1993 PAXMAN Abortion Epidemic en ALatina

The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America Author(s): John M.
Paxman, Alberto Rizo, Laura Brown, Janie Benson Reviewed work(s): Source: Studies in Family Planning, Vol. 24, No. 4 (Jul. - Aug., 1993), pp. 205-226 Published by: Population Council Stable URL: http://www.jstor.org/stable/2939189 . Accessed: 17/11/2011 13:09
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The Clandestine The Epidemic: Practice ofUnsafe in Abortion Latin Amerca

JohnM. Paxman, Alberto Rizo, Laura Brown,and JanieBenson
In Latin America, induced abortionthe is fourth commonly method most used offertility regulation. Estimatesthe of number induced of abortions performed year Latin each in America range 2.7 from to7.4million, from to27percent allabortions or 10 of performed developing inthe Because restrictive nearly ofthese world. all of laws, in abortions, for except those performed and Barbados, are Belize, Cuba, clandestine unsafe, their and and are principal sequelae the cause death women reproductive Oneof of leads among of age. every to unsafe three five abortions to in hospitalization, resulting inordinate consumption of scarce costly and rehealth-system sources. Increased and contraceptive prevalence restrictive abortion have decreased laws not clandestine This how epidemicunsafe be addresses the abortion practices. article of might Recommendations providing outpatient include and challenged. treatment strengthening safer to women's to family planning programsimprove use access information contraceptiveandtheir andtosafe termination In pregnancy procedures.addition, laws existing andpolicies governing legal abortion beapplied their can to can fullest extent, indications legal abortion bemore for broadly and constraintsabortion on relaxed. interpreted,legal practices beofficially can (STUDIES
IN FAMILY PLANNING 1993;24, 4: 205-226 )
A decade ago the recent Nobel laureate Octavio Paz wroteoftwo coexisting Mexicos, "one fictitious, another real." He wenton to observe: Abortion a clearexample ofthissituation. is Prohibitionsagainst the practicefortify unreal the country-the one of frustrations-against the one of the facts-the countryof reality.(Paz, 1982:11) Whereabortionis concerned, Paz's insight may well apply to Latin America and the Caribbean in general. The reality nearly30 yearsofa clandestineepidemic. is
John Paxman, M. J.D. is Adjunct Professor Health of BostonUniversity Services, SchoolofPublicHealthand Director, KeeneAssociates, Lexington, MA. Alberto Rizo, M.D. is former Director LatinAmerica, Regional for Pathfinder International is nowan independent and consultant Bogota', in Colombia. Laura Brown, M.P.H. is a student theMedicalSchooloftheLUniversity at ofNorth Carolina, ChapelHill,NC. Janie Benson, M.P.H. is Director theResearch Evaluation and of Division, IPAS (International Projects Assistance Services), NC. Carrboro, Address correspondenceJohn Paxman,Keene all to M. 5 Associates, Sheridan Street, Lexington, 02173. MA
This articleexaminestheimplications thedistincof tions between the "real" and the "fictitious," and explores what mightbe done to reconcilethem.Recognizing thatLatinAmericaand theCaribbeanmake up a vast and diverse regionabout which generalizationsare difficult, focuson thefollowingquestions:What trends we and practicesdescribetheincidenceofinduced abortion in Latin America? What are the consequences of these trendsand practicesforwomen's health?What are the costsofclandestine abortion-both economicand social? Whatpropelsthepractice? How does contraceptive practicerelateto abortion? Whatlimits qualityofinduced the abortionand impedes women's access to safe abortion care?And finally: Whatmustbe done to remedythecurrentsituation?
Incidence of Induced Abortion

Some research suggeststhatindigenoussocietiesin Latin America and the Caribbean resortedto induced abortion both before and afterthe Spanish conquest (Viel, 1988; Devereaux, 1976; Ramos, 1977). However, only in thetwentieth century thepracticeofunsafeabortion has surfacedas a majorsocial and healthproblem-one that has been widespread forat least threedecades. Induced such as abortionis associated with a mix of influences,
Studies in FamilyPlanning
Volume 24 Number4 July/Aug 1993 205
socioeconomicchange,an increasein thedesireto reduce natural fertility, an absence of access to or reliable -and use ofcontraception. Thereare two opinions on thematter.One opinion holds thatdespite a steadilyincreasing rate of contraceptive use, the incidence of unsafe abortion in Latin America remains high and the total number of abortionsmay be on the rise,particularly among urbanpopulations,whichaccountformorethanone-half of the region's people (Gaslonde, 1975 and 1976; Frejka et al., 1989; IFRP, 1980; Viel, 1988). The otheris thatthe actual incidenceofinduced abortion decliningand that is the total number of abortionsis holding steady, if not falling(Soza et al., 1990;Weisner,1990). Data on the extent of induced abortion in Latin America,however,are inconsistent, rangingfromsheer speculationto carefully calculated estimates. Substantial is underreporting a majorproblem.Surveysbased solely on hospital data or small, but focused,surveystend to produce gross underestimates induced abortions, of because accuratereporting discouraged by thenatureof is thesubjectand thegeneralillegality theinducingpracof ticethatprecedeshospitalization.' Moreover,researchon induced abortionin LatinAmericahas been in hiatusfor to nearlya decade, a situationat least partlyattributable the fundingpolicies of the United States Agency forInternational Development(USAID), whichwere radically changed in the early 1980s and subsequentlyhardened by what is now known as the "Mexico Citypolicy."2 The extent theabortion of problemin thehemisphere first came to lightthreedecades ago in Chile, one of the few countrieswith consistently accurate abortiondata (Liskin, 1980; Requena, 1965). In 1960 57,368 Chilean women were hospitalizedfortreatment abortioncomof plications;theyaccounted for24 percentof all obstetrical admissions to hospitals. The vast majorityof these abortionswere thoughtto have been illegallyinduced. Because only about one illegal abortionin threewas estimatedto requirehospitalization(Armijoand Monreal, 1965;Monreal,1976),theoverallnumberofinduced abortionswas calculatedto be substantially higher-approximately143,420.In 1970 it was estimatedthatone abortion occurred for every two live birthsin Chile (Gall, 1972). The legal statusof abortionhas remainedrestrictive. Principallyas a resultof social change and the increased availability of familyplanning, the estimated abortionratedeclined from77.1 per 1,000women of reproductive age in 1960 to 32.2 per 1,000 women of reproductiveage in 1987 (see Table 1). The total abortion rate (the numberof abortionsexperiencedby the averhas between2.6 age woman over herlifetime) fluctuated (in the 1960s) and 1.6 (in the 1970s) (Frejka and Atkin, 1990). However, as shown in Table 2, the estimatedannual numberofabortions Chile,mostillegal,continues in
Table 1 Numbers womenhospitalized induced-abortion of for complications, hospital-based abortion rates(per 1,000 WRA) and abortion ratios (per 100 livebirths), estimated totalnumber of abortions, abortion and rates(per 1,000 WRA),byyear,Chile, 1940-89
Number of women hospitalized for abortioncomplicationsa 16,560 21,581 30,065 35,795 57,368 56,130 46,980 44,456 43,792 40,904 43,004 45,042 46,294 Hospitalbased abortion rate 13.9 17.0 22.4 24.4 30.8 27.2 20.1 17.3 14.8 12.8 12.9 13.3 13.4 Hospitalbased abortion ratio na na na na 20.0 18.6 18.7 17.7 16.5 15.6 15.4 15.9 16.0
Year 1940 1945 1950 1955 1960 1965 1970 1975 1981 1985 1987 1988 1989
a
Total numberof abortions b 41,400 53,953 75,163 89,488 143,420 140,325 117,450 111,140 109,480 102,260 107,510 112,605 115,735
Abortion ratec 34.8 42.6 56.0 61.0 77.1 68.1 50.1 43.3 37.0 31.9 32.2 33.1 33.4
Note: na = data notavailable. Based on hospital registration. ofthese are assumed to be inducedabortions Most forwomen reproductive (WRA),butsomearespontaneous.Intheircalculations of age for Brazil, Colombia,and Peru,Singhand Wulf (1991) estimated thatbetweenonesixth and one-half abortions hospital spontaneous (2.48 percent births). of in are of bEstimated according thenumber abortions to of in performed hospital, multiplied by 2.5 (100/40), where40 wouldbe theknown percentage. c Based on thesame number womenofreproductive as thefigures ratesfor of age for womenhospitalized for abortion-related treatment. Source: PreparedbyJorgeMartinez (1990) as citedinWeisner, 1990 and updated with assistance from Singhand Wulf theAlanGuttmacher of Institute. from Data Chile, of Ministry Health (1982-90) and Instituto Nacional de Estadisticas (1985-90). Additional information hospital-basedabortion for services: 1940-55, Viel (1988); number and ratesfor womenofreproductive 1960-87, Silva (1989); percent age: of abortions 100 livebirths: per Silva (1989).
of and Table 2 Estimated numbers inducedabortions abortion ratios American (per 1,000 livebirths), Latin 10 countries, by to country, according years ofestimates
Country(years ofestimates) Argentina (1987, 1989) Brazil(1973, 1975, 1980, 1983,1985) Chile (1987,1989,1990) Colombia(1981, 1985) Cuba (1989) Dominican Republic (1984, 1988) Mexico(1976, 1979, 1980,1989) Peru (1977,1981) Uruguay (1968) Venezuela (1985, 1987)
a
Numberof abortions 400,000 322,000-3,294,400 100,000-190,000 150,000-351,200 187,000 60,000-65,000 440,000-1,600,000 27,000-207,000 150,000 400,000
Abortion ratio 500 85-822 154a 176-411 81.8b na 200-500 43-177 na na
Note: na = data notavailable. b Abortion Abortion ratio 1987. for ratio 1988. for Sources: Argentina-1 987: Llovetand Ramos (1988); 1989: Comisi6n para el Derecho al Aborto (1989); Brazil-1 973, 1975: Liskin (1980); 1980: Pereirade Melo (1982); 1983: Merrick (1983); 1985: Singhand Wulf (1991); Chile-1987, 1989: Silva (1989); 1990: Weisner(1990); Colombia-1 981: Cardenas (1982); 1985: Singhand Wulf(1991); Cuba-1989: Soza et al. (1990); DominicanRepublic-1984, 1988: Paiewonsky(1988); Mexico-1 976, 1979: Liskin (1980); Tomaro(1981); 1980: Leal
(1980);1989: PAHO (1989);Peru-1977:Liskin (1980);1981: Singh Wulf ); and (1991 MinisterioSalud(1981 Uruguay-1968: de ); Requena(1968b); Venezuela-1985, 1987:Weisner (1990).
