The overview of the status of abortion in Latin America and the Caribbean presented in this review of the literature on the topic shows that when it is performed in unsafe, high-risk conditions, it is obviously a public health problem. But what underlies this conclusion, on which there is a consensus in the literature, are the conditions of economic, social, ethnic and gender inequality, and above all, the lack of the enactment of sexual and reproductive rights. In fact, these conditions are reflected in the different degrees of access to sexual and reproductive rights that occurs in almost all the countries in the region, since it is often only the wealthier women who can afford a safe abortion, while the rest have abortions in unsafe conditions, which leads to appalling consequences at the individual and familial level and at various levels of society. The problem of abortion pertains both to the subjective and private sphere (intimate life, relationship with one’s partner) and to the public sphere. The practice of abortion is therefore intimately linked to the work of state institutions, in the sphere of legal, judicial, health and education institutions and in particular to those responsible for the design and implementation of health and population policies.
The legal framework for abortion in the countries in the region varies from total prohibition of the practice to performing abortions at the woman’s request. Most Latin American countries lie between these two extreme situations, in which abortion is not penalized in certain conditions, such as when the pregnancy seriously threatens the woman’s health or life or the pregnancy is the result of rape or incest, when there is malformation of the fetus or on occasions, as a result of financial problems. Even in the cases permitted by law, there are restrictions on access to abortion, including the establishment of the legal time limits during which a woman may interrupt her pregnancy, the authorization of one or more physicians, or the fact that, for moral or religious reasons, the latter may declare themselves to be conscientious objectors and therefore be unwilling to perform an abortion.
In over a dozen countries in the region, for example, abortion is authorized in the event of rape or incest. Even under these circumstances, however, the right to abortion is not recognized by judicial organizations or else medical authorities prevent it from being performed. Dramatic examples of this include that of Paulina in Mexico and Rosa in Nicaragua, whom the authorities prevented from interrupting their pregnancies which were the result of rape. The fulfillment of this and other grounds on which an abortion is legally authorized lead one to question the relevance of restrictive or authorized legislation in the matter that do not always translate into concrete situations.
This evinces the existence of both institutional and moral obstacles that mean that abortion, even when permitted, is a de jure rather than a de facto right, in other words, a right that is neither authorized nor exercised by women. At the same time, doctors’ refusal to perform legal abortions or to deal with the complications of an interrupted pregnancy compound the mistreatment suffered by women at the hands of health personnel who sometimes even denounce them. Despite this, in certain countries in the region, doctors have promoted changes in the law, and developed post-abortion care programs (PAC), realizing the need to guarantee access to quality health services where abortions are performed on any woman requiring them.
The aforementioned legal and institutional restrictions and prohibitions also constitute a blatant violation of women’s sexual and reproductive rights, recognized at international conferences such as those in Cairo (1994) and Beijing (1995). These obstacles reveal the powerful male domination of women’s sex and reproductive lives, in addition to their deliberate will to exercise strict social control over them, which takes place within the sphere of the couple, family and society. The title and work of Ortiz-Ortega (2001) Si los hombres se embarazaran, ¿el aborto sería legal? (If men got pregnant, would abortion be legal?) is telling.This question refers to the attitudes men would adopt if they got pregnant or had to cope with the responsibility of an unplanned or unwanted pregnancy. It also refers to the decisions that would be taken regarding the legislation and health guidelines for regulating abortion.
Despite the small number of studies on men’s participation in abortion carried out in the region, the information available confirms the fact that they play a key role in this practice. They can obviously determine the decision to interrupt or continue a pregnancy within the couple, in which male and female roles are particularly intensely expressed. Women’s subordination to men is still extremely deeply-rooted in conservative societies such as those of most Latin American countries. Likewise, the importance of the affective and emotional relationship within the couple, as well as the type of conjugal relationship, largely determine the man’s involvement in the decision whether or not to resort to abortion.
In the public sphere, forbidding abortion does not prevent its widespread practice. On the contrary, it encourages it to be performed in unsafe conditions that threaten women’s health and even lives. This situation obviously does not affect all women in the same way. As mentioned earlier, the consequences of abortion are usually more serious for those with few financial resources who are therefore obliged to interrupt their pregnancies in unsuitable conditions. Conversely, even in countries where abortion is illegal, there is always a “parallel market” which enables women to have abortions in more hygienic, safer conditions, and with qualified personnel, yet at a very high price, which can only be afforded by a privileged few. Consequently, as Langer so rightly pointed out (2002), “a society that allows some women to have an abortion without risks or difficulties, while others experience (great) danger is not a democratic society.”
