Embedding research capacity strengthening in multi-country studies in low-and middle-income countries: learnings from sexual and reproductive health research.

Research capacity strengthening (RCS) can empower individuals, institutions, networks, or countries to define and prioritize problems systematically; develop and scientifically evaluate appropriate solutions; and reinforce or improve capacities to translate knowledge into policy and practice. However, how to embed RCS into multi-country studies focusing on sexual and reproductive health and rights (SRHR) is largely undocumented. We used findings from a qualitative study, from a review of the literature, and from a validation exercise from a panel of experts from research institutions that work on SRHR RCS. We provide a framework for embedded RCS; suggest a set of seven concrete actions that research project planners, designers, implementers, and funders can utilise to guide embedded RCS activities in low- and middle-income countries; and present a practical checklist for planning and assessing embedded RCS in research projects.

Paper ContextMain findings: Building on findings from a primary qualitative study, a literature review, and a consultation with experts on capacity strengthening in LMICs, we propose a systematic approach to embedded RCS.Added knowledge: We present a framework for embedding RCS in multi-country studies and propose seven action points and a checklist for the implementation of RCS in multi-country research projects with considerations for sexual and reproductive health and rights research.Global health impact for policy and action: An easy-to-use checklist can enable global health researchers and policymakers to ensure RCS is an integral component of multi-country research.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave.

BACKGROUND: There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence. RESULTS: Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSIONS: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave.

BACKGROUND: The COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 threatened already precarious health services. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of COVID-19 disease. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. Descriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses. RESULTS: Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%) people and 640 (14.1%) people reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) compared to the period before COVID-19 measures (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSION: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

[Development of a comprehensive public policy for adolescent pregnancy prevention in UruguayDesenvolvimento de uma política pública abrangente de prevenção da gravidez na adolescência no Uruguai]. / Desarrollo de una política pública integral de prevención del embarazo en adolescentes en Uruguay.

This article presents the main characteristics and achievements of Uruguay's National and Intersectoral Strategy for Prevention of Adolescent Pregnancy, implemented from 2016 to 2020. This strategy was implemented in a context in which unintentional adolescent pregnancy continues to be a major social problem for Uruguay and the Region, necessitating comprehensive, sustained, and evidence-based public policies. In Uruguay, adolescent fertility rates have remained high for over a decade. In addition to intersectoral action by government and civil society, the strategy received scientific assistance from the academic community, and technical and financial cooperation from regional and international organizations. Its actions and measures were adopted based on a socio-ecological vision, with cultural sensitivity, a gender-transformative approach, and a human rights perspective. Major barriers include social norms that value maternity as the main life project for women living in poverty, gender stereotypes (pregnancy as the exclusive responsibility of adolescent girls, without involving adolescent boys), the stigma of abortion, a lack of sexual and reproductive health services, and resistance to raising the visibility of pregnancy in girls under 15 years of age who are victims of structural and family violence. It is necessary to ensure the continuity of public policies--adjusted to a gender and human-rights approach--that take into account new scenarios such as the one imposed by the COVID-19 pandemic.

Este artigo apresenta os principais aspectos e os resultados da Estratégia Nacional e Intersetorial para Prevenção da Gravidez na Adolescência, implementada no Uruguai entre 2016 e 2020. A gravidez não intencional na adolescência persiste como uma questão social importante no Uruguai e na Região, exigindo políticas públicas com base em evidências científicas que sejam abrangentes e permanentes. A fecundidade na adolescência no Uruguai tem se mantido elevada há mais de uma década. Além da ação intersetorial do governo e da sociedade civil, a estratégia aprovada recebeu orientação científica de entidades acadêmicas, e cooperação técnica e financeira de organismos regionais e internacionais. As ações e as medidas da estratégia foram elaboradas a partir de uma visão socioecológica, com sensibilidade cultural e enfoque transformador de gênero e uma perspectiva de direitos humanos. Entre as barreiras mais importantes enfrentadas estão as normas sociais que valorizam a maternidade como principal projeto de vida para a mulher que vive em situação de pobreza, os estereótipos de gênero (a gravidez é vista como responsabilidade exclusiva da adolescente, sem envolver o parceiro adolescente), o estigma do aborto, a oferta insuficiente de serviços de saúde sexual e reprodutiva, e a resistência a dar visibilidade à gravidez de menores de 15 anos que são vítimas de violência estrutural e intrafamiliar. É necessário garantir a continuidade das políticas públicas que incorporem uma perspectiva de gênero e direitos humanos, e que sejam adaptadas aos novos cenários da pandemia de COVID-19.

