The decriminalisation of abortion in Colombia as cautionary tale. Social movements, numbers and socio-technical struggles in the promotion of health as a right

ABSTRACT

This paper discusses the complexity of contemporary struggles for collective health in Colombia, by analysing the efforts of different actors to inscribe abortion as a matter of public health and as a human right. In 2006 the Colombian Constitutional Court (Sentence C 355 of 2006) partially decriminalised abortion in specific circumstances. Such a change in regulation was the result of the strategic coordination of international organisations, researchers and women’s social movements. These groups produced a powerful network of international regulation and epidemiological data about abortion’s mortality and burden of disease in order to move the discussion from the moral field to public health and international law. Despite the significance of the sentence in terms of civil rights, ten years after the regulation there is no clarity about its impact. Conservative sectors within the government have limited the operation of the regulation, through eliciting convoluted rules for hospitals and care providers. On the other hand, data about safe abortions are weak and precarious. Recently groups opposed of abortion have exploited such weakness to undermine the impact of the decriminalisation and to criticise the justification of legalising abortion as a matter of public health.

KEYWORDS:

• Abortion
• sexual and reproductive rights
• Colombia
• strategic litigation
• quantification

Abortion and sexual and reproductive rights in Colombia

In Latin America, the decriminalisation of abortion and the promotion of other reproductive rights have been the result of the work of civil society (Baer, 2002). Women’s organisations and international public health authorities have promoted a public debate about the consequences of unsafe abortion and, in general, about reproductive rights in universities, media and civil courts. In the case of Colombia such work has been framed into the civil rights protected by the National Constitution of 1991. Different social movements have used the mechanisms of political participation opened up by this constitution.

The decriminalisation of abortion in specific circumstances in Colombia was the result of the work of feminist scholars and women’s organisations. In addition to their local work in media, street demonstrations and courts, they recruited international healthcare authorities and sexual and reproductive health organisations such as Planned Parenthood and the Alan Guttmacher Institute (AGI). They strategically situated the discussion about abortion as a matter of public health and human rights, moving the debate from the traditional moral and philosophical confrontations.

The controversy about abortion in Colombia has its origins in the decade of the 1970s with the introduction of reproductive technologies, birth control policies, second-wave feminism and the international impact of US legalisation (Roe vs Wade, 1973). These elements triggered a fight for the social and medical control of sexuality and reproduction between the state ‒ influenced by the Catholic Church and social groups ‒ and international networks promoting women and sexual and reproductive rights (Maldonado, 2014; Ruibal, 2015; Viveros, 1996, 2003; Viveros & Gil, 2006). Since then, many bills tried to change regulation through parliamentary mechanisms. Since the 2000s the strategy changed and women groups focused their actions on influencing High Courts, specifically the Constitutional Court (Jaramillo & Alonso, 2008). Such strategy has been successful in decriminalising abortion in the region and in the promotion of other sexual and reproductive rights such as the same-sex right to adoption and civil union.

In the last five decades, eight bills and four Constitutional lawsuits were presented to decriminalise abortion in Colombia. The latest request was presented by the Colombian lawyer Monica Roa, representative of the organisation Womeńs Link Worldwide. This lawsuit lifted the total ban by allowing the ‘voluntary interruption of pregnancy’ in the following cases: (i) when a doctor certifies that the life or health of the pregnant woman is threatened; (ii) when a doctor certifies that the foetus has an abnormality incompatible with life; (iii) when a pregnancy results from rape, incest or unconsented embryo transplant (Sentence C 355 of 2006, p. 301).¹

Although in many ways Roe v. Wade (1973) set the rhetoric of those groups advocating for a change in legislation regarding abortion in Colombia, in terms of legal strategy such groups constructed abortion as a matter of public health and human rights, rather than a matter of individual choice. Accordingly, the decriminalisation of abortion has been promoted as a public health intervention, intended to reduce mortality rates of women forced to use risky and unregulated practices (Maldonado, 2014).

This paper discusses the complexity of contemporary struggles for collective health in Colombia, by analysing the efforts of different actors to inscribe abortion as a matter of public health and as a human right. The decriminalisation of abortion was the result of the strategic coordination of international organisations, researchers and women’s social movements. These groups produced a powerful network of international regulation and epidemiological data about abortion’s mortality and burden of disease in order to move the discussion from the moral field to public health and international law.

