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"The health exception": a means of expanding access to legal abortion.

Abstract: In most Latin American countries, abortion is not illegal if there is a risk to the life or health of the woman. This article discusses the process of expanding the interpretation of this "health exception" to mean that even the possibility of harm to health should make an abortion legal--which then becomes a mechanism for expanding women's right of access to safe abortion services. The article reports on an assessment of the impact of disseminating information on this interpretation of risk to health in Latin America, and how a regional process of debate and training of health service providers in 2009-10 has influenced the views and practice of health professionals in Argentina, Colombia, Mexico and Peru. The training included human rights arguments for applying the health exception in a comprehensive manner. All the respondents recognized the importance of interpreting risk to health as far more than the risk of death. Data from two clinics in Colombia also show an important increase in the number of women who had a legal abortion following this training. Dissemination of information and training on the health exception must continue--to protect women's right to health, reduce mortality and morbidity among those with unwanted pregnancies and encourage timely access to safe abortion services.

Keywords: abortion law and policy, risk to health, human rights, abortion providers and services, beliefs/norms/values, Latin America

Resume

Dans la plupart des pays d'Amerique latine, l'avortement n'est pas illegal en cas de risque pour la vie ou la sante de la femme. Cet article examine le processus d'elargissement de l'interpretation de cette << exception sanitaire >> pour signifier que meme la possibilite d'un danger pour la sante devrait rendre l'avortement legal, ce qui devient a son tour un mecanisme elargissant le droit des femmes a avoir acces a des services d'avortement sur. L'article rend compte d'une evaluation de l'impact de la diffusion d'informations sur cette interpretation du risque sanitaire en Amerique latine, et comment un processus regional de debat et de formation des prestataires des soins de sante en 2009-2010 a influence les idees et la pratique de professionnels en Argentine, en Colombie, au Mexique et au Perou. La formation comprenait des arguments fondes sur les droits de l'homme pour appliquer l'exception sanitaire sans restriction. Tous les repondants ont reconnu qu'il etait important d'interpreter le risque pour la sante comine bien davantage que le risque de deces. Des donnees de deux dispensaires en Colombie montrent aussi une nette augmentation du nombre de retomes ayant avorte legalement apres cette formation. La diffusion de l'information et la formation sur l'exception sanitaire doivent continuer, pour proteger le droit des femmes a la sante, reduire la mortalite et la morbidite en cas de grossesse non desiree et encourager un acces ponctuel a des services d'avortement sur.

Resumen

En la mayoria de los paises latinoamericanos, el aborto no es ilegal si la vida o salud de la mujer corren riesgo. En este articulo se trata el proceso de ampliar la interpretacion de esta "excepcion de salud" en el sentido de que el aborto deberia ser legal incluso cuando existe la posibilidad de danos a la salud, lo cual seria un mecanismo para ampliar el derecho de las mujeres a tener acceso a servicios de aborto seguro. El articulo informa sobre la evaluacion del impacto de difundir informacion sobre esta interpretacion del riesgo para la salud en Latinoamerica, y como el proceso regional de debate y capacitacion de profesionales de la salud en 2009-10 ha afectado los puntos de vista y practicas de profesionales de la salud en Argentina, Colombia, Mexico y Peru. En la capacitacion se plantearon argumentos de derechos humanos para aplicar la excepcion de salud de una manera integral. Todas las personas entrevistadas reconocieron la importancia de interpretar el riesgo para la salud como mucho mas que el riesgo de muerte. Los datos de dos clinicas en Colombia muestran un aumento importante en la cantidad de mujeres que tuvieron un aborto legal despues de esta capacitacion. Es imperativo continuar la difusion de informacion y capacitacion en la excepcion de salud para proteger el derecho de las mujeres a la salud, disminuir las tasas de mortalidad y morbilidad de las mujeres que tienen embarazos no deseados y fomentar el acceso oportuno a servicios de aborto seguro.

