Abortion Legal Services in Uruguay

ABORTION LEGAL SERVICES IN URUGUAY

How they work: achievements and challenges

The information herein is based on the results of the study on “Monitoring the implementation of sexual and reproductive health and abortion services in 10 out of 19 national departments.

Systematizaton of results.” Observatory Studies, MYSU 2013-2017.

Monitoring 10 out of 19 Uruguay is one of the countries in the region with major advancements in terms of recognition of sexual and reproductive rights and the implementation of public policies that guarantee the exercise of those rights, in compliance with international human rights commitments. Furthermore, our country has played an important role in promoting the Montevideo Consensus adopted at the First Regional Conference on Population and Development (ECLAC, Uruguay 2013) and has adopted the Sustainable Development Goals (SDGs) agreed by the United Nations system.

Law 18987 of 2012 on Voluntary Termination of Pregnancy (VTP) is among the major achievements. Since then, the National Observatory on Gender and Sexual and Reproductive Health of MYSU has monitored its implementation at national level. In the 2013-2017 period, information was collected from the public service provider (National Administration of State Health Services – ASSE, by its Spanish acronym) and from private service providers with wider coverage, in 10 out of 19 departments in the country.

Likewise, the pathways to legal abortion services, used since 2010 within the framework of the sexual and reproductive health (SRH) services provided by the National Comprehensive Health System (SNIS, by its Spanish acronym), were identified.

This document is meant to disseminate the findings on how legal abortion services worked after five years of existence. The objective is to report on the identified advancements, the regional disparities and the barriers that hinder universal coverage and the access of all women in need of legal termination of pregnancy.

The information collected feeds into an innovative field of public policy that requires inputs to assess the direction and needs evidence to make the necessary adjustments for a better response.

This is our contribution, as a civil society organization that embraces the mission to defend and promote sexual and reproductive rights with a generational and gender equity perspective.

Fact sheet:

10 departments were monitored: Salto, Paysandú, Río Negro, Soriano, Rivera, Cerro Largo, Florida, Maldonado, Rocha and Montevideo that concentrates 64% of the total population (2,210,995 people).

Information was collected from 24 public and private health institutions from 19 localities (department capitals and main cities).

The sexual and reproductive health services under study were: contraception; pregnancy, childbirth and postpartum; HIV/AIDS; domestic and sexual violence; legal abortion and support for adolescents.

The methodology used was quantitative and qualitative, using a self-administered form in the health institutions and indepth interviews with qualified respondents and women and men aged 15-49 with health coverage in each department under study.

Monitored Health Institutions MYSU 2013 ‐ 2017

DEPARTMENT

SALTO

SORIANO

DEPARTMENT POPULATION

124,878

82,595

RÍO NEGRO

54,765

PAYSANDÚ

113,124

RIVERA

107,187

INSTITUTION

ASSE CAM

TYPE

Public Private

ASSE CAMS Círculo Católico (only abortion)

Public Private Private

ASSE AMEDRIN CAMY - Cooperativa de Asistencia Médica de Young

Public Private Private

ASSE COMEPA Cooperativa Médica de Paysandú ASSE

Public Private Public

CASMER COMERI

Private Private

MALDONADO

177,349

ASSE Mautone La Asistencial

Public Private Private

FLORIDA

69,283

ASSE COMEF

Public Private

CERRO LARGO

89,374

ASSE CAMCEL

Public Private

ROCHA

73,685

ASSE COMERO

Private

MONTEVIDEO

1,318,755

Hospital Pereira Rossell Hospital Policial Médica Uruguaya COSEM RAP-ASSE*

Public Public Private Private Public

10 DEPTS.

2,210,995

24 INSTITUTIONS

Public

LOCALITY UNDER STUDY

Salto (capital) Mercedes (capital), Cardona and Dolores

STUDY YEAR

2013

2014

Fray Bentos (capital), Young

2014

Paysandú (capital)

2014

Rivera (capital)

2015

Maldonado (capital), San Carlos, 2015 Pan de Azúcar, Piriápolis Florida (capital) Melo (capital), Río Branco Rocha (capital), Chuy, Castillos

2015 2016 2016

2016/2017

19 LOCALITIES

The legal shift In 2012, after almost three decades of legislative debate, the law of Voluntary Termination of Pregnancy (VTP, Law 18987) was approved by Parliament. A feminist demand that prevailed in the public sphere through alliances between political players and social movements for social justice and for the defense of human rights.

This law regulates the practice of abortion through a system of requirements and conditions. Termination is allowed up to 12 weeks of pregnancy, at the sole request of a woman, up to 14 if pregnancy resulted from rape, and with no time limit when there is a risk to women’s health or there is a fetal malformation incompatible with extrauterine life.