In what follows, this article describes the efforts of women organisations and other interest groups to transform the debate about abortion in Colombia into a matter of International Law and Public Health. Firstly, it provides an analysis of the role of statistics and quantification in the success of the prolife strategic litigation. Numbers and a sociology of quantification contributes to understand the development of the controversy after the decriminalisation of abortion and the justification strategies elicited by both parts. Secondly, it describes the bureaucratic obstacles and difficulties in the enforcement of the Court decision. The opposition of high officials and the lack of data infrastructure have made extremely difficult the access to safe abortion in the country. Finally, this article reflects on the power and fragility of numbers. It shows the changing strategies of conservative groups that oppose sexual and reproductive rights. These groups have contested ‘official’ statistics to undermine the definition of abortion as a public health concern.

Despite the significance of the decision in terms of civil rights, ten years after the regulation there is no clarity about its impact. Conservative sectors within the government have limited the operation of the regulation, through eliciting convoluted rules for hospitals and care providers. On the other hand, data about safe abortions are weak and precarious. Recently, groups against abortion have exploited such weakness to undermine the impact of the decriminalisation and to criticise the justification of legalising abortion as a matter of public health.

This story provides an interesting case for analysing the political, legal and technical challenges that social movements face in tackling social and gender inequalities in healthcare. A socio-technical approach to the development of this controversy shows the importance of data infrastructures in the attainment of political objectives, and the entanglements between knowledge, regulation and grass-root processes.

Civil society, evidence and strategic litigation

The study of abortion in Colombia has been from diverse political approaches and disciplines, from theological and philosophical perspectives (Cotes, 2005), public health and medicine (Alan Guttmacher Institute [AGI], 2006, 2011), economics and sociology (Faúndes & Barzelatto, 2005; González, 2005; Gómez, 2006; Viveros, 1996; Viveros & Gil, 2006; Zamudio, 2000), to legal studies (Hoyos, 2005; Jaramillo & Alonso, 2008; Velazquez, 2006), among others. Within this scholarship gender studies have explored in detail the social dimensions of this debate and its implications in terms of gender politics. These works have understood the debate as a cultural and political fight between traditionalist and modern conceptions of the state and society (Viveros, 1996; Jaramillo & Alonso, 2008; La Mesa por la Vida y la Salud de las Mujeres [MVSM], 2009; Dalén, 2011). From this perspective, some works have analysed the discourses and rhetoric of the groups in debate (Dalén, 2011; Viveros, 1996), others have analysed the role of experts (Maldonado, 2014; Viveros, 1996) and the role of women’s social movements (Jaramillo & Alonso, 2008; MVSM, 2009).

Other academic works have studied the legal frame used to build the decision C 355 of 2006. Jaramillo and Alonso (2008) trace the two strategies developed by the organisation involved in the lawsuit, access to the mass media and the process of the lawsuit. By doing so, they argue, there is transformation in the conceptual apparatus that the decision introduced to the National Constitutional tradition. The C 355, according to the authors, makes a distinction between ‘life as a good’ and ‘life as a right’.

Although engagement and concern with women’s health of this scholarship is shared by many, these works have a tendency to approach only the groups in favour of legalising abortion, ignoring some of civil society’s other expressions of civil and political mobilisation. Social movements have had increasing impact on the relationships between knowledge and politics, specifically between biomedical knowledge, regulation and healthcare provision (Brown & Zavestoski, 2004; Epstein, 1996; Murphy, 2012). These movements have learnt about the importance of strategically influencing the state’s decision making. Recent work (Ruibal, 2015) has addressed the organisation of a counter-reformation in Colombia that has gone beyond traditional actors such as the Catholic Church, involving highly placed officers in government and religious grass-roots movements.

This paper focuses on the political use of numbers, specifically the quantification of the burden of abortion in the discussion about sexual and reproductive rights in Colombia and in Latin America. During litigation and discussion in the Constitutional Court, the production of figures about the death and illness caused by unsafe abortion was a key argument in favour of decriminalisation. However, once the change of regulation had taken place, health authorities noted the difficulties of keeping a reliable register of legal and illegal voluntary interruptions to pregnancy. This lack of statistics and clinical register have contributed to the misinformation and confusion about the limits of the legality of abortion in Colombia. This is partially orchestrated by conservative officers within public institutions and the government, such as the former General Prosecutor Alejando Ordoñez (Ruibal, 2015).

Figures and statistics have become the centre of discussions about abortion in the country and the region. The effort to decriminalise abortion in Chile and Mexico has triggered a discussion about the reliability of the data produced by national governments and international organisations about mortality and burden of disease related to unsafe abortion. In 2012 the Chilean epidemiologist Elard Koch published a series of papers questioning the methodology used by the AGI to estimate unsafe abortion in Mexico and Colombia. This opened a controversy about the reliability of the statistics about abortion and most importantly about the impact of the decriminalisation of abortion in the reduction of maternal mortality (MMR) and post-abortion emergencies. Religious universities and anti-abortion² groups have embraced this critique to reopen the discussions about decriminalisation and the status of abortion as a matter of public health.

