A Public Health Problem

Studies on the consequences of abortions on women’s health are primarily based on surveys carried out in hospitals, by interviewing women admitted for abortion-related complications and obtaining information on maternal mortality associated with abortion. Nevertheless, these studies only give us a partial view of the scope of abortion and its consequences. In fact, it is assumed that several severe complications that lead women to seek health services are recorded as being the result of an abortion, yet in other cases, they are registered in different concepts. A study in Sao Paulo Brazil found that approximately half the deaths associated with pregnancy were registered in another category (Laurenti, 1993).

Likewise, given that not all women have access to health services, for economic and social reasons or because of geographical difficulties, data from hospital records fail to reflect reality accurately (Guillaume, 2004). Lack of access to health services is more common among women from rural or marginalized areas and among adolescents and young women, because of their lack of financial resources. It is exacerbated by the moral and social stigmatization to which women who seek abortions are subjected and to the inadequate standards of the professional health services to which they have access, among other reasons.

However, a large number of those abortions that are performed in highly risky conditions, leading to a high incidence of complications and an often unknown number of maternal deaths, could be prevented (Quiroz Mendoza et al., 2003; Berer, 2004). A study on the association between the grounds for abortion permitted by national laws and abortion itself shows that in over 160 countries there is a pattern according to which those with more liberal abortion laws have a lower incidence of unsafe abortion and a much lower rate of mortality due to this practice. Moreover, most abortions in these countries are safe, particularly when the reasons why women interrupt their pregnancies coincide with the legal grounds (Berer, 2004). Empirical evidence clearly shows the need to legalize abortion through the greatest possible expansion of the grounds for permitting the interruption of pregnancy.

Morbidity

Since not all women that are victims of abortion complications go to medical institutions and/or receive medical treatment, it is difficult to estimate and determine the frequency with which its consequences occur. The risks to which women are exposed are significant and may increase if they lack information for identifying the signs of complications. They may postpone a visit to the doctor for any of the following reasons: being embarrassed to ask about and receive information on their state of health, not knowing where they should go to receive help, fear of being denounced, lacking financial autonomy or autonomy regarding their decisions, or because of the lack of adequate services. Moreover, women are often obliged to wait for long periods to be attended to (Langer, 2003; Deidre, 1999; Langer Glas, 2003).

It is estimated that between 10% and 50% of unsafe abortions require medical care and treatment for complications, even though not all women request them (World Health Organization, 1998), and approximately 800,000 women are hospitalized in Latin America every year for abortion complications (Alan Guttmacher Institute, 1994). The total number of women admitted for abortion complications is a proxy indicator of the intensity with which abortion in risky conditions continues to endanger women’s health and lives. In their study of six countries in the region, Henshaw et al. (1999) estimate that five to ten out of every thousand women hospitalized annually are admitted due to abortion complications, this rate being 8.1 for Brazil and 5.4 for Mexico. Likewise, Singh indicates that 10 to 15 out of every thousand women hospitalized are admitted for this same reason in the Dominican Republic, Chile, Peru and Egypt (Singh, 2006).

As we mentioned in the previous chapter, this type of complication and its degree of severity are closely linked to the methods used for aborting. Some of the complications cannot be exactly determined or measured in the short term, such as, for example, sterility. In the early 1990s in Peru, it was estimated that for every maternal death that occurred as a result of abortion, there was the possibility that 60 to 100 women would suffer complications or injuries that could seriously affect their future fertility (Gutiérrez and Ferrando, 2004). In an opinion survey on the practice of abortion, conducted in that country in 2001, Ferrando (2002) demonstrates that the likelihood of suffering complications depends on the women’s socio-economic status, place of residence and type of abortion provider she consults. For example, the risk of complication in that country is estimated at 30.5%. But this risk is 44% for women in poor rural areas, 27% for poor urban zones and between 24% and 5% for women living in non-poor urban zones. The author also shows that the probability of hospitalization after an abortion is 14%, with differences according to the women’s socioeconomic level and place of residence; 13.6% for poor women in urban zones and 18.5% for rural areas. Of the women considered, only 1.5% of those living in urban zones were hospitalized, as opposed to 9.4% from rural zones.

