Demonstration of women for the legalization of abortion in Rio de Janeiro, in 2016.
Demonstration of women for the legalization of abortion in Rio de Janeiro, in 2016. PHOTOS: Public Photos

This week, the Argentine Senate votes to legalize abortion. It has already been approved by the Chamber of Deputies and after an organized and democratic mobilization of more than 1 million women, the conquest of this right is being widely discussed in all Latin American countries. 

Read an interview with deputy Monica Macha in the Argentine newspaper

Read the article published by in 2017 below

Women enter and leave the Pérola Byington Hospital, in downtown São Paulo, with a secret they will probably keep forever. They arrive alone, with fear and shame. Most have been victims of sexual violence and are there to have an abortion. “If you tell anyone, it's a friend. Talking to the family is more complicated”, says Daniela Pedroso, head of psychological care at the institution's Legal Abortion Service.

In Brazil, termination of pregnancy is allowed only in cases where it is the result of rape and there is a risk of death for the mother. This right has existed since 1940. However, the first technical standard of the Ministry of Health to properly regulate and implement the procedure in the public network was written 59 years later, in 1999. The right to abort anencephalic fetuses was recognized in 2012 by the Supreme Court Federal.

Pérola Byington is a reference center in women's health and in the performance of these procedures. “We reach one third of all abortions registered each year in the country”, says doctor Jefferson Drezett, coordinator of the Sexual Violence and Legal Abortion Outpatient Clinic.

In 2016, about 320 women underwent legal abortion by the doctor's team, a number that is almost double the number of interventions made in the previous year. “If you combine all the other services in the state of São Paulo in one year, they will reach a fraction of what is done in Pérola. That concentration is terrible,” says Drezett.

The reality is that there are still few services that practice legal abortion and the comprehensive care provided for in these cases. This is evidenced by the data obtained by the research Legal Abortion Services in Brazil – a National Study, coordinated by anthropologist Débora Diniz, professor of Bioethics at the University of Brasília and researcher at Anis – Instituto de Bioética. Diniz was one of the main articulators of the action in the Federal Supreme Court (STF) that admitted abortion in cases of anencephaly in 2012.

The research showed that, between 2013 and 2015, a total of 5.075 women went to the public network in various parts of the country to undergo the procedure, but only 2.442 were successful. The study did not investigate what happened to women who were unable to have an abortion, but it is not wrong to imagine that many ended up in clandestine clinics.

The study evaluated 68 referral centers registered with the Ministry of Health, of which only 37 were actually performing abortions. In seven states, there was no service available and 70% of the consultations were carried out in the Southeast region. This idea is reinforced by the volume of patients from outside São Paulo treated at “Pérola”. In 2016, they represented half of the service's movement. “About 18% were referred by public services in the state that, publicly, say they are able to perform legal abortion, but do not”, points out obstetrician Drezett.

Difficulties abound to complicate the life of women who need to undergo legal abortion. One of them is the refusal of some doctors to perform the procedure. They are supported by the code of medical ethics and by a technical rule that allows rejecting the task for “conscientious objection”. The same norm, however, determines that accredited public services must guarantee timely care by another professional from the institution or from another service. What's more, conscientious objection is not recognized in the absence of another doctor to attend to the woman, if there is a risk of death or the omission of care could cause harm.

Requesting documents that are no longer legally required in cases of sexual violence is another barrier. Many people do not know, but it is not mandatory to present a police report or a report from the Legal Medical Institute. Despite this, 14% of the services in activity still ask for such evidence, as shown in the study conducted by Diniz.

Even supported by the law, a woman who arrives at legal abortion services can still be mistreated. Unfortunately, it is common in the country to find doctors and health service employees capable of instilling suspicions about the history of reported violence. A 2012 survey of Brazilian gynecologists and obstetricians showed that 43% of physicians declared conscientious objection when they were unsure whether the woman was telling the truth about the rape.

“The ambiguity that legal abortion causes because it is an exception to the rule of criminalization generates these distortions. Instead of listening to, welcoming and caring for women in suffering, professionals assume a police stance, promoting the intrusion of an investigative requirement in what should only be health care”, says Diniz.

Doctors' resistance is more intense in relation to abortion due to sexual violence than to the termination of a risky pregnancy. “Professionals know that up to 35% of all maternal mortality is related to health complications that are accentuated during pregnancy”, says the doctor. Offering comprehensive assistance to victims of sexual violence is another challenge.

Even among the services registered by the Ministry of Health, there are few that provide care as required, as pointed out by Thomaz Gollop, coordinator of the Study Group on Abortion (GEA) and professor of Medical Genetics at the University of São Paulo. .

The integrality mentioned by Gollop encompasses reception, psychological support, collection of material for DNA extraction and possible identification of the aggressor, emergency contraception, prevention of sexually transmitted diseases and, when indicated, termination of pregnancy. “Of the more than five thousand municipalities in the country, only 1% would have this service, even if incomplete”, says Gollop.

The specialist attributes this shortage to factors such as political pressure from mayors, city councils and various religious cults. Add to that the complicity of the state. “Health services have ignored this responsibility without being bothered by the authorities”, points out obstetrician Drezett.

The “forgetfulness” of the topic extends to medical faculties, especially those linked to universities governed by religions. “Like many issues related to sexual and reproductive rights, the issue of abortion is no longer discussed and remains a taboo for most medical schools and doctors in general,” says Gollop. “It is not part of the curriculum of faculties, congresses and symposia in the area. And when included in the schedule, this happens on the last day of the event, when there is a minimum audience.”