A woman requesting the termination of pregnancy is required to have a consultation with an interdisciplinary team formed by professionals in the gynecology, mental health and social service areas. In these consultations, the woman receives information about maternity support programs, adoption as an alternative and the risks of unsafe abortion practices.

Afterwards, the woman has a minimum of five days to reconsider this, before receiving the medication that causes the abortion.

All institutions (either public or private) within SNIS must provide this service. When centers do not have professionals available, they must refer patients to other providers that render the service. The same happens with institutions that ideologically oppose abortion (Círculo Católico and Hospital Evangélico).

Those seeking and performing abortions (the woman, companion and the professional involved) outside SNIS institutions or not complying with the requirements and conditions set forth, remain outside the law and can be prosecuted for the crime of abortion, still in force in the criminal code.

Foreign national women with less than a year of residency in the country are not entitled to abortion services under this law.

VTP Process 5 days of reflection VTP 1

VTP 2

VTP 3

The intention to terminate pregnancy is expressed.

Meeting with a multidisciplinary team (Team explains the nature of abortion and alternatives to this)

Termination procedure

VTP 4

(Most termination procedures are carried out using medication)

Postabortion check‐ up and contraception counseling.

Current situation of abortion services

LEGAL ABORTIONS PERFORMED According to data from the Ministry of Public Health (MSP, by its Spanish acronym) 34,589 legal terminations of pregnancy were carried out between 2013 and 2016.

Evolution of the number of legal VTP (2013-2016) 7171

98 953

479

Annual rate of legal VTP by age group, every 1,000 women

9719

9362

8337

The number of legal abortions increased while services were implemented, people found out information about their availability through the SNIS and trust in the confidentiality of healthcare services increased. Since 2013, the number of legal abortions performed in the interior of the country has exceeded those carried out in Montevideo. The average rate of abortion every 1,000 women is 11.5 and there is no difference across age groups.

2692

584

280 4082

10 10 11

9

2014 Total

2015 Montevideo

12 11 12

548 171 2014

2013 2013

11 11 12

2015

2016

Total VTP rate (15-49 yrs.)

VTP rate among adult women (20-49 yrs.)

VTP rate among adolescents (15-19 yrs.)

2016 Interior Source: MSP

Between 6% and 8% of women who started using healthcare services for VTP, desist from abortion during the stages of the process imposed by law. The majority of women seeking VTP care services have their mind made up and do not change it.

Almost all legal abortions (98,8%) were performed using medication.

Although there are problems to implement services in the territory, during monitoring it was possible to confirm that abortion services are provided in all departments.

Source: MSP

Evolution of the number of VTP (2013-2016) January 2013 - December 2016 period INTENTION

2013

VTP 3

7171

94%

8337

92%

9362

94%

9719 94%

Continue w/preg.

4479

6%

4953

8%

5280

6%

5548 6%

TOTAL VISITS

2014

100% 2692

2015

100% 3584

2016

100% 4171 100% 4082

Source: MSP

Difference in numbers before and after the law When abortion was illegal, the estimated incidence of abortions was between 16,000 and 33,000 annually. However, in 2016 the official figures indicated less than 10,000 legal abortions in that year.

Incidence of abortion:

If we compare the rate of abortion in Uruguay with the rate in other countries such as those in Western Europe where abortion is also legal and contraception programs have a long-standing history, the rate is low. This difference could be another indicator of the persistence of clandestine practices.

BEFORE THE LAW

AFTER THE LAW

7,171 women in 2013 8,513 women in 2014 9,362 women in 2015 9,719 women in 2016

16,000 33,000

Estimated clandestine abortions/year

Had abortions through legal and safe services.

Implementation, operation and dissemination of VTP services

Concern: Observation: Women do not abort because there are legal services, rather they have progressively started to use them when they become aware that these are available and trust that they will be treated respectfully.

There is still a gap between the estimated figures before the law and the official figures of legal abortions. Clandestine practice persists. Two women passed away after the law was passed, one in 2013, who

never sought legal services, another one in 2016, who consulted the services but was 13 weeks pregnant and information provided on harm and risks could not prevent the unsafe practice and died from septicemia.

Rates of abortion, selected regions * L. America and the Carib.

Europe Western Europe Uruguay

40 30 19 11.5

Source: prepared based on data from MSP Uruguay 2017, Guttmacher Institute 2016, Sedgh et al. 2016 * In the case of Uruguay, the rate of abortion corresponds to women aged 15-49, in 2016. In the rest of the regions, the rate of abortion refers to women aged 15-44 and it is an average of the 2010-2014 period.

Monitoring outcomes in 10 out of 19 departments SYSTEM PROBLEMS AND SETBACKS VTP 1

Some system setbacks were detected in legal abortion services.

This could mean that many women still resort to clandestine abortion practices.

