The new abortion law being prepared by the government will require a restructuring of the healthcare system. Gynecology leaders and industry professionals assure that public centers today are not prepared to take on – as established by the new text – the more than 74,000 voluntary abortions that are performed annually in private clinics (usually organized), or due to lack of resources , training or desire of doctors.
There is a phrase that requires this conversion if the draft prepared by the Ministry of Equality and to which EL PAÍS had access is kept. It requires that the abortion “be performed at a public health center or, in exceptional cases, at an accredited private center.” This changes the existing paradigm that has established the following: “Medical support for voluntary termination of pregnancy will be carried out in centers of the public health network or associated with it. [concertados]”.
Until now, abortions performed in private centers (subsidized) are not the exception, but the rule. According to the latest data from the Ministry of Health, since 2020, 84.5% of the 88,269 voluntary abortions have been performed in non-state centers.
According to this report, four autonomous communities (Extremadura, Castile-La Mancha, Madrid and Murcia) did not report any abortions in public centers, although this newspaper confirmed that there are hospitals in which they were carried out and that they do not displayed in the collected statistics.
The essence of the new rule, as stated in its preamble, is to pave the way for women who experience difficulties in exercising this right and to put an end to this territorial disparity. This is also in line with what is clearly stated in the General Health Act: although it does not state that the agreement should be an “exception”, it does say that the provision of any service should preferably belong to the state. And this is what is happening with the vast majority of healthcare. Abortion is an anomaly.
“Like any health intervention, it must be publicly available. Like anyone. This is a way to normalize the situation,” says Lucia Mazarrasa, a retired nurse and human rights activist.
David Larios, president of the Health Lawyers Association, said the new text insists that it is a step on the “right” path and that it is a “wake-up call” in an area where it has been widely adopted. otherwise. He misses that he collects what should be the very “exceptional” situations in which you can make an agreement so that there is no “emptiness”.
It is also not clear how a system that has been in place for almost four decades will change, and what would require a change in the way the service is provided. The Ministry of Health declined to comment on the project. In any case, it is the responsibility of the Autonomous Communities to ensure this right in community centers.
Long history of matched clinics
The germ of the current situation comes from the legalization of abortion in 1985. The existing social network was unable to deal with them: it faced a wall of conscientious objection to abortion by many professionals. In this way, a network was woven, which today amounts to almost a hundred centers throughout Spain.
Today, conscientious objection to military service is a direct problem in a minority of cases. As a rule, this happens with those that could be called therapeutic: in which a woman wants to carry a pregnancy, but along the way she encounters a problem and decides to terminate it (9% of cases). There are no official figures, but there are hospitals where these types of interventions are not performed, either because all physicians object, or because an initial objection by their team or head of service resulted in them never being performed. . Many gynecologists have never been asked because their service does not practice them.
This leads to the fact that there are women who have seen how they were denied this right in their own hospital, and were forced to look for other ways. One of the goals of the new law is precisely to ensure that all hospitals have teams that can perform abortions so that situations like this do not happen again. To this end, the law calls for the creation of a register of conscientious objectors so that all services can be reorganized.
In other cases, the so-called voluntary (the remaining 91%, which is usually a simpler procedure), women usually do not face the problem of conscientious objection, as they are sent directly to schemes in which this does not happen: in most cases they go to a government center to terminate their pregnancy and it refers them, depending on where they live, to a public or private clinic. They don’t get rejected. But often they cannot choose a community center.
Enriqueta Barranco, a gynecologist and professor at the University Research Institute for Women and Gender Studies at the University of Granada, pays great attention to the difference between these two types of abortions. “It makes no sense for hospitals to invest in better diagnostic departments if a mother is found to have a congenital malformation or health risk and has to travel to another province to terminate her pregnancy. This has to stop,” he says. However, he believes that the current system works well in most cases for women who voluntarily want an abortion in the first few weeks. “Many times they seek solitude and specialization that are not available in public hospitals. We may face additional hurdles if we channel everything through hospitals,” he says.