Desarrollo de una política pública integral de prevención del embarazo en adolescentes en Uruguay

[RESUMEN]. Se presentan las principales características y logros de la Estrategia Nacional e Intersectorial para la Prevención del Embarazo en Adolescentes, implementada en Uruguay entre 2016 y 2020. Este proceso se desarrolló en un contexto en el que el embarazo no intencional en adolescentes continúa siendo un problema social relevante para Uruguay y la Región, por lo que se requieren políticas públicas integrales, sostenidas y basadas en evidencias científicas. En Uruguay, la fecundidad adolescente se ha mantenido en niveles elevados por más de una década. Además de la acción intersectorial del Gobierno y la sociedad civil, la estrategia aprobada contó con asesoramiento científico desde el ámbito académico y la cooperación técnica y financiera de organismos regionales e internacionales. Las acciones y medidas adoptadas se basan en una visión socio-ecológica, con sensibilidad cultural, enfoque transformador de género y perspectiva de derechos humanos. Entre las barreras más importantes están las normas sociales que valoran la maternidad como el principal proyecto de vida para las mujeres que viven en contextos de pobreza, los estereotipos de género —el embarazo como una responsabilidad exclusiva de las adolescentes, sin involucrar a los adolescentes varones—, el estigma del aborto, la insuficiente oferta de servicios de salud sexual y reproductiva, y la resistencia a visibilizar el embarazo en niñas menores de 15 años víctimas de la violencia estructural e intrafamiliar. Es necesario asegurar la continuidad de las políticas públicas, ajustadas a un enfoque de género y de derechos humanos, y que se tomen en cuenta los nuevos escenarios, como el que impone la pandemia por COVID-19.

[ABSTRACT]. This article presents the main characteristics and achievements of Uruguay’s National and Intersectoral Strategy for Prevention of Adolescent Pregnancy, implemented from 2016 to 2020. This strategy was implemented in a context in which unintentional adolescent pregnancy continues to be a major social problem for Uruguay and the Region, necessitating comprehensive, sustained, and evidence-based public policies. In Uruguay, adolescent fertility rates have remained high for over a decade. In addition to intersectoral action by government and civil society, the strategy received scientific assistance from the academic community, and technical and financial cooperation from regional and international organizations. Its actions and measures were adopted based on a socio-ecological vision, with cultural sensitivity, a gender-transformative approach, and a human rights perspective. Major barriers include social norms that value maternity as the main life project for women living in poverty, gender stereotypes (pregnancy as the exclusive responsibility of adolescent girls, without involving adolescent boys), the stigma of abortion, a lack of sexual and reproductive health services, and resistance to raising the visibility of pregnancy in girls under 15 years of age who are victims of structural and family violence. It is necessary to ensure the continuity of public policies––adjusted to a gender and human-rights approach––that take into account new scenarios such as the one imposed by the COVID-19 pandemic.

[RESUMO]. Este artigo apresenta os principais aspectos e os resultados da Estratégia Nacional e Intersetorial para Prevenção da Gravidez na Adolescência, implementada no Uruguai entre 2016 e 2020. A gravidez não intencional na adolescência persiste como uma questão social importante no Uruguai e na Região, exigindo políticas públicas com base em evidências científicas que sejam abrangentes e permanentes. A fecundidade na adolescência no Uruguai tem se mantido elevada há mais de uma década. Além da ação intersetorial do governo e da sociedade civil, a estratégia aprovada recebeu orientação científica de entidades acadêmicas, e cooperação técnica e financeira de organismos regionais e internacionais. As ações e as medidas da estratégia foram elaboradas a partir de uma visão socioecológica, com sensibilidade cultural e enfoque transformador de gênero e uma perspectiva de direitos humanos. Entre as barreiras mais importantes enfrentadas estão as normas sociais que valorizam a maternidade como principal projeto de vida para a mulher que vive em situação de pobreza, os estereótipos de gênero (a gravidez é vista como responsabilidade exclusiva da adolescente, sem envolver o parceiro adolescente), o estigma do aborto, a oferta insuficiente de serviços de saúde sexual e reprodutiva, e a resistência a dar visibilidade à gravidez de menores de 15 anos que são vítimas de violência estrutural e intrafamiliar. É necessário garantir a continuidade das políticas públicas que incorporem uma perspectiva de gênero e direitos humanos, e que sejam adaptadas aos novos cenários da pandemia de COVID-19.

