Misoprostol Is a Game-Changer for Safe Abortion and Maternal Health Care. Why Isn’t it More Widely Available?

 

by Francine Coeytaux, Public Health Institute (PHI)

and Elisa Wells, Independent Consultant

May 28

 

http://rhrealitycheck.org/article/2013/05/28/why-arent-we-taking-advantage-of-the-potentially-game-changing-drug-misoprostol/  

 

Misoprostol: Have you heard about this small, inexpensive, and most importantly available pill that can save women’s lives? Pragmatic Brazilian women first discovered the potential of misoprostol (or Cytoteca, in their parlance) in the 1980s. According to the label on this widely used peptic ulcer drug, it was not to be taken during pregnancy as it could induce bleeding. Living in a country with very restrictive policies and little access to safe abortion services, they recognized the opportunity to circumvent the system and, by word of mouth, spread the word to other women about this easily obtainable pill that could help them safely end an unwanted pregnancy.

 

Thirty years later, women in countries around the world are beginning to do the same-continuing to spread the word, talking to each other about misoprostol, and trying to get their hands on these pills. The women who are accessing the drug in their communities and taking it by themselves have shown us that there are relatively few health risks involved with misoprostol. What began in Brazil as a natural public health experiment has been validated by rigorous clinical studies conducted by international groups such as the World Health Organization and Gynuity. These studies have shown that the use of misoprostol for abortion is very safe, especially when taken early on in the pregnancy; while not as effective as when taken in combination with mifepristone (another abortion pill), misoprostol taken alone will safely terminate 75 to 90 percent of early pregnancies when taken as directed.

 

Misoprostol has also been proven to have numerous other lifesaving properties, including the ability to prevent and treat postpartum hemorrhage and to induce labor. It is registered in more than 85 countries, usually as an anti-ulcer medication, and is used off-label by clinicians around the world for numerous reproductive health indications. In addition to these clinical uses, we are beginning to see positive public health outcomes from community-based use of misoprostol. In countries where abortion is restricted and women are using misoprostol, we have seen a reduction in infections. And in under-served communities, where women delivering at home are taught to take misoprostol immediately after delivery, postpartum hemorrhage is significantly reduced.

 

If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide-postpartum hemorrhage and unsafe abortion-why have we not taken more advantage of this exciting technology? Given the global attention being paid to meeting the fifth Millennium Development Goal (MDG 5)-that of reducing maternal mortality-it is difficult to fathom why we continue to squander the opportunity misoprostol offers us.

 

The public introduction of any new technology takes time and is not easy; the introduction of emergency contraception is just one of the latest examples. Reproductive health advocates have been working for decades to increase women’s access to this safe, effective, and non-abortifacient technology. While much progress has been made around the world, the recent action of the Obama administration to prevent full over-the-counter access in the United States is a sad illustration of the hurdles women face in accessing reproductive health technologies. The hurdles we face in introducing misoprostol will be even higher given three inherent characteristics:

It has multiple indications, including abortion.

It is only “second best” to existing drugs, competing with a “gold standard.”

It can be used by women without the assistance of a provider.

The Challenge of Multiple Indications

Misoprostol’s greatest clinical asset-the fact that it can be used for numerous reproductive health indications-also poses enormous challenges for implementation. As mentioned, misoprostol has many uses: to both prevent and treat postpartum hemorrhage, to induce labor, to induce abortion, and for post-abortion care. But these multiple indications pose two major challenges for implementation, one political and the other educational.

 

The political challenge lies in overcoming the stigma of abortion. A survey we conducted in 2010 of organizations that were working with misoprostol for postpartum hemorrhage revealed that the second biggest barrier to the introduction of misoprostol was its association with abortion. To quote one respondent who was asked about the challenges and opportunities for its introduction: “Hypersensitivity of misoprostol as an abortifacient [is a barrier]. We see this in clinical providers, government officials, even donors-a disproportionate concern that if misoprostol were to be made available for PPH prevention and treatment, it would be used for abortion. This is a major obstacle in accepting misoprostol for other OB/GYN indications-the abortion stigma.”

 

This political fear is strong, despite the evidence that all indications of misoprostol use are potentially life-saving. And because of this fear, there is a great deal of sidestepping going on as organizations begin to introduce misoprostol at the community level for postpartum hemorrhage while trying to stay clear of its potential use for abortion. “We feel there is tremendous promise for use of misoprostol for [postpartum hemorrhage], so we do not want to jeopardize that application by highlighting the other indications,” said another respondent.

 

The political controversy only exacerbates the programmatic challenge of informing women, their partners, and their health-care providers of the different doses and the proper timing of administration needed for different indications. This is usually facilitated by the registration and labeling of products in appropriate doses for each of misoprostol’s various indications.  

 

But because the vast majority of misoprostol use is currently done “off-label”(it’s being used for an indication other than the one the product is registered for) there is an urgent need to find ways to get women accurate information about how to use it for the different reproductive health purposes. Mobile technologies are beginning to open the information door to some women, but challenges remain. We need to find ways of achieving a broader level of knowledge about correct use, and to help women differentiate between the proper uses for each indication, including abortion.

 

The Challenge of Competing Against a “Gold Standard”

For both indications-abortion and postpartum hemorrhage-misoprostol is the second best option, up against another drug long considered the “gold standard.” For abortion, the most effective medical abortion regimen is mifepristone combined with misoprostol; when used together, the success rate is 93 percent, and when misoprostol is used alone it is 78 percent successful. Thus, where mifepristone is available, such as in the United States, it is the drug of choice.

 

In the case of postpartum hemorrhage, injecting oxytocin is the first line of treatment because, when oxytocin is at full potency, it is more effective than misoprostol. But oxytocin, unlike misoprostol, needs to be refrigerated. As a result, the quality of the drug is easily compromised by exposure to heat-a problem in many Global South countries. Finally, the administration of oxytocin requires that the women deliver in a health-care facility, another “gold standard” established by the medical community.

 

In reality, in many places in the world, we are not meeting these “gold standards,” in spite of decades of trying to do so. Mifepristone is far from universally available, oxytocin stock-outs are common in many places and/or the quality has been compromised, and many women continue to deliver at home, without skilled attendants. In these situations, misoprostol is a very good alternative and even has the advantage of being in pill form, making home use possible and safe.

 

Which brings us to the third challenging characteristic…

 

Women Can Use it Without the Assistance of a Provider

Another survey respondent summed it up nicely: “This is a gender issue. Misoprostol faces this unbelievable barrier because it is a drug for women.”

Therein lies both the greatest opportunity and the greatest challenge.  

 

Misoprostol has the potential to be a game-changer when it comes to maternal health precisely because it can be used safely and effectively by women themselves. The foremost obstacle to achieving MDG 5 is the weak health-care infrastructures of many countries. Misoprostol offers the opportunity to circumvent this obstacle for two of the three principal causes of maternal mortality-postpartum hemorrhage and unsafe abortion. Yet despite growing evidence that women can safely and effectively take misoprostol by themselves, in their homes, for both uses, health-care practitioners are insisting on controlling access to the drug, viewing it as an important addition to their clinical tool kit and a service only they can “provide” instead of as a pill that can be used by women, to help themselves, with little or no assistance from a health-care provider. The failure to relinquish control over the use of misoprostol not only gets in the way of women who are intent on helping themselves, it risks negating the most attractive aspect of this new technology: it’s self-use properties. To quote another respondent to our survey: “Many people are more concerned about what might happen with an intervention (i.e., side effects) than what might happen without an intervention (i.e., maternal death). In this case, women are more likely to be harmed by omission of the intervention than from any danger posed by the intervention itself.”

