Clandestine Abortion in Mexico: A Question of Mental as Well as Physical Health

Abstract

Abstract

This paper reports on research carried out in Mexico City in 1995–1996 on the meaning of motherhood, contraception, an unwanted pregnancy or child, and the experience of illegal, clandestine abortion, as described by 12 women of different ages, class, education and marital status who had one or more clandestine abortions. A priest, two doctors from the public health system, a group of gynaecologists and nurses and a health social worker were also interviewed. The data show that it is the illegal and clandestine nature of abortion that has a negative effect on women in Mexico. Although terminating a pregnancy can also be a difficult experience in itself, it became traumatic for most (though not all) of the women interviewed due to the dominant Catholic church doctrine that abortion is a sin, and because of the criminal law punishing those who have abortions, which forces women to have the procedure in high risk conditions, all of which adversely affected their mental and physical health. In spite of this, all the women considered abortion a personal decision that they had to make. Even those who believed that termination of pregnancy was the transgression of a divine commandment also believed that it was a rightful and necessary decision, given their circumstances.

Résumé

Une recherche menée à Mexique en 1995–1996 s'est penchée sur la signification de la maternité, la contraception et une grossesse ou un enfant non désiré, et l'avortement illégal, clandestin. Cette expérience a été décrite par 12 femmes d'âges, de classes, de niveaux d'instruction et de situations de famille différents ayant subi un ou plusieurs avortements clandestins. Un prêtre, deux médecins du système public, un groupe de prestataires de services et un travailleur social ont également été interrogés. Les données montrent que c'est la nature illégale et clandestine de l'avortement au Mexique qui crée un effet négatif sur les femmes. Bien qu'une interruption de grossesse puisse être une expérience difficile en soi, elle est devenue traumatique pour la plupart des femmes interrogées (mais pas toutes) en raison de la doctrine catholique dominante selon laquelle l'avortement est un péché, et du code pénal qui punit les avortements, ce qui force les femmes à avorter dans des conditions à haut risque, aux dépens de leur santé mentale et physique. Pourtant, toutes les femmes considéraient l'avortement comme une décision personnelle. Même celles qui pensaient que l'interruption de grossesse violait un commandement divin croyaient qu'il s'agissait d'une décision juste et nécessaire, compte tenu de leur situation.

Resumen

En la Ciudad de México en 1995–1996 se llevó a cabo una investigación acerca del significado de la maternidad, la anticoncepción, un embarazo o un/a hijo/hija no deseado/a, y la experiencia del aborto ilegal y clandestino, descrito por 12 mujeres de distintas edades, clases sociales, nivel de educación y estado civil, quienes habı́an tenido uno o más abortos clandestinos. Se entrevistaron además a un sacerdote, dos médicos a de salud público, un grupo de ginecólogos y enfermeras, y una asistente social de la salud. Los datos indican que es la naturaleza ilegal y clandestina del aborto en México que causa un efecto negativo en las mujeres. Si bien el terminar un embarazo es puede ser una experiencia difı́cil en sı́, para la mayorı́a (aunque no todas) de las mujeres entrevistadas, les fue traumático debido a la doctrina de la iglesia católica que califica el aborto como un pecado, y por la ley que penaliza a quienes abortan. A consecuencia, las mujeres se ven forzadas a buscar abortos en condiciones de alto riesgo, lo cual les afecta negativamente tanto la salud fı́sica como mental. A pesar de ello, todas las mujeres consideraban que la decisión de abortar era una decisión personal que debı́an tomar. Aquellas que creı́an que terminar el embarazo significaba transgredir un mandato divino, también creı́an que habı́an tomado una decisión necesaria y correcta, considerando las circunstancias en que se encontraban.

Key Words:

• clandestine and unsafe abortion
• mental health
• reproductive histories
• Catholic Church
• Mexico

“… when I see other children who are not loved, who are battered … That's why I don't want any more children. They shouldn't be born. If we say abortion is a crime, at least it is committed only once. The crimes against an unwanted child, however, are committed every day.” (Amelia)

The need for safe, legal abortion as a matter of good public health policy has been argued mainly on the basis of the evidence of maternal mortality from abortions performed in unsafe conditions in countries where it is illegal. Although abortion is acknowledged as the third most important cause of maternal mortality in Mexico, annual figures are only estimates because of its clandestine nature. Figures range from 110,000 deaths per year from the governmental Consejo Nacional de Poblaci ó n (National Council on Population) [1] to 850,000 per year from the non-governmental Comit é por una Maternidad sin Riesgos (Committee for Safe Motherhood) [2].

