Legal :a comparative analysis of health regulations

International Planned Parenthood Federation

Legal abortion: a comparative analysis of health regulations

Federación Internacional de Planificación Familiar – IPPF/RHO IPPF/WHR External Advisory Committee

Spanish version English version Ana Labandera/ President, Asociación Obstétrica del Bernard M Dickens/ Professor Emeritus of Health Law and Policy and Co-Director, Uruguay Canada International Reproductive and Sexual Health Programme, Faculty Aníbal Faúndes/ Professor of Obstetrics, Faculty of Medical of Law, University of Toronto. Sciences Unicamp and Coordinator, Cara Davies/Canada Research Assistant, International Reproductive and Sexual Health Working Group on the Prevention of Programme, Faculty of Law, University of Toronto. , International Federation Joanna Erdman/ Director, Health Equity and Law Clinic and Co-Director, of Gynecology and Obstetrics (Figo) Canada International Reproductive and Sexual Health Programme, Faculty Cristina Villarreal/ Director, Orientame of Law, University of Toronto. Colombia Manuelle Hurwitz/ Head, Global Comprehensive Abortion Care Project, International Leonel Briozzo/ Executive Director, Iniciativas Sanitarias England Planned Parenthood Federation. Uruguay Maria Mercedes Reproductive Health Law Scholar, International Reproductive and Cavallo/Canada Sexual Health Programme, Faculty of Law, University of Toronto. Luis Tavara Orozco/ Coordinator, Sexual and Reproductive Peru Rights Committee, Latin American Martin Hevia/ Reproductive Health Law Fellow, 2009, International Reproductive Federation of Obstetrics and Gynecology Canada and Sexual Health Programme, Faculty of Law, University of (Flasog) Toronto and Assistant Professor, Universidad di Torcuato di Tella, Buenos Aires, . Luisa Cabal/USA Director, International Legal Program, Center for Milton Castelen/ Reproductive Health Law Scholar, International Reproductive and Canada Sexual Health Programme, Faculty of Law, University of Toronto. María Luisa Director, Grupo de Información en Nelcia Robinson/ Caribbean Association of Feminist Research and Action (CAFRA). Sánchez/Mexico Reproducción Elegida (Gire) Trinidad-Tobago Rodolfo Gómez Senior Health Systems Advisor, Ipas Rebecca Cook/ Faculty Chair in International Human Rights and Co-Director, Ponce de León/USA Canada International Reproductive and Sexual Health Programme, Faculty Silvina Ramos/ Director and Researcher, Centro de of Law, University of Toronto. Argentina Estudios de Estado y Sociedad (Cedes) Sandra Dughman/ Reproductive Health Law Scholar, International Reproductive and Tania Di Giacomo Coordinator, Women’s Health, Canada Sexual Health Programme, Faculty of Law, University of Toronto. Do Lago/Brazil Department of Health, State of San Pablo Upeka de Silva/ Programme Officer, Global Comprehensive Abortion Care Project, Vicente Díaz/Mexico Executive Director, Mexfam England International Planned Parenthood Federation.

Internal Advisory Committee Carrie Tatum Evaluation Coordinator Maria Antonieta Alcade Deputy Director of Public Affairs Ilka Rondinelli Senior Quality of Care Advisor Rebecca Koladycz Manager, Institutional Development Marcela Rueda Program Coordinator Victoria Ward Director of Programs

Translation: Nicole Lisa This publication is available at www.ippfwhr.org Production: Cotidiano Mujer Helen Martins/Portfolio Publishing The full text of this book and the laws and regulations of Design and layout: gliphosxp the different countries are available on the CD included D.L.: 350.501/09 with this publication, as well as additional information on the issue. ISBN: 978-9974-8171-5-9 Please note that the English version of Legal Abortion: A © IPPF/WHR Comparative Analysis of Health Regulations contains some additional text and slight changes from the Spanish version. Any part of this publication may be copied, reproduced, distributed or adapted These changes arose from discussions with the editorial without prior permission from the author or publisher, provided the recipient of the review committee and suggestions from the team at the materials does not copy, reproduce, distribute or adapt material for commercial gain, International Reproductive and Sexual Health Programme, and provided that the authors are credited as the source of such information on all Faculty of Law, University of Toronto. copies, reproductions, distributions and adaptations of the material. IPPF/WHR would appreciate receiving a copy of any materials in which this publication is used. Legal aabortion: comparative analysis of health regulations A review of and selected countries in Europe and Africa

International Planned Parenthood Federation/Western Hemisphere Region Team Giselle Carino: Safe Abortion Program Officer – IPPF/WHR Ana Cristina González Vélez: Author - Regional Consultant Juanita Durán: Research Assistant Jennifer Friedman: Safe Abortion Program Coordinator – IPPF/WHR

Giselle Carino is the Safe Abortion Program Officer for the IPPF/WHR Regional Office and is responsible for developing and spearheading strategies to address the issues of unwanted pregnancy and unsafe abortion in Latin America and the Caribbean. Her experience with IPPF/WHR programs includes support for the implementation of recent initiatives on gender-based violence and emergency contraception. Before joining IPPF/WHR, she worked for the Inter-American Parliamentary Group on Population and Development, advocating with Latin American parliamentarians and other originators of public policy for the commitments to sexual and reproductive rights made in Cairo and Beijing. Giselle holds a Political Science degree from Argentina and a Master’s degree in Public Policy from New York University. Ana Cristina González Vélez is a doctor and graduate of the Pontificia Bolivariana University, Medellín, Colombia. She has a Master’s degree in Social Health Research from the Centro de Estudios de Estado y Sociedad, CEDES, Buenos Aires, Argentina. She worked as a physician and advisor for PROFAMILIA, Bogotá, from 1996 to 2000 and as the National Director of Public Health in Colombia from 2002 to 2004. She is an expert in sexual and reproductive health and rights, health sector reforms and advocacy. She has been a member of many national boards (National Institute of Health, Colciencias, INVIMA) as well as international boards (Association for Women’s Rights in Development, WHO Americas Advisory Panel) and has participated actively in meetings on population, development and gender, and in diverse fora of the international women’s movement. She has written books and articles for international journals on sexual and reproductive health and rights. She has worked as a consultant and conducted research with the support of the World Health Organization, the Pan American Health Organization, the Rockefeller Foundation, the Center for Reproductive Rights and the United Nations Population Fund, among others. Juanita Durán is a lawyer focusing on constitutional law and a graduate from EAFIT University, Medellín, Colombia. She was a junior justice researcher for the Corporación Excelencia en la Justicia and advisor to the Colombian Senate and is currently an assistant magistrate for the Constitutional Court of Colombia. Jennifer Friedman is a Program Coordinator for the Safe Abortion team at IPPF/WHR. Prior to joining IPPF/WHR, she worked in community health services as a counselor and coordinator of HIV prevention programs and school-based health education programs. She holds a BA in Latin American Studies from Brown University and a joint Master’s Degree in Public Health and Social Work from Columbia University. Acknowledgements IPPF/WHR would like to thank everyone who made this publication possible: the IPPF team, whose members provided support for their different areas, the committees – both advisory and editorial – for their patience and generosity, and a group of people, women and men from many countries around the world, who provided the information requested and who contributed consistency and integrity to the analysis: Adriana Ortega Ortiz, Joanna Erdman, Silvia Salinas, Moira Rimassa, Susana Chávez, Flora Tristán, Mariana Romero, Lourdes Novelo, María Consuelo Mejía, Yamila Azize, Mary Rivera, Nirvana González, Alicia Miyares, Concha Colomer, Montserrat Limárquez, Teresa Lanza, Ximena Machicao, Lupe Pérez, Alexia Escobar, Marge Berer, Mónica Arango, Luisa Cabal, Lucy Garrido, Cecilia Barros, Jacqueline Sharpe, Dona Da Costa Martinez and Rodolfo Gomez Ponce de León. Thanks also go to the following IPPF Member Associations: Asociación Panameña de el Planeamiento de la Familia (APLAFA), Panama; Bem–Estar Familiar no Brasil (BEMFAM), Brazil; the Association of Trinidad-Tobago (FPATT); Instituto Peruano de Paternidad Responsable (INPPARES), Peru; Fundación Mexicana para la Planeación Familiar (MEXFAM), Mexico; and Asociación Puertorriqueña Pro Bienestar de la Familia (PROFAMILIA), Puerto Rico.

Contents

Preface ...... 9 Foreword...... 11 Executive summary...... 15 I. Methodology...... 21 i. Criteria used to select the countries...... 23 ii. Criteria used for the analysis...... 24 iii. The consultation process...... 27

II. Objectives ...... 29 III. The legal situation of the countries analyzed...... 33 i. Countries that stipulate legal grounds for abortion with provisos for gestational age in non-criminal laws and regulations...... 35 ii. Countries that criminalize abortion except in special circumstances as stated in their penal code...... 38

IV. Comparative analysis of the regulations...... 41 i. Organization of services...... 43 ii. Service quality: guaranteeing rights and quality standards...... 66 iii. Education and training of service providers...... 114 iv. Data collection, monitoring and oversight systems ...... 118 v. Funding of services...... 128 vi. Administrative issues...... 130 Some conclusions...... 142

V. Recommendations for developing regulations that guarantee access to abortion services...... 145 i. Barriers ...... 149 ii. Recommendations...... 155

Index of laws and regulations...... 193 Index of documents...... 197

Preface

Supporting a woman’s right to choose to legally and safely terminate her pregnancy is central to the mission of the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR). To achieve this mandate, IPPF/WHR has developed and  implemented regional initiatives that promote equity, social justice and equality of rights in the delivery of health services, with the aim of improving opportunities in the field of sexual and reproductive health. These strategies are implemented in coordination with IPPF/WHR Member Associations and allied organizations that are committed to ensuring the full exercise of these rights and to promoting safe and legal abortion in Latin America and the Caribbean.

IPPF/WHR believes that the right to achieve the highest standard of health is a basic human right. It also believes that efforts to achieve well-being through health promotion and comprehensive services must include at least three main components: reducing the occurrence of unwanted pregnancy – and, therefore, the need for abortion – by promoting policies for comprehensive sexuality education and access to contraception; promoting women’s right to make informed decisions about their lives with freedom and integrity; and increasing access to legal abortion services. Timely and equitable access to quality abortion services as permitted by law must, therefore, form one of the fundamental components of sexual and reproductive health policies.

It is within this framework that IPPF/WHR initiated this comparative analysis of health regulations for legal abortion in several countries in Latin America and the Caribbean. The goal was to examine current trends in this area. To expand the analysis, this comparison also includes health regulations from countries outside the region that represent major advances or new thinking. In addition, the team has created a model regulation, which includes the essential elements for guaranteeing women’s access to safe, legal and timely abortion services.

IPPF/WHR hopes this comparative analysis will form a basis for decision making that will advance sexual and reproductive health and that it will also contribute to efforts to find common ground in the face of challenges that continue to cause controversy and inhibit consensus. In many cases, the analysis aims to identify measures that in and of themselves may constitute barriers to access rather than creating conditions that enable women to exercise their rights.

This publication is the first attempt to establish a model regulation based on a comparison of current regulations. The next crucial step must be to develop strategies that incorporate the vision of clients and health professionals, whose perspectives and experiences of legal abortion services enable them to determine the true effectiveness of regulations.

This initial effort to present a model regulation arose out of the conviction that decriminalization, and even legalization, of abortion is not enough to guarantee access to safe, timely and quality abortion services. The establishment of effective policies and 10 health regulations is an essential step to ensure compliance with the law. These policies, in turn, can be used to make sure that health systems offer women with unwanted pregnancies a range of integrated services that focus on their health and well-being, to create instruments that deepen the commitment of health professionals and clarify their responsibilities, and to guarantee that mechanisms are in place for women to exercise their rights to legal abortion.

Carmen Barroso Regional Director International Planned Parenthood Federation Western Hemisphere Region Foreword

This report provides a comparative analysis of health regulations designed to ensure the implementation of laws enabling the provision of legal abortion services. The proposed model regulation sets minimum standards for what is required by governments and 11 health care providers to ensure women’s access to safe, dignified and timely services. It is an important document that should be widely read by those concerned with improving the delivery of abortion services to all women, irrespective of their circumstances.

Significantly, the report takes a human rights approach. It explains how regulations should be designed in order to comply with women’s human rights and fundamental freedoms. A human rights approach provides a language and a process by which harms are recognized, named and identified as human rights violations, and ultimately rectified.

Naming of the harmful treatment to which women are subjected in their various pathways to abortion services is especially important, because so often the treatment is not understood as harmful. Naming a practice as harmful is a precondition to remedying it, in much the same way that diagnosing a condition as a disease is essential for its treatment.

Harms to which women are exposed in the abortion context can be understood as harms that fail to distribute health resources according to women’s health care needs (distributional harms), and harms that are detrimental to women’s dignity, autonomy and privacy (recognition harms). This report addresses both kinds of harms, because women can not access services unless they are available, and will not access services unless they are treated with compassion and respect. The proposed model regulation explores the ways in which governments and health care providers can address and remedy both distributional and recognition harms.

Indicators are often helpful in identifying these harms. Some countries have developed a series of health service indicators that measure the quality of the delivery of the service, and health status indicators that measure the outcomes of the health service. Important health status indicators include morbidity and mortality rates from unsafe abortion and, for example, the percentage of performed during the first 10 weeks of pregnancy. These indicators need to be disaggregated by age, rural status and, for example, ethnicity, to ensure that subgroups of women have equal and timely access to services. Where deaths due to unsafe abortion are high, health status indicators can be used to name the harms to women, and to quantify their impact.

Determining how these harms constitute human rights violations is the next step in a human rights approach. This requires identifying the human rights, whether expressed in national constitutions, international human rights treaties or national laws, or health regulations, and explaining why the harm constitutes a violation. The distributional 12 harms can be conceived as violating rights such as ( the right to the highest attainable standard of care because services are not adequately provided, ( the right to nondiscrimination in access to care because services are not equally available to all women irrespective, for example, of their age, race, disability, rural location, or ability to pay.

Recognition harms may violate rights such as

( the right to be free from inhuman or degrading treatment because of the dignity denying treatment to which women are subjected, ( the right to liberty or security of the person because of the denial of women’s decisional autonomy or her moral agency.

Once the harms are named and it is understood which human rights are violated, the next step in a human rights approach is to hold those accountable for the human rights violations they have caused. Indicators shift the burden to governments to explain why they are not doing more to address the preventable causes of women’s premature death. Holding violators of human rights standards accountable is central to a human rights approach to abortion. Those who violate women’s human rights in the abortion context can be held accountable in multiple ways, including politically, professionally and legally. Indicators, for example, can be used legally to argue before a court of law, or before human rights tribunals that women are being discriminated against on account of their sex-specific health care needs.

The ways in which violators will be held accountable will often depend on the context. For example, ministries of health might be held legally accountable for neglecting health services, such as abortion, that only women need. Neglecting health care that only women need is a form of discrimination against women that ministries are obligated to address and remedy. As this report explains, this neglect can come in many ways, such as not supplying the necessary medications, and not providing the necessary training for health care providers.

This report will be invaluable to communities working together to eliminate discrimination and other human rights violations in the abortion context, and ensure that governments distribute health care services for sex-specific needs, and that all women, irrespective of their circumstances, are accorded recognition and respect in their various pathways to abortion.

Rebecca J. Cook Joanna N. Erdman 13 Co-directors International Reproductive and Sexual Health Programme Faculty of Law, University of Toronto July 2009

Executive summary

This publication – Legal Abortion: A Comparative Analysis of Health Regulations – is the result of a comparative analysis of laws and health regulations governing access to legal abortion in 13 countries: Bolivia, Brazil, Canada, Colombia, Guyana, Italy, Mexico, 15 Norway, Panama, Peru, Puerto Rico, South Africa and Spain.

As described in the foreword, this publication seeks to promote access to safe and legal abortion services by developing health regulations and guidelines that are grounded in a human rights framework. Applying a human rights framework to the delivery of health services is fundamental to achieving the right to health for all citizens and creating a health system in which people are empowered to freely make decisions about their lives. There is no area where this is more important than in the provision of sexual and reproductive health services, particularly abortion-related services.

The challenge remains of how to genuinely apply and integrate these rights into the actual delivery of services and the way that health systems are run. Efforts to define the right to health by international human rights bodies and scholars have identified that the right to health requires the following four key features of health care services: availability, accessibility, acceptability and adequate quality. The implementation of comprehensive and well-designed health regulations is an important way to ensure that these features are put in place. As described throughout this document, there are countries around the world whose laws permit abortion in specific circumstances. However, in practice, there are tremendous barriers for women seeking to access these services. The failure of governments to provide these lawfully entitled services constitutes a violation of both local laws and international human rights standards. While the existence of health

 Cook, R and Dickens, BM (2003) Human rights dynamics of reform. Human Rights Quarterly. 25, pp.1–59.  Cook, RJ (2009) Transparency in the delivery of lawful abortion services. Canadian Medical Association Journal. 180(3), pp.272–273. regulations and ethical and quality of care standards will not remove all barriers to access, they are an essential element of transparent health services.

There is no universally agreed upon definition of a human rights approach to health; however, health policies and guidelines that follow a human rights framework are grounded in certain key elements. These include the principle of non-discrimination – guaranteeing that such policies aim to eliminate differential access to health services and ensure that all clients receive ethical treatment. Another key element is the involvement of community members and civil society groups in developing and implementing national and local health-related policies. Such a framework also includes mechanisms to hold governments accountable in their legal obligations to respect, protect, promote and fulfill the right to health. When governments are negligent in these obligations, citizens must have access to systems of redress that will hold the government to account. 16 Finally, within such a framework, there must be acknowledgement of the underlying determinants of health and the need to coordinate with other sectors to improve health outcomes and access to health services.

As the work of Paul Hunt and others shows, the creation of indicators and standards to monitor states’ implementation of the right to health is an essential part of a broader human rights approach to health care. The comparative review of health regulations in this publication, and the proposed model regulation for legal abortion services, are an innovative attempt to establish minimum standards for what is required of governments and health providers to ensure that women have access to safe, high quality abortion services as permitted under the law. IPPF/WHR hopes that efforts to create new regulations, or improve existing ones, will be carried out in close collaboration with governments, civil society and community actors in order to guarantee that health service provision is firmly grounded in a human rights framework.

The book is organized into a prologue and five chapters. The first chapter,Methodology , includes explanations of the criteria used to select countries and to find and analyze information, as well as details about the consultation process used to produce the book.

The second chapter, Objectives, sets out the goals of the publication. These highlight the fact that regulations should reduce or eliminate barriers to access to services, and

 Yamin, AE (2002) Challenges and possibilities for innovative praxis in health and human rights: reflections from Peru. Health and Human Rights. 6(1), pp.35–62.  Backman, G, Hunt, P, Khosla, R et al (2008) Health systems and the right to health: an assessment of 194 countries. The Lancet. 372(9655), pp.2047–2085. provide clarity and a framework for health providers on how to implement safe abortion services. The objectives are:

( to compare abortion-related laws and regulations enacted by different countries ( to create a tool that provides information on the measures and content contained in the different regulations that can be used to guide decision making on laws and regulations that facilitate access to legal abortion services ( to create a model proposal for health regulations and guidelines that foster timely access to safe and legal abortion services

The third chapter – Legal situations of the countries analyzed – describes the legal situation of abortion in each of the selected countries and classifies each country according to whether abortion is partially or fully legal. Countries that stipulate specific grounds for legal abortion in their non-criminal laws and regulations include Canada, Guyana, Italy, Norway, Puerto Rico and South Africa. Countries that criminalize abortion except 17 in special circumstances as stated in their penal code include Bolivia, Brazil, Colombia, Mexico, Panama, Peru and Spain.

The fourth and longest chapter is the Comparative analysis of the regulations, which is organized by various criteria. These criteria were defined on the basis that they would ideally be included in abortion regulations in order to effectively eliminate barriers and guarantee timely access to legal abortion services, or they were a part of the current regulations in the countries researched.

 Because this publication is intended for use by decision makers and lobbying groups, the comparative analysis is extensive. IPPF/WHR hopes that it will be used as a guide for creating regulations that protect women’s rights. Countries may choose from the many components those that best fit their situation.  Extensive information about the legal situation of each country is included in the CD that accompanies this publication.  The analysis addresses the following topics: organization of services (guiding principles; service networks at all levels; determining referral and counter-referral systems and their operation; level of care of services. It includes determining the level of care in accordance with duration of pregnancy; service provision models; counseling and support models/activities. It includes different options for unwanted pregnancy; services for young people; models of care for abortion in specific circumstances (for example, ); professionals with authorization to perform the procedure; guaranteeing service provision; post-abortion counseling and care; timeframes for service provision). Service quality: guaranteeing rights and quality standards (: general rules for consent, consent of minors, consent of women who cannot directly give it themselves, conscientious objection; confidentiality of services: medical confidentiality; privacy of services; consideration of the client’s culture; systematic dissemination of information to promote services to the general public; content of information provided to individual women; protocols for surgical and . Specifically, it includes measures on laboratory tests and ultrasound before an abortion; pregnancy tests; pain management; description of abortion techniques (surgical and medical); prophylactic antibiotics; management of complications; establishing biosecurity standards; infrastructure requirements for service provision; accreditation mechanisms for professionals; gestational limits). Education and training of service providers (education and training in medical and psychosocial aspects (gender perspective, rights and empowerment) of abortion for all health personnel (physicians, midwives, nurses and The fifth and final chapter offers recommendations for health regulations on legal abortion. These recommendations are essentially guidelines for defining the components and principles that should be included in all abortion regulations in order to promote access to services and guarantee that sexual and reproductive rights related to abortion can be exercised. The chapter therefore includes an analysis of potential sources of barriers to access: barriers related to the organization of services; barriers related to service quality and the exercise of rights; barriers related to data collection, monitoring and oversight systems; economic barriers; and administrative barriers.

The chapter also presents recommendations to reduce each set of barriers: measures to reduce barriers related to the organization of services; measures to eliminate barriers related to service quality and rights; measures to eliminate barriers related to the education and training of health professionals; measures to eliminate barriers related to 18 data collection, monitoring and oversight systems; measures to reduce barriers due to costs; and measures to reduce administrative barriers.

The recommendations included in the final chapter stem from the belief that legal reform alone is not enough to guarantee access to safe and timely abortion services. Health regulations are essential for increasing women’s awareness of their rights to safe abortion, for ensuring the existence of instruments that make it possible to enforce these rights, particularly women’s , and for ensuring the implementation of quality services. Put simply, the model can serve as an important political advocacy tool for countries where there are no abortion regulations or where existing regulations are not designed to protect women’s sexual and reproductive rights. It is important to emphasize that the success of such regulations also depends on the presence of committed health professionals who have not only been adequately trained at a technical level, but who also understand the importance of their role in working for social change through the provision of quality and humane sexual and reproductive health services.

counselors); continuing education at health facilities; emotional support for women and respect for their decisions; eliminating harmful customary practices such as requiring partner’s consent; social and/or moral sanctions against abortion, and so on; the role of health sciences faculties; creating a multi-disciplinary team to manage unwanted or unplanned pregnancies). Information, monitoring and oversight systems (data management systems, including reporting complications and infections (epidemiological monitoring system); monitoring and oversight systems of facilities that provide services; appeal or review mechanisms when services are denied; prohibition against labor or social discrimination against abortion providers; sanctions for denying services; management of medical records). Funding of services (service costs: payment; instruments to identify the socio-economic situation of different populations). Administrative issues (requirements for accessing abortion services; defining and clarifying grounds for abortion; availability of abortion drugs ( and ); grounds for denial of services). These recommendations must form part of a comprehensive package of sexual and reproductive health care policies that provide the necessary services for women facing unwanted pregnancies and create measures to prevent future unwanted or unplanned pregnancies. In the area of prevention, there are two important areas of action: implementation of quality sexuality education, and promotion of and access to contraceptive methods, including methods for preventing pregnancy and sexually transmitted infections (dual protection). In relation to services for women with unwanted pregnancies, the full range of options should be available: termination of pregnancy (by medical or surgical abortion) where allowed by law, promotion of risk-reduction strategies for unsafe abortion, outpatient care for incomplete abortion, adoption counseling and, finally, for those women who decide to continue the pregnancy, quality prenatal, childbirth and post-partum care with appropriate social support as well as the existence of social policies that support and protect parents and families. 19

I. Methodology

  ( ( ( ( ( in and, criteria: following the on based made was situation selection The the of analysis complete fairly particular, a of the measures being undertaken to undertake ensure access to legal abortion to services. team research the enabled this selection in are region, the few there regulations because Instead, regions. other of or region, Caribbean and America Latin the of representative be to intended Africa South Rico, Puerto Peru, Panama, analysis: the After establishing criteria, the following countries were for selected the comparative Criteria to select used countries the i. 1 I. 0

where the regulations have been in place for a long time (Italy and Spain). and (Italy time along for in place have been regulations the where Africa (South abortion to respect with situations generally legal advanced countries, (European to ofan with that countries analysis regulations more provide information pertinent regulations ground-breaking speaking); with countries project; abortion safe in aregional participating are Associations Member IPPF/WHR where countries some of inclusion Americas; in the representation subregional to ensure countries of some inclusion services abortion to legal access on regulations with countries Methodology Regulations on incomplete abortion and hemorrhage during the first trimester were not included because, because, included not were trimester first the during hemorrhage and abortion incomplete on Regulations used was internet the then and identified was countries of group preliminary larger a conclusion, this reach To In In democratic government. democratic conditions unsafe publication. this of focus the in are which services, performed abortion legal often address not – do – they initiated already abortions for care health support often they although obstetricians, and issues. gynecologists of associations organizations, websites in about abortion each as and country and the agencies specifically websites well international institutions, women’s as thematic examined parliaments, research The health, of regulations. extensive ministries most of or best the had countries which research to South oii, rzl Cnd, ooba Gyn, tl, eio Norway, Mexico, Italy, Guyana, Colombia, Canada, Brazil, Bolivia, Africa te brin euain wr eatd ihn h bodr rcs o etbihn a new, a establishing of process broader the within enacted were regulations abortion the , and Spain . This small sample size is not not is size sample small This .  ; 1 0 and Norway) or or Norway) and 

23 I. Methodology Together, these criteria formed the basis for the research, the 11 Latin American Federation of Obstetric and Gynecological Societies (FLASOG), HealthIPPF, Organization. Ipas The rulings ofand various constitutionalthe Pan courts, American such as in Colombia, were also considered. Examples include the World Health Organization, International Federation of Gynecology and Obstetrics (FIGO),

11 Following is a list the of issues and criteria that were analyzed the in comparison: adolescentsorderaddress in to recommendations particulartheir make situationandto that would specificallyfoster the exerciseof their sexual andreproductive rights. Finally, it is important to clarify that this analysis has two Firstly, limitations regulations in its on reporting. post–abortion care were not included, because access to legal the abortion services. focus Secondly, the information concentrates ison regulations on that exclusively address legal abortion; therefore, regulations or laws that may it address issues discussed is in the analysis were not included. possible that other typesFor these of reasons, when it is stated specific that issue, it the isimportant to regulations bearin mind that these analyzed limitations areinevitable do given not address a the scope this of project. recommendations for abortion-related public international health bodies. guidelines the during refined were criteria set The V. Chapter out in recommendations the and itself by analysis various recommendationsmodel the for included initially were that criteria somestage: research them about insufficientinformation was becauseanalysisthere the in included not were in the regulations of the selected countries; theynot were,excluded however, from the model. guaranteeing to significantly contributeelements theto believedmodel The includes all rights to access legal abortion services. Each component, regulations, if would contribute to includedthe reduction and/or in elimination of barriers public to access. health Additionally, for each section of the analysis, concrete information was sought on ii. Criteria the analysis used for The regulations were analyzed based on the elements that would ideally be found specific in regulations governing access to legal abortion, as well as on the criteria and

I. Methodology 24 / / / / / / / standards quality and rights guaranteeing quality: Service / / / / / / / / / / / / of services Organization / - - - on: measures specifically, laws and regulations); or compulsory guidelines delivery (service abortion and medical for surgical protocols women individual to provided information of content abortion legal to related rights about education includes this public: general the to services promote to information of dissemination systematic different speak who languages professionals health of availability example, for culture; client’s the of consideration services of privacy confidentiality medical services: of confidentiality objection conscientious iii. ii. i. consent: informed provision service for timeframes health reproductive and sexual other and services contraceptives to access care: and counseling post–abortion provision service guaranteeing for responsible entities procedure the perform to authorization with professionals rape) example, (for circumstances specific in abortion for care of models required is payment when services, of payment for mechanisms include these people: young for services adoption services, abortion legal the seek continuing to pregnancy, options for women; dissuade unwanted these pregnancy: include different do not and making decision women’s autonomous encourage that models/activities support and counseling includes this care: model provision service abortion trimester second and care pregnancy of duration outpatient the with accordance in care of level the determining including services, of care of level operation their and systems counter-referral and referral determining national and departmental local, levels: all at networks service principles guiding pain management pain tests pregnancy on) so and tests, blood other syphilis, (HIV/AIDS, abortion an before ultrasound and tests laboratory themselves it give directly cannot who women of consent minors of consent consent for rules general 25 I. Methodology description of abortion techniques (surgical and medical) prophylactic antibiotics management of complications establishing biosecurity standards grounds for denial of services management of medical records service costs: payment mechanisms (including sliding scale fees) instruments to identify the socio-economic status of different populations requirements for accessing abortion services: criminal report, health professionalslegal-medical involved in determining if the procedureexamination should be performed and number of defining and clarifying grounds for abortion availability of abortion drugs (misoprostol and mifepristone) sanctions against abortion) the role of health sciences faculties/medical schools creating a multi-disciplinary team to manage unwanted or unplanned pregnancies data management systems, including reporting complications and infections (epidemiologicalsystem) monitoring monitoring and oversight systems of facilities that provide services appeal or review mechanisms when services are denied prohibition against employment or social discrimination against abortion providers sanctions for denying services infrastructure requirements for service provision, including certification and accreditation of facilities accreditation mechanisms for professionals gestational limits education and training in medical and psychosocial aspects empowerment)of for all health personnelabortion (physicians, midwives, nurses(gender and counselors) perspective, rights and continuing education at health facilities emotional support for women and respect for their decisions eliminating harmful customary practices (for example, requiring partner’s consent, social and/or moral - - - - / / Funding services of / / Administrative issues / / / / / Information, monitoring and oversight systems / / / / / / / / Education and training service of providers / / / /

I. Methodology 26 14 13 12 health. reproductive and sexual in professionals and activists scholars, legal well-known from involvement with perspectives. their contribute and document final the review to formed was region the from professionals and the finalpublication. Finally,an editorial committee ofwell-known medical and ethics unique information provided by each organization, and enriched refined the discussions were held with the safe division This abortion of range ofIPPF/WHR. and viewpoints, the services. abortion of provision the and/or research law, of areas the in activists and leaders well-known are members whose region the in and developing the model regulation – was with discussed a group of four organizations countries comparing regulations, abortion on information analyze to matrix a creating countries, selecting included which – analysis comparative the process, the Throughout iii. The consultation process countries. of the in each key from contacts collected also that the comparative analysis could be created. Information on regulations was abortion legal the the Once so were evaluated regulations specific of identified, been had country issues. each for framework each these on addressed that information regulations for identify to researched order in was countries internet the outline, this on Based

Milton Castelan, University of Toronto;Milton of University Castelan, Toronto;Maria Cavallo, of Mercedes University Cook, Rebecca University Luisa Luisa Cabal, Center USA; Centro Silvina Ramos, Rights, for de de Reproductive y Estudios Estado (CEDES), Sociedad London; Nelcia Robinson, CAFRA; Upeka de Silva, IPPF, London. London. IPPF, Silva, de Upeka IPPF, CAFRA; Robinson, Hurwitz, Nelcia London; Manuelle Toronto; of University Hevia, Martin Toronto; of University Erdman, Joanna Toronto; of University Dughman, Toronto;Sandra of University Dickens, Toronto;Bernard of University Davies, Toronto; Cara Gómez Rodolfo Pablo; FLASOG. San of State the Tavara Luis and Orozco, Uruguay; del of Obstétrica Health Asociación of the President of Labandera, Ana Ipas; León, de Ponce Department Health, Women’s of Coordinator Lago, do Cristina and Mexico; (GIRE), Elegida Reproducción Colombia. ORIENTAME, en Villarreal, Información de Grupo Sánchez, Luisa María Argentina; Leonel Briozzo, Iniciativas Sanitarias, Uruguay; Vicente Díaz, MEXFAM; Aníbal Faúndes, FIGO; Tania di Giacomo Giacomo di Tania FIGO; Faúndes, Aníbal MEXFAM; Díaz, Vicente Uruguay; Sanitarias, Iniciativas Briozzo, Leonel 13 The English edition included an additional editorial review process process review editorial additional an included edition English The 14 12 In addition, ongoing discussions discussions ongoing addition, In 27 I. Methodology

II. Objectives

15 understanding the with rights reproductive and sexual foster that measures choose to create even may contrary, the to barriers or With access this rights. haveundermine overview, governments the option on which, and framework rights a favor clearly which see to and regulations abortion in trends the understand to important is developments these of overview An regions. other as well as countries Caribbean and American Latin national inauthorities countries different with information both about in developments provides It decisions. making for tool valuable a is analysis comparative the addition, In well-being. and women’s health to guarantee ineffort an services abortion legal of provision the and rights reproductive and sexual for advocate non- that – and governmental governmental both – society of sectors different by used be can model This services. abortion safe to how implement on providers health to guidance and clarity provide to and services, to eliminating access or promote to reducing order in for barriers tool a as seen be should regulation model proposed The ( ( ( were: project of the main objectives The II.

and legal abortion services safe abortion legal and to access timely foster that regulations health for proposal model a create to services abortion to legal facilitateaccess that regulations and laws on making decision guide to used be can that regulations different the in contained content and measures the on information provides that tool a create to countries by different enacted regulations and laws abortion to compare Because this publication is intended for use by decision makers and lobbying groups, the comparative analysis is is analysis comparative the groups, lobbying and makers decision by use for intended is publication this Because Objectives extensive. IPPF/WHR hopes that it will be used as a guide for creating regulations that protect women’s rights. rights. women’s situation. protect their fit that best that those regulations components many the from creating choose may Countries for guide a as used be will it that hopes IPPF/WHR extensive. 15 31 II. Objectives 32 II. Objectives to encourage governments to implement health measures that protect these rights. rights. these protect that measures health to implement governments to encourage arguments as two realities are weighty should These serve preventable. abortion unsafe and rights, specifically the right to life,is revealed by the fact thatmostdeaths related to of violation The cultures. minority or indigenous to belong who or areas isolated in live the most commonly women, the affect poorest least women, educated and women who complications is revealed of by Inequality women’s that the fact abortion-related rights. Maternal deaths due to unsafe clearly abortion demonstrate inequality and the violation of therefore and health to in general. rights human right the of element fundamental a are rights these that III. The legal situation of the countries analyzed

regulations lawsand non-criminal in age gestational III. to gestational age, transgressing these laws does not result in criminal punishment. result not does laws these transgressing age, to gestational related often abortion, legal to access limit that grounds are there although countries, Canada, Guyana, Italy, Norway, Puerto Rico and South Africa belong to this group. In these grounds stipulate Countries for that legal abortion provisos with for i. 1 code. penal in their out set as circumstances special in except abortion penalize that countries (ii) and regulations; and laws criminal non- in abortion for grounds are legal formulate that countries (i) groups: general two into divided in countries the exceptions, are there Although gestation. of duration to according access determine generally that countries in laws non-criminal reviewing by penal the reviewing and by exceptions, special some with criminalize generally that in countries abortion codes determined was countries selected the in situation legal The

The situation of Canada differs somewhat from the other countries in this group. Abortion was decriminalized in Canada as a result of a of result a as Canada in decriminalized was Abortion group. this in countries other the from somewhat differs Canada of situation The code, it is of no force or effect. effect. or penal force in the no of is it remains code, still section the While unconstitutional. code penal in the abortion on section the rendered which ruling, Court Supreme and laws non-criminal regulations in abortion grounds for legal formulate that Countries The legal situation of the countries analyzed South Africa South Rico Puerto Norway Italy Guyana Canada 1 in special circumstances as stipulated in in code penal stipulated their as circumstances special in except criminalize that abortion Countries Spain Peru Panama Mexico Colombia Brazil Bolivia

III. The legal situation of the 35 countries analyzed 36 III. The legal situation of the countries analyzed In to the 6, mother Regulation (Art. for the Social Protection of and Motherhood Voluntary labor the puts mother’s life at risk or fetal malformations are that present pose a danger or if the pregnancy may 4).be performed an days, abortion 90 After malformation (Art. conception; the of circumstances the to family due or economic situation; social, her to due mother; the of health mental or physical the to In 1995). 7, Act, Termination Medical (Art. of Pregnancy child unborn her of or woman the of grave health mental or physical prevent the to injury to permanent or woman the of life the save to only allowed is abortion weeks, 16 6). After (Art. partner her or woman pregnant the by method contraceptive recognized a of faith good in use the of spite in resulted pregnancy the that evidence clear is there where (vi) and HIV-positive; be to known is woman pregnant the where (v) effect; that to statement a submits and incest or rape of act an by caused was pregnancy her that believes reasonably woman pregnant the where (iv) mind; unsound of person a is she handicapped; (iii) the pregnant woman is not capable of taking care of an infant because seriously tobe as abnormalities mental or physical such suffer would it born, childwere future considered); and is current situation woman’s social the and case, economic latter the (in health injury mental grave or or physical woman her pregnant to the of life the to risk involve of would continuation the pregnancy (i) the if terminated be can pregnancy weeks, 12 and eight Between ( person of the security and liberty life, to right the establishing article the specifically Freedoms, and Rights of Charter Canadian the with conflict in was abortion criminalizing provision code penal In 17 16 without restriction. After 12 weeks it can be terminated (i) when the pregnancy, childbirth In 1978). of Pregnancy, Interruption

Italy Canada Norway Guyana From the context, it is clear that this refers to sex crimes. The original states: «Per l’interruzione volontaria volontaria l’interruzione «Per states: original The crimes. sex to refers this that clear is it context, the From il concepimento…» il avvenuto e’ cui in circostanze alle o familiari, o sociali o economiche, condizioni sue alle o salute, di stato suo al o della prosecuzione la quali le per un per la il pericolo serio o gravidanza, sua parto o in fisica la salute comporterebbero psichica, relazione maternita circostanze accusi che donna la giorni, novanta primi i entro gravidanza della foreseeable…» or shall take into practitioner account the pregnant woman’s entire actual whether and social environment, economic medical or authorized practitioner a (1)(b)(i), medical in subsection of as a woman mentioned the health pregnant The original states: «In determining whether the continuance of a pregnancy would involve risk of grave injury to to injury grave of risk involve would pregnancy a of continuance the whether determining «In states: original The , a pregnancy may be terminated before 90 days when it poses a grave danger danger grave a poses it when days 90 before terminated be may pregnancy a , , abortion was legalized by a Supreme Court ruling, which found that the the that found which ruling, Court Supreme a by legalized was abortion , , , there are no limitations on abortion before eight weeks of pregnancy. pregnancy. of weeks eight before abortion on limitations no are there , similar to South Africa, a pregnancy can be terminated before 12 weeks weeks 12 before terminated be can pregnancy a Africa, South to similar R versus

Morgentaler , 1988 16 (ii) there is substantial risk that if the the if that risk substantial is there (ii) ). 17 or due to fetal anomaly or or anomaly fetal to due or 2 19 18 19962004). and Amendment, and Act would (iii) it would pose it a risk of injury to the 2, (i) fetus Choice (Art. on Termination if of Pregnancy only terminated or fetus; the of be malformation severe a in result may would it (ii) life;woman’s the endanger pregnancy a weeks, 20 After woman. the of severe a the would continued the from pregnancy socialsignificantly affect or economic circumstances (iv) suffer or incest; would or rape from fetus resulted pregnancy the the (iii) abnormality; that mental or physical risk substantial a the mental or exists (i) physical there if woman’s (ii) the permitted to health; injury is of it risk a gestation pose of would pregnancy weeks continued 20 and 13 Between request. woman’s In and psychological emotional, woman’s the age. well as as familial factors physical, includes which health, or life woman’s the to risk a is there unless denied be can termination viability, fetal After viable. is fetus the before situation any in denied be not may termination law, the Under Rico. Puerto for Montalvo Hernández Colón versus In 1978).Termination 1975, of Pregnancy, Amendments, with concerning 50 No. Act 2, (Art. approved be not shall termination the viable, considered so. do to reasons important are there if only terminated may be pregnancy a week, 17th the After degree. considerable a to retarded mentally is code; penal the in described behavior criminal of result the is pregnancy the when (iv) pregnancy; during child may the that risk major a or harmful influences or disease is as a of genotype, result from its disease a serious suffer there when (iii) situation; life the difficult place a may in child woman the of care or childbirth pregnancy, the when (ii) woman; the of or care of the child may inresult strain unreasonable the 0

Puerto Rico Puerto ot Africa South The context indicates a level of suffering that a woman is not reasonably expected to endure. In other texts, this this texts, other In endure. to expected reasonably not is woman a that suffering of level a indicates context The Rape, incest and sexual relations with minors younger than 16 years of age of 16 than years younger minors with relations sexual and incest Rape, unless there are particularly important grounds for doing so.» so.» doing for grounds important particularly are there unless burden’. ‘undue as described is situation The original states: «A pregnancy may not be terminated after the eighteenth week of pregnancy has elapsed elapsed has pregnancy of week eighteenth the after terminated be not may pregnancy «A states: original The o vru Wade versus Roe , abortion is abortion legal in the as same in circumstances the United States under , abortion is permitted without restrictions before 12 weeks at the the at weeks 12 before restrictions without permitted is abortion 19 and (v) when the woman is suffering from severe mental illness or or illness mental severe from suffering is woman the when (v) and decision. This guarantee was granted in the decision decision the in granted was guarantee This decision. , 377 Federal Supp. 1332, 1974, of the US Court District 18

on on the or physical health mental . 2 0 However, if the fetus is is fetus the if However, Acevedo Acevedo

III. The legal situation of the 37 countries analyzed 38 III. The legal situation of the countries analyzed code theirpenal stated in as circumstances In as certified by a physician; (iii) when the pregnancy is the result of a duly reported act act reported duly a of result the is pregnancy the when (iii) physician; a by certified as as certified by aphysician; (ii) when agrave malformation of thefetus makes lifeunviable (i) toa danger the life or health of constitutes the woman exceptions: the continuing when the pregnancy reiterated regulations technical The Constitution. the with conflict Court In opinion. have amedical must and prosecutor public or judge a from authorization request must woman the cases, such in abortion To an obtain agenesis. renal and syndrome Patau’s anencephaly, as such life, with incompatible malformation fetal of cases in request woman’s a at or judges by authorized fact in are reiterated in the Technical Regulations for Care. a As Humane abortions Abortion result, were grounds these and , the outside life with incompatible malformation fetal 128, (Art. violence ofsexual act another or rape ofstatutory result the is pregnancy ifthe or 266, (Art. means by other avoided be cannot danger this if mother the of health or life the to danger avoid to and incest, or rape statutory marriage, by followed not is that purposes sexual for abduction rape, In unique. are somewhat situations their legal although Colombia, and Mexico includes group This abortion except special in criminalize that ii. Countries 21 417 rape (Art. of bis, result the is pregnancy the when weeks 12 until or defects mental or physical grave with born be will fetus the that believed is it or woman the of life or health the Definitions (3. incest or ( egg fertilized a ( of implantation or insemination artificial or non-consensual act sexual and abusive or a carnal access non-consensual constituting In Norma Técnica para la Atención de la Interrupción Voluntaria ILE Embarazo del Técnica la Interrupción de laNorma Atención para Definiciones

Bolivia Brazil Spain Colombia Statutory rape refers to sexual relations that involve some type of coercion or power imbalance (due to age or or age to (due imbalance power or coercion of type some involve that relations sexual to refers rape Statutory and someone who is over 18, even if it is consensual. is it if 18, even over is who someone and minor a between relationship sexual any to refers rape statutory example, for States, United the In factors). other ea Code Penal ruling, which found that criminalizing abortion in certain circumstances was in was circumstances certain in abortion criminalizing that found which ruling, , , terminations are authorized up to 22 weeks when there is a grave danger to danger grave a is there when weeks 22 to up authorized are terminations , abortion is permitted if there are no other means of saving the woman’s life woman’s the saving of means other no are there if permitted is abortion , termination of a pregnancy is permitted when the pregnancy is the result of result the is pregnancy the when permitted is oftermination a pregnancy ), Technical Regulations on Care for the Voluntary Interruption of Pregnancy Penal Code Penal , abortion was decriminalized in some circumstances by a by circumstances some in decriminalized was abortion , . ae a hs lo salse gons o aoto i te ae of case the in abortion for grounds established also has law Case ). ). Penal Code, 1972 Code, Penal ).

