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10.1177/1049732304267693QUALITATIVE HEALTH RESEARCH / October 2004Erviti et al. / COPING WITH ABORTION
Strategies Used by Low-Income
Mexican Women to Deal With Miscarriage
and “Spontaneous” Abortion
Joaquina Erviti
Roberto Castro
Ana Collado
This study focuses on lowest income Mexican women attended for abortion-related compli
-
cations in a public hospital. The objective was to investigate the women’s experience of hav
-
ing a so-called “spontaneous” abortion and their related strategies to avoid stigmatization.
Four strategies emerge from women’s testimonies: presenting themselves as women who
“play by the rules,” pleading ignorance of the pregnancy, stating that they had already
accepted their pregnancy, or presenting the abortion as the result of an accident. Women use
these strategies to deflect any blame to which they might be subjected and as a means of deal-
ing with the stigma attached to a behavior that transgresses social norms regarding repro-
duction. Far from being passive receptors of the social imperative, which makes motherhood
compulsory, women oscillate strategically within the margins of a seemingly uniform
normative discourse and thereby ensure their moral survival. The authors discuss results
within the framework of praxis theory.
Keywords: experiences; strategies; abortion; women; Mexico
A
vailable treatment and care for abortions, the effects of abortion on women’s
health, and the subjective experiences of women who abort depend on the
national context in political, legal, and sociocultural terms (Harden, & Ogden, 1999;
Rylko-Bauer, 1996). In most developing countries, abortion is penalized legally.
Criminalizing abortion forces women to have clandestine abortions, whichare
often unsafe. In these countries, lowest income women most often resort to clandes
-
tine abortions and most often die from complications following an abortionin
unsafe conditions (Alan Guttmacher Institute, 1994; Birth Control Trust, 1998;
Henshaw, Singh, & Haas, 1999; United Nations, 1995). Prevailing political, legal,
and sociocultural contexts impede the creation of services for women who abort
and pose legal and social barriers to those wishing to access existing services.
1058
AUTHORS’ NOTE: We are grateful for the financial support of the Carnegie Foundation, the Pan-
American Health Organization andtheInterdisciplinary Program of Women’sStudies.We are also grate
-
ful to Dr. Mario Bronfman, who encouraged us to initiate this project, and to Clara Juarez and Rosario
Valdes, who carried out the interviews. We also want to especially thank the women who shared their
experiences with us.
QUALITATIVE HEALTH RESEARCH, Vol. 14 No. 8, October 2004 1058-1076
DOI: 10.1177/1049732304267693
© 2004 Sage Publications
In Mexico, as in many other countries, abortion is a highly politicized issue. In
general terms, abortion is penalized by a law dating back to 1931. The law makes
exceptions only for abortions resulting from negligence on the part of the pregnant
woman, in which case they are carried out to save the mother’s life, or if the preg
-
nancy is the result of rape. Some Mexican states have legalized other circumstances
for abortion, such as serious fetal malformation or if the pregnancy poses grave
risks to the woman’s health. Standing as an exception, the state of Yucatan includes
economic factors as a valid reason for having an abortion (Bermudez, 1998; Perez
Duarte, 1993). Nonetheless, Mexico has no clear regulations regarding legal abor
-
tion, and consequently it is extremely difficult to gain access to or provide an abor
-
tion, even when the corresponding legal authorization has been granted (Grupo de
Información en Reproducción Elegida [GIRE], 2000a, 2000b; Poniatowska, 2000).
In addition to these legal and administrative restrictions, a complex social and
moral climate exists concerning abortion in Mexico. A series of recent surveys
showed that, in private, 83% of Mexicans in 1994, and 85% in 2000 considered that
the decision to terminate a pregnancy should lie with the woman and her partner
(GIRE, 2000c; Population Council, 2001). In public, however, the prevalent dis
-
course condemns abortion and labels women who have one and those who help
them as criminals (Aponte & Roman, 1999; Muñoz & Cruz, 2000; Ortiz-Ortega,
2001; Roman & Aponte, 1998). Through the mass media, the Catholic Church and
conservative organizations such as the Comité Nacional Pro Vida (National Pro-life
Committee, which has now changed its name to Cultura por la Vida—Culture for
Life) and the Unión Nacional de Padres de Familia (National Parents’ Union)
(UNPF), negative stereotypes of women who are suspected of having deliberately
terminated a pregnancy are disseminated. These are the same institutions and
social actors who make speeches and promote initiatives against sexual freedom
and the use of contraceptives.
In Mexico, women who have an abortion, whether induced or spontaneous,
must face in their personal lives and health experiences the consequences of a policy
that claims to be aimed at controlling demographic growth but that, in reality, con
-
tinues to penalize the practice of abortion. This population policy, with strategies
aimed at modifying demographic behavior, stigmatizes those who do not ade
-
quately control the size of their family. Government-directed campaigns identify
those who have many children as irresponsible, especially if they have low incomes
(Elu, 1994; Erviti, 2001). Even though the negative consequences of abortions
undertaken in insecure and clandestine conditions are recognized, the legislative
proposals directed at totally legalizing abortion continue unapproved. The Catholic
Church and the conservatives in Mexico agree on a policy concerning abortion,
indicated by demonstrations, the diffusion of messages of moral condemnation by
the media, and lobbying on the part of political groups at the level of legislative and
executive power. Avery visible case was the suspension of a law that legalized abor
-
tions undertaken for socioeconomic reasons in the state of Chiapas in 1991, and the
subsequent public excommunications on the part of the Bishop and the Pope on his
visits to Mexico directed against those legislators who promoted the change in the
law, both in the Chiapas case as well as in Mexico City in the year 2000.