 

Obviously, as we work to make misoprostol available at the community level we need to acknowledge that it is a powerful drug and that incorrect use can lead to serious consequences-such as uterine rupture during labor induction. While some would use this as an argument for placing restrictions on access, we see this as a call to put accurate and comprehensive information about its safe use into the hands of women.

 

The Way Forward

This week policy makers from around the world are gathering in Malaysia at the third Women Deliver Conference to continue to share ways of reducing maternal mortality. Misoprostol is the single-best opportunity to do just that. But the true potential of this simple and cost-effective technology lies in our willingness to abandon our “provider” frame and put the pills directly in women’s hands. Our challenge is to let women be the shapers and the users of this new technology, not the beneficiaries of what we can provide or what we think they need. Can we stop worrying about women’s “misuse” or “abuse” of misoprostol and show that we truly trust women with their own reproductive health care? Let us remember that it was women who discovered this drug in the first place, specifically to circumvent the weakness of the health-care system. Let us give them back this powerful tool and get out of their way.  Our responsibility is to ensure that women have easy access to the pills and all the knowledge necessary to use them effectively and safely.

 

New website www.doctorsforchoiceireland.com

The website www.doctorsforchoiceireland.com has just gone live.

Doctors for Choice is an alliance of independent medical professionals and students advocating for comprehensive reproductive health services in Ireland, including the provision of safe and legal abortion for women who chose it.

We believe that women should be supported to make their own decision regarding their sexual and reproductive health and to manage their own fertility, with doctors and nurses providing expert advice and care without judgment, recourse to the law or fear of criminal sanction.

We welcome your support. If you are a doctor or a medical student we will gladly welcome you into membership. You can contact us at doctorsforchoice@gmail.com

Follow them on Twitter and Facebook.

 

e: doctorsforchoice@gmail.com

t:  @doctors4choice

f:   Doctors For Choice Ireland

w:  www.doctorsforchoiceireland.com

 

Suicide in Pregnancy is much rarer now ‘thanks to legal abortion’

http://www.nwci.ie/news/2013/03/22/suicide-in-pregnancy-is-much-rarer-now-thanks-to/

22 Mar 2013

Dr Peadar O’Grady, Doctors for Choice speaking at seminar “Abortion – The Lives and Health of Women”

Article by Dr Peadar O’Grady, Consultant Child and Adolescent Psychiatrist and member of Doctors for Choice

It is important in discussing the relevance of suicide in the current abortion debate that good medical practice does not come second place to legal arrangements for certification. Maternal mental health matters because of the effects on the mother of mental distress, self-harm and the catastrophe of a completed suicide, but also because of the devastating effects any and all of these can have on any children involved. It is often observed that during pregnancy the incidence of mental health problems and suicidal ideas is high but the risk of completed suicide is lower than usual for comparable women. Even so, because the total of maternal deaths in pregnancy is low, suicide is still one of the top 4 causes of maternal deaths in developed countries.

Groups at higher risk of suicide are those with an unwanted pregnancy, particularly teenage mothers and those on low incomes. In its 2009 report on Maternal Mental Health, the UN’s World Health Organisation (WHO) has highlighted the increased risk of mental health problems in, “unintended pregnancy especially among adolescent women”. The WHO emphasises the further risk from factors such as poverty and lack of support, “in contexts in which there are strong, gendered role restrictions on women including lack of reproductive rights”. ‘Reproductive rights’ for women means the right to decide whether or not they want to have children and, if so, how many and when.  To be vindicated this right requires access to abortion services but also access to good quality obstetric, contraceptive and STD services as well as sex education and information. In his 2011 journal article ‘Suicidal Mothers’, Salvatore Gentile agreed that maternal suicide attempts during pregnancy were increased where there was: “teen age, unplanned pregnancy, unmarried status or recent divorce, unemployment, and difficult access to safe abortion service(s).”

It has also been observed that suicide in pregnancy (and the year after delivery, known as the ‘puerperium’) has become much less common with access to legal abortion services. Professor Robert Kendell summarised this conclusion in the title of his 1991 review in the British Medical Journal: ‘Suicide in pregnancy and the puerperium, much rarer now: thanks to contraception, legal abortion and less punitive attitudes’. It is therefore clear from the WHO and peer-reviewed research that restricting access to abortion, that is, denying women ‘the right to choose’, raises the risk of suicide in pregnancy.

Despite this the opposing notion that choosing an abortion increases the risk of mental health problems, and even suicide, persists. This false conclusion is a misreading (often deliberate and repeated) of the fact that there is often a higher incidence of mental health problems found in people who have had abortions than among those giving birth. However ‘correlation is not causation’. When previous mental health and unwanted pregnancy are taken into account there is no higher rate after an abortion. This makes abortion a ‘risk indicator’ rather than a ‘risk mediator’. As we have seen the likely mediators are unwanted pregnancy and previous mental health problems. It is also well known that, following abortion, mental health problems are more common where the woman has had a negative attitude to abortion before and a negative reaction after, especially when she has been under pressure to have an abortion. The ‘right to choose’ must be without pressure to choose a certain way. Good counselling and practical support before and after this decision is the key to supporting women with unwanted pregnancies.

A similar example of prejudice clouding judgement is the observation that LGBT individuals are at higher risk of mental health problems. One conclusion (by many of the same fundamentalist Christians who populate the anti-choice lobby) is that homosexual or transgendered people should be ‘cured’ from this presumed ‘disease’. The modern psychiatric approach, based on evidence, has been to reject the notion of homosexuality or transgender as diseases by identifying the high incidence of bullying and discrimination as causative factors, or ‘risk mediators’, for mental health problems in this group.

When the allegation, that abortion leads to mental health problems or suicide, is systematically investigated, it is found to be false. In the US the American Psychological Association in 2008 found there was no credible evidence that choosing to have an abortion raised the risk of mental health problems. In the UK the National Collaborating Centre for Mental Health’s review in 2011 reached the same conclusion. Where there the choice of legal abortion services is available there is no increase in suicide (or mental health problems) caused by choosing an abortion with informed consent.

Anti-choice proponents have emphasised that ‘Abortion is not a treatment for suicide’ and ignored the fact that there is no such narrowly-defined thing as a ‘treatment’ for suicide. However, abortion, for those who choose it with proper supports, can be as much a ‘treatment’ for the risk of suicide as blood pressure tablets are a ‘treatment’ for the risk of a heart attack. Both can be preventive, lowering the impact of a relevant risk factor; that is, the distress of an unwanted pregnancy and high blood pressure respectively. The ‘treatment’ for unwanted pregnancy is ‘non-directive counselling’ and the ‘treatment’ for suicidal risk in unwanted pregnancy is ‘risk-reduction’, which includes facilitating the choice of accessing abortion services.