Social movements and patients’ organisations have been key actors in the shaping of contemporary healthcare. Their work has transformed standards of care, advocating for the inclusion of new technologies and treatments and for the establishment of new relations between health professionals and particular groups of patients (Brown & Zavestoski, 2004; Epstein, 1996). Their advocacy has involved in many cases a deep engagement with the production of biomedical and technical knowledge. These groups have contested the design of medical trials, supported and encouraged research on specific drugs and have raised some issues as matters of concern through the production and communication of statistics and other forms of evidence (Adams, 2016; Akrich, Leaneb, Roberts, & Arriscado, 2014; Epstein, 1996; Murphy, 2012). The importance of the production of evidence in the governance of contemporary healthcare has been recognised by patients’ organisations and some of them have critically appropriated this framework to enhance their own claims (Akrich et al., 2014; Moreira, 2012).

Drawing on sociology of quantification this paper explores the strategic role of statistics and indicators in the contemporary struggles for sexual and reproductive rights in Colombia. Science and technology studies (STS) and sociology have shown an increasing interest in studying the numbers and effects of quantification in policy, public affairs (Desrosières, 1998) and healthcare (Epstein, 1996; Murphy, 2012).The sociological analysis of quantification has focused on numbers’ practical uses and the ways in which these are related to wider networks of practices (Desrosières, 1998; Espeland & Stevens, 2009; Fourcade, 2011). Through a discursive analysis of technical literature, regulation and press, this research provides an account of the tensions between evidence, reproductive rights, and the social movements that converge in the debate about abortion. These stories provide an interesting case for analysing the political, legal and technical challenges that face social movements and confrontations inside civil society when values and goals are contradictory. Finally, this paper wishes to open a discussion about the importance of numbers and statistics in public arenas and highly divisive political debates.

The methodological strategy used in this work is a discursive analysis of Colombian regulation, technical studies, newspapers and websites that document the debate about abortion in Colombia over the last decade. Specifically, I present a detailed analysis of decision C 355 of the National Constitution of Colombia and the regulation formulated by the National Ministry for Social Protection regarding IVE (voluntary interruption of pregnancy) from 2006 to 2010. Finally, to the extent that international organisations and groups have been engaged with the national discussion, I explore additional connections that complement the Colombian sources. I include in this discursive analysis AGI reports about abortion and the controversies that have grown around these reports and statistics.

Numbers and matters of concern: Making abortion a question of public health

Since the decade of the 1970s different social organisations have escalated around the idea of sexual and reproductive health and rights (Viveros, 2003; Viveros & Gil, 2006). This movement has taken as its flagship the decriminalisation of abortion. One of the most visible organisations within the movement is La Mesa. In 2004 leaders of this organisation discussed the possibility of decriminalising abortion through litigation in the Constitutional Court.

La Mesa has worked in the promotion of sexual and reproductive health since 1993. This organisation is a good example of the use of medical and technical expertise as instrument in wider political strategies. Different activists, women’s organisations, universities and think tanks converged in the agenda set by this board. The strategy was to open a public debate about the criminalisation of abortion as a human rights violation in parallel with discussion about the constitutionality of the current regulation. While some works (Jaramillo & Alonso, 2008) have understood the decriminalisation as the result of the work of experts and a highly trained circle of activists with experience in international law and lawsuits, La Mesa (board for the health and lives of women) highlights the role of a grass-rooted women’s social movement as the main actor in the transformation of abortion restrictions in reaching a consensus and coordinated mobilisation between the diverse social groups promoting gender equity. However, in terms of strategy, the focus of the group was to present abortion decriminalisation to the court as a matter of human and international right and as a problem of public health for national healthcare authorities.

The Colombian government, particularly, the Ministry of Health, embraced the last argument. In the deliberations of the Constitutional Court the ministry presented ‘evidence’ and figures to show the impact on public health of unsafe abortion in the country (C 355 of 2006) quoting a study developed by the AGI in 2006 about unsafe abortion in Colombia and the National Health Survey developed by Profamilia, a Colombian sexual and reproductive health organisation. AGI’s (2006) study calculated that in 2004 in Colombia around 30.000 unsafe abortions were performed. Additionally these studies established a connection between unsafe abortion and poverty, portraying the decriminalisation as an issue of social justice.

