Social Science & Medicine 261 (2020) 113220

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Social Science & Medicine

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“Obviously there is a conflict between confidentiality and what youare T required to do by law”: Chilean university faculty and student perspectives on reporting unlawful ∗ Alejandra Ramma,b, , Lidia Casasc, Sara Correab, C. Finley Babad, M. Antonia Biggsd a Escuela de Sociología, Universidad de Valparaíso, El Litre 1028, Valparaíso, Chile b Instituto de Investigación en Ciencias Sociales (ICSO), Universidad Diego Portales, Chile c Centro de Derechos Humanos, Facultad de Derecho, Universidad Diego Portales, Chile d Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, CA, USA

ARTICLE INFO ABSTRACT

Keywords: Background and objectives: While Chile recently decriminalized in cases of rape, lethal fetal anomaly, Abortion and to save a woman's life, most abortions are still criminalized. We assessed medical and midwifery school Confidentiality faculty and students' views on punishing and reporting people involved in unlawful abortion, and their un- Healthcare systems derstanding of their obligation to protect patient confidentiality and to report unlawful abortions. Higher education Methods: We interviewed 30 medical and midwifery school clinician faculty from seven public, private, secular Religion and Catholic-affiliated universities, all located in the metropolitan region of , Chile. Medical (n=239) Neoliberalism Chile and midwifery (n = 79) students at these same seven universities completed an online survey. We coded faculty Latin America interview transcripts, and analyzed codes related to maintaining patient confidentiality and reporting unlawful abortion. We summarized student views related to reporting and imprisoning people involved in unlawful abortion, and used general estimating equation (GEE) models to identify the factors associated with support for criminalization. Results: Faculty and students generally did not support reporting or imprisoning anyone involved in an unlawful abortion and believed that protecting patient information takes precedence over reporting. Yet, faculty described pressures to report in the public sector and several cases where they or their colleagues were involved in reports. Most students somewhat/strongly agreed (78%) that patient information concerning an unlawful abortion should be kept confidential; 35% strongly/somewhat agreed that a clinician involved in an unlawful surgical abortion should be imprisoned, and 18% agreed that the woman involved should be imprisoned, with students from secular universities being significantly less likely to support reporting and punishing people involved in unlawful abortion, than students from Catholic universities. Discussion: There is a need to clarify clinicians' ethical obligations in abortion care, in particular in Catholic universities, so that they can ensure that their patients have access to high quality confidential health care services.

1. Introduction professionals. In countries where abortion is criminalized, physicians may be more likely to adhere to the law rather than to principals of The protection of patient privacy and confidentiality is a core medical ethics (Frampton, 2005). medical ethical principal dating back as early as the Hippocratic Oath Chile just recently began recognizing patients' rights (Ministry of (O'Brien and Chantler, 2003). Yet unintentional and intentional brea- Health, 2012). Yet in the case of abortion, the critiqued ches in patient confidentiality are widespread (Beltran-Aroca et al., the practices of health professionals in Chile who were not only 2016; Elger, 2009). Several Latin American countries, including Chile, breaching patient confidentiality but also interrogating and extracting have conflicting laws related to maintaining patient confidentiality and confessions from people seeking post-abortion care (UN Committee reporting unlawful abortions, which creates confusion among health against Torture, 2004). In response, Chile's Ministry of Health

∗ Corresponding author. Escuela de Sociología, Universidad de Valparaíso, El Litre 1028, Valparaíso, Chile. E-mail address: [email protected] (A. Ramm). https://doi.org/10.1016/j.socscimed.2020.113220 Received in revised form 13 June 2020; Accepted 12 July 2020 Available online 17 July 2020 0277-9536/ © 2020 Elsevier Ltd. All rights reserved. A. Ramm, et al. Social Science & Medicine 261 (2020) 113220 instructed health care workers to refrain from interrogating and ob- abortion or to provide information on how to have an abortion. Data on taining information from women having unlawful abortions (Ministry abortion incidence is dated and incomplete. Estimates range from of Health, 2009). Recently, guidelines for caring for women who had 60,000 to 300,000 abortions per year or approximately 45 abortions abortions were issued, reminding health professionals of their legal and per 1000 reproductive-age women (Singh and Wulf, 1994). Penalties ethical obligations to respect and protect a patient's dignity, privacy, for unlawful abortions vary depending on whether the abortion in- and confidentiality, and affirming patients' rights to make their own volved a health professional, violence, or coercion. A health profes- sexual and reproductive health decisions (Undersecretariat for Public sional is defined as anyone with a formal degree in a health-related field Health, 2011). The laws around patient confidentiality and reporting such as physicians, midwives, nurses, pharmacists, and dentists, but not are contradictory in that the code of criminal procedure requires health lay health workers. While health professionals can face up to 15 years in professionals to report any evidence of a suspected crime, while also prison and the woman having the abortion can face up to 5 years, stating that they can abstain from reporting in order to protect patient health professionals are less likely than other people to be charged or confidentiality (Ministry of Justice, 2000). Furthermore, public sector convicted (Ministry of Justice, 1874). From 2010 to 2017, there were employees are legally required to report crimes they encounter during 37 cases against health professionals and only one resulted in a con- their work, including unlawful abortion (Treasury Department, 2005). viction, while there were 1243 cases of abortions that did not involve a A health professional who fails to maintain patient confidentiality can health professional, of which 108 resulted in a conviction (Corporación be punished with a jail sentence, whereas they must only pay a fine for Humanas, 2018). Unfortunately, these data only specify whether a failing to report a crime (Ministry of Justice, 1874). Yet, to our health professional was involved, and do not specify whether the cases knowledge, no health professional in Chile has ever been charged for were against women self-managing an abortion or other people. breaching patient confidentiality in a case involving abortion. Despite When health professionals report unlawful abortions this can com- arduous efforts to remove the reporting requirement, it remained intact promise patient trust and confidentiality, and deter people from ac- when Chile recently decriminalized abortion in 2017 (Piquer Romo, cessing needed medical care (Cavallo, 2010; Clarke and Mühlrad, 2018; 2019). Oberman, 2018; Zureick et al., 2018). The criminalization of abortion Abortion criminalization relies mostly on health care providers to in Chile has meant that pregnant women are limited to illegal and report suspected cases to the police (Constantin, 2018). Over half (56%) unregulated procedures, and risk incarceration and mistreatment by of ob-gyn physicians surveyed in El Salvador and 44% in Peru said that health professionals and the criminal justice system, which dis- they had participated in reporting suspected abortion cases to the police proportionately impacts those with the fewest resources. The practice of (McNaughton et al., 2006; Sánchez Calderon et al., 2015). In Chile, a reporting unlawful abortion is more common in public than in private review of 250 investigative case files indicated that 42% of abortion health care facilities and prosecutions in Chile involve mostly low-in- reports were made by hospitals or medical centers (Castillo Ara, 2010). come women (Casas-Becerra, 1997; Casas and Vivaldi, 2013). Health professionals may be the primary reporters of unlawful abor- tions due to fears of being accused of being involved in, or of not re- 1.2. Economic liberalism and moral conservatism in health and education porting, an unlawful abortion, and the belief that reporting is manda- tory (Constantin, 2018; Gogna et al., 2002; McNaughton et al., 2006; The neoliberal ideology of Chile's military dictatorship not only Sánchez Calderon et al., 2015). For example, among a group of nearly resulted in eliminating legal access to abortion but also introduced 500 ob-gyn physicians surveyed in Argentina, 60% believed that a changes to the educational and health care systems that further con- woman admitted to the public hospital due to complications resulting tributed to socioeconomic inequities (Gideon, 2014; Mönckeberg, from an abortion, must be reported to the police (Gogna et al., 2002). 2011). The dictatorship expanded private health care and promoted a Some providers explained that they felt they must report to the police to two-tiered health care system (Martínez-Gutiérrez and Cuadros, 2017; avoid facing a lawsuit for malpractice. Unger et al., 2008). The current private health care system serves ap- proximately 14% of the population, mostly high-income people. While 1.1. Criminalization of abortion in Chile most physicians work in the private sector, most of the population (78%) accesses care within the public health care system (Ministry of Abortions in Chile have almost always been completely banned Social Development, 2018). The law decriminalizing abortion desig- except for abortions to save a woman's life, which were allowed from nated the already overburdened public sector to provide legal access to 1931 to 1989. The complete ban on abortion was reinstated in 1989, abortion and gave private health care institutions the flexibility to re- during the last year of the country's right-wing military dictatorship, fuse to provide abortion care by permitting them to claim conscientious with the backing of upper-class, religious conservative groups (Pieper objection at the institutional level (Maira et al., 2019). Mooney, 2009). In 2017, almost thirty years after Chile's return to de- The dictatorship also profoundly changed the country's higher mocracy, the country decriminalized abortion in three limited circum- education system, expanding private universities, including religiously- stances: 1) to save a woman's life, 2) for lethal fetal anomaly, and 3) for affiliated universities that promoted conservative and religious ideol- pregnancies due to rape. The current law allows only physicians to ogies (Brunner, 1997; Mönckeberg, 2011). Faculty members, physi- provide an abortion but grants any health professional (e.g. physicians, cians, and other staff working within these private, religiously-affiliated midwives, anesthetists, and nurses) present during the abortion pro- universities are often required to share and respect the religious values cedure the right to claim conscientious objection refusals. While re- of the institution. Religiously-affiliated universities are mostly Catholic fusals for post-abortion care are not permitted, private institutions can and support and attract Chile's upper class, right-wing, and Catholic claim conscientious objection at the institutional level (Montero and elite (Brunner, 2009). Soon after legal reform, two prestigious Catholic Villarroel, 2018). With the change in the , the Ministry of universities registered as objectors at the institutional level, affirming Health trained providers across the country and provided public hos- that they will not provide abortion to anyone within their affiliated pitals with the equipment to perform procedures. private health centers and hospitals. Today, private universities account Previously, medical training on abortion provision was inconsistent for 73% of undergraduate enrollment and can be religiously affiliated, across medical schools, but likely limited to the management of mis- whereas public universities are all secular (not religious) (SIES, 2019). carriages, pregnancy, and post-abortion complications, and relied on The recent decriminalization of abortion on three grounds provides dated surgical techniques such as . us with a unique opportunity to assess current and future health pro- In the current context, the majority of abortions in Chile remain fessionals’ views on reporting and punishing people involved in abor- criminalized, except for abortions in the three narrow circumstances. tion, in a context where there has been a heightened level of social Outside of these three circumstances, it remains illegal to perform an debate and polarization around the issue. In this setting, our study