In a survey of health professionals conducted in Guatemala in 2003 (Prada et al., 2005), the same conclusions were obtained: poor women were more likely to suffer complications (68% of poor women in rural areas as opposed to 62% in urban zones). Of the non-poor women that suffered complications, 47% were from rural zones and 32% from urban zones. Considerable differences were also observed among the women that did not received medical care: 39% were poor women from rural areas and 28% from urban areas. Of the non-poor women that lacked medical care, 21% lived in rural zones and 12% in urban zones. Another survey was undertaken of health institutions in this country, according to which 22,000 women were treated for abortion complications in 2003.

Abortion risks also depend on the methods used and on the degree of training of those that perform them. Likewise, access to trained providers depends on women’s place of residence and economic status. It is believed that in poor rural areas of Latin America, an average of 73% of women that terminate their pregnancies perform abortions on themselves or seek abortions from unqualified personnel (Singh, 2006). In Brazil, 20% of clandestine abortions take place in private clinics, where there may be better conditions for performing them. Conversely, 50% of the abortions performed by the women themselves or unqualified personnel are followed by complications, due to the precarious situations in which they are performed (Hardy and Costa, quoted in Langer Glas, 2003). Another author notes that in this country, in order to provoke an abortion, women use knitting needles, sticks, or drugs not requiring a medical prescription, such as synthetic prostaglandine misoprostol in order to provoke powerful uterine contractions (Espinoza and Carillo, 2003).

The methods regarded as being the most risky are usually traditional ones, such as the insertion of objects into the uterus, the ingestion of drugs in more than the prescribed dose and the use of chemical products (Paxman et al., 1993). Although medical abortion methods, such as D&C, offer greater security than traditional ones, they may entail high risks when performed by non-qualified personnel in an unsuitable sanitary environment. Sometimes the procedures used end in abortion failure, problems in the unborn child (malformations, stillbirth), the risk of miscarriages in subsequent pregnancies, or health problems for the woman.

At the same time, it is has been found that with the use of misoprostol, the rate of complications and their severity is usually lower (Misago et al., 1998; Costa, 1998). For health personnel, the cost of complications due to abortions caused by this drug is less than that of other methods (Barbosa and Arilha, 1993). In Brazil, as a result of the use of Cytotec and the increase in the use of antibiotics, the number of women hospitalized as a result of abortions, which was 342,000 in 1992, had declined by 30% by 1997 (Faúndes 1997, quoted in Singh, 2006). Other authors, however, have mentioned the risk of complications in the fetus if misoprostol is incorrectly used and if the abortion is incomplete due to procedural failures (González et al., 1998, 1998; Rocha, 1993).

The most frequent complications from abortion consist of: injuries to the genital organs, chronic pelvic discomfort, infections, hemorrhages, perforations of the uterus, hysterectomies, problems of sterility and incontinence and finally, as the most dramatic expression of the precarious situations in which many abortions are performed, the woman’s death (Anderson, 1998; Langer Glas, 2003). It is important to highlight that maternal morbidity due to abortion is an issue that has rarely been explored and about which there is no systematic, reliable information, even in the cases in which women go to legitimate medical centers for care. In Argentina, the only estimate of the magnitude of morbidity related to abortion comes from Argentinean patients discharged from public hospitals, which in 1995 totaled 53,978 women with abortion complications (Gogna et al., 2002).

In a study on the medical treatment of women with incomplete abortions, conducted between 2002 and 2003 in the hospitals of the Mexican Health Secretariat, 58,129 procedures were registered in 119 units, which represented 54% of the total number of patients discharged from hospital throughout the country. D&C was used on most women, rather than manual endouterine aspiration (MEA), a method whose use is recommended by the World Health Organization (Quezada et al., 2005).

On the basis of the medical records of 808 users of an urban clandestine abortion service in a South American country which, despite being clandestine, has trained personnel and appropriate sanitary conditions, it was found that only 3% of the women attended had minor complications due to the procedure used, such as profuse but controllable bleeding, pelvic pain, vagal reaction (drop in blood pressure and dizziness) and subsequent menstrual irregularity. Some women also experienced a deep sense of guilt, anxiety or depression. These complications required medical care but they did not constitute a threat to the women’s lives or long-term health. Another 2% experienced severe complications such as pelvic inflammation, hemorrhages, retention of fetal tissue, fever and suspected uterine perforation. Women with over 12 weeks’ gestation presented the highest rate of minor complications (9%). This study also showed that abortion service users are now younger and better educated than before. Likewise, it confirmed the increase in women’s unprotected, premarital sexual activity (Strickler et al., 2001). In Panama, it is estimated that the practice of abortion has contributed to up to 25% of hospital morbidity (Moreno, 1998).

