What are the main Arguments surrounding the Decriminalization of Abortion?

The terms of the debate regarding abortion have changed over time, largely due to the evolution of conceptual developments in feminist arguments. From the position in favor of its legalization/decriminalization, this debate has occurred in terms of women’s autonomy, individual responsibility and freedom of conscience, sexual and reproductive rights, women’s empowerment, their physical and mental health, power and gender relations, the public and the private, ethics, citizenship, and the democratization of society. From another position that opposed to abortion’s legalization and decriminalization, the view of life from the moment of conception has been the basis of debate, or at least the most visible one.

The intensity and results of the debate have not been the same for all countries in the region, and an important role has been played by access to the centers of power of the various actors, as well as by the advance of the democratic process within these countries. In general terms, the proposals in the various countries have been adapted to their political and legal circumstances. (Profamilia, 1993).

The Feminist Movement

The feminist movements of the second wave have been possibly the most significant subversive phenomenon of the twentieth century because of their profound questioning of the single, hegemonic thoughts on human relations and the socio-political, economic, cultural and sexual contexts in which they developed. Latin-American feminisms have been an active and crucial part of this process in the region (Vargas Valente, 2002).

In the female liberation movements of the 1970’s and 1980’s in the United States and European democracies, the struggle to legalize abortion played a key role. It symbolized a woman’s right to fulfill herself in different fields beyond that of motherhood, to be a person with her own rights, and to reject the obligation to continue with an unsought or unwanted pregnancy. In the 1970’s the legalization of abortion became the banner of feminist struggles and assumed the nature of defending women’s lives, so that feminists of the time conducted campaigns specifically on the right to abort (Durand and Gutiérrez, 1999). According to these authors, pioneering feminists regarded fertility control as a moral asset, “the freedom and responsibility to choose” of which women cannot be deprived and to which they should have access without endangering their lives or health, an argument which, together with the movement to legalize abortion, was permanently present in the struggle to legalize contraception.

In many Latin American and Caribbean countries, the feminist movement has had a visible presence in the debate on abortion since the 1970’s due to, among other things, the success the movement was having in the United States and Europe and the organization of the United Nations Conference on Women that took place in Mexico City in 1975. Since then, the discourse and the form of advocating changes in the world have varied considerably (Lamas, 2003). Below some of the main arguments used by these actors.

The Right to Decide

In the 1970’s feminism in the region was characterized by self-determination, adopting the concept of voluntary motherhood that had been used by Italian women to modify abortion laws to achieve its legalization, basing their arguments on reasons of social justice and public health (Lamas, 2001). In the 1980’s, the feminist movement adopted a worldwide strategy focusing on the “right to decide”. It included, among other things, the issue of the right to abortion as a condition of self-determination and freedom for women. The concept of reproductive rights was assumed by numerous feminists who claim it as part of the fulfillment both of new and old rights, which, in many countries, coincided with the increase in population policies. Within this scenario, during the 1990’s, the language of sexual and reproductive rights obtained international legitimization. This was the result of discussions and agreements that emerged from the United Nations conference and of the process that implied the adoption of these terms, first in the academic sphere and in the women’s movement and then in United Nations international documents, national laws and the public discourse of decision makers.

The position held by feminists that fight for the decriminalization of abortion is based on the right of women to choose whether they want to be mothers and to have the freedom to define the number and spacing of their children, an issue that is closely linked to women’s autonomy or lack thereof. They therefore claim free access to contraception and abortion and emphasize the fact that women, not others, own their own bodies, and therefore it is they who must decide freely concerning them (Tarrés Barraza, 1993, www.decidir.org.mx). For the defenders of this decision, faced with the dilemma of abortion, one should emphasize the right of the person present, the woman who is pregnant, over the fetus’ projected life (Ortiz Lemus, 1992). An additional part of the project of these feminists is the attempt to break with the ideology imposed by the Catholic religion throughout history. This ideology refers both to the idea that female sexuality cannot exist and is not justified by sexual pleasure, but only in relation to motherhood, in other words, if the aim of sexuality is purely procreation, and the limitations imposed on women, who are deprived of the possibility of proposing and opting for other forms of life within a social sphere (Hierro, 2003).

The question of unplanned or unwanted pregnancies and their emotional, economic and social impact on the lives of women and their families has become one of the central arguments of feminists, closely linked to their right to decide (De Barbieri, 2003; Lamas,2001; and 2003). The importance of the results of pregnancy, the product, within the framework of the feminist position implies the need for all children that are born to be really wanted (Ortiz, Lemus, 1992). Likewise, it proposes that in the new contexts, “sexual encounters multiply, and ideological and material obstacles to assuming responsibility for one’s sexual life lead not only to thousands of abortions but also to thousands of births of unwanted children. These children, formerly welcomed as insurance for one’s old age, are experienced as a burden in a society that offers no support in the difficult job of child-rearing” (Lamas, 2003). Therefore women’s resistance in the face of possible excommunication is indicative of the fact that although abortion is regarded as a sin by the Catholic religion and is illegal, for women that choose to interrupt an unwanted pregnancy it means “that to them, their conscience is first and that choosing motherhood is a right that belongs to them, which is why voluntary motherhood is the only legitimately ethical option” (Lamas, 2003) (p.113). It has also been pointed out that the discourse linked to the freedom of women is associated with social justice, since it is women belonging to the poorest population groups who have been the main victims of the effects of unsafe, illegal abortion (Tarrés 1993).

The Right to Health

The language of sexual and reproductive rights is also linked to that of sexual and reproductive health. This binomial, health and rights, is not conceptually divisible, since one sphere implies the other. The argument of abortion as a public health problem has frequently been used since it implies the adverse consequences of unsafe conditions to perform abortions. Although it is inherently impossible to quantify induced abortions, the estimates that have been made and continue to be made reflect their high incidence and the corresponding morbi-mortality. Its costs as a health problem also involve the person, the family, the health sector, the work sector and society as a whole (see Chapter Seven). “Public health arguments seek to create an awareness of the incidence and prevalence of unwanted  pregnancies, speak of the ability, or lack thereof, of health systems to provide safe abortion, identify gaps in the availability of the service and estimate its costs” (Hessini, 2005) (p. 89). An example of the use of this type of argument is the publication by Ipas Central America and the Nicaraguan Society of Gynecology and Obstetrics (SONIGOB) on the lack of regulation in Nicaragua of therapeutic abortion, the only kind permitted in there, and its effect.(McNaughton et al., 2003). It is important to stress that public health arguments can also be applied in certain countries where abortion is legal (Nunes, 2001).