There has been less research on the extent of morbidity from unsafe abortions, especially regarding the negative effects on women's mental health. Right-wing groups have used potential, negative psychological effects – even from safe abortions – to condemn abortion, arguing that the procedure itself is harmful to women's well-being. Such allegations are not based on evidence, but are derived from a deliberate lack of analysis of the conditions in which abortion is carried out in many countries, including Mexico, where it is illegal and therefore takes place in dangerous circumstances [3].

The fact that most abortions are illegal in Mexico ¹ [4] is a reflection of the dominant thinking in our culture. This is linked to the idea that sexuality and reproduction must be restricted and regulated by judicial, religious, medical and educational institutions which rarely respond to people's needs, in this case to women's needs. In this context, sexuality does not belong to individuals, but to the institutions which rule them.

The legal, cultural, religious and social conditions prevalent in Mexico have consequences not only for the proliferation of clandestine abortions but also for the meanings that women ascribe to pregnancy and its termination, which are in turn affected by the experience of obtaining the procedure. It is the context of moral disapproval, illegality and inaccessibility of abortion services that has an impact on women's mental health.

This paper is based on the fact that in Mexico motherhood is the main function that women have been appointed to fulfil and which defines them as persons. Reproduction carries a plethora of meanings beyond its biological aspect and historical particularity, which transform it into a universal and irrevocable phenomenon. Stigma therefore tends to surround the woman who has an abortion, regardless of her specific situation and needs.

This notion of being a woman developed gradually from the clash between the image of Mary, the mother of Jesus Christ, from Spanish Catholic culture and pre-Hispanic female goddesses in the 16th century, including both Guadalupe, the dark virgin whose cult is still so popular in Mexico, and Tonantzin, the ancient goddess-mother. These images have been strong influences in the construction of a Mexican national identity, within which the cult of motherhood has been so important ² [5][6][7][8].

These dominant images affect individual experience and determine how people see themselves and are seen by others, and the way they experience their bodies and desires [9]. Women who abort are no exception to this. They also have an effect on public policies and legal dispositions. Thus, the decision to have an abortion and its practice becomes an expression of resistance to the social construction of femininity, beyond any meanings which individual women may attribute to it.

The research

This paper draws on research carried out in 1995–1996 on the exclusion and social condemnation of women who have undergone an abortion, through an analysis of the dominant meanings of femininity, pregnancy, motherhood and abortion itself.

We wanted to ascertain whether the negative effects that abortion is said to have are universal or are related to the material, legal, cultural and subjective context in which abortion is experienced and carried out. We explored these questions through the qualitative analysis and interpretation of the reproductive histories of 12 women from Mexico City, whose age, class, education and marital status varied, but who had all had at least one abortion.

The choice of participants came about because we questioned the notion that there is a defined `profile' of women who have abortions. As Cabrera [3] argues, pregnancy termination is present in all societies, regardless of race, class or religion. The main difference relates to the quality of the procedure, with good quality of care reserved for women who can afford expensive clinics and physicians. Thus, health is a question of socio-economic status and not of rights, as it should be.

In order to analyse the dominant narratives in Mexican society as well as women's histories, we also interviewed a priest, two doctors from the public health system, a group of service providers from the private sector (gynaecologists and nurses) and a health social worker. All of them worked in Mexico City, but cannot be further identified because of the clandestine character of abortion in the country.

It was also very difficult to find women who were willing to be interviewed. We went to several public hospitals to try to talk to women while they were being treated for incomplete abortion, but not only did their emotional state and physical condition make it impossible to interview them there, but also the fact that they were in danger of being reported to the authorities for an illegal act.

We also tried a process of open invitation through several physicians who agreed to help us contact women. This strategy failed as well, we think due to the need for secrecy among middle-class women.

Finally, we were put in contact with women who agreed to become participants through some civil society organisations, especially those working for women's rights. They were very willing to tell their stories, whether because they needed to be listened to or because they wanted to contribute to making safe abortion a right for all women. We made sure that the interviews were conducted in what the participants considered a safe environment, which often meant away from their homes and daily activities.

We recorded and transcribed the interviews, making sure that the women remained anonymous. The analysis and interpretation were based on these texts, through codes and categories inductively constructed from the data. After the analysis, we talked to the organisations who put us in touch with the women about the results of the research, and they in turn informed the women. The interviews produced a vast amount of material; we will present here the most important aspects of some of the recurring themes.

The study participants and their reproductive histories

At the time of their last abortion, 10 of the women were between 26 and 40 years old, the two youngest ones were under 18 and the oldest one was 46.