[Adolescents faced with the decision to terminate a pregnancy in a context of legal abortion]. / Las adolescentes frente a la decisión de interrumpir un embarazo en un contexto de aborto legal.

The article presents the results of a study on the experiences of adolescents that decided to terminate a pregnancy in the context of legal abortion services in Montevideo, Uruguay, from 2016 to 2018. The main objective was to examine the decision-making process and access to legal abortion from the perspective of the adolescent girls themselves. This involved analyzing circumstances, motives, and persons that influenced the decision and the ways this was handled in the health services. A cross-sectional, exploratory, and descriptive study was designed, based on a qualitative methodology. The main technique used for collecting the information was a semi-structured interview with 14 adolescents 17 to 19 years of age who had voluntarily terminated a pregnancy in public healthcare services. The motives for the abortion reveal the weight of socially accepted reasons, incorporated as their own. The interviews showed that the adolescent's mother plays an important role as the reference for the decision. The adolescents reported that they had made the decision to have the abortion before going to the health service. The results highlight the positive role of a legal framework that enables voluntary abortion services. The results help understand the experiences of adolescents facing a difficult life decision, the family's role, particularly that of the adolescent's mother, the legal framework's place in the decision, the weight of stigma and moral sanctions, and expectations towards care in health services.

El artículo presenta resultados de una investigación sobre las experiencias de las adolescentes que decidieron interrumpir su embarazo en el marco de los servicios legales de aborto en Montevideo (Uruguay), realizada entre los años 2016 y 2018. Su objetivo principal fue examinar el proceso de toma de decisión y el acceso al aborto legal, desde la perspectiva de las propias adolescentes. Ello implicó analizar circunstancias, motivaciones y personajes que influenciaron en la toma de la decisión y cómo ésta se tramitó en el servicio de salud. Se diseñó un estudio transversal de tipo exploratorio y descriptivo, basado en metodología cualitativa. La técnica principal que se utilizó para la recolección de la información fue la entrevista semidirigida, se entrevistó a 14 adolescentes entre 17 y 19 años de edad que interrumpieron voluntariamente un embarazo en los servicios públicos de salud. Los motivos para abortar dan cuenta del peso que tienen las razones socialmente aceptadas, incorporadas como motivos propios. Se observó que la madre juega un papel importante como referente en la decisión. Las adolescentes manifestaron tomar la decisión de abortar antes de haber concurrido al servicio de salud. Se destaca el papel positivo de la existencia de un marco legal que habilita servicios de aborto voluntario. Los resultados contribuyen a comprender los procesos que viven las adolescentes frente a una decisión vital difícil, el rol de la familia, en particular de la figura materna, el lugar que tiene el marco legal en la toma de la decisión, el peso del estigma y la sanción moral, y las expectativas respecto de la atención en servicios de salud.

O artigo apresenta os resultados de uma pesquisa, desenvolvida entre 2016 e 2018, sobre as experiências de adolescentes que decidiram interromper a sua gravidez nas unidades de saúde para aborto legal em Montevidéu (Uruguai). Tinha como objetivo principal analisar o processo de tomada de decisão e o acesso ao aborto legal, do ponto de vista das próprias adolescentes. Isso envolvia avaliar as circunstancias, motivações e personagens que influenciaram a tomada de decisão e a forma como se deu no sistema de saúde. Foi construído um estudo transversal do tipo exploratório e descritivo baseado numa metodologia qualitativa. A técnica principal utilizada para a coleta de informação era a entrevista semiestruturada; foram entrevistadas 14 adolescentes entre 17 e 19 anos de idade, que tinham interrompido voluntariamente uma gravidez no sistema público de saúde. Os motivos para abortar refletem o peso das razões socialmente aceitas, incorporadas como motivos próprios. Observou-se que a mãe desempenha um papel relevante, como referente na decisão. As adolescentes afirmaram ter tomado a decisão de abortar antes de se dirigir à unidade de saúde. Destaca-se o papel positivo da existência de um marco legal que habilita serviços de aborto voluntário. Os resultados contribuem para o entendimento dos processos vivenciados pelas adolescentes diante de uma decisão vital difícil, o papel da família, em especial da figura materna, o lugar ocupado pelo marco legal na tomada da decisão, o peso do estigma e da sanção moral, além das expectativas sobre o atendimento nas unidades de saúde.