Certain organizations that have traditionally worked closely with the health sector, such as Ipas or the Population Council, have produced documents and publications designed to raise awareness among professionals in the sector (Ipas, 2001) and have also become joint participants with the latter in workshops, management and defense campaigns and publications. A crucial role is also played by health sector personnel in the provision of safe abortions where there are legal grounds, along with medical and ethical responsibility. Within this context, arguments on bioethics, understood in a progressive, liberal sense, have provided an additional framework for exploring the debate on abortion (www.andar.org.mx; www.gire.org.mx).

In countries where laws are restrictive, the grounds on which abortion is not penalized are based largely and almost solely on questions related to health, thereby evoking the same principal emphasized at the beginning of family planning programs: to preserve the health of mother and child. As illustrated in the previous chapter, abortion is permitted in many countries to save the women’s life, to preserve her physical or mental health or because of fetal malformations. This is also the case in the recent decriminalization of abortion on three grounds in Colombia: risk to women’s life or health, severe fetal malformation, and rape, (this last case also includes the protection of women’s autonomy and personal integrity) (The Economist, 2005). The problem of sexual violence is linked both to abortion and women’s physical and mental health. For example, in Mexico and Brazil, certain management and defense organizations have linked the provision of abortion in rape cases to integral services for the victims of violence. This is an extremely important line in the debate in the region, since the legislation of nine Latin American and Caribbean countries permits abortion if pregnancy is the result of rape or incest (Hessini, 2005) (see Chapter One).

A more recent argument raised by various institutional and personal actors refers to the right to abortion as part of human rights. There are various recent materials that include lists of certain rights and their applicability to abortion. Among those mentioned are: the right to health, life, freedom from discrimination, freedom from inhumane or degrading treatment and violence, right to information and to the benefits of scientific advances, equality, freedom of conscience, intimacy and confidentiality, and the right to decide on the number and spacing of one’s children (www.decidir.org; HRW, 2005).

This line of argument, which is relatively new, was preceded by the work on reproductive rights linked to a human rights perspective, for which the promotion and protection of health requires specific explicit efforts to promote human rights and dignity (Gruskin and Grodin quoted p. 275 in Yanda et al., 2003). Including this point of view implies noting the negative effects on health of factors such as social disparity, discrimination and gender violence.

A Question of Social Justice

Feminists’ struggle in the sphere of women’s sexual and reproductive health has not only been expressed in attempts to decriminalize abortion. Nowadays, discussion focuses on the conditions in which women abort and could abort, since they do so despite legal prohibitions. In the region, researchers have noted that even in cases where the law permits abortion, several factors intervene to hamper the exercise of this right. Among these, feminist discourse emphasizes the democratic demand that requires equal access to the medical service of interrupting an unwanted pregnancy as a question of social justice, since obtaining an abortion in safe conditions is conditioned by women’s financial capacity (Women’s Global Network for Reproductive Rights Newsletter, 1994). Whereas a minority has the economic means and necessary information to obtain access to abortions in optimal conditions, the majority of women resort to highly risky or clandestine methods, which also create serious consequences for their physical and mental health, in addition to entailing high economic costs. “Conceiving of abortion as a regulated health service in public hospitals is the only way of not perpetuating the unfair inequality gap for economic reasons that determines the risks (differential and inequity) of maternal mortality and morbidity associated with the practice of abortion and its illegality” (Lamas 2003) (p.111).

Gender Inequalities, Democratization and Citizenship.

In the 1990’s, feminism emerged as a social movement that enabled women to become active political subjects, vindicating and legitimizing their demands and denouncing the situation of subordination and inequality in which they lived. Thus, key concepts emerged within feminism, such as empowerment and ownership. The first raises the challenge to male domination and female subordination and the transformation of the structures and institutions that reinforce and perpetuate gender discrimination and social inequality and enable women to have access to and control over material resources and information. At the same time, the latter, as its name suggests, refers to the definition of ownership rights (Durand and Gutiérrez, 1999). Within this framework, a conceptual revision was made of a key issue in any political claim and the language of rights, from which the women’s movement was not excluded: citizenship, which was taken up as one of the main banners.

One of the pillars of the most recent debate focuses on the analysis and discussion of abortion as an issue that is closely linked to the process of redefining female identity in relation to male identity, gender relations, and the role played by males in the practice of abortion and, generally speaking, in the reproductive sphere. A propos of this, Scavone (1999) points out that “the most influential theoretical axis orienting the debate on contraception, abortion and contraceptive techniques in Latin America comes from the various trends in feminist criticism and is based on the fields of reproductive health, reproductive rights and ethics and/or bioethics analyzed through the perspective of social relations of sex/ gender” (p. 23). Feminists believe that abortion is not desirable and may even be a traumatic experience, yet its decriminalization/legalization is an important point to gain in the recovery of women’s bodies, not only in relation to conservative ideology and the State but also vis-à-vis men in terms of prevailing gender relations (Lamas, 2001; Bernal, 2003). Castañeda Salgado (2003) points out (p.21) that questioning the role of men – in their capacity as physicians, priests, leaders of religious associations and parents’ associations, lawyers, judges, functionaries, spouses, occasional partners, etc. – is raised not only on the basis of direct participation in aborted pregnancies but also from their position of subjects who feel they have the right to judge and punish women that abort: ‘where are the men who participated in the pregnancy of women who decided to interrupt them?’, It has been pointed out that they tend to play a contributory role: they are the presence that obliges women to make this decision to abort but in absentia; and in any case, the masculine presence continues to be fundamentally patriarchal and condemnatory of women.. The growing participation of sensitive men in the vindication of women’s human rights and the construction of committed fatherhood is also an example of the paradoxes in which this debate is currently unfolding” (see Chapter 9).