In Ireland, abortion, and even access to information on abortion, is heavily restricted with a criminal sanction, confirming the ‘punitive attitude’ Prof Kendell referred to over 20 years ago. Women are forced to travel, usually alone or with a very restricted support network because of the costs of travel. As a result, in this Irish context, the restriction of access to abortion services is mediated by restrictions on travel. The following groups, whose ability to travel is compromised, are therefore at an increased risk of restricted access to abortion and hence at an increased risk of suicide:

• Women too sick to travel
• Adolescents and young women
• Women with young children
• Migrant women
• Women with Disabilities
• Women with no or low incomes
• Women whose pregnancy, involves a fatal foetal malformation
• Women pregnant as the result of rape or child sexual abuse.

The obvious solution to these risk factors is to end the unnecessary, dangerous, and, for the most part, ineffective legal restrictions on abortion services. This is the very successful approach taken in Canada for the last 25 years. Abortion there is subject to healthcare guidelines and not criminal law; just like every other medical service. It is an ongoing absurdity that pregnant women are in some way considered to be exceptions to the usual rules of capacity to make a decision.

It seems likely however that, instead of the Canadian model, emergency legislation in Ireland will deal only with the risk to just some of those whose ability to travel is restricted. The ‘need’ to distinguish between, and medically certify, a risk to the life, as opposed to the health, of pregnant women has put an emphasis on suicide that shows little concern for either crisis pregnancy or suicide.

In summary, in terms of mental health concerns, it is important to stress that unwanted pregnancy and previous trauma or mental health problems are the most relevant risk factors for mental health in pregnancy and that women on low incomes and child and adolescent mothers are at particular risk; the focus should be on care and support. Restriction of access to abortion increases suicide risk and supported choice reduces suicide risk. While there is no medical need for aspecial legal framework for abortion, doctors are perfectly capable of certifying the need to support a woman’s choice of abortion services to reduce her risk of mental health problems and suicide.

Doctors for Choice is an organisation of doctors who wish to promote choice in reproductive healthcare. This means advocating for informed consent as the basis for decision making within the doctor-patient relationship. The NWCI and Doctors for Choice recently organised a Seminar on “Abortion – The Lives and Health of Women”, see presentations from the seminar.

 

Inter-American Human Rights Commission to hold landmark hearing on abortion rights

 

 

3 March 2013

 

Ipas News

 

Inter-American Human Rights Commission to hold

landmark hearing on abortion rights

 

On Friday, March 15th, the Inter-American Commission on Human Rights will hold a landmark hearing on the negative impactof criminal abortion laws. It is the first time the IACHR will hear testimony on theharmful effects these laws have on the lives of young girls and women and their families in Argentina, Bolivia, Brazil and Peru.

 

Ipas and Ipas Bolivia, in collaboration with Women’s Link Worldwide, ISER/Brazil, Promsex/Peru, Argentina, the Special Rapporteurship on the Right to Sexual and Reproductive Rights/Dhesca Brazilian Platform and Asociación por los Derechos Civiles/Argentina, will present findings from legal research on the impact of abortion criminalization on women’s lives, health and criminal justice systems. These findings indicate that states are systematically violating women’s rights to health, equality and non-discrimination, privacy and due process of law. The organizations will present recommendations to the IACHR on measures to be taken by states to respect and protect women’s human rights.

 

Legal indications for abortion are extremely limited throughout Latin America, and several countries-Nicaragua, El Salvador, the Dominican Republic and Chile-have outlawed abortion entirely, even when necessary to save a woman’s life. Previous regional human rights decisions have called on states to ensure access to abortion in narrow circumstances-such as when a pregnancy threatens a woman’s health or if she’s been raped. This hearing will address the broader social and legal impact of criminal laws.

 

The hearing will be take place 11:30 a.m. at the IACHR’s Rubén Darío Room (8th floor), 1889 F Street, NW, Washington, DC. It will also be webcast live on IACHR’s web site. It will be conducted in Spanish, with translation available.

 

Argentina: Safe Abortion Hotline with Misoprostol

Great article in the Argentine newspaper Pagina 12, about a network of women, called Pink Rescue, who accompany other women in the use of misoprostol for safe abortion. They give information, advise about risks and help make sure the women get a checkup afterward.

Articulo excelente sobre Socorro Rosa servicio de acompañamiento de mujeres que están usando el misoprostol para abortar con seguridad. Dan información, consejan sobre los riesgos y ayudan a segurar que la mujer haga un examen de control despues.

http://www.pagina12.com.ar/diario/suplementos/las12/13-7899-2013-03-16.html

 

Germany: Failure to provide assistance to rape victim

Parliamentary Assembly

Assemblée parlementaire

   

Doc.13110

24 January 2013

 

Failure to provide assistance to rape victim in Cologne, Germany, 15 December 2012

 

Written question No. 624 to the Committee of Ministers

by Ms Carina HÄGG, Sweden, Socialist Group

 

On 15 December 2012 in Cologne, Germany, two Catholic clinics rejected assisting a suspected rape victim in providing a gynaecological check-up for reasons claimed to be related to the ethics rules and procedures governing the hospitals which fall under the authority of the Catholic hierarchy in Germany. The 25 year old young woman woke up on a bench in a public park after having been drugged at a party she attended in Cologne with no memory of what happened in the intervening hours. With her mother, she went to a general practitioner who suspected that the young woman could have been the victim of rape/sexual assault. The general practitioner prescribed emergency contraception which is standard practice under German law in cases of rape/sexual assault, thus providing the young woman the ability to exercise her right to decide according to her own convictions whether to carry through or interrupt a possible pregnancy resulting from the sexual assault. After informing the police and in order to investigate possible criminal acts the general practitioner contacted two nearby hospitals for further medical testing, ie. conducting a ‘rape-kit’ – these were St.Vinzenz-Krankenhaus in Cologne-Nord and Heilig-Geist-Krankenhaus in Longerich (both happen to belong to the Foundation of Cellitinnen of Holy Maria).

 

However, both hospitals rejected the check-up of the suspected rape victim. Their Ethics Commissions had held consultations with Catholic Church authorities, after which the decision was taken to rule out such gynaecological check-ups in such cases since they are connected with a possible unwanted pregnancy as well as providing the victim with emergency contraception. The refusal to provide medical treatment based on Catholic ethics was maintained by the two hospitals even after the general practitioner clarified that he had already provided the suspected rape victim with the emergency contraception (which the Catholic hospitals would therefore not have had to provide).

 

In Germany, failure to provide assistance to a person in danger (unterlassene Hilfeleistung) is an offense according to paragraph 323c of the Penal Code (Strafgesetzbuch).

 

Ms Hägg,

 

To ask the Committee of Ministers:

 

– whether such actions by the Catholic hospitals in Cologne are in line with both the letter and the spirit of the laws in relation to the protection of victims of sexual assault/rape, specifically paragraph 323c of the German Code penal?

 

– whether it is known how many hospitals / health centres may be able to legally circumvent national laws in relation to the protection and assistance to victims of sexual assault based on  so-called ‘ethical’ grounds in Council of Europe member States?

