Women's abortion seeking behavior under restrictive abortion laws in Mexico

Abortion is regulated in Mexico at the state level, and it is permitted under certain criteria in all 32 states, except in Mexico City where first-trimester abortion is decriminalized. Yet, more than a million abortions occur in Mexico each year. But most terminations occurring outside of Mexico City are clandestine and unsafe due to profound stigma against the procedure, lack of trained providers, lack of knowledge of where to find a safe abortion and poor knowledge of the laws. While this situation is moderated by the increasing use of misoprostol, a relatively safe method of abortion, the safety of the procedure cannot be assured in restrictive legal contexts. The purpose of this study is to explore women’s experiences with induced abortion in three federal entities with different legal contexts, and whether abortion seeking behavior and experiences differ across these settings. The study was carried out in three states, representing three different degrees of restrictiveness of abortion legislation. Queretaro with the “most restrictive” law, Tabasco with a “moderately restrictive” law, and Mexico state with the “least restrictive” law. We hypothesize that women living in more restrictive states will resort to the use of more unsafe and risky methods and providers for their abortion than their counterparts in less restrictive states. Women who recently obtained abortions were selected through snowball sampling and qualitative data were collected from them using semi-structured indepth interviews. Data collection took place between mid-2014 and mid-2015, with a final sample size N = 60 (20 from each state). Various themes involved in the process of abortion seeking behavior were developed from the IDIs and examined here: women’s knowledge of the abortion law in their state, reasons for having an abortion; the methods and providers used and women’s positive and negative experiences with abortion methods and providers used. Our results indicate that abortion safety is not associated with the restrictiveness of abortion legislation. Findings show that there is a new pattern of abortion service provision in Mexico, with misoprostol, a relatively safe and easy to use method, playing an important role. Nevertheless, while access to misoprostol tends to increase the safety of abortion, the improvement is moderated by women and their informants (relatives, friends and partners) not having accurate information on how to safely self-induce an abortion with misoprostol. On the other hand, some women manage to have safe abortion in illegal setting by going to Mexico City or with the support of NGOs knowlegeable on abortion. Findings demonstrate the importance of decriminalization of abortion, but meanwhile, harm reduction strategies, including promotion of accurate information about self-use of misoprostol where abortion is legally restricted will result in safe abortion.

Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross‐country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers’ advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy.

ObGyn societies have the potential to advance women's health and rights to safe abortion care by strengthening their advocacy role through a multi‐strategy approach.

Abortion Decriminalisation in New South Wales: An Analysis of the Abortion Law Reform Act 2019 (NSW)

Abortion was decriminalised in New South Wales in October 2019. While New South Wales is the seventh jurisdiction in Australia to decriminalise abortion and regulate it under health legislation, the recent passage of the Abortion Law Reform Act 2019 (NSW) (the Act) saw the adoption of a number of principle-based amendments that distinguish it from abortion legislation in other Australian jurisdictions. This article critiques key sections of the Act regarding sex selection abortion, a doctor's duties in relation to offering a woman counselling, the distinct crime of abortion coercion, and the protection of conscience for health professionals. It also identifies where future research may assist us in understanding both the application of these new legal requirements, and the community's experiences with abortion.

Men's support for abortion in Upper East and Upper West Ghana

The second leading cause of maternal mortality in Ghana is unsafe abortion. Research in Ghana shows that men's support influences women's use of safe abortion services. The aim of this study was to understand what men know about abortion, why they support their partners to seek an abortion, and to identify effective ways to reach men with abortion information. We conducted eleven focus groups and ten in-depth interviews with men of reproductive age in rural Ghana. Inclusion criteria were written consent, age and marital status. Focus groups and interviews were conducted in local languages using a semi-structured guide. Focus groups and interviews were audiotaped, transcribed, translated, computerised and coded for analysis. Most men knew the difference between unsafe and safe abortion and would support their partner to have an abortion. Messages that reinforce safe abortion as acceptable and that address fears of death or barrenness should be developed to educate men about safe abortion. Multiple channels to communicate these messages should be used and include pictures, video or audio for those men who cannot read. Through an intensive intervention inclusive of men, women's access to safe abortion services can be improved in Ghana.

