Introduction

Abortion was illegal in Portugal until 1984. Even today, the Portuguese Penal Code considers abortion a crime against intrauterine life. Over the years, Portugal’s legislation incorporated different grounds for legal abortion. First, in 1984, the Assembly of the Republic ruled to allow legal abortion in situations of serious maternal and fetal disease, rape, and in a broader sense, crimes against sexual self-determination. These situations have thus been accepted for 35 years in Portugal’s health services.

A national referendum was held in 1998 on the question of decriminalization of voluntary termination of pregnancy. The result was 50.9% against and 49.1% in favor. Abstention exceeded 50% (only 31.9% of the country’s registered voters participated), which made the referendum non-binding.

A second referendum was held in 2007 on decriminalization of abortion at the woman’s request, and the pro-choice movement won with 59.3% of the votes (43.6% of the electorate participated). Based on this result, voluntary abortion was no longer illegal when performed up to the 10th gestational week in official or officially accredited health services ¹1. Portugal. Lei nº 16/2007, publicada em 17 de abril. Exclusão da ilicitude nos casos de interrupção voluntária da gravidez. https://www.saudereprodutiva.dgs.pt/legislacao/interrupcao-voluntaria-da-gravidez/lei-n162007-publicado-a-17-de-abril-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/legi... ^,22. Portugal. Portaria nº 741-A/2007, publicada em 21 de junho. Regulamentação da Lei nº 16/2007 de 17 de Abril de 2007. Interrupção voluntária da gravidez. https://www.saudereprodutiva.dgs.pt/legislacao/interrupcao-voluntaria-da-gravidez/portaria-n741-a2007-publicado-a-21-de-junho-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/legi... .

There is no information on the absolute number of abortions performed at the woman’s request before 2007. The fact that they were performed illegally meant that the number could only be estimated indirectly based on the number of treatments for complications recorded in health services, or based on studies and surveys conducted in Portugal up to that year.

According to the National Fertility Survey in 1997, 2% of Portuguese women 15-24 years of age, 5.1% of those 25-34 years of age, and 9.7% of those 35-49 years of age reported having had at least one abortion in their lives ³3. Serviço de Estudos Demográficos e Sociais, Gabinete de Estudos e Conjuntura, Instituto Nacional de Estatística. Inquérito à fecundidade e família: resultados definitivos: 1997. https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_publicacoes&PUBLICACOESpub_boui=133771&PUBLICACOESmodo=2(acessado em 19/Ago/2019).
https://www.ine.pt/xportal/xmain?xpid=IN... . Data analysis from the Sentinel Physicians’ Network and hospital discharge diagnoses in 1993-1997 ⁴4. Matias Dias C, Marinho Falcão I, Marinho Falcão J. Contribuição para o estudo da ocorrência da interrupção voluntária da gravidez em Portugal Continental (1993-1997): estimativas utilizando dados da Rede de Médicos Sentinela e dos diagnósticos de altas hospitalares (grupos de diagnósticos homogêneos). Epidemiologia 2000; 18:55-63. estimated approximately 20,000 illegal abortions per year. In a study by the Family Planning Association ⁵5. Vilar D, Souto E, Sampaio M, Alves MJ. A situação do aborto em Portugal - práticas, contextos e problemas. http://www.apf.pt/sites/default/files/media/2017/a_situacao_do_aborto_em_portugal_-_formato_pdf.pdf (acessado em 13/Ago/2019).
http://www.apf.pt/sites/default/files/me... with 2,000 women 18-49 years of age from the entire country, 20% had undergone at least one abortion.