2 A. Ramm, et al. Social Science & Medicine 261 (2020) 113220 examines a topic on which there is very little research, despite its re- information from university websites and administrators. So as to levance. Building upon previous work (Biggs et al., 2020; Casas et al., in capture a range of perspectives from each institution, we aimed to in- press), this study explores and assesses the attitudes of faculty members terview two to three faculty members from each selected department and students in medical and midwifery schools toward reporting and (medical and/or midwifery) within each university. All interviews were imprisoning women and providers involved in abortion; and whether conducted in person by two female, native-born Chileans, both with a they believe that reporting should differ between the public and private Master's in Sociology, and trained in qualitative research methods and sectors. in-depth interviewing techniques, in a private location of the partici- pant's choice (university offices, clinical offices, and cafes). Before the 2. Method interviews, faculty participants read and signed a consent form and gave their permission to be audio-recorded. As fieldwork was con- We conducted a cross-sectional study that utilized qualitative and ducted, the two interviewers and the lead author met regularly to dis- quantitative methods. We conducted in-person semi-structured inter- cuss progress, identify lines of inquiry, and emerging themes. We views with faculty members from medical and midwifery schools in conducted interviews from April 2017 to September 2017, overlapping seven universities located in Santiago, Chile, and surveyed students in with the period when abortion was decriminalized in August 2017. these fields at the same universities. This study received human sub- To field the student survey, research staff emailed department ad- jects’ approval from the Committee of Ethics of Diego Portales ministrators and student council leaders requesting them to distribute a University, Santiago Chile. link to the online survey to their medical and midwifery students. Six departments at four universities shared the link with students directly, 2.1. Faculty interview guide and student survey development through student listservs or department Facebook pages. At the two universities (four departments) that did not respond to emails, research We developed a semi-structured interview guide that asked faculty staff distributed small paper flyers that included the survey linkanda members nine overarching questions regarding their attitudes about QR code to medical and midwifery students. Student participants re- abortion, abortion provision, and how they approach the conflicting viewed an online consent form and gave their consent if they agreed to obligations of protecting patient confidentiality versus reporting un- participate, then continued to the online survey. After completing the lawful abortion in their current practice and training curricula. We also survey, participants had the option to enter into a drawing for a gift presented faculty members with specific scenarios, such as a woman card worth $40 USD/24,000 Chilean pesos and we randomly selected seeking information on how to self-manage an abortion or seeking post- 25 winners. We collected student surveys from October 2017 to May abortion care, and asked them how they would instruct their students to 2018, shortly after legal reform. approach these cases in their practice. We designed the interview guide to be free-flowing, allowing participants to introduce new ideas, while 2.3. Analyses also ensuring that we covered certain topic areas. The interview guide also collected demographic data, including education, teaching ex- We utilized a grounded theory approach to analyze the faculty in- perience (years), religion, and political affiliation. We conducted one terviews (Glaser and Strauss, 2006). The qualitative analytic team in- pilot interview to test and finalize the interview guide, which resulted cluded the lead author and the two interviewers. We transcribed and in eliminating some questions that were perceived to be biased in analyzed all interviews in Spanish, and coded them in NVivo qualitative support of abortion. analysis software. After independently reviewing each transcript, two We developed a 43-item student survey by drawing on the pub- researchers identified key themes and developed a code list that they lished literature and the faculty interview findings. Based on interview discussed, revised and applied, iteratively. The final code list included findings we added survey questions that differentiated between re- 27 codes that reflected the main themes covered in the interviews. The porting in public and private health care settings. The survey assessed present analysis focuses on the two codes related to patient con- students’ attitudes towards criminalizing, punishing, and reporting fidentiality and reporting unlawful abortion. The researchers sorted the unlawful abortion as well as their opinions about abortion and con- code list by participant background characteristics, including whether scientious objection around abortion. The items on punishing and re- they worked in a secular or Catholic university and whether they porting unlawful abortions were drawn from surveys and interviews identified as a practicing Catholic or not. This allowed us togetamore with obstetricians and gynecologists working in public hospitals in robust and insightful analysis, linking individual discourses to faculty Argentina (Ramos et al., 2001). A pilot test with five students led us to members’ backgrounds. The lead author analyzed and summarized the clarify the wording of some questions and to include additional re- two codes through a process of constant comparison, identifying simi- sponse options, before distributing the survey to the main sample. larities across interviews. Besides, the lead author identified negative cases, that is, cases that were discordant with the most common dis- 2.2. Recruitment settings courses discovered through the process of constant comparison. Nega- tive cases are useful in accounting for the range of views concerning a We identified seven universities that offer midwifery and/or med- subject, highlighting the complexity of social interactions (Seale, 1999). ical degrees with a specialization in ob-gyn located in the metropolitan For the student survey, we examine responses to seven Likert-scaled region of Santiago, to serve as faculty member and student recruitment questions regarding students’ views about whether health professionals sites. We included a mix of public and private, secular and Catholic who provide and women who obtain abortions should be reported or universities, with a high volume of students seeking degrees in mid- punished. For each of the seven statements, respondents were given wifery or in medicine with an ob-gyn specialty. This included seven four possible answer choices (strongly disagree, somewhat disagree, medical and five midwifery departments within these seven uni- somewhat agree, strongly agree). For logistic regression analyses, these versities. We estimate that the seven participating universities serve items were dichotomized (strongly or somewhat agree vs strongly or over 7000 students seeking medical or midwifery degrees, representing somewhat disagree). A total of 95 did not respond to the outcome 72% of medical and 38% of midwifery students in the metropolitan variables of interest and were excluded from all analyses. region of Santiago and 36% of medical and 16% of midwifery students As independent variables we included university type, gender, age in the country (CNED, 2019). group, type of degree sought, region where student completed high Clinical faculty members within the schools of medicine or mid- school, political affiliation, religion, frequency of attendance ofre- wifery who taught classes in ob-gyn or related fields were eligible and ligious services, and year in medical/midwifery school (see Table 1). invited to participate. We obtained faculty members' contact Region where participant completed high school was included to