If at the outset the feminist movement in the United States, Europe and Latin America advanced proposals that unified women’s struggle with the struggle for “revaluation” and/or democratic recovery, linking the lack of democracy in public spheres to women’s status in private spheres, nowadays this argument constitutes another of the central pillars of the debate. The struggle to affirm reproductive rights in Latin America occurs at the same time as the struggle for basic civic rights and constitutes one of the specific characteristics of this region (Vargas, 2002; Scavone, 1999). As Lamas points out, “the voluntary interruption of pregnancy takes one back to central issues of the modern notion of citizenship, such as personal autonomy, non-intervention by the State in private life and freedom of conscience” (p. 115) . This means, in the author’s view, that given the lack of a broad public debate or a political climate for publicly discussing specific contents of the government’s agenda, those who seek legal changes regarding abortion are forced to resort to civic protests to ensure that this issue receives respectful, socially egalitarian legal treatment. Consequently, in the 21st century, the demand to decriminalize abortion looks to the lay nature of the State and the importance it assumes in the construction of all women’s citizenship, since the current dilemma is played out within the sphere of individual freedom and social responsibility (Castañeda Salgado, 2003; Lamas 2003).

Another argument in the abortion debate is the recognition of the right to pleasure. It is essential to recognize that sexuality and gender relations are extremely important, which is why the need to provide education on sexuality, including gender and power components, at various stages of life is emphasized for all women, not only married women or common law wives. Reinforcing female autonomy within the public sphere reinforces their autonomy in the private realm (Bono Olvera, 1999).

Finally, the tension between the two antagonistic positions, one favoring the decriminalization and legalization of abortion and one opposing it, expresses different approaches. Both of them may agree that abortions must be prevented. A central radical discrepancy between them is that some think that all abortions should be prohibited, whereas others point out that it is essential to legalize and decriminalize its practice as a health measure, and as a means of preserving rights.  Whereas one position advocates broad sexual education and broad access to and dissemination of contraceptives along with the availability health services, others argue that sexual activity must be restricted to marriage and sexual abstinence advocated, particularly among young people (Lamas, 2003). In this respect, the feminist movement has argued that the practice of abortion should not be dealt with under the penal code but rather should be regulated by other organizations since it relates to a public health problem, to social inequality, inequity in relations between the sexes and to respect in the exercise of a reproductive and sexual rights (Bernal, 2003;Barsted, 1997).

The Hierarchy of the Catholic Church and its Position on Abortion

The aim of making the world believe that the Catholic Church is a homogeneous entity conceals the diversity of positions that exist within it on various themes, particularly sexuality, reproduction and abortion (Mejía, 2003) (p. 71).

The Catholic Church hierarchy has been one of the most visible, forceful and powerful players in the debate on abortion. The official position nowadays is absolutely antiabortion (understood as opposition to its practice and/or its decriminalization/legislation in any situation or circumstance) and its most successful manifestations in the public debate have tried to transmit the idea of a single criteria regarding the total criminalization of its practice, based on respecting life from the very moment of an unborn child’s conception. However, this does not constitute, nor has it constituted, the only way of understanding the abortion issue from a Christian or even Catholic perspective (Mejía, 2003; Cazes Menache, 2001; Maguire, 1991; Hume, 1993; Munera, 1994; Fisher, 2000; Encuentro de Investigadores sobre Aborto Inducido en América Latina y el Caribe, 1994). As Mejía and Careaga (1996) point out, the official doctrine of the Catholic Church begins with a specific argument that frames the moral problem within extremely narrow limits, by considering it “from the very moment of the ovule’s fertilization by the sperm as a new human person subject to all its alienable rights” (p.387). On the basis of this Cosmo vision of the origin of human life, as it is widely recognized, the interruption of a pregnancy constitutes murder. The discussion therefore revolves around the uncertain, complex foundations of this argument, combining various scientific perspectives such as biology, genetics, physiology and embryology as well as physiological, philosophical, ethical, theoretical and legal considerations.

The church’s position vis-à-vis abortion has changed over time, as have the arguments wielded to sustain it. In his essay on the history of ideas on abortion in the Roman Catholic Church (Hurst, 1993), Hurst first points out the incoherencies and unresolved issues in the Church’s treatment of abortion. These now include at least two concerns: is abortion practiced to conceal sexual sins; and does its practice constitute the commission of murder. A propos of this, and placing the discussion of abortion within the broadest field of Christianity, the author suggests that this debate must take into account, first of all, the hylomorphic conception that constitutes an essential Christian tenet, which assumes the integrity of body and soul and is opposed to any idea that separates bodily and spiritual nature. Secondly and closely related to the dogma of the hylomorphic conception, one must consider precisely when the embryo becomes a human being, or hominization. In order to illustrate the importance of this argument in the debate on abortion within the sphere of Christianity, Hurst quotes modern theologian Joseph Doncel, who says that there cannot be a mind before the organism is ready to receive it, nor can there be a spirit before the mind is capable of receiving it. He also holds that there can be no human soul as long as the embryo is in a vegetative state of development, and therefore there is no human presence during the early weeks of pregnancy.

Another relevant aspect of the stance on abortion adopted by the Catholic Church is the relationship between sexuality and procreation, a sphere that comes into conflict with the archaic perception of sexuality linked to the purpose of procreation that underlines the Church’s teaching. For the Church abortion has always been a sin. It serves to cover up evidence of sexual acts whose aim is not procreation, i.e. acts of fornication and adultery (Hurst, 1993; Güereca Torres 2003; Fisher, 2000; Gudorf, 2004).

Conservative groups, led by the church hierarchy, have struggled to eliminate women’s self-determination regarding their sexuality and reproduction. They have had and still have the political power to influence the reduction of international aid funds for reproductive health programs in developing countries (Mundigo, 2005), boosted by, for example, measures with a multi-national impact promoted by the US government, such as the “Gag Rule”, or the “Mexico City Law” prohibiting NGO’s that receive funds from USAID, (the US Government Development Agency) from implementing programs or interventions that touch on the issue of abortion (Mollmann and Chávez, undated).