The access paradox: abortion law, policy and practice in Ethiopia, Tanzania and Zambia

INTRODUCTION

Unsafe abortion is a major contributor to the continued high global maternal mortality and morbidity rates. Legal abortion frameworks and access to sexuality education and contraception have been pointed out as vital to reduce unsafe abortion rates. This paper explores the relationship between abortion law, policy and women's access to safe abortion services within the different legal and political contexts of Ethiopia, Tanzania and Zambia. The research is inspired by recent calls for contextualized policy research.

METHODS

The research was based in Addis Ababa (Ethiopa), Dar es Salaam (Tanzania) and Lusaka (Zambia) and had a qualitative exploratory research design. The project involved studying the three countries' abortion laws and policies. It moreover targeted formal organizations as implementers of policy as well as stakeholders in support of, or in opposition to the existing abortion laws. Semi-structured interviews were carried out with study participants (79) differently situated vis-à-vis abortion, exploring their views on abortion-related legal- and policy frames and their perceived implications for access.

RESULTS

The abortion laws have been classified as 'liberal' in Zambia, 'semi-liberal' in Ethiopia and 'restrictive' in Tanzania, but what we encountered in the three study contexts was a seeming paradoxical relationship between national abortion laws, abortion policy and women's actual access to safe abortion services. The study findings moreover reveal that the texts that make up the three national abortion laws are highly ambiguous. The on-paper liberal Zambian and semi-liberal Ethiopian laws in no way ensure access, while the strict Tanzanian law is hardly sufficient to prevent young women from seeking and obtaining abortion. In line with Walt and Gilson's call to move beyond a narrow focus on the content of policy, our study demonstrates that the connection between law, health policy and access to health services is complex and critically dependent on the socio-economic and political context of implementation.

CONCLUSIONS

Legal frameworks are vital instruments for securing the right to health, but broad contextualized studies rather than classifications of law along a liberal-restrictive continuum are demanded in order to enhance existing knowledge on access to safe abortion services in a given context.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania

BACKGROUND

Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime.

METHODS

The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health.

RESULTS

Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy.

DISCUSSION AND CONCLUSIONS

The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.

Decriminalization of abortion - A human rights imperative

This chapter reviews the evolving consensus in international human rights law, first supporting the liberalization of criminal abortion laws to improve access to care and now supporting their repeal or decriminalization as a human rights imperative to protect the health, equality, and dignity of people. This consensus is based on human rights standards or the authoritative interpretations of U.N. and regional human rights treaties in general comments and recommendations, individual communications and inquiry reports of treaty monitoring bodies, and in the thematic reports of special rapporteurs and working groups of the U.N. and regional human rights systems. This chapter explores the reach and influence of human rights standards, especially how high courts in many countries reference these standards to hold governments accountable for the reform and repeal of criminal abortion laws.

Exploring the relationship between lay theories of gender and attitudes to abortion in the context of a national referendum on abortion policy

The relationship between lay theories of gender and attitudes to abortion policy has received minimal empirical attention. An ongoing theoretical debate in the psychological essentialism literature queries whether biological attributions causally influence social attitudes or primarily function to justify existing attitudinal commitments. The current research used the context of a national referendum on abortion in Ireland to investigate whether endorsement of certain gender theories is contingent on their rhetorical construction as supporting particular attitudes to abortion. Two experimental studies were conducted online in the three weeks preceding the Irish abortion referendum. The studies tested whether participants would adapt their causal gender beliefs after reading that biological (Study 1; N = 348) or social (Study 2; N = 241) accounts of gender supported or conflicted with their intended vote in the referendum. Both studies showed the opposite effect: causal gender theories presented as conflicting with participants' voting intentions subsequently showed elevated support, relative to theories that purportedly aligned with participants' voting intentions. While results confirm that lay theories of gender are mutable, the direction of effects does not support the proposition that gender theories are selectively endorsed to support existing socio-political attitudes to abortion. Potential mechanisms for the results observed are discussed.

Political Institutions and the Comparative Medicalization of Abortion

Comparative-historical research on medicalization is rare and, perhaps for that reason, largely ignores political institutions, which tend to vary more across countries than within them. This article proposes a political-institutional theory of medicalization in which health care policy legacies, political decentralization, and constitutionalism shape the preferences, discourses, strategies, and influence of actors that seek or resist medicalization. The theory helps explain why abortion has been more medicalized in Britain than the United States. The analysis finds that the American medical profession, unlike its British counterpart, focused on defending private medicine rather than protecting its power to "diagnose" the medical necessity of abortions; that American political decentralization aided the establishment of abortion on request by encouraging strategic innovation and learning that shaped social movement strategies, medical issue avoidance, and the growth of nonhospital clinics; and finally, that constitutionalism promoted rights discourses that partially crowded out medical ones.

