Using Human Rights Principles to Promote Quality of Abortion Care in Brazil

It is estimated that almost 1.5 million abortions occur annually in Brazil, with almost 30% of pregnancies ending in abortion.¹ The practice of abortion in Brazil is a clear demonstration of social inequality; historically, under-privileged women have had no access to expensive private clinics and suffered more complications due to unsafe abortion. Unsafe abortion represents the fourth largest cause of maternal mortality in Brazil, and is highest in the northeast region, where poverty is high.²³

Although abortion is legal on two grounds, when there is no other way to save the woman's life and when pregnancy is a result of rape,⁴ until very recently, legal abortions were not being provided.

Since the 1980s, many women's groups and clinicians have taken action to block regressive abortion laws⁴ and make legal abortions available through training of providers. The emphasis of women's health advocates has been on gradual normalisation and decriminalisation of abortion in Brazil, by making abortion a topic of public discussion, so as to present the problem to society.⁵

In 1996, following the First Inter-Professional Forum for the Provision of Legal Abortion,⁴ the focus was broadened to ensure that women victims of sexual violence should have access to legal abortions. In 1998, Guidelines for the Prevention and Care of the Consequences of Sexual Violence against Women and Adolescents⁷ were published and became a key tool for health professionals to offer accessible and appropriate service for women who had been raped. Today, the number of hospitals providing legal abortion services in Brazil has increased considerably.⁴

Since the early 1990s, induced abortion by self-administration of misoprostol has played an important role in Brazil and may be a viable option for legal abortion, since it is highly effective in early pregnancy and relatively inexpensive. Use of this drug for abortion purposes is illegal in Brazil, though it is widely used and can be found on the black market or in pharmacies, where it is sold for treatment of gastric ulcers. In a 1996 study in the northeast region, of 2,074 women who admitted terminating a pregnancy, 66% reported using misoprostol. Almost 90% had both taken the tablets orally and inserted them vaginally.⁸ Therefore, it is necessary to raise awareness of the use of this drug among both women and post-abortion care providers.

Quality of health care is a key issue for the government and policies are needed to ensure timely care for incomplete abortions in order to reduce maternal mortality and morbidity.

Before the year 2000, sharp curettage for complications of unsafe abortion represented the second most common obstetric procedure performed in Brazilian public hospitals, with delivery the most common.⁹ Since 2000, manual vacuum aspiration (MVA) has been recommended under Decree No.569 for use in public hospitals in place of sharp curettage where possible, because it is safer.¹⁰ Changes in such practices take time, however, and MVA is still not being used by many doctors. Some have not been trained. Others appeared to be using MVA but were writing “sharp curettage by MVA” in medical records. This discovery was one of the reasons why the Ministry of Health decided to develop national technical guidelines, to ensure that the Brazilian public health system becomes a provider of post-abortion care that is safe and humane.

Most physicians have little information about the abortion law and have been afraid of the consequences of doing even legal procedures. Moreover, there has been a lot of pressure by the Catholic Church to block women's access to legal abortion care. In 1989, the Mayor of São Paulo, Luiza Erundina, put through Decree No. 692/89 that made it compulsory to provide legal abortions in the city's public hospitals.⁶ Hospital Jabaquara was the first to provide a legal abortion; others slowly followed.

In 2003, the Technical Area for Women's Health led a process to create national guidelines for abortion care. An expert task force comprised of the Brazilian Ministry of Health's Coordinator for Women's Health, Ipas Brasil, the Feminist Health Network, the Latin America Committee on Women's Rights (CLADEM), the Center for Mother and Child Research of Campinas (Cemicamp), ABRASCO and the Brazilian Federation of Societies of Gynecology and Obstetrics (FEBASGO) met from May 2003 to November 2004 to develop National Technical Guidelines for Humanised Abortion Care. These guidelines were to be in line with the 1994 International Conference on Population and Development (ICPD):

“Reproductive rights are recognized as human rights by different international treaties and conventions, and include the right of each person to have control and decision over his/her sexuality and reproduction, free from coercion, discrimination and violence.” ³

The Guidelines have five main sections:

• Legal and ethical aspects of abortion

  This section provides an analysis of legal abortion care in Brazil and reviews the ethical principles that should guide health care providers, which include autonomy, beneficence, non-malfeasance and justice. These principles must be the primary basis on which post-abortion care is provided. According to the Brazilian Federal Constitution, based upon the principles of human dignity and parental responsibility, couples have the freedom to use family planning and the State is compelled to provide education and resources so that couples can exercise this right, free from coercion by the public or private sector (Federal Constitution, Art. 226, Para.7).

• Providing support and information

  This section is about provider interaction and communication with women, and the importance of providing information, counselling and support.

  “The action to inform should promote self-determination, according to the ethical principle of autonomy.” ⁹

  It emphasises women's need for respect, kindness and compassion during post-abortion care. It explains that women with abortion complications are emotionally and physically hurt and need attention. Therefore, health professionals must use a sensitive approach, which includes avoiding being judgmental, being aware of women's concerns and needs, being open to talking about pregnancy, unsafe abortion and reproductive health, informing women of the procedures that must be carried out and offering them contraception to avoid another unwanted pregnancy.

• Partnership between the community and service providers

  This section is about empowering women, adolescents and other community members to prevent unwanted pregnancies and unsafe abortion. It calls on service providers to ensure that the human and material resources of health care services are allocated to address the community's expectations and needs.

• Clinical guidance and recommendations of the International Federation of Gynecology and Obstetrics and the World Health Organization

  The fourth section considers the prevention of unsafe abortion as a crucial aspect of women's reproductive and sexual health, according to Paragraph 63.iii of the ICPD Programme of Action.

  “In circumstances where abortion is not against the law, health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible.”

  The Guidelines recommend MVA for pregnancies of less than 12 weeks LMP, and say that when MVA is not possible, sharp curettage is acceptable. For pregnancies of more than 12 weeks, it recommends medical abortion with misoprostol.¹¹

• Family planning

  This section is about the needs of women and adolescents who wish to protect themselves against unintended pregnancy. A woman who has had one abortion may be at risk of another abortion.⁹ Hence, family planning is central to women's sexual and reproductive health, and health professionals must inform women and their partners of methods to avoid unwanted pregnancy and future abortions.

  There is enormous discrimination and stigma in the public health services towards women who seek post-abortion care, which results in the refusal to admit women to certain hospitals. There has been a distress signal from the public health system and from under-privileged women for humanised post-abortion care. The National Technical Guidelines for Abortion Care are an opportunity to expand women's access to good quality post-abortion care and represent the recognition by the Brazilian government of the importance of implementing human rights related to sexual and reproductive health in fulfillment of its international obligations.