by Daniel FM Suárez-Baquero, Ilana G Dzuba, Mariana Romero, C Finley Baba, M Antonia Biggs
Health Equity March 2024;8(1):189–197. DOI: 10.1089/heq.2023.0050
Abstract
Introduction: In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant person’s life is at risk, (ii) fetal non-viability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile.
Methods: Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semi-structured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes.
Results: We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion.
Discussion and health equity implications:
Although the 2017 law expanded legal access to abortion in Chile, significant barriers remained. Compounded with social stigma, and the socio-economic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.
Introduction (first paragraphs)
From 1989 to 2017, Chile was one of the few countries that banned abortion without legal exception. On August 21, 2017, Chile made an important legal shift and decriminalized abortion on three grounds: (i) risk to the pregnant person’s life, (ii) fetal nonviability, and (iii) rape or incest; estimated to provide a legal option for only 3% (n=2550) of the abortions annually. However, Chile’s Ministry of Health (MOH) data suggest that the actual number of abortions granted on legal grounds was only a small fraction, about half, of the original estimates. The lower rate of legal abortions was likely due, in part, to the medically unnecessary legal requirement that abortions be performed by licensed physicians in facilities with high-risk obstetric units, as well as the high number of institutions and physicians who claimed conscientious objection. Initial data suggested that most obstetrics and gynecology specialists claimed conscientious objection, with nearly half of those practicing in public hospitals refusing to provide care to those seeking an abortion due to rape.
While abortion in Chile is only legally permitted in limited circumstances, it is well known that thousands of people have abortions outside of the formal health care sector, oftentimes with the support of accompaniment groups. According to the Guttmacher Institute, between 2015 and 2019, there were ∼170,000 pregnancies that ended in abortion. Many of these abortions involved the use of pills up to 24 weeks gestation. According to a retrospective analysis of anonymized case records from accompaniment groups based in Argentina, Chile, and Ecuador from 2016 to 2018, 316 individuals had safe and effective medical abortions between the 13th and 24th weeks of pregnancy, using a combination mifepristone-misoprostol regimen.
These findings demonstrated the safety and effectiveness of self-managed medical abortions supported by an accompaniment model for abortions both early and later in pregnancy, especially in regions with legal constraints. Similarly, another recent study found that self-managed abortion was safe, effective, and acceptable among people who had abortions outside of the formal health care sector in Chile and received less judgmental, more supportive and informative services than they had received within the formal health care setting.
An exploration into women’s lived experiences trying to access abortion in Chile offers a compelling vantage point from which to assess the implementation of abortion laws globally. The intricate tapestry of abortion legislation in Latin America encompasses diverse approaches, ranging from:
— more progressive policies in countries like Colombia, Cuba, and Mexico, that decriminalize all abortions up to 24 weeks gestation and beyond 24 weeks for abortions due to rape and maternal or fetal health indications to
— Uruguay and Argentina, that allow abortion under specific circumstances, to
— complete bans on abortion in El Salvador and Nicaragua, where people involved in suspected abortions can be punished for up to 8 years in prison.
This regional variation underscores the intricate interplay of socio-political factors that shape abortion laws and ensure or deny abortion access.
Chile’s move to expand access to abortion contrasts with recent developments in the United States and Poland, that have moved to restrict access to abortion. In the United States, the decision that overturned the landmark Roe v. Wade case removed federal protections on abortion, unraveling decades of abortion rights progress and highlighting the fragility of reproductive rights even in an established democracy.
The central aim of this study is to detail individuals’ experiences accessing legal abortion care in Chile soon after decriminalization. Through this multiple-case study, we document the lived experiences of four people who identified as women yet found themselves unjustly denied the services they were unequivocally entitled to. By delving deep into these personal narratives, our research aims to better understand women’s experiences seeking and being denied care, including the barriers faced, pregnancy outcomes, and their experiences seeking care outside the legal framework. By sharing their stories we reveal challenges in the implementation of legal reform and provide insight in how to improve access.
PHOTO: Al Jazeera by Charis McGowan, at rally in favour of abortion rights, Santiago, 8 March 2023