phases of the abortion conflict, and published statistics and studies, as well as media reports where appropriate. Documents considered include government reports, legal statutes, other official documents, professional guidelines, issue briefs, and additional written material sources. Further secondary data analysis included research and evaluation reports, demographic and epidemiological studies, and opinion poll data. The author has also examined the extant literature on different aspects of abortion and the attendant policy debate.

An additional important line of evidence comprises the author’s own primary data collected over the past three decades, in which he first conducted over 30 elite interviews with major actors in the abortion debate. These included representatives from the government sector (including a former Minister of Health), political parties (including Parliamentary deputies and senators), the Catholic Church (including one former cardinal and several bishops), and other groups. Since then, he has conducted further interviews, including with academics, researchers, activists from various non-governmental groups (NGOs), journalists, and other observers of the abortion debate. Collectively, these sources have enabled inferences and significant insights to be drawn on the issues studied, information to be triangulated and synthesized, and conclusions to be drawn.

The Polish case illuminates the consequences of sharp restrictions on access to safe and legal abortion care that may occur in a relatively high-income country without enabling readily available means of prevention and with relatively fragile democratic institutions, as well as how women’s lives have been disrupted by the changing socio-political currents. The overreach of political and religious conservatives may yet serve to undermine the Church’s social standing, at least in the short term, and appears to have contributed to a decline in religious practice, especially among younger adults. At the same time, changes in abortion technology, attitudinal shifts, and other factors are enabling attempts to circumnavigate some of the recently imposed restrictions, thereby mitigating some of the tangible public health threats posed, particularly for women.

3. The Neglected Public Health Context and Dimensions to a Longstanding Problem

Before considering the development, specificity, and recent trajectory of this conflict, it is first important to understand the magnitude of the problem and its fundamental public health context. The latter in particular has been largely neglected by the main protagonists in this dispute and in academic discussions of the Polish case that focus on its religious, sociological, medical, legal, or political dimensions. Additional information is provided in subsequent sections concerned with different phases of this conflict, and the evolving contextual realities are subsequently revisited with respect to consideration of the public health threats posed by the most recent ban on abortion.

Official statistics on abortion have long been considered unreliable by all parties to this conflict (Kulczycki 1995). This is due to stigmatization and the contested legality of the procedure, as well as the reality of the underground black market where many abortions occur. Consequently, there are no complete statistics on how many Polish women currently have abortions and how many have done so in recent decades. After abortion was legalized in 1956, the official data published by the Central Statistical Office underreported abortions because only procedures conducted in hospitals and clinics had to be recorded (and not those in physician’s private facilities, where a growing share of pregnancies were terminated for a fee). Abortion became a major method of fertility regulation once it was effectively available upon demand within a context of limited provision of sexuality education and of limited access to modern contraceptives that were suboptimal at the time. Indeed, it is generally assumed that close to 500,000 abortions may have been performed annually in the 1970s/1980s (Fuszara 1991; Kulczycki 1995).

Abortions performed on socioeconomic grounds soon far exceeded those obtained for therapeutic reasons. The procedure became safer as it was made widely available in public hospitals, and as technology, gynecological services and living standards improved. Unsafe procedures were significantly reduced, so that the abortion-related mortality rate declined from 255 deaths per annum in 1957 to 12 cases in 1973 (Fuszara 1991) and continued to decline thereafter. Over time, physicians who had started to provide free terminations in public hospitals increasingly switched to charging handsomely for terminations in private clinics. Estimates suggest that between 50,000 and 85,000 clandestine abortions occurred annually (Kulczycki 1995, 1999; Okólski 1983; Szamotulska 1985). Access has consistently been a greater problem in rural areas, where the availability of reproductive health services and health care overall tend to be more limited.

There were 105,333 registered abortions in 1988, falling to 30,900 in 1991 (Kulczycki 1999). In the three decades since 1993, the first year of the new anti-abortion law, the official count of legal abortions has stood at about 1000 annually (Central Statistical Office 2007), an unrealistically low count for a population of 38 million people. Abortion rights activists and non-governmental organizations (NGOs) have estimated that despite the ban, in the first two decades of this century, about 150,000 Polish women terminated pregnancies every year (Federacja 2021). Even some anti-abortion opponents reluctantly acknowledge that the legal bans imposed in 1993 and strengthened in 2020 have not significantly reduced the incidence of abortion. Rather, abortions have long been pushed ‘underground’ or out of the country, with many women traveling abroad to receive abortions and increasingly using abortion pills to do so (Ciaputa 2019).

Throughout, many more women and couples came to rely on abortion for birth control than would have done had modern contraceptives been more widely accessible and their benefits better understood. However, the range, quality, and availability of modern contraceptives has remained limited amidst the deficient and minimal provision of sex education. This has contributed to many cases of contraceptive non-use and failure, leading in turn to many unintended pregnancies that were frequently terminated. The main methods of family planning used were the traditional ones of withdrawal and periodic abstinence (or calendar rhythm), as well as condoms, although these and intrauterine devices (IUDs) were inferior to present day designs. Oral contraceptive pills only became available in the 1970s, and fears of side effects associated with the high hormonal dosages of earlier pills have long been pervasive. Abortion came to be widely perceived as an unfortunate necessity to regulating fertility, somewhat uncomfortable for many and unpalatable to a strident minority (Kulczycki 1995). Women who sought abortions were of all childbearing ages, although representative data have always been lacking. However, the lack of effective contraceptive use among women who have reached their desired family size led to abortion being more common among older childbearing age groups than in the advanced capitalist societies (Frejka 1983).

As the push to restrict abortion services gathered pace with the onset of democratic transition, some physicians continued to offer procedures through classified advertisements for gynecological services or other euphemisms (Kulczycki 1995; Mishtal 2015). Abortion referral agencies to help women access abortion services abroad also emerged in all Polish cities. Women with economic means were more likely to travel to Western European countries seen as offering better-quality services, such as Austria, Belgium, Germany, the Netherlands, and Sweden. Women with fewer resources were more likely to be referred to clinics in Belarus, the Czech Republic, Lithuania, Slovakia, Russia, or Ukraine. Approximately 16,000 women reportedly received such referrals for abortion overseas between 1993–94, the first year of the new law (Federacja 2013). After several activists who organized abortion travel abroad were prosecuted under the new penal code provisions, referral agencies continued to operate by adopting a lower public profile (Ciaputa 2019).

Poland joined the EU in 2004 and, three years later, the Schengen Agreement, which facilitates the free movement of people, goods, services, and capital with the EU. This simplified travel by Polish women to secure abortion services in Western European countries. Additionally, the spread of low-cost airline networks from across Europe into many smaller Polish cities has made such travel abroad for abortion purposes more feasible and reduced the need for many women to seek clandestine abortions in Poland. Although this movement was disrupted for a short period during the COVID-19 pandemic, more women are now believed to be travelling overseas to procure abortions after access to such services was restricted further in Poland in 2020. Based on the author’s observations, discussions with health professionals and patient advocacy groups, and a review of digital marketing and social media, it is evident that the use of use of abortifacient pills, sometimes brought into the country through various means, has also accelerated in recent years.

4. The Antecedents to Current Conflict and Major Phases of Controversy

4.1. Abortion Policies and Realities in the Inter-War and Communist Periods

After Poland re-gained independence in 1918, its laws reflected the penal codes of its former partition powers (Austria–Hungary, Prussia, and Russia). These were slowly harmonized by the Second Polish Republic (1918–1939), which had a multiethnic and multiconfessional structure, with the Catholic Church dominant in number of religious adherents. It also held a privileged position within the state’s constitutional structure but could not monopolize religious and moral discourse. The view that Catholic morals and patriarchal norms extended to a rejection of abortion prevailed. The 1932 penal code allowed a pregnancy to be terminated without a time limit if it resulted from a criminal act (rape or incest) or endangered a woman’s health or life. A subsequent executive ordinance specified that the former indication needed a public prosecutor’s testimony, and the latter required approval from two physicians (Zielińska 1987, 1990). However, illegal abortions remained common and were often crudely undertaken, with poor, rural, and working-class women more often resorting to procedures in more hazardous circumstances.