Constitutional Constitutional )). 21

mother or to avoid serious and permanent harm to her health (Art. 119, (Art. 1924 health her to harm permanent and serious avoid to or mother Code 144, (Art. fetus the of or mother the of life the endanger conditions gravehealth In of148, Mexicothe Penal womanCity Code). (Art. of the fetus at risk; and when the pregnancy is the result of criminal behavior on the part could result in physical or mental damage to such an extent that they may put the survival that grounds genetic or diagnosisthat a defects congenital giveshas the sufficient fetus performing an abortion would result in grave consequences to the not woman’swhen insemination; health;artificial when non-consensual or rape of result the is pregnancy the Code 144, (Art. restriction without pregnancy of weeks 12 first the during In In

Peru Mexico Panama ). ). After 12 the weeks, penal code sets out the following grounds for abortion: when ). , abortion , is allowed abortion when it is the only means of saving the life of the expectant , the, , a pregnancy may be terminated when conception is the result of rape, or or rape, of result the is conception when terminated be may pregnancy a , penalcode MexicoCity was modified in April wasmodified in to 2007 allow terminations Mexico City Penal City Mexico Penal Code, Code, Penal Penal

III. The legal situation of the 3 countries analyzed 9

IV. Comparative analysis of the regulations

d. c. dignity, dignity, autonomy, and ethical and guaranteed moral authority to make a decisions must be respected, be always must women priority and must services be for provided by a care professional; above all, health the woman’s freedom, regulations, the to According b. a. include: which principles, corebioethical four the for respect on based In a provision or about how he or she should act in a situation not specified in law.practice, these principles guide health providers when there is doubt about the meaningparametersasguide theyacttoservice delivery ofimplementation and provisions.theof In abortionservices.Establishing principlesregulationstheof part a as importantis because Two regulations, in Brazil and Colombia, establish principles Guiding guiding principles for thei. provision of legal of services Organization i. methodology. on chapter the the in in described outline the on effect based is in analysis The regulations survey. this for health selected countries the of analysis comparative a forms chapter This IV. Brazil cultural, religious, moral or other aspects to interfere in their relationships with with relationships their in interfere women social, to allow aspects cannot other or and moral impartiality religious, with cultural, act must professionals health justice: (do harm) no of actions one’s effects undesirable or adverse the reducing patient, the to harm least the cause always must actions nonmaleficence: (do good) beneficence: the ethical obligation to maximize the benefit and minimize the harm harm the minimize and benefit the maximize to obligation ethical the beneficence: life and body her about woman’s the to right makeautonomy: decisions Comparative analysis of the regulations , personalized and humane care for women accessing legal abortion services is is services abortion legal accessing women for care humane and personalized , 43 IV. Comparative analysis of the regulations 44 IV. Comparative analysis of the regulations In In 22 women in their area may have a pregnancy termination performed at any time, taking into annuallyQuality ( toon Service General the Ministry’s Office be kept current and available for clients who require and these services shall be reported and have professionals who are willing to provide abortion services. This services, information gynecological-obstetric levelshall high and medium low, provide to authorized are network, the within that, institutions those Quality Service on Office Welfare’sGeneral (which are responsible for local public referservices) must sector to the ofMinistry Social the Health Promotion Entities (insurers) and the Departmental and District Health Offices available in all national 1).territories (Art. recentThe most regulatory provision says that In 5). (Art. periods time established legally the within abortions perform to possible make including it that techniques diagnostic urgent the services, necessary the of availability Legales monitor shall region Abortos each in de authority Práctica la para Preceptivos Dictámenes Abortions Legal of Performance the for Spain 1). (Art. abortion for services social and health of development and promotion the for are responsible obligations, and of powers their (1978)of Pregnancy Italy divisions. geographic and governmental of levels other to apply they how define or scope in national are they that specify few A jurisdiction. their of extent the define not do services abortion of provision legal the out set that regulations Most national and departmental local, levels: all at networks Service ii. ( Service of Characteristics (6. continuity and appropriateness security, timeliness, accessibility, of Pregnancy (5. Professional Ethics, Ethics, (5. Professional aside laid be must care dehumanizethe may that preconceptions and allprejudices and

Colombia Norway, Colombia Governmental and geographic divisions refer to governmental districts that generally correspond to geographical to geographical correspond generally that districts to governmental refer divisions geographic and Governmental areas. In some countries they are called territorial bodies, in others they are called departments, municipalities, municipalities, departments, on. so and called states, are counties, they others in bodies, territorial called are they countries some In areas. , the clarified in the in clarified Características del Servicio del Características Regulation Regulation for the Social Protection of Motherhood and Voluntary Interruption state that services shall that state be services provided in accordance with the guiding principles county municipalities are required to organize services so that the that so services organizehospital to requiredmunicipalities are county , , the the , Regulatory Decree 4444 of 2006 of 4444 Decree Regulatory explicitly stipulates that the state, regions and local entities, as part part as entities, local and regions that state, the stipulates explicitly ehia Rgltos n ae o te outr Itruto of Interruption Voluntary the for Care on Regulations Technical Technical Regulations for Humane Abortion Care, 2005 Care, Technical Abortion Humane for Regulations Royal Decree on Accredited Centers and Mandatory Reporting Reporting Mandatory and Centers Accredited on Decree Royal )). ( el ert sbe eto Ardtds y Acreditados Centros sobre Decreto Real mandates that legal abortion services be be services abortion legalthatmandates Circular 031 of 2007 , 1986) that the health health the that 1986) , 22 For example, in example, For ). ). 24 23 Federal Distrito el en Embarazo del Interrupción la con relacionados Salud de City Servicios los de Operación y Organización Mexico in Pregnancy of Termination the to related the of 9 (Art. performed» be can procedure a likely such is that it where and abortions legal provides that hospital a to manner timely and responsible appropriate, an in woman pregnant the refer shall procedure, the perform to able not are who facilities, care level primary In system later. as discussed health of a referral, concept the fit necessarily the not does aresult, as of and, out transfer a correctly more is latter The request. woman’s the at provided be can for that services and assistance social situations about information receive to exceptional referrals in county another to referrals for provides specifically that it is a of critical sexual aspect comprehensive and health reproductive care. counter-referrals for family planning counseling at lower levels of care in spite of the fact have a referral system always in must place services for abortion patients complexity with low of complications. Very providers that few establish explicitly to is establish it sector, systems counter-referral and referral mention regulations When work they how and systems counter-referral and iii. Formulating referral kind. of this have not provisions do as such countries By contrast, demand to institutions. in specific use services can women that tools as serve they because important are services of The explicit definitions in the regulations ofColombia and Norway regarding availability Implementation of the Act concerning Termination of Pregnancy, 1975 19, (Art. geographical areas specific serve shallinstitutions and units municipality, county officer,the consultation medical with in The regulation reiterates this obligation 19) (Art. and also assigns authority to the county 14,(Art. account the limitations imposed by health personnel who object for reasons of conscience

Mexico From the context of the law, it is understood that the county medical officer is an administrative authority in in authority administrative an is officer medical county the that understood is it law, the of context the From institution of lower level care for family planning or other follow-up care). follow-up other or planning family for care level lower of institution jurisdiction. a geographic mean aspecific to with seems authority governmental municipality county the Similarly, region. geographic a over jurisdiction with sector health the Counter-referral systems involve referrals back to the original referring institution (in this case referrals back to an an to back referrals case this (in institution referring original the to back referrals involve systems Counter-referral Act No. 50 concerning Termination of Pregnancy, 1975, with Amendments, 1978 , referrals are provided for in the following terms: «Physicians belonging to belonging «Physicians terms: following the in for provided are referrals , General Guidelines on the Organization and Operation of Health Services Services Health of Operation and Organization the on Guidelines General Peru )). , Puerto Rico Puerto , Panama ( , Mexico Lineamientos Generales de de Generales Lineamientos 23 to decide which hospitalwhich decide to 24 , within the health health the within Brazil ). Regulation for the Regulationfor

and Norway Bolivia ).

45 IV. Comparative analysis of the regulations 46 IV. Comparative analysis of the regulations regulations clearly define the different levels of health care facilities (community, low, (community, facilities care health of levels different the define clearlyregulations reproductivehealth andfamilyof2006).The ofRegulatoryplanning2 Decree4444 (Art. and sexual promoting services to cases complexity low counter-referrals in ensure also must Theywoman’shealth. the or pregnancy the durationof the by merited is it when of pregnant women with medium to high complexity cases when complications occur and guarantee the operation of the referral and counter-referral systems to ensure the transfer the regulations. In essence, system administrators and health professionals are obligated referralTheto andcounter-referral in system (3. organizations Counseling). and Protection non-governmental feminist or groups women’s services, referral to patients directing by or establishment the of capacity technical the are with accordance in teams Medical sector. them resolve to and health case each in risks and needs health the satisfy in and identify to required to (2005) limited not Care system Abortion referral comprehensive Humane for Regulations Technical The Rico) Puerto en Salud las de Facilidades de Funcionamiento of Operation Health Facilities Rico in Puerto as complications, well H, as with (Art. services» other support for the ofuse radius a and from necessary with patient the suffering ambulance services (1)mile one a within facility hospital a with agreement formal or contract a writing in established «Thehave shall including: facility provided, services the on limitations some In weeks to have a hospital referral center for cases whereof Legal it is Abortionsnecessary (Art.(1986) 1). requires health establishmentsIn that may perform abortions up to 12 to hospital care must be made: be must care to hospital Pregnancy Terminationof a Requesting Clients for ( services back-up gynecological with institution level secondary or to a level and secondary institution, for a of pregnancy more than 12 to weeks, a tertiary made is referral a 12 than ofless weeks, pregnancy a For procedure. the for woman the preparing and examining of purpose sole the has level this at provided care However, In approved or institution an to woman the 2). (Art. counseling for provider refer to or abortion an performing after (1995) in Similarly, medium, high), the services each provides and referrals across them (Appendix 1).

Spain, Puerto Puerto Rico, South Africa South requires general physicians or authorized general physicians to offer counseling counseling offer to physicians general authorized or physicians general requires the Royal Decree on Accredited Centers and Mandatory Reporting for the Performance Guyana abortions may be performed in family planning and abortion centers with , abortion care – as in Colombia – begins at the primary level of care. care. of level primary the at begins – Colombia in as – care abortion , , the the , Medical Termination of Pregnancy Act – Legal Supplement B Supplement Legal – Act Pregnancy of Termination Medical Colombia ( Reglamento General Reglamento para lay el Operación ). The regulations state that referrals referrals that state regulations The ). is mentionedis invarious ofsections , 1999). General General Regulation for the Referral Guidelines Guidelines Referral Brazil

set out a 25 the termination of in pregnancy accordance with of Atweeks gestation. the level first of Regulations Technical the of 1 Appendix Colombia of care level and iv. Services regulations. Panama Termination concerning 1975). Act of of the Pregnancy, Implementation the for Regulation 14, (Art. performed be to procedure the for institution or unit hospital county where she lives. In this the case, county medical official refermust her to another be taking into account the woman’s – the wishes outside the maybe procedure must performed that assistance social and provided, procedure the about information receiving after in found be can provisions All these ( ( ( to referrals: Finally, apply followingprinciples the not are services to the appropriate regional 1.5). for or designated institution (Art. such district purposes if that referred be must indicating abortion an request who clients institutions, by care primary in available of level considerations the geographical account into and take that complexity referrals for provides Africa South Additionally, ( ( ( In

Norway Services, Department of Health: Western Cape of Western Health: Department Services, ( monitored be can service the for demand the that so referred of clients kept be ofnumbers the must a record in all cases made be must booking a telephone relevant all client; the accompany letter in the included be must must information worker health the from letter referral a Cape Western Health: suspected or abuse, alcohol ( or pregnancy ectopic drug disorders, clotting blood anemia, diabetes, if the woman has an acute or chronic medical condition, such as heart disease, asthma, suspected are if complications over 12 is weeks pregnancy if the to the woman if she decides to continue the pregnancy. the continue to decides she if woman the to From the context of the law, it is understood that this is information about the forms of social assistance available available assistance of social forms the about is information this that of law,the is it understood context the From , 25 Peru establishes a relationship between level of care and weeks of gestation. gestation. of weeks and care of level between relationship a establishes , referrals are provided in two specific cases. The first is when the woman, woman, the when is first The cases. specific two in provided are referrals , euss diinl nomto (r. ) Te eod ae cus hn – when occurs case second The 3). (Art. information additional requests

and Italy Protocol for Termination of Pregnancy Services, Department of Department Services, Pregnancy of Termination for Protocol do not explicitly these of specify types in systems their abortion ) Policy on the Management of Termination of Pregnancy Pregnancy of Termination of Management the on Policy Circular H97/2000 clearly indicates the level of care needed for for needed care of level the indicates clearly ) . 47 IV. Comparative analysis of the regulations 48 IV. Comparative analysis of the regulations In Two countries clearly propose a model of integrated care for women: Colombia and Brazil. model provision v. Service 106.) page on provision service of for weeks requirements Infrastructure of (See performed. is number termination the which at the pregnancy on depending requirements training different establish do In of Circular H97/2000). Cape, Western Health: Department Services, Pregnancy of Termination of Management the on 1.1,Policy (Art. possible as soon pregnancy as clinics care of primary and termination centers health decentralize community to to services need the express regulations the Overall, back-up (Referralservice) Guidelines for a Clients Requesting Termination of Pregnancy). 12care (after (if it level to has a hospital or tertiary gynecological toweeks) a secondary weeks), 12 than (less care secondary to referred be must they itself, procedure the for However,Cape). Western Health: of Department Services, Pregnancy Terminationof of Management the on Policy 1.2, (Art. level care primary the at system Health Provincial of care. As a result, clients who request a termination of service pregnancy shall enter the In level of care. tertiary ahighor at provided be can services above law.all the current by Consequently, permitted are that ofpregnancy stages and of weeks full nine pregnancy. Atcan tobe level, provided services inthe abortion secondary all circumstances up abortion medical and providers) well-trained with 15 to (up can care, by be abortions performed up to 12 full of weeks pregnancy for Humane Abortion Care (2005) is to set out a humane and personalized care model for prioritizes ensuring and proper support focus for women. rights The objective a of emphasizes the clearlyTechnical it model’,Regulations ‘support the Called model. Colombian In of Service). Characteristics 6, woman’sthe health» (Art. rights and sexual in and AIDS, that reproductive general of allpromote self-care services HIV/ infections, transmitted sexually of prevention contraception, of methods effective such as services, pre- counseling, and family post-abortion planning counseling, access to to other access health, reproductive and of sexual framework integrated within an and, complications abortion of the management for includes care pregnancy «Integrated of interruption state: voluntary Pregnancy of Interruption Voluntary the for Care on Regulations Technical The services. complementary and related all also but procedure,

South South Africa Brazil Spain Colombia , the integrated model of care includes services similar to those included in the inincluded those similarto services includescare of integratedmodel the ,

and , abortion regulations conform to a model that includes not only the the only not includes that model a to conform regulations abortion , Guyana , there is a clear division about which services can be provided at each level , although the regulations do not refer to levels of care, they they care, of levels to refer not do regulations the although , 26 1978). be Termination concerning No. 1975, 50 of Act Pregnancy, 2, Amendments, with shall she (Art. her woman, offer can the society that for assistance the about guidance difficulties and information offered serious to lead could pregnancy situation a the In where herself. decision the make can she that so information of provision the of consists counseling principle, In pregnancy. her terminating about decision final the In voluntary. is counseling warning that In understood. is it that and provide information, that health they ensure professionals must it is received accurately, and is regulations, set out in detail. some Regulations that in countries state when these In woman. the with addressed in regulations The include. must it components the of some also but specify counseling – the of Brazil form the and only not Colombia influence Peru, in to those as try such not – regulations should Some decision. professionals her health that warning a with begin making decision autonomous woman’s a promote to measures include that regulations the All models support and vi. Counseling ( ( ( ( ( essential elements to implement the model: followingregulationstheinclude The service. effective andsustainable safe, a intocare offer a new paradigm for women, health institutions and society that transforms abortion womenhavewho abortion.regulationsanThe provide guidelines forcare,theybut also

Norway of women that advance integration women’s with health other services and the social inclusion again pregnant want to get who women for counseling and services planning family post-abortion of provision the criteria bioethical and legal ethical, on based complications, related and abortion for care clinical appropriate may that arise concerns to other and needs health physical and woman’semotional the to respond that counseling and support guarantee and resources mobilize expectations community's the meet that services abortion, unsafe and prevent to pregnancies professionals unwanted health and community the between relationship close a The original text reads: «Integração com outros serviços de promoção à saúde da mulher e de inclusão social às às social inclusão de e mulher da saúde à promoção de serviços outros com «Integração reads: text original The mulheres.» , the technical regulations spell out emphatically that the woman must make that the woman must emphatically out spell regulations , the technical 26 (1. Conceptual Framework for Abortion Care) (1. Abortion Framework for Conceptual Peru

and Colombia Brazil Brazil even suggest questions and issues that should be be should that issues and questions suggest even , counseling is an important component of the the of component important an is counseling , , the regulations specifically include an explicit explicit an include specifically regulations the , 4 IV. Comparative analysis of the regulations 9 50 IV. Comparative analysis of the regulations In a contraceptive method, especially in stressful situations, such as during childbirth or or childbirth during as such situations, stressful in especially method, contraceptive a choose not or choose to pressure of type any to subjected be to «not right the making, mistakenly, as promoting legal among includes, other abortion, client’s rights in decision en Orientación/Consejería Salud Sexual y Reproductiva ( ( ( ( ( ( ( include: must it minimum the elements specifies also It decision. informed an make to woman the for information sufficient providing as counseling of goal the Counselling Pregnancy Client 2, (Art. the client hand, other the Preparation).On and the Assessment to open options including pregnancy, of termination the to Western Cape (Circular H97/2000) indicates that counseling must cover all related aspects the one hand, the Protocol for Termination of of Department Pregnancy Services, Health: the governing rules the of provision On establish counseling. regulations The and 2004). the after 4, and (Art. before pregnancy a of termination counseling, non-directive and non-mandatory of provision the In 27 rapport: develop 1) del Instituto Materno Perinatal The abortion.»

South South Africa Peru respecting and supporting the woman’s decision without judgement (Art. 2) (Art. judgement without woman’s the decision supporting and respecting the after procedure use for available methods contraceptive about information of provision or procedure the on details providing pregnancy the concerns and feelings opinions, her client to the express encouraging continuing example, (for adoption) alternatives available discussing of pregnancy atermination requesting is she reasons to the listening confidential are services that woman the assuring to prevent another pregnancy. another prevent to the about method to need a to information Begin choose general contraceptive pregnant. provide became patient the when use of contraceptive status and use contraceptive past about out find and etc; friends, members, family system: the support patient’s is identify her whether in partner involved supportive); coercive, the (absent, decision her identify by situation knowledge; finding out about her work, family, and relationship housing situation; identify abortion?» Evaluate the to and her response patient’s about evaluate the abortion beliefs identify her consultation: to have an are going you if decided you «Have Key question: to have an abortion. news?» the Decision about feel do you «How Key question: of contradictions. any perception explore patient: the location with to explore issues two a raise in relationship cordial may a professional health The own. one’s and build reactions patient’s the interview, observe and consultation, the for the appropriate of confidentiality the about information initial provide ‘Developing rapport’ includes various steps: apply the five steps for sexual and reproductive health counseling, counseling, health reproductive and sexual for steps five the apply steps: various includes rapport’ ‘Developing , the the , aul n eul n Rpoutv Hat Counseling Health Reproductive and Sexual on Manual Technical ofInstitute Maternal Regulations the Perinatal , the termination of act indicates that pregnancy the state shall promote 27 to build a cordial relationship with the patient, notify her that that her notify patient, the with relationship cordial a build to , Department , of Department Health: Western Cape (Circular H97/2000), define , INMP) sets out a model five-step for abortion counseling: Choice on Termination Act Termination on Choice , 2006), , which 2006), has been regarded, Guidelines for Pre-Termination for of Guidelines

and Amendment ( Norma TécnicaNorma ( Manual de de Manual , 1996 , 30 29 28 ( Counseling and (Information performed» is procedure the pregnant woman’s informed which decision, must be by documented the the woman in before culminate should counseling and «information that states it Finally, health. her to harm permanent or serious pose or life her endanger not do options such whenever tointhe abortion, addition However, ofoptions other content. informed be a woman must define specifically not does it although professional, appropriate the by provided support, legal and respect social psychological, and include must confidentiality Counseling privacy. woman’s maintain the they that and counseling provide obstetricians that mandates on It quality. service of binding aspect essential only an as procedure is abortion an after it and during although before, available be counseling making, that mandates It facility. decision that at personnel with women Embarazo assist del to Legal Interrupción guidelines la para Casos de Manejo de The appointment, a follow-up the woman’s to reaction the information provided; 4) informed and consent; 5) establish the woman’s3) decision; reaction: analyze the that client’s could affect opinions expressing from refrain must professional health the which during procedure, knowledge and beliefs her support: 2)provide abortion; about explore thoroughly and confidential, is consultation the 2.b. The 2.a. Setting to the hospital; and information her sexually of understand: risks, life: health. physical and mental her given decision, make to the has she time much how discuss professionals. other and lawyers, workers, social psychologists, as such essential her. assist to time any at available are personnel its and facility the that feel should client The emergency. of case member decisions; in or Case Management Protocol Management for Case Legal Abortion

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are to to in 51 IV. Comparative analysis of the regulations 52 IV. Comparative analysis of the regulations appropriate information appropriate and refer her, if (Technical appropriate Regulations on Care for provide must professional health the adoption, consider or pregnancy the continue to while date, a later decides woman the If at effective. more and safer is return abortion early an that must her reminding woman makethe means to it time if enough even with decision, definitive woman a the provide must and professional requirements health legal the the pregnancy, explain her end to decides woman a when Finally, decision for support example). for resources, and to procedures emotional (which information refers and making) provide (to counseling provide distinguish to need regulations the Colombian the between that emphasize to important is It documents. the Rights, Convention Cultural on the Elimination and of All Forms of Discrimination Social Against Women, and other Economic, on Covenant International the in rights standards human international by reinforced are criteria These obligations.» ethical their and as rights other wellrights compliance with as the health reproductive professionals’ her exercise to woman’sa capacity both support should «It responsibility: professional’s well-informed a make health a can and right woman’s a is she information that emphasize they so addition, In decision. information the retains and understands woman the that ensure must professionals health that emphasize Colombiaregulationsin The the only regulations that includes instructions for specific situations. cases of sexual violence to ensure the woman receives appropriate counseling. It is one of woman alone and refer her for additional counseling. This same step should be initiated in decision.healthWhen professionalscoercion pressure,theyorsuspect should talk tothe of risks the health, her to transmission to her poses child and preventative pregnancy measures so thethat she can make risks a well-informed the about information includes HIV/AIDS with women individual. trained for Counseling a by provided confidential and In – as a recipient of services – to make decisions and care for her health in accordance accordance in the health of her guidelines for the care with and decisions make to – services of recipient a as – woman the for necessary information ofthe review a includes counseling model, this In provided. assistance of the effectiveness and accessibility the as well as choose; to right men’s and women’s Support for respect care. differences; humane of components key are includes treatment a counseling that woman’s respects dignity; listening, recognizing and accepting and support punishment. result, of fear a or As anguish anxiety, as such feelings, many experiencing be may The regulations. technical services abortion seek who women the that noting context, provide to attempt and regulations model support the of component fundamental a In of Pregnancy). Interruption Voluntary the

Brazil Colombia , providing information to women in an appropriate and humane manner is is manner humane and appropriate an in women to information providing , te ehia rgltos tplt ta cusln ms b voluntary, be must counseling that stipulate regulations technical the , Sistema Único de Saúde de Único Sistema , Brazil’s public health care system. system. care health public Brazil’s , 31 abortion. Peruvian Guyana information. the in Provisions adolescents. for services special for need the recognize that regulations have countries few very that found research the general, In people for young Services vii. Aspects). Medical and advantages the (4. of complication the rates each effects and method, associated disadvantages adverse of discussion appropriate after procedure, to option preferred the the have must choose woman the law, by allowed abortion elective of case the In itself. procedure the about decisions woman’s a respect also must professionals Health process and respect the woman and her decisions (3. Support and Counseling). thatisthe result of rape, the health professional must actto facilitate the decision making circumstances led to the unwanted pregnancy. When a woman decides to end a pregnancy verbalize their feelings and understand what they mean to their lives,repeat abortion, andit isimportant understandfor women totakewhat time toreflect on their experiences, to not want to be a mother, sexuality and her relationship withopportunityquestionsasktoabout motherhood her whether andwomandoes thewants or partner. In order to prevent should psychologistswomen’s listentotoconcerns. conversationthisonesthatsuggestgood Theythe or a be is workers social that recommend regulations the example, For health method. in this trained result, be must a professionals As care. of model new a create to aims that encompasses approach but educational information, an provide to obligation the includes only woman not the it with because contact of stages all at utilized and mainstreamed be should model dialogue with the woman. in regulations The technical encourages that environment an create their must about professionals Health talk needs. to and women feelings encourage can that principles basic all are to needs and identify complaints; validate to conflict; of situations in the leadership values; provide own to one’s capacity imposing or prejudice without listen to ability the addition, In Counseling should promote self-determination in keeping with the principle of autonomy.

‘Young people’ includes adolescents and young adults up to 24 years of age. of 24 to up years adults young and adolescents includes people’ ‘Young requires special counseling for young women who have an abortion. regulations address sexual and reproductive rights, but not specifically specifically not but rights, reproductive and sexual address regulations Colombian 31 regulations address adolescents, services and providing providing and services adolescents, address regulations

Brazil stipulate that this support stipulate that this support 53 IV. Comparative analysis of the regulations 54 IV. Comparative analysis of the regulations c. b. a. required to pay particular attention to pay particular required are counselor any and practitioner medical authorized or practitioner medical a age, of makes it a condition that when the termination involves a woman younger than 18 years In exist. services these that aware are adolescents that and important also is It adolescents. to costs necessary accessible are and locations be hours, opening may the that so services services existing reorganizing ‘adolescent-friendly’ suggests that say regulations same The ( Consent informado consentimiento Informed and Information Counseling, (6.3 confidential are consultation the and information the that explicitly told is adolescent the that important equally is it trust, build to order In responses. different suggesting health for and important questions repeating language, understandable in is questions simple asking friendly, it records, medical their to professionals be skilled in obtaining this include being information; to some suggestions relating information share to to approach integrated an for difficult it find may adolescents Since skills rights.» their for respect and sexuality for develop adolescent to responsible «endeavor those must that stating services information, providing of provision the address Pregnancy In 32 must: services these that friendly,youth specifies it is complications be to order In abortion health. reproductive and adolescents’ improve that services abortion among included incomplete for care outpatient addition, In (information, complications its 6). (page services)» and counseling and education, during abortion for consideration care into «Integrated taken includes be stage should this what of description The adolescents. on specifically a chapter includes life stages, different during health sexual describes which Health The

Guyana Colombia making her and, where appropriate, her partner aware of modern family planning planning family modern of aware partner her appropriate, where and, her making of responsibility full the on partner parenthood her appropriate, where and, her educating guidance moral methods (Art. 2.5) (Art. methods directing her and, where appropriate, her partner to someone who can provide provide can who someone to partner her appropriate, where and, her directing This measure should be viewed with caution because its application may restrict women’s rights. women’s restrict may application its because caution with viewed be should measure This Peruvian ( Plan General de la Sanitaria Nacional Estrategia de Salud Sexual y Reproductiva te eia Triain f rgac At Lgl upeet (1995) B Supplement Legal – Act Pregnancy of Termination Medical the , te ehia Rgltos n ae o te outr Itruto of Interruption Voluntary the for Care on Regulations Technical the ,

General General Plan of the National Health Strategy for Sexual and Reproductive )). 32 to: ssrmet, nomcó y información Asesoramiento, ), 33 management general that state They violence. sexual and abortion address Pregnancy In hepatitis. and HIV infections, transmitted sexually for to test appointment a follow-up uterine contents for later DNA testing for the judiciary. It that states it is to important set the of sample a preserving recommend also regulations The it. desires she if counseling adoption and support prenatal with provided be should She met. be cannot abortion an for request her that told be should woman the therefore and recommended, not and is aspiration vacuum abortion misoprostol, after 12 medical After 20 weeks. the weeks, regulations indicate and that a termination of weeks pregnancy 12 for to up aspiration procedure vacuum recommend They the curettage. describe regulations The pre-existing any and use to procedure which abortion. the may that affect conditions determine to order in medical through examinations pregnancy of duration the establishing recommends it example, for procedure; related to the aspects specific regulates abortion that addresses chapter The different out spell generally regulations information, counseling and measures that support The must be implemented in these cases. violence. of victims for care integral of as(chapters 9 part are and classified 10). circumstances services abortion In other words, (2005) Adolescents and Women against Violence Sexual from In of rape. cases for All countries includecare with models of for models care abortion circumstances specific circumstances specific in forabortion of care Models viii. (B. counseling abortion-related address explicitly ( that Adolescents for Counseling not adolescents does for but specifically privacy, services counseling emphasize for need the outlines it Finally, ( ( ( ( ( ( (

Brazil Colombia seek the community's support (page 2) (page support community's the seek staff astable maintain to adolescents services providing on havenot any restrictions confidentiality ensure private be waiting times have short hours opening convenient with in location aconvenient be Rape and related issues are addressed in the section on Administrative issues, (i) requirements for accessing accessing for requirements (i) issues, Administrative on section the in addressed are issues related and Rape abortion services. abortion , the Technical Regulations for the Prevention and Treatment of Injuries Resulting te ehia Rgltos n ae o te outr Itruto of Interruption Voluntary the for Care on Regulations Technical the , 33 Consejería para adolescents para Consejería ), page 31).), page

address abortion in these 55 IV. Comparative analysis of the regulations 56 IV. Comparative analysis of the regulations been included, the Public Prosecutor’s Office will check whether the requirementstogetherwiththe medicalof and psychologicalArticle expertreports.Once thedocumentation has issuedbythe Public Prosecutor’s Office, must be attached to the criminal investigation file of the Agreement). If the victim wants to end her pregnancy, her request, included in a file After this, the expert must provide a written report to the Public Prosecutor’s Office (Art. 3 mustprovide preliminary information about emergency contraception andlegal abortion. Prosecutor’sOffice must support this right by referring the victim to medicala expert who informed of the possibility of obtaining an Accordingabortion. toOnce thethe reportregulations, has beenwhen filed,a thewoman Public initially clients. for support and procedure of the aspects administrative regulates which reports a Violación de rape, Casos los she en Emergencia should de Anticoncepción y be Embarazo del immediatelyLegal inContraception the of Case Rape ( on Termination and Legal Emergency the out Order Procedures which sets of Pregnancy situations: General of Mexico City these in care abortion a is on there regulation addition, In specific bis). 131 (Art. abortions subsequent avoid to order in recovery familial and personal encourage to support and counseling professionals necessary health the provide shall violence, sexual of situations in abortion an after that stipulates In Consent). Informed and Information Counseling, by 412Resolution it and of or the modify it, it 2000 expand regulations that (6.3 support Women and Minors ( Abused for Care on Guidelines the with accordance in care, follow-up and counseling evidence, forensic of collection infections, transmitted contraception, sexually or injuries for treatment emergency care, psychological and physical includes survivors rape for 34 Agreement). 4of the (Art. decision responsible and and make informed can a free, she that so alternatives and support existing abortion about information sufficient and objective impartial, will truthful, she given where be Crimes, Sexual of Victims for Center Therapy Support a to woman the refer must Office Prosecutor’s Public the Department, Health the informing as well As because an abortion must be performed at the woman’s request. when an abortion is requested before 12 weeks, it is not necessary to follow this procedureabortion within 24 hours. However, in accordance with the new regulations in Mexico City, 131 bis of the Penal Procedures Code for Mexico City are met. If they are, it authorizes a legal

Mexico should be met. met. be should However, for the purpose of pursuing criminal charges in the case of rape, the requirement of filing a legal report report a legal of filing requirement the of rape, case in the charges criminal of pursuing purpose However, for the , the the , Penal Procedures Code Procedures Penal Guía para la atención de la mujer y el menor maltratado ( Acuerdo del Procurador General de justicia del Distrito Federal General del de Acuerdo del Procurador justicia Distrito Instructivo sobre el Procedimiento de sobre el la Procedimiento Interrupción Instructivo ( Código de Procedimiento Penal Procedimiento de Código Agreement of the Attorney Attorney the of Agreement 34 ) for Mexico City Mexico for ), laid down , 2006), 2006), , ), to the Termination of Pregnancy in Mexico City, 2007 City, in Mexico Terminationto the of Pregnancy bis, 4 and 4 (Art. procedure the toperform services abortion provide that facilities medical at Mexico of Interruption Voluntary and (1978). Motherhood Pregnancy of Protection Social physician the a on by Regulations performed in case be the is This to obstetrics. and abortions gynecology in specializing requires countries of group second The 7).abortion (Art. therapeutic to applies only provision this however, country; the in medicine that adds authorized the of to is procedure specialists medical the practice responsibility Abortion Therapeutic on physician (Art. 144). In with Amendments, 1978). included in the penal code 3, (Art. Act No. 50 concerning Termination of Pregnancy, 1975, medicalapractitioner,by withoutspecification.further However, requirementthe not is Norway stipulating a specialty. In these countries, this information is in the penal code. Peru although with different levels of detail. The first group of countries – consisting of Almost all the countries reviewed specify which health professionals may abortions perform to perform authorization with abortions, ix. Professionals genetic testing for inclusion in the criminal investigation 8 of(Art. the Agreement). duringthe procedure and send it to the appropriate laboratories for histopathological or biologicalmaterialcollectobtainedalso must expert procedure.The thebefore identity Health the is foraforensic sent it bygenetics the Publicexpert, Prosecutor’s to Office, verify the victim’s addition, In rights. her of Departmentthat determines theplace, day andtime ofthe procedure exerciseandthat arranges full the to favorable create conditions they do nor word her or decision woman’s the respect fully not do regulations the processes, verification additionalthese creating InAgreement). the of 5 (Art. crime reported the of date the coincideswith age gestational the whetherdetermines expert medical forensic the obtained, been has information this Once pregnancy. of duration and pregnancy confirm to tests of consists verification process The rape. of result the is These regulations also govern the verification process to determine whether the pregnancy Panama

and General Guidelines on the Organization and Operation of Health Services related related Services Health of Operation and Organization the on Guidelines General allows appropriately trained general surgeons, gynecologists and obstetricians obstetricians and gynecologists surgeons, general trained appropriately allows addresses the issue in a similar manner; it states that abortions must be performed

Brazil te ea cd as sae ta te rcdr ms b promd y a by performed be must procedure the that states also code penal the , – simply–mention physicianthatprocedure,athe perform withoutmust Resolution Resolution 1 of April 1989 of the National Multidisciplinary Commission ( Comisión Multidisciplinaria Nacional de Aborto Terapéutico Aborto de Nacional Multidisciplinaria Comisión ). Italy , as laid down in the the in down laid as , Bolivia ) , 57 IV. Comparative analysis of the regulations 58 IV. Comparative analysis of the regulations In contrast, the Hospital Belén de Trujillo Protocol on Abortion Case Management not not Management Case Abortion on Trujillo Protocol de Belén Hospital the contrast, In trained Human Provisions, in Specific Resources). (VI counseling for abortion therapeutic (gynecologists, professionals health other or specialists’ obstetricians However, licensed and anesthesiologists) medical obstetricians, professional. ‘professional health names each section of resources duties human the the distinguish clearly not do (2007), in regulations Institutional perform. can physicians general and trained gynecologists which procedures the regulations do between not distinguish general, In Pregnancy). of Interruption Abortion, Voluntary the Surgical for (7.3.Care on Regulation physician Technical general trained or must gynecologist curettage a by and performed dilatation be and aspiration vacuum procedure: the on depending Colombia 10, (Art. practitioner any medical prevent grave permanent injury to her physical or mental health, it may be by performed 6). However,(Art. institution approved when the termination is toan save the life in of the woman or to practitioner the medical weeks, authorized 16 an by and 12 performed be between may is termination pregnancy the If direction. her or his assistant under an and acting – abortions perform to trained practitioner general a or experience, with gynecology and obstetrics in specialist qualified duly a as registered physician any – practitioner medical authorized an by administered be may procedure the duration, law2). current (Art. When the is pregnancy more than under eight and weeks not physician more than 12general weeks’ qualified duly a as registered person any is, 5.1); that a than other (Art. practitioner method medical a by supervised or appropriate administered by may it procedure, surgical any by weeks eight before performed is abortion In 35 before 12 weeks, which may be performed by a registered midwife or nurse2). (Art. 2004), abortion must be performed by a medical practitioner, except abortions performed abortions. Finally, psychologists and workers social nurses, Resources). (Human personnel, bank blood trained care intensive specialists, anesthesiologists, procedures, gynecologist-obstetricians abortion medical services: and surgical abortion in trained for needed resources human other describes the also but procedure, the perform may professionals health which states only «Registered Guyana Act.» this of terms in training prescribed undergone addition in has who South Africa 35 is unique in that different health professionals may perform the abortion abortion the perform may professionals health different that in unique is , who performs the procedure depends on the duration of pregnancy. If the the If pregnancy. of duration the on depends procedure the performs who , codn t te hie n emnto At n Aedet 19 and (1996 Amendment and Act Termination on Choice the to According midwife: means is the only country that legally allows registered midwives to perform a person Peru, registered Medical Termination of Pregnancy Act TerminationMedical of Pregnancy such as the Perinatal Maternal Institute Guidelines Guidelines Institute Maternal Perinatal the as such as such under the Nursing Act, 1978 (Act No. , 1995). 50 of 1978), and Termination 1975). of Pregnancy, concerning Act the of Implementation the for Regulation 19, (Art. county the in areas municipality, to decide which shallhospital units/institutions serve specified geographical county the with consultation in officer, medical the empowers and 19) (Art. above the 14). (Art. regulation The reiterates any time, objectors intotaking account conscientious so services that the women in their area may have a termination pregnancy at performed hospital organize to required are municipalities county (1978), that states Amendments in Similarly, 1978).of Pregnancy, Interruption Voluntary and Motherhood of Protection Social the for 1, Regulation abortion (Art. for services health social develop and promote to authorities, and functions it is the of responsibility the state, the regions and local entities, within the scope of their it make within topossible 5). abortions the perform timeframes (Art. legally In established that techniques diagnostic urgent including available, abortion for necessary In services. In 16 bis). (Art. health facility private or public another involve they when even requests her to respond and Act Health Mexico Ethics). (5. Professional public at abortions perform who professionals maintain to obligation state’s the is it that stipulating by involve hospitals and public abstract, the in state, the to services abortion guarantee to responsibility In administrative to belongs responsibility this entiresystem. the involves it in that unique is Colombia authorities. Italy, and Mexico Norway, In facilities. health public at provision service for guarantees addressed only regulations that found research the Mexico, and Brazil In criteria. other within found is information this cases many In provision. service guaranteeing for responsible is who establishes criterion This provision service forguaranteeing responsible Entities x. obstetrics, and gynecology in specializing worker. asocial and aides health nurses, physician a facilities have for must requirements they accreditation that but stipulate details, further specify not does Decree In Spain Spain Brazil specifically involves public health facilities that, according to the the to according that, facilities health public involves specifically