VTP 2

Women stepped back

VTP 3

Women stepped back

VTP 4

Women stepped back

STIGMA

During the legal VTP process women face…

Lack of information about services Conscientious objection Lack of professionals Services are not available on a daily basis

Reasons why women stepped back

1 LACK OF KNOWLEDGE ABOUT THE LAW AND THE SERVICES Abortion services are not properly promoted In general, neither healthcare providers nor the Ministry of Public Health disseminate information about abortion services. Therefore, some women are not aware of them and do not use them, others know them by word of mouth or through an inquiry made to the healthcare center. Lack of adequate information might put women at risk and left out of the service provided by law.

2 FEAR OF SANCTION OR FEAR TO REVEAL THE REASON FOR THE VISIT Abortion stigma is the moral sanction and prejudice suffered by women who abort and professionals who perform it. On the country’s coastline, particularly in the departments with high levels of conscientious objection, stigma has hindered the legal process of termination of pregnancy. It is no coincidence that in Soriano, a female judge restrained an abortion in the case of a woman who met the legal requirements. Likewise, in Salto, a group of mothers organized a workshop, in a public high school, with antiabortion rights propaganda.

Interviewees expressed that one of the reasons why they did not seek legal services was fear to sanctions or to the disclosure of confidential information by the healthcare centers.

3 NO ABORTION EQUIPMENT IN THE PLACES OF RESIDENCY In five of the departments monitored, VTP equipment only works in department capitals (Salto, Paysandú, Rivera and Florida, Río Negro); women living in other places must travel to another location to use this service. Women must travel long distances not only in these cases but also when healthcare centers have 100% conscientious objectors.

Travelling causes the following problems: 

Difficulties to reach remote or unknown places (e.g., when they must travel to Montevideo or another department).



Caregiving problems in the family while they are absent from home for a longer period.



Loss of paid work hours.



The solitude felt for not having enough resources to cover the expenses of a travelling companion.



The need to explain the reason for absence which might cause rejection.



Lack of resources to bear all the expenses involved.

In Young, women travel to Fray Bentos (the department capital) 100 km away. In Mercedes, private and public providers deal with VTP 3 by referring their services to Dolores or Cardona (38.6 and 96 km away respectively). The public healthcare center also refers services to Fray Bentos (34.7 km away). When Fray Bentos services are overcrowded, they refer patients to Hospital Pereira Rossell in Montevideo. Women living in Castillos travel to Rocha (57 km away) and those from Río Branco travel to Melo (80 km away).

“We believe that some women decided to continue with pregnancy because it is not easy to travel to Montevideo. Some of them, had never been to Montevideo. (…) And, additionally, when they are 11 weeks pregnant, they need to stay in hospital alone, 2 or 3 days in Montevideo, with their small children back here…” (Interview to a professional provider in Montevideo).

4 LACK OF PROFESSIONALS TO RENDER SERVICES The law only authorizes professional gynecologists to perform VTP 3, reducing the number of specialists that could be involved at this stage. On the other hand, 98.8% of terminations are carried out with medication. In other countries where abortion is legal, medication is prescribed by other duly trained professionals.

In 2016, the Court of Administrative Law ordered multidisciplinary teams to work jointly but they used to work either jointly or consecutively. In this context, institutions face difficulties to guarantee this service.

On the other hand, some clinics do not have enough professionals from different fields (to make up the teams) and it is not possible to cover all days and schedules.

MYSU identified, particularly in the interior of the country, absence of professionals in the social work and psychology fields (e.g., in Maldonado and Chuy).

Teams and staff are not trained enough in sexual and reproductive health. Based on information from interviews,

there is little dissemination of information about norms and techniques among the staff directly involved, as well as little awareness among the rest of the staff dealing with women with unwanted pregnancies.

5 CONSCIENTIOUS OBJECTION AS A BARRIER The high percentage of professional gynecologists who are conscientious objectors of VTP represent a barrier for women’s access to legal abortion services. MYSU found that conscientious objection is over 60% in 6 out of 10 monitored departments. Except for AMEDRIN in Río Negro and COMEF in Florida, no healthcare service was found without conscientious objectors.

The main problems of conscientious objection are found along the coastline (Salto, Paysandú, Río Negro and Soriano) and in the northeast (Rivera and Cerro Largo). MYSU found locations with 100% objectors: Mercedes (capital of Soriano), Young (second most important city in Río Negro) and Castillos (the third largest populated city in Rocha).

The uneven geographical distribution of physicians alleging conscientious objection harms women in the interior of the country, particularly, those living in rural areas and the most vulnerable ones.