Abortion law reform was debated in women’s magazines and physicians’ circles. In the 1920s and 1930s, the writings of Tadeusz Boy-Żeleński, a noted literary critic and physician, were particularly influential in raising awareness about botched abortions, a woman’s right to terminate her pregnancy, and the negative aspects of uncontrolled fertility, especially among the poor. Additionally, Boy-Żeleński railed against the dangers arising from the Catholic Church’s domination over social life, which he accused of being narrow-minded, self-interested, lacking a humane perspective, and hindering social progress (Boy-Żeleński [1930] 2020). His arguments in favor of conscious motherhood and the need for family planning led to the opening of the first Planned Parenthood clinic in Warsaw in 1931, although both pre-war and post-war attempts to expand such a network faltered (Kuźma-Markowska and Ignaciuk 2020).

The 1932 penal code provisions initially prevailed after German forces invaded Poland in 1939. Nazi law allowed abortions to Polish women from 1942 to 1945 (David et al. 1988), the only period in Polish history when abortion was officially legal on request. After World War II, the imperatives to replace the calamitous wartime losses of population (over 6 million people) and to rebuild the devastated economy minimized discussion of abortion law reform. A new Communist regime assumed power in 1947, and soon public criticism and debate of policy differences and alternatives was no longer tolerated. Abortion initially remained forbidden, as was sexuality education, and family planning methods were not yet promoted. By the 1950s, when the health system was still being rebuilt, the number of clandestine abortions rose again. Between 1950 and 1955, 80,000 women were reportedly hospitalized in a serious condition and diagnosed with having had an earlier miscarriage (Klich-Kluczewska 2012). At this time, modern contraceptives that women could use were not yet widely available in any country.

In 1956, Communist Poland followed Soviet legal precedent and repealed the ban on abortion, allowing it if the woman was experiencing ‘difficult living conditions’ or medical exigencies, or if a well-grounded suspicion existed that pregnancy was the result of a crime. Beyond being obliged to follow Moscow’s example, the Communist authorities saw that legalizing abortion could undermine Catholic Church teaching on the topic and its authority in the public eye. Officially, legislators sought to combat the risks associated with illegal underground abortions (often conducted by inadequately trained and equipped practitioners) and wanted to maintain women’s productive and procreative potential. Women were encouraged to work and granted sweeping access to abortion services that Western democracies did not embrace until several decades later.

In 1959, the Ministry of Health issued an executive order that eased administrative hurdles for securing the documents and approvals needed to seek an abortion (Zielińska 1987). The social grounds under which pregnancies could be terminated were never clearly defined, and frequently no proof was requested, so that abortion became available practically upon a woman’s request and provided free of charge in public hospitals. It could also be obtained for a physician’s fee in private outpatient clinics and in medical cooperatives from gynecologists and obstetricians, as well as surgeons. Referring physicians or those performing abortions were obliged to inform women about family planning and contraceptive methods. No gestational time limits were specified, leaving it up to the physician to decide (on the basis of contemporary accepted medical knowledge) if abortion was medically safe. In 1981, the Ministry of Health instructed that abortion after 12 weeks of pregnancy were counterindicated (Czajkowska 2012).

Women were caught in between a rock and a hard place. They were mothers and homemakers in the minds of Communist rulers and Catholic leaders. The government and employers also saw them as workers outside the home and gave generous maternal and childcare benefits compared to Western capitalist societies, but women were excluded from more meaningful social and economic advancement (Fidelis 2010; Perkowski 2017). As in other Communist states, they were obligated to carry a double burden of duties (Sargent 1996), a situation not wholly different from the ‘double burden’ described in capitalistic societies (Hochschild 1989). Despite its legal permissibility, abortion was heavily stigmatized within Poland’s overwhelmingly Catholic population, as were preventative family planning services.

The passage of the liberal new law and subsequent rules in the late 1950s did not eliminate illegally performed terminations, which continued to be performed in private practice. The reported number of abortions performed in outpatient clinics fell from 48,421 in 1962 to 30,347 in 1966, although some of these would have been initiated elsewhere and others would have started as miscarriages (Czajkowska 2012). While the law did not include a conscience clause, some physicians refused to provide abortions on religious grounds, and many more who declined to perform them in public hospitals would do so on a fee basis in their private practice. This, alongside the poor quality of family planning services and the declining birth rate, helps explain why the incidence of abortions was believed to have increased steadily in the 1970s, even though the officially registered count stood at no more than 150,000 annually. Most estimates suggested that from 250,000 to 620,000 abortions were being performed annually in the mid- to late-1970s (Okólski 1983), although the estimation methods used to produce these tallies were crude and inexact (Szamotulska 1985). If about half a million abortions occurred, as seems likely, this would suggest that every second pregnancy was interrupted.

4.2. Sowing the Seeds of Change

The Communist authorities failed in their attempts to suppress their bitter ideological opponent, the Catholic Church, in the postwar period. They saw the Church as an institution with the clergy, yet the authorities also confronted an entire community of Catholic faithful, albeit with different levels of religiosity. After Poland regained independence in the twentieth century, Catholic norms led to an increased identification of the Church with the Polish nation and a stronger endorsement of national activism (Porter-Szűcs 2011). The Church was historically well woven into the nation’s fabric, had suffered with the people and contributed to their resistance in World War II, and was now about to play an even more prominent role in modern Polish history.

The Polish Church was seen as the defender of human rights and of the struggle for freedom from Soviet rule. It exerted a growing role as mediator between an oppressive state and its subjugated people and acquired more soft power built on moral strength. It consistently opposed abortion, although it could not directly confront the state. Differences between Catholic and socialist teachings and moralities over abortion, marriage, and the family sphere and the social position of women meant that conflict in these areas was inevitable. The Church’s authority grew further with the election of Karol Wojtyła, Cardinal of Kraków, as Pope John Paul II (1978–2005), the first non-Italian pope since the 16th century and the second longest-serving pope in history (Weigel 1999). His stewardship of the Catholic Church worldwide provided impetus for efforts to restrict access to abortion services. Earlier, as an archbishop, Wojtyła developed a social philosophy that stressed dignity and the defense of human rights. These developments strengthened the Church’s historic role as protector of national identity and helped engineer a peaceful transition to democratic rule. It also enabled Church leaders and others to assert that a new law on abortion was in keeping with Poland’s Catholic roots and should replace the ‘ungodly’ Communist law on abortion and preempt the introduction of legal abortion services, as was increasingly occurring in the Western liberal democracies (Kulczycki 1999).

Following a regime change in 1970 that opened up limited political space to voice alternative views, the Church stepped up its calls to reverse permissive abortion legislation through pastoral letters and appeals made by the Polish Primate, the episcopate, and in countless sermons made by parish priests (Wyszyński 1990). They cited the high number of abortions performed as evidence for the need to reform the law and to buttress the Church’s moral case. These calls were echoed in the expanding Catholic press and in the new premarital courses set up by the Church that slowly began to discuss what Church leaders considered responsible love and parenthood (Wojtyła 2013) and ‘natural family planning’ (Jarska 2019; Kuźma-Markowska and Ignaciuk 2020). The latter excludes the use of other forms of contraception that the Church dismisses as ‘artificial’ (Noonan 1986). Rather, it focuses on modern versions of periodic abstinence, comprising a form of pregnancy planning based on women monitoring and recording different fertility signals and symptoms during their menstrual cycles to help plan or avoid pregnancy. Although claims for its effectiveness have often been made (Ryder 1983), it is seldom used because it is demanding and cumbersome and does not work for many women with less regular cycles or in less stable relationships. Both the Church and the state saw family planning as a women’s responsibility. With the state not building an adequate network of preventive family planning services, women again found themselves caught between a rock and a hard place.