An understanding of abortion in terms of public health was key in the Constitutional Court’s discussions. The ruling is full of references to the burden of illegal abortion in terms of women’s mortality and morbidity. In many cases the sources of the figures are not quoted. However the main source of data about abortion in Colombia, at the time of the debate, was the study developed by the AGI (2006) about unsafe abortion. In other articles (Maldonado, 2014) I have shown the impact of this study in influencing court decisions by presenting the citation network that supports judges’ reasoning and argumentation. The Guttmacher study is assumed by the court to be evidence of the public health character of abortion in the country.

These numbers and the relations that they assume are the result of calculating fecundity rates, maternal mortality and actual number of births in specific populations. The court adopts this reasoning, as it is noted in the decision C 355 of 2006.

Therefore, in the poorest towns of the country converge high fecundity rates, high unemployment, unmet basic needs, precarious access to education and a poor performance in other healthcare indicators such as child and maternal mortality. This reflects inequalities and gaps in the social development of these communities. (C 355 of 2006, p. 1020)

Despite accepting the importance of this argument, at the time of the debate the court complained about the lack of epidemiological studies about abortion in the country. The Lancet, three years after the ruling, notes still the lack of reliable figures about legal and unsafe abortion in the country (The Lancet, 23 February 2009).

The production of statistics about abortion is a complex and contested matter. Abortion is still a taboo subject in many countries and an illegal practice prosecuted in some nations. Although figures about legal abortion should be produced in the same manner as other medical statistics through hospitals’ medical registers, in practice they tend to be under-reported (Brack & Rochat, 2016. On the other hand, estimations about unsafe abortion are very complex. Most of them are inferred from a wide and diverse set of sources such as hospitalisation for abortion, maternal mortality associated with unsafe abortion, and by contrasting the difference between estimated pregnancies and actual number of births in the population.

These data are complemented by information from the Ministry of Health and the National Institute of Legal Medicine. However none of these sources captured abortion. An indirect estimation of abortion had to rely on the identification of population at risk. High fecundity and poverty became key relations in the estimation of abortion figures. Such a way of estimating those figures highlights the vulnerability of specific populations, for example adolescents and rural immigrants. For instance, the National Survey of Demography and Health (ENDS) has shown a steady increase in adolescent pregnancy, growing from 19% in 2000 to 21% in 2005. These data are some of the elements for guessing the burden of abortion in the country.

In Colombia the main source of epidemiological data about sexual and reproductive health is ENDS. This is part of the international survey (DHS+) produced by Macro International and supported by the US Agency for International Development (USAID) and the United Nations Population Fund (UNFPA). Since the 1990s this survey has been not only a tool to provide decision makers with information about sexual and reproductive health but also a mechanism to open discussions in the media and public arenas about the importance of these issues. The statistics about abortion in Colombia have shared in this. They have reported matters of fact in order to produce matters of concern (Latour, 2004) in Colombian society.

Healthcare data and statistics in many regions of the country are mostly precarious. In the case of sexual and reproductive health most data are produced by independent organisations such as Profamilia and the Centre of Social Dynamics at Universidad Externado. The Ministry of Health manages the main epidemiological data with the National Health Institute. However in matters of social and reproductive health the main technical source is the DHS (ENDS).

At the time of the debate another important figure was related to the number of illegal abortion in Bogotá. The city’s Health Department calculated that 37,000 unsafe abortions are performed every year in Bogotá (Secretaria de Salud de Bogotá, 2006). This number supported the AGI’s estimates and contributed to the understanding of decriminalisation as a matter of public health. However, a year after the Constitutional Court’s ruling, a new debate arose about the impact of decriminalisation.

The figures about legal and illegal abortion in Colombia remain deeply confusing and a matter of intense debate. A year after the Constitutional Court’s decision, local media asked public authorities about the impact of decriminalisation in terms of numbers of performed abortions. One of the earliest attempts to estimate the impact of abortion decriminalisation was published in a Colombian newspaper El Tiempo in 2007. According to data provided by Bogotá’s Health Department, during the first year ten legal abortions were performed in hospitals in Bogotá, seven related to interruption of pregnancy as a result of rape (El Tiempo, 2007). However, the Secretary of Health noted that possibly many private clinics were not reporting the procedure.

