In every country, regardless of the legal status of induced abortion, some women experiencing an unintended pregnancy turn to abortion to end it.[1] Chile is no exception to this worldwide pattern. Yet data on contraceptive use, unintended pregnancy and other determinants of abortion in the country are either incomplete or nonexistent because large-scale studies like the Demographic and Health Surveys that are available for most developing countries are not conducted in Chile.

In addition to this lack of survey data, the clandestine nature of abortion in Chile makes all aspects of the procedure difficult to research. The only national study, conducted in 1990, estimated that women in Chile had approximately 160,000 induced abortions annually, for a rate of 45 per 1,000 women aged 15–49.[2] More recent—but less substantiated—estimates cited in the media have ranged from 60,000[3] to 300,000[4] abortions each year.

No data exist on the characteristics of women obtaining abortions in Chile, nor on their reasons for doing so. As one researcher points out, "we do not know…who are the women who practice clandestine abortion, from what social backgrounds, at what ages, from what regions of the country, the sexual or reproductive…backgrounds of these women, the types of interventions they resort to and how they carry these out."[5] However, it is widely agreed that Chilean women who resort to unsafe pregnancy terminations, and subsequently seek treatment for complications, tend to come from the country’s more disadvantaged groups.[6,7] It is likely that Chilean women’s reasons for seeking abortion are similar to those most commonly given by women around the world: the desire to delay or stop childbearing, fear of disrupting their education or employment, lack of economic means to raise a child, lack of support from their partner, problems in their relationship with the father and the perception that they are too young to have a child.[8]

Abortion-related deaths and injuries appear to have declined dramatically

In the 1960s, many Chilean women undergoing unsafe abortions died as a result, or suffered serious short- or long-term health complications for which they did not receive the medical treatment they needed.[9] In 1960, there were 294 maternal deaths per 100,000 live births,[10] and one-third of these deaths were attributable to unsafe abortion.[11] One in five hospital beds in obstetric departments were occupied by women receiving postabortion treatment.

Chile’s maternal mortality ratio fell to 55 deaths per 100,000 live births by 1990, and to 22 by 2013.[12] The precise contribution of unsafe induced abortion to overall maternal mortality is unclear, but experts agree that far fewer deaths result from unsafe induced abortion now than was the case 50 years ago. This decrease in abortion-related mortality has been attributed to increasing use of safer abortion methods (primarily misoprostol), improvements by Chile’s public health institutions in the management of post-abortion complications and lower fertility resulting from improved access to family planning services.[13]

National-level hospital discharge data provide indirect clues that the frequency with which clandestine abortion results in health complications severe enough to require hospitalization is also declining. Cases of morbidity resulting from all pregnancies that were not carried to term fell from 56,391 in 1964[14] to 30,434 in 2012,[15] representing a decline in the morbidity rate from 32 to eight hospitalizations per 1,000 Chilean women of childbearing age. Because of underreporting and likely misdiagnosis, it is difficult to distinguish what proportion of these hospitalizations involve women with complications from unsafe abortion attempts as compared with those requiring care for complications related to other reasons pregnancies are not carried to term (such as ectopic or molar pregnancy, or spontaneous pregnancy loss). More research on this topic is needed.

Misoprostol is increasingly available in Chile

Small-scale studies and anecdotal evidence suggest that wealthier Chilean women have access to safe abortions from skilled providers, whose most commonly used techniques are thought to be dilation and curettage, manual vacuum aspiration and, increasingly, medication abortion using misoprostol.[16,17] Poorer Chilean women usually cannot afford to pay the fees charged by private obstetricians and gynecologists for safe procedures. However, increased access to misoprostol outside of formal health care settings demonstrates that lack of wealth may no longer be the insurmountable barrier to a relatively safe abortion that it once was. A small study from 2013 of women charged with breaking Chile’s abortion law found pregnancy terminations using misoprostol cost US$75–$215,[18] whereas procedures of varying levels of safety carried out by physicians are said to cost as much as US$2,000.[19]

Although illegal when sold or used to induce abortion, misoprostol can easily be acquired in Chile through the Internet and is also available through some providers of clandestine abortion. When used in the first nine weeks of pregnancy and at the correct dosage, the drug successfully ends a pregnancy in 75–90% of cases.[20] When used after the first trimester or at the wrong dosage, this method can result in incomplete abortion, heavy bleeding and other complications. Many unscrupulous online vendors appear to be selling fake pills or supplying women with incorrect dosages and charging high prices for them.[19] The medication often comes without information on its correct use, even when the correct dosage is supplied.