Reasons why women stepped back

Conscientious objection in the country

SALTO

RIVERA

PAYSANDÚ

Medium level of CO (30- 60%)

RÍO NEGRO

Young

High level of CO (>60%)

CERRO LARGO

Mercedes

Low level of CO (<30%) Unmonitored departments

SORIANO FLORIDA

ROCHA

Places with 100% CO

Source: MYSU survey 2013-2017

Conscientious objection has impact on service quality: referrals result in work overload at the clinics receiving patients from other locations and a controlled and accompanied process of abortion for women is not always guaranteed.

6 FEW POSTABORTION CHECK‐UPS According to figures from the Ministry of Public Health, almost one third of the women going through VTP 3 do not reach VTP 4, this means that they neither get postabortion check-ups nor contraception counseling.

Castillos

MONTEVIDEO

MALDONADO

MYSU found differences among the monitored institutions: there are providers with 100% or high percentages of women going through VTP 4 (Hospital of Chuy in Rocha; Hospital of San Carlos and Red de Atención Primaria [Primary Care Network] in Maldonado; and COSEM and Hospital Policial in Montevideo). Other providers show substantially lower percentages in VTP 4 (CASMER in Rivera or Hospital Pereira Rossell in Montevideo). Furthermore, the MSP data shows that of all women going through VTP 4 in 2016, 84% left the medical office with a contraception method.

CHALLENGES TO IMPROVE RESPONSE WOMEN CANNOT CHOOSE The manual vacuum aspiration (MVA) is an outpatient practice known throughout the world as an abortion technique. However, it is not available for legal abortion services in Uruguay, therefore, women cannot choose. MSP has promoted the use of medication instead of encouraging MVA training for staff or promoting this technique among user population.

EXCLUDED WOMEN Immigrant women with less than a year of residency in the country are excluded from this law. They must seek clandestine abortion services. This is unfair, discriminatory and does not align with the commitments undertaken by the Uruguayan government at international and regional level.

Dissemination of information on abortion services to prevent unsafe abortions: reinforce information on the scope and requirements of the law and access to services.

A better promotion of a comprehensive sexual and reproductive health policy: the Ministry of Public Health must strengthen its teams and build leadership so that institutions provide abortion services within the framework of sexual and reproductive health service provision.

Secure resources: secure human resources, streamline efforts, provide supplies for universal coverage and provide the best care services for women who abort within all gestational time limits allowed by law.

The inclusion of sexual and reproductive rights in curriculum development and continuing education: ensure abortion service provision and sexual and reproductive health services by duly trained professionals.

Strengthen the accountability system: it is necessary to improve the collection of information, systematization and public availability of data to monitor and assess response in abortion practice.

Development of a complaints-handling process: to improve the method by which complaints are handled will help remedy the absence of services, poor quality care or noncompliance of norms.

Adjustment of the regulatory framework: the implementation follow-up revealed that the law of voluntary termination of pregnancy is based on assumptions that do not reflect reality. Women are not increasingly aborting because there are legal abortion services but there is no guarantee that these services will be able to cover all the requirements of women with unintended pregnancies. The idea that implementing a cumbersome procedure will discourage practice is only affecting women in more vulnerable conditions, undermining the mission that led to the enactment of the law. Therefore, the legislative power must review the content so that healthcare institutions are able to find solutions to the problems identified and provide adequate abortion services in the country.

Mujer y Salud en Uruguay (MYSU) is a feminist nonprofit organization with the mission to promote and defend sexual and reproductive health and rights from a generational and gender equity perspective. It was created in 1996 with the purpose to gather people and organizations working on women’s health. In 2004 it became a nonprofit civil association, specialized in this field.

The areas of work are: research, policy advocacy, counseling, training and communication.

In 2006, they identified the need to create a political-technicalcitizen tool to monitor the commitments undertaken by the Uruguayan government before the international human rights system. Thus, the National Observatory on Gender and Sexual and Reproductive Health was created with the aim to produce knowledge on the impact of public policies, evaluate the capacity to meet the needs and demands of the population, for better sexuality and reproduction-related decisions. The findings of the annual studies are meant to be a useful resource for decision-makers, service providers, user population, social organizations and media.

The observatory, as a resource, is recognized for having social, political and scientific value. The findings have been able to confirm the scope of implementation of programs and services, identify barriers to access, deficiencies in quality care, gaps in population demands and requirements, and build proposals to fill gaps and improve response. Some of the recommendations have been adopted by authorities to reshape policies, its data has been included in national reports submitted to the United Nations within the framework of accountability processes, and they have raised the interest of different players, contributing to a better performance.

Salto 1267 ‐ 11200 Montevideo ‐ Uruguay Tel: (+598) 2410 3981 / 2410 4619 email: mysu@mysu.org.uy www.mysu.org.uy www.mysu.org.uy/observatorio

This publication was made with the support of:

This publication was made in 2017 with the support of: