The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America

Author(s): John M. Paxman, Alberto Rizo, Laura Brown and Janie Benson
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
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 The Clandestine Epidemic: The Practice
of Unsafe Abortion in Latin Amerca

John M. Paxman, Alberto Rizo, Laura Brown, and Janie Benson

In Latin America, induced abortion is the fourth most commonly used method offertility regula-
tion. Estimates of the number of induced abortions performed each year in Latin America range
from 2.7 to 7.4 million, or from 10 to 27 percent of all abortions performed in the developing
world. Because of restrictive laws, nearly all of these abortions, except for those performed in
Barbados, Belize, and Cuba, are clandestine and unsafe, and their sequelae are the principal cause
of death among women of reproductive age. One of every three to five unsafe abortions leads to
hospitalization, resulting in inordinate consumption of scarce and costly health-system re-
sources. Increased contraceptive prevalence and restrictive abortion laws have not decreased
clandestine practices. This article addresses how the epidemic of unsafe abortion might be
challenged. Recommendations include providing safer outpatient treatment and strengthening
family planning programs to improve women's contraceptive use and their access to information
and to safe pregnancy termination procedures. In addition, existing laws and policies governing
legal abortion can be applied to their fullest extent, indications for legal abortion can be more
broadly interpreted, and legal constraints on abortion practices can be officially relaxed. (STUDIES
IN FAMILY PLANNING 1993; 24, 4: 205-226 )

A decade ago the recent Nobel laureate Octavio Paz This article examines the implications of the distinc-
wrote of two coexisting Mexicos, "one fictitious, another tions between the "real" and the "fictitious," and ex-
real." He went on to observe: plores what might be done to reconcile them. Recogniz-

Abortion is a clear example of this situation. Pro- ing that Latin America and the Caribbean make up a vast

hibitions against the practice fortify the unreal and diverse region about which generalizations are dif-

country-the one of frustrations-against the ficult, we focus on the following questions: What trends

one of the facts-the country of reality. (Paz, and practices describe the incidence of induced abortion

1982:11) in Latin America? What are the consequences of these

Where abortion is concerned, Paz's insight may well
apply to Latin America and the Caribbean in general.
The reality is nearly 30 years of a clandestine epidemic.
John M. Paxman, J.D. is Adjunct Professor of Health
Services, Boston University School of Public Health and
Director, Keene Associates, Lexington, MA. Alberto Rizo,
M.D. is former Regional Director for Latin America,
Pathfinder International and is now an independent
consultant in Bogota', Colombia. Laura Brown, M.P.H. is a
student at the Medical School of the LUniversity of North
Carolina, Chapel Hill, NC. Janie Benson, M.P.H. is
Director of the Research and Evaluation Division, IPAS
(International Projects Assistance Services), Carrboro, NC.
Address all correspondence to John M. Paxman, Keene
Associates, 5 Sheridan Street, Lexington, MA 02173.
trends and practices for women's health? What are the
costs of clandestine abortion-both economic and social?
What propels the practice? How does contraceptive prac-
tice relate to abortion? What limits the quality of induced
abortion and impedes women's access to safe abortion
care? And finally: What must be done to remedy the cur-
rent situation?
Incidence of Induced Abortion
Some research suggests that indigenous societies in Latin
America and the Caribbean resorted to induced abor-
tion both before and after the Spanish conquest (Viel,
1988; Devereaux, 1976; Ramos, 1977). However, only in
the twentieth century has the practice of unsafe abortion
surfaced as a major social and health problem-one that
has been widespread for at least three decades. Induced
abortion is associated with a mix of influences, such as

Studies in Family Planning Volume 24 Number 4 July/Aug 1993 205

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socioeconomic change, an increase in the desire to reduce Table 1 Numbers of women hospitalized for induced-abortion
natural fertility, -and an absence of access to or reliable complications, hospital-based abortion rates (per 1,000 WRA)
and abortion ratios (per 100 live births), estimated total number of
use of contraception. There are two opinions on the mat-
abortions, and abortion rates (per 1,000 WRA), by year, Chile,
ter. One opinion holds that despite a steadily increasing
1940-89
rate of contraceptive use, the incidence of unsafe abor-
Number
tion in Latin America remains high and the total num- of women Hospital- Hospital-
ber of abortions may be on the rise, particularly among hospitalized for based based Total
abortion com- abortion abortion number of Abortion
urban populations, which account for more than one-half Year plications a rate ratio abortions b ratec
of the region's people (Gaslonde, 1975 and 1976; Frejka 1940 16,560 13.9 na 41,400 34.8
et al., 1989; IFRP, 1980; Viel, 1988). The other is that the 1945 21,581 17.0 na 53,953 42.6
1950 30,065 22.4 na 75,163 56.0
actual incidence of induced abortion is declining and that 1955 35,795 24.4 na 89,488 61.0
the total number of abortions is holding steady, if not 1960 57,368 30.8 20.0 143,420 77.1
1965 56,130 27.2 18.6 140,325 68.1
falling (Soza et al., 1990; Weisner, 1990).
1970 46,980 20.1 18.7 117,450 50.1
Data on the extent of induced abortion in Latin 1975 44,456 17.3 17.7 111,140 43.3
1981 43,792 14.8 16.5 109,480 37.0
America, however, are inconsistent, ranging from sheer
1985 40,904 12.8 15.6 102,260 31.9
speculation to carefully calculated estimates. Substantial 1987 43,004 12.9 15.4 107,510 32.2
underreporting is a major problem. Surveys based solely 1988 45,042 13.3 15.9 112,605 33.1
1989 46,294 13.4 16.0 115,735 33.4
on hospital data or small, but focused, surveys tend to
Note: na = data not available.
produce gross underestimates of induced abortions, be-
a Based on hospital registration. Most of these are assumed to be induced abortions
cause accurate reporting is discouraged by the nature of forwomen of reproductive age (WRA), butsomearespontaneous. Intheircalculations
for Brazil, Colombia, and Peru, Singh and Wulf (1991) estimated that between one-
the subject and the general illegality of the inducing prac-
sixth and one-half of abortions in hospital are spontaneous (2.48 percent of births).
tice that precedes hospitalization.' Moreover, research on bEstimated according to the number of abortions performed in hospital, multiplied by
2.5 (100/40), where 40 would be the known percentage. c Based on the same
induced abortion in Latin America has been in hiatus for
number of women of reproductive age as the figures for rates for women hospitalized
nearly a decade, a situation at least partly attributable to for abortion-related treatment.

the funding policies of the United States Agency for In-
ternational Development (USAID), which were radically
changed in the early 1980s and subsequently hardened
by what is now known as the "Mexico City policy."2
The extent of the abortion problem in the hemisphere
first came to light three decades ago in Chile, one of the
few countries with consistently accurate abortion data
(Liskin, 1980; Requena, 1965). In 1960 57,368 Chilean
women were hospitalized for treatment of abortion com-
plications; they accounted for 24 percent of all obstetri-
Source: Prepared by Jorge Martinez (1990) as cited in Weisner, 1990 and updated
with assistance from Singh and Wulf of the Alan Guttmacher Institute. Data from Chile,
Ministry of Health (1982-90) and Instituto Nacional de Estadisticas (1985-90).
Additional information for hospital-based abortion services: 1940-55, Viel (1988);
number and rates for women of reproductive age: 1960-87, Silva (1989); percent of
abortions per 100 live births: Silva (1989).
Table 2 Estimated numbers of induced abortions and abortion
ratios (per 1,000 live births), 10 Latin American countries, by
country, according to years of estimates

cal admissions to hospitals. The vast majority of these Country (years Abortion
of estimates) Number of abortions ratio
abortions were thought to have been illegally induced.
Argentina (1987, 1989) 400,000 500
Because only about one illegal abortion in three was es-
Brazil (1973, 1975, 1980,
timated to require hospitalization (Armijo and Monreal, 1983,1985) 322,000-3,294,400 85-822
Chile (1987,1989,1990) 100,000-190,000 154a
1965; Monreal, 1976), the overall number of induced abor-
Colombia (1981, 1985) 150,000-351,200 176-411
tions was calculated to be substantially higher-approxi- Cuba (1989) 187,000 81.8b
mately 143,420. In 1970 it was estimated that one abor- Dominican Republic
(1984, 1988) 60,000-65,000 na
tion occurred for every two live births in Chile (Gall, Mexico (1976, 1979,
1980,1989) 440,000-1,600,000 200-500
1972). The legal status of abortion has remained restric-
Peru (1977,1981) 27,000-207,000 43-177
tive. Principally as a result of social change and the in- Uruguay (1968) 150,000 na
creased availability of family planning, the estimated Venezuela (1985, 1987) 400,000 na

abortion rate declined from 77.1 per 1,000 women of re-
productive age in 1960 to 32.2 per 1,000 women of re-
productive age in 1987 (see Table 1). The total abortion
rate (the number of abortions experienced by the aver-
age woman over her lifetime) has fluctuated between 2.6
(in the 1960s) and 1.6 (in the 1970s) (Frejka and Atkin,
1990). However, as shown in Table 2, the estimated an-
nual number of abortions in Chile, most illegal, continues
Note: na = data not available.
a Abortion ratio for 1987. b Abortion ratio for 1988.
Sources: Argentina-1 987: Llovet and Ramos (1988); 1989: Comisi6n para el
Derecho al Aborto (1989); Brazil-1 973, 1975: Liskin (1980); 1980: Pereira de Melo
(1982); 1983: Merrick (1983); 1985: Singh and Wulf (1991); Chile-1987, 1989: Silva
(1989); 1990: Weisner (1990); Colombia-1 981: Cardenas (1982); 1985: Singh and
Wulf (1991); Cuba-1989: Soza et al. (1990); Dominican Republic-1984, 1988:
Paiewonsky (1988); Mexico-1 976, 1979: Liskin (1980); Tomaro (1981); 1980: Leal
(1980); 1989: PAHO (1989); Peru-1977: Liskin (1980); 1981: Singh and Wulf (1991 );
Ministerio de Salud (1981 ); Uruguay-1968: Requena (1968b); Venezuela-1985,
1987: Weisner (1990).

