**2. Legal status of abortion in Latin America**

and the wealthy, and rural and urban dwellers. Throughout Latin America, multiple studies have demonstrated a variety of ethnic, financial, and social risk factors for unintended and unwanted pregnancies, unmet need for family planning, and unsafe abortion. These include widespread poverty, lower education levels, high fertility rates, early age at first intercourse, adolescent and teen pregnancy, rural areas of residence, cultural and language barriers in health-care facilities which are especially prevalent among indigenous women, sexual violence, and insubordination [1, 2]. Because the predominant religion in these countries is Roman Catholicism, religious doctrine has significantly impacted the use of family planning methods. In particular, abortion is unlawful in almost all Latin American countries, except under certain circumstances that are determined by national laws. Because of widespread unmet need for contraception, poverty, stigmatization, and unacceptably large numbers of adolescent and teenage pregnancies, women have historically sought to terminate unwanted pregnancies by means of unlawful abortion in these countries. With the advent of the Zika virus pandemic in 2015 and its spread throughout Latin America, this situation has increased. With the recognition that girls and women who become infected with the Zika virus while pregnant are at risk for developing such poor obstetrical outcomes as spontaneous abortion, stillbirth, infants with microcephaly, and other forms of fetal malformation, even if they exhibit no symptoms during gestation, the demand for abortion has increased. More than 97% of women in Latin America and the Caribbean live in countries where access to abortion is either restricted or banned altogether. In six Latin American countries, abortion is not permitted for any reason, including rape or to save the life of the mother [3]. As a result, they must often seek terminating their pregnancies through less-than-legal means, including performance of abortions in an environment lacking even minimal medical and sanitary standards and often performed clandestinely by persons lacking the necessary medical skills. The potential health consequences of unsafe abortion to the mother are well known [4]—just prior to the advent of the Zika pandemic in 2014, a minimum of 10% of all maternal deaths in Latin American and Caribbean countries, representing almost 900 girls and women, resulted from complications of unsafe abortions [5]. About 760,000 women in the region are treated annually for complications from unsafe abortion [3]. The ongoing public health problem of unsafe abortion was to be unexpectedly exacerbated when a newly emergent virus, the Zika virus, began to spread through South America in 2015 [6]. As it became known that the virus was responsible for the occurrence of microcephaly and other fetal malformations, it left those women at risk in endemic areas without a viable alternative to carrying a potentially infected fetus through to delivery. As a result, there has been an increased demand for abortion, even though it is illegal in most Latin American countries and, in some cases, can result in the incarceration of both the mother and abortionist, nurse, or physician. Penalties can be extreme—up to 10 years in prison for mothers having abortions in Paraguay and Honduras. In El Salvador, several single mothers have been imprisoned for having miscarriages during their pregnancy; women convicted of having an

52 Family Planning

abortion face imprisonment of up to 50 years [7].

This chapter discusses the legal, medical, and social issues surrounding the dilemma among the predominantly poor women of Latin America who are impacted by the emergence of the Zika virus pandemic, its effect on the unborn fetus, and their fears of having a malformed infant.

The countries which compose Central and South America have the most restrictive and harsh penalties for performance of an abortion of any region in the world (**Figure 1**). In four Latin American countries—Suriname, El Salvador, Honduras, and Nicaragua—abortion is not permitted legally for any reason whatsoever, including in cases of rape, incest, or to save the life of the mother [3, 8–10].

Chile had been included in the list of countries that completely prohibit abortion, with penalties of up to 5 years in prison, until the government lifted the ban in 2017 [11, 12]. In Guyana, abortion is legal in the first 8 weeks of pregnancy, after which it can only be legally performed when it endangers the health of the mother or fetus. The legality of abortion in Mexico is determined by each individual state—in Mexico City, abortion was decriminalized in 2007 only if performed during the first 12 weeks of gestation; however, the rest of Mexico has much stricter regulations [13]. Two countries in Central and South America permit legal abortion

**Figure 1.** The status of abortion law in Latin America, United Nations 2013 report. In some cases, this map may not accurately depict the content of this article. Legal on request; restricted to cases of maternal life, mental health, health, rape, fetal defects, and/or socioeconomic factors; restricted to cases of maternal life, mental health, health, rape, and/or fetal defects; restricted to cases of maternal life, mental health, health, and/or rape; restricted to cases of maternal life, mental health, and/or health; restricted to cases of maternal life; illegal with no exceptions. After Wikipedia, Abortion Law. Available from: https://en.wikipedia.org/wiki/Abortion\_law.


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

Pregnant and Out of Options: The Quest for Abortion in Latin America Due to the Zika Virus…

http://dx.doi.org/10.5772/intechopen.72377

55

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.

In 2015 the already desperate situation that pregnant girls and women in Latin American countries found themselves in when seeking to terminate a pregnancy was made worse by the introduction of a new emerging viral agent into Brazil, the Zika virus. This virus, previously

identified only from Africa and Oceania, was new to the Western Hemisphere [29].

complications arising from illegal abortion procedures.

**4. The Zika virus pandemic and pregnancy**

**Figure 2.** Number of abortions performed in Latin America prior to the Zika epidemic, 1990–1994 and 2010–2014 [3].

only in those cases to save the life of the mother—Paraguay and Guatemala [14, 15]. Brazil permits abortion to save the life of the mother, as well as in cases of rape and anencephaly [16]. In Panama, abortion can also be performed in cases of rape as well as fetal impairment or with parental authorization [17]. Five Latin American countries permit abortion to save a mother's life and preserve physical health—Argentina, Bolivia, Costa Rica, Ecuador, and Peru [3, 18, 19]). In addition to the aforementioned reasons, both Belize and Colombia permit abortion to preserve the mental health of the woman [20, 21]. Only one country in Latin America permits legal abortion—Colombia passed the legislation in 2012, and elective pregnancy termination in that country is now widely available [22].

However, criminalizing abortion in Latin American countries does not prevent abortion—similar to other regions of the world, unsafe abortions occur most frequently as a result of harsh regulations governing the access of girls and women to legal and safe termination of pregnancy [4].

During the period extending from 2010 to 2014 (and prior to the Zika virus outbreak), an estimated 6.5 million induced abortions occurred each year in Latin America and the Caribbean, up from 4.4 million during 1990–1994. As can been seen in **Figure 2**, the greatest number occurred in South America, where there were 4.6 million performed annually in 2010–2014. The annual rate of abortion was estimated at 44 procedures per 1000 women of reproductive age (15–44 years old). The Latin American abortion rate is approximately 48 for married women and 29 for unmarried women. Even prior to the introduction of Zika virus in this region, the proportion of pregnancies ending in abortion had increased between 1990–1994 and 2010–2014, from 23 to 32% [3].