Several authors have stated that there is no agreement within the church on the interpretation of abortion, despite the hegemonic stand of absolute rejection. For Melo, the important thing is “to prove that there is no unanimity in the church on the interpretation of abortion in terms of homicide and that the theological currents of previous eras regarding the animation of the fetus are clearly reflected in the ecclesiastic penitential legislation, wherein penalties for abortion vary (Melo, 1994). As Mejía points out, “it is even more painful to know that the official Church of today is unaware of the richness and variety of positions that have been part of the moral theology in the history of Catholicism. In certain vital aspects, the constitutional Church and the people of God speak the same language: this is the case of social justice and human rights, but there are others in which disagreements are increasingly profound” (Mejía, 2003) (pp. 70-71).

The Decriminalization of Abortion and the Right to Decide, by Progressive Christian Groups

“Outside the Church, in feminist circles and women’s movements, Catholics For a Free Choice (Católicas por el Derecho a Decidir in Spanish, CDD) is the only group that defines itself as Catholic and which, from this perspective, has produced studies on the history and consequences of traditional Catholic morals on the everyday lives of women and on Latin-American cultural values. For other feminist groups, there is no point engaging in a polemic with the Church: in the face of clerical harassment, they argue from the defense of laity; a church can only impose its criteria on its faithful, not on civil society. CDD Latin America agrees on this distinction but acknowledges the need to discuss within the Church itself the ideological and cultural importance of 500 years of Spanish Christian evangelization in Latin America, which is part of our identity and transcends specific confessional practice. In other words, the guilt imbued by the church in sexuality and in women’s personal development goes far beyond the limits of practicing Catholics and becomes confused with social morals, and these morals must be worked on and modified from their roots.” (Catholics for the Right to Decide, undated,). With this mission in mind, CDD provides various lay groups working to defend women rights with solid arguments to include in their documents and publications. A study of health service providers in Honduras is one example. In its second chapter includes statements proposed by this group (Centro de Derechos de Mujeres, 2004).

In the Latin American region, CDD, whose regional office was founded in 1987, constitutes an extremely important movement, perhaps not in terms of numbers, but certainly from the point of view of diversification and divergence from the terms of the debate within the Catholic Church and actions undertaken, which from the point of view of Christianity work in favor of decriminalizing abortion. As Rosado Nunes and Soares (1999), members of CDD in Brazil, suggest, “opposed to the proposals condemning abortion, there is another Catholic discourse with more nuances, ranging from expressing doubts on the Church’s position to the justifying the decision to interrupt pregnancy as a moral behavior and even one that is religiously defendable” (p.272). The same authors state that, “together with official church documents, there are a set of theological and pastoral texts that ethically and religiously validate women’s decision to have an abortion. These arguments, however, have very little public visibility, given the church’s repression of discourses other than the official one” (pp. 287-288) (Rosado Nunes and Soares 1999; CDD, 1998; Franzoni, 2002).

Initially, this group comprised of Catholic women, aimed to work within the health sector in order to “contribute to the reflection on and construction of an ethic of sexuality and procreation based on justice, committed to the search for dignity and a better quality of life for women” (Rosado Nunes and Soares, 1999) (p. 289). In addition, the group’s proposals and actions were aimed at publicizing women’s right to decide as capable moral agents and the right to dissent from those Church teachings that have not been declared infallible. Their arguments, as an ethical and moral option, are focused on the defense of and access to safe, effective contraceptive methods and the decriminalization of abortion as expressions of freedom of conscience (Alanis, 2001; Mejía, 2003; Anonymous, 2002). In countries where the state is officially secular, such as Mexico, CDD defends state and social laicism as a key element for the protection of individual guarantees and the full exercise of women’s citizenship. (Mejía, 2006; CDD, 2003).

The greater legitimacy and basis of these arguments, expressed in the predominant secular climate in Catholic societies, becomes clear when one considers the results of the various studies conducted by CDD on the opinions, attitudes and behaviors of Catholics in different parts of the world regarding various aspects of their sexual and reproductive lives and abortion.(Catholics for the Right to Decide 2004; Catholics for a Free Choice and Catholics for the Right to Decide, 2003).

These studies’ findings clearly illustrate the enormous gap and divergence existing between the norms imposed by Catholic doctrine and the way the majority of the faithful regard issues related to sexuality, divorce, abortion, sex education and contraceptive use. Likewise, the results indicate the distinction made by the Catholic population between the religious or public sphere and the private sphere, where it seeks to emphasize freedom of conscience.

With respect to abortion, the results of surveys conducted in Bolivia, Colombia and Mexico (found in the text “What do Catholics Think About Abortion?”) show that the opinion of a large sector of the faithful is a long way from the norm established by the hierarchy: approximately half and nearly two thirds of the interviewees stated that abortions should be permitted in some or all circumstances (49%, 56% and 60% respectively for each country); percentages that increase considerably under certain specific conditions such as when the women’s life is in danger, when her health is at risk, when a women has AIDS, when there is a fetal malformation and when the pregnancy is the result of rape. At the same time, most Catholics feel that the decision should be exclusively that of the women and her partner (79%, 70% and 88%) and should not be in the hands of the Catholic Church. Moreover, a considerable proportion think this decision should be made by the women alone, particularly in Mexico (17%, 22% and 33%) –relatively not so small percentages, given the strong influence of religious and cultural norms prevailing in these countries. Likewise, many Catholics believe that the fact that a woman has had an abortion does not make her less of a good Catholic (50%, 37% and 53% respectively) nor does it make those that supported a women worse Catholics (59%, 39% and 55%). A majority opposed expelling a woman from the Catholic Church for having had an abortion (74%, 67% and 81% respectively). Related to contraceptive practice, the overwhelming majority of Catholics has used contraceptive methods and also thinks public health services should offer these methods free and promote the use of condoms to combat HIV/AIDS. In the case of teenagers, survey results show they should have access to the entire range of contraceptive methods, including those prohibited by the Catholic Church (Catholics for the Right to Decide 2004; Catholics for a Free Choice and Catholics for the Right to Decide, 2003; Catholics for a Free Choice, 2004).