206 Studies in FamilyPlanning
tobe high:between100,000 and 190,000 (Weisner, 1990). Cuba also has fairly reliable data, but in contrastto mostotherLatinAmericancountries, government its has progressivelylegalized abortion practices (Hollerbach, 1980 and 1988). The number of legally permissibleinduced abortions in Cuba rose from28,500 in 1968 to 131,536in 1974; it then fell to 103,974in 1980 and rose again to 160,926in 1986 (David and Pick de Weiss, 1992; Soza et al., 1990). Since 1986 the number of legally induced abortionshas dropped slightly. The 1980 decline was attributed increaseduse ofmoderncontraceptives, to and the 1986 rise to a concentration large numbersof of proceduresamong youngwomen (Soza et al., 1990). The totalinduced abortionratedeclined substantially (from 2.1 in 1974 to 1.4 in 1980-81),but subsequentlyincreased to 1.8 (1987-88) (Soza et al., 1990;Frejkaand Atkin, 1990). As a factorcontributing fallingfertility Cuba, into in duced abortionappears to have been used increasingly to avertunwantedbirths-risingfrom 65.4 induced abortionsper 100 live birthsin 1974 to 81.8 in 1988 (see Table 3) (Soza et al., 1990). As Table 2 indicates,takentogether, Chile and Cuba-two relatively small countries-at presentappear to accountforslightly more than375,000 induced abortionsannually. Peru is one of the few Latin American countriesto have studied abortionpracticesofficially. The Ministry of Health observed in its 1981 report,El Abortoen los Establecimientos Salud delPeru', de thatclandestine, illegal abortionis "a serious public health problem,with high human and social costs" (p. 2). Assumingthatone in four clandestine abortions resulted in hospitalization, the report estimated the total number of induced abortions to be 27,000 annually,with a ratio of 137 induced of Table3 Number induced live ratio abortion abortions, births, and rate (per100live births), abortion (per1,000WRA), Cuba, 1974-90 byyear,
Year 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988
1990
abortions to 1,000 live birthsin 1977 and 143 in 1978. Other,unconfirmed estimateswere higher, suggestinga ratioof200 abortionsper 1,000live births(Ministerio de Salud, 1981). Although the data are problematic,Latin America and the Caribbean appear to have one of the highestincidences of induced abortionin the developing world. As earlyas themid-1970s, International the Planned Parenthood Federation (IPPF) estimatedthe annual number of induced abortions(predominantly unsafe and illegal) to be five million (IPPF, 1976), with 65 abortions per 1,000women of reproductiveage, and 30 abortions per 100 pregnancies(Tietze and Henshaw, 1986). These figuresimplied thatbetween one-fourth and one-third ofall pregnancies were "intentionally aborted"(acobson, 1990). Using IPPF data fromLatin Americancountries, Rochatand his colleagues (1980) calculated a ratioof325 abortionsper 1,000live births, shown in Table 4. By 1977 theestimate annual numbersofabortions of had dropped to 3.25 million, or about 25 percent of abortions performedin all developing countries(IPPF, 1977). This estimateapproximatedthelower end oftherange ofother estimates three sixmillion (from to inducedabortions) and may representsubstantial underestimation.Recently, Henshaw (1990)has putthefigure four at million. Singh and Wulf(1991) have refined estimateson the thenumberofinduced abortionsin Peru,Brazil,and Colombia.Theyuse data from hospitaladmissionsand surveys to gauge presentpractice,separatingspontaneous abortionsfromthose thatare induced, and then multifor plyingthefigure induced abortionsaccordingto different of estimates thenumbersofinduced abortions that requirehospitalization-one in four, one in five, and one
Legal abortions 131,536 126,107 121,415 114,829 110,431 106,549 103,974 108,559 126,745 124,791 139,588 138,671 160,926 152,704 155,327
-
Live births 199,091 192,941 187,555 168,960 148,249 143,551 136,900 136,211 159,759 165,284 166,281 182,067 166,049 179,477 187,911
-
Abortion ratio 65.4 65.4 65.2 69.2 75.0 76.5 76.1 79.6 79.3 75.9 84.1 83.6 96.6 84.6 81.8
96.0
Abortion rate 69.5 61.5 52.9 47.2 55.3 58.7 58.0

60.0 -
Table4 Regional estimates induced of abortions, abortion ratios and (per1,000live ofabortions areillegal, births), proportion that byregions covered International by Planned Parenthood Federation Unmet NeedsSurvey, 1977
Region Africa West East Caribbean East and Southeast Asia and Oceania Indian Ocean LatinArAmerica MiddleEast and North Africa Total Numberof births (000) 5,241 5,117 389 20,064 29,901 9,814;: 5,714 66,420 Numberof abortions (000) 116 456 66& 1,778 7,568 3,192 537 13,713 Abortion ratio 21.4 89.0 X 1169.7 176.7 253.1 325.2 94.0 206.5 Percent illegal abortions 100 100 80, 96 99
100
95 99
Note: -= calculations made this not for year. Sources: SOCUDEF,Havana, internal document, cited Soza etal.,1990; 1989, in United Nations, 1992;Henshaw, 1990;Vasquez, 1992.
South Korea, Hong Kong, Singapore, countries fewerthan million with one population, andcountries lacking affiliates. IPPF Source: Rochat al.,1980. et
Note: Excludes Europe, UnitedStates, Canada, Australia, New Zealand, Japan,
Volume 24 Number 4 July/Aug 1993 207
in seven. For Peru (1977,1981),Singh and Wulfestimate the numberof induced abortionsto be as low as 65,466 and as high as 207,060.For Brazil (1980, 1985), the estimates varyfrom322,071to 3,294,385, huge range. For a Colombia theestimatesrangefrom150,513to 315,197. The mostrecentestimatesof thenumberofinduced abortionsin 10 Latin American countries(representing 85 percent theregion'spopulation) are shown in Table of 2. The total ranges from2.2 million to 6.8 million. For the 1970s the total abortion rates (not shown) were: Chile, 1.6 (IPPF, 1978); Cuba, 1.4 (Sociedad Cientifica Cubana para el Desarrollo de la Familia [SOCUDEF], 1989; Soza et al., 1990); Mexico, 1.5 (Acosta et al., 1976); Peru, 1.3 (Ministeriode Salud, 1981); and Brazil, 0.5 to 1.5 (Merrick, 1983). Frejkaand his colleagues (1989) concluded thatmore than one-halfof the women in some Latin Americancountrieswill experienceat least one induced abortionduringtheirlifetimes. Table 5 chartsthe lifetime abortion prevalenceofwomen in 10 LatinAmerican countries.
et al., 1977).The WorldHealth Organization(WHO) now referral includes VA as an essential service at the first level ofcare (WHO, 1991a). laws in However, principallybecause of restrictive Latin Americaand theCaribbean,abortionis morecommonly induced by substandard methods rangingfrom to the use of herbal abortifacients the insertionof cathetersor metalsounds intotheuterus.Some ofthesemethsafein the some are relatively ods are merelyineffective, and some are lethal.The least skilledpersonnel, hands of problematicmethod used in Chile, according to hospiwas D&C, usuallyillegallyemployedby phytal records, sicians and trainedmidwives (as shown in Table 6). The othermethodswere likelyto be used by nonmedicalpersonnel or by the pregnantwoman herself(Armijo and Monreal,1968). an A woman seeking to terminate unwanted pregmoredangerousmethto nancymayresort progressively accountfrom Chile illustrates: ods, as thiscontemporary First,I had two injectionsof Methergin.Afterbreakfast red wards,for three days,I drankbefore wineboiledwithborageand rue,towhichI added nine aspirins.My body was fullof pimplesbut I waA did notabort. fewdays laterI drankcement Then I went to a lady ter.It did not workeither. intome. I had to who inserted rubbercatheter a use it,after the thingsI did I could not keep all the child because he could have malformations. (Weisner,1990:90) herbsand plantsare among the oldest Abortifacient and mostwidespread means used forinducingabortion. In Latin America abortifacientsnow include various modern pharmaceuticals,such as "hormonal preparaor tionsand uterinecontractors, medicinesmeantto cure otherdiseases" (Frejkaet al., 1989: 18). In the Sao Paulo area of Brazil,50 percentor more of all abortionsare esan timatedto have been induced withCytotec, antiulcer drug thatinitiateslabor; afterusing it,women oftengo to a hospital to complete the abortion (Fautndes, 1990). decree the purchase of Cytotecis now (By government at to restricted special prescriptions specifiedpharmaanecdotal Research cies [Abortion Notes,1992].) At first, of who induced abortions Table6 Number women reported who by percent werehospitalized, method, and,ofthese, 1962 Chile, Santiago,
Abortionmethod Curettage Drugs Catheter Numberof women who reportedabortions 504 119 581 Percent hospitalized 19.0 34.5 41.8
Methods Used to Induce Clandestine Abortion

of Accordingto Liskin(1980),thesafety an induced abortiondepends on fourfactors: themethod;(2) theskill (1) of the provider;(3) the duration of the pregnancy;and (4) the accessibilityand quality of medical facilitiesto treatcomplications.Doctors in privateofficesand hospitals primarily employ dilatationand curettage(D&C) and vacuum aspiration (VA) (Tomaro, 1981). VA has been shown to be saferthanD&C foruterineevacuation (Tietze and Lewit,1972; Cates and Grimes,1981; Grimes abortion and Table5 Percentage women of induced reporting in and of percentage pregnancies ending induced abortion, total American 1965-80 abortion 10 rates, Latin countries, country, by
Country Argentina Percent of women reporting induced abortion 33 Oa Percent of pregnancies ending in induced abortion Total abortion ratesb
Brazil Chile Colombia

Guatemala
13.3 23.8 na
37.3a 23.9a 29.5a
7.7 28.9 29.2

14.4a
14.Oa
0.5-1.5 2.0 1.2-1.5 1.5 na na na 1.3

na na
na
Mexico Nicaragua
Panama
30.7
13.0 (1976)
9.Qa 34.8a (1960) 19.2a
Paraguay Peru
a
15.3 20.0
17.0 12.3
age areexpected haveintheir to lifetimes. Source: Compiled Paxman by from selected surveys, 1965-80, including those summarized Liskin by (1980), Frejka Atkin and (1990), Weisner and (1990).
Note: na = data notavailable. Spontaneous and inducedabortion. b Range ofestimates thatwomenofreproductive for1970s ofnumbers abortions of
Douches other and Not stated
55 63
36.4 27.0
(1980). (1968), cited Liskin in Source: Armijo Monreal and
in Planning 208 Studies Family
suggestedthatbothwomen and health-care information an personnelbelieved thismode ofcommencing induced abortionto be saferthan othermethods because the final procedure was carried out in a hospital setting (Paxman, 1988a; O'Keefe, 1989). While thismay be true, associated in the literaCytotechas been more directly in of turewiththepractice "illegal"abortion Brazil(Costa 1991).3 (See also Barbosa and Vessey, 1993; Schonhofer, and Arilhain thisissue.) metal sounds, and sticks rubbercatheters, Inserting The ofvarious sortsintotheuterusis a commonpractice. purpose is to rupturethe amnioticsac, and to produce thatwill expel the embryoor fetus. uterinecontractions oftenresultin severe These methods,some self-applied, and perforation, sepsis. In severalcounbleeding,uterine widely available as urinarycathtries,rubbercatheters, eters,appear to be a tool of choice forwomen wanting a to interrupt pregnancy(Tomaro, 1981). Some 25 years of ago, Armijoand Monreal (1968)foundthatthepractice was widespread a (sonda)intothecervix inserting catheter to in Chile;as Table 6 shows,itwas themethodmostlikely it More recently, was reported that lead to hospitalization. catheterinsertionis commonlyfollowed by the use of or eitherself-induction a douches and drugs,suggesting abortionists (Frejka used on advice from practice follow-up etal., 1989;PAHO, 1985). At threemajorhospitalsin Chile,Weisner(1988) surveyed 350 women hospitalizedwithcomplicationsfrom induced abortion;she found thatfornearlyone-halfof these women the procedure was self-inducedand that one-third had sought help froma clandestineabortiongroup ist.Seventy-one percentof thewomen of the first rubbercatheters their abortions inserting by had initiated or sounds,also a prevalentmethodin otherLatinAmeriof In can countries. Bogota', Colombia,80 percent women had used sounds hospitalizedforabortioncomplications of in self-induced procedures;in Bolivia 27 percent those hospitalized had insertedforeignbodies; and in Paraguay 37.8 percentof women who had undergone ille(Cardenas de gallyinduced abortionshad used catheters Santamaria,1982; Bailey et al., 1988; Weisner,1990). A study in Mexico indicated thatsuch methods carrythe risks:At least 65 percentofwomen hospitalized greatest from withcomplications abortionreportedthattheyhad of the triedto self-induce interruption their pregnancies. (Tomaro,1981). As Frejkaand his colleagues pointout, "a large prousing defiportionof induced abortionsare performed cienttechniques,under unhygienicconditions,without adequate medical supervisionand oftenin a hostileand (1989: 1). Because ofthenadisapprovingenvironment" ture of the laws governing abortion in most of Latin Americaand theCaribbean,nearlyall induced abortions
illegal,use substandardprocedures,and are technically thus jeopardizcarrysubstantialrisksof complications, ing thelives and healthofwomen.