A wide range of groups in civil society in Latin America, as in other parts of the world, are engaged in a constant struggle to improve conditions of access to abortion, by appealing to reproductive rights, particularly women’s autonomy and right and decide about their reproduction. They are also trying to eliminate the restrictions imposed on women’s rights, on the grounds that one should respect the rights of the newborn and men’s right to fatherhood, Several debates have taken place on these positions, which are usually promoted by movements to promote women’s right to free choice. These movements have seen the growing participation of professionals and those responsible for health systems, who have been sensitized by the consequences of unsafe abortion on women’s health and lives.
Other political forces and conservative groups that support the Catholic hierarchy have engaged in a permanent campaign to prevent abortion under any circumstances, on the grounds of “the unborn child’s” right to life. However, even within the Catholic Church, which is hegemonic in Latin America, there are opposing positions. Not all Catholics oppose the decision to interrupt a pregnancy. For example, the civil organization, “Catholics for the Right to Choose” recall that women’s faculty to choose the alternative that best suits them as regards their reproduction is compatible with the essential principles of Catholicism, such as freedom of conscience. This last is not only interpreted as a right to be exercised by health professionals but as the right of all women to decide on their own bodies.
Unsafe abortion in Latin America and the Caribbean has numerous consequences. Interruption of pregnancy continues to be one of the leading causes of the high maternal mortality prevailing in many countries in the region. But even when the complications of abortion do not prove fatal, they often produce effects ranging from chronic pain to sterility. Likewise, abortion raises ethical and moral dilemmas for doctors and other health personnel, forcing them to choose, for example, between meeting a request for abortion, either clandestinely or by concealing it, or allowing a woman’s pregnancy to continue, despite the fact that she does not wish to have a child. At the same time, doctors tend to have polarized views on abortion, since whereas some focus on the public health problem caused by unsafe abortion, others underline their moral convictions that may oppose this practice. Abortions performed in unsanitary conditions also entail high costs for health services, whose budget is reduced by having to deal with the complications derived from this practice, which also imply an extra workload for medical personnel.
Another aspect barely dealt with in the literature reviewed refers to the social and familial costs resulting from unsafe abortion. These include the death or physical disability of a mother as a result of a badly performed abortion: the social stigma and expenses a woman faced with a trial or imprisoned for having an abortion is forced to deal with, in addition to the psychological effects of interrupting a pregnancy under traumatic conditions. Refusing to give an abortion may also have consequences for the woman and the baby she is carrying, since she will give birth to the result of an unwanted pregnancy.
Illegal abortions are often performed using high-risk methods for women’s health, the use of which, as Langer-Glass states (2003) reflects their despair, since the lack of resources forces them to abort in these conditions. The consequences of abortion are therefore closely linked to the methods used. In the countries in the region, where the vast majority of abortions are clandestine, women use natural methods such as plants, chemical products, inserting objects into the uterus or taking drugs, such as misoprostol (Cytotec), which is widely used in Brazil. This product, the use of which is becoming increasingly widespread, is fairly acceptable when used in the correct dose. Even is misoprostol is used incorrectly, the complications are less severe than when other methods are used. According to Blanchard et al (1999) using this drug for the purposes of abortion is safe and effective, which is why it has helped reduce the maternal mortality associated with the interruption of pregnancy.
At the same time, the prohibition of abortion has meant that it has been insufficiently studied, since empirical evidence of the issue is still partial, fragmentary and ambiguous. Having an overview of this practice and measuring its incidence in order to determine its characteristics and consequences remains difficult, since the clandestine nature of abortion in the region encourages under-registration. Despite this, specific studies undertaken on specific populations or women hospitalized for abortion-related complications confirm the high frequency and scope of this practice, as documented by the World Health Organization in publications on unsafe abortion worldwide. Given the difficulties of obtaining accurate detailed measurements on the status of abortion and its evolution over time –two essential aspects for understanding this phenomenon and the impact of programs related to the latter- various techniques have been used. Some of them are more sophisticated and have been developed to measure various aspects of the phenomenon, such as the characteristics of those that abort, the conditions in which they do so and the consequences of this practice. However, the mere use of sophisticated methods that in principle provide greater levels of accuracy does not guarantee that the estimates obtained of them are closer to reality. For this reason, and as various researchers have pointed out, the best choice is a combination of different methods and sources of information for estimating the incidence and other aspects of abortion. This enables one, among other things, to compare the results obtained using different techniques and methodologies and therefore be more certain of whether the information is reliable. In the case of Latin America and the Caribbean, it would also be useful to establish methodologies and common criteria for classification in relation to the practice of abortion, since they would thereby by able to undertake research on the issue that would provide an overview of this phenomenon in the region.
