Complex problems, comprehensive interventions.

Introduction

Abortion is a response to a pregnancy that is unplanned, unwanted, unintentional and/or cannot be brought to term. Women have very limited options in these circumstances. They can continue the pregnancy and raise the child, continue the pregnancy and give the infant up for adoption or interrupt the pregnancy. The decision that each woman makes depends on a number of factors, including her life circumstances, immediate family and social situation, current legislation and access to the information and resources that she will need to follow the path that she has chosen to take.

Women have used abortion to terminate unwanted pregnancies for centuries. Until the arrival of modern birth control methods, it was almost the only way of having a sexual life with no reproductive objectives. (2) Despite the advent of contraceptives, unplanned pregnancies and abortion continue to be a reality as we enter the 21st century for many reasons. There are no completely effective methods of birth control. Also, some sexual relations are forced. One of the key aspects of sexuality and reproduction is the subjective facet (people make mistakes and forget things) and those involved are not always in a position to assume maternity and/or paternity at that time. Sometimes they have other plans for their lives.

There are some specific factors that contribute to the practice of unsafe abortion. These include restrictive legal contexts; social pressure that condemns pregnancy in women who are young, poor or do not have a formal partner; lack of equitable access to comprehensive sexual and reproductive health services and timely, pertinent and high-quality information; and failure to recognize and respect sexual and reproductive rights. Unsafe abortion is a serious public health problem and a leading cause of death among women of childbearing age at the global level (WHO, 2003). In Uruguay, unsafe abortion was the leading independent cause of maternal morbidity in 2001 (Briozzo, 2004).

The Process of Legal Change

Since 1985, when the country returned to democracy following 12 years of military dictatorship, initiatives have been introduced to modify the Criminal Code to decriminalize abortion. The current law (No. 9.763), which dates back to 1938, establishes that abortion is always a crime but that the punishment may be reduced or suspended by the judge if the pregnancy is terminated by a doctor during the first three months or if the woman's life is at risk. (3)

The number of years that the law has been in effect does not reflect its application. Access to legal abortion (in cases that meet the conditions specified above) was never granted. It is impossible to meet the conditions set out in the law because it states that abortion is always illegal, yet allows for some ambiguity regarding extenuating and exempting circumstances (Dufau, 1989). Even if this law could be applied, it would have to be modified to eliminate the phrase "family honor" because the good that it seeks to protect is inadmissible. Granting a reduced sentence in a case of abortion to "save a family's honor" is comparable to the legal horror of exonerating a rapist on the condition that he ask his victim to marry him.

Furthermore, the fact that very few arrests have been made combined with the widespread practice of interrupting pregnancies proves that the current law is ineffective. (4) In fact, the only cases in which arrests have been made involve situations in which the woman died. The only thing that this punitive law has generated and promoted is clandestine practices, most of which are performed in high-risk conditions that jeopardize women's health and lives.

The criminalization of abortion in Uruguay is aimed mainly at imposing a climate of social condemnation and censorship based on the double moral standard that looks to lay blame on and subjugate women who present evidence that they have had an abortion.

The social debate on abortion in Uruguay has coincided with the process of recovering, rebuilding and expanding the country's democratic life. It is therefore affected by tensions inherent in profound cultural transformations. An analysis of the expansion of the social basis of support for the decriminalization of abortion over the past 20 years must consider the broader context of the construction of democracy, citizenship and social participation.

Five bills to decriminalize/legalize abortion have been discussed in the General Assembly since 1985. This is proof that real efforts are being made to adjust the legislation to reflect reality and respond to social demands. These initiatives have sought to address the problem progressively in a comprehensive manner, introducing measures that ensure universal access to sex education and birth control and promote responsible maternity and paternity. All of the legislative initiatives were focused on the need to resolve a social and public health problem--namely, the practice of clandestine and unsafe abortions--and looked to promote measures (particularly the two most recent bills) (5) to expand democracy in Uruguay by recognizing and respecting the plurality of value systems and protecting individual liberty in the exercise of sexuality and control of reproductive capacity.

This search for legislative responses that respect human rights and are sensitive to individuals' demands and needs is part of the ongoing process of overcoming problems that have persisted for many years. The failure of four consecutive legislatures to pass these bills during the post-dictatorship period reflects the dominance of the logic of political negotiation, the electoral cost associated with such action and/or the influence of powerful sectors that wish to maintain the status quo and the hegemony of their beliefs and values.

However, women's and feminist organizations have forged an alliance with other actors to sustain social discussion of abortion and transform that right into a demand of civil society. This, along with the manifest commitment of Assembly members, led to the development of a new bill through the current legislature (2005-2009) that was approved in the Senate in November 2007 and is awaiting approval in the Chamber of Representatives.

The President of the Republic, Dr. Tabare Vazquez, announced that he would veto any Assembly initiative to decriminalize abortion, but although he tried to limit legislative debate, he could not stop it. Today, the people expect Uruguay's General Assembly to give its full support to the bill through the Chamber of Representatives. This should be accompanied by a coalition of social forces to ensure that the Executive Branch ratifies the approved law and facilitates its prompt implementation.

