The European Journal of Contraception and Reproductive Health Care, 2014; 19: 75–77
EDITORIAL
Is there a need for a new abortion law in Spain? Iñaki Lete∗, Joaquim Calaf † and Eduardo López-Arregui‡ ∗University
Hospital Araba,Vitoria, †Autonomous University, Barcelona, and ‡Euskalduna Clinic, Bilbao, Spain
K E Y WO R D S
Abortion law; Induced abortion; Spain
In the last decennia, access to safe induced abortion has been considered in developed societies a necessary measure taking into account women’s very basic rights related to preservation of their health and to deciding themselves about their body and later life. The awareness that unsafe abortion is a major cause of severe maternal morbidity and mortality all over the world has been the most important reason for its legalisation in many countries. Where abortion is illegal, particularly in developing countries where properly trained healthcare personnel are not readily available and modern contraceptives are not easily accessed, termination of pregnancy (TOP) is often a high-risk procedure1–3. Consequently, every developed country respectful of women’s rights and concerned about safe motherhood must provide access to effective contraception and legal, medicalised abortion, as is the case in the vast majority of European countries. The question is: does this presently apply to Spain or do we need a new law to meet these requirements?
A B R I E F H I S T O R I C A L O V E RV I E W
The Abortion Law currently in force In Spain, under Franco’s fascist regime, abortion was illegal and women had to submit to unsafe procedures
in clandestine facilities or, when wealthy enough, would travel abroad. The first abortion regulation was enforced in 1985 when the socialist government passed a law permitting abortion for three different indications: (i) a pregnancy being the result of a rape, (ii) fetal malformations, and (iii) when the pregnancy was considered a risk for either the physical or the psychological wellbeing of the woman. This decriminalisation allowed Spanish women to access safe abortion without having to travel abroad. However, most cases where the pregnancy was labeled as threatening the psychological wellbeing of the woman were in fact abortions for personal reasons instead of health-related matters, and hence were covered by fake psychological reports. This kept the majority of the women having an abortion in a situation of legal uncertainty and was responsible for information on the real causes for TOPs to remain unidentified. The new law, which was approved by the Spanish Parliament in 2010, takes into consideration the woman’s freedom of choice and, like other European legislations, it recognises that her decision is of paramount importance. This law, currently in force, allows a woman to seek an induced abortion without any prerequisites up to 14 weeks of gestation. Specific medical conditions must be put forward to justify a request for abortion made between 14 and 22 weeks.
Correspondence: Iñaki Lete, Professor, Servicio de Ginecología, Hospital, Universitario Araba-sede, Santiago Olaguibel 29, 01004 Vitoria, Spain. Tel: ⫹ 34 945007724. Fax: ⫹ 34 945007901. E-mail: [email protected]
© 2014 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2014.894973
A new abortion law in Spain
Lete et al.
At a still later gestational age, only in strictly selected cases of severe malformations, incompatible with neonatal survival and evaluated by an ‘ad hoc’ expert committee, can TOP be considered. RECENT DEVELOPMENTS
A threat to women’s rights The Spanish Government recently announced its intention to amend the law regulating abortion, which was enforced only four years ago. That announcement had an important impact on public opinion, both in Spain and abroad, as reflected by commentaries spread by the media and mass demonstrations against the change of the law. Is there any need to change the law? Let us overview some possible justifications. What has the current law achieved? After the present law was enacted, the number of abortions in Spain decreased from 113,031 abortions in 2010 to 112,390 abortions in 20124 even though the procedure was reimbursed by the National Health System. Moreover, 90% of these abortions were performed during the first trimester of the pregnancy, 68% before 8 weeks, and, in some regions, by means of the administration of a combination of mifepristone and misoprostol, before 7 weeks. Such early abortions help to avoid major complications. It thus appears that, with an easier access and better registration, the number of abortions has decreased. It should be stressed that the 2010 law also includes measures to facilitate the access to effective contraception The earlier the abortion is done, the lower the risk for women, especially if the procedure takes place in a medical setting. The World Health Organization declared that early medical abortion with misoprostol is safe, effective and recommended5. The new restrictive law which is in the making can be responsible for a rise in the number of second-trimester abortions, which are commonly associated with more – and more severe – complications6. In Spain, 188 sites currently have the approval to perform abortions; these include hospitals, nonhospital settings, and family planning centres.The modification proposed by the conservative government presently in power means that the abortion activity in 76
these facilities will become illegal, doctors working there will be considered as outlaws and, finally, the centres concerned will be closed. As a result thereof, thousands of Spanish women will be forced to choose between a safe abortion in another European country, a medically unsafe abortion in a clandestine facility, or one carried out by a healthcare professional who will knowingly transgress the law, in accordance with his/ her medical ethics, and – like his patient – be liable to prosecution for having done so. The first option will be limited to a small group of women among the wealthiest in a society involved in a deep financial crisis. The second one could be the only resource for many women, thus exposing them to the well known health risks of sepsis, perforations, pelvic inflammatory disease, infertility, and – in some cases – death. The present conditions are very different but, in 1976, there were up to 200 maternal deaths among the 100,000 women who had an abortion, that year, in Spain. On the contrary, pregnancy terminations currently performed by trained healthcare providers (HCPs) have a very low rate of complications7. In the era of globalisation and internet, many women can confidentially purchase the drugs needed for a medical, self-induced TOP. But lacking both knowledge and expertise they may use the compounds improperly, thus running the risk of developing complications such as the rupture of an undetected ectopic pregnancy, incomplete abortions, haemorrhage, and infection. Is a new law needed to avoid conflicts between professionals accepting and those objecting to an active participation in abortions? This is certainly not the case.The abortion law enacted in 2010 fully respects the beliefs, perceptions and confessional affiliation of the HCPs potentially involved in these procedures. No claims have been put in by professionals who would have been forced to perform medical acts against their free will; this has never been an issue in the media nor was it reported by medical organisations or unions. Also the majority of the population has accepted the law as no one underwent an abortion under coercion. Clearly social peace, both among professionals and in the population at large, has not been threatened and there can be no justification of that kind to consider that changing the law is needed.