3 A. Ramm, et al. Social Science & Medicine 261 (2020) 113220

Table 1 Table 2 Characteristics of student respondents. Medical and midwifery students’ endorsement (somewhat or strongly agree) of statements about reporting and punishing providers and women involved in Total University type abortion.

Catholic Secular Total % (n = 68) (n = 250) A doctor or midwife working in a public health facility should report ... N%% % A woman confirmed to have had an unlawful abortion (n = 318) 28 A woman suspected of having had an unlawful abortion (n = 317) 22 Total 318 100 21 79 A doctor or midwife working in a private health facility should report ... Type of degree being sought A woman confirmed to have had an unlawful abortion (n = 315) 29 Midwifery (Ref.) 79 25 34 22 A woman suspected of having had an unlawful abortion (n = 318) 22 Medicine-Undecided 157 49 49 50 A woman… specialty who has an unlawful abortion should be imprisoned (n = 317) 18 Medicine-Gynecology 82 26 18 28 should have access to information on how to have a safe abortion 78 specialty with pills (n = 316) Attends a private university 198 62 100 52 A doctor and/or midwife who ... Year in medical or midwifery school gives or prescribes medication abortion pills () so 37 1st-2nd 139 44 50 42 that a woman can 3rd-4th 105 33 31 34 have an unlawful abortion should be imprisoned (n = 316) 5th year or higher 74 23 19 24 performs a safe, surgical, but unlawful abortion should be 35 Female 198 62 66 61 imprisoned (n = 317) Missing 1 < 0.5 1 0 serves a woman who has had an unlawful abortion has the 78 Age group obligation to keep 17–19 years 76 24 28 23 this information confidential (n = 317) 20–24 years (Ref.) 187 59 54 60 25–31 years 52 16 16 16 Missing 3 1 1 1 Single/not married 313 98 99 98 covariate data, given that we had very little missing data (≤1%). As a Born in Chile 311 98 97 98 sensitivity analysis, we performed identical analyses using multiple Missing 1 < 0.5 0 < 0.5 imputation with chained equations for missing covariate data. We ac- Lived one year or more outside 18 6 13 4* counted for clustering by university in all analyses and conducted all of Chile Political affiliation analyses in STATA 15. We report significance at P ≤ .05. Right/Center right 77 24 57 15* Center 24 8 4 8 Center left/left 152 48 15 57* 3. Results None (Ref.) 65 20 24 20 Missing 1 < 0.5 0 < 0.5 3.1. Student survey Religion Catholic 117 37 65 29* Protestant/Evangelical 13 4 4 4 We distributed the survey link to about 2000 medical and midwifery Other 14 4 4 4 students at these seven universities and 459 opened the link; we re- None/Atheist/Agnostic 174 55 26 62 moved 46 responses due to ineligibility, and 95 responses due to (Ref.) missing outcome data, leaving a final sample of 318 or 77% of those Frequency of religious attendance Once a week/2-3 times a 40 13 24 10* eligible who opened the survey (318/413). These seven universities month included three private Catholic universities, and four secular uni- Once a month/2-3 times a 48 15 35 10* versities (two private and two public); seven medical schools and five year midwifery departments. Student characteristics are presented in Hardly ever/never (Ref.) 226 71 41 79 Missing 4 1 0 2 Table 1. Region where completed high school Most students somewhat/strongly agreed (78%) that a doctor or Santiago metropolitan 247 78 84 76 midwife who sees a woman who has had an unlawful abortion has the region (Ref.) obligation to keep this information confidential; about one-quarter Northern Chile 21 7 7 6 somewhat/strongly agreed that a doctor or midwife working in a public Southern Chile 47 15 9 16 Other country 3 1 0 1 or private facility should report women suspected (22% and 22%, re- Type of high school attended spectively) or confirmed (28% and 29%, respectively) to have hadan Public (Ref.) 68 21 9 25 abortion (Table 2). Most students (78%) agreed that women should Private-subsidized 117 37 18 42 have access to information on how to have a safe abortion with pills and Private-self-paid 133 42 74 33* 18% endorsed the view that a woman who has an unlawful abortion Ref. = Reference group; *Differences by university type are based on results of should be imprisoned. general estimating equation models, accounting by clustering by university, and In bivariate (Fig. 1) and adjusted analyses (Tables 4 and 5), students are statistically significant at p < .05. from Catholic universities were significantly (p < .001) more likely to support reporting and punishing people involved in an abortion than account for urban/rural differences in abortion attitudes (Baba et al., students from secular universities. In multivariable analyses, factors 2020). We calculated frequencies of student characteristics by uni- associated with endorsing the view that a doctor or midwife working in versity type (Table 1) and views about reporting and punishing other a public or private health facility should report a woman suspected or medical professionals and women involved in abortion (Table 2 and confirmed to have had an unlawful abortion included political affilia- Fig. 1). For multivariable models, we used logistic general estimating tion and year in school (Table 4). Students in their third year of school equation (GEE) models, and selected model covariates a priori. These or higher, and whose political affiliation was center-left or left had included respondent characteristics that are known to be associated significantly lower odds of agreeing that a public or private facility with abortion attitudes, based on the existing literature (Thomas et al., should report a woman suspected or confirmed to have had an abortion. 2017). In multivariable models, we used listwise deletion for missing Those whose political affiliation was right or center-right had twoto three times higher odds of agreeing that a public or private health