Notes from the field: political norm change for abortion in Pakistan

This commentary describes positive political norm change on abortion despite a restrictive abortion law. As we describe it, the approach in Pakistan has involved careful efforts to maintain government ownership, leadership, and accountability for safe abortion care and service delivery by Pakistani health authorities early and throughout, with technical support from civil society as requested. This commentary suggests that careful collaboration and mutual support by NGOs working on expanding access to abortion can have a lasting and efficient impact on improving political norms and government ownership over abortion care. In most restrictive settings, political norms may be extremely challenging to address due to the institutionalised nature of abortion stigma and resistance, and NGOs can spend many years of resources trying unsuccessfully to challenge and eliminate these barriers. The experience in Pakistan has been a nontraditional approach to political norm change, as it starts by centring the issue of unsafe abortion squarely within the authority and responsibility of the Pakistani government to avert maternal deaths, within the current legal parameters. Emphasis on the public health needs for safe abortion care and current government obligations in Pakistan, as we describe, has led to increased dialogue and discussion about the need for further reforms by government stakeholders who were previously less willing to meaningfully address this health topic. We believe this approach demonstrates significant promise for future progressive change, and we hope this information will be a valuable resource for others working in the field.

Zika and abortion in Brazilian newspapers: how a new outbreak revived an old debate on reproductive rights

Since the beginning of the Zika virus epidemic, the Brazilian Ministry of Health has reported over 2000 confirmed cases of microcephaly associated with Zika virus in Brazil, with the cases concentrated in the northeast states. The Zika epidemic reopened a debate in Brazil that has played out in the national newspapers about expanding the abortion law to provide autonomy and legal protection to women. The argument for expanding the abortion law to include microcephaly secondary to Zika virus infection called for autonomy for women and, more broadly, protection of reproductive rights. The argument against expanding the current abortion law was separated into two main moral veins: those citing eugenics and those citing religious beliefs. However, the debate on abortion in the case of microcephaly accomplished more than giving a voice to two different viewpoints; it exposed health disparities that exist in Brazil, which were magnified by Zika virus, and reopened the political arena for discussion of the abortion law.

Who Was Afraid of Pregnancy Tests? Gestational Information and Reproduction Policies in France (1920-50)

Though resulting from a long-term process, the need to manage pregnancies both medically and bureaucratically became a state concern, especially from the 1920s onwards. A woman's official obligation to notify the state of her pregnancy (and therefore to know it on time) goes beyond a matter of biopolicies and poses a range of contradictions. 'Pregnant or not?' - as an issue of knowledge - is a powerful tool for apprehending the tensions between individual freedom, privacy, institutional requirements and professional powers.In order to better understand the historical meaning of pregnancy diagnostics in mid-twentieth-century France, this paper combines three dimensions: uncertainty and its management; the informational asymmetry between institutional agents and women; and the diachronic dimension of gestation. Writing this history sheds more light on an apparent paradox: while knowing and notifying one's own pregnancy became a duty, the tools that could help women eliminate some doubt right from the first months of their pregnancy - in particular the innovation of laboratory diagnosis - was seen as a danger. When, in 1938, private laboratories began publishing advertisements for the laboratory test in the most widely-read newspapers, tending to reframe it as a commercial service, the anti-abortion crusade was increasing its propaganda and its political pressure. This crusade's legal victory proved incomplete, but for a long time some of the most conservative physicians recommended great parsimony in prescribing testing. Combined with reducing the legal time limit for notification, this conflict shows how the state injunctions towards women could look like a 'double bind'.

The Right to Know? The Politics of Information about Contraception in France (1950s-80s)

In 1920 in France, a law was passed prohibiting abortion, the sale of contraceptives and 'anti-conception propaganda'. While contraception was legalised in 1967 and abortion in 1975, 'anti-natalist propaganda' remained forbidden. This article takes seriously the aim of the French state to prevent the circulation of information for demographic reasons. Drawing from government archives, social movement archives and media coverage, the article focuses on the way the propaganda ban contributed to shaping the public debate on contraception as well as lastingly impacting the ability of the state to communicate on the subject. It first shows how birth control activists challenged the legal interdiction against communicating about contraception (1956-67) without questioning the natalist obligation. It then shows how, after 1968, communication on contraception became a power struggle carried out by various actors (sexologists and feminist and leftist activists) and how the dissemination of information about contraception was thought of as a way to challenge moral and social values. Finally, the article describes the change of state communication policies in the mid-1970s, leading to the first national campaign on contraception launched in 1981, which defined information as a task that women should take on.

