The importance of openly discussing abortion for the protection and promotion of women’s health

As many articles in Supplement issue highlight, the topic of “abortion” is extremely controversial and causes reactions rooted in religious, moral, philosophical, legal, health and human rights perspectives. The word abortion carries a heavy stigma that leads people to seek to avoid being connected with it. This essential issue of stigma is presented in many of the articles included in this Supplement.

Part of the articles presented in this Thematic Section refer to the situation in some countries in the region, especially Argentina, Uruguay, Brazil ¹ and Colombia ², as examples of countries in which there is greater or lesser progress in access to safe abortion, but also El Salvador ³, as an extreme example of restriction and intolerance toward abortion. The articles further describe the cases of European countries that recently changed their legislation, such as Portugal ⁴ and Ireland ⁵.

Personally, I feel that there is an erroneous idea in the abortion debate, when it is claimed that there is an opposition between people in favor of and against abortion. I believe that this is not the real controversy because, in reality, there are no people “in favor of abortion” or who desire that an increasingly high number of abortions take place. The true controversy is between those in favor of criminalizing abortion and those who oppose this criminalization. On one side are those who believe that abortion should be banned, that it is a crime to be punished, and that this punishment should fall on the person who voluntarily terminates their pregnancy and the person who helps in this process. On the other side are those who believe that criminalization is not the solution because it does not reduce the number of abortions, that it is unfair because it only punishes the woman and not the man who caused or contributed to the pregnancy, often even against the woman’s will, and because it more directly and severely affects poorer, less educated, younger and more vulnerable women, while those who have resources do not suffer the same consequences of this criminalization.

Although there are still conservative waves, in the medium-to-long term, there is a process of legal liberalization that favors access to safe abortion, as shown in this Thematic Section, in the case of Portugal ⁴, Uruguay ¹, Colombia ² and Ireland ⁵. Just in the case of Portugal, the article notes that this liberalization did not lead to an increase in the number of abortions ⁴. In fact, worldwide, the liberalization of abortion laws lead, in the medium term, to a reduction in abortion rates ⁶.

This is an important fact that must be emphasized because it shows the uselessness of restrictive laws that only have negative consequences for women’s health, in addition to a high social cost. The case of El Salvador is exemplary, where not only highly restrictive laws are maintained, but there is also a practice that restricts access even further ⁷. The article shows that this restriction leads to an increase in the number of suicides among pregnant teenagers who see no way out other than sacrificing their own lives. The article does not show another absurdly extreme situation present in El Salvador: ectopic pregnancies cannot be terminated while a heartbeat can be detected in the embryo; doctors must wait for the Fallopian tube to rupture, which explains the high incidence of maternal death from ectopic pregnancy in this country ⁸.

The inclusion of the article on El Salvador in this Thematic Section is very important because it shows the absurdity of restrictive laws, which not only do not meet their goal of reducing abortions, but are highly efficacious in harming the health and sacrificing the lives of many women ^9,10,11. The only thing that explains why these laws remain unchanged is the fact that those who can change them are unaffected by these restrictions, since those with economic means do not suffer any of their consequences, whether resolving the problem in their own country in highly costly private clinics or by traveling abroad.

Many articles highlight the evident fact that changing the law is not enough for women to have access to safe abortion services. There must be services and providers willing to perform terminations. Doctors frequently claim objection of conscience and refuse to provide the necessary treatments established by law. One of these articles shows that, in some cases, those who claim objection of conscience go beyond and create obstacles to others who provide the service, instead of facilitating care, as medical ethics codes recommend ¹².

We know, however, that, in many cases, the refusal to provide care in public services has more to do with the fear of the stigma associated with abortion, since the information that someone has performed abortions will be public and they may be accused of being “abortionists”, rather than because of a true objection ¹³. We also know that doctors’ positions change according to the proximity to their own lives of the problem leading to abortion. The disposition to meet a demand for termination is lower for an unknown woman than for a client, greater for a family member and even greater when the problem affects their own partner or herself, if the doctor is a woman ¹⁴.

Another important aspect is that the current availability of medication abortion has greatly facilitated access to safe abortion. It is no longer necessary for providers to be trained in surgical procedures, especially manual vacuum aspiration (MVA), which facilitates the practice of the legal termination of pregnancy at the community level by a general practitioner or family doctor, up to the 9^th week of gestation, as is emphasized, for example, in the article on the legal change in Ireland ⁵.

It is important to remember that the World Health Organization (WHO) revisited the subject of which health professionals could provide these services with no loss of safety, classifying not only general practitioners but also general and obstetric nurses into the same category of safe provision of abortions using medication or MVA ^15,16. The Brazilian legislation, however, refers to “abortion provided by doctors”, which leaves out the possibility of non-medical professionals acting in this field.