The reasons for resorting to abortion are extremely varied and depend on the context and the conditions of the woman who needs to interrupt her pregnancy. Women may abort at various stages in their lives out of a desire to limit their number of offspring or space their pregnancies. They may also do so if they have no children and wish to prevent the exercise of their sexuality from leading to unwanted pregnancy as tends to happen with teenagers or young people whose access to contraception is limited and difficult. In other cases, abortion is a resource for dealing with an unforeseen pregnancy as a result of the failure of contraceptives, an unprotected sexual relationship or the difficulties many women experience in negotiating the prevention of pregnancies and sexually-transmitted diseases with their partners (STD). Other causes of unwanted pregnancies and abortions are rape and incest, serious manifestations of violence against women, a widespread phenomenon in most of the countries in the region.
Younger women are especially vulnerable to this type of violence. Likewise, it is a well-known fact that under certain circumstances, teenage pregnancy and abortion may be traumatic events from the biological, psychological, social and health point of view, particularly among sectors with higher levels of poverty and low educational attainment. They are also a major cause of maternal morbi-mortality among young women. They also reflect the lack of access to reproductive health services and therefore of the conditions for teenagers and young women to exercise their rights.
One of the most noticeable results of the bibliographical review carried out was that in certain Latin American countries, abortion is more common among women with higher educational attainment. It continues to be an important resource for many of those with access to a broader, more diversified “supply” of contraceptive methods. It is also striking that is regarded as a more frequent practice in urban contexts, which would seem to reflect cultural changes and more intense living conditions there, in other words, where one has access to a more diversified, broader and affordable supply of contraceptive methods. However, it also speaks of the lack of studies on this issue in rural settings.
Abortion has played a key role in the fertility transition in various countries. It may serve as a resource for regulating fertility when it replaces contraceptive methods or serve to complement them if, for example, these method fails and lead to unwanted pregnancies. This situation may be due to the unavailability of contraceptives, resulting, among other things, from the insufficiency or inadequacy of family planning methods or when the methods used are ineffective, as often happens with natural methods. It may also be due to the incorrect use of either traditional or modern methods. Emergency contraception (EC) is extremely useful in these cases. This method is particularly appropriate for women that have irregular or unforeseen sex, as often occurs among younger women. Although EC is still not sufficiently widespread in Latin America, Mexico and other countries in the region have already included in their guidelines related to family planning, which will encourage use of the method, although conservative sectors have attributed abortive effects to it, with no justification. Health providers still require more and better training on the safety and benefits of this method.
The widespread prevalence of abortion reflects women’s wish to regulate their fertility, a wish to which family planning programs do not always respond either adequately or according to their needs.
We are convinced that the reduction of the practice of abortion in risky conditions, with the aforementioned consequences, is primarily a question of political will. To achieve this, it is essential to sensitize various sectors of society, particularly those responsible for policies and programs concerning the exercise of women’s sexual and reproductive rights. Actions must also be undertaken to create greater awareness of the risks involved in unsafe abortions and thereby prevent the persistence of this tactic. It is essential to shift from the theoretical and discursive acceptance of reproductive rights to the establishment of the conditions guaranteeing their fulfillment. Likewise, efforts must be redoubled to prevent violence, particularly sexual violence, from being inflicted on women and to acknowledge their right to the interruption of pregnancy when they have been the victims of forced sexual relations.
Given the public policies aimed at reducing population growth, together with the growing number of women wishing to have smaller families, very little attention tends to be paid to certain issues. These include the fact that the objectives of policies, such as population reduction, have been achieved, to a greater or lesser degree, due to the widespread practice of abortion in several countries in the region. This has obviously entailed a high cost for the health, safety, integrity and dignity of women, which also affects the family and society, due to the precarious conditions in which abortions tend to be carried out.
Despite the advances in family planning services and the increasing availability of modern contraceptive methods, unwanted and unplanned pregnancies will continue to occur, as happens even in developed countries. Many women will also continue resorting to abortion as a means of controlling their fertility. This reality means that abortion must be performed in the best possible conditions. The termination of a pregnancy should not be a traumatic experience that also endangers women’s health and lives, as is the case in countries where the procedure is illegal and therefore often performed by untrained personnel in unsanitary surroundings. Abortion must be a safe procedure, for which it is essential to undertake a series of actions, such as those described below.
It is essential to expand access to family planning and to improve the corresponding programs to ensure that they meet the needs of women and men, as well as teenagers. It is also essential to check the quality of the information, education and counseling provided, in order, among other things, to incorporate women who, for a variety of reasons, do not use contraceptive methods, into the respective programs.