The Arguments or Positions of Health Professionals

The various positions of health professionals, ranging from doctors to medical assistants, are not solely derived from their professional training but also result from their ideologies and religious beliefs. Although the interruption of pregnancy is often permitted on certain grounds, the personal beliefs of these actors influence the way they accept regulations that permit it. In fact, an unfavorable attitude on the part of service providers to legal abortion exacerbates the possible consequences of this practice or procedure. The institutions and the doctors that deal with complications due to unsafe abortions also control access to legal abortion, and the care given to women is often accompanied by a moralizing discourse, which induces guilt and reflects a total lack of respect.

The literature describes the significance the medical community gives abortion as well as their perceptions of it. Above all, due to its restrictive legal status,  they recognize it as a public health problem and, one of the main factors contributing to the higher rates of maternal mortality and morbidity and often refer to the large amount of resources required for dealing with abortion complications (Faúndes and Ardí 1997; Faúndes et al, 2004 ; Langer, 1999; and 2002; and 2003; Langer et al., 2000; and 2002; Elú, 1992; Gogna et al., 2002; McNaughton et al., 2002; González de León-Aguirre, 1990; and 1993 and 994; Llovet and Ramos,1998; Faúndes and Barzelatto, 2005). However, these arguments have not sufficed to mobilize them or to turn medical service providers and health professionals into constant, active participants in the debate, with the exception of certain valuable members of the medical community who have engaged in activities to reduce the inequities and injustice caused by illegal, unsafe abortion. The reasons that underline their scant participation in the debate range from ethical and religious considerations to ignorance of the legal framework and/or a lack of understanding or misinterpretation of the latter, and include real fears or assumptions about possible sanctions. Other reasons mentioned include medical training that fails to sensitize future professionals about women’s needs and rights, as well as the economic advantages for certain health providers of engaging in illegal abortion procedures. Moreover, these professionals face ethical dilemmas in relation to their convictions, the medical guidelines in force ––which are sometimes obsolete–– and technological development. An example of this last is their position vis-à-vis organ transplants, the prolongation or definitive suspension of the lives of patients with irreversible illnesses or in coma, assisted reproduction and the manipulation of pregnancies, among other issues that are now highly debated and which belong to the sphere of bioethics, within which abortion is situated (http://www.andar.org.mx/).

Two crucial aspects must be considered in doctors’ positions on abortion. The first is the medical institutional dimension, whose vertical authoritarian structure implies that hospital personnel must obey the regulations regarding legal abortion, although conscientious objection is also recognized as an element used by certain physicians to avoid performing abortions. At the institutional level, in some countries such as El Salvador, doctors are obliged to report women seeking services whose abortions show signs of having been induced. This not only constitutes a violation of women’s rights but also influences the obligation to maintain professional secrecy among health personnel (McNaughton et al., 2004). The second aspect to consider is the cultural, moral and ideological one, in which not all professionals share the Catholic Church hierarchy’s position or alternatively, where the Catholic position on sexuality and reproduction may be the dominant one in their respective countries. Thus, for example, although the great majority of them agree with the use of modern contraceptive methods, a far smaller number approves of the performance of abortion in determined circumstances, even those most closely linked to their duty as doctors (such as saving women’s lives or protecting their physical or mental health).

The opinions and attitudes of health professionals regarding abortion are extremely important, not only because of their medical authority and technical participation in various aspects of abortion –such as complications from the latter or its clandestine, legal or illegal practice– but also as key actors who can influence legal reforms and the conditions in which it abortion occurs. Several studies have been carried out in the region on the opinions and attitudes of doctors regarding abortion, revealing the coexistence of various positions, although there is a majority with more conservative attitudes as opposed to a minority of professionals with a broader, clearer awareness of the problem.

The institutional provision of services for the interruption of pregnancy is an issue that polarizes doctors and creates major controversies between them. Refusing or providing these services, even in the cases permitted by law, depends largely on the personal criteria of health professionals and/or of the medical authorities in the institutions where they work. However these criteria are highly influenced by religious or conservative groups as, for example, in the case of Paulina in Mexico or Rosa in Nicaragua (Reproductive Health Matters 2003; Lamas et al., 2000; Lamas and Bissell, 2000; Gonzáles de León Aguirre, 1994).

A KAP-type study (knowledge, attitudes and practices) of health service providers in the IPPF associations in six Latin American countries with restrictive abortion laws (the names of the countries have been concealed to protect the confidentiality of those who have answered the surveys), sought to determine service providers’ will and capacity to participate in activities aimed at increasing access to safe abortion services. A total of 799 answers were taken into account, corresponding to those of clinical providers, which included doctors, nurses, nursing assistants and other persons that directly provide services (Dabash et al., sd.). In keeping with the results of other researches, this study found that, despite the fact that health providers believe it to be appropriate to offer abortion services as part of reproductive services, they also expressed a degree of discomfort at the possibility of becoming personally involved in its provision. A significant majority (67%) agreed that the expansion of services to include quality abortion services was a key step in reducing the costs of unsafe abortion, yet only half these providers thought their institution should offer these services. Nearly half (44%) said that they would not feel comfortable working in a place that provided the service of terminating pregnancies.

Other results reveal the influence of religious, legal and cultural norms currently in force. As far as the association between religious beliefs and abortion, one out of every three providers stated that they believed that abortion was a sin while four out of every ten said that they would support a friend or relative’s decision to put an end to an unwanted pregnancy. As for their perception of women who had had abortions, 57% of the providers thought that they were irresponsible. In regard to the reasons for permitting abortion, this survey agrees with others aimed at health service providers, since the results indicate a high degree of acceptance (92%) when the aim was to save a woman’s life, when pregnancy was the result of rape or incest (85%), when there was fetal malformation (82%) or there was a risk to the woman’s health (69%). Half agreed that economic reasons were valid, but only a quarter agreed that abortions should be performed in the event of contraceptive failure (28%). Only a very small minority said that abortion should be permitted for professional reasons (4%). This study also provided an interesting perspective on the choice of methods for interrupting pregnancy among the population studied.