The interval between their most recent abortion and our interviews with them varied, from several hours after the procedure in the case of the woman who had a legal abortion that was the result of rape, to 20 years later. This obviously meant there were certain differences in how they felt about the abortion, but what seemed more meaningful was the ambivalence some of them felt about pregnancy and being pregnant, the religious beliefs they held regarding abortion, and the clandestine and unsafe conditions of the procedure (Table 1

Table 1 History of live births and abortions of the 12 women

Name	Age	Occupation	Yrs. school	Reproductive history	Couple status
Clarisa	29	Psychologist	20	2 abortions	Divorced/new partner
Lolita	34	Domestic worker	4	3 children > 1 abortion	Married
Mara	37	Family business	6	6 children > 1 abortion	Married
Amelia	32	Self-employed	6	1 abortion > 3 children	Married
Olivia	39	Seamstress/employed	9	4 children > 1 abortion > 1 child	Married
Marcela	65	Pension/housewife	9	1 child > 1 abortion > 1 child	Widow
Susana	43	Government employee	9	3 children > 1 > abortion	Married
Ana Marı́a	42	Secretary/family business	13	1 abortion > 1 child > 1 abortion > 1 child	Divorced
Malena	26	Student/teacher	14	1 abortion	Single
Patricia	33	University lecturer	20	3 abortions	Single
Pilar	28	Social worker	12	2 abortions	Single

).

The meaning of pregnancy and contraception

One important distinction that came out in the interviews was that pregnancy did not seem to mean the same as having a child. That is, most of the women appreciated and even desired their pregnancies, but did not feel the same about actually giving birth to and having a child. According to Viggetti-Finzi “in these cases, actual pregnancy, even when unwanted, responds to a need for reassurance of a woman's fertility” [10].

Although in our culture pregnancy is supposed to be a source of women's power, it also seems to blur women's sense of individuality. As the following statement shows, pregnancy seemed to make a woman worthy in the eyes of her partner, but only during the time of gestation. Once the child was born, Mara felt her value as a person decreased considerably, which in the end make her feel only as if she were a gestating womb:

“… when I told him [her husband] that I was pregnant, he was very happy, he took good care of me, but once the baby was born, he was much happier with the baby than with me.” (Mara)

Since being a woman is so closely linked to motherhood, even the women who had managed to acknowledge their own needs and to construct their own spaces often found it difficult to achieve their goals. The higher their socio-economic level, however, the closer the women were to being able to imagine an independent life project. The women who were professionals or on the way to becoming professionals greatly valued their careers. They nevertheless unquestionably assumed that it was mainly their responsibility to raise their children.

“I'm the one who bears the brunt.” (Clarisa)

Contraception was one of the most complex subjects for the women. The decision not to get pregnant involved contradictory feelings and motives that were difficult to pinpoint. The irregular contraceptive behaviour of the great majority of the women, whatever their chosen method, seemed to evidence a great reluctance to act fully on their decision.

First, even those women with a higher level of schooling often failed to accept that they were at risk of pregnancy. Contraceptive misuse or discontinuation was common and one or more of the following conditions seemed to be operating:

•	the women ignored or lacked knowledge of both female physiological processes and contraceptive methods, or
•	they had knowledge of both but were not close to role models who approved of or had actually used contraceptive methods, or
•	they knew of and were close to role models who could be imitated, but there was interference from a largely unconscious wish to get pregnant and/or to have a child, or
•	it was impossible to negotiate contraception with their partner.

The desire to know whether they were fertile seemed to prevail among this group of women (and surely among many others) in spite of their conscious desire not to have a child at the moment when they got pregnant. At the same time, the use of pregnancy as a means of reinforcing an unstable relationship also appeared to have motivated their behaviour. The central contradiction they expressed seemed to be an unconscious desire to get pregnant versus a conscious decision to avoid pregnancy.

Furthermore, actually choosing and using a modern contraceptive method was viewed by the women as an extremely complex process. If a woman considers herself as a subject vis-à-vis her body and her sexuality, she is more likely to take care of herself. Recognising the need to use contraception implies that she values herself as well as others, a perception which challenges the surrender and self-denial that femininity is identified with.

It could also imply an acceptance of sexual pleasure over and above reproduction. In fact, in some cases the women seemed to prefer the risk of pregnancy to the stigma generated by using contraception, which would have implied renouncing motherhood. It should nevertheless be noted that the women were seldom fully conscious of these processes. They only recognized them in the course of narrating their histories.