The European Journal of Contraception and Reproductive Health Care
A new abortion law in Spain
Does the law currently in force enable one to submit to- or to perform uncontrolled abortions? This, again, is definitely not the case. The regulation of the provision of abortion care through the National Health Service network ensures a very strict control of the procedures taking place. Information must be provided on the gestational age at which the abortions are carried out, the characteristics of the women concerned, and the complications occurring. This allows the setting up of strategies to reduce unwanted pregnancies, and to initiate efficacious contraception immediately post-abortum. CONCLUDING REMARKS
To go back 30 years in time will create a tragic gap in sexual and reproductive health (SRH) care between most European countries and Spain, and it will, in this respect, reduce the latter nation’s citizens to the very insufficient level of care characterising Third World regions. Such restriction imposed on individual rights reflects a lack of tolerance and sensibility that was unthinkable only four years ago, when Spain was among the countries worldwide with the most liberal regulations of individual rights with regard to SRH-related issues. According to the aforementioned data, the extremely restrictive law proposed by the government, if enforced, may prevent some 100,000 women residing in Spain from accessing proper abortion care every year.
Lete et al.
Spain is constitutionally a secular State; individual rights should not be mixed nor confounded with the moral, ethical and religious beliefs of the most reactionary members of a ruling party. To make things even worse, the new regulation entails an absolute lack of compassion towards women carrying a malformed fetus. According to the proposed draft, some 3000 women who yearly will confront such a diagnosis would have to let their pregnancy progress without interference and deliver their undesired and crippled child. That same government, which proposes to make the abortion law more restrictive, has recently put forward a 50% reduction in the subventions for dependent sick or handicapped persons. Hopefully, this private bill amending the Spanish abortion law will be either withdrawn or radically modified as a consequence of actions undertaken both in the country and internationally. If the government should reconsider its plans, this might lead to the promulgation of a new law, which ideally should be approved by a large majority in parliament. The prior consultation of unbiased experts in the fields of sociology and the biology of reproduction may lead to a law that will remain unchanged for many years. We hope to have succeeded in demonstrating that the 2010 law must not be changed: indeed, it is adapted to the social and sanitary reality of the country, and meets the people’s needs. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper.
REFERENCES
1. Amy JJ. The shortest lecture on fertility control. Eur J Contracept Reprod Health Care 2009;14:321–3. 2. Potts M. Abortion perspectives. Eur J Contracept Reprod Health Care 2010;15:157–9. 3. Brookman-Amissah E. Saving women’s lives in Africa through access to comprehensive abortion care. Eur J Contracept Reprod Health Care 2012;17:241–4. 4. Ministerio de Sanidad, Servicios Sociales e Igualdad. (Abortos realizados) – Datos estadisticos. Accessed 6 February 2014 from: http://www.msssi.gob.es/profesionales/salud Publica/prevPromocion/embarazo/tablas_figuras.htm
5. World Health Organization. Safe abortion: Technical and policy guidance for health systems. Geneva, Switzerland: World Health Organization 2012:4. 6. Grossman D, White K, Hopkins K, Potter JE. The public health threat of anti-abortion legislation. Contraception 2014;89:73–4. 7. Weitz TA, Taylor D, Desai S, et al. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health 2013;103: 454–61.