In recent years, a growing number of hospitals all over Brazil are carrying out the legal termination of pregnancies resulting from rape, facilitated by the Ministry of Health’s Norm that only requires the woman’s statement, detailed in the clinical history, to perform the terminaiton ¹⁷. This is an advance of great proportions, however, the health causal has been forgotten, which should be a reason for initiatives that take it into greater consideration. The sexual violence causal, however, currently offers Brazilian women more opportunity for accessing legal abortion.

In short, this Supplement provides highly relevant information on a subject about which texts are not published frequently and insistently enough for the stigma to be reduced and for people to stop viewing abortion only in its negative aspects and to begin to understand it as a frequent event in the lives of women, an event that, to many women, represents a solution, not at all pleasureful, but that brings tremendous relief once resolved.

Referências

• ¹
  Galli B. Desafios e oportunidades para o acesso ao aborto legal e seguro na América Latina a partir dos cenários do Brasil, da Argentina e do Uruguai. Cad Saúde Pública 2020; 36 Suppl 1:e00168419.
• ²
  González-Vélez AC. A produção de conhecimento especializado como eixo central na implementação do aborto legal na Colômbia. Cad Saúde Pública 2020; 36 Suppl 1:e00132719.
• ³
  Rodríguez Alarcón JS, Perico MF. O impacto da pobreza e da violência na saúde e nos direitos reprodutivos das mulheres em El Salvador. Cad Saúde Pública 2020; 36 Suppl 1:e00039119.
• ⁴
  Vicente LF. Aborto por opção da mulher: a experiência portuguesa da implementação da Rede Nacional. Cad Saúde Pública 2020; 36 Suppl 1:e00036219.
• ⁵
  Murphy C. A Irtlanda desde a revogação da Oitava Emenda. Cad Saúde Pública 2020; 36 Suppl 1: 00211119.
• ⁶
  Faúndes A, Shah IH. Evidence supporting broader access to safe legal abortion. Int J Gynecol Obstet. 2015; 131:S56-S59.
• ⁷
  Zureick A, Khan A, Chen A, Reyes A. Physicians' challenges under El Salvador's criminal abortion prohibition. Int J Gynaecol Obstet 2018; 143:121-6.
• ⁸
  Faúndes A, Gil MP. Restricted abortion law in El Salvador. Int J Gynaecol Obstet 2019; 145:136.
• ⁹
  Sperber A. El Salvador's total ban on abortion risks women's health. Lancet 2018; 391:1758-59.
• ¹⁰
  Torjesen I. Rape survivor is sentenced to 30 years in jail under El Salvador's extreme anti- abortion law. BMJ 2017; 358:j3327.
• ¹¹
  Viterna J, Bautista JSG. Pregnancy and the 40-year prison sentence: how "abortion is murder" became institutionalized in the Salvadoran Judicial System. Health Hum Rights 2017; 19:81-93.
• ¹²
  FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women's Health. Ethical issues in obstetrics and gynecology. 2015. https://www.figo.org/sites/default/files/uploads/wg-publications/ethics/FIGO%20Ethical%20Issues%202015.pdf4893.pdf (acessado em 13/Fev/2020).
  » https://www.figo.org/sites/default/files/uploads/wg-publications/ethics/FIGO%20Ethical%20Issues%202015.pdf4893.pdf
• ¹³
  Faúndes A, Duarte GA, Osis MJD. Conscientious objection or fear of social stigma and unawareness of ethical obligation. Int J Gynaecol Obstet 2013; 123 Suppl 3:S57-9.
• ¹⁴
  Faúndes A, Duarte GA, Neto JA, Sousa MH. The closer you are, the better you understand: the reaction of Brazilian obstetrician-gynaecologists to unwanted pregnancy. Reprod Health Matters 2004; 12(24 Suppl):47-56.
• ¹⁵
  Department of Reproductive Health and Research, World Health Organization. Health worker roles in providing safe abortion care and post abortion contraception. https://apps.who.int/iris/bitstream/handle/10665/181041/9789241549264_eng.pdf;jsessionid=80E3C193E6469B87EF8F6C3C9E6B7C9C?sequence=1 (acessado em 13/Fev/2020).
  » https://apps.who.int/iris/bitstream/handle/10665/181041/9789241549264_eng.pdf;jsessionid=80E3C193E6469B87EF8F6C3C9E6B7C9C?sequence=1
• ¹⁶
  Faúndes A. Misoprostol: an essential drug in reproductive health. Journal of Pregnancy and Reproduction 2018; 2:1-3.
• ¹⁷
  Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Norma técnica: prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes. 3ª Ed. http://bvsms.saude.gov.br/bvs/publicacoes/prevencao_agravo_violencia_sexual_mulheres_3ed.pdf (acessado em 13/Fev/2020).
  » http://bvsms.saude.gov.br/bvs/publicacoes/prevencao_agravo_violencia_sexual_mulheres_3ed.pdf

Publication Dates

• Publication in this collection
  6 Apr 2020
• Date of issue
  2020

History

• Received
  10 Jan 2020
• Reviewed
  11 Feb 2020
• Accepted
  18 Feb 2020