Aside from the increase in misoprostol use among those who can obtain and afford it, abortion methods in Chile have changed very little since the 1990s. Those who are unable to obtain safe services through trained providers still resort to traditional methods, which are often unsafe, ineffective or both. These range from drinking boiled beer or herbal teas to inserting knitting needles, scissors or rubber catheters into the cervix.[21,22]

Poor women bear the brunt of abortion-related prosecution

Each year, Chilean women and men are reported to local authorities for having or assisting in an induced abortion.[16,18] Poor women are thought to be the most likely to use unsafe abortion methods and the most likely to seek postabortion treatment in public health facilities, which are the source of almost all abortion-related denunciations to the criminal justice system. According to national police reports, between 2003 and 2012, a total of 3,570 women and 975 men in Chile were sentenced for these infractions of the existing penal code.[16] The lawyer who analyzed these statistics concludes that cases of "criminal prosecution are very selective, involving most of all…the poorest women."[16]

The number of women who are incarcerated for obtaining an abortion has dropped dramatically in recent years, from 88 in 2003 to five in 2012, and most are now sentenced to probation. The length of sentences for women convicted of obtaining or assisting in an abortion between 2003 and 2012 ranged from 1.5 to three years, as mandated in the penal code.[23] Doctors and professional midwives found to have performed abortions received sentences of 3–5 years; unskilled or untrained providers (including traditional birth attendants) received sentences of no more than three years.

Data about contraceptive use in Chile are lacking

In the absence of survey data on pregnancy intentions and contraceptive use, it is impossible to estimate the level of unmet need for modern contraception. The only available estimate of contraceptive use for Chile is for the combined population of men and women aged 15 and older—a nonstandard measure that does not permit assessment of the needs among women of reproductive age.[24] Unless the vast majority of women who want to avoid pregnancy are using effective contraceptive methods consistently and correctly, both unintended pregnancy and abortion are likely occurring at substantial levels.[25,26]

Data on adolescents and young adults hint at the particular risks and challenges faced by young people in Chile. As of 2009, the average age at first intercourse was 16 for men and 17 for women, and more than nine in 10 young people aged 15–29 had never married, indicating than many young people become sexually active well before they are likely to want to have a child.[27] Yet school-based sex education may not be meeting adolescents’ needs for comprehensive, evidence-based information: A 2006 assessment of Chile’s official sex education program concluded that the program did not include instruction on the negative consequences of unwanted pregnancy in adolescence or provide advice that could help students avoid early out-of-wedlock childbearing.[28] As of 2009, four in 10 sexually experienced women aged 15–19 had had an unintended pregnancy, and 7% of young people aged 15–29 who had experienced an unintended pregnancy reported that it had ended in an induced abortion.[27] This low proportion likely reflects underreporting, however, due to the illegality of the procedure.

Summary

The deficit of knowledge on the prevalence and consequences of induced abortion in Chile prevents a fully informed debate on the impact of clandestine abortion on Chilean women and families. Research is needed to fill this gap and provide policymakers and health care providers with the information they need to devise sound policies and interventions that best promote the nation’s public health. New data and policies are particularly important to verify and address the inequities suggested by the existing data: Poor women appear to be at an elevated risk for obtaining unsafe procedures and for being prosecuted as a result.

Worldwide, induced abortion—whether legal or clandestine— is most often sought in response to unintended pregnancy. Most Chilean couples want to have small families, and to achieve their desired family size and avoid the need for abortion, they need to use effective contraceptive methods correctly and consistently for the majority of their reproductive lives. Research on unintended pregnancy and unmet need for contraception is needed both to contextualize women’s recourse to abortion and to help assess and improve women’s ability to plan the timing and number of their pregnancies.

REFERENCES

BOX REFERENCES