III. Background

Maternal mortality and morbidity in Peru

Peru is a developing country with the second highest maternal mortality ratio in Latin America after Bolivia. Peru receives assistance from foreign governments and donor agencies but does not designate enough of its resources to women’s health, including combating maternal mortality and morbidity.² According to the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), there are 410 maternal deaths per 100,000 live births in Peru every year,³ although these figures are higher than official government estimates.

Peru’s restrictive abortion laws and policies, which criminalize abortion generally and provide only vague guidance on when an abortion may be procured lawfully, also contribute to maternal death and disability. Approximately 16 percent of maternal deaths in Peru are attributable to unsafe abortions,⁴ but accurate estimations are difficult because the unsafe abortions are clandestine. Many of the deaths and injuries from unsafe abortion are avoidable given that abortion, when legal, accessible, and practiced by trained providers with proper equipment and under sanitary conditions, is a very safe medical procedure, and generally far safer than childbirth.⁵

Abortion prevalence and conditions warranting therapeutic abortion

Based on a study conducted by Flora Tristan and Pathfinder International, the estimated number of all abortions performed annually in Peru is 352,000, or one abortion for each live birth.⁶ The estimate suggests that each year five percent of Peruvian women of reproductive age are likely to undergo an abortion. In Lima that number approximates to 100,000 abortions annually.⁷ It is unclear how many of those might have been eligible for a legal therapeutic abortion instead.

Despite the many barriers to accessing legal therapeutic abortions in Peru’s public health system and the dearth of reliable records, the numbers of such procedures appear to have been rising. At the request of Human Rights Watch, the Ministry of Health sent a file of national statistics on therapeutic abortions performed in public hospitals for the last five years available. Just for the greater Lima metropolitan area, the estimated number of therapeutic abortions has seemingly shown a dramatically rising trend—26 in 2002, 41 in 2003, 24 in 2004, 215 in 2005, and 699 in 2006.⁸ For one hospital alone, the number of abortions listed as “medical abortions” rose from three in 2002 to 137 in 2005 to 687 in 2006.⁹ But rather than a drastic growth in the number of abortions performed, these statistics illustrate the erratic tallying and classification of legal abortions performed in the public sector. The tally includes a number of lawful medical procedures that are emergency obstetric services.¹⁰ Furthermore, these figures are still below the estimated level of necessary interventions.

There are no reliable data collection procedures in Peru on the number of severe or fatal complications during pregnancy for the pregnant woman or the fetus. Based on studies of the prevalence of severe and often fatal congenital malformations in different countries and the wide range of medical conditions that could threaten the life or health of the pregnant woman, there are likely hundreds of cases in addition to those officially recorded where women and girls would be eligible to consider a therapeutic abortion but did not receive one.¹¹ For example, one calculation estimates that every year in Peru there are 945 births of fatally malformed babies.¹² Anencephalic births are but one example: according to its own statistics, the Ministry of Health reports at least 80 women with anencephalic pregnancies every year who do not receive a therapeutic abortion.¹³

Anencephaly is fetal malformation incompatible with life, in which the brain and spinal cord fail to develop in utero. When the outcome is not a stillbirth, death usually occurs within hours or days after birth.¹⁴ Carrying an anencephalic fetus can be a great source of mental anguish and pose physical risks for the pregnant woman.¹⁵

As with anencephaly, there are dozens of medical conditions that could warrant a therapeutic abortion to save the life of the mother and preserve her health and well-being. To that end, a group of reproductive health specialists from nine medical associations in Peru developed a clinical profile to establish criteria for consideration of legal pregnancy interruption. Their list, neither exhaustive nor prescriptive, includes over 30 pathologies that could lead a pregnant woman to consider a therapeutic abortion.¹⁶ Dr. Luis Távara is an internationally recognized obstetrician and gynecologist, former president of the Peruvian Society of Obstetrics and Gynecology (Sociedad Peruana de Obstetricia y Ginecología, SPOG), and the former president of the sexual and reproductive health committee that organized the workshop. He published a document that focuses solely on why anencephaly should justify a therapeutic abortion for the pregnant woman on both physical and mental health grounds,¹⁷ arguing that abortions in such cases should be considered lawful due to the serious and permanent harm such a pregnancy can cause to a woman’s mental and physical health.