In Argentina, the results of the study conducted between 1998 and 1999 on 467 obstetricians and gynecologists from public hospitals in the Metropolitan Area of Buenos Aires showed that the majority of them considered abortion to be a serious public health problem.  The majority also felt that doctors should provide services for abortion that are not illegal, that abortion should not be penalized if it is to save the women’s life or in the event of rape or fetal malformation, and that women that had an abortion and those who performed it should not go prison. It was also found that approximately 40% of the interviewees believe that abortion should not be punished when it is a woman’s autonomous decision. Those that expressed a more positive attitude towards the decriminalization of abortion mentioned a combination of reasons, both involving public health and social equity, which they felt should be considered (Gogna et al., 2002).

In Brazil, a study conducted in 2003 with a large number of gyneco-obstetricians who said that they had helped their patients or relatives have an abortion or that they themselves had personally dealt with an unwanted pregnancy, showed that having experienced an abortion makes one more understanding of the fact that there are circumstances in which abortion is the best or only solution. Nearly a quarter of the female doctors and a third of male doctors had personally dealt with at least one case of unplanned pregnancy, and 80% of these were aborted. The grounds on which the majority of doctors accept abortion are rape (77%), when a women’s life is in danger (79%) and when there are fetal malformations (77%) (Faúndes et al., 2004). Moreover, the authors found a close link between the degree of religious conviction and having performed an abortion, an issue which proved to be much more important for doctors or their partners who had personally experienced an unwanted pregnancy.

At the same time, health professionals have participated in the discussion prompted by the use of Cytotec (Misoprostol) as an abortive. Although this medication had been approved in over 70 countries for the treatment of gastric ulcers, the scope of its use for abortion in Brazil made it more visible and let to debate on the subject. In this context, gynecologists advocated keeping it on the market, given its therapeutic importance in inducing birth and abortions retained, because they felt it was important in reducing the risks of having an illegal abortion (Scavone, 1999). They argued that Cytotec reduced the risks of complications for women and made it easier for doctors to treat these complications (Barbosa and Arilha, 1993).

In Honduras, the Women’s Rights Center (2004) conducted a national survey on a representative group of gyneco-obstetricians from this country, distinguishing between the data provided in answers given by men and women in this profession. In this country, in which abortion is totally prohibited, it is revealing that the majority of the gyneco-obstetricians found at least one reason that would medically justify abortion (80.6%) and thought that permitting medically indicated abortions would help reduce maternal mortality (69.5%).

In Mexico, the position of doctors as a professional group has generally been conservative, ambiguous and reserved in relation to the problem of abortion, although certain doctors admittedly have a broader view of the problem, particularly as it concerns circumstances related to their professional practice. A propos of this, Elu (1992) suggests that, “on the basis of ethical or moral considerations, significant sectors of doctors have opposed the modification of laws regulating the practice of abortion, while the majority of those who provide welfare services at public health institutions have remained on the margins of public debate on the matter” (quoted p. 190 in González de León Aguirre, 1994). González de Leon Aguirre’s research conducted in this country in 1994 shows that the medical profession largely accepts interrupting pregnancies for medical reasons, to save women’s lives or preserve their health, in the event of rape, or when there are fetal malformations. However, only a minority has a favorable attitude when other circumstances such as socioeconomic conditions, contraceptive failure or the personal decision to abort are involved. In certain cases, double standards have been observed in the services provided by health institutions. They are publicly opposed to abortion and condemn it, but in their private practice, they perform abortions for profit and without any ethical or moral consideration or responsibility towards the needs of those who pay for their services.

Evidence from another study carried out in Mexico City with 193 physicians from various specialties (interns, pediatricians, gynecologists and neurologists), show that only 15% of the total number of doctors agree with allowing abortion by personal choice, although the procedure is more widely accepted among interns and pediatricians than among obstetricians and neurologists. However, the proportion of acceptance of abortion rose to nearly 60% when fetal malformation was involved (Casanueva et al., 1997). Other studies with female and male residents at hospitals in the Federal District conducted in 2000 and 2001 demonstrate the scarce knowledge they have of the legal status of abortion: only a third believe abortion to be legal on certain grounds in Mexico City. The findings concerning the attitudes and opinions regarding abortion reveal the prevalence of an attitude that is more favorable to the interruption of pregnancy on certain legal grounds, such as the reasons associated with medical causes, but less favorable when abortions involve personal reasons and reasons of conscience, such as the women’s socioeconomic situation or personal decision, contraceptive failure and the abandonment or death of the spouse (González de León and Billings, 2001). Contrasting data emerged regarding the person entitled to decide whether to abort. In some cases people expressed a more liberal view, encouraging women to make the decision and in other cases people expressed more conservative views, relegating the decision to the couple and, on certain occasions, requiring the participation of the doctor. Moreover, they warned of the need to have certain legal guarantees for the performance of an abortion, since doctors who would be prepared to perform one would do so only provided they had safe conditions for the procedure and/or institutional support. Other findings suggest that when considering the role played by these professionals, it is essential to take into account their training, which deprives them of sufficient knowledge to consider the practice of abortion as a social and public health problem or to understand its legal aspects and psychological effects (González de León Aguirre, 1994).

The results of another survey undertaken at the national level on doctors in urban localities in Mexico in 2002, show that a majority of them correctly identified certain legal circumstances that permit abortion (84%) whereas a minority thought that abortion was always illegal (16%). The opinions of this sector on the circumstances in which abortion should be legal reinforce the opinions expressed earlier and are closely linked to their work as medics, since the majority believe that abortion should be legal when it endangers women’s lives, when their health is at risk or when the fetus has severe congenital malformations. They also admit that it should be performed when the pregnancy is the result of rape (93%, 87%, 82% and 86% respectively). An interesting and at the same time worrying finding revealing the discrepancies between the legal, institutional or public framework and medical practice is the fact that, in the case of a woman who has had an incomplete abortion or post-abortion complications or a women requiring a legal abortion, only 23% of the doctors interviewed reported that they would treat these cases directly whereas 22% would treat certain cases and refer others. On the other hand, a significant proportion (40%) would refer all cases. This professional group expressed a clear need for training: 81% declared that they were interested in having more information on legal aspects, 65% requested more information on ethical aspects, while 56% expressed interest in the methods and techniques for performing legal abortions (García et al., 2003; Lara et al., 2004).

