Introduction
After decades of mobilization and advocacy to make abortions safe and legal, some countries in Latin America and Asia have recently introduced important changes to abortion laws, making it legal under specific criteria such as health risks and pregnancy weeks.
We celebrate these changes – especially in a Post-Roe era – as they recognize abortion as a fundamental right for women and people with the capacity to gestate. However, in this piece, we want to highlight the barriers that women face when seeking an abortion, even when it is legalized. In doing so, we want to emphasize the importance of the nuances that existing policies have and that having an act that says abortion is accessible does not mean it always translates on the ground.
In the next part of this article, we will share the main grounds on which abortion is legal, followed by a section on the barriers faced in accessing abortions, with specific examples from Argentina, Colombia, India, and Nepal. Finally, we will close with some initiatives led by civil and grassroots organizations that have supported the access to safe abortions on the ground.
Abortion around the world
Globally, abortion is a common medical procedure. Out of 121 million unintended pregnancies occurring annually between 2015 and 2019, 61% ended in abortion. This translates to 73 million abortions per year. Abortion is a fairly common and safe health intervention, when carried out using the method recommended by WHO, under suitable medical conditions and certified doctors. Nonetheless, global estimates demonstrate that 45% of all abortions are unsafe. This is a critical public health and human rights issue, as unsafe abortion is increasingly concentrated in developing countries (97% of unsafe abortions) and among groups in vulnerable and marginalized situations. The legal status of abortion makes no difference to a woman’s need for an abortion, but it dramatically affects her access to safe abortion. Between 4.7% and 13.2% of all maternal deaths are attributed to unsafe abortions, which equates to between 13,865 and 38,940 deaths caused annually by the failure to provide safe abortion. Simply put, unsafe abortions are a leading cause behind maternal death rates which are preventable.
The three cornerstones of an enabling environment for abortion care are: (1) respect for human rights including a supportive framework of law and policy; (2) availability and accessibility of information, and (3) a supportive, universally accessible, affordable, and well-functioning health system.
According to the WHO, there are six main grounds for abortion that are used as the basis for the law in most countries: risk to life, rape or sexual abuse, serious fetal anomaly, risk to physical and sometimes mental health, social and economic reasons, and on request. The table below summarizes what are the grounds in which abortion can be legal in the countries of analysis.
| Grounds for abortion* | Argentina | Colombia | India | Nepal |
| Risk to life | Y | Y | Y | Y |
| Rape or sexual abuse | Y | Y | Y | |
| Serious fetal anomaly | Y | Y | Y | Y |
| Risk to physical and sometimes mental health | Y | Y | Y | Y |
|
Social and economic reasons |
Y | Y | N | Y |
| On request | Y | Y | N | Y |
*Some of these are available based on conditions such as weeks of gestation
In Latin America, Argentina and Colombia have recently moved from partial decriminalization of abortion to the legalization of abortion on request. In Argentina the Congress approved the Law 27.610 ‘Access to Voluntary Interruption of Pregnancy’ or IVE in 2020, allowing abortion on request till up to 14 weeks of pregnancy – while maintaining the three previous grounds (rape, risk to life or health of the pregnant person) as before.
In Colombia, abortion was partially decriminalized in 2006 under three grounds: rape, fetal malformation and when the woman’s health is in danger. In cases an abortion did not meet these criteria, both women and doctors could be sentenced to up to 54 months in prison. More recently, in 2022, the Constitutional Court made abortion legal on request up to the week 24 of pregnancy, making it the country with the most liberal regulation regarding abortion in the region.
According to the Center for Reproductive Rights global map of abortion legislation, India has one of the most liberal abortion laws among Asian countries, allowing abortion on the grounds of several physiological and social reasons, in addition to women’s health, rape cases and fetus anomalies.Legalized in 1971 by the Medical Termination of Pregnancy (MTP) Act, the law allows the procedure on women until week 24 of the pregnancy. However, single or unmarried women struggle to access safe legal abortions, as there is a socio-cultural pressure on them to seek the permission of parents or a partner in some cases. In the cases of abortion for married women, due to the unrecognized nature of marital rape women often seek abortion services in unauthorized facilities or at home. As a result, unsafe abortions are the third leading cause of maternal mortality in India, and close to 8 women die from causes related to unsafe abortions each day, according to the United Nations Population Fund (UNFPA)’s State of the World Population Report 2022.