From Feminist Struggle to Citizen Demand

These issues, which had been taboo in Uruguayan society, have begun to be addressed thanks to a strong, sustained intervention by social actors who have promoted a new consensus on the defense of and respect for individuals' right to make decisions regarding their sexuality and reproduction.

There are various reasons for the construction of a new social consensus on such problematic and controversial issues. The continued presence of unsafe abortion as a social problem and the permanence of the topic in the fields of health, law and the media are, in our opinion, fundamental. These arguments should be rooted in the growing process of citizen recognition and legitimization of sexual and reproductive rights as part of a social agenda based on the universality, comprehensiveness and indivisibility of human rights.

The number of deaths resulting from unsafe abortions increased sharply in 2001. At that time, the country also was facing a deepening economic crisis, and an increasing number of people were living in conditions of social marginality and exclusion. The result was an immediate demand for comprehensive programs designed to prevent unwanted pregnancies. As a result, the work that women's and feminist organizations had accumulated over the preceding 20 years had a greater public impact.

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The Coordinacion Nacional de Organizaciones Sociales por la Defensa de la Salud Reproductiva (National Network of Social Organizations for the Defense of Reproductive Health) was created in 2003. This entity brought together feminist, union, religious, professional and human rights groups as well as organizations that focused on sexual diversity and young people, creating an unprecedented alliance around this agenda. The Main Administrative Council of the Universidad de la Republica and the Uruguayan Medical Union, both of which enjoy a great deal of political and social legitimacy, issued public statements declaring their support for the network.

The consensus reached by these actors was based on the project's comprehensiveness and the importance of recognizing unsafe abortion as a public health issue and a matter of equality and social justice. The agreement also was based on affirming that sexual and reproductive rights are fundamental human rights and that women have the right to make decisions regarding their bodies. Abortion as an aspect of personal freedom in the right to choose when to have children, how many to have and how far apart to have them became part of the country's political agenda, alongside other important national issues.

The public opinion polls taken in Uruguay since 1985 reflect a notable change in attitudes toward abortion over the past few years. In the 1980s, 25% of Uruguayans accepted the idea that women had the right to voluntarily interrupt a pregnancy during the first three months of gestation. By 2007, that number had increased to 65%. (6)

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Decreased Risk and the Exercise of Rights

An in-depth analysis of the practice of abortion is inscribed in the complex linking of biomedical, philosophical, legal, ethical, psychological, social, cultural, moral, ideological and political aspects.

The integrationist and pro-development approaches that characterized the UN Decade for Women (1976-1985) focused on policies and programs directed at recognizing and promoting the role of women and their contribution to countries' development. In the field of health policy, this approach, which some theorists called Women in Development (WID) (Moser, 1991; Young, 1991), led to an emphasis on women's contribution to their community's health through the performance of their roles of wife, caretaker and manager of the domestic realm (Lopez Gomez, et al., 2003).

The emphasis placed on the role of mother strengthens the invisibility of woman as a person and a rights bearer. The Woman, Health and Development approach (De los Rios, 1995) has sustained the maternal-child model and assistance-oriented nutrition programs directed at poor women. The main purpose of these actions is to decrease child mortality rates by focusing on the mother-child dyad. This dyad is centered on the figure of woman as mother and the figure of child as son or daughter, with the absence of male participation in the exercise of paternity.

Health services for women based on care during pregnancy, delivery and the post-partum period were not traditionally accompanied by strategies to transform the conditions that generate subordination on the basis of gender. Recent research on practices, needs, actions and health policies have opened new perspectives and generated knowledge that allows us to think about women's health from other approaches. Health policies and services directed at women must incorporate and articulate the satisfaction of practical and strategic gender needs with criteria of mainstreaming and comprehensiveness (Molineaux, 1985; Moser, 1991; Young, 1991). The practical needs include those associated with the sexual division of labor and women's traditional biological reproductive and social role (focused actions designed to overcome inequities). The strategic needs and interests sustained in the questioning of women's position in society seek to subvert the gender order that places them in a position of subordination and to empower women as rights bearers.

The Gender in Development (GID) approach that emerged as a new paradigm during the 1980s allowed us to focus on the role of health as a criterion of gender equality (Gender, Health and Development). The deconstructive analysis of the segregation of social functions on the basis of an individual's gender introduces the analysis of power in relationships between men and women. This includes power relations between doctor and patient, within healthcare teams and among the various professions in that field. The goal of this approach was to achieve a socio-historical reconstruction of the feminine and masculine in terms of greater equality, solidarity and justice.

"From this perspective, it is understood that the female body is the field in which the exercise of gender power is based and where the exercise of gender power is located, particularly in regard to sexuality and reproductive decisions. Conceiving of women from their 'comprehensive self' (in their condition of being sexed and sexual, biological, socio-cultural, political and subjective) and as subjects with the right to have and exercise their rights, requires radical changes in healthcare paradigms and models and the practices of the professionals involved." (Lopez Gomez, et al., 2003)

The charity perspective dominated the public policy approach in the field of reproductive health. Rather than overcoming social inclusion, this approach contributed to it. The only way to destroy such attitudes is to transform needs into rights (Avila, 2000).

