Yomira Cuadros faced motherhood at an early age, as well as the obstacles of a sexist society like Peru’s, regarding her reproductive decisions. In the apartment where she lives with her family in Lima, she expresses faith in the future, now that she has finally started attending university, after having two children as a result of unplanned pregnancies. CREDIT: Mariela Jara/IPS

By Mariela Jara
LIMA, Nov 18 2022 (IPS)

No woman in Peru should have to die, have her physical or mental health affected, be treated as a criminal or have an unwanted pregnancy because she does not have access to abortion, said Dr. Rocío Gutiérrez, an obstetrician who is the deputy director of the Manuela Ramos Movement, a non-governmental feminist center that works for gender rights in this South American country.

In this Andean nation of 33 million people, abortion is illegal even in cases of rape or fetal malformation. It is only legal for two therapeutic reasons: to save the life of the pregnant woman or to prevent a serious and permanent health problem.

Peru thus goes against the current of the advances achieved by the “green wave”. Green is the color that symbolizes the changes that the women’s rights movement has achieved in the legislation of neighboring countries such as Uruguay, Colombia, Argentina and some states in Mexico, where early abortion has been decriminalized. These countries have joined the ranks of Cuba, where it has been legal for decades."I didn't tell my parents because they are very Catholic and would have forced me to go through with the pregnancy, they always instilled in me that abortion was a bad thing. But I started to think about how pregnancy would change my life and I didn't feel capable of raising a child at that moment." -- Fatima Guevara

But Latin America remains one of the most punitive regions in terms of abortion, with several countries that do not recognize women’s right to make decisions about their pregnancies under any circumstances. In El Salvador, Honduras, Nicaragua, the Dominican Republic and Haiti it is illegal under all circumstances, and in some cases draconian penalties are handed down.

In the case of Costa Rica, Guatemala, Peru and Venezuela, meanwhile, abortion is allowed under very few conditions, while there are more circumstances under which it is legal in Bolivia, Brazil, Chile and Ecuador.

“In Peru an estimated 50,000 women a year are treated for abortion-related complications in public health facilities,” Dr. Gutiérrez told IPS. “This is not the total number of abortions in the country, but rather the number of women who reach public health services due to emergencies or complications.”

The obstetrician spoke to IPS from Buenos Aires, where she participated in the XV Regional Conference on Women, held Nov. 7-11 in the Argentine capital.

Gutiérrez explained that the cases attended are just the tip of the iceberg, because for every abortion complicated by hemorrhage or infection treated at a health center, at least seven have been performed that did not present difficulties.

Multiplying by seven the 50,000 cases treated due to complications provides the shocking figure of 350,000 unsafe clandestine abortions performed annually in Peru.

The doctor regretted the lack of official statistics about a phenomenon that affects the lives and rights of women “irreversibly, with damage to health, and death.”

Gutiérrez said that another of the major impacts is the criminalization of women who undergo abortions, due to mistreatment by health personnel who not only judge and blame them, but also report them to the police.

Obstetrician Rocío Gutiérrez (C), deputy director of the feminist Manuela Ramos Movement, stands with two fellow activists holding green scarves – representing the struggle for reproductive rights – during the XV Regional Conference on Women held this month in the city of Buenos Aires. CREDIT: Courtesy of Rocío Gutiérrez

Under article 30 of Peru’s General Health Law, No. 26842, a physician who attends a case of presumed illegal abortion is required to file a police report.

Gutiérrez also referred to the fact that unwanted pregnancies have numerous consequences for the lives of women, especially girls and adolescents, in a sexist country like Peru, where women often do not have the right to make decisions on their sexuality and reproductive health.

Healing the wounds of unwanted motherhood

By the age of 19, Yomira Cuadros was already the mother of two children. She did not plan either of the pregnancies and only went ahead with them because of pressure from her partner.

In 2020, according to official data, 8.3 percent of adolescents between the ages of 15 and 19 were already mothers or had become pregnant in Peru.

Cuadros, whose parents are both physicians and who lives in a middle-class family, said she never imagined that her life would turn out so differently than what she had planned.

“The first time was because I didn’t know about contraceptives, I was 17 years old. The second time the birth control method failed and I thought about getting an abortion, but I couldn’t do it,” Cuadros told IPS.

At the time, she was in a relationship with an older boyfriend on whom she felt very emotionally dependent. “I had made a decision (to terminate the pregnancy), but he didn’t want to, he told me not to, the pressure was like blackmail and out of fear I went ahead with the pregnancy,” she said.

Making that decision under coercion hurt her mental health. Today, at the age of 26, she reflects on the importance of women being guaranteed the conditions to freely decide whether they want to be mothers or not.

Peruvian activists go topless to demand the right to legal abortion, during a demonstration in the streets of the capital on Mar. 8, 2018. CREDIT: Mariela Jara/IPS

In her case, although she had the support of her mother to get a safe abortion, the power of her then-partner over her was stronger.

“Becoming a mother when you haven’t planned to is a shock, you feel so alone, it is very difficult. I didn’t feel that motherhood was something beautiful and I didn’t want to experience the same thing with my second pregnancy, so I considered terminating it,” she said.