Desarrollo de una política pública integral de prevención del embarazo en adolescentes en Uruguay / Development of a comprehensive public policy for adolescent pregnancy prevention in Uruguay / Desenvolvimento de uma política pública abrangente de prevenção da gravidez na adolescência no Uruguai

RESUMEN Se presentan las principales características y logros de la Estrategia Nacional e Intersectorial para la Prevención del Embarazo en Adolescentes, implementada en Uruguay entre 2016 y 2020. Este proceso se desarrolló en un contexto en el que el embarazo no intencional en adolescentes continúa siendo un problema social relevante para Uruguay y la Región, por lo que se requieren políticas públicas integrales, sostenidas y basadas en evidencias científicas. En Uruguay, la fecundidad adolescente se ha mantenido en niveles elevados por más de una década. Además de la acción intersectorial del Gobierno y la sociedad civil, la estrategia aprobada contó con asesoramiento científico desde el ámbito académico y la cooperación técnica y financiera de organismos regionales e internacionales. Las acciones y medidas adoptadas se basan en una visión socio-ecológica, con sensibilidad cultural, enfoque transformador de género y perspectiva de derechos humanos. Entre las barreras más importantes están las normas sociales que valoran la maternidad como el principal proyecto de vida para las mujeres que viven en contextos de pobreza, los estereotipos de género —el embarazo como una responsabilidad exclusiva de las adolescentes, sin involucrar a los adolescentes varones—, el estigma del aborto, la insuficiente oferta de servicios de salud sexual y reproductiva, y la resistencia a visibilizar el embarazo en niñas menores de 15 años víctimas de la violencia estructural e intrafamiliar. Es necesario asegurar la continuidad de las políticas públicas, ajustadas a un enfoque de género y de derechos humanos, y que se tomen en cuenta los nuevos escenarios, como el que impone la pandemia por COVID-19.

ABSTRACT This article presents the main characteristics and achievements of Uruguay's National and Intersectoral Strategy for Prevention of Adolescent Pregnancy, implemented from 2016 to 2020. This strategy was implemented in a context in which unintentional adolescent pregnancy continues to be a major social problem for Uruguay and the Region, necessitating comprehensive, sustained, and evidence-based public policies. In Uruguay, adolescent fertility rates have remained high for over a decade. In addition to intersectoral action by government and civil society, the strategy received scientific assistance from the academic community, and technical and financial cooperation from regional and international organizations. Its actions and measures were adopted based on a socio-ecological vision, with cultural sensitivity, a gender-transformative approach, and a human rights perspective. Major barriers include social norms that value maternity as the main life project for women living in poverty, gender stereotypes (pregnancy as the exclusive responsibility of adolescent girls, without involving adolescent boys), the stigma of abortion, a lack of sexual and reproductive health services, and resistance to raising the visibility of pregnancy in girls under 15 years of age who are victims of structural and family violence. It is necessary to ensure the continuity of public policies--adjusted to a gender and human-rights approach--that take into account new scenarios such as the one imposed by the COVID-19 pandemic.

RESUMO Este artigo apresenta os principais aspectos e os resultados da Estratégia Nacional e Intersetorial para Prevenção da Gravidez na Adolescência, implementada no Uruguai entre 2016 e 2020. A gravidez não intencional na adolescência persiste como uma questão social importante no Uruguai e na Região, exigindo políticas públicas com base em evidências científicas que sejam abrangentes e permanentes. A fecundidade na adolescência no Uruguai tem se mantido elevada há mais de uma década. Além da ação intersetorial do governo e da sociedade civil, a estratégia aprovada recebeu orientação científica de entidades acadêmicas, e cooperação técnica e financeira de organismos regionais e internacionais. As ações e as medidas da estratégia foram elaboradas a partir de uma visão socioecológica, com sensibilidade cultural e enfoque transformador de gênero e uma perspectiva de direitos humanos. Entre as barreiras mais importantes enfrentadas estão as normas sociais que valorizam a maternidade como principal projeto de vida para a mulher que vive em situação de pobreza, os estereótipos de gênero (a gravidez é vista como responsabilidade exclusiva da adolescente, sem envolver o parceiro adolescente), o estigma do aborto, a oferta insuficiente de serviços de saúde sexual e reprodutiva, e a resistência a dar visibilidade à gravidez de menores de 15 anos que são vítimas de violência estrutural e intrafamiliar. É necessário garantir a continuidade das políticas públicas que incorporem uma perspectiva de gênero e direitos humanos, e que sejam adaptadas aos novos cenários da pandemia de COVID-19.