Rising labor unrest in the 1970s led to the emergence of the independent Solidarity union in 1980, which received critical advice and support from the Catholic Church. During the political turmoil of 1980–81, the Church reinterpreted the slogan for renewal (odnowa) as the moral and societal renewal of the nation. It staked a strong moral critique of abortion and ‘artificial contraception’ and fostered the growth of several Catholic anti-abortion groups such as ‘Gaudium Vitae’ (‘Joy of Life’), ‘Troska o Życie’ (‘Care for Life’) and ‘Pro Familia’ (‘Pro-Family’). These and other Church-affiliated organizations, as well as the Church’s pre-marital courses, press, and sermons, dwelt on the moral and health risks of abortion and castigated oral contraceptives as harmful to women’s fecundity and health, heightening fears of side effects associated with the high hormonal dosages of hormonal contraceptives then available.

The imposition of martial law and suppression of the Solidarity movement stifled further debate about abortion. Nevertheless, the continuing economic and political malaise and loss of Communist authority led to the 1989 multiparty elections that ushered in the democratic transition in Poland and across East–Central Europe. Meanwhile, the Church continued to denounce abortion during the 1980s and advocate for legal protection of fetal life (Drążkiewicz 1991). Through Catholic physicians and lawyers under the patronage of the Episcopal Commission of the Family, the Church was able to address Parliamentary committees in 1988 and 1989 and initiate work on a draft bill on the protection of ‘the conceived child’ (Buxakowski 1990; Grześkowiak 1991).

The increasingly close ties developed between members of the medical profession, Solidarity, and the Church were rooted in the disillusionment experienced by many healthcare professionals with the state’s growing neglect of the healthcare system since the early 1970s (DiP 1983) and in the push for professional power (Kennedy 1991). Senior Catholic physicians and healthcare professionals assumed important roles in Solidarity’s leadership and in the Chamber of Physicians. Established in 1989, this independent body promptly assumed much professional power and committed to help support efforts to revise the 1956 Abortion Act so that it would protect ‘conceived life’ (Krajewska 2021) At its 1991 General Assembly, the Chamber narrowly approved a new Medical Code of Ethics—drafted by a small working group dominated by physicians with close connections to the Church—that forbade physicians from performing abortions except on narrowly defined medical or juridical grounds, under the threat of revoking their license to practice. Physicians were allowed to refuse to perform abortions for reasons of conscience but were then legally obliged to direct the patient to another physician. The Minister of Health was not even sent a copy of the code, which was loudly criticized for its content, disregard for the current law, and the high-handed way it had been rushed through (Kulczycki 1999). However, many physicians remained silent and disengaged, effectively enabling the re-alignment of the medical profession’s corporate autonomy towards the new elites without adequate regard for women’s rights or health (Krajewska 2021). This state of affairs changed little until the first stirring of change in the last few years.

4.3. Democratic Transition and the Reversal of Legal Abortion

The first free elections held in the former Soviet Bloc countries of East–Central Europe were overwhelmingly won by candidates endorsed by the Solidarity Union. Social liberals and conservatives alike embraced an alliance with the Church, a key source of patriotic resistance to communism. Lech Wałęsa, head of the Solidarity movement and the 1983 Nobel Peace Prize winner, served as president from 1990 to 1995. A devout Catholic, he bowed to strong pressure from the Catholic Church that inserted itself into the political vacuum and soon leaned on compliant legislators to advance bills to de-legalize abortion. Bishops and priests spoke often from their pulpits to packed congregations about the immorality of abortion. The Church hierarchy consistently reaffirmed the need to safeguard the right to human life at its earliest and most vulnerable stages.

Democratization brought with it an unexpected backlash against women’s rights, including a sharp return to the discourse of traditional gender roles, with women perceived as wives and mothers. The Church had increasingly championed the causes of human rights and pluralism and now exerted a growing role in matters of social policy that fell within its domain of interest. Although most scholars and journalists emphasized the key role of the clergy, the Catholic laity also took an active role in public debate at the community level and in lobbying Parliament. In addition to the important role served by senior Catholic physicians, committed activists belonged to groups with close ties to the Church such as the Polish Federation of Movements to Defend Life. Politicians with strong anti-abortion views assumed influence in the newly founded and powerful Christian National Union, the dominant conservative–nationalist party of the period. Political and intellectual freedom rapidly expanded, but reproductive rights were soon diminished, with abortion vilified by its opponents and pushed further underground—or abroad, for those who could afford it. As abortion increasingly became a taboo, key members of different Catholic organizations within the anti-abortion movement prepared and pushed additional drafts of the Unborn Child Protection Bill (Grześkowiak 1991) and lobbied the new Parliament more aggressively to propose an abortion ban (Zielińska 1993).

As the political scene increasingly fractured, the Solidarity-led government bought the support of the Catholic parties and Church by pushing through Parliament the law on ‘Family planning, protection of the human fetus, and conditions for the termination of pregnancy’. Poland’s first female prime minister supported adoption of the new law, passed in January 1993, that permitted abortion only in cases of a threat to the pregnant woman’s life or health (prior to fetal viability, qualified as up to 22 weeks of gestation), an unlawful act (up to 12 weeks of gestation), or fetal abnormalities (up to 22 weeks of gestation). Abortions could only be conducted if a public prosecutor confirmed a rape or incest; if a physician issued a written opinion confirming the threat to a woman’s health or life; and if prenatal screening or other medical evidence indicated a high probability of severe and irreversible fetal anomaly or incurable disease threatening fetal life. The law provided no punishment for the pregnant woman, but up to two years’ imprisonment for an illegal abortion provider (Republic of Poland 1993).

The rhetorical shifts in the abortion debate were reflected in the replacement of the words ‘embryo’, ‘fetus’, and ‘pregnancy’ with the new concepts of the ‘unborn child’, ‘conceived child’, and ‘the child in the mother’s womb’ in the rubric of the sharply restrictive 1993 law. Additionally, conservative media ideologically linked to the government and ruling parties, as well as the statements of the clergy and other Church entities, reproduced and amplified the anti-abortion discourse across the public sphere (Koralewska and Zielińska 2022). Despite the ban on abortions that had occurred on socio-economic grounds, these groups depicted the new law as a ‘compromise’ because pregnancies could still be terminated in the rarer cases of rape, incest, fetal abnormalities, or threats to a woman’s life. This enabled Christian nationalist politicians and clergymen to continue to press for more restrictive abortion legislation.

Religious instruction on family life education, including the value of conceived life, was to be provided in public schools. Despite much opposition, resistance to all these moves proved ineffective. For example, women’s groups that emerged to advocate for reproductive rights lacked resources, organizational capacity, and societal standing. They were also hampered by the past identification of women’s organizations as tools of the Communist party (Kulczycki 1995; Zielińska 1993, 2000).

The law led to a sharp decline in reported abortions performed, but vastly more continued to be conducted clandestinely and went unreported, with the state essentially ignoring clandestine clinics so long as their activities were out of sight. Anti-abortion protests became more common at hospitals that still conducted legal abortions, with harassment of both physicians and pregnant women who sought abortions. In one well-publicized early case, a visually impaired woman whose pregnancy endangered her health was denied a legal abortion by several physicians, and her condition deteriorated after she gave birth. Her criminal lawsuit was rejected, and her case was appealed to the European Count of Human Rights, which accepted one part of the complaint, leading the plaintiff to be awarded damages (European Court of Human Rights 2007). However, an official Church newsletter compared her to a Nazi war criminal for wanting to murder her own child (Federacja 2013). While it would be simplistic and erroneous to extrapolate from such known incidents to estimate large numbers of grievous cases, it is undeniable that many others would not have been reported and publicized.

4.4. The First Anti-Clerical Backlash and the Return to a Restrictive Policy Regime (1993–2015)

Widening economic disparities associated with systemic change, as well as widespread concern at the imperious behavior of Church leaders and their perceived interference in secular affairs, led to several leftist parties being voted into power and forming a new governing coalition later in 1993. After an amendment proposed to the penal code was vetoed by the president, the left-leaning Parliament appeared not to consider bold abortion reform worth fighting for. Despite including former Communists who were resolutely anticlerical, the new government lacked partners to push reform and was preoccupied with steadying the economy, building its own credibility, and seeking some conciliation with the Church in the meantime.