Unwanted pregnancy or unwanted child

The reasons why the women did not wish to continue their pregnancy varied substantially and included:

•	conflicts with their partner that did not create an appropriate environment for a child's birth and upbringing (lack of stability, domestic violence, in the process of getting divorced or separating, second relationship);
•	unfavourable economic conditions and impossibility of providing for a(nother) child;
•	number of existing children; no wish to have another child; felt motherhood role had been fulfilled;
•	personal projects;
•	rape.

Conflict within the relationship with their partner made having a child seem highly inappropriate for some of the women. In some cases, they would have been happy to have the child, but the emotional relationship between the woman and her partner did not allow for it. It is precisely due to changing circumstances that the very same woman may respond completely differently to her different pregnancies. For example, Patricia was diagnosed as infertile while in one relationship. Her first two pregnancies (and abortions) occurred during a relationship with a married man:

“For me, being pregnant was good news because it was a relief to know that the diagnosis of infertility was wrong … [But when] I told him I was pregnant, he said `I'm glad you're pregnant, but it's very unfortunate' – it was difficult for him to divorce his wife and separate from his daughters.” (Patricia)

Some of the women who, like Patricia, had no children, had an intense desire to become mothers. This made the decision to have an abortion extremely painful and difficult, particularly as it was accompanied by a lack of certainty that they would be able to get pregnant again. These were all women with higher education, who had a greater possibility of being autonomous and whose expectations from a relationship were therefore higher.

Among the others with higher education, however, having an unwanted child would have interrupted their personal plans. It was clear that they did not want the pregnancy or the child, but social mandates made it difficult for them to acknowledge this openly.

The position of the women who already had children was again different. It was not so clear to them whether they wanted another child or not, partly due to the fact that their motherhood role was already being fulfilled. Furthermore, they felt that an additional child could endanger their ability to be a good mother. There was, however, another dimension that went beyond the difficulties of having another child and that was having a partner with a history of child abuse. Two of the women had no wish to bring a child into the world because of this.

“[My husband] would kick and beat his children and he wouldn't pay any attention to our daughters … so I said, “Oh God! What should I do? I didn't want to get pregnant. What I am carrying inside me is not to blame, but for it to come into this life …” I said to myself, “I'd better risk [abortion]. I don't really want my family to grow in size.” (Olivia)

To sum up, although most of the women struggled with these issues, they managed to take ownership of their bodies in practice by recognising the reasons why they had to terminate their pregnancies and then actually doing it. The difficulties came from the notion that this form of taking care of themselves could be considered an offence against their status as moral beings and their gender identity. The struggle between obedience/self-renunciation and transgression/self-assertion seemed to be a recurring theme, in which ownership of their bodies prevailed and strategies to face the consequences were clearly present.

Experience and conditions of the abortion

The women who had the resources to take a more or less autonomous decision regarding one or more of their abortions, were also accompanied by a family member and had previously received health care. They were the ones who managed to obtain better abortion care, in that during the procedures none of them experienced any complications or needed hospital admission for post-abortion treatment.

The women who had more than one abortion often had different experiences in each of them. Some of the women who had more than one abortion and those with fewer social and economic resources, had to resort to local midwives or to self-induced abortion using surgical probes, teas and/or injections. All of them experienced complications from these abortions and required attention at a clinic or hospital. These women had no one to accompany them during the process either. A deep solitude and sense of isolation prevailed in these experiences. None of the women actually knew what was happening to their bodies; mostly they remembered feelings of terror, emptiness and death.

Another reason why the experience was negative in some cases was that the clandestine doctors made it clear they had only a commercial interest in providing abortions, and completely disregarded the women's concerns and fears.

In contrast, some of the procedures were performed by providers who had the medical, technical and material resources to provide appropriate medical care, particularly in case of emergency. They showed an understanding attitude and that they were willing to help a woman resolve her situation without questioning her decision. This produced a very much needed sense of security and well-being that made the women feel safe during the abortion. One of these was Clarisa, a middle-class professional who had the economic and social resources to have a safer procedure:

“[The doctor] told me at the beginning that she believed it was a woman's choice to have children or not, that she was actually one of the doctors who defended women before the law because she performed abortions. That made me feel very good.” (Clarisa)

Psychosocial effects

Those women who took autonomous decisions to have an abortion, with an awareness of their own rights, experienced positive emotional effects and made a rapid and total recovery. Ana Marı́a, Clarisa and Mara never mentioned feeling guilty. Whether they were mothers or not, all three expressed great relief and a sense of immediate calm after the abortion. They interpreted it as a postponement of procreation rather than a transgression of a divine commandment.

