LUCÍA: NICARAGUA

When she was 13 years old, she faced sexual violence and its consequences at the hands of a priest in her town.

Without access to information or comprehensive sexual education, she was forced to give birth even though she expressed her desire not to become a mother and was not physically or emotionally prepared to do so.

Her assailant is still at large.

Source: Regional Movement Girls, Not Mothers. One Campaign, One Movement. 2022

INTRODUCCIÓN

Dealing with unintended pregnancy and abortion in girls and adolescents (G/A) under 15 years of age is to talk about a human rights (HR) and public health problem that, despite its frequency in countries such as ours and its repercussions on the physical, emotional, and social health of these individuals, still lacks a health, multisectoral and ethical approach. It is really the most unprotected population group in terms of health^1).

WHO defines adolescence as the period between 10-19 years of age. Within this period, two stages can be distinguished: early adolescence (10-14 years) and late adolescence (15-19 years)^2). Adolescence is the critical step between childhood and early adulthood, a period in which individual, behavioral and health changes occur, and a period in which problematic or harmful behaviors can also be prevented or ameliorated. For girls, many of the developmental changes related to adult reproductive capacities are often completed before intellectual capacities, decision making, developmental skills are fully matured, and gender-specific roles are reinforced^3).

In one of our publications, we say: 'Adolescent sexuality is characterized by difficulty in agreeing on a behavioral model with their partners, as well as by unstable relationships, emotional conflicts, secrets, rebellious attitudes and, frequently, unprotected sexual relations, especially in the first moments of their sexual activity. Adolescent girls are also frequently exposed to gender-based violence (GBV) and especially sexual violence (SV). As a consequence of these conditions, many unwanted pregnancies occur during adolescence, when girls and their partners become sexually active, without considering contraception (MAC) or accessing appropriate services'^4).

Reproductive health (RH) care, and particularly abortion, following unintended pregnancy in G/A <15 years often raises medical, ethical, and bioethical issues in complex ways. One definition of adolescent pregnancy expresses 'It is

an unplanned or unanticipated pregnancy that occurs in a woman or couple who are financially dependent on others, do not have a stable relationship, are usually forced to interrupt their developmental process (schooling, employment, life plans), abandoned by their partner and/or family, and for which they have not acquired physical or psychological maturity'^5).

Resolving these problems may give rise to dilemmas between the ethical principles of the relationship between a patient and health care providers, which we will develop further below^6). Responsibility for these problems lies with all social sectors of the State; however, the role of the health sector is decisive in addressing them^7).

WHY DOES PREGNANCY OCCUR IN ADOLESCENTS UNDER 15 YEARS OF AGE?

The Peruvian Demographic and Family Health Survey (ENDES, for its acronym in Spanish) 2020 warns that the specific fertility rate (SFR) calculated for <15 years is 2 per 1000 adolescents, while for adolescents aged 15-19 years it is 31 per 1000 and that the pregnancy rate in <15 years is 0.3%^8). A recent Peruvian National Institute of Statistics and Informatics (INEI, for its acronym in Spanish) publication reports that the proportion of live births in Peru in G/A <15 years has remained constant, 0.3%, over the last 5 years^9). Evidence shows that the highest levels of fertility in G/A <15 years, as well as child unions or marriages, are concentrated in the lower socioeconomic levels and in rural or indigenous contexts^10).

In very young G/A, the initiation of sexual relations is not always a conscious or free decision or a decision that foresees risks. Even if the relations are consensual or accepted, adolescents often have little control over sexual initiation, in addition to other factors, such as earlier menarche^11). To understand with what resources a G/A faces decision making about his/her body, it is necessary to consider the degree of evolutionary maturity in relation to the development of his/her autonomy and assertiveness, which has a biological component and another one, associated with his/her social and economic-cultural environment that can facilitate or limit the exercise of the same. A Cochrane review on the reduction of adolescent pregnancy conducted in 2016 concludes that one of the factors that should be contemplated is that of delaying the onset of sexual relations^12).

In general terms, we can say that pregnancy in G/A <15 years of age is a multifactorial cause in which all members of a society are involved. Some of the causes¹³ are: early unions, gender inequality, obstacles to human rights, poverty, violence and sexual coercion, national policies that restrict access to contraceptives and sex education, lack of access to education and reproductive health services, underinvestment in the human capital of adolescent girls, among others.