4 A. Ramm, et al. Social Science & Medicine 261 (2020) 113220

Fig. 1. Students' endorsement (somewhat or strongly agree) of statements about reporting and punishing providers and women involved in abortion by university type. facility should report a woman with a suspected (adjusted Odds Ratio 3.2. Faculty member interviews (aOR) 3.11, 95% Confidence IntervalCI ( ) 1.33, 7.26) or confirmed (aOR 2.70, 95% CI 1.21, 6.04) unlawful abortion. Midwifery students We invited (via email or phone) 114 faculty members and 30 agreed had significantly higher odds of believing that women suspected of to participate in the qualitative interviews. Faculty respondents re- having an abortion should be reported than medical students with an presented the same seven universities as the students surveyed. Faculty undecided specialty (aOR: 2.67, 95% CI 1.07, 6.63). Students who members’ demographic information appears in Table 3. All faculty completed high school in the metropolitan region (aOR: 2.20, CI: 1.11, participants were practicing clinicians, mostly physicians (60%). The 4.34) had higher odds of agreeing with the view that a doctor and/or majority taught at a secular university, were female, had children, and midwife who sees a woman who has an unlawful abortion should keep described themselves as religious. Nearly all who described themselves this confidential. as practicing Catholics worked at a Catholic university and nearly all With regards to views about punishing a doctor or midwife involved who did not, taught at secular universities. On average, faculty mem- in an unlawful surgical or medication abortion, those who attended bers had 12 years of university teaching experience. secular universities (aOR 0.36, 95% CI: 0.16, 0.78 and aOR 0.30, CI: Faculty interviews offered often similar views as students, but they 0.14, 0.66, respectively) and those in their third year of medical/mid- provided a more nuanced and deeper perspective about the wifery school (aOR 0.35, CI: 0.16, 0.78 and aOR 0.42, CI: 0.19, 1.32, respectively) or higher (aOR 0.12, CI: 0.04, 0.37 and aOR 0.26, CI: 0.09, Table 3 0.77, respectively) had significantly lower odds of agreeing that the Characteristics of medical and midwifery faculty participants. clinician should be imprisoned (Table 5). Students whose political af- N % filiation was right or center-right had over two to three times higher odds of agreeing that a clinician involved in an unlawful surgical (aOR: Total 30 100 3.31, CI: 1.44, 7.59) or medication abortion (aOR: 2.95, CI: 1.33, 6.52) Female 17 57% should be imprisoned. Students with regular attendance at religious Years teaching < 5 years 4 14% services had over four times higher odds of agreeing that a clinician 5–9 years 10 34% involved in an unlawful surgical (aOR: 4.84, CI: 1.81, 12.96) or medi- 10–19 years 8 28% cation abortion (aOR: 4.93, CI: 1.67, 12.90) should be imprisoned. 20 or more years 7 24% With regards to views about women involved in abortion, students Clinical degree Medicine 18 60% who completed high school in the metropolitan region (aOR 0.32, CI: Midwifery 12 40% 0.14, 0.72) and in their fifth year of medical/midwifery school or Specialization higher (aOR 0.14, CI: 0.03, 0.63) had lower odds of agreeing that the Obstetrics and/or Gynecology 17 57% woman involved in an unlawful abortion should be imprisoned. Those Maternal-fetal medicine 4 13% whose political affiliation was right or center-right (aOR: 5.01, CI: 1.87, Infertility 2 7% Bioethics 2 7% 13.45) had higher odds of agreeing with this view. Concerning the view Neonatology 2 7% that women should have access to information on how to have a safe Sexual health 2 7% abortion with pills, students from secular universities were significantly Other 3 10% more likely (aOR: 6.45, CI: 2.72, 15.31) and those with frequent re- University type Private-Secular 9 30% ligious service attendance less likely (aOR 0.33, CI: 0.12, 0.90) to agree Private-Catholic 10 33% with this view. Public-Secular 11 37% When we repeated the same set of multivariable analyses using Political affiliation multiple imputation methods, results were mostly similar, except that Right/Center right 10 34% the odds of endorsing the belief that women should have access to in- Center/None 8 27% Center left/left 11 38% formation on how to have a safe abortion with pills was significantly Religion lower among people with a right/center-right political affiliation (aOR Catholic-Practicing 11 38% 0.42, CI: 0.18, 0.98) than those who identified as center/no political Catholic-Not practicing 8 28% affiliation (not shown). Atheist, agnostic or atheist 6 21% Other 4 14% Has children 23 77%

