The European Journal of Contraception and Reproductive Health Care, August 2009;14(4):245248

EDITORIAL

Reections on the legalisation of abortion in Portugal

Miguel Oliveira da Silva
Department of Obstetrics and Gynaecology, Hospital de Santa Maria, Lisbon Faculty of Medicine, Preventive Medicine Institute and Medical Ethics, University of Lisbon, Portugal
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KEYWORDS

Induced abortion; Illegal abortion; Ethical issues; Portugal; Law; Legal abortion; Legislation

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Induced abortion up to ten completed weeks has been legal in Portugal since April 2007. In 1984 and 1997, two laws decriminalised abortion in three different situations: (1) For maternal indications (up to 12 completed weeks); (2) For fetal indications (up to 16 completed weeks since 1984, and up to 24 completed weeks since 1997); (3) In case of rape, renamed since 1997 crime against sexual freedom (up to 12 completed weeks between 1984 and 1997, up to 16 completed weeks since then). While these three indications still apply, a new, most important change took place in April 2007 when induced abortion up to ten completed weeks, whatever its indication, became legal and was fully paid for by the National Health Service (NHS). Teenagers less than 16 years old must have parental permission. Before April 2007 illegal abortions caused several fatalities, their exact number being unknown. Maternal deaths due to clandestine abortion decreased after vaginal and/or oral misoprostol started being used. Sometimes this drug was not prescribed but self administered. In 2007 the death of a teenager related

to misoprostol overdose was reported in Lisbon1. Also maternal morbidity due to illegal abortion (perforation, haemorrhage, uterine infection, septicaemia, chronic pelvic pain, Asherman syndrome, psychological problems) was not rare. Maternal morbidity and mortality caused by illegal abortion were underdiagnosed and under-reported; ofcial data certainly underestimated both. Frequently, it was hard to distinguish between spontaneous and induced illegal abortion complications, as many women did not tell the truth. Ethical discussions, occasionally quite emotional, involving the media, the Catholic Church, law specialists, journalists and medical practitioners were frequent since the early 1980s. Many arguments went back and forth but, ultimately, a change occurred in the public opinion between the two national referendums. The latter, which took place in June 1998 and February 2007, had divergent outcomes (Table 1). Neither reached the quorum of 50% of electors participating in the vote needed for a legally binding result. As, at the last referendum, 59.2% of the voters accepted legal abortion up to ten completed weeks, Parliament amended the abortion law accordingly in April 2007. The new law came fully into effect in July 2007 (Table 1). The favourable effects legalisation had on public and womens health are undeniable, as even most

Correspondence: Professor Miguel Oliveira da Silva, MD, PhD, Preventive Medicine Institute, Lisbon Faculty of Medicine, Avenida Professor Egas Moniz 1649-028, Lisbon, Portugal. Tel: 351 964032948. E-mail: mos@fm.ul.pt

2009 European Society of Contraception and Reproductive Health DOI: 10.1080/13625180903053740

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Oliveira da Silva

Table 1

Legal abortion referendums results Participation in the vote (%) 31 43.6 Yes votes (%) 49 59.2 No votes (%) 51 40.8

Years 1998 2007

Portuguese pro-life movements supporters will acknowledge. According to ofcial gures, no maternal deaths due to legal induced abortion have been reported since July 2007, and abortion complications have dramatically dropped. Unfortunately, so far, reliable comparative data on abortion complications before and after the change of the law are hard to nd. Indeed, previously, statistics were grouped indistinctly under the same heading complications of spontaneous and induced illegal abortions.
INDUCED ABORTION RATE TRENDS

legalisation, which does not allow us to distinguish a clear epidemiological trend. Most previous estimations of illegal abortions done in Portugal were speculative and unreliable. The only acceptable study dealt with abortion complications treated in hospitals; it suggested that around 20,000 induced abortions took place yearly during the 1990s3 (there were 2,607,397 women of reproductive age in 2000). But these gures should be interpreted cautiously for there are no reliable statistics concerning an illegal intervention. One may have to wait a few years before a trend will become evident. Possibly, as happened in Britain after abortion was legalised, a steady drop will take place after an initial rise4. First and foremost, the abortion rate is related to contraceptive prevalence. This leads us to my next point.
PREVENTING REPEAT ABORTION