Finding herself in that unwanted situation, she fell into a deep depression and was on medication, and is still in therapy today.

“I went from being a teenager to an adult with responsibilities that I never imagined. It’s as if I have never really gone through the proper mourning process because of everything I had to take on, and I know that it will continue to affect me because I will never stop being a mother,” she said.

She clarified that “it’s not that I don’t want to be a mother or that I hate my children,” and added that “as I continue to learn to cope, I will get better, it’s just that it wasn’t the right time.”

She and her two children, ages nine and seven, live with her parents and brother in an apartment in the municipality of Pueblo Libre, in the Peruvian capital. She has enrolled at university to study psychology and accepts the fact that she will only see her dreams come true little by little.

“Things are not how I thought they would be, but it’s okay,” she remarked with a newfound confidence that she is proud of.

Gutiérrez said more than 60 percent of women in Peru have an unplanned pregnancy at some point in their lives, and argued that the government’s family planning policies fall far short.

The National Institute of Statistics and Informatics reported that the total fertility rate in Peru in 2021 would have been 1.3 children on average if all unwanted births had been prevented, compared to the actual rate of 2.0 children – almost 54 percent higher than the desired fertility rate.

“There are a set of factors that lead to unwanted pregnancies, such as the lack of comprehensive sex education in schools, and the lack of birth control methods and timely family planning for women in all their diversity, which worsened during the pandemic. And of course, the correlate is access to legal and safe abortion,” said Gutiérrez.

She lamented that little or no progress has been made in Peru in relation to the exercise of sexual and reproductive rights, including access to safe and free legal abortion, despite the struggle of feminist organizations and movements in the country that have been demanding decriminalization in cases of rape, artificial insemination without consent, non-consensual egg transfer, or malformations incompatible with life.

University student Fátima Guevara decided to terminate an unwanted pregnancy when she was 19 years old. Four years later, she is sure that it was the right decision, in terms of her plans for her life. The young woman told her story at a friend’s home, where she was able to talk about it openly, in Lima, Peru. CREDIT: Mariela Jara/IPS

The obscurity of illegal abortion

The obscurity surrounding abortion led Fátima Guevara, when she faced an unwanted pregnancy at the age of 19, to decide to use Misoprostol, a safe medication that is included in the methods accepted by the World Health Organization for the termination of pregnancies.

“I didn’t tell my parents because they are very Catholic and would have forced me to go through with the pregnancy, they always instilled in me that abortion was a bad thing. But I started to think about how pregnancy would change my life and I didn’t feel capable of raising a child at that moment,” she told IPS in a meeting at a friend’s home in Lima.

She said that she and her partner lacked adequate information and obtained the medication through a third party, but that she used it incorrectly. She turned to her brother who took her to have an ultrasound first. “Hearing the fetal heartbeat shook me, it made me feel guilty, but I followed through with my decision,” she added.

After receiving proper instructions, she was able to complete the abortion. And today, at the age of 23, about to finish her psychology degree, she has no doubt that it was the right thing to do.

The Ibrahim Malik public hospital in Khartoum, Sudan. Abortion is only legal in Sudan under very specific circumstances. As a result a number of women continue to access unsafe abortions. Courtesy: Abdelgadir Bashir

By Reem Abbas
KHARTOUM, Jun 22 2020 (IPS)

Omnia Nabil*, a Sudanese doctor, who worked in one of the largest hospitals in Khartoum, the country’s capital, was devastated to witness the deaths of 50 young women who had unsafe abortions during a space of just three months.

“I would see 16 cases of failed abortions on a given day. I would insert my hand and pull out syringes or leaves, unsanitary items that were inserted by midwives to induce a miscarriage,” Nabil told IPS.

For Sudanese women, getting an abortion is often a very lonely and dangerous process because it is only allowed in very specific cases.

Article 135 of the Criminal Law of 1991 legalises “miscarriage” only to save the mother’s life, if she is a victim of rape in her first trimester or if the foetus is dead. However, in all cases, women need their husband’s consent for the procedure.

Women who do not meet these requirements generally end up going to traditional midwives. But it places the women’s lives at risk. And if caught, it is an offence punishable with imprisonment of up to six years or a fine.

• This Northeast African nation of some 41 million people was ruled for 30 years by dictator Omar al-Bashir until he was removed from power by the country’s military in April 2019 after mass pro-democracy protests.
• Under Al-Bashir’s rule the country experienced decades of war and repression resulting in the current internal displacement of 2.1 million people. 

Sudan’s transitional government, formed in August 2019, allocated 40 percent of its parliamentary seats to women. This resulted in laws restricting freedom of dress, movement and work being repealed and female genital multination being criminalised. However, there have been no changes to the law on abortion.

Abortion – a dangerous and lonely procedure

But as international organisations working on reproductive health were slowly shut down in years prior to the transitional government being formed, small groups or networks of people have been working together to ensure that women are able to access safe abortions.

Because most women can’t access hospitals or healthcare facilities because they fear arrest, they end up having the abortions alone, or with little help. Sarah Ali* was one of them.

