Abstract
Abstract
Abortion is legal in Brazil if it is the only means to save the woman's life or if the pregnancy is the result of rape. Although this has been the law for over 60 years, it has almost never been applied until recent years. In the past five years, the number of hospitals providing care to women victims of sexual violence has increased from 4 to 63, of which 40 are currently providing legal abortions. This paper describes a sensitization project and advocacy work carried out from within the obstetric and gynaecology establishment which has succeeded in motivating many key individuals and hospital staff to provide services for pregnancy termination in cases of rape. The dialogue between medical leaders and women's rights advocates and the emphasis on comprehensive care of women who have suffered sexual violence are key elements in the success of this initiative. The support of medical professionals, the organization and strength of the women's health and rights movement, the political support at federal, state and city government levels, including from the Federal Ministry of Health, and ongoing advocacy within the medical establishment have all been important elements in making the provision of services a reality.
Résumé
Au Brésil, l'avortement est légal si c'est le seul moyen de sauver la vie de la femme ou si la grossesse résulte d'un viol. Bien que cette loi date de plus de 60 ans, elle n'avait presque jamais été appliquée jusqu'à récemment. Ces cinq dernières années, le nombre d'hôpitaux traitant les femmes victimes de violences sexuelles est passé de 4 à 63, dont 40 assurent des avortements légaux. Cet article décrit un projet de sensibilisation et de plaidoyer mené depuis le secteur de l'obstétrique et de la gynécologie, qui a réussi à inciter des individus clés et du personnel hospitalier à fournir des services d'interruption de grossesse en cas de viol. Le dialogue entre les responsables médicaux et les défenseurs des droits des femmes, et l'accent sur les soins complets aux femmes qui ont subi des violences sexuelles sont des éléments essentiels du succès de cette initiative. L'appui des médecins, l'organisation et la force du mouvement en faveur de la santé et des droits des femmes, l'appui politique aux niveaux fédéral, des Etats et municipal, notamment du Ministère fédéral de la santé, et les activités de plaidoyer actuellement menées dans le monde médical ont aidé à faire de la prestation de ces services une réalité.
Resumen
El aborto es legal en Brasil solo para salvar la vida de una mujer o si el embarazo ha resultado de una violación. Aunque la ley desde hace 60 años, casi nunca se ha hecho cumplir hasta los últimos cinco años. El número de hospitales que proveen servicios a mujeres vı́ctimas de violencia sexual ha aumentado de 4 a 63, 40 de los cuales actualmente proveen servicios de aborto legales. Este artı́culo describe un proyecto de sensibilización, defensa y promoción, iniciado por la profesión gineco-obstétrica, que ha logrado motivar al personal de los hospitales a proveer servicios de aborto en casos de violación. El diálogo entre los dirigentes del gremio médico y las activistas para los derechos de las mujeres, además del énfasis en el costo de los servicios para las mujeres víctimas de violencia sexual, son elementos claves en el éxito de esta iniciativa. El apoyo de los profesionales médicos, la organización y fuerza del movimiento a favor de la salud y los derechos de la mujer, el apoyo polı́tico a nivel federal, estatal y municipal, incluyendo el Ministerio de Salud, y las actividades de defensa y promoción dentro del gremio han contribuido a que la provisión de estos servicios sea una realidad.
At the end of 2001, all but a few state capitals in Brazil had at least one public hospital which had openly carried out a legal abortion, and plans for service provision were in progress in the rest. This is an eloquent expression of the growing official recognition that termination of pregnancy within the limits of the law is a legitimate part of the gynaecological care every woman deserves. Moreover, almost all the main Faculties of Medicine have also carried out legal abortions in their University Hospitals, giving the seal of greater legitimacy to these services.
Although there is a great deal left to do before we achieve recognition of women's right to terminate a pregnancy to the full extent of the law, the progress we have made to date would have been unthinkable just a few years ago. How could this have happened in a predominantly Catholic Latin American country? This paper describes the process we went through and some of the main actors involved in making it happen.