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to be high: between 100,000 and 190,000 (Weisner, 1990).
Cuba also has fairly reliable data, but in contrast to
most other Latin American countries, its government has
progressively legalized abortion practices (Hollerbach,
1980 and 1988). The number of legally permissible in-
duced abortions in Cuba rose from 28,500 in 1968 to
131,536 in 1974; it then fell to 103,974 in 1980 and rose
again to 160,926 in 1986 (David and Pick de Weiss, 1992;
Soza et al., 1990). Since 1986 the number of legally in-
duced abortions has dropped slightly. The 1980 decline
was attributed to increased use of modern contraceptives,
and the 1986 rise to a concentration of large numbers of
procedures among young women (Soza et al., 1990). The
total induced abortion rate declined substantially (from
2.1 in 1974 to 1.4 in 1980-81), but subsequently increased
to 1.8 (1987-88) (Soza et al., 1990; Frejka and Atkin, 1990).
As a factor contributing to falling fertility in Cuba, in-
duced abortion appears to have been used increasingly
to avert unwanted births-rising from 65.4 induced abor-
tions per 100 live births in 1974 to 81.8 in 1988 (see Table
3) (Soza et al., 1990). As Table 2 indicates, taken together,
Chile and Cuba-two relatively small countries-at
present appear to account for slightly more than 375,000
induced abortions annually.
Peru is one of the few Latin American countries to
have studied abortion practices officially. The Ministry
of Health observed in its 1981 report, El Aborto en los
Establecimientos de Salud del Peru', that clandestine, illegal
abortion is "a serious public health problem, with high
human and social costs" (p. 2). Assuming that one in four
clandestine abortions resulted in hospitalization, the
report estimated the total number of induced abor-
tions to be 27,000 annually, with a ratio of 137 induced
abortions to 1,000 live births in 1977 and 143 in 1978.
Other, unconfirmed estimates were higher, suggesting a
ratio of 200 abortions per 1,000 live births (Ministerio de
Salud, 1981).
Although the data are problematic, Latin America
and the Caribbean appear to have one of the highest in-
cidences of induced abortion in the developing world.
As early as the mid-1970s, the International Planned Par-
enthood Federation (IPPF) estimated the annual num-
ber of induced abortions (predominantly unsafe and il-
legal) to be five million (IPPF, 1976), with 65 abortions
per 1,000 women of reproductive age, and 30 abortions
per 100 pregnancies (Tietze and Henshaw, 1986). These
figures implied that between one-fourth and one-third
of all pregnancies were "intentionally aborted" (acobson,
1990). Using IPPF data from Latin American countries,
Rochat and his colleagues (1980) calculated a ratio of 325
abortions per 1,000 live births, shown in Table 4. By 1977
the estimate of annual numbers of abortions had dropped
to 3.25 million, or about 25 percent of abortions per-
formed in all developing countries (IPPF, 1977). This es-
timate approximated the lower end of the range of other
estimates (from three to six million induced abortions) and
may represent substantial underestimation. Recently,
Henshaw (1990) has put the figure at four million.
Singh and Wulf (1991) have refined the estimates on
the number of induced abortions in Peru, Brazil, and Co-
lombia. They use data from hospital admissions and sur-
veys to gauge present practice, separating spontaneous
abortions from those that are induced, and then multi-
plying the figure for induced abortions according to dif-
ferent estimates of the numbers of induced abortions that
require hospitalization-one in four, one in five, and one

Table 3 Number of induced abortions, live births, abortion ratio

(per 100 live births), and abortion rate (per 1,000 WRA), Cuba, Table 4 Regional estimates of induced abortions, abortion ratios
by year, 1974-90 (per 1,000 live births), and proportion of abortions that are illegal,
Legal Abortion Abortion
by regions covered by International Planned Parenthood
Year abortions Live births ratio rate Federation Unmet Needs Survey, 1977

1974 131,536 199,091 65.4 69.5 Number of Number of Percent

1975 126,107 192,941 65.4 - births abortions Abortion illegal
1976 121,415 187,555 65.2 61.5 Region (000) (000) ratio abortions
1977 114,829 168,960 69.2 -
Africa
1978 110,431 148,249 75.0 52.9
West 5,241 116 21.4 100
1979 106,549 143,551 76.5 -
East 5,117 456 89.0 100
1980 103,974 136,900 76.1 47.2
1981 108,559 136,211 79.6 - Caribbean 389 66& X 1169.7 80,
1982 126,745 159,759 79.3 55.3 East and Southeast
1983 124,791 165,284 75.9 -
Asia and Oceania 20,064 1,778 176.7 96
1984 139,588 166,281 84.1 58.7
Indian Ocean 29,901 7,568 253.1 99
1985 138,671 182,067 83.6 - LatinArAmerica 9,814;: 3,192 325.2 100
1986 160,926 166,049 96.6 - Middle East and
1987 152,704 179,477 84.6 - North Africa 5,714 537 94.0 95
1988 155,327 187,911 81.8 58.0 Total 66,420 13,713 206.5 99
1990 - - 96.0 60.0
Note: Excludes Europe, United St
Note: -= calculations not made for this year. South Korea, Hong Kong, Singapore,
Sources: SOCUDEF, Havana, internal document, 1989, cited in Soza et al., 1990; and countries lacking IPPF affiliat
United Nations, 1992; Henshaw, 1990; Vasquez, 1992. Source: Rochat et al., 1980.

Volume 24 Number 4 July/Aug 1993 207

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in seven. For Peru (1977,1981), Singh and Wulf estimate et al., 1977). The World Health Organization (WHO) now
the number of induced abortions to be as low as 65,466 includes VA as an essential service at the first referral
and as high as 207,060. For Brazil (1980, 1985), the esti- level of care (WHO, 1991a).
mates vary from 322,071 to 3,294,385, a huge range. For However, principally because of restrictive laws in
Colombia the estimates range from 150,513 to 315,197. Latin America and the Caribbean, abortion is more com-
The most recent estimates of the number of induced monly induced by substandard methods ranging from
abortions in 10 Latin American countries (representing the use of herbal abortifacients to the insertion of cath-
85 percent of the region's population) are shown in Table eters or metal sounds into the uterus. Some of these meth-
2. The total ranges from 2.2 million to 6.8 million. For ods are merely ineffective, some are relatively safe in the
the 1970s the total abortion rates (not shown) were: hands of skilled personnel, and some are lethal. The least
Chile, 1.6 (IPPF, 1978); Cuba, 1.4 (Sociedad Cientifica problematic method used in Chile, according to hospi-
Cubana para el Desarrollo de la Familia [SOCUDEF], tal records, was D&C, usually illegally employed by phy-
1989; Soza et al., 1990); Mexico, 1.5 (Acosta et al., 1976); sicians and trained midwives (as shown in Table 6). The
Peru, 1.3 (Ministerio de Salud, 1981); and Brazil, 0.5 to other methods were likely to be used by nonmedical per-
1.5 (Merrick, 1983). Frejka and his colleagues (1989) con- sonnel or by the pregnant woman herself (Armijo and
cluded that more than one-half of the women in some Monreal, 1968).
Latin American countries will experience at least one in- A woman seeking to terminate an unwanted preg-
duced abortion during their lifetimes. Table 5 charts the nancy may resort to progressively more dangerous meth-
lifetime abortion prevalence of women in 10 Latin Ameri- ods, as this contemporary account from Chile illustrates:
can countries. First, I had two injections of Methergin. After-
wards, for three days, I drank before breakfast red
wine boiled with borage and rue, to which I added
Methods Used to Induce Clandestine nine aspirins. My body was full of pimples but I
Abortion did not abort. A few days later I drank cement wa-
ter. It did not work either. Then I went to a lady
According to Liskin (1980), the safety of an induced abor- who inserted a rubber catheter into me. I had to
tion depends on four factors: (1) the method; (2) the skill use it, after all the things I did I could not keep
of the provider; (3) the duration of the pregnancy; and the child because he could have malformations.
(4) the accessibility and quality of medical facilities to (Weisner, 1990: 90)
treat complications. Doctors in private offices and hos-
Abortifacient herbs and plants are among the oldest
pitals primarily employ dilatation and curettage (D&C)
and most widespread means used for inducing abortion.
and vacuum aspiration (VA) (Tomaro, 1981). VA has
In Latin America abortifacients now include various
been shown to be safer than D&C for uterine evacuation
modern pharmaceuticals, such as "hormonal prepara-
(Tietze and Lewit, 1972; Cates and Grimes, 1981; Grimes
tions and uterine contractors, or medicines meant to cure
other diseases" (Frejka et al., 1989: 18). In the Sao Paulo
Table 5 Percentage of women reporting induced abortion and area of Brazil, 50 percent or more of all abortions are es-
percentage of pregnancies ending in induced abortion, and total timated to have been induced with Cytotec, an antiulcer
abortion rates, 10 Latin American countries, by country, 1965-80
drug that initiates labor; after using it, women often go
Percent of Percent of preg- Total
to a hospital to complete the abortion (Fautndes, 1990).
women reporting nancies ending in abortion
Country induced abortion induced abortion ratesb (By government decree the purchase of Cytotec is now
Argentina 33 Oa 14.Oa na restricted to special prescriptions at specified pharma-
Brazil 13.3 7.7 0.5-1.5
cies [Abortion Research Notes, 1992].) At first, anecdotal
Chile 23.8 28.9 2.0
Colombia na 29.2 1.2-1.5
Guatemala 37.3a 1 4.4a na
Table 6 Number of women who reported induced abortions
Mexico 30.7 13.0 1.5
Nicaragua 23.9a 9.Qa na and, of these, percent who were hospitalized, by method,
Panama 29.5a 34.8a (1960) na Santiago, Chile, 1962
19.2a (1976) na
Number of women who Percent
Paraguay 15.3 17.0 na
Abortion method reported abortions hospitalized
Peru 20.0 12.3 1.3
Curettage 504 19.0
Note: na = data not available.
Drugs 119 34.5
a Spontaneous and induced abortion.
Catheter 581 41.8
b Range of estimates for 1970s of numbers of abortions that women of reproductive
Douches and other 55 36.4
age are expected to have in their lifetimes.
Not stated 63 27.0
Source: Compiled by Paxman from selected surveys, 1965-80, including those
summarized by Liskin (1980), Frejka and Atkin (1990), and Weisner (1990). Source: Armijo and Monreal (1968), cited in Liskin (1980).