When Ali found out about her pregnancy, she struggled to find a nurse or doctor who would help her obtain an abortion.

“I was running out of options and a midwife working at a private hospital had agreed to help me, but was unable to find the pills. I was entering my 11th week when I received the pills sent in a package by Women on Web,” Ali, who no longer lives in Sudan, told IPS.

The pills, a combination of mifepristone and misoprostol, were sent by Women on Web, a Canadian non-profit organisation that “advocates for and facilitates access to contraception and safe abortion services to protect women’s health and lives”, according to its website.

• The organisation provides women with abortion pills within the first 10 weeks of their pregnancy, after an online consultancy, which allows those who have a problem accessing a safe abortion to have a medical abortion in their homes. According to the organisation, a medical abortion in the first 10 weeks is “very low risk of complications and resemble having an early miscarriage”.

“After the procedure, I was able to go back to the midwife for a check-up and make sure I didn’t get an infection,” said Ali.

There are no recent statistics on unsafe abortions in Sudan. However, according to Women Deliver, “An estimated 25.1 million unsafe abortions take place [globally] each year. Every year, approximately, 6.9 million women in developing countries are treated for complications from unsafe abortions, and complications from unsafe abortions cause at least 22,800 deaths each year.”

Nabil watched as women who had unsafe abortions and came to the hospital for help eventually died.

“They would usually die from what we call septic abortion, which is essentially an infected abortion process and even though I was pro-choice from early on, this tragedy inspired me to start the abortion network,” said Nabil, who has since left the country.

Underground networks help women access safe abortions

With a core group of doctors, doctors-in-training and supporters, Nabil created a network to obtain misoprostol for patients and supported them if they had future complications. The network was a small and deeply-secure structure.

“The work was dangerous. At some point, we had a patient in the hospital and the doctor treating her suspected that she was unmarried, she called the police and I had to help her and her partner escape,” said Nabil.

Knowing the risks, Nabil took her precautions. She had a separate phone and always used a fake name with patients seeking abortions.

The core team worked for years without getting caught and recruited younger doctors when those in the team had moved on to other jobs.

“We tried to support girls from lower-income households and offered them the pills at reduced prices relying on our acquaintances in the field. But in the end, we were unofficial and dependent on word of mouth, so you have to know someone to make the initial contact,” said Nabil.

In the last few years, the network’s capacity was reduced as more of its members moved on to other countries seeking better economic situations. Nabil continued to help from a distance and her close friend was the last one in the network, until he also left the country.

Shrinking space for service providers 

The last statistics on the use of misoprostol dates back to 2011, when DKT International, a health charity operating in Sudan and the largest non-government provider of reproductive health products and services at the time, published a report stating that 450,000 units of Misoprostol and 16,000 kits of MVA were used/sold that year.

DKT came under attack in 2012 when radical parliamentarians clashed with the Minister of Health over family planning, abortion equipment and the distribution of condoms.

But things became worse when the government shut down another international organisation working on reproductive health.

“This organisation had provided an important device called vacuum aspirator or NVA for abortion and miscarriage cases and it was registered in Sudan until the government stopped it. It is life-saving and important and now few doctors have it and can only do it under the table,” said Salma Habib* an activist working on SRHR issues here.

In the meantime, there is one doctor in Sudan who is willing to perform medical abortions and support his patients in taking misoprostol, but he has been banned from working here since 2006.

When Dr. Abdelhadi Ibrahim, a young Ob/Gyn specialist moved to Sudan from the UK in the 1997, young women patients started asking him to perform abortions.

Ibrahim estimated that he had provided safe abortions to at least 10,000 women over a period of seven years and helped many others restore their hymens to indicate virginity.

In 2006, Ibrahim was arrested and tried in a high-profile court case and was sentenced to six years in prison and his license was revoked by the Sudan Medical Council.

“Until today, I am fighting to get back my license. I won two law suits and the council continued to stall and now after the revolution, they just made appointments in the council and a committee should be formed to look into it, I must’ve visited the council’s building hundreds of times,” Ibrahim, who he has not worked in 14 years and was forced to sell some of his property to support himself, told IPS.

Abortion pills too costly for most women

In the meantime, prices of medical abortion pills have soared.

“Today, most women can not afford a safe abortion in Sudan. The pills could cost at least $142 to $214 or even more and the quality of the pills and their expiration date could be a problem because you are buying from the black market after all,” said Habib, who added that there are fake pills on the market also.

Most Sudanese women have to use traditional midwives as they can’t access the expensive pills. It places them at risk to unsafe abortions.

The procedures performed by midwives are often dangerous, but in addition the midwives often criminalise the behaviour of their patients.

“I know a girl who was circumcised by a midwife after an abortion and was told that this is to stop her from having sex again, it is clear that midwives could punish you or take advantage of your situation,” said Ali.

But as Nabil’s abortion network closed, parallel networks sprung up. Habib supports her network by accessing pills from Women on Web and from trusted sources inside Sudan.

“There are people working now, I don’t know many of them, but one of my former clients is now leading the same efforts and helping other women,” said Nabil.

*Names changed to protect identity.