The European Journal of Contraception and Reproductive Health Care
77
Copyright of European Journal of Contraception & Reproductive Health Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EDITORIAL
Is there a need for a new abortion law in Spain? Iñaki Lete∗, Joaquim Calaf † and Eduardo López-Arregui‡ ∗University
Hospital Araba,Vitoria, †Autonomous University, Barcelona, and ‡Euskalduna Clinic, Bilbao, Spain
K E Y WO R D S
Abortion law; Induced abortion; Spain
In the last decennia, access to safe induced abortion has been considered in developed societies a necessary measure taking into account women’s very basic rights related to preservation of their health and to deciding themselves about their body and later life. The awareness that unsafe abortion is a major cause of severe maternal morbidity and mortality all over the world has been the most important reason for its legalisation in many countries. Where abortion is illegal, particularly in developing countries where properly trained healthcare personnel are not readily available and modern contraceptives are not easily accessed, termination of pregnancy (TOP) is often a high-risk procedure1–3. Consequently, every developed country respectful of women’s rights and concerned about safe motherhood must provide access to effective contraception and legal, medicalised abortion, as is the case in the vast majority of European countries. The question is: does this presently apply to Spain or do we need a new law to meet these requirements?
A B R I E F H I S T O R I C A L O V E RV I E W
The Abortion Law currently in force In Spain, under Franco’s fascist regime, abortion was illegal and women had to submit to unsafe procedures
in clandestine facilities or, when wealthy enough, would travel abroad. The first abortion regulation was enforced in 1985 when the socialist government passed a law permitting abortion for three different indications: (i) a pregnancy being the result of a rape, (ii) fetal malformations, and (iii) when the pregnancy was considered a risk for either the physical or the psychological wellbeing of the woman. This decriminalisation allowed Spanish women to access safe abortion without having to travel abroad. However, most cases where the pregnancy was labeled as threatening the psychological wellbeing of the woman were in fact abortions for personal reasons instead of health-related matters, and hence were covered by fake psychological reports. This kept the majority of the women having an abortion in a situation of legal uncertainty and was responsible for information on the real causes for TOPs to remain unidentified. The new law, which was approved by the Spanish Parliament in 2010, takes into consideration the woman’s freedom of choice and, like other European legislations, it recognises that her decision is of paramount importance. This law, currently in force, allows a woman to seek an induced abortion without any prerequisites up to 14 weeks of gestation. Specific medical conditions must be put forward to justify a request for abortion made between 14 and 22 weeks.
Correspondence: Iñaki Lete, Professor, Servicio de Ginecología, Hospital, Universitario Araba-sede, Santiago Olaguibel 29, 01004 Vitoria, Spain. Tel: ⫹ 34 945007724. Fax: ⫹ 34 945007901. E-mail: [email protected]
© 2014 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2014.894973
A new abortion law in Spain
Lete et al.
At a still later gestational age, only in strictly selected cases of severe malformations, incompatible with neonatal survival and evaluated by an ‘ad hoc’ expert committee, can TOP be considered. RECENT DEVELOPMENTS
A threat to women’s rights The Spanish Government recently announced its intention to amend the law regulating abortion, which was enforced only four years ago. That announcement had an important impact on public opinion, both in Spain and abroad, as reflected by commentaries spread by the media and mass demonstrations against the change of the law. Is there any need to change the law? Let us overview some possible justifications. What has the current law achieved? After the present law was enacted, the number of abortions in Spain decreased from 113,031 abortions in 2010 to 112,390 abortions in 20124 even though the procedure was reimbursed by the National Health System. Moreover, 90% of these abortions were performed during the first trimester of the pregnancy, 68% before 8 weeks, and, in some regions, by means of the administration of a combination of mifepristone and misoprostol, before 7 weeks. Such early abortions help to avoid major complications. It thus appears that, with an easier access and better registration, the number of abortions has decreased. It should be stressed that the 2010 law also includes measures to facilitate the access to effective contraception The earlier the abortion is done, the lower the risk for women, especially if the procedure takes place in a medical setting. The World Health Organization declared that early medical abortion with misoprostol is safe, effective and recommended5. The new restrictive law which is in the making can be responsible for a rise in the number of second-trimester abortions, which are commonly associated with more – and more severe – complications6. In Spain, 188 sites currently have the approval to perform abortions; these include hospitals, nonhospital settings, and family planning centres.The modification proposed by the conservative government presently in power means that the abortion activity in 76
these facilities will become illegal, doctors working there will be considered as outlaws and, finally, the centres concerned will be closed. As a result thereof, thousands of Spanish women will be forced to choose between a safe abortion in another European country, a medically unsafe abortion in a clandestine facility, or one carried out by a healthcare professional who will knowingly transgress the law, in accordance with his/ her medical ethics, and – like his patient – be liable to prosecution for having done so. The first option will be limited to a small group of women among the wealthiest in a society involved in a deep financial crisis. The second one could be the only resource for many women, thus exposing them to the well known health risks of sepsis, perforations, pelvic inflammatory disease, infertility, and – in some cases – death. The present conditions are very different but, in 1976, there were up to 200 maternal deaths among the 100,000 women who had an abortion, that year, in Spain. On the contrary, pregnancy terminations currently performed by trained healthcare providers (HCPs) have a very low rate of complications7. In the era of globalisation and internet, many women can confidentially purchase the drugs needed for a medical, self-induced TOP. But lacking both knowledge and expertise they may use the compounds improperly, thus running the risk of developing complications such as the rupture of an undetected ectopic pregnancy, incomplete abortions, haemorrhage, and infection. Is a new law needed to avoid conflicts between professionals accepting and those objecting to an active participation in abortions? This is certainly not the case.The abortion law enacted in 2010 fully respects the beliefs, perceptions and confessional affiliation of the HCPs potentially involved in these procedures. No claims have been put in by professionals who would have been forced to perform medical acts against their free will; this has never been an issue in the media nor was it reported by medical organisations or unions. Also the majority of the population has accepted the law as no one underwent an abortion under coercion. Clearly social peace, both among professionals and in the population at large, has not been threatened and there can be no justification of that kind to consider that changing the law is needed.