A new leftist president, who was elected in late 1996, signed into law new legislation restoring abortion on socioeconomic grounds (Republic of Poland 1996). This in turn was struck down by the Constitutional Tribunal, a judicial body composed of 15 judges elected by the Parliament for a nine-year term and established to scrutinize the constitutionality of legislation and of activities of state institutions. The Tribunal ruled the new abortion law unconstitutional because Article 38 of the Polish Constitution, which protects ‘the life of every human being’, included unborn life. The Tribunal left the new law nominally in place until a new election was held several months later. The victorious center–right coalition (Solidarity Election Action) formed the major voting bloc in the new Parliament, which declined to challenge the Tribunal’s ruling, allowing the new government to effectively reinstate the 1993 ban in December 1997 (Republic of Poland 1997).

An uneasy status quo prevailed thereafter, although controversy always simmered and extended to other areas of reproductive health, particularly assisted reproductive technologies, which Church leaders, allied politicians, and the media increasingly characterized as sinful (Korolczuk 2016; Radkowska-Walkowicz 2012). The Church put its weight behind key democratic causes, including Poland’s campaign for EU membership in the early 2000s, but in implicit exchange expected liberals not to rock the boat regarding issues that it regarded as sacrosanct. Abortion was still accessible at a price through the private market, though the quality of care provided varied. Such abortions later became more difficult to obtain due in part to the deterrent effect of the penal provisions for the imprisonment of physicians performing abortions outside of the limited conditions in which they were allowed. However, the state rarely sought to prosecute clandestine clinic workers, and women increasingly traveled to clinics just over the borders in the Czech Republic, Germany, and Slovakia. In this period of uneasy tension and relatively subdued public conflict, there were very few abortion-related trials, and no physicians, women, or activists were convicted.

Few advocates openly called for a full return to the liberal abortion rights of Communist times. The activities of the anti-abortion camp were more widespread and included regular ‘family marches’ and billboard campaigns with outsize fetuses. In 2011, lawmakers took up a draft bill that anti-abortion activists submitted to Parliament as a civil initiative (a process by which concerned citizens collecting over 100,000 signatures of registered voters can submit legislative proposals to Parliament). This petitioned to ban abortions altogether, even for women who were raped, carrying pregnancies with fetal malformations, or facing health risks. Parliament dismissed a bid by left-wing politicians to drop the law project, which had sufficient support to send it to a Parliamentary committee for further amendments. The ruling center–right Civic Platform Party was divided on the bill, which was then rejected by most members of Parliament.

5. Conflict Intensification (2015–2023)

5.1. The Elimination of Abortion Exemptions

The conservative nationalist Law and Justice Party won control of both the presidency and Parliament in 2015. As part of its traditionalist agenda, it embraced a near-absolute abortion ban and positioned itself as protector of the family in the face of multiple threats. Renewed assaults were launched on the small-scale reproductive health initiatives that existed. The Ministry of Health questioned the over-the-counter availability of emergency contraception and classed it as a prescription-only drug, thereby making it inaccessible for many women. Access to contraception was tightened further and the (male) condom became the only over-the-counter contraceptive available. More comprehensive forms of sexual education were criticized. The government promptly curtailed funding for the small-scale, state-subsidized in vitro fertilization (IVF) treatment program and groups working to prevent violence against women. The government repeatedly threatened to withdraw from a European treaty protecting women, alleging that it sought to normalize homosexuality and was incompatible with Poland’s social and family values. Also, it did little to stop the intimidation of women’s group activists (Nowicka and Regulska 2020) and the increasing attacks made by conservative politicians and Church leaders on the rights of lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) people, who were depicted as threats to family life (Mott 2022).

The archbishop of Kraków, a prominent archconservative voice in the Church and head of the episcopal commission overseeing Church-state relations, echoed the government’s rhetoric. He decried the ‘rainbow plague’ of ‘LGBT ideology’ that threatened Poland in the same way that Nazism and Bolshevism had in the past (Motak et al. 2021). He also warned that Brussels, Berlin, and New York were seeking ‘to impose a neo-Marxist vision of a new order on Poland’, including the ‘so-called rule of law’ and ‘gender ideology’ (Notes from Poland 2021). As in Hungary and Russia, conservative and ecclesiastical elites in Poland saw new contemporary notions related to gender and sexual orientation as undermining their world vision, religious authority, and national identity (Koralewska and Zielińska 2022; Nunez-Mietz 2019; Żuk and Żuk 2020). Equally, the perceived LGBTQ+ threat served as a convenient ruse to deflect public attention away from economic problems and other substantive policy issues, and as a rallying cry for religious conservatives and nationalists. The purported challenge to traditional and natural family relationships was even loosely linked to threats to the nation’s fertility. The government had introduced cash allowances and other pronatalist incentives to boost the country’s falling birth rate, although it was later surprised these were ineffective and, blinded to its own ideology, did not appear to see that ending IVF treatments might prevent a modest rise in birth rates from occurring.

The emboldened anti-abortion movement started lobbying for a Parliamentary draft initiative to outlaw abortion entirely. Conservative politicians initially failed to restrict abortion, with more restrictive legislation twice failing to pass in Parliament. The first draft law, proposed by anti-abortion groups and backed by Church leaders, sought to ban abortion except when a pregnant woman’s life was in danger and to lengthen the penalty for those administering an abortion from two years in prison to five. The proposed bill was similarly presented as a citizens’ initiative to Parliament, which refused to consider policy alternatives that would permit continued limited access to abortion. The Ordo luris Institute for Legal Culture, an ultra-conservative legal think-tank whose members included the education minister, spearheaded the initiative (Meyer Resende and Hennig 2021). Many who backed the bill dismissed its unpopularity and its evident punitive nature, which did not allow exceptions for rape cases. One archbishop even suggested that in rape cases, ‘the stress is so strong that fertilization is less likely to occur’ (Economist 2016).

This proposed tightening of existing restrictions in September 2016 sparked outrage and provoked a wave of mass protests. This included a one-day nationwide women’s strike (‘Black Monday’) that brought marchers dressed in black (symbolizing the death of choice and of their own futures) into the streets of numerous cities. Protests organized by women’s and other groups continued and their unexpected scale led the government to back down. The so-called ‘Black Protest’ was the most visible sign to date of resistance to the socio-cultural conservatism that had taken hold in Poland following the installation of the populist right-wing government a year earlier.

The Law and Justice Party’s dominance of the legislature and executive enabled it to expand its hold on the judiciary, including the appointment of judges to the Constitutional Tribunal. The apparent abuse of the judiciary and dominance over all branches of power soon led to accusations that the ruling party was failing to adhere to Polish and European constitutional law (Smith 2018). Deep unease also ensued about its attempts to dominate media channels. The political conflicts suggested a growing rule-of-law crisis and led the European Commission to refer Poland to the European Court of Justice. These events were occurring amidst democratic backsliding globally and when EU leaders repeatedly accused Hungary’s populist leaders of undermining democracy through illiberal statements and actions over migration, multiculturalism, press freedom and LGBTQ+ rights (Rinaldi and Becker 2021). In 2019–20, over 100 municipalities declared themselves to be LGBT-free zones.

Meanwhile, anti-abortion groups increasingly questioned the constitutionality of Poland’s existing law on the premise that pregnancies unrelated to rape or not threatening a woman’s life could be construed as eugenic practices. In 2018, another legislative initiative was proposed by an anti-abortion organization that gathered enough signatures to meet the threshold for Parliamentary discussion. The bishops conference urged Parliament to consider the proposed bill without delay. The ruling party’s leader (himself unmarried and childless) stated that ‘women should give birth even to children in very difficult circumstances where the child has no chance of surviving’, so that they can be ‘baptized, buried, and given a name’ (Economist 2018). The Council of Europe and UN experts urged lawmakers to reject the bill, but the Parliamentary committee for human rights did not object. A wave of non-violent protests again disrupted the government’s plans and led it to withdraw the bill.

