Abortion Providers

Among health providers, there are those that facilitate abortion regardless of whether or not it is permitted, which exposes them to the risk of suffering legal or other sanctions. There are professionals that have a positive attitude toward women who resort to abortion. But there are also doctors that oppose this resource, even in the cases permitted by law, due mainly to their own moral or religious convictions. Thus, doctors sometimes cite conscientious objection as a reason for not performing abortions. This situation particularly affects adolescents, whose greater vulnerability means that they are often unaware of their reproductive rights. Moreover, there are situations in which doctors or health institutions denounce women admitted to hospital for complications from abortion (Cortés, 2005; McNaughton, 2004).

The standard of professional training of health personnel – general practitioners, midwives, gynecologists, etc. – varies according to their functions. Their perception of the problem of abortion, and therefore their attitude towards those that interrupt a pregnancy, may also vary. Various studies have documented the mistreatment, stigmatization, and criticism suffered by women when they are treated by personnel that oppose abortion (Blanco Muñoz and Castañeda Camey, 1999; Abernathy, et al., 1994). A study on the opinions of medical students on abortion conducted at a university in Mexico City (González de León and Salinas, 1997) also showed how doctors’ lack of training in relation to this practice may largely be due to the fact that during their professional studies, they receive extremely limited information on the subject. In another study, also undertaken in the Mexican capital (Acuña, et al., 2005), the authors note that doctors usually lack the training to be able to provide counseling in the event of an abortion. The consequence of this, they say, is that these doctors often try to dissuade women from aborting, and even resort to deception, rather than respecting their decision to interrupt a pregnancy.

As mentioned earlier, in addition to consulting doctors, women also seek the advice of pharmacy employees and vendors of medicinal plants, unqualified “abortion providers to perform them”, or they simply interrupt their pregnancies on their own, with all the risks this involves. The usually difficult search to find these providers explains the frequent performance of late abortions, which increases the risks involved (Strickler, et al., 2001). Persaud (1994) emphasizes the difficulties experienced by adolescents in finding someone who can perform an abortion on them in time. This not only means that they undergo late abortions, but also often leads young women to try to abort on their own.

A study of the experiences of women from four Latin American countries (Mexico, Peru, Ecuador and Colombia) where medical abortions were performed, Lafaurie et al. (2005) highlights the role of networks of friends and acquaintances in helping women find a way of undergoing an abortion.

The literature reflects the enormous diversity of situations in which women resort to abortions and the quality and safety of this practice. According to Lovera (1990), in Mexico, illegal abortions are performed in both extremely clean hospitals and in doctors’ surgeries that lack the necessary conditions of hygiene. The costs and risks of these two situations are extremely different. The practice of abortion is illegal in Mexico, with very few exceptions, so women look to midwives or medical students to perform an abortion on them, usually with risky methods (involving plants and the insertion of objects), whereas wealthier women can afford quality medical services (Brito de Marti, 1994).

Other studies highlight the negative attitude of midwives toward abortion (Castañeda et al., 2003; Blanco Muñoz and Castañeda Camey, 1999; Billings et al. 1999). The study by Pick et al. (1999) highlights the role of pharmacy employees and plant sellers as key actors that supply women with supposedly abortive products. Likewise, in Paraguay, a study highlights the role of pharmacy personnel in the dissemination of pseudo-abortive products (Krayacich de Oddone et al., 1991).

The authors of a study conducted in Brazil on women that work at the university found that although 20% of clandestine abortions are performed by doctors at clinics, those performed outside health services are carried out by the women themselves or by unqualified personnel, which in both cases increases the possibilities of severe complications (Hardy et al., 1993).

In Haiti, where abortion is illegal, it is usually performed by quacks in the back rooms of certain establishments (Guest, 1994).

Likewise, in Peru, 84% of rural women and 64% of poor urban women that need to interrupt a pregnancy attempt to abort on their own or seek the assistance of unqualified midwives. Conversely, 95% of rich women from urban settings seek the services of health professionals (Ferrando, 1994; Espinoza Barco, 1994). According to Fort (1993), in this latter case, private physicians and nurses are the most highly sought-after providers of this service, and on certain occasions, professionals from public health institutions are used. According to this author, curettages are only performed by physicians.

A study in Uruguay showed that over half of all abortions were performed by doctors (58%), 40% by midwives and 2% by the women themselves (Comisión Nacional de Seguimiento de Beijing, 1995).

In Bolivia, doctors performed 75% of all abortions, 28% of these in their own offices and 25% in clinics. Likewise, 15% of women require hospitalization to treat complications following abortion (Dávalos and Mojica, 1995).

The findings of a survey conducted by doctors from four countries (Honduras, Mexico, Nicaragua and Puerto Rico) reveal the knowledge these professionals have of abortive methods (Espinoza et al., 2004). One of the most frequently cited methods is D&C. One of the main methods involving medicine is misoprostol. Nevertheless, these professionals usually have insufficient knowledge of the correct doses of this product. Doctors themselves simply point out that misoprostol use may trigger abortion, although the woman should use a health service immediately afterwards to complete the procedure. This research project discusses the advantages and disadvantages of misoprostol. These include the risk that the method will fail, in the event that the woman medicates herself or obtains a prescription without medical advice. However, the study does mention the fact that one advantage of this product is that it reduces the likelihood of serious complications from abortions, in comparison with other clandestine methods.

The results of a survey conducted in Mexico on the knowledge, attitudes and practices of doctors and gynecologists regarding abortion show fairly controversial opinions that depend largely on whether or not interrupting a pregnancy is legal. In the study, only 20% of the persons consulted agreed with an abortion “if the woman decided to have one” as opposed to the 93% that accepted this practice “if the pregnant woman ran the risk of dying”. 87% approved of the cases in which “the woman was in danger of suffering a serious risk to her health.” When faced with a woman who had undergone an incomplete abortion, had complications following an abortion or who wished to have a legal abortion, 40% of the doctors reported that they referred their cases to other persons while 23% would take charge directly and 22% would deal with some of the cases and refer the rest to other doctors. Conversely, 63% of the gynecologists surveyed said that they would deal with them themselves. The participants in the study said that they had fairly limited knowledge of abortion methods yet at the same time expressed a wish to be given training in these methods (García et al., 2003). Another study confirmed that in Mexico, the quality of care given to women admitted to hospital for complications from abortion should undoubtedly be improved (Elú, 1999).

In their study of the use of misoprostol as an abortive product (Cohen et al., 2005), the authors analyzed the health personnel’s standard of training and showed how an incorrect dose of the medicine, which ignored the protocols for prescription, could cause serious problems. The authors conclude that doctors are the most suitable choice for providing information on the use of misoprostol and guaranteeing the confidentiality of both the woman concerned and those that provide the medicine. Conversely, midwives, pharmacy staff and others that recommend the use of misoprostol act more like counselors than prescribers. Pharmacy employees admit that they lack the necessary training to engage in this practice and the illegal act it implies. However, they themselves are the main suppliers of this product, particularly in the case of self-inflicted abortions. As we pointed out, they often prescribe incorrect or ineffective does or ones with side effects, as has been the case in Mexico.

At the same time, access to abortion is not always easy, even in countries where it is legal. This situation is reflected, for example, in Puerto Rico, where 93% of abortions are performed at private clinics for high fees, making them unaffordable for adolescents (Azize Vargas, 1994; 1993). This forces women from less advantaged classes to resort to the services of poorly trained midwives and nurses (Marchand-Arias, 1998).

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