However different the estimates of abortion complications in countries where its practice is illegal may be, the data obtained always contrast with that on abortions performed in countries whose legislation permits it, where abortions are therefore performed in suitable conditions. In these latter countries, only 5% of the women that interrupt their pregnancies experience complications (Langer Glas, 2003).

Mortality

Maternal mortality following an abortion is difficult to measure, and in most cases it is estimated on the basis of the maternal deaths registered in hospitals. Moreover, declarations of the causes of death vary widely, depending on whom they are submitted by. This undoubtedly contributes to the underreporting of deaths from abortion. Espinoza and López Carillo (2003) state that: “In 1967, the Pan-American Health Organization identified the fact that in Latin America and the Caribbean, 33% of maternal deaths attributable to abortion are not classified as such.” An even larger proportion (60%) of maternal deaths directly related to abortion but classified as infectious problems were identified in two independent studies conducted in Colombia and Brazil during the 1980s (Espinoza and López Carillo, 2003).

On the basis of World Health Organization figures (World Health Organization, 2004), of the 19 million unsafe abortions estimated to have taken place worldwide in the year 2000, almost 97% were in developing countries, and nearly 70,000 women died as a result of complications from this practice. This accounted for approximately 13% of the total number of maternal deaths and a rate of 50 deaths from abortion for every 100,000 live births (Table 1). The incidence of mortality associated with unsafe abortions varies by country on whether or not abortion is legal there. Rates are also influenced by operating regulations and conditions of access to and quality of health services. The risk of death associated with an unsafe abortion is at least twenty times greater in developing than in developed countries, and in certain backward regions it may be up to 40 or 50 times higher. In developing countries, the risk of mortality associated with illegal abortion varies from 100 to 1,000 for every 100,000 maternal deaths (in the United States, the figure is 50 in cases of illegal abortion) and a mere 4 to 6 in countries with legal abortion status (World Health Organization, 2004).

The Latin American and Caribbean region is the one that apparently has the highest proportion in the world of maternal deaths due to the practice of unsafe abortion (17% of total maternal deaths), albeit with a lower mortality rate (30 deaths from abortion for every hundred thousand live births) than that observed in Asia (40 for every hundred thousand live births) and one over three times lower than that estimated for Africa (100 abortion deaths for every hundred thousand live births). The differences within the region show that South America is the sub-region with the highest proportion of maternal deaths caused by unsafe abortion (19%), followed by the Caribbean (13%) and to a lesser extent Central America (11%). The proportion of maternal deaths related to abortion also varies considerably by the different countries in the region, from 8% in Mexico to 33% in Argentina, 37% in Chile and 50% in Trinidad and Tobago (Abou Zahr and Ahman, 1998; Center for Reproductive Law and Policy, 2000; Bermúdez Valdivia, 1998).

In 1996, the Pan-American Health Organization indicated that abortion was the main cause of maternal mortality in Argentina, Chile, Guatemala, Panama, Paraguay and Peru; the second main cause in Costa Rica and the third main cause in Bolivia, Brazil, Colombia, Ecuador, El Salvador, Honduras, Mexico and Nicaragua (OPS, 1998).

According to a study conducted in Nicaragua by Padilla et al. (2003), unsafe, clandestine abortion was the fourth leading cause of maternal mortality in that country during the period from 2000-2002. Nevertheless, the authors affirm, there is obvious underreporting of obstetric deaths that could be related to the interruption of pregnancy in unsuitable conditions. On the other hand, in Bolivia, one of the Latin American countries with the highest rates of maternal mortality, it is estimated that at least 30% of maternal deaths are caused by abortions. It is calculated that 60 women die annually for every 10,000 abortions in that country (Pommier, 1991). Another study notes that abortion is responsible for 27% to 35% of maternal deaths in that country (Rayas and Catotti, 2004). This same source notes that for Nicaragua, the number of maternal deaths was estimated at 165 for every 100,000 live births between 1995 and 2001. It also acknowledges the fact that abortion-related deaths are often concealed as indirect obstetric causes.