We must think about how strategies for decreasing the risks of unsafe abortions can contribute to the transformation of charity-oriented and paternalistic practices in health services and the empowerment of women in the strengthening of the exercise of rights. (7)

While the main purpose of the health strategies that focus on reducing damage is impacting maternal morbidity and mortality, its impact will increase if it goes beyond epidemiological factors to incorporate and address psychosociocultural factors in a substantive manner.

The confluence of inter-disciplinary approaches and dialogue and articulation among various actors becomes a key condition for the development of comprehensive strategies that effectively improve the quality of women's lives.

One excellent example of joint efforts based on community participation is the local experience of the health policy "Advice for Safe Maternity: Measures for Protecting Maternity from Abortions Performed in Risky Conditions" (Asesoramiento para una maternidad segura. Medidas de proteccion materna frente al aborto provocado en condiciones de riesgo, Ministry of Public Health, Ordinance No. 369, 2004), which MYSU launched in 1996.

This experience illustrates the importance of intervening simultaneously in a health center (by raising awareness among and training the staff) and the community (by involving local actors and the general population) to achieve comprehensive counseling and treatment services that satisfy the specific needs and demands of women who are dealing with an unwanted pregnancies and considering abortion.

We believe that the progress made over the past few years in terms of broadening public debate and the social base of support for a legal change on abortion; the inclusion of sexual and reproductive rights on the country's social and political agenda; the approval and implementation of health norms for decreasing the risk of unsafe abortion; the incorporation of sexual and reproductive health in training programs and services; and the strengthening of alliances among actors has created a propitious space for solidifying more comprehensive responses to complex problems that do not allow for reductionist approaches.

To promote the exercise of sexual and reproductive rights, Uruguay must adjust its legislation to meet the growing citizen demand for the legalization of abortion. This legal change will represent the recognition of women's right to choose and will provide adequate support for professional intervention in this area.

Bibliography

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Abracinskas, L., A. Lopez Gomez (2001) "Los derechos sexuales y los derechos reproductivos en la arena politica. Estrategias de advocacy desde la sociedad civil organizada." Paper presented at the Regional Seminar "ONG y Gobernancia," Programa MOST-UNESCO, Montevideo.

Abracinskas, L., A. Lopez Gomez (2004) Mortalidad materna, aborto y salud en Uruguay. Un escenario cambiante. Montevideo: MYSU.

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Notes

(1.) MYSU, Mujer y Salud en Uruguay, http://www.mysu.org.uy.

(2.) According to national studies, at the beginning of the 20th century abortion was the main form of birth control available to Uruguayan women. This is thought to be one of the reasons that the country underwent a demographic transition earlier than the rest of the region (Sapriza, 1989).

(3.) The law establishes four exemptions: rape, family honor, economic distress and risk to the woman's life and health.

(4.) Estimates range from 150,000 abortions per year (Hermogenes Alvarez, 1974) to 33,000 (Sanseviero, et al., 2003).

(5.) The Reproductive Health Defense Bill (2002-2004) and the Bill to Defend the Right to Sexual and Reproductive Health (2007).

(6.) Selios, L. "La opinion publica, la democracia representativa y el aborto" in: Abracinskas, L., Lopez Gomez, A., eds. Aborto en debate. Dilemas y desafios del Uruguay democratico (Montevideo: MYSU, 2007).

(7.) This approach is the context in which MYSU and the Psychology Department of the Universidad de la Republica conducted a training program for 250 professionals (nursing, psychology, social work and midwifery staff) from the Ministry of Public Health's services in "Sexual and Reproductive Health with an Emphasis on Preventing Teen Pregnancy" (2004). In 2005-2006, MYSU and the Departments of Psychology and Medicine at the Universidad de la Republica) trained some 250 medical professionals from the same services (Proyecto Infamilia, Mides--IDB).

For additional references, contact LACWHN's Communications and Publications Department at [e-mail].

Lilian Abracinskas serves on the board of Mujer y Salud en Uruguay (MYSU, Women and Health in Uruguay) and is the Executive Coordinator of CNS Mujeres por Democracia, Equidad y Ciudadania (Women for Democracy, Equality and Citizenship). Alejandra Lopez Gomez also serves on the MYSU board and is the Coordinator of the Free Course on Reproductive Health, Sexuality and Gender, Psychology Department, Universidad de la Republica. This article draws on some of the reflections published originally in "Problemas complejos, intervenciones integrales. Aborto inseguro, mortalidad de mujeres, reduccion de incidencia y ejercicio de derechos," in Briozzo, L., ed., Iniciativas sanitarias contra el aborto provocado en condiciones de riesgo (Montevideo: Ed. Arena, 2006).