5 A. Ramm, et al. Social Science & Medicine 261 (2020) 113220 circumstances when health professionals feel obligated to report. We with the [abortion] pill. I go to evaluate her. I see the rest of the pill. describe faculty members’ experiences and views about reporting un- The [supervising] physician says, “All right, you are going to report lawful abortion and whether their perceived obligation to report con- this,” and I say, “No, I'm not going to report any woman who's had flicts with their obligation to maintain patient confidentiality. Ofthe30 an abortion.” “But it's mandatory,” [the physician says] and I said, faculty participants, 29 responded to the question on the issue of re- “If you decide to report her, go ahead and do it yourself. I'm not porting vs maintaining confidentiality. going to report her.” Faculty members at Catholic universities were less supportive of Faculty members also described cases when they believed that re- abortion than faculty members from secular universities. Although not porting was justified. One male physician, from a Catholic university, explicitly asked, many faculty members described experiences where with less than 5 years of teaching experience, states that women who do they or their colleagues reported suspected cases of unlawful abortion, not express remorse are more prone to be reported, “in the case that a even though they did not necessarily support reporting people who woman arrived without showing any care about what she did. I think have abortions. One male physician, with 10–19 years of teaching ex- that case would probably be reported”. perience, from a Catholic university and opposed to abortion explains. In contrast to students, faculty members generally agreed that they “If the patient tells me [she had an abortion], I don't think I would are legally mandated to report an unlawful abortion, and that this ob- report her […] but there is no way I would perform an abortion on her, ligation is greater in public than in private health care facilities. Faculty either.” Another male physician who taught at a Catholic university, members explained that the limited ongoing contact with public sector and with more than 20 years of teaching experience, describes why he patients facilitates reporting. As one faculty midwife describes: does not support punishing women who have an abortion. “When a woman has an abortion, in our [Catholic] view she has made an attempt A: In the private sector, you are not obligated to call the police. against the life of another person, but we also believe in mercy […], in Q: You're not? acting in a merciful rather than punitive manner.” While faculty members never mentioned cases of health profes- A: No, because the physician is not going to do that under any cir- sionals who were reported, those few who supported criminal prose- cumstance. cution, targeted clinicians providing abortion. When explaining that Q: So, in other words, reporting happens more in the public sector? prosecutions should focus on the providers, one male physician at a Catholic university, with 10–19 years of teaching experience, justifies A: Yes, because there [public sector] your hands are tied, that's just his response by assuming that women who have abortions have no what you have to do. [When you report] there's no relationship agency, “abortion should be decriminalized for the people who are the between the physician and the patient who leads the physician to victims of abortion, but it should be a crime for those who promote it.” report. No! That patient is someone you don't know, and you're A female faculty midwife from a Catholic university, with more than putting yourself at risk professionally [if you don't report]. In the 20 years of teaching experience, describes her compassion for a 15-year private sector, you have been following the patient who calls you to old with severe complications who was reported to the police. Her request an abortion. (Female, midwife, secular university, 10–19 experience shows the conflicting issues involved in reporting: years teaching) The only person that girl had was her grandma […] to send the In this midwife's account, she is invested in maintaining the privacy grandma to jail would mean that the girl would be left on her own in of her private sector patients, with whom she has a longstanding re- the world, with no support network. Well, it was discussed and lationship and faces fewer risks for not reporting, than with her public discussed […] the report was made, it went to trial, and the phy- sector paitients. sicians themselves spoke on the grandma's behalf. So, that was an Both secular and Catholic university faculty members described emblematic case of how difficult it is, because you say, “I'll report reporting experiences that occurred solely while working at public it,” but the issue is not that simple. health facilities, particularly in public hospital emergency rooms, where they were more likely to observe evidence of an abortion. A One secular-university faculty member, the only to openly reject physician faculty member describes such cases: pressures to report, similarly described her compassion for the people reported by her colleagues, while firmly stating that she would not The patient comes in with the placenta or the cord hanging out, but involve herself in reports: with no evidence of a fetus or embryo. Those situations fall more into the illegal area […] from any perspective; we've had to report I know people who report. It does happen. There are girls who are them according to our understanding and observation of the reg- even handcuffed while they're waiting for the police to come be- ulations. It's not that we as doctors ask our patients about it. (Male, cause they had an abortion, and I see the context: usually the ones physician, secular university, 20 or more years teaching) who have abortions are not the crazy young girls running around from party to party […]. They're mothers who have small children A female physician at a Catholic university, with 10–19 years of waiting for them at home […]. I'm not capable of making the de- teaching experience, similarly refers to cases with visible evidence that cision to report them. (Female, physician, < 5 years teaching) necessitated reporting. “I've often seen girls come in with Misoprostol in their vagina, so it was evident, although they always denied it. […] We This faculty member describes how a health professional's right to had to report it, and that's what we did.” conscientious objection relieves them of their obligations to report: Faculty members described their obligation to report as overriding I've never done it [reporting], nor do I intend to, and when the kids their obligation to protect patient confidentiality when there is visible [students] ask me, I talk about conscientious objection. I don't think evidence of an induced abortion, which was most likely to occur in it's my obligation to report them, and if the protocol says to, either public hospital emergency rooms. One faculty midwife from a secular the resident or the shift supervisor will have to decide. But I myself university, with 10–19 years of teaching experience, explicitly states “If never report. you are in your private practice […] you can avoid any kind of re- porting […] but in the ER, at the hospital, is where it's complicated This same faculty member describes an experience while she was in because if you noticed it, you have to report it. So, patient con- medical school where she actively resisted the responsibility of re- fidentiality doesn't apply there.” porting in a public hospital, despite pressures from her supervisor. When asked specifically about how they balanced seemingly con- The physician sees a patient whom a midwife accuses of coming in flicting obligations to maintain patient confidentiality and to report

6 A. Ramm, et al. Social Science & Medicine 261 (2020) 113220

Table 4 Characteristics associated with student views about whether doctors or midwives should report an unlawful abortion, according to multivariable logistic regression analyses.

A doctor or midwife working in a public or private health facility should report a A doctor and/or midwife who sees a woman who has had an woman … (n = 310) abortion unlawfully should keep this confidential (n = 312)

Suspected of having had an unlawful Confirmed of having had an unlawful abortion abortion

% aOR [95% CI] % aOR [95% CI] % aOR [95% CI]

University type Secular 17 0.53[0.23,1.20] 21 0.39[0.18,0.84] 82 1.84[0.83,4.08] Catholic (Ref.) 43 56 62 Type of degree being sought Medicine-undecided spec. 17 26 78 (Ref.) Medicine-OB/GYN specialty 21 1.46[0.66,3.24] 26 1.12[0.54,2.34] 88 2.02[0.88,4.65] Midwifery 33 2.67[1.07,6.63] 35 0.86[0.40,1.85] 68 0.68[0.33,1.40] Year in medical or midwifery school 1st-2nd (Ref.) 32 40 74 3rd-4th 13 0.38[0.15,0.96] 25 0.66[0.29,1.49] 79 1.18[0.51,2.73] 5th-7th/just graduated 15 0.34[0.10,1.20] 12 0.24[0.07,0.78] 84 1.59[0.50,4.99] Gender Female 21 0.48[0.23,0.98] 25 1.02[0.95,1.10] 81 0.97[0.90,1.03] Male/Other (Ref.) 24 33 73 Age group, years 17-19 36 2.14[0.91,5.01] 45 2.19[0.97,4.95] 72 0.79[0.33,1.88] 20-24 (Ref) 17 24 80 25-31 19 1.78[0.56,5.66] 17 0.93[0.31,2.84] 81 0.81[0.28,2.34] Political affiliation Center/None (Ref.) 26 33 77 Right/Center right 43 3.11[1.33,7.26] 55 2.70[1.21,6.04] 63 0.51[0.22,1.18] Center left/left 9 0.42[0.18,0.96] 13 0.43[0.20,0.91] 86 1.07[0.50,2.32] Religion Catholic or other religion 31 41 69 (Ref.) None 15 0.92[0.40,2.14] 18 0.70[0.32,1.50] 85 1.64[0.75,3.57] Frequency of religious attendance Hardly ever/never (Ref.) 17 22 81 Once a month/2-3 times a 29 1.03[0.36,2.95] 40 0.99[0.38,2.59] 75 1.54[0.58,4.12] year Once a week/2-3 times a 40 1.43[0.54,3.76] 55 1.70[0.68,4.30] 59 0.67[0.26,1.68] month Where completed high school Santiago metropolitan 22 0.85[0.39,1.83] 26 0.55[0.27,1.11] 80 2.20[1.11,4.34] region Other location (Ref.) 24 35 69 Type of high school attended Public (Ref.) 21 24 79 Private-subsidized 21 0.95[0.39,2.31] 25 0.98[0.43,2.22] 79 1.27[0.57,2.85] Private-self-paid 24 0.66[0.26,1.67] 35 0.69[0.30,1.62] 76 1.34[0.58,3.10]

