Abortion Due to the Lack of Contraception or its Failure

Most unwanted pregnancies occur for two reasons: either a woman is using a contraceptive method that fails or she is not using any method at all (Guillaume, 2004). Women’s contraceptive history is closely linked to their decision to abort.

For Bankole et al., (1998), determining the prevalence of unwanted or unplanned pregnancies and their proximate causes, the lack of contraceptives or failure of them, are essential to understand the context in which women resort to abortion. According to the authors, in Latin America, postponing having children or limiting the number of one’s offspring are less likely reasons for aborting than in other regions. This, they note, is partly due to the high prevalence of sterilization, which reduces the importance of abortion as a means of limiting the size of the family. Like many others, these authors conclude, on the basis of a review of several studies, that improving contraceptive practice is essential for reducing the incidence of abortion. However, they note, due to individual or institutional limitations or circumstances beyond people’s control, it is always necessary to guarantee the right to abortion.

Like Mundigo (1993), Faúndes and Barzelatto (2005) note that in most countries in the region at the beginning and during the early stages of demographic transition, many women began to resort to abortion because of to the difficulty of obtaining contraceptive methods or because of the slow increase in the availability of the latter. This period saw an extremely high index of abortions, which began to fall when better conditions of access to contraception were created.

These authors mention various factors that helped increase the number of unwanted pregnancies and therefore of abortions: the failure of contraceptive methods, particularly traditional methods such as abstinence and coitus interruptus, failure rates for which are extremely high, and incorrect use of the Pill and other methods that depend on the user’s repeated actions. Other authors also cite “lack of knowledge of reproductive physiology, lack of support from one’s partners in contraceptive use, a negative perception of modern methods, a preference for less effective methods or their incorrect use and the idea that pregnancy is something that will not happen,” as reasons for abortion.” (Mora Téllez and Villarreal, 1993; Amuchástegui and Rivas Zivy, 2002; Lafaurie et al., 2005). Likewise, one of the conclusions of the Researchers’ Meeting on Abortion in Latin America and the Caribbean (Encuentro de Investigadores sobre Aborto Inducido en América Latina y el Caribe, 1994) reveals “the scant use of contraceptives among women that resort to abortion and the lack of contraceptive practice due to the lack of continuity in its use and the transition from one method to another.”

At the same time, condom failure is also common. Additionally, condom use depends on the capacity for negotiation of sexual relations: male methods place women in a dependent position that is reinforced in societies where male domination is greater.

Guillaume (2004) notes that hormonal contraceptive failure has mainly to do with its improper use (particularly irregular pill taking). According to the author, this may be due to the fact that women usually lack proper counseling, designed on the basis of their needs when these methods are prescribed. It may also be due to the degree of responsibility and awareness women adopt in this respect. For example, women are not always informed of the amenorrhea that may occur after an injectable method is used. They are often unaware of the wide range of contraceptive choices available, or of the possibility of changing method in the event of dissatisfaction or unpleasant side effects. In addition to this type of failure, insufficient contraceptive use may be explained by the lack of information on the way the methods prescribed work or are used, the users’ dissatisfaction with them (Chávez and Britt Coe 2005), or difficulty in gaining access to family planning programs.

Lack of contraceptive practice may also be explained by men’s reluctance to use these methods (see Chapter 9). In a study conducted on poor women in Mexico, Erviti found that in some cases, men made decisions about women’s bodies and whether or not their partners should get pregnant. This, notes the author, shows the conditions of subordination in which women live, since (men) “often refuse to allow their partners to use contraceptives out of distrust, since women that use them (according to men perception) are more inclined to engage in sexual relations outside their relationship with their partners” (p.174) (Erviti, 2005).

Faúndez and Barzelatto (2005) underline that the risk of unwanted pregnancies increases due to the prevalence of forced sex. They also point out that despite its prevalence, rape is not a common determinant of unwanted pregnancies. They add, however, that the consequences of this fact may not be sufficiently known due, above all, to the fact that rapes are difficult to detect in surveys.

Women may also reject contraception due to bad experiences or fear of using these methods, often based on false beliefs. They often obtain information from the social networks to which they belong, whose knowledge of the subject is not always reliable. This information “is inconsistent, which confuses women, making them fear the methods, as a result of which many of them have stopped believing in them.” (p. 42) (Mora Téllez et al., 1995).