The introduction and dissemination of more appropriate methods for preventing or interrupting pregnancy, such as misoprostol and mifepristone, will enable women to be offered more effective alternatives and therefore largely reduce the number of unsafe abortions. Emergency contraception, as a preventive method that does not carry the stigma of being abortive, is particularly promising for these women, particularly young women, for the reasons mentioned earlier.
Another aspect worth pointing out is the implementation of post-abortion care (PAC) programs in reproductive health services. The experience of various countries shows that these countries can substantially improve the quality of services for women with abortion complications, since they usually include techniques that that proved effective, such as manual endouterine aspiration. In addition to benefiting users, the use of these techniques has also helped reduce medical care costs and encourage post-abortion contraceptive practice. This last is extremely important in preventing the repetition of abortions, which all the consequences this entails, among women that have interrupted one or more pregnancies.
The success of these programs, however, requires the training, not only of medical personnel, but also and particularly of nurses and midwives. But proper abortion care and its complications go beyond this. It requires the revision and modification of legislations and modifications, so as not to sanction those that have abortions and the health professionals that perform safe abortions, since otherwise, as mentioned earlier, this only encourages unsafe abortions.
In the case of teenagers, from the perspective of health systems, it is essential to implement programs that meet their sexual and reproductive needs, in order to prevent unplanned or unwanted pregnancies in this sector of the population as far as possible and therefore substantially reduce their “need to resort to abortion,” as well as preventing them from contracting STD. Given the lowering of age at first intercourse, and the greater frequency with which this occurs outside marriage, young women constitute a sector in which there is greater social vulnerability and therefore greater risks. This situation largely explains the increase in abortion among teenagers which usually, due to their lack of resources, performed clandestinely and unsafely, with the risk of suffering complications. It is, however, essential to encourage a more tolerant mentality and attitude to youth sexuality and to pregnancy outside wedlock, as facts that are an undeniable reality. It is important to sensitize young people, particularly males, about the need to use preventive measures when they have sex.
It is also essential to overcome the barriers and circumstances that limit women’s right to decide freely about their own reproduction. To this end, it is necessary to encourage more open attitudes towards sexuality and family planning; improve women’s and men’s sexual education in schools and the community, and encourage greater sexual equality. It is also essential to encourage shared responsibility for contraception and child-raising among men and women and persuade health service personnel to be more sensitive to women’s needs and concerns.
Although the practice of abortion in Latin America and the Caribbean has elicited increasing interest among researchers in the region, research on this issue is still insufficient for providing in-depth knowledge on the phenomenon. Since most of these studies have been undertaken in urban contexts, and often in hospital settings, they only partially reflect the status of abortion in this part of the world. It is essential to increase research on the subject in order to be able to generate more integral knowledge on aspects of abortion, such as its health and social consequences. This knowledge could help sensitize legislators, those responsible for public health systems and those responsible for administering justice on the urgent need to reform the legal framework and health guidelines regulating this practice. This is an urgent task that should be rigorously dealt with by academia, together with other professionals and sectors actively involved in the problem of abortion. To this end, research should be financed on the incidence as well as the characteristics and consequences of abortion in various countries in the region, the results of which should be representative for each of them. Likewise, better techniques should be used in health institution registers in order to have more reliable information on the scope and characteristics of maternal morbi-mortality related to abortion in the region.
Given the complexity of the problem of induced abortion, a multidisciplinary approach is required for a better understanding of the issue. This would provide researchers with sufficient elements to be able to draw up proposals and initiatives that would help, among other things, to overcome the paralysis resulting from the polarization of antagonistic, conflicting positions on the voluntary interruption of pregnancy. Public debate on abortion is necessary and could make valuable contributions to an understanding of the issue. This should, however, be based on scientifically rigorous, broad information, in order to help create value judgments on the topic, which would enable public and NGO interventions to be designed, aimed at reducing the incidence of unsafe abortion, and therefore prevent the consequences of this practice.
One would hope that the scenario described in this book, which is full of questions and concerns, would encourage the leaders of the countries in the region to check and modify the current legislative framework on abortion, as well as the public policies and actions of reproductive health programs, particularly those related to the practice of abortion and family planning.
One of the characteristics defining a democratic state is respect for human rights, of which sexual and reproductive rights form part. The full exercise of these last rights involves undertaking various actions. These include guaranteeing universal access to quality reproductive health services, as well as promoting gender equity and social equality, as anticipated in the international commitments signed by nearly all the countries in Latin America and the Caribbean, as well as the rest of the world. For this reason, it is hoped that a democratic state will meet the reproductive health demands of all women. The question Dixon Mueller (1990) raised over ten years ago is still relevant, however: Why do most women in developing countries continue risking their lives or frequently suffer serious health consequences due to the simple fact of regulating their fertility, when it is the state’s responsibility to provide them with safe, affordable health services?