Consequences of Unsafe Abortion

Maternal Mortality The most devastating outcome of unsafe abortion is death. Worldwide, WHO has attributedthe deaths of 200,000 women annually to unsafe abortion-25 to 50 percentof all maternaldeaths (Mahler, 1987). Jacobson notes that many of these abortions "are performedby under unsanitary conditionsor are unskilledattendants with self-inflicted hangers,knitting needles,toxicherbal 1990:38). In Latin America teas,and thelike" (Jacobson, from inducedaborunsafe, illegally resulting complications cause ofdeathin women tionare consideredtheprincipal et aged 15 to39 years(Frejka al.,1989;PAHO, 1985). Estimatesof maternaldeaths due to abortionvary. the from late 1970scalculated Using regionalinformation by IPPF, Rochatand his colleagues estimatedtheworldwide mortality rate to be 500 deaths per 100,000illegal abortions-one death forevery200 procedures (Rochat et al., 1980). This rate would place the numberof abortion-related maternaldeaths in Latin America and the Caribbean at thattimebetween 13,000and 27,000-the same number as if all women of reproductiveage in a cityof65,000to 135,000were to die withina year!Using data fromthe mid-1960sfromten cities in eight Latin Puffer and Griffith (1976) attributed Americancountries, 34 percentofall maternal deathsto unsafeabortionpracHerz and Measham (1987) placed tices. More recently, totalpregnancy-related deathsin LatinAmericaat 34,000 per year. If thatfigurewere accepted as accurate,abortion-related deathswould be in linewiththelower,IPPFderived estimateof 13,000of a decade earlier-slightly of less than one-third all maternaldeaths. Roystonand Armstrong (1989) have also calculated the rate of abortion-related deaths-50 per one millionwomen aged 1549 in Latin America. In 1990,89.4 millionLatin Amerithat can womenwerein that group;hence, year, during age to an estimated 4,472womencould have been expected die of thatapfrom complications inducedabortion-a figure Overall,therange of abortionpears overlyconservative. related deaths in Latin America can be estimatedto be between4,500and 11,000per year. As Table 7 shows,duringthe1960sand 1970s,in several cityhospitals in Latin America,more than 30 perto centofmaternaldeaths were attributed complications arising fromabortion,most of them illegally induced. deathsin hospitalsin Santiago, Nearlyhalfofall maternal Caracas, and Guatemala City were abortion-related
1993 209 Volume 24 Number4 July/Aug
Table 7 Percentageofdeaths inhospital attributed to complications inducedand spontaneousabortion a of as proportion all maternal of deaths inhospital, country, by according yearsand place ofstudies,1969-79 to
Percent of maternal deaths attributed to abortion complications 44.1
Country Brazil
Period and place of study 1955-77, Hospitaldas Clinicas,Faculdade de Medicinade RibeiraoPreto 1968, Allhospital discharge records 1963-73, NationalHealth Service hospitals 1970-78, Maternal and Child Institute, Bogota JubileeHospital, 1971, Victoria Kingston 1973, Concepci6n Palacios Caracas Maternity Hospital,
Chile
39.7 37.4
Colombia Jamaica Venezuela
40.3a 33.3 70
Note: na = data notavailable. a Mortality to septicabortion due only. Source: Liskin (1980).
(Puffer and Griffith, 1976).Over a nine-year period at the Maternal and Child Institutein Bogota, Colombia, 210 cases of septic abortionaccounted for40 percentof all maternaldeaths. One in 10 women admittedto hospital with sepsis died; other abortion-related complications resultedin an additional 257 deaths duringthesame period. Women with sepsis were 25 times more likely to die thanwere women whose abortioncomplicationsdid not become septic (Lozano et al., 1979). In Peru in 1977, 21 percentof maternaldeaths were reportedto be the resultofillegal abortion;theincidencerose to 26 percent in 1978. Public hospital recordsof 10,000abortioncases showed only5 percentoftheinduced abortionsto be leof gal; the vast majority cases resultedfromincomplete abortionsinduced illegally, percentofwhichwere sep3 tic (Ministeriode Salud, 1981). Table 8 shows the proportion of maternal deaths resultingfromclandestine abortions in selected Latin American and Caribbean countriesforthemid-1980s. Officialfiguresreportedto the World Health Organizationattribute lower percentagesofmaternalmortal-
ityto abortion-yet thenumbersremainsubstantial. Accordingto theInternational Classification Diseases, for of 15 LatinAmericancountries, maternaldeathsdirectly attributableto abortion (both spontaneous and induced) averaged 15.7 percentbetween 1980 and 1986 (PAHO, 1986 and 1989). For 1981 and 1982,WHO placed thefigures at 18.6percent and 17.8percent, respectively (WHO, 1987; Weisner, 1990). For the 1970s, using the average number of registered deaths due to abortion, Tietze (1980) placed the figureat 18.5 percent.The discrepancies in maternalmortality statistics almost certainly result fromunderreporting. Estimatesbased on hospital recordsare not likelyto be trulyrepresentative, because theydo notregister deaths in theregion,and because all abortion-related cases are not always reportedas such. For example,when a carefulexaminationofrecordswas made in Brazil, abortion-related deaths at one hospital were found to be underreported as much as 40 perby cent;in MIedellin, Colombia, a surveyof theregistries of maternal deaths, 25 percent of which were said to be revealedthattheywere underestimated abortion-related, by 50 percent(O'Keefe, 1989; Escuela Nacional de Salud de Putblica Medellin,1992). In eveiy instancethe statistics point to a problemof substantialdimensions.Mortality due to abortionis between 10 and 100 timeshigherin Latin America than in mostEuropean countries(Frejkaand Atkin, 1990).Tietze and Henshaw (1986) estimated the likelihood of death frominduced abortion to be 20 times greaterin Latin Americathanin developed countries. Cuba deaths reIn lated to abortion (both induced and spontaneous) remained a major cause of maternalmortality from1979 to 1982-even after abortionhad been legalized. By 1986 the mortality ratio had declined to 37 per 100,000live births,comparable to the ratio in Chile, where family planningwas moreemphatically promoted.Fora decade or more,themortality forlegal abortionin Cuba has rate remained at just 1 per 100,000 procedures (Nebreda Moreno and Avalos Triana, 1986), comparable to rates in developed countries withlegalized abortion.This low rate has been attributed the use of saferprocedures, to which are discussed below. Morbidity Mortalitystatistics presentbut a small part of the total pictureof the consequences of illegal abortionin Latin Americaand theCaribbean;morbidity ratescompletethe picture.However inadequate hospital admission statistics may be, theyremain the leading indicatorof abortion-related morbidity. Surveys in El Salvador, Guatemala, Paraguay, Chile, and Brazil have indicated that between 20 and 48 percentof women who had ever experiencedan abortion(whether induced or spontaneous)
from Table 8 Percentageofmaternal deaths resulting illegal 980s mid-1 abortions, country, by
Country Argentina Chile Colombia Percent 35 36 29
30
Jamaica Source: Basedon Royston Armstrong, (1989)andRoyston and eds. (1989).
Costa
Rica
33
soughtmedical treatment withtheMinistry Social Welfare, after their abortion(Liskin, holdingcontracts last of the 1980). In the Dominican Republic 21 percentof women nation's largest health-careprovider, 201,597 women with induced abortions found their way to hospitals were hospitalized for "abortions in progress." These (Paiewonsky, 1988). Estimates are consistent in sugcases represented12 percentof all obstetric-gynecologigestingthatone of every threeto fiveillegallyinduced cal admissions withinthe systemforthatyear (Pereira abortions requires hospitalization. In countries where de Melo, 1982). A decade earlier,in a major maternity safer abortion services using the latest techniques are hospital in Salvador, Bahia, Brazil, 21 percentof 1,697 widely available in clinics, in Braziland Colombia, the as women admitted during a three-month period were estimatelessens to one in seven, accordingto Singh and treated for abortion-related complications (Cavalcante Wulf (1991). But the figuremightbe as low as one in 10 Farias, 1972). In Chile in 1964,56,000cases were treated or more. in hospitals; 24,427 (43 percent) were septic. By 1978, Complicationsof unsafe abortioninclude pelvic inpartlyas a resultof the expanding familyplanningprofections,hemorrhage and shock, cervical lacerations, gram,thisnumberhad fallento 37,980,of which 15,510 uterineperforations, damage to thebladder and inand (41 percent)were septic(Onetto,1980). In 1987thenumtestines. the Throughout 1970sa majorhospitalin Bogota' ber of hospitalizationsagain rose to 43,004(Silva, 1989), averaged nearly6,000 admissions forsuch abortion-re- mostlybecause the population of women of reproduclated complicationsper year,one of every fivepatients tive age had expanded and contraceptives had been admitted.The situationin Mexico is similar.Over a five- made moredifficult obtain. to year period, threemajor maternity Singh and Wulf (1991) have recently made a more hospitals in Mexico Cityaveraged between themmorethan 12,000abortion- sophisticatedanalysis of the hospitalizationsattributed related cases annually. These represented14 percentof to complicationsof induced abortion.Noting thatmost thehospital'sadmissionsand a rateof44 hospitalizations hospitalsdo notseparatespontaneousabortionfrom othper 1,000women ofreproductive age (15-44) coveredby ers,theyestimatethatforevery 100 birthsthereare but thesocial security 2.48 miscarriagesrequiringhospitalization.During the systemin thosethreecatchment areas (Ordontez, late 1970s and early 1980s they put the number of in1975). Between 1969 and 1972 in El Salvador, where hospitalizationrates were lower, the proportion duced abortions requiring hospitalization at between of septic cases increased fromone in fiveto one in four 21,822and 41,412in Peru, between 107,357and 470,626 in Brazil,and at 50,171in Colombia. While unsafe abor(Morris and Monreal, 1974). Later abortions are more likely to require hospitalization.In Santiago, Chile, 47 tion is still a major cause of morbidity, modernization percentof women abortingbetween the thirdand fifth has improved the picturein some areas. Withimprovemonthsof pregnancyrequired hospitalization;only 18 ments in abortiontechniquesand betterprovider care, monthrequired percentofthoseaborting some Latin Americanhospitalsare now beginningto see duringthefirst hospitaltreatment (Armijoand Monreal,1968). fewerwomen with infections and women with less seIn the late 1970s the International vere infections Research Fertility and trauma (Singh and Wulf,1991),parProgram (IFRP, now Family Health International) conticularlyin Colombia where induced abortionhas been ductedone ofthelargestmultinational surveyseverdone virtually "medicalized,"thatis, made widelyavailable in of women hospitalized for abortion-related treatment. the majorcitiesand performed medical personnelusby Abortion LatinAmerica in of (1980) chartedthe treatment moderntechniques, ing althoughthe practiceof induced cases in ninecountries. 27,722abortion morethan Slightly abortion still is technically illegal. one-thirdof the respondentsreportedhaving had preCosts ofAbortion vious abortions. The vast majoritywere women who sought medical help for complications ensuing from Treating abortion-related complications exactsenormous abortionsinitiatedoutside thehospital.The surveysubeconomic,social, and personal costs. As Fortney(1981) stantiatedthe generalizationthatclandestineor unsafe botched abortiontypically succinctly observed,treating induced abortionproceduresare morelikelyto produce requires "2 or 3 days in hospital,15 to 20 minutesin the "Patients operatingroom,antibiotics, complications necessitating hospitaltreatment. anaesthesia,and quite often with minorcomplications none do notgo to thehospi- blood transfusions"(Fortney,1981: 579; see also Figaor tal to requesttreatment," report the notes;italso acknowl- Talamanca, 1979; Figa-Talamanca et al., 1986). The exdo tentof resourcesemployed to treatabortioncases is inedged thatsome womenwithseriouscomplications not makeitto thehospitalin time(IFRP,1980:4). ordinate.For example,about halfof theBrazilianhealth The IFRP surveywas dwarfedin termsof the numdirectedtoward system'sobstetrics budget is currently ber of cases, however,by the Brazilian studySequelasdo treatingcomplications from induced abortion-even AbortoCustose Im>plicacoes Sociais.In 1980,at institutions thoughsuch cases represent only 12 percentof obstetric