Note. aOR: Adjusted odds ratios; CI: 95% confidence intervals; Ref. Referent group; bold items are statistically significant at p < .05 based on adjusted mixed effects logistic regression analyses. unlawful abortion, many agreed that these two obligations created a this point: professional conflict. As a midwife states: Patient confidentiality is never compromised, and it also doesn't The law requires you to do it [report]. So, I think when there's a conflict with the duty to report. It is very hierarchical, soifit[ob- legal problem where you could lose your license to practice if you serving a suspected abortion] does happen to you, you tell the di- don't do it, obviously there is a conflict between the issue of con- rector or your shift supervisor, and in general it's rare for you to fidentiality and what you are required to do by law. (Female, mid- have to do the legal paperwork yourself; instead it's done by the wife, Catholic university, 5–9 years teaching) administration of the institution where you're working. But patient confidentiality is always maintained. (Male, physician, Catholic In this account, the respondent erroneously believes that she could university, < 5 years teaching) lose her license to practice if she does not report, suggesting confusion about reporting requirements and penalties. In this physician's account, the public health care sector bureau- In contrast, several faculty members expressed that they did not cracy and hierarchical structure, enables him to hold the perception perceive a conflict between their obligaion to protect patient con- that he is maintaining patient confidentiality, while complying with his fidentiality and reporting unlawful abortion. Faculty members re- perceived obligation to report. For him, reporting to the hospital au- conciled these seemingly conflicting views by defining patient con- thorities does not breach patient confidentiality. He later describes an fidentiality narrowly and dependent on who receives the private patient example of a confidentiality breach, “What you clearly cannot do istell information. For example, sharing patient information with supervisors the woman who's in the next bed that this woman had an intentional was not assessed as a breach of confidentiality. A physician illustrates abortion, or her family or anyone.”

7 A. Ramm, et al. Social Science & Medicine 261 (2020) 113220

Other faculty members, even those who had reported patients, ex- Also, faculty members described their obligation to report cases pressed the belief that patient confidentiality supersedes the obligation when there was clear evidence of an abortion, a situation they reported to report an unlawful abortion. As one male physician at a Catholic as most frequently occurring in the public hospital emergency room. university, with 10–19 years of teaching experience, states, “We're Similarly, in El Salvador, most of the cases reported involved later doctors, so patient confidentiality is the most important thing as longas abortions, likely late-term miscarriages (Citizen's Coalition for the we save the patient. Afterward, it's up to the lawyers.” This physician Decriminalization of Abortion on Grounds of Health Ethics and Fetal seems to justify reporting behaviors by distancing himself from any Anomaly, 2014). influence he might have on the legal process. Interestingly, while faculty members shared that midwives may be 4.2. A punitive and contradictory regulatory frame the first to report a suspected abortion, usually to their supervising physician, a midwife, with 10–19 years of teaching experience at a Practicing clinicians rationalize reporting behaviors by redefining secular university, shared that the midwife's role in reporting is not the meaning of reporting and confidentiality, by breaching patient decisive. She explains, “In the committees that resolve abortion issues, confidentiality, and paradoxically maintaining that their main ethical we [midwives] are not considered. They don't call the midwife. They obligation is to protect their patient's privacy and provide them health call the physician, the supervisor, the director.” care. Similarly, in interviews with staff at a labor and delivery unit offering abortion care in the United States, some people contested and 4. Discussion redefined the meaning of participating in abortion work, so that their work aligned with their personal beliefs and values (Czarneckia et al., We found that most medical and midwifery students and faculty 2019). members do not support reporting or punishing anyone involved in a Maintaining patient confidentiality is a necessary means of hon- suspected unlawful abortion and believe that this information should be oring a patient's autonomy, including their bodily autonomy and to kept confidential (Table 2), although views differed by university type, ensure the health of the broader community. Sharing personal patient professional degree (medical vs midwifery), religion, and political af- information can compromise and harm a patient's reputation and au- filiation (Fig. 1 & Table 4). In addition, perceived external pressures to tonomy (O'Brien and Chantler, 2003; Schleiter, 2009). A trusting report in the public health sector resulted in more frequent reporting in doctor-patient relationship requires that the patient can trust that they that sector. Similarly, midwives were more likely to report, perhaps will not be harmed when accessing health care, including when seeking because they hold lower-level positions and are subject to more su- post-abortion services. Restrictive abortion laws tend to compromise pervision than physicians. While students and faculty members ex- the quality of post-abortion care (Suh, 2019). When patients trust their pressed greater support for punishing a clinician than a woman in- providers, they are more likely to access and encourage others to access volved in an unlawful abortion, clinician faculty members described no health care, which can prevent the spread of disease and ensure a cases involving a health professional. These findings are consistent with healthy population. While there are some circumstances, such as doc- a review of legal cases where almost none involved health professionals umenting the incidence of disease and protecting people from harm, (Corporación Humanas, 2018). when breaking patient confidentiality is considered acceptable, such a We found that people representing Catholic universities, with a breach usually requires patient consent and the sharing of the least right-wing political affiliation, and practicing Catholics were more amount of information to the fewest number of people (Frampton, supportive of reporting and imprisoning people involved in an unlawful 2005). In certain countries, doctors are required to report cases invol- abortion than their counterparts (Tables 4 and 5). These results agree ving gunshot wounds, abuse, and evidence of a crime to the criminal with research that has highlighted the role of Chile's religious-right in justice system (Schleiter, 2009). However, confidentiality protections blocking the liberalization of abortion (Alvarez Minte, 2020; Blofield, for pregnant women are often compromised in cases where the fetus has 2006; Htun, 2003). Thus, Catholic universities created or strengthened rights (Hooper et al., 2012). For example, in the U.S., pregnant women under the Pinochet dictatorship, seem to have had a strong influence in have been charged with child endangerment and even murder, for using shaping the views of future health professionals by instilling notions alcohol or drugs while pregnant (Chavkin and Breitbart, 1996). that are consistent with those of the Catholic Church and conservative In Chile, the value of the fetus at the expense of the pregnant woman political parties (Casas Becerra, 2019). is manifested in the heavy criminalization of abortion and the strong value for maternity which characterizes the Chilean health care system 4.1. Reporting bias: public vs private health care systems (Gideon, 2014). This and other studies show that, in practice, health professionals regularly incur breaches of confidentiality (Beltran-Aroca While students held the belief that reporting should not differ be- et al., 2016; Elger, 2009), suggesting that some providers are not tween public and private sector settings, faculty members described honoring or valuing the pregnant woman's autonomy and are favoring differential reporting practices owing to the public system's greater the fetus's rights over women's rights to receive confidential care. In this institutional oversight and hierarchical structure, the belief that they study, we found that women who have abortions and seek medical care are required to report in the public sector, seeing patients who are more are vulnerable to confidentiality breaches, particularly if seeking care at likely to present with visible evidence of abortion, and because the a public hospital. Women's vulnerability is increased by current reg- patient-provider relationship in public health care settings tends to be ulations that require reporting, especially in the public sector. These more fragmented. In contrast, faculty members described more per- regulations give legitimacy to people opposed to abortion and who sonal relationships with private sector patients which reinforced the want to punish women who choose abortion. Furthermore, these reg- provider's desire to ensure patient satisfaction and to maintain con- ulations pressure even those health professionals who consider re- fidentiality. In describing the criminal reports they had witnessed or porting to be unethical, to act against their personal codes of ethics, and performed, clinical faculty members maintained their sense of ethics to report. We heard from only one clinician in this study who actively and moral responsibility, by deflecting the negative consequences re- resisted being involved in criminal reports, but interestingly described sulting from reports onto administrators and the legal system. Faculty doing so on the grounds of conscientious objection, rather than pro- members did not view their participation in reports as directly related tecting patient confidentiality. She describes the obligation to report to the criminal prosecution of patients. This perception enabled clin- unlawful abortion as going against her personal values and beliefs. Her icians to hold two seemingly conflicting views which both supported case might be described as one of “conscientious commitment” to protecting patient information, while also complying with their per- abortion provision, taking place in a restrictive context for women's ceived obligation to report suspected cases. reproductive health (Czarneckia et al., 2019, 182).