In 2008, the book Causal Salud: interrupcion legal del embarazo, etica y derechos humanos (The Health Exception: Legal Abortion, Ethics and Human Rights) was published, (1) as a result of a regional consensus among a wide range of people and institutions from different disciplines in Latin America. (2) The "health exception" refers to the risk to a woman's health if the pregnancy continues as a legal ground for abortion. The health exception has been interpreted in different ways in different countries. For instance, in some countries, it is interpreted to mean that a woman's life must be in imminent danger for the health exception to apply.

In this article, the health exception is understood to mean that the possibility or likelihood of an adverse effect on or harm to the woman's health if the pregnancy continued would make an abortion legal. According to the World Health Organization, the risk of an adverse effect is sufficient, the harm does not actually need to occur. (3) From this perspective, an expanded use of the health exception as a ground for abortion could have a positive impact in reducing mortality and morbidity in women with unwanted pregnancies, by facilitating timely access to legal abortion services.

Although the health exception has been in the penal codes and regulations of many countries in Latin America* for decades, (1) its application has been marginal, partly because of restrictive interpretations of the concepts of health, risk, life and autonomy. This restrictive interpretation gave rise to work by women's health advocates to expand the understanding of the scope of the health exception.

The discussion of the health exception was developed initially in Colombia after the Constitutional Court issued Judgment C-355 in 2006, which decriminalized abortion when the pregnancy is the result of rape or incest, when the life or health of the woman is at risk, and in cases of fetal malformation incompatible with life, when certified by a medical doctor. It was then taken up in other countries in the region, and in 2008, a virtual regional forum was created that served to build a common conceptual understanding of the health exception, its scope and interpretation within a human rights framework. The consensus interpretation we achieved includes the following:

* the right to health should be seen as interdependent with the right to life; this is necessary to ensure the continuity of a dignified life; (4)

* everyone has the right to health, that is, the highest attainable standard of physical, mental and social well-being, as outlined by treaties and human rights organizations; (5,6)

* the right to health gives content to the health exception, which means that physical, mental and social well-being are grounds for a legal abortion;

* the protection of the right to health assumes that other rights are also protected, such as the right to autonomy (the right to decide how much injury or impairment the person is willing to endure), the right to the full development of human personality and the right to information. (7,8)

A training guide was produced, and in 2009 training of trainers was carried out with health professionals, especially doctors, decision makers in the health profession, professionals in the public and private sectors, and civil society in Colombia by La Mesa por la Vida y la Salud de las Mujeres (La Mesa) ** and then by allies in Argentina, Peru and Mexico, among other countries. In addition, several online campaigns were conducted consisting of videos, a Wikipedia entry, and dissemination of information on key websites. There was also dissemination of information in academic and health professional association meetings, with the aim of sharing this conceptual framework with obstetrician-gynaecologists and general practitioners who provide abortion services, teach or manage health services. Although women seeking legal abortions continue to face multiple barriers, (9) the broadening of the interpretation and application of the health exception by health professionals has resulted in more women being able to have safe abortions when the pregnancy constitutes a potential health risk.

In 2012 La Mesa decided to conduct a qualitative assessment of the impact of disseminating this interpretation of the health exception (extent of understanding and views), and the changes it has led to in the practice of health professionals in the Latin American region.

Methodology

The assessment used two qualitative instruments consecutively: (i) a general questionnaire directed to all members of the virtual forum on the health exception and to professionals who participated in the first workshop for trainers organized by La Mesa in 2009; and (ii) a semi-structured questionnaire aimed at health professionals who were abortion providers and who participated in the discussions on the health exception or had received training on the health exception. In both questionnaires there was space for open answers. In addition, statistics were collected from two national-level Colombian institutions that have conducted training on the health exception for their personnel (some of whom were also interviewed individually). The goal was to obtain an estimate of access to abortion services through the application of the health exception.

