Main barriers to services linked to voluntary pregnancy termination on three grounds in Chile.

Introduction: After decades of absolute criminalization, on September 14, 2017, Chile decriminalized voluntary termination of pregnancy (VTP) when there is a life risk to the pregnant woman, lethal incompatibility of the embryo or fetus of genetic or chromosomal nature, and pregnancy due to rape. The implementation of the law reveals multiple barriers hindering access to the services provided by the law. Objectives: To identify and analyze, using the Tanahashi Model, the main barriers to the implementation of law 21,030 in public health institutions. This article contributes to the follow-up of this public policy, making visible the obstacles that violate women's rights of women to have dignified access to abortion and that affect the quality of health care in Chile. Material and method: Qualitative design, following the postpositivist paradigm. The sample consisted of relevant actors directly related to pregnancy termination. Snowball sampling and semi-structured interviews were used. Grounded theory was used through inductive coding, originating categories regrouped into meta-categories following Tanahashi's model. The rigor criteria of transferability, dependability, credibility, authenticity, and epistemological theoretical adequacy were used. The identity of the participants and the confidentiality of the information were protected. Results: From January 2021 to October 2022, 62 interviews were conducted with 20 members of the psychosocial support team; 18 managers; 17 members of the biomedical health team; 4 participants from of civil society, and three women users. The main obstacles correspond to availability barriers, accessibility barriers, acceptability barriers, contact barriers, and effectiveness barriers. Conclusions: Barriers to access abortion under three grounds violate the exercise of women's sexual and reproductive rights. It is urgent to carry out actions of control and follow-up of this public policy to the corresponding entities.

Primary care and abortion legislation in Chile: A failed point of entry.

While Chile's partial decriminalization of abortion in 2017 was a long overdue recognition of women's sexual and reproductive rights, nearly four years later the caseload remains well below expectations. This pattern is the product of standing barriers in access to abortion-related health services, especially at the primary care point of entry. This study seeks to identify and describe these barriers. The findings presented here were obtained through a qualitative, exploratory study based on 19 semi-structured interviews with relevant actors identified through non-random sampling and snowballing techniques. Coding was inductive and complemented by semantic content analysis. The authors find that the key barriers in primary care to accessing legal abortion are unfamiliarity with the law, insufficient practitioner training, intersectoral discrimination, and the stigma surrounding abortion. They conclude that the government needs to exercise its constitutional mandate as guarantor of public health and act promptly to safeguard and guarantee the abortion rights of Chilean women.

Primary health care, access to legal abortion and the notion of ideal victim among medical practitioners: The case of Chile.

In 2017, Chile enacted new legislation allowing access to legal abortion on three grounds, including rape. This article summarizes a qualitative, exploratory study that examined the role of primary healthcare services in the treatment of rape survivors in order to identify challenges and strengths in accessing legal abortion. The relevant data was collected through 19 semi-structured interviews conducted with key informants. The angry legislative debate that preceded enactment of the 2017 abortion bill evidenced the presence of strong biases against survivors of sexual violence. At the time, abortion opponents sought, inter alia, to discredit women who report rape, arguing that such claims would be misused to secure illicit abortions. In actual fact, however, rape has turned out to be the least used of all grounds for abortion, with girls and teens making up the smallest group of seekers. This article presents our findings on rape-related issues, notably the biases and shortcomings of medical practitioners regarding the new abortion law. We noted with concern their failure to screen for sexual violence and propensity to stigmatize the victims, a phenomenon that becomes exacerbated when it involves particularly vulnerable populations, such as girls and women who are poor, homeless, migrant, or who abuse alcohol or drugs. We further noted that prevalent stereotypes based on the notion of the ideal victim can revictimize girls and women and work to defeat the intent of the law. In Chile, the primary healthcare system is a key point of entry for abortion. In this highly charged arena, however, lack of political will, compounded by the COVID-19 pandemic, have kept health care practitioners from undergoing timely, gender-sensitive training on the new law, a key requirement for ensuring dignified care and respect for women's rights. We conclude that if government policy is to prevent multiple, intersectional discrimination, it must recognize the diversity of women and adapt to their specific contexts and singularities.