The ecological model developed by Robert Blum at the Johns Hopkins Bloomberg School of Public Health communicates the diversity of factors that affect G/A and increase the likelihood of becoming pregnant. It presents a systematization of forces from a national level, such as policies for adolescent access to contraceptive methods or lack of enforcement of laws prohibiting child union, community, school, peers, family, to a personal level, such as a girl's socialization and the way she forms her opinion about pregnancy. Most of the determinants in this model operate at more than one level^13).

In conclusion, the determinants of pregnancy in G/A are complex, have many origins, have many dimensions, and vary across regions, countries, age and income groups, families and communities, and are more prevalent in less advantaged sectors.

RISKS OF PREGNANCY ON THE HEALTH OF G/A UNDER 15 YEARS OF AGE

The biomedical approach still predominates, focusing diagnoses on physical health, leaving aside the concept of health as a state of physical, mental, and social well-being^14). The health of G/A under 15 years of age is at high risk during pregnancy, which can expose them to the possibility of maternal death and even lead to suicide^1,15).

PHYSICAL HEALTH RISKS

Those younger than 15 years have higher biomedical risks that are related to pregnancy and childbirth compared to those aged 15-19 years. A pregnancy may complicate the condition of the G/A, in that the newborn is more likely to be underweight and die, findings similar to those found in our study of adolescents <15 years of age in 4 regions of Peru^1,16). In this study we found urinary tract infection, preeclampsia-eclampsia, preterm delivery, postpartum hemorrhage, puerperal infection, and anemia as frequent complications(1). A WHO publication states that G/A who become pregnant at 14 years of age or younger are more prone to preterm delivery, low birth weight, perinatal mortality, and newborn health problems. These risks increase in malnourished girls, and the child is at risk of death^17).

The CLAP publication on more than three million births in Latin America found that maternal mortality in the group of adolescents aged 1014 years is 146.5, while that found in the group aged 15-19 is 79.9 and in the group aged 20-40 years is 88.9 per 100,000 live births. In addition, it was found that girls <15 years were at higher risk of prolonged labor, cesarean section, or instrumental delivery^18). Obstetric fistula is found in other latitudes^19).

In the INEI publication on live births (LB) in Peru in adolescents <15 years and adolescents between 15-19 years in the years 2019 and 2020, there are differences in both groups, which show the higher risk of the younger ones^9).

In Peru we do not have exact information on maternal mortality (MM) in <15 years but, according to the National Center for Epidemiology, Prevention and Disease Control of MINSA. we will say that death in these G/A has not changed much in the last 6 years, since between 2015 until week 35 of 2021 it has remained between 5.1%-8.0% of total maternal deaths.

Data on safe or unsafe abortions in G/A between 10-14 years of age in developing countries are scarce, but approximate estimates were made for the 15-19 age group, where about 3.2 million unsafe abortions are recorded per year^20).

MENTAL HEALTH RISKS

The G/A <15 years old may feel stigmatized by a pregnancy at an early age and want to have an abortion, which, as in many countries, is illegal, with a negative outcome for their health. Childbirth and puerperium, in addition to having to bear the responsibility of caring for a newborn, also bring specific risks to her mental health. High rates of depressive and anxiety symptoms have been observed in adolescents during pregnancy and postpartum, which are higher than in adults^1,21).

Global Planned Parenthood publication of the study conducted in Ecuador, Guatemala, Peru, and Nicaragua on the health consequences of G/A between 9-14 year of age pregnant reveals that most of them suffered some complication during pregnancy. More importantly, this study inquired about the consequences on the mental health of these girls: a large proportion reported symptoms of depression, anxiety, and in those victims of sexual violence, post-traumatic stress disorder. In Peru and Nicaragua, between 7-14% of those interviewed considered suicide during pregnancy, as well as post-traumatic stress^1,22).

Biomedical and psychological risks and pregnancy as a product of sexual abuse and motherhood as a consequence of an unwanted pregnancy constitute harm to the comprehensive health of G/A. Being forced to become mothers in a situation of lack of resources and family support increases their vulnerability to poverty, exclusion, violence, and dependency. In this sense, forcing a G/A to carry a forced or unwanted pregnancy is a violation of her HR^23).