, the penal code states that only physicians may perform abortions. The Royal The abortions. perform may physicians only that states code penal the , and , the Technical Regulations for Humane Abortion Care (2005) assign the the assign (2005) Care Abortion Humane for Regulations Technical the , , revised in 2004, shall provide free quality services at the woman’s request request woman’s the at services quality free provide shall 2004, in revised , Spain Norway Italy , the in health authority each for region is keeping responsible services , governmental authorities are responsible for guaranteeing abortion for are guaranteeing , abortion authorities responsible governmental , Act No. 50 concerning Termination of Pregnancy (1975), with with (1975), Pregnancy of Termination concerning 50 No. Act , Mexico City City Mexico Italy , 5 IV. Comparative analysis of the regulations 9 60 IV. Comparative analysis of the regulations services. In addition, these entities are required to keep this information updated updated information this keep to required are entities these addition, In services. abortion willingprovideprofessionalstohave that and services, gynecological-obstetric facilities those on withinauthorized thenetwork to provide informationlow, medium andhigh level Quality Service on Office General Welfare’s Social of to Ministry the Offices to Health send District and Departmental and Entities Promotion Health requiring added was obligation additional an 2007, In 2006). of regulations 4444 Decree technical Regulatory 2, other (Art. and Assurance the Quality of for provisions System the Obligatory the with decree, accordance in providers abortion of number appropriate an guarantee to required are administrators system health general, in Finally, 2). jurisdictions (Art. their in system public the within care of levels all at services abortion for care timely and access real guarantee to required are authorities 1). regional case, (Art. any In agreements have authorities regional private or the which public with facilities the by service provided health be must women unaffiliated and abortion poor hand, for other the services On contracts. have to required are providers insurance which the with institutions provider service private or public the via provided are services national insurance plan contributory or the subsidized insurance plan. For women, these the to belong they whether of regardless services, to access women’s guaranteeing for via system her insurance. Health Promotion Entities (insurance providers) are responsible and on (public private)the woman’s and depends health affiliation tosystem thehealth In Medical 4, (Art. institution the managing or 1995). B, Supplement –Legal Act Termination of Pregnancy owning person the of and institution register, and a nationally circulated newspaper, the name and of address every approved the in publish to ordered is Ministry the but assigned, In information about access to contraceptives, they are unique in that they require require they that in unique are they information contraceptives, about contraceptives to be provided to the woman tobefore she is discharged. access detailed about very provide information not do regulations African South the of Although mention contraception. brief make simply Panama and Norway Guyana, Italy, while information, to Access differed. detailed highly provided provide Peru and Colombia detail Brazil, issue; recurring of a was contraceptives level the and itself information the although criterion, this on information provided analysis the in included countries the all Almost contraceptives, to access complications, care: and counseling xi. Post-abortion as services, abortion 1, safe decriminalized by law (Art. annually of provision report the must on information they with and Office General services, the to these need who clients all to available and services health reproductive and sexual other and Guyana Colombia , the authority responsible for guaranteeing abortion services is not clearly clearly not is services abortion guaranteeing for responsible authority the , , guaranteeing abortion services is the responsibility of all actors in the the in actors all of responsibility the is services abortion guaranteeing , External Circular 2137External May of 2007 22 Gazette , the official government government official the , ).

weeks, women who have these procedures must be kept under observation until the the until expelled. have been placenta and fetus observation under kept be must procedures these have who women weeks, 12 after abortions for abortion incomplete and hemorrhage of risk higher the to longer. Due take may recovery her that informed be must woman the administered, were wall with a bimanual examination. Moreover, if significantsedatives or general anesthesia For late it abortions, is important to confirm thesize of theuterus through the abdominal evaluation. health ageneral for procedure the after days 15 and seven between visit follow-up a require also regulations the abortion, surgical must They recovery. For perforation. uterine her may indicate these painsince about to complaints respond also monitor and support and comfort with woman the provide recovery is monitored. During recovery from surgical health abortion, must professionals The procedure. the as time same as about dual It is protection. preferable that contraceptive are methods provided at the in as about all well preventing pregnancy and contraceptive their methods effectiveness be must told methods that they are at planning high risk of Information be must provided repeat abortion. family use not do who Women methods. planning family for need subsequent the of and contraception, time of period short a within returns fertility post-abortion that informed be first must on woman a that indicate regulations counseling The contraception. emergency including includes management Post-abortion 2005). Care, Abortion Humane for Regulations Technical Counseling, and Information Providing (V and complications emergency, possible of case in go to visit where and follow-up do to what contraception, days, 15 to following the within access general methods, during planning family women fertility, of to return provided be should return of information menstruation, activity, sexual resuming hygiene routines, personal counseling: what specifies also It fainting. and pain, prolonged or intense malaise, general and chills fever, period, normal a than excessively more bleeding pain, bleeding, abdominal prolonged prolonged care: emergency require that symptoms the lists also and The abortion. the for reason the is this when malformations fetal alone in requiring that information be provided on how to prevent pregnancies involving of toappointment follow-up determine the whether procedure Italy has is been successful. symptoms the a includes management about post-abortion Peru, and Colombia Africa, Brazil, In South topic. information this mentions detailed only Norway while experiences, include post-abortion normal and complications Colombia and Peru Brazil, Colombian Brazilian regulation includes a section on normal recovery after an abortion abortion an after recovery normal on section a includes regulation regulations are also highly detailed. They require that post-abortion post-abortion that require They detailed. highly also are regulations 61 IV. Comparative analysis of the regulations 62 IV. Comparative analysis of the regulations it is important to that it consider of the safebeginningis benefit important contraception immediately day.the same of some which However,may be started methods, with certain associated for as record appropriate ofthe contraception, medical each woman and the limitations hormonal and IUDs including discussed, be should methods contraceptive all abortion, the an leaves «After contraception: about she recommendations some before make regulations The contraception, facility. emergency including contraception, abortion post- on counseling and information receives woman every that ensure to professionals the of in one regulations ofthe aspects is important most management post-abortion of part as methods contraceptive to Access of Pregnancy). Interruption Voluntary the for Care out rule on Regulations to(Technical abortion and incomplete or expected pregnancy molar as pregnancy, is ectopic it that verify to conception of product the examining includes management pain). abdominal dayand Post-abortion one than more lasts that fever bleeding, (excessive care medical require that symptoms and cramping) vomiting, nausea, period, heavy a than greater or similarto bleeding weeks, several for or period menstrual a to similar (bleeding be symptoms must normal including information recovery, about written provided and oral simple, clear, cases, all In complications. other any or infections no are there that and completed been has abortion the that to confirm order in days 15 to 10 within made be must visit follow-up a the that state procedure, regulations the after immediately confirmed be cannot abortion medical a When complications. for check and expulsion confirm must professional health attending the should remain under clinical observation for four to the six hours after taking woman after a that a indicated is it where , cases In normal. are signs vital their and to able immediately feel situations they as soon various as facility the leave may women manage complications, no are there If to procedure. how address regulations The sexually transmitted infections and HIV/AIDS, and all activities that assist a woman to of Service). (6. Characteristics health own woman her for care a assist that activities all and HIV/AIDS, and infections transmitted sexually of prevention of contraception, methods to effective access family counseling, planning counseling, post-abortion include should services general, In protection. dual promote and infections provide preventing information and HIV sexually about transmitted must they contraception, to addition In method. temporary a as to well as it access to able how and not are they if and methods, where information provide about by they the must woman, chosen the provide method planning family provide to capacity the have abortions providing facilities that recommend regulations The later. regret might she which crisis, the to response in decision this made not has woman the that ensure must professionals health that indicate regulations the sterilization, chooses woman a When risks.» any than associated greater may be Colombia . The regulations require health health require regulations The . must: or practitioner authorized medical practitioner the medical procedure an abortion after that state regulations the addition, In 1995). Act, Pregnancy of Termination Medical 4, (Art. partner her appropriate, where and, termination for of the medical pregnancy her creating counseling pre- and guidelines for post-abortion any woman seeking treatment In 1978). of Pregnancy, Interruption Voluntary and Motherhood of Protection Social the for Regulation 14, (Art. prevention about information with provided be should woman the present, are abnormalities or malformations fetal when addition, In fertility. her controlling about information with Italy of Termination for Protocol Aspiration. Circular H97/2000). Cape, of Western Health: Department Vacuum Services, Pregnancy Manual – (4. discharged Pharmacology is woman the Applied before facility the at provided be should contraception Preparation). and Similarly, emergency Client Assessment (2. necessary ifis it counseling oftocontinuing and further contraception use ensure appointment a include follow-up The emphasis on contraception in the regulations is noteworthy. It states that services must ( ( ( ( following: the with provided being after discharged be should she stable, is condition woman’s the If if necessary. anti-D administer negative, and havebleeding diminished and the is uterus well and contracted; if the woman is Rh- monitor in recovery a area comfortable for one or two hours; check that abdominal pain uterine contractions; the inspect tissue removed from the uterus to ensure completeness; 4, (Art. specify toprocedures be regulations included check management: in vital signs, bleeding post-abortion and procedure The 2004). the and 1996 after Amendment, and and Act Termination on before Choice – counseling non-obligatory and directive In South Africa South Guyana client the to convenient time a at weeks three or two within follow-up a for appointment requested or worker required asocial is if it with counseling for appointment provision and counseling contraceptive attention emergency immediate require that symptoms and signs and menstruation, of and prescribed medication, about routine personal hygiene, resumption of sexual activity taking recovery, normal of signs about information and counseling post-operative also requires the physician who performs the abortion to provide the woman woman the provide to abortion the performs who physician the requires also , the regulations delegate to the Ministry of Health the responsibility for for responsibility the Health of Ministry the to delegate regulations the , , the termination of pregnancy act requires the state to promote non- promote to state the requires act pregnancy of termination the , 63 IV. Comparative analysis of the regulations 64 IV. Comparative analysis of the regulations b. must must be trained to provide appropriate treatment, follow-up and care biopsychosocial to Pregnant Women ( de Salud Servicios del de Sistema Protección Social In and treatment 19). post-operative (Art. contraception about guidance individual necessary the receive women necessary that the ensure take to will unit measures hospital the for responsible superintendent medical the the that says for (1975)also Pregnancy Regulation of Termination concerning The Act 1978). the of Implementation Amendments, with 1975, Pregnancy, of concerning Termination 50 No. Act 14, (Art. methods the about counseling with provided be must in regulations The medical general include women to provide contraception. family for and planning especially abortion, the after support to required is government the services In the of desires the by 2). (Art. abide pregnancy of her termination the seeking is who woman must counselor not or is practitioner or is medical participation the partner’s appropriate, the if determining when that say regulations The a. incompleteabortion,to ensure that the procedure hasappropriatelybeen performed.In management, monitoring for signs that may indicate complications, such as pain, or even up visit. Similarly, the Hospital Belén de Trujillo Protocol includes, as part of post-abortion and symptoms indicating a problem; and 4) follow-up, which should take place at a follow-professional must inform the woman about caring woman,for her health, healthsigns the which theofduring care, normal post-abortion 3)recoverychoices; her to respect and optionsexplore contraceptives about information comprehensive and contraception procedure;feelingstheprejudiceheraboutidentify to judgementorderprovide2) in or support, emotional 1) clientwithoutrelationshipthe steps: awith professionalbuild healthshould the which during several into divided procedure, in the Institute after counseling Maternal for Perinatal the of Regulations Technical The of. consist should follow-up or appointments treatment, the what indicate not does However,it abortion. an or childbirth following immediately women Panama Mexico to deal with the social and psychological consequences of the termination of the the of termination pregnancy the of consequences psychological and social the with deal to them enable to partner her appropriate, where and, patient the to advice such give to Ministry the counseling such provide by approved institution or individual any to her refer or behavior counsel the patient and, when appropriate, her partner about responsible sexual sexual responsible about partner her appropriate, when and, patient the counsel , the Mexico City Health Act, amended in 2004, states that the counseling counseling the that states 2004, in amended Act, Health City Mexico the , , in the the in , Atención Atención de la Mujer Embarazada Norway Provision of Health Services in the Social Welfare System Welfare Social the in Services Health of Provision make it mandatory that women who request contraception contraception request who women that make mandatory it , 2005), the chapter on Health Care for ) stipulates that health professionals Peru lo provide also ( Oferta de de Oferta ae o sxa voec ad o-osnul riiil neiain rqet ms be must resolved requests within 24 insemination: hours. The Mexico artificial City Health Act specifies a non-consensual deadline for and public health violence sexual of cases in Health of Ministry the to request the for time waiting maximum the regulates Code In Abortion). Therapeutic on Commission Multidisciplinary National the of 1989 April of 1 Resolution whenever a for request an is abortion made and periodically to issue regulations 11,(Art. 5). timeframe shallpossible The commission within meet (Art. the of shortest pregnancy stage early an at services receive may women of number greatest the that so facilitated be to facilities state in abortion therapeutic a for request the to related issues technical Panama 5).not (Art. is obligatory it that indicating possible,» extent the «to followed be to is timeframe this but days, five of period a within performed be should procedure the that states abortion, In Circular Cape, H97/2000). Western Health: of Department Services, Pregnancy of Termination of Management 1.7, the on (Art. Policy possible as soon as appointment an given be must client the termination, trimester second a of case the In appointment. an for scheduled be should client the which by date the clerk booking tothe indicate should practitioner referring The pregnancy. of week 12th the of end the before facility appropriate an in procedure the for scheduled be must trimester first the of end the before abortion an Africa South exception of Colombia and South Africa, the established waiting times are obligatory. authorizationgoes into is intended effect as a time for reflection. withIncases, most the is general, this period is used to resolve administrativeIn provision. procedures. service withOne endingexception and to pregnancy fromthe theterminate rule to starting request woman’s days, the 10 to hours 24 from range times waiting that found research The provision forservice Timeframes xii. analgesics, fever and discharge. symptoms indicating a problem: excessive bleeding, intense pain that does not respond to aboutcontraceptive methods,prevention of HIV and sexually transmitted infections, and reinforceand informationpreparation procedure,giveninincludingthe for information additionto monitoring, it requires health professionals to provide to support the woman

found Mexico Colombia

in does not stipulate a waiting time, but requires administrative procedures and and procedures administrative requires but time, waiting a stipulate not does

, waiting times are governed by various regulations. The Penal Procedures Procedures Penal The regulations. various by governed are times waiting , Italy , does not set a specific time period but indicates that clients who request request who clients that indicates but period time specific a set not does eouin 95 f 2006 of 4905 Resolution , where,waiting a time ofseven days from thewoman’s untilrequest the , which enacts the technical regulations for for regulations technical the enacts which , 65 IV. Comparative analysis of the regulations 66 IV. Comparative analysis of the regulations This section firstly examines general rules about informed consent for all women. women. all for However, consent age. of years 14 informed than younger minors for about rules specific examines rules it Secondly, general examines firstly section This consent Informed i. standards quality and rights guaranteeing quality: ii. Service Procedures (Administrative procedure quickly the more to even request ( resolved the be of should time the necessary, from if pass and, may week one than more that no indicates Protocol Trujillo de Belén Hospital the Similarly, performed. is abortion therapeutic the when to request the of date the from pass may days calendar 10 than in Finally, in 2007). amended was item –this City in Mexico Termination of Pregnancy torelated the of Services Health on the Organization Operation and Guidelines General 15, (Art. hours 48 is period time the 12weeks, before is it If pregnancy.» the of length the with increase which health, maternal to harm and risks decrease to order facility,in woman within a maximum period of ten calendar days from the appointmentfirst at pregnant the the for resolution a providing possible, as early as an performed be for to abortion «necessary procedures administrative the expedite require to They authorities performed. unit is hospital procedure the when and the facility between the time at of appointment amount first the govern guidelines these but (2006); City Mexico in Termination to the related of Pregnancy Services of Health Operation and Organization 16 the on bis). Guidelines timing: General the However, governs also regulation another (Art. request woman’s the after days five within services provide must which facilities, for women with disabilities constituted a significant variable among the different different the among variable significant a regulations. constituted disabilities with women for consent regarding laws the that found also research The 14. under those to limited are no countries consent of issues some countries other in in and consent, give can varies, age of 18years under adult minors an be to considered is woman a which at age The 2. 1. issue: important this the to address following questions two The according give consent. directly oflaws cannot country, each who, individuals those for consent of issue the to limited includes solely and not minors, is consent give can who of problem the that found research the Procedimientos administrativos Procedimientos know when consent for abortion has been given? been has abortion for consent when know Who cannot consent directly, for what reasons and how does a health professional professional health a does how and reasons what for directly, consent cannot Who to abortion? an directly consent can Who Peru , the Perinatal Maternal Institute Guidelines (2007) state that no more more no that state (2007) Guidelines Institute Maternal Perinatal the , )). Agreement is indicated by the client or patient’s signature on the form.» form.» the on signature patient’s client or by the indicated is Agreement coercion. or manipulation persuasion, from free information, with provided being after decision this make must client the and aware, and voluntary free, be must agreement This needs. health her satisfy that alternatives possible among clientmakes bychoosing the following terms: «The rational to agreement a medical or surgical operation that the rights, and reproductive is and not it specificallyabout abortion, defines informedsexual consent in to related issues general addresses (2006) Counseling Health and Reproductive Sexual on Manual the While issue. this governing regulations relevant other two Although 16). (Art. professionals of team health by the respected be must which responsibility for the assumes agreement. physician, If her the with woman does together not who, agree, individual she the assumes responsibility, of agreement voluntary the involves decision This freely. decide to right the have individuals that principle the on based is autonomy her for respect and choice of freedom this for Protection consent.» via informed to pregnancy her end decision makeso that can she a and responsible free consequences and risks their and used be will that procedures the about abortion legal a requires who woman pregnant the to provided be information understandable and timely sufficient, «objective, that stipulate later regulations responsible same 3). The and (Art. manner» informed free, a in decision her make can so woman available pregnant alternatives the and that assistance the as well as effects and consequences procedures, risks, the about information timely and sufficient truthful, objective, provided requires a legal abortion once the health facility has, as part of its obligation, compulsory define (2007) informed City consent as Mexico the in «voluntary agreement, in writing, Pregnancy of of the Termination woman the who requests or to related Services Health In to consent. informed their giving are and provided understand they that to ensure women be must that information of type the via expressed the be On can it forms. hand, consent other include regulations some and written, be must be it must often consent given: woman’s the way the in expressed decision is this autonomous hand, and one the free On of making. goal the state explicitly regulations the all Almost a. the address situations. different to models specific identify to separately analyzed is point Each disability. of type some have who women as such consent, give directly cannot who women and The analysis examines general rules about informed consent and specificrules for minors Mexico General rules for consent for rules General Peru , for example, the General Guidelines on the Organization and Operation of Operation and Organization the on Guidelines General the example, for , does not have a health regulation that addresses abortion, there are are there abortion, addresses that regulation health a have not does 67 IV. Comparative analysis of the regulations 68 IV. Comparative analysis of the regulations Interruption of Pregnancy (1978) indicate only that the request for abortion services services abortion 1). (Art. woman by the for in person made be must request the that only indicate (1978) Pregnancy of Interruption In requires approved. is procedure the merely when verified be consent woman’s the that informed Protocol Trujillo de Belén Hospital the Guidelines, Institute Maternal Appendix includes a form for informed Also consent. in After or Before Counseling ( Procedure Provisions, the Specific (VI pregnancy» the of remainder the for care health provide must professionals Health respected. be must decision woman’s pregnant the valid and be will not consent the case, which in procedure, the refuse and decision her change may woman pregnant the that mind in kept be must «It that note partner. her be witness the that suggested is It form. prepared fill a out must woman pregnant the At them. of this end process, the clarify her helping with womanpregnant and the of conflicts and possible the ofdoubts exploring importance stress guidelines The woman. pregnant the of health and life the for appropriate so, do to in situations, which the except incase physician shall emergency make the person most decision designated legally the of responsibility the is it consent, give cannot woman a When pregnancy. the continuing by affected be may that health and/or life her is it since pregnancy the end to whether decide to entitled is woman pregnant the abortion, therapeutic of case the in point starting a how As given. be may consent on informed rules various establish also guidelines The performed.» is it before treatment or with procedure any provided refuse, to «be or for, consent to informed give right to apply the necessary information and includes all This Act abortion. Health therapeutic General of the cases in to them contained rights the employees reiterate to facility, apply that which of Guidelines, Institute Maternal Perinatal the Additionally, 36 any of woman a for pregnancy a of termination the for that stipulate regulations the 1975).Moreover, Pregnancy, ofTermination concerning Act the of Implementation for the Regulation 5, (Art. request woman’s the at solicited be only may woman the other than individuals of opinions the that state also regulations The (1978). Amendments 4), (Art. herself according to Act No. 50 concerning Termination of Pregnancy, 1975, with Similarly,in

Italy to help her clarify them.» clarify her help to with the of pregnant remainder woman and the conflicts and to It doubts pregnancy. is possible explore important care for health must provide the professionals Health be valid and the must woman’s be pregnant not respected. decision will consent the case, which in procedure, the refuse that and mind decision in her Keep change may witness. woman a pregnant as the act partner her that Suggest the process. completed, the once with proceed consent; can informed professional for health provided form the out fill will woman, pregnant the with together The original of Article 4, Informed consent, reads: «After completing the previous steps, the health professional, professional, health the steps, previous the completing «After reads: consent, Informed 4, Article of original The , the Regulations on the Social Protection of Motherhood and Voluntary Voluntary and Motherhood of Protection Social the on Regulations the , Norway Consejería inicial o antes del Procedimiento del antes o inicial Consejería , the termination of a pregnancy must be requested by the woman woman the by requested be must pregnancy a of termination the , Peru ), point 5). Additionally, the the Additionally, 5). point ), , in contrast to the Perinatal 36 Finally, the guidelines guidelines Finally, the 3. 2. 37 1. patient: to the provided be must that information of level minimum the about specific is Act Consent Informed General The 1. complete receive to it: to receive not right the establishes right also information, the establishing to addition in which, information medical to right the includes law This 3). (Art. health» her or his affects that action an allow to information appropriate receiving after faculties her or his of use full the in manifested (2002) the However, 1986). Abortions, Legal not of is Performance consent case the for which Reporting Mandatory and in Centers Accredited on Decree Royal 4. emergencies, (Art. required for exception the is abortion governing In before consent oral or administering treatment for the written termination of pregnancy. require may be, may case the as practitioner, medical where the pregnant woman is of unsound mind, the medical practitioner or an authorized In not8.4). does toneed be informed (Art. he and obtained be not need consent his partner, her inform to patient the encourage althoughmarital the status, medical practitioner or authorized medical practitioner may

Spain Guyana with the following basic information: followingbasic the with 4). (Art. information adequate or a perform technique or a procedurespecific shall alsobe for responsible providing their of fulfillment information the to right guarantee shall patient the for responsible physician The will. free toown their according make tothem help decisions in order needs their to be appropriate and and truthful understandable is be that manner shall a in and patients to actions communicated medical all of part a is information Clinical consequences. its and risks its procedure, of nature each and minimum purpose the the at include and record, medical the in noted be verbally, provided be shall generally Information respected. be must and people all of right the is informed be to available information, from apart what is excluded by law. In addition, the desire not Before obtaining his or her written consent, the physician shall provide the patient patient the provide shall physician the consent, written her or his obtaining Before all know to right the have patients health, their affecting actions any Regarding A medical practitioner is any person registered as a duly qualified general physician under current law (Art. 2); an 2); an (Art. law current under physician general qualified aduly as registered person any is practitioner A medical with experience, or a general practitioner trained to perform abortions (Art. 2). (Art. abortions perform to trained practitioner ageneral or experience, with is any practitioner medical authorized as physician registered a duly in and specialist qualified gynecology obstetrics defines informed consent as «the free, voluntary and aware consent of a patient patient a of aware consent and voluntary free, «the as consent informed defines , by contrast, the only explicit provision regarding consent in the regulations regulations the in consent regarding provision explicit only the contrast, by , te eia Triain f rgac At 19) salse ta, except that, establishes (1995) Act Pregnancy of Termination Medical the , . Health professionals who assist during the medical procedure procedure medical the during assist who professionals Health General Informed Consent Act Act Consent Informed General 37 6 IV. Comparative analysis of the regulations 9 70 IV. Comparative analysis of the regulations In in order to guarantee that she makes an informed decision (5. Professional Ethics). ensuremust that the information provided resolves all the woman’s doubts and concerns risk and she is unable to express her desires (4. Consent). Furthermore, health professionals Code, say that the woman’s consent is necessary for the procedure except In when her life is at Consent). Informed (6.3.3 obtained» requiring be person third a without of notification or and authorization permission, the discrimination that or coercion from free services, these receive to including those over years fourteen of age. This decision must thereflect women’s desire termination shall of voluntary require pregnancy the informed of consent adult women, «The that add regulations The obligatory. not is which form, consent informed model signed a be include They record.» shall medical the to «it attached be that and procedure abortion state the before regulations the format, and timing the to regard With complete and true clear, life.» and health her on effects and received risks procedures, the rights, her about information has she which for pregnancy of termination and legal voluntary a to consents and requests she that woman pregnant voluntary the and of free statement «the as it defines which Pregnancy, of Interruption Voluntary the As shown, most countries with abortion regulations address the issue of informed informed to country. country of issue the from vary expressed address is it how about rules the regulations and detail of level However, the consent. abortion with countries most shown, As consent. informed mention not Rico do Finally, Puerto Bolivia and Abortion). Therapeutic on Commission Multidisciplinary limited to cases of therapeutic 3, abortion (Art. Resolution 1 of April 1989 of the National Panama 5.2). (Art. pregnancy to the terminate required be shall woman’s the than the other consent of additional no that consent 5.1) adds and (Art. informed woman the with performed be must procedure the that establishes The Choice on Termination Act and (1996Amendment and in 2004)

Brazil Colombia d. c. b. a. contraindications (Art. 10) (Art. contraindications of treatment type to the related directly or knowledge the probable risks under normal conditions according to and experience scientific patient of the circumstances personal to the related risks the safely the relevant or significant consequences of the treatment when performed performed when treatment the of consequences significant or relevant the , the Technical Regulations for Humane Abortion Care (2005), reiterating the Civil requires the woman’s consent to be given in writing, but this requirement is is requirement this but writing, in given be to consent woman’s the requires , informed consent is governed by the Technical Regulations on Care for for Care on Regulations Technical the by governed is consent informed , South South Africa simply 39 38 discrepancies. possible resolve to no is mechanism there and of a representative authorization the requires procedure the as pregnancy the end to wish woman’s minor the to value no assigning of solution representative). her by or woman C. pregnant Provisions, (General decision» this make also may mothers already are who age of years sixteen than younger Adolescents procedure. the authorize and In representative. legal her and sixteen or between eighteen «pregnant adolescents years contrast, of parents age may her request of authorization the require 16 age than of younger years women adolescent to facility this at provided services abortion that (2007) Guidelines Institute Maternal Perinatal the However, abortion. legal In regulations. various the by differently resolved are issues These rights. parental holding those or legal her of representatives those and desires minor’s the between discrepancies potential resolve to value the (i) include of mechanisms problematic, existence the (ii) and making; are in decision wishes to minor’s the that assigned areas or difference, of areas These the case-by-case a basis. to reason, on minors this of able consent For informed fully for country. rules the by reviews considered varied section were following pregnancies women their end which to at decision age the make the that found research The b. consent. informed for models provide also they in writing; provided to be consent Peru enforced. be can that anyone else’s decisions, opinions and desires can be excluded, and that this exclusion implies this perspective, rights a From wishes. own woman’s the is consent for criterion Another important ofaspect the regulations in these three countries is that the definitive at provided must cover least and the their and procedures, risks potential consequences. true is same The informed. to toconsidered be the provided woman for consent in her order as such Countries

Peru Consent of minors Consent The requirements for The requirements consent of minors do not apply to minors who to decide continue the even pregnancy though While writing this publication, the Perinatal Maternal Institute suspended this directive and it is no longer being being longer no is it and directive this suspended Institute Maternal Perinatal the publication, this writing While applied. minor. the of that only required, not is member family a of consent the case, latter the In risks. health present may itself pregnancy for i te eiaa Mtra Isiue Guidelines), Institute Maternal Perinatal the (in , , as earlier, mentioned there is no national law of the regulating aspects technical the regulations Mexico in Spain specifically indicate the minimum information that must be must that information minimum the indicate specifically 38

and Colombia

These guidelines resort to the extreme extreme the to resort guidelines These . In these three countries, the information Colombia

and

Consent by the the by Consent Spain 39

establish require require 71 IV. Comparative analysis of the regulations 72 IV. Comparative analysis of the regulations representative, who give consent consent give who representative, be must age of years 16 than younger Adolescents be must age of years 18 and aided 16 between adolescents that state principle, in (2005), involvement In the representatives. allow her of do countries these although wishes, minor’s the to only value Brazil system, the rules for consent can only be determined in each specific case. understandtheprocedure andtheriskrepresentsitpresented as thephysician.by thisIn thatinclude othercomponents minor’sthe suchas intellectual criteriaemotionaland mixedcapacity to on relies rather but age, as such criteria objective fully provide not does representative.a givenbyAdditionally, consentshouldthatbeappears it regulationthis explicitlyprovide asolution for consent of minors younger than 16 years of age, although be taken into consideration as part of the decision making process. This accordingregulation todoes not the physician’s judgement, risk, grave ofthe because parents necessary shall is intervention medical representative. However, whenbe informed and their opinion shall emancipatedlegallyare who if she is older than 12 years of age. For minors who are not incapable or incapacitated, and consent shall be given by the legal representative of the minor understandingafter listeningthe consequencesto her of opinionthe procedure, which may occur at any giveage.consent when patienta In whois minora thisisnot intellectually case, oremotionally capable of Similarly, in of minors by stating that they must obtain the consent of their legal representativeTherapeutic (Art. 3).Abortion, whichregulates accesstherapeuticto abortion, nullifies desiresthe In 4 practitioner medical authorized or practitioner medical the although age, any of girl a in Similarly, 19962004). and Termination on Amendment, Choice and Act 5.3, (Art. them to consult not chooses minor the because denied be not would abortion however, friends; the or family members guardian, her with toconsult minor the advise than 18 years of shall nurse midwife age, a or practitioner, medical registered registered her of wishes the against representatives. abortion an have to refuses she if even respected, be must where case the is adolescent able to she her shall wishes, express consent and her wishes 0

Panama from their parents and gain the legal rights of an adult. adult. an of rights legal the gain and parents their from ‘Emancipated’ is a legal term referring to minors who have gone through a legal process to become emancipated emancipated to become process a legal through gone have who to minors referring term a is legal ‘Emancipated’ by their parents or legal representative who give consent consent give who representative legal or parents their by , South Africa South Rslto 1 f pi 18 o te National Multidisciplinary the Commission on of 1989 April of Resolution 1 , Spain Guyana

The The te eea Ifre Cnet c sae ta a representative may a that states Act Consent Informed General the , , the regulations stipulate that for a termination of pregnancy for for pregnancy of termination a for that stipulate regulations the , South African South

and Brazil Guyana 4 0 or older than 16 years of age, consent is not given by a by givennot is consentage, of years16 than older or , the Technical Regulations for Humane Abortion Care Care Abortion Humane for Regulations Technical the , for , by contrast, are at the opposite extreme and assign assign and extreme opposite the at are contrast, by , regulations establish that if the woman is younger younger is woman the if that establish regulations them.

However, the regulations state that in any in that state regulations the However, represented represented by their parents or a or parents their by with with the adolescent. the

42 41 Federal Distrito el en Niños y Niñas ( City Mexico of Act Boys and Girls of Rights the of 49 Article pregnancy. the terminating not or terminating of consequences and risks Sexual of Victims the for about information impartial and Center objective truthful, with former the provide Therapy Crimes Support the at personnel the that representative ensure services shall social «the that states It rights. parental holding those of and of Rape, which governs where cases there is a thebetween conflict decision of the minor on Legal Termination of Procedures Pregnancy and Contraception Emergency in the Case In 9). (Art. officer medical county the of consent the with only performed be may termination the the has parental authority view expressed that the should not pregnancy be terminated, value absolute an reasons particular are there unless contrary. the to views, her be or shall his authority express parental to exercising opportunity an person given the age, of years 16 under is abortion In Voluntary and Motherhood 1978). of Pregnancy, of Interruption Protection Social the on Regulations 12, (Art. judge a consulting without and representative the of consent the without procedure the order may professional health the performed, be to abortion the for urgent is it if addition, appeal. subsequent a for provisions no are there which for action legal a of means by to pregnancy allow the to maywoman the end decide into consideration, wishes her guardianships. supervises who judge local a to opinion, his with case, the sends physician the request, if or is claims the opposed Withinrepresentative a seven ofconflict days ofinterests. the the to risk or woman’s pregnant consent, life, a toit when is the not obtain representative’s possible is there when days resolve 90 than more to of pregnancies in mechanism or pregnancy special of days a has 90 but first the within made is age, request the if applied be may of mechanism The discrepancies. years 18 than younger minors for Italy 1995). Act, of her parents or guardian or to Medical 8.3, Terminationnotify them (Art. of Pregnancy may encourage her to inform her he parents, is not required either to obtain the consent

Mexico Norway In other words, the decision is not subject to any further judiciary action. judiciary further any to subject not is decision the words, other In luogo.» del tutelare «giudice is Italian The requires authorization by representatives with parental rights or guardianship guardianship or rights parental with representatives by authorization requires , the the of Agreement Order the Attorney General of establishes Mexico City , the Termination of Pregnancy Act says that if the woman requesting the the requesting woman the if that says Act Pregnancy of Termination the , 41

As a result, the representative’s opinion is considered but is not given given not is but considered is opinion representative’s the result, a As Within five days, the judge, after listening to the woman and taking taking and woman the to listening after judge, the days, five Within

(Art. 4). When there is a discrepancy, because the person exercising exercising person the because discrepancy, a is there When 4). (Art. ), the social services representative shall serve the the serve shall representative services social the ), Ley de los Derechos de las de Derechos los de Ley

According 42

to In 73 IV. Comparative analysis of the regulations 74 IV. Comparative analysis of the regulations other other person.» prevail, especially if there is a conflictbetween their fundamental rightsand those ofany shall rights their adolescents, or girls boys, to relation in taken be must that measure or that establishes Rights, Adolescencia, la y Infancia C-355 case with accordance in Pregnancy). of Care Interruption Voluntary on the for Regulation Technical Consent, Informed (6.3.3 minor» fourteen-year-old the of consent the on impinging without health, of protection with determination self to right patient’s the reconcile to attempt an be immediate must there cases, all requires «In that indicates it case the of urgency discrepancies, resolve to established not is mechanism the specific a Although intervention. unless relatives the of or authorization the guardians requires parents, abortion an age, of years 14 than younger minors In 7). (Art. interest» best of this element inalienable an as rights, those of exercise fundamental the indicates rather but exercised, be may others that so sacrificed be specific should rights her some that within mean not obligations does which and and rights circumstances, holding person a as with end her this to providing means others’, the any over rights her prioritizing development, integrated her to appropriate most is which that of consists «it that indicating Mexico, by signed that end, it defines the minor’sinterests. best interestsbest in her accordance protecting and with wishes international minor’s the instruments of importance the emphasizes investigation.» criminal make a determination in consultation with the Attorney appropriate Deputy General for to order in decision minor’s the consideration into take and minor the of interests best 43 people all obligates that imperative the as understood is adolescents’ and girls boys, of

Colombia Although C-355 of 2006, the Constitutional Court ruling that decriminalized abortion in extreme cases, did not did cases, extreme in abortion decriminalized that ruling Court Constitutional the 2006, C-355of Although consent without infringing on the consent of minors younger than fourteen years of age.» appropriate, shall establish specific rules regarding representation or guardianship for minors or adults unable to give to authorize treatment and thattheirsurgery On bodies. affect the of subject the abortion, legislator, if he deems it objective criteria, such as age, are the only determinants for establishing the extent of freely given consent by minors and that theiraffect bodies even when they are highly invasive. The ruling «discards the concept that merely has law case Constitutional recognizedwishes…» the right of minors’ minors to the free developmenton of and personality the ofpossibility infringeconsenting to treatmentthat future the in policies abortion establishing from legislators prohibited and procedures invasive about decisions make to right the have «…thatminors recognized also ruling the addition, In minors.» of dignity and autonomy personality, of development free «…completelythe ofminors younger than 14, forby deeming minors youngerabortions than 14 a crime in all circumstances, nullified wishes the rejecting categorically that was decision this for basis The crime. a considered be must age of 14years under minors for performed abortions all that establishing law the overturned the It guidelines. ofas used be sections can ruling some pregnancy, the terminate to 14 under minors of decision the about rules specific establish , in accordance with the Ministry of Social Welfare’s regulations regarding regarding Welfare’sSocial of regulations Ministry the with accordance in ,

Article of8 Article the theinterests defines best minor:

«In every administrative, judicial or other of type decision action, The mechanism therefore consists of a third party decision, but but decision, party third a of consists therefore mechanism The 2006 43

) and the Children and Adolescent Code Code Adolescent and Children the and ,

seily rils ad 9. and 8 Articles especially

These regulations should be interpreted interpreted be should regulations These

«The term interests ‘best ril 9 Peaec of Prevalence 9, Article (Código de la de (Código

To establish the same rules for adolescent girls and disabled women via a system that that system a via women disabled and girls adolescent for rules same the establish in Spain, to Similar medical and information autonomy, to rights Act.» by this regulated documentation the disability with associated special respective with needs clients their or within patients guarantee «to governments provisions regional specific issue and to state jurisdictions, of heads ( the of Provision power the Additional Fourth the Finally, 9). (Art. possible dignity.» extent the to personal decision the in her participate shall for woman the that respect states law the with addition, and patient the of favor «…in and health and needs circumstances the to appropriate be must representatives by consent indicate that regulations the performed, be not should abortion the that decides member family close or representative the where situations for mechanism no is there Although shall give consent. relationships close that with the indicate familialregulations individuals have a ties or legal representative, the allow not does state situation.» own her or his for psychological responsibility take to or patient physical whose or decisions make to able a via consent give must is who wishes out representative: sets woman’s (2002) the Act Consent to Informed value General the assign of 3 to effort an makes differences, that resolve to but mechanism specific a have not does that countries the of One in and decision. makes the who ajudge is it Italy action, of course a determine should opinion physician’s the that states Africa establish South not representative. a have not does woman the do when do to what establish Italy countries and Spain Most representative. her and woman considered. the between differences be resolve to mechanisms wishes woman’s the that require regulations the Panama, except countries all in However, representative. woman’s the of consent the require to is rule general the disability, mental of type some of because themselves it give directly cannot who women of consent for that found research The again, Once earlier. cited of Pregnancy Interruption Voluntary the for Care Technicalon the in Regulations described as discrepancies resolve to account intotaken rights.» other over prevail and interdependent and universal are which rights, of all human their satisfaction simultaneous and integral toguarantee c. Consent of women who cannot directly give it themselves give it directly cannot who of women Consent Puerto Rico Puerto

«patients, who, in the opinion of the physician providing care, are not not are care, providing physician the of opinion the in who, «patients, Brazil and the Technical Regulations for Humane Abortion Care (2005) (2005) Care Abortion Humane for Regulations Technical the Bolivia

do not define rules for the consent of minors. consent the for rules define not do

Disposición adicional cuarta) cuarta) adicional Disposición

When the woman does not not does woman the When

These provisions must be be must provisions These Spain establishes . Article Article .