208 Studies in Family Planning

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information suggested that both women and health-care
personnel believed this mode of commencing an induced
abortion to be safer than other methods because the fi-
nal procedure was carried out in a hospital setting
(Paxman, 1988a; O'Keefe, 1989). While this may be true,
Cytotec has been more directly associated in the litera-
ture with the practice of "illegal" abortion in Brazil (Costa
and Vessey, 1993; Schonhofer, 1991).3 (See also Barbosa
and Arilha in this issue.)
Inserting rubber catheters, metal sounds, and sticks
of various sorts into the uterus is a common practice. The
purpose is to rupture the amniotic sac, and to produce
uterine contractions that will expel the embryo or fetus.
These methods, some self-applied, often result in severe
bleeding, uterine perforation, and sepsis. In several coun-
tries, rubber catheters, widely available as urinary cath-
eters, appear to be a tool of choice for women wanting
to interrupt a pregnancy (Tomaro, 1981). Some 25 years
ago, Armijo and Monreal (1968) found that the practice of
inserting a catheter (sonda) into the cervix was widespread
in Chile; as Table 6 shows, it was the method most likely to
lead to hospitalization. More recently, it was reported that
catheter insertion is commonly followed by the use of
douches and drugs, suggesting either self-induction or a
follow-up practice used on advice from abortionists (Frejka
et al., 1989; PAHO, 1985).
At three major hospitals in Chile, Weisner (1988) sur-
veyed 350 women hospitalized with complications from
induced abortion; she found that for nearly one-half of
these women the procedure was self-induced and that
one-third had sought help from a clandestine abortion-
ist. Seventy-one percent of the women of the first group
had initiated their abortions by inserting rubber catheters
or sounds, also a prevalent method in other Latin Ameri-
can countries. In Bogota', Colombia, 80 percent of women
hospitalized for abortion complications had used sounds
in self-induced procedures; in Bolivia 27 percent of those
hospitalized had inserted foreign bodies; and in Para-
guay 37.8 percent of women who had undergone ille-
gally induced abortions had used catheters (Cardenas de
Santamaria, 1982; Bailey et al., 1988; Weisner, 1990). A
study in Mexico indicated that such methods carry the
greatest risks: At least 65 percent of women hospitalized
with complications from abortion reported that they had
tried to self-induce the interruption of their pregnancies.
(Tomaro, 1981).
As Frejka and his colleagues point out, "a large pro-
portion of induced abortions are performed using defi-
cient techniques, under unhygienic conditions, without
adequate medical supervision and often in a hostile and
disapproving environment" (1989: 1). Because of the na-
ture of the laws governing abortion in most of Latin
America and the Caribbean, nearly all induced abortions
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are technically illegal, use substandard procedures, and
carry substantial risks of complications, thus jeopardiz-
ing the lives and health of women.
Consequences of Unsafe Abortion
Maternal Mortality
The most devastating outcome of unsafe abortion is
death. Worldwide, WHO has attributed the deaths of
200,000 women annually to unsafe abortion-25 to 50
percent of all maternal deaths (Mahler, 1987). Jacobson
notes that many of these abortions "are performed by
unskilled attendants under unsanitary conditions or are
self-inflicted with hangers, knitting needles, toxic herbal
teas, and the like" (Jacobson, 1990: 38). In Latin America
complications resulting from unsafe, illegally induced abor-
tion are considered the principal cause of death in women
aged 15 to 39 years (Frejka et al., 1989; PAHO, 1985).
Estimates of maternal deaths due to abortion vary.
Using regional information from the late 1970s calculated
by IPPF, Rochat and his colleagues estimated the world-
wide mortality rate to be 500 deaths per 100,000 illegal
abortions-one death for every 200 procedures (Rochat
et al., 1980). This rate would place the number of abor-
tion-related maternal deaths in Latin America and the
Caribbean at that time between 13,000 and 27,000-the
same number as if all women of reproductive age in a
city of 65,000 to 135,000 were to die within a year! Using
data from the mid-1960s from ten cities in eight Latin
American countries, Puffer and Griffith (1976) attributed
34 percent of all maternal deaths to unsafe abortion prac-
tices. More recently, Herz and Measham (1987) placed
total pregnancy-related deaths in Latin America at 34,000
per year. If that figure were accepted as accurate, abor-
tion-related deaths would be in line with the lower, IPPF-
derived estimate of 13,000 of a decade earlier-slightly
less than one-third of all maternal deaths. Royston and
Armstrong (1989) have also calculated the rate of abor-
tion-related deaths-50 per one million women aged 15-
49 in Latin America. In 1990, 89.4 million Latin Ameri-
can women were in that age group; hence, during that year,
an estimated 4,472 women could have been expected to die
from complications of induced abortion-a figure that ap-
pears overly conservative. Overall, the range of abortion-
related deaths in Latin America can be estimated to be
between 4,500 and 11,000 per year.
As Table 7 shows, during the 1960s and 1970s, in sev-
eral city hospitals in Latin America, more than 30 per-
cent of maternal deaths were attributed to complications
arising from abortion, most of them illegally induced.
Nearly half of all maternal deaths in hospitals in Santiago,
Caracas, and Guatemala City were abortion-related
Volume 24 Number 4 July/Aug 1993 209
Table 7 Percentage of deaths in hospital attributed to ity to abortion-yet the numbers remain substantial. Ac-
complications of induced and spontaneous abortion as a cording to the International Classification of Diseases, for
proportion of all maternal deaths in hospital, by country,
15 Latin American countries, maternal deaths directly at-
according to years and place of studies, 1969-79
tributable to abortion (both spontaneous and induced)
Percent
averaged 15.7 percent between 1980 and 1986 (PAHO,
of maternal
deaths attributed 1986 and 1989). For 1981 and 1982, WHO placed the fig-
to abortion Period and
ures at 18.6 percent and 17.8 percent, respectively (WHO,
Country complications place of study
1987; Weisner, 1990). For the 1970s, using the average
Brazil 44.1 1955-77, Hospital das
Clinicas, Faculdade de number of registered deaths due to abortion, Tietze
Medicina de Ribeirao Preto
(1980) placed the figure at 18.5 percent. The discrepan-
Chile 39.7 1968, All hospital discharge
cies in maternal mortality statistics almost certainly re-
records

37.4 1963-73, National Health

Service hospitals
Colombia 40.3a 1970-78, Maternal and Child
Institute, Bogota
Jamaica 33.3 1971, Victoria Jubilee Hospital,
Kingston
Venezuela 70 1973, Concepci6n Palacios
were Caracas
Maternity Hospital, found to be
Note: na = data not available.
a Mortality due to septic abortion only.
Source: Liskin (1980).
(Puffer and Griffith, 1976). Over a nine-year period at the
Maternal and Child Institute in Bogota, Colombia, 210
cases of septic abortion accounted for 40 percent of all
maternal deaths. One in 10 women admitted to hospital
with sepsis died; other abortion-related complications
resulted in an additional 257 deaths during the same pe-
riod. Women with sepsis were 25 times more likely to
die than were women whose abortion complications did
not become septic (Lozano et al., 1979). In Peru in 1977,
21 percent of maternal deaths were reported to be the
result of illegal abortion; the incidence rose to 26 percent
in 1978. Public hospital records of 10,000 abortion cases
showed only 5 percent of the induced abortions to be le-
gal; the vast majority of cases resulted from incomplete
abortions induced illegally, 3 percent of which were sep-
tic (Ministerio de Salud, 1981). Table 8 shows the pro-
portion of maternal deaths resulting from clandestine
abortions in selected Latin American and Caribbean
countries for the mid-1980s.
Official figures reported to the World Health Orga-
nization attribute lower percentages of maternal mortal-
sult from underreporting. Estimates based on hospital
records are not likely to be truly representative, because
they do not register all deaths in the region, and because
abortion-related cases are not always reported as such.
For example, when a careful examination of records was
made in Brazil, abortion-related deaths at one hospital
underreported by as much as 40 per-
cent; in MIedellin, Colombia, a survey of the registries of
maternal deaths, 25 percent of which were said to be
abortion-related, revealed that they were underestimated
by 50 percent (O'Keefe, 1989; Escuela Nacional de Salud
Putblica de Medellin, 1992).
In eveiy instance the statistics point to a problem of
substantial dimensions. Mortality due to abortion is be-
tween 10 and 100 times higher in Latin America than in
most European countries (Frejka and Atkin, 1990). Tietze
and Henshaw (1986) estimated the likelihood of death
from induced abortion to be 20 times greater in Latin
America than in developed countries. In Cuba deaths re-
lated to abortion (both induced and spontaneous) re-
mained a major cause of maternal mortality from 1979
to 1982-even after abortion had been legalized. By 1986
the mortality ratio had declined to 37 per 100,000 live
births, comparable to the ratio in Chile, where family
planning was more emphatically promoted. For a decade
or more, the mortality rate for legal abortion in Cuba has
remained at just 1 per 100,000 procedures (Nebreda
Moreno and Avalos Triana, 1986), comparable to rates
in developed countries with legalized abortion. This low
rate has been attributed to the use of safer procedures,
which are discussed below.
Morbidity

Mortality statistics present but a small part of the total

Table 8 Percentage of maternal deaths resulting from illegal picture of the consequences of illegal abortion in Latin
abortions, by country, mid-1 980s America and the Caribbean; morbidity rates complete the
Country Percent picture. However inadequate hospital admission statis-
Argentina 35 tics may be, they remain the leading indicator of abor-
Chile 36
tion-related morbidity. Surveys in El Salvador, Guate-
Colombia 29
Costa Rica 30
mala, Paraguay, Chile, and Brazil have indicated that
Jamaica 33 between 20 and 48 percent of women who had ever ex-
Source: Based on Royston and Armstrong, eds. (1989) and Royston (1989). perienced an abortion (whether induced or spontaneous)