SOCIAL HEALTH RISKS

Unintended pregnancy impacts economic and social progress and maintains the cycle of intergenerational reproduction of poverty; it increases the number of people who are inactive in the labor market^24). In the G/A study in 4 regions of Peru, the most serious impact of pregnancy was in the social sphere: school dropout, family poverty, serious labor difficulties, stigmatization in health services, within the family and in the family environment^1).

LONG-TERM RISKS

If G/A <15 years old do not live with their parents or go to school, there is a high probability that they will not receive support from family or peers to face the problems that arise after pregnancy and do not have the opportunities to integrate as productive agents of society. These G/A may become domestic workers. They are less able to seek and receive social services and therefore need help to minimize their vulnerability to exploitation^1).

The child of an adolescent mother is at risk of physical abuse, neglect of care, malnutrition, and developmental delay. Few of them have social benefits for their health care because their parents do not have jobs with such benefits. Teenage fathers often drop out of school in order to support their families. It is also common for them to have worse jobs and lower pay than their parents and to be subjected to stress. In general, all this leads to emotional disorders that hinder the exercise of happy parenthood and continue the circle of intergenerational poverty^25).

CARE FOR UNINTENDED PREGNANCY IN G/A <15 YEARS OF AGE

There are barriers, challenges and myths about abortion in early adolescence and this responds to several reasons: naturalization of pregnancy in G/A, lack of training of providers, lack of regulation and resources, among others, forcing these G/A into forced pregnancy or exposing them to unsafe practices, with serious risk to their health^26). If violence is not proven, the mere fact of early pregnancy indicates the violation of other rights such as access to contraception, sex education and others. In all cases of G/A <15 years of age, there is sufficient evidence of the risk to health and life involved in continuing the pregnancy, so that therapeutic abortion can be performed, overcoming the suspicion of SV^27).

Therapeutic abortion has been approved in Peru since 1924 within the Penal Code, which was updated in 1991. The presence of this law gave way to the National Guide for Therapeutic Abortion Care, approved in 2014^28), the same that was confirmed in its content by the Constitutional Court. We do not have official statistics about abortions performed on girls aged 10-14, whether safely (albeit clandestinely) or under risky conditions. ‘If the abortion is performed by properly trained personnel under modern medical conditions, complications are extremely rare, and the risk of death is negligible'^19,29).

Pregnancy in G/A <15 years of age should be considered a medical emergency, because it is high risk and as such should follow the following guidelines^27,28,30):

Timely diagnosis

Counseling on rights and options

Continuation of pregnancy or therapeutic

abortion

Counseling and provision of contraceptives

Follow-up.

Take care not to do during care^3,30):

Assuming the naturalization nor the desire for pregnancy in girls and adolescents.

Assuming consensual sexual relations and therefore summoning the girl's or adolescent's partner without a comprehensive evaluation and her express consent.

Invisibilize the coercion, violence and abuse to which the G/A may be subjected in their family and social environment, which may be a determinant that has contributed to pregnancy.

Assuming that the G/A ‘did not take care of herself because she did not want to’. Access to information and contraceptive methods is still restricted.

BIOETHICAL RATIONALE FOR THERAPEUTIC ABORTION IN G/A <15 YEARS OF AGE

Before developing a bioethical analysis of therapeutic abortion in G/A, it is well worth reviewing some expert publications on ethical issues regarding abortion.

The CMP Code of Ethics and Deontology, which is mandatory for all physicians, states^31):

'THE ROLE OF MEDICINE. The role of medicine is oriented towards respect for life and the achievement of the highest quality of life, it is a scientific and humanistic profession whose mission is the care of both individual and collective health, which implies promoting and preserving it, as well as preventing, treating, relieving, and comforting the patient and their relatives, accompanying them respectfully and empathetically in the course of agony and death'.

MEDICAL ETHICS AND DEONTOLOGY. MED-

ical ethics orients the conduct of physicians towards the good, to seek the right, the ideal and excellence. Medical deontology establishes what physicians should and should not do. The Code of Ethics and Deontology contains a set of guidelines and precepts whose compliance guarantees a dignified, autonomous, and integral professional practice of the members of the Peruvian Medical Association, within the framework of respect for the rights of patients. It applies to all members and concerns their personal and social morals.

....The dignity of the person morally obliges the physician to treat every other person, in health or disease, always as an end and not only as a means and, therefore, with diligence, empathy, compassion, loyalty and responsibility.