Two main sets of actors
There is no doubt that the strength and organization of the women's rights movement in Brazil has been a fundamental factor. Their campaigns have resulted in enough political leverage to influence the Parliament and the Executive on several occasions, most often in blocking the passage of regressive laws, which have been tabled regularly though less often in recent years than previously Citation[1]. Women's rights groups who are members of the Rede Feminista Sexualidade e Sa ú de (Feminist Network for Sexual and Reproductive Rights, usually called RedeSaúde) have had an even more decisive influence at the state and municipal levels, where they have been successful in passing progressive municipal decrees or laws, to good effect at local level Citation[2].
The partnership between women's health advocates and obstetrician–gynaecologists was not something that happened from one day to the next. It started with a few of the less radical feminist groups and a few progressive obstetrician–gynaecologists in the late 1970s and early 1980s, with the campaign to transform vertical family planning programmes into integrated women's health services that respect women's right to control their own fertility without pressure or coercion Citation[2]Citation[3].
The mistrust between women's rights advocates and predominately male obstetrician–gynaecologists was not easily broken. Their common aims, however, led to a dialogue which, though it was not always easy or successful, by the late 1980s had created sufficient mutual trust that a steadily growing number on both sides saw each other more as allies than as adversaries. It was this dialogue that sensitized and motivated an increasing number of influential physicians into establishing legal abortion services Citation[4].
While the women's movement fostered a more favourable political environment, the other key element was the involvement of the obstetrician-gynaecologist establishment. The willingness or unwillingness of physicians to carry out abortions is the decisive factor that determines whether the law is applied or not. This explains why legal abortions are not being carried out in most of Latin America, and why even women who fulfill the conditions for a legal abortion have to continue risking their lives or paying large amounts of money for a clandestine abortion.
The international environment was also favourable. An international meeting in 1991 called by the World Health Organization in collaboration with the International Women's Health Coalition on “Creating Common Grounds”, provided a seal of approval to dialogue between physicians and the women's health movement Citation[5]. Later on, FIGO (International Federation of Obstetricians and Gynaecologists) promoted two Latin American meetings, both held in Brazil, to discuss the problem of abortion. FIGO's support gave even greater legitimacy to promoting women's right to abortion within the terms of the law, from the gynaecologists' point of view, than the programmes of action of the Cairo and Beijing conferences Citation[6].
It was in this context that it was possible to make progress in involving doctors in the implementation of services for pregnancy termination for women whose situation fulfilled the legal conditions. The abortion law in Brazil does not say, as most people believe, that abortion is simply illegal in the country. The Penal Code, which dates from 1940, establishes in Article 128, two conditions under which abortion is not a criminal act: when pregnancy is the result of rape and when there is no other mean to save the woman's life Citation[7].
The problem was that the law had almost never been applied. Women, health providers and society were largely not aware of the conditions under which abortion is not criminalized in the Penal Code. Moreover, even those who knew what the code says did not know how the law could be put into practice. Thus, until very recently, women who got pregnant following rape had no place to go to obtain a legal termination of pregnancy, and in most public hospitals, physicians tended to believe that there was no condition which justified the termination of pregnancy as the “only means to save the woman's life”.
The first initiatives to provide services
At first, there were occasional, localized initiatives which originated from within individual hospitals to provide legal abortions to women victims of rape; at the same time, a number of women's groups sought to motivate municipal governments to enforce service provision in their hospitals.
One example of these early initiatives was the teaching hospital of the State University of Campinas where abortions for rape victims were occasionally carried out by decision of the heads of the Gynaecology and Obstetrics Departments. The same university funded a semi-independent organization called SOS-Ação Mulher (SOS-Action for Women), who provided counselling, support and referrals for women suffering from violence. Women who became pregnant following sexual violence were referred to the university hospitals, where they were almost always able to obtain an abortion.
Although several physicians were opposed to offering this service and an even greater number refused to carry out the abortions, both the head of Gynaecology and the head of Obstetrics carried out the abortions if no other doctor was available. This arrangement worried some of the influential physicians within the Department, until it was made official through a consultation with the University Legal Office in 1994.