When arriving at hospitals with postabortion complications, women are often distrusted. Many put off going to the hospital as much as possible because of reports made to the police by doctors, employees or agents of the health services. In the view of the judge and professor José Henrique Torres, professor of Criminal Law at the Pontifical Catholic University of Campinas (PUC-Campinas), it is the accusers who are committing a crime.


According to the medical code of ethics, the confidentiality relationship between doctor and patient cannot be violated. “The police should disregard these reports because they are illicit evidence, committed in a criminal way. The Public Prosecutor’s Office, instead of instituting an investigation to investigate the woman’s conduct, should do so for violation of professional secrecy and the crime of the person who made the complaint.”

For Torres, there is an incompatibility between Brazilian legislation, the international human rights system and women's assistance and health: “Criminalization itself causes deaths of women, terrible consequences and has a very large social cost. It cannot protect the fetus, life. On the contrary, it harms the health and lives of women”.

Therefore, the issue needs to be addressed in ways other than the drastic, severe and repressive penalization of women. The expert argues that criminalization contravenes several constitutional principles. “When a society has a problem to be faced, it must resort to legislative measures and public policies before criminalizing it, which should be the last alternative to be put into practice by the state”, he explains.

Prohibition of abortion would also contradict the principle of suitability, since it does not reduce the rate of procedures performed. “Research shows that women do not stop having the procedure done because it is criminalized,” says Torres. The principle of rationality is also wounded. In the case of abortion, criminalization pushes women into clandestine care, killing them and leaving sequelae. “The state cannot cause even greater problems,” says the judge. Each year in Brazil, 700 to one million abortions are performed, according to Torres.

“It is a consented illegality. If we have a million abortions performed, we should have a million women prosecuted. This does not happen because the idea is to keep criminalization as a constant threat against women, with the objective of controlling the female body and sexuality”, analyzes the judge.

A way forward, according to the expert, would be the line adopted in a decision by the STF, which recently stated that there is no crime of abortion until the third month of pregnancy. Although it concerns a specific case, it is considered an advance in the decriminalization of the act and can influence magistrates of other instances. Other countries have already consented to abortion in early pregnancy, such as Portugal, Italy, France and Spain.

“Brazil has very restrictive rules on abortion, inspired by Mussolini's fascist Italian legislation,” says Gollop. In addition, attempts at setbacks emerge every now and then, such as the proposal by former deputy Eduardo Cunha (PMDB), who wanted to force women to go to the police station before receiving assistance. “Cunha's intention was not to punish the aggressor, but to see if the woman was not lying”, points out Drezett.

In the opinion of the anthropologist Débora Diniz, we are below what we could. “But, on the initiative of women, the topic has remained on the agenda and should mature”, says the specialist. May it be quick. Clandestine abortion is the fifth leading cause of maternal mortality in Brazil. It is estimated that it takes the lives of 300 Brazilian women each year.

Model to be copied

Daniela Pedroso, head of psychology at the Pérola Byington Legal Abortion Service, alongside Dr. Jefferson Drezett, coordinator of the Sexual Violence and Legal Abortion Outpatient Clinic.
Daniela Pedroso, head of psychology at the Pérola Byington Legal Abortion Service, alongside Dr. Jefferson Drezett, coordinator of the Sexual Violence and Legal Abortion Outpatient Clinic. PHOTO: Luiza Sigulem

Daniela Pedroso, head of psychology at the Pérola Byington Legal Abortion Service, alongside Dr. Jefferson Drezett, coordinator of the Sexual Violence and Legal Abortion Outpatient Clinic. Photo: Luiza Sigulem[/caption]

At Pérola Byington Hospital, care for those seeking legal abortion begins with a conversation to listen to each woman's story and assess whether she is at risk, whether she needs shelter and social assistance. Afterwards, an emotional, psychological and health assessment is carried out.

Most are referred by the police, the Legal Medical Institute or other health services. “But we're seeing an increase in spontaneous demand for care,” says gynecologist and obstetrician Jefferson Drezett, who heads the Sexual Violence and Legal Abortion Outpatient Clinic. This would be a result of the dissemination of services over the Internet and works as an indication that women are less dependent on intermediaries to find the places of service.

After the exams, the woman will sign five documents. In them, he is responsible for what is declared to have a legal abortion, authorizes the procedure and says he is aware of the alternatives. The medical team approves or not the request and, finally, makes a technical evaluation of the time of pregnancy to check if it is compatible with the time since the rape.

Between 25% and 30% of women do not get approval to have a legal abortion. The main reason is the gestation time exceeding the technical limit to interrupt it - until the 20th week or until the 22nd if the fetus weighs less than half a kilo. The second most frequent impediment is that pregnancy is not the result of sexual violence.

“Often, the woman has been raped and is pregnant, but not by the rapist,” says Drezett. After the procedure, psychologist Daniela Pedroso, who has been supporting women who go to the hospital for 20 years, says that a feeling of relief prevails.

“They feel that they can go back to life, work, studies – go back to who they were before they got pregnant.” According to the psychologist, approximately 25% of women thought about suicide. “The trauma is greater in relation to rape and the lack of option to have an abortion than the procedure itself”, says the specialist.

Due to the complexity of the situation, “Pérola” offers psychotherapeutic follow-up for six months to a year. Half of the women agree to attend the sessions.

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