Most of the physical health justifications for therapeutic abortion have been assiduously outlined by the Professional Society of Obstetricians and Gynecologists in Peru, and approved by the larger Medical College of Peru.¹⁸ In addition, the Medical College of Peru has endorsed legal access to abortion for pregnancy as the result of reported rape and sexual violence, and for severe or fatal fetal malformations, recognizing that both can have physical and mental health repercussions.¹⁹

International assistance

Although the onus of change, responsibility, and accountability is on the state of Peru, international donors have also had a role in supporting Peru’s public health system and a variety of reproductive health programs, including culturally sensitive birthing practices and emergency obstetric care. But access to therapeutic abortion is not included among them at present.

Since the 1970s the United States Agency for International Development (USAID) has been one of the largest bilateral donors of foreign aid to the Peruvian government, especially for maternal and other reproductive healthcare services, through both government services and nongovernmental organizations (NGOs).²⁰ But for the past eight years it has also operated under the Mexico City Policy (also known as the Global Gag Rule), reinstated on the first day of the George W. Bush administration. This policy prohibits foreign NGOs receiving family planning assistance funds from USAID from providing or promoting abortion as a family planning method, among other restrictions. This prohibition has been interpreted by USAID to deny funding to organizations that provide legal voluntary abortion services, lobby for abortion law reform, and offer referrals to safe abortion services, even when these activities are funded from other sources.²¹ While the policy clearly makes some exceptions for abortions, such as in the case of rape, incest, or when the life of the pregnant woman would be endangered, under a strict interpretation of the policy, no funds could be designated for information about or provision of therapeutic abortions to preserve the health of the mother or for fetal abnormalities incompatible with life.

In spite of available financial resources, none of the other major or traditional international donors, including the United Nations Population Fund and the Spanish Agency for International Cooperation (Agencia Española de Cooperación Internacional), is currently supporting direct efforts to ensure access to therapeutic abortion in the public healthcare sector. However, the United Kingdom’s Department for International Development gave a grant of £3 million to the International Planned Parenthood Federation (IPPF) in 2006 to kick-start the Global Safe Abortion Programme for work exclusively with its affiliates, like the Peruvian Institute for Responsible Parenthood (Instituto Peruano de Paternidad Responsable, INPPARES) in Peru. Those affiliates-- one per country in about 180 countries worldwide-- are mandated to work toward stopping unsafe abortions and ensuring that internationally agreed targets to reduce the number of maternal deaths in the world’s poorest countries are achieved by 2015.²²

As a part of that global program, IPPF established a separate pool of money known the Safe Abortion Fund in 2006 with additional funding from the governments of Denmark, Norway, Sweden, Switzerland, and the UK, for groups such as Marie Stopes International, Manuela Ramos in Peru, and others, which have seen a decline in their family planning and reproductive health services partly as a result of loss of US funding. The Safe Abortion Fund is established to “increase access to comprehensive safe abortion services, with particular regard for the needs of marginalized and vulnerable women.”²³

The long history of international donor involvement in sustaining healthcare services in Peru shows prior commitment to this issue that could be rekindled with proper political will and support.

² One overarching problem is the amount of health spending in Peru, a figure that has decreased proportionately as a percentage of GDP in recent years at the same time that overall GDP increased, indicating that cuts in health spending were not due to a lack of available resources. According to an extensive report on maternal mortality by Physicians for Human Rights, “by objective measures, Peru is not currently devoting the maximum extent of available resources to realize the right to health, or to address maternal health concerns in particular. As compared with other countries with comparable GDP per capita, Peru’s health system faces a dramatic shortage of funding.” Physicians for Human Rights (PHR), Deadly Delays: Maternal Mortality in Peru: A Rights-Based Approach to Safe Motherhood (PHR: Cambridge, MA, 2007), p. 9.