These authors show that the effectiveness of contraceptive methods depends on their correct use in a study they undertook in 1993 in Colombia, based on the testimony of 60 women treated by the outpatient treatment service for incomplete abortions in the main headquarters of Oriéntame, a civil organization in that South American country. The answers of these women, interviewed weeks after treatment, reiterate the fact, as shown in other studies consulted, that the main reason for not using contraceptives, despite not wishing to get pregnant, is the fear of side-effects and their possible consequences. The authors also stress that for some women, these consequences are less important than discontinuing contraceptives and therefore having an unwanted pregnancy and eventually aborting. They also observe that some women fail to use contraceptives because of their belief that they are unable to become pregnant. Half the women interviewed, particularly adolescents, had used condoms or methods that are proven to be ineffective, such as the rhythm method. Likewise, the older the participants in the study, the more likely they were to use modern methods, particularly the IUD and the Pill. Of the women interviewed, half of them had not used any method at all at the time they became pregnant or admitted not using it properly. Of the remaining interviewees, only a minority reported that despite using injectable contraceptives, the IUD or having had their tubes tied, they still became pregnant.

The medical literature reports that in theory, no contraceptive method is 100% effective. As has been shown, they all have some possibility of failure. Yet, whereas modern methods are fairly effective, natural methods are quite ineffective and often fail, which translates into unwanted pregnancies or abortions. This is compounded by failure derived from the incorrect use of a method. This is closely linked to women’s knowledge of the biological process through which pregnancy occurs and in general, of the ways their own bodies work. Contraceptive use depends on women’s control of their own sex lives, which includes the capacity to negotiate with their partners over the method to be used, particularly if it involves male contraception. This control also depends on their access to family planning methods and programs (Faúndes and Barzelatto, 2005).

Contraceptive use may appear unjustified for women that have sex rarely, irregularly or are insufficiently experienced in this respect, particularly when they are young. This is linked, among other things, to the frequency with which unwanted pregnancies occur when women are forced to have sex, as in the case of rape or incest. A study by the Population Council conducted at the Mexico City General Hospital (Lara et al., 2003) found that of 231 women who had become pregnant as a result of rape, over two thirds (66%) were adolescents with a very low contraceptive practice (2%) at the time of the sexual assault.

The contraceptive methods used often do not correspond to women’s needs, their stage of life or their fertility expectations. Thus, for certain women, abortion is a means of spacing or limiting births while for others, it is a solution if they have problems with their partners or relatives or any other types of problems at the time of their pregnancy. (Salas Villagomez, 1998). In other cases, as Persaud notes, certain population groups have been excluded from family planning services, such as indigenous women or those in rural areas. This is particularly true of adolescents, even in urban areas (Persaud, 1994).

The economic, socio-cultural, institutional and political context is different in each country, which explains why contraceptive use is also different between and within them. This is true of Brazil and Colombia, where over 80% of women in some kind of a union have used some type of modern contraception method at some time, whereas in Guatemala and Haiti, fewer than a third of the female population with these characteristics have done so (CRR, 2003). Likewise, women who do not want anymore children and do not use contraceptive methods or resort to periodic abstinence or coitus interruptus- two methods regarded as inefficient- are 17% in Colombia and 43% in Bolivia among women aged 14 to 44 (Alan Guttmacher Institute, 1996).

This shows that it is obviously not enough simply to consider the proportion of women using contraceptive methods, without specifying which methods are used and therefore without considering that the effectiveness of each one may vary enormously. Many couples, for example, resort to periodic abstinence, the effectiveness of which depends largely on whether the women are absolutely familiar with her fertility cycle (Mundigo, 1993). Other women use modern methods yet fail to understand the importance of using them properly or continuously (CRR, 2003). As mentioned earlier, even in countries with highly developed contraceptive use, failure in the latter or their improper use leads to unwanted pregnancies that often end in abortion (Bajos et al., 2002).

Several studies performed in various Latin American countries confirm the direct (or close) relationship between abortion and the lack or improper use of contraceptive methods. These studies also underline the factors leading to the absence of contraceptive practice.