1
This finger-pointing, hegemonic discourse has consequences for all women
who have suffered complications because of an abortion, whether it was induced or
spontaneous, and who have had to seek medical care, principally in public health
institutions. In effect, every woman who arrives at a public hospital in the process of
Erviti et al. / COPING WITH ABORTION 1059
having an abortion is suspected of having done something to terminate the preg
-
nancy (Valle Gay, 1994). This suspicion is especially strong if the abortion is associ
-
ated with an infection and the woman is perceived as “typifying” the kind of
woman who would abort, for example, low socioeconomic status with a large num
-
ber of children, or under age 20. The existing literature demonstrates that the qual
-
ity of care these women receive and their treatment as human beings depends on
whether hospital staff label their abortion as spontaneous or induced (i.e., legiti
-
mate or illegitimate) when they arrive at the hospital (Gonzalez de Leon-Aguirre,
1994; Rance, 1997; Roth, 1986). As presented in the following, this labeling process
obliges women to use a series of discursive strategies to present their case in the best
possible light within the dominant ideology, primarily with the objective of distanc
-
ing themselves from any suspicion that they might have provoked the abortion.
Such discursive strategies have not been studied previously in Mexico. The study of
such strategies, in the framework of praxis theory, might offer tools for improving
attention to women who are delivered to hospital for complications relating to abor
-
tion. This study presents the results of research carried out in the state of Morelos,
Mexico, with the objective of analyzing the experiences of lowest income women
who were given emergency care for a spontaneous abortion in a public hospital.
WOMEN AND ABORTION IN
MEXICO AND LATIN AMERICA
Traditionally, researchers in Mexico and Latin America have been interested in
determining the magnitude of the problem of abortion (Llovet & Ramos, 2001), and
demonstrating the serious effects abortion has on maternal morbidity and mortality
rates.
In spite of the attitudes directed toward abortion, each year a significant num-
ber of Mexican women opt for pregnancy termination. Illegality and secrecy sur
-
rounding abortion makes it difficult to know exactly how many abortions take place
in Mexico, or if they should be classified as “induced” or “spontaneous.” Figures
vary from an estimated 850,000 induced abortions every year (Lopez Garcia, 1994)
to 102,000 induced abortions in 1997 according to official data (CONAPO, 2000).
Other sources show that every year, more than half a million abortions take place,
and that 3 out of 4 abortions treated in public hospitals are induced (Henshaw et al.,
1999; Singh & Wulf, 1994). The most recent national sociodemographic surveys
have shown that approximately 1 out of 5 women who have been pregnant at some
time in their lives have had an abortion (CONAPO [National Population Council],
2000). Furthermore, complications following an abortion are the fourth leading
cause of maternal death in Mexico (Lezana, 1999).
In Mexico, there are gross inequities concerning access to health care, depend
-
ing on socioeconomic status. About 40% of the population lives in extreme poverty
(Boltvinik & Hernandez Laos, 1999). Approximately one third (30%) of Mexican
households receive two thirds of the national income, whereas 70% of households
receive only a third of the national income. In the lowest income households, the
women have the worst living conditions, and the majority of women continue to
depend economically on their families. Women in Mexico generally consist of the
least educated sector of the population; they participate in informal and unstable
1060 QUALITATIVE HEALTH RESEARCH / October 2004
work and receive low pay. (Half do not have a fixed income, and two thirds do not
have benefits, either health insurance or retirement pay, and they work more than 40
hours a week.) Only one third of Mexican women are employed. Of the 13.3 million
women who pertain to the economically active population, only 4.7 million are edu
-
cated beyond the secondary level; 2.1 million female workers do not receivean
income, and 7.7 million do not have benefits (health insurance or retirement pay)
(Arroyo et al., 2002). Those with little money can access only public services offered
by the Ministry of Health. Consequently, the individuals who are treated in these
institutions belong to the most marginalized groups in society. This inequality is
also evident in terms of access to safe abortions, even clandestine ones, and concern
-
ing the kind of attention received when complications arise (GIRE, 2000c). It has
been documented that women who live in highly marginalized areas are twice as
likely to die of abortion complications as women who live in less marginalized areas
(Lozano, Hernandez, & Langer, 1994).
Over the past few years, diverse studies exploring the implications of un
-
wanted pregnancies and induced abortion among different social sectors have
been published (Cardich & Carrasco, 1993; Mora, 1994; Rance, 1994; Rivas &
Amuchastegui, 1996). One of the most relevant contributions made by these studies
is that they describe women who abort as active social agents, capable of disagree-
ing with the dominant ideology and moral values and of taking an individual de-
cision to terminate their pregnancy, even if this means opting for a backstreet
abortion.
Other studies have shown how moral, legal, and social sanctions can influence
a woman’s experience of abortion and make it difficult for a woman to admit, even
to herself, her desire to terminate a pregnancy. For example, a study carried out in
Bolivia shows that women might long for the “failure” of a pregnancy or attempt a
“natural abortion,” acting in a way that poses a risk to their health, before resorting
to an induced abortion. Induced abortion is considered “abnormal” and imposes
feelings of guilt and the risk of being punished (Rance, 1994).