A bureaucratic counter-reform and conservative social movements

Ruibal (2015) has identified two main phases in the process of implementation of Decision C-355 in Colombia. The first one (2006‒09) was marked by the active role of government agencies, in particular the Ministry of Health, in enacting regulations to implement the decision and to provide abortion services through the public health system. The second phase (2010‒15) has been marked by a strong reaction led by powerful conservative actors in key positions within the state, who have systematically attempted to obstruct the implementation of Decision C-355 and the development of demographic and epidemiological data to diminish the impact of decriminalisation. In response, feminist organisations have developed creative litigation strategies to demand the right to information about abortion services and organisations such as the AGI have continued their work in providing data about the impact of abortion in Latin America and in Colombia, stating that the problem remains a problem of public health in the region.

The process of regulation and implementation of the ruling was slow and strongly contested. The Ministry of Health enacted Decree 4444 of 2006 and produced technical guidelines for the voluntary interruption of pregnancy. However, the lack of adequate information and the resistance of many practitioners, and hospitals arguing conscientious objection and refusing to treat cases were the biggest obstacles to the implementation of the ruling. As a consequence many women had to go to the courts again asking practitioners to obey the law. This created additional rulings (T 714 of 2007, T 209 of 2008 and T 388 of 2009) declaring that hospitals and organisations cannot argue conscientious objection to deny medical attention and interruption of pregnancy. In cases in which practitioners refuse to deliver these services, the hospital should guarantee that other professionals are available to provide the healthcare being sought.

The Catholic Church has historically led the opposition to abortion. However, in the last decade, this movement has been transformed by a coalition of Christian churches. Catholic bishops and Christian preachers have been representatives of the anti-abortion movement in the country both in media and in courts. Additionally religious universities and national and international anti-abortion organisations have submitted amici curiae presenting arguments in favour of their position to the Constitutional Court at different times in the debate.

Both parts of the controversy made intensive use of amici curiae during the debate in the Constitutional Court (Maldonado, 2014). At that time the anti-abortion groups adapted their own discourse. moving their arguments from an ethical and theological framework to a jargon based on demography. The Population Research Institute was particularly visible (PRI, 2005). Anti-abortion organisations have attempted to appropriate the language of research organisations which they have perceived as biased. The PRI presents itself as a non-profit organisation whose goal is to criticise the overpopulation myth, expose human rights violations related to population control and promote people as the biggest natural resource. However, most of its work is focused on fighting abortion and its decriminalisation. One of amicus curiae of this organisation notes:

A comparative analysis of maternal mortality rates and decriminalization of abortion between countries shows that there is not significant co-relation or evidence to argue that the decriminalisation (liberalisation) of abortion has an impact in reducing maternal mortality. (PRI, 2005)

Through amici curiae different interest groups presented legal and scientific evidence that they considered may influence the decisions of the court. In the ruling that decriminalised abortion ‒ decision C 355 of 2006 ‒ the Constitutional Court presented a register of the different amici curiae and citizens’ declarations. These elements constitute a rhetoric device to show that the court’s ruling was based on listening carefully to the different voices of society.

However, during discussions in the Constitutional Court the amici curiae of the PRI failed to be recognised as a legitimate source of scientific data and the court did not recognise its expertise. A citation analysis of the court’s ruling shows that while the Guttmacher reports are repeatedly used as a source of information, the PRI is not quoted once (see Maldonado, 2014). The PRI could not obtain the same legitimacy as AGI. The institute has a well-established reputation as a non-profit organisation devoted to the study and analysis of policy in sexual and reproductive health. It works closely with the World Health Organization (WHO) and other international organisations such as the UNFPA. However, as I will show in the last section the anti-abortion movement has improved its technical skills, producing improved engagement with statistics and numbers to legitimise their political agenda.

In the last ten years, different conservative groups in Colombia have transformed the rhetoric and methods adopting the strategies of other social movements to oppose the advancement of sexual and reproductive rights claims. As Ruibal notes they have appropriated the ‘language of rights, mobilisation based on civil society organisations, legislative lobbying and strategic litigation’ (Ruibal, 2015, p. 19). This has been displayed in recent attempts to make referenda about abortion, the right of lesbian, gay, bisexual and transgender (LGBT) couples to adopt and be married.

At first, these groups’ actions were relatively uncoordinated without a clear leadership. However, the appointment of conservative activists at key state institutions triggered a big counter-mobilisation against sexual and reproductive health and rights and specifically against the decriminalisation of abortion. In 2009, a prominent conservative public official, Alejandro Ordoñez, was appointed as General Prosecutor, head of the Procuraduría General de la Nación. This institution was created by the 1991 Constitution to cover the duties of both Inspector General and Attorney General. This institution should enforce the Constitution, general laws, judicial decisions and administrative acts.

