Rarely has abortion been on the agenda as much as it has in recent weeks. The reform of the 2010 law, which aims to guarantee it in public centers, started the process a month ago and, although it still has a long way to go, it has already opened debates that had gone unnoticed. Even so, the stigma and silence that surrounds it continue to underpin the lack of knowledge about a right that in 2020, the year of the pandemic, was exercised by 88,269 women. In fact, there is hardly any mention of how to abort, with what medical methods it is done or which ones are used more in Spain.
There are two main procedures when performing an abortion: the instrumental or surgical and the pharmacological. Both are equally safe and effective, but the former is an intervention carried out by a professional team and the latter uses only medication. And, although there is no consensus on whether the pharmacological treatment can be extended for a few more weeks, the two coexist for abortions, in general, until week 9 of pregnancy, which is the vast majority. When pregnancy is terminated for medical reasonsIn 10% of cases, instrumental techniques always come into play, which are more complex and longer processes.
In general, according to official data, the instrumental method is used more by far, while the pharmacological method is a minority, although it has been growing progressively in recent years. In 2011, the first full year of application of the law, 90% of abortions were surgical, a figure that has dropped to 76% in 2020. Even so, there are interruptions that are not qualified in the reports of the Ministry of Health in neither of the two categories and appear in "other". They were in 2019 and 2020 a not insignificant amount and the vast majority correspond to pharmacological abortions in Catalonia, as stated in the report of Health of the Generalitat.
The distribution, however, is very different depending on the ownership of the centers where abortions are performed. In private clinics, with which the Administration arranges 85% of interventions in a model that the abortion reform wants to reverse, most of them are done in an instrumental way. And the opposite happens in the few publicly owned ones that perform abortions. In fact, a double phenomenon has occurred in recent years: as clinics have been performing fewer interventions and public centers have been assuming more, the number of pharmacological abortions carried out in Spain has increased.
However, the figures are an approximation because it is practically impossible with the available public information to know exactly how many abortions correspond to each method. "The institutional surveillance and information systems on abortion are totally deficient and present the data in a confusing, incomplete and decontextualized way", denounces Silvia Aldavert, coordinator of the Association of Sexual and Reproductive Rights of Catalonia. For its part, the Association of Clinics for the Voluntary Interruption of Pregnancy (ACAI) made a proposal to Health in 2019 to improve the collection and classification of data, which has been the same for 12 years, but received no response.
But what does each method consist of? The surgical is usually performed in operating rooms, although it is not a surgery. It is an intervention with local anesthesia or sedation and in which the medical staff uses dilators and cannulas to dilate and aspirate. For the pharmacological, a combination of two drugs is used. Mifepristone, which stops the continuation of pregnancy and which in Spain is prohibited from leaving health centers; and misoprostol, which the woman will take 48 hours later. The process usually lasts between two and four hours, is usually carried out at home and is accompanied by an analgesic regimen.
What all the voices consulted for this report point to is that the important thing is that women have the ability to choose the method that best suits their circumstances, something that is stipulated in the law and recommended by the WHO. "Both have advantages and disadvantages. The instruments are immediate, there is subsequent bleeding but it is less than in the pharmacological one and, although they are usually very infrequent, there is some more possibility of complications. The pharmacological one causes more pain and bleeding and a subsequent control is needed to corroborate that there has been expulsion, something that does not happen in 5% of cases," summarizes Abel Renuncio, a gynecologist at Burgos Hospital, who has been practicing medical abortions since January.
Precisely this past week, ACAI presented a reissued study from 2014 that asked 1,536 women who had aborted in clinics which method they prefer: the results suggest that more than eight out of ten choose the instrument. And the reasons they wield are speed, safety or avoiding pain. Those who opt for the pharmacological usually do so because of "fear" of the other method. The association insists that the key is for women to be able to choose, but in their opinion, public health "is not prepared" for this and denounces that public institutions "are promoting pharmacological abortion, reducing the quality of service", in words of Eva Rodríguez, vice president of ACAI.
What is happening is that some communities, such as Catalonia or the Balearic Islands, have begun to assume abortions in public health through health centers, but only those that are carried out with pills, while they continue to refer to clinics the instrumentals. An extreme case that does not occur anywhere else, however, is that of the Balearic Islands, according to ACAI, which denounces that "public health only covers pharmacological abortions", so that if a woman requires the surgical one "she must pay for it".
Added to this are more and more hospitals that are committed to incorporating practice into their services. A recent experience is that of the Hospital de Burgos, which since last January has performed pharmacological abortions thanks to the efforts of the gynecology service with the view that "in the short or medium term" the center will also assume the instrumental ones.
Abel Renuncio recognizes that this last possibility is the ideal, but considers that the hospital has taken "a first step" in order to guarantee abortion in public health. "I understand it as bringing or facilitating access to many women," he points out. The gynecologist puts the focus on the fact that before all the women in Burgos, whether they chose pharmacological or instrumental, were referred to Valladolid to a concerted clinic. It is something that thousands of women have to go through every year who live in provinces where there are no private centers to arrange the service nor does the public one assume it.
"What we cannot do is sacrifice the quality of care and the choice of method to guarantee accessibility," says Aldavert, from the Association for Sexual and Reproductive Rights. Catalonia is the community that practices the most pharmacological abortions because they are accessible in health centers, but if the woman chooses surgery, she must do it in a concerted clinic. In Lleida, for example, public health was able to carry out the pharmacological tests, but those who reject them must travel to Barcelona. "In the end, there is a violation of the right to choose because it is biased, there is not the same territorial access," the expert believes.
To this they add from ACAI the literalness of the reform of the abortion law that the Government processes, and that wants to guarantee accessibility and put an end to the displacement of women to exercise their right. But from the association of clinics they denounce that the free choice of the method "may be undermined" because the text is "ambiguous", since it specifies that the centers will offer the pharmacological and/or surgical method.
In practice, this may imply that there are services in which one is dispensed and others in which the other is carried out, a possibility that, far from being ideal, is "opening a door", for Renuncio. "It is more important that a quality service is provided, with objective information and support," says the gynecologist, for whom generalizing pharmacological abortion is not a problem and sees it as "striking" that if both techniques are equally effective, the data between surgical and pharmacological are so disparate. "If the pharmacological implies that they can do it close to their home, and not like now, that many have to move, I think that deep down it humanizes and normalizes this right and removes all that burden of stigma and exceptionality," he adds. .
The Association for Sexual and Reproductive Rights applauds initiatives such as that of the Burgos Hospital, and even more so if they include support protocols such as that of the Castilian-Leon center, which initiates a contraception and follow-up program with each woman who aborts – whenever she wishes. However, what Aldavert fears beyond specific cases is that the path Spain takes to guarantee abortion in public centers is to "impose" pharmacological abortion to the detriment of surgical abortion, just because the former "is cheaper , distances health personnel from the process, requires less training and practice, and generates fewer professional and ethical inconveniences".
Basically, what there is a problem with conscientious objectionsomething that entire hospitals and autonomous communities cling to in order not to assume public abortions despite the fact that the law establishes "that it should not be above the right to abortion", summarized from the Feminist Movement of Salamanca, which claims training of professionals in both techniques and the regulation of objection so that public health cannot continue to look the other way.
Graphics made by Victòria Oliveres and Ana Ordaz