In 75 IV. Comparative analysis of the regulations 76 IV. Comparative analysis of the regulations South Africa South Consent. Informed (6.3.3health…» of protection withdetermination self to patient the of right disregarded; the regulations state: «In all cases, there must be an attempt to reconcilecompletely the not are wishes woman’s theHowever, intervention.immediate necessitates case the of urgency the unlessrequired relativesis guardiansor parents, of consent the incapable: mentally or unconscious are who women and consent, directly cannot who In with 1975, Pregnancy, of Termination 1978). concerning Amendments, 50 No. Act 9, (Art. officer medical county the of consent the with terminated guardian be may the pregnancy the If 4).consent, denied has (Art. practitioner medical her of request the at guardian auxiliary an appoint shall court the guardian, no has woman the If operation. the of significance the of understanding capable is that she if it may assumed be shall obtained be consent the guardian may submit directly the for request a termination. The pregnancy woman’s the contrary. If the from or illness woman severe retardation, mental mental is suffering to reasons particular are there unless views, her or his express to opportunity an given are identical. The law that states if the woman is the mentally disabled guardian shall be In wishes. their express or to discern able not are tofor reason, who, whatever women refers disability regulations, of these purposes even if she to refuses have an against the abortion of For wishes the her representatives. the where case woman is any able to in express her she wishes, shall that consent and her indicating wishes must be respected, but representative, the of consent the requires 44 personae’, ‘curator her of consent the with found, be cannot termination persons [the (i) such if (ii) week: and guardian legal 20th or natural… her of and consent the with 13th performed] the be may between or weeks 12 first termination the the about before decision a make to time in recover will she that prospect no is a termination and of there or her is pregnancy, in a of state unconsciousness continuous that she is completely incapable and of appreciating understanding the of consequences obligatory. The law that states when a woman is severely mentally disabled to the extent not although urged is representative the with consultation but physician, the prevails of that is that – opinion the correctly, more – or, wishes the Specifically, are definitive. wishes not latter’s the that clearly states it but representative, her of and woman the

Colombia Norway health-related affairs of an incapacitated individual. individual. incapacitated an of affairs health-related Within common law, ‘curator personae’ refers to a person appointed by a court to manage the personal and and personal the manage to court a by appointed person a to refers personae’ ‘curator law, common Within

Technical Regulations on Care for the Voluntary Interruption of Pregnancy). , the rules for consent of minors and women who have some of type disability , the regulations also set out the same rules for the consent of minors, women does not have a mechanism to resolve conflicts between the wishes of wishes the between conflicts resolve to mechanism a have not does 44 provided that that provided 2. 45 the refused, is consent if However, representative. legal their through consent give In representative gives consent for a woman who is incapacitated for legal reasons 3). (Art. TherapeuticAbortion, binding only in of cases therapeutic abortion, requires that a legal performed. be abortion an that to right request the woman the to appeal. subject not is that decision a make time, been has there if parties the to listened having may, expressed. been has it if view of point guardian’s and illness containing the ofa and details the source, guardianships its report the woman’s request supervises who judge a to send shall choice of physician the or facility the at physician pregnancy. the about do to wants heard. be should opinion guardian’s woman). the legally not from is he separated (provided spouse a or guardian a by given be may consent doubt, in opinion. his gives simply spouse or guardian the and (1978) ofto Pregnancy a judicial Interruption authority, decision the Voluntary delegate in contrast, By 1. followingcases: in the consent refuses spouse or guardian the if even termination the with proceed may they agree, a course training and prescribed the practitioner completed has who medical nurse or a midwife or registered practitioners medical two when personae’, or ‘curatorspouse guardian, legal or natural her with consultation after that, states further It prescribed the completed has who nurse 5.4). (Art. thereto or consent training course midwife registered medical a a and or practitioners practitioner medical two unless terminated be not may pregnancy the In

Peru Panama to the fetus 5.5, (Art. Choice on Termination Act and Amendment, 1996 and 2004). woman’slife, mayresult severe ina malformation riskofoftheainjuryfetus pose or After the 20th week of gestation, if they are of the opinion that it would endanger abnormality. the mental or physical asevere from physical or mental health or a there risk exists substantial that the fetus would suffer the opinion that the continued would pregnancy pose a risk of injury to the woman’s Up to the 20th week of gestation, if the health personnel mentioned above are of are above mentioned personnel health the if gestation, of week 20th the to Up The guidelines discuss absolute and partial legal incapacity in the following terms. Absolute legal incapacity: incapacity: legal Absolute terms. following the in incapacity legal partial and absolute discuss guidelines The minors younger than 16 years of age, except for those acts determined by law; individuals who for whatever whatever for who individuals law; by determined acts those for except age, of years 16 than younger minors , the Perinatal Maternal Institute Guidelines require that women with disabilities , Resolution 1 of April 1989 of the National MultidisciplinaryNationalon Commissionthe of 1989April of 1 Resolution , Italy

The judge’s decision is issued as a title is – granting issued judge’s this The decision is an instrument , the Regulations on the Social Protection of Motherhood and and Motherhood of Protection Social the on Regulations the ,

If the spouse or the woman presents the request, the the request, the presents woman the or spouse the If

Within seven days of the request, the attending attending the request, the of days seven Within

In all cases, the woman must confirm what she she what confirm must woman the cases, all In

If the woman’s mental state is is state mental woman’s the If

After five days, the judge judge the days, five After

45

77 IV. Comparative analysis of the regulations 78 IV. Comparative analysis of the regulations and conscientious objector, as discussed below. Africa physician to become an objector. defining conscientiousestablishing objection and guarantees while women, for Italy objector. an is who physician a encounter who women for guarantees (3) and objector; an become to regulated: are areas three general, In abortion. timely and safe a provide to able is who professional health a to woman the woman’s life or health was in an danger. obligation establish most to Furthermore, refer the when objection conscientious invoking from physicians prohibited majority the and The research did not findany country that allowed conscientiousobjection by institutions, objection Conscientious ii. operation. the for request the shall sign guardian legal the or member family closest the that state regulations The function. this perform shall psychologist a medical board must include a psychiatrist. If the the involved, health is facility incapacity mental does of not degree some has have who woman a a when addition, psychiatrist, In health of the woman. judicialbodyin order to proceed with the actions allowed by law to preservethe life and attending physician or the health facility is obligated to communicate with the appropriate and

is no reason to impose such protection, the person is entitled to make decisions without restrictions. without make to decisions entitled is person the protection, such impose to reason no is there If individual. the protect they when justified may only are incapacity, partial and and to absolute linked those as such abortion an making, of decision on Limitations consequences pregnancy. of termination a of about the manner informed an in and management effectively understands decide the regarding perfectly woman judgements this rational However, make to resources. economic ability the lacking is she because transactions legal into enter autonomously not may spendthrift a be to found was she because rights civilian her lost has who even pregnancies their terminate to a woman example, For issues. seeking reproductive about women to make decisions able are and on discernment possess they set when are limitations laws, other on reliance of type of this result a As autonomously. transactions legal into enter may individuals whether govern incapacity partial and whose on absolute laws individuals general The of any view, is unjustified. point from which, and regulations abortion in the as included addicts; drug incapacity general drunks; govern that laws the on relies habitual interpretation This rights. management, civilian of deprivation entail bad sentences in acted have to judged individuals retarded mentally 18, than younger spendthrifts, wishes; their them from expressing and that prevents 16 deterioration from mental suffering than people people, older minors incapacity: legal Partial doubt. a beyond wishes their express cannot that mutes blind and people blind deaf mutes, deaf and of discernment; deprived are reason Norway is the only country that regulates all three. allregulates that country only the is Spain specifically concentrate on allowable restrictions to labor rights in relationthe specifically in to concentrate rights allowable labor on to restrictions only partially defines conscientious objection. The regulations in regulations The objection. conscientious defines partially only concentrate on defining conscientious objection and the procedure for a for procedure the and objection conscientious defining on concentrate

Not all countries regulate all regulate areas. allNot countries Peru

(1) what is conscientious objection; (2) procedures (2) procedures (1)objection; conscientious is what and

Mexico

Brazil only regulate guarantees for women,

and

Colombia

concentrate Guyana South

on

In 46 objectors in this matter» (Art. 16 bis 7). provisionongoingtheservicesavailabilityandof conscientious notpersonnelareofwho notbeinvoked. pregnancy is urgent to preserve the health or life non-objectingof the physicianswoman, soconscientious that services objectionmay alwaysmay be available: conscientiousobjection in urgent cases and requires facilities to guarantee the presence of thatobjectors «…refer the woman to non-objectinga physician.» religiouspersonalonconvictions,beliefs orsimultaneously but establishes obligationthe ( ( rules: two least at to mention important is It rulings.) in other reiterated cases. some in abortion allow to code penal the a such not or issued.» been whether has regulation of independent exercised be may and exists it that objection, that in spite of the lack of regulation which from suffers the same problem. Code ( Deontology the in addressed generally also is It law. of force the have not does ( Spain of Association Medical the ( Deontology and Ethics of Code the in abortion, with legal texts that allow some rules to be defined.For example, it is addressed, in conjunction Spain hours.» of forty-eight a maximum within provided be substitutions or replacements necessary the that require or provide guidelines of the facility,corresponding or, in their the absence, of Ministry Health, must not be invoked when such exemption in results torisks women’s health.» may belief or conscience of «…reasons that state Act, Health General the of XII Article In Código Código Deontológico

Mexico

Peru the transfer of objector personnel to services unrelated to abortion is not not is abortion to unrelated 1987) ruling of 20 January services Court (Constitutional or ranking salary, her toor his reduce not does personnel it as long as discriminatory objector of transfer the nurses invoked and be may only it by physicians This information is included in guidelines issued by the Ministry of Health that IPPF/WHR was unable to obtain; obtain; to unable was IPPF/WHR that Health of Ministry the by issued guidelines in included is information This pp.99–121. underpinnings). constitutional its abortion: to objection (Conscientious in cited is it however, does not regulate the issue of However,objection. conscientious there are various te eiaa Mtra Isiue udlns 20) floig h mdl of model the following (2007), Guidelines Institute Maternal Perinatal the , , the Mexico City Health Act, amended in 2004, allows conscientious objection based

Itshall bethe obligation ofpublic health facilities toguarantee the timely Cebría García, María (2003) La objeción de conciencia al aborto: su encaje constitucional constitucional encaje su aborto: al conciencia de objeción La (2003) María García, Cebría )

of the Nursing ( Association

(Ruling of 11 April 1985, which revised the law reforming reforming law the revised which 1985, 11 April of (Ruling raiain éia Colegial Médica Organización

«…it is worth noting, in reference to conscientious «…it in noting, to reference conscientious is worth

However, the has Court Constitutional recognized

Organización Organización Colegial de Enfermería Subsequently, this decision has been been has decision this Subsequently, 46 Código de Ética y Deontología y Ética de Código Anuario de la Facultad de Derecho de Facultad la de Anuario

«When the termination of

Additionally,itprohibits ). However, this code code this However, ).

They They add:

«The . XXI, XXI, . ) of ) ), 7 IV. Comparative analysis of the regulations 9 80 IV. Comparative analysis of the regulations Refusal to discharge obligations when faced with a particular task could lead to breach breach to lead could task particular a with faced when obligations discharge to Refusal 1.15). (Art. abortions perform shall incumbent the that requirement the with vacancies itto advertise may be necessary services, foravailability abortion personnel of sufficient 1.14). (Art. are provided the that reproductive toin ensure services order health state regulations The comprehensive user-friendly and accessible equitable, that essential is It 1.15.1).(Art. action group a as not and members staff individual by expressed be mayonly objection Public physician. non-objecting a to woman health facilities, 1.13).however, the (Art. the ensure must provision of services refer Conscientious must she or he objector, an is including services, abortion, must also be For respected. this reason, if the health provider to However,in the right Constitution. to rights clients’ health established of conscience freedom the with accordance in abortion regarding objection conscientious invoke to In problem.» her to resolve care provided shall be she that certainty the an official of thePublic or accordingOffice medical Prosecutor’s toreport, the case, with such and Counter-referral Form and of with alldocuments legal importance, other important physician non-objecting or to a hospital a which to performs woman legal the abortions using refer the discreetly Referral and responsibly immediately, shall abortion to objects risk. imminent at life woman’s pregnant the place that cases those in except conscience, of reasons for procedures abortion in participating from abstain concepts. same the reiterating while abortions, for referred be inwhich must women theand define circumstances points same law these regarding of provisions the develop further (2006) City in toTerminationMexico the of Pregnancy related Services Health of Operation and Organization the on Guidelines General The and nursing homes must guarantee abortion in the circumstances allowed within their their within allowed circumstances the in abortion guarantee must homes nursing and objection cases, all In Hospitals services. physician. post-abortion and pre- providing from objector the provincial exempt not does the to submitted being after month one it mayin shall revokedbe which go case into conditions, effect or invokedthese outside into or of effect the ofcertification the facility that will Objection provide services. these law the comes must month after first within the it director to health the communicated be also home, nursing or hospital a with affiliated personnel of case the in physician; provincial the to communicated be must and advance in presented be must the However,objection procedures. from absent be to allowed are consequently and objection In Circular H97/2000). Cape, of Western Health: Department of 1.15.2,contract (Art. Policy on the Management of Termination of Services, Pregnancy South Africa South Italy as:

, health and auxiliary personnel are also permitted to invoke conscientious conscientious invoke to permitted also are personnel auxiliary and health , results of laboratory or other tests and authorization for the abortion issued by issued abortion for the authorization and tests other or of laboratory results , the regulations stipulate respect for the right of health care workers workers care health of right the for respect stipulate regulations the ,

«Health professionals may professionals «Health

The physician who who physician The 47 set out rules regarding the guarantees for women when abortions requesting there is an Pregnancy of Interruption Voluntary the for Care on Technical Regulations personnel The 5). (Art. administrative not providers, direct for only and objection, conscientious – In 11, 1995). by law Act, authorized (Art. Termination Medical of Pregnancy termination pregnancy any in participating to objection conscientious of affirmation or person the on oath under given lie statement a by shall provided be may proof Such objection objection. such claiming conscientious of proof of burden the proceedings legal any in that warn regulations the However, conscience. his against is it if abortion in regulations The 20). (Art. terminations in pregnancy they assisting or performing from exempted whether to be wish known it make shall performed be may terminations pregnancy where who termination. apply to Health including or personnel pregnancy facilities institution, the post must be prepared to out carry the duties and on imposed tasks the hospital unit to appointed person the that employment for condition a make it professionals, health throughout the country, the county municipality may, when job advertising vacancies for personnel appropriate are there that Toensure Services. Health the of Directorate the to and officer medical county the to simultaneously sent be shall report the of copy A are available as well who at of as the terminations, anynumber posts. vacant time for pregnancy personnel health the include and objectors conscientious are who personnel health of categories different of number the of municipality county the notify quarter, either who each shall, institution or hospital the of head personnel administrative The operation. the after or health to only before woman the assist who those to not applies and itself, operation the in assist or perform objection conscientious to right The institution. or hospital the of head administrative the to explanation, detailed more a via the medical superintendent, shall, terminations pregnancy in assist or perform to wish not do conscience, of reasons a follow to professionals objectors. as registered to be in order procedure health require also Guyana and Norway in regulations The and Motherhood of 1978). of Pregnancy, Interruption Voluntary Protection Social the for Regulation 9, (Art. urgent was case the unless abortion, an in part takes professional health the if revoked be to understood is exempt health from personnel the performing procedure if it is urgent. Finally, objection carry out As abortion services. in all the other countries, conscientious objection does not as must regions, among establishments, the others, availability of personnel to sufficient

Colombia From the context, medical superintendent seems to refer to an administrative authority of the health institution. health the of authority administrative an to refer to seems superintendent medical context, the From , Regulatory Decree 4444 of 2006 only allows individual – not institutional institutional not – individual allows only 2006 of 4444 Decree Regulatory , Guyana state that no one is legally obligated to participate in an an in participate to obligated legally is one no that state 47 give notificationwritten ofsuch awish, with together

In Norway , health personnel who, for for who, personnel health , 81 IV. Comparative analysis of the regulations 82 IV. Comparative analysis of the regulations In personnel directly involved in the procedure ( procedure in the involved directly personnel rules regarding conscientious objection in the Code of Medical Ethics. Medical of Code the in objection conscientious regarding rules d. c. b. a. observed: shall be rules abortion. legal to object not do who colleagues to related trained to women refer must they that state which codes, ethical followprofessional to directly personnel health objection, they are obligated the abortion, believe perform that they cannot providing this service conscientious exercising by When, professional. the of refusal the of because patients to trauma minimize to attempt which objection, esne a facilities. at non-objecting available have personnel to always obligation (iv) and professional; trained a to refer to obligation (iii) emergencies; in or woman, the to risk a present would it when lesser or greater a to and, area is always the the this same: objective extent, in uniform quite are regulations the shown, As Ethics). (5. Professional hospitals public at abortions perform who professionals maintain to obligation state’s the and facility the at professional by another performed is to obligation the that procedure the guarantee complications are needed, which is an post-abortion for emergency situation. services when or physician the of absence the of result a as injury or harm suffer may woman the when procedure, the perform can who physician other no is there when life, woman’s the save to required is abortion the when except allowed

Brazil who requests an abortion, without prejudice to subsequent decisions by the the by decisions (6.2. appropriate subsequent to prejudice and legitimate was without objection conscientious the whether about Board Ethics Medical abortion, an requests who woman pregnant the of identity the about confidentiality maintain must Providers woman. of the life health the or to protect obligation greater provider’s the pregnant the of part as abortion, the when perform must danger, she woman’sor imminent in life or he is possible, a not and/or is provider service, the non-objecting a provide to to referral timely able professional only the is objector the When be services. guarantee can who accessible easily and otherwise is that one or facility same counseling the within provider necessary non-objecting available the and trained a with to immediately provided referred be must woman pregnant The about therapeutic options or alternatives to the abortion if there are any. are if there abortion to the alternatives or options therapeutic about her change to decision. order in options woman’s a the limit nor about abortion information and hide rights or woman’s provide to refuse not may facilities and Providers , the Technical Regulations for Humane Abortion Care (2005) reiterate the the reiterate (2005) Care Abortion Humane for Regulations Technical the ,

Neither may health professionals or facilities deny a woman information information woman a deny facilities or professionals health may Neither The regulations state the following: the state regulations The

Admission of Pregnant Women ( Women of Pregnant Admission

Several countries limit conscientious objection to medical medical to objection conscientious limit countries Several

(i) objection only by individuals; (ii) prohibition (ii) only prohibition by (i) individuals; objection Colombia

In such circumstances, the following the circumstances, such In Admisión de la gestante de Admisión , , Norway

The The regulations also establish and

Italy In general, it is is it general, In ). ).

)). Norway nursing homes and outpatient clinics that perform abortions, which must delete the the delete must which abortions, perform that clinics outpatient and homes nursing In 213).(Art. years» three to months six for office from disqualified and dismissed years. three to trade months or six for expertise profession, his performing from suspended be shall he and increased half be by shall term prison the nature, scientific or technical a of was information by information confidential confidential the if or the trade or expertise received profession, position, or employment, of his means of learned employee the If labor. days’ hundred one to twenty-five of equivalent the for fined and years to two months six for for his gain, shall information such or own be or imprisoned who uses another’s person, that to confided been has or to known reveals made been has which harm, information, their confidential to and consent, to right the has who individual an of consent the crime: a code confidentiality penal medical of City violation the make Mexico to is the in confidentiality to right individuals’ guarantee to used 9). (Art. stay hospital her during patient the to security offer to and confidentiality respect to dignity, patient’s the respects that treatment provide the to obligate abortions legal performing in (2006) involved are who City personnel paramedical Mexico and medical in Pregnancy of Termination the to related Services In for responsibility the included, are is reinforced. confidentiality maintaining institutions when therefore, infringements; is for This performed). is sanctioned abortion person the is rests obligation the the whom with person the because where important hospital the of example, (for obligations in except files), medical for responsible physician in charge of the procedure, participating nurses in the procedure or the people information. obligation to maintain personal confidentiality of informationis placed woman’s on individuals (suchas the the and procedure the about information to access restricting by or confidentiality medical maintain to obligations via services of confidentiality include type this of regulations with countries all Almost iii. Confidentiality topic. this on Finally, women all country. for the throughout coverage guarantee to order in objector an not is employee potential the that recruitment, for a as condition to require, it permissible is that states explicitly

Italy Mexico South Africa South , restrictions about confidentiality of services are only imposed on hospitals, hospitals, on imposed only are services of confidentiality about restrictions , , the General Guidelines on the Organization and Operation of Health Health of Operation and Organization the on Guidelines General the ,

of services: medical confidentiality , Puerto Rico Puerto

When the employee is a public servant, he shall also be be also shall he servant, public a is employee the When , Panama Colombia

and Bolivia , which also establishes institutional institutional establishes also which , do not have any regulations regulations any have not do

«Any person who, without without who, person «Any

In contrast, the method method the contrast, In

Across the board, the the board, the Across 83 IV. Comparative analysis of the regulations 84 IV. Comparative analysis of the regulations In 2005). Care, Technical Abortion Humane for Regulations Counseling, and Protection (3. information of confidentiality and privacy guarantee must teams medical addition, In Ethics). in Professional (5. Code Ethics included Medical the and is Act Adolescent and Children it the since adolescents for twice established is obligation This woman. the to caused harm all for compensation pay must and ethics of board a before brought or confidentiality.Anyone who does not uphold thisobligation may be prosecuted criminally and with her consent. This is based on the spontaneous ethical and of legal obligation to instances maintain medical Office abortion or to Prosecutor’s reveal that an Public abortion has except been performed, to protect the the woman or judiciary police, the from In 4). information» to patient (Art. access legal guarantee to protocols and regulations appropriate, where create, shall and section previous the that law.» by established as authorization previous without information this access may one no that and health their about information of nature confidential the «to respect people of all right the privacy, to right the of part as defines, (2002) Act for Reporting the of Performance 1986). Legal Abortions, Mandatory and Centers Accredited on Decree Royal4, (Art. confidentiality ensures that and abortion the perform legally to related documents to required the consent given by the pregnant woman – be must kept documents in a way reports, medical as such – Spain 1978).Pregnancy, of Interruption Voluntary and (Art. Motherhood of Protection abortion Social the the on 11, for Regulations basis the provided that documentation the and procedure the regarding physician provincial the to send they information the from identity woman’s This regulation addresses not only confidentiality, as it must be observed by each each by observed obligated be «are that facilities of must obligations the it also but team, as medical the of confidentiality, member only not addresses regulation This of Service). (6. Characteristics to right privacy» and woman’s privacy statistical for utilized be only purposes. shall and confidential is information epidemiological in dignity. information and privacy all to rights woman’s of pregnant the and preserve to order itself confidentiality procedure the the diagnosis, observe the and shall consultation the therefore of and confidentiality medical maintain to obligated is abortion to related care health provides or of knows that team health a of that of stipulates Service, Interruption of Characteristics Voluntary in the Pregnancy, for Care on Regulations Technical The confidentiality. Colombia Brazil

Hat cnes hl aot iey esrs o urne te ihs ae in named rights the guarantee to measures timely adopt shall centers «Health , similarly, establishes confidentiality as a restriction on information. Documents Documents information. on restriction a as confidentiality establishes similarly, , , physicians and health professionals are prohibited from revealing to authorities

Abortion facilities shall guarantee confidentiality and respect the pregnant pregnant the respect and confidentiality guarantee shall facilities Abortion , confidentiality ofservicesis alsoaddressed from the ofperspective medical

«Any person who is a member member a is who person «Any

The The General Informed Consent

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This means that that means This also establishes b. 48 Terminationconcerning 1975). of Pregnancy, Act the of Implementation the for Regulation 25, (Art. or years 10 hospital least at the for at institution stored securely kept be shall case the in documents the and record Art. (Amendments, obtained be to information the for refuse to right her of also be obtained only with the woman’s consent and, in each case, she must be informed consent. her with only obtained be may and confidentiality to subject be normally will conditions insurance and social health, consent to obtain information. woman’s the for need the and confidentiality reinforces simultaneously regulation The (Art. 11). knowledge to his come has that anything concerning confidentiality consent. maintain to her obligation an given under is has cases of examination woman the in the participating Everyone that provided standpoints, insurance and social health, the from situation woman’s the regarding information obtain may committee the secrecy, professional observe to obligation statutory the despite that (1978), states a. except: disclosed be not shall woman each for kept be must that records the of part as Officer Medical toChief the given anyinformation that state specifically regulations (Art. person another benefit to or benefit own their for information any use not may and procedure the to relating to access an maintain approved facility ofmust and confidentiality issues thedocuments of or an any approved employed establishment, person by or working at, or having legal In Consent). Informed and (6.3. information» clear on based and freely so do others to also that ensure who patients do authorize such toinformation confidential be revealed authorization. without it share not and information patient’s the protect to In

Guyana Norway to a member of the police for the purpose of instituting criminal proceedings under under criminalproceedings instituting of purpose the for police the of member a to regulations these Act – Legal Supplement B, 1995) B, Supplement –Legal Act 5, TerminationMedical was terminated (Art. of pregnancy woman Pregnancy whose the of writing in consent the with person, other or practitioner medical authorized the Act; for the purpose of carrying out scientific research;or to amedical practitioner, by the Chief inMedical Officer the ofperformance hisunder thefunctions Act Medical Termination of Pregnancy Act. Pregnancy of Termination Medical , any medical professional, authorized medical professional, owner or director , Act No. 50 concerning Termination of Pregnancy (1975), with Amendments (1975), Amendments TerminationPregnancy with of concerning 50 No. Act ,

According to the Act, information concerning the woman’s 4 Mdcl emnto o Penny c, 1995). Act, Pregnancy of Termination Medical 14,

Information not classified as confidential may confidential as classified not Information

Counseling, Information Information Counseling,

They must must They

11). The 48

and The The 85 IV. Comparative analysis of the regulations 86 IV. Comparative analysis of the regulations 50 49 Ethics). (5. with with patients their Professional relationships from interfering prejudices the principle of which justice, requires tohealth professionals prevent cultural and other include based, is abortion for care humanized which on principles, bioethical addition, In Counseling). and Information Providing (V. in provided is information that language does state that physicians must adapt to the model client’s world view, at ‘support’ least in relation the to the barriers, cultural overcome to measures concrete stipulate not do In culture. Only culture client’s of the v. Consideration delivery. and labor for aside set area the from separate be must area this medications; the taking after comfortably wait can women where chairs with area private a indicated, is observation when and, counseling for area private a guarantee a clean procedure area that provides privacy. provides that area procedure clean a and counseling for area private a have minimum, a as must, performed are procedures procedure. each for conditions facility specifies which regulation, the of 2 Appendix in addressed providing when as well as services» patient (6.3. Counseling, Information the and with Informed Consent). This speaking obligation is when explicitly both possible, privacy of level highest the provide facilities that «…to facilities ensure health require regulations is services of privacy the on regulations with country only The of services iv. Privacy topic. Finally, However, Although reported. being of fear for manner a timely in services seek not may who, health women’s for consequences serious with professional health the in confidence of the In confidentiality. medical of violation this against astatement issued unanimously associations recently prosecutable a and a of Brazil young person 50 practical the appropriate medical Peru Sindicato issued woman Brazil

for It It states that facilities where vacuum aspiration and dilatation and evacuation and in Uruguay , terms, 49 confidentiality Peru injuries crime

Declaration South Africa South authority.» Colombia Médico for , although the Technical Regulations for Humane Abortion Care (2005) (2005) Care Abortion Technical the Humane for although , Regulations , this the or

the was due when violates General crime del to not , In of Uruguay, Uruguay a the other included sharp of the have regulations that consideration for address the woman’s women’s Health symptoms voluntary , Faculty words, Puerto Rico Puerto instrument, and 2007. among Law, rights the of the abortion indicate This Art. Medicine Ethics law the as Declaration a 30, well bullet, does countries Board a after and states criminal as of not

weakens a the she of For medical abortions, the facility must must facility the abortions, medical For traffic respect was Bolivia that the chosen University was abortion in Federación «a accident reported response the medical physician for do not have on regulations this doctor-patient is of this obligated or the confidentiality by to Médica analysis, any who the the Colombia Republic, other prosecution physician provides to del relationship it report

Interior type is the in important medical these she of law, this of because such Arbitration . The technical technical The . of on violence consulted; 16 due circumstances. information confidentiality May attention to to note that Tribunal 2007 the these loss is the to of to a to introduce bias during information-giving. It is worth noting that two of the three three the of crimes establish by definition, area this are criminalthat regulate which, laws two provisions that noting worth is It information-giving. during bias introduce to it is prohibited or not the information is understood, whether to no regulations address Mexico fully understood. the in conditions with which be the it provided, goal must that this be information must addresses second the and women, to provided be must that information the of content Information at the individual level has two important components: women individual to provided of information Content vii. Circular H97/2000). Cape, of Western Health: 1.12,(Art. on Policy the of Management TerminationDepartment Services, of Pregnancy intercourse sexual unprotected or failure method of cases in contraception emergency provide and topromote made be must all efforts that state regulations the addition, In pregnancies. unplanned and unwanted avoid to make methods to contraceptive of individuals use regular active sexually persuade to used be must opportunity every end, Toto terminations. resort women before be prevented this must unwanted pregnancies Although Health City Mexico Act). the adding and code penal City Mexico the amending decree the out to5 a from provisional, broad carry informational the about campaign (Art. reforms Assembly Legislative City Mexico the requires it addition, In 8). 16bis (Art. pregnancies unplanned or unwanted from resulting abortions of number the reducing of goal the with parenthood on responsible and policies rights training reproductive health, comprehensive reproductive and apply sexual and promote to government the requires action level community 1). (Appendix In important an as abortion» and an planning with family rights on emphasis reproductive and sexual about information and education «collective Only services promote to of information dissemination vi. Systematic serve. they communities of the languages the speak who staff to employ obligation for Care on Pregnancy). Regulations of Technical Interruption Voluntary Women, the Pregnant of Admission (6.2. provided is Colombia public general the to Colombia only regulates the content of information provided to women. Although there are South Africa South requires the culture client’s requires to be taken information into when consideration Mexico

and Mexico , the most recent reform of the Mexico City Health Act, in 2007, Act, Health ofCity reform the Mexico recent , the most does not stipulate specific actions, the regulations state that that state regulations the actions, specific stipulate not does establish measures in this area. The former sets out out sets former The area. this in measures establish

Both provisions may be understood as the the as understood be may provisions Both

the the firstaddresses the

87 IV. Comparative analysis of the regulations 88 IV. Comparative analysis of the regulations and facilities where it may be performed and, if the procedure will not be performed performed be not will procedure the if and, performed be may it where facilities and inform the also woman about the must for requirements an specific abortion toThey her her.case, the dates to available services counseling family and assistance social about and pregnancy the terminating or continuing of consequences social and psychological In 16 bis). tohealth» their (Art. consequences as well as pregnancy, of termination to information addition in have may women truthful options other about and timely provide shall institutions health «Public states: in reformed 2004, Act, Health City Mexico the Finally, bis). 131 (Art. decision» woman’s the manner. responsible This information shall and be provided immediately and informed shall not intend free, to influencea or delay in decision her make can woman pregnant risks, procedures, the available that so alternatives and assistance the the well as as effects and consequences about information sufficient and truthful objective, impartial, with women provide to obligated be shall institutions] health manner, [public «All that: similar very a in states, City Mexico of Code Procedures Penal The 148). responsible (Art. and manner» informed free, a in decision her make can so woman available pregnant alternatives the and that assistance the as well as effects and consequences risks, women with truthful, and objective, sufficient timely pregnant information about theprocedures, provide to obligated be shall «Physicians states: code penal City Mexico The provisions. abortion new creating when emphasizes codes how coercive these provisions actually are. penal It is to important within avoid this lawmix of regulations criminal to appropriate not are that aspects legal Including punishments. establish and acts criminal define to than other areas regulates of regulation criminal in inwellas the but Mexico countries not other just – classification no penal other abortion, to specific is categorization of type This punishments. and should be fully explained to the client (Art. 2, Client Assessment and Preparation, Preparation, and H97/2000). Circular Assessment Cape, Client Western Health: of 2, Department Services, (Art. Pregnancy of Termination client procedure for Protocol the the to abortion, explained the fully to agrees be woman should the if that establish regulations the pregnancy 4, (Art. Choice on Termination Act and 1996Amendment, and 2004). Likewise, counseling to and women, before and mandatory non-directive the after termination of non- provide to obligation the with accordance in interpreted be must which 6), Act (Art. Pregnancy of Termination on Choice the to according rights their of informed be Similarly, 1986). Abortions, Legal of Performance the for Reporting Mandatory and Centers Accredited on Decree Royal (Art. facility another about information provide requested, is it where facility the in Spain , health professionals are also obligated to inform women about the medical, medical, the about women inform to obligated also are professionals health , South Africa South

In addition, in accordance with the Choice on Termination Act and and Act Termination on Choice the with accordance in addition, In simply requires that all women who request an abortion must must abortion an request who women all that requires simply

9, to understand. to extensive than less those described is above. guidelines the of scope the although quality, service of part essential In Counseling). and Information Provisions, Specific (VI choices and wishes woman’s a for respect and expression; and conscience of freedom confidentiality; and right to complete, truthful, for and impartial information; useful dignity, the respect privacy counseling: during respected be must that rights the reiterate also guidelines The and warnings for medicines that are prescribed and administered. diagnosis the and includingalternative treatments, process, as well as the the risks of, about contraindications, information precautions ongoing given and be complete to comprehensible, and services the of conditions and terms other any and charges, and fees information from the General Health Act and to relatedapplyrights reiteratethefacility, theythatthem on onlybinding to areGuidelines Institute therapeutic Maternalabortion, Perinatal the Although understood. be should information the that also but Peru for the Implementation of the Act concerning Termination of Pregnancy, 1975).the final decision, the doctor may refer her to another competentcompetent agencyperson. (Art. 3, Thisguidance givenmaycollaborationbein welfarewitha officer, health visitor other or offeredgovernmenttheby 2), doctortheshalland(Art. make sure thatreceivesshe this. doctor shall also provide information concerning the informationavailability concerning of socialthe with womanmedicalassistance the provide obligation nature to doctor’s programs the establishes simply and It woman.effects the of to the operation. If she so desires, the Norway ( ( ( ( Act: this under rights her of woman the inform should professional health the 2004), (1996 and Amendment the Peru

of Pregnancy Counselling, Department of Health: Western Cape, Circular H97/2000) Cape, of Western Health: Department Counselling, of Pregnancy (Guidelines for Pre-Termination services of the termination of pregnancy the locality willavailable be counseling post-termination and pre- to not chooses if she denied be cannot termination the but friend, a or member family a parents, her consult to advised be should minor A procedure. the for required is consent woman's the only weeks 13th the 20th and between under circumstances, and, certain weeks 12 first the within pregnancy of termination a request may she right is one of the countries that establishes not only what information should be provided, , the Hospital Belén de Trujillo Protocol also indicates that information is an an is information that indicates also Protocol Trujillo de Belén Hospital the , does not explicitlynotdoes specifythecontent theinformationof providedthatbemust

to be given truthful, timely and complete information about the services, any services, the informationaboutcomplete and timelytruthful, given be to

Content must include information about sexually transmitted infections infections transmitted sexually about information include must Content

If the woman wants other guidance, such that she herself is able to make

It It states that information must be complete, precise and easy

Regulation

including

8 IV. Comparative analysis of the regulations 9 9 IV. Comparative analysis of the regulations 0 b. b. c. a. carrying out treatment for the termination of a pregnancy, the medical practitioner shall: and list a considerable amount of information that must be provided. 1995). Act, TerminationPregnancy of 10,Medical waived(Art. counselinghealth,mentalrequirementsbe may physicalor her to injury permanentgraveprevent or woman, the of life the save to terminationis the after the woman has requested the termination of her pregnancy (Art. 4). hours 48 of waitingperiod a regulationsforprovideshall counseling,facilitatethe such to thatpartner.appropriate, Unusually,stateswhereher law and, the pregnancy her of terminationtheinformation aboutseeking woman any information forsuch provide to before the abortion, it delegates to the Ministry the responsibility for drafting regulations In decision informed an make to Counseling). and (Information woman the for is goal the protocol, the to According follow-up.» for need the and activities, sexual and activities normal resume may patient the when used, be the pain will be managed, risks and complications associated with the procedure that will how last, will procedure the long how menstruation), during as such bleeding and pain provided: facility. the by and HIV, of the the stages and procedure different the family offered planning methods a. shall: partner her or abortion an requesting woman the counsels who person the that and provided be should information what states law The termination. the seeking woman of the wishes to the shall refer counselor or practitioner medical the counseling, in partner the involve to appropriate is it whether determining that in states law, law the also Guyanese to the specific is and unusual, is information receive also may partner the that consideration the Although

Guyana or or ensure that the woman and, where appropriate, haveher partner been counseled partner her appropriate, where and, procedure the requesting woman the counsel period period after the woman has made a for request an so abortion, that the woman and, waiting 48-hour the of partner her appropriate, where and, woman the advise and Ministry by the authorized by aperson long-term effects of the termination of a pregnancy termination of the effects long-term and immediate possible the and procedures operative the of them of either inform of pregnancy termination procedure the to undertake not or whether decide partner her appropriate, where advise either of them on courses of action that are available as alternatives to the the to alternatives as available are that action of courses on them of either advise

what what will be done during and the what after procedure, may (cramps, happen atog te a rqie ta te oa b poie wt information with provided be woman the that requires law the although ,

It also specifies that specifies also It

In addition, information about contraception should be provided. be should contraception about information addition, In

«Information about abortion procedures must be be must procedures abortion about «Information

In fact, the regulations address this area in depth in area this regulationsaddress the fact, In

It

states

However, when

that

before

g. f. e. d. In obligations include being attentive to the woman’s concerns by providing information information providing by concerns woman’s the to attentive being include obligations dialogue. a in participant active an considered woman, is the to who given care the on and them, to openly and truthfully responding and concerns woman’s the to listening by provided, is it how on also but provided, be must (2005). Care Abortion Humane for the for tois an fundamental pregnant woman the abortion who Technicalrequests ‘support’ Regulations of concept the suggests, name its As client. the to provided be must However, contraception. about information and care the when follow-up including woman sexual relations, may normal activity, resume with the method, associated and the complications of risks pain type management, last, what will be done during and after the procedure, symptoms, how long the procedure will The technical regulations also specify what such information must include, at a minimum: Consent). Informed and way that the respects woman’s privacy and confidentiality» (6.3. information that indicate later regulations same the effectively; transmitted is information the that of the information and characteristics as well as including to additional measures ensure Admission of the Pregnant Woman). other information so that she may make an informed decision about and the health, procedure» and life(6.2. her on procedures those of effects and risks the used, be may that and cultural level;psychological and conditions educational and indicate the procedures her to appropriate understood; easily true; clear; complete; be shall woman pregnant of provision the the to provided information The requires counseling. emotional timely and information truthful services abortion quality of provision «The services: quality c. Colombia (Art. 2, Medical Termination of Pregnancy Act – Legal Supplement B, 1995) B, Supplement –Legal Act Termination Medical 2, of Pregnancy (Art. for arrangements the continuation of counseling the after termination of pregnancy reasonable make pregnancy, her terminate to decides who woman a of case the in services other or fostering availability of adoption, in the case of a woman who todecides continue her pregnancy, her advise about the it of terminating or pregnancy of continuing the consequences give such advice that will enable either of them to infections to how avoid and these deal transmission about with the information social including and infections, psychological transmitted sexually about them of either advise services planning die ihr f hm f ehd o cnrcpin n te viaiiy f family of availability the and contraception of methods of them of either advise Brazil

«must be complete, precise, easily understood and must be provided in a in provided be must and understood easily precise, complete, be «must , according to the technical regulations, information is one component of component one is information regulations, technical the to according , may have the most comprehensive regulations about information that that information about regulations comprehensive most the have may

As As shown, this regulation refers both to the content The emphasis is not just on the information that that information the on just not is emphasis The

For example, the health team’s health the example, For

Counseling, Counseling, Information

9 IV. Comparative analysis of the regulations 1 9 IV. Comparative analysis of the regulations 2 Protocols forviii. medical surgical and abortion public. general the for or individually either to women, Rico Puerto procedure. the from her to dissuade in part, seeks, abortion 2).to seek (Art. an Clearly,abortion. the information given to a an woman who requests her cause may that problems any overcome her help to and woman, the by faced issues motherhood or pregnancy potential any resolve help to be would intention the Here, intervention. special a make to services social local her requesting by or directly acting by either – woman pregnant the assist also may advisors Family respected. is pregnant are who women working protecting law the that ensure to way best the and area; her in available services welfare and health social, law; regional and state under rights her describe (1978) Pregnancy family advisors of assistance what Interruption Voluntary and Motherhood of Protection at findingsolutions toother theThe than pregnancy Regulationsonabortion. the Social aimed is which women, to provided be must that information the in bias some include area, this In (V. support Counseling). and Information post-abortion and complications subsequent avoid to self-care about procedures information and how with they willprovided be be the performed, state also of the must woman’s health, woman test results, the that state regulations The view. world client’s the to adapting as well as language, non-verbal to attention paying and communication effective establishing questions, her answers and needs her meets that 52 51 with legal provisions with a broader purpose (regulating access to that services) abortion three different groups: of providing services. abortion This section includes provisions or measures that specificallyaddress the technicalaspects 53

Family counselors. Family It is possible that the laws and regulations analyzed for this chapter do not provide a complete picture of the legal of legal the picture a complete do not provide for chapter this analyzed and regulations laws that the is possible It Refers to protocols that are obligatory. are that protocols to Refers Rights Commission’s ruling on the case ( case the on ruling Commission’s Rights Human UN the in included recommendations the to respond to efforts first the of one represented and research at the of time the were developed being Guidelines Institute Maternity since the Perinatal were included protocols is it because included not the were of scope is which to Peru was the outside laws. limited research, national to an exception this rule; protocols the hospital of types these general, In laws. national of part a not are that care of have own their protocols hospitals that in it individual in For each this country. is issue situation particular, possible

The ‘support’ system attempts to take seriously women who request an abortion. an request who women takeseriously to attempts system ‘support’ The , Italy Panama is a special case because it is the only country whose laws seem to seem laws whose country only the is it because case special a is

(a) countries with specificprotocols forabortion care; (b) countries and Bolivia

The The research found that the countries tobelonged one of 51 must offer a pregnant woman, some of which include include of which some woman, pregnant a offer must K.L. versus Peru versus K.L. do not any define rules regarding information given ). 52 , 53

Providing Providing

54 Most abortion. an before administered are tests countries only require a physical examination; are laboratory tests optional. what regulate countries Several a. examined. now are of care to protocols related issues of the Some Bolivia of case abortion. therapeutic the in binding only are they but services, abortion accessing for some requirements specifies Abortion Therapeutic on Commission Multidisciplinary National the of regulations. own their in address must facilities issues what this services; abortion law does not but, requirements directly instead, specifies establish addition to the penal code, another law requirements addresses for facilities that provide Rico Puerto 16). (Art. care of toprotocols define authority the given is Health of Ministry the and law, by regulated also is abortion In professionals. health and facilities to related issues addresses only abortion by law, but there are no protocols of care. Group (b) In is more diverse. various circulars and guides on the technical aspects of abortion services. Gynecology,of TrujilloBelénde Hospital.SouthAfrica,in And Circular H97/2000compiles Guidelines (2007) and the Case Management Protocol Peru,facilitiesfor haveLegal developed protocolsAbortion ofcare, including (2006), thePerinatal DepartmentMaternal Institute In (2005). Care Technical Abortion Humane Regulations the for Pregnancy. Brazil has of gestationweekstoof theTechnicalin Regulations CareforontheVoluntary Interruption issued by the Ministry of Social Welfare, which Decree state 4444 of which2006 requires procedures abortion servicesshall to be be subjectused toaccording the includes (a)administrativeGroup provisions area. in this of provision any type without countries (c) and care; abortion on protocols for information relevant include

(for example HIV/AIDS, syphilis, other blood tests) tests) blood other syphilis, HIV/AIDS, (for example Laboratory tests and ultrasound before an abortion abortion an before ultrasound and tests Laboratory by the Health Department. Health the by licensed is that laboratory clinical a by test pregnancy blood a given be to pregnant is she sure not is who patient that a remains in physician until the the health facility last has patient and that been rules discharged, requiring any requiring rules protocols, biosecurity personnel, for training and counseling initial patient, each for required tests For example, the law delegates organization of the facility, roles and obligations of personnel, procedures and and procedures personnel, of obligations and roles facility, the of organization delegates law the example, For and Canada

and Panama Colombia belong to group (c). to group belong

r breln css ihn hs ru. n uro io in Rico, Puerto In group. this within cases borderline are Italy , Brazil , Mexico , Peru Spain

and and is unique in that the decree that governs Norway

South

Africa

, access to abortion is regulated to, access abortion 54 I Colombia, Regulatory In .