Ordoñez led different actions in order to sabotage the court’s decision on abortion. First he appointed as prosecutor for issues related to childhood and family to the conservative activist Ilva Myriam Hoyos, leader of the opposition to the decriminalisation of abortion. Second, he opened an enquiry into the use of misoprostol in hospitals. He argued that such a drug was unsafe and expensive in comparison with other methods. Ordoñez told public officials in charge of the implementation of abortion services that they could go to jail for reducing public finances by purchasing misoprostol.³ In addition in 2009, the prosecutor ordered the investigation and suspension of the construction of the Clínica de la Mujer (Women’s Clinic) in the city of Medellín, intended to provide sexual and reproductive health services (La Silla Vacía, 11 July 2012).

However the most serious action, in terms of obstacles to the delivery of healthcare services related to abortion and post-abortion events, was a lawsuit led by the prosecutor in 2009 demanding Decree 4444. Such a decree regulates the organisation of these services, giving guidelines for the implementation of the court’s decision. ‘The State Council upheld the claim, immediately suspended the Decree, and declared it null in March 2013’ (Ruibal, 2015).

These actions encouraged the coordinated resistance of different actors in the country to defend the decriminalisation. New lawsuits were presented to the Constitutional Court. This court kept the support of its ruling, extending the health exception. New decisions included a more comprehensive definition of health, introducing mental health as a criterion in making abortion legal. Finally, in 2016 the Council of State removed Ordoñez from his position as prosecutor after an enquiry that found serious offences in his election. Ordoñez responded by claiming that such a decision was politically motivated and that it was a request from the far-left guerrillas to sign a peace agreement. He joined the campaign of the elected President of Colombia Iván Duque in the 2018 Presidential Election.

The current General Prosecutor Fernando Carrillo has shown a more favourable stand regarding sexual and reproductive health, closing the debate within state institutions about the implementation of the Constitutional Court ruling. However, the debate about abortion in Colombia is not over. The presidential election (2018) has offered an opportunity for the mobilisation of abortion and other reproductive rights as some of the resources to exert influence on voters in a country that is experiencing increasingly cultural and political polarisation. Meanwhile anti-abortion organisations in the country and in the region have focused on debating the public health and epidemiological legitimation of the decriminalisation of abortion.

I conclude this paper by briefly presenting the controversy between a team of Latin American bioethics and epidemiology researchers led by the Chilean Elard Koch (Melisa Institute) and the AGI about the methodologies of estimation of legal and unsafe abortions and the impact of decriminalisation on the reduction of maternal mortality rates (MMR). This controversy has surged in the context of the debate about the decriminalisation of abortion in Chile. The Colombian case has been presented in this discussion as a model of strategic litigation. The main argument under debate is if the decriminalisation of abortion contributes to the improvement of public health.

The double edge of numbers: Problems in the production of statistics

This controversy was triggered by a report published by the AGI in 2011 presenting statistics about induced abortions performed in Colombia. The report stated that ‘an estimated 400,400 induced abortions were performed in Colombia in 2008, of which only 322 were reported as legal procedures’ (AGI, 2011). Additionally it noted that the number of abortions has increased over the last decades. The institute estimated that in 1989, there were 288.400 abortions. The increase is explained in connection with a demographic expansion in the number of women of reproductive age (AGI, 2011).

This report relies on a study conducted by Prada and colleagues who have estimated the rate of abortion in Colombia in the last three decades (Prada, 2013; Prada, Singh, & Villarreal, 2012). Despite the increase in abortions the authors argue that the rate has remained relatively stable: 36 abortions per 1000 women of reproductive age in 1989, compared with 39 per 1000 in 2008. Additionally they argue that the highest rates of complications after abortion are found in the Pacific area, one of the poorest areas of the country.

In 2012 Elard Koch from the Elisa Institute and his colleagues published a paper in the journal Ginecología y Obstetricia de México contesting the estimations made by the AGI, specifically the estimated number of 400,400 clandestine abortions for Colombia. They specifically criticise the methodology of these studies, describing Guttmacher’s methods in the following terms:

[F]irst, (Guttmacher) authors estimated the losses from spontaneous and induced abortions from the opinion of 289 subjects who work in an equal number of Colombian health institutions through the opinion survey entitled “Health Facilities Survey”. Subsequently, an expansive multiplier (×3, ×4, ×5, etc.) was applied to the numbers obtained by this survey that also emerges from a subjective opinion of another 102 respondents of the “Health Professional Survey” selected by convenience. (Koch et al., 2012, p. 360)