Las adolescentes frente a la decisión de interrumpir un embarazo en un contexto de aborto legal / Adolescents faced with the decision to terminate a pregnancy in a context of legal abortion / As adolescentes frente à decisão de interromper uma gravidez em um contexto de aborto legal

El artículo presenta resultados de una investigación sobre las experiencias de las adolescentes que decidieron interrumpir su embarazo en el marco de los servicios legales de aborto en Montevideo (Uruguay), realizada entre los años 2016 y 2018. Su objetivo principal fue examinar el proceso de toma de decisión y el acceso al aborto legal, desde la perspectiva de las propias adolescentes. Ello implicó analizar circunstancias, motivaciones y personajes que influenciaron en la toma de la decisión y cómo ésta se tramitó en el servicio de salud. Se diseñó un estudio transversal de tipo exploratorio y descriptivo, basado en metodología cualitativa. La técnica principal que se utilizó para la recolección de la información fue la entrevista semidirigida, se entrevistó a 14 adolescentes entre 17 y 19 años de edad que interrumpieron voluntariamente un embarazo en los servicios públicos de salud. Los motivos para abortar dan cuenta del peso que tienen las razones socialmente aceptadas, incorporadas como motivos propios. Se observó que la madre juega un papel importante como referente en la decisión. Las adolescentes manifestaron tomar la decisión de abortar antes de haber concurrido al servicio de salud. Se destaca el papel positivo de la existencia de un marco legal que habilita servicios de aborto voluntario. Los resultados contribuyen a comprender los procesos que viven las adolescentes frente a una decisión vital difícil, el rol de la familia, en particular de la figura materna, el lugar que tiene el marco legal en la toma de la decisión, el peso del estigma y la sanción moral, y las expectativas respecto de la atención en servicios de salud.

The article presents the results of a study on the experiences of adolescents that decided to terminate a pregnancy in the context of legal abortion services in Montevideo, Uruguay, from 2016 to 2018. The main objective was to examine the decision-making process and access to legal abortion from the perspective of the adolescent girls themselves. This involved analyzing circumstances, motives, and persons that influenced the decision and the ways this was handled in the health services. A cross-sectional, exploratory, and descriptive study was designed, based on a qualitative methodology. The main technique used for collecting the information was a semi-structured interview with 14 adolescents 17 to 19 years of age who had voluntarily terminated a pregnancy in public healthcare services. The motives for the abortion reveal the weight of socially accepted reasons, incorporated as their own. The interviews showed that the adolescent's mother plays an important role as the reference for the decision. The adolescents reported that they had made the decision to have the abortion before going to the health service. The results highlight the positive role of a legal framework that enables voluntary abortion services. The results help understand the experiences of adolescents facing a difficult life decision, the family's role, particularly that of the adolescent's mother, the legal framework's place in the decision, the weight of stigma and moral sanctions, and expectations towards care in health services.