In Nepal, the Safe Motherhood and Reproductive Health Rights (SMRHR) Act was passed in 2018 which broadened the grounds on which abortions were available. This included up to 12 weeks with the consent of the woman and up to 28 weeks in cases of rape, incest, or cases of health concerns, physical or mental, threat to life, or fetal anomalies.
Barriers to accessing safe abortion
Despite the legalization of abortion on several grounds – including legalization on request – women and individuals who gestate can face multiple barriers when it comes to accessing a legal, safe abortion, which we have broadly categorized in four forms described below.
The first barrier highlights the lack of information (or misinformation) about the legal status of abortion, especially in countries where regulations have recently changed. This barrier particularly affects vulnerable women who might not be aware of their rights, as well as health providers who fear repercussions from the judicial system.
An example of this is prevalent in Nepal. The 2016 Demographic and Health Survey in Nepal found that 41% of women in the age of 15-49 were aware of the legal status of abortion and only 23% knew that abortion case be obtained up to 12 weeks for any reason. There was further lack of awareness on where they can seek abortion, and that the service is available for free at public health centers. This lack of awareness leads to reliance on unapproved providers at exorbitant costs, and many times even cheap but unsafe procedures.
There are some tools that can narrow this information barrier. Since 2010, Argentina has a hotline run by the Ministry of Health that provides sexual health information and counseling, including support and referrals to those seeking abortions. Between January and November 2021, the hotline received 19,000 consultations about abortions (in contrast to the 80,000 inquiries registered between 2010 and 2020). The government, with support of abortion rights organizations, has also incorporated topics about body autonomy and abortion in the school curricula, emphasizing it as a right for women and individuals who gestate (Mason-Deese, 2022).
The second barrier is linked to the country’s regulatory framework, when laws do not provide clear information on abortion procedures or allow arbitrary interpretations. “La Mesa por la Vida y la Salud de las Mujeres” (henceforth La Mesa), a grassroot organization in Colombia that helps women accessing legal and safe abortions after they have faced challenges in the access through the public system reports that health care facilities refer women seeking an abortion to different specialties (psychology, social work), which usually end in an unjustified dilation of the procedure. Additionally, 21% of abortions are denied due to the women’s number of pregnancy weeks, whereas according to the law, abortion after 24 weeks is still legal under the preliminary grounds of rape, women’s health and fetus malformation.
Similarly, in Nepal, while there exists a new act for sexual health and reproduction that allows for abortion under a range of cases, the penal code still specifies older limits to performing abortions. A critical difference is that while the Penal Code allows for abortions until any stage if the pregnancy poses a risk to a woman’s life, there is a limit of 28 weeks in the SMRHR Act for any such case.
The third barrier refers to the challenges in service delivery on ground, mostly related to the structural inequities in the healthcare system; including lack of adequate staff and medical facilities in rural areas, scarce or deficient referral processes; limited clinical options; and mistreatment from health workers. In Argentina, the provision of safe abortions in poor and rural regions is still a challenge due to the lack of trained and adequate staff. For example, in Tartagal, a city of 75,000 inhabitants, there is only one medical professional willing to provide abortions (Liz Mason-Deese, 2022). Additionally, barriers to accessing ultrasounds services during the early stages in the pregnancy can influence the person’s decision about having an abortion.
Another article describing the struggles to implement abortion in Colombia highlights the lack of training for physicians during their medical education to carry out abortions; especially during the second trimester of pregnancies (Stifani, et. al., 2018).
Finally, the fourth barrier is linked to social, religious and cultural motivations that stigmatize abortion, among those who seek it and those who provide it. Social stigmas hamper access to abortion in many ways. Shame in seeking physical and emotional support, doctors denying procedures in some cases or needing the involvement of a parent or partner are some ways in which this occurs. For instance, in India, multiple socioeconomic inequalities and cultural stigma add to the difficulties for a women left with an unwanted pregnancy. These challenges deter many women from accessing the care that is their right. A similar socio-cultural phenomenon takes place in Nepal as well, with women not seeking services because of cultural barriers or factors such as lack of autonomy.