210 Studies in Family Planning

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sought medical treatment after their last abortion (Liskin,
1980). In the Dominican Republic 21 percent of women
with induced abortions found their way to hospitals
(Paiewonsky, 1988). Estimates are consistent in sug-
gesting that one of every three to five illegally induced
abortions requires hospitalization. In countries where
safer abortion services using the latest techniques are
widely available in clinics, as in Brazil and Colombia, the
estimate lessens to one in seven, according to Singh and
Wulf (1991). But the figure might be as low as one in 10
or more.
Complications of unsafe abortion include pelvic in-
fections, hemorrhage and shock, cervical lacerations,
uterine perforations, and damage to the bladder and in-
testines. Throughout the 1970s a major hospital in Bogota'
averaged nearly 6,000 admissions for such abortion-re-
lated complications per year, one of every five patients
admitted. The situation in Mexico is similar. Over a five-
year period, three major maternity hospitals in Mexico
City averaged between them more than 12,000 abortion-
related cases annually. These represented 14 percent of
the hospital's admissions and a rate of 44 hospitalizations
per 1,000 women of reproductive age (15-44) covered by
the social security system in those three catchment areas
(Ordontez, 1975). Between 1969 and 1972 in El Salvador,
where hospitalization rates were lower, the proportion
of septic cases increased from one in five to one in four
(Morris and Monreal, 1974). Later abortions are more
likely to require hospitalization. In Santiago, Chile, 47
percent of women aborting between the third and fifth
months of pregnancy required hospitalization; only 18
percent of those aborting during the first month required
hospital treatment (Armijo and Monreal, 1968).
In the late 1970s the International Fertility Research
Program (IFRP, now Family Health International) con-
ducted one of the largest multinational surveys ever done
of women hospitalized for abortion-related treatment.
Abortion in Latin America (1980) charted the treatment of
27,722 abortion cases in nine countries. Slightly more than
one-third of the respondents reported having had pre-
vious abortions. The vast majority were women who
sought medical help for complications ensuing from
abortions initiated outside the hospital. The survey sub-
stantiated the generalization that clandestine or unsafe
induced abortion procedures are more likely to produce
complications necessitating hospital treatment. "Patients
with minor complications or none do not go to the hospi-
tal to request treatment," the report notes; it also acknowl-
edged that some women with serious complications do not
make it to the hospital in time (IFRP, 1980: 4).
The IFRP survey was dwarfed in terms of the num-
ber of cases, however, by the Brazilian study Sequelas do
Aborto- Custos e Im>plicacoes Sociais. In 1980, at institutions
though such cases represent only 12 percent of obstetric
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holding contracts with the Ministry of Social Welfare, the
nation's largest health-care provider, 201,597 women
were hospitalized for "abortions in progress." These
cases represented 12 percent of all obstetric-gynecologi-
cal admissions within the system for that year (Pereira
de Melo, 1982). A decade earlier, in a major maternity
hospital in Salvador, Bahia, Brazil, 21 percent of 1,697
women admitted during a three-month period were
treated for abortion-related complications (Cavalcante
Farias, 1972). In Chile in 1964, 56,000 cases were treated
in hospitals; 24,427 (43 percent) were septic. By 1978,
partly as a result of the expanding family planning pro-
gram, this number had fallen to 37,980, of which 15,510
(41 percent) were septic (Onetto, 1980). In 1987 the num-
ber of hospitalizations again rose to 43,004 (Silva, 1989),
mostly because the population of women of reproduc-
tive age had expanded and contraceptives had been
made more difficult to obtain.
Singh and Wulf (1991) have recently made a more
sophisticated analysis of the hospitalizations attributed
to complications of induced abortion. Noting that most
hospitals do not separate spontaneous abortion from oth-
ers, they estimate that for every 100 births there are but
2.48 miscarriages requiring hospitalization. During the
late 1970s and early 1980s they put the number of in-
duced abortions requiring hospitalization at between
21,822 and 41,412 in Peru, between 107,357 and 470,626
in Brazil, and at 50,171 in Colombia. While unsafe abor-
tion is still a major cause of morbidity, modernization
has improved the picture in some areas. With improve-
ments in abortion techniques and better provider care,
some Latin American hospitals are now beginning to see
fewer women with infections and women with less se-
vere infections and trauma (Singh and Wulf, 1991), par-
ticularly in Colombia where induced abortion has been
virtually "medicalized," that is, made widely available in
the major cities and performed by medical personnel us-
ing modern techniques, although the practice of induced
abortion is still technically illegal.
Costs of Abortion
Treating abortion-related complications exacts enormous
economic, social, and personal costs. As Fortney (1981)
succinctly observed, treating botched abortion typically
requires "2 or 3 days in hospital, 15 to 20 minutes in the
operating room, antibiotics, anaesthesia, and quite often
blood transfusions" (Fortney, 1981: 579; see also Figa-
Talamanca, 1979; Figa-Talamanca et al., 1986). The ex-
tent of resources employed to treat abortion cases is in-
ordinate. For example, about half of the Brazilian health
system's obstetrics budget is currently directed toward
treating complications from induced abortion-even
Volume 24 Number 4 July/Aug 1993 211
admissions (Pereira de Melo, 1982; Jacobson, 1990). A
WHO study conducted a decade ago that included Ven-
ezuela found that blood transfusions were the most ex-
pensive component of abortion-related treatments, ac-
counting for nearly half the total cost, which also
included surgery, anesthesia, medication, and intrave-
nous fluids (Figa-Talamanca, 1979). In the early 1960s
when Chile, prompted first by a concern for women's
health and then by a preoccupation with economic costs,
began to address the public health aspects of unsafe abor-
tion, women seeking care for abortion complications at
emergency services in hospitals in Santiago received 18 per-
cent of all blood transfusions, and consumed 27 percent of
emergency blood reserves (Plaza and Briones, 1963).
Using data from the Dominican Republic, Ramfrez
and Garcia (1975) calculated that treating complications
from an induced abortion cost the equivalent of US$176
per case-more than two times the cost of treating an
incomplete but uncomplicated abortion, and 12 times
more than for a normal birth. More recently in Chile,
Gayain (1990) estimated the cost of treating "nonspon-
taneous" abortions within the National Health System
in 1987. Discounting beforehand the expected cost of
treating spontaneous abortions and assuming an aver-
age patient stay of 5.9 days, 9,440 cases of induced abor-
tion cost the equivalent of $1,336,128.4 In the mid-1970s,
Viada (1976) estimated that if patients coming to the Felix
Bulnes Hospital (in Chile) with complications from sus-
pected illegal abortion had instead undergone abortions
performed by trained physicians, the total costs of their
hospital treatments over the course of a year could have
been reduced by 87 percent.
Studies both in Chile and Colombia have indicated
that women with septic abortions stay in the hospital two
to three times longer than do women in cases of sponta-
neous and nonseptic abortion (Liskin, 1980). In addition,
the demand for maternity hospital space created by abor-
tion cases may cause other women to be discharged be-
fore they have fully recuperated, thus contributing to
subsequent health problems for new mothers and their
infants (Viel, 1976). According to Gayain (1990), if the One-third had had a previous abortion; nearly 12 per-
practice of unsafe abortion were significantly curtailed-
thus freeing beds for women who have recently given
birth-20 percent of newly delivered women in Chile
could have an additional bed/day "with all the advan-
tages this would mean for the mother and the newborn"
(cited in Weisner, 1990: 104).
Among the less tangible costs of induced abortion is
psychological distress (Londonio, 1989), which is more
difficult to assess. Although the literature on this subject
is often criticized for relying on "impressionistic case re-
ports," it indicates that in settings outside Latin America
where abortion is legal, "feelings of guilt, regret and sad-
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ness, when noted, are mild and transitory, usually fol-
lowed by a sense of relief associated with successful cri-
sis resolution" (David and Pick de Weiss, 1992:47). Little
is reported about the psychological impact of clandestine
abortion, the most common type of abortion throughout
Latin America.
Although abortion is regarded as a grave religious
sin, Weisner (1988) found that for a substantial majority
(76 percent) of the women she interviewed in Chile, the
distress caused by an unwanted pregnancy outweighed
the distress of personal conflicts and fears about abor-
tion. About one-fifth of the women were ambivalent
about their pregnancies, and tended to feel both relief
and remorse after their abortions. In an earlier and simi-
lar study (Weisner, 1982), about one-fourth of 357 women
expressed guilt. Recent research in Venezuela and Co-
lombia has shown that the abortion experience evokes a
complex combination of feelings-relief, guilt, depression,
and confusion-and that while the fact of the abortion is
accepted, the experience leaves emotional scars that usu-
ally heal but may never wholly disappear (Machado, 1979).
Determinants of Unsafe Abortion
Characteristics of Women
Understanding the problem of unsafe abortion requires
that the characteristics of women who seek it be stud-
ied. Abortion in Latin America (1980) contains a wealth of
information, based on interviews and hospital records
of more than 27,000 women hospitalized for abortion
complications in nine countries in the late 1970s (IFRP,
1980). The majority of these women were either married
(48 percent) or living in union (34 percent); fewer than
one-fifth (18 percert) were single. More than half (55 per-
cent) had had two or more live births and had at least
two living children at the time they sought an abortion;
just under one-fourth were nulliparous. Half of the
women were 20 to 29 years old; 14 percent were in their
teens (although most were married or living in unions).
cent had had two or more abortions (which finding par-
tially confirmed tendencies toward multiple abortions
indicated by surveys in the 1960s). Only one-fourth of
the women had practiced contraception prior to the preg-
nancy they were aborting. Most had fewer than seven
years of education. The vast majority of women were
from urban areas, many from slums, probably because
the hospitals in the study were all in urban areas.
The women in the IFRP study were younger and of
lower parity than were women in studies conducted dur-
ing the 1960s, reflecting, according to the report, a
"marked change over the last decade in the kinds of
women having abortions" (p. 74). The study concluded
that a disturbing and increasing number of women had
begun to use abortion to space or postpone childbirth,
even as contraceptives were being made more widely
available. The study supported the impression that ille-
gally induced abortion in Latin America was also being
used to end childbearing after desired family size had
been reached, a phenomenon first noted by Centro
Latinoamericano de Demograffa (CELADE) studies in the
early 1970s in Bogota', Lima, Asuncion, Panama City, and
Buenos Aires (Gaslonde, 1975).
In her extensive compilation of abortion research,
Liskin (1980) observed that recent studies have failed to
confirm earlier indications "that abortion was most fre-
quent at the middle socioeconomic levels of society and
least frequent at the extreme upper and lower levels" (p.
149)-a pattern noted by Requena (1968a and 1968b) in
the early 1960s in 12 Latin American countries. In Latin
America patterns of induced abortion may be less influ-
enced by such single indicators as education than by de-
sires to limit fertility as an expression of general socio-
economic advancement, and the availability or lack of
contraceptives (Liskin, 1980). The United Nations Popu-
lation Fund (UNFPA), for example, estimated that three-
quarters of the Latin American and Caribbean women
not practicing contraception desired to postpone, space,
or limit their pregnancies (Sadik, 1989). In a series of sur-
veys in Latin America and the Caribbean, Morris (1988)
found that substantial proportions of unmarried women
aged 15-24, with at least one pregnancy, regarded their
first pregnancy as "unintended" (50 percent in Mexico
City; 53 percent in Costa Rica; 66 percent in Brazil; and
76 percent in Jamaica). The degree of unwantedness or
"unintendedness" of a pregnancy is generally thought to
be a key influence in women's decisions to seek abortion.
Two recent surveys-one conducted in Mexico, the
other in Buenos Aires-hint at divergent trends in the
late 1980s. Whereas the age distributions found by David
and Pick de Weiss (1992) in Mexico were similar to those
found in the 1980 IFRP study, a surprising 49 percent of
the 156 women in the Mexico sample were single, and
more than half (61 percent) were nulliparous. Of those
with children, one-third had one child. Eighty-five per-
cent of the sample reported the present abortion as their
first. Before seeking assistance, one-third of the women
had unsuccessfully attempted self-induced abortion, pri-
marily using injections and herbs; only 22 percent re-
ported having experienced abortion-related complica-
tions. Fifty-four percent had ever used some form of
contraception (reflecting the contraceptive prevalence
rate of 53 percent for Mexico in 1989). The most frequent
explanation for having an abortion (21 percent) was the
woman's unwillingness to marry her partner, followed
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by financial reasons (18 percent), unwillingness to have
a baby at that time (15 percent), having too many chil-
dren already (10 percent), and being too young to have
the child (9 percent) (David and Pick de Weiss, 1992).
In Argentina the total fertility rate is relatively low
(3.0), and, until recently, policies have been antagonistic
to contraception. Llovet and Ramos (1988) found that
only 28 percent of women who had undergone induced
abortion were single and nulliparous. A key factor in
women's decisions was whether they had emotional and
economic support for the pregnancy from their partners.
Of the married women, 55 percent used abortion in lieu
of contraception to space their pregnancies or to limit
their number of children. The studies in Argentina and
Mexico underscore again how difficult it is to generalize
about patterns in Latin America. The patterns in Mexico
and Argentina are different, as are the social, political,
and economic circumstances out of which they arise.
Contraceptive Practice
In her article "Choice at Any Cost," Jacobson (1988) wrote
that the "reality of abortion signals a social failure-the
failure of millions of individuals to prevent pregnancy
through the use of contraception and the failure of gov-
ernments in developing countries to fill the unmet need
for family planning" (p. 30). Although the situation may
be more complicated than Jacobson's implication would
suggest-that merely by making contraceptives avail-
able, abortion will go away-a connection between con-
traception and abortion cannot be denied. In recent years
contraceptive use in Latin America (measured among
married women of reproductive age) has climbed
steadily, and access to contraceptives seems to be improv-
ing (Population Crisis Committee, 1987). In the 1960s the
contraceptive prevalence rate was only 14 percent, but in
1992 it was estimated to be 55 percent, with 46 percent us-
ing modern methods (Population Reference Bureau, 1992).
These figures are largely for women in unions and,
therefore, may be skewed, since they ignore other women
who may be sexually active and therefore at risk of preg-
nancy. The rates of effective contraceptive use for all
women in Latin America may be much lower than the
surveys indicate. Even if this impressive rate is accurate,
it means that nearly one-half of Latin American women
in union are not practicing contraception. Not all of these
women are at risk of unintended pregnancy; some wish
to be pregnant, some are pregnant, some infertile, and
some sexually inactive. Therefore, between 20 and 30 per-
cent of women are in need of contraception. In this group,
particularly among adolescent women for whom contra-
ceptive use rates are very low, the problem of unsafe in-
Volume 24 Number 4 July/Aug 1993 213
duced abortion exists in the face of unwanted pregnancy.
In Bolivia, for example, which has one of the lowest rates
of contraceptive use in Latin America, 60 percent of the
women treated for abortion complications in several hos-
pitals reported that they had not used contraceptives
prior to pregnancy (Bailey et al., 1988).
Increased contraceptive practice might be expected
to lead to lower rates of induced abortion, but this has
not always been the case. Theorizing from the experi-
ence of Western industrialized nations, Potts (in Hodg-
son, 1981), amalgamating the earlier work of Tietze and
Bongaarts (1975), forecast what might happen to the prac-
tice of induced abortion as contraceptive use increases.
In the early and middle transitional phases, women in-
creasingly adopt attitudes favoring lower fertility, yet
have not adopted contraception; during this time abor-
tion frequencies may actually increase. However, even
moderate levels of contraceptive use can have a rapid
and dramatic impact, as the frequently cited case of Chile
demonstrates (shown in Figure 1). When the Chilean
National Health Service began issuing free contraceptives
in 1964, as a direct response to the problem of induced
abortion, contraceptive use was low and rates of illegal
abortion were high (Fauindes and Hardy, 1978; Onetto,
1980; Liskin, 1980; Barzelatto, 1988). Between 1964 and
1978 contraceptive use rates increased from 3.2 percent
to 23 percent; the number of women admitted to hospi-
tals for treatment of abortion complications fell from
56,000 to 37,900; and abortion-related mortality fell dra-
matically, from 11.8 deaths per 10,000 live births to
4.2 (IPPF, 1978). Although socioeconomic and other fac-
tors have also influenced these changes, the data clearly
suggest that increased contraceptive availability and use
is associated with decreased reliance on abortion as a
remedy for unwanted fertility. Confirmation of this can
be found in later years. When the Pinochet government
restricted access to contraception in the mid-1980s, the
incidence of induced abortion rose.
Cuba's experience is similar in some ways and dif-
ferent in others. In about 1964 abortion was given de facto
legalization, and in 1979 was legalized de jure (Holler-
bach, 1980). In 1968 the number of legal abortions was
28,500, rising to 131,536 in 1974. By 1980, the number fell
to 103,974, but rose again in 1988 to 155,327 (Soza et al.,
1990; Hollerbach and Diaz-Briquets, 1983). In 1984 more
than 40,000 abortions failed to comply with the require-
ments set out in the law, and hence were termed "ille-
gal" (Paxman, 1988b). Mirroring this pattern, the legal
abortion rate rose between 1968 and 1974 from 16.7 to
69.5 per 1,000 women aged 15-44, then declined in 1980
to 47.2, and rose again in 1984 to 58.7. The abortion ra-
tio, as measured against live births, continued to rise and
has only fallen recently, in 1987. Over the last 15 years
214 Studies in Family Planning
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the total rate of legal abortion has fluctuated only slightly:
from 2.1 per lifetime per woman in 1974 to 1.8 in 1988. If
Potts's formula is applied to Cuba, the transition to contra-
ception would appear not yet made.
Yet contraceptive practice in Cuba is reported to be
substantial.5 The National Fertility Survey of 1987 indi-
cated that 75 percent of women between the ages of 15
and 49 were practicing some form of contraception: one-
third were using the IUD and one-quarter had been ster-
ilized. Overall, 68 percent were using modern methods.
One might infer from Table 3 that contraceptive practice
in Cuba began to have an effect only after 1986, when a
two-year drop in abortion rates and numbers was re-
ported. But contraceptive failure reportedly has been
high (probably as the result of misuse and defective
methods). Twenty percent of women surveyed in 1987
had become pregnant while using a contraceptive. More
recently, nearly two-thirds of a sample of young women
who became pregnant said they had done so while us-
ing an IUD (Soza et al., 1990). In their analysis Soza and
colleagues point out that while contraceptives are easily
accessible, purchase is difficult. They note that contra-
ceptive use rates have aided in a decline of abortion rates
for women over 30, but have had much less impact on
the growing number of younger women. Nevertheless,
birth rates fell between 1973 and 1986 from 25.0 per 1,000
in the population to 16.2. The birth rate is currently 18.
David and Pick de Weiss (1992) suggest that this "was
accomplished by reliance on induced abortion as a back-
up method in situations of contraception nonuse or fail-
ure" (p. 49). This, and other explanations, put in ques-
tion the apparent ability of contraceptive practice to
diminish abortion rates. In 1986 the ratio of abortions to
live births had reached 96.6 per 1,000 and has since fallen
a bit, then risen. Where abortion is legal, contraceptive
use may have little impact on both the abortion rates and
ratios, especially where contraceptives are ineffective. In
Cuba the influence of contraceptive use on abortion prac-
tice is less obvious than in Chile.
Chile and Cuba-the two Latin American countries
for which the most detailed and long-term information
is available-represent only a part of the region's wider
spectrum of experience with contraception and abortion.
In Brazil, for example, contraceptive prevalence per se
has been neither a good measure of correct contracep-
tive use, nor an accurate predictor of abortion practice.
The current contraceptive prevalence rate in Brazil ap-
proaches 65 percent; 56 percent of all women say that
they use a modern method. Most get their reversible con-
traceptives through the private, commercial sector. Only
since 1986 has there been a public family planning pro-
gram. Earlier, family planning was officially made avail-
able at public facilities only to high-risk women. In Bra-
Figure 1 Rates of contraceptive use, abortion-related mortality and hospitalizations, and maternal death rate
per 10,000 live births, Chile, 1964-89