The fact that women internalize society’s moral and ethical views (as transmit
-
ted through education and the mass media), which condemn abortion, does notpre
-
vent them from aborting. This is because when faced with an unwanted pregnancy,
practical considerations carry more weight than abstract norms related to these cir
-
cumstances (Mora, 1995). These women, therefore, legitimize their own abortions
while publicly supporting the repressive discourse that condemns abortion.
A study carried out in Brazil with women who sought medical attention in a
public hospital for complications associated with an induced abortion revealed that
women use particular strategies to confront the dominant discourses condemning
women who abort. By demonstrating a general acceptance of the use of traditional
medicinal remedies for the “regulation of menstruation” in their discourses, these
women covertly expressed their disagreement with the hegemonic ideology about
the illegality and immorality of induced abortion (Nations, Misago, Fonseca,
Correia, & Campbell, 1997), as these same remedies can also be used to provoke
abortion.
Other studies have noted how medical professionals reproduce discourses that
condemn abortion when they interact with women (Rance, 1997). This analysis
reveals that medical terminology is permeated with moral categories, such as the
medical concepts of spontaneous abortion and induced abortion. Both termsare
Erviti et al. / COPING WITH ABORTION 1061
clearly associated with the dominant moral discourse: the first being guilt free,
whereas the second is deserving of blame. Both are thus indicators of the climate of
suspicion that surrounds a woman’s attempt to prove the veracity of her story,
claiming that her abortion was, indeed, spontaneous. The power of such discourses,
in which women are portrayed as solely responsible for induced abortions, nega
-
tively influences the quality of care these women receive when they arrive at a hos
-
pital suffering from an incomplete abortion. Many medical professionals even con
-
sider an unsafe abortion to be a self-inflicted punishment for erring women who
have rejected their socially assigned destiny to become mothers. However, it is also
clear that this position is not homogeneous among medical staff. Even though neg
-
ative attitudes toward abortion are evident (Gonzalez de Leon & Billings, 2001;
Lazarus, 1997), some dissent from the dominant discourse has also been docu
-
mented (Rodriguez & Stickler, 1999). These opposing discourses and practices are
framed within personal-professional conflicts related to the various meanings
assigned to abortion (Roe, 1989).
However, one aspect that has been ignored until now is the study of the mean
-
ing and implications of abortions that are presented as so-called spontaneous abor
-
tions in countries with highly restrictive abortion legislation. As we have pointed
out, spontaneous abortions in Mexico are far from being unproblematic. This could
be because the social mandate decrees that every pregnancy should end with the
birth of a child and that, therefore, each woman is responsible for achieving this or
for failing to do so. In addition, the category of spontaneous abortion provides an
excuse for women who have, in reality, induced an abortion but who seek refuge by
using information management strategies that might help them avoid stigmatiza-
tion and blame. This study is focused on lowest income women’s experiences of
“spontaneous” abortion. We seek to demonstrate that these experiences not only are
problematic but also demand that women take an active role to present their abor-
tion as spontaneous, and therefore legitimate, to diminish any suspicion that they
are responsible for the abortion.
METHOD
All research participation in this project was voluntary and took place only after
having fully informed consent had been given. The participants were 34 low-
income women who had been admitted to the emergency room of a public hospital
in Cuernavaca, Morelos, Mexico, during 1997 experiencing complications from
miscarriages and induced abortions. First, we conducted participant observation in
the hospital over a 10-day period to define the trajectory the women followed when
they enter the hospital for abortion-related complications (Strauss, Fagerhaugh,
Suczek, & Wiener, 1997). That is, we were aiming at identifying both the varying
attention received by women and the principal patterns of interaction between doc
-
tors and women in the hospital, from the moment of the women’s admission until
discharge. We complemented this information through interviews with the doc
-
tors responsible for the areas of gynecology and gynecological obstetrics. Second,
we applied a questionnaire to 48 women to collect information on their socio
-
demographic characteristics, reproductive history, and abortions. These women
represented nearly 10% of women attended to in the hospital during the period of
investigation. Third, we conducted in-depth interviews with 34 women to recon
-
1062 QUALITATIVE HEALTH RESEARCH / October 2004
struct the material and emotional experiences of the women during pregnancy and
abortion, and their interpretation of the experience of abortion.
The public hospital in which we carried out the research treats about two
women daily who arrive at the emergency room with an abortion in progress. These
women usually report that they began to bleed unexpectedly as the result of an acci
-
dent or fall, or after undertaking some heavy physical tasks. All women are treated
with dilation and curettage (D&C). Once they have been treated, the women spend
one night in the hospital under medical supervision and are discharged the follow
-
ing day.
We carried out the interviews during the second day of hospitalization, before
the women were discharged. In some cases, the women preferred to be interviewed
after leaving the hospital, when they were at home, at a time convenient for them.