8 .Rm,e al. et Ramm, A. Table 5 Multivariable logistic regression analyses predicting student views about punishing clinicians and women involved in abortion.

A doctor and/or midwife who … A woman…

performs a safe, surgical, but unlawful offers a woman MAB for an unlawful who has an abortion unlawfully should have access to information on how abortion should be imprisoned abortion should be imprisoned should be imprisoned (n = 309) to have a safe abortion with pills (n = 308) (n = 308) (n = 309)

% aOR [95% CI] % aOR [95% CI] % aOR [95% CI] % aOR [95% CI]

University type Secular 26 0.36[0.16,0.78] 28 0.30[0.14,0.66] 12 0.35[0.14,0.88] 86 6.45[2.72,15.31] Catholic (Ref.) 68 72 41 45 Type of degree being sought Medicine-undecided spec. (Ref.) 33 35 14 77 Medicine-OB/GYN specialty 33 0.79[0.39,1.62] 33 1.07[0.53,2.16] 19 1.54[0.63,3.75] 85 1.57[0.63,3.91] Midwifery 41 1.27[0.61,2.65] 48 0.93[0.44,1.96] 27 1.72[0.70,4.27] 71 0.69[0.27,1.72] Year in medical or midwifery school 1st-2nd (Ref.) 42 47 24 80 3rd-4th 31 0.35[0.16,0.78] 35 0.42[0.19,0.93] 17 0.50[0.19,1.32] 72 0.43[0.15,1.15] 5th-7th/just graduated 27 0.12[0.04,0.37] 23 0.26[0.09,0.77] 9 0.14[0.03,0.63] 80 1.15[0.30,4.38] Gender Female 32 1.03[0.95,1.11] 35 1.03[0.95,1.13] 17 1.06[0.97,1.15] 78 1.76[0.81,3.82] Male/Other (Ref.) 40 40 20 76 Age group, years 17-19 40 0.65[0.29,1.49] 43 0.83[0.37,1.89] 23 0.89[0.33,2.38] 79 0.76[0.27,2.16] 20-24 (Ref) 32 36 17 78 25-31 37 2.14[0.76,5.97] 33 1.75[0.66,4.63] 15 1.89[0.52,6.94] 73 0.61[0.20,1.83]

9 Political affiliation Center/None (Ref.) 36 39 17 77 Right/Center right 66 3.31[1.44,7.59] 68 2.95[1.33,6.52] 42 5.01[1.87,13.45] 51 0.45[0.19,1.06] Center left/left 18 0.81[0.40,1.63] 21 0.60[0.30,1.21] 7 0.59[0.22,1.58] 91 1.90[0.80,4.52] Religion Catholic or other religion (Ref.) 50 55 29 63 None 23 0.64[0.31,1.31] 23 0.77[0.37,1.61] 10 0.92[0.35,2.38] 90 1.65[0.69,3.90] Frequency of religious attendance Hardly ever/never (Ref.) 25 27 12 86 Once a month/2-3 times a year 48 1.59[0.64,3.97] 54 1.50[0.59,3.77] 31 2.50[0.80,7.78] 58 0.51[0.19,1.36] Once a week/2-3 times a month 75 4.84[1.81,12.96] 77 4.93[1.88,12.90] 44 3.46[1.18,1.14] 47 0.33[0.12,0.90] Where completed high school Santiago metropolitan region 35 0.77[0.39,1.54] 36 0.80[0.40,1.60] 15 0.32[0.14,0.72] 78 2.14[0.95,4.80] Other location (Ref.) 37 41 28 74 Type of high school attended Public (Ref.) 32 28 16 85

Private-subsidized 30 1.08[0.49,2.35] 33 0.69[0.32,1.48] 18 0.94[0.36,2.45] 77 0.50[0.19,1.34] Social Science&Medicine261(2020)113220 Private-self-paid 41 1.12[0.49,2.52] 46 0.47[0.21,1.07] 20 0.25[0.08,0.77] 74 1.50[0.52,4.30]

Note. aOR: Adjusted odds ratios; CI: Confidence Intervals; Ref. Referent group; Bold items are statistically significant at p < .05 based on adjusted mixed-effects logistic regression analyses. A. Ramm, et al. Social Science & Medicine 261 (2020) 113220