Implementation of the network for abortion care up to 10 weeks gestational age

It has now been 12 years in Portugal that voluntary abortion up to the 10th week of pregnancy is legal, when performed in official or officially accredited health services ¹1. Portugal. Lei nº 16/2007, publicada em 17 de abril. Exclusão da ilicitude nos casos de interrupção voluntária da gravidez. https://www.saudereprodutiva.dgs.pt/legislacao/interrupcao-voluntaria-da-gravidez/lei-n162007-publicado-a-17-de-abril-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/legi... ^,22. Portugal. Portaria nº 741-A/2007, publicada em 21 de junho. Regulamentação da Lei nº 16/2007 de 17 de Abril de 2007. Interrupção voluntária da gravidez. https://www.saudereprodutiva.dgs.pt/legislacao/interrupcao-voluntaria-da-gravidez/portaria-n741-a2007-publicado-a-21-de-junho-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/legi... . This includes units of the National Health Service (NHS in Obstetrics-Gynecology) and private units certified for this purpose by the proper bodies (namely under the General Health Division). Over the years, there were as many as four accredited private units. There are currently only two such units in operation in Lisbon.

Following the referendum in 2007, it was necessary to create a network for abortion care up to the 10th gestational week, and several fundamental issues determined the characteristics of the services and the network in this response, namely:

(a) The existence of a preexisting maternal-child referral network to serve as the basis for implementing and linking the care;

(b) Publication of a set of clinical protocols ⁶6. Organização dos serviços para implementação da Lei nº 16/2007 de 17 de abril. Circular Normativa nº 11/SR de 21.06.2007 da Direcção-Geral da Saúde. https://www.saudereprodutiva.dgs.pt/normas-e-orientacoes/interrupcao-voluntaria-da-gravidez/organizacao-dos-servicos-para-implementacao-da-lei-n-162007-de-17-de-abril-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/norm... ^,77. Direcção-Geral da Saúde. Interrupção cirúrgica da gravidez até às 10 semanas de gestação. Circular Normativa 2007; nº 10/SR. https://www.saudereprodutiva.dgs.pt/normas-e-orientacoes/interrupcao-voluntaria-da-gravidez/interrupcao-cirurgica-da-gravidez-ate-as-10-semanas-de-gestacao-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/norm... ^,88. Direcção-Geral da Saúde. Interrupção medicamentosa da gravidez. Circular Normativa 2007; nº 9/SR. https://www.saudereprodutiva.dgs.pt/normas-e-orientacoes/interrupcao-voluntaria-da-gravidez/interrupcao-medicamentosa-da-gravidez-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/norm... ^,99. Direcção-Geral da Saúde. Modelo Normalizado do Consentimento livre e esclarecido para a interrupção da gravidez. Circular Informativa 2007; nº 20/SR. https://www.saudereprodutiva.dgs.pt/normas-e-orientacoes/interrupcao-voluntaria-da-gravidez/modelo-normalizado-do-consentimento-livre-e-esclarecido-para-a-interrupcao-da-gravidez-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/norm... ;

(c) The simultaneous introduction of a mandatory national online registry for entering data from all the public and private services ¹⁰10. Direcção-Geral da Saúde. Norma nº 001/2013 de 29/01/2013. Registo de complicações de interrupção de gravidez. Definições e modelo de registo. https://www.saudereprodutiva.dgs.pt/normas-e-orientacoes/interrupcao-voluntaria-da-gravidez/norma-n-0012013-de-29012013-pdf.aspx (acessado em 19/Ago/2019).
https://www.saudereprodutiva.dgs.pt/norm... ;

(d) Annual publication of data on termination of pregnancy for all reasons;

(e) the availability of mifepristone and the existence of studies that allowed its safe use in medical termination of pregnancy;

(f) continuing training and exchange of experiences among the health professionals working in these services and consultations. A clear example of this is the continuity of National Meetings on Consultations on Termination of Pregnancies, gradually extended to other professionals or areas of interest;

(g) regular audits on the quality of both public and private services, which allowed guaranteeing continuous improvement in the quality of the services provided.