In a totally separate effort, the women's health movement in the city of Rio de Janeiro campaigned and lobbied the city council until they passed a municipal law in 1988, requiring that specific municipal hospitals provide women with pregnancy terminations if they complied with the requirements of the Penal Code Citation[8]. The resistance by physicians and other health personnel in those hospitals, under pressure from the Catholic Church, was so great that the law has not been fully implemented during the almost 15 years since it was passed Citation[9]. Several raped women who had judicial approval for pregnancy termination could not get an abortion in Rio; only a few legal abortions, no more than two or three per year, had been carried out in the city.
A similar initiative in the city of São Paulo, the following year, was far more successful. The largest Brazilian city (and one of the most populated in the world, with around 10 million people) elected a woman as mayor for the first time in the city's history. A municipal decree, similar to that of Rio de Janeiro, was approved in March 1989, but at the same time measures were taken to put it into operation. A female physician, who was also a well-known women's rights leader, was named as coordinator of women's health services for the city. She actively worked with the staff of the municipal hospitals, and one was selected to set up this new service. The issue of a woman's right to an abortion when the law allowed it was discussed with all the health personnel. As a result, a group of physicians, social workers and other health professionals became committed to putting the law into practice Citation[10].
The result was that one municipal hospital – Hospital Dr. Arthur Ribeiro Saboya – known as Hospital Jabaquara – started in November 1989 to provide abortions for women who had been raped who requested it. Although only a few legal abortions were carried out, the resulting public discussion and the good reception these services received were more important than the small numbers of women attended.
During the early 1990s the public debate on abortion continued, but there was little progress in terms of access to legal abortion. One exception was when a small number of judges, no more than four or five, responded positively when they found themselves confronted with a new challenge – having to decide whether to authorize an abortion in cases of severely malformed fetuses whose chances of survival were nil Citation[11]. Their decisions were based on the increased risk of maternal complications late in pregnancy due to the malformation, as giving sufficient reason to authorize the termination, especially since the fetuses were not viable Citation[12].
These rulings did not become known to the larger public until 1994, when an apparently innocent interview with the then Director of the State University of Campinas Women's Hospital made the headlines of the major national newspaper. The interview was about a woman who had been prosecuted and imprisoned for having a clandestine, induced abortion. The Director of the hospital said that as the woman's ex-husband had raped her, she could have had a legal abortion at the University Hospital. Asked if the hospital did abortions in other cases, the Director said that they also did them in cases of risk to the woman's life, which was within the law, and also when the fetus had a malformation incompatible with extra-uterine life. The next day's headlines read: “University Hospital carrying out (illegal) abortions” Citation[13].
The story opened up an intense debate, with widespread support for the granting of abortion in cases of severe fetal malformation. The news that some judges had authorized such abortions led a larger number of judges to adopt the same position. The Conselho Federal de Medicina (Federal Medical Council) and other organizations promoted a change in the law to include fetal malformation among the conditions under which abortion was not a crime. By the second half of the decade, opinion polls showed that a majority of the population were in favour of legalization of abortion in such cases, and it became increasingly more common that Brazilian judges were willing to authorize them with little delay Citation[14]Citation[15]Citation[16]. A bill to reform the Criminal Code, which is currently in the hands of the Ministry of Justice, includes a clause to that effect Citation[1].
Otherwise, little changed in terms of new legal abortion service provision from 1989 to 1996. Apart from the three hospitals carrying out abortions in Rio de Janeiro, São Paulo and Campinas, only one other hospital in São Paulo initiated services in 1994, the Perola Byington Hospital Citation[17]. In Rio de Janeiro, CEPIA, a woman's rights NGO, was very active in the promotion of legal abortion in public and teaching hospitals. They worked with a medical school and were able to get women's rights issues onto the medical residents' curriculum. However, they did not succeed in getting the practice of legal abortions in Rio expanded, due to strong resistance on the part of the medical establishment Citation[8]Citation[9]. The new government of the State of Pernambuco, in the northeast, named a feminist physician as coordinator of women's health and was in the process of replicating the experience of São Paulo, with the installation of services in one public hospital in Recife in 1996.