Volume 24 Number4 July/Aug 1993 211
admissions (Pereira de Melo, 1982; Jacobson,1990). A WHO studyconducteda decade ago thatincluded Venwere the most exezuela found thatblood transfusions treatments, acpensive componentof abortion-related counting for nearly half the total cost, which also included surgery, anesthesia, medication,and intravenous fluids (Figa-Talamanca, 1979). In the early 1960s when Chile, prompted first a concern forwomen's by healthand thenby a preoccupationwitheconomiccosts, began to address thepublichealthaspectsofunsafeabortion,women seeking care forabortioncomplicationsat in in services hospitals Santiagoreceived18peremergency and of centofall blood transfusions, consumed27 percent blood reserves 1963). emergency (Plaza and Briones, Using data fromthe Dominican Republic, Ramfrez and Garcia (1975) calculated thattreating complications froman induced abortioncost the equivalent of US$176 per case-more than two times the cost of treatingan incomplete but uncomplicated abortion,and 12 times more than for a normal birth.More recentlyin Chile, Gayain(1990) estimatedthe cost of treating"nonspontaneous" abortionswithinthe National Health System in 1987. Discounting beforehand the expected cost of treatingspontaneous abortionsand assuming an average patientstayof 5.9 days, 9,440cases of induced aborIn tioncost the equivalent of $1,336,128.4 the mid-1970s, thatifpatients Viada (1976) estimated comingto theFelix Bulnes Hospital (in Chile) withcomplicationsfromsuspected illegal abortionhad insteadundergoneabortions performed trainedphysicians,the totalcosts of their by over thecourse of a year could have hospitaltreatments been reduced by 87 percent. Studies both in Chile and Colombia have indicated thatwomen withsepticabortions stayin thehospitaltwo to threetimeslongerthando women in cases of spontaneous and nonsepticabortion(Liskin,1980). In addition, thedemand formaternity hospitalspace createdby abortion cases may cause otherwomen to be dischargedbefore they have fullyrecuperated,thus contributing to subsequent health problemsfornew mothersand their infants(Viel, 1976). According to Gayain (1990), if the curtailedpracticeofunsafeabortionwere significantly thus freeing beds forwomen who have recently given birth-20 percentof newly delivered women in Chile could have an additional bed/day "with all the advanand thenewborn" tages thiswould mean forthemother (citedin Weisner,1990: 104). Among theless tangiblecosts ofinduced abortionis psychological distress (Londonio,1989), which is more difficult assess. Althoughtheliterature thissubject to on is oftencriticized relying "impressionistic for on case reports,"itindicatesthatin settings outside LatinAmerica whereabortionis legal, "feelings guilt,regret of and sad-
ness, when noted, are mild and transitory, usually followed by a sense of relief associated withsuccessfulcrisis resolution"(David and Pick de Weiss, 1992:47). Little is reported about thepsychological impactof clandestine the abortion, most commontypeof abortionthroughout LatinAmerica. Althoughabortionis regarded as a grave religious sin,Weisner(1988) found thatfora substantialmajority (76 percent)of the women she interviewedin Chile, the distresscaused by an unwanted pregnancyoutweighed the distressof personal conflicts and fearsabout abortion. About one-fifth the women were ambivalent of about theirpregnancies,and tended to feel both relief and remorseafter theirabortions.In an earlierand similar study(Weisner, 1982),about one-fourth 357 women of expressed guilt. Recent researchin Venezuela and Colombia has shown thatthe abortionexperienceevokes a of complexcombination feelings-relief, guilt, depression, and confusion-and thatwhile the factof the abortionis leaves emotionalscars thatusuaccepted,the experience allyhealbutmayneverwhollydisappear(Machado,1979).
Determinants UnsafeAbortion of
Characteristics Women of
Understandingthe problemof unsafe abortionrequires that the characteristics women who seek it be studof ied. Abortion LatinAmerica in (1980) containsa wealth of information, based on interviewsand hospital records of more than 27,000 women hospitalized for abortion complicationsin nine countriesin the late 1970s (IFRP, 1980). The majority thesewomen were eithermarried of (48 percent)or living in union (34 percent);fewerthan one-fifth percert)were single.More thanhalf(55 per(18 cent) had had two or more live birthsand had at least two livingchildrenat the timetheysoughtan abortion; just under one-fourthwere nulliparous. Half of the women were 20 to 29 years old; 14 percentwere in their teens (althoughmost were marriedor livingin unions). One-thirdhad had a previous abortion;nearly 12 percenthad had two or more abortions(whichfinding partially confirmedtendencies toward multiple abortions indicated by surveys in the 1960s). Only one-fourth of thewomen had practicedcontraception priorto thepregnancy theywere aborting.Most had fewerthan seven years of education. The vast majorityof women were fromurban areas, many fromslums, probablybecause thehospitalsin thestudywere all in urbanareas. The women in the IFRP studywere youngerand of lowerparity thanwere women in studiesconductedduring the 1960s, reflecting,according to the report, a "marked change over the last decade in the kinds of
212 Studies Family in Planning
by financialreasons (18 percent),unwillingnessto have women having abortions"(p. 74). The study concluded a baby at thattime (15 percent),having too many chilnumberof women had and increasing thata disturbing begun to use abortionto space or postpone childbirth, dren already (10 percent),and being too young to have thechild (9 percent)(David and Pick de Weiss, 1992). even as contraceptiveswere being made more widely rate In Argentinathe totalfertility is relativelylow available. The studysupported the impressionthatillepolicies have been antagonistic (3.0), and, untilrecently, gally induced abortionin Latin America was also being Llovet and Ramos (1988) found that to contraception. used to end childbearingafterdesired familysize had only 28 percentof women who had undergoneinduced been reached, a phenomenon firstnoted by Centro abortion were single and nulliparous. A key factorin (CELADE) studiesin the de Latinoamericano Demograffa theyhad emotionaland women's decisionswas whether Lima,Asuncion,Panama City,and early1970sin Bogota', partners. their from economicsupportforthepregnancy Buenos Aires (Gaslonde, 1975). In her extensive compilation of abortion research, Of the marriedwomen, 55 percentused abortionin lieu to of contraception space theirpregnancies or to limit Liskin (1980) observed thatrecentstudies have failedto confirm earlierindications"thatabortionwas most fre- theirnumberof children.The studies in Argentinaand it Mexico underscoreagain how difficult is to generalize quent at the middle socioeconomiclevels of societyand in in upper and lower levels" (p. at about patterns Latin America.The patterns Mexico least frequent theextreme as and Argentinaare different, are the social, political, 149)-a patternnoted by Requena (1968a and 1968b) in out and economiccircumstances ofwhichtheyarise. the early 1960s in 12 Latin Americancountries.In Latin of America patterns induced abortionmay be less influenced by such singleindicatorsas education thanby deContraceptivePractice as sires to limitfertility an expressionof general socioeconomic advancement,and the availabilityor lack of (1988)wrote In herarticle"Choice at AnyCost,"Jacobson (Liskin,1980). The United Nations Popucontraceptives lationFund (UNFPA), forexample,estimatedthatthree- thatthe "realityof abortionsignals a social failure-the failureof millions of individuals to preventpregnancy quartersof the Latin American and Caribbean women and the failureof govthroughthe use of contraception desired to postpone,space, contraception not practicing countriesto filltheunmetneed in ernments developing or limittheir pregnancies(Sadik, 1989).In a seriesofsurforfamily planning" (p. 30). Althoughthesituationmay veys in Latin America and the Caribbean,Morris(1988) would women be morecomplicatedthanJacobson'simplication of foundthatsubstantialproportions unmarried regarded their suggest-that merelyby making contraceptivesavailaged 15-24, withat least one pregnancy, betweenconable, abortionwill go away-a connection first pregnancyas "unintended" (50 percentin Mexico years and abortioncannotbe denied. In recent traception City;53 percentin Costa Rica; 66 percentin Brazil; and contraceptiveuse in Latin America (measured among 76 percentin Jamaica).The degree of unwantednessor to married women of reproductive age) has climbed is of thought "unintendedness" a pregnancy generally seems tobe improvand access to contraceptives in steadily, be a keyinfluence women'sdecisionsto seekabortion. 1987).In the 1960sthe ing (Population Crisis Committee, Two recentsurveys-one conducted in Mexico, the but prevalenceratewas only 14 percent, in contraceptive otherin Buenos Aires-hint at divergenttrendsin the uswith46 percent to 1992itwas estimated be 55 percent, foundby David late 1980s.Whereastheage distributions Bureau,1992). ingmodernmethods(PopulationReference and Pick de Weiss (1992) in Mexico were similarto those These figuresare largelyforwomen in unions and, 49 foundin the 1980 IFRP study,a surprising percentof may therefore, be skewed,sincetheyignoreotherwomen the 156 women in the Mexico sample were single,and at who maybe sexuallyactiveand therefore riskofpregmore than half (61 percent)were nulliparous. Of those contraceptiveuse for all nancy. The rates of effective with children, one-third had one child. Eighty-five percentof thesample reportedthepresentabortionas their women in Latin America may be much lower than the of surveysindicate.Even ifthisimpressiverateis accurate, first. Beforeseekingassistance,one-third the women abortion, pri- it means thatnearlyone-halfof Latin Americanwomen had unsuccessfully self-induced attempted Not contraception. all ofthese in union are notpracticing marilyusing injectionsand herbs; only 22 percentrewomen are at riskof unintendedpregnancy;some wish complicaported having experienced abortion-related and to be pregnant,some are pregnant,some infertile, tions. Fifty-four percent had ever used some formof between20 and 30 perTherefore, some sexuallyinactive. the contraception(reflecting contraceptiveprevalence In rateof53 percentforMexico in 1989). The mostfrequent centofwomen are in need ofcontraception. thisgroup, explanationforhaving an abortion(21 percent)was the among adolescentwomen forwhom contraparticularly followed woman's unwillingnessto marryher partner, ceptiveuse ratesare verylow, theproblemof unsafein-
duced abortionexistsin thefaceofunwantedpregnancy. In Bolivia,forexample,whichhas one ofthelowest rates use of contraceptive in Latin America,60 percentof the in women treated abortioncomplications severalhosfor pitals reportedthat they had not used contraceptives priorto pregnancy(Bailey et al., 1988). practicemightbe expected Increased contraceptive to lead to lower rates of induced abortion,but this has not always been the case. Theorizing fromthe experience of Westernindustrializednations,Potts (in Hodgson, 1981),amalgamatingthe earlierwork of Tietze and whatmight happen to thepracBongaarts (1975),forecast use increases. tice of induced abortionas contraceptive phases, women inIn the early and middle transitional yet creasinglyadopt attitudesfavoringlower fertility, during thistime aborhave not adopted contraception; tion frequenciesmay actually increase. However, even use can have a rapid moderate levels of contraceptive citedcase ofChile and dramaticimpact,as thefrequently demonstrates(shown in Figure 1). When the Chilean NationalHealthServicebegan issuingfreecontraceptives in 1964,as a directresponse to the problem of induced use was low and rates of illegal abortion,contraceptive abortionwere high (Fauindesand Hardy, 1978; Onetto, 1980; Liskin, 1980; Barzelatto,1988). Between 1964 and use rates increased from3.2 percent 1978 contraceptive to 23 percent;the numberof women admittedto hospitals for treatment abortion complications fell from of fell mortality dra56,000to 37,900;and abortion-related matically, from 11.8 deaths per 10,000 live births to 4.2 (IPPF, 1978). Althoughsocioeconomicand otherfactorshave also influencedthese changes,the data clearly availabilityand use suggestthatincreasedcontraceptive is associated with decreased reliance on abortion as a of Confirmation thiscan remedyforunwanted fertility. be found in lateryears.When the Pinochetgovernment in restricted access to contraception the mid-1980s,the incidenceofinduced abortionrose. Cuba's experienceis similarin some ways and difin In was givende facto ferent others. about 1964abortion legalization,and in 1979 was legalized de jure (Hollerbach, 1980). In 1968 the numberof legal abortionswas 28,500,risingto 131,536in 1974.By 1980,thenumberfell but rose again in 1988 to 155,327(Soza et al., to 103,974, 1990; Hollerbachand Diaz-Briquets,1983). In 1984 more than40,000abortionsfailedto complywiththe requirementsset out in the law, and hence were termed "illethis pattern,the legal gal" (Paxman, 1988b). Mirroring abortionrate rose between 1968 and 1974 from16.7 to 69.5 per 1,000women aged 15-44, thendeclined in 1980 to 47.2, and rose again in 1984 to 58.7. The abortionracontinuedto riseand tio,as measured againstlive births, has only fallenrecently, 1987. Over the last 15 years in