O artigo apresenta os resultados de uma pesquisa, desenvolvida entre 2016 e 2018, sobre as experiências de adolescentes que decidiram interromper a sua gravidez nas unidades de saúde para aborto legal em Montevidéu (Uruguai). Tinha como objetivo principal analisar o processo de tomada de decisão e o acesso ao aborto legal, do ponto de vista das próprias adolescentes. Isso envolvia avaliar as circunstancias, motivações e personagens que influenciaram a tomada de decisão e a forma como se deu no sistema de saúde. Foi construído um estudo transversal do tipo exploratório e descritivo baseado numa metodologia qualitativa. A técnica principal utilizada para a coleta de informação era a entrevista semiestruturada; foram entrevistadas 14 adolescentes entre 17 e 19 anos de idade, que tinham interrompido voluntariamente uma gravidez no sistema público de saúde. Os motivos para abortar refletem o peso das razões socialmente aceitas, incorporadas como motivos próprios. Observou-se que a mãe desempenha um papel relevante, como referente na decisão. As adolescentes afirmaram ter tomado a decisão de abortar antes de se dirigir à unidade de saúde. Destaca-se o papel positivo da existência de um marco legal que habilita serviços de aborto voluntário. Os resultados contribuem para o entendimento dos processos vivenciados pelas adolescentes diante de uma decisão vital difícil, o papel da família, em especial da figura materna, o lugar ocupado pelo marco legal na tomada da decisão, o peso do estigma e da sanção moral, além das expectativas sobre o atendimento nas unidades de saúde.

From harm reduction to legalization: The Uruguayan model for safe abortion.

Advocacy by feminists and healthcare providers was essential in passing the 2012 bill legalizing abortion in Uruguay, which was primarily framed in terms of a public health imperative. Prior to legalization, a group of influential physicians had established a "harm reduction" approach consisting of pre- and postabortion counseling with a focus on safer abortion methods. The existence of a network of providers from this initiative facilitated the implementation of abortion services after legalization. Particularities of the Uruguayan model include a strong focus on medical abortion, and a multidisciplinary approach to patient counseling. The implementation of services was largely successful, and rates of abortion-related morbidity and mortality have decreased. Remaining concerns include high rates of conscientious objection and insufficient human resources to staff interdisciplinary counseling teams. The focus on medical abortion has led to a lack of method choice. Finally, data collection gaps complicate monitoring and identification of barriers to access.

[Legal health services of abortion in Uruguay. Strategies of the primary health care public services]. / Servicios legales de interrupción voluntaria del embarazo en Uruguay. Estrategias de los servicios públicos del primer nivel de atención.

OBJECTIVE: To analyze the strategies developed by the health centers to implement the law of legal abortion (LA) in public services of the primary care in Montevideo, Uruguay. MATERIALS AND METHODS: A qualitative research was conducted combining techniques of document analysis, self-administered questionnaires to key informants, and in-depth interviews with directors of health centers. A simple summative index of accessibility to abortion services was built. RESULTS: The law approved in Uruguay in 2012 demanded the development of a strategy to promote women's accessibility to LA in the public primary care system. The services failed to fully implement the strategy, due to institutional barriers. CONCLUSION: Despite the wide availability of LA services in primary care and that they are an integral part of sexual and reproductive health benefits, there is an important barrier to their use in the number of gynecologists that appeal to conscientious objection.

OBJETIVO: Analizar las estrategias desarrolladas por los centros de salud para implementar la ley de interrupción voluntaria del embarazo (IVE) en los servicios públicos del primer nivel de atención en Montevideo, Uruguay. MATERIAL Y MÉTODOS: Investigación cualitativa, que combinó técnicas de análisis documental y cuestionarios autoadministrados a informantes clave y entrevistas semidirigidas a directores de centros de salud. Se construyó un índice sumatorio simple de accesibilidad a las prestaciones de IVE en el centro de salud. RESULTADOS: La ley aprobada en Uruguay en 2012 exigió el desarrollo de una estrategia para favorecer la accesibilidad de las mujeres a la IVE en el primer nivel de atención público. Los servicios no lograron implementar cabalmente la estrategia por dificultades institucionales. CONCLUSIÓN: Pese a la amplia disponibilidad de servicios públicos de IVE en el primer nivel de atención y a que forman parte de las prestaciones en salud sexual y reproductiva, lo que favorece integralidad en la atención, persiste una barrera importante en el alto porcentaje de ginecólogos objetores de conciencia.