In Panama , a resolution resolution a , Puerto Puerto Rico Guyana ,

9 IV. Comparative analysis of the regulations 3 9 IV. Comparative analysis of the regulations 4 effect, each hospital may determine what tests are necessary before an abortion. an before necessary are tests what may determine hospital each effect, (Art. terminated be to is pregnancy whose women of treatment preliminary and examinations for unit the shall hospital for guidelines prepare responsible the necessary evaluate (Art. and pregnancy woman the of the duration the examine must doctor the weeks, 12 after weeks; 12 before Pregnancy (1975) requires an evaluation of the duration of the pregnancy for terminations Norway test). (Coombs included be should antibodies Rh detect and to determine that tests out. carried be not should do tests or regulations examinations The which specify pregnancies. their terminate to wish who women all to tests any require should regulations services establish to guarantee directly a physical examination and laboratory not do Center) Abortion abortion provide that allfacilities that stipulate do they and performed, be to examinations Planning Family H, (Art. 1999 of In accessing to obstacle an services. abortion become not must examinations that stipulates that country and examinations are to tests offered women. pregnant Uniquely, contrast, By optional. are tests laboratory examination; in Guidelines Institute Maternal Perinatal The case. specific each in needed as only administered be should and required not are tests offered, be Colombia In antibodies. of presence the and Rh identify to tests laboratory includes also this Rico and 56 55 the or is uterus anteverted retroverted in another that position evaluation may affect a by determined examination, pelvic gestation bimanual of weeks of number and confirmed be should pregnancy ( (6.4. pregnancy intrauterine an is it that verify and gestation of weeks of number the determine pregnant, is woman the that confirm also He must or she with abortion. associated factors and risk social psychological biological, the and health woman’s the evaluate must physician the consultation first the during As mentioned earlier, an evaluation is required in Consulta de Primera Vez por Medicina General Medicina por Vez Primera de Consulta

Puerto Rico Puerto The regulations also establish treatment: all women with an Rh-negative result and with sensitivity should be be should sensitivity with and result Rh-negative an with women all treatment: establish also regulations The administered anti-D immunoglobulin (RhoGAM) within 72 hours of the abortion. the of hours 72 within (RhoGAM) immunoglobulin anti-D administered The laboratory tests are referred to as optional, but are often considered to be a routine part of care. of part aroutine be to considered often are but optional, as to referred are tests laboratory The Norway , the Regulation for the Implementation of the Act concerning Terminationof concerning Act the of Implementation the for Regulation the , , a physical examination is required; except for testing for HIV, which must must which HIV, for testing for except required; is examination physical a , Brazil require a physical evaluation of the woman before an abortion; in Puerto Puerto in abortion; an before woman the of evaluation physical a require , although the General Regulations for the Operation of Health Facilities ofHealth Operation the for Regulations General the although , does not require any test or examination to be performed, only that that only performed, be to examination or test any require not does

during which the health professional should ascertain if ascertain should professional health the which during

8).

In addition, the medical superintendent who is is who superintendent medical the addition, In 55 Colombia )).

The regulations later clarify that the the that clarify later regulations The

First General Medical Consultation Consultation Medical General First . According to the regulations,

Peru However, they clearly state state clearly they However, also require a physical physical a require also Colombia

is the

19);in 56 only

In including abdominal palpation, and speculum and bimanual examinations. In addition, addition, In examinations. bimanual and speculum and palpation, abdominal including In anti-D for administer test to serologic a and to addition Aspects). (4. Medical women HIV for atest and syphilis in all Rh-negative are to who tests women to typing immunoglobulin blood offer to professionals diseases (Clinical Examination and Auxiliary Tests ( opportunity to do a Pap smear and any other tests that would help to diagnose associated includingserologic and tests Rh. The protocol indicates that tests, the clinical blood examination optionalis an some lists also complications It pregnancy). ectopic pregnancy-related mole, hydatidiform as of (such and infections transmitted sexually of symptoms and signs of identification and pregnancy, of duration and pregnancy of includesconfirmation which examination, clinical a requires Protocol Trujillo de Belén Hospital The Provisions). Specific (VI. risk anesthetic or of surgical evaluation an case, the on depending and, diseases concomitant diagnose to help that tests other (HCG), gonadotrophin chorionic human measuring ultrasound, HIV, (RPR), blood typing and Rh; evaluation hematocrit; of coagulation profile; or and serologic tests: rapid plasma hemoglobin reagin measuring examination: physical the to optional as for measures, other among following the identify guidelines The pregnancy, pregnancy. of termination a request the who women confirm to and and infections, genital other tract or vaginal infections transmitted sexually of an signs examination, identify gynecological a to examination includes that examination a clinical conduct first to in Guidelines Institute Maternal Perinatal The of Pregnancy). Interruption Voluntary the for Technical Care on Regulations include obligatory, (6.4.1.3. not ultrasound and are typing blood they (HCT), hemoglobin/hematocrit although administered, be may that Examinations abortion. to accessing abarrier constitute not does testing HIV that HIV; for testing however, it is vital that to is testing offered all voluntary women. At the same time, it is imperative about wishes woman’s a respect always must professionals check-up. prenatal first the or pregnancy of trimester first the during test) rapid or (ELISA HIV for screen to is women all to offered be must ( Exam (6.4. care medical specialized to referral or procedures additional require malaria)may that as (such diseases other or anemia as well as tract, reproductive the of the physician should check for signs of sexually or infections transmitted other infections abortion. surgical a complicate or pregnancy the of In Brazil ot Africa South xmn físico Examen , the Technical Regulations for Humane Abortion Care (2005) require health health require (2005) Care Abortion Humane for Regulations Technical the , , health professionals must also begin with a physical examination, examination, physical a with begin also must professionals health , )).

The only laboratory test – and subsequent counseling – that that – counseling subsequent and – test laboratory only The Peru Examen clínico y exámenes auxiliares (2007) require health professionals professionals health require (2007)

The regulations also indicate that that indicate also regulations The

The regulations state that health health that state regulations The

Paraclinical Tests, Tests, Paraclinical

1.2.

Physical )). 9 IV. Comparative analysis of the regulations 5 9 IV. Comparative analysis of the regulations 6 confirmed, but does not indicate a method (Case Evaluation and Preparation before before Preparation and ( Termination Evaluation (Case method a indicate not does but confirmed, in Similarly, the Technical of Pregnancy Interruption for on the Care Voluntary Regulations Rico, 1991).Facilities in Puerto Health of Operation the for Regulations General Center, Abortion and Planning Family H, (Art. Health of for Department the by test licensed is blood that a laboratory clinical a given in be pregnancy to pregnant is she sure not is who patient any require that In examination. clinical the during confirmed be should pregnancy the that state does it administered, be to test pregnancy a require Trujillo explicitly de not Belén does Protocol Hospital the In report. police the with compare to duration its establish to rather but pregnancy, the verify to not is purpose its case, this in pregnancy; of termination the for grounds the In doubt. in is pregnancy the of two in existence only and In tests; requirement. a pregnancy it is countries address that regulations have countries five Only b. Circular H97/2000). Cape, of Western Health: Department Services, of Pregnancy the using infections transmitted sexually syndromic approach 2, (Art. Clientand Preparation, Assessment Protocol for Termination symptomatic treat to professionals health blood grouping typing), HB, Rh (blood RPR, and a Pap smear It if also requires necessary. made: be should investigations relevant that indicate Finally, regulations the suspected. for an ultrasound if the duration of the is pregnancy or uncertain an ectopic is pregnancy referred be should woman the and test, urine a by confirmed be should pregnancy the the pregnancy should be confirmed in the apregnancy public or private health as facility aprerequisite In a with duration its estimate and exam.» pelvic bimanual pregnancy the «Confirm specific: more is protocol in Protocol Trujillo de Belén Hospital The evacuation.» uterine delay or hinder not should However, and such tests signs. the physical menstruation the performing last of date the between no inconsistencies are is there when there or or pregnancy the present about clearly certainty not are pregnancy of signs typical the unless necessary uro Rico, Puerto Mexico South Africa South Colombia Requiring a pregnancy test apregnancy Requiring , for cases of sexual violence, the Mexico City Penal Procedures Code states that states that «Laboratory analyses to corroborate pregnancy may not be be not may pregnancy corroborate to analyses «Laboratory that states vlain peaain e cs ats e a interrupción la de antes caso del preparación y Evaluación , a urine test is always used to verify the pregnancy. In In pregnancy. the verify to used always is test urine a , facilities have the delegated responsibility to create regulations regulations create to responsibility delegated the have facilities Puerto Rico Puerto Mexico Peru

and requires a uterine pregnancy to be be to pregnancy uterine a requires , it is required when a sexual crime is is crime sexual a when required is it , Colombia , it is indicated when the the when indicated is it , Peru )). Later, the the Later, )). , although although , or light sedation together with verbal support are sufficient» (7.2.1. Pain Medication Medication (7.2.1. Pain ( sufficient» are support verbal with together sedation and/ light anesthesia or local analgesics, cases, most In anesthesia. and anxiety; reduce which tranquilizers, pain; of pain feelings for relieve which used analgesics, are abortion: combination, during management in or alone either drugs, of types «Three and tranquilizers anesthesia. analgesics, used: be should that medications of types three indicate regulations The provided. be always must medication pain former; the replace not may which support, mandate medical also the regulations Together with support, emotional procedure. the during side her at remains who friend a or member family a partner, or spouse a as such support, facility, the of constraints space the whether on anyone other depending than decide, the to medical personnel woman should the be present to to left provide emotional is It procedure. the during support specialized given be client should the possible, at the procedure, to act in a calm and friendly way. They also recommend that, whenever the reason, this For pain. regulations require of the person performing the perception procedure, as the well as result, all a personnel present as and, fear reduce may woman the of respectful is that attention medical and counseling that indicates which support, emotional on component a includes It management. pain on chapter a have Pregnancy In to alleviate pain. support emotional and medications to how use on regulations that pain address four These management. countries all provide information Colombia c. Circular H97/2000). Cape, of Western Health: Department Services, Pregnancy of Termination for Protocol Preparation, and Assessment Client 2, Africa South 5). (Art. crime reported of date the the with coincide not forensic medical the facility, does or does age health the gestational the whether determine to information this by use can expert issued results the has Office Prosecutor’s to confirm theexistence of theand pregnancy todetermine its duration. Once the Public performed be may tests appropriate the that so choice, her of facility health private or public a to woman the send to Office Prosecutor’s Public the requires latter The (2006). Termination Contraception in and the of Emergency Procedures Case of Rape Pregnancy the Agreement in of the out Attorney General set of is Mexico City, which test the established Order this on ofLegal purpose The bis).131 (Art. termination the authorizing to Medicación para el dolor el para Medicación Colombia Pain management , ot Africa South te ehia Rgltos n ae o te outr Itruto of Interruption Voluntary the for Care on Regulations Technical the , simply indicates that a urine pregnancy test should be administered (Art. (Art. administered be should test pregnancy urine a that indicates simply )). , Peru

and Brazil are the only countries with identified identified with countries only the are 9 IV. Comparative analysis of the regulations 7 9 IV. Comparative analysis of the regulations 8 notes notes that it may be if it used the or it patient the requests necessary. provider considers include used be to tranquilizers It medications analgesics, does and not but anesthetics. recommend general anesthesia, that specifies and aspirations vacuum manual all for In Pain (III. cases specific 2005). in Care, Technical Abortion Humane for Regulations Management, except anesthesia, general of use the recommend not does it Finally, procedure. the hindering is anxiety their if some tranquilizers require addition, may women In sedation. or anesthesia paracervical with sufficient are narcotics or analgesics procedures, most In suffering. unnecessary avoid to them needs woman the be applied and verbal support offered, but associated drugs should be administered when The regulations state that, when conditions are favorable, paracervical anesthesia should to all women. offered be must pain medication that state regulations the regulations, Colombian the to similar However, costs. and complications reducing environment that makes it possible to avoidan foster administering too support humanized many and medications, thereby empathetic warm, and used; be will that procedures in regulations technical the management, pain for support emotional considering When (7.2. Pain Management). Assurance Quality for System Obligatory the of regulations the with accordance in procedure, the of complexity the for care of level it, or requests it is appropriate for her case, the client shall woman be referred the to if the that appropriate note do but anesthesia, general of use the recommend not do they Finally, curettage. and dilatation for anesthesia local and/or or analgesics sedation, light heavy and dilatation: procedures; aspiration vacuum cervical most for for anesthesia local recommendations and/or sedation specific have also regulations The 57 1. of level care: First South Africa medications. the administer to procedures the describes also protocol The sufficient.» are support verbal to plan reduce treatment pain. «In local and analgesics, anesthesia the most cases, light sedation of together with part considered is support verbal Colombia, and Brazil in As

Peru Brazil - Pre-operative (one following): of the Pre-operative four quadrants of the cervix. Care is needed to avoid injecting the local anesthetic intravenously. anesthetic local the injecting avoid to needed is Care cervix. the of quadrants four in the mucosa the cervical under injected lidocaine, as such fast-acting anesthesia local with be used should block To decrease the woman’s discomfort when cervical dilatation is required for a surgical abortion, a paracervical paracervical a abortion, surgical a for required is dilatation cervical when discomfort woman’s the decrease To paracetamol 1000mg orally 1000mg paracetamol , the Hospital Belén de Trujillo Protocol requires pain management to be used used be to management pain requires TrujilloProtocol de Belén Hospital the , state that the use of criteria for clinical evaluation; a careful analysis of the the of analysis careful a evaluation; clinical for criteria of use the that state recommends pain medications according to the level of care: 57

light 3. 2. 58 surgical the for prepare to procedure. used are methods medical cases; all in aspiration vacuum method. appropriate most the decide to used be must that criteria of the one is procedure of the effects tophysical the reaction In abortion. surgical and medical between differentiate often also Countries used. be may methods which determines pregnancy the of stage the countries, allthese In regulations. the in out set the circumstances of each case. However, the chosen method must follow the specific steps the therefore, ofuse on one or the method another depends physician’s and judgement procedures are explained, none of these countries mandate the use of a specificmethod; as well techniques, these as on studies of the level each. of effectiveness using of methods various and techniques various describes it as detail, of amount most detail. and content of terms in differently so does each although Only d. Applied (4. Pregnancy depression of Termination Circular H97/2000). Cape, respiratory of Western Health: Department for Services, Protocol of Aspiration, case Vacuum Manual in – alternatives Pharmacology offers also circular The alternatives: suggested with level, first as Same of level care: Second

Post-operative: operation: the During ------Description of abortion techniques (surgical and medical) and (surgical techniques of abortion Description methods, 2003. methods, This section of the Colombian regulation is based on the World Health Organization guidelines for abortion abortion for guidelines Organization Health World the on based is regulation Colombian the of section This Peru this is an expensive drug) expensive an is this that (noting IVI 5mg Dormicum or (IVI) injection intravenous by 100µg Fentanyl pre-operative as Same ‘verbocaine’ interaction: client-provider good (lidocaine) if needed block, paracervical 5mg diazepam or orally 1mg orally lorazepam needed: as indicated are anxiolytics 75mg orallydiclofenac orally 400mg ibuprofen , Mexico , South Africa South Brazil , it is worth noting that the woman’s potential response or or response potential woman’s the that noting worth is it , , Colombia South Africa South

and Brazil is unique in indicating manual manual indicating in unique is regulate abortion techniques, techniques, regulate abortion Colombia 58

Although gives the the gives the 99 IV. Comparative analysis of the regulations 100 IV. Comparative analysis of the regulations

59 for reserved Procedures). (4. Medical be situations exceptional should microsurgery that indicate regulations The fetus. the expel to as necessary, inwith aspiration or conjunction curettage, abortion, is medical permitted medical include methods abortion, vacuum acceptable aspiration and trimester, curettage. During the second first trimester, the the only method During Procedures). Medical (4. curettage and dilatation and aspiration, vacuum methods, abortion medical include used be may that methods abortion regulations, in the to According (2005) procedures. various Care Abortion Humane for Regulations Technical The Salud en Procedimientos de codifiesprocedures in the Unified Classification Healthof Procedures ( regulations, abortion technical the enacted which 2006, of 4905 Resolution addition, In of Pregnancy). Interruption Voluntary the for Care on (Technical Regulations of cervix the prepare risk to techniques are included Also with methods. surgical increased on emphasis an gemeprost, or and misoprostol prostaglandin, morbidity mifepristone, using higher methods describe for regulations The potential account. into taken are care the hospital require might that complications week, 12th the After indicated, are misoprostol and weeks. 12 first the during procedures for necessary, when method surgical a with conjunction in abortion, medical or aspiration vacuum manual In 61 6 0

Colombia Cervical preparation is suggested for pregnancies of more than nine full weeks for nulliparous women younger younger women nulliparous for weeks full nine than more of pregnancies for suggested is preparation Cervical The regulations provide detailed information on the options given below. They also include possible drug drug possible include also They below. given options the on information detailed provide regulations The The regulations restate that mifepristone is not registered in Colombia and list the following recommended recommended following the list and Colombia in registered not is mifepristone that restate regulations The in registered not is Mifepristone ( ( ( using: 12 than weeks, more of full pregnancies with women all and 18than years ( ( preparation: cervical for techniques Court. Constitutional the by decriminalized circumstances three the in abortions for used) be can it which ( ( ( length: its to due entirety its in description the not but here, provided are sections pertinent the to References administration. of methods and combinations vaginal administration of 1mg of gemeprost, three hours before the procedure (7.1. procedure Preparation). the before Cervical hours three 1mg of gemeprost, of administration vaginal procedure the before hours 36 mifepristone, of 200mg of dose oral performed is surgery the before hours six to four misoprostol of 400µg of administration oral or vaginal the in description regulations) see Methods; Abortion (7. forceps and aspiration using (7.3.3.), evacuation and dilatation gemeprost or misoprostol as such aprostaglandin of doses repeated by followed mifepristone mifepristone, followed by a prostaglandin (7.4.1.1) accompanied by vacuum aspiration (performed in an an in (performed aspiration vacuum by (7.4.1.1) accompanied prostaglandin a by followed mifepristone, described in 7.3.2.) in described room; operating procedure in an room or operating (performed and gynecology-obstetrics dilatation curettage (7.4.2.) misoprostol 7.3.1) in described are gynecology-obstetrics procedures and or Instruments room. room operating operating room, gynecology surgery, minor for used room room, examining , as stated, , the as stated, regulations are highly The detailed. regulations recommend , CUPS) (Art. 4). (Art. , CUPS) Colombia 6 0 and vacuum aspiration and dilatation and curettage. curettage. and dilatation and aspiration vacuum and . In 2007, misoprostol was approved (by expanding the indications for for indications the expanding (by approved was 2007, In . misoprostol 59 At this stage, mifepristone mifepristone stage, this At Brazil Clasificación Única

also describe 61

62 13 21 and between weeks. use for (2) methods of weeks and gestation are of divided into detail two number groups: (1) the in up methods to with 12 regulates weeks of and associated pregnancy are Peru, which in pregnancy, terminate also to Protocol, methods Trujillo de Belén Hospital the contrast, By uterus the curettage.» through evacuating by completed be generally must procedure the expelled, been have contents the Once guidelines. the in out set as weeks twenty-one to sixteen from weeks, fifteen to thirteen of age gestational the to according misoprostol for regimen treatment therapeutic the «Apply following: and the 13recommend guidelines the between weeks, 21 methods For weeks. 12 until methods recommended or as aspiration misoprostol vacuum manual establish (2007) Guidelines Institute Maternal Perinatal the Furthermore, criteria. discharge and complications procedure, the to guide by-step step- used, be thatmust equipment requirements, indications, definitions, Both include ( aspiration vacuum manual for another ( curettage uterine for protocol a includes guide The provide care for incomplete or abortion and complications, abortion not legal abortions. to is protocols these of purpose the that clarify to important is it However, uterus. the Clínica de Emergencias Obstétricas in Finally, Mexico in Pregnancy City). of Termination the to related Services Health of Operation and Organization the on Guidelines General 14, (Art. procedure the performs who surgeon and or the pregnancy the of judgement general the gynecologist-obstetrician attending say that they may be medical or on depending surgical the methods number of of weeks Mexico Curettage). to and follow (Manual Vacuum Aspiration steps the and for surgical procedures the necessary equipment The drug regulations dosages, describe under remain must abortion. the to complete needed is method woman if asecondary to determine observation the terminations, trimester second For outpatient. an as so do or completed is abortion the until hospital in remain to wishes she whether and regulations require the provider to discuss with the woman her response to the that is earlier the mentioned point procedure important one abortions, medical trimester first For

This paragraph includes an error in the original, Guideline No.—DG–INMP—2007 of the Perinatal Maternal Maternal Perinatal the of No.—DG–INMP—2007 Guideline original, the in error an includes paragraph This contents of the paragraph. paragraph. the of contents the but contradicts which age period, is by for only used this one which that gestational could misoprostol assume Weeks,» Twenty-one and Thirteen between Uterus the to Empty is «Methods paragraph of the title The Institute. , in contrast, does not describe what methods should be used. However, it does However,does it used. be should methods what describe not does contrast, in , Peru , the the , 62 Practical Clinical Guide for Emergency Obstetrics Emergency for Guide Clinical Practical , 2007) rules establishes for using methods to evacuate Aspiración Manual Endouterina Manual Aspiración Legrado Uterino Legrado , Appendix 4) and and 4) Appendix , ( Guía de Práctica Práctica de Guía , Appendix 5). Appendix , 101 IV. Comparative analysis of the regulations 102 IV. Comparative analysis of the regulations the procedure. The woman must be informed about symptoms that need emergency emergency care. need that symptoms about informed be must woman The procedure. the before day the 22:00 at another and hours 16:00 at misoprostol of 200µg of tablet one management of administration advises regimen outpatient The cases, should be according to circumstances. all In necessary. if later hours six 200µg and orally misoprostol of later on depending the of status 17the Between cervix. and 20 it weeks, indicates 400µg that states of 400µg should misoprostol be taken orally, with the dose repeated six hours protocol the weeks, 16 13and between terminations, trimester second later.For hours of three tablets to two two of performed be may use procedure the vaginally; the or orally (400µg) misoprostol indicates it site, on performed For terminations possible. if trimester only, site first on used is misoprostol that recommends it termination, pain the on It contraception. section for preparation b), section d) In protocol. the (see to and alternatives recommends even treatment; and notes management Rh c) pain preparation; b) a) 00); areas: page on four management addresses section first The aspiration. vacuum by manual alwaysaccompanied is it since measure, preparatory to a as procedure only indicated is abortion medical medical 5), mentioned, As (Art. procedure. the that Aspiration describes which Vacuum Manual describes – Procedure which Surgical and 4), aspiration, for (Art. prepare Aspiration Vacuum Manual – In of pregnancy. to weeks according administered be must that doses different the recommends admitting the pregnant woman and initiating a medical abortion. 13It the Between operation. required and for the and performing techniques 21it weeks, identifies the instruments the procedure, protocol The describes is permitted. available, curettage not is equipment the if or but, aspiration preferred are vacuum misoprostol electric and aspiration that vacuum manual states protocol the pregnancy, of weeks 12 to Up knowledge clinical and theircompetence (5. on Surgical Procedure based – Manual past, Vacuum Aspiration, the Protocol in used methods with continue should physicians that availablecomplications.ambulancebeof an and casemust Finally,in protocolthe states Intravenousfluids hospital.level secondary a to referred be shouldclient the prepared, stillnotis administered.misoprostol ofcervix shouldthe be doseIf further skill;a not, if with a paracervical block and cervical dilatation provided the practitioner has thesedation/analgesia. necessary If the cervix is not sufficiently dilated, the procedurecan be performed to lightunder examination prepared.Vacuumperformed aspirationis be shouldcervix vaginal the determine if a perform and pregnancy, of gestation of length the confirm have occurred with misoprostol use (pain or bleeding), mightensurethat symptoms anythat about woman thetest ask professionalsshouldHealthprocedure.results arethe of available,day the on 08:00 at admitted be should patient the that indicatesprotocol The South South Africa , the protocol divides techniques into two groups: Applied Pharmacology f. In 63 unsafe of consequences the address to tend provisions These Peru. and Bolivia as such care, abortion legal regulate not do that countries the in manner detailed and most the frequently in most appear complications of management the addressing Provisions ( and an examination of the tissue after the evacuation (Procedures to Evacuate the Uterus among other measures. For the latter, management, it waste recommends one and dose of attire, prophylactic antibiotics medical and spaces clinical equipment, specifies of It disinfection facility.» the by continually implemented practices, best «the replaces biosecurity of nothing use infections control and prevent to that notes it former, the For and related the to second one related the of to use medications. the of use instruments, In infections. transmitted sexually of rate the reduce to violence sexual of cases in antibiotics of use prophylactic the recommend (2005) Adolescents and Women against Violence Sexual from Resulting reproductivo tracto del with before antibiotics the (6.4.2.1. procedure Tract( Reproductive Infections treatment require regulations the infection, of symptoms clinical with presenting cases and cleanliness play disinfection an role essential that in preventing the after infections procedure. Finally, state in also regulations The antibiotics. of performed use be routine may the without abortions that clarify they however, abortion; the after infection of risk the half by reduces this because procedure the during routinely used be should in Pregnancy of Interruption Voluntary the for Care on its use; in Brazil, its to use is of cases restricted sexual violence. The Technical Regulations Antibiotic prophylaxis is only addressed in e. CircularH97/2000). Cape, Western Health: of Department Services, Pregnancy of Termination for Procedimientos para la evacuación del útero del la evacuación para Procedimientos

Peru Brazil Management of complications Management Prophylactic antibiotics Prophylactic single or double valve syringes may be used. However, double valve syringes are more appropriate for use in in use for appropriate more are syringes 2.1). valve (Art. 10 at gestation of 12 to double weeks pregnancy of However, terminations used. be may syringes valve double or single vacuum manual equipment at aspiration own the number in their indicated the order protocol and should that for of terminations trimester first pregnancy, facilities that states Guidelines, Standardized 2, Art. H97/2000, Circular In the Policy on the Management of Termination of Pregnancy Services, Department of Health: Western Cape, Cape, Western Health: of Department Services, Pregnancy of Termination of Management the on Policy the In , the Hospital Belén de Trujillo Protocol recommends two prophylactic methods: methods: prophylactic two Trujillo de Belén recommends Protocol Hospital the , , the Technical Regulations for the Prevention and Treatment of Injuries Injuries of Treatment and Prevention the for Regulations Technical the , 63 )). Peru )). , Colombia Colombia

and Brazil

state , which recommend that Infecciones Infecciones antibiotics 103 IV. Comparative analysis of the regulations 104 IV. Comparative analysis of the regulations the 65 64 Guidelines Institute Maternal In Perinatal services).» the and both on counseling education, chapter (information, complications a its incomplete and for includes care abortion «integrated stages, include life stage this during different Considerations during adulthood. health sexual describes which The ( Abortion ( Hemorrhage Obstetric obstétricas emergencias las de prevención y/o to Improve Care ( and/or Prevent Obstetrics Emergency Reproductiva y Sexual Salud en Integral Atención the In complications. In complications. with abortion of septic treatment the for equipment In legally. performed are that procedures in deficiencies address which care, abortion legal for a framework with in countries toregulations the in contrast abortion 66

Peru Universal Maternal Infant Insurance Program Insurance Infant Maternal Universal This also covers treatment for incomplete abortion with dilatation and curettage or manual vacuum aspiration aspiration vacuum manual or curettage and dilatation with abortion incomplete for treatment covers also This without complications; incomplete abortion with infection that requires hospitalization in a facility with the the with facility a in hospitalization requires that infection with abortion incomplete complications; without parto al posteriores meses seis los hasta embarazada mujer la para ( Childbirth After Months Six Until Women Pregnant ( for Protocols Insurance, Infant Women Maternal Universal Pregnant for Consultation (Integrated sepsis obstetric 21(pages to due 24),to by and pelviperitonitis complicated septic abortion post-abortion adnexitis, septic abortion to Evacuation of the Uterus ( for possible convulsions and cardiorespiratory complications» (VI Specific Provisions. Managing Complications Anesthesia-related laparotomy.Related exploratory complications: an local anesthesia perform is safer organs,than general the anesthesia. When toadministering general damage anesthesia, be is prepared there If antibiotics. administer ofconception have retained.beenUterine perforation: Infrequent. Monitorsigns, vital control vaginal bleedingand products the uterusif the Administerre-evacuate andcounts.cellantibiotics blood highwhite uterusandsensitive bleeding,vaginal prolonged pain, pelvic ordischarge, abdominalvaginal or fluid cervical fever,foul-smellingchills, laparoscopy or laparotomy.exploratory Infection: Rare after appropriately evacuation. performed Symptoms include perforation. Depending on the cause, it may be necessary to: there-empty uterus, replace under liquids evacuation or blood surgical or perform uterineor Requires conception,tears theof trauma, Hemorrhaging:anesthesia. cervical products retained maytooccurdue misoprostol. or aspiration vacuum manual with occur may abortion: Missed 112 (page following). treatment and necessary the provide to capacity the with a facility with the provide in to abortion hospitalization requires that capacity perforation incomplete uterine by the complicated with abortion treatment; incomplete and facility treatment; a necessary in necessary the hospitalization requires provide that to shock hypovolemic capacity or the hemorrhaging with facility requires that a abortion in septic by complicated hospitalization abortion incomplete treatment; necessary the provide to capacity For vaginal bleeding before 22 weeks of gestation, the regulations cover the treatment of incomplete abortion abortion incomplete of treatment the cover regulations the gestation, of weeks 22 before bleeding vaginal For «Incomplete abortion: in the case of manual vacuum aspiration it is infrequent. If it occurs, re-empty the uterus. the re-empty occurs, it If infrequent. is it aspiration vacuummanual of case the in abortion: «Incomplete National Health Strategy for Sexual and Reproductive Health General Plan (2004) Plan General Health Reproductive and Sexual for Strategy Health National , various regulations include provisions for the management of abortion abortion of management the for provisions include regulations various , Sospecha de Aborto de Sospecha Integrated Sexual and Reproductive Health Care Guide Care Health Reproductive and Sexual Integrated Manejo de las complicaciones de la evacuación uterina aeo e a hmrais obstétricas hemorragias las de Manejo ). 65 , n te eto o Mngmn of Management on section the and ), , 2004), there is a section on Measures Measures on section a is there 2004), , 66 covers the costs of medications and and medications of costs the covers n te optl eé d Trujillo de Belén Hospital the and osla nerl aa a ue embarazada mujer la para integral Consulta )). Medidas Medidas para mejorar la atención )). ) includes Suspected Suspected includes ) 64 ( Bolivia, Bolivia, Guía de de Guía Protocolos Protocolos ), , 67 that states Guidelines, Standardized Pregnancy, Cape, of Western Termination Health: of of Management Department the Services on Policy 2, Chapter followed. are guidelines general that sure making and equipment aspiration of vacuum manual reuse In use. such for designed in receptacles objects sharp of to dispose specifically, Peru in TrujilloProtocol de Belén Hospital the prophylaxis, for indications on section the In (with cover). objects sharp for areceptacle and in curettage Appendix 2, which require a receptacle with a cover for materials disposable Colombia g. Circular Cape, H97/2000). Western Health: of Department Management the Services, on Pregnancy Policy of Termination 2.4, of (Art. savings cost huge involves it because abortion, Africa South of Pregnancy). Interruption Voluntary ( Complications of of pregnancy, failed termination, hemorrhage and uterine perforation (7.5. Management Colombia 2005). Care, Technical Abortion Humane for Regulations Aspects, Medical (4. miscarriage recurrent and abortion infected abortion, missed abortion, incomplete Brazil on. so and perforation, uterine infection, hemorrhage, abortion, Protocol,

South Africa South Establishing biosecurity standards standards biosecurity Establishing The protocol states: «When procedures are performed by trained personnel, complications are minimal. However, are minimal. complications personnel, by trained are performed procedures «When states: protocol The anesthesia, be prepared for possible convulsions and cardiorespiratory complications.» cardiorespiratory and convulsions possible for prepared be anesthesia, general administering When anesthesia. general than safer is anesthesia Local laparotomy. a perform organs, the to damage is there If performed. be can laparoscopy a available is laparoscope a If necessary. are been antibiotics have and conception of products the if uterus the is Uterine not perforation generally retained. and detected will itself. If resolve it re-evacuate is often only detected, observation and antibiotics Administer counts. cell blood white high and uterus sensitive bleeding, vaginal prolonged pain, pelvic or abdominal discharge, vaginal or fluid cervical foul-smelling fever,chills, include Symptoms evacuation. performed appropriately after Rare laparotomy. or exploratory laparoscopy or perform or blood liquids replace the uterus, to: re-empty it may cause, be necessary on Depending the May or tears perforation. occur of uterine due trauma, cervical conception, to products retained complications If aspiration. vacuum manual of occur, the case uterus. May re-empty the occur with in manual vacuum rare or aspiration Requires surgical evacuation. misoprostol. are which complications, possible mind in keep lo pcfe te eea olgto t dsoe f aeil aporaey and, appropriately materials of dispose to obligation general the specifies also ecie poeue fr hetnd brin cmlt aoto, inevitable/ abortion, complete abortion, threatened for procedures describes 67 sets out some biosecurity rules for vacuum aspiration and dilatation and and dilatation and aspiration vacuum for rules biosecurity some out sets details the indications for the following complications: incomplete termination care for abortion complications refers to procedural deficiencies: incomplete incomplete to refers deficiencies: procedural complications care for abortion indicates that manual indicates vacuum for mayaspiration incomplete be used also , biosecurity standards concentrate on establishing guidelines for the the for guidelines establishing on concentrate standards biosecurity , aeo e Complicaciones de Manejo ), Technical Regulations on Care for the the for Care on Regulations Technical ), 105 IV. Comparative analysis of the regulations 106 IV. Comparative analysis of the regulations Colombia requirements. infrastructure of specifying facility, without type the indicate merely regulations the Italy, and Panama In conditions. available describe they requirements, creating than facilities: rather to individual specific are that accreditation have not care do for protocols actually also are regulations existing Italy because is this and Peru, In Panama mechanisms. Peru, type. first the to limited are that performed havethe requirements met been (accreditation). Provisions in Colombia and Mexico be will abortions where indicate facility that the (certification); and those by (2) (1) those met that require be some types: form of must verification process two to that demonstrate conditions into the divided be can requirements Infrastructure provision forservice requirements ix. Infrastructure Circular H97/2000). Reuse, Instrument VacuumManual Aspiration and Control Infection for (Guidelines storage and disinfection, level high or sterilization cleaning, decontamination, reuse: for instruments vacuum manual processing for steps basic four describes It method. alternative acceptable only the is followed disinfection level high be available, not is should sterilization if sterilized; – be should injuries cannulae that states also needle-stick It strictly. from protection and blood disposal universal waste and safe practices control infection – precautions standard including aprons and hand gowns, gloves),washing, using (masks, barriers that states protocol Circular This 2.3, (Art. instruments reusing when followed H97/2000). be must Reuse Instruments 2.2). The guidelines of the protocol for Control Infection and Manual Vacuum Aspiration (Art. produced be can suction adequate no until reused be may cannulae and syringes 68 the and Entities Social Welfare’s of Promotion Ministry the inform shall Health Offices Health District and the Departmental that states 2007 of 0031 Circular addition, In and dilatation medicines. and infrastructure and aspiration procedure; appropriate biosecurity, cover vacuum of requirements The abortion. for medical type for and evacuation, requirements the on between depending differentiates medications it and instruments required and requirements physical the specifies 2 Appendix Pregnancy). of Interruption Voluntary Social (SOGCS) Security (6. of Characteristics TechnicalService, Regulation on Care for the for Healthcare System for System General the Obligatory ofthe section Care in Health the within Assurance Quality defined standards certification with comply to services

In Colombia, this ministry performs the functions of the Ministry of Health, among others. among Health, of Ministry the of functions the performs ministry this Colombia, In explicitly spells out the obligation of health facilities that provide abortion abortion provide that facilities health of obligation the out spells explicitly 68

requirements and effective compliance with medical infrastructure requirements requirements infrastructure medical with 3). (Art. woman of the lifehealth to the and compliance save necessary effective and requirements In addition, the law states that accreditation is conditional on maintaining these minimum 2). (Art. centers must or submit a establishments to request their regional respective government the with Private facilities. accredited of comply lists publish periodically authorities that health requirements; establishments or centers public for automatic is Accreditation 1). facilities(Art. hospitalization and nursing and supplies, blood units, or bank obstetrics blood appropriate or an units, recovery gynecology and minimum, anesthesia units, a analysis laboratory as have, must weeks or 12 pregnancies after high-risk for abortions abortions perform that centers health accredited, be To necessary. as referred be can cases to which center ahospital and expanders; volume educational and informational materials; facilities for and clinical and analysis, anesthesia recovery; blood supplies or abortion, plasma the perform to equipment equipment, waiting a room); and in recovery and equipment basic toaddition examination specialized equipment, procedure, the for appropriate rooms counseling, and information for offices reception, for areas include that installations physical and center health any for appropriate facilities and and health hygiene as (infrastructure equipment requirements requires also worker. It social a and personnel health auxiliary staff, nursing obstetrics, before abortions 12 weeks must have, at a least, physician specializing in gynecology and that (1986),provide low-risk of Legal Abortions private or health establishments centers to the Royal Decree on Accredited Centers and Mandatory Reporting for the Performance In 2006). City, in Mexico the on Guidelines General bis, Termination to 4 the related of Pregnancy Services of Health Operation and Organization (Art. procedure the for available surgeons general Ambulatoria ( Surgery Outpatient Major of Performance the or For public whether abortions, entitled regulation the legal in detailed requirements the with comply must facilities, private perform that facilities medical that establishing Mexico Quality. Service on Office General current kept and be available for clients who and require shall shall services these annually be toreported the information This services. abortion have provide which to and willing care personnel gynecological–obstetric level high and medium low, provide to authorized network the within facilities those about Quality Service on Office General Spain addresses requirements for the type of facility and medical personnel, personnel, medical and facility of type the for requirements addresses , by contrast, the law explicitly states that facilities must be accredited. According ), and must have gynecological-obstetric personnel or ),personnel appropriately trained and must have gynecological-obstetric Para la práctica de la Cirugía Mayor Mayor Cirugía la de práctica la Para 107 IV. Comparative analysis of the regulations 108 IV. Comparative analysis of the regulations b. b. a. approved: shall be institution no that states It law. the in detailed also are requirements resource human and Infrastructure below. discussed as approval, of the took place. functioning Failurenon- to provide this or information may result in the cancellation deterioration change, the which on date the from days 14 within case, any in but, possible as soon as made be must notification Such arrangements. clinical other or or nurses practitioners, medical of and equipment any medical staff, deterioration or non-functioning as medical-technical such personnel in changes any include These Act. the the under inform treatment providing to of safety required the reduce may is that changes any institution of Ministry approved an managing or owning person The a. to: consideration due given having duration, weeks’ eight than more of pregnancies of termination medical the for may grant owning or the managing person an approval institution to provide treatment The law states that the Ministry of Health acting on the advice of the chief medical officer, certification. its lose to facility the cause will that situations various mentions also It application. the of part ofproof as submit compliance to the authorities and must of requirements with a series comply must which facilities, for system approval and certification a (1995)down B lays In a. of institution: an shorter period and a may or be years renewed by two the for minister.valid be The willminister may regulations cancel the these approval under institution an of approval The Guyana equipment and facilitiesavailable and institution in the equipment institution in the working by or employed regulations these or Act the of provision any contravenes or with comply to fails or refuses institution iv. iii. ii. i. unless the following are provided in the facility: in the provided followingare the unless hygienic and conditions safe under there done be may pregnancies of termination that satisfied is Ministry the unless personnel technical and nurses staff, medical the of experience and training the if anyone employed by the institution or the person owning or managing the the managing or owning person the or institution the by employed anyone if

adequate facilities for recovery from anesthesia from recovery facilities for adequate use emergency for fluids parenteral and drugs and abdominal performing for surgery gynecological supplies and instruments table, operating an anesthetic equipment, resuscitation equipment and sterilization equipment sterilization and equipment resuscitation equipment, anesthetic , Article 4 of the Medical Termination of Pregnancy Act – Legal Supplement Supplement Legal – Act Pregnancy Terminationof Medical the of 4 Article , 69 ( ( ( the to compliance of proof demonstrate authorities. must circumstances, certain in except and, conditions specific with comply to required are facilities 2004), and (1996 Amendment in Similarly, Termination concerning 1975). Act of of the Pregnancy, Implementation hospital the for 19, Regulation of (Art. terminations list pregnancy perform a that institutions and publish units to obligated is municipality county the services, abortion availability of guarantee to also and requirements, these with compliance guarantee To ( ( ( following conditions: the fulfills institution if the terminations before the or 12th health center pregnancy to week perform of pregnancy the case this maygiveapproval home toofficer medical nursing a officer. The medical county county in authority, administrative an to compliance of proof submit also must In be must certificate The forms. displayed by an approved certification institution in a prominent place andin the institution. application include regulations The heard. to be opportunity areasonable institution the giving without of institution an all approval the cancel or restrict cannot for Ministry The procedures. medical specific more or institution an of approval entire the canceling termination of pregnancy procedures, the of Ministry may decide to instead restrict approval to one case, latter the In b.