All of the women were told the purpose of the interviews was research and that
their participation was completely voluntary. The research protocol was approved
by the committee for ethics and investigation of two academic institutions in Mex
-
ico (National Autonomous University of Mexico and the National Institute of Pub
-
lic Health) and the hospitals where the study was carried out. Participation was
conditional to the guarantee of informed consent. During the interview, the women
who requested support or who described problems of violence with their partner or
problems with their health, or who simply required help were channeled to centers
or networks for attention. Some women were asked if they would be willing to par-
ticipate in a second interview in their own home with the participation of other fam-
ily members, usually their husband, mother, and/or young children to complement
the information on family characteristics. This second interview was accepted by 6
women. Most of the interviews were carried out with no other family members
present.
The interviews were taped and transcribed in their entirety. They were subse-
quently systematized using Ethnograph software.
2
For the codification of the inter-
views, we divided the material into the various stages of the women’s experience
before arriving at the hospital: pregnancy, health care during pregnancy, the first
signs of an abortion, evaluation of these signs, and the decision to go to the hospital;
as well as their emotions, feelings, behavior, and attitudes concerning the preg
-
nancy and abortion. In each case, the fundamental idea was to identify the mecha
-
nisms used by women to attribute a specific meaning to their pregnancies and abor
-
tions, and to identify the main social determinants related to these mechanisms.
The analysis of the transcribed interviews was based on repeated readings of
each testimony: searching for codes, for subjects, and for the voices identified as rel
-
evant to the research questions (Brown, Tappan, Gilligan, Miller, & Argyris, 1989).
Through this process of successive readings, we became sensitive to dissonant and
contradictory voices. With the first detailed reading of each transcript and the inter
-
play between our theoretical framework and inductive analysis, we identified
voices that superficially appeared to conform to the dominant discourse but also
revealed resistance to it. After this first reading, we were attentive to the emergence
of these voices in other interviews. Listening to the stories of women who were
treated for abortion complications in the hospitals, we heard voices that affirmed
dominant cultural discourses about women and abortion but were so intimately
intertwined with contrary opinions that in the same sentence voices could be identi
-
fied defying these hegemonic discourses. The process of applying interviews was
suspended when we realized that these themes had been theoretically saturated
Erviti et al. / COPING WITH ABORTION 1063
(Glaser, 1978). This explains why 34 in-depth interviews were completed over a
time span of 16 months.
RESULTS
Profile of the Participants
As is the case for the majority of people treated in the hospitals run by the Ministry
of Health in Mexico, the women in this study were characterized as living in condi
-
tions of poverty (Erviti, 2001). The majority (56%) were “internal” immigrants (i.e.,
born in other Mexican states), who had not studied beyond primary school level
(65%), who lived with their partners without being legally married (59%), who ded
-
icated their time exclusively to the household (79%), and who earned very little
(half reported monthly incomes of less than U.S.$100 a month) and so were econom
-
ically dependent on their partners (85%) (see Table 1). They were aged between 14
and 40, and 1 in 4 was under 20. The majority had one or two children, and 1 in 4 had
experienced either a miscarriage or an induced abortion. Apart from one, all the
women professed themselves to be Catholic. The women in this group mentioned
falls, heavy physical work, and serious disagreements with their partners as the
causes of their abortions. Only one stated that the abortion had been provoked.
Almost half (44%) presented a clinical diagnosis of incomplete abortion, 3 were
diagnosed with an abortion in progress, and in the case of 1 out of 5 women no spe-
cific diagnosis was given. Three women were diagnosed with septic abortions.
Women’s Social Context: Captivity and Isolation
Through their narratives, most
3
of the women interviewed presented a vision of the
world, and of themselves, centered on their home life. Both marriage and mother
-
hood provoked feelings of “captivity,” as reflected in the following testimony:
It has been an ordeal for me ever since I got married; I never go out; I dedicatemy
time to my baby, to my family, but up until now I haven’t been out to enjoy myself.
Captivity is an analytical category that recurs through the history of women’s
oppression and is entrenched in dominant power relations: “Women are captive
because they have been deprived of autonomy, of independence to live, of govern
-
ing themselves, of the possibility to choose and the capacity to decide” (Lagarde,
1990, p. 165). The cause of women’s captivity is their tendency to be dependent on
and dominated by others, a situation that promotes social and cultural repro
-
duction. Among the group of women in this study, the majority did not have paid
jobs (inside or outside of the home), and only 7 earned their own money by work
-
ing outside the home, mainly as domestic workers. The reasons given by the women
for not working outside the home were generally related to the sexual division of
labor and to gender roles (the man is designated as the provider and the womanas
the caretaker of the family and the home), or, as they expressed the case, someone
needs to look after the children, daycare is too expensive, and their male partner
resisted:
1064 QUALITATIVE HEALTH RESEARCH / October 2004
I told (my partner) that I wanted to work, that I could work for me and he could
work for himself. He said “no, better not, I don’t want you to work, whatever you
need, I’ll provide.” And he doesn’t want me to work.
Furthermore, the invisibility of women’s domestic work, the fact that it is unpaid,
and women’s lack of resources tend to marginalize women in decision making and
choices about consumption. Consequently, women’s possibilities for participation
in and/or for making their own decisions are limited. The decisions that they can
make alone are restricted to what to eat and what to wear:
What to wear, what to make for dinner, how I look, nothing else.
Well, now I can’t decide anything by myself because he’s my partner.