Percentage of women aged 15-44 using contraceptivesa Abortion-related deaths per 10,000 live births
25 12

20 N I 10

15

60

10 1
/ ~~~~~~~~~~~~~~4

5
2

0OI I I I 0 0
1964 '66 '68 '70 '72 '74 '76 '78 '80 '82 '84 '86 1964'66 '68 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90
Year Year

Hospitalizations for abortion complications per 1,000 Maternal deaths per 10,000 live births
women age 15-44
30 30

25 25

20 _'n 20

0 15 2 15/

- i 0 10

5 5

0 I0 11 11 11111 1 11

1965 '70 '75 '81 '85 '87 '88 1964 '66 '68 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88
Year Year

a These are the percents of all women whose contraceptives are supplied by the government health services and the family planning
association. The total contraceptive prevalence was put at 43 percent in1978 and estimated by Singh of the Alan Guttmacher Institute to be 56
percent in 1989 (APROFA, 1978 and 1989).
Source: Liskin, 1980, updated by authors with assistance from Weisner (1990) and Chile, Ministerio de Salud, 1982-90.

zil the most common method of fertility control is female
sterilization; more than one-quarter of recent survey re-
spondents report having been sterilized, most through a
unique system that provides the service after two
cesarian births (Arruda et al., 1987). A large number of
women, therefore, have been removed from the group
that might undergo induced abortions. Although contra-
ceptive misuse is basically undocumented, it appears to
be prevalent in Brazil, especially in the case of oral con-
traceptives, the second most commonly used method
(Arruda et al., 1987). Many women are therefore at risk.
With approximately 30 million women of reproductive
age in Brazil, the number of abortions induced annually,
according to Singh and Wulf's (1991) estimates, is be-
tween 300,000 and 3.3 million. In Brazil the impact of con-
traception on the abortion rate is not yet clearly defined,
but it may be less direct than in Chile and similar to that
in Cuba, even though abortion is highly restricted by law
in Brazil.
Contraceptive failures, as shown by the Cuban ex-
perience, have been linked to abortion practice. They also
confound the Potts paradigm. In 1975 Tietze and
Bongaarts noted that even with perfect use, no modern
contraceptive method is 100 percent effective. The im-
pact of contraceptive failure accumulates over time; the
longer a method is used, the higher the chance it will
fail (Tietze, 1974). Bongaarts and Rodriguez (1989), who
have scrutinized failure rates for modern contraceptive
methods in six Latin American countries, report annual
levels of failure vacillating between 6.4 percent (Costa

Volume 24 Number 4 July/Aug 1993 215

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Rica) and 16.4 percent (Peru). What percentages of these
failures, or pregnancies, resulted in induced abortions?
In Bolivia two-fifths of all women admitted to the hospi-
tal for treatment of abortion complications reported that
they had used contraceptives during the month prior to
conception (Bailey et al., 1988). Earlier, the Pan Ameri-
can Health Organization had estimated that for every 100
women using "effective" contraception, 2.2 induced abor-
tions can be expected annually; for those using "less ef-
fective" contraception, 8.6 abortions; and for those us-
ing no methods at all, 10.0 abortions (PAHO, 1985).
Overall, the relationship between contraceptives and
abortion practices in Latin America appears to be con-
sistent with the observation of David and Pick de Weiss
(1992: 53).
of induced abortion, especially where indications for le-
gal abortion are restricted-as in virtually all of Latin
America and the Caribbean, except Barbados, Belize, and
Cuba (see Table 9) (Jones, 1982; IFRP, 1980). Restrictive
laws create a situation in which safe abortion becomes
essentially unavailable, so that health systems generally
do little to offer even those abortion-related services that
are legal (for example, offering services to save the life
or health of the woman), although the need for such sup-
port is clear. Where limited access to abortion is permit-
ted, legal abortions may, nonetheless, be authorized only
rarely. Obtaining a legal abortion is often a painfully slow
process, and women may be subjected to reproachful at-
titudes of medical personnel, with the result that some
turn to clandestine practitioners. Thus, restrictive laws