Likewise, it was estimated that in Brazil, there were 9,680 maternal deaths as a result of the practice of abortion during the period from 1995-2000, although it has been observed that the total number of abortion-related deaths is declining, due, to a great extent, to the fact that more women have opted for sterilization. Another study also attributes this decline “to the greater access to contraceptive methods, including irreversible methods, such as having one’s tubes tied and the spread of the use of Cytotec, despite the fact that sale of this product is not legal in the country” (Rede Feminista de Saúde, 2005). Other authors note that during the 1990s, abortion was the third leading cause of maternal mortality, whereas in Rio de Janeiro it was the most frequent (De Souza e Silva, 1993). By 1998, official sources reported that total abortion accounted for 6% of all maternal deaths (the latter estimated at 130 for every 100,000 live births), 4.7% if ectopic pregnancies are excluded, and 3.4% in the case of induced abortion. According to the profile of maternal mortality, this figure makes abortion the fourth leading cause of deaths from direct obstetric reasons, after eclampsia, hemorrhage and puerperal infection (Rocha and Andalaft Neto, 2003). These authors point out that when the importance of abortion as a cause of maternal mortality is considered, it is vital to take into account the severe complications linked to its clandestinity, such as hemorrhages and infections, which may be recorded as maternal deaths without being associated with abortion. This constitutes another factor in underreporting and therefore in underestimation.

In Honduras, on the basis of hospital discharge records, it is estimated that unspecified abortions (whether miscarriages or induced abortions, incomplete and without complications) constitute the third leading cause of mortality. In a survey applied to 182 gyneco-obstetricians in this country, 99% said that they had found incomplete abortions and/or complications from the latter in their medical practice (Centro de Derechos de Mujeres, 2004). In Guatemala, it is estimated that between 1993 and 1997, 17% of maternal mortality was caused by abortions, and that from July 2003 to December 2004, over 13,000 cases of incomplete abortion were treated at hospitals in this Central American nation (Ministerio de la Salud Pública y Asistencia Social, 2005). In Peru, where abortion is the fourth leading cause of maternal death, this practice constituted 17% of the total deaths in the early 1990s (Gutiérrez and Ferrando, 2004).

According to the United Nations, during the period from 1995 to 2000, 3,000 women may have died in Mexico as a result of unsafe abortions (Quiroz Mendoza et al., 2003). Abortion, as mentioned earlier, was the third leading cause of maternal mortality in the country and it represented 8.5% of the deaths related to pregnancy and childbirth. Many of these deaths were due to hemorrhages (Consejo Nacional de Población, 2000; González de León Aguirre et al., 2002). In another study conducted by the Mexican Social Security Institute during the period from 1992 to 2001, of the 2,578 maternal mortality cases registered, it was found that 178 deaths (7% of the total) were caused by abortion complications. Of these, only 17% were registered as the result of an abortion, a figure which, in the authors’ view, may be indicative of underreporting by women that abort for fear of experiencing penal conflicts. Of all the abortions registered, nearly a quarter of the deaths occurred during the first pregnancy and nearly half from the third or more pregnancy (Velasco Murillo and Navarrete Hernández, 2003). In their study of the state of Morelos and the Municipality of Nezahualcóyotl, in the state of Mexico, Walker et al (2004) estimate that abortion complications contributed 13.5% of the maternal deaths analyzed and 21% for the state of Morelos alone.

In Uruguay, abortion complications are one of the leading causes of maternal deaths, and it is estimated that during the period from 1997 to 2001 at least a quarter of these (25.8%) were due to this practice. In a hospital that admits low-income women for problems due to abortion complications, abortion was responsible for just under half of maternal deaths (46.1%) during the same period. This indicates that the situation is extremely unfavorable for poor women, who are exposed to a far greater risk of death from abortion. The probability of maternal death is two and a half times higher for these women than for the rest of the country’s women (Briozzo et al, 2003). Another study in the same country notes that 48% of maternal deaths are attributed to abortion performed in risky conditions (Global Health Council, 2002 quoted in (Rayas and Catotti, 20004; Rayas et al., 2004).