The Center for Research on Maternal and Child Health of Campinas (CEMICAMP), a Brazilian NGO in Campinas associated with the State University of Campinas, had long had as one of its priorities the provision of abortion services within the limits of the law, but was only able to initiate a programme in 1995. In 1996, they started by carrying out a study to identify the strategies used by women who successfully obtained a legal abortion in the three first hospitals to provide them and the procedures these institutions followed. Judges, public prosecutors and professors of criminal law were interviewed to determine the legal requirements for proceeding with a legal pregnancy termination Citation[18].
With this information in hand, CEMICAMP, in consultation with RedeSaúde, organized a meeting called “First Inter-Professional Forum for the Provision of Abortion under the Law”, in Campinas in November 1996. From that first Forum onwards, CEMICAMP has been working in consultation with RedeSaúde. Fifteen of the most prestigious professors of obstetrics and gynaecology attended, together with professors of bioethics, medical and criminal law, judges, public prosecutors, chiefs of women's police, women's rights advocates and social scientists Citation[19]. The current law on abortion was discussed, as well as the reasons why it was not being implemented. The procedures that hospitals should follow in order to provide legal abortion services were outlined. The professors who attended were highly motivated by the discussion and committed themselves to setting up services in their hospitals within the following few months. It was also agreed that a second forum would be held one year later, to monitor progress.
Each Forum has taken place in a different city – Campinas, Brasilia, Porto Alegre, Goiania, Rio de Janeiro and São Paulo, respectively. They have served to create a sense of partnership and provide support to those already providing or intending to provide services and develop common protocols for the provision of services, as well as common procedures to be followed by hospitals interested in implementing these services. The number of participants increased each year, from 35 in 1996 to 81 in 2000, and dropped back to 39 in 2001.
The president of the Brazilian Federation of Gynaecology and Obstetrics (FEBRASGO) who attended, ensured that the report of each Forum was published in Femina, FEBRASGO's official journal Citation[20]. Moreover, a few months later the FEBRASGO Council approved the creation of a National Scientific Committee on Abortion According to the Law and has now co-sponsored five annual Forums. The president of this Committee has played an important role in the organization and functioning of legal abortion services in the Municipal Hospital of Jabaquara in São Paulo. He also participated in the first Forum and has been one of the organizers of all the succeeding Forums, which have been held every year since. These meetings continue to monitor progress and discuss obstacles encountered, and allow the sharing of successful strategies for starting services Citation[9]Citation[20]Citation[21]Citation[22].
During the first Forum, it was acknowledged that it is not only women who get pregnant after rape who need care but all women who have experienced sexual violence. Hence, the second Forum discussed the provision of comprehensive care for women who have suffered sexual violence in general Citation[20] both emergency care immediately following the assault and provision of abortion to those who become pregnant and request it Citation[23].
Emergency care of women victims of sexual violence includes psychological support, emergency contraception and prevention and treatment of sexually transmitted infections (STIs) and HIV. A comprehensive programme of care for victims of sexual violence was more widely accepted by physicians and society in general than the more narrow focus on women who fall pregnant.
This same strategy was adopted by the Federal Ministry of Health which, in an act of great courage, published “Guidelines for the Prevention and Care of the Consequences of Sexual Violence against Women and Adolescents” in the second half of 1998 Citation[24], in response to demand from women's groups and progressive health professionals. The most controversial component are the legal requirements for providing pregnancy terminations, which include the written request of the woman or her legal guardian if she is a minor and reporting of the sexual assault at a police station. Although there have been at least three attempts by conservative parliamentarians to suspend the Guidelines, they have been defeated by a majority of the Congress, who are in favour of maintaining them Citation[1].
Many different institutions have carried out activities which, directly or indirectly, have helped in the setting up of legal abortion services. Women's groups mobilized by RedeSaúde have been very effective in lobbying state and municipal governments of large cities to develop programmes for the comprehensive care of women who suffer sexual violence Citation[2]Citation[25]. These initiatives have received the technical and financial support of the Federal Ministry of Health, who have contributed in several other ways as well. They have promoted the exchange of experience between centres with well-organized services and those at different stages of development. In 1999, the Ministry of Health created a new Section on Violence and Accidents, and soon afterwards the Thematic Group on Gender Violence.