.... Health is recognized as a right inherent to human dignity, in such a way that the physical, mental, and social well-being that the human being can achieve constitutes a right that the State is obliged to guarantee, considering the different determinants that intervene in the state of health of persons ''

'Art.32º The physician must respect the right of women, without any discrimination, to have access to therapeutic abortion when this measure is the only way to save the life of the pregnant mother or avoid permanent damage to her health, adhering to the established guidelines'.

Art.33º If the physician has, because of his moral or religious values, a position contrary to therapeutic abortion (conscientious objection), he has the power to refuse to perform the act. However, it is his duty to ensure that the pregnant mother receives proper care, or to provide it himself if it is an emergency and there is no other professional who can take care of the patient'.

Art.34º The physician who attends adolescents who have sexual relations has the duty to provide guidance on the importance of assuming their sexuality in a responsible manner and to use appropriate contraceptive methods to prevent unwanted pregnancies and Sexually Transmitted Infections (STI), respecting their free, conscious, and voluntary decision, preserving their confidentiality'.

The Latin American Federation of Obstetrics and Gynecology Societies (FLASOG) issued the Declaration of Santa Cruz in 2002, which assumes the defense of Sexual and Reproductive Rights, one of which is the right of women to have access to abortion in accordance with the legislation of each country^32).

FIGO, in its ethical considerations in Obstetrics and Gynecology states: 'There is a broad consensus that abortion is ethically justified when it is performed for medical reasons to protect the life and health of the mother Associations and OB/GYNs should encourage reforms to laws and policies that restrict young people's access to reproductive health services, promote sexual and reproductive education of young people and their right to access services, ensuring their confidentiality The primary duty of conscience of OB/GYNs shall at all times be to treat and benefit or prevent harm to the patients for whose care they are responsible. In the treatment of patients, any conscientious objection shall be secondary to the aforementioned primary duty'^33). A survey conducted a few years ago in many countries reveals progressive compliance with these recommendations^34).

On the other hand, the American College of Obstetricians and Gynecologists (ACOG) considers that the abortion service is essential for reproductive health care³⁵ and therefore general obstetricians and gynecologists should provide this procedure^36).

Abortion is as old as human civilization. It was practiced in ancient Egypt and was perhaps the first method of fertility control. Despite Hippocrates' statement, abortion was also practiced in ancient Greece, as well as in Rome, Arab culture, and Byzantine culture^37). Despite being an ethical dilemma, it continues to be practiced in contemporary Greece^38).

The various existing religions have participated in the discussion on the subject; however, we can include in this article some views found in the literature.

Turkey is one of the three Islamic countries that accept abortion on demand^39). Ethical and legal considerations have led India to accept abortion, which has contributed to an attempt at equity with women⁽⁴⁰). In Israel, it is hospital ethics committees that authorize abortion at the request of women^41). The Catholic religion has been characterized as very resistant to accepting abortion, with the exception of the so-called second effect. However, the Spanish S.J. and gynecologist

F. Abel expresses that it is necessary a reflexive conduct from the medical ethics in relation to abortion. He proposes more flexibility on the issue of therapeutic abortion in order to achieve a peaceful and respectful coexistence between the different points of view of the population^42).

The prestigious Colombian physician Jorge Villarreal, now deceased, tells us that the origin of induced abortion is to be found in unwanted pregnancy, which is associated with medical and non-medical factors. He adds that abortion should be approached from a bioethical perspective, which is above all an ethic that has a scientific and non-denominational background. He calls on us to approach the subject with humility, knowledge, and mental attitude, without trying to impose our ethics^43).

The renowned American ethicist and obstetrician-gynecologist FA Chervenak tells us that the medical response to the abortion conflict should not be based on a moral state about the fetus. The moral conscience of the obstetrician must be fixed that before the fetus is viable, abortion is ethically justified, when the woman requests it and is aware of it^44).

Other authors put abortion before an ethical and bioethical reflection that must be exercised to justify a decision, despite the different scientific, sociological, religious, and other discussions^45,46).

Physicians who attend and treat people with some type of suffering may consider that a pregnancy resulting from rape in an adolescent should be qualified as high risk or a crisis of anguish following a rape, ethically justifying an abortion. This intervention is aimed at protecting the rights and autonomy of minors^47,48).