In 2020, Catholic bishops and lay groups pressured the governing Law and Justice Party to impose a stricter law preventing abortions in the case of fetal abnormalities, which had been used for almost all of the 1000 legal abortions performed annually (Sas 2022). The government was eager to change the law but realized this would prove problematic given the likely mobilization of public opposition. Instead, it pushed for a review of the existing law by the Constitutional Tribunal to which, in very controversial circumstances, it had earlier appointed several judges known to be closely affiliated to it. In October 2020, the Constitutional Tribunal found abortion unconstitutional in the case of severe and irreversible fetal abnormalities because it violated the constitutional protection of human dignity. The Tribunal’s president stated that aborting a fetus with abnormalities constituted ‘eugenic practices’ and ‘a directly forbidden form of discrimination’ (Republic of Poland, Constitutional Tribunal 2021).

The ruling tightening the law further effectively eliminated legal abortions because over 97% of procedures were then being performed on these grounds. It sparked the largest mass protests seen since the collapse of communism. The government waited for the protests to die down which were occurring during mid-winter and the ongoing COVID-19 pandemic. The ruling took effect in late January 2021 following publication of the Tribunal’s judgment in the official Journal of Laws (Dziennik Ustaw).

5.2. Organized Resistance to Abortion Bans, Attitudinal Shifts and Changing Narratives

Groups supporting abortion and women’s rights secured a major victory in 2016 when thousands of Polish women wearing black regalia demonstrated against and stopped legislation proposed to impose a near-total ban on abortion. The ‘Black protest’ additionally called attention to the threat of further attempts to outlaw abortion. After Poland’s constitutional court imposed such a ban in October 2020, hundreds of thousands of people took to the streets, with demonstrators united by the red lightning bolt symbol adopted by the Women’s Strike and the emergent abortion rights movement. Many protesters also opposed the government’s heavy-handed approach, the ruling coalition’s domination of all three branches of government, and Church interference in what many perceived as private matters. The protests engaged many young people, men and women alike. Smaller rallies against the ruling and in support of the protests were organized in other European countries (Pronczuk 2020; Santora et al. 2020).

Nationwide protests against the ruling included unprecedented scenes with sit-ins staged at Sunday mass, demonstrators shouting at priests, and cards with lightning bolts placed in offering baskets. Protests occurred outside the ruling party’s offices and politicians’ homes. The most notable public confrontation saw police standing between members of far-right and nationalist associations and abortion-rights protesters at the steps of Warsaw’s Holy Cross Church, a monumental baroque church opposite the main University of Warsaw campus. The most symbolically important battle occurred in protests near the Curia headquarters of Kraków, which is also the residence of its metropolitan archbishop. Protestors labelled this ‘the house of Satan’ with reference to the dominant conservative national Catholic wing of the Church and best represented by Kraków’s current metropolitan archbishop Marek Jędraszewski. The label stood in sharp contrast to the deference and special fondness in which this citadel of power was held only a short while ago as the former residence of Pope John Paul II (then Cardinal Wojtyła) (Motak et al. 2021).

Protests and street fights continued through January, when the ban went into effect, with police using tear gas in some cases. Many protests occurred in small- and medium-sized towns typically seen as conservative strongholds, prompting the Law and Justice Party’s leader to call on supporters to defend churches ‘at any cost.’ He further declared that the Church is the ‘repository of the only moral system commonly known in Poland’ and that ‘rejection of it is nihilism’ (Notes from Poland 2021). State television channels included much commentary infused with anti-feminist rhetoric; protestors in turn used sarcastic and profane slogans in response to what they saw as the lack of respect for women shown by the government and Church leaders. Several thousand protesters were subsequently brought to court and many were accused of causing an ‘epidemiological threat’ by encouraging protests during the pandemic. Judges dismissed the vast majority of charges as they determined that the government’s decree outlawing mass gatherings during the COVID-19 pandemic had violated the constitutionally guaranteed right to assembly. Several women’s leaders were targeted and subsequently appeared at public events only with a police escort (Neumeyer 2021; Nowicka and Regulska 2020).

The protests proved a rearguard action in the losing fight for abortion rights. However, as the first mass manifestation of women’s solidarity for maintaining limited abortion rights, they may yet have lasting impact on the abortion debate. First, they gave rise to a more vociferous women’s and abortion rights movement. The All-Poland Women’s Strike (Ogółnopolski Strajk Kobiet, OSK) that emerged from the ‘Black Protests’ helped organize protest actions throughout this most recent phase of abortion controversy (Motak et al. 2021). Whereas women’s groups had earlier rejected the label of feminist because of its tainted associations with the Communist period (Wolchik 1998), protest placards and slogans suggested an increased willingness to identify with feminism and reproductive rights.

Secondly, the protests injected the language of reproductive rights into the public discourse, where it appears to have gained some traction. It is no longer straightforward to dismiss reproductive rights in the name of democracy or the nation–state, at least among younger and middle-aged adults. Many are well aware that they live in the only major EU country to make abortions practically no longer obtainable even when a pregnancy might threaten a woman’s life. (The small island state of Malta, which is also staunchly Catholic, prohibits abortion in all cases, as do the microstates of Andorra and Vatican City). This awareness and frustration may yet give rise to a changed narrative regarding abortion. For the first time also, abortion came to be framed as part of public health, whereas the dominant public discourse had previously focused on irresponsible women and amoral illegal practitioners.

The scale of the backlash against the government revealed a major gap between public opinion and the party’s traditionalist agenda. Following the Tribunal’s ruling in summer 2020, support for the ruling party fell by some ten percentage points to 30–35%, although this decline was also likely attributable to the government’s faltering pandemic response. The demonstrations may have also heralded shifts in women’s hitherto passive acceptance of gender stereotypes and a more general shift toward secularization, especially among younger adults. While it is still too early to ascertain if these societal shifts have become entrenched, the protests have undeniably broken a longstanding taboo against challenging the Catholic Church. Only two to three decades earlier, it was being widely lauded for its resolute support, wise counsel, and heroic leadership in the national resistance to Soviet Communist rule. The events may have accelerated a shift towards secularization as well as in the prevailing narrative about abortion. Church statistics show that the proportion of people regularly attending Sunday mass has fallen from 50.3% in 1990 to 36.9% in 2019, and 28.3% in 2021. While the latter statistic is likely affected by the pandemic, the overall decline has been particularly pronounced among young people, whose participation in religious practices has fallen by about half over the course of one generation (ISKK 2022).

Opinion polls probing public attitudes about abortion are notoriously sensitive to question phrasing and field execution. Numerous abortion polls have been conducted in Poland, but few are reputable. Nevertheless, nationally representative polls have consistently shown a sharp polarization of opinion and no societal consensus favoring either strong restrictions or its availability on request. Most people are somewhat troubled by abortion but want to maintain some mitigating grounds for abortion. Support for an outright ban declined somewhat after passage of the 1993 law, but by 1997, support waned for easier access to abortion services, although it has always been greater among those with higher educational attainment and lower parity and those living in urban areas (Kulczycki 1999).

Attitudes to abortion became more restrictive in the first two decades of this century as most adults came to accept the limited exemptions for abortion under the restrictive law of this time. The Public Opinion Research Center (CBOS) has routinely canvassed public attitudes about abortion among adults aged 18 years or older. In 2010 and since, its periodic surveys have consistently shown overwhelming support for abortion when a woman’s life or physical health is threatened by pregnancy (80–90%); lower but still strong support in rape or incest cases (73–79%); and majority but weaker support if fetal anomalies would likely lead to the birth of a disabled child (53–64%). Support for legal abortion declines significantly in other situations where it is now banned: in 2010, 23% of adults believed abortion should be legal if the woman was experiencing a difficult material situation and only 18% approved of the procedure if a woman did not want to have a child (CBOS 2010). In 2014, CBOS found that 20% of adults approved of abortion on request of a woman (Hipsz 2014).