In Cuba, where abortion at the woman’s request is legal and abortions are performed under medical supervision with trained professionals, maternal mortality associated with legal abortions in 1998 was 4.6 for every 100,000 live births, a considerably lower figure than that recorded for the rest of the region. As a result of the expansion and improvement of the quality of abortion services, particularly for women in the first six months of pregnancy, and the generalization of use of the menstrual regulation procedure, mortality resulting from abortions in this country has fallen to extremely low levels (Mayo Abad, 2002).

A comparison of 1990 and 2000 figures suggests that maternal mortality has fallen in the Latin American region, due to a larger number of abortions being performed in hygienic conditions with appropriate modern techniques, as well as an increase in the prevalence of modern contraceptive techniques. This situation is also related to the international commitments agreed to by countries in the region, which predict the achievement of the goal of expanding access to and the quality of services for dealing with the consequences of abortion, thereby reducing the levels of maternal morbi-mortality. This goal was set at the United Nations Millennium Summit held in 2000. However, it has yet to be achieved in the majority of countries in the region.

Legal Supply or “Parallel Abortion Market”?

Although penalizing abortion does not restrict its practice, it does contribute to the development of a “parallel” (or clandestine) market in which more or less qualified people offer abortions. They may be doctors, midwives, or people without any kind of training that perform abortions in an unhealthy atmosphere with methods that are extremely risky for the woman.

As mentioned in Chapter 2, Public Debate on Abortion, many women and even health professionals, are unaware of the conditions under which the law authorizes abortion. Assuming that an abortion cannot be legally performed women resort to the informal sector (Espinoza and Lopez Carrillo, 2003). In some countries, legal, bureaucratic and medical barriers may be an obstacle to abortions permitted by law, as has been observed in Mexico (Becker et al., 2002), where the right to abortion in the event of rape is rarely exercised due to the complicated legal procedures involved in authorizing it. This leads certain doctors to refuse to perform abortions in these circumstances (Lara et al., 2003). Medical personnel in health institutions often channel women they refuse to attend into the parallel abortion market.

Most studies agree that although all women theoretically have access to public services, when they experience abortion complications or incomplete abortions, very limited care is available outside the the main urban centers. Access to safe abortion, even under conditions of illegality, is always easier for women living in cities, particularly those belonging to a high socio-economic level (Langer Glas, 2003). At the same time, clandestine services not only jeopardize women’s lives but also translate into greater complications, which in turn lead to high medical expenses, prolonged hospitalizations, and the inevitable corruption of legal and police institutions that cover up these practices (Center for Reproductive Law and Policy, 2000).

The results of the study conducted in 1992 in Brazil, Colombia, Chile, Mexico, Peru and the Dominican Republic show that in rural zones, the majority of women of limited means provoke abortions themselves or seek the help of an untrained person. This also occurs among poor women in urban zones, where it is estimated that nearly two fifths of them use the services of doctors, trained midwives or nurses, while over half perform their own abortions or resort to untrained personnel. Conversely, women with more resources in urban areas tend to seek out trained health professionals in order to have an abortion. Poor Colombian, Dominican and Mexican women living in urban zones seem to have more chance than their peers in other countries in the region of being cared for by trained health personnel. In Brazil, however, a greater proportion of urban women in better financial circumstances apparently use the services of untrained persons (almost a quarter) as opposed to 5% to 15% in other countries. This may possibly be due to misoprostol, which middle-class women from this South American countries use as an abortifacient (Alan Guttmacher Institute, 1994). According to the opinions of health professionals, it is estimated that over half the women that have abortions with untrained persons or by provoking them themselves have a higher possibility of suffering complications. Conversely, between a fifth and less than a third of women are at risk of complications when they use the services of a trained midwife or nurse, as opposed to between 7% and 14% when they consult a physician. Likewise, according to the study, poor women are at risk of greater complications than women with high incomes, because of the negative effect on their health of their precarious living conditions. This is exacerbated by the limitations of the medical services they seek, which are often staffed by personnel with a lower level of training, use riskier methods, and interrupt pregnancies even when they are at an advanced stage of gestation.

In Uruguay, 80% of clandestine abortions are medicalized – that is, performed by health professionals, whether doctors or nurses with university training. The remaining 20% are performed using various “popular” methods. The price and the place where abortions are performed vary (Sanseviero, 2003).