Barranco argues that a reform like the one proposed “should not be taken lightly”. “Today, these private clinics are staffed by professionals who have the best knowledge of the techniques. Neither at the faculties, nor at the residences, doctors are trained to do them. So if they move [los abortos] to community centers before needing training in public fund management, which is not achieved overnight,” ditch.
Several gynecologists interviewed disagree with the wisdom of accepting all abortions in hospitals. Txanton Martínez-Astorquisa, president of the Spanish Society of Gynecologists and Obstetricians (SEGO) and head of service at the Cruces Hospital in Bilbao, says this does not make technical sense as many procedures are performed on an outpatient basis. She assures that, at least in her Autonomous Community, the system works: “What must be guaranteed is that all women have access to this service in a quality and free manner, whether it is public or consensual.” Tony Paya, head of obstetrics and gynecology at the Hospital del Mar, defended in an article in this newspaper that “the system’s capacity is limited”: “If you have to do all voluntary abortions, there is no room for anything else.”
Other gynecologists consulted, slipped another problem: abortion is not the procedure that you like to do. “He is not engaged in professional activities,” says one who prefers to remain anonymous. “If, after all, everyone has to go through public health, and they touch you every day because the rest of your service objects, you also declare that you can devote yourself to other things,” he muses.
According to José Ramón Repullo, professor of health planning and economics at the National School of Health, it is conscientious objection to military service that is the main obstacle that the new law could face, since the public network has 400 hospitals. “Whether abortions are done in public or private centers does not matter much from an economic point of view; in community centres, the cost structure is more expensive, but a few complementary interventions benefit from incurring only marginal costs; in the private sector, especially in clinics specializing in intravenous injections [interrupciones voluntarias del embarazo]costs are adjusted by the specialization model itself.”
Repullo believes that the problem lies in organizational and personnel management: “In order to ensure that the community center will perform abortions, and that none of its specialists activate the conscientious objection clause, they must be able to condition their contracts on this circumstance. And this is impossible, because a subsequent objection can always be raised. This problem is partially solved by outsourcing processes to private centers that are guided by a strong commitment and social activism in favor of abortion as a women’s right. However, he admits that this solution is not suitable for complex cases or late pregnancy, which includes surgical procedures that must be performed in hospitals. “Here, the public health network — more than any given hospital — can and should provide a good response,” he says.
To ease the public outcry, communities like Catalonia and Valencia are betting on pharmacological abortion. These are pills that women can take at home and are used in just under a third of cases in Spain. Although they require medical supervision, as the failure rate reaches 5%, the preparation of the healthcare system for this process will be much less.
The Association of Accredited Voluntary Abortion Clinics (ACAI) argues that moving down this path could be a step backwards in women’s rights. Its president, Francisca Garcia, explains that there are downsides to medical abortion, such as heavy bleeding and pain. “The instruments are practiced with sedatives for a little over an hour, and the woman goes home with everything decided, without even knowing it. These are two completely different techniques, each with its own advantages and disadvantages. But it is up to the woman to decide which one she wants,” she says. According to their data, 70% choose instrumental intervention, which usually consists of dilatation and aspiration of the fetus.
The sector stands up for the fact that in the 12 years of the current abortion law, nothing has been done to train public centers in these methods and that this cannot be a change the next day. “If this is finally done, perhaps our clinics will remain for women who want to pay for quality services,” says Garcia.
Nurse Lucia Mazarrasa considers it unacceptable that pharmacological abortion is mainly offered in the state system. “What needs to be guaranteed is that women can choose the service that suits them best by consulting and in community centers, as is the case with any other assistance. You need to train professionals, but it’s not so difficult. And if there is no other way out, then these private clinics should be included in the network,” he assures.
Be that as it may, the Ministry of Equality intends to change the existing paradigm. “It will be possible to have an abortion in public, it is unbelievable that eight out of 10 women have an abortion in private, our healthcare system is one of our greatest prides,” Angela Rodriguez, Secretary of State for Equality and Against Gender. Violence.
With information from Sonia Visoso, Javier Martin-Arroyo, Mikel Hormazabal, Ferran Bono, Lucia Bojorquez, Juan Navarro, Amaya Otasu D Bernat Cole.
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