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Anthropologists and other researchers studying reproductive issues in Latin America have been alarmed by the effects of the pandemic on their interlocutors. Our research on abortion in Brazil affords some insights into its unfolding impact upon women. Here, abortion is prohibited, except in three situations:  Risk of life for the woman; sexual violence; and anencephaly of the foetus. However, since most cases are not covered, illegal, clandestine abortions are the norm. Each year hundreds of thousands of women buy Cytotec (misoprostol) on the black market, a drug restricted under law to hospital use. Despite difficult access to this medication, clandestine use has led to a significant reduction in maternal deaths from unsafe abortion over the years (Domingues et al, 2020; Löwy & Corrêa, 2020). With the coronavirus pandemic, however, illegal access to Cytotec has been further restricted (REDE COVIDA, 2020). The fear is that a rise in maternal deaths and illness as a result of unsafe abortions is well under way.

There are significant differences to how women manage to achieve an abortion which reflect the extreme inequality entrenched in Brazil. Low-income women mainly use Cytotec to induce an abortion and knowledge of this medicinal method is widespread amongst them. Middle and upper-income women, on the other hand, usually terminate pregnancies surgically in private clinics, for which they pay large sums to private doctors (Silveira, McCallum and Menezes, 2016).  As part of the research for her PhD thesis on abortion, in 2019 Mariana interviewed Maria, a black, working class woman who had interrupted an unwanted pregnancy with Cytotec. Maria, who managed to find the medication with the help of a neighbour, followed the vendor’s advice on the required dose. Although she did not know their origin nor whether they would work, she bought six pills. For this she paid the equivalent of 50 Euros, a considerable sum from her point of view, considering the minimum monthly wage of roughly 175 Euros. The pills worked, but only partially. The bleeding did not stop, and so, like many other women in a similar situation, Maria sought medical assistance. She went to a public maternity hospital, where she knew she would probably be given a curettage to finalize the abortion.

A note of explanation is in order here. In Brazil, it is estimated that half or more of the women who clandestinely induce an abortion have complications similar to Maria’s. They know that these can be treated in free public ‘maternity’ hospitals linked to the Unified Health System- the SUS (Domingues et al, 2020). However, the fact that, nominally, these are spaces dedicated to motherhood has consequences for the kind of care they receive.  The healthcare workers in these institutions treat any woman under their care as a potential or actual mother. Since the Portuguese term ‘aborto’ refers to both induced abortion and also spontaneous foetus loss – that is, miscarriage – when Maria explained that she was ‘suffering an aborto’ the default interpretation of her claim should be that she was in the throes of a miscarriage. In practice, however, the health professionals who cared for her probably harboured the suspicion that she had illegally induced an abortion, a view perhaps enhanced by her condition as poor, young and black, though it is regularly extended to all women, whatever their perceived racial or class status (McCallum, 2008).  Symbolically, in the wards the situation evokes a binarism: women in labour as ‘mothers’, as against women in the throes of or with complications from abortos, who are ‘anti-mothers’, (McCallum, Menezes & dos Reis 2016). The assumption that they have induced abortion and the highly negative values attached to this, which are enmeshed in the practical arrangements for care of such women, contribute to the generation of the category ‘anti-mother’. This is the context in which ‘obstetric violence’ occurs frequently and doubtless supports and induces the phenomenon.

In the past, under a previous government, initiatives at national level aimed to improve treatment of women admitted to hospital in the process of aborto. Notably, an officially sanctioned ‘technical note’ suggested measures to ‘humanize’ care for abortion and miscarriage in public hospitals (Brasil, 2011). Hospital managers reacted unevenly to this official protocol and in many institutions little changed after it was emitted. In 2020 the COVID-19 pandemic had a clear negative impact on the more positive outcomes. For example, in March 2020 the only service in Brazil that supported completion of an ongoing miscarriage (or incomplete abortion disguised as such) at home, through self-administered medication under the aegis of nurses in daily telephone contact, was suspended. The hospital management justified this decision with the argument that there was a need to focus all efforts on responding to the pandemic. (Information provided by Ana Gabriela Lima Bispo de Victa, currently completing a PhD thesis about this service at ISC/UFBA).

Middle class women who find themselves in need of an abortion are also suffering increased difficulties as a result of COVID-19. In March 2020, at the beginning of the pandemic in Brazil, Frida, another of Mariana’s interlocutors, became pregnant. Also hailing from Salvador in Bahia state, she is a white, middle-class 26-year-old who recently moved to the far South of the country. “I talked to my boyfriend and we decided that I can’t have a child now,” she told Mariana. Although Frida is considerably better off than Maria, for her too this decision was just the start of a difficult search for a means to abort:

“At first I was lost, I thought about going back to Salvador, because friends knew of a private clinic. That was the plan, if it didn’t work out in the city where I live now. So I searched the internet for gynaecologists who were feminists, one of them was part of a feminist collective. I made an appointment and went to find her – Dr.V. She would not do the procedure, but she advised on how to access the medication (Cytotec), which she said was the safest. I thought it was strange that the medicine was safer, but then I researched and saw that it was indeed safer. But she told me that because of the pandemic, medicines are taking too long to arrive, and advised me to see a doctor at another clinic. But she told me that the ideal would be to use medicine.”