Conscientious objection as structural violence in the voluntary termination of pregnancy in Chile.

Introduction: After three decades of the absolute prohibition of abortion, Chile enacted Law 21,030, which decriminalizes voluntary pregnancy termination when the person is at vital risk, when the embryo or fetus suffers from a congenital or genetic lethal pathology, and in pregnancy due to rape. The law incorporates conscientious objection as a broad right at the individual and institutional levels. Objectives: The aim of the study was to explore the exercise of conscientious objection in public health institutions, describing and analyzing its consequences and proposals to prevent it from operating as structural violence. Materials and methods: This study uses a qualitative, post-positivist design. At the national level, according to the chain technique, people who were identified as key actors due to their direct participation in implementing the law were included. Grounded theory was used to analyze the information obtained through a semi-structured interview. The methodological rigor criteria of transferability or applicability, dependability, credibility, auditability, and theoretical-methodological adequacy were met. Results: Data from 17 physicians, 5 midwives, 6 psychologists, 8 social workers, 2 nursing technicians, and 1 lawyer are included. From an inductive process through open coding, conscientious objection as structural violence and strategies to minimize the impact of objection emerge as meta-categories. The first meta-category emerges from the barriers linked to the implementation of the law, the infringement of the rights of the pregnant person, and pseudo conscientious objection, affecting timely and effective access to pregnancy termination. The second meta-category emerges as a response from the participants, proposing strategies to prevent conscientious objection from operating as structural violence. Conclusion: Conscientious objection acts as structural violence by infringing the exercise of sexual and reproductive rights. The State must fulfill its role as guarantor in implementing public policies, preventing conscientious objection from becoming hegemonic and institutionalized violence.

Prevalencia y características de objetores de conciencia a la Ley 21. 030 en instituciones públicas / Prevalence and characteristics of conscientious objectors to Law 21. 030 in public institutions

INTRODUCCIÓN: La Ley 21.030 permite la objeción de conciencia al personal de salud al interior del pabellón y a las instituciones privadas. Ha sido considerada conflicto de intereses no monetario, al anteponer los valores personales, afectando el cumplimiento del deber profesional. OBJETIVOS: Establecer la prevalencia de funcionarios/as objetores/as en los hospitales de la red pública del país y caracterizarles según edad, género y nacionalidad. MÉTODO: Estudio cuantitativo, analítico y transversal. Se utilizaron medidas de tendencia central y dispersión. Para medir la asociación entre variables sociodemográficas, profesión y causal objetada, se utilizaron las pruebas de χ2, exacta de Fisher y de Kruskal-Wallis. RESULTADOS: En 57 hospitales, se observa una mayor frecuencia de objetores en causal 3. En 443 objetores, la mediana de edad fue de 43 años, el 64,8% mujeres y el 87,4% de nacionalidad chilena. En las zonas centro y sur del país se concentra la mayor proporción de hospitales con más del 50% de objetores. CONCLUSIONES: La dificultad para obtener información impide conocer cabalmente la magnitud de la objeción de conciencia. Resulta preocupante la alta prevalencia de objetores, específicamente en la causal violación. La objeción no puede operar como barrera que vulnere los derechos y la dignidad de las mujeres.

INTRODUCTION: Law 21.030 incorporates conscientious objection for health personnel inside the surgical ward and allows its invocation by private institutions. It has been considered a conflict of interest, not monetary, by putting personal values first, affecting the fulfillment of professional duty. OBJECTIVE: To establish the prevalence of objectors in the countrys public network hospitals and characterize them according to age, gender, and nationality. METHOD: Quantitative, analytical, and cross-sectional study. Central and dispersion trend measures were used. For measuring the association between sociodemographic variables, profession and causal objected, test χ2, Fisher exact and Kruskal-Wallis test were used. RESULTS: In 57 hospitals, a higher frequency of objectors were observed in the third causal. In 443 objectors, the median age was 43 years, 64.8% are women, and 87.4% are Chilean. The central and southern areas of the country have the highest proportion of hospitals, with more than 50% objectors. CONCLUSIONS: The difficulty for obtaining the information prevents fully knowing the magnitude of conscientious objection in Chile. The high prevalence of objectors, specifically in the causal violation is worrying. The conscientious objection cannot operate as a barrier that violates the rights and dignity of women.