This evidence clearly illustrates that one of the main consequences of conditions of access to legal or clandestine abortion services is the different range of options available to women according to their socio-economic status. This reflects the profound social inequity characterizing the region. The higher a woman’s economic level, the more likely she is to have a safe abortion, whether in a hospital that operates legally or even in clandestine medical facilities. Conversely, for women without resources, often the only option is to abort on their own, with an extremely high risk for their health and even their lives (Rayas and Catotti, 2004; Rayas et al., 2004). As several authors point out, women with few resources experience higher mortality and morbidity, suffer continuous risks due to the lack of access to reproductive health services, and are more vulnerable than women with a higher economic status. This is because they seek abortion services from untrained personnel lacking the necessary infrastructure, which implies greater risks (Yanda et al., 2003, Langer Glas, 2003).

The risk of abortion complications is also closely linked to the financial status of the women that resort to this practice. The Alan Guttmacher Institute (AGI) (1994) undertook a survey in six Latin American countries according to which 5 out of every 10 women resident in poor rural zones that have provoked their own abortions suffered complications, as opposed of 4 out of every 10 in poor urban areas. Conversely, only one out of every 10 urban women in the high-income group had abortion-related complications. These results confirm that the poorest women are far more at risk when they abort, since they resort to poorer quality health services and use less efficient, and more dangerous, abortive methods. In cases of extreme necessity, they may even interrupt their pregnancies on their own (Rayas and Catotti, 2004; Rayas et al., 2004).

A Cost for Public Health Systems

Abortion has economic consequences for both women and their families and society. Public health systems are forced to allocate a considerable proportion of their reproductive health budget, insufficient as it is in Latin American countries, to dealing with abortion complications.

One of the least recognized and inadequately evaluated impacts is the economic cost of abortion, both to women themselves and their families and to public hospital services and health systems in general. It is extremely difficult to measure the costs of illegal abortions, particularly those performed in the private medical sector and rural zones, in order to have a medium- and long-term estimate of the morbidity associated with these abortions (Benson, 2005).

The national impact of abortion complications translates into the spending of medical and financial resources that affect the public health system. In Latin America, “After normal childbirth, treating women with unsafe abortion complications consumes the largest amount of government resources assigned to sexual and reproductive health” (Grupo de Información en Reproducción Elegida, 2003).

Singh (2005) estimates the costs of unsafe abortion from the total number of women hospitalized annually as a result of abortion complications (p. 22-23). As the author notes, this is a rough, preliminary estimate, given the small number of countries with the necessary information on record. Nevertheless, it may be used to calculate the direct costs of care due to complications. According to the author, 6.16 million women throughout the world are hospitalized annually due to abortion complications. Of these, over 1.70 million correspond to Africa, 3.35 million to Asia and 1.12 million to Latin America and the Caribbean. Singh indicates a hospitalization rate for Central and South America of 8 abortions for every thousand women aged 15 to 49. These figures are based on a recent study, according to which the abortion rate among women in Peru in 2002 was 7.5 for every thousand, whereas in Guatemala it was 8 for every thousand. In the Caribbean, the rate was 3 per thousand, largely due to the high number of safe abortions performed in Cuba as well as the better provision of abortion services in other countries in this sub-region.

During the 1990s, abortion complications in Mexico placed a heavy burden on public health systems, since they involved a hospital occupation rate of 600,000 beds per year, equivalent to approximately 1,500 per day, with an average length of stay of 1.8 days (Quiroz Mendoza et al., 2003; López García,1994).

Studies conducted in Chile estimate that public expenditure on treatment and hospitalization due to abortions is USD$15,000,000 a year (Lavín, quoted in Center for Reproductive Law and Policy, 2000).

But one should consider not only the economic costs but also the effective actions that should be implemented to reduce these costs. In Mexico, it is a well-known fact that the quality of post-abortion services has improved since the Cairo Conference, although attention and access to legal abortion services are still insufficient. Women and medical service providers lack the necessary information, and the majority of legal regulations and norms concerning the interruption of pregnancy lack explicit procedures (Rayas and Catotti, 2004; Rayas et al., 2004). The results of an evaluation conducted in 2003 in Nicaragua, quoted by the same authors, show that this country experiences the following problems related to abortion services: they are often of insufficient quality, equipment is in poor condition, and they are unable to provide the continuous training the personnel require. These limitations hamper the follow-up and evaluation of cases, of which there is definite underreporting.