BIOETHICAL ANALYSIS

After the horrors of World War II, the nations of the world signed the Universal Declaration of Human Rights, signifying the defense of the dignity of the individual. The advancement of science and technology gave way to the care of potential harm to the life and health of patients, so Potter wrote his book in 1971 'Bioethics, Bridge to the Future'. After the Belmont Report, Beauchamp and Childress established in 1979 the four principles of bioethics: autonomy, beneficence, non-maleficence and justice, in line with Human Rights. The Lisbon Declaration of the World Medical Association on the rights of patients was adopted by many states in the world, and Peru also incorporated them^31,49). Today, bioethics occupies a prominent place in the medical sciences^50), particularly on the subject of abortion^51,52).

Andrés Calle, a prestigious Ecuadorian obstetrician-gynecologist, writes that medicine is governed by ethical guidelines based on the philosophical concepts of 'do good and do no harm', the latter attributed to Hippocrates. From its origins, medical ethics respects a set of virtues that physicians must exhibit, among which bioethical reflection occupies an important place. In his writings, he emphasizes the principles of justice and beneficence, but when it comes to the doctor-patient relationship, he includes the principles of autonomy and non-maleficence^53).

The bioethical conflict over abortion cannot be won by anyone, given that there are radical positions that are confused with religious positions, to more moderate positions that appeal to principlism to confront the crisis and emphasize the principle of justice that goes beyond religious and political positions^54).

It is well known that in countries where abortion is restricted, the rates of complications and maternal deaths from induced abortion are higher. Hence the need to approach therapeutic abortion in G/A <15 years of age in terms of the four principles of bioethics, incorporating scientific knowledge over ideological positions^55). This is what we will apply in the following analysis.

The mere fact that pregnancy in G/A <15 years is a medical emergency that occurs in people who have not yet reached their biological, mental and social maturity, that it originates as an unintended and often forced pregnancy, that it is liable to severe complications during pregnancy, delivery, puerperium and even in the medium and long term, is sufficient argument to grant privileged care to these young women and if their decision is to terminate it, it really represents a therapeutic abortion. Let us apply the principles of bioethics to this discussion.

The principle of autonomy is to respect human rights, gender equity and respect for interculturality, since we must accept the freedom of each woman to decide whether or not to procreate. In the case of G/A <15 years of age, we speak of progressive autonomy avoiding restrictions, typical of some tendencies. Accepting such a decision obliges the health professional to provide sufficient information about the pregnancy and its possible evolution and to present options to consider whether or not to continue with the pregnancy. Informed consent is a fundamental requirement for this. This principle may be limited by the conscientious objection of the professional, who will have the obligation to refer the case to another professional or to resolve it if he/she is the only professional in the jurisdiction where the case is presented. The physician should give priority to his professional conscience before his individual conscience^56-59).

The principle of beneficence establishes the obligation to do good and take care of health, avoiding complications. When faced with a problem case, such as pregnancy in a G/A <15 years old, always weigh the risks against the benefits. This principle includes providing quality services, which means providing adequate information, good case management, technical capacity, maintaining good personal relationships, and ensuring continuity and constellation of services. Keep in mind that unwanted pregnancy due to health reasons means a great risk of clandestine abortion, possibilities of complications and maternal death that should be avoided^56,60-62).

Since Hippocrates we have known the primum non noscere, which is really the principle of non-maleficence, which obliges us to do no harm, to protect the health and life of women and in this case of the G/A <15 years old who are very vulnerable to complications in their physical, mental and social health, and in their lives in the medium and long term as defined above; therefore, to do everything necessary to avoid harm. In the therapeutic termination of pregnancy, a G/A <15 years of age is treated at high risk, not only to cause harm, but also to protect her human rights; this means not exposing her to further harm to avoid damage to her health^1,56).

The principle of Justice is a concept of social character and is based on the principle of equity; it is a right of all, which the State and society must guarantee. For this it will be necessary to avoid inequalities for the therapeutic termination of pregnancy in the G/A <15 years, without discrimination linked to age, race, ethnicity, education, socioeconomic level; since we see that poorer women have more restrictions in medical care and are victims of clandestine abortion, complications and maternal death by being forced to carry a pregnancy they do not want^56,63).

In conclusion, when we discuss pregnancy and therapeutic abortion in G/A <15 years of age based on bioethical values and principles, it is pertinent to refer to the conceptions of specialists and people in general, since ethical criteria help us to reduce the suffering of girls, by recognizing the right of these young women who, within their progressive autonomy, can decide, taking care to do good at all times, avoiding harm and acting with social justice^64,65).