In a qualitative study on abortion using medication in Mexico, Colombia, Ecuador and Peru, in which 49 women who had undergone abortions were interviewed, Lafaurie et al. (2005), found that 34 of them did not use contraceptive methods and that 12 had become pregnant as a result of the failure of the method they used, among which there was a woman whose partner had deceived her by saying that he used a “male injection” when they had sex. The other three had been victims of sexual violence.

The Pathfinder organization undertook a study in six hospitals in Peru to evaluate the impact of training on post-abortion services, the acceptance of contraceptive methods and users’ satisfaction with the services provided. Thirty five per cent of the women interviewed said that the reasons why they had rejected contraception before they became pregnant were because they were unsure about the consequences of using these methods; another 35% said that they had not been offered contraceptive methods while the remaining 15% lacked information on the existence of family planning programs (Ferrando, 1999).

In Colombia, a survey was carried out on 602 urban women whose ages ranged from 16 to 48, who received treatment for incomplete abortions in 1991, had higher educational attainment and were engaged in some form of economic activity. It was found that only 57% of these women had been using at least one contraceptive method when they had become pregnant, only 12% of these had been using modern methods, and 36% were not using the method correctly. Of the remaining women interviewed, 43% had not been using any contraceptive at all (Villarreal Mejía and Mora Téllez, 1993).

Other research projects conducted in Colombia corroborate similar trends and patterns. The study conducted by the Colombian Federation of Obstetrics and Gynecology on 15 hospitals to analyze morbi-mortality due to abortion found that 42% of the women admitted as a result of abortions said that they did not wish to have any more children, 67% did not use any form of contraceptives, while only 37% had received family planning services at hospitals (Villarreal, 1992). A study of the factors associated with abortion and unplanned pregnancy carried out in 2003 in three Colombian cities (Usme, Ciudad Bolívar and Santa Fe) found that 71% of the women interviewed did not use any type of family planning (Lafaurie et al., 2005). In another study, conducted in Bogotá, of 301 women that had had an abortion, the authors noted that 33% said that they had not been using any form of contraceptive at the time they became pregnant while 67% had used a traditional or barrier method. They also added that the factors that most prevented couples’ contraceptive practice, according to the women, were: the harmful effects of hormonal methods and IUDs, the use of contraception as a male form of control over women and difficulties in the couple’s communication over the choice and use of methods (Mora Téllez, et al., 1999).

Another study, undertaken in 1995 at a clandestine urban abortion facility in a country in a Southern Cone country found that three fifths of all women did not use contraceptive methods at the time of pregnancy. Nearly half were adolescents, 60% of which used traditional methods (Strickler et al., 2001).

A study conducted by the Pro Mujeres organization in 1991 on women that had had an abortion in Puerto Rico found that 59% of the participants had used some form of contraception before becoming pregnant. Half of them had used abstinence or withdrawal, while 32% had used other contraceptive methods that they stopped using because of the side effects they produced (Reproductive Health Matters, 1993; Azize Vargas et al., 1993).

Chile has an extremely high prevalence of abortion, even though it is totally forbidden. At the same time, contraceptive practice is extremely widespread, with modern methods being both affordable and available for the entire population (Den Draak, 1998, p. 194 quoted by Bay et al, 2004). Nevertheless, as another author suggests, the increase in this high abortion rate may possibly be due to the fact that access to permanent contraceptive methods, which are the safest, may not be that easy. Although health clinics in the public sector provide free IUDs, oral contraceptives, diaphragms and condoms, having one’s tubes tied is highly regulated, even when it is medically recommended, while many doctors refuse to perform vasectomies (Alexander, 1995).

Padilla and McNaughton (2003) undertook a study in Nicaragua on the basis of the records of the Department of Integral Attention for Women and the information generated by the Maternal Mortality Surveillance System of the Ministry of Health, during the period from 2000-2002. Its results show that 65% of the women that died during the period analyzed had not used any contraceptive method, and that 96 of them (of the total of 445 that died from causes related to pregnancy, childbirth and puerperium) became pregnant despite using some form of contraception. The authors consider that these maternal deaths, or at least a significant number, could be linked to unwanted pregnancies.