thetotalrateoflegal abortion fluctuated has onlyslightly: from2.1 per lifetime woman in 1974to 1.8in 1988. If per Potts'sformula applied to Cuba, thetransition contrais to would appear notyetmade. ception Yet contraceptive practicein Cuba is reportedto be substantial.5 The National Fertility Survey of 1987 indicated that75 percentof women between the ages of 15 and 49 were practicing some form contraception: of onethirdwere using theIUD and one-quarter had been sterilized. Overall, 68 percentwere using modernmethods. One mightinfer from Table 3 thatcontraceptive practice in Cuba began to have an effect only after1986,when a two-yeardrop in abortion rates and numbers was reported. But contraceptivefailure reportedlyhas been high (probably as the result of misuse and defective methods). Twentypercentof women surveyed in 1987 had become pregnant while using a contraceptive. More recently, nearlytwo-thirds a sample ofyoung women of who became pregnantsaid theyhad done so while using an IUD (Soza et al., 1990). In theiranalysis Soza and are colleagues pointout thatwhile contraceptives easily accessible, purchase is difficult. They note that contraceptiveuse rateshave aided in a declineofabortionrates forwomen over 30, but have had much less impact on the growingnumberof youngerwomen. Nevertheless, birth ratesfellbetween1973and 1986from 25.0 per 1,000 in the population to 16.2. The birthrate is currently 18. David and Pick de Weiss (1992) suggest thatthis "was accomplishedby relianceon induced abortionas a backnonuse or failup methodin situationsof contraception ure" (p. 49). This, and otherexplanations,put in question the apparent ability of contraceptivepractice to diminishabortionrates.In 1986 the ratioof abortionsto live births had reached96.6 per 1,000and has sincefallen a bit,then risen.Where abortionis legal, contraceptive use may have little impacton boththeabortionratesand In are ratios,especiallywherecontraceptives ineffective. of Cuba theinfluence contraceptive on abortion use practiceis less obvious thanin Chile. Chile and Cuba-the two Latin Americancountries forwhich the most detailed and long-term information is available-represent only a partof the region's wider of and spectrum experiencewithcontraception abortion. In Brazil, forexample, contraceptive prevalence per se has been neithera good measure of correctcontraceptive use, nor an accurate predictorof abortionpractice. The currentcontraceptive prevalence rate in Brazil approaches 65 percent;56 percentof all women say that reversible contheyuse a modernmethod.Most gettheir the commercial sector.Only traceptives through private, since 1986 has therebeen a public familyplanningprogram.Earlier, family planningwas officially made available at public facilities only to high-risk women. In Bra-
and maternal death rate and Figure 1 Rates of contraceptive use, abortion-related mortality hospitalizations, per 10,000 live births, Chile, 1964-89
25 Percentageof women aged 15-44 using contraceptivesa 12 deaths per 10,000live births Abortion-related
20
10
8
60
10
/
5
~~~~~~~~~~~~~~4
2
I I
0OI
0 0 I 1964'66 '68 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 Year Maternal deaths per 10,000live births 30 25
1964 '66 '68 '70 '72
'74 '76 '78 '80 Year
'82 '84 '86
30 25
Hospitalizations forabortion complications per 1,000 women age 15-44
20
0
-
_'n 20
15
i0
2 15/ 10 5
I0
11 11 11111 1 11
5
0
1965
'70
'75
'81 Year
'85
'87
'88
1964 '66 '68 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 Year
a These are the percentsofall women whose contraceptives supplied by thegovernment planning healthservicesand the family are Institute be 56 to prevalencewas put at 43 percentin1978and estimatedby Singh of the Alan Guttmacher association.The totalcontraceptive percentin 1989 (APROFA, 1978 and 1989). Weisner(1990) and Chile,Ministeriode Salud, 1982-90. Source: Liskin,1980,updated by authorswithassistancefrom
is control female zil themostcommonmethodoffertility of recentsurveyremore thanone-quarter sterilization; a mostthrough spondentsreporthavingbeen sterilized, unique system that provides the service after two cesarian births(Arruda et al., 1987). A large numberof have been removed fromthe group women, therefore, Althoughcontrathatmight undergoinduced abortions. ceptivemisuse is basically undocumented,it appears to be prevalentin Brazil,especiallyin the case of oral contraceptives,the second most commonly used method at (Arruda et al., 1987). Many women are therefore risk. 30 With approximately millionwomen of reproductive age in Brazil,thenumberofabortionsinduced annually, according to Singh and Wulf's (1991) estimates,is between300,000and 3.3 million.In Braziltheimpactofcon-
on traception theabortionrateis notyetclearlydefined, but it may be less directthanin Chile and similarto that by restricted law in Cuba, even thoughabortionis highly in Brazil. Contraceptivefailures,as shown by the Cuban expractice. Theyalso have been linkedto abortion perience, confound the Potts paradigm. In 1975 Tietze and use, no modern Bongaartsnoted thateven with perfect The immethod is 100 percenteffective. contraceptive failureaccumulates over time;the pact of contraceptive longer a method is used, the higherthe chance it will fail(Tietze,1974). Bongaartsand Rodriguez (1989),who have scrutinizedfailurerates formodern contraceptive methodsin six Latin Americancountries, reportannual levels of failurevacillatingbetween 6.4 percent(Costa
Rica) and 16.4 percent(Peru). What percentagesofthese failures, pregnancies,resultedin induced abortions? or In Bolivia two-fifths all women admittedto thehospiof tal fortreatment abortioncomplicationsreportedthat of theyhad used contraceptives duringthe monthpriorto conception(Bailey et al., 1988). Earlier,the Pan Amerithatforevery100 can HealthOrganizationhad estimated 2.2 womenusing "effective" contraception, induced abortionscan be expected annually; forthose using "less ef8.6 fective"contraception, abortions;and forthose using no methodsat all, 10.0 abortions(PAHO, 1985). and Overall,therelationship betweencontraceptives abortionpracticesin Latin America appears to be conwiththeobservationof David and Pick de Weiss sistent (1992:53). is means In some countries, abortion theprimary of fertility control;in others,abortionand conwith traception increasetogether.... [Generally,] the passage of time contraceptivepractice imto proves and resort abortiondeclines,although itis nevertotally eliminated. This statementconcurs with Potts's paradigm, but does not explain what has occurred in Cuba. Induced abortion ranks among the four most commonly used methods of fertility regulationin Latin America,along withfemalesterilization, pill,and theIUD (Paxman, the 1988b). Indeed, seven out of ten women using contrawill ceptivemethodsof 95 percenteffectiveness require at least one abortionduring theirlifetimes theywish if to have only two children-the number becoming the norm in Latin America (Tietze, 1980; Frejka, 1984). As Pottsand Requena concluded separately the1960sand in 1970s,contraception reduces but does not eliminatethe need forabortion.At present,"one-quarter deliberate of controlin Latin America is being achieved by fertility induced abortion"(Frejkaand Atkin,1990: 11). Abortion practicewill never be eliminatedin Latin America. The use onlypointofdebate is how muchtheeffective ofconwill reduce the abortionrate.Using calculatraceptives tionsmade by Nortman,Frejkaand Atkinestimatethat in the late 1980s annually were 12.4 millionlive births, 8.8 millionbirths avertedby contraception, between and 1.3 and 3.4 million birthsaverted by induced abortion (1990: Table 3).
of induced abortion, especiallywhere indicationsforlegal abortion are restricted-as in virtuallyall of Latin Americaand theCaribbean,exceptBarbados,Belize,and Cuba (see Table 9) (Jones,1982; IFRP, 1980). Restrictive laws create a situationin which safe abortionbecomes essentiallyunavailable, so thathealthsystemsgenerally to even thoseabortion-related servicesthat do little offer servicesto save the life are legal (forexample, offering or healthofthewoman), althoughtheneed forsuch supportis clear.Where limitedaccess to abortionis permitbe ted,legal abortionsmay,nonetheless, authorizedonly is a slow rarely. Obtaininga legal abortion often painfully atprocess,and women may be subjectedto reproachful titudesof medical personnel,with the resultthatsome laws turnto clandestinepractitioners. Thus, restrictive notonlyreinforce biases againstabortionper se, but they they also appear to stimulate manyoftheunsafepractices intendedto prohibit. were,to some extent, Laissez-faireenforcement the law also produces of dangerous and deadly results. Clandestine abortion laws. In a in flourishes countrieswith highlyrestrictive fewcountries(notablyColombia), abortionpracticedon thefringes thelaw (orin bold oppositionto it)is openly of carriedout. In othercountries, clantoleratedand freely destine abortionists with relativeimpunity act because thelaw is rarelyor sporadicallyenforced, thoughextoris tionby police and judicialauthorities common.In some aborplaces morethan30 yearshave passed sincecriminal untionwas lastprosecuted; even wherewomendie from and others medicalpersonnel who safe,illegalprocedures, the perform unsafe abortionsare rarelyfound and convicted.What thelaw says (de jure) and what happens in are gap reality facto) separated theimmense between (de by that fiction reality OctavioPaz remarked and upon. Access she Once a woman has decided to seek an abortion, faces the challenge of trying make her particularcircumto stance conform legal boundaries,or, alternatively, to of findingaccess to an abortionoutside of the law. Sometimesthe legal provisionsin forcein Latin America coincidewitha woman's interests-for example,ifan abortion is permittedin order to save her life.More often, the legal maneuvers necessary to gain access to legal abortionservices may be frustrating, complicated,and in timeconsuming.Whereabortionis permitted thecase of rape, incest,or some othersexual crime, the process and cumbersomethata woman's remay be so lengthy quest remainspending aftershe has given birth(Portumillionsof Latin gal and Claro, 1988). Not surprisingly, Americanwomen annuallyseek riskyabortions. Because of the restrictiveabortion laws in Latin America and the Caribbean, women who have decided
Abortion-related Services: AccessandQuality

Laws andPolicies
Laws and policies are among the most important deterof minants thequalityofavailable abortion services. They influence directly frequency adverse consequences the of
Table 9 Legal statusofinducedabortion selected countries Latin in in America and theCaribbean,bycountry, 1993
Circumstances in which abortion is legal Risk to life X Risk to physical health X Risk to mental health Rape or incest Risk of fetaldeformity Socioeconomic hardship Elective
Country Argentina
Illegal
Comments and referencesto statutes The rape indication initially appliedtothe pregnancy a womanwith of "severemental illnessor retardation" was eliminated a but by decision.Criminal court Code Arts. 85-88, as amended byLaw No. 17567,6 December 1967 and Decree No. 3992 of2 December 1984.