In some countries, abortion is the primary means not only reinforce biases against abortion per se, but they

of fertility control; in others, abortion and con- also appear to stimulate many of the unsafe practices they

traception increase together.... [Generally,] with were, to some extent, intended to prohibit.

the passage of time contraceptive practice im- Laissez-faire enforcement of the law also produces

proves and resort to abortion declines, although dangerous and deadly results. Clandestine abortion

it is never totally eliminated. flourishes in countries with highly restrictive laws. In a

few countries (notably Colombia), abortion practiced on
This statement concurs with Potts's paradigm, but
the fringes of the law (or in bold opposition to it) is openly
does not explain what has occurred in Cuba. Induced
tolerated and freely carried out. In other countries, clan-
abortion ranks among the four most commonly used
destine abortionists act with relative impunity because
methods of fertility regulation in Latin America, along
the law is rarely or sporadically enforced, though extor-
with female sterilization, the pill, and the IUD (Paxman,
tion by police and judicial authorities is common. In some
1988b). Indeed, seven out of ten women using contra-
places more than 30 years have passed since criminal abor-
ceptive methods of 95 percent effectiveness will require
tion was last prosecuted; even where women die from un-
at least one abortion during their lifetimes if they wish
safe, illegal procedures, medical personnel and others who
to have only two children-the number becoming the
perform the unsafe abortions are rarely found and con-
norm in Latin America (Tietze, 1980; Frejka, 1984). As
victed. What the law says (de jure) and what happens in
Potts and Requena concluded separately in the 1960s and
reality (de facto) are separated by the immense gap between
1970s, contraception reduces but does not eliminate the
fiction and reality that Octavio Paz remarked upon.
need for abortion. At present, "one-quarter of deliberate
fertility control in Latin America is being achieved by Access
induced abortion" (Frejka and Atkin, 1990: 11). Abortion
Once a woman has decided to seek an abortion, she faces
practice will never be eliminated in Latin America. The
the challenge of trying to make her particular circum-
only point of debate is how much the effective use of con-
stance conform to legal boundaries, or, alternatively, of
traceptives will reduce the abortion rate. Using calcula-
finding access to an abortion outside of the law. Some-
tions made by Nortman, Frejka and Atkin estimate that
times the legal provisions in force in Latin America co-
in the late 1980s annually were 12.4 million live births,
incide with a woman's interests-for example, if an abor-
8.8 million births averted by contraception, and between
tion is permitted in order to save her life. More often,
1.3 and 3.4 million births averted by induced abortion
the legal maneuvers necessary to gain access to legal
(1990: Table 3).
abortion services may be frustrating, complicated, and
time consuming. Where abortion is permitted in the case
of rape, incest, or some other sexual crime, the process
Abortion-related Services: Access and Quality may be so lengthy and cumbersome that a woman's re-
quest remains pending after she has given birth (Portu-
Laws and Policies
gal and Claro, 1988). Not surprisingly, millions of Latin
Laws and policies are among the most important deter- American women annually seek risky abortions.
minants of the quality of available abortion services. They Because of the restrictive abortion laws in Latin
influence directly the frequency of adverse consequences America and the Caribbean, women who have decided

216 Studies in Family Planning

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Table 9 Legal status of induced abortion in selected countries in Latin America and the Caribbean, by country, 1993

Circumstances in which abortion is legal

Risk to Risk to Risk of Socioeco-

Risk to physical mental Rape or fetal de- nomic Elec-
Country Illegal life health health incest formity hardship tive Comments and references to statutes

Argentina X X The rape indication initially applied to the

pregnancy of a woman with "severe mental
illness or retardation" but was eliminated by a
court decision. Criminal Code Arts. 85-88, as
amended by Law No. 17567,6 December 1967
and Decree No. 3992 of 2 December 1984.

Barbados X X X X X X Pregnancy due to rape is considered a "grave"

injury to health; doctor must consider woman's
social and economic environment as part of
determination of risk to health. Medical
Termination of Pregnancy Acts (Act No. 4 of 11
February 1983) Secs. 4-14.

Belize X X X X X Physician may consider risk of pregnancy to

"existing children" as par
Code Ordinance 33, Sec. 108-110 (1980).

Brazil X X Penal Code Arts. 126-129, Decree Law No.

2848, 7 December 1940 as amended in 1941
and 1969.
Sao Paulo
(municipality) X X Induced abortion in case of rape must be
performed during first 1

Cuba X X X X X X Elective during first 12 weeks of pregnancy; other

indications used during second trimester.
Criminal Code, Chap. 6, Arts. 320-324,15
February 1979.

Dominican General principles of criminal law apparently

Republic X (X) permit induced abortion where necessary to save
the life of the woman. C
modified by Law No. 1690. 19 April 1948.

El Salvador X X X Penal Code Arts. 161-169, Decree No. 270 of 3

February 1973.

Jamaica X X X Offenses Against the Person Law, Chap. 208

(1864).

Honduras X Decree 13-85 of 26 February 1985.

Mexico X X Abortion due to unintended "imprudent' act of

woman also legal. Penal Code of 2 January
1931, Arts. 329-334.
Veracruz
Durango and
Coahuila X X X

Peru X X X Legislative Decree 121 of 12 June 1981, Sec. 21

as amended by Penal Code Arts. 159-164
(Normas Legales No. 178,1991).

Sources: UNFPA (1979); UNFPA and Harvard Law School (1980-89); WHO (1 980-91); Boland (1 992b).

to terminate their pregnancies face major dilemmas. They
must usually pursue their intention secretively. In Bra-
zil and Mexico, for example, the Public Health Code pro-
hibits any announcements or advertising related to in-
duced abortion. Women rely on informal (but often
substantial) referral networks or clandestine practitioners
where or with whom choices are few and quality of ser-
vices cannot be easily evaluated. The process may be fur-
ther complicated by moral and religious prohibitions as
well as by fear of legal reprisals. Even the limited ad-
equate services that function within the limits of the law
may remain unknown to the women needing them.
In developing countries such as those found in Latin
America, restrictive abortion laws exacerbate economic
injustices. By limiting and intruding into decisionmaking
processes, the law encourages individuals to search for
clandestine services. The practices thus promoted are not
only dangerous, but also exploitative, because clandes-
tine abortionists often charge exorbitantly high fees.
Women of sufficient economic and social rank can almost

Volume 24 Number 4 July/Aug 1993 217

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always obtain relatively safe, hygienic abortions. But
women with few resources-such as young, single ado-
lescents hiding their pregnancies from their families, or
poor women with many children-are not usually so for-
tunate. In rural areas physical and economic access to
high-quality services is more limited than in urban ar-
eas; rural women may run even greater risks of compli-
cations or death. Despite such hardship, millions of Latin
American and Caribbean women succeed every year in
obtaining clandestine or self-induced abortions.
Quality of Services
The worldwide trend toward progressive health-oriented
legislation has made substantial improvements in the
quality of regulated services (Tietze and Henshaw, 1986);
the case of Cuba is proof enough. Where access is legally
restricted and the frequency of clandestine abortion high,
however, the quality of services is almost always defi-
cient. Conspiring with desperate women's needs, the law
creates conditions in which untrained and incompetent
practitioners thrive (Potts et al., 1977).
A number of studies show that in developing coun-
tries where induced abortion is illegal, women face far
greater risks of mortality and morbidity than do women
in countries where abortion has been legalized (Corvalan,
1979; Liskin, 1980; Tietze and Henshaw, 1986). As already
noted, abortions performed in unhygienic, traumatic con-
ditions cause large numbers of women to require emer-
gency hospital care (IFRP, 1980). Where abortions are
practiced in unfavorable conditions, the resulting mater-
nal mortality is higher than mortality due to childbirth
itself (Tietze, 1969). As Jacobson (1990) points out, "It is
the number of maternal deaths, not abortions, that is most
affected by legal codes" (p. 7). Restrictive abortion laws,
although avowedly intended to protect women from the
consequences of incomplete abortions and to enforce no-
tions of public morality, are clearly not sufficient to de-
ter clandestine practices. Frejka and Atkin (1990), among
many others, expect Latin American women to continue
to ignore legal restraints and to find personal solutions
to their fertility crises. They predict that "the incidence
of induced abortion in Latin America will remain high,
at least through the 1990s, even if its legislation contin-
ues to be restrictive" (p. 20).
Resolving the Dilemma of Unsafe Abortion
Contraception as Prevention
The rationale that motivated Chile to legitimize contra-
ception as a means to reduce the problems associated
with unsafe induced abortion is as appropriate now as it
was nearly 30 years ago. Efforts to make contraceptives
widely available pay huge dividends. For example,
through 1984 in Mexico, for every peso spent on contra-
ceptives, nine were saved on maternity- and abortion-
related costs. Over a six-year period, the Mexican family
planning program was shown to have averted 3.6 mil-
lion unwanted pregnancies and 363,000 induced abor-
tions (Nortman et al., 1986). Yet by choosing to focus on
pregnancy prevention, such measures generally fail to
acknowledge the issue of preventing abortion. Some
observers continue to maintain that connections between
contraception and abortion are as yet inconclusive
(PAHO, 1986). And, as Lopez-Escobar noted long ago,
the contraceptive approach has a distinct advantage be-
cause it "does not touch on the theme of legalizing abor-
tion-which would clash with [Latin American] moral-
ity at the social level and with life itself at the individual
level-but rather on the subject of avoiding a calamity"
(L6pez-Escobar et al., 1978: 59).
Assumptions have long been made that abortion
rates and numbers would diminish as family planning
programs evolved. A decade ago the IFRP report con-
cluded with the common-sense assertion that the inci-
dence of unsafe abortion could be "greatly reduced by
ensuring that contraception is available to all who want
it" (IFRP, 1980: 67). In fact, inadequate family planning
programs appear to have perpetuated the problem of
unsafe abortion: As expectations of avoiding pregnancy
rise, so does the need for abortion if pregnancy occurs
during contraceptive use. Even where contraceptive use
is high-as in Mexico, Colombia, and Brazil-so is the
incidence of unwanted pregnancy, and as the number
of women of reproductive age rises, the number of abor-
tions remains high (Robey et al., 1992). When an un-
wanted pregnancy is caused by contraceptive failure, it
has a high probability of ending in induced abortion.
More effective contraceptive practice is needed to reduce
the problem of unsafe abortion. Even by the most con-
servative estimates, approximately 2.7 million such abor-
tions occur annually in Latin America. As the IFRP re-
port stated, it is "absolutely essential to strengthen
contraceptive services to reduce the number of unwanted
pregnancies that end in induced abortion" (IFRP, 1980:
77). Family planning programs will have to be redesigned
to cater directly to the needs and preferences of women
themselves, providing appropriate contraceptives with
information for their correct use.
This strengthening is necessary in at least two im-
portant areas. First, the rate of contraceptive misuse must
be reduced. In Colombia, for example, nearly half of the
women surveyed made incorrect transitions from one
cycle of pills to another; 43 percent made such errors as
not taking the pill every day; and 10 percent periodically