Internet-savvy middle-class women have been able to purchase the correct pills to induce a medical abortion online, sometimes through the websites of international feminist NGOs. However, rapid delivery is no longer possible due to the major disruptions caused by the coronavirus pandemic, as Dr.V made clear. (This point is corroborated by REDE COVIDA, 2020). Knowing this, Frida made an appointment at the clandestine clinic Dr.V indicated. She went there with her boyfriend, but neither the latter’s presence nor the 5000 Reals (roughly 1000 Euros) that they paid ensured that the couple received the kind of treatment usual in expensive private healthcare. The doctor subjected her to sexual abuse, demanded that she expose her breasts, and insulted them both cruelly. “It was one of the worst days of my life. He said a lot of nonsense to me and my boyfriend, I was very angry, but there was nothing I could do.” Frida and her boyfriend even thought about desisting and looking for another clinic. She feared the doctor might rape her under general anaesthetic. “I was very scared. Being unconscious with him, I didn’t know what he was going to do to me. But I was afraid of not finding another person to do the procedure, especially in the pandemic, so we decided to do it.” The abortion took place on the same day. She recovered without complications.

Maria and Frida belong to different social classes and racial groups. The clandestine abortions posed risks to both, but statistically low-income women suffer the most serious complications, for diverse reasons.  More of them use unsafe methods, confront more barriers in their search for abortion, experience greater financial difficulties and abort later on in the pregnancy. As well as the fear of mistreatment by healthcare providers black and indigenous women suffer the effects of institutional racism. The result is that studies show higher rates of morbidity and mortality for the black population due to unsafe abortions (Góes et al., 2020).

However, as we have seen, Frida’s acumen in looking for a feminist doctor and her ability to pay considerably more than Maria did not protect her from experiencing fear, confusion, and sexual and obstetric violence. The gynaecologist who humiliated her followed a pattern premised on a concept of “anti-mother”, which our previous ethnographies of maternal and abortion care has shown to be endemic. Taking advantage of the complete vulnerability of his ‘patient’, vindicated and protected by the criminalization of abortion, he felt free to act as he pleased whilst profiting from her situation – and that of countless other women like her.

The COVID-19 pandemic in Brazil has led to increased difficulties of access to illegal abortion and to the intensification of women’s suffering. But it has also substantially reduced access to legal abortion, despite the reported increase in domestic violence, including rape (MacKinnon e Bremshey, 2020). In a move that turned out to be typical, one of the few hospitals that offers legal abortion in São Paulo, the Pérola Byington Hospital, suspended this service from March 26th2020 in order to redirect efforts to combatting Covid-19. It resumed again several days later, after the Public Prosecutor’s Office of the State of São Paulo intervened (REDE COVIDA, 2020). However, survey data from the NGO ‘Article 19’ indicates that only 55% of hospitals offering legal abortion service are in operation during the pandemic (MAPA DO ABORTO LEGAL, 2020).

The politics of abortion but also of reproductive and sexual healthcare is key here. Although some individuals and sectors of federal agencies support continued access to legal abortion, the extreme right-wing federal government does not.  On May 1rst 2020, officials in the Brazilian Ministry of Health issued a technical note recognizing sexual and reproductive health services as essential, including safe abortion in cases provided for by law. The technical note reinforced actions already foreseen in the federal ‘Policy of Integral Attention to Women’s Health’, which predates the accession to power of the current government (Brasil, 2020a; Brasil, 2020b).  It reiterated the importance of continued provision of these services. Three days later, the Ministry of Health backtracked and reported that the document had been improperly circulated.  Two employees were dismissed – the coordinators of the Women’s Health and Men’s Health sectors in the ministry. Activists and feminist and research organizations opposed the suspension of the technical note and the dismissal of employees. But the Ministry of Health failed to position itself officially on the strengthening and maintenance of legal abortion services during the pandemic (REDE COVIDA, 2020).

The difficulty in accessing safe abortion in Brazil is both a political and a practical issue, one that reflects the profound gender, race and class inequalities of Brazilian society. Latin America has become the new epicenter of the pandemic (Watson, 2020) and investment in national health systems is urgently required. But without well-structured policies to address sexual and reproductive health issues, women’s lives, already subject to many tribulations as a result of entrenched resistance to the legalization of abortion, and hostile attitudes to the millions of women who must interrupt pregnancies, the damage inflicted by the coronavirus pandemic will be considerably worse.