Is induced abortion increasing or decreasing in Portugal? In 2008, 16,839 legal abortions were done for so called social indications. Of these, 12.26% were carried out on teenagers (less than 20 years old), and 15.65% on non-Portuguese resident citizens2. Since during the second half of 2007 the total number of legal induced abortions was 6,036, some people argue that induced abortions increased by 39% from 2007 to 20082. Yet, this reasoning is unfounded. Indeed: (1) Whereas the law came into effect in the second half of 2007, human and logistic resources were not yet available initially all over the country; (2) Many women with unwanted pregnancies were at that time still reluctant to search for ofcial services for an induced abortion. This was partly due to the propaganda of previous status quo supporters, who had claimed that attendance of ofcial services meant bad quality and loss of privacy. It is plausible that some women then preferred to submit to an illegal abortion; (3) Before July 2007, thousands of Portuguese women went abroad (mainly to Spain) to be aborted. This is no longer the case but attitudes did not change at a moments notice. It is still too early to determine whether abortions have increased or decreased. Two years have gone by since

Most repeat abortions are the manifestation of a failure of the health care system, in the eld of sexual and reproductive health. Twenty percent of the women aborted in Portugal in 2008 had already had at least one induced abortion (probably illegal) previously. Moreover, 244 women (1.4%) reported having had more than one legal induced abortion in the course of the year 20082. Leaders of some of Portuguese pro-life groups, after having voted in 2007 against legalisation, now contend that a repeat abortion should be paid for by the applicant even when performed within the NHS. Some of their brothers in arms plead for making illegal a second induced abortion under the social clause. But the doctors task consists of helping patients, not of judging or punishing them. In that line of thought, a number of bioethicists and medical practitioners who refuse to endorse the aforementioned restrictive proposals would prefer the law to give health care takers access to a different conscientious objection status. Repeat abortion could reect the womans and/or her partners negligent behaviour, and many doctors would prefer not to be the accessory to an intervention they morally disapprove of. According to the current law, women are required to go to a family planning (FP) consultation two weeks after the abortion. No national data are available, but 40% of the women who had their pregnancy terminated in the major Portuguese teaching hospital

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do not show up for the post-abortion consultation (Joaquim Silva Neves, personal communication). This is hardly acceptable to some as both legal induced abortion and FP consultations are free in the Portuguese National Health System. Fortunately, the contraception to be used has been discussed and agreed upon before the abortion. Another suggestion to change the law would consist, in cases of repeat abortion within 12 months, of obliging the woman (and her partner) to pay a tax corresponding to part of the cost of the procedure. A similar arrangement already exists within the NHS regarding many other healthcare interventions such as certain outpatient consultations and surgery, for instance. By all means we should grasp why these women (and their partners) fail to use an efcient contraceptive method.
SELECTIVE CONSCIENTIOUS OBJECTION?

ABORTION METHOD AND WOMENS CHOICE: ETHICAL MISCONDUCT?

Different perspectives are now emerging about the conscientious objection status: while some believe that a selective conscientious objection status could allow doctors to refuse being actively involved in certain situations, such as a second legal abortion, others oppose this measure, arguing this could lead women to resort again to illegal abortion. The Health Ministry recently assessed the quality of some private clinics where legal abortions are carried out; it appears that this question needs further discussion5. By the current law, when a health professional whether a gynaecologist, an anaesthetist or a nurse claims conscientious objection, even if only once, he or she will have to object to all induced abortions, no matter what the specic situation is. If the conscientious objection status changes, one could accept to participate in certain cases, and refuse to do so in others. This could bring about a change in medical attitude and behaviour towards the current law, eventually increasing the number of professionals willing to work in abortion consultations. Some doctors and bioethicists reject this argument, arguing that this would inevitably lead to an unacceptable level of subjectivism. Although this has not been ofcially acknowledged, around 80% of the Portuguese gynaecologists invoked conscientious objection after the 2007 law was approved.