Other studies provide evidence that reflects the differences observed between the practice of abortion and the use of contraceptives according to the different characteristics of the women interviewed.

In a study undertaken in 1992 in urban areas of Colombia, Zamudio et al. (1999) found that 77% of the women that had undergone abortions were not using any contraceptive method at the time of pregnancy, a proportion that totaled 71% in Bogotá. The differences in contraceptive use between social strata were not very great: although the middle and upper class sectors had better contraceptive rates, at 22.6%, this was only 5% higher than those among the lower sectors. Conversely, contraceptive practice associated with women’s activity is highly differentiated: among those that worked at the time of their abortion, just under a third had used some form of contraceptive method (29.1%), whereas among those that were not employed, less than a fifth (19%) had done so. The least protected population, in terms of contraception, was the population that was studying at the time of their abortion, since 84.5% had not been using any method. These figures clearly show that this sector of the population is at a greater risk of having unwanted pregnancies, which tend to end in abortions. They also found that a fifth of all abortions (21.6%) occurred despite contraceptive use, either because the contraceptives were incorrectly used or because the method itself was ineffective. On the basis of the testimonies of women with unwanted pregnancies, the author stresses the presence of erratic behaviors when their contraceptive history is analyzed.

They also observed that the experience of abortion exerts a different influence on women’s contraceptive behavior, according to their different characteristics. For women as a whole, contraception varies less than one might think according to how many abortions they have had. Among those having their first abortion, 21% of the women had used a contraceptive method, among those having second and third abortions, this proportion rose to 28%, while among women with subsequent abortions, it fell to 17.8%. However, an important differentiation by generation is observed: the pattern of the last group was due to the fact that it comprised older women, in whose reproductive history contraception played a small role and who were more afraid of the harmful effects attributed to contraception. Conversely, contraceptive use among the students and therefore younger women that participated in the study evolved very differently: only 12% had used some form of contraception before their first pregnancy that ended in abortion, a proportion that doubled among the group having second abortions (29.5%) and was five times higher in the group having a third (61.3%).

In a similar vein, in 1992, Paiewonsky (1999) explored, among other things, the link between contraceptive use and employment status, on the basis of women admitted to two hospitals in the Dominican Republic due to complications from abortion. The results indicated a slight variation between the four different groups of activity identified: contraceptive use was higher among those that worked, either in the formal or the informal sector of the economy (81% and 80% respectively) while contraceptive practice declined slightly among those that were unemployed at the time of the survey and those that had never worked (71% and 75% respectively).

In Argentina, a group of lower class women were interviewed between November 1992 and January 1993. These women lived in geographical areas where public family planning services are inadequate and where the women experienced great difficulty obtaining quality medical care, in addition to suffering the consequences of undergoing unsafe, illegal abortions. Data from the survey indicate that 40% of the 404 women that did not wish to become pregnant used pills, condoms, injections, IUDs and the rhythm method, in descending order. This suggests that knowledge of the use and effectiveness of contraceptive methods was extremely low in this case (López, 1994).

At the same time, as pointed out in Chapter 4, “Socio-demographic Profile and Motivations of Women Who Resort to Abortion,” the link between abortion and contraception is also evinced by the fact that certain women, especially younger ones, fail to use contraceptive methods since they do not believe they are exposed to the risk of pregnancy or do not foresee having sexual relations. The same situation occurs in cases of rape or when women have sex sporadically (Guillaume, 2004). This circumstance leads, logically enough, to the frequent occurrence of unwanted or unplanned pregnancies.

One thought-provoking aspect of some of these studies is the fact that the poor quality of a contraceptive method or its incorrect use may constitute a reason for women’s accepting or rejecting abortion. In a study undertaken by Misago and Fonseca (1999) in Brazil, only 2% of the interviewees believed that an abortion should be performed in the event of contraceptive failure. Another study undertaken in Mexico on women’s opinions, in which 48% of the women are estimated to have had an induce abortion and 40% are estimated to have had what was probably an abortion rather than a miscarriage, the figures were slightly higher: one out of every seven to ten women felt that a pregnancy should be interrupted if a particular method failed (Núñez, 2001; García and Becker, 2001). This would suggest that in the event of contraceptive failure, women could feel obligated to interrupt the pregnancy that the contraceptive was meant to prevent, although they may not wish to, which partly affect their freedom to decide and therefore their sexual and reproductive rights.

