This study examined the experiences of women who obtained legal abortion care through the public sector in Uruguay following decriminalization. The vast majority of women felt that abortion should be the right of every woman, yet most believed it was still difficult to obtain. Some women feared judgement from providers before they arrived at care, and others felt negatively towards themselves or other women who seek abortions. Abortion stigma has not been well documented in Latin America. The data presented here contribute to the field by elucidating the internalized, feared, and enacted stigma experienced by women seeking legal abortion services in Uruguay, as well as their beliefs about the abortion law.
While most participants in this study reported receiving non-judgmental abortion care, nearly one quarter of women said they felt judged by a hospital staff member during their recent service. They reported experiencing this judgement while receiving services and at the reception. A qualitative study in 2014 at the same hospital in Uruguay also found that hospital staff can perpetuate stigma and obstruct access to care; this applies in particular to staff who are not on SRH teams, such as sonographers [17]. Research in Colombia similarly found that women seeking legal abortion services may fear and experience mistreatment and stigma [27], and nearly one third of women in a study in Cape Town, South Africa, reported seeking abortion care outside the formal care sector due to worries about stigma and mistreatment from health care providers [28]. These findings indicate the importance of sensitizing staff across administrative and service provision teams to reduce their discriminatory behavior towards women seeking care. This is particularly relevant given the model of public sector service provision in Uruguay, which integrates abortion care with other services in a hospital setting. This model requires that women interact with hospital staff, such as ultrasound technicians or receptionists, who do not work exclusively on abortion care and may be less supportive of the right to abortion. In 2013, Iniciativas Sanitarias, through an agreement with the Ministry of Health and the Administration of State Health Services, implemented training and sensitization with hospital staff in the public sector in Uruguay. They changed hospital protocol to limit the interaction of abortion clients with personnel external to abortion provision. Periodic assessments of women’s experiences in care can inform the development of additional strategies to mitigate the risk of enacted stigma towards women who seek abortion.
It is noteworthy that women in this study who had more than one abortion in their lifetimes had three times the odds of feeling judged while obtaining abortion care than those seeking their first abortion. A qualitative study in the same hospital in 2014 found unfavorable attitudes towards women who have more than one abortion among both health professionals and abortion clients [17]. These qualitative findings together with our quantitative results suggest that stigma towards women with more than one abortion may have affected women seeking care at the CHPR at the time of the study. Given concerns that a focus on preventing “repeat abortion” carries with it negative judgement of abortion, it may be that the “repeat abortion prevention policy” implemented at the CHPR exacerbated this particular aspect of abortion-related stigma. This policy, which entails provision of post-abortion contraception, is still being implemented at the hospital. While this is a common public health approach, the framing around preventing “repeat abortion” may contribute to abortion stigma [19], in Uruguay and elsewhere.
Most women in our study expressed perceived stigma in the form of concerns about being judged by others in their community for having an abortion. The data suggest that younger women were more worried about being judged than older women. This is similar to findings in Nigeria that younger women have higher levels of individual-level abortion stigma [26]. Studies in different contexts have also found that women anticipate judgement for seeking abortion, and that fear of judgment may impede access to safe abortion care [17, 20, 29, 30]. Healthcare facilities can play a role in supporting women who experience stigma or anticipate judgement [29]. For example, counseling can help women address feelings of self-judgement and identify coping strategies. In addition, information, education and communication activities could convey the message that everyone is welcomed for non-judgmental care and that young people have the right to equal access to health services by law.
Women in this study also tended to have moderate to high levels of internalized stigma in the form of self-judgment or feeling guilty about having an abortion. Some also expressed negative attitudes towards women who have abortion, by, for instance, saying that they were irresponsible. These findings are consistent with qualitative results from the same hospital in Uruguay indicating that women felt guilt and other negative feelings about their own abortion; they also strongly judged other women who sought abortion, particularly those with more than one abortion [17].
This was the first time, to our knowledge, that the ILAS was adapted for abortion clients in Latin America. While our findings may not be directly comparable due to differences in context, it is noteworthy that the mean score was higher (indicating greater stigma) in Uruguay on both sub-scales compared to findings from the United States in 2011 [24]. The internalized and perceived stigma measured by the ILAS are likely influenced by social norms. In this study, perceived and internalized stigma in care were more commonly reported than enacted stigma. This may reflect that health care providers had already been trained to provide accurate information and counseling on safer methods of pregnancy termination through the harm-reduction model implemented at the CHPR since 2001. As such, hospital staff had already been sensitized on the topic of safe abortion for 11 years before decriminalization, whereas the women in this study may have only encountered public discourse about the topic in the short period since decriminalization. Because it takes time to shift social norms, hospital staff likely had more opportunity for gradual change in their beliefs about abortion, whereas the general population in Uruguay was still early in that process. In their 2014 qualitative study in the CHPR, Cárdenas et al. found that both abortion clients and providers believed that the legal change had favorably influenced Uruguayan perspectives about abortion [17]. As time passes after the legal change, social norms in Uruguay may continue to gradually shift in favor of abortion access, as has been shown in Mexico City [31]; this may eventually reduce women’s experiences of stigma when seeking care. Future studies could explore whether and why women’s experience of abortion-relation stigma have changed over time in Uruguay.
While women in this study tended to agree with the abortion law in general, some disagreed with particular components. Many found the five-day waiting period to be unnecessary; these findings are similar to studies in the United States where women reported little conflict in their decision to seek abortion and highlighted potential negative effects on their emotional well-being as a result of the waiting period. One study in the United States found that waiting periods can increase logistical and financial barriers to care [32]. A substantial group of women in our study (40%) felt that the gestational age limit should be lower than the current limit, which is consistent with findings in other contexts that women who seek abortion care may nonetheless support limiting access to this service for others [33]. The survey did not ask participants the gestational age at the time of their own abortion, which limits analysis of variations in their attitudes by this indicator. However, we postulate that the support among some participants of an earlier gestational age limit in Uruguay relates to their experiences of internalized stigma or judgment towards other women who seek abortion, as described above.
While few participants in this study knew that conscientious objection was legal, the majority of women believed it should be permitted. Conscientious objection and refusal by physicians can have consequences on women’s access to services despite decriminalization, particularly in areas with limited abortion providers such as outside of metropolitan areas. For example, while most hospitals in Uruguay report compliance with the current law, all gynecologists in one province objected after the law changed, essentially denying access to women who could not travel to another province [9]. Majority support for the general concept of conscientious objection even among abortion clients points to the importance of establishing strong referral networks in case of refusals. Additional research is currently being conducted on conscientious objection in Uruguay from the perspective of providers; however, further research is needed on client perceptions about this topic in different contexts.
This study has some limitations. First, the data presented here were gathered in 2014, just after decriminalization, and may not reflect current experiences with or attitudes towards abortion in Uruguay. Second, this study describes women’s beliefs about their abortion immediately after their service but does not address whether and how these may shift as time passes after their abortion. Third, the survey did not gather data on participant religion, religiosity, or gestational age at abortion, which might have helped us better understand the factors associated with different beliefs about abortion. Fourth, only women 18 years of age or older were eligible for this study for ethical reasons, thus, we did not capture the experiences of those younger than 18 years. In addition, over one third of recruited clients were lost to follow-up. While this level of loss to follow-up is within the expected range for clinical or public health studies, women who did not participate in follow-up interviews may systematically differ from those who did, which may bias the findings and conclusions of the paper.