Ramos and Viladrich (1994) add that in Argentina, the hospital care received by women from the lowest social strata is basically conditioned by the illegal, clandestine status of abortion. They also note that health service personnel are more concerned with preserving the pregnancies of the women they attend than with helping or supporting them in accordance with their needs. The quality of care depends on the interaction established between a woman and her doctor, who may either show an understanding attitude towards here or, at the other extreme, threaten to denounce her.

Other authors have highlighted the importance of implementing programs or introducing less costly, safer procedures, designed to deal with the complications derived from poorly-performed abortions, in order to limit their ill consequences. The aim of these measures is to reduce the cost of treatment and the duration of hospital stays. It would also be useful to develop a post-abortion counselling system and establish family planning programs to prevent repeat abortions. Apropos of this, Foster Rosales et al. (2003) have proved that the introduction of manual aspiration methods to replace D&C leads to an 11% reduction in costs and a 27% reduction in hospital stays. Benson et al. (2004) compare the costs of instrumental inter-uterine D&C and MVA by analyzing the various costs of abortion services, from the admission to the discharge of users. This study, undertaken in five Mexican hospitals, considers the length of hospital stay, the personnel involved, the time spent with each service user, as well as the medication and equipment used. It concludes that the benefits of MVA translate into a reduction of the average length of hospital stay (between 25% and 45%) and a reduction of between 28% and 54% of the average cost per woman attended.

One study in Nicaragua reports that an average of 5,500 women are admitted annually to health facilities due to abortion complications (Rayas and Catotti, 2004; Rayas et al., 2004). Another study, conducted in the same country in 1992, found at least 700,000 USD could be saved simply by reducing the number of days in hospital, by in-out treatment of women with incomplete abortions, and by using MVA (Blandón et al., 1998).

At the Aurelio Valdivieso Hospital, in Oaxaca, a state in the Mexican southeast, the introduction in 1996 of a program to deal with abortion complications led to a 35% reduction in hospital stays. The cost of each intervention fell from 264 to 180 USD per woman attended, in other words, a saving of 84 dollars (Brambila et al., 1999). The authors also note that after normal childbirth, treating women with unsafe abortion complications consumes the largest amount of public resources assigned to reproductive health. Levin et al. (2005) confirm this in their study on the financial impact of unsafe abortion in Mexico. According to the researchers, “hospitalization for the management of incomplete abortion increases costs from the range of 1,000 to 2,500 pesos to 8,000 to 12,000 pesos, according to the procedure and type of institution”.

Unlike most countries in the region, in Cuba, abortion is legally institutionalized and better conditions have been created within the hospital systems to deal with women that have them. As Martínez Pérez (1994) points out, the authorities have managed to considerably reduce the incidence of maternal morbidity and mortality, and reliable hospital records are available, making it possible to evaluate the costs of dealing with abortion. The author conducted a study at the Hospital Materno Infantil 10 de Octubre (10 de Octubre Mother and Child Hospital) in a municipality of Havana, using the cases dealt with in the abortion services in 1992. Either D&C or the menstrual regulation method was used in these cases. One of the study’s findings was that the cost of abortions is related to the length of gestation, due to the procedures and services that must be used in each case. They also found that once the decision to terminate a pregnancy has been made, it is better to diagnose and treat a pregnancy early rather than perform a late abortion. A higher cost corresponded to abortion in the second trimester of gestation, which rose, according to this study, to 119 Cuban pesos, just over half of which was for the women’s stay in a hospital or clinic. Conversely, the unit cost of abortions during the first three months of gestation was 26 pesos, five times less than in the previous case. Most of these costs were related to operating costs in the D&C room. At the same time, the cost of menstrual regulation – 8.50 Cuban pesos – was three times lower. In this case, the procedure accounted for the highest cost, since the menstrual regulation method does not require hospitalization. If one compares the cost of these procedures with that of contraceptives, then one can see that, from the financial point of view, it is better for a couple to use contraceptives for a year than for the woman to abort or have her menstruation regulated.

The latter cases illustrate how legal restrictions on abortion engender high financial costs. Their effects, as we shall see in the next section, are particularly adverse on women with fewer resources, who are usually obliged to interrupt their pregnancies in extremely unsuitable conditions and, without any doubt, with higher costs.

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