 

– whether the public at large as well as victims’ associations and women’s groups should be informed in advance of all such hospitals / health centres in Council of Europe member States which may legally be allowed to circumvent national laws in relation to the protection and assistance to victims of sexual assault based on so-called ‘ethical’ grounds so that they may be able to better guide victims of sexual assault/rape?

 

Australia: Locking up pregnant women

http://www.essentialbaby.com.au/pregnancy/pregnancy-nutrition-and-wellbeing/locking-up-pregnant-women-20130212-2e9ln.html

Locking up pregnant women

Date January 16, 2013

Amy Gray

Queensland’s Child Protection Inquiry has received a submission from the Queensland Police Union (QUPE) advocating that pregnant women who use drugs and alcohol should be locked up or placed under conditions to protect their unborn babies.

Inside the nine page document are a series of recommendations of changes to be made to the Child Protection Act, chiefly concerned with the QUPE complaining at having to do DoCs work and their plans to regulate all those wayward pregnant women.

As they state in their submission, the part of the Act which pertains to the rights and liberties of a pregnant woman “needs to be abolished.” A woman is now considered secondary to the pregnancy she carries.

 The QUPE calls on the inquiry for the rights to:

• request intervention orders against pregnant women
• take the mother into care pending birth
• impose forced medical check ups
• impos[e] conditions on the mother during the pregnancy, which may extend to where she resides and who she has contact with during her pregnancy

In case it’s not clear, the Queensland Police Union would like to start rounding up, monitoring and curtailing the personal choices and liberties of pregnant women.

Though this organisation has delivered a shoddily presented and ill-conceived set of recommendations to a panel, it does not mean it will be accepted or, even if it is, inquiry recommendations are often left to mould on shelves without adoption. So far, so ineffectual. What is newsworthy here is how the Queensland Police Union, whose members protect and defend their state, view women. And they don’t view them well at all.

Socially, this is not news for women. With every chastisement, unsolicited recommendation and unbidden hand that launches at our bellies, we’ve long known we were pregnancy-policed by the public. Now it appears real police would like to get in on the fun and tell us that we are hosts for the child – not a mother growing dependent life, not even two parties: we are the lesser life form because it’s all about the baby.

Helpfully, the Queensland Police Unionclarifies that it is not calling for anti-abortion laws, which must be a blessing for those living in a state with ambiguous abortion laws at best. Because it’s never a legal slipperly slope for female body autonomy when you request the legal rights of a woman be removed, right?

Let us leave aside for the moment the fact that this recommendation comes from the same union that complains about the workload of administrative duties relating to investigating children at risk and sex offenders in the community.

Instead, let us focus on the impact of this decision for women within society within the framework of statistics.

The Australian Institute of Health and Welfare in their Drugs in Australia 2010 report state that “Alcohol, tobacco and illicit drug use was significantly lower among pregnant women than women who were not pregnant. The proportion of pregnant women smoking has declined from 2001 to 2010.“

The report lists the findings of a National Drugs Strategy Household Survey which found that alcohol consumption amongst pregnant women dramatically drops, with 48.9 % abstaining completely, 48.7 reducing their alcohol intake and 2.0% maintaining their existing drinking (the level of which is not verified). Only 0.2% of respondents increased their intake of

When it comes to illicit drug use, 8.3% of women who were pregnant and/or breastfeeding in the past 12 months admit to the use of cannabis, pharmaceutical for non-medicinal purposes and other illicit drugs. Bear in mind that this figure includes women who had used drugs prior before they knew they were pregnant and, according to the report, “are significantly lower than for other women in the community”.

Bearing in mind the above statistics, if a system exists that penalises and curtails a pregnant woman for drug or alcohol issues, how likely would a woman be to actually seek assistance for the matter? The fear of being taken into ‘care’, restricted from seeing people she knows and other restrictions would prevent her from seeking the help she may need.

Karen Healy, President of the Australian Association of Social Workers agrees. In an interview with the Australian, she branded the proposal “concerning” and that “It could lead to women not disclosing they are using drugs to medical practitioners…It may actually reduce the capacity of medical professionals to monitor these children.”

So, not only would this recommendation actually not prevent the risky behavior, it could potentially not only drive it underground but also scare women away from support.

So, who will think of the babies, you ask? Who will protect them from their mothers? There is no doubt there are at risk pregnancies – but they are not widespread  and policing and punishment won’t help. Only rational programs and support will. There is no doubt this is a complex area but if we don’t learn from the horrors of past generations, we will never solve problems for the future.

Consider also the implications of who would be under review should this recommendation become enacted. Will it be across all classes? Or will only women from lower-socio economic backgrounds be targeted?

As stereotypes and our national sport of bogan-bashing goes, poorer people are often depicted as drinking more than any other class in Australia. This is a particularly curious stereotype given statistical analysis shows that personal income rises, so too does alcohol consumption across both genders. (Drinking Patterns in Australia 2001-2007, Australian Institute Health and Welfare). One can’t shake the feeling these desired powers would be used almost exclusively against lower socio-economic brackets.

The more troubling aspect of this recommendation is disturbing matter of race that underpins it all. As part of the Inquiry’s aims, the Commissioner has called for recommendations to “reduce the over-representation of Aboriginal and Torres Strait Islander children in the child protection system”.

So, is it a logical conclusion that the Queensland Police Union would apply these requested powers over the same over-represented community? That the focus of this would be of pregnant women of Aboriginal and Torres Strait Islander heritage?

It is our indigenous communities who face the most intervention and there is no doubt there are challenges and problems for them, just as with many other Australians. But legislating against them (again) will not work, nor does the evidence show that it ever has worked.

The report from Queensland’s Child Protection Inquiry is due in April, a month before National Sorry Day. People around the country will gather to remember the apology from five years ago. It is a time when we recall the horrors suffered by Australia’s indigenous population. A population who still suffer from reduced education, health, social and economic opportunities than other Australians. A population whose children were stolen from them in an effort to make them assimilate and disappear into Australia’s population. A population targeted by the Queensland Police Union and other groups who still want to curtail their liberty and take their children.

What is the point of saying sorry if we keep trying to make the same mistake?

 

Commentary: What the Spanish abortion law has meant for European women

http://www.abortionreview.org/index.php/site/article/1323/

31 January 2013

Dr Carlos Morín, the Barcelona abortion doctor facing a possible sentence of 273 years in prison for practising almost a hundred abortions, has been absolved of all charges. Jennie Bristow discusses the circumstances and broader implications of his trial.

Another 10 defendants also faced heavy prison charges for illegal abortion, forgery, conspiracy and professional intrusion; however, the Barcelona court has ruled the abortions were carried out according to the law, and ‘with the consent and under the express request of the pregnant women’, the Spanish newspaper El País reports (1).

With this ruling, notes El País, ‘the Court of Barcelona has closed today an episode that marked a before and after in the Spanish legislation on abortion’. The Morín case attracted attention across Europe because, as the London Times reported back in 2011, ‘hundreds of women from Britain, Spain and other parts of Europe who were seeking late abortions were treated at the Ginemedex and TCB clinics in Barcelona, which were run by Dr Morín’. (2)

In Spain and beyond, the Morín case highlights some unsettling features of the legal and cultural situation surrounding abortion laws in Europe , and their implications for women and doctors. Above all the case shows how quickly, in a febrile cultural climate, countries can shift from being a haven for desperate women who could not be treated elsewhere in Europe into a hell for the doctors who helped them.