Koch and colleagues argue that Guttmacher methods do not work ‘with objective data based on real vital events, the whole estimate is based on imaginary numbers underlying mere opinions’. Moreover, they argue that Guttmacher overestimates more than nine times the complications due to induced abortion in hospital discharges and more than 18 times the total number of induced abortions (Koch et al., 2012, p. 360). Koch’s team make visible their interest behind this methodological and statistical critique. They argue that Guttmacher numbers have strong implications for the policy of the Latin American region. As they note,

in other Latin American countries where the same methodology was applied including Argentina, Brazil, Chile, Mexico, Peru, Guatemala, and Dominican Republic, the number of induced abortions was also largely overestimated. These results call for caution with this type of report that alarms public opinion. (Koch et al., 2012, p. 370)

Koch and colleagues propose an alternative method that relies on hospitals’ clinical records of post-abortion events and on the use of data from Chilean healthcare to calculate missing information to be estimated in Colombia.

The AGI did not ignore such a critique and developed a detailed response. Guttmacher’s researchers note that they used a method called abortion incidence complications method (AICM). ‘It was developed about 20 years ago and has been widely used in studies that have appeared in reputable peer-reviewed journals. It is recognised by experts in both the academic community and international organisations, such as the World Health Organization (WHO)’ (AGI, 2012, p. 2).

They argue that this method is used in countries where abortion is legally restricted and in those where, despite its legality, it is still unsafe because of social stigma or for problems with data and healthcare infrastructures. ‘When abortion is illegal or stigmatised, the procedure is performed in secrecy; as a result, women are reluctant to report it, and providers are reluctant to register it’ (AGI, 2012, p. 4). The social and legal complexity of abortion demands in Latin America yield estimates, rather than exact values.

The AICM relies on two types of data to estimate the number of abortions: ‘the number of women who receive facility-based treatment for induced abortion complications; and the proportion of all women having abortions who receive facility-based treatment for complications’. In many cases an inflation factor is applied to the number of women treated in health facilities for induced abortion complications to yield the total number of induced abortions. In the Colombia case this is done because the quality of hospital records has ‘deteriorated to an unacceptable level after decentralisation and the reform of the health system in 1993’ (AGI, 2012, p. 4).

Guttmacher experts note that Koch and colleagues erroneously state that the Colombia Health Facilities Survey (HFS) is based on a convenience sample. The HFS sample is selected through use of a multistage stratified cluster sampling technique. After a detailed analysis of each element of the Koch critique, they conclude that he and his team fail in both their attempt to discredit the AICM and their attempt to present a credible alternative for estimating abortion incidence in countries where the procedure is highly restricted. ‘Their approach is simplistic, highly misleading and simply wrong. Its underlying assumptions have no scientific basis and show no respect for contexts, a significant problem’ (AGI, 2012, p. 9).

Koch’s proposal relies on calculating abortion rates using demographic indicators based on ‘real vital events’ or ‘standard rates from known populations’. Guttmacher notes that such methods fall into the fallacy of assuming that high-quality data from one population could be applied to other populations without any modification, and that applying such measures to a different population will generate reliable estimates for that population. ‘This is not the case for any demographic measure, as such measures are influenced by many country-specific factors; it is especially erroneous with regard to abortion in settings where the procedure is illegal and stigmatised, and occurs clandestinely’ (AGI, 2012, p. 9).

Koch and his colleagues have continued their critique of the Guttmacher reports. They claim epidemiological data show that abortion related complications do not significantly affect MMR in Chile. This work has been published in peer-review journals, in general interest blogs such as the AAAS (American Association of the Advancement of Science) and some of them in highly ranked journals such as the Public Library of Science’s PLOS one. Koch’s work shows a transformation in the strategies of anti-abortion groups in Latin America. They have embraced a more ‘scientific’ and ‘technical’ approach to the debate about abortion and have designed a more sophisticated strategy to influence public opinion and decision makers.

In a blog entry from the international organisation World Youth Alliance (WYA), one of the contributors notes her favourable impressions of Koch’ work.

With the use of statistics, he talked about the positive impact of the results of his studies, demonstrating that decriminalizing abortion is not related to the decrease of the MMR. The most important conclusion was that maternal mortality reduction is due to access to good infrastructure in a health care system, which includes high levels of education for women. Also, he noted that Article 119 of Chilés Health Code, which prohibits abortion, helped in the reduction of maternal mortality by 93.8%. One of the reasons why Chile has one of the lowest rates of maternal mortality in Latin America is because of this legislation, which was adopted in 1989. (WYA, 2017)

The WYA itself reflects a new type of anti-abortion organisation. It presents itself as an international collaboration of activists concerned with the reduced scope of the United Nations population policy, specifically with its focus on abortion. The organisation argues that its goal is the promotion of the dignity of the person and of alternatives to abortion. It keeps its discourse very secular, mimicking the language and style of reproductive rights organisations and other international rights movements.