218 Studies in Family Planning

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ran out of supplies. Overall, 60 percent misused the pill
within a two-week period, a finding that was correctly
termed "alarming" (Potter et al., 1988). Contraceptive
misuse can be reduced by improving the quality of in-
formation and counseling available, as well as by broad-
ening the range of contraceptive methods available. Sec-
ond, every hospital that treats abortion complications
should have an aggressive postabortion contraception
program. Most do not. Substantial research, some de-
cades old, indicates that many women are receptive to
contraceptive information immediately following an in-
duced abortion (Hardy and Herud, 1975; Fauindes et al.,
1968; Rosenfield and Castadot, 1973; Benson et al., 1992)
(see Figure 2). The contraceptive needs of women with
demonstrated tendencies toward high rates of abortion,
as well as other high-risk women (for example, young
single women, women who have achieved desired fam-
ily size, contraceptive dropouts), must be more assidu-
ously addressed.
Improving Safety of Abortions
Experience in industrialized countries in North America
and Western Europe has shown that legalizing abortion
and access to contraceptives can eradicate many of the
dangers inherent in clandestine practices. But the con-
tinuing challenge in Latin America and the Caribbean
will be to improve the quality, and thereby the safety, of
induced abortion procedures-whether or not they are
regulated by liberalized laws. The problem "is not only
changing the numbers of abortions performed, but how
those which occur can be made safer and how complica-
tions of abortion can be treated more effectively so that
fewer women die" (Winikoff et al., 1991: 47).
In the developing world, dilatation and curettage re-
mains the most common method for treating abortion
complications. When D&Cs are performed by physicians
in hospital settings, procedures are typically carried out
in operating rooms where women are sedated. They usu-
ally remain in the hospital overnight. In contrast, in the
developed world, vacuum aspiration (also called suction
curettage) is used for most first-trimester uterine evacu-
ations; it requires neither heavy sedation nor an over-
night hospital stay and is usually performed in a treat-
ment room or on an outpatient basis rather than in an
operating room. VA has been shown to be safer than
D&C for first-trimester uterine evacuation (Tietze and
Lewit, 1972; Cates and Grimes, 1981; Grimes et al., 1977).
The World Health Organization now includes VA as an
essential obstetric service for all first-level referral hos-
pitals (WHO, 1991a). Manual vacuum aspiration (MVA),
a portable, nonelectric variation of VA, has been used
successfully in a variety of health-care settings world-
wide for more than 20 years and has been shown to be
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Figure 2 Contraceptive use before and after hospital treatment for
abortion, by country, 1979
Brazila
Chile . .......
Colombia
El Salvador
Guatemalaa Before
Honduras lZ After
Mexicom
PanamaI
Peru
I l l I
0 20 40 60 80 100
Contraceptive use (percent)
aPostabortion figures are unavailable.
Source: IFRP, 1980
less costly to hospitals than D&C (Johnson et al., 1993a:
32). MVA can be employed by trained paramedical per-
sonnel, which facilitates the decentralization of abortion
care.
Replacing D&C with VA, and particularly with
MVA, could allow care to be delivered on an outpatient
basis, thereby greatly reducing the consumption of such
expensive and scarce health-care resources as anesthe-
sia, surgical facilities and personnel, medication, and in-
travenous fluids. By enabling the expansion of care sites,
the use of MVA could increase women's access to safe
abortion services, and thus greatly reduce the mortality
and morbidity associated with clandestine abortion.
In the leading maternity hospital in Bogota, Colom-
bia, the use of VA equipment in the 1980s by competent
practitioners has been credited for a recent decline in
abortion-related maternal deaths: down from 20 to 30
percent to fewer than 8 percent of maternal deaths (David
and Pick de Weiss, 1992; Paxman, 1988a). Such results
point to changing social attitudes. Of Colombia, where
contraception is widely accepted, David and Pick de
Weiss say, "unintended and unwanted pregnancies are
no longer accepted as they once were. With safe and rea-
sonably priced abortions available from experienced
practitioners, women have found a way of controlling
their fertility when contraception fails" (1992: 54).
At present, treatment of abortion complications and
legal abortion procedures usually take place at second-
ary and tertiary levels of government health systems. Pro-
visions for timely services for more women at the pri-
Volume 24 Number 4 July/Aug 1993 219
mary care level would significantly reduce the morbid-
ity and mortality associated with delays in receiving care
(WHO, 1991b). Reducing abortion-related deaths and mor-
bidity among rural populations will require care sites closer
to women's homes. Such decentralization has yet to be
widely implemented, although initial efforts have been
made in some countries, including Mexico and Nicaragua.
MVA is currently used in public hospitals in a num-
ber of Latin American countries for treatment of incom-
plete abortion. MVA is a safe, appropriate technology for
reaching rural and urban women. The experience of a
small, rural public health center in Nicaragua illustrates
the potential for improved treatment of incomplete abor-
tion. The center serves a population of about 100,000
people. Uterine evacuation was performed by D&C, but
an anesthesiologist was frequently unavailable. The cen-
ter referred most patients with incomplete abortions to
a better facility about an hour's drive away, but care was
often delayed because there were no emergency vehicles
and public transporation was minimal. After staff were
trained and services were well established, MVA became
the standard technique for uterine evacuation, and vir-
tually all first-trimester patients with incomplete abor-
tions were treated with MVA at the center (Abernathy
and Chambers, 1991; McLaurin et al., 1991).
A study in one Mexican state has already examined
the feasibility of placing MVA services at lower levels
within the health-care system (Chambers et al., 1992). All
medical providers agreed that MVA services should be of-
fered, citing their ease of use. At urban public hospitals in (Tomaro, 1981). Expanding the climate for discussion of
Mexico and Ecuador, the use of MVA instead of D&C has
reduced the duration of patient stay and lowered hospital
costs for treatment of first-trimester incomplete abortion
(Johnson et al., 1992,1993a, and 1993b). MVA requires lower
levels of pain-control medication than does D&C, allow-
ing patients to recover more quickly and often avoid an
overnight stay. Some MVAs were even performed in an
outpatient area rather than in an operating room.
Medical and administrative personnel in several
public hospitals in Chile are using the introduction of
the MVA technology as an opportunity to examine their
abortion treatment services, including patient education,
postabortion family planning, and attitudes of provid-
ers toward abortion patients. Officials at one Ecuador-
ian hospital are modifying their discharge protocols to
reduce overly long patient stays. After adopting the MVA
technique at Ministry of Health hospitals in one state in
Mexico, officials noted a reduction in charges to patients,
because most evacuation procedures are performed on
an outpatient basis. Also in Mexico, the Social Security
System is in the initial stages of introducing MVA as the
method used for treatment of first-trimester incomplete
abortion patients at secondary and tertiary hospital 1ev-
220 Studies in Family Planning
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els (Johnson et al., 1992,1993a, and 1993b).
Another new technology is RU 486, now being used
extensively in France and approved for use in England.
RU 486 is an abortifacient that acts by preventing uter-
ine implantation of the blastocyst, or by preventing gesta-
tion if implantation is complete. It is 87 percent effective
when used alone, and 96 percent effective in combination
with a prostaglandin (Bernard et al., 1986; Silvestre et al.,
1990). The body of scientific knowledge about RU 486 is
new and expanding, and what the drug's impact on abor-
tions performed in the developing world will be is un-
certain. However, this new technology has "the greatest
chance for successful introduction when a strong deliv-
ery infrastructure exists, where follow-up for each client
can be guaranteed, and when suitable back-up for failed
procedures is available" (McLaurin et al., 1991: 25; see
also Banwell and Paxman, 1992; Cook, 1989a). The use
of the prostaglandin Cyotec in Brazil hints at what might
happen if RU 486 becomes available in the region. Dis-
cussions are under way aimed at its approval and its in-
troduction into the United States. This development is
not likely to speed the drug's use in Latin America, be-
cause of the difference in the legal status of abortion it-
self. That abortion has been legal in the United States for
the past 20 years has had no impact on the process of
legalization in Latin America.
Promoting safer techniques and training providers
who are already performing abortions is made difficult
by the clandestine nature of present abortion practices
abortion care among providers could help to accelerate
the adoption of new health-protecting techniques. Be-
yond discussion, there is need for appropriate training.
In addition, safe contraception and abortion services re-
quire health-system infrastructures that include trained
personnel, facilities for delivering quality services and
follow-up care, backup provisions for failures, and de-
centralized care sites to encourage earlier treatment. In
Latin America the greatest immediate need will continue
to be that of treating abortion complications. Introduc-
ing safer technologies can begin at that point. Where in-
novative ventures can be undertaken, experience in Co-
lombia and Mexico suggests that the quality of abortion
services can be upgraded-both within and at the edge
of the law (Villareal and Mora, 1992).
Legal Approaches and Change
Attempts at abortion law reform are affected by public
opinion and political climate. Public debates are heated
and vociferous. Many in Latin America, as elsewhere, see
the abortion issue as part of a larger moral and religious
universe, rather than as an issue of public health or
women's rights. Attempts to liberalize abortion laws
have been termed morally unacceptable-at the same
time that strict enforcement of restrictive laws has been
recognized as impossible (Ortiz Umana, 1973; Nuniez et
al., 1991). In settings like these, the process of change is
slow; every advance is hard won. For example, despite
1990 legislative approval for a more liberalized abortion
law in the Mexican state of Chiapas, its status to date
remains uncertain (Boland, 1992a). The new legislation
would have expanded the criteria for legal procedures
to include possible fetal genetic defects; family planning
(with the couple's joint consent); single marital status;
and when the pregnancy could be considered "impru-
dent." The Council of Mexican Bishops complained vig-
orously when the law was enacted, and the governor and
legislature of Chiapas set it aside for further study. The
law was then referred to the Mexican Human Rights
Commission for an opinion on its constitutionality; the
issue is still undecided.
More than a decade ago four alternative directions
for change in Latin American abortion laws were sug-
gested: "strict enforcement of existing laws; liberaliza-
tion of the laws; continuation of the present legislation,
with abortion gradually replaced by contraception; or
continuation of the present legislation combined with
greater social permissiveness and increased violation of
the law" (Isaacs and Sanhueza, 1975: 46). Today, each
direction is being followed in one or another part of Latin
America and the Caribbean. Authorities periodically at-
tempt to prosecute, or extort from, those who violate the