Context

Carlos Morín’s Ginemedex clinic in Barcelona has been the focus of attention by anti-abortion groups and media organisations for several years. In 2004, the British newspaper The Sunday Telegraph conducted an undercover investigation into the practice, by the abortion provider British Pregnancy Advisory Service (BPAS), of giving women the Ginemedex clinic’s telephone number when they were too late in the gestation of their pregnancies to be given an abortion under British law. A ‘supplementary report’ published by the Sunday Telegraph one month later ‘alleged that a general practitioner based in the South Birmingham Primary Care Trust had offered to facilitate the referral of a late abortion to the same clinic’. (3)

In Britain, the maximum ‘time limit’ for abortion (except in cases of fetal anomaly or to save the mother’s life and health) is 24 weeks; and pressure on the ‘late’ abortion services at that time meant that a woman presenting for an abortion at gestations over 21 weeks could not always obtain treatment in Britain. In such circumstances, staff at BPAS would sometimes pass on to these women the telephone number of the Ginemedex clinic, where abortions were conducted up to and beyond the 24-week British limit.

The Sunday Telegraph investigations caused significant fall-out in Britain . The Chief Medical Officer (CMO) conducted a thorough investigation of practices at BPAS, and in a report published in September 2005 (3) concluded that, while some of the advice given to the undercover journalist by staff at the BPAS helpline was unacceptable and that training issues should be addressed, BPAS had not broken any laws and continued to run a good service for women needing abortions at later gestations.

The CMO noted that ‘a woman is entitled to travel to another member state of the European Union for a termination of pregnancy’, and that information received from the Catalan Health Authority at the time of writing his report indicated that ‘there is no evidence of the Spanish clinic having acted outside of Spanish abortion law’.

The CMO’s most significant conclusion, for Britain , was that the circumstances leading to women being given the number of the Spanish clinic indicated broader inadequacies in the late abortion service in Britain , where the lack of provision meant that some women were denied access to the abortions to which they would have been legally entitled. The CMO called for an inquiry in the late abortion service in Britain – to date, this has not been acted upon.

Over in Spain , the campaign against Carlos Morín continued. In 2006, a Danish TV company conducted an undercover investigation of the clinic; this prompted another inspection by the health authorities, which found nothing illegal. The ‘ultra-Catholic’ group E-Christians then lodged a complaint about Morín at the Barcelona doctors’ association, which failed. In 2007, following a legal complaint against Morín by an employee, the clinic was searched, documents confiscated, and Morín arrested.

The puzzling thing to arise from this chronology of events is, what changed between 2006 – when the health authorities were apparently satisfied with Morín’s practices – and 2007, when he was arrested and his practice shut down? Again, it is fruitless to speculate on specific details that may emerge over the course of the case. But given broader developments in the Spanish abortion law from 2007, it is necessary to look at the changing cultural, political and legal context in which the Morín case has developed.

The Spanish abortion law, 2004-2007

As things stood in 2004, abortion was permitted under Spanish law for the following reasons:

• The pregnancy is the result of rape – up to 12 weeks gestation;
• The fetus, if carried to term, will suffer from severe physical or mental defects – up to 22 weeks;
• The abortion is necessary to avoid a grave danger to the life of or the physical or mental health of the pregnant woman – no time limit. (4)

In this respect, the Spanish law was similar to the British abortion law: with the exception of rape cases, abortion was not available on request, but it put the onus on the clinician to interpret it according to the woman’s circumstances. Under British law, abortion is legal up to 24 weeks’ gestation on the grounds that the pregnancy risks damage to a women’s mental or physical health; this is interpreted broadly, so that most of those women with an unwanted pregnancy who are motivated to ask for an abortion are considered to be at risk of psychological damage if the abortion is denied.

In a similar fashion, so the Spanish law came to be interpreted in its least restrictive form, and practiced outside of the national healthcare system. As the CMO’s report noted, in Spain in 2005 ‘Nearly all abortions are carried out in private clinics and 97% of abortions are carried out under the last ground shown above. In 2003, 79,800 abortions were carried out; 1.9% of these were at 21 weeks or more.’

The CMO’s report also cited statistics from the Barcelona newspaper La Vanguardia about the extent of late abortions performed to women from outside Spain: ‘The article also said in 2003, that out of all the patients seen within the 26 centres in Catalunya, 812 patients were foreign and only 14 of these were from the United Kingdom overall. 98.9% of the abortions performed on foreigners were of less than 22 weeks. In three cases it was in the 24th week and in five in the 26th week.’
This detail indicates a number of key points about the legal situation in 2004:

• Abortion in Spain was legal beyond the 24-week British time limit;
• Clinical practice at the Barcelona clinic was above board, in that it was inspected and approved by the Catalunyan health authorities;
• A small proportion of the abortions carried out in Spain were at ‘late’ gestations of only 21 weeks, and an even smaller proportion were carried out beyond the UK time limit of 24 weeks;
• A very small proportion of clients had come from the UK , and most of those were being treated at gestations that were legal in the UK – but presumably, they could not access the procedure here.

In other words, there was no scandal here waiting to be uncovered. The situation in Spain was legal and accepted by the health authorities; and this provided a haven for a small proportion of women travelling from countries where abortion was either illegal or inaccessible. What suddenly seems to have changed in 2007 was not the practice in Spain , but the cultural and political climate in which abortion was provided.

The Spanish abortion law, 2007-date

In 2010, the Sexual and Reproductive Health and Voluntary Termination of Pregnancy Act became law in Spain , replacing the previous legislation. This provides for abortion on request, funded by the state, up until the fourteenth week of gestation; but it is far more restrictive of abortions carried out later on. In this regard, the new Spanish law follows a pattern established in some other European countries, where there has been a ‘trade off’ between liberalisation in the first trimester of pregnancy – abortion on request – against greater restrictions on abortions at later gestations.

The new law seems to have been greeted by abortion providers as a mixed blessing. It was provoked by the bizarre situation in 2007, where a number of abortion clinics were raided by the Guardia Civil, medical records were seized, and clinic staff arrested or investigated. Following this, 40 clinics (over half of those in Spain ) suspended their work because they could no longer guarantee the provision of the service, or the safety of their staff. The situation revealed the fragility of an unclear law in circumstances that can quickly change, and the new abortion law has the merit of clarifying to women what they are allowed to seek, and to doctors what they are allowed to perform.

But at a conference of abortion and contraception providers held in Seville , Southern Spain , in autumn 2010, Eva Rodriguez of the abortion clinics’ association ACAI showed a thought-provoking film examining the new law, and also indicating its negative side. One contributor to the film drew attention to the arbitrariness of the 14-week time limit for abortion on request – why should women be accorded less capacity to decide in week 15, or 20 of their pregnancy? There remained difficulties with the financial and practical aspects of implementing the law, including concerns about regional differences. And of course, for women – in Spain and abroad – who need abortions after 14 weeks’ gestation – things have become that much harder. (5)

This situation indicates a shifting climate of expectation around abortion in Spain . As Ann Furedi, chief executive of BPAS, notes, ‘what has happened in Spain seems less to be a discovery of wrong-doing than a redefinition of wrong-doing’. And it is this notion of wrong-doing that needs to be discussed outside of the court, as a moral and political issue.