Since 1998, in addition to the annual Forums, CEMICAMP and FEBRASGO have also worked to:
| • | identify obstetrician–gynaecologists, public health professionals, local government officials, women police officers and other professionals who were willing to take the lead in establishing new legal abortion services at local level; | ||||
| • | make direct contact with the heads of department and directors of Women's or Maternity Hospitals to ask if they are interested and willing to establish legal abortion services. Those who have expressed interest have been invited to the Forums and consultants have been provided to help them to organize internal meetings in their own hospitals or cities to discuss the issues and given other support until they are able to implement services; | ||||
| • | set up visits to well-established programmes which have agreed to act as models and provide training for interested professionals from other institutions which are in the process of setting comprehensive care for women victims of sexual violence; and | ||||
| • | the provision of direct technical assistance for the setting up of hospital-based services, not only by physicians but also by nurses, social workers and psychologists, emphasizing the interdisciplinary involvement required in the provision of these services, and the organization of local meetings in a number of cities ( Table 1 Number of activities per year July 1998 through June 2001 | ||||
Another institution, which has made an indirect contribution to these efforts is Ipas Brazil, who have carried out courses in the use of manual vacuum aspiration (MVA) for early abortion procedures and in the management of complications of abortions in many parts of the country.
Results
Thanks to the above strategies, and the increasing support from women's health advocates, health professionals and the Ministry of Health, the number of hospitals providing legal abortion services has increased considerably.
From four hospitals in two states providing services in 1996, there were 63 hospitals and clinics in 24 of the 27 states providing services as of December 2001. These include the teaching hospitals of the main medical schools, which not only add academic credentials to these activities but provide a model of care for students and residents. The exception is Rio de Janeiro, where the main university hospitals are still resistant to participating in this national movement.
All 63 hospitals had already been providing emergency services for women who suffered sexual violence and 40 had carried out abortions. Most of the other 23 had not done abortions because there had been no requests; only in a few has the staff not felt prepared when asked. Several hospitals initiated services for emergency care only but after having gained experience of helping women in this situation, they also began doing abortions.
Between January and September 2000, in the 37 hospitals that reported to CEMICAMP on these services, more than 1500 women received emergency care following sexual violence and just over 100 abortions were carried out. As emergency contraception with levonorgestrel is available in Brazil as part of emergency care, the programme may well have prevented more unwanted pregnancies than the total number of terminations indicates.
Although the number of legal pregnancy terminations carried out in the country has increased over time and with the opening of new services, it is only a small number compared to the number of unintended pregnancies occurring every year after forced sexual relations. The demand has in fact not increased at the same rate as the availability of services, whether because women are not yet fully aware these services exist or are afraid they will be exposed to public knowledge. There have been a few isolated cases of women who obtained a judicial order for a pregnancy termination whose names have appeared in the media. The source of information in these cases has been the police and not the health service. These reports have at least two types of negative effect. First, they give the message that women need a judicial order to obtain a legal abortion after rape; this is not only incorrect but is seen by most women as an insurmountable obstacle. Secondly, they suggest that any woman requesting an abortion runs the risk of similar exposure.
Until more women know about the services and feel more secure that confidentiality will be preserved, the number of legal abortions will grow very slowly. We believe, however, that the fact that the medical establishment is progressively accepting legal abortion as a legitimate part of its activities in the promotion and protection of women's health is very important in itself. While five years ago the few hospitals that provided services and the physicians responsible for them saw themselves at the margins of the obstetrics and gynaecology establishment, those who continue not to provide services now feel they have to excuse themselves for tardiness in responding to the legitimate claims of women.
This does not mean there is no opposition. The anti-abortion movement is very active in Brazil and there are highly qualified professors of obstetrics and gynaecology who strongly oppose the practice of abortion in all cases. On the other hand, an ever-increasing majority have been able to express a favourable attitude towards abortion in cases of rape and severe fetal malformation.