Metrics of Survival: Post-Abortion Care and Reproductive Rights in Senegal

Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I demonstrate how health professionals have deployed indicators such as number of women and abortion type treated in government hospitals to demonstrate commitment to global mandates on reproductive rights. These indicators obscure discrimination against women suspected of illegal abortion as health workers negotiate obstetric treatment with the abortion law. By measuring hospitals' capacity to keep women with abortion complications alive, post-abortion care (PAC) indicators have normalized survival as a state of reproductive well-being.

Expanding reproductive justice through a supportability reparative justice framework: the case of abortion in South Africa

Theoretical refinement of the concept of reproductive justice has been called for. In this paper, I propose the use of a supportability reparative justice approach. Drawing on intra-categorical intersectionality, the supportability aspect starts from the event of a pregnancy to unravel the interwoven embodied and social realities implicated in women experiencing pregnancy as personally supportable/unsupportable, and socially supported/unsupported. The reparative justice aspect highlights the need for social repair in the case of unsupportable pregnancies and relies on Ernesto Verdeja's critical theory of reparative justice in which he outlines four reparative dimensions. Using abortion within the South African context, I show how this framework may be put to use: (1) the facilitation of autonomous decision-making (individual material dimension) requires understanding women within context, and less emphasis on individual-driven 'choice'; (2) the provision of legal, safe state-sponsored healthcare resources (collective material dimension) demands political will and abortion service provision to be regarded as a moral as well as a healthcare priority; (3) overcoming stigma and the spoiled identities (collective symbolic dimension) requires significant feminist action to deconstruct negative discourses and to foreground positive narratives; and (4) understanding individual lived experiences (individual symbolic dimension) means deep listening within the social dynamics of particular contexts.

Queering abortion rights: notes from Argentina

In recent years, there have been calls in activist spaces to 'queer' abortion rights advocacy, to incorporate non-normative notions of gender identity and sexuality into abortion struggles and services. Argentina provides an interesting site in which to examine these developments, since there is a longstanding movement for abortion rights in a context of illegal abortion and a recent ground-breaking Gender Identity Law that recognises key trans rights. In this paper, we analyse public documents from the abortion rights movement's main coalition - the National Campaign for the Right to Legal, Safe and Free Abortion - alongside interviews with 19 Campaign activists to examine shifts and tensions in contemporary abortion rights activism. We trace the incorporation of trans-inclusive language into the newly proposed abortion rights bill and conclude by pointing to contextual factors that may limit or enhance the further queering of abortion rights.

Coercing Women's Behavior: How a Mandatory Viewing Law Changes Patients' Preabortion Ultrasound Viewing Practices

Over the past two decades, US states have enacted legislation regulating ultrasound scanning in abortion care, including mandating that abortion patients view their ultrasound image. Legal scholars have argued that, by constructing ultrasound viewing as a necessary part of patients' abortion decision making, these laws aim to control and constrain how women make personal decisions about their bodies and parenthood. To date, however, the discussion of the impact of ultrasound viewing laws on women's decisional autonomy has occurred in the abstract. Here, we examine the effect of Wisconsin's mandatory ultrasound viewing law on the viewing behavior of women seeking care at a high-volume abortion-providing facility. Drawing both on chart data from patients before and after the law went into effect and on in-depth interviews with women subject to the mandatory viewing law, we found that the presence of the law impacted patients' viewing decision making. Moreover, we documented a differential effect of the law by race, with larger impacts on the viewing behavior of black women compared with white women. Our findings call for renewed attention to the coercive power of laws regulating abortion on a macrolevel, investigating not only how they affect individuals' behavior and experience but also which individuals are impacted.

Motivations and Experiences of People Seeking Medication Abortion Online in the United States

CONTEXT

State legislation restricting access to abortion in the clinic setting raises the possibility that an increasing number of individuals in the United States will self-manage their abortion at home. Medications sourced online represent a potential pathway to abortion self-management. Yet, very little is known about the reasons U.S. residents may seek abortion online or their experiences finding medications and information.