Cecilia McCallum. Professorial Fellow, Department of Social Anthropology, University of St. Andrews. Associate Professor, Department of Anthropology and Ethnology, UFBA, Brazil; Professor in the Postgraduate Program in Collective Health, ISC- UFBA; Member of MUSA- The Gender and Health Studies Program – at

Mariana Pitta Lima. Psychologist and Doctoral Student in Public Health Studies at ISC-UFBA (The Collective Health Institute, Federal University of Bahia), Brazil; Associated to MUSA- The Gender and Health Studies Program – at ISC-UFBA. Researcher in the field of social sciences and humanities in health. Current research is focused on the ultrasound imaging and abortion public health care in Brazil. ISC-UFBA.

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Brasil. 2020a. Nota Técnica No 16/2020-COSMU/CGCIVI/DAPES/SAPS/MS. Ministério da Saúde. Secretaria de Atenção Primária à Saúde.

Brasil. 2020b. Ministério da Saúde esclarece nota técnica. Ministério da Saúde.. Available from: https://www.saude.gov.br/noticias/agencia-saude/47009-ministerio-da-saude-esclarece-nota-tecnica

Cardoso, B.B; Vieira, F.M. dos S.B; Saraceni, V. 2020. Abortion in Brazil: what do the official data say? Cadernos de Saúde Pública, v.36, supl.1, e00188718.

Domingues, R,M.S.M; Fonseca, S.C; Leal, M. do C.; Aquino, E. M. L.; Menezes, G. 2020. Unsafe abortion in Brazil: a systematic review of the scientific production, 2008-2018. Cadernos de Saúde Pública, v.36, supl. 1, e00190418.

Goes, E.F. et al. 2020. Racial vulnerability and individual barriers for Brazilian women seeking first care following abortion. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, supl. 1, e00189618.

Lima, M.R.P; Mccallum, C.A; Menezes, G. M. S. 2020. The ultrasound scene in abortion care: practices and meanings in a public maternity hospital in Salvador, Bahia State, Brazil. Cadernos de Saúde Pública, v. 36, supl. 1,  e00035618.

Löwy, I. & M.C. D.V. Corrêa, 2020. The “abortion pill” Misoprostol in Brazil: women’s empowerment in a conservative and repressive political environment. American Journal of Public Health 110, 677_684,https://doi.org/10.2105/AJPH.2019.305562

MAPA DO ABORTO LEGAL, 2020. Available from: https://mapaabortolegal.org/

McCallum, C.; Menezes, G.; & dos Reis, A.P.  2016. The dilemma of a practice: experiences of abortion in a public maternity hospital in the city of Salvador, Bahia. História, Ciências, Saúde-Manguinhos23(1), 37-56. https://doi.org/10.1590/S0104-59702016000100004

McCallum, C. 2008. Víctimas egoístas: perspectivas sobre la sexualidad, raza, clase y adolescencia desde un hospital de maternidad en Salvador, Brasil). In: Raza, etnicidad y sexualidades. Ciudadanías y multiculturalismos en América Latina. Bogotá: CES. Pp. 137-166.

MacKinnon, J.; Bremshey,A.. 2020. Perspectives from a webinar: COVID-19 and             sexual and reproductive health and rights, Sexual and Reproductive Health   Matters, 28:1, DOI: 10.1080/26410397.2020.1763578

REDE COVIDA. 2020. Saúde e direitos reprodutivos no cenário da Covid-19. Salvador, Bahia, June. Available at: https://covid19br.org/relatorios/saude-e-direitos-reprodutivos-no-cenario-da-covid-19/

Silveira, Paloma; McCallum, Cecilia; Menezes, Greice. 2016. Experiências de abortos provocados em clínicas privadas no Nordeste brasileiro. Cad. Saúde Pública,  Rio de Janeiro ,  v. 32, n. 2,  e00004815.

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[1] Cecilia McCallum. Professorial Fellow, Department of Social Anthropology, University of St. Andrews. Associate Professor, Department of Anthropology and Ethnology, UFBA, Brazil; Professor in the Postgraduate Program in Collective Health, ISC- UFBA; Member of MUSA- The Gender and Health Studies Program – at ISC-UFBA.

[2] Mariana Pitta Lima. Psychologist and Doctoral Student in Public Health Studies at ISC-UFBA (The Collective Health Institute, Federal University of Bahia), Brazil; Associated to MUSA- The Gender and Health Studies Program – at ISC-UFBA. Researcher in the field of social sciences and humanities in health. Current research is focused on the ultrasound imaging and abortion public health care in Brazil.

 

“Illegal Cytotec pills apprehended by the Brazilian Federal Tax Office in May 2020, and handed over to the Federal Police. (From a report in an online newspaper.)”

COVID-19 AND WOMEN’S WORSENING ACCESS TO ILLEGAL AND LEGAL ABORTION IN BRAZIL, Mariana Pitta Lima and Cecilia McCallum