All this highlights the importance of accumulated scientific experience with the protocol for medical abortion. Such experience, alongside the availability of mifepristone, allowed the publication of clinical protocols and studies published in Europe and the USA on its safe use in the hospital and outpatient settings. The combination of these factors made Portugal one of the countries that most used medical termination of pregnancy, with data published and presented in scientific meetings. Currently, all countries that wish to implement safe abortion services can draw on even more experience and information on the safe use of medical abortion.

Results of the implementation over the years

The number of abortions performed in the country as a whole increased in the initial years after 2007 and has decreased steadily since 2011. Before decriminalization, the estimated number of illegal abortions was 20,000 per year ³3. Serviço de Estudos Demográficos e Sociais, Gabinete de Estudos e Conjuntura, Instituto Nacional de Estatística. Inquérito à fecundidade e família: resultados definitivos: 1997. https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_publicacoes&PUBLICACOESpub_boui=133771&PUBLICACOESmodo=2(acessado em 19/Ago/2019).
https://www.ine.pt/xportal/xmain?xpid=IN... . This number has never been exceeded since 2011 ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... (Figure 1), and the woman’s choice has been the principal reason for termination of pregnancy (Table 1).

Most abortions are performed in units of the NHS (ranging from 67% to 72% of the abortions performed over the years) ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... . When a unit of the NHS does not have the capacity to perform a termination of pregnancy, the woman should be referred in timely fashion to another unit in the NHS or to an officially accredited private unit. As provided in the legislation approved in 2007, the referral is always covered financially by the NHS.

In Portugal, medical abortion (with mifepristone and misoprostol, according to guidelines from the General Health Division) is the most common form of termination. This approach has increased over the years and is currently practiced in 70.2% of the cases ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... . Medical abortion is currently used in 95%-97% of the cases in NHS units, while surgical abortion is performed in 97%-98% of cases in private health services ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... .

Foreign women residing in Portugal also have access to free abortion care, accounting for 15%-19% of the women who have undergone abortions over the years ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... .

Some two-thirds of the women are 20-34 of age (64-65% in different years). The proportion of abortions in women under 20 has always been low, ranging from 12% in 2008 to 10% in 2017 ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... .

Women accessing abortion services can also choose a safe, comfortable, and free contraceptive method, since contraception is free of charge for all women in Portugal in the SNS units. Some 93-97% of women seeking abortion then chose a contraceptive method, with an increase over the years in the choice of long-lasting methods (from 26% to 38%) ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... .

The number of emergency treatments for complications of illegal abortions has decreased considerably since 2007, when Law n. 16/2007 was enacted. The published reports show an important decrease in serious complications (uterine and other organ perforation and sepsis), as shown in Table 2 and in the reports published by the General Health Division on hospitalizations due to complications of illegal and legal abortion ¹³13. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de análise das complicações relacionadas com a interrupção da gravidez 2013-2014. https://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez/relatorio-de-analise-das-complicacoes-relacionadas-com-a-interrupcao-da-gravidez-2013-2014.aspx (acessado em 13/Ago/2019).
https://www.saudereprodutiva.dgs.pt/publ... .

From 2001 to 2007, 14 maternal deaths associated with complications of abortion were reported (out of a total of 92 maternal deaths in the same period) ¹⁴14. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório Mortes Maternas em Portugal, 2001-2007. https://www.saudereprodutiva.dgs.pt/publicacoes/diversos/relatorio-das-mortes-maternas-2001-2007-pdf.aspx (acessado em 13/Ago/2019).
https://www.saudereprodutiva.dgs.pt/publ... . Since 2007, two maternal deaths have been reported: one due to an illegal abortion in 2008 and one associated with a drug-induced abortion in 2010. The latter case was associated with a rare complication, but already described in other countries, of toxic shock with Clostridium sordellii¹⁴14. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório Mortes Maternas em Portugal, 2001-2007. https://www.saudereprodutiva.dgs.pt/publicacoes/diversos/relatorio-das-mortes-maternas-2001-2007-pdf.aspx (acessado em 13/Ago/2019).
https://www.saudereprodutiva.dgs.pt/publ... .

