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Court ends Colombia's abortion ban

2006; Elsevier BV; Volume: 367; Issue: 9523 Linguagem: Inglês

10.1016/s0140-6736(06)68715-1

1474-547X

Mike Ceaser,

Ethics and Legal Issues in Pediatric Healthcare

Until recently, Colombian law prohibited all abortions. Nevertheless, about 300 000 to 400 000 women undergo the procedure each year, often performed by untrained backstreet abortionists. A May 10 court decision has now depenalised abortion in three circumstances. Mike Ceaser reports. Cardiologist Miguel Ronderos walks between the rows of small beds in Bogota's Cardioinfantil Foundation Hospital. Many of these newborn babies have congenital defects that will cause anguish for their parents and cost their families and society fortunes. “In North America and Europe, 90% of major malformations are detected in the womb”, says Ronderos. “Here in Colombia we don't reach 1%.” Supporters of legal abortion hope this situation will change with a ruling on May 10, 2006, by the Constitutional Court that legalises the procedure in cases of rape, when the pregnancy endangers the woman's life or health, and when the fetus has severe malformations. Until the decision, Colombian law prohibited abortion in all circumstances, so doctors rarely bothered to undertake prenatal tests for even severe congenital defects, since women had no legal option to end their pregnancies. Despite the prohibition, about 300 000 to 400 000 illegal abortions have been performed annually in Colombia. Until the new decision, Colombia, together with Chile and El Salvador, were the only three Latin American nations that prohibited abortion in all circumstances. The court ruling came in response to a lawsuit filed last year by Monica Roa, an attorney with Women's Link Worldwide. She argued that Colombia's abortion law unjustly discriminated against women, especially the poor. One study estimates that clandestine abortions cause 28% of maternal deaths in Colombia, a disproportionate number of which are among poor women. “The women who live in rural areas are the ones who pay the cost in health, or even with their lives”, because abortions are illegal, she says. Before the ruling, all abortions carried prison terms of up to 4·5 years for the woman who terminates her pregnancy and for the abortionist. In practice, in the few cases actually prosecuted, the women were usually sentenced to house arrest. Advocates for abortion rights celebrated the court's decision, while Catholic organisations vowed to have it reversed. Observers debated the ruling's breadth, particularly whether the term “health” used in the decision included psychological problems and non-life threatening illnesses, and whether fetal malformations included non-fatal disorders such as Down's syndrome. Abortion-rights advocates also expressed concern that women have access to the procedure. In some other Latin nations where there is a legal right to abortion, women are still unable to obtain the procedure because doctors refused to perform it. While the court decision took effect immediately, the legislature and health ministry are expected to write regulations for its implementation. Ronderos, for one, expects the court decision to be interpreted broadly, and that the public-health system even plans to cover the procedure. The decision “gives the doctor the prerogative to use his own evaluation”, of whether or not an abortion is justified, Ronderos said. Colombia's prohibition has generated a flourishing underground abortion industry beyond the oversight of health officials. As a result, abortion providers have ranged from doctors operating in well-equipped medical clinics to untrained midwives. Marcela Caicedo, a social worker with a women's health education programme in a poor area of Bogota, says that a woman nearby does abortions in a dirty house with peeling paint. Caicedo says she doubts the woman has even a high-school diploma, much less medical training. Many of the more established clandestine abortion clinics are located in a central area of Bogota full of old homes, small restaurants, and store front clinics that offer ultrasound and other health services for women. On the pavements, men hand out cards advertising treatment for “delayed menstruation”. In one clinic with a sign advertising general medicine services and varicose vein treatment with a “German technique”, a reporter posing as the partner of a Colombian woman was told the “procedure” would cost about US$50. In a second clinic two blocks away, an abortionist described the operation as fast and easy. He assured the woman that her fertility would not be impaired. “There are women who have abortions and get pregnant again right away”, he said. But a 27-year-old woman who paid about $40 for an abortion in that clinic said she was not given anaesthetics