Barbados
Pregnancy due to rape is considereda "grave" injury health; to doctormustconsiderwoman's social and economicenvironment partof as determination risk health.Medical of to Termination Pregnancy of Acts(ActNo. 4 of11 February 1983) Secs. 4-14. Physician mayconsiderrisk pregnancy of to as Criminal "existing children" partofformula. Code Ordinance33, Sec. 108-110 (1980). Penal Code Arts. 126-129, Decree Law No. 2848, 7 December 1940 as amended in1941 and 1969. in Inducedabortion case ofrape mustbe first performed during 12 weeks ofpregnancy.
Belize
Brazil
Sao Paulo (municipality)
Cuba
first Elective other during 12 weeks ofpregnancy; indications used during second trimester. Criminal Code, Chap. 6, Arts. 320-324,15 1979. February of law Generalprinciples criminal apparently permit wherenecessaryto save inducedabortion the life thewoman.Criminal of Code Art. 317, 1948. modified Law No. 1690. 19 April by
Dominican Republic
(X)
El Salvador
Penal Code Arts.161-169, Decree No. 270 of3 1973. February the OffensesAgainst Person Law,Chap. 208 (1864). 1985. Decree 13-85 of26 February
Jamaica
Honduras Mexico
X X X
Abortion to unintended due act "imprudent' of womanalso legal. Penal Code of2 January 1931, Arts. 329-334.
Veracruz Durangoand Coahuila Peru
X X X X
X Decree 121 of12 June1981, Sec. 21 Legislative as amended byPenal Code Arts. 159-164 (NormasLegales No. 178,1991).
Sources: UNFPA (1979); UNFPAand Harvard Law School (1980-89); WHO (1980-91); Boland (1992b).
to terminate their pregnancies facemajordilemmas.They In must usually pursue theirintention secretively. Brazil and Mexico,forexample,thePublic Health Code prohibitsany announcementsor advertisingrelated to induced abortion. Women rely on informal (but often substantial) referral networks clandestine or practitioners where or withwhom choices are few and qualityof services cannotbe easilyevaluated. The processmaybe furthercomplicatedby moral and religiousprohibitions as well as by fear of legal reprisals.Even the limited ad-
withinthelimitsofthelaw equate servicesthatfunction may remainunknownto thewomen needing them. In developing countries such as thosefoundin Latin America,restrictive abortionlaws exacerbateeconomic intodecisionmaking injustices. limiting By and intruding processes,the law encourages individuals to search for thuspromotedare not clandestineservices.The practices because clandesonly dangerous,but also exploitative, tine abortionists often charge exorbitantlyhigh fees. Women ofsufficient economicand social rankcan almost
was nearly30 years ago. Efforts make contraceptives to widely available pay huge dividends. For example, through1984 in Mexico, foreverypeso spenton contraceptives,nine were saved on maternityand abortionrelatedcosts.Over a six-year period,theMexican family planning programwas shown to have averted 3.6 million unwanted pregnancies and 363,000 induced abortions (Nortmanet al., 1986). Yet by choosing to focuson pregnancyprevention,such measures generallyfail to acknowledge the issue of preventing abortion. Some observers continueto maintainthatconnections between contraception and abortion are as yet inconclusive QualityofServices (PAHO, 1986). And, as Lopez-Escobar noted long ago, The worldwidetrendtowardprogressive health-oriented the contraceptive approach has a distinct advantage belegislation has made substantial improvementsin the cause it "does nottouchon thethemeoflegalizingaborqualityofregulatedservices(Tietzeand Henshaw, 1986); tion-which would clash with [Latin American]moralthecase ofCuba is proofenough. Whereaccess is legally ityat thesocial level and withlifeitself theindividual at restricted thefrequency clandestineabortionhigh, and of level-but ratheron the subjectof avoiding a calamity" however, the quality of services is almost always defi(L6pez-Escobar et al., 1978:59). cient.Conspiringwithdesperatewomen's needs,thelaw Assumptions have long been made that abortion createsconditionsin which untrainedand incompetent rates and numberswould diminishas familyplanning practitioners thrive(Pottset al., 1977). programsevolved. A decade ago the IFRP reportconA numberof studies show thatin developing councluded with the common-senseassertionthat the incitrieswhere induced abortionis illegal, women face far dence of unsafe abortioncould be "greatlyreduced by greaterrisksof mortality morbidity and thando women is ensuringthatcontraception available to all who want in countries whereabortion been legalized (Corvalan, has it" (IFRP, 1980: 67). In fact,inadequate familyplanning 1979;Liskin,1980;Tietzeand Henshaw, 1986).As already programs appear to have perpetuated the problem of in noted,abortions traumatic conperformed unhygienic, unsafe abortion:As expectationsof avoiding pregnancy ditionscause large numbersof women to requireemerrise, so does the need forabortionif pregnancyoccurs gency hospital care (IFRP, 1980). Where abortions are use. Even where contraceptive use duringcontraceptive practicedin unfavorableconditions, resulting the materis high-as in Mexico, Colombia, and Brazil-so is the nal mortality higherthan mortality is due to childbirth incidence of unwanted pregnancy,and as the number itself(Tietze, 1969). As Jacobson(1990) pointsout, "It is ofwomen ofreproductive rises,thenumberofaborage thenumberofmaternal thatis most deaths,notabortions, tions remains high (Robey et al., 1992). When an unaffected legal codes" (p. 7). Restrictive abortionlaws, by wanted pregnancyis caused by contraceptive it failure, women from the althoughavowedly intendedto protect has a high probabilityof ending in induced abortion. noconsequences ofincompleteabortionsand to enforce More effective contraceptive practiceis needed to reduce tions of public morality, clearlynot sufficient deare to the problem of unsafe abortion.Even by the most conterclandestinepractices. Frejkaand Atkin(1990),among 2.7 servative estimates, approximately millionsuch abormanyothers, expectLatin Americanwomen to continue tions occur annually in Latin America. As the IFRP reto ignorelegal restraints and to findpersonal solutions port stated, it is "absolutely essential to strengthen to theirfertility crises. They predictthat "the incidence servicesto reduce thenumberofunwanted contraceptive of induced abortionin Latin America will remainhigh, pregnanciesthatend in induced abortion" (IFRP, 1980: at least throughthe 1990s,even ifits legislationcontinwill have tobe redesigned 77). Familyplanningprograms ues to be restrictive" 20). (p. to caterdirectly the needs and preferences women to of with themselves,providingappropriatecontraceptives for information their correct use. Resolving the Dilemma of Unsafe Abortion This strengthening necessaryin at least two imis areas. First, rateofcontraceptive the misusemust portant as Contraception Prevention be reduced. In Colombia, forexample,nearlyhalfof the fromone The rationalethatmotivatedChile to legitimizecontra- women surveyed made incorrecttransitions cycle of pills to another;43 percentmade such errorsas ception as a means to reduce the problems associated nottakingthepill everyday; and 10 percent withunsafeinduced abortionis as appropriatenow as it periodically
always obtain relativelysafe, hygienic abortions. But women withfewresources-such as young,single adolescentshiding theirpregnanciesfromtheirfamilies, or poor women withmanychildren-are notusually so fortunate.In rural areas physical and economic access to high-quality services is more limitedthan in urban areas; ruralwomen may run even greaterrisksof complicationsor death.Despite such hardship, millionsofLatin Americanand Caribbean women succeed everyyear in obtainingclandestineor self-induced abortions.
ran out of supplies. Overall, 60 percentmisused the pill withina two-weekperiod, a findingthatwas correctly termed "alarming" (Potteret al., 1988). Contraceptive misuse can be reduced by improvingthe quality of information and counselingavailable, as well as by broadmethodsavailable. Seceningtherangeofcontraceptive ond, every hospital that treatsabortion complications should have an aggressive postabortioncontraception program.Most do not. Substantial research,some decades old, indicates thatmany women are receptiveto information immediately followingan incontraceptive duced abortion(Hardy and Herud, 1975; Fauindeset al., 1968;Rosenfieldand Castadot, 1973; Benson et al., 1992) needs of women with (see Figure 2). The contraceptive demonstrated tendenciestoward high ratesof abortion, women (forexample, young as well as otherhigh-risk single women, women who have achieved desired family size, contraceptive dropouts),must be more assiduously addressed. ImprovingSafetyofAbortions in Experiencein industrializedcountries NorthAmerica and WesternEurope has shown thatlegalizing abortion can eradicate many of the and access to contraceptives dangers inherentin clandestinepractices.But the continuingchallenge in Latin America and the Caribbean the of will be to improvethequality,and thereby safety, induced abortionprocedures-whether or not theyare regulatedby liberalized laws. The problem "is not only but changingthe numbersof abortionsperformed, how thosewhichoccur can be made saferand how complications of abortioncan be treatedmore effectively that so et fewerwomen die" (Winikoff al., 1991:47). reIn thedevelopingworld,dilatationand curettage mains the most common method fortreatingabortion When D&Cs are performed physicians by complications. in hospital settings, carriedout proceduresare typically in operating roomswherewomen are sedated. TheyusuIn in ally remainin the hospital overnight. contrast, the developed world,vacuum aspiration(also called suction uterineevacucurettage)is used formost first-trimester ations; it requires neitherheavy sedation nor an overin nighthospital stay and is usually performed a treatment room or on an outpatientbasis ratherthan in an operating room. VA has been shown to be safer than D&C forfirst-trimester uterineevacuation (Tietze and Lewit,1972;Cates and Grimes,1981;Grimeset al., 1977). The World Health Organizationnow includes VA as an service forall first-level referral hosessential obstetric pitals(WHO, 1991a). Manual vacuum aspiration(MVA), a portable,nonelectricvariation of VA, has been used successfullyin a varietyof health-caresettingsworldwide formore than 20 years and has been shown to be
for use beforeand afterhospitaltreatment Figure 2 Contraceptive 1979 by abortion, country, Brazila Chile Colombia El Salvador Guatemalaa Honduras
Mexicom
.......