In this context, it is vital to promote and strengthen solid ethical References training for medical and midwifery students from a human rights per- spective that includes mechanisms for resolving ethical-legal dilemmas Alvarez Minte, G., 2020. Resistance to sexual and : maternalism and and confusion over reporting requirements (McNaughton et al., 2006). conservatism. In: Ramm, A., Gideon, J. (Eds.), Motherhood, Social Policies and Women’s Activism in Latin America. Palgrave Macmillan, Cham, pp. 123–144. An example of this kind of training includes workshops currently being Baba, C.F., Casas, L., Ramm, A., Correa, S., Biggs, M.A., 2020. Medical and midwifery carried out in El Salvador as part of the International Federation of student attitudes toward moral acceptability and legality of abortion, following de- criminalization of abortion in Chile. Sex. Reprod. Healthc. 24, 100502. Gynecology and Obstetrics (FIGO) Initiative for the Prevention of Un- Beltran-Aroca, C.M., Girela-Lopez, E., Collazo-Chao, E., Montero-Pérez-Barquero, M., safe Abortion in coordination with local organizations and authorities Muñoz-Villanueva, M.C., 2016. Confidentiality breaches in clinical practice: what (Faúndes and Padilla de Gil, 2019). Ethical training in Chile and other happens in hospitals? BMC Med. Ethics 17–52. Biggs, M., Casas, L., Ramm, A., Baba, F., Correa, S.V., Grossman, D., 2019. Future health countries should consider the differing legal frameworks attributed to providers' willingness to provide abortion services following decriminalisation of the public and private health care systems, so as to give clinicians abortion in Chile: a cross-sectional survey. BMJ Open 9, e030797. ethical and practical tools to protect patient confidentiality consistently Biggs, M., Casas, L., Ramm, A., Baba, C., Correa, S., 2020. Medical and midwifery stu- dents' views on the use of conscientious objection in abortion care, following legal regardless of the health care system in which they practice. reform in Chile: a cross-sectional study. BMC Med. Ethics 21. Blofield, M., 2006. The Politics of Moral Sin: Abortion and Divorce in Spain, Chileand Argentina. Routledge, New York. 4.3. Limitations of the study Brunner, J.J., 1997. From state to market coordination: the Chilean case. High. Educ. Pol. 10 (3/4), 225–237. This study has some limitations. Data was collected around the time of Brunner, J.J., 2009. Tipología y características de las universidades chilenas: documento para comentarios. Universidad Diego Portales, Santiago. legal change. As students and faculty members gain exposure to the cur- Casas, L., Vivaldi, L., 2013. La Penalización del Aborto como una Violación a los Derechos rent law allowing abortion in some circumstances, support for punishing Humanos de las Mujeres. In: Vial, T. (Ed.), Informe Anual sobre Derechos Humanos en Chile 2013. Ediciones Diego Portales, Santiago, pp. 69–120. and reporting unlawful abortions may change. Over time, we anticipate Casas Becerra, L., 2019. La academia entre los “seculares y los confesionales”. In: Casas that universities will develop more standardized approaches and com- Becerra, L., Maira, G. (Eds.), Aborto en Tres Causales en Chile: lecturas del proceso de prehensive curricula with regards to managing legal and unlawful abor- despenalización. Centro de Derechos Humanos Universidad Diego Portales, Santiago, pp. 203–232. tions. Another limitation is our low response rate to our student survey, Casas, L., Freedman, L., Ramm, A., Correa, S., Baba, C., & Biggs, M. (in press). Chilean raising concerns of response bias. While low response rates are common medical and midwifery school faculty views on the use of conscientious objection for for web-based surveys, particularly surveys covering sensitive topics abortion services, during a time of legal reform. Int. Perspect. Sex. Reprod. Health.. Casas-Becerra, L., 1997. Women prosecuted and imprisoned for abortion in Chile. Reprod. (Edwards et al., 2009), we may have underrepresented students from Health Matters 5, 29–36. private and Catholic institutions. While approximately one-third of med- Castillo Ara, A., 2010. Aborto e infanticidio: cómo sostener una adecuada defensa. Defensoría Penal Pública, Santiago. ical and midwifery students attend a Catholic university among the uni- Cavallo, M., 2010. Conflicting duties over confidentiality in Argentina and Peru. Int.J. versities surveyed, they only represented about one-quarter of our sample Gynaecol. Obstet 112, 159–162. (CNED, 2019). Nonetheless, in previously published analyses of these Chavkin, W., Breitbart, V., 1996. Reproductive health and blurred professional bound- aries. Wom. Health Issues 6, 89–96. same data, we found no statistically significant differences between par- Citizen's Coalition for the Decriminalization of Abortion on Grounds of Health Ethics and ticipant characteristics and rates of survey completion (Biggs et al., 2019). Fetal Anomaly, 2014. From hospital to jail: the impact on women of El Salvador's total criminalization of abortion. Reprod. Health Matters 22, 52–60. By including students and faculty members from a broad range of uni- Clarke, D., Mühlrad, H., 2018. Abortion Laws and Women's Health. Discussion Paper versity types we believe we achieved sufficient variation that is re- Series. IZA-Institute of Labor Economics, Bonn, Germany. presentative of views from various contexts. CNED, 2019. Indices base de datos: matrícula 2005-2018. Consejo Nacional de Educación, Santiago. Constantin, A., 2018. Muerte o cárcel: persecusión y sanción por aborto. CLACAI, Lima- 5. Conclusions Perú. Corporación Humanas, 2018. Realidad del aborto en Chile. Corporación Humanas, Santiago. Our findings are relevant not only to Chile, but to other countries in Czarneckia, D., Anspachb, R.R., De Vries, R.G., Dunn, M.D., Hauschildt, K., Harris, L.H., Latin America. Other Latin American countries share similar legislation 2019. Conscience reconsidered: the moral work of navigating participation in abor- tion care on labor and delivery. Soc. Sci. Med. 232, 181–189. related to confidentiality and reporting, have similar, stratified, and Edwards, P., Roberts, I., Clarke, M., Diguiseppi, C., Wentz, R., Kwan, I., et al., 2009. gender-biased health care systems, and have similar influences of the Methods to increase response to postal and electronic questionnaires. Cochrane Catholic Church on higher education. In this context, it is critically Database Syst. Rev. 3, MR000008. Elger, B.S., 2009. Factors influencing attitudes towards medical confidentiality among important to reduce providers’ confusion about their ethical obligations Swiss physicians. J. Med. Ethics 35, 517–524. to both their patients and the criminal justice system so to ensure that Faúndes, A., Padilla de Gil, M., 2019. Restricted abortion law in El Salvador. Int. J. women accessing care can receive confidential, high-quality health care Gynaecol. Obstet 145, 136. Frampton, A., 2005. Reporting of gunshot wounds by doctors in emergency departments: services and feel safe accessing them. a duty or a right? Some legal and ethical issues surrounding breaking patient con- fidentiality. Emerg. Med. J. 22, 84–86. Gideon, J., 2014. Gender, Globalization, and Health in a Latin American Context. Credit author statement Palgrave Macmillan, New York. Glaser, B.G., Strauss, A.L., 2006. The Discovery of Grounded Theory: Strategies for MAB and LC conceived and designed the study and obtained Qualitative Research. AldineTransaction, New Brunswick. Gogna, M., Romero, M., Ramos, S., Petracci, M., Szulik, D., 2002. Abortion in a restrictive funding. AR, FB, and SC participated in study planning, site recruit- legal context: the views of obstetrician–gynaecologists in Buenos Aires, Argentina. ment, review of data collection instruments, data collection and data Reprod. Health Matters 10, 128–137. Hooper, C.R., Iqbal, R., Gass, C., 2012. Maternal confidentiality: an ethical, professional curation. AR and SC coded the qualitative transcripts. AR conducted all and legal duty. Obstet. Gynaecol. Reprod. Med. 22, 108–110. qualitative analyses and MAB conducted all quantitative analyses. AR Htun, M., 2003. Sex and the State: Abortion, Divorce, and the Family under Latin and MAB prepared the original draft of the manuscript. All authors American Dictatorships and Democracies. Cambridge University Press, Cambridge. Maira, G., Casas, L., Vivaldi, L., 2019. Abortion in Chile: the long road to legalization and reviewed, edited and approved the final manuscript. its slow implementation. Health Hum. Rights 21, 121–131. Martínez-Gutiérrez, M.S., Cuadros, C., 2017. Health policy in the concertación era (1990- Acknowledgements 2010): reforms the chilean way. Soc. Sci. Med. 182, 117–126. McNaughton, H.L., Mitchell, E.M.H., Hernandez, E.G., Padilla, K., Blandon, M.M., 2006. Patient privacy and conflicting legal and ethical obligations in El Salvador: reporting This work was supported by a grant from the University of of unlawful abortions. Am. J. Publ. Health 96, 1927–1933. Ministry of Health, 2009. Ordinario A15 1675. Departamento de Asesoría Jurídica, California, San Francisco (UCSF), National Center of Excellence in Santiago. Women's Health and an anonymous foundation. Its contents are solely Ministry of Health, 2012. 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