The demonisation of ‘late’ abortions

In recent years, and around the world, doctors conducting abortions in later gestations of pregnancy have found themselves in the news headlines, and the reaction is interesting to examine. The murder of the American Dr George Tiller in 2009 shocked those inside and outside the pro-choice movement – it is, thankfully, generally considered to be wrong to murder somebody for going about his lawful business, even if that lawful business is the controversial practice of second-trimester abortion. (6)

On the other hand, the arrest of the rogue Philadelphia doctor Kermit Gosnell in 2010 was shocking to those on both sides of the abortion debate, because of the illegality, brutality and clinically unsound nature of his practices. Those who argue for legal abortion beyond the first trimester do so precisely to protect women – who, when desperate for an abortion, will go to any lengths to obtain one – from charlatans such as these. (7)

As a society – even one like America, which is so polarised around the abortion debate – we set great store by what is legal and clinically safe medical practice, and what is not. This is why advocates of women’s right to abortion seek to make this practice legal, so the woman and her doctors can be safe. It is why the fact that most abortions happen in the first trimester does not mean that women do not need access to abortion beyond that time – as research has amply demonstrated (8), a small proportion of women will always need access to late abortion, and the ‘right to choose’ should not just mean ‘only three months to make your mind up’.

And this is also why abortion advocates and doctors will push for women to have access to safe care to whatever gestation they possibly can within the law. If abortion providers were interested in having an easy life, they a) probably wouldn’t work in abortion services in the first place, and b) would seek to provide women with the cheapest, easiest services they possibly could, even if this meant slamming the door in the face of those women presenting with more challenging conditions or gestations. But they don’t.

The fact is, those who work in abortion services are motivated by the care of women who come to them in difficult circumstances, and it is frustrating – at times heartbreaking – when the service that is provided cannot meet these women’s needs. For this reason, the British Government’s Department of Health should get on with the task its Chief Medical Office set the country back in 2005, which was never taken up: to review women’s access to abortions in later gestations, and find ways of improving the service. (3)

In Britain , abortion is legal on broad grounds up until the twenty-fourth week of pregnancy. But women are not always able to access abortions at this stage. The burden of ‘late abortion’ provision has been taken on by independent sector clinics, which cannot always accommodate women’s needs; also, delays in the care pathway can mean that by the time a woman is referred to an abortion provider, she is already too close to the gestational limit to be helped. There should be greater collaboration between independent providers and the NHS to ensure these women can be helped, and greater acceptance within the health service that women are entitled to the ‘late abortions’ that they need.

In Spain , Carlos Morín should have been able to expect fair treatment from the courts, and the open-minded support of his international colleagues in the pro-choice world. All those negotiating their way around sometimes unclear, and often changing, abortion laws in the current climate should be aware that those prepared to do the most to help women are also often the most likely to attract the ire of anti-abortion campaigners, media organisations, and politicians. In such cases, the first casualty is the woman who needs her abortion.

(1) Absuelto el doctor Morín en el caso de los abortos. El Pais, 31 January 2013
(2) Doctor charged with 101 illegal abortions. The Times ( London ), 16 September 2011
(3) An Investigation into the British Pregnancy Advisory Service (BPAS) Response to Requests for Late Abortions: A report by the Chief Medical Officer. Department of Health, September 2005
(4) Summarised by An Investigation into the British Pregnancy Advisory Service (BPAS) Response to Requests for Late Abortions: A report by the Chief Medical Officer. Department of Health, September 2005
(5) Achieving Excellence in Abortion Care’: Report on the ninth Congress of FIAPAC. Abortion Review, 25 October 2010
(6) Comment: One family’s tragedy, not a political indicator. By Jennie Bristow. Abortion Review, 2 June 2009
(7) Late abortion: the new clash in the Choice Wars. By Ann Furedi. spiked, 3 March 2011
(8) See for example Second-Trimester Abortions in England and Wales, by Roger Ingham, Ellie Lee, Steve Clements and Nicole Stone, University of Southampton 2007.

 

Canada: The benefits of decriminalizing abortion

http://www.rabble.ca/columnists/2013/01/benefits-decriminalizing-abortion

By Joyce Arthur

| January 4, 2013

On January 28, 2013, Canada will celebrate 25 years of reproductive freedom. Since our Supreme Court struck down Canada’s abortion law in 1988, our country’s experience is proof that laws against abortion are unnecessary. A full generation of Canadians has lived without a law and we are better off because of it.

Canada is the first country in the world to prove that abortion care can be ethically and effectively managed as part of standard healthcare practice, without being controlled by any civil or criminal law. Our success is a role model to the world.

History: Previous laws and one Doctor’s civil disobedience 

In the 1988 Morgentaler decision, the Supreme Court of Canada ruled that our criminal law on abortion violated the constitutional right to “security of the person” under our Charter of Rights and Freedoms. One justice, Bertha Wilson, also found that women’s rights to life, liberty, conscience, privacy, and autonomy were compromised by the law. She stated that every individual must be guaranteed “a degree of personal autonomy over important decisions intimately affecting his or her private life. Liberty in a free and democratic society does not require the state to approve such decisions but it does require the state to respect them.” 

The struck-down law was a liberalized one that passed in 1969, replacing a strict ban on abortion. The 1969 law required women to apply for permission from a hospital committee, which would decide if a woman’s health or life was at risk. The law obstructed access for women because most hospitals did not even establish committees, while some that did refused to approve most or all applications. In practice, access to abortion was spotty and unfair. Long delays at hospitals also increased the health risks for many women. Abortion clinics were illegal. 

Dr. Henry Morgentaler had begun performing safe — but illegal — abortions in his private office in Montreal in 1968, a year before the new law passed. In 1967, he told a Parliamentary committee that women had a right to abortion on request without having to state a reason. After the 1969 law passed, he continued to break the law because he knew that sending women to a committee for approval was a discriminatory barrier that increased medical risks to women.

During his 20-year battle, Dr. Morgentaler challenged the law by opening illegal abortion clinics in three cities and inviting media coverage of his safe abortion services. Police raided the clinics several times, resulting in repeated arrests and trials that eventually led to the historic Supreme Court victory on January 28, 1988.

Reaping the benefits of decriminalization 

The evidence now vindicates Dr. Morgentaler’s perspective and Canada’s legal position. After 25 years with no legal restrictions on abortion whatsoever:

– Doctors and women handle abortion care responsibly.
- Abortion rates are fairly low and have steadily declined since 1997.
- Almost all abortions occur early in pregnancy.
- Maternal deaths and complications from abortion are very low.
- Abortion care is fully funded and integrated into the healthcare system (improving accessibility and safety).
- Further legal precedents have advanced women’s equality by affirming an unrestricted right to abortion. 
- Public support for abortion rights has increased. 