Norway appropriate surgical equipment surgical appropriate theater to operating an access staff nursing and to medical access 18). (Art. operation the after hours four least at to for remain able are room haveoutpatients where must recovery a The institution equipped properly laparotomies. out to carry and transfusions, blood and to give anesthetics equipment including equipment, technical necessary the have must institution The administering anesthetics. ofexperience necessary thewith includepersonnel also institutionmust the of staff The termination.pregnancy perform to ability necessary the of evidence show can surgicalunit,gynecological or ahaving workedin after who, surgical specialistor or gynecologicala is who doctor ainclude institution must the of staff permanent The requirements above in the of achange because if it is not desirable that the institution should continue to be an approved institution The text of the law does not specify what these circumstances are. circumstances these what specify not does law the of text The , facilities must not only comply with certain infrastructure conditions, but but conditions, infrastructure certain with comply only not must facilities , 69 ot Africa South Facilities must have following: the Facilities must , under the Choice on Termination of Pregnancy Act and and Act Pregnancy of Termination on Choice the under , 109 IV. Comparative analysis of the regulations 110 IV. Comparative analysis of the regulations In Circular Cape, H97/2000). Western Management Health: the of Department on Services, Policy Pregnancy Aspiration, of Termination Vacuumof Manual Procedure Surgical 5, client the (Art. to support emotional provide to attendant an and procedure the out carry to practitioner vacuum a – manual people two that with room private indicate a in aspiration also performed be should They vacuum aspiration LTD. manual (PTY) own Biomedical their SA from order toinstruments facilities all require regulations The 3). (Art. services of pregnancy termination offering are they that types authorities administrative these the of notify charge must however, facilities, in of person The Council. the Executive obtain the to of required member not a is of approval weeks 12 to up services pregnancy of termination and services maternity 24-hour provides requirements, the with complies that facility health the a in with published Council notification Executive the of member a by approved be must facilities addition, In ( ( ( ( ( ( ( ( hospital in the state or health area or region where it is requested (Art. 8). (Art. requested is it where region or area health or state in the hospital a in performed be shall Multidisciplinary procedure the National that adds the Abortion of Therapeutic on 1989 Commission April of 1 Resolution 144). (Art. center health in code penal The of Health. of Ministry the number from decree a on the depends however,perform may facilities of authority; types these abortions regional the by the authorized with is complies facility and the if requirements days, 90 before homes nursing in performed be also may They facilities. health other and hospitals public specialized in performed be also may abortions that add they However, the hospitals. from general in may unit physicians by gynecology-obstetrics facility performed of be should type they that what indicating state abortions, perform merely (1978) Pregnancy of Interruption Voluntary and Motherhood of Protection Social the on Regulations the former, the In abortions. Italy safe waste disposal infrastructure disposal waste safe facilities to in-patient access and observation for equipment communication telephone clinical for observation equipment control measures infection appropriate transfer emergency for arise need the should transport to appropriate access facility or center referral emergency an to access and equipment resuscitation emergency equipment injection intramuscular and intravenous

and Panama Panama , the regulations only indicate the of type facility that may perform requires therapeutic abortions to be performed in a state state a in performed be to abortions therapeutic requires Gazette, h ofca gvrmn rgse. oee, any However, register. government official the c. b. In a. listed: areas of the more or has he if practitioner medical a in one experience or can demonstrate as trainingand obstetrics in undertaken gynecology recognized be to of Guyana requirements of the Council satisfy Medical shall the practitioner medical registered a that says (1995) B ix. viii. vii. vi. v. iv. iii. ii. i. requirements: following the fulfills who a physician by performed be must abortion via pregnancy a terminate to procedure any that states In procedure. actual the for qualifications professional’s the establishing However, abortion. of area in Rico,particularly Puerto the are requirements not always clearly specific related to the goal of the in training their and professionals health for qualifications out set to seek they that clear is it requirements, accreditation the given Only forprofessionals mechanisms Accreditation x. detailed. more is protocol former The infrastructure requirements. establishing than rather supplies, and equipment infrastructure, about information including facilities, own their describe – Trujillo Protocol de Belén Hospital In

license narcotics federal and state current Guyana

Peru uro Rico Puerto annual enrollment in an approved cardiopulmonary resuscitation course resuscitation cardiopulmonary inapproved an enrollment annual Examiners of Rico Medical Board Puerto by the issued license year one than less not of for a period at any hospital gynecology and in obstetrics experience had if has he obstetrics and in gynecology surgery of house months six completed has if he years Center) Family H, Abortion and Planning in(Art. force rules to the according years Examiners of Rico Medical Board Puerto of the Rules Education Continuing the to according education continuing current of proof (for sterilization) male if he has practised gynecology and obstetrics for a period of not less than three three than less not of period a for obstetrics and gynecology practised has he if two every re-evaluated and faculty medical the by approved privileges for request documents required the physician containing each file for of individual an existence or gynecology and obstetrics in residency of diploma) (or certificate the of copy certificate health current of Health Department of the Registry Professionals Health in the recorded Puerto Puerto Rico , both hospital protocols – the Perinatal Maternal Institute Guidelines and the the and Guidelines Institute Maternal Perinatal the – protocols hospital both , , Article 3 of the Medical Termination of Pregnancy Act – Legal Supplement Supplement Legal – Act Pregnancy Terminationof Medical the of 3 Article , , the General Regulations for the Operation of Health Facilities (1999) Facilities Health of Operation the for Regulations General the , , Guyana

and Mexico regulate professional accreditation. In principle, 111 IV. Comparative analysis of the regulations 112 IV. Comparative analysis of the regulations f. e. the pregnant woman or of genetic or congenital anomalies of the fetus. They need to need They fetus. the of anomalies congenital or genetic of or woman pregnant the of health psychological or physical the to risks documenting reports medical issuing for 6). for The also guidelines accreditation require physicians who are different responsible an the (Art. health social privatefacility or public, awith affiliated be by must addition, professional health In issued completed. was documentation program academic with the that proved guaranteeing institution be must which gynecology-obstetrics, in to specializing be physicians out abortions who carry for preferable health professionals related to the Services Termination that it establish in is of Mexico (2006) Pregnancy City In Act The certification. with doctor forms. certification and the application includes provides Council Medical the of secretary the When the training provided by the chief medical officer. officer medical has chief been the to completed satisfactorily, directed are training for authorized Applications practitioner. an medical as practitioner medical registered a certifying experience for the appropriate determine deemed to power the has Guyana of Council Medical The training. such for appropriate is fee what determine time to time from may Ministry 3).The and to as qualify an under paragraphs a, authorized b, practitioner medical d c, 3.2 or e (Art. practitioner medical a for order in required supervision and training such for provision The Ministry, acting on guidelines that may be provided by the Medical Council, shall make d. In certain countries, gestational age limits are part of the specific criteria for legal legal for criteria specific the of part are linking duration with abortion, of for grounds the pregnancy termination of pregnancy. limits age gestational countries, certain In limits xi. Gestational 6). of (Art. issues» social and ethical legal, in emotional, and Interruption medicine in «both Voluntary trained appropriately the be to professionals for health require Care Pregnancy on Regulations Technical the professionals, Although 7). (Art. health facility social or private public, a with affiliated be must the health in professional was program completed; addition, that the academic provide proof of their specialty with documentation issued by an institution guaranteeing Mexico if he holds a postgraduate degree or diploma in gynecology and obstetrics, the the obstetrics, and gynecology in diploma or degree of such course the during training or gained diploma experience or degree postgraduate a holds he an if as qualified be to minister the practitioner by medical authorized provided training the completed has he if Ministry by the approved in ahospital of pregnancy termination f e a asse a eitrd eia pattoe i promn 2 css of cases 25 performing in practitioner medical registered a assisted has he if Colombia , the General Guidelines on the Organization and Operation of Health Health of Operation and Organization the on Guidelines General the , does not explicitly establish an accreditation system for health health for system accreditation an establish explicitly not does 72 71 70 rule However,a code. penal the from removed completely 251 was section of provision exculpatory the if result would which person the of security to right woman’s pregnant «The the of of the fetus would objective protecting severity the not breach justify of the stated: and Estey Beetz to in this For the task example, their Judges legislature. opinion, be as interpreted an intention must not limits to and on gestational toimpose abortion delegate silence its explicitly, point this mention not did court the Although abortion. Canada trimester. first the in performed be preferable to is it abortions that for state does it although regulations, abortion the decriminalized in or that situations case specific in court the in either in abortion, situation for limits the gestational examine to important is it Finally, age. gestational on limitation atacit may be which to 21 weeks, up oftermination for the pregnancy Trujillode Belén procedures – Protocol specify only and – both protocols Guidelines the the Hospital Maternal Perinatal Institute permitted, In City). in Mexico in effect Code, Penal 144, 12 (Art. before demand on weeks abortion allow 2007 in City Mexico in code penal the to 14).Changes (Art. weeks 20 than more be not may pregnancy the of duration of the that Termination stated the 2006) City, Mexico to in Pregnancy related Services Health of Operation and Organization the on Guidelines (General services pregnancy of termination of provision the regulated that Before 2007, the Mexico penal code did not set gestational limits. However, the guidelines of pregnancy. termination voluntary the for limits gestational establish do abortion, legal for grounds the regulate which limits. codes, gestational penal find Spanish and to Mexican common the However, less is it abortion, legal for grounds the establish advances. pregnancy the as limited more become to and the grounds terminate a pregnancy intoare divided three periods, in established health regulations or technical guidelines. In Such limits are most common in countries where the for circumstances legal are abortion and

Peru However, the technical regulations include a table indicating the most appropriate method according to duration duration to according method appropriate most the indicating table a include regulations technical the However, in of pregnancy duration and abortion for grounds establish that Countries III, Chapter see information, more For of pregnancy, which goes up to a maximum of 22 weeks. 22 of amaximum to up goes which pregnancy, of III. Chapter of content the on expands that information country includes only section This 00). (page code penal the in stated as circumstances special in except abortion penalize that Countries and 00) (page regulations and laws non-criminal pregnancies. advanced more with women for particularly services, These examples demonstrate how systems that establish specific grounds for abortion often restrict access to to access restrict often abortion for grounds specific establish that systems how demonstrate examples These Norway , the penal code does not set gestational limits on abortion. When abortion is is abortion When abortion. on limits gestational set not does code penal the , , where a Supreme Court ruling ( , gestational limits are of of, part the gestational criteria system for they legal abortion; 70 By contrast, when countries use penal codes to codes penal use countries when contrast, By R versus Morgentaler, 1988 72 Colombia oehn smlr curd in occurred similar Something Italy , South , which does not set set not does which , ) fully decriminalized

Africa , Guyana 71

113 IV. Comparative analysis of the regulations 114 IV. Comparative analysis of the regulations promote and update training for health personnel and related auxiliary personnel on on personnel auxiliary related and personnel health for training update and promote to facilities hospital and universities regions, require (1978) Pregnancy of Interruption In be must courses them. to attend personnel for what important is it that stresses year and each specifies offered Africa South occur. should it often how and training for responsible is who establishes Italy content. the with only itself concerns Colombia whiletraining, to ways implement suggest in Brazil regulations Italy the and that found encompasses only medical aspects of abortion and related issues. In addition, the research Italy,trainingin contrast, By component. important most the is Brazil,in latter the fact, In component. sensitization a including addresses abortion, of training aspects Colombia, psychosocial and and medical Brazil In personnel. medical training for measures Of the regulations reviewed, only (pain management, aspects medical in training and Education i. iii. Education providers of service training and Charter.» 1of the section under acceptable be would which proportionality a achieve possibly could lawful, be to abortion an for months, early the to opposed as that would require a higher degree of danger to health in the latter months of pregnancy, including group discussions, clinical supervision, confronting attitudes and convictions convictions and attitudes confronting supervision, clinical discussions, group including professionals, health sensitize help may that activities suggest regulations The practice. everyday for care of model new a create to to is goal trained The clients. to and support true sensitized provide appropriately be must women to services abortion provide with Consistent the earlier,model discussed support 15). (Art. training implemented is program information on regional legislation and and social, health training and welfare annual to services guarantee that an hold topics. should related regions that and suggest childbirth regulations The education, sexuality of understanding their expand to wish who personnel related and personnel health for meetings and courses topromote less harmful to the woman’s physical and mental are health. In that addition, they termination require regions pregnancy of techniques modern more of use the and childbirth, issues relating to responsible family planning, contraceptive methods, stages of pregnancy, Italy counselors) and nurses midwives, (physicians, personnel health forall empowerment) and rights perspective, (gender abortion of aspects psychosocial and counseling) post-abortion methods, abortion , the Regulations on the Social Protection of Motherhood and Voluntary Voluntary and Motherhood of Protection Social the on Regulations the , Italy , South South Africa Brazil , Brazil states that states who professionals

and Colombia

had specific o te elh em rsetn ad eivn wa te oa sy, epn hr to her helping says, woman the what believing and respecting team: health the for tomeasures Specific ensure compliancesystem. include asupport number of obligations to emotional for support and clients, their form respect decisions, an integral of part the Colombia decisions fortheir respect iii. Emotional and forwomen support 8). (Art. services of abortion provision adequate to ensure in order facilities to provide ongoing information, training and education for health health professionals and managers requires regulations, abortion technical the enacted which 2006, Colombia facilities health at training Ongoing ii. Circular H97/2000). Cape, of Western Health: Department Services, of Pregnancy the 1.16, it availablewho (Art. need to personnel of on the TerminationPolicy Management for requirement is counseling the professional to access confidential that and is in pregnancy of involvedtermination the staff Africa, for provided is South support adequate that by ensure to services only of manager addressed point, important An ( ( ( ( available: are following training courses 1.11.1 (Art. included is 1.11.4).courses to such of organizers for information The contact to personnel relevant attend training. They add that should courses be annually; offered In of Service). (6. Characteristics medicines and supplies equipment, essential including infrastructure, have appropriate shall the services that suggest regulations the training, this complement To aspects. appropriately trained, not just in medicine but also in emotional, legal, ethical and social of say (2006) Pregnancy that shall services abortion be provided by professionals who are in Finally, 2005). Care, Abortion Humane for on sexuality and reproductive practices (3. Support and Counseling. Technical Regulations workshops training and sensitization and concerns, of exchange care, health in implicit ot Africa South training for physicians in abortion care (Art. 1.11) (Art. care in abortion training physicians for on training includes (this aspiration) vacuum manual for techniques midwives registered for course care abortion 160-hour workshop counseling of pregnancy post-termination and pre- one-day workshop clarification values one-day Colombia is the only country with specific regulations on this issue. Resolution 4905 of 4905 Resolution issue. this on regulations specific with country only the is , South , the regulations strongly urge all physicians, nurses and social work work social and nurses physicians, all urge strongly regulations the ,

Africa , the Technical Regulations on Care for the Voluntary Interruption Interruption Voluntary the for Care on Regulations Technical the , , Brazil

and Canada have regulations on this issue. In In issue. this on regulations have Brazil , 115 IV. Comparative analysis of the regulations 116 IV. Comparative analysis of the regulations supported without judgement (Art. 2, Guidelines for Pre-Termination of Pregnancy Pregnancy of Pre-Termination for Guidelines 2, (Art. judgement without supported Africa South him the right to veto a woman’s decisions about the fetus she is carrying. argumentthefather’sthat legislationthegivesfetus lawsupport to a interest incase or as a juridical person under the Civil Code of Canada; and (ii) there is nothing in the Quebec to grant her appeal. The most important arguments were that (i) a fetus is not recognized continue the to pregnancy. woman The the case ordered went court to lower the Supreme A her. Court, stop which to decided injunction unanimously an filed he and abortion, anwanted she decided Shepregnant. months’ two was partner relationshiphis whena decisionto endapregnancy belongs exclusively to the woman. Inthis amancase, ended In Women, Technical Regulations on Care for the Voluntary Interruption of Pregnancy).continue a pregnancy even if she has grounds Thefor a legal abortion (6.2. Admission Counseling, of and Pregnant Protection (3. 2005). Care, health Technical Abortion Humane for Regulations reproductive and rights sexual menstruation, abortion, unsafe pregnancy, the about talking and repercussions; possible and partner her with relationship her about to;asking belongs she group social the of reactions the investigating self-esteem; encourage to seeks that attitude understanding an adopting support subsequent as offering necessary; reinforcing and the woman’s support importance; emotional respecting her immediate their emotional providing state; process; include this obligations in involved also are professionals services social and health Mental the woman may encounter,the problems and comfort. while prioritizing well-being her to solutions offering confidence, encouraging experiences, life and feelings her express e nepee a a efr t acut o clua cnieain a i te Technical the could in Regulations was that considerationon cultural Care for found for the accountVoluntary measure to Interruption effort of closest Pregnancy an in as The interpreted be abortion. against sanctions moral and social eliminate harmful customary practices, such as requiring a partner’s consent or addressing to specifically intended measures included regulations that any find not didreview The practices customary harmful iv. Eliminating of information. provision the on result, the measures in a this As section should be making. considered decision in conjunction autonomous with encourage the to measures intended specifically be may women In to it addition, is note important that in information provided tosome cases individual Circular H97/2000). Cape, of Health:Western Department Counselling,

Canada Colombian te urm Cut case Court Supreme the , simply establishes that the woman’s decision must be respected and and respected be must decision woman’s the that establishes simply regulations simply establish the obligation to respect the client’s decision to rmly ess Daigle versus Tremblay (1989) Colombia hwd ht the that showed , which state 74 73 of reference. terms own its of sets Tomás.Santo commission at The Hospital assistance staff or ofmedical the technical members the request are to who psychiatrists or – specialists disease infectious necessary as such professionals health when other – right the reserves commission The commission. of the members the names 1988 No.of 02007 2 of August Resolution Health Ministry of the woman or of the fetus. life the endanger that problems health of serious grounds the on abortions therapeutic authorize to is commission the of role The commission. multi-disciplinary a of creation of code penal The pregnancies unwanted manage to team amulti-disciplinary vi. Creating inclusion in educational programs within academia is optional, not mandatory. notetothatColombia,important inits is issue, the itaddress only thecountrythat does In addition to highlighting the lack of information about this 8). (Art. programs criterion postgraduate and undergraduate their within services in existing abortion providing regulations,of aspects legal and ethical technical, the cover to power the have of which the institutions regulations, higher enacted technical 2006, abortion education Only faculties sciences of health role The v. 49). page (see women 123)judging page against prohibitions and (see discrimination labor against prohibitions 66), page (see parties thirdof consent the requesting against prohibitions as such barriers, and actions practices as customary regarded eliminate be to may analysis this for studied measures the of many However, and reproductive rights and, generally, all actions that aim to increase self-care. methods of contraception, prevention of sexually transmitted infections, HIV/AIDS, sexual such as pre- and post-abortion counseling, family planning counseling, access to effective managementservices:abortionto complicationsabortionof other toaccessservices and access timely to restrictionsadditional constitute not should services followingthe that

The head of the Ministry of Health’s Maternal Infant Program, who coordinates the commission; the head of the the of head the commission; the coordinates who Program, Infant Maternal Health’s of Ministry the of head The abortion. to unrelated regulations or laws within but issue, this address may countries Other the head of the Obstetrics and Gynecology Unit at the Hospital Metropolitano Complex of the Social Security Security Social the of Complex Metropolitano ( Hospital Agency the at Unit Gynecology and Obstetrics the of head Tomás; Santo the Hospital at Unit Gynecology and Obstetrics the of Services Admission and Emergency of head the Santo Tomás; at Hospital Services Santo Tomás; Unit at the head of Hospital Obstetrics and Gynecology Obstetrics Colombia Caja de Seguro Social Seguro de Caja a a esr rltd o hs su. codn t Rslto 40 of 4905 Resolution to According issue. this to related measure a has Panama ); and a lawyer from the Ministry of Health’s Legal Consultancy Department. Department. Consultancy Legal Health’s of Ministry the from alawyer and ); (Art. 144) may be the only provision that requires the the requires that provision only the be may 144) (Art. 74 73 117 IV. Comparative analysis of the regulations 118 IV. Comparative analysis of the regulations Only Only complications reporting including systems, management Data i. iv. Data collection, monitoring oversight and systems 2005). Care, Technical Abortion Humane for Counseling. Regulations and Support (3. nurse and worker,psychologist social a includes team the care: related unwanted pregnancies. Its stated purpose is to provide support and humanized abortion- contrast, By or officer welfare 22). trained (Art. experience work social a with visitor health be shall person the Instead, doctor. a being from person this prohibits regulation The appeals. abortion to that joinconsiders the board member in situation The 76 75 6). (Art. services to abortion women’s real access and services of quality the monitor to order in complications abortion-related of reporting requires ( accordance with the specificdefined instruments bythe Public Health Monitoring System in performed be must abortion of monitoring health Public Welfare. Social of Ministry RIPS Salud, de Servicios ytm. hs en ta ti ifrain ut e oriae wt te iity of Ministry the with coordinated be must information this that means This systems. management data national in included be to abortion to relating information requires In to asuperior. reported simply is it Africa, South and in Norway while database, report to a sent is statistical data Spain, and In Colombia procedure. the about to providers requires explicitly information Colombia about complications. In Norway, procedure. the information recorded the is more specifically about information general includes data this Africa, South and Guyana Colombia, In information. collect to required is procedure the performs who person the countries, six these In criterion. to the Individual Health Services Delivery Registry ( Registry Delivery reported Services Health Individual be the to must procedures abortion all addition, In institutions. private and public Welfare’s Social system) monitoring (epidemiological infections and itm d Vglni e Sld úlc, SIVIGILA Pública, Salud en Vigilancia de Sistema

Colombia Equivalent to the Ministry of Health. of Ministry the to Equivalent may countries Some below. examined are regulations and laws abortion in described systems management Data have general laws or regulations on this topic that are outside the scope of this project. project. this of scope the outside are that topic this on regulations or laws general have Colombia Brazil , Resolution 4905 of 2006, which enacted the technical abortion regulations, 76 , Norway Guyana integrated health information system, and must be reported by all by reported be must and system, information health integrated requires a multi-disciplinary team to be set up, but not to manage manage to not but up, set be to team multi-disciplinary a requires ), in accordance with statistics requirements laid down by the the by down laid requirements statistics with accordance in ), is somewhat similar; the medical officer nominates a third nominates officer medical the similar; somewhat is , Mexico , Norway , South Africa South ). Finally, the resolution specifically specifically resolution the Finally, ). Registro Individual de Prestación de de Prestación de Individual Registro 75

and Spain

addressed this 78 77 ( in Files Clinical of NOM–168–SSA–1998 with created accordance be to files requires City Mexico in Pregnancy of Termination the to related In 9/1985, of 5July). Law Organic with accordance in performed pregnancy of terminations voluntary about information 2000 3, February (Art. purposes statistical for used clients been identify has individual it might after about destroyed that be information to way requires any resolution in the published addition, not In is individuals. it that ensure and information of The Order of 16 July 1986 also states that health authorities must maintain confidentiality used. procedure and procedure the for reason client, the about The region.» said outside data form collection procedure has been modified to includeand family, work the data socio-economic had who region their in residing women to provided services abortion about information region official each of authorities health the to available makes and information statistical nationwide with publication annual an creates analyzed, and tabulated compared, been has data collected the once Office, of General Health Ministry Public the «Annually, that the indicates Affairs of Consumer and Health Public website The 5). (Art. quarter every authorities local to province by oioig ytm ht olcs aa nationwide. data collects that system monitoring General de Salud Pública the information send in ( towhich, turn, must the Public Health Office General authority health the to reported be must pregnancy of allterminations that establishes In Security. Social Healthcare for System of type and town (contributory/subsidized/exceptions) group, affiliation age indicate must two first The complications. of summary a (3) and provided; was counseling contraception which in cases the of summary a and (2) diagnosis; by analysis divided summary an quarterly (1)a conduct includes: that shall report quarterly Entities a submit Promotion Health and Offices Health and District Departmental that states it systems, collection on data individual Based in provisions. information the above the to added law, by decriminalized as services, abortion safe of provision the on information regarding 2007, May 22 of 0031 Circular External

Spain Mexico iitro e aia y osm: www.msc.es/profesionales/saludPublica/prevPromocion/embarazo/home. Consumo: y Sanidad de Ministerio Exceptions refer to armed forces personnel, as well as some public sector employees. In effect, they are covered covered are they effect, In employees. sector public some as well as personnel, forces armed to refer Exceptions htm#datos system. health subsidized national the under claims file to entitled not are and plans health own their by , the , the General Guidelines on the Organization and Operation of Health Services Order Order of 16 June 1986 (Information and Statistics ( , of the Office of the Undersecretary, on statistics and epidemiological epidemiological and statistics on Undersecretary, the of Office the of , ) (Art. 1). Monitoring shall be carried out using an epidemiological 77 or lack of affiliation to the General General the to affiliation of lack or 78 This office provides information information provides office This Expediente Clínico Expediente Información Información y estadística Resolution of 4 of Resolution ), including the the ),including Dirección Dirección )) 11

IV. Comparative analysis of the regulations 9 120 IV. Comparative analysis of the regulations set of records. The report shall include specified data from the records, as well as details as well as shallrecords, includefrom the specified data report Therecords. of set perform abortions shall submit a to report authorized tofacility the every quarter,county each medical ofofficer basedend onthe thesecond at that states law the addition, In 25). any at (Art. time record the request who doctor was approached by the woman. The of Director-General Health may Services at 10least of An the years. extract record is sent to the and medical officer county to the for hospital the at kept up locked tobe documents and Finally,records lawrequires the is decision the board, the by members. by the signed and considered dated is which record, in the entered is case a When records. case separate keep The boards and the hospitals or institutions where pregnancy terminations are performed in nature. statistical more are which records, of set second a for basis a as used is records of set first This time. any at be made availableThey must of for them who Health, the may Director-General request sent to the county medical officialand to thedoctor who wasapproached by the woman. be must records these abortion; an for request each of procedure administrative the to Norway 19). (Art. clients abortion of a record provides clinical file The treatment. and procedure the of record and application, surgery for request the client, Prosecutor’s Public the of official an Aid Office toas byVictims System, well as the results ofadministered issued to diagnostic tests the rape of grounds the on pregnancy of form for a legal termination of pregnancy, medical reports, authorization for of for a services violence and injuries, referral termination and counter-referral form, informed consent form, discharge form, request for and record of surgery, social work investigation, record admission care, urgent for notes medical record, medical original documents: following 79 Directorate of the Health Services covering the following: the to quarterly reports individualsubmits aboutmedicalofficer county operations. The

The following information should be recorded: name of hospital/institution; case number; the date on which the which on date the number; case hospital/institution; of name recorded: be should information following The grounds for the pointminority of view if the decision was not unanimous. the and unanimous; was decision the whether rejection; for grounds the include should it Board, Appeals the by for approval and the reasons for the point of view of the if minority the decision was not unanimous. If it is rejected grounds the include should it Board, Appeals the by approved is it If minority. the of grounds the andunanimous was rejection the whether rejection, groundsforthe include should it Board, Primary the by rejected is application When an application is approved by the Primary Board, the record should include the grounds for approval. When an whether or not the operation was performed; and the reason why the operation was not performed if this is person whothe submitted case. the application; whether it was the tonecessary application; obtain the the forwarded consent who of thedoctor county the medical of officer; name the pregnancy; the of duration presumed induced; were andbirths, the number of children now living; the number of previous pregnancy terminations and the number that received hospital/board the application; the name and date of birth of the patient; civil status; the number of previous uses two types of records. The first is a detailed record that provides follow-up is follow-up record thatprovides adetailed first The of records. types two uses 79 n oesgt ad pi rqie iseto ad vrih. n tl, y otat the contrast, by Italy, In oversight. and inspection requires Spain and oversight, and monitoringrequiresColombia countries. the similaritiesamong few areHowever, there in topic this on provisions found research The services provide that of facilities systems oversight and Monitoring ii. 1995). Act, Termination of Pregnancy 14, Medical (Art. Act of this contravention of the of any provision in respect proceeding legal any for or law any under so do to authority having person any by or required court any by lawfully when or functions their discharging of purposes the for disclose, to refuse to entitled they are nor record; the to related matter or document information, law states that there is no provision to prevent any of these personnel from disclosing any The information. to the access lawful with anyone else by, and in, employed working or the medical practitioners, However,person owning or managing an approved authorized specified. institution or person practitioners, not medical all on is binding is that information provision further a such has law the of purpose The 14). (Art. data relevant other any and termination the for reasons treatment, address, name, the include shall authorized medical or practitioner managing person an approved institution. The record practitioner, medical the by administered was treatment the where facility the at kept In Circular H97/2000). Cape, of Western Health: Department Services, of Pregnancy of Management the on Termination Policy 1.8, (Art. file client’s in the manner usual the the anonymous copy of the Notification form(Annexure A), the recordsshould be kept in on Choice 7, for that except (Art. state regulations The 1996 and 2004). Termination and Amendment, Act confidential remain shall identity woman’s the that states law The the of name the omitting – woman of – which toHealth, will the Department maintain a record of this performed information. procedures abortion and for requests about a of termination pregnancy, the the in person charge of of the facility month shall send, by one mail, registered information Within facility. that in out carried pregnancy a of termination every of notified be shall who facility, health the of inform charge in and person information the the record to pregnancy a terminates who nurse or midwife Africa South of Termination concerning Act the of 1975).Pregnancy, Implementation the for Regulation 26, (Art. ( ( ( ( Guyana the number of rejections number the cases of approved number the forwarded and received of appeals number the above the on based received information , the law states that a record of every termination of pregnancy shall be be shall pregnancy of termination every of record a that states law the , also establishes the obligation of any medical practitioner, registered registered practitioner, medical any of obligation the establishes also Colombia , Guyana , Spain

and

Italy . 121 IV. Comparative analysis of the regulations 122 IV. Comparative analysis of the regulations the Act and its regulations and to advise the minister on securing its effective operation. the Act. The Minister of Health shall appoint an Advisory Board to monitor conduct under implementation ensure of additionalspecifically monitoringto measuresout(1995) sets B SupplementLegal – TerminationMedicalAct Pregnancy the ofof 61995). Article Act, TerminationPregnancy Medicalof15, (Art. procedures abortion any obstruct to power of the police force that is conducting an investigation. These provisions do not include the to comply with, any provision of the Act. The above shallapproved institution,be to ascertain withoutwhether there has prejudicebeen any contraventionto any of,orthe or so,failure doingpowers of suspected reasonably is or pregnancy,terminations of supervises or medicalpractitionerallreasonableaadministerswhere at maypremisesenteranytimes In Accredited on 1986). Decree Abortions, of Legal Performance the for Royal Reporting Mandatory and Centers 3, (Art. administrations health appropriate by oversight In provisions the of the with decree 7, (Art. comply Regulatory of Decree2006). to 4444 failure for sanctions issue to power the have authorities oversight Welfare, and the regions within their respective jurisdictions. In addition, monitoring and regulations, the authority to monitor health belongs to the head of the Ministry of Social In are in compliance with the provisions of the Act that regulate access to abortion services. an oversight system, empowers a health system official to visit facilities to verify that they although it does not state what the criteria are. Guyana, rather than subjecting facilities to oversight. Only Colombia clarifies that specific criteria for monitoring shall beestablished, system seems to be a form of political oversight. All three establish who is responsible for 81 8 c. b. a. namely: Act, of the purposes to achievethe be appropriate may that minister the to recommendations make time, to time from and, working are regulations its and Act the how assess shall board legal The organizations. religious, medical as and such organizations, non-governmental than from more chosen not of members consisting nine balanced, and broad-based be shall Board Advisory The 0

Colombia Guyana Spain to improve the standard of maternal health of maternal standard to improve the abortions of septic incidence the to reduce of pregnancies terminations of medical incidence the to reduce From the context, it is understood that this is an administrative authority for the health sector. health the for authority administrative an is this that understood is it context, the From denying for sanctions issues, Administrative on section the in found be can sanctions about information More services (see page 124). page (see services , the law simply requires centers and facilities to submit to inspection and and inspection to submit to facilities and centers requires simply law the , , thechief, medicalofficer , according to Resolution 4905 of 2006, which enacted the technical abortion 81 or anyorpublic officer authorized by him writingin 8 0 82 Decree of 4444 2006: «In no case shall conscientious objection, not invoking conscientious Only iv. Requirements ( higher authority, which will respond within 48 hours (VI Specific Provisions, Administrative or if the medical board has denied a woman’s request, she may appeal to the appropriate In regulations. in the reiterated is officer.The decisions of theboard are reached by asimple majority (Art. medical 8).county the by appointed doctor, a not Thisis who thirdperson a procedure includes board the cases, appeal In above. stipulated limit time the within application her withdrawn has woman the unless re-examination, for board another to case the submits woman, the with the consultation woman in who, decision, officer medical its the county the to made documents the has and forwards board it once automatic, reason, this is For action. process its halt appeal to whether the chooses words, other In rejection. the of board unless she withdraws the application within three days after she has been notified another by examined be will decision the that informed be must representative her or woman the board, the by rejected is application woman’s a (1978), when amendments In Guidelines. Institute Maternal Perinatal the in Peru, in and, procedure the of description detailed highly a has which Norway, in only exist services abortion deny that decisions for processes appeal Explicit denied are services when mechanisms or review Appeal iii. the Social Protection of Motherhood and Voluntary Interruption of Pregnancy, 1978). 16,Regulationson jurisdiction(Art. its relates to it as report theInterior presentsthe of regions are requested to submit supplementary information to the report. The present Department to parliament a report on the implementation of the law, provisions. includingThe law requiresprevention. that before The February of each year, the Ministry of Health shall Finally, regulations. its and Act of the impact the assessing for appropriate deems it as research encourage and data request may Board Advisory The

Peru Norway Prohibition Art. 13 and 14, Regulation for the Implementation of the Act concerning Termination of Pregnancy, 1975. Pregnancy, of Termination concerning Act the of Implementation the for 13 14, and Regulation Art. Colombia Italy , if the hospital authority does not process the request or exceeds the time limit,timethe exceeds or request theprocess not doesauthority hospitalthe if , , according to Act No. 50 concerning Termination of Pregnancy (1975), with Pregnancy of Termination concerning 50 No. Act to according , establishes a form of political oversight of the implementation of abortionimplementation ofthepolitical oversightofof form a establishes Requisitos administrativos

against prohibits discriminatory practices related to abortion in Regulatory Regulatory in abortion to related practices discriminatory prohibits

employment 82

or

social ) Perinatal Maternal Institute Guidelines, 2007).

discrimination

against

abortion

providers 123 IV. Comparative analysis of the regulations 124 IV. Comparative analysis of the regulations of the decree. Sanctions are those established in the Obligatory System for Quality Quality for System Obligatory the in Assurance established those are Sanctions decree. the of Colombia Colombia, Peru and Brazil, which hold institutions liable, although only public hospitals. inindividualliability, exceptis rulegeneral Brazil). The and (Colombia,Peru disciplinary ofliability, type whichadministrativemay be (Peru), civil (Brazil) eventuallyor criminal or Africa)orprison (Norway, Guyana and South Africa). Othercountries simply establish the what sanctions to impose (Colombia and Mexico), order fines (Norway, Guyana andSouth countriesprovisionslegalotherSomerefertoabout sanctions. impose topower the has authority which regulations its in clarifies country No law. the with comply to failures into investigations initiate may who specifies Colombia Only abortion. to access delay administrative thatimposition of barriers the confidentiality; sanctions Colombia of and violationssanction also Norway and GuyanaAfrica, South abortion. legal a performing sanctions for refusing to provide services. Only abortion. to access regulate that law of provisions the Norway specifically and countries, the all general, In services fordenying Sanctions v. abortion. of unsafe to cases responding when manner judgemental Along similar the lines, regulations in 5). facilities»(Art. health or professionals health woman, for for discrimination the pregnant a circumstance constitute the decree or objection having a termination performed voluntary of under the pregnancy terms of 84 83 to be sent to other authorities when the constitute facts a crime or disciplinary infraction a or security preventative measure in advance. It also requires notice of such proceedings oras a of by result takenhaving orany person, presented complaint by aofficial, report (of one’s own accord), at the request of an interested party, by information state held that a procedure leading by to the imposition a of may sanctions be initiated public sua sponte

up to six months; suspension or revocation of the legal status of individuals who provide health services; and and services; health provide who services. individuals health provide to of authorization of status revocation or suspension legal the of revocation or for suspension months; services health six to provide that up facilities the of management technical and/or administrative the in intervention issued; was resolution facility. or building the establishment, time the of closure the permanent or at temporary and license; or established registry of cancellation value or suspension maximum products; of seizure the to up wage minimum daily the times The sanctions established by these regulations include fines up to 200 times the monthly legal minimum wage; wage; minimum legal monthly the times 200 to up fines include regulations these by established sanctions The up fines to successive warnings; include by a regulations these to sum established equivalent 10,000 The sanctions hv dvlpd bod oml fr acin fr alr t cml with comply to failure for sanctions for formula broad a developed have , 83 uses a general formula to sanction failure to comply with any of the provisions and in Article 49 of Law 1049 of Law 100 of ofin and 1990Article 1993.Law and Brazil South Africa require to health in professionals act a non- Colombia sanctions any person who avoids , Mexico Brazil , xlcty pls out spells explicitly Guyana 84 The regulations regulations The , Peru

and 85 an approved institution or any other person with lawful access to an approved institution practitioner,medicalanywhere authorized employedbypractitioner, medical person or pregnantwomanshall liable be fine toaof $7,000 and imprisonment months;for six (iii) where any statement made by a pregnant woman is intentionally false (ii) or misleading, months; thesix for imprisonment and $20,000 of fine a to liable be shallinstitution the which is false, that person or, for an approved institution, the person owning or managing required by documentsthe or law records orthe maintainmaintains to refuses such institutionapproved a any recordfor but person anyit is incomplete or contains any statement In (5. institutionally and individually 2005). Care, liable Technical Abortion Humane for Ethics, Regulations Professional held be may staff their and hospitals public damage due to negligence on the part of the professionals who provide abortion services, regulations also state The that if the experiences. woman she physical, experiences or psychological that emotional harm mental or physical the for or woman the of death the for criminal civilgrounds and liableon held lawby allowed may be circumstances inthe contrast, By ( Final Provisions (VIII applies that liability legal the about prejudice without of Institute, Maternal the National Perinatal personnel general liability administrative in results provisions its with In 13). (Art. of pregnancy termination the for application an about making decision in information false for and secrecy professional of observance violating law, the with in (1978) Amendments Norway with (1975), Pregnancy of Termination concerning 50 No. Act of Operation City). in Mexico Termination to the related of Pregnancy and Services Health Organization the on Guidelines General City 22, Mexico (Art. applicable the instruments in legal out set sanctions in results guidelines the of provisions The of 2006). 4444 Decree Regulatory 2, (Art. services of abortion health facilities that impose administrative barriers that unnecessarily delay the provision or managers on sanctions of imposition the require specifically regulations The 7). (Art.