In Nicaragua, the results of an opinion study on 198 gyneco-obstetricians conducted in 2001 by the Nicaraguan Society of Gynecology and Obstetrics (SONIGOB) on a norm (under discussion at the time) regulating therapeutic abortion and the medical and ethical consequences of the latter show that only 9 out of the total number of interviewees thought that abortion should be penalized. Additionally, the vast majority believed that there are cases in which therapeutic abortion would be necessary to save a women’s life (over 90%). Many of the interviewees also supported a legislative reform permitting abortion in the event of rape or fetal malformation (McNaughton et al., 2002). Another recent study by this author and other colleagues (McNaughton et al., 2005) on the role played by doctors regarding abortion, considering the ambiguous legal framework that surrounds therapeutic abortion in Nicaragua, explains the inconsistencies in and consequences of this framework in access to the legal interruption of pregnancy and the abortions conducted by health professionals. The findings were extremely relevant and can undoubtedly be extended to many other countries with restrictive legislation, showing that health professionals decide to perform an abortion on the basis of factors that are tangential to the risk and health criteria established as part of medical logic. These include the woman’s contraceptive behavior, her gestational age, and the evaluation of the credibility of the reasons the woman gives. This situation, as the authors state, not only reflects the subjectivity and precariousness of doctors’ decisions, given their limited capacity to predict health risks or to diagnose a pregnancy that has been a result of a rape, but also leads one to question, in terms of equity and credibility: should the decision whether or not to terminate a pregnancy for therapeutic reasons rest in the hands of this professional sector? Moreover, this fact also implies recognizing the complex meanings of a wanted or unwanted pregnancy and above all the impossibility of separating the importance and role of this pregnancy from the evaluation of maternal risks. Given this situation, the authors emphasize the importance of guaranteeing the exercise of women’s rights to life and health as well as the need for a political framework that would protect women and health providers, so as not to leave women’s access to a legal abortion dependent on the influence of political and religious ideologies, ignorance of the law or erroneous interpretations of the criteria to be taken into account in order to provide a therapeutic abortion.

Regardless of the opinions given in the surveys, several public expressions were found of certain health professionals in the region and sometimes even of medical associations declaring themselves against unsafe abortions.(Anonymous, 2005. Their influence is also perceived in the publication of various descriptive and explanatory materials for general distribution (Faúndes and Barzelatto, 2005) and in the drafting of treaties to favorably influence the elimination of risky abortion practices (Sanseviero, 2003). The intervention of this professional sector in the debate and their active participation in public entities related to abortion is extremely relevant for all the reasons given earlier.

The Acceptability and Social Legitimacy of Abortion within the General Population.

In addition to the studies of Catholics and health professionals mentioned earlier, various research projects have been carried out which, though relatively few, are designed to explore the attitudes, perceptions and opinions of the general population, according with certain characteristics. The valuable evidence they provide sheds light on the cultural scenario and ideological and political climate resulting from the legal framework imposed on the practice of abortion, the social and culturally constructed norms, and the conditions under which women resort to this practice (Profamilia, 1993; Bailey, 2003; Barrig, 1993; Becker et al., 2002; García and Becker, 2001; Gutiérrez et al., 1996; Llovet and Ramos, 2001; Encuentro de investigadores sobre aborto inducido en América Latina y el Caribe, 1994; Htun, 2003; Pick de Weiss and David, 1990; Weisner et al., 1994; Amuchástegui Herrera, 2002; García Romero et al., 2000; http://www.chasque.net/frontpage/comision/dossieraborto/cap5_1.htm). Some of these surveys also enable a review of public opinion on the role of other actors, such as the state, the Church, the medical profession, and women’s partners in women’s private decisions.

The results of these studies generally indicate a more open and positive attitude among the various population sectors interviewed than that which has traditionally characterized those who oppose abortion for any reason. However, at the same time, these attitudes are more conservative than the positions of those who advocate abortion at the women’s request. In between these two extreme positions lies the majority of population. They accept the practice of abortion in certain restricted circumstances, i.e. when there is a health problem when a women’s life is in danger, when the pregnancy is a result of rape, and when there is fetal malformation This reflects the fact that women’s autonomy or freedom of decision and the exercise of their rights has yet to be legitimized and socialized among the population. Likewise, evidence from the surveys supports the process of secularization that prevails in the majority of countries in the region as regards the Church’s influence in private life. Although knowledge of current legislation is somewhat inaccurate, there does seem to be in some cases a clear distinction made by interviewees between what legislation is and what it should be.

In Argentina, the survey on contraception and abortion taken between 1992 and 1993 measured the agreement or disagreement of the female population of low socioeconomic status living in greater Buenos Aires regarding a series of circumstances in which abortion is performed (López, 1997). Whatever their social characteristics, the circumstances most favorably regarded by the population interviewed were those cases in which pregnancy is the result of rape, women’s life is endangered, or where health problems or fetal malformation exists. The approval profiles show that women over 35 are in agreement with allowing abortion in circumstances linked to health or pregnancy resulting from rape. On the other hand, those under 25 tend to agree in situations more closely related to women’s autonomy and decision-making. Women with lower educational attainment are, predictably, less likely to support an abortion in all circumstances. The analysis by marital status of the interviewees shows that common-law wives –followed by married women– are the most receptive to abortion in various circumstances. This is particularly true of those who associate it with a mother’s health problems, fetal problems or as a result of rape. Finally, women interviewed about whether or not they have used any contraceptive method indicate that those who have not used any contraceptive method were the least accepting of abortion, whereas those that had used contraception at some time or were using it at the time of the survey were more supportive of abortion in circumstances related to women’s health problems, rape and, to a lesser extent, when they thought they had obtained their desired family size (López, 1997). Another survey conducted among residents of Buenos Aires showed that over half of the interviewees favored abortion because of reduced economic circumstances, while just over a quarter agreed it should be the women’s decision (Htun, 2003).