Abortion in Chile: The Long Road to Legalization and its Slow Implementation.

Until as recently as September 2017, Chile was one of the few countries in the world that did not permit abortion under any circumstances. Although the Health Code had permitted therapeutic abortion (i.e., on health grounds) from 1931, this was repealed in 1989 as one of General Pinochet's last acts in office. It took more than 25 years to reverse the ban. Finally, a new act was approved allowing abortion on three grounds: when a woman's life is in danger, when there are fetal anomalies incompatible with life, and in the case of rape. Since the law allows abortion only in limited cases, most women must continue to seek illegal abortions, as previously. In this paper, we explore the historical context in which Chile's 2017 bill was finally passed. We then analyze the legislative debate leading up to the passage of the law. Lastly, we present the results of a community-based participatory research effort carried out by an alliance between feminist and human rights organizations. Chile's law was passed almost two years ago, and this research shows the persistence of various obstacles that hinder women's access to legal abortion, such as the use of conscientious objection, a lack of trained health care providers, and a lack information for women.

Pregnancies and Fetal Anomalies Incompatible with Life in Chile: Arguments and Experiences in Advocating for Legal Reform.

Chile allows abortion under no circumstances. Whether it's fetal anomaly incompatible with life or congenital malformation resulting in little or no life expectancy, all Chilean women are expected to carry their pregnancies to term. In this context, in January 2015 the Chilean Congress began debating a bill to legalize abortion on three grounds, including fatal congenital malformation. The medical community, including midwives, has presented its views for and against, especially on how the law may affect clinical practices; in addition, women, many of whom have experienced a fatal congenital malformation diagnosis, have weighed in. This qualitative study draws on 22 semi-structured interviews with nine certified nurse-midwives, one neonatologist, nine obstetrician-gynecologists, one psychiatrist, one psychologist, and one sociologist who provide care during gestation, pregnancy, delivery, and post-delivery in the public and private sectors, plus three interviews with two women and the former partner of a woman who underwent the experience. These interviews starkly illustrate the plight facing women carrying nonviable fetuses, including women's shock upon receiving the diagnosis, their feelings of bereavement and loss, and the clinical practices used in an attempt to ease their suffering under the weight of exceedingly difficult legal restrictions. These interviews confirmed that compelling women to carry nonviable fetuses to term violates their human rights. They also show that the chances of legislative change are real and that such change will present new challenges to the Chilean health care system.

Abortion in Chile: the practice under a restrictive regime.

This article examines, from a human rights perspective, the experience of women, and the practices of health care providers regarding abortion in Chile. Most abortions, as high as 100,000 a year, are obtained surreptitiously and clandestinely, and income and connections play a key role. The illegality of abortion correlates strongly with vulnerability, feelings of guilt and loneliness, fear of prosecution, physical and psychological harm, and social ostracism. Moreover, the absolute legal ban on abortion has a chilling effect on health care providers and endangers women's lives and health. Although misoprostol use has significantly helped to prevent greater harm and enhance women's agency, a ban on sales created a black market. Against this backdrop, feminists have taken action in aid of women. For instance, a feminist collective opened a telephone hotline, Linea Aborto Libre (Free Abortion Line), which has been crucial in informing women of the correct and safe use of misoprostol. Chile is at a crossroads. For the first time in 24 years, abortion law reform seems plausible, at least when the woman's life or health is at risk and in cases of rape and fetal anomalies incompatible with life. The political scenario is unfolding as we write. Congressional approval does not mean automatic enactment of a new law; a constitutional challenge is highly likely and will have to be overcome.