Conclusion

As a result of Portugal’s new legal provisions, data on termination of pregnancy is now collected, analyzed, and published annually by the General Health Division. Portugal now has more than 10 years of systematically collected data, clearly showing that women who undergo abortion are distributed across all reproductive age brackets, schooling levels, and professions. Some have already had children, and others will go on to have children in the future. Women who have an abortion can have children in other years. They are no different from other women.

The possibility of accessing safe abortion services has not led to an increase in the number of abortions performed. Before decriminalization, the estimated number of abortions performed in Portugal was 20,000 per year ³3. Serviço de Estudos Demográficos e Sociais, Gabinete de Estudos e Conjuntura, Instituto Nacional de Estatística. Inquérito à fecundidade e família: resultados definitivos: 1997. https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_publicacoes&PUBLICACOESpub_boui=133771&PUBLICACOESmodo=2(acessado em 19/Ago/2019).
https://www.ine.pt/xportal/xmain?xpid=IN... . This number has never been exceeded since decriminalization. Since 2011 there has been a steady decrease in termination of pregnancies, both in absolute numbers and in the abortion rate per 1,000 live births. In Portugal, in 2010 there were 199 abortions per 1,000 live births, decreasing to 192 per 1,000 live births in 2015 and dropping again to 179.8 per 1,000 live births in 2017 ¹¹11. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de Registros de Interrupção da gravidez. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... ^,1212. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatórios anuais referentes aos dados de 2007 a 2017. http://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez.aspx (acessado em 19/Ago/2019).
http://www.saudereprodutiva.dgs.pt/publi... . Using this indicator for purposes of international comparison, the number of abortions per 1,000 live births in Portugal has always been below the average for Europe, which was 216 per 1,000 live births in 2010 and 203 per 1,000 live births in 2015, with no estimates currently available for the years 2016 and 2017 ¹⁵15. World Health Organization. European Health Information Gateway. Abortions per 1000 live births. https://gateway.euro.who.int/en/indicators/hfa_586-7010-abortions-per-1000-live-births/ (acessado em 19/Ago/2019).
https://gateway.euro.who.int/en/indicato... .

Since the introduction of the new legal provisions, there have been important decreases in maternal mortality, in the overall number of complications in general and specifically in serious complications from illegal and unsafe abortions ¹³13. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório de análise das complicações relacionadas com a interrupção da gravidez 2013-2014. https://www.saudereprodutiva.dgs.pt/publicacoes/interrupcao-da-gravidez/relatorio-de-analise-das-complicacoes-relacionadas-com-a-interrupcao-da-gravidez-2013-2014.aspx (acessado em 13/Ago/2019).
https://www.saudereprodutiva.dgs.pt/publ... ^,1414. Direcção-Geral da Saúde. Programa Nacional de Saúde Reprodutiva. Relatório Mortes Maternas em Portugal, 2001-2007. https://www.saudereprodutiva.dgs.pt/publicacoes/diversos/relatorio-das-mortes-maternas-2001-2007-pdf.aspx (acessado em 13/Ago/2019).
https://www.saudereprodutiva.dgs.pt/publ... . The knowledge acquired over these years has furnished experience for improving clinical interventions in other situations, such as spontaneous abortion and retained abortion. In short, the combination of political will and dedicated work by the health professionals that prepared the terrain, implemented the network, and monitored the entire process was essential for success. The Portuguese experience has been presented in international scientific meetings. In 2018, an article analyzing this implementation was published in the The International Federation of Gynecology and Obstetrics (FIGO). This is an open-access publication that readers are urged to consult ¹⁶16. Stifani BM, Vilar D, Vicente L. "Referendum on Sunday, working group on Monday": a success story of implementing abortion services after legalization in Portugal". Int J Gynaecol Obstet 2018; 143 Suppl 4:31-3..

References

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