This lack of autonomy in women’s lives conditions how they respond to any
adverse situation. For example, when considering leaving their partner because of
Erviti et al. / COPING WITH ABORTION 1065
TABLE 1:
Characteristics of Women Interviewed (N = 34)
Socioeconomic Variable Number Percentage
Age
20 years 8 23.5
20-29 years 20 58.8
≥ 30 years 6 17.7
Marital Status
Single 3 8.8
Married 9 26.5
Consensual union 20 58.8
Widowed or separated 2 5.9
Place of birth
State of Morelos 15 44.1
Other states 19 55.9
Level of schooling
Without education (illiterate or incomplete primary) 12 35.3
Complete primary 10 29.4
Secondary or more 12 35.3
Occupation
Homemaker 27 79.4
Domestic work 2 5.9
Employed 2 5.9
Student 1 2.9
Other 2 5.9
Number of living children
01029.4
1 or 2 16 47.1
> 2 8 23.5
Number of previous miscarriages and/or abortions
02573.5
1 7 20.6
≥ 225.9
Religion
Roman Catholic 33 97.1
Other 1 2.9
serious domestic violence (1 of 5 women interviewed reported violence on the part
of their partner), many of the women expressed a fear of living with a new and stig
-
matized identity, that of a “separated woman”: “How am I going to face up to the
fact that I left him?”
Women’s captivity is also expressed by their social isolation. In another study,
we have documented that these women have weak and dysfunctional social net
-
works (Castro & Erviti, 2003). They live in marginal areas of the city or in rural areas,
and often face geographical and/or economic barriers for accessing health services.
This double marginalization—of poverty and gender—often imposes great isola
-
tion; these women are almost exclusively dedicated to their homes and have limited
possibilities for maintaining social relations and seeking health services.
Moral Survival Strategies
Our analysis of women’s testimonies illustrates the enormous effort they make to
avoid any attempt on the part of society to blame them: first for not having pre
-
vented a pregnancy and second for having induced an abortion.
“Accepting” Social Norms:
Pregnancy Prevention and Self-Care During Pregnancy
The first strategy consists of presenting themselves as women who “play by the
rules” to avoid being accused of having done something wrong. The dominant
medical discourse establishes the need for women to plan their pregnancies for
health care and economic reasons. Family planning programs promote the useof
contraceptives, principally those controlled by the woman (Sayavedra, 1997), there-
fore assigning the responsibility for pregnancy to her. However, for many women,
their lack of autonomy, their beliefs related to reproduction, inadequate material
access to contraceptives, cultural barriers, and, on some occasions, neglect on the
part of the staff of institutional programs (Figueroa, 1996) might undermine this
medical mandate for them to plan their families.
The fact that women are blamed for their fertility and for not having prevented
unwanted pregnancies explains the self-exonerating tone with which many explain
the origins of their pregnancy: Most of the women said that the pregnancy had not
been planned—“I was taking precautions and I injected myself”—nor desired—“he
(my partner) told me that not now, that that was how the situation was”—and at
least 1 out of 3 women said that they had left the prevention of pregnancies in their
partner’s hands: “He would take care of me [he made sure I didn’t get pregnant]...
he didn’t come inside me.”
In some cases, women expressed exaggerated compliance with the norms of
the dominant medical discourse, as in the case of the woman whose pregnancy
occurred when she was using an intrauterine device (which she had had in place for
2 years): “I don’t blame the IUD, or anybody, it was my fault because I didn’t check it
every month.”
By stating that she does not hold anyone else responsible for her pregnancy, this
woman demonstrates that she has internalized the dominant medical discourse.
However, even more suggestive is her affirmation that she failed because she did
1066 QUALITATIVE HEALTH RESEARCH / October 2004
not go for her check-up “every month,” indicating that she knows it is essential for
her to be always available for medical surveillance, despite the fact that her knowl
-
edge of the details, in this case how often she should go for check-ups, mightbe
incorrect.
“Ignorance” or Ambiguity About the Pregnancy
Besides blaming women for unwanted or unplanned pregnancies, the dominant
discourse assigns them the responsibility for self-care during their pregnancy and
for the positive outcome of the pregnancy. A series of social norms regarding the
behavior of pregnant women—what a woman should or should not do—regulate
the care that is considered necessary for the development of a “normal” pregnancy.
This discourse labels women as negligent if they do not take the necessary precau
-
tions and therefore lose their baby (Lupton, 1999; Root & Browner, 2001). To avoid
these accusations, women often turn to a second strategy, which is to plead igno
-
rance of their pregnancy. However, as in the previous example, women make an
effort to show that their ignorance is selective: At the same time as stating that they
did not know that they were pregnant, they insist that they know what the medical
discourse indicates that they should know.
It is often said that it is better to take care of yourself when you are pregnant, that
you shouldn’t carry heavy things, and that day I went to fetch water and when I
arrived I went to wash in the river ...Iwasreally nauseated and everything made
me angry, but I thought that I wasn’t pregnant, because I am really irregular.
In their testimonies, women express their awareness of the precautions a preg-
nant woman should take, conforming to hegemonic medical knowledge. However,
these norms often contradict the conditions in which lowest income women live,
specifically the need to complete physically demanding tasks:
[The doctor told me] to be calm, that I shouldn’t get upset about anything, that it
could harm the baby . . . the only thing that he recommended me to do was to rest.
But, I mean “lie down, don’t do any housework, don’t do anything, I wouldn’t
advise you to sweep, or get the water from the tank ...ordothewashing, those are
my only recommendations.”
