Multicountry research on comprehensive abortion policy implementation in Latin America: a mixed-methods study protocol

INTRODUCTION

Access to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some important improvements in Latin America in terms of laws and policies on abortion. However, the predominant environment is still restrictive, and many women, adolescents and girls still face multiple barriers to exercise their reproductive rights. This research will systematically assess comprehensive abortion policies in five Latin American countries (Argentina, Colombia, Honduras, Mexico and Uruguay). The aim is to identify barriers, facilitators and strategies to the implementation of abortion policies, looking at four key dimensions-regulatory framework, abortion policy dynamics, abortion service delivery and health system and health outcomes indicators-to draw cross-cutting lessons learnt to improve current implementation and inform future safe abortion policy development.

METHODS AND ANALYSIS

A mixed-method design will be used in the five countries to address the four dimensions through the Availability, Accessibility, Acceptability and Quality of Care model. The data collection tools include desk reviews and semi-structured interviews with key actors. Analysis will be performed using thematic analysis and stakeholder analysis. A regional synthesis exercise will be conducted to draw lessons on barriers, facilitators and the strategies.

ETHICS AND DISSEMINATION

The project has been approved by the WHO Research Ethics Review Committee (ID: A66023) and by the local research ethics committees. Informed consent will be obtained from participants. Data will be treated with careful attention to protecting privacy and confidentiality. Findings from the study will be disseminated through a multipurpose strategy to target diverse audiences to foster the use of the study findings to inform the public debate agenda and policy implementation at national level. The strategy will include academic, advocacy and policy arenas and actors, including peer-reviewed publication and national and regional dissemination workshops.

The Shift From Criminalization to Legalization of Abortion in Argentina

This Viewpoint discusses passage and implementation of Law 27.610, which legalized abortion in Argentina under certain circumstances, and examines the ongoing clinical issues and legal challenges to the law.

Abortion as an Essential Health Service in Latin America During the COVID-19 Pandemic

Background

The rapid increase in demand for health services as a result of the COVID-19 outbreak has created significant challenges for health systems. National and international health authorities have declared reproductive health services as essential, particularly those related to prevention, care during pregnancy, delivery and postpartum, as well as abortion services. This research was conducted by a regional team in cooperation with nine local organizations that are members of the Latin American Consortium against Unsafe Abortion (Consorcio Latinoamericano Contra el Aborto Inseguro, CLACAI).

Objectives

Our research aimed to examine the provision of reproductive healthcare services, with a focus on abortion, in nine countries during the first few months of the pandemic (March to September 2020).

Methods

Our research design developed a set of quantitative and qualitative indicators to monitor the availability and accessibility of abortion services during the COVID-19 pandemic. Researchers collected the quantitative data by reviewing regulations and other documents, government and civil society reports, and official statistics; the qualitative data was acquired through interviews with key actors, and non-representative surveys completed by healthcare professional and end users of reproductive services.

Results

Although six of the nine countries we researched deemed reproductive health services essential, only two of these six countries considered abortion services to be essential, and all nine countries reported difficulties in accessing abortion services. Restrictive abortion laws remained in place in the majority of countries (seven), and as a result access to abortion services became even more limited than it had been before the pandemic. At the same time, good practices to facilitate access to abortion services in healthcare facilities, updated regulatory frameworks, and collaboration between civil society and government agencies were identified and should continue to be promoted even after the pandemic crisis has subsided.

Conclusions

The pandemic catalyzed what was already happening in each country, and as such abortion services have become more accessible in countries like Argentina, where the so-called green wave has been generating social, legal and policy changes, whereas in countries such as Ecuador, where abortion is legally restricted and opposed to by the government, access to safe abortion became even more difficult than it was before the pandemic. However, the general trend has been a lack of adequate adaptation in order to guarantee quality in abortion care. That said, there have also been some interesting and positive service provision initiatives, such as telemedicine, implemented in at least two countries, which, if maintained long-term, could improve access to safe abortion.

Regulating Conscientious Objection to Legal Abortion in Argentina: Taking into Consideration Its Uses and Consequences

Claims of conscientious objection (CO) have expanded in the health care field, particularly in relation to abortion services. In practice, CO is being used in ways beyond those originally imagined by liberalism, creating a number of barriers to abortion access. In Argentina, current CO regulation is lacking and insufficient. This issue was especially evident in the country's 2018 legislative debate on abortion law reform, during which CO took center stage. This paper presents a mixed-method study conducted in Argentina on the uses of CO in health facilities providing legal abortion services, with the goal of proposing specific regulatory language to address CO based not only on legal standards but also on empirical findings regarding CO in everyday reproductive health services. The research includes a review of literature and comparative law, a survey answered by 269 health professionals, and 11 in-depth interviews with stakeholders. The results from our survey and interviews indicate that Argentine health professionals who use CO to deny abortion are motivated by a combination of political, social, and personal factors, including a fear of stigmatization and potential legal issues. Furthermore, we find that the preeminent consequences of CO are delays in abortion services and conflicts within the health care team. The findings of this research allowed us to propose specific regulatory recommendations on CO, including limits and obligations, and suggestions for government and health system leaders.

Health care providers' opinions on abortion: a study for the implementation of the legal abortion public policy in the Province of Santa Fe, Argentina

Background

In Argentina, abortion has been decriminalized under certain circumstances since the enactment of the Penal Code in 1922. Nevertheless, access to abortion under this regulatory framework has been extremely limited in spite of some recent changes. This article reports the findings of the first phase of an operations research study conducted in the Province of Santa Fe, Argentina, regarding the implementation of the local legal and safe abortion access policy.

Methods

The project combined research and training to generate a virtuous circle of knowledge production, decision-making, and the fostering of an informed healthcare policy. The project used a pre-post design of three phases: baseline, intervention, and evaluation. It was conducted in two public hospitals. An anonymous self-administered questionnaire (n = 157) and semi-structured interviews (n = 27) were applied to gather information about tacit knowledge about the regulatory framework; personal opinions regarding abortion and its decriminalization; opinions on the requirements needed to carry out legal abortions; and service’s responses to women in need of an abortion.

Results

Firstly, a fairly high percentage of health care providers lack accurate information on current legal framework. This deficit goes side by side with a restrictive understanding of both health and rape indications. Secondly, while a great majority of health care providers support abortion under the circumstances consider in the Penal Code, most of them are reluctant towards unrestricted access to abortion. Thirdly, health care providers’ willingness to perform abortions is noticeably low given that only half of them are ready to perform an abortion when a woman’s life is at risk. Willingness is even lower for each of the other current legal indications.

Conclusions

Findings suggest that there are important challenges for the implementation of a legal abortion policy. Results of the study call for specific strategies targeting health care providers in order to better inform about current legal abortion regulations and to sensitize them about abortion social determinants. The interpretation of the current legal framework needs to be broadened in order to reflect a comprehensive view of the health indication, and stereotypes regarding women’s sexuality and abortion decisions need to be dismantled.

Electronic supplementary material

The online version of this article (doi:10.1186/1742-4755-11-72) contains supplementary material, which is available to authorized users.