Questionnaire I was sent to 47 people from Argentina, Brazil, Colombia, Spain, Mexico, Peru, Uruguay and the USA and was completed by 27 of them. This was a heterogeneous group, similar to the group working on the regional consensus (general practitioners, obstetrician-gynaecologists, lawyers, counsellors, midwives, psychologists, political scientists, bioethicists, sociologists). Questionnaire 2 was sent to 49 people and answered by 33 of them, from Argentina (10), Colombia (9), Mexico (2), and Peru (12). Only 28 of the respondents met the criteria of being direct providers of abortion services so only their responses were considered. This group were found through a snowball strategy among providers who had received training on the health exception. Forty-two per cent were obstetrician-gynaecologists; the others were mainly general practitioners and midwives. They were located mainly in cities outside their countries' capital cities.

Questionnaire I sought to identify specific actions developed to implement the health exception; the legal processes, arguments and health regulations that were used for this; information about the abortions performed under the health exception and training provided to service providers. Questionnaire 2 investigated the effects that the health exception arguments have had on professional practice and timely access to abortion, as well as the health risks to which the health exception was applied beyond the risk of death, and also in relation to rape, fetal malformation and teenage pregnancy. The views of the service providers in relation to women's reproductive autonomy and conscientious objection were also studied.

Regarding quantitative data, the number of abortions per year (starting in 2006 when abortion was legalized in Colombia) and the number of abortions where the health exception was applied (starting when the discussion of the health exception began in 2008, and ending in 2010 after training on the health exception had been conducted in each institution), were analyzed in two private institutions that operate on a national level. This information establishes a correlation between changes in the discourse and what has happened in practice in those two institutions.

The qualitative findings presented below are based on the descriptive responses of the interviewees with some discussion by the author.

Findings

Activities to disseminate the conceptual framework

Since 2008, the health exception has been the subject of conferences and workshops, and training courses for physicians, health service managers, counsellors, nurses, midwives, feminists and lawyers in Argentina, Colombia, Spain, Mexico, Peru and Uruguay. In Peru, training was conducted in hospitals in the cities of Junin, Ayacucho, Cusco, Piura, Trujillo and Lima, with the aim of drafting protocols for therapeutic abortion provision based on the health exception. In Mexico, there is a network of 15 lawyers from 12 states who work on cases of violation of rights when a woman is denied a legal abortion. With the training given, the lawyers obtained the tools to identify cases of wrongful denial of services or to support the inclusion of the health exception in the laws of Mexican states where it is not currently considered. In Argentina and Colombia abortion services have been provided under the health exception and the use of the health exception has been promoted at subnational levels in Argentina, Colombia and Mexico. Academic articles have been written about it (Personal communication, a lawyer, Argentina). The original book has been disseminated and adapted for diverse audiences--women, scientific societies, media, legal professionals and health authorities in Argentina, Colombia, Mexico and Peru.

Litigation has been conducted in Colombia and legal arguments developed for cases in which women request an abortion on the grounds of the health exception. La Mesa has carried out particularly important work to defend the right of access to legal abortion on the grounds of risk to health on behalf of 400 women who have been denied a legal abortion in Colombia in the last five years.

Training sessions for public officials at the State level were conducted on how to develop protocols on therapeutic abortion based on the health exception, which also included information on law reform and the analysis of maternal deaths from complications of unsafe abortions in Argentina, Colombia, Spain, Peru, Uruguay. Lastly, the International Planned Parenthood Federation Western Hemisphere Region created a regional work strategy for the health exception, and have trained management and technical teams from five of their member associations. They also translated the health exception position statement into English (www.despenalizaciondelaborto.org.co/IMG/pdf/Health_exception-2.pdf.).

Regarding legal arguments made on the grounds of the health exception, two decisions by the Constitutional Court of Colombia have made use of the arguments contained in the regional consensus, which has contributed to wide application of the health exception in Colombia. In the case of ruling T-585/10, the Court's arguments were consistent with the health exception and in ruling T-841/11 those same arguments were used after an advocacy process led by La Mesa. In the latter judgement the Court recognized that: (i) health is a comprehensive concept that includes not only physical but mental aspects; (ii) it is not necessary for a risk to life to exist and that there is enough reason to allow access to abortion if there is a threat to health; and (iii) it is important to respect women's reproductive autonomy.