The most recent CBOS poll conducted in December 2020, shortly after the Tribunal’s ruling, found considerable stability in views regarding the circumstances under which abortion could be legally allowed, with 14% of adults favoring abortion in all circumstances and 3% implacably opposed. Additionally, when asked about different degrees of fetal malformations, 75% of respondents supported permitting abortion if the fetus had incurable defects that would lead to its death; 64% were supportive if severe fetal malformations would lead to the birth of a disabled child; and 38% supported abortion in the event of an infant being born with Down’s syndrome, whereas 46% opposed such procedures (Feliksiak and Roguska 2020).

In July 2022, an Ipsos poll that surveyed abortion views in 27 countries found that 22% of Polish adults aged 16–74 years old believed abortion should be legal in all cases up to the 12th week of gestation and 33% thought it should be legal in most cases, whereas 18% believed it should be illegal in most cases and 12% that it should be illegal in all cases. The remaining 15% of respondents did not know or preferred not to say. Support for liberalizing access to abortion in most or all cases was higher among young adults and among women (Ipsos 2022). Examination of other polling reported in the media also showed somewhat increased tolerance of abortion since the Tribunal’s decision, with the caveat that over half of those respondents favored simply returning to the previous abortion ban.

EU institutions consistently criticized the Law and Justice Party for its restrictive abortion law proposals, as well as for flouting liberal democratic norms with respect to women’s other rights; the rights of non-heteronormative people; and the independence of the media and of the judiciary. In turn, both the party and the government it heads have accused the European Commission in Brussels of seeking to impose its “politically correct” views on a population wedded to tradition. The government has likened the EU to Poland’s former Soviet overlords and raised doubts as to the applicability of its laws to Poland. This has led to much conflict and, as with the policies of the Hungarian populist leader Victor Orban, much grandstanding over EU funding which the commission has reduced for both countries. However, relations between the EU and Poland’s government have improved since the Russian invasion of Ukraine in 2022. The government’s strong support for Ukraine and the economic boost generated by the large presence of Ukrainian refugees may yet mitigate the loss of votes for the governing Law and Justice Party, which faces another election in October 2023.

Collectively, these changes may indicate significant long-term developments, but they should not be overestimated. The Catholic Church remains very influential in Polish society, where patriarchal norms are still embedded and compliant conservative lawmakers remain dominant. In July 2021, even the liberal–centrist Civic Platform Party (the main governing party between 2007 and 2015) voted against debating a bill to remove criminal liability for doctors who performed abortions in cases of fetal impairment. It is undeniable, however, that although Church leaders and associations and social and political conservatives have achieved a long-sought goal in securing a near-total legal ban on abortion, the wisdom of their actions has been severely questioned by much of the population, and their power may have been compromised in the process. They have also ignored the public health threats their actions had posed.

6. Public Health Threats

6.1. Continuities and Changes in Abortion Practice

Abortion remains universally acknowledged to be a mass-scale phenomenon, despite the further tightening of the law and the lack of meaningful records. Estimates continue to suggest that about 150,000 Polish women terminate pregnancies every year, and the actual number is now even more difficult to estimate due to the increased resort to medication abortion (accomplished with drugs instead of surgery).

According to official data, 1057 legal terminations were conducted in Poland in 2017, including 22 procedures performed due to a threat to the mother’s life and health and 1035 due to severe and irreversible fetal defects, with none connected to criminal offenses (Republic of Poland, Report of the Council of Ministers 2020). The Ministry of Health reported 1110 abortions in 2019, 1074 (97%) of which involved cases of fetal defects, the majority (271) being for Down’s syndrome without other anomalies (Zakolska 2020). Even before the elimination of the exception for fetal defects, however, access to prenatal diagnosis and care was inadequate, especially outside major cities. Women would sometimes learn of severe fetal defects only after the allowable deadline for termination had passed. Therefore, passage of the ban greatly exacerbated their suffering, as they would be forced to carry such pregnancies to term which, additionally, could endanger their own lives. Another troubling aspect to such ethically problematic cases relates to the loss of scarce hospital resources in overburdened obstetrics and gynecology wards and emergency rooms, which also prevents other hospitalized cases from receiving due attention.

Very few legal terminations occur under the remaining two exceptions to the new abortion ban. The process of securing the required permissions poses a procedural obstacle course. Rape victims find it further traumatizing and humiliating to obtain the necessary certificate from a prosecutor, adding to their pain. A ‘serious risk’ to the mother’s health now competes with that to the fetus. Hospitals have been known to refuse abortions even in conditions of rape, for which they do not provide access to emergency contraception. Additionally, few abortions now occur in backstreet clinics due to stiff penalties for providers, greater ease of travel overseas to terminate unwanted pregnancies (sometimes referred to as ‘abortion tourism’), changes in abortion technology, and the fact that more NGOs and activists now help women procure self-administered abortifacient pills.

After Poland joined the EU and the Schengen Agreement, easing travel within the EU borders, Polish women increasingly traveled abroad to have abortions. This became effectively risk-free and often less expensive than seeking a clandestine abortion in Poland, even after factoring in travel and overnight accommodation. These logistics are even taken care of by some women’s collectives such as Ciocia Basia (‘Aunt Barbara’), a Berlin-based volunteer group created to assist Polish women travelling to the city for an abortion and helping cover costs for those unable to afford the journey and the procedure (Ciaputa 2019). In late 2019, it joined ranks with other domestic and overseas-based groups to form the first pan-European feminist initiative, called Abortion Without Borders, to assist Polish women seeking information about and access to abortion services, with most contacting it to order pills to take at home (Sussman 2022). In the two years since the Tribunal’s ruling, it has supported 78,000 people to access abortion services safely, including 1200 who terminated their second trimester pregnancies in clinics in other European countries. Women with late-term abortions might be sent to the Netherlands or the UK, which effectively allow termination up to 24 weeks of gestation. Also, many abortion clinics in multiple EU countries now list the availability of services in Polish on their websites. Such knowledge is passed on readily through word-of-mouth, simplifying the process further.

In 2003, Women on Waves, a Dutch NGO seeking to prevent unwanted pregnancies and unsafe abortions in countries that restrict reproductive rights, generated much publicity when it sailed its boat specially equipped to provide sexual and reproductive health services to a harbor near Gdańsk. Polish women could receive non-surgical abortions, counseling, and contraceptive services because its boat was moored beyond Polish territorial waters and operating under the jurisdiction of the Netherlands. Abortion opponents staged counter-demonstrations, and police charged Women on Waves for distributing abortion pills allegedly within Poland, only to later drop the charges for lack of evidence. Police questioned women who boarded the boat, having obtained their names from customs officials who collected their passports, and were condemned for violating the women’s privacy (Mishtal 2015). In 2015, Women on Waves again drew much publicity when a staged flight of two drones carrying abortion pills from across the German border to women and journalists waiting nearby in Poland was filmed (Nowicka and Regulska 2020). The main Catholic daily Nasz Dziennik described the stunt as a ‘drone of death’. The head of the Polish Association of Human Life Defenders (Polskie Stowarzyszenie Obrońców Życia Człowieka, PSOŹL) warned this could lead to genocide akin to when the Nazis tried to destroy Poland by promoting abortion and contraception (Ciaputa 2019). Abortion opponents, alarmed at the prospect of a new front in the conflict, variously labelled this action as anti-Catholic, pro-Communist, antipatriotic, and harmful to women. Conservative politicians uniformly deplored this foreign interference in their virtuous struggle.

More women can be expected to procure needed medications, either passed on by friends or well-wishers or obtained by mail after being ordered from readily available websites and phone numbers. Advertisements nowadays appear online for gynecologic or other safe services that can be obtained discretely by women. Agencies will often advise on purchasing abortion pills that can be used safely and effectively for early-term abortion and on what to know about such non-surgical procedures. Women are more aware of and interested in such services. Medication abortions are cheaper than surgical abortions that were often earlier obtained from shadowy underground clinics, although an unregulated market of abortifacient pills would also prove problematic should counterfeit pills and price gouging emerge. An increasing number of these informally secured medical abortions are unsupervised; however, the World Health Organization (WHO 2022) recently endorsed ‘self-managed’ abortion up to 12 weeks gestation as the safest way to terminate an early-stage pregnancy. Such abortions are believed to have become more common in many countries during the pandemic. In about 5% of cases, the pills may not be effective and another dose must be taken, and on occasion, antibiotics are needed to cope with excessive pain and bleeding. New helplines have been formed to provide assistance using various telecommunication technologies, often operating from overseas.

