**3. Who performs illegal abortions in Latin America?**

In Latin American countries, all but one of which do not legally permit abortion on request, women will often seek the services of untrained or inadequately trained persons in dangerous and unsterile conditions or attempt to self-induce an abortion. Because of such circumstances, abortion mortality rates are up to 100 times higher in Latin America than in industrialized nations. For reasons that are obvious, there are scant published data available on who actually perform illegal abortions in Latin American countries. It must be remembered that not all illegal abortions are unsafe and not all unsafe abortions are illegal. Illegal abortions can be divided into those that are (1) performed clandestinely by medically qualified physicians in their medical offices or clinics; (2) performed by an individual, sometimes a physician but often by an abortionist who is medically unqualified, in an environment lacking the minimum medical standards, often termed "back alley," "back street," or "back yard" abortions; and (3) a self-administered abortion by the pregnant woman. Of these, the latter two are considered unsafe abortions and are probably responsible for the large majority of fatalities and medical complications arising from illegal abortion procedures.

In many Central and South American countries, a large part of the population has indigenous ancestry—this is especially true for Mexico, Honduras, Guatemala, Brazil, Peru, Ecuador, Bolivia, Colombia, and Chile. Unfortunately, indigenous women frequently reside in poor, rural, and medically underserved areas and have little access to modern medical care and family planning education and interventions. As a result, indigenous women in Latin America are more likely to have high rates of adolescent and teen fertility and unintended or unwanted pregnancies and are disproportionately affected by adverse reproductive and sexual health outcomes [23]. It is not surprising that unsafe induced abortion is practiced among indigenous women, where it contributes to the high rate of maternal morbidity and mortality among these populations. It has been estimated that 18% of maternal mortality in Ecuador, 16% in Peru, and 28% in Colombia resulted from complications due to unsafe abortion [24]. In Guatemala, where 40% of women are indigenous and abortion is illegal except to save the life of the mother, the annual abortion rate is 24 per 1000 women of reproductive age, with 22,000 women treated in 2003 for abortion complications [25]. In Mexico, indigenous women are five times more likely to abort unsafely than are nonindigenous women [26]. These figures are probably significant underestimates of the true prevalence of unsafe abortion and burden of abortion-associated complications among indigenous women, a result of underreporting bias and challenges to data collection. Because of harsh penalties to the woman and their abortion provider, demographic research is hampered by the illegality of abortion throughout most of Latin America, together with issues relating to stigmatization, social, religious, and political constraints. This sampling bias is significant, as it often does not include those girls/women who successfully complete an unsafe abortion, cannot seek medical care or hospitalization because of geographic and financial barriers, or decline to seek medical care for fear of legal or social repercussions [27].

Because many indigenous communities where unsafe abortions are practiced are in rural or isolated areas that are not routinely serviced by a physician or nurse, the procedures are typically performed either by the pregnant women herself or with the aid of another indigenous woman who has some experience in terminating pregnancies. In a study of elective abortion performed among women in Guatemala, 49–63% of indigenous women had obtained their abortions from traditional birth attendants (TBAs), and less than 15% had been attended by trained professionals (compared to two-thirds of higher socioeconomic class women in urban centers) [25]. Self-induced abortion appears to be more common among those women residing in rural areas—abortion services are unavailable or limited because of the geographic isolation. In a study across 20 cities in Peru, Bernabé-Ortiz and colleagues [28] found that the prevalence of induced abortion in the jungle regions was nearly twice as high as that in the coastal and highland regions.