“I felt freer. I felt released from a problem … calm. Another opportunity will come my way, I'm sure. As far as I remember, I've never felt any remorse, in spite of my Christian upbringing.” (Ana Marı́a)

Following the principle that voluntary motherhood requires appropriate economic and emotional conditions that grant security to both mother and child, Clarisa and Ana Marı́a felt no guilt or regret for having had an abortion.

“… for me it was like an addition to my self-esteem since it is a decision I made, something I truly believed in and that I actually managed to carry out. It did not create the slightest conflict for me … It has never created conflict for me, to the extent that I am able to talk about it.” (Clarisa)

Two women, Marcela and Susana, who wanted to have more children but did not have the conditions in which to take care of them, suffered greatly after the abortion. They nevertheless did not describe pregnancy termination as a moral transgression, nor the feeling of having committed a heinous offence, but rather the emotional pain and suffering caused by the loss.

Abortion had different consequences for the remaining eight women. To a greater or lesser extent, they fell prey to feelings of guilt and the need for repentance. Their narratives show that guilt emerged from the sense of having committed a moral and religious transgression, to which God would respond by punishing them. However, their families pronounced even more severe sentences on them than the Church's own representatives.

“I felt guilty in myself. My father used to say, `God punishes. He doesn't forgive.' I felt God was going to punish me. I was afraid of God.” (Amelia)

These feelings of suffering were not only related to a sense of loss or the image of a yearned-for child or wanted motherhood, but to the feeling of having carried out an act against a defenceless being, which had gone “unpunished”. Even Leticia, whose pregnancy was the result of rape and whose abortion had been approved in court said, “I killed someone innocent. I feel depressed”.

On the other hand, in spite of adhering to the dominant discourse of Catholicism, the fact that they resorted to abortion shows that at a certain level they decided not to comply because they had to take the reality of their lives into account.

Discussion

The illegal and clandestine nature of abortion in Mexico creates a context in which negative effects are difficult to avoid. In spite of this, we also encountered the liberating possibility of reflection, self-awareness and clear decisions in some of the women. Although terminating a pregnancy can be a difficult experience in itself, it became traumatic for two main reasons for most of the 12 women in this study. On one hand, there is current Catholic doctrine, which condemns abortion as a serious sin that offends God, which too often leads to feelings of transgression, danger and humiliation that are difficult to cope with and overcome. On the other is the criminal law, which penalises abortion in most circumstances and threatens to punish those who have abortions, which forces women to have the procedure in high risk conditions. Both adversely affect women's mental and physical health. These findings are in line with research which suggests that psychologically negative effects of abortion are linked more to the conditions in which it is carried out than to the decision and the procedure itself [11][12][13].

Although there have been encouraging, favourable changes in abortion law in Mexico City, and intense debate nationally in the past two years all over Mexico, provision of legal abortions in the health services and law enforcement is far from adequate. For instance, doctors can refuse to carry out the procedure on grounds of conscience, or the paperwork needed from the local authority can take too long to prepare, beyond the first trimester of pregnancy. Hence, the prevailing conditions of secrecy and risk still apply in most cases.

This study was done before these political changes began to take place, but now that the subject is on the public agenda, it is important to show just how much women have been affected by restrictive laws and public policies, as well as by cultural constructions of motherhood that still prevail amongst many physicians and law enforcement officials, as well as the Church.

In this context, aggravated by the silence that surrounds unwanted pregnancy, women cannot always take the decision to have an abortion in a calm and untroubled way. If women were openly allowed to consider all the alternatives available, through open discussions in the education system and through the provision of counselling services within the health sector, the risk would be substantially reduced for them. And although decriminalisation of abortion in itself would not automatically resolve the negative psychosocial consequences we saw in this study – not least since the Church's position, the way health care providers view abortion and the social construction of gender would not immediately be modified – decriminalisation would open the way to reducing the negative impact that illegal, clandestine abortion has had on Mexican women.

Acknowledgements

Part of this article was originally published in M Rivas Zivy and A Amuchástegui Herrera, Voces e Historias sobre el Aborto, Mexico City: EDAMEX/Population Council, 1996, and reprinted here with kind permission.

Notes

1 Abortion is legal (but not in all states) only when pregnancy results from rape or forced insemination, when the mother's life or health is in danger, when the fetus is malformed, or when the mother has three children or more children and proves she cannot support another (only in one state) [4].

2 For a discussion regarding the place of the myth of Guadalupe in the construction of a supposed national Mexican identity and how this is gendered (see [5][6]). To trace the origins of the cult of Mary and its relationship to Indian cultures. See [7][8].