The first known death attributable to the more restrictive abortion ban occurred several months after it went into effect in 2021. The pregnant woman died of septic shock after she went into premature labor and physicians waited to operate until the death of her seriously malformed fetus, whose condition was first diagnosed eight weeks earlier. Physicians had repeatedly ignored warning signs, even though the fetus was lacking amniotic fluid, and denied medical intervention. Her family later went public with the case, prompting demonstrations in her honor in many towns. Her final distressed text messages sent to her parents before death stated: ‘My life is in danger. They cannot help as long as the fetus is alive thanks to the anti-abortion law. A woman is like an incubator’. The hospital defended the medical team’s actions, stating that they had acted in accordance with the law and done ‘everything in their power’ to save the woman’s life (Bennhold and Pronczuk 2022).

6.2. The Ambiguous Position of the Medical Profession towards the Abortion Bans

The Ministry of Health subsequently issued guidelines reminding physicians that ‘they should not be afraid to take obvious decisions’ if there is a serious risk to a woman’s health and life. However, this has done little to assuage physicians’ fears of prosecution in potential negligence cases related to the revised law. At least two similar cases emerged in 2022, where physicians refused to perform medically mandated abortions due to fear of losing the right to practice and of criminal liability.

Defenders of the restrictions dismissed these incidents as extreme cases attributable to physicians’ poor judgment. They asserted that the law would have no chilling effect on medical practice because it still gave physicians too much latitude to perform abortions. However, these tragedies became an additional source of grievance for defenders of abortion rights and highlight risks to women posed by enforcing such restrictions, which have burdened with anxiety all decisions that women, their partners, and their physicians make regarding problematic pregnancies. Most dramatically, this includes situations involving severe fetal defects, rape, or threats to the woman’s life, which can also occur when early symptoms are not always evident, such as in ectopic pregnancy cases.

In the course of democratic transition, healthcare professionals were content to see the changes in the political economy that the country desperately needed. The medical profession stayed largely silent as the professional re-alignment with the new state proceeded and glossed over the adoption of attitudes hostile to improving reproductive health services. Most of the medical profession, including obstetricians and gynecologists, remained curiously disengaged as successive attacks occurred on different aspects of reproductive rights ahead of the enactment of the first abortion ban. Following its re-constitution, the Chamber of Physicians was co-opted by conservative medical groups who ran roughshod over any opposition to the new restrictions on abortion adopted in its new Medical Code of Ethics. The Chamber and profession allowed themselves to be part of the conservative legal activism that had taken root across many sectors and did not oppose subsequent rulings of the Constitutional Tribunal that restricted abortion access further. This has allowed for the widened scope of conscientious objection, whereby physicians and hospitals who sign a conscience clause based on faith may refuse abortion even in legally permissible situations. Additionally, they could cite the clause and refuse to give prescriptions needed for emergency contraception.

The restrictive stance of the profession toward access to abortion services is only now being revisited, a generation later. In late 2020, the Chamber of Physicians, the Society of Gynecologists and Obstetricians, and the Society of Human Genetics expressed ‘deep concern’ regarding the more severe restrictions countenanced by the Constitutional Tribunal (Krajewska 2021). However, the motives behind such professed concern appeared to be mixed and rooted as much in the feared loss of professional autonomy and interests as in any renewed awareness of the adverse implications of such restrictions for women’s health and autonomy. However, many physicians and healthcare workers sympathized with abortion rights supporters and opposed the new restrictions, which could foreshadow a rupture in the ideological alliance between the medical profession and state authorities. Professional leaders are mindful that the major public protests may herald shifting socio-political currents that could result in future changes in abortion legislation and practice.

In June 2022, the Minister of Health approved a new legal provision requiring physicians to collect records on all pregnancies that would be entered into the central medical information system. The Ministry of Health claimed the data were required to meet EU health regulations on patient data, that only physicians would have access to it, and that it was part of the digitization of existing medical information. Critics argued that pregnancy information was already collected in medical records and it was unclear why more data should be needed and who would have access to it. Additionally, the move was staunchly criticized as an attempt to monitor whether pregnant women give birth or to track those who travel abroad for abortions (Holt 2022). Moreover, women who had experienced miscarriage could be falsely accused of terminating their pregnancies, whereas others could be fearful of becoming pregnant due to fears of having to give birth in every situation and of possible criminal consequences.

6.3. The Beleaguered State of Reproductive Health Services

Prevention efforts to avoid the need for abortion remain grossly deficient. Recently the European Parliamentary Forum for Sexual and Reproductive Rights (2022) ranked Poland’s contraceptive policies as ‘exceptionally poor’ and the worst among 46 European countries based on a range of measures related to costs, their reimbursement by the health system (including for young people, unemployed, low-income and other vulnerable groups), available counseling and methods, and provision of information. Poland was the only country with emergency contraception unavailable and whose national health system does not cover long-acting reversible contraceptives.

Many physicians remain uncomfortable about prescribing contraception. Primary health care services do not include contraceptive counseling and the public health care system lacks family planning programs and services. The Federation for Women and Family Planning (Federa), a Warsaw-based NGO set up in 1991 to replace the former discredited state-supported family planning organization, has been unable to reinvigorate family planning services in the face of numerous barriers, although it serves an important advocacy role. During the Covid pandemic, the government considered contraception as non-essential, impeding supplies which came from abroad. Sex education in schools remains limited, with scant information provided on modern contraceptives. Anti-abortion groups and the current government continue to criticize more comprehensive forms of sex education, with the WHO’s suggested content characterized as ‘highly controversial’ by Church-associated groups. These included the Ordis luris institute, which has also encouraged pharmacists to refuse to sell contraception by citing ‘conscientious objection rights’ and has promised them free legal aid if challenged.

Since the recent period of conflict intensification began, there has been more solidarity among abortion-rights activists, who skirt carefully around existing restrictions. Many have been threatened with imprisonment for distributing abortifacient pills, whose legal status is somewhat of a grey area, although the provision of instructions on how to buy and use such medications is not legally inadmissible. The newly restrictive law criminalizes only abortion providers, meaning that self-managed abortions are not criminalized. A new front in the abortion conflict could be opened should anti-abortion opponents call for the law to be tightened yet again by preventing and punishing distribution of such pills, although any such measure would be very difficult to enforce. However, in 2023, a co-founder of the Abortion Dream Team, an activist group helping women access drugs to facilitate terminations abroad, was prosecuted for providing assistance to a woman seeking abortion medications. This was the first conviction of its type in Poland or in Europe (Strzyżyńska 2023). The woman’s rights activist was sentenced to eight months of community service but appealed the verdict and vowed to continue her work. Anti-abortion opponents, including Ordis luris, which was a civil party in the trial, had demanded a prison term, for which there was no legal basis. The judge in the case was a former prosecutor appointed by the justice minister who himself was also the former national attorney (Strek et al. 2023).

6.4. Inadequate Support for Disadvantaged Women with Problematic Pregnancies Who Give Birth

In sharp contrast to its determination to stop abortions, the state offers only minimal support for the needs of single mothers, including those who have fled domestic violence, and for parents of disabled children or those forced to bring to term a pregnancy where the fetus is found to have profound birth defects. Under communism, childcare was free and most workplaces had on-site facilities to encourage mothers to join the work force. That system, despite its limitations, collapsed after 1989 in the wake of the economic crisis, systemic transition, and the rekindled vision of women as mothers and caregivers in the domestic sphere.

The Law and Justice Party, elected in 2015 on a pro-family platform, saw an opportunity and passed one of Europe’s most generous child benefits programs. However, the revised family policy still lacks childcare, a precondition for mothers to return to work, and special support for the parents of disabled children. Over the past decade, groups of parents of disabled children have twice picketed the Parliament to protest the lack of state support, in 2014 and 2018. By raising money through donations, some Church parishes and priests have offered support in the form of temporary shelter, food, and childcare for single women with problematic pregnancies and in financial and emotional distress. Such charitable assistance can help but is hard to maintain and cannot substitute for greater state support.