Servicios legales de interrupción voluntaria del embarazo en Uruguay. Estrategias de los servicios públicos del primer nivel de atención / Legal health services of abortion in Uruguay. Strategies of the primary health care public services

Resumen: Objetivo: Analizar las estrategias desarrolladas por los centros de salud para implementar la ley de interrupción voluntaria del embarazo (IVE) en los servicios públicos del primer nivel de atención en Montevideo, Uruguay. Material y métodos: Investigación cualitativa, que combinó técnicas de análisis documental y cuestionarios autoadministrados a informantes clave y entrevistas semidirigidas a directores de centros de salud. Se construyó un índice sumatorio simple de accesibilidad a las prestaciones de IVE en el centro de salud. Resultados: La ley aprobada en Uruguay en 2012 exigió el desarrollo de una estrategia para favorecer la accesibilidad de las mujeres a la IVE en el primer nivel de atención público. Los servicios no lograron implementar cabalmente la estrategia por dificultades institucionales. Conclusión: Pese a la amplia disponibilidad de servicios públicos de IVE en el primer nivel de atención y a que forman parte de las prestaciones en salud sexual y reproductiva, lo que favorece integralidad en la atención, persiste una barrera importante en el alto porcentaje de ginecólogos objetores de conciencia.

Abstract: Objective: To analyze the strategies developed by the health centers to implement the law of legal abortion (LA) in public services of the primary care in Montevideo, Uruguay. Materials and methods: A qualitative research was conducted combining techniques of document analysis, self-administered questionnaires to key informants, and in-depth interviews with directors of health centers. A simple summative index of accessibility to abortion services was built. Results: The law approved in Uruguay in 2012 demanded the development of a strategy to promote women's accessibility to LA in the public primary care system. The services failed to fully implement the strategy, due to institutional barriers. Conclusion: Despite the wide availability of LA services in primary care and that they are an integral part of sexual and reproductive health benefits, there is an important barrier to their use in the number of gynecologists that appeal to conscientious objection.

Tensiones entre lo (i)legal y lo (i)legítimo en las prácticas de profesionales de la salud frente a mujeres en situación de aborto / Tensions between the (il)legal and the (il)legitimate in professional health practices regarding women who seek abortion

RESUMEN La implementación de una estrategia sanitaria de atención pre y post aborto adoptada a partir del año 2004 en Uruguay, en un escenario legal restrictivo previo a su despenalización en 2012, abrió una ventana de oportunidad para vincular a las mujeres en situación de embarazo no deseado y aborto con los servicios de salud con el objetivo de disminuir su práctica insegura. En este contexto, este artículo busca indagar cuáles son y cómo operan las tensiones generadas por el cambio de un enfoque materno-infantil hacia otro centrado en la salud y los derechos sexuales y reproductivos. A través de entrevistas semiestructuradas y grupos focales, se analizan las prácticas de los/as profesionales y sus esquemas de percepción y apreciaciones, en la atención a mujeres en situación de embarazo no deseado y aborto en los servicios del Sistema Nacional Integrado de Salud (SNIS) en Montevideo. Los resultados obtenidos brindan insumos para analizar algunas de las barreras y dificultades que se pueden observar actualmente en la implementación de la nueva ley.

ABSTRACT The implementation of a pre- and post-abortion health care strategy, adopted in 2004 in Uruguay within a restrictive legal context prior to the decriminalization of abortion in 2012, opened a window of opportunity to link women facing unwanted pregnancies and abortion to health services in order to prevent unsafe abortion practices. This article looks into the tensions generated by the change of focus from maternal-child health to health and sexual and reproductive rights, and how those tensions operate. Using semi-structured interviews and focus groups, the practices and perception and assessment frameworks of professionals in their care of women facing unwanted pregnancy and abortion in the National Integrated Health System in Montevideo are analyzed. The results offer insights into some of the barriers and difficulties that can currently be observed in the implementation of the new law.

[Tensions between the (il)legal and the (il)legitimate in professional health practices regarding women who seek abortion]. / Tensiones entre lo (i)legal y lo (i)legítimo en las prácticas de profesionales de la salud frente a mujeres en situación de aborto.

The implementation of a pre- and post-abortion health care strategy, adopted in 2004 in Uruguay within a restrictive legal context prior to the decriminalization of abortion in 2012, opened a window of opportunity to link women facing unwanted pregnancies and abortion to health services in order to prevent unsafe abortion practices. This article looks into the tensions generated by the change of focus from maternal-child health to health and sexual and reproductive rights, and how those tensions operate. Using semi-structured interviews and focus groups, the practices and perception and assessment frameworks of professionals in their care of women facing unwanted pregnancy and abortion in the National Integrated Health System in Montevideo are analyzed. The results offer insights into some of the barriers and difficulties that can currently be observed in the implementation of the new law.