³ United Nations Children’s Fund (UNICEF), “At a Glance: Peru,” undated, http://www.unicef.org/infobycountry/peru_statistics.html#24 (accessed June 25, 2007).

⁴ Luis Távara et al., “Current state of maternal mortality in Peru” (“Estado actual de la mortalidad maternal en Perú”), Gynecology and Obstetrics (Peru), vol. 45, no. 1 (1999), pp. 38-42.

⁵ Up to the sixteenth week of pregnancy, abortion is 10 times safer than childbearing, and the risk of death from abortion remains lower than the risk of death from childbirth throughout most of the second trimester. Rachel N. Pine, “Achieving Public Health Objectives through Family Planning Services,” Reproductive Health Matters, no. 2 (November 1993), p. 79.

⁶ Delicia Ferrando, Clandestine Abortion in Peru: Facts and Figures 2002 (Lima: Centro de la Mujer Peruana Flora Tristan and Pathfinder International, April 2002), p. 26.

⁷ Ibid., p. 27.

⁸ Email communication from Marco Polo Bardales Espinoza, General Office of Statistics and Information (Oficina General de Estadísticas e Información), Ministry of Health, to Human Rights Watch, October 16, 2007.

⁹ Email communication from Marco Polo Bardales Espinoza to Human Rights Watch, April 4, 2008.

¹⁰ Human Rights Watch telephone interview with Marco Polo Bardales Espinoza, Ministry of Health, Lima, March 2008. Further investigation revealed that the Ministry of Health uses a list of eight categories to classify abortions, all of which are medically necessary interventions upon arrival at the hospital and therefore should be non-punishable. The categories are ectopic pregnancy, hydatidiform mole (molar pregnancy), other abnormal products of conception, spontaneous abortion, medical abortion (meaning “medically necessary”), other abortion, non-specified abortion, failed abortion attempt, and post-abortion complications. However, there is no glossary of terms that explains to the medical doctors the differences in these mostly administrative terms.

¹¹ Luis Távara Orozco, Sheilah Verena Jacay Murguía, and María Jennie Dador Tozzini, Notes for action: Women’s right to legal abortion. Fulfillment of the right to therapeutic abortion and the foundation for broadening legal exceptions to abortion in cases of rape or fatal congenital malformations (Apuntes para la acción: El derecho de las mujeres a un aborto legal. Cumplimiento del aborto terapéutico y fundamentación para la ampliación de las causales de aborto por violación y por malformaciones congénitas incompatibles con la vida), (Lima: Centro de Promoción y Defensa de los Derechos Sexuales y Reproductivos (PROMSEX), September 2007), p. 49.

¹² Luis Távara Orozco, Why fatal congenital malformations and rape justify a legal abortion (Porqué las malformaciones congénitas letales y la violación justifican un aborto legal) (Lima: Centro de Promoción y Defensa de los Derechos Sexuales y Reproductivos (PROMSEX), 2008), pp. 8-9.

¹³ “Therapeutic abortion authorized at national level” (“El aborto terapéutico autorizado a nivel nacional”), RPP Noticias, March 8, 2007, http://www.rpp.com.pe/portada/nacional/68474_1.php (accessed July 10, 2007).

¹⁴ Jerrold B. Leikin, MD and Martin S. Lipsky, MD (eds.), American Medical Association Complete Medical Encyclopedia (New York: Random House Reference, 2003), p. 160.

¹⁵ Polyhydramnios, postural hypotension, hypertension, premature membrane rupture, breech birth or other forms of dystocia, and amniotic embolisms are some of the physical consequences that an anencephalic pregnancy can have on maternal health. Equally important are the potential consequences on the emotional health of the pregnant woman, including anxiety, severe depression, and post-traumatic stress disorder (PTSD). For PTSD, one-third of women may recover within one year, while another third still experience symptoms 10 years after having received the diagnosis. See Távara Orozco, Why fatal congenital malformations and rape justify a legal abortion, p. 11.

¹⁶ The list includes: chronic kidney failure, systemic lupus erythematosus (an auto-immune disorder), chronic arterial hypertension with organ damage, congestive heart failure, chronic liver failure, gastrointestinal cancer requiring radiation or chemotherapy, respiratory failure, advanced diabetes mellitus, malignancies of the central nervous system, treatment-adverse epilepsy, invasive cervical cancer and other gynecological cancers, unresolved ectopic pregnancy, precedents of postpartum psychosis or suicide risk, rape and sexual violence for increased risk of subsequent pathologies, and multi-drug-resistant tuberculosis. PROMSEX, “Therapeutic abortion in Peru: It is legal and saves lives” (“El aborto terapéutico en el Perú: es legal y salva vidas”), PROMSEX pamphlet series, 2008. Furthermore, the same group recommended that fetal malformations (like anencephaly) must be included explicitly in article 119 of the criminal code (see footnote 34) , but did not draft specific guidelines on the topic at that time. Sociedad Peruana de Obstetricia y Ginecología, Comité de Derechos Sexuales y Reproductivos, “Medical Associations’ Workshop to identify the clinical profile for therapeutic abortion” (“Taller de Sociedades Médicas para identificar el perfil clínico para el aborto terapéutico”), December 2005.

¹⁷ Távara Orozco, Why anencephaly should justify a therapeutic abortion, p. 6.

¹⁸Colegio Médico del Perú, Consejo Nacional, Comisión de Alto Nivel de Salud Reproductiva, “First Workshop on Sexual and Reproductive Rights, Lima, Peru, 21 and 22 March 2007” (I Taller Nacional sobre Derechos Sexuales y Reproductivos), May 2007, pp. 16-17, 19-20.

¹⁹ Ibid.

²⁰ United States Agency for International Development, USAID/Peru: Country Strategic Plan for Peru, FY 2002 to FY 2006, http://peru.usaid.gov/docmtos/ApprovedPeruStrategicPlanFY2002-06.pdf (accessed August 2, 2007).

²¹ Memorandum from Francis A. Donovan, Bureau for Management, Office of Acquisition and Assistance, Office of the Director within USAID, to all contracting officers and negotiators, regarding Voluntary Population Activities—Restoration of the Mexico City Policy, February 15, 2001, http://www.usaid.gov/business/business_opportunities/cib/pdf/cib0103.pdf (accessed March 12, 2008). Excerpts of the memorandum on the restoration of the Mexico City Policy follow: “Abortion is a method of family planning when it is for the purpose of spacing births. That includes, but is not limited to, abortions performed for the physical or mental health of the mother but does not include abortions performed if the life of the mother would be endangered if the fetus were carried to term or abortions performed following rape or incest (since abortion under these circumstances is not a family planning act)….To actively promote abortion means for an organization to commit resources, financial or other, in a substantial or continuing effort to increase the availability or use of abortion as a family planning method. This includes, but is not limited to…. [p]roviding advice that abortion is an available option in the event other methods of family planning are not used or are not successful or encouraging women to consider abortion (passively responding to a question regarding where a safe, legal abortion may be obtained is not considered active promotion if the question is specifically asked by a woman who is already pregnant, the woman clearly states that she has already decided to have a legal abortion, and the family planning counselor reasonably believes that the ethics of the medical profession in the country requires a response regarding where it may be obtained safely)…. Excluded from the definition of active promotion of abortion as a method of family planning are referrals for abortion as a result of rape, incest or if the life of the mother would be endangered if the fetus were carried to term. Also excluded from this definition is the treatment of injuries or illnesses caused by legal or illegal abortions, for example, post-abortion care.” (pp. 7, 9).

²² “UK Government announces support to help combat threat to women's health in developing world,” UK Department for International Development press release, February 6, 2006, http://www.dfid.gov.uk/news/files/pressreleases/reproductive-health060206.asp (accessed March 12, 2008).

²³ International Planned Parenthood Federation, http://www.ippf.org/en/What-we-do/Abortion/Safe+Abortion+Action+Fund+awards+111m+to+reduce+unsafe+abortion.htm (accessed March 31, 2008).

July 2008

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