Another study conducted in the Brazilian city of Sao Paolo in 1999 (Vieira, 1999) offers additional evidence on this topic. Of the women aged 15 to 49 interviewed for the research, 40% to 41% had undergone sterilization or had used the Pill, 4% had used natural methods such as coitus interruptus and the rhythm method, 4% had utilized the condom and 3.6% the vasectomy, injectable methods or the IUD. The author highlights the proportion of women who had a negative attitude toward the abortion, particularly among those that used the Pill (48% of the total) and sterilization (38%) compared with those that used other contraceptive methods (14%). Likewise, those that chose sterilization justified the use of this method because of its effectiveness. It was significant that 22% of the women sterilized were 24 or under.

A similar perception is observed among health professionals. Very few physicians declared that they were in favor of the legalization of the right to abortion in the event of contraceptive failure. According to one study, (Ramos et al., 2005), only 4% of those in Brazil, 14% of those in Argentina and 15% of those in Mexico are in favor of this, reflecting the need to sensitize doctors on the subject.

Social, Cultural and Institutional Barriers to Contraceptive Use

According to Zamudio et al. (1999), the link between contraception and abortion forms part of what is known as the “culture of prevention”. This is shaped within a much larger space than socio-demographic conditions and includes technical-institutional aspects (availability of contraceptives, access to them, information, costs and autonomy), medical aspects (the effects of contraception on the body) and a wide range of socio-cultural dimensions, which – as social constructions – define preventive behavior. The authors also hold that in developing countries, conditions and structural possibilities are too precarious to consolidate a culture of prevention, which is reflected in “the lack of clear, stable working conditions, strong organizational structures, foreseeable rules of the game, strong, broad social security structures, and fair mechanisms of access and social participation.” Given these circumstances, they add, “the population is unlikely to develop a culture of planning, within which prevention is regarded as an everyday way of acting”. Thus, in conditions of unemployment, poorly paid jobs, and everyday, structural inequity, “the population develops a sense of opportunism, a sense of the moment and a taste for chance, and this skill enables them to deal with everyday unforeseen conditions and cope with its risks.” The authors add that the absence of a preventive culture and conduct can largely be explained by other dimensions such as a) the conditions of inequality and power relations between the genders, male control or domination of women, the limitations of inter-gender communication, the weakness of the male perception of the link between sexuality and reproduction, women and men’s perceptions of their relationship as a couple and the reaction to these perceptions, b) the social representations of the health consequences of modern contraceptive use and c) women’s relationships with their own bodies and their self-esteem, which leads them to resort to abortion out of fear of using safe contraceptives and the troublesome side-effects they attribute to them.

Access to family planning, counseling and a wide range of contraceptive methods is often hampered or even prevented by a wide range of barriers. These include the geographical and social reasons that deny this access to specific population groups such as adolescents, economic barriers (such as the cost of contraceptive methods), socio-cultural ones (religious or cultural disapproval, opposition from or difficulty negotiating with one’s partner) as well as a range of prejudices (fear of side effects or infidelity on the part of one’s partner) (CRR, 2003).

One of the main conclusions of the Researchers’ Meeting on Abortion in Latin America and the Caribbean (Encuentro de Investigadores sobre Aborto Inducido en América Latina y el Caribe 1994) is that in the region, “the supply of contraceptive assistance is scarce and incomplete, with very little diversification of available methods and a lack of knowledge of cultural barriers.”

In the countries where contraception is permitted and forms part of government reproductive health and family planning programs, the incidence of abortion is closely linked, among other things, to the shortcomings of these programs. Some of these are related to the lack of importance states, departments, municipalities, or other administrative units place on family planning and reproductive health programs; existing health and family planning services; the range of methods offered; the effectiveness and safety of the methods used or offered; the information given to women and the voluntary acceptance of various means of preventing pregnancy (p.110) (Cochrane, 1993).