and that when she cried too loudly the employees threatened her with the police and then hurried her out as soon as the procedure was over. Her post-abortion ultrasound was done in another clinic with a hair salon sign on its front. The woman, who requested anonymity, now fears she is infertile. According to press reports, in early February, a 23-year-old mother of two named Viviana died in the clinic that offered the “German technique” while having an abortion. She had gone to the clinic with her sister, who later told reporters that Viviana had been 4 or 5 months pregnant and feared what the father of her two children would do if he found out. The sisters arrived at the clinic at about 1500 h, and Viviana paid 500 000 pesos ($222), which is a large sum for a lower-middle class family in a nation with a monthly minimum wage of $181. At about 1700 h, the doctor emerged to say that Viviana was bleeding badly. At 0400 h, he acknowledged that Viviana was dead and sent the sister home in a taxi after giving her 20 000 pesos and two beers, and telling her to say that she had been out drinking alone. But the sister returned with her father and the police. They found the clinic vacant, except for Viviana's body and the doctor, who insisted that he had just dropped by to pay the rent, the sister told local media. “At no time did the [doctor] call an ambulance”, she told local television. The doctor was arrested and released pending an investigation. After Viviana's death, this clinic was closed, with yellow police tape in the windows. But nearby other clinics continued offering their services. In a second recent case, a 34-year-old mother of four was diagnosed with ovarian cancer while 3 weeks pregnant. Doctors refused to perform an abortion or treat her cancer because that would harm the fetus. In Bogota's Simon Bolivar Hospital, gynaecologists Daniel Montenegro and Fred Lozano treat about five women a month for complications after abortion. Almost all of their patients are younger than 30 years, the doctors say, many are teens and most are poor. While the doctors recall one case of a young woman who had had 22 abortions, they said that after one, most do not repeat their mistake. Years ago, they often saw “catastrophic” cases, such as a woman in 1982 who arrived with pieces of her intestine protruding from her vagina. Although surgeons found fragments of a fetus near her liver, the woman died still denying she had had an abortion, Montenegro recalls. In recent years, however, the number of serious complications has declined, the gynaecologists say. They attribute this improvement to the increased availability of contraceptives since the early 1990s, as well as to the use of the morning-after pill. But the greatest decrease, they say, is owing to the popularisation of the use of misoprostol, a prostaglandin analogue used to treat gastric ulcers but which can also induce abortions. However, in poorer, rural areas, the incidence of complications from abortion continues to be high. In the city of Ibague, with 400 000 inhabitants, health officials recorded three deaths from abortion complications last year. Ibague authorities became so concerned about the high incidence of sexual assault that late last year they began distributing free morning-after pills. Montenegro and Lozano say Bogota's clandestine abortion industry has become so institutionalised that clinics often phone the hospital before sending over patients suffering complications. The gynaecologists add that most of the illegal clinics' abortionists are actually qualified physicians. Both doctors support limited depenalisation of abortion, because they believe it will make the procedure safer for women in extreme situations. But even if abortion were completely legal, they say, they would refuse to do the operation except in the three situations included in the ruling. “When a pair of kids have their fun and then want an abortion, no”, says Montenegro. “That's an act of irresponsibility.” Even providing care after an abortion can bring doctors ethical dilemmas. Attorney Roa says that since she filed her lawsuit, increasing numbers of doctors have reported to police women who seek help for post-abortion complications. Roa says that doing so violates a doctor's legal obligation to preserve a patient's privacy. Yet, although they say they have never done so, Montenegro and Lozano defend informing police when they see that an abortionist has committed malpractice “As a citizen, one has the obligation to denounce illegal acts”, says Lozano. Ronderos of the Cardioinfantil hospital expects safe, legal abortion will become so accessible that the clandestine industry will shrink dramatically. And he expects to see far fewer newborn babies with severe deformities. “Having a non-viable baby isn't anybody's reason for being a parent”, he said.