In Brazil, an opinion survey conducted in 1997 among residents of Sao Paolo showed that over half the interviewees indicated that abortion legislation should remain unchanged, up from a third in 1994; whereas a fifth believed that the law should be more permissive (compared with two-fifths of the interviewees in another study in 1994). However, another slightly lower proportion stated that abortion should be decriminalized. In Chile, the results of a newspaper survey conducted in 2000 showed that the vast majority of those who responded believed abortion should be permitted when the women’s life was in danger. Over half agreed that abortion should be allowed in the event of rape, and a similar proportion supported it in the event of fetal malformation, indicating that the majority of the population interviewed was in favor of less restrictive legislation (Htun, 2003).

In Mexico, the Population Council conducted a national survey in 2000 designed to discover the opinions and attitudes of the general population on legislation concerning abortion and related issues. The population interviewed included a sample of 3000 people between the ages of 15 and 65 and virtually everyone in the sample (90%) regarded themselves as Catholic. The results show that over two-thirds of those interviewed believed that abortion should be legal in certain circumstances, one out of every 10 women believed that the right to have an abortion was the women’s decision, while the rest felt that abortion should be prohibited in all cases. The circumstances in which the majority of the interviewees agreed that abortion should be legal are similar to those found in studies mentioned in the previous sections: when a women’s life was in danger, when her health was at risk, when the pregnancy was a result of rape or when fetal defects were present (80%, 75%, 63% and 52% respectively). The circumstances in which interviewees’ opinions were less favorable to abortion were when the woman was under age, when there was a lack of economic resources, when the woman was a single mother, or in the event of contraceptive failure (20%, 17%, 11% and 11% respectively). When asked who should most appropriately advise a woman on her decision to interrupt her pregnancy there was a greater inclination toward the family sphere (family, 31%) and the woman’s partner (27%), although doctors were given some responsibility (26%). Only a minority believed that representatives of the Catholic Church would be the most appropriate persons to advise women (12%). As for the influence various sectors of the population should have in the legislative sphere, nearly half the interviewees believed that women’s opinions should be given more attention, followed by those of society as a whole and, to a lesser extent, those of doctors (48%, 29% and 14% respectively). Only a minority said that the Church should be regarded as a sphere of influence (7%), a statement repeated by the vast majority of the interviewees, who believed that legislators should not vote for laws according to their religious beliefs. A propos of the interventions of health institutions, the study reveals that the majority of the population agreed that all public hospitals should offer legal abortion services (García Sandra, 2001; García and Becker, 2001). An article written subsequently on the basis of the analysis of the survey (García et al., 2004) described includes recommendations for strategies in favor of safe abortion. These include the need to inform the Mexican population about the grounds for legal abortion and the steps to be taken to obtain the service, informing them that abortions are safe –most important– when provided legally, the fact that the religious and personal opinions of legislators should not come into play in legislative work and decisions, and that the stigma associated with sexuality should be reduced.

A previous survey conducted in 1991 in three areas of Mexico City (Palma and Núñez, 1991, quoted in Palma et al., 2000) confirms that, in general terms, there was greater acceptance of abortion when the reasons were associated with the mother’s or fetus’s health: when the mother had an infectious disease, such as AIDS (87%), when the mother suffered from extreme alcoholism (76%), when there was a risk of physical and mental defects (72%), when the mother’s health was at risk (70%) and when pregnancy was the result of rape (70%). The authors draw attention to the high acceptance of abortion in the event of infectious diseases in women. In this study, it is striking that the reasons for abortion that the population interviewed regard as least legitimate are related to women’s general well-being and autonomy. These include when a women did not have a partner (7%), when a young women decided or wished to complete her studies before becoming a mother (14%), when there had been contraceptive failure (15%), when an under age women became pregnant and did not yet want to become a mother (17%), and when a woman did not yet feel capable or mature enough to be a mother (23%). This same study shows that over two-thirds of the population disagrees with the total prohibition of abortion promoted by the Church (70%), which is all the more surprising given the profound influence of Catholicism in Mexico, and specifically regarding abortion.

The opinion and knowledge of teenagers and youth about the legal framework of abortion in Mexico was the subject of a survey conducted in the year 2000. For this study, data were analyzed from a representative nationwide sample of 907 men and women whose ages ranged between 15 and 25. The results indicate the interviewees’ insufficient knowledge about abortion, since over half were unaware of the legal situation in their respective states. The majority of these (82%) believed that abortion had never been legal while the rest either did not know or thought that it was legal, a situation which is accentuated among interviewees with lower educational levels and residents of rural areas or areas outside Mexico City. The majority of the interviewees believed that abortion should be legal when it is a result of rape or the women’s life or health is in danger, while a minority thought it should be legal in the case of single women or under-age women, those living in adverse economic conditions, or when pregnancy was the result of contraceptive failure (Becker et al., 2002).

In view of the conflict over decriminalizing abortion in the state of Chiapas in Mexico in 1990, several national surveys were conducted to determine whether public opinion was for or against decriminalizing abortion and to determine the circumstances in which this opinion inclined towards one or the other. One of the surveys, conducted in three stages, between 1990 and 1991, showed that the vast majority of the interviewees (82%) approved when the mother’s health was at risk, approval being greater in the case of men, those with medium or high income, and far less among widowers. In the case of fetal malformation, over half agreed, the proportion being larger among women, older people and those with medium level income. In contrast, only a fifth approved of abortion when the women’s partner did not wish to have any more children, once again the proportion being greater among men than women and among those between the ages of 30 and 50. A slightly smaller proportion, slightly less than a fifth, said that they agreed if the mother was unmarried. In this case young people as well as those from the higher socioeconomic strata were those most permissive of abortion (Este país, 1991).

In 2000 in Uruguay, a survey was carried out among 998 Uruguayans aged 15 and over. “The interviewees in this survey are a representative sample of the population of these ages resident in cities with 10,000 or more inhabitants throughout the country. The results show that although only 31% spontaneously answered that the solution to the problem of abortion was simply to legalize it, there are enormous differences according to the interviewees’ level of formal education.  Only 18% of those with primary education proposed legalization, a percentage that rises to 38% among those with medium educational attainment and to 50% among university students. Conversely, nearly 5% of university students declared that they would like to prohibit abortion, three times lower than the figure for people with less formal education. (http://www.chasque.net/frontpage/comision/dossieraborto/cap7_2.htm).

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