Guyana Peru currently there is a trend towards full compensation. full towards atrend is there currently although liability, for administrative is imposed indemnification economic cases, In most by facility. a health public employed employees state are they since Institute Maternal Perinatal the of members of actions the for liable be The state incurs administrative liability due to the actions of its employees and officials. In this case, the state may state the case, this In and officials. employees of its due to actions the liability administrative incurs state The Mexican Mexican , the Perinatal Maternal Institute Guidelines (2007) say that failure to comply comply to failure that say (2007) Guidelines Institute Maternal Perinatal the , , using the same formula, finesestablishes or imprisonment for failure to comply ,liability is broad and penalties include both fines and imprisonment: (i) when Brazil regulations also use the general formula that failure to comply with the the with comply to failure that formula general the use also regulations clearly states that physicians who refuse to provide abortion services services abortion to provide refuse who physicians that states clearly Disposiciones finales Disposiciones 85 for the health professional and and professional health the for )). 125 IV. Comparative analysis of the regulations 126 IV. Comparative analysis of the regulations In records. medical processing for rules general on achapter includes Act Consent Informed General the but abortion, about rules specific any have not does for should the be In included. abortion reality, administrative necessary procedure Spain in only information Mexico, relating to the By contrast, the information required. about detailed more much is Colombia although procedure, abortion the and pregnancy the to related is record medical the in recorded is that information Peru, and Colombia In Only records of medical vi. Management and Act Termination on 19962004). and Amendment, Choice 10.2, (Art. requirements not confidentiality does with who anyone comply for penalties out sets also It 10.c). (Art. years 10 exceeding not be guilty of an and offence liable on conviction to a fineor to for imprisonment a period shall pregnancy a of termination the for facility a to access obstructs or pregnancy a of Finally, the law in unless it was carried out in a negligent manner» 9). (Art. treatment oftreatment,pregnantconsentedsuchterminatethe womantotowherehas pregnancy a supervision the or of, out carrying the for liable be way any in shall him that«no medical practitioner orauthorized medical practitioner authorizedorperson by for three months (Art. 12, Medical Termination of Pregnancy Act, 1995). The law alsocomply to states with fails any provision or of refuses this Act shall or contravenes be liable who to a person fine of any $10,000 (iv) and andimprisonment year; one for imprisonment and $100,000 of fine a to liable be shallinstitution approved the managing or owning contravenestherules governing confidentiality of information person thator the person 86 other words, the first day of bleeding – and if the menstruation was normal. menstruation,womenshouldasked day be aboutthetheirfirst of menstruation last in – delayin a after pregnancy a suspect tobegin manywomenrecord. medicalBecause the in inclusion for clients from requested be must thatinformation the detail in regulate

Colombia It It must also include: name, identification: identity document, age, level, race, education, civil status, socio-economic of infertility. Family history: chronic hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, metabolic metabolic diabetes, disease, heart eclampsia, pre-eclampsia, hypertension, chronic history: Family infertility. of and treatment history and HIV/AIDS, infections transmitted sexually of of discharge, or vaginal current use, history dates and use method contraceptive periods, menstrual two last the of dates pattern, cycle menstrual menarche, of age history: Gynecological birth. of last date of births, number Births: pregnancies. molar pregnancies, ectopic abortions, pregnancies, between time of pregnancies, number pregnancies: history: Obstetric pregnancy. current the during and treatments complications Diseases, information. other or to radiation, toxins exposure substances, psychoactive use, alcohol use, tobacco given), (medications allergies traumas, information, nutritional , occupation, insurance origin affiliation, (urban, rural), address and telephone number. Personal , history: Colombia , the Technical Regulations on Care for the Voluntary Interruption of Pregnancy , Peru South AfricaSouth , Mexico

states that states anyone who the prevents termination lawful and Spain address the management of medical records. of the records. management medical address 86 87 ( ( ( the ( include to required are procedure 8): (Art. record the medical client’s the in for following responsible personnel medical The 20). (Art. dignity and honor to privacy, rights fundamental the under protected is information personal that and confidentiality absolute with managed be procedure and treatment of diagnostic (Art. 19). The guidelines results explicitly the add for record that the and application, medical records surgery as for must request the well client, the to administered as tests System, Victims to Aid the Office the of Prosecutor’s official on an Public by pregnancy issued insemination of artificial termination non-consensual or a rape of authorize grounds to form consent accessing informed for abortion: procedure administrative the to related information should additional they However, include rules. general the with accordance in kept are clients abortion in Termination the to Pregnancy of related Services Health of Operation and Organization the on Guidelines General The nausea, vomiting, fatigue, tenderness, change in appetite, breast frequent urination as and pelvic such pain. symptoms, other identify should it addition, irregular. In or include the first day of the last normal menstruation and whether menstruation is regular record be kept, In

Peru authorization by an official of the Public Prosecutor's Office if sexual violence or violence sexual if are a factor insemination artificial non-consensual Office Prosecutor's Public the of official an by authorization decriminalized 12 by law (after weeks) for abortions abnormalities and congenital on the duration of the pregnancy report (up to 12 pregnancy durationof the the on weeks) report procedure the for consent The medical record should at least include the first day of the last normal menstruation; regularity or irregularity of or irregularity day at should record the regularity include first of The least medical the menstruation; normal last and the identification of other symptoms: breast tenderness, nausea, vomiting, fatigue, change in appetite, appetite, in change fatigue, vomiting, nausea, ( Anamnesis Provisions, tenderness, Specific (VI pain breast pelvic and urination frequent symptoms: other of identification the and to relevant records and the surgical procedure; an cycle; of obstetric, the evaluation menstrual personal, ( Conditions Pre-existing (6.4.2. any about information and abortion the woman medications is the taking and currently how they used may during during the with medications interact procedure used medications any to allergies ( disorders, Anamnesis bleeding (6.4.4. abortion: status current and received treatment examinations, symptoms, familial of previous progress and symptoms, initiation examination: or the for signs reasons Other partner. the neurovegetative from support mood, and support tension, emotional condition: psycho-social of Evaluation cervical-vaginal. or urinary infections: of Symptoms edema. progressive migraines, Persistent ultrasound). and/or pregnancies, multiple (date size of of period, uterus duration pregnancy last probable other. disorders, Current tumors, pregnancy: tuberculosis, mental epilepsy, disorders, congenital infections, system, autoimmune history, , the Perinatal Maternal Institute Guidelines (2007) require that a complete medical 87 as does the Hospital Belén de Trujillo Protocol. The medical record should Condiciones preexistentes Condiciones Mexico Mexico City (2006) require that medical records for for records medical that require (2006) City )). Anamnesis )). Anamnesis )). Risk factors for for factors Risk )). 127 IV. Comparative analysis of the regulations 128 IV. Comparative analysis of the regulations Regulatory Decree 4444 of 2006 states that abortion services must be available to all to available be must services abortion that states 2006 of 4444 Decree Regulatory to provide quality abortion services free at the woman’s request (Art. 16 bis). In In sector. as such others, while different as such two countries, Some to models. according measures explicit have countries some However, services. abortion for funding of source the to some clarify sufficient not is it but information, provides indirect programs insurance of types different or from inclusion services The these costs. of service exclusion of issue the address not do regulations the general, In payment costs: Service i. Funding of services v. Circular H97/2000). Cape, of Western Health: Department Services, Pregnancy of Termination for Protocol 2, (Art. complete be should record medical the Africa South of purpose care health the necessary facilitating with understanding right patient’s a up-to-date considered is and This status. truthful health patient’s the a of for necessary information should record all medical the incorporate that stipulates basically law The records. medical for general rules the specifies (2002) Act Consent Informed General The record. medical the in Spain 88 contributory the to belong who women for that establishes system health Colombian Health Plan of both and the subsidized a contributory As the insurance programs. result, evacuation by aspiration Health to terminate a in for pregnancy» legal in abortion the Compulsory Security Social on Council National the of Subsequently, charge. without contracts) (or existing facilities with facilities private public by provided 1); be shall (Art. women system poor for health services the that in establishes and affiliation or pay to ability their of regardless women,

Mexico Minimum requirements: a) documentation relevant to the clinical statistical form; b) authorization for admittance; for admittance; form; b) authorization statistical to the clinical relevant a) documentation requirements: Minimum form; h) additional examinations reports; i) informed consent form; j) anesthesia report; k) report from the the therapeutic from n) plan; and report progress report. k) discharge p)care and clinical chart; signs nursing o) vital m) report; administered; nursing ; report anesthesia anatomy morbid j) l) form; registry; consent birth or informed room operating i) reports; examinations additional h) form; g) orders; e) referral/information medical f) d) and examination; progress; anamnesis physical report; c) emergency does not have any specific regulationson the information thatshould be included , the Mexico City Health inamended requires Act, public 2004, health facilities does not have specific regulations in this area, but it does indicate that that indicate does it but area, this in regulations specific have not does Colombia , establish cost structures that also involve the private private the involve also that structures cost establish , 88 Mexico (Art. 15). (Art. , establish that public sector services are free, free, are services sector public that establish , included the procedure «uterine «uterine procedure the included Agreement 350 350 Agreement Colombia , the 89 ( abortion accessing was it words, other in – inconsistent with purpose the purposes of the authorized parent legislation – discernible and created a any barrier to havewomen not did it because to indirectly prevent legal The abortions. court found the regulation to be ‘unauthorized’ they because violates are the medically law necessary the because regulation is designed hospital a in performed are that those to abortions funded publicly limiting that found Court to pay. Supreme required were The women and defunded were services abortion basic health were services paid for with public funds. As a result, necessary non-medically are services medically required. This case law deemed to is services because be important the that determines Agency the when hospital a in performed was procedure the that by filed case a it did so the under condition among health basic services, it Although abortion included reviewed Court Supreme Agency. Island Services by the Health and Community a issued regulation against Morgentaler Edward Prince the recently, More necessary. were services abortion whether about question amedical decide court’s The professionals. to authority the have not did medical body political a that reasoning the on by based was decision determined be should decisions such that and required’ ‘medically are services abortion whether decide to bodies political for statute the with inconsistent was it that ruled court The insured. be not could services abortion result, a as insured; be not could required’ ‘medically considered not were that services that held that abortion was not ‘medically Columbia required’. British A of previous regulation Council indicated in that Lieutenant–Governor the by issued regulation a against Association Liberties Civil Columbia British the by filed case a on ruled Columbia British In fees. to scale sliding subject may be paraclinical examinations and Medications death. and illness of risk the given discriminate, to used be they may neither sliding scale fees may nor co-payments become a barrier to access to nor services; that clarify general specifically regulations the the this, to Added to payment. from exempt are according rules, which, programs care preventative maternal-infant within integrated be may services abortion that possible is it Colombia, in abortion regarding changes legal the given However, amount system. the the to on contributes person depends affiliated the make that must client the that payment another the of case, beneficiary this the In is person. but plan the to directly contribute not does service the insurance program

Canada case someone who contributes to the system. the to contributes who someone Women who are not classified as poor pay into the health care system to some extent or are beneficiaries of of beneficiaries are or extent some to system care health the into pay poor as classified not are who Women Civil Liberties Association versus British Columbia British versus Association Liberties Civil , case law has defined some rules regarding the cost of abortion services. In services. abortion of cost the regarding rules some defined has law case , 89 Morgentaler versus Prince Edward Island Edward Prince versus Morgentaler services may services be subject to a if co-payment the woman who requires (1988) , 1995 , the Supreme Court of Court Supreme the , ). 12

IV. Comparative analysis of the regulations 9 130 IV. Comparative analysis of the regulations Brazil This may be the most regulated criterion. Of the countries reviewed, only services abortion foraccessing Requirements i. vi. Administrative issues public. to the provided are that to all services it sectors; applied are system poorest this in Classifications hospitals. public of network the via care the health identify and population free of provision the or the subsidies through system health the in inclusion their prioritizes classify to order in well-being socio-economic of factors different analyzes that survey a is This populations. different SISBEN, mechanism, a contain Security services. in abortion However, for specifically populations different of situation socio-economic No countries had provisions regarding or specific instruments mechanisms to identify the populations of different situation socio-economic the identify to Instruments ii. Africa South Bolivia code. aspecific assigned is services abortion are aspiration procedures financed by the UnifiedHealth and System foradmission legal 1998), manual vacuum Women and Adolescents, against Violence from Sexual Resulting in Finally, 93 92 91 9 requirements: unique afew well as as countries this broad range of information, it is topossible some identify commonalities among the Most refer requirements to administrative procedures to Within access services. abortion 0

The 1998 regulation required women to sign a document stating that she had been raped and attesting to the the to attesting and raped been had she that stating document a sign to women required regulation 1998 The – Saúde da Ministério truthfulness of the statement. It also required a police report. apolice required also It statement. the of truthfulness cases. afew in To project. the of scope the to due is abortion that affect laws general more to was able team only include limitation the research to information, access This facilitate topics. other on regulations or laws specific or general in SUS). by reimbursement for (Included 13 of 2001 48 August No. –Ordinance Health The research did not find specific provisions in abortion regulations. In some countries, this topic may be included may be included topic this countries, some In regulations. in abortion provisions specific not find did research The Sistema de Identificación de Beneficiarios. de Identificación de Sistema 93 , do not include in for requirements services accessing abortion their regulations. Panama Brazil Colombia do not have any provisions relating to service costs. relatingto service have not any do provisions (Technical Regulations for the Prevention and Treatment of Injuries Injuries of Treatment and Prevention the for Regulations (Technical , uro Rico Puerto Portaria nº 48 de 13 de Agosto de 2001 de Agosto de 13 de 48 nº Portaria , the laws regulating the General System for Healthcare Social Social Healthcare for System General the regulating laws the , , Peru , 92 Italy o dniy h scoeooi stain of situation socio-economic the identify to 9 0 , Guyana (Inclusão para reembolso pelo SUS). Ministry of of Ministry SUS). pelo reembolso para (Inclusão , Norway , Spain Puerto Puerto Rico , Brazil

and and 91

e. d. b. abortion services within that facility. The guidelines specify a procedure beginning with with beginning a procedure specify within that facility. guidelines The services abortion accessing for requirements establish also (2007) Guidelines Institute Maternal Perinatal 119). However, (Art. the representative legal her of or woman pregnant the of consent within the penal code. The law requires abortions to be performed by a physician with the Peru a. c. The most unusual requirements include the following: the include requirements unusual most The ------include: requirements common most The requirements. establishes barely Africa South contrast, In regulations. of the body ( duration of pregnancy related to age, gestational for requirements are accessing services determined by the ( grounds those with associated services abortion accessing for requirements some law same In countries that have decriminalized abortion, and where grounds for abortion are are abortion for grounds where and abortion, decriminalizedhave that countries In All countries that establish grounds for abortion in criminal law also establish in the the in establish criminalinlawalso abortion for grounds establish that countries All Norway has the most detailed procedure, which constitutes the greater part of the the of part greater the constitutes which procedure, detailed most the has Norway is among the countries that define grounds for abortion and related requirements and related requirements for abortion the that grounds is among countries define and insurers or facilities from imposing new requirements. requirements. new imposing facilities from or insurers prohibit and them reiterate literally regulations The ruling. Court Constitutional In effective. becomes order Italy malformation. of fetal in cases abortions for malformations to identify systems Spain violence.) sexual ( authority. administrative non-medical a by Authorization ( request woman’s the at initiated procedure administrative An physicians.) or three two one, by certification pregnancy, durationof the the on malformations. fetal and woman Colombia Spain life;woman’s the to is risk the if one, of and malformations, fetal in specializing Opinion of a physician or a medical board. ( board.) the on professional anon-medical includes that board; disciplinary to the health or life ( of the or malformations. woman, fetal ( Review filed. of cases by a be medical board to verify if the must case fulfills thegrounds for risks report police Colombia a rape, of cases In Colombia Italy requires a waiting period of seven days for the woman beforeto the reflect Peru requires a medical report from an approved institution with specialized specialized with institution approved an from report medical a requires , in cases of risk to the mother’s life or physical or psychological health; health; psychological or physical or life mother’s the to risk of cases in , ). and , medical certification is required for risk to the life or health of the the of health or life the to risk for required is certification medical , , Mexico , the requirements to access legal abortion services are stated in a in stated are services abortion legal access to requirements the , Bolivia Norway , Norway Panama . Guyana , after 12 weeks and there is an appeal mechanism, mechanism, appeal an is there and weeks 12 after , , South Africa South and requires astatement.) requires Italy Bolivia , South Mexico ). , Guyana

Africa , the opinion of two physicians Panama and

and Italy Guyana Panama Mexico , ). Mexico Peru i css of cases in , , depending depending , , by a multi- , Norway , Spain ,

131 IV. Comparative analysis of the regulations 132 IV. Comparative analysis of the regulations 94 health grave of reasons for abortions for that establishes Abortion Therapeutic on Commission Multidisciplinary National the of 1989 (Art. April of 1 consent Resolution woman’s effect, the In 144). with center health state a must in physician abortion a the by cases, performed be both In abortion. the authorizes and risks health grave the determines Health of Ministry the by appointed commission multi-disciplinary a risk, at fetus the of or mother the of life the put conditions health grave When pregnancy. of months two first the within performed is abortion the that and authority appropriate the to reported is crime the rape of cases in that requires it code; penal the in services Panama complicated. less slightly are steps the but procedure, board. medical a from procedure the for authorization the to up woman the to information of provision the 95

1. After receiving the physician’s report on the medical status of the pregnant woman, the procedure is initiated initiated is procedure the woman, pregnant the of status medical the on report physician’s the receiving 1.After about woman pregnant the informs physician attending The 1. steps: following the includes procedure The perform the procedure, which shall be scheduled as soon as possible. 8. The time period from the date of the the of date the from period time The 8. possible. as soon as scheduled be shall which procedure, the perform to of physician a chief designates the immediately informs chief the and request, the record, supporting medical grounds are the 7.there If in conclusions. their writing in noted be must which basis legal request, the the on of report a thereof lack issues – or if – re-examined woman case the the or expanded considers be may record specialization, medical appropriate the an necessary with professional(s) another of advice the request who may – physician the Board; professionals medical three of Medical consisting – a Board Medical creates The 6. board. and the to it present shall request case the the evaluated receives chief The 5. sufficient. is fingerprint undocumented, her and/or illiterate is woman must the and if number; record Document medical the Identity of National and part signature a the be include moment, this from shall, appropriate, as representative, legal her or woman pregnant the by submitted 3. form consent the and request Unit. The 4. Form or abortion. Consent therapeutic a 2) for Informed the (Appendix Services submits so, do to unable is Gynecology-Obstetrics she if or representative, legal Obstetrics her or of woman pregnant chief The the to it forwards who physician, the 1) to attending (Appendix Care Abortion Therapeutic legal for her Request or the woman submits so, do pregnant to unable The is 2. she if health. representative, mental and physical or life her to risk the and tests diagnostic the three gynecologist-obstetricians, one of whom is the attending physician. The Medical Board may request the the request may ( Board Board (Medical case the of Medical knowledge with The professional(s) another of physician. advice attending the is whom of one gynecologist-obstetricians, of three consist shall Board Medical The Procedures). (Administrative procedure the perform to physician a designates are there If 4. record. medical the in the writing prepares the physician patient for the grounds 5. for attending request, the in The supporting abortion. unit chief noted be must which request, the of thereof lack or basis legal the on report a issues – considers re-examined woman the or medical expanded specialization, be may record three appropriate medical the of an necessary if – with consisting case the – professional(s) Board another of Medical advice The the 3. of request member may colleagues. – a her be or professionals shall his to case the case the evaluated present initially and who board physician the the Board; Medical a create and the of request chief the the to abortion, an for request the Unit. 2. for The Gynecological-Obstetric chief Unit reasons of should begin immediately the processing her Gynecological-Obstetric include must which request, woman’s the by Requirements). Administrative Provisions, Specific (VI hours than no 48 greater a period within shall respond which authority, higher appropriate the to appeal may woman pregnant the request, her denied has board medical the if or limit time the exceeds or request the process not does chief the has If 10. procedure administration. the facility’s Once the 9. inform shall days. chief the calendar 10performed, been exceed not must abortion therapeutic the of date the to request is also one of the countries that establishes requirements to access abortion abortion access to requirements establishes that countries the of one also is 94 h Hsia Bln e rjlo rtcl salse a similar a establishes Protocol Trujillo de Belén Hospital The 95 Junta médica Junta )). 96 v. iv. iii. ii. i. the abortion to be authorized by the Public Prosecutor’s Office, including: ofrape or non-consensual artificial inseminationas wellas a number of requirements for administrative procedure an to establishes access Codelegal Proceduresabortion Penalservices when The 148).the pregnancy (Art. is requiredthe alsoresult is consent woman’s pregnantthefetus;the ofsurvival the todanger a posetheythat extent thedamageto that the fetus has genetic or congenital malformations that may result in malformation,physical the law orrequires themental opinion of two specialists who agreefetal thatdanger. Forit is a possible pose not does delay the when and possible when physician’s report physicianattendingfromthephysicianthatfirst the shouldstatessecond and consider a report medical a requires law the health, to danger grave a represents pregnancy the 12weeks. after abortion to accessrequirements forthe establishes City Mexico In commission decides that the termination is justified, it issues the authorization (Art. 10). decision 6).(Art. In finalno circumstances may and the authorization study be omitted 9). its(Art. When the for Abortion Therapeutic on Commission Multidisciplinary National timelythemanner toa indocuments the send andrequirements thethatmetare verify health and obstetrics unit of othereach hospital in each area or region of will analyze the requests there, opinion written the professionals who request shall collaborate with shall its 4).members (Art. The chief of the commission gynecology the necessary, When ( ( ( required: followingare to the authorize, authority the has commission the which risk, at fetus the or life mother the of the put that conditions

Mexico elements that allow the Public Prosecutor’s Office to deduce that the pregnancy is pregnancy the that deduce to Office Prosecutor’s Public the allow that elements health privatefacility or any by public pregnancy of the confirmation insemination artificial non-consensual or of rape crime the for report a police existence of the pregnancy, as well as its termination (Art. 131 bis) (Art. termination its well as as pregnancy, of the existence in Mexico City shall, at the woman’s an perform request, examination that proves the City Mexico for code penal new the 151and of 150 Articles in established as insemination artificial or rape of result the and/or other informationlaboratory tests that confirm 3) the diagnosis(Art. based is request the which on diagnoses or diagnosis the substantiating and specifying report medical a consent and request woman’sthe written the the pregnant woman’s for request a termination of pregnancy. Public health facilities pregnant is she that statement victim’s the Under the new laws, abortion must be performed at the woman’s request up to 12 weeks of pregnancy. pregnancy. of 12 to up weeks request woman’s the at performed be must abortion laws, new the Under i adto t te eio iy ea cd, h Pnl rcdrs oe for Code Procedures Penal the code, penal City Mexico the to addition in , 96 When 133 IV. Comparative analysis of the regulations 134 IV. Comparative analysis of the regulations are authorized to issue an opinion. For the presumption of physical or mental defects of are authorized ofdefects or an to mental opinion. physical For the issue presumption specialty health ofwith the that corresponding the the lawphysicians woman, indicates When the abortion is to avoid serious danger to the life or to the physical or psychological are they required. when reports medical maywho issue (1986) specifies Abortions Legal The Royal Decree on Accredited Centers and Mandatory Reporting for the Performance of 417 (Art. bis). cases) in certain omitted be may requirement (this report medical a issue must performed be will procedure the be would fetus where the one the than other If facility a rape. defects, of psychological or physical result serious with born the is pregnancy It the if situations. report emergency police in a requires omitted be may consent, woman’s the and requirement, This a procedure. the requires performs who law one the than the other danger,physician a from in report medical is health when psychological therefore, or met; physical are or life grounds woman’s the specific the to related requirements certain that in omitted be of cases malformation) with the mayof consent the pregnant woman. However, it criterion also states ‘approved’ (the facility or center health public or private by that a it physician is and or performed in a under an physician’s approved supervision In consent form and a medical report on duration of pregnancy are required (Art. 4 bis). probability criteria» (Art. 5). In cases before 12 weeks, the woman’s analyticalwrittentechniques. request,diagnosisThe shallwrittendetermine presumptiononbased beriskandof includingultrasoundsimilarprocedures,or biochemical analysis, cytogeneticanalysisand tests, diagnostic conjunction with examinations in specific on based preferably be shall includeincasesoffetal anomaly: «The medical reportgeneticon congenitalor anomalies theTermination Pregnancyof Mexico in(2006) City specifywhat themedical reportmust OrganizationGeneralGuidelinestheTherelatedHealthOperationServices onto and of of rape, kidnapping or incest, of the lawrape, or kidnapping incest, a requires criminal to proceeding be initiated. The In services. abortion seek who women for burdens disproportionate create easily may on procedures complex based extremely for be requirements These 6). and (Art. criteria risk probability of presumption determine shall diagnosis the that specific reiterates it abnormalities, addition, In infections). from chromosomal resulting malformations diagnose diagnose to techniques analytic to equipment cytogenetic diseases, metabolic diagnose similar to equipment or biochemical (ultrasound malformations, diagnose case to of equipment type each for required equipment diagnostic the have required To to procedures. abortion perform obtain such authorization, the facility must that from different is opinions issue to authorization This government. regional the by authorized be must report medical the for opinion an issues that facility the fetus, the Spain Bolivia , the penal code establishes some medical requirements for abortion, including including for abortion, requirements medical some establishes , code the penal , requirements vary by situation. To terminate a pregnancy that is the result result the is that pregnancy a terminate To situation. by vary requirements , her physician of choice. If the reasons for terminating the pregnancy are related to the torelated are pregnancy terminatingthe for reasons the If choice. ofphysician her sociala health public facilitymedical or office, a to go woman may the days, 90 first the within performed be willterminationpregnancy theof if result, a pregnancy.As the of duration the on depend andregulations technical the by established areRequirements In example. for in Peru, as countries leaving while other access, open the the possibility that for insurers or health facilities all requirements may impose additional establish requirements, in regulations provisions cases, the most in from examined: differs regulation this point, this On ( ( health or insurers prohibit and to services: barriers new imposing from providers decision court the reiterate literally regulations The the woman and a police report when the pregnancy is the result of sex crimes. stated earlier, medical certification is required when there is danger to the life or health As C-3552006).of (ConstitutionalofCase incest» fertilizedor implantation Court, aegg of insemination or artificial non-consensual or act sexualabusive and non-consensual a or constitutingaccesscarnal act reportedduly a ofresult the is pregnancythe (iii) when or physician; a by certified as unviablelife fetal makes fetus the ofmalformation grave a constitutes a danger to the life or health of the woman as certified by a physician;pregnancy is (ii) performed in when the following cases: (i) when the continuance of the pregnancy abortion has not been committed when, with the woman’s consent, the termination of thedecriminalized abortion in certain specificthat rulingcircumstances. court The the decision by states: established are requirements,«Therelated crimeand grounds, of the above; In woman’s the with physician 1972). Code, Penal a 266, (Art. judicial authorization appropriate by and consent performed be must abortions cases, all In purpose. same the fulfill will that measure other any be not must there the that of states but health woman, or life the save to procedures administrative full establish not does law

Colombia Italy, barriers that unnecessarily delay the provision of abortion services, such as as of 2006). 4444 Decree Regulatory 2, such (Art. woman pregnant the services, abortion on burden excessive an mayrepresent that procedures other and ofwaiting periods or provision the lists waiting boards, by authorization or review physicians, various by delay authorization unnecessarily administrative that imposing from barriers prohibited are professionals health and Managers of Pregnancy). ( de IVE procedimientos Procedures Abortion Legal on Information (6.3.2 abortion for precondition a be never may woman the by method contraceptive a of Acceptance the grounds for access to abortion services are not regulated by criminal law.criminal by regulated not are services abortion to access for grounds the , the penal code does not set out grounds for abortion as in the countriesthe in as abortion for grounds out set not does code penal the , ) Technical Regulations on Care for the Voluntary Interruption Información sobre sobre Información 135 IV. Comparative analysis of the regulations 136 IV. Comparative analysis of the regulations termination is within one of the grounds for authorization (only for risk to the life or or life the to risk for (only authorization for grounds the of one within is termination the effect, in that, consider shall treatment the for responsible practitioner medical the duration, 12 and eight weeks’ between is pregnancy the If grounds. the and pregnancy Guyana 1978). of Pregnancy, Interruption Voluntary and Motherhood of Protection 7,toSocial 5 the for Regulation (Art. omitted be may physician provincial the inform to procedure danger, in the is woman the oflife the When performed. be to abortion the for order in certification the of informed be must be of hospital the director The will specialists. with may consult physician The performed. termination the where hospital the at be gynecologist-obstetrician a must by grounds these certified life, woman’s the to risk grave a constitute or health woman, mental the of or physical the endanger that abnormalities or malformations fetal of reasons for is abortion the and duration, days’ 90 than more of is pregnancy the When authorized facility for the termination of pregnancy. pregnancy and is asked to reflect forseven days; after that time the woman may go to an the duration of the and request the documents that consultation the after certificate a facility for the termination of pregnancy. If there is no urgency, authorizedthe an woman to must go be given may woman the certificate, this situation.With the of urgency the documenting certificate a with woman the provide must they proceed, totermination the for reasons urgentdiscovers above facilities described or people the of any If birth. the maintaining after and before woman whilethe help father,to offered be biological confidentiality, must assistance and the and woman the of dignity the for respect of be reviewed with the woman and the father – if the woman agrees – within a framework and possibilities for overcoming the reasons the woman wishes to end the pregnancy must woman’s economic, social or familial conditions, possible solutions to the existing problems Medical Termination of Pregnancy Act, 1995). Act, TerminationMedical of Pregnancy 10, (Art. omitted may be opinions medical these health, mental or physical to her injury permanent grave prevent to or woman, the the of life the when save to addition, necessary is In termination 7). (Art. practitioners medical authorized three by approved is the permanent injury to the physical or mental health of weeks, the woman or her 16 unborn child and After 6). (Art. grounds the termination may all only be if performed on there is risk to based the woman’s life but or to prevent judgement grave a make must practitioners medical authorized two duration, 12 16 weeks’ and between is pregnancy the If mind). unsound of is woman the if or malformation fetal woman, the of health also establishes a system where the requirements depend on the duration of duration the on depend requirements the where system a establishes also 97 serious or disabilities mental severe with women or minors for request; woman’s the at is initiated the procedure 12 In cases, both for after terminations and the second weeks. speaking, it is divided into one two parts, for terminations of before pregnancy 12 weeks above, stated As

services: abortion for provisions following the includes Norway in procedure administrative The ( ( ( ( ( ( ( ( ( ( ( ( ( board. The woman shall be informed immediately of this, as well as of the further progress of5). the case (Art. a to pregnancy of termination for application the forward shall doctor the 12weeks, than more of duration a If,superintendentbasisofhasthefindthatontheirexaminations, medical hadthepregnancy the hisordeputy 5). (Art. possible as soon as performed is this that operation, an of event the in and, with dealt is application the that ensuring for responsible is deputy his or superintendent medical The 5). (Art. woman) the of treatment preliminary and investigations laboratory of (results practice medical [ shorter a for operation the postpone to necessary be may It 4). (Art. performed be to is operation the where institution approved or unit other to hospital the reference, a written with together forward application, the immediately to duty his is it elapsed, has pregnancy of week 12th the before operation the perform to possible is it that finds doctor the If pregnancy. the of duration the of make assessment an shall doctor The 1). (Art. herself woman the by of care taken been has this unless application the of formulation written a the for responsible be to shall woman, the retarded mentally with is consultation in or doctor, The guardian. the by illness submitted be submitted mental also may be severe application the degree, from shall considerable suffering application is the woman the board], If a practitioner. require medical not a to does [which pregnancy of week 12th the Before 1978). amendments, with 1975, Pregnancy, of Termination concerning 50 No. Act 10, (Art. Act this of provisions the to regard without an risk to impending the constitutes woman's where the life In pregnancy or cases it health, may be terminated 8). (Art. board another by may examined be decision the is rejected application the If special verbally. In may communicated be decision the decision. cases, the for reasons the of informed be shall behalf, her on acting writing. person in the or substantiated woman, be The shall pregnancy of termination refuse or authorize to board the by decision The 7). (Art. reached, doctors two of be consisting aboard by shall woman, the with pregnancy consultation after of termination regarding decision The performed. be may operation the where institution other or unit hospital a to woman the refer immediately shall board the elapsed, has pregnancy of show that it If fully investigations prepared. all, is after before the the to possible, 12thoperation perform week been has it as soon as decided be shall case the board, a to directly submitted been has application the When aboard. to made, been have application, the forward that immediately observations the and by woman the procedure, forward put reasons the concerning the report written the with together about information given been has woman the shall, when doctor the elapsed, has pregnancy of week 12th the before operation the approved perform to or impossible is it hospital If another to woman the 6). (Art. refer operation the perform to shall possible be may it where institution officer medical county The explanation. written a with together officer medical county the to immediately medical forwarded be serious shall are case the contrary, there the to that grounds reason the for operation the perform to refuses deputy his or superintendent is If out. in to the event the that be where operation the carried medical unit or to institution other the hospital reference, the with written together the application, forward the about procedure, has information given been the woman after shall, the 12th before the doctor of week pregnancy, the operation to perform it If is possible 5). (Art. aboard to or a doctor to may submitted be has elapsed 12ththe of pregnancy week after termination for pregnancy application The 2). (Art. care satisfactory with child the provide to ability woman's the of taken be shall Account 2). (Art. contrary the to reasons medical serious no are there That Norway a te ot eald diitaie procedure. administrative detailed most the has sic ] period out of consideration for responsible responsible for consideration of out period ] 97

Broadly Broadly 137 IV. Comparative analysis of the regulations 138 IV. Comparative analysis of the regulations If the physician denies her request, it may be reviewed by an Appeals Board. After 12 After Board. Appeals an by reviewed be may it request, her denies physician the If must who specialty), authorize the termination a and refer the woman to a facility where it specify may be performed. not does (it physician a to made be should request weeks, the 12 Before representative. her by submitted be may request the illness, mental ( ( ( ( ( ( ( she may provide additional information if she so wishes (Art. 13). (Art. wishes so she if information additional provide may she 3) appeal; the examine shall board as to which a preference to express has expired, days of three limit time the until 2) access, has she of rejection; notification received has she time the from days three within it has withdrawn she unless Board Appeals an for presented be will application 1)the that: state also shall notification the Board, Primary the by rejection a of event the In minority. the of view of point the for were reasons the what the decision, the which is the It decision based. shall also be was the whether and decision stated unanimous, in understand of cases dissent, on to problem the to woman approach the and the legislation the enable of content the to to refer also shall order decision the for in grounds necessary is it that extent the To the for factors decision. determining the of account brief a include shall reasons the rejected, is application the When receive written notification. If the application is approved, the reasons shall be stated with reference to the the to reference with stated be shallgrounds in § 2 […and] reasons the notification shall the also state the date and approved,place of admission to hospital [ is application the If notification. written receive […and]verbally givenmay be notification womantheshallthe subsequently cases specialinBoard, Primary the in rejected is application the If same. thefor reasons the and acting decision the of notification behalf, person herwritten on the or woman, the give immediately shall Board) Appeals the or Board Primary (the board The 12). (Art. substantiated simultaneously be shall and writing in be shall decision The majority. a simple by is in Board A reached must the be Appeals unanimous. decision termination a to Board authorize pregnancy Primary the by decision A prepared. been has case the after possible as soon as reached be shall decision The 11). (Art. contrary the to reasons express to particular are there unless board, the to or opportunity doctor the to the views given his/her be shall guardian the or authority parental exercising person the retarded, 16is woman the under If of or age is years mentally a decision. for reaching as possible a foundation complete as be should there that consideration the against decision a for quick consideration the weigh evaluation its in shall board the be approved, will application the that indicates will information available the If application have to be rejected. the that indicates information available the when postponed be rule a as shall case the the on light case, more shed to order in necessary is woman the by statement a that opinion the of is board the If person. competent other or advisor legal a by accompanied board the attend to right the has She verbally. or writing in either board the to known views her make to opportunity the given be shall woman The life woman's situation. the concerning obtained be may report a decision, the to relevant is it If possible. as elucidated is as well case the that for ensuring is responsible board The as possible. as quickly with be dealt shall case The the to 10). (Art. reference, performed be may written operation the where a (institution) with unit hospital together application, the forward immediately shall board the elapsed, has 12ththe of before pregnancy week operation the to all, perform after it is that possible, show investigations If 9). (Art. agency competent another to or office, guidance afamily to board, the on not doctor a to case the of preparation the entrust may woman, the with consultation in board, The doctors. for above described rules same the with accordance in case the prepare itself shall board the institution, other unit or from a hospital has forwarded been a or board, if the application approached If the woman has directly 8). (Art. board the to report, written the the with together forward application, immediately shall doctor The situation. life her and woman the of health of status the including has made, this the observations unless concerning information include shall also pregnancy, report The of by done herself. the woman been termination for in reasons her prepare, on to report obligation an written a under woman, is the doctor with The consultation 7). (Art. herself woman the by of care taken been has this unless with of the the woman for guardian, and/or the formulation shall application, be the written responsible mentally is or illness mental severe retarded from to a suffering degree, considerable is the may application woman be the by submitted If the board. guardian. The a doctor, to in or consultation doctor a to woman the by submitted be shall elapsed has pregnancy of 12th the week after pregnancy of termination for application An sic ] (Art. 13).] (Art. 98 to define them but to identify the authority that may do so,as in InstituteGuidelines MaternalHospitaltheTrujilloandBelénde Perinatal in Protocolthe in as done specifically, them define to is first The abortion. for of the terms. However, the research found two different methods of defining the grounds part, the laws that originally establish the grounds for abortion do not criminalexplain law.the in At most theydefined meaning literally abortion transcribefor the criminalgrounds lawthe provisionsanalyze and, fornot the most do countries most of regulations The forabortion grounds clarifying and Defining ii. of pregnancy. stage that at termination permitting grounds of the or midwife, tonurse or a be of registered the opinion that the termination is within one physician another with consulting after physician, general pregnancy. a requires of it weeks, 20 stage After that at termination a permitting grounds the of one within falls termination the that woman, the with consulting after opinion, the of be to physician weeks, 20 and 13 between terminations for Finally, request. administrative this than other requirements no are there However, regulations. abortion the and law abortion the in both included is procedure approve are or rejections the reject automatically sent request; to an appeals board. This board a to made be must request the weeks,