Responsible abortion care: Since 1988, the Canadian Medical Association (CMA) has successfully managed abortion just as it does for every other medical procedure — by applying policy and encouraging medical discretion for doctors, subject to a standard code of ethics.

Doctors abide by CMA policy and guidelines, and follow best medical practices based on validated research and clinical protocols. Criminal laws are inappropriate and harmful in medicine because they constrain care and negatively impact the health of patients. 

Low and declining abortion rates: Canadian women had 93,755 abortions in 2009 — the last year for which reliable numbers are available. This translates to an annual abortion rate of 14 per 1000 women of childbearing age, approaching the lowest rates in the world. Incidentally, the annual abortion rate in the United States has also declined significantly in the last decade, and now sits at 15 abortions per 1000 women of childbearing age. 

Although western European countries and the U.S. enforce various legal restrictions on abortion care, their declines in abortion rates are not attributed to the effect of laws, but largely to more effective and increased use of contraceptives. The evidence is clear that contraception and family planning services are key to reducing unintended pregnancy, which is the main cause of abortion. In countries where abortion is legal and contraceptive use improves over time, abortion rates decline predictably and often dramatically. This pattern has repeated itself countless times around the world, including in Canada, where our abortion rate has declined by at least 14 per cent since 1997, and by 29 per cent amongst teenagers. 

Earlier abortions: At least 90 per cent of abortions in Canada are now performed on request in the first 12 weeks. The procedure is very safe and 97.6 per cent of terminations (in hospitals) have no complications. Less than 2 per cent of abortions occur after 20 weeks (again in hospitals only), and these are performed only in cases of severe fetal anomaly or under compelling maternal life or health circumstances. A similar situation exists in every country independently of any laws — the majority of women seeking abortions will present early, while a small number of women will always need later abortions because of exceptional circumstances. 

Low complication and death rate: About half of abortions are now done in private clinics in Canada, virtually all by 16 weeks of pregnancy. Since early abortions are safer than later abortions, and hospitals handle the later and more complex cases, our hospital statistics likely overestimate the number of later abortions, as well as maternal deaths and complications from abortion. Statistics Canada reported that in 1995, less than 1 per cent of abortions in Canada resulted in any complication at all, whether minor or more serious. Further, Canada has one of the world’s lowest maternal mortality rates from legal abortion. Between 1976 and 1994, the mortality rate was estimated to be 0.1 deaths for every 100,000 abortions — about one every ten years — compared to a rate of 0.7 in the U.S (from 1988 to 1997). Maternal death from legal abortion remains virtually unheard of in Canada today. 

Funding and integration into healthcare system: Abortion care has become better integrated into the Canadian healthcare system, partly because it was already being done in hospitals and funded as “therapeutic abortion” before 1988. However, between 1988 and 2006, the pro-choice movement successfully challenged provincial governments to also fund all procedures done at private clinics. Today, only the province of New Brunswick refuses to pay for abortions at one private clinic, in defiance of federal law. (The Canada Health Act guarantees funding and equitable access for all “medically required” treatment, which includes abortion.) Full government funding for abortion is essential to protect women from discrimination, facilitate early access, ensure acceptable standards of care, and prevent the service from becoming marginalized or further stigmatized.

Further legal precedents: Subsequent court rulings have solidified the Morgentaler decision, which has been widely cited in other rulings due to its advancement of women’s constitutional rights. The Supreme Court appears to have adopted Justice Wilson’s broader approach to such rights, recognizing for example that the right to liberty includes the autonomy to make decisions of fundamental personal importance. Our federal Criminal Code states that the legal status of “human being” accrues only after exiting the birth canal alive, a definition validated by several Supreme Court decisions that established that fetuses are not legal persons and that women’s rights must prevail. In a 1999 decision, Dobson v. Dobson, the Supreme Court ruled that: “A pregnant woman and her foetus are physically one, in the sense that she carries her foetus within herself. The physical unity of pregnant woman and foetus means that the imposition of a duty of care would amount to a profound compromise of her privacy and autonomy.” 

Increased public support: Strong public support exists for abortion rights in Canada, despite lingering social stigma against abortion that is continually reinforced by anti-choice propaganda. Even though half of Canadians appear to want some restrictions on abortion, this anti-choice article on polling shows a gradual increase in pro-choice support since the 1980’s. A 2012 poll revealed that 49 per cent of Canadians support abortion on request at any time, while only 6 per cent want a total ban. (In comparison, 30 per cent of Americans want it fully legal while 15 per cent prefer a total ban.) 

Having no laws is not enough 

Of course, the lack of restrictive laws alone does not guarantee access or availability of services. Canada still has problems with access because of ongoing abortion stigma, inadequate training in medical schools, reluctance of politicians to implement improvements, and simple geography — abortion is much easier to access in larger cities than in Canada’s vast rural areas and North, where women often must travel to find abortion care. However, another benefit of decriminalization is that we have been able to focus our time on addressing these issues instead of struggling against restrictive laws. 

Key to understanding the incidence of abortion is that it can never be eliminated. We will never live in a perfect world — contraception is far from 100 per cent effective, people are human, and continuing inequality means that disadvantaged women will experience higher rates of unintended pregnancy. The lowest possible abortion rates — the rates of 6 to 7 per 1000 women of childbearing age that were achieved in the past by Holland and Belgium — require a sustained commitment and dedicated resources in areas such as family planning and reproductive health services, comprehensive sex education, and doctor training. The other key element in reducing abortion is to advance women’s status and equality so they are more empowered to avoid unintended pregnancy. 

Vigilance is also required due to the endless tenacity of the anti-choice movement. Since 1988, Canada has seen 45 attempts to recriminalize or restrict abortion through the introduction of Private Members Bills or Motions in Parliament. Not one has passed, and nor is one likely to pass. Despite the loud voices and campaigning power of anti-choice activists, women’s rights are well established in Canada and sexual and reproductive health is understood as a vital facet of overall health. 

The moral high road: Decriminalizing abortion

The rest of the world is catching up to Canada. Two Australian states have also successfully decriminalized abortion in recent years. And in 2011, a groundbreaking report to the United Nations boldly called on all states to decriminalize abortion. The UN’s Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health described laws restricting abortion as an abuse of state power. Such restrictions “infringe human dignity by restricting the freedoms to which individuals are entitled under the right to health, particularly in respect of decision-making and bodily integrity.” 

Looking at Canada, concerns that other countries may have about eliminating punitive laws on abortion are clearly unfounded. Even with our remaining issues, our outcomes are exemplary. We can all thank Henry Morgentaler for that. 

The Canadian pro-choice movement will do all it can to ensure that Canada never goes back, and we encourage other countries to embark upon a similar journey. When women can make their own reproductive decisions without interference from the state, society takes the moral high road — one that saves lives, raises women’s status and potential, and ultimately benefits everyone. 

 

Joyce Arthur is the founder and Executive Director of Canada’s national pro-choice group, the Abortion Rights Coalition of Canada (ARCC), which protects the legal right to abortion on request and works to improve access to quality abortion services.

The author would like to thank Jane Cawthorne for contributing to this article.