7. Conclusions

This article has examined the protracted nature and recent junctures of the abortion dispute in Poland, including the roles and strategies of key groups and the public health threats that have arisen, as well as attempts made to navigate them. We have focused on how the problem of abortion has been alternatively identified and problematized; how policy initiatives have been developed, promoted, and pushed onto the agenda; and how and why they have been stalled, stopped, and at other times successfully enacted and implemented. Using both documentary analysis and interviews with key actors in this conflict, these developments have been considered within an understanding of the prevailing contextual processes in society and of how power and ideas have been contested socio-politically.

The unresolved nature of the controversy and the public health challenges that have emerged as a result of the recently imposed abortion bans strongly suggest that more policy shifts will follow. Conservative nationalist politicians and factions of the Catholic clergy and Church-affiliated groups have succeeded in their efforts to impose further restrictions, but these may not prove sustainable, not least because policymaking is still insufficiently informed by public health evidence and realities. This has again left abortion policy mired between religious and political dictates and strictures. Additionally, women have been left caught between legal restrictions and societal expectations, as had also occurred during the Communist period. Despite abortion affecting women most directly, they have been largely sidelined from the public conflict by its main protagonists. Yet again, abortion policy and women’s decision-making autonomy and health have been caught between a rock and a hard place. The consequent public health threats have been largely overlooked and considered collateral damage by those seeking to restrict access to abortion services, as well as understudied by researchers.

Poland and the United States of America (USA) are the only two democratic countries to have rolled back abortion rights in the 21st century. The Constitutional Tribunal’s 2020 judgement further tightening the already strict anti-abortion law anticipated the U.S. Supreme Court’s 2022 ruling overturning the Roe v. Wade decision that had made terminating a pregnancy legal for 49 years. Both rulings adopted a similar tone and language even though the substantive legal questions differed. Both rulings showed contempt for women’s rights and failed to consider the public health consequences. However, the U.S. ruling against abortion does not correspond to the situation in Poland, where a virtually complete legal ban on abortion has ensued. In the US federal system, many states would continue to allow abortion services, despite the Supreme Court’s move to outlaw the procedure. Also, notwithstanding these attempts to bring legal closure to a multidimensional problem, many women with unwanted pregnancies will invariably seek to travel across borders to obtain abortions in more lenient jurisdictions, be it across state lines in the US or overseas in the case of Poland. Moreover, the comparatively recent advent of medication abortion allows a way to obtain abortions if medical practitioners stop providing them.

Throughout Poland’s dispute, abortion has remained a mass scale phenomenon, although its relative safety, ease of access, and modus operandi has changed over time and varied for different groups. A two-tier system has long been evident that has continued to adjust to changing realities. For a long time, clandestine but safe procedures were available within Poland for economically advantaged women and poorer quality services and outcomes were more common among less-privileged and rural women. As abortion access became restricted in the 1990s, more women with economic means began to seek abortions overseas and poorer women continued to seek clandestine abortions within Poland or sometimes in neighboring countries that offered less costly procedures. As visa-free and lower cost travel across EU borders became easier, even more women traveled abroad for safe and legal services. The growing availability of abortifacient pills has recently disrupted this market further, as medication abortions are cheaper, safer, and more anonymous. These are presently overwhelmingly obtained overseas, but the pills will inevitably become more widely available through various channels in Poland.

One of the many unintended consequences of the near-total abortion ban is that physicians are sometimes afraid to remove malformed fetuses until late in gestation when the situation becomes more traumatic and may endanger a pregnant woman’s life. Many physicians who have claimed conscientious objections to pregnancy termination have either referred women who qualify on legal grounds for abortion to other practitioners too late in the gestation process or have refused to do so at all. Undoubtedly, the consequences of the recent bans on abortion could have been far worse just two generations ago, when Romania provided a real-life test case of what could happen. After the former dictator, Nicolae Ceauşescu, outlawed abortion and contraceptive services in 1966 in an attempt to boost the country’s population, birthrates quickly fell again as women and couples sought to find ways around the bans. By the time communism collapsed in Romania in 1989, over 10,000 women had died from clandestine abortions obtained in unsanitary conditions, and women who sought abortions and those who helped them faced prolonged imprisonment if caught. Moreover, an estimated 170,000 children were found warehoused in filthy, overcrowded orphanages previously hidden from view, many left with severe developmental impairment and mental health issues. Upon the fall of the Ceauşescu regime, the second decree of the transitional government was to overturn the ban on abortion (Hord et al. 1991; Kligman 1998; Nelson et al. 2014).

Poland’s ruling Law and Justice Party, conservative nationalist clergy, and other anti-abortion groups have avoided discussion of near-miss maternal deaths (when a pregnant woman comes close to dying but survives the life-threatening complications) or actual pregnancy-related deaths that might be attributable to women being denied medically indicated abortions. Few such deaths have occurred, not least because women are now increasingly able to obtain abortions overseas. However, all these groups continue to minimize the public health threats posed and have yet to learn that criminalizing abortion does not lead to women having more babies. They have also not understood that their actions have alienated many people, particularly among younger generations, and have likely accelerated secularizing shifts. The religious right has achieved a long-sought goal but may have compromised their power in the process. While a collective Polish Catholic identify remains in place, it is possible that the Catholic consensus that dominated politics after the fall of communism is over, with far-reaching effects.

The 2016 ‘Black Protests’ and the 2020 ‘Women’s Strike’ did not safeguard abortion rights, which were curtailed in the Constitutional Tribunal ruling. Nevertheless, the protests constituted the largest demonstrations of popular anger against restrictions on abortion and women’s rights, as well as against the ultra-conservative policies of the religious right. The protests not only strengthened women’s rights activism; they had also mobilized a broader cross-section of society with diverse political views from across the country. Further, they rendered the word ‘abortion’ no longer taboo and instilled the language of reproductive rights into the abortion debate, as well as public health arguments into how it is framed. This may yet change the dynamics of future controversy. However, these trends should not be overestimated. Public acceptance of abortion rose, but only to a limited degree, and not all women who felt slighted are united behind the cause of reproductive rights. Also, although support for the ruling party fell, it has since risen as the country rallied in support of the government’s strong support for Ukraine following Russia’s invasion in 2022. This widely perceived existential threat has similarly helped ease for now the considerable tensions over Poland’s democratic backsliding with the EU and the USA, although the political scene remains fractured.

The current government and ecclesiastical circles are unwilling to acquiesce, and judicial protest will not currently succeed. The next national elections are scheduled for autumn 2023. Increased grassroots activism, the decline in religious observance and piety, and distaste for the Church hierarchy’s political interference and mishandling of clergy sexual abuse cases (Kość 2023) will continue to influence debate. The ruling party’s success has rested on targeted social transfers and benefits, deep respect for the nation’s Catholic identify and accommodation of the Church hierarchy’s wishes, and its exploitation of collectivist fears (Kuisz and Wigura 2023; Mounk 2023). However, the cause of reproductive rights can no longer be so readily dismissed in the name of democracy and the Catholic nation.

Many abortion rights activists have pegged their hopes on the prospect that their case may end up in the European Court of Human Rights, where they might expect a more favorable outcome. They may yet be granted such a lifeline. In February 2023, the European Commission referred Poland to the European Court of Justice over violations of EU law by the Constitutional Tribunal which, it was asserted, no longer met the requirements of an independent and impartial tribunal as previously established by law (Strupczewski 2023). This was part of the wider ‘rule of law’ clash between the EU and the eurosceptic Law and Justice Party that has been ongoing since 2015 and which recently resulted in the suspension of substantial (>€35 billion) pandemic recovery and other EU funds. Although the populist right has refused to back down before, it may find it difficult to forsake such funds as it faces a slowing economy and a tight electoral challenge. While a compromise may not include policy over abortion, both the legal and political landscape may yet change sufficiently for opportunities to shift such policy again.