In Peru, these arguments have been taken into account in the development of the Ministry of Health's National Therapeutic Abortion Protocols for abortion service providers, in response to the recommendations made to the State by CEDAW in the case of KL v. Peru, and in the debates on the modification of the penal code. (10,11) In Mexico, the arguments have been used to try to reform the law to include the health exception in the states of Colima and Puebla, successfully in the former, unsuccessfully in the latter, according to an interviewee from Equidad de Genero, a member of ANDAR (National Alliance for the Right to Decide).

The health exception has also been the subject of regulatory efforts in Argentina, including the creation of a comprehensive care guide on non-punishable abortions in Argentina in 2010, in provincial health regulations in the province of Santa Fe, and in the legal framework of the province of Chubut. The arguments have also been used in the development of the national protocol for the prevention of unsafe abortions in Colombia (pending publication by the Health Authority), and in the State of Guerrero, Mexico, in the general guidelines for the organization and operation of legal abortion services. These initiatives are the responsibility of ministries of health, departments of health and the heads of departments in hospitals. The regulations cover both public and private health services in Colombia, Argentina and Mexico, but only public health services in Peru.

Understanding and applying the health exception

The key concepts of the health exception are to do with the meaning of risk, of health as an integrated concept, the use of the health exception for adolescents, and the relationship between risk to health, rape and fetal malformation. These concepts were explored with our interviewees along with their understanding of autonomy and conscientious objection. Overall, in the countries of those interviewed, the existence of the health exception offers a form of certainty for professionals trying to apply the concepts involved in a comprehensive manner.

All of those interviewed recognized the health exception as a conceptual framework for improving access to legal abortion, enabling more timely care for women, extending the interpretation of health risks beyond the risk of death, and also increasing the number of women assisted.

"In absolutely no way should one wait until harm has occurred. The health exception should be considered when there is a risk to the welfare of the woman, whether it be physical mental or social." (Medical epidemiologist, Antioquia, Colombia)

In relation to risk, the mere presence of risk, and not only a serious risk, or a doubt regarding potential harm, should be enough to apply the health exception. In general, it was agreed by those interviewed that a woman facing an unwanted pregnancy is already at risk and that for her, waiting for the consequences of the continuation of pregnancy to manifest itself would amount to expecting a heroic act on her part. Despite the progress related to a better understanding of health risks, however, there are still some professionals who believe that in certain situations (situations where there is some doubt about the certainty of harm to the woman), there should be interdisciplinary committees to help make these decisions.

For over 93% of those interviewed, the health exception should be applied whenever there is a possibility of physical, mental or social harm. As regards pregnant adolescents, it is argued that the health exception should always be applied because pregnancy poses physical risks and will have a great impact on the life plans of every adolescent. Additionally, it is recognized that it is important to provide safe abortion services to avoid the complications of an unsafe abortion. For some providers, it is important to obtain parental consent or the consent of a legal guardian, as appropriate for each case.

The application of the health exception when a woman's mental health is affected is considered by providers as part of a comprehensive understanding of the concept of health. As such, this risk makes the application of the health exception necessary for preserving health in a broad sense (and preventing suicide) without it being necessary to have a history of psychiatric illness or a psychiatrist's assessment. For these service providers, in general, the application of the health exception to protect mental health does not require a psychiatric assessment. It is enough to consult a psychologist, general practitioner or specialist. However, a small group did consider it necessary to have a diagnosis from a psychiatrist or a specialist.

Some of the reasons that justify the application of the health exception are when there is anxiety, low self-esteem and psychological pain. All of these feelings can be related to emotional suffering resulting from an unwanted pregnancy and are all examples of mental health risks. It is not necessary to be diagnosed with a "psychiatric illness" for there to be a risk to mental health.