The European Journal of Contraception and Reproductive Health Care
A new abortion law in Spain
Does the law currently in force enable one to submit to- or to perform uncontrolled abortions? This, again, is definitely not the case. The regulation of the provision of abortion care through the National Health Service network ensures a very strict control of the procedures taking place. Information must be provided on the gestational age at which the abortions are carried out, the characteristics of the women concerned, and the complications occurring. This allows the setting up of strategies to reduce unwanted pregnancies, and to initiate efficacious contraception immediately post-abortum. CONCLUDING REMARKS
To go back 30 years in time will create a tragic gap in sexual and reproductive health (SRH) care between most European countries and Spain, and it will, in this respect, reduce the latter nation’s citizens to the very insufficient level of care characterising Third World regions. Such restriction imposed on individual rights reflects a lack of tolerance and sensibility that was unthinkable only four years ago, when Spain was among the countries worldwide with the most liberal regulations of individual rights with regard to SRH-related issues. According to the aforementioned data, the extremely restrictive law proposed by the government, if enforced, may prevent some 100,000 women residing in Spain from accessing proper abortion care every year.
Lete et al.
Spain is constitutionally a secular State; individual rights should not be mixed nor confounded with the moral, ethical and religious beliefs of the most reactionary members of a ruling party. To make things even worse, the new regulation entails an absolute lack of compassion towards women carrying a malformed fetus. According to the proposed draft, some 3000 women who yearly will confront such a diagnosis would have to let their pregnancy progress without interference and deliver their undesired and crippled child. That same government, which proposes to make the abortion law more restrictive, has recently put forward a 50% reduction in the subventions for dependent sick or handicapped persons. Hopefully, this private bill amending the Spanish abortion law will be either withdrawn or radically modified as a consequence of actions undertaken both in the country and internationally. If the government should reconsider its plans, this might lead to the promulgation of a new law, which ideally should be approved by a large majority in parliament. The prior consultation of unbiased experts in the fields of sociology and the biology of reproduction may lead to a law that will remain unchanged for many years. We hope to have succeeded in demonstrating that the 2010 law must not be changed: indeed, it is adapted to the social and sanitary reality of the country, and meets the people’s needs. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper.
REFERENCES
1. Amy JJ. The shortest lecture on fertility control. Eur J Contracept Reprod Health Care 2009;14:321–3. 2. Potts M. Abortion perspectives. Eur J Contracept Reprod Health Care 2010;15:157–9. 3. Brookman-Amissah E. Saving women’s lives in Africa through access to comprehensive abortion care. Eur J Contracept Reprod Health Care 2012;17:241–4. 4. Ministerio de Sanidad, Servicios Sociales e Igualdad. (Abortos realizados) – Datos estadisticos. Accessed 6 February 2014 from: http://www.msssi.gob.es/profesionales/salud Publica/prevPromocion/embarazo/tablas_figuras.htm
5. World Health Organization. Safe abortion: Technical and policy guidance for health systems. Geneva, Switzerland: World Health Organization 2012:4. 6. Grossman D, White K, Hopkins K, Potter JE. The public health threat of anti-abortion legislation. Contraception 2014;89:73–4. 7. Weitz TA, Taylor D, Desai S, et al. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health 2013;103: 454–61.
The European Journal of Contraception and Reproductive Health Care
77
Copyright of European Journal of Contraception & Reproductive Health Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