 

 

Chile: Abortion Hot Line Is in Legal Gray Area

Taking Calls on Abortion, and Risks, in Chile  

 

By Aaron Nelsen   

Published: January 3, 2013  

http://www.nytimes.com/2013/01/04/world/americas/in-chile-abortion-hot-line-is-in-legal-gray-area.html?pagewanted=all&_r=1& 

  

Roberto Candia for The New York Times

Volunteers for the Safe Abortion Hot Line in Chile routinely wear masks when showing support in public for the organization in a country where abortion is illegal under any circumstances.

 

SANTIAGO, Chile – Every time the phone rings, Angela Erpel feels her nerves swell. Sometimes it is a scared teenager on the other end, or a desperate mother of three. There are the angry ones, too, with callers playing the sounds of crying babies or sending text messages with pictures of aborted fetuses.  

 

Then Ms. Erpel, 38, a sociologist who volunteers at Chile’s Safe Abortion Hot Line, gathers herself and settles into a familiar dialogue on the use of misoprostol, a drug that will induce a medical abortion.

 

“We don’t give them a moral guide or advice; we only provide information,” she said.

 

Since the hot line began in 2009, volunteers spread across this long, thin country have taken turns answering tense calls from women seeking information about abortion every evening from 7 p.m. to 11 p.m. There have been more than 12,000 calls so far, and they continue rolling in at a steady clip.

 

In a country where abortion is entirely illegal, even in cases of rape or when a woman’s life is in danger, the hot line is a risky endeavor. Operating in a legal gray area, volunteers face a daunting prison sentence if a conversation veers too far from a lawyer-approved script. The hot line already has had three lawsuits brought against it, though all were eventually dropped.

 

According to the law, having an abortion carries a penalty of 5 to 10 years in prison, depending on the circumstances, while doctors and others who perform an abortion or assist with one could face up to 15 years, prosecutors say. In practice, however, fewer than 500 cases have been prosecuted over the last several years.

 

“I think there is a certain sensitivity to the social conditions behind these abortions, such as poverty or rape or teenage pregnancy,” explained Paula Vial, a lawyer and former public defender in Santiago.

 

Beyond the legal consequences, the 30 hot line volunteers are keenly aware of the social ramifications of taking an active role in such a polarizing issue. They wear masks when promoting the hot line at public gatherings, and are often vague about the details of their volunteer work in their daily lives. Many fear losing their jobs or driving a wedge into personal and family relationships. Indeed, Ms. Erpel was the only volunteer willing to go on the record about her work with the hot line, and even she is usually circumspect about it.

 

“It’s complicated,” she explained. “I’m open about being in an organization, but not necessarily that I work directly with abortion.”

 

Abortion was not always a clandestine affair in Chile. The current law that strictly bans it was one of the final acts of the dictatorship. In 1989, shortly before relinquishing power, Gen. Augusto Pinochet ended a tradition of legal abortion dating to 1931, in which a pregnancy that threatened a woman’s life, or a fetus that was not viable outside the womb, could be terminated. Chile’s law now is one of the strictest in the world.

 

By contrast, Uruguay legalized abortions in the first trimester for any reason last October, joining Guyana and Cuba as Latin American countries with broadly legalized procedures. Abortion is also legal in Mexico City. But Chile has remained a socially conservative country, after 20 years of economic growth and the election in 2006 of a woman as president.

 

“The hierarchy of the Catholic Church has had a very strong influence in public policy,” said Claudia Dides, a spokeswoman for the Movement for the Legal Interruption of Pregnancy.

 

In a pivotal case in 2008, Karen Espíndola, then 22, learned in her 12th week of pregnancy that her fetus had holoprosencephaly. Fetuses with the condition have a single-lobed brain, and most die before they are born. It is a common reason for terminating a pregnancy.

 

Ms. Espíndola sought an abortion, appealing to the president and setting off a national conversation over abortion. In February 2009, Ms. Espíndola gave birth to Osvaldo, who died in 2011.

 

“In reality he was never conscious he was alive,” she lamented. “He fought to breathe; he was fed through a tube. We all suffered a lot. Nobody here is a winner.”

 

Chile has witnessed a swell of liberal social movements in recent years, with gay men and lesbians pressing for the country’s first hate-crime legislation, environmentalists stalling dam-building projects in Patagonia, and students pushing for an overhaul of the education system.

 

Advocates contend that abortion rights sentiment bubbles near the surface as well, but the government has pushed back.

 

After criticizing the abortion hot line in the news media, the Ministry of Women started a hot line of its own. It is attended by psychologists and social workers who answer calls from men or women looking for information or support when facing what the ministry calls an “abortion situation” or “post-abortion syndrome.”

 

“Maternity, one of the most satisfactory experiences in the life of a woman, can go through difficult and desperate moments,” Minister Carolina Schmidt said at the time the government hot line began.

 

Other influential anti-abortion organizations offer to guide women considering abortion away from the procedure.

 

“If you help that person define what is troubling them and making them think of an abortion, and together you find a solution, in the end the person decides for life and her child,” said Victoria Reyes, director of assistance for Foundation Chile United. “We are convinced the second victim of abortion is the woman; the woman who has an abortion carries that guilt.”

 

The government reported several hundred adoptions in 2011, but it estimates 120,000 abortions, in a country with a population of about six million women from 15 to 64 years old.

 

Misoprostol, sold under the brand name Misotrol in Chile, has changed the way many of those abortions are performed. The drug was originally developed as an ulcer medication, and its warning label advised that, in excess, misoprostol would cause a woman to miscarry. Before long, women in countries with little or no access to safe abortions were using the drug to do that very thing.

 

Misoprostol “is a revolution for women,” said Rebecca Gomperts, founder of the Dutch organization Women on Waves. “Even where abortion is illegal and women don’t have a doctor, or they are poor, they still have a way to do a safe abortion.”

 

The abortion hot line is Ms. Gomperts’s creation. A medical doctor and former Greenpeace activist, she realized in 1999 that it was possible for a ship sailing under a Dutch flag to take women from countries where abortion is illegal to international waters to administer misoprostol.

 

Before departing Chile, Women on Waves helped set up the abortion hot line, training volunteers how to discuss misoprostol according to World Health Organization guidelines.

 

There are now five abortion hot lines in South America: in Argentina, Chile, Ecuador, Peru and Venezuela.

 

Misoprostol was taken off pharmacy shelves in Chile under Michelle Bachelet, the former president who now runs the United Nations’ agency for women’s advancement, so access to the drug is almost entirely a black market transaction.

 

Dozens of Web sites offer misoprostol at exorbitant prices, and sometimes of dubious quality.

 

One 29-year-old lawyer who became pregnant a few months ago said she paid $300 for the necessary 12 pills.

 

“To meet someone in a clandestine place, hoping they aren’t a police officer, wondering if they are even giving you the right pills, knowing that you could go to prison when all you want to do is exercise your right as a woman is horrifying,” the lawyer said on the condition of anonymity to avoid prosecution.

To its volunteers, the Safe Abortion Hot Line stands as a simple equation – 30 women and a single cellphone that gets passed among them. This month, they expanded: they released an abortion manual on using misoprostol.

 

Occasionally, women call back the hot line after a successful abortion, but more often the volunteers never know the outcome.

 

“That’s always the hardest part,” Ms. Erpel said.