METHODS

In January-June 2017, anonymous in-depth interviews were conducted with 32 people from 20 states who sought abortion medications online (30 women and two men seeking medications for their partners). Participants were asked about their (or their partners') motivations for considering self-managed abortion, the sources of medications they identified and any other methods they considered. Transcripts were coded and analyzed according to the principles of grounded theory.

RESULTS

The analysis revealed four key themes: Seeking abortion medications online can be a response to clinic access barriers both in states with and in ones without restrictive abortion laws; self-managed abortion can be a preference over clinical care; online options offer either information or medications, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives.

CONCLUSION

Current online options for abortion medications leave many important needs unmet, particularly for women who encounter barriers to obtaining clinic-based abortion services. There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible.

Who Should Regulate Preimplantation Genetic Diagnosis in the United States?

Unlike in many European countries, preimplantation genetic diagnosis (PGD) is not regulated in the United States. As a result, PGD may be used for any condition for which genetic testing is available, at the discretion of fertility specialists and their patients. This essay explores the question of who should be responsible for regulating PGD in the United States. Federal or state regulation of PGD in the United States is likely to be challenging and problematic for several reasons, including the proximity of PGD to the abortion debate. I propose that PGD regulation in the United States can be most appropriately performed by health professionals using professional society guidelines that set standards for clinical practice.

Defining the Best Interest of a Child: Who Comes First - The Child or the Fetus?

In 2017, a 10-year-old girl, who was allegedly raped and impregnated, was denied an abortion on the basis of the Medical Termination of Pregnancy Act 1971. This perspective re-examines this issue while prioritizing the best interest of the child. We recommend that boards should be constituted at district-level hospitals, headed by senior pediatricians, and supported by obstetricians, psychologists, neonatologists, medical social workers, and others to decide the course of action - in particular, the outcome, irrespective of the weeks of pregnancy. If not compatible with the child's life, earlier termination of pregnancy should be considered ensuring the availability of state-of-the-art care to the newborn and the young mother.

Implementing safe abortion in Ghana: "We must tell our story and tell it well"

In the first years of the new century, the Ministry of Health/Ghana Health Service determined to reduce abortion-associated morbidity and mortality by increasing access to safe care. This was accomplished by interpreting Ghana's restrictive law so that more women qualified for legal services; by framing this effort in public health terms; by bundling abortion together with contraception and postabortion care in a comprehensive package of services; and by training new cadres of health workers to provide manual vacuum aspiration and medical abortion. The Ministry of Health/Ghana Health Service convened medical and midwifery societies, nongovernmental organizations, and bilateral agencies to implement this plan, while retaining the leadership role. However, because of provider shortages, aggravated by conscientious objection, and because many still do not understand when abortion can be legally provided, some women still resort to unsafe care. Nonetheless, Ghana provides an example of the critical role of political will in redressing harms from unsafe abortion.

Nursing and Hospital Abortions in the United States, 1967-1973

Before elective abortion was legalized nationally in 1973 with the U.S. Supreme Court decision Roe v. Wade, seventeen states and the District of Columbia liberalized their abortion statutes. While scholars have examined the history of physicians who had performed abortions before and after it was legal and of feminists' work to expand the range of healthcare choices available to women, we know relatively little about nurses' work with abortion. By focusing on the history of nursing in those states that liberalized their abortion laws before Roe, this article reveals how women who sought greater control over their lives by choosing abortion encountered medical professionals who were only just beginning to question the gendered conventions that framed labor roles in American hospitals. Nurses, whose workloads increased exponentially when abortion laws were liberalized, were rarely given sufficient training to care for abortion patients. Many nurses directed their frustrations to the women patients who sought the procedure. This essay considers how the expansion of women's right to abortion prompted nurses to question the gendered conventions that had shaped their work experiences.

The Over-Medicalization and Corrupted Medicalization of Abortion and its Effect on Women Living in Poverty

Many current abortion regulations represent an over-medicalization of abortion or a corruption of abortion's true medical nature, with disproportionate consequences to women with lower incomes and lesser means. This article explores the effects of unnecessary and harmful abortion restrictions on women living in poverty. A brief summary of the major abortion rights cases explains how the Constitution, as currently interpreted, vests the government and sometimes the medical profession with the power to protect women's health, rather than granting this power to women themselves. The article then argues for a new approach for protecting women's health and respecting their dignity by reframing reproductive rights as health rights that women themselves can assert.