"There is no need to be mentally ill. It is enough that the pregnancy is unwanted for there to be a risk." (Obstetrician and forensic expert, Trelew, Argentina)

The health exception also allows doctors to link health with other situations, such as fetal malformation and rape, both of which affect women's health. In general, the health service providers considered rape as affecting mental and physical health, including complications such as sexually transmitted infections, as well as a violation of rights that affects the social dimension of health. This means that the health exception should be applied in cases of rape. Also, the fact that a woman was assaulted implies that she should not be forced to continue with the pregnancy. In this case, respect for the autonomy of the woman is emphasized and access to legal abortion can help to minimize the fear associated with reporting a rape, and to reduce shame and the obstacles women face when seeking legal help.

With regard to fetal malformation, there is the possibility of psychological trauma for a woman facing the prospect of either stillbirth, almost certain death or little chance of survival after delivery, or little or no chance of quality of life. Severe fetal malformation was recognized as having repercussions for a woman's emotional health and that abortion can prevent possible harm in this health dimension, without the malformation necessarily being incompatible with life. In addition, some malformations arise from conditions that also affect the woman's health. These situations give particular importance to women's right of autonomy in deciding whether to continue the pregnancy.

"If it is possible to avoid, no woman wants to see her child suffer." (Obstetrician, Lima, Peru)

Finally, the effect of an unwanted or unplanned pregnancy on a woman's life plans is considered to be part of risk to health in the comprehensive sense of this concept. In these cases, the mental and social dimensions of a woman's health are affected and the denial of abortion violates her right to determine her own life. Only one of the abortion providers did not agree that the impact on life plans justified abortion, because the woman does not have the right to determine her life plan if it results in the "loss of another life". It was also argued that this perspective meant abortions could be done for any reason. Indeed, this is the area for which it is most difficult to argue for the application of the health exception. *** However:

"... the simple fact that [the pregnancy] affects a woman's life plans means that it also affects her emotional health". (Physician, Cali, Colombia)

This is closely related to the perception that the health exception must be interpreted beyond the scope of the traditional illnesses that have been used to allow "therapeutic abortion". Expanding and extending the concept of health to include the psychological, mental and social aspects also expands broader concepts of illness and well-being.

Arguments from authorities, especially arguments emanating from international human rights frameworks and included in the health exception framework, are very important for professionals. They may use them to promote care for women who seek to terminate a pregnancy to ensure their health. These arguments have served to promote the establishment of services in hospitals, even helping to overcome restrictions established in national regulations and have also served for the consolidation of models of care based on respect for sexual and reproductive rights.

"All women have the right to decide at what moment in their lives they want to be pregnant and whether that pregnancy affects them physically, psychologically or socially. In any case, it is better to let the woman decide." (Midwife, Chimbote, Peru)

Belief that women should make the decision

Given the importance that respect for the autonomy of women has in the health exception conceptual framework, it is important to note that all of the doctors interviewed believe that women should make the decision about abortion when their health is at risk. The woman is the one who has to decide how much risk she is willing to assume and how much injury she is willing to accept.

"If we do not require people to give blood against their will, why can a woman be asked to risk her life in childbirth?" (Obstetrician, Trelew, Argentina)

In this sense, it is the duty of professionals to provide all the relevant information. Only one of the persons interviewed openly expressed the opinion that there are two unique cases where this decision cannot be made exclusively by the woman. One is when the woman displays an obvious psychiatric disorder. The other is when the case involves a minor and where legal consent of a parent or guardian is legally required. Whether or not such consent should be required (it is not always required in every country) is still often a matter of contention.