The care of women victims of sexual violence has been included on the programmes of a number of professional meetings and courses, thus creating a generally receptive environment which did not exist even one or two years ago. In preparing this paper, we asked the FEBRASGO-affiliated obstetrics and gynaecology societies how many sessions on sexual violence they had included in their local meetings or courses during the 12 months to September 2001. Some 60% of the members responded; 14 such sessions had been organized.
Lessons learnt and future challenges
We believe our experience is worth sharing with medical professionals and human rights activists from other countries. We have shown that working within the obstetrics–gynaecology establishment to make legal abortion available, in tandem with the women's health movement, is feasible and has a major effect on the chances of success.
For the dialogue between women's rights advocates and gynaecologists to be successful, certain conditions should be fulfilled. Physicians should be sensitive to human rights in general and open-minded enough to be able to listen and understand new concepts, previously foreign to them. Women should be tolerant, able to understand physicians' difficulties in dealing with abortions they would carry out. Women and physicians should also be able to express their ideas without being aggressive or unnecessarily offensive to one another.
Those with influence and prestige in both groups should be prepared to interfere constructively if the dialogue appears to change into a battle of misunderstanding. Those who have learned to understand the point of view of both sides and are able to articulate convincingly the points of common agreement are key persons in such a dialogue. Doctors who may have great difficulty accepting a woman's argument in defence of women's rights will be more willing to accept the very same argument from a colleague they respect and who understands and respects their point of view.
Secondly, a comprehensive approach to sexual violence, which includes pregnancy termination when required has a far stronger appeal to physicians and other health workers and is a far more acceptable approach than one limited to pregnancy termination in cases of rape. Moreover, hospitals and health professionals may start off by providing only emergency care to women and children who have suffered sexual violence, with no intention of providing abortions but after seeing the consequences of sexual violence firsthand, they may well end up also providing pregnancy terminations. This is clearly the case for at least one university hospital in the south of Brazil.
Thirdly, the involvement of a few influential leaders with courage and charisma can make the difference between inertia and progress in this delicate subject.
Fourthly, the use of misoprostol for inducing an abortion has facilitated the acceptance of pregnancy termination by health professionals. Early abortion with this method takes the surgical act of aspirating the contents of the uterus out of the hands of physicians, and transfers it to the action of a drug. In more than one institution, abortions have been carried out only after physicians learned how to induce abortions with misoprostol.
Finally, we are convinced that the successful provision of these services depends on institutional acceptance that they are a component of women's health care. As long as these services remain a separate activity involving only a few professionals, they are more exposed to attack by anti-abortion activists and their continuation will be at risk.
The progress achieved has been greater than expected and a great deal has been accomplished. Other institutions have realized that this is a strategy to be followed and are working in the same direction. The Ministry of Health itself is collaborating in this effort.
There is still a lot to be done before termination of pregnancy to the full extent of the law is accepted as a legitimate medical intervention and part of normal health care routine. Now, both the provision of and demand for services need to be improved. The strategy of providing comprehensive care for women victims of sexual violence appears to be effective towards these ends in Porto Alegre, Brasilia and Campinas.
The interpretation of the other legal condition for abortion, when it is the only means to save the woman's life, has yet to be addressed in Brazil. Many physicians currently believe there are few if any medical conditions which justify abortion for health reasons. The fact is, however, that there are many chronic illnesses which increase the risk to the life of the woman during pregnancy manyfold and women should have the right to decide how much risk they are willing to accept.
The model of working from within the medical establishment has been accepted as appropriate by other institutions and similar efforts have been initiated in other countries in the region, including Mexico, Peru, Bolivia and the Dominican Republic. Progress has so far been faster in Mexico, where the Brazilian experience has been influential.
The task ahead is probably greater than that achieved so far. The strengthening of the alliance between women's health and rights advocates and obstetrician–gynaecologists is crucial to continuing down this successful road.
Acknowledgements
The financial support of the David and Lucille Packard Foundation is gratefully acknowledged.
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