Ethical arguments for access to abortion services in the Republic of Ireland: recent developments in the public discourse

The Republic of Ireland has some of the most restrictive abortion legislation in the world which grants to the 'unborn' an equal right to life to that of the pregnant woman. This article outlines recent developments in the public discourse on abortion in Ireland and explains the particular cultural and religious context that informs the ethical case for access to abortion services. Our perspective rests on respect for two very familiar moral principles - autonomy and justice - which are at the centre of social and democratic societies around the world. This article explains the context for the deployment of these concepts in order to support the claim that the current legislation and its operationalisation in clinical practice poses serious risks to the health, lives and well-being of pregnant women, tramples on their autonomy rights and requires of them a self-sacrifice that is unreasonable and unjust.

Health Law: The Past and the Future

In the first 25 years of the Journal of Law and Medicine issues relating to abortion, euthanasia, turning off of life support, pandemics, cloning, surrogacy, technological change, patenting of DNA, regulation of health practitioners, health services in the Information and Genomic eras, mental health law, elder law, and medical negligence have figured prominently in the published scholarly contributions. This editorial reflects on the evolution of health law in its many aspects, contrasting issues that were contentious in 1993 with those that are in 2018 and reflecting on what is likely to continue to attract interdisciplinary analysis and the need for critical evaluation in the decades ahead.

Provider Conscientious Refusal of Abortion, Obstetrical Emergencies, and Criminal Homicide Law

Catholic doctrine's strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials.

The impact of the legalisation of abortion on birth outcomes in Uruguay

This study investigates the short-term impact on the quantity and quality of births of an abortion reform in Uruguay that legalised termination of pregnancy until the 12^th week of pregnancy in the short run. We employ a differences-in-differences approach, comprehensive administrative records of births, and a novel identification strategy based on the planned or unplanned nature of pregnancies that came to term. Our results suggest that this policy change has led to an 8% decline in the number of births from unplanned pregnancies, driven by the group of mothers aged between 20 and 34 years old who have secondary education. This decline has triggered an increase in the average quality of births in terms of more intensive prenatal control care and a lower probability of births among single mothers. Furthermore, we document a positive selection process of births because of the reform, as adequate prenatal control care and Apgar scores rose among the affected demographic group.

The Impact of a 72-hour Waiting Period on Women's Access to Abortion Care at a Hospital-Based Clinic in North Carolina

BACKGROUND In 2015, North Carolina became the 5th state to pass legislation requiring women to undergo state-mandated counseling 72 hours prior to abortion. Whether this legislation has changed the timing of abortion decision-making or receipt of care is not known.METHODS This is a cross-sectional study using anonymous survey data from women presenting for abortion at a hospital-based abortion clinic in North Carolina. Data were collected for 8 weeks immediately before and after implementation of the new waiting period.RESULTS 26/48 (54%) of eligible patients participated. More than half (56%) of women made their abortion decision relatively quickly (less than or equal to 3 days), but had a median time-to-care of almost a week.LIMITATIONS This small study is the 1st recent evaluation of abortion decision-making and receipt of care immediately before and after implementation of a 72-hour waiting period in a Southern state. Only women presenting for care at a single hospital-based clinic were surveyed. Data were self-reported.CONCLUSION In our clinical setting, most women decided to have an abortion quickly but still waited 10-15 days before receiving care. Extended waiting periods provide no medical benefits and the potential for harm and delay of care remains.

Freedom of Expression, Belief and Assembly: The Banning of Protests Outside of Abortion Clinics in Australia

This article considers the phenomenon of safe access zone laws in Australia that seek to prohibit certain activities that occur outside abortion facilities during protests. While they are characterised as a reasonable reaction to concerns that certain activities may harm women and infringe their rights to privacy and security, such laws do so at the expense of the protesters' right to freedom of political communication and cover activities such as sidewalk counselling and praying. This article critically examines the content and scope of these laws in each jurisdiction, identifies recent cases involving prosecutions for violations of safe access zone laws and considers the impact of the implied freedom of political communication on their constitutional validity in light of recent High Court decisions.

Access to abortion under the heath exception: a comparative analysis in three countries

BACKGROUND

Despite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception.

METHODS

We conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors.

RESULTS

The health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law.

CONCLUSIONS

The health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.