The place of conscientious objection

Finally, with regard to conscientious objection when the ground for abortion is the health exception, more than 60% of interviewees thought that whoever is asked to provide abortion on health grounds, or grounds of rape or fetal malformation, has an ethical duty not to object. This idea is much more emphatic when it comes to public services or to professionals devoted to sexual and reproductive health, where conscientious objection was not considered an option by the majority of respondents. However, some considered that conscientious objection must be respected as a right, but accompannied by a guarantee that there are mechanisms in place to ensure timely referral to safe care for women. This means preventing conscientious objection from becoming an obstacle to access. There was one exception to conscientious objection agreed, that is, in cases of emergency, for which women should receive immediate care.

Q: "Do you believe there are reasons that justify a provider of sexual and reproductive health services in claiming conscientious objection when the health exception is applied?"

A: "No. It is a woman's right and a physician's ethical duty to provide the service." (Obstetrician, Mexico City, Mexico)

In brief, the level of discourse, the understanding of the concept of the right to health and their application in the health exception were clearly reflected in this group of service providers. If confronted with any doubt about what to do, the emphatic answer was that they would agree with the interpretation that best favoured the health of the woman. It seems that through the expansion of the health exception, many of the providers interviewed were maximizing the public good, protecting women's integrity, respecting their authority, allowing them to enjoy the right to sexual and reproductive health, and protecting their health. In contrast, they believed that a restrictive interpretation might restrict human rights, in this case the right to health.

Measuring the effect on service delivery

To show the impact of work on the health exception, quantitative data were analyzed from Orientame and Profamilia, two NGOs that specialize in the provision of sexual and reproductive health services in Colombia. In the case of Orientame, Table I shows that in 2006-2008, after abortion was partially decriminalized by the Constitutional Court, (4) most of the legal abortions were on grounds of sexual violence. There was a dramatic change in 2009, when the number of legal abortions rose dramatically and almost all of them were based on the health exception, alongside a similar number of cases on grounds of sexual violence as in previous years. This change can be explained by the introduction of training on the health exception in this institution and its application.

With Profamilia, Table 2 shows that the same trend can be observed as with Orientame, that in 2010 the number of legal abortions began to rise after training on the health exception was introduced.

Conclusion and recommendations

In 2008, when a group of allies in Latin America decided to initiate a process of promoting understanding of the health exception in accordance with protection of the right to health, the intention was to ensure its full implementation in favour of timely access to abortion services. In Colombia, the partial decriminalization of abortion was particularly important in advancing this initiative, given that one of the three exceptions was the health exception.

The findings confirm that this work has helped service providers to interpret the health exception within a human rights framework, consistent with protection of the right to health, and has also served to increase women's access to abortion on health grounds, as observed in the data from Orientame and Profamilia.

To further this work, the following should be continued and expanded to more countries:

* the dissemination of information and materials on the health exception;

* training for service providers, decision makers, medical students, women and academia;

* improving the documentation of the reasons for the health exception in clinical records to show the extent to which it is applicable;

* initiating a deeper analysis of the need for protection of health on social grounds, as this is the most difficult for health professionals to recognize and support;

* documenting cases where the health exception is denied to women and showing how this violates their human rights;

* promoting the health exception model to increase access to abortion on other legal grounds, thus moving towards greater recognition of the legitimacy of abortion--which is the most important condition for achieving the decriminalization of abortion.

"At the moment when I dared to start performing abortions, the only things I took into consideration were a woman's free will and respect for her autonomy." (Obstetrician and Forensic Expert, Trelew, Argentina)

Doi: 10.1016/S0968-8080(12)40668-1

Acknowledgements

Special thanks to the members of La Mesa; Carolina Melo Arevalo, Cristina Villarreal and Beatriz Quintero; each of the 60 people who responded to the questionnaires and to everyone who has been working since 2007 to ensure that the "health exception" is applied in a comprehensive manner consistent with human rights.

References

(1.) Gonzalez Valez AC, Duran J. Causal salud: interrupcion del embarazo, etica y derechos humanos. Montevideo: La Mesa por la Vida y la Salud de las Mujeres/Colombia, Alianza Nacional por el Derecho a Decidir/Mexico y Federacion Latinoamericana de Sociedades de Obstetricia y GinecologialFLASOG; 2008.