In Argentina, anti-abortion activists have filed lawsuits in at least 10 provinces seeking to have the law 27.610 be declared unconstitutional. In Chaco, a conservative province, the judge issued a preliminary injunction blocking the law from taking effect for at least two months before it was revoked by a higher court. Especially in conservative and rural areas, these groups are making sure that doctors know that they can refuse to terminate pregnancies, thus promoting stigma and fear among women who seek an abortion in these regions (Politi, 2021).
Relevance of grassroots initiatives
Despite multiple legal and cultural barriers, some grassroots organizations and movements have been influential in improving and strengthening access to abortion on the ground.
Mirar Project in Argentina
The Mirar Project is a civil society observatory that monitors the implementation of Law 27.610. Coordinated by the Center for the Study of State and Society (CEDES) and Ibis Reproductive Health, the Mirar Project works on five different actions: data collection and systematization of abortion indicators, context-specific research, dialogue with key actors and stakeholders, national and international dissemination of abortion regulation in Argentina, and compilation of lessons learned on the implementation of the Law 27.610.
In 2021, the Mirar Project launched the first report aimed to inform about the progress and challenges of the implementation of the IVE in its first year of legalization. The report includes statistics about the supply, availability of abortion services and the context, both legal and socio-sanitary, in which the law it is being implemented. In addition to numbers, the Mirar report compiles the testimony of key participants in the implementation process, including actors at the national and local level, health care providers, members of the civil society, and experts in issues related to the field of justice.
La Mesa por la Vida y la Salud de las Mujeres in Colombia
La Mesa is a group of non-profit organizations and individuals that provides legal counseling and support to women who are denied or have faced difficulty obtaining legal abortions. Its efforts positioned La Mesa as a legal expert and interpretation of the abortion law, and its advocacy work led the Constitutional Court to issue at least 15 other decisions to protect Colombian women’s access to abortion (Stifani et. Al., 2018).
Additionally, during the legalization of abortion in the country, La Mesa played a key role assisting the Ministry of Health in developing clinical protocols and guidelines for the implementation of the procedures.
Pratigya Campaign in India
The Pratigya Campaign constitutes a group of organizations and individuals who are working towards protecting and advancing women’s access to safe abortion care in India. They work with governments, organizations and media at the national and state levels. They take a multipronged approach, including engaging with providers to understand existing Medical Abortion (MA) service provision practices and evolve standardized and practical guidelines for MA use; working on data from the census and devising strategies to address adverse impacts of declining sex ratios; advocating with various government organizations for amendment to MTP Rules to allow for various interim measures to ensure greater access to safe abortion care and medical support, such as providing drugs, more clinics etc. More specifically for advocacy, they work to facilitate engagement with media on sexual and reproductive rights and ensure that abortion issues find a place in the Indian media landscape on a regular basis. They review existing media guidance available on abortion and adapt it to local contexts; translate it into local language and disseminate it widely, helping make information more easily accessible in a country where languages vary from state to state.
Conclusions
These datapoints and existing factors at play demonstrate that legal norms alone are insufficient in guaranteeing access to abortion. Barriers to abortion can come from different sources, including the lack of information about regulation changes, interpretations of the law, social barriers and the inequality in health care services. Consistent monitoring and advocacy for reproductive health services are essential. A critical feature across all countries we discussed here has been the active role of civil society organizations in advocating for and making information available on sexual and reproductive rights—especially for abortion services. In the global context, major nations like the US overturning laws that protect these rights turn back many years of efforts in the fight for access to abortion, because despite legalization in many countries, there are many other hurdles people have to overcome to seek safe and legal abortions.
In the case of abortion, which is a basic human right for people, information gaps continue to persist due to various reasons in both regions. For this reason, dissemination of information becomes critical. While civil society plays a large role in filling this gap, their efforts must be complemented with a more centralized effort to make information on procedures, costs, legality, and accessibility remain in public knowledge.
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