Before
lZ
After
PanamaI Peru 0
20
40
60
80
100
use (percent) Contraceptive figures unavailable. are aPostabortion 1980 IFRP, Source:
et less costlyto hospitals than D&C (Johnson al., 1993a: 32). MVA can be employed by trainedparamedical perof the sonnel,whichfacilitates decentralization abortion care. Replacing D&C with VA, and particularly with MVA, could allow care to be delivered on an outpatient reducingtheconsumptionof such greatly basis, thereby scarce health-careresources as anestheexpensive and and personnel,medication,and insia, surgicalfacilities travenousfluids.By enablingtheexpansion ofcare sites, the use of MVA could increase women's access to safe abortionservices,and thus greatlyreduce the mortality and morbidity associated withclandestineabortion. In theleading maternity hospitalin Bogota,Colombia, theuse of VA equipmentin the 1980sby competent has been credited for a recentdecline in practitioners abortion-related maternaldeaths: down from20 to 30 deaths(David of to than8 percent maternal percent fewer and Pick de Weiss, 1992; Paxman, 1988a). Such results point to changingsocial attitudes.Of Colombia, where contraceptionis widely accepted, David and Pick de Weiss say, "unintendedand unwanted pregnanciesare no longeraccepted as theyonce were.Withsafeand reasonably priced abortions available from experienced women have found a way of controlling practitioners, fails" (1992:54). when contraception theirfertility At present, treatment abortioncomplicationsand of legal abortionproceduresusually take place at secondProhealthsystems. levelsofgovernment aryand tertiary visions fortimelyservices formore women at the pri-
marycare level would significantly reduce the morbidityand mortality associated withdelays in receiving care deathsand morabortion-related (WHO, 1991b).Reducing willrequire bidity amongrural populations caresitescloser to women's homes. Such decentralization has yet to be widely implemented, although initialefforts have been made in some countries, Mexicoand Nicaragua. including MVA is currently used in public hospitalsin a number of Latin Americancountriesfortreatment incomof MVA is a safe,appropriatetechnology pleteabortion. for reachingrural and urban women. The experience of a small,ruralpublic healthcenterin Nicaragua illustrates thepotential improvedtreatment incomplete for of abortion. The center serves a population of about 100,000 people. Uterineevacuation was performed D&C, but by an anesthesiologist was frequently unavailable. The centerreferred most patientswith incompleteabortionsto a better facility about an hour's driveaway, but care was often delayed because therewere no emergency vehicles and public transporation was minimal.Afterstaff were trainedand serviceswere well established, MVA became the standard technique foruterineevacuation, and virtually all first-trimester patientswith incompleteabortions were treatedwith MVA at the center(Abernathy and Chambers,1991;McLaurin et al., 1991). A studyin one Mexican statehas already examined the feasibility placing MVA services at lower levels of withinthehealth-care system(Chamberset al., 1992).All medicalproviders MVA services shouldbe ofagreedthat their ease ofuse. At urbanpublichospitalsin fered, citing Mexico and Ecuador,theuse ofMVA insteadofD&C has reducedthedurationofpatient stayand loweredhospital costs fortreatment first-trimester of incompleteabortion et MVA requires (Johnson al.,1992,1993a, 1993b). and lower levels of pain-control medicationthandoes D&C, allowing patientsto recovermore quicklyand oftenavoid an in overnight stay.Some MVAs were even performed an area rather thanin an operating room. outpatient Medical and administrative personnel in several of public hospitals in Chile are using the introduction theMVA technology an opportunity examinetheir as to abortiontreatment services, includingpatienteducation, postabortionfamilyplanning,and attitudesof providers toward abortionpatients.Officialsat one Ecuadorian hospital are modifying theirdischarge protocolsto reduceoverlylong patient stays.After adoptingtheMVA of techniqueat Ministry Health hospitals in one statein in noteda reduction chargesto patients, Mexico,officials because most evacuation procedures are performed on an outpatientbasis. Also in Mexico, the Social Security MVA as the Systemis in theinitialstages ofintroducing methodused fortreatment first-trimester of incomplete abortionpatientsat secondaryand tertiary hospital 1ev-
els (Johnson al., 1992,1993a,and 1993b). et Anothernew technology RU 486,now being used is in extensively France and approved foruse in England. RU 486 is an abortifacient thatacts by preventing uterine implantation theblastocyst, by preventing of or gestationif implantation complete.It is 87 percenteffective is when used alone,and 96 percent in effective combination witha prostaglandin (Bernardet al., 1986;Silvestre al., et 1990).The body of scientific knowledgeabout RU 486 is new and expanding, and whatthedrug'simpacton abortions performed the developing world will be is unin certain.However, thisnew technology has "thegreatest chance forsuccessfulintroduction when a strongdeliveryinfrastructure exists,where follow-upforeach client can be guaranteed,and when suitableback-up forfailed procedures is available" (McLaurin et al., 1991: 25; see also Banwell and Paxman, 1992; Cook, 1989a). The use oftheprostaglandin Cyotecin Brazilhintsat what might happen ifRU 486 becomes available in the region.Discussions are under way aimed at its approval and its introductioninto the United States. This development is not likelyto speed the drug's use in Latin America,because of the difference the legal status of abortionitin self.That abortionhas been legal in theUnited Statesfor the past 20 years has had no impact on the process of legalizationin LatinAmerica. Promotingsafertechniques and trainingproviders who are already performing abortionsis made difficult by the clandestinenature of presentabortionpractices (Tomaro,1981). Expanding the climatefordiscussion of abortioncare among providerscould help to accelerate the adoption of new health-protecting techniques. Beyond discussion,thereis need forappropriatetraining. In addition,safe contraception and abortionservicesreinfrastructures include trained that quire health-system personnel,facilitiesfordeliveringquality services and and defollow-upcare, backup provisions forfailures, In centralizedcare sites to encourage earliertreatment. LatinAmericathegreatest immediateneed will continue to be thatof treating abortioncomplications.Introducing safertechnologiescan begin at thatpoint.Whereinnovativeventurescan be undertaken, experiencein Colombia and Mexico suggeststhatthe qualityof abortion servicescan be upgraded-both withinand at the edge ofthelaw (Villarealand Mora, 1992).
and LegalApproaches Change

are Attemptsat abortionlaw reform affected public by opinion and politicalclimate.Public debates are heated and vociferous. as see Many in LatinAmerica, elsewhere, theabortionissue as partofa largermoral and religious universe, rather than as an issue of public health or women's rights.Attemptsto liberalize abortion laws
have been termed morally unacceptable-at the same timethatstrict enforcement restrictive of laws has been recognizedas impossible (Ortiz Umana, 1973; Nuniezet al., 1991). In settingslike these,the process of change is slow; everyadvance is hard won. For example, despite 1990 legislativeapproval fora moreliberalizedabortion law in the Mexican state of Chiapas, its status to date remainsuncertain(Boland, 1992a). The new legislation would have expanded the criteriaforlegal procedures to include possible fetalgeneticdefects;family planning (with the couple's joint consent); single maritalstatus; and when the pregnancycould be considered "imprudent." The Council ofMexican Bishops complained vigorouslywhen thelaw was enacted,and thegovernor and legislatureof Chiapas set it aside forfurther study.The law was then referredto the Mexican Human Rights Commission foran opinion on its constitutionality; the issue is stillundecided. More than a decade ago fouralternativedirections forchange in Latin American abortionlaws were sugof gested: "strictenforcement existinglaws; liberalization of the laws; continuation the presentlegislation, of with abortion gradually replaced by contraception;or continuationof the presentlegislation combined with greatersocial permissivenessand increased violationof the law" (Isaacs and Sanhueza, 1975: 46). Today, each direction beingfollowedin one or anotherpartofLatin is Americaand theCaribbean. Authorities periodicallyattemptto prosecute,or extort thosewho violate the from, law, but convictions rare;morefrequent thecases are are of official harassment, usually with the aim of extorting payments.Only a few laws have been liberalized (Cook and Dickens,1978and 1988;Boland, 1992b).Unquestionably, contraceptiveuse has risen, doubtless averting many abortions,yet not fullysupplantingunsafe practices.Finally,induced abortion, althoughstillillegal,has been "medicalized" in a few countries-principally in Colombia, where the qualityof care forwomen seeking earlyabortionshas been improved, and socialacceptance of the practicestrengthened (Villarealand Mora, 1992). Isaacs and Sanhuezadid notanticipate situation Honin the duras, Argentina, Ecuador,Chile, and Nicaragua,where abortion laws have becomeevenmorerestrictive they than werea decade ago. The Cuban experiencegives clear evidence thatliberalized laws, includingdecriminalizing abortionpractice,are associated withimprovedaccess and qualityof services,and, in thelong run,witha markeddecrease in adverse consequences. This experiencebears out Viel's prediction in (1976) thatlegalized abortion LatinAmerica would "ensure well-performedoperations and fewer abortion-related deaths" (p. 122). WeretheCuban model to be followed elsewherein Latin America,many of the
deleterioushealthconsequences ofunsafeinduced abortion would be diminished.But laws are not likelyto be liberalized soon in Latin America. Policymakers, social and many women opchurch officials, commentators, pose legal change (Lopez-Escobar et al., 1978; Cardenas de Santamaria,1982). Realityand fiction continuetheirstruggle.Both literatureand experienceteach thatit is "verydifficult for thelaw by itself provide a solutionto theproblem[of to unsafe induced abortion],"particularly the intention if is to eradicatetheunsafepracticethrough punitivemeasures (Sulbrandtand Ferrera, 1975:23). Legal change by itself notenough.Complementary is measures,likethose discussed above, mustalso be taken.Yet thequestionremains: How can laws and policies be used as agents of of change to lessen thenegativeeffects unsafeabortion? Several optionsare possible forLatin America.Most byTaken together, pass statutory reform. they can be regarded as evolutionary steps to legal reform. laws where abortion arerestrictive, abortion-related First, as services be clarified legaland ethical can duties, particuabortions.Women larlyfor the treatment incomplete of should not be deterred fromseeking proper medical treatmentbecause they fear punishment, and health workersshould not be reluctantto proceed with treatmentbecause theythinkit is illegal or because theyare biased against the women needing the treatment.A woman who had undergone repeated illegal abortions describedhersituation: My womb was so infected that the doctors couldn't touch me. One doctor wanted to treat me and the otherdidn't. One said to the other, 'Ifyou send herback home she'll die on theway.' So they operated on me, scraping my womb clean, almost without anesthesia as a kind of punishment. (Gall, 1972:8) The treatment an incomplete of abortion notonlyleis gal; itis also an ethical duty(Cook, 1989b;Paxman,1980). whenlegalabortions Second,laws and policies defining can bepracticed, where circumstances restrictive, even the are can beappliedto their narrather thanto their fullest extent, rowest. this way broader access to abortionservices In would be grantedto women meetinglegal criteria, is as the case in El Salvador, where the menstrualregulation technique is widely available and openly used for the abortionsthatare legal (United Nations, 1992). This approach is also being used in Sao Paulo, Brazil.As partof an attemptto preemptthe adverse consequences of unsafeillegal abortion, statehealth-care the systemwas rethe law and to make availquired to implement existing able legally authorized abortions (for pregnancies threatening woman's life, in cases ofrape) (Pinotti the or
Volume 24 Number 4 July/Aug1993 221
and Fauindes,1989). Althoughapplying the law in this way may affect only a minisculeproportionof induced abortioncases, itdoes expand theavailabilityofsafe services and servesan important symbolicpurpose, signaling that the governmenthealth program is providing abortion-related services. the can Third, indications legalabortion begivenexfor panded interpretations. Althoughmanystatutes permit intervention when a woman's health is threatened, these In statutes almostalways narrowly are interpreted. some countries, access to safe abortionhas been appreciably expanded withoutalteringthe law, simplyby instructing doctors to employ the World Health Organization definitionof health as the basis for decisionmaking: "Health is a state of complete physical,mental and social well being and not merelythe absence of disease or infirmity" (Cook, 1989b;Paxman, 1980). In 1964in Cuba, the stage was set forexpanding access to abortionwithout changingthe law by interpreting Social Defense the Code in termsof theWHO definition (Hollerbach,1980: 101). As thatexperiencepointsout,expanded criteria for decisionmakingcan greatlyenhance women's access to services.The challengeis to place into legallypermitted which necessarily use the wider technical definitions, carrywiththemnotonly a wider practicalbut also a politicalsignificance. rather revolutionary than Fourth, evolutionary approaches can be taken officially on by relaxing legalconstraints abortionpractice. Several Latin American countries(for example, Colombia,Mexico,and Peru) have eased legal restrictionsby allowing a de facto situation to prevail a of fathrough network well-run, low-cost, high-quality some of which have been grantedlicenses to adcilities, dress the problem of incomplete abortion (David and Pick de Weiss, 1992). This evolution has taken place in theabsence ofstatutory reform. can and abortion statutes bereformed, safeinduced Fifth, decriminalized. a few Latin Americancountriesthe inIn dications forlegal abortionhave been expanded or attemptsat liberalizationhave occurred (most notablyin Cuba, Belize, and Barbados). Some countries (for exhave made their ample,Honduras,Chile,and Argentina) and have stalled. laws morerestrictive, in othersreforms For example,in 1979 efforts bringColombian laws in to line with those of the restof Latin America-restrictive and staunchly thoughsuch laws were-were short-lived opposed. This was also the case in Honduras in 1985, when relativelymoderate legal requirementswere rescinded after fierce a polemic. The debate featuredplacards bearing such messages as "Abortionis assassination"and "A doctorwho killsbabies is capable ofkilling adults" (Portugaland Claro,1988). Isaacs and Sanhueza (1975), writing the option to of
liberalize abortionlaws, observed, "It is not the kind of arena into which legislatorsrush to enter" (p. 47). For thisreason alone, abortionlaws will not likelybe liberalized in the near future;attempts to do so in Latin America to date have largelyfailedfora combination of political, social,cultural, and religiousreasons.However, if a countryhas as a goal the resolutionof such public health problems as maternalmortality and morbidity, whichare caused in partby legal restrictions abortion, to then liberalization,certainlydecriminalization,makes sense. Accordingto estimates, legalizing abortionpractices would reduce maternalmortality rates by at least 20 to 25 percent(Paxman,1988b;Jacobson, 1990).Among the changes thatcan be made are: (1) removingcriminal penalties applied towomenwho seekabortion, sincein the faceofsuchpenalties womenareinclined postponeseekto ing propermedical attention when theysuffer complications;(2) expandingthe legal indications whichaborfor tion is authorized, since doing so tends to improve and in accessibility toresult safer and (3) elimiprocedures; nating procedural requirements encumber process that the ofauthorizing sincetheseworktodelaythetimabortions, ing of permissible abortions, thuscreating additionaland risks(Paxman,1980;Cook, 1989b). unnecessary
Conclusion
Ample evidence supportsthe view thatthetwo "countries" Paz wrote about, "one fictitious, otherreal," the existin therealm of abortion.It is equally apparentthat the two must draw nearerto one another,thatthe gap betweensocial practice and normsoflaw and policymust be closed. The law and policy must adjust to the practice-rather thantheotherway around. This adjustment will take enormous politicalwill, somethingthatfor30 years has been lacking in Latin America. The statutes themselves need notneccessarilybe changed-although fromthe perspectiveof women's health,the world experiencehas shown thatliberalizingthemis themosteffectiveway of combatingthe dreadful effects clanof destineabortion.But at a minimum, some de factolegal impedimentsto the wider availabilityof safe induced abortionservicesmust be removed. Legal changesaside, widespread and propercontraceptiveuse mustalso be further promotedbecause such use averts many unwanted pregnancies and tends to lower the need forinduced abortion.At the same time, even withgood contraceptive women will conpractice, troltheirfertility whatevermeans theycan manage, by includingthedangerouspracticeofself-induced clanor destineabortion.Thus, the complementary approach of improving safety all induced abortion-related the of pro-
222 Studies Familv in PlanninL
cedures mustalso be supported.Abortionrates(at least such as Chile) have in countrieswith reliable statistics, over thelast two decades. In othercountries, been falling practice, the however,despiteadvances in contraceptive estimatedincidence of clandestineabortionremains at an unacceptable level. Partly as a result of increased age, thenumbers populationsofwomen ofreproductive ofabortionsremainhigh. for probThe three strategies addressingtheabortion use increasingaccess to and correct lem are interrelated: introducingand using safe abortion of contraceptives; and promoting legal change.All threemust technologies; epidemic of unsafe be pursued at once if the persistent induced abortionin Latin America is to be adequately addressed (McLaurin et al., 1991).