At the same time as demonstrating knowledge of the norms with which preg
-
nant women should comply in terms of how to look after themselves, the women
interviewed might find a justification for not complying with these norms, which is
that they did not know that they were pregnant:
I didn’t know I was pregnant ...Ifelt normal, nothing, I didn’t feel anything. I mean,
I was late, but I said “maybe something’s made me late,” but I never thought I was
pregnant because I had no ailments, no symptoms of being pregnant . . . that’s why I
didn’t even know . . . till that day when I felt really ill ...Ithought maybe it was
something like that but I wasn’t sure.
The ambiguous attitude toward their pregnancy that some women display is based
on the irregular timing of their menstrual cycle:
Erviti et al. / COPING WITH ABORTION 1067
I thought I was pregnant because my period didn’t start . . . [but] as I didn’t feel nau
-
seated or faint, nothing, I thought it couldn’t be that and I left it . . . since my periods
are irregular.
Ignorance of their pregnancy also liberates women from being held responsi
-
ble for not seeking medical help at the first signs of an abortion. Not knowing
about the pregnancy and the similarity between these symptoms and those of
menstruation—“I thought it was a normal period”—justifies the fact that many
women wait many hours at home, monitoring their symptoms or treating them
-
selves, before seeking medical help.
“Acceptance” of the Pregnancy
A third strategy used for evading blame consists of maintaining an ambivalent atti
-
tude concerning the desire to be pregnant, affirming that although the pregnancy
was not planned or desired, it had already been accepted. This strategy incorporates
and reproduces religious discourses, which ordain that every pregnancy must be
accepted. Women seek to avoid being labeled as “suspicious” by using the logic that
if they had already accepted the pregnancy, there is no reason to think that they
would act to terminate it:
To tell the truth I wanted it to be born, although I hadn’t said anything to my hus-
band. I said “that’s it. God wants us to have another so, let it be born.”
This woman also condemned women who have abortions and the act of abor-
tion itself. She incorporated arguments used by the Church against abortion, using
expressions like “God doesn’t like it” or “it’s a lost life” to condemn abortion. More-
over, she establishes differences between her case—“I didn’t provoke it . . . I sus-
pected that I was pregnant and then I thought I wasn’t so I didn’t look after
myself”—and those of other women: “There are many women who provoke an
abortion and that’s a crime, isn’t it?” She also recites, as if it was learned by heart, the
conservative argument that the fetus is a living being, which condemns deliberately
interrupting a pregnancy:
She [the fetus] is a human, it’s a life which is going to come into this world, imagine
if they said that you weren’t going to be born or that they didn’t want me to be born,
but I was born, it’s a life.
If it is God’s will for a woman to become pregnant, it is also His will to terminate
a pregnancy. Women construct their own meaning for abortion, in most cases
employing explanations related to external causes, to fate, and to an external will,
“God wanted it that way,” to explain why the pregnancy ended. These strategies
seem to indicate that when faced with suspicion, women seek to exonerate them
-
selves from blame by making it clear that their will was not involved and that, on the
contrary, they accepted the event as part of a destiny that they did not choose.
These women argued that they had not intended to terminate the pregnancy
and that although they had not planned the pregnancy, they accepted it. At least 1
out of 4 women stated that God decided about the pregnancy and abortion, and that
they resigned themselves to either:
1068 QUALITATIVE HEALTH RESEARCH / October 2004
I don’t understand it ...Ihave no idea . . . only God knows what he does and why.
If I’m already pregnant, what could I do? Nothing, only wait, but God didn’t let me,
he took it away from me, never mind, he knows why he did it.
Accidents or Unintentional Actions
Finally, a fourth strategy to escape blame consists of presenting the abortion as the
result of an “accident” or as the unintentional consequence of routine activities.
Falls and heavy physical work as causes of an abortion suggest that the womanis
responsible and acted deliberately to terminate the pregnancy. Consequently, these
women insist that they did not know that they were pregnant:
I fell once but I didn’t know I was pregnant.
That happened to me, that I fell. I went back and I felt that my hip hurt ...Ididn’t
think I was pregnant . . . afterwards, I thought I was because my hip hurt.
Before going to the hospital, many women go to folk healers, pharmacists, or
doctors and receive traditional medicines or home remedies, such as massages,
teas, pills, and injections. But as these treatments might raise “suspicions” that they
acted to terminate the pregnancy, all of the women maintained that these actions
were aimed at preventing an abortion:
They gave me tea so that I wouldn’t lose the baby.
They gave me some injections, the kinds that prevent miscarriages.
These practices can contribute to either maintaining the pregnancy or favoring
an abortion. Because of its semantic ambiguity, the visit to the midwife is constantly
presented as “proof” that something was done to prevent an abortion. This con
-
struction of meaning might be part of women’s strategy to avoid blame.
These self-exonerating strategies reflect the fact that, at least at the level of dis
-
course, these women endorse the social norms that condemn induced abortions
and, consequently, blame and condemn those who transgress these norms. Never
-
theless, although other women, who conform to a certain stereotype, might be
attributed blame for their actions concerning their own case, the women inter
-
viewed often affirmed that circumstances were different and that because of this
they do not deserve blame personally:
I don’t like this, that women have abortions ...Iused to think badly of people who
had abortions . . . sometimes, there are women who abort because they don’t want
them . . . they want to be like virgins . . . me, why would I want to abort if I’m mar
-
ried? I have a husband.