On the other hand, Koch’s organisation (the Melisa Institute) has set an anti-abortion research agenda in biomedicine. In addition to their work contesting the statistics that have supported the decriminalisation of the abortion in Latin America, the institute is devoted to the study of foetal malformations and the development of surgical and medical intervention to preserve its life.

This new institutional setting and the adaptation of conservative social movements represent a challenge in the promotion of sexual and reproductive rights in Latin America. These groups are adopting a more coordinated and strategic approach to intervene in public policy beyond the traditional mechanisms of the Catholic and Evangelical Christian churches. This movement has learnt about the importance of producing ‘evidence’ and numerical data in the legitimation of their own political agenda. Additionally, learning from the strategies of other social movements, including the experience of women’s organisations in changing national policies, they are aware of the importance of thinking in terms of Latin America rather than keeping only a national specific focus. They have learnt that the constitutional order is increasingly international and that changes in regulation in other countries can affect national and local policy.

Conclusion

This paper has shown some of the struggles of the groups that promote collective rights in Colombia, specifically of those devoted to the liberalisation of abortion and the promotion of sexual and reproductive rights. After a landmark change of regulation, decision C 355 of 2006, these groups have experienced a series of difficulties and a complex reaction from conservative sectors and social movements within Colombian society. They have faced the sabotage of high officials in the Colombian government who have used their political position to promote their personal agendas and religious beliefs. But also they have had to deal with precarious data infrastructures that make it difficult to demonstrate impacts and to monitor the impact of court decisions. Most importantly opposition to the liberalisation of abortion has adapted to a policy environment sensitive to international regulation and to technical and scientific evidence.

Opposition to abortion has triggered the engagement of citizens into politics and has empowered new advocates such as the Christian churches as influential political actors. Debates around sexual and reproductive health reveal the diversity of citizenship, the tensions within civil society and in the increasing polarisation of political cultures in Latin America. This study of abortion allows us to explore the production of values within civil society groups and the strategies of these groups to promote their own valuation strategies as normative stands.

The debate about abortion reveals a wider transformation in the definition of human life, its value and limits in Colombia and Latin America, and changes in the politics of life. The controversies around abortion show the impact that changes in reproduction technologies have had on different social groups. Some of them have embraced such transformation; others have perceived them as a threat. In recent times Colombia has experienced an increasingly cultural and political polarisation, different groups are clashing to materialise their ideas and representations of body and society.

Finally, numbers have an important role in public arenas. Statistics sometimes have been used as a mechanism to avoid political discussion in public debates, attending to the assumed ‘objectivity’ of numbers. However, once numbers get into the centre of discussion, they are open to debate and become a contested matter. The production of statistics in the debate about abortion in Colombia shows a transformation in the ways in which numbers are read and become entangled with wider politics. Such transformation presents a challenge to public health authorities, experts and reproductive rights activists who have to create better numbers, more accountable and more accessible to wider audiences. Citizens need to learn to distinguish between good and bad calculations, between statistics as rhetoric devices and numbers as representations of collective realities.

Acknowledgements

The author would like to thank Derly Sánchez Vargas and the anonymous reviewers for their helpful and encouraging comments on earlier versions of this article.

Disclosure statement

No potential conflict of interest was reported by the author.

ORCID

Oscar Javier Maldonado http://orcid.org/0000-0002-0142-3625

Notes

1. Although there are no reported cases of unconsented embryo transplant in Colombia, the court included this condition as a legitimate cause for requesting legal abortion. This debate is relatively rare in connection with the discussion about abortion but it has been discussed in relation to the ethics of embryo transplant. This condition is understood in connection with medical practice but not regarding those cases in which women became pregnant because their sex partners did not allow them access to birth control (Andrews, 1984).

2. The debate about abortion has elicited a language deeply politically charged to call the parts in controversy. Groups in favour of abortion have called themselves ‘pro-choice’ while anti-abortion groups have adopted the name ‘pro-life’. In this paper I have tried to avoid such politics of language by referring to ‘pro-life groups as anti-abortion.

3. This policy was outrageous and clearly politically motivated. Misoprostol is widely considered a very safe and affordable drug. It was included by 17th Expert Committee on the Selection and Use of Essential Medicines in 2008 in the WHO List of Essential Medicines because of its importance for treating post-partum haemorrhage (PPH). Besides the use of misoprostol for inducing abortion, it is an important drug to stock in obstetric services around the world.