Armijo,R. and T. Monreal. 1965. "The problemof induced abortionin Memorial FundQuarterly 4: 263-280. 43, Chile." Milbank induced following . 1968."Factorsassociatedwithcomplications 4, abortion."Journal SexResearch 1: 1-6. of e Arruda, Jose M. et al. 1987. Pesquisa sobreSaude Materno-Infantil Planejamento Familiar:1986. Rio de Janeiro:Sociedade Bem-Estar FamiliarPress. Asociaci6n Chilena para la Protecci6nde la Familia (APROFA). 1978. en Investigaci6nen el Uso del Anticonceptivos Chile. Santiago: APROFA. en . 1989. El Uso de Metodosde Anticoncepci6n Chile.Santiago: APROFA. Bailey, PatriciaL. et al. 1988. "A hospital study of illegal abortionin HealthOrganization 1: 2722, Bolivia." Bulletin thePan American of 41. M. Banwell,Suzanna S. and John Paxman. 1992. "The searchformeanof Journal Public ing: RU486 and the law of abortion." American Health82, 10: 1,399-1,406. Barzelatto, Jose.1988. "Abortionand its relatedproblems."In InfertilEds. S.S. Ratnam,E.S. Teoh, and C. Anandakumar.Park Ridge, ity. NJ:Parthenon. Benson,Janieet al. 1992. "Meeting women's needs forpost-abortion Care2. family planning:Framingthequestions." Issuesin Abortion NC: IPAS. Carrboro, of Bernard,M. et al. 1986. "Termination early pregnancyby a single dose of mifepristone (RU486), a progesteroneantagonist."Euroand and Biology pean Journal Obstetrics Gynecology Reproductive of 28: 249-257. Boland, Reed. 1992a. "New abortionlaws run into problems." People (IPPF) 19, 1: 41. healthin . 1992b. "Selected legal developmentsin reproductive 1991." Family Perspectives 4: 178-185. 24, Planning Bongaarts, Johnand G. Rodriguez. 1989. "A New Method forEstimatFailure Rates." Working PaperNo. 6. New York: ing Contraceptive The Population Council. Cardenas de Santamaria, M.C. 1982. "El aborto y la mujer." In La Ed. RealidadColombiana. M. Le6n. Bogota: Asociaci6n Colombiana para Estudio de Poblaci6n (ACEP). and David A. Grimes.1981. "Morbidity and mortalCates, WillardJr. and Medicaland ityin the United States." In Abortion Sterilization: SocialAspects. J.E.Hodgson. London: Academic Press. Ed. Cavalcante Farias, F. 1972. "Condicionamentos socioecon6micos do abortamento PaulistadeHospitais10,2: 25-31. provocado." Revista Chambers,Virginiaet al. 1992. "Study forassessing the sustainability of and quality of MVA in the Ministry Health system, Zacatecas, Mexico." Carrboro, NC: IPAS. Unpublished. Nacional de Estadisticas(INE). AnuariosDemogrdficos Chile, Instituto 1985,1986,1987,1988, 1989y 1990.Santiago,Chile: INE.
Notes
1
those thattracetheiroriThe laws in Latin America,particularly gins to thecivillaw systemin Spain and Portugal,defineverynarunderwhicha legal induced abortion may rowlythecircumstances of take place. The huge majority theinduced abortionsperformed and are, perforce, illein Latin America failto meet these criteria yet gal. For an interesting opposing,view on why these abortions may notbe illegal,see Cook, 1991. In early 1981 fundingfromUSAID forresearchtouchingon the subjectof induced abortionwas suspended. Then, at the Internaheld in Mexico Cityin August 1984, tionalPopulation Conference announced thatit would no longer the United States government in countries involved fundnongovernmental organizations foreign promotions, or political in abortion-relatedservices, referrals, change, even when such activitieswere separatelyfunded with the organization's own monies. This policy was abruptlyabanfew doned in thefirst days oftheClintonadministration. The warning on the insertof the product says: "Cytotec (misoprostol)mustnotbe used by pregnantwomen. Cytotecmay cause Miscarriagescaused by Cytotecmay be incomplete miscarriages. and could lead to dangerous bleeding." 9,440 cases @ 5.9 days = 55,696 hospital days x $29 per day $1,336,128.
=
4 5
are Althoughcontraceptives said to be widely available bothfrom have been shortages theNational Health Serviceand in drugstores, reportedin recentyears,even thoughsome of the contraceptives, in notablytwo typesof pills,are manufactured the country(Soza et al., 1990).
References
Mary and Virginia Chambers. 1991. "Nicaragua trip reAbernathy, port." Carrboro,NC: InternationalProjects Assistance Services (IPAS). Unpublished. Notes21, 3-4. 1992.Citingregulationon CytotecpreAbortion Research 9 Register, September. in scription Brazil,Official Acosta, M. et al. 1976. El Abortoen Mexico. Mexico City: Fondo de CulturaEcon6mica.
de 1982,1983, Hospitalarios Chile, Ministeriode Salud. Anuarios Egresos de 1984,1985,1987,1990.Santiago,Chile: Ministerio Salud. Comisi6n para el Derecho al Aborto.1989.Buenos Aires,Argentina. drugs: Medical and legal isCook, Rebecca J. 1989a. "Antiprogestin sues." Family Perspectives 267-272. 21,6: Planning . 1989b. "Abortionlaws and policies: Challenges and opportunities."International Journal Gynecology Obstetrics and Supplement of No.3: 61-89. .1991. "Clandestineabortionsare not necessarilyillegal." Famn-
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Cook, Rebecca J.and BernardM. Dickens. 1978. "A decade of change in abortionlaw: 1967-77." American Journal PublicHealth68, 4: of 637-644. . 1988. "Internationaldevelopments in abortion laws: 19771988." American Journal PublicHealth78, 10: 1,305-1,311. of Corvalan, H. 1979. "The abortionepidemic." In Birth Control-An International Assessment. Eds. M. Potts and P. Bhiwandiwala. Baltimore:University Park Press. Costa, Sarah H. and MartinP. Vessey. 1993. "Misoprostoland illegal abortionin Rio de Janeiro, Brazil." Lancet 341: 1,258-1,261. David, Henry P. and S. Pick de Weiss. 1992. "Abortionin the Americas." In Reproductive Healthin theAmericas. Washington,DC: Pan AmericanHealth Organization.
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in Planning 226 Studies Family

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The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America Author(s): John M.

The Clandestine The Epidemic: Practice ofUnsafe in Abortion Latin Amerca

Incidence of Induced Abortion

Volume 24 Number4 July/Aug 1993 205

Abortion ratio 500 85-822 154a 176-411 81.8b na 200-500 43-177 na na

206 Studies in FamilyPlanning

Abortion rate 69.5 61.5 52.9 47.2 55.3 58.7 58.0

Note: Excludes Europe, UnitedStates, Canada, Australia, New Zealand, Japan,

Volume 24 Number 4 July/Aug 1993 207

Methods Used to Induce Clandestine Abortion

Brazil Chile Colombia

7.7 28.9 29.2

0.5-1.5 2.0 1.2-1.5 1.5 na na na 1.3

9.Qa 34.8a (1960) 19.2a

Douches other and Not stated

(1980). (1968), cited Liskin in Source: Armijo Monreal and

in Planning 208 Studies Family

Consequences of Unsafe Abortion

1993 209 Volume 24 Number4 July/Aug

Colombia Jamaica Venezuela

Jamaica Source: Basedon Royston Armstrong, (1989)andRoyston and eds. (1989).

210 Studies in FamilyPlanning

Volume 24 Number4 July/Aug 1993 211

212 Studies Family in Planning

1993 213 Volume 24 Number4 July/Aug

214 Studies in FamilyPlanning

1964 '66 '68 '70 '72

'74 '76 '78 '80 Year

'82 '84 '86

Hospitalizations forabortion complications per 1,000 women age 15-44

1993 215 Volume 24 Number4 July/Aug

Abortion-related Services: AccessandQuality

216 Studies in FamilyPlanning

Sao Paulo (municipality)

Veracruz Durangoand Coahuila Peru

1993 217 Volume 24 Number4 July/Aug

218 Studies Family in Planning

1993 219 Volume 24 Number4 July/Aug

and LegalApproaches Change

220 Studies in FamilyPlanning

Volume 24 Number 4 July/Aug1993 221

222 Studies Familv in PlanninL

Volume 24 Number 4 July/Aug1993 223

ily Planning Perspectives6: 283. 23,

America: Selected Reports, American Health Organization Pan

In Pregnancy Termination. G.I. Zatuchni, Sciarra, J.J. Eds. J.J. and

nity." International of JournalHealth Services 3: 375-389. 16,

andPracticesFertility in America: Selected of RegulationLatin Reports,

International Planning Family Perspectives4: 125-129. 11,

demiology Abortion Practices Fertility of and of Regulation Latin in

224 Studies Family in Planning

Volume 24 Number4 July/Aug1993 225

Planning 6: 97-119. 3, Studies Family in

Ex1976. Demographic The The American Explosion: Latin Viel, Benjamin.

data."International Planning 17, Family Perspectives 1: tility survey

Care. and Guidelines Abortion on . 1991b.Technical Managerial

in Planning 226 Studies Family

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