To summarize, confronted by a discourse that “suspects” women of having pro
-
voked an abortion, women seek to justify abortion and avoid blame by present
-
ing their behavior as irreproachable. Although they maintain an ambiguous atti
-
tude regarding their knowledge of the pregnancy, they claim that ultimately, they
wanted the pregnancy to continue normally. They also state that they were not
aware of what was happening when the abortion occurred and present the causes of
Erviti et al. / COPING WITH ABORTION 1069
the abortion as accidents or unintentional actions. Moreover, describing the symp
-
toms of abortion as similar to menstruation justifies the delay in identifying the
abortion and differentiating it from a normal period. Women argue that treatments
such as massages, teas, pills, and injections were taken as precautions in the attempt
to prevent an abortion. Following the deployment of these discursive strategies to
counter the social blame to which women are subjected regarding abortion, most
women maintain that their pregnancy and abortion were products of an outside
force to which they submit as part of divine will, or they mention the accidental
nature of the event. In neither scenario can the woman be held responsible.
DISCUSSION AND CONCLUSIONS
The context of abortion in Mexico determines the moral survival strategies used by
women to escape the blame and stigmatization associated with abortion. Guilt is
important in controlling behavior, because it legitimizes the punishment of the per
-
son who has transgressed social norms and because it increases their desire to obey.
Guilt about individual transgressions plays a significant role in socializing the sub-
ject by reinforcing the values expressed in the norms, which have been violated
by the individual, therefore making him or her more obedient (Balandier, 1989;
Douglas, 1969; Foucault, 1990; Goffman, 1963). Aconcrete example of a “normaliza-
tion” process achieved by the construction of categories of risk and guilt is that of
the modern medical discourse concerning the risks associated with pregnancy. The
social pressure and surveillance of the pregnant woman’s body regulate her life
with respect to food, exercise, and social and sexual relations: in other words, the
“care” a pregnant woman should take of herself (Ehrenreich & English, 1978;
Layne, 1990; Lupton, 1999; Root & Browner, 2001). In Mexico, where conservative
discourse proclaims that every pregnant woman should carry her pregnancy to full
term, two types of risk are constructed for pregnant women (i.e., two areas for sur
-
veillance and monitoring are established): as we mentioned above, risks of a bio
-
medical nature, which indicate the type of physical care pregnant women should
take of themselves; and, on the other hand, the social risks (from moral disqualifica
-
tion to criminal charges) faced by every woman who does not do her best to main
-
tain her pregnancy and to give birth at the end of her pregnancy.
Women who have had an abortion, and are, therefore, suspected of not accept
-
ing motherhood as a central norm for women’s lives, face the stigma assignedtoa
person who has violated society’s norms with his or her “bad” behavior (Goffman,
1963). This explains in part why in Western culture, at least in some developing
countries such as Mexico, maternal “failures”—that is, both spontaneous and in
-
duced abortions—are experienced in silence (Layne, 1990). Various studies have
documented that people who are stigmatized for transgressing certain moral codes
resort to information management strategies to avoid stigma and its consequences
(Miall, 1994; Park, 2002; Remennick, 2000; Scott & Lyman, 1968). In this study, we
document that women who attend public hospitals to be treated for abortion use a
series of information management strategies (Goffman, 1959) aimed at confirming
that the abortion was spontaneous and thereby avoiding the suspicion that they
induced the abortion.
Furthermore, Mexican popular culture provides individuals with two concepts
that not only explain but also attribute meaning to diverse misfortunes: God’s will
1070 QUALITATIVE HEALTH RESEARCH / October 2004
and “accidents.” Within the framework of popular religious thought, God’s will is
invoked as an unpredictable force, over which it is impossible to have control and
which is present in all of life’s events. Most religious traditions provide human
beings with elements to make sense of experience and to explain extraordinary
events, their own lives, and the ways of the world (Geertz, 1973). On the other hand,
in the context of daily life, the notion of an accident is used to account for incidents
that arise where there has been no intention or motivation on the part of the affected
party, therefore absolving them of all responsibility. In the strictest sense, these two
categories, that of God’s will and that of accidents, are, at least in theory, contradic
-
tory. The former refers to a premodern world, in which nothing happens unless God
permits it. The latter refers to a secularized world, in which there is no longer space
for magical or supernatural forces to explain the world. The notion that accidents
simply occur is characteristic of modernity (Green, 1997). However, the infor
-
mation management strategies that Mexican women use as they attempt to avoid
the stigma resulting from a successful accusation that they had induced their own
abortion include the possibility of using both of these categories with no apparent
contradiction.
The hegemonic social discourse on abortion and on the role women play in
reproduction condition the experience of abortion. This can be seen both in the way
women incorporate the dominant discourse and in the way they use strategiesto
evade suspicion and/or blame without denying the dominant discourse. The skill
with which women elaborate strategies to cope with the abortion process can be dis-
cerned through their narratives; in other words, the analytical perspective adopted
in this study permits us to discern that women are constantly active (assigning new
meaning to their behavior, rejecting social condemnation, etc.). This analytical pos-
ture is in contrast to a naive assessment, which explains unwanted pregnancies and
abortions in terms of lowest income women’s “alienation,” the product of igno-
rance and poverty, and in terms of their “inability” to assume control over their own
bodies. This interpretative perspective allows us to appreciate the skills women use
to oscillate strategically between the margins of a seemingly uniform normative
discourse, but one that they know how to interpret to ensure their moral survival.