In 2008, 29.8% of legal abortions were performed in private clinics, mostly under general anaesthesia; these interventions also were fully covered by the NHS2,5. There are no available data on the social and economic status, nationality and age groups of women seeking private clinics. Perhaps this would be one of the keys to understand their motives. The main reasons for choosing a private clinic for pregnancy termination are presumably related to privacy and discretion, which cannot always be safeguarded in the NHS. For instance, in one university hospital the waiting room is common for all pregnant women, whether attending the prenatal consultation or the abortion consultation. Although one might argue that this would enhance the condentiality, this is not the case: usually women sit in different places within the same room, according to expected pregnancy outcome. According to the aforementioned report of the Health Ministry5, most abortions in Portuguese private clinics are done by vacuum aspiration and/or curettage. This contrasts with the NHS practice in hospitals, where medical abortions are performed, the most effective and best-tolerated regimens being those using oral mifepristone and oral and/or vaginal misoprostol. Doses and route of administration may differ; in the Hospital de Santa Maria, in Lisbon, use is made of 200 mg mifepristone orally followed by 800 mg misoprostol vaginally, which achieves complete abortion at eight weeks in more than 95% of the cases. If these data are conrmed and should apply to all centres, there will be no good reason for choosing surgical abortion as a rst option, at least before eight weeks gestation. There are not many studies on the cost of abortion, but complication rates related to each method should be taken into consideration as they inuence cost. The preference given to surgical methods in private clinics has raised speculations about its real motives. While some suspect that economic interests play a role surgical abortion and general anaesthesia being more expensive than medical abortion, respectively 444 and 341 Euros6 others claim that private clinics mainly deal with 9 or 10 weeks gestations (occasionally more and then illegally) for which medical abortion alone is less appropriate. It would be ethically indefensible that surgical options be determined by

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economic considerations. Clarication is needed in order for deontological measures to be taken. We must still address the question regarding whose right it is to choose the abortion method. Should it be the woman, after she has been fully informed, as is the case in many centres in Europe, or should the doctor decide on his own?
CONCLUDING REMARKS

Two years have passed since the new law came into effect in Portugal. Activists criticise the law, arguing that it promotes a permissive and unsafe sexual and contraceptive behaviour; they already claim the need

for another law or, at least, additional guidelines that would solve some of the open questions mentioned. The Minister of Health, Dr Ana Jorge, a paediatrician, considers that it is too early to revise the existing law. The key to reduce repeat abortion, she says, is an efcient and stronger link between hospitals and health centres FP consultations. At this time one can only emphatically stress that no deaths are associated with legal abortions and that abortion-related morbidity has dramatically dropped. Public health gains after the approval of the current law are evident, although it is clear that the laws application is still imperfect. Let us address the problems and consolidate the public health gains.

REFERENCES

1. Henriques A, Lourenco A, Ribeirinho A, et al. Maternal death related to misoprostol overdose. Obstet Gynecol 2007;109:48990. 2. Direccao-Geral da Saude. Relatorio dos registos de interrupcao de gravidez ao abrigo da Lei 16/2007, referente ao perodo de Janeiro a Dezembro de 2008. Accessed 28 February 2009 from: http://www.saudereprodutiva.dgs.pt/default.aspx? cr12220 3. Matias Dias C, Marinho Falcao I, Marinho Falcao J. Contribuicao para o estudo da ocorrencia da IVG em Portugal continental (1993 a 1997): Estimativas utilizando

dados da rede de medicos sentinela e dos diagnosticos de altas hospitalares. Epidemiologia 2000;18:5563. 4. Baird D. Therapeutic abortion. In Glasier A and Gebbie A, eds. Handbook of family planning and reproductive healthcare. London: Churchill Livingstone 2000: 24954. 5. Inspeccao-Geral das Actividades em Saude. Relatorio IGAS n8 400/2008. Accessed 28 February 2009 from: http:// www.igas.min-saude.pt/ 6. Direccao-Geral da Saude. Portaria n8781-A/200. Tabela de precos do SNS (Gravidez, parto, aborto). Accessed 28 February 2009 from: http://www.saudereprodutiva.dgs.pt/?cpp1

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