(2.) Gonzalez Valez AC. La construccion de un consenso: la causal salud en America Latina. Buenos Aims: CEDES; 2009.

(3.) World Health Organization. World Health Report: Reducing Risks, Promoting Healthy Life. Geneva: WHO; 2002.

(4.) Corte Constitucional de la Republica de Colombia. Sentencia C-355 de 2006.

(5.) Hunt P. Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Human Rights Commission. 60th Session. Theme 10 provisional programme. EICN.412004149. United Nations; 2004.

(6.) World Health Organization Constitution, adopted during the International Health Conference, New York, 1946.

(7.) Committee on Economic, Social and Cultural Rights. General comment No. 14. The right to the highest attainable standard of health. Art. 12.22nd Session, 2000. E/C.121200014. United Nations; 2000.

(8.) Article 19. Association for Civil Rights. Access to information: an instrumental right for empowerment, 2007. www.article19.org/pdfs/publications/ati-empowerment-right.pdf.

(9.) Situacion de la obligacion de los Estados de adoptar medidas para garantizar sin discriminacion el derecho de toda mujer al goce del mas alto nivel de salud reproductiva. Acceso al Aborto legal y seguro. Bogota: La Mesa por la Vida y la Salud de las Mujeres; July 2012.

(10.) UN Human Rights Committee. Opinion on the case of Karen Noelia Llantoy Huaman v. Peru. Communication No. 1153/2003. United Nations; 2005.

(11.) Kismodi E, Bueno de Mesquita J, Andion Ibanez X, et al. Human rights accountability for maternal death and failure to provide safe, legal abortion: the significance of two ground-breaking CEDAW decisions. Reproductive Health Matters 2012;20(39):31-39.

(12.) Ministerio de Salud Publica del Uruguay. Ordenanza 369 de 2004.

* Argentina, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, Guatemala, Mexico, Panama, Paraguay, Peru, Uruguay and Venezuela have an established health exception, allowing abortion to protect a woman's health or life.

** La Mesa (Advocates for Women's Life and Health) is comprised of individuals and organizations advocating the decriminalization of abortion in Colombia. It was one of the driving forces in the formation of a regional consensus on the health exception and one of the main organizations that has promoted training on the health exception with its allies, both nationally and internationally (www.despenalizaciondelaborto.org.co/).

*** In such cases, the harm reduction model, advising women on the use of misoprostol, can be applied. The harm reduction model has been adopted in countries such as Uruguay and Argentina. (12) Its goal is to reduce the harm of negative effects from unsafe abortions. It includes a pre-abortion consultation (information about induced abortion in risky conditions, and services such as the use of prophylactic antibiotics and how to use misoprostol properly). The woman decides what she will do and acts alone. In a post-abortion consultation, the aim is to confirm that the pregnancy has ended, detect any complications and provide contraception.

Ana Cristina Gonzalez Valez

Consultant; External researcher, CEDES, Buenos Aires; member, La Mesa por la Vida y la Salud de las Mujeres, Bogota, Colombia. Correspondence: acgonzalez@adinet.com.uy
Total 1. Total numbers of abortions by legal grounds, 0rientame,
Colombia, 2006-2011

                         2006   2007   2008   2009   2010    2011

Total abortions             7     29     55    858   2,112   4,066
Risk to health or life      2      6     31    844   2,093   4,052
Sexual violence             5     23     23     11      19      13
Fetal malformation          0      0      1      3       0       1

Table 2. Total numbers of abortions by legal grounds,
Profamilia, Colombia, 2006-2011

                         2006   2007   2008   2009   2010    2011

Total abortions             0      2     13     17    382   1,349
Risk to health or life      0      0      7      3    353   1,321
Sexual violence             0      2      6     14     29      28
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Author:Velez, Ana Cristina Gonzalez
Publication:Reproductive Health Matters
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Geographic Code:3COLO
Date:Nov 1, 2012
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