by Lillian Abracinskas, Santiago Puyol
Global Public Health, May 2020
Summary
As time goes by, the world experiences advances and setbacks in the field of sexual and reproductive health and rights. But new challenges appear in terms of professional performance and implementation of services created by newer laws and policies. The development of new ethical frames in dialogue with disputed value systems is one of the main obstacles to ensuring universal access and comprehensive services to guarantee the exercise of these rights.
Since 2002, Uruguay has been one of the few countries in Latin America and the Caribbean that has achieved significant advances regarding sexual and reproductive rights by recognizing them as human rights. The passage of several laws has resulted in the implementation of programs in SRHS and legal abortion as being considered mandatory for the National Health System. The follow-up and monitoring of this process by the Observatory of Mujer y Salud en Uruguay (MYSU) has demonstrated how changes in the legal framework led to a new stage for health-care providers, politicians, and decision makers and also for the social movement that has historically advocated for this agenda, all now facing new problems and challenges—some of which are completely unexpected. The high prevalence of conscientious objection exercised by physicians and OB/GYNs in refusing the provision of care in SRHS is one of the ethical dilemmas that needs to be discussed to innovate solutions to the problems and promote best practices from a gender equity and human rights paradigm.
Background
Since 2001, as summarized in Table1, Uruguay has undergone a series of legislative reforms in the field of sexual and reproductive health and rights, accompanying international and regional commitments on population and development and human rights (MYSU,2014), such as the International Conference on Population and Development (ICPD) (El Cairo, 1994), or its regional expression in the Montevideo Consensus (ECLAC,2013). This process has intensified over the last decade, with the incorporation of multiple services into the Integrated National Health System (INHS) (MYSU,2017).
The wide range of legislation on sexual and reproductive health and rights in Uruguay covers, among other things, abortion, contraception, comprehensive sexual education, gender-based violence and LGBTIQ+ rights. This process of legal reform and recognition of what is called the “new rights agenda” is, in turn, part of a process of the national health sector reform, which establishes the universality of coverage and mandatory sexual and reproductive health services for both private and public health institutions (MYSU,2017).
These changes in the legal framework, and in particular the legalization of abortion, have been “the fruit of more than two decades of advocacy, led by feminist organizations in alliance with trade unions, student groups and other actors, including the medical sector and key political leaders” (Wood, Abracinskas, Correa, & Pecheny,2016, p. 1).
The paper goes on to discuss in depth:
- sexual and reproductive health services in Uruguay: implementation gaps in policies
- ethical dilemmas in the implementation of services
- conscientious objection, and other ethical dilemmas.
It concludes: “Not only is SRH an important aspect of health, but it is also an important issue of human development and human rights for every person, with a particular impact on women as they have historically been considered subject to the control and supervision of “men of the family” as well as exposed to the decisions of political and religious leaders and the will of health professionals.
“Despite the great expansion, development, and improvement in health-care services, these health systems have not been able to meet the demands in the field of sexuality and reproduction, either because the availability of services is insufficient, because they are inefficient, or because there is a lack of correspondence with the expectations and perspectives of comprehensive care. Gender equity problems need to be dealt with, and there needs to be more sensitivity to ethnic diversity and attention to sexual orientation and gender identity. On many occasions, people’s rights are violated, and their autonomy is taken away. Uruguay is no exception and must therefore face these challenges.”