A state’s inability to offer family planning services or make them available to the entire population constitutes another barrier. This is compounded by the rejection of certain population groups of contraceptive methods, for religious or other reasons, the authorities’ denial of this service to minors, parents’ opposition to their children being informed or receiving contraceptive services and the reluctance of husbands or sexual partners to let their partners use contraceptives (Bankole et al., 1998).

In the case of Peru, for example, a major barrier to obtaining sterilization is that the local legislation regards this procedure as equivalent to abortion, even though the two are quite different (Huaman, 1994). Another study conducted in the same country notes that reproductive health programs give priority to curative aspects to the detriment of prevention and that they fail to prioritize sex education. These situations are partly due to the fact that the Catholic Church obstructs the development of programs related to these issues. At the same time, the vast majority of men do not participate in family planning programs, child-rearing or household chores (Aramburú, 1991). “The lack of geographical access to health services, personal attitudes, cultural patterns and the lack of information on the correct use of methods and their side effects explains why 56% of Peruvian women of reproductive age and 31% living with their partners either do not use any family planning method or fail to do so correctly” (Lafaurie et al., 2005).

In La Paz, Bolivia, a qualitative study on unwanted fertility and the barriers to using family planning services showed that, contrary to popular belief, certain cultural norms of the Aymara Indians living in urban centers are compatible with fertility regulation, while other norms prevent access to such regulation. It is common for members of this community to discourage the discussion of sexual issues and contraceptives among family members, friends or health providers; rumors and stories are spread about the supposedly harmful effects of modern family planning methods; and there is deeply-rooted suspicion, distrust or fear of modern medicine and medical professionals, as well as taboos about medicalized abortions (Population Council, 1994).

The use of emergency contraception (EC), a method which, as indicated in other chapters, is particularly suitable in the case of rape or unprotected sex, can also be discouraged by these barriers. For this very reason, as Langer (2003) points out, it is essential to improve the dissemination of this virtually unavailable resource that has yet to be approved in many countries, largely because it is confused with and regarded as a method of abortion. Other authors warn of the lack of information among health providers or those responsible for public policies regarding the safety and benefits of this method. Several surveys reveal that health providers’ are ignorant of the way it works and even attribute abortive effects to it. Once they have received the necessary training, however, some providers acknowledge the importance of the method in reducing the number of unwanted pregnancies and abortions (Larrea et al. 2003; Galvão et al., 1999; Gould et al., 2002; Hardy et al., 2001).

The fact that certain women prefer to resort to abortion rather than use contraceptive methods raises the need to analyze the advantages abortion could have in relation to family planning and conversely, the advantages of the latter over abortion. Apropos of this, David and Pick de Weiss (1992) note that, in order to be effective, preventing pregnancy required a high degree of shared responsibility in sexual behavior, which implies having sufficient information and education about contraception, as well as a greater awareness of the measures to be taken before having sex. Conversely, as the authors point out, resorting to an abortion requires less education as regards sexual and reproductive health. A late period and the anxiety caused by the possibility of an unwanted pregnancy are often enough to make a woman seek an abortion. Unlike most contraceptive methods, abortion is 100% effective – if performed properly, it is performed once, regardless of the time of intercourse, and it provides a guarantee, not just a probability of preventing pregnancy. Abortion does not interfere with sexual activity – except in the event of complications – nor does it entail the health risks that, according to some women, are entailed by modern contraceptive methods. Moreover, the authors point out, when remorse is associated with abortion, the guilty feelings are similar to those related to the repeated use of contraceptives. Conversely, they add, abortion constitutes only a single violation of a woman’s value system.

Apropos of this last point, Guillaume (2004) notes that certain women in Africa prefer to resort to abortion rather than use a medicalized contraceptive method. This preference, she says, can be explained by their fear of the side effects attributed to these methods, such as the risk of getting cancer or of becoming infertile, particularly after the prolonged use of certain contraceptives. It is particularly surprising that those that mention these fears ignore the fact that with an abortion, a woman runs a greater risk of becoming sterile, particularly if the abortion is not performed properly. At the same time, it has been pointed out that one of the possible advantages of abortion over contraception in young women is that it enables them to test their fertility, whereas they may perceive that contraceptives either question or threaten it.

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