law, but convictions are rare; more frequent are the cases
of official harassment, usually with the aim of extorting
payments. Only a few laws have been liberalized (Cook
and Dickens, 1978 and 1988; Boland, 1992b). Unquestion-
ably, contraceptive use has risen, doubtless averting
many abortions, yet not fully supplanting unsafe prac-
tices. Finally, induced abortion, although still illegal, has
been "medicalized" in a few countries-principally in
Colombia, where the quality of care for women seeking
early abortions has been improved, and social acceptance
of the practice strengthened (Villareal and Mora, 1992).
Isaacs and Sanhueza did not anticipate the situation in Hon-
duras, Argentina, Ecuador, Chile, and Nicaragua, where
abortion laws have become even more restrictive than they rowest. In this way broader access to abortion services
were a decade ago.
The Cuban experience gives clear evidence that lib-
eralized laws, including decriminalizing abortion prac-
tice, are associated with improved access and quality of
services, and, in the long run, with a marked decrease in
adverse consequences. This experience bears out Viel's
prediction (1976) that legalized abortion in Latin America
would "ensure well-performed operations and fewer
abortion-related deaths" (p. 122). Were the Cuban model
to be followed elsewhere in Latin America, many of the
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deleterious health consequences of unsafe induced abor-
tion would be diminished. But laws are not likely to be
liberalized soon in Latin America. Policymakers, social
commentators, church officials, and many women op-
pose legal change (Lopez-Escobar et al., 1978; Cardenas
de Santamaria, 1982).
Reality and fiction continue their struggle. Both lit-
erature and experience teach that it is "very difficult for
the law by itself to provide a solution to the problem [of
unsafe induced abortion]," particularly if the intention
is to eradicate the unsafe practice through punitive mea-
sures (Sulbrandt and Ferrera, 1975: 23). Legal change by
itself is not enough. Complementary measures, like those
discussed above, must also be taken. Yet the question re-
mains: How can laws and policies be used as agents of
change to lessen the negative effects of unsafe abortion?
Several options are possible for Latin America. Most by-
pass statutory reform. Taken together, they can be re-
garded as evolutionary steps to legal reform.
First, where abortion laws are restrictive, abortion-related
services can be clarified as legal and ethical duties, particu-
larly for the treatment of incomplete abortions. Women
should not be deterred from seeking proper medical
treatment because they fear punishment, and health
workers should not be reluctant to proceed with treat-
ment because they think it is illegal or because they are
biased against the women needing the treatment. A
woman who had undergone repeated illegal abortions
described her situation:
My womb was so infected that the doctors
couldn't touch me. One doctor wanted to treat
me and the other didn't. One said to the other,
'If you send her back home she'll die on the way.'
So they operated on me, scraping my womb
clean, almost without anesthesia as a kind of
punishment. (Gall, 1972: 8)
The treatment of an incomplete abortion is not only le-
gal; it is also an ethical duty (Cook, 1989b; Paxman, 1980).
Second, laws and policies defining when legal abortions
can be practiced, even where the circumstances are restrictive,
can be applied to their fullest extent, rather than to their nar-
would be granted to women meeting legal criteria, as is
the case in El Salvador, where the menstrual regulation
technique is widely available and openly used for the
abortions that are legal (United Nations, 1992). This ap-
proach is also being used in Sao Paulo, Brazil. As part of
an attempt to preempt the adverse consequences of un-
safe illegal abortion, the state health-care system was re-
quired to implement the existing law and to make avail-
able legally authorized abortions (for pregnancies
threatening the woman's life, or in cases of rape) (Pinotti
Volume 24 Number 4 July/Aug 1993 221
and Fauindes, 1989). Although applying the law in this
way may affect only a miniscule proportion of induced
abortion cases, it does expand the availability of safe ser-
vices and serves an important symbolic purpose, signal-
ing that the government health program is providing
abortion-related services.
Third, the indications for legal abortion can be given ex- if a country has as a goal the resolution of such public
panded interpretations. Although many statutes permit in-
tervention when a woman's health is threatened, these
statutes are almost always narrowly interpreted. In some
countries, access to safe abortion has been appreciably
expanded without altering the law, simply by instruct-
ing doctors to employ the World Health Organization
definition of health as the basis for decisionmaking:
"Health is a state of complete physical, mental and so-
cial well being and not merely the absence of disease or
infirmity" (Cook, 1989b; Paxman, 1980). In 1964 in Cuba,
the stage was set for expanding access to abortion with-
out changing the law by interpreting the Social Defense
Code in terms of the WHO definition (Hollerbach, 1980:
101). As that experience points out, expanded criteria for
decisionmaking can greatly enhance women's access to
legally permitted services. The challenge is to place into
use the wider technical definitions, which necessarily
carry with them not only a wider practical but also a po-
litical significance.
Fourth, evolutionary rather than revolutionary approaches Conclusion
can be taken by officially relaxing legal constraints on abor-
tion practice. Several Latin American countries (for ex-
ample, Colombia, Mexico, and Peru) have eased legal re-
strictions by allowing a de facto situation to prevail
through a network of well-run, low-cost, high-quality fa-
cilities, some of which have been granted licenses to ad-
dress the problem of incomplete abortion (David and
Pick de Weiss, 1992). This evolution has taken place in
the absence of statutory reform.
Fifth, statutes can be reformed, and safe induced abortion years has been lacking in Latin America. The statutes
decriminalized. In a few Latin American countries the in-
dications for legal abortion have been expanded or at-
tempts at liberalization have occurred (most notably in
Cuba, Belize, and Barbados). Some countries (for ex-
ample, Honduras, Chile, and Argentina) have made their
laws more restrictive, and in others reforms have stalled.
For example, in 1979 efforts to bring Colombian laws in
line with those of the rest of Latin America-restrictive
though such laws were-were short-lived and staunchly
opposed. This was also the case in Honduras in 1985,
when relatively moderate legal requirements were re-
scinded after a fierce polemic. The debate featured plac-
ards bearing such messages as "Abortion is assassina-
tion" and "A doctor who kills babies is capable of killing
adults" (Portugal and Claro, 1988).
Isaacs and Sanhueza (1975), writing of the option to
222 Studies in Familv PlanninL
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liberalize abortion laws, observed, "It is not the kind of
arena into which legislators rush to enter" (p. 47). For
this reason alone, abortion laws will not likely be liber-
alized in the near future; attempts to do so in Latin
America to date have largely failed for a combination of
political, social, cultural, and religious reasons. However,
health problems as maternal mortality and morbidity,
which are caused in part by legal restrictions to abortion,
then liberalization, certainly decriminalization, makes
sense. According to estimates, legalizing abortion prac-
tices would reduce maternal mortality rates by at least
20 to 25 percent (Paxman, 1988b; Jacobson, 1990). Among
the changes that can be made are: (1) removing criminal
penalties applied to women who seek abortion, since in the
face of such penalties women are inclined to postpone seek-
ing proper medical attention when they suffer complica-
tions; (2) expanding the legal indications for which abor-
tion is authorized, since doing so tends to improve
accessibility and to result in safer procedures; and (3) elimi-
nating procedural requirements that encumber the process
of authorizing abortions, since these work to delay the tim-
ing of permissible abortions, thus creating additional and
unnecessary risks (Paxman, 1980; Cook, 1989b).
Ample evidence supports the view that the two "coun-
tries" Paz wrote about, "one fictitious, the other real,"
exist in the realm of abortion. It is equally apparent that
the two must draw nearer to one another, that the gap
between social practice and norms of law and policy must
be closed. The law and policy must adjust to the prac-
tice-rather than the other way around. This adjustment
will take enormous political will, something that for 30
themselves need not neccessarily be changed-although
from the perspective of women's health, the world ex-
perience has shown that liberalizing them is the most ef-
fective way of combating the dreadful effects of clan-
destine abortion. But at a minimum, some de facto legal
impediments to the wider availability of safe induced
abortion services must be removed.
Legal changes aside, widespread and proper contra-
ceptive use must also be further promoted because such
use averts many unwanted pregnancies and tends to
lower the need for induced abortion. At the same time,
even with good contraceptive practice, women will con-
trol their fertility by whatever means they can manage,
including the dangerous practice of self-induced or clan-
destine abortion. Thus, the complementary approach of
improving the safety of all induced abortion-related pro-
cedures must also be supported. Abortion rates (at least
in countries with reliable statistics, such as Chile) have
been falling over the last two decades. In other countries,
however, despite advances in contraceptive practice, the
estimated incidence of clandestine abortion remains at
an unacceptable level. Partly as a result of increased
populations of women of reproductive age, the numbers
of abortions remain high.
The three strategies for addressing the abortion prob-
lem are interrelated: increasing access to and correct use
of contraceptives; introducing and using safe abortion
technologies; and promoting legal change. All three must
be pursued at once if the persistent epidemic of unsafe
induced abortion in Latin America is to be adequately
addressed (McLaurin et al., 1991).
Notes
1 The laws in Latin America, particularly those that trace their ori-
gins to the civil law system in Spain and Portugal, define very nar-
rowly the circumstances under which a legal induced abortion may
take place. The huge majority of the induced abortions performed
in Latin America fail to meet these criteria and are, perforce, ille-
gal. For an interesting yet opposing, view on why these abortions
may not be illegal, see Cook, 1991.
2 In early 1981 funding from USAID for research touching on the
subject of induced abortion was suspended. Then, at the Interna-
tional Population Conference held in Mexico City in August 1984,
the United States government announced that it would no longer
fund nongovernmental organizations in foreign countries involved
in abortion-related services, referrals, promotions, or political
change, even when such activities were separately funded with
the organization's own monies. This policy was abruptly aban-
doned in the first few days of the Clinton administration.
3 The warning on the insert of the product says: "Cytotec (miso-
prostol) must not be used by pregnant women. Cytotec may cause
miscarriages. Miscarriages caused by Cytotec may be incomplete
and could lead to dangerous bleeding."
4 9,440 cases @ 5.9 days = 55,696 hospital days x $29 per day =
$1,336,128.
5 Although contraceptives are said to be widely available both from
the National Health Service and in drugstores, shortages have been
reported in recent years, even though some of the contraceptives,
notably two types of pills, are manufactured in the country (Soza
et al., 1990).
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