Frequent affirmations by women that both the pregnancy and the abortion were
unwanted events might be more indicative of women’s ability to use the domi
-
nant discourse in their favor than a description of how they experienced these
circumstances.
In this study, we show the specific way in which lowest income women in
Morelos, Mexico, act to deal with abortion and unwanted pregnancies; this way of
acting—or collection of moral survival strategies—stems from women’s general
position of subordination and the particular conditions of the women in this study.
Lowest income women, aware of their doubly subordinate position, disregard fem
-
inist discourse’s claims about women’s rights (Juliano, 1998) and thus do not ques
-
tion a system that obliges them to carry an unwanted pregnancy to full term. How
-
ever, at the same time, they elaborate strategies that ensure their survival in moral
terms, where the possibility exists that they will be suspected of having provoked
their own abortion. Women can use these strategies because of their social invisibil
-
ity and because the strategies are disguised as a formal acceptance of and submis
-
sion to social norms. This position contrasts with feminist positions that question
the discrimination of women and their subordinate position, and demand that
women participate in the decision of whether to become mothers. In other words,
Erviti et al. / COPING WITH ABORTION 1071
even in cases of extreme subordination, women appear to find a way of acting
according to their own will, using the resources offered by the dominant discourse
to avoid condemnation.
However, beyond stating that this way of dealing with an event like abortionis
representative of the gender conditions that these women live, it is of interest to
reflect on the health risks and levels of suffering that result from these strategies.
Future investigation should incorporate both dimensions of suffering as identified
by Morse (2001): emotional suffering and enduring. Lowest income women are
often survivors of these processes, which imply health risks that are not treated in
an opportune manner. For example, in many cases, the events that are said to have
caused the abortion (such as falls or massages accompanied by certain teas) might,
if left untreated, cause death by hemorrhaging or sepsis. Because of the difficulty of
accessing health services, particularly in the case of nighttime emergencies, there is
an increased risk to the survival of these women. The fact that some delay seeking
help until they are seriously ill indicates not only their extreme socioeconomic
marginalization but also the context of social condemnation that surrounds any
form of abortion in this country.
In this work, we have shown how gender and class are two powerful sources of
oppression that have decisive influence over the suffering of women; we have also
argued that these sources of suffering are a constitutive part of the strategies
employed by women to avoid stigmatization (Georges, 2001). In the framework of
praxis theory, hospital attention for women who are tended for abortion-related
complications might benefit from these findings.
Given the negative context that surrounds abortion and its impact on women’s
lives, and to counterbalance stereotyped images, we propose that it is necessary to
publicize images of women who have had abortions and also to work with health
professionals who treat women after abortions. This might help to modify the nega-
tive and suspicious attitudes toward abortion and the tendency to blame these
women, both factors which might contribute to women delaying seeking medical
help when the first symptoms appear.
Finally, the secret and illegal nature of abortion in Mexico creates challenges for
abortion research. It is difficult to quantify the problem of abortion, and, on the
other hand, studies that seek to further an interpretative-sociological understand
-
ing of abortion are scarce. Therefore, we would like to emphasize the need for fur
-
ther studies of the type presented here. Women’s narratives hold the key forex
-
plaining both how dominant discourses work and also how these discourses can be
adapted and resisted. Thus, this type of research offers the possibility of disman
-
tling current forms of domination and segregation that oblige women to implement
strategies for managing the interpretation of abortion. These strategies might be the
only way of avoiding the stigmatization and suffering experienced by women
when they refuse to comply with the mandate of compulsory motherhood.
NOTES
1. In recent years, the Legislative Assembly of Mexico City (ALDF) “updated” the penal code to
incorporate the same conditions in the law that were present in the penal codes of 17 federal states in
Mexico. The law was approved, but the conservative opposition presented the argument before Mexico’
Supreme Court of Justice that this was unconstitutional. Finally, in January 2002, the court voted by a 6-
1072 QUALITATIVE HEALTH RESEARCH / October 2004
to-5 majority that the law was unconstitutional. However, a minimum of 8 out of 11 votes are required for
a law to be declared unconstitutional, and so the law was not dismissed.
2. This software, as many other of the type already existing in the market, is a useful tool for the
management of data based on texts, such as narrative and verbal accounts. It helps in classifying the dif
-
ferent fragments of the texts by facilitating the coding process, thus permitting their reading by these
codes, subcodes, subjects, groups of subjects, and so on. Therefore, it is a useful device in the process of
interpreting qualitative data.
3. When we speak of “majority,” we refer to the fact that at least 2 out of 3 women presented the
phenomena.
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Joaquina Erviti, Ph.D., is a researcher at the Regional Center for Multidisciplinary Research, National
Autonomous University of Mexico, Cuernavaca, Morelos, Mexico.
Roberto Castro, Ph.D., is a researcher at the Regional Center for Multidisciplinary Research, National
Autonomous University of Mexico, Cuernavaca, Morelos, Mexico.
Ana Collado, Ph.D., is a professor of sociology in the Facultad Ciencias Económicas, University of Bar-
celona, Spain.
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