That abortions were mainly performed in the public health network and that their referral to the private network constituted an exception. This is the objective proposed by the abortion reform in force since March 2023 to try to change the dominant model in Spain, which gives priority to carrying out voluntary terminations of pregnancy (IVG) in concerted clinics. However, in light of the latest data, the standard has not succeeded, for the moment, in promoting significant change: 81.45% of abortions were performed last year in private centers, which represents a drop of only one point compared to 2022.
This implies that, although IVE has been a health benefit included in the service portfolio since 2010, it is still not normally assumed by public health. This is something that has happened since the decriminalization of this right in 1985 – although in only three cases – and, in general, it involves women starting the process in their public center of reference, but more later, for the intervention itself, they are referred to clinics with which the Administration organizes the service and the users do not pay for it. Only 18.5% of them remained in the public circuit in 2023.
The situation is worse in communities where the number of abortions performed in public centers is minimal. In some cases, they don’t even reach 50 years old, despite the fact that they perform thousands of procedures per year. This is happening in Andalusia – where almost 20,000 abortions were carried out in 2023 and only 26 in public – or in Castile-La Mancha (five in public compared to 3,573 in total). The same thing happens in Murcia, which recorded only 25 interventions out of 3,657, and in Aragon (out of 1,815 abortions, only 39).
The situation is extreme in Extremadura, Ceuta and Melilla, where there has not been a single abortion in public throughout the year. In addition, there are two communities in which this figure does not reach a hundred: Madrid (71 out of 17,800 interruptions) and Asturias (74 out of 1,878).
For Gema Fernández, lawyer for Women’s Link, the data reflects “how much remains to be done” to comply with the law: “The ten months of 2023 that have been in force should be more visible in the figures if there were political events. desire to change things. The rule stipulates that the service “will be offered in the centers of the public health network” and will only be referred to those “exceptionally” concerted. “The law is clear, what cannot be is that we live in a permanent exception,” believes the expert.
The number of private abortions has gradually decreased. Thus, these went from almost all (they were 98.2% in 2010, the year of approval of the law on deadlines) to 81.45% in 2023. The decrease – and therefore the increase consequent interruptions in public centers – has been occurring regularly, around a percentage point each year, a trend that was also repeated last year, with the entry into force of the new rule on abortion.
“In practice, there are still 17 models of abortion care and in most cases the law is not respected or its implementation is not followed. Work is being done in certain places to improve, but it is ad hoc and at the discretion of specific teams,” summarizes Silvia Aldavert, coordinator of the Association for Sexual and Reproductive Rights.
And the files of the objectors?
To try to guarantee the change of model, the reform proposed to regulate conscientious objection through the creation of registers of objectors. The idea is to record on paper the number of professionals who refuse to perform abortions for ideological reasons in each community with the aim of organizing services to provide this service. In practice, it is a way of preventing entire health departments or hospitals from hiding behind a widespread conscientious objection to not performing abortions in public.
Communities such as La Rioja, Murcia, the Canary Islands, Cantabria or the Valencian Community have already created their registers; Castile-La Mancha is working on it and others like Galicia or Navarre are waiting for the Ministry of Health to also do its part and finalize the protocol with the “minimum conditions” that these registers must incorporate, as provided for by law. Just this week, Minister Mónica García announced that she already had a project on the table and that she would present it “before the end of the year” to the Interterritorial Health Council.
On the other hand, there are the communities, led by Madrid, which not only have not registered, but are boycotting the measure. President Isabel Díaz-Ayuso had already opposed it at the time and this week, the Minister of Health, Fátima Matute, spoke in the same direction and accused Health of using the register “as a political ram”: “Why do you have to make a list of opponents and not of those who provide this service? What is the purpose of this, he said.
The more public there is, the more pharmacology there is
The new law establishes that centers must offer the two methods that currently exist to carry out voluntary terminations of pregnancy: surgical and pharmacological, for which only pills are used. The vast majority of women abort with the first technique, chosen by 70% in 2023, even if this percentage has gradually decreased from 90% in 2011.
The distribution is, however, very different depending on the ownership of the centers: while in public centers the pharmacological center prevails, in subsidized clinics, most are instrumental. In fact, in recent years a parallel phenomenon has occurred: as the public has increasingly considered abortions, the number of pharmacological abortions has increased. And this is clearly seen in the case of some communities like Cantabria, La Rioja or the Balearic Islands, which practice many more abortions in public than the rest, but the majority with pills.
This is the way in which public health seems to be increasing the proportion of its interventions, a path that is sparking debate among associations, professionals and experts. Some are aware that the situation is not ideal and know that centers should offer both techniques, but they consider it “a first step”. Other voices suggest that, in practice, “the right to choose the method recommended by the law is sacrificed”. It is not that women cannot choose to have a surgical abortion, but there are cases in which, if they do, they are referred to private clinics, even outside their province.
In this province no
A paradigmatic example is that of La Rioja, one of the communities that, until recently, did not intervene. However, the creation of a sexual and reproductive health care center settled the unpaid debt and women in Rioja began to be able to have an abortion, but only through the pharmacological method. If they choose the instruments, they are forced to travel abroad, including to a clinic in Pamplona.
For Aldavert, this is an example of how “with the current structures of the public health system,” women “cannot choose on an equal basis” in many places. “It is not at all a question of opposing the method in itself, but it is true that it is cheaper and simpler and also the one which has the least implications in terms of conscientious objection professionals”, he specifies, slipping that there would be those who would be ready to distribute the pills, but not to intervene surgically during an abortion.
Rioja women who wish to terminate their pregnancies in the operating room are not the only ones who have to travel to exercise their right. Although following a complaint filed by a woman defended by Women’s Link, the Constitutional Court ruled a year ago that forcing a woman to travel violates her fundamental rights, this continues to be done. In fact, 12 provinces did not report procedures in 2023, but some women received them. As? Be referred to other locations. These are Jaén, Huesca, Teruel, Toledo, Guadalajara and Cuenca in Castile-La Mancha, Cáceres and Ávila, Segovia, Soria, Palencia and Zamora in Castile and León.
This is because in these provinces the public system does not provide abortions, but there are no private clinics with which to arrange services. “It is something very serious that this continues to happen and even more so after the constitutional decision. This is a violation of rights, but it also has direct consequences for the women themselves. You should keep in mind that in order to move you will need to seek permission from work, have support from your family, and even be willing to tell them. And that may be something that not everyone wants or can afford,” says Fernández.