Appointment of boards: one member shall be the medical superintendent of the unit where the operation is to be be to isoperation the where unitsuperintendent the medical of the shallbe member oneboards: ofAppointment not be older than 70. Members receive remuneration for 23their and(Art. services 24). 22). Members are nominated for a four-year period. The county medical officer may release a member; members may shall be a woman. Members of the Appeals Board shall not have considered the application in the Primary Board (Art. welfareasa orhealthofficervisitor and have experienceofsocialwork. At onemember ofleast theBoardAppeals to join the board which shall consider the appeal. The person in question, who shall not be a doctor, shall be trained shall be appointed with similar qualifications 21). (Art. The county medical officer shall nominate the member who is havea [ appointed person shall not belong to of the the staff unit where the operation is to must Thebedoctor performed. the medical superintendent. The second member of the board shall be appointed by the county medical officer. The superintendent’smedicalthe unitperformed, bytheandtochosen permanent attached deputy, anotheror doctor ( ( ( Regulation for the Implementation of the Act concerning Termination of Pregnancy, 1975). Pregnancy, of Termination concerning Act the of Implementation the for Regulation 17,woman (Art. The available officer. information fresh is medical there unless county anew considered the case the of have to right the request have not the does at consideration new for case the up take to Board Primary new a for access is there Board, Appeals the by rejected is application woman's the that event the In be should wish 16). (Art. this resident is woman the where board, county the in aboard by specific a by with dealt is a shall be to As examined rule, the appeal the appeal contrary. reasons are there no particular provided with the complied that wish a expressed has woman the If 15). (Art. performed be will operation the where unit another hospital to transferred is woman the that ensure shall officer has medical county board, the the of approval, the member against a voted as performed, be to is operation the where unit the of superintendent medical the where but Board, Appeals the by approved is pregnancy of termination for application the where cases In sic ]knowledge of social medicine. At leastone member of the board should be a woman. members Deputy 98 consisting of two physicians, who may who physicians, two of consisting ot Africa South Panama Peru ipy eurs a requires simply ; the second is not secondisthe ; . 13

IV. Comparative analysis of the regulations 9 140 IV. Comparative analysis of the regulations 99 2). (Art. of pregnancy termination the for arequest merit that to health Therapeutic Abortion in Abortion Therapeutic on Commission Multidisciplinary National the of 1989 April of 1 Resolution contrast, By services. abortion legal seeking women of rights the guarantee to difficult with it making regulations thereby content, of distinct proliferation the in result may regulation level national a the of how of lack example clear a is services, abortion to access determining tools different performed. be to termination the a for for exist to death of necessary risk not is it that states Protocol Trujillo de grounds. Belén health of Hospital the interpretation Similarly, restricted a constitute may it exhaustive, is list this abortion. an request may she which for societies, medical Peruvian nine from compiled health, mental or physical woman’s a endanger that conditions of list a provide guidelines the case, second the In health. mental and physical including as interpreted be must law criminal the in health of concept the that (ii) harm and health; woman’s permanent the to and grave avoiding (b) and woman; pregnant the of life the saving (a) met: be to need both not do that abortion for grounds two are there that (i) code: penal the of provisions the to relating rules two define guidelines the case, first the In pregnancy. of termination a request may woman a which in situations specific of list a providing analysis, this on based and, meaning its of understanding an gain to law the the in grounds for the established abortion penal code. It does so in two ways: analyzing of definitions the clarify to attempt (2007) Guidelines Institute Maternal Perinatal The 1 00

Advanced Advanced kidney failure; women on dialysis; with lupus severe erythematosus kidney damage; chronic hypertension and with evidence of damage to the target organs and/or with associated morbidities (severe hypertension); class class hypertension); (severe morbidities associated with and/or organs target to the of damage evidence with and of pregnancy; a Medical Board shall issue a report documenting that they endanger the life and health of the the of health and life the ( endanger Abortion Legal they for that (Indications woman pregnant documenting report a issue shall Board Medical a pregnancy; of mole hydatidiform the termination may justify partial processes clinical that other notes and the protocol addition, In hemorrhaging. severe treatment; with all to resistant gravidarum hyperemesis severe treatment; to respond not does that epilepsy hemorrhagic chemotherapy; or radiotherapy surgery, failure; requires that organs reproductive the in neoplasia respiratory severe tuberculosis; malign organs; of to damage the target evidence with pulmonary hypertension renal failure; chronic chronic severe disorders; multi-drug-resistant advanced failure; heart that system. nervous central the in neoplasias malign cancers and damage; organ with mellitus diabetes advanced woman; gynecological other cancer; ovarian cervical severe a posing risk to hemorrhaging with mole the pregnant invasive hydatidiform partial or chemotherapy; chorioamnionitis; radiotherapy require treatment; pregnancy; to ectopic resistant unruptured syndrome cent; per hyperstimulation 85 than blood and less 50mm of under oxygen saturation of pressure oxygen partial by risk demonstrated the to failure due respiratory treatment suicide; or psychiatric to homicide respond of not does that psychosis post-partum of history demonstrated chemotherapy; or radiotherapy surgery, requires that neoplasia gastro-intestinal malign varices; esophageal with thrombosis vein portal-splenic C, hepatitis B, hepatitis by caused failure liver chronic disease; heart ischemic and hypertension failure and due heart (valvular non-valvular), to or disease congestive heart acquired congenital III–IV According to the protocol, abortion is justified in the following cases: congenital or acquired heart disease with with disease heart acquired or congenital cases: following the in justified is abortion protocol, the to According Panama 99 However, although the law does not explicitly state that that state explicitly not does law the although However, states that the full commission shall define grave risks gravethat shall the fulldefine commission risks states Indicaciones para la Interrupción Legal del Embarazo del Legal Interrupción la para Indicaciones 1 00 The situation in Peru, with with Peru, in situation The )). 102 101 Welfare, Social of Ministry the by submitted request the to response law. In by allowed as pregnancy of terminations voluntary in use for misoprostol ingredient active the of Surveillance Food and Drug for Institute National the of ( the requested Welfare ( Methods Abortion (Medical registry health the on not were gemeprost and mifepristone that add regulations The uses. indicated the among not was gynecology-obstetrics but country, the in available was misoprostol issued were regulations the time the at that indicate (2006) Pregnancy In that state specifically (2005) Care available are in oxytocin and misoprostol Abortion Humane for Regulations Technical The in Peru. Prostokos name commercial the under SS/DIGEMID/DERD/DR 1988 No. addition, In pregnancy.» of trimester third the in childbirth induce to cervix the prepare the to nor hemorrhage uterine post-partum treat to of used be not may Commission Pharmacological the b. and abortion, incomplete and by missed for used may a. be Institute: Maternal Perinatal authorized tablets, 200µg misoprostol Drugs and «For Supplies Medications, concluded: ( of report Office General The the preparation. above, described cervical reasons for the use and atony uterine to due hemorrhage for uterine treatment abortion, of for treatment missed of misoprostol use the regarding Institute Maternal Perinatal the from request a to response in issued was Access to and Use of Medications In abortion. legal not abortion, incomplete and abortion to missed only reference in medications, authorizing for responsible body the from report technical a rather but medications, ofavailability the mention that regulations the not is it Peru in that clarify to important also is It mentioned. drug only the was Misoprostol available ( abortion. for third the of in and, availability availability the their indicate about ( two regulations in reference: some the made countries in three Only medications. information little found research The drugs of abortion Availability iii. iecó Gnrl e eiaets Isms Drogas y Insumos Medicamentos, de General Dirección Sala Especializada de Medicamentos y Productos Biológicos Productos y Medicamentos de Especializada Sala Peru Colombia This (INVIMA). Surveillance Food and Drug for Institute National the of Committee Review authorization. this revalidate to attempting is it country; the into , resolution Technical Report 23–2005 23–2005 TechnicalReport te ehia Rgltos n ae o te outr Itruto of Interruption Voluntary the for Care on Regulations Technical the , is currently not Specialized Section on Medications and Biological Products Products Biological and Medications on Section Specialized in effect Métodos médicos de ILE de médicos Métodos of 20 February 2003, authorized the use of misoprostol misoprostol of use the authorized 2003, February 20 of ( Dirección Dirección Ejecutiva de Accesos y Uso de Medicamentos because ( Informe Técnico Informe 23–2005 the Brazil laboratory Colombia 101 (4. Medical Procedures). (4. Medical that )). In 2007, the Ministry of Social Social of Ministry the 2007, In )). requested ), to state that they were not not were they that state to ), ) finds that the acquisition of acquisition the that finds ) 102 ) ) of the Review Committee Committee Review the of to expand the indication indication the expand to of the Executive Office of Office Executive ofthe the registration Peru Executive Resolution Resolution Executive and and has Brazil not brought ), to ), it ) 141 IV. Comparative analysis of the regulations 142 IV. Comparative analysis of the regulations by a comprehensive appeals process. appeals by acomprehensive Moreover, in Norway, this system of specificgrounds for refusal ofservices is complemented 6). evaluation this for (Art. basis may The ministry more issue detailed guidelines about the medical criteria that form the the woman, to an a be risk operation present assumed must toserious her life or health. of status the to due that, nature a such of are that conditions means grounds’ medical ‘serious that adds It grounds. medical deputy serious on his operation the or deny to power has superintendent who medical the concerning only is it Act that states the It operates. of services of Implementation the for Regulation refusal for grounds latter the how (1975)detail in TerminationPregnancy of establishes the time, same the At 6). (Art. procedure the to performing contrary grounds medical serious are there that consider deputy his or superintendent medical the (2)if 2); and (Art. viable is fetus (1978), two establishes grounds: (1) amendments (1975),after with 18 Pregnancy weeks if of Termination there concerning are 50 reasons to No. consider that Act the denied. be Only of services fordenial iv. Grounds is it of pregnancy. terminations legal for in Colombia words, misoprostol to use possible other In year. same the of 3905 Resolution and 4444 Decree of provisions the with accordance in 2006, of C-355 Case in established circumstances specific the in oxytocic an as used be may ingredient active this that ruled Committee Review the of Products Biological and Medications on Section Specialized the misoprostol, of profile pharmacological the of understanding community’s medical the considering after and 1 issues with – exclusively not although – concerned primarily are regulations countries, those in that emphasize to important is it However, South Italy. and in Norway case Guyana, the Africa, is Such exists. regulation of type some criminalized, not is abortion the detail, of in level the included in also countries thereby but creating great the differences number among countries. As a in general by rule, in only countries where not issued widely, vary regulations analysis the comparative chapter, this in shown As Some conclusions 0 3

In this situation, the case shall be forwarded immediately to the county medical officer together with a written written a with together officer medical county the to immediately forwarded be shall case the situation, this In it may be possible to perform the operation (Art. 6). (Art. operation the perform to possible be may it where institution approved or hospital another to woman the refer shall officer medical county The explanation. Norway explicitly establishes in its regulations the grounds on which services may services which on grounds the regulations its in establishes explicitly 1 0 3 medical confidentiality in order to address these topics effectively in the model. in the effectively topics these address to order in confidentiality medical (in general, and for minors and for women with disabilities), and objection conscientious services, individual of ofanalysis was and An conducted provisions for in-depth other informed issues. consent refusal to for sanctions provided access, for information requirements care, counseling, post-abortion women, to related provisions include issues regulations these and these of chapter. Some next the in attention, described model proposed the for more examples provide much received have issues other contrast, By others. among systems, oversight and monitoring collection, data and standards, biosecurity professionals, health of training and education public, services, abortion for general the to information of dissemination care services, of privacy the of services, youth-friendly models including comprehensive sufficiently, systems), referral counter-referral (including addressed and networks not service appropriate are principles, guiding issues of establishment some panorama, this Within issue appropriate regulations on women’s access to safe therapeutic abortion. but rather the United Nations Human Rights Committee that ordered the state in 2005 to inof cases fetal malformation incompatible with life. In Peru, it was not adomestic court Brazil,the Supreme hasCourt played adefinitive role in access safeto and legal abortion In choose. towomen’sright of extent the andfunding relatingdecisionsto other made havecriminalization courts theCanada,constitutions. their respectiveIncontrary to was absolute that found and abortion banninglaws reviewed constitutional courts Canada, took the lead in guaranteeing women’s access to safe and legal abortion. In Colombia and interest in the issue of access to safe abortion. The Regionallyresearch and worldwide, it is important tofound note that the judiciaryseveral is gradually taking cases an where judges services. abortion to legal access have improved greatly regulations these extent, which Caribbean, allow abortion the at and the woman’s America liberal request until Latin 12 most in weeks the researched of pregnancy; countries to has a the significant of City regulations Mexico abortion abortion. of aspects all on regulations detailed has Colombia rule. this to exceptions the are Mexico and Colombia complications. abortion are abortion quite limited. However, both Peru and to Bolivia have access regulations extensive on on regulations level national the Peru, of words, and Bolivia Panama, effects In the other complications. reduce to In attempt rather but complications. access, guarantee abortion not do on regulations the concentrate or limited are regulations circumstances, is a in crime except certain abortion where countries in most By contrast, that countries the Of tests). care. for protocols has South Africa only group, to first this standards, belong biosecurity methods, abortion example (for care of protocols to relating issues include not do and objection) conscientious consent, relatedspecifically toaccess (for example administrative forinformed procedures access, 143 IV. Comparative analysis of the regulations 144 IV. Comparative analysis of the regulations recommendations from international organizations and highlights the provisions provisions the highlights and perspective. arights to promoting conducive most are that organizations document in this analyzed international consideration from into takes model recommendations The importance. utmost the of is chapter next the in For many reasons, incorporating these different issues into the proposed model discussed procedures. these to complete woman the on burden the with authorization, obtaining for procedures administrative difficult and long to violence sexual of cases in report police a of requirement the from ranging – countries all almost in occurring – services abortion safe to most barriers the frequent as identified were access for Requirements performed. are abortions where facilities for demands infrastructure excessive or performed, is procedure the when and These included waitingmandatory the periods between authorization for the procedure to– that the barriers found access. with clearly regulations research measures constitute minority the in were these although – cases few a In abortion. safe to access women’s improving and barriers reducing towards moving is regulations in trend the general, In services. abortion legal and safe to access to relating processes all standardize to effort an in conditions to rights guarantee to and disparate culturalpolitical, legal within and provision contexts social varying service attempt guidelines whose Organization, Health World the such as institutions, international of recommendations the following of importance the management, pain tests, (laboratory of management and complications, so care on) the comparative analysis clearly demonstrates of protocols to related areas all in Finally, V. Recommendations for developing regulations that guarantee access to abortion services

The aim is to eliminate or reduce barriers to access. access. to barriers reduce or eliminate to is aim The regulatory frameworks, in accordance with the context and opportunities in each country. Each category includes recommendations on measures that should be incorporated within ( ( ( goals: followingthree the to advance developed was proposal This chapter. previous of the sections relevant the referencing footnote a has model the the in in included reviewed category each regulations analysis, the on based are recommendations these Since services. for developing regulatory frameworks that guarantee women’s timely access to abortion to provide a ofthat more catalog as comprehensive can components these a serve guide seek chapter this in recommendations model the therefore incorporate; should ideally this for they that components the all basis include not do reviewed regulations However, the important model. an provide therefore and framework rights a within services abortion legal to access timely guarantee to exceptions, few a only with intended, are countries different by adopted measures health the chapter, previous the in shown As subject. the on experts and/or bodies by international issued recommendations as well as regulations health national existing of review in-depth an on based regulations, abortion developing for recommendations and proposal model a creating of prospect One of the most important motivations for undertaking this comparative analysis was the V. services to minimize risks to health and encourage comprehensive, high quality legal abortion care of levels different at access to barriers eliminate or reduce to measures establish to services of abortion in all health aspects reproductive and to improve sexual and rights reproductive and sexual of exercise the to favorable conditions encourage to Recommendations for developing regulations that guarantee access to abortion services The model begins by looking looking by begins model The

V. Recommendations for developing regulations that 147 guarantee access to abortion services V. Recommendations for developing regulations that 148 guarantee access to abortion services and regulations inhibits the provision of services as providers lack clarity about their their about clarity lack and responsibilities clients are unaware providers of their rights and as what they from should expect services of provision the inhibits regulations and guidelines such of absence the that clear also is it said, That care. adequate provide to effort an in regulations interpret broadly more to providers and institutions health for needed flexibility the prevent can regulations detailed addition, In clients. or providers access to specificservices bycreating additional bureaucratic requirements forhealth care promote than rather hinder often can regulation Excessive impact. negative potential a is it regulations, abortion important to of bear in role mind positive that the the creation of emphasized health regulations has and guidelines publication may have this While support. social appropriate with post-partum and todecide continue the provision of pregnancy, integrated care for childbirth pregnancy, who women those finally, for and services, related to referral and counseling adoption of promotion abortion), surgical care for outpatient abortion, incomplete and for abortion, unsafe strategies harm reduction (medical law by allowed cases in pregnancy of termination available: be should needs health reproductive woman’s a to respond best that options of range full the pregnancies, unwanted of management the In to protection. relation dual including methods, contraceptive to access and of promotion and education, of sexuality quality areas of implementation action: there are important two implement pregnancies. to unwanted and future prevent pregnancies to unplanned measures or unwanted facing women for and reproductive health care policies that seek to provide the necessary services These recommendations should form part of a comprehensive package of sexual barriers. these addressing for recommendations and keycomponents identifying to abortion turns then and accessing services when face may women barriers of types different the at and autonomy.and and to prepare health professionals to provide quality care that women’s respects dignity training in order to ofand ensure interpretation proper implementation the regulations for opportunities adequate provide governments and institutions health that essential is it this, Toachieve women. treat systems health way the shifting in play they role the allies of base of strong within the such and the importance regulations, who medical community understand a create to helps involvement Such regulations. health effective The involvement of is offrom health a part the professionals creating fundamental start services. abortion-related of context the within particularly rights, women’s of exercise favorablethe to not only remove barriers to can care, but can regulations actively promote access health and well-designed that believes IPPF/WHR system. care health their

In the area of prevention, prevention, of area the In create create conditions lack of integrated models of care, including the provision of counseling and support support and counseling of provision the including care, of models integrated of lack definition appropriate tothe related are they Likewise, of counter-referralsystems. and referral of operation and lack the as well as tertiary), and care health secondary, all (primary, at levels and national) and state, or departmental municipal, or (local levels all geographic at networks service of lack tothe related also are barriers of types These stigmatized less be mayprocedure theprofessionals health whereofand greatest number barrierposea toaccess as into departments, states or municipalities divisionoutsideits theand urban,largest or rural cities.locationis thewhetherlocated, population is the where considerations as address such must analysis any and level this at Multiple arise barriers of services organization the to related Barriers issues. of rights; data monitoring collection, and funding; and oversight systems; administrative exercise and care of quality services; of organization categories: five into divided been to the that factors eliminateare necessary them. For ease of havebarriers these analysis, have barriers Because it that many allsources, is regulations address different important security. and timeliness of guarantee the with and rights reproductive and sexual for protection full of framework a within domain. this in government the of actions the by in part monitoring services, to these access and encourage actively demand population general the that extent the to abortion of acceptance the requires with – most humane environment that can be on provided by health professionals. so the in and and conditions paytechnical best the under to quality, highest the of ability services language, age, origin, race/ethnicity, of their place of level, regardless component) education – basic women a all for as care coverage appropriate to benefits and insurance a health (including the into system addresses women of entry that effective the process ensuring from issues comprehensive of range a encompasses therefore Access woman’s decision. a respecting and care providing be should who professionals health from or community timely a in and family, from friends, partners to services resistance location, of geographic because manner accessing to abortion, the for paying with difficulties from range These care. to barriers of types many face pregnancies their end to decide who Women Barriers i. , in other words, in the urban areas of the most important or largest cities. abortionservices mayconcentratedbe areasinwith the

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V. Recommendations for developing regulations that 14 guarantee access to abortion services 9 V. Recommendations for developing regulations that 150 guarantee access to abortion services abortions and unwanted pregnancies unwanted and abortions unsafe of impact health and social the about awareness raise to system legal the and media the system, educational the by action of lack the example, for public health arena to the address issue the of and unsafe unwanted abortion pregnancy; outside sectors among efforts systematic and coordinated of lack support is in category finaland thisOne consideration the procedure. during and after provided information of quality the risk at put may it facilities, health to referrals and information provide to trained appropriately not are staff their and pharmacists If legal or abortion services, the ‘informal’ involvement of other such actors, as pharmacies. that serve an role important in providing women with information about where to access women’s access to services. These include, for example, the lack of social to support networks obstacles as act may that also addressed to be may need considerations other several implemented, are above mentioned barriers the reduce to measures Finally,when even ( ( ( ( ( services: organization of to the fundamental are that elements various define Barriers may be created within this category by the failure of the regulations to adequately adolescents. of needs the specific for addressing important are which particularly for clients, services barriers related to quality of care and protection of human rights. Barriers arise when when arise Barriers rights. human of protection and common care of most quality to the related of barriers one is it, giving difficulty have reasons various for who women of issue The others. among integrity, to right bodily the and to information, in violations of women’s including rights, but not limited to the right to health, the right health manifest frequently linked;quality within are related tofundamentally barriers service services rights guaranteeing and care – of quality quality Ensuring of rights. aspect of exercise substantive the more a to related components includes parameters, category or this standards traditional to addition in However, issue. this on impact an have all measures and broad, is practically quality regulatory The very concept of service Barriers provision of services for other areas directly related to abortion services, such as as such services, abortion HIV/AIDS and violence to gender-based related directly areas other for services of provision care and management post-procedure hours facility/clinic operating methods medical and of surgical provision appropriate necessary) not is it when care specialized stipulating the types of professional(s) who are authorized to perform these procedures (avoiding

of rights of exercise carethe and quality to related nomd consent informed , which includes establishing consent for minors or or minors for consent establishing includes which , . the the 1 between relations area, power unequal this the in down measures break to implement help to must facilities information health for difficult very is it Although barrier. additional an toallowed constitute is a when receiving keyservices of and part not therefore the language must be process, and counseling during to her of provided all information the A woman’s understanding does not therespect woman’s decision. created when the information provided is not sufficient, is not trustworthy, is not areclear which or individuallevel, the informationon to barriers at look to important also is It theyneedan abortion they can request one within the legal framework of their country. if that ensure and rights their of awarenesswomen’s increase to order in addressed be nor providers have accurate information about abortion laws. This barrier is critical: it must evenaboutservices theywhen are available, andinaddition,neither often, women very know barriernotinformation:relatedprimaryto dothe responsiblefor often women is of aware work) public community and thecampaigns communications through(including make services abortion to actions collective and systematic of lack the Moreover, cultural and stigma. social associated any from women protecting for essential is privacy absolute since access, to of lack the abortion, as such service stigmatized highly any with as Finally, responsibilities. ethical professional their within physicians for obligations highest the of one is confidentiality for addition, respect In conditions. riskier under performed services abortion from complications potential to exposed often are they result, a as and providers, untrained from services Violations of causeconfidentiality women todelay out seeking services offear or to seek Similarly, care. delay who or towomen is category not a provide so that coverregulated be it deny who services does for those which must this in barriers of source significant Another manipulated. been has provided been has that information the or information necessary the all with preceded been not has decision woman’s the when her, or of required is party third a of consent unnecessary the when consent, full her without woman a on performed is procedure a 1 0 0 5 4

In general, poor quality of care in the formal health system becomes a barrier to access as women share their their share women as access to barrier a becomes system health formal the in care of quality poor general, In information has been used to persuade the public that includerisks abortion breast cancer orrates. high mortality informational misinformation; ‘scientific’ inexample,have forresulted women informationto some provide to thatpurport that campaigns aware be to important is it countries, other and States United the in experiences Given system. health formal the in providers from services requesting than rather providers unqualified or untrained out seek to likely more are women other of with other women poor in treatment experiences As their a community. experiences, upon these hearing result, rvc fr brinrltd services abortion-related for privacy 1 0 4 1 0 confidentiality 5 is essential to service provision. provision. toservice essential is osiniu objection conscientious

can create barriers ,

V. Recommendations for developing regulations that 151 guarantee access to abortion services V. Recommendations for developing regulations that 152 guarantee access to abortion services – with even graver consequences – result in women not accessing health services or or services health accessing not women in result – consequences can graver and even with professionals – health of recommendations result the to easily ‘listen’ can to warmth failing human women of in lack A services. abortion care request quality who provide women staff) to medical the just (not professionals health which be may process entire the of aspect critical Finally,most the and women guarantee that of care. provision the for conditions optimal measures professionals health biosecurity with accordance in appropriately care procedures technical abortion out carry tofailure or for procedures, simple for unnecessary are requirements that infrastructure instituting in example, belong for also facilities category: of this accreditation and preparation the from resulting Barriers woman’s delayed. are the life health or endanger that conditions for tests diagnostic other or malformations fetal diagnose to examinations cases, other In of type certain or test a examination can create requiring sometimes new – barriers including economic ones – for women. example, For possible. care of level complex least the at services integrated establish to seek that guidelines delivery service clear of lack abortion. an to have – to science of order name in the in requirements – excessive subjected are they cases some In under term. the care of receive not do sense broadest the in women well-being and health preserving for conditions evidence-based optimal that means standardized, of often lack procedures the technical standards, quality of area the In where they do not have the power to negotiate their sexual needs or contraception. negotiation skills needed by women facing an violence. unwantedbased pregnancy who are in a relationship women and men in society by addressing, for example, issues related to gender- 106 and obstetric (particularly associations medical When care. abortion comprehensive systematically in role active an including health from a women’s perspective, rights and sexual takereproductive addressing to to schools universities medical of and of faculties area) failure this sciences into the health entry belated to (or failure related the and adequately often subjects are these address problems care of quality These women’s rights. undermine can within intoand an these habitual solidify institution practices often individual providers enough. early them accessing not Deborah 110. and Maine, Maine D (1994) (Columbia t s lo motn t ty n udrtn te eiin aig and making decision the understand and try to important also is It Too far University), to walk: maternal for 106 example, troyia attds n peuie hl by held prejudices and attitudes Stereotypical mortality has in analyzed context. delays Social Science and Medicine and Science Social leading the human warmth with with warmth human the This is often due to the the to due often is This to maternal death. . 38(8), Thaddeus, pp.1091– S 1 with compliance facilities’ health impedes and problem a of magnitude the obscures difficulties. many causes manner timely a available in information to make of systems factual absence the therefore and sector health the within Data and collection health are statistics a part of fundamental decision making monitoring oversight and collection, systems data to related Barriers contraception. emergency and of methods contraceptive use the including in general, behaviors sexual healthy promote to and pregnancies unplanned or unwanted future avoid or reduce to counseling post-abortion appropriate of lack the is training to related barrier Another service. of integrated type this limits teams for the client with full for respect her the Often decisions. lack of support inter-disciplinary health emotional particular, in and, management abortion techniques, management These gaps in education and training also other affect of aspects health care, such as pain training place. takes such that ensure must institutions must but and services ofin health charge those addition, In are involvedcare. inhealth providing only, who doctors to professionals other all and counselors workers, social be limited nurses, midwives, to extend cannot training This perspective. values and clarification empowerment rights, gender, a with training including services, abortion professionals allfor training health These problems are also linked to provision. to service obstacles in greater result can it rights, these of exercise the favor not do professionals health other and associations) gynecological 0 7

Oversight functions may have different names in different countries, but generally refer to the power of health health of power the to refer generally but countries, different in names different have may functions Oversight and timely information systems. information timely and should also be Organization). Health it used to (Pan American disseminate population. the of conditions health specific about information and of necessary relevant collection and reliable timely ongoing, the systematic, provisions.» other establishes and that Security ensure Social for Healthcare System to of General the 1122aspects Law some Colombian monitoring modifies from of «which 2007 adapted to are definitions subject These country). each bodies in systems other health all governing regulations and the with comply society they civil involving and services, and care health monitoring and providing and insuring for financing, responsible bodies the institutions) and guiding assisting health orienting, preventing, of (warning, evaluation and monitoring to related actions and (activities inspection to to punish those that actions from depart the law, whether and by or involved is action are These functions omission. related closely authority its under individual or entity any which in administrative–scientific) technical, economic, financial, (legal, situation or a irregular to critical correct to by sanctions order also vary (which context) authorities

Analysis and interpretation of data should be the basis of decision making and and making decision of basis the be should data of interpretation and Analysis

Lastly, monitoring also refers to epidemiological activities, in which case it is is it case which in activities, epidemiological to refers also monitoring Lastly, the the lack of initial training or inadequate refresher on the medical and psychosocial aspects of safe aspects psychosocial and medical on the

All these components depend on depend sound All components these 1 0 7 Lack of data data of Lack

V. Recommendations for developing regulations that 153 guarantee access to abortion services V. Recommendations for developing regulations that 154 guarantee access to abortion services evcs wih rqety xed hi cpct t pay. to capacity their exceed frequently which services, establishing regulations private clear using to resort often women of facilities, public in provision service for obligations absence the seek to who due women pregnancies; by their mentioned terminate barriers to first the of one often is services for Paying barriers Economic abarrier. also is denied been has that abortion an for mechanisms appeal of lack the addition, comply. In not do that facilities on sanctions corresponding and request abortion an to response in provision service for limits time or specific periods time establish to systems of absence the in manifests commonly barrier often oversight of enormous Lack services. these an providing be should that is providers or facilities for oversight repercussion of type of any without implemented, absence or followed not the simply are regulations many problems, because these to addition In scarce. also is topics related other and claims objection conscientious or services of analyses cost-benefit on Information abortions. unsafe of prevalence the on that on are other of aspects services, critical abortion for decision making and, above all, they obstacles the complexity the as on pregnancy), unwanted to the rise giving encounter, conditions the or (such services abortion request who women of experiences the records. medical the in of contained information ofquality the revisions including ofproviders, evaluations the involve not do they when and clients, of opinion and perspective the account into take not do evaluations care of quality and monitoring when created are Similarly,problems services. abortion in providing all, above timeliness complications) and, detecting example (for standards care of quality regulations, and laws 1 oversight governmental under fall services. and not pricing of segmentation to leading systems, do entities private public to while only applied facilities, be to continue costs to related measures addition, In services. of abortion covercosts the not do plans insurance health private and public many addition, In services. of free receive sectors must which population the identify to tools government of lack the by exacerbated further are supportive. not are parents when especially entails, that difficulties plan or insurance, obtain must parental approval in order towith all receive services, the health parents’ their on dependent often are they because who, adolescents for critical 0 8

Although the information included in medical records is confidential, there should be mechanisms in place to to place in mechanisms be should there confidential, is records medical in included information the Although analyze the quality of the information recorded and of the care provided. care the of and recorded information the of quality the analyze 1 0 8 Problems also stem from the paucity of research focusing on on focusing research of paucity the from stem also Problems

This situation is particularly particularly is situation This

Economic barriers barriers Economic to craft regulations that protect sexual and reproductive rights and guarantee timely timely guarantee and rights reproductive and sexual protect that regulations craft to order in that clear is it chapters, previous in presented analysis the by demonstrated As ii. Recommendations services. of denial abortion the for force a powerful may exert which discrimination, social or employment prevent to abortions perform who professionals Barriers of this type also arise out of legal ambiguities or the lack of protection for health abortions. perform who professionals on medical requirements excessive and denials service against appeal to appropriate mechanisms of lack define requests, service to to respond to facilities for limits failure time maximum the from stemming barriers includes also category This their petitions, which in some places is tonecessary authorize an abortion. hear to refuses even or women, on requirementsadditional imposes commonly system known to be highly effective in inducing abortion early in pregnancy. Similarly, the judicial well as measures that restrict the availability of drugs as (suchabortion, as anmisoprostol), seeking iswhich woman are the wellwhich under grounds the to addition in requests abortion on limits gestationaladministrative) imposing(often measures includes also It for example in attempts to interpret the extent of health or economic hardship exceptions. This category includes the (often restricted) definitions of specific grounds for anabortion, facilities (as administrative procedures) or of institutions outside the health sector. health of practices the in manifest often they because category separate a intodivided of these barriers may be related to the organization or quality of services, they have been institutionrequirementaas – toobtain authorization fortheprocedure. Although many a as system (legal) medicalhighlyprofessionalaspecializedof or professional judicialanexample offorhead the – the of involvementone than moreparticipation of the tocircumstances, certain the in abortion prerequisiteto from gamut the run barriers. measures enormous create that measures administrative of array an to subjected disproportionately often are services abortion request who Women barriers Administrative abortion. to legal access to expand for efforts successful essential is that change of process a facilitates awareness increased This abortion. and pregnancy about decisions their and lives women’s of reality the to sensitized are increasing for makers that and providers and decision ensuring their rights, mechanism about women’s awareness important an is services affordable to access Guaranteeing These These

V. Recommendations for developing regulations that 155 guarantee access to abortion services V. Recommendations for developing regulations that 156 guarantee access to abortion services 3. 3. 2. 1. are: test in the steps basic The principle. or right fundamental each on effect its togauge proportional to is measure a used whether is and principles and rights between conflicts resolve to a in context used wider be also can test The equality. to right the affects measure a not or whether without access test. the proportionality using by to enhanced be can barriers process eliminateThis women. on to burdens disproportionate helps creating and professionals health to certainty provides that framework regulatory comprehensive a in culminating eventually process in regulations can be a gradual measures these incorporating In this drafting respect, countries. many different for of resource list a be exhaustive to intended an is includes it as model recommendations this ‘ideal’ that clarify to important is it Furthermore, solution. aprovisional provide facilitiescan by health created guidelines regulations, national of absence the in that note to important is However, it providers. and women for confusion enormous cause can and another one contradict often which country. each in the sector health overseeing level ofstructure the administrative possible the highest at act administrative an in included be should category each in recommendations The administrative. and oversightfunding;systems;monitoringand collection, professionals; data of services; quality of care and exercise of rights; education and The trainingmeasures included of in the health model are divided into six categories: services. these access to a attempting when on face women measures barriers the eliminate adopt and reduce and to issues of establish variety to necessary is it services, abortion safe to access 1 barriers. of new asource become not to care, access promote and aim barriers toshould reduce that in regulations belief created the been has model This 11 0 0 9

the measure will provide. measure the Judge whether the impact on the rights in conflict is justified by the protection that that protection the by is justified inconflict rights the on impact the whether Judge measure. by the affected willnegatively that be rights the Identify to guarantee). seeks it (the right measure of the purpose the Identify Whenever possible, these provisions should not be part of penal codes; they should be part of health health of part be should they codes; penal of part be not should provisions these possible, Whenever while if the restriction is related to characteristics that are not surmountable (such as race or gender) the test test the gender) or race as (such surmountable not are strict. be should that characteristics to related is restriction the if while (such as that age), be should is the lenient, surmountable to judgement related a characteristic limitations imposes regulations. The proportionality test has different degrees relating to the rigor of the judgement. For example, if a measure measure a if example, For judgement. the of rigor the to relating degrees different has test proportionality The 1 0 9 This will avoid the proliferation of guidelines from different entities, entities, different from guidelines of proliferation the avoid will This

11 0 This is a tool to foster critical thinking that aims to determine

organization 111 or delay impede, would that interference services. abortion legal for of awoman’s request implementation the arbitrary complicate from freedom to right the and autonomy to right the a of protection the reinforces On respect of principle the system. note, similar health the with interactions their all in safeguarded is services abortion legal seeking clients of privacy the that ensure to seeks principles these of application the privacy; to right the to tied closely are privacy and confidentiality of principles The rights, rights. human to protect a framework provides solidarity, and of co-responsibility interpretation favorable includes which confidentiality,privacy, respect, integration, continuity,promptness, timeliness, security, principles, of group second The services. abortion legal to related situations over arise conflicts or of doubts when providers and service of health guide professionals should the decisions principles the includes group perspective ethical an from first which nonmaleficence, and The beneficence autonomy, justice, rights. human of protection the to relate that others and ethics of realm the to belong that some are there principles, these Of framework. rights human and ethical the and principles to these important between relationship is the it out below, point detail more in described are principles guiding these While doubt is there whenever application. its or rights aregulation about women’s favors best that action of course the must they adopt that mandating personnel, medical and judicial administrative, at directed principle specific a include regulations abortion that rights. recommended these is guarantee it Consequently, to act to providers and facilities assist to and principle the to in regulations that with together applications toclarify rights, specific ensureadherence rights. This is called the protected the with keeping in best application or interpretation the adopt to facility or provider the obligates rights for respect this doubt, in is application its or of regulation a meaning the when result, a As applied. be favorableshould right most specific a the of that interpretation establishing clause explicit an towards documents trend a rights is in including there Currently arises. conflict a whenever providers and facilities guidelines that principles These establish as serve the basis of decision making for health delivery. service in force guiding the as serve should and regulations the in principles articulated basic of framework a within considered be services must abortion legal to access to barriers reducing for measures recommended The principles Guiding

The comparative analysis of this issue is on page 43. page on is issue this of analysis comparative The pro pro homine principle .

This This principle is increasingly being included 111

that should be clearly

V. Recommendations for developing regulations that 157 guarantee access to abortion services V. Recommendations for developing regulations that 158 guarantee access to abortion services the need to reduce economic disparity among women so that all women have equal equal have services. and legal and women to safe access and all opportunity equality, that so to women right among disparity the economic in reduce to embedded need the deeply is solidarity of principle the Finally, contexts all in services by law. permitted of implementation the facilitate that conditions and financial of institutional concurrence a on dependent is services to access effective that given health to right the of protection the to connected also is co-responsibility of principle principles The well-being. promote and minimizerisks health, these protect that conditions ensure and well-being; and are health security to for abortion legal services health to the necessary access and to effective guarantee interact right women’s continuity protect promptness, to timeliness, fundamental integration, of principles The 115 114 113 112 The most important guiding principles that should be included in abortion regulations

See See Although Although the state is for responsible public health, in countries where other are sectors involved in provision, service 43. page on defined are nonmalficence and beneficence autonomy, Justice, all involved sectors, including the private sector, must contribute resources for abortion services. abortion for resources contribute must sector, private the including sectors, involved all Both for the client’s decisions and for confidentiality. for and decisions client’s the for Both Colombia and and Brazil , which define principles for service provision. service for principles define , which ------solidarity co-responsibility security continuity promptness timeliness integration privacy confidentiality respect nonmaleficence beneficence autonomy justice of rights favorable interpretation 113 114 115 Brazil . 112 119 118 117 116 of uncertainty. in astate or in suspense patient keeping the from abortion and providing evasive being from in prohibited are care, involved post-abortion and individuals pre- including All services, complications. prevent or health her maintain life, her save to necessary is it when or pregnancy of termination the requests Timeliness possible level of health. highest the maintain and life woman’s the preserve to activities and services other all and rehabilitation treatment, diagnosis, prevention, information, education, Integration services. torelation abortion of information and the of privacy in women their obligation to respect they understand that so toall employees information training (iii)and providing and record; medical her in included information the of and woman the by provided information the of privacy the guarantee to conditions creating (ii) care; post-abortion and pre- including services, (i) adapting the physical space in facilities to provide privacy for women seeking abortion Privacy it. from divulging or benefit own their for it using available tomethods ensure that such information is not divulged and all is prohibited use from to obligated is pregnancy, her terminated has who woman a of life intimate or private the or pregnancy, of termination a about information implicit or explicit given indirectly or directly is who anyone employment, their of a condition As confidentiality. Confidentiality adopted. be must rights women’s with keeping in best application or interpretation the doubt, in is application rights of interpretation Favorable

In the Childhood and Adolescence Code of Colombia, Law 1098 of 2006 articulates the use of this principle as as principle this of use the articulates 2006 of 1098 Law Colombia, of Code Adolescence and Childhood the In The following sources were consulted for the definition of this principle: principle: this of definition the for consulted were sources following The 1993 of 100 of Law regulates the nursing profession in Colombia and establishes other provisions» and Case T–881 of 2003 (Hon (Hon 2003 of T–881 Case and Gil). Escobar provisions» Rodrigo other establishes and Colombia in profession nursing the regulates aap.org.ar/publicaciones/forense/forense–10/tema–1.htm M ( Uruguay against unsafe abortion: forensic medical foundations) riesgo: de condiciones en provocado aborto el contra médicas children. to applied The following sources were consulted for the definition of this principle: Rodríguez Almada, H (2002) (2002) H Almada, Rodríguez principle: this of definition the for consulted were sources following The La práctica pericial psiquiátrica y su contexto ético ético contexto su y psiquiátrica pericial práctica La : Abortion services must ensure respect for women’s privacy. This includes at least: www.mednet.org.uy/dml/actividades/archivos/inmed–pay030614.ppt#256,1 : Abortion services must be provided at the time that a woman or her provider : Abortion services shall be provided in an integrated manner and include include and manner integrated an in provided be shall services Abortion : 118 : This principle is founded on the obligation to maintain professional professional maintain to obligation the on founded is principle This : Colombia 116 was consulted for the definition of this principle. this of definition the for consulted was : When the meaning of a regulation or its its or regulation a of meaning the When : . Montevideo: Faculty of of Medicine, University the Republic, (Expert psychiatric practice and the ethical context) ( context) ethical the and practice psychiatric (Expert ) 117

fundamentos médico legales legales médico fundamentos Colombian 119 Law 266 of 1996, «which «which 1996, of 266 Law ) and Bruno, A and Bosco, Bosco, and A Bruno, and ) (Medical initiatives initiatives (Medical Iniciativas Iniciativas www.

V. Recommendations for developing regulations that 15 guarantee access to abortion services 9 V. Recommendations for developing regulations that 160 guarantee access to abortion services to perform the procedure at the earliest possible stage of pregnancy. stage possible earliest the at procedure the to perform and (iv) aimin (iii) each as indicated case; with comply health standards; safe techniques with (ii) performed be equipment; and with appropriate by trained health professionals provided be (i) least: at shall, services abortion obligation, this with To comply women. Security be should services met, been have requirements continued. the whether unclear is it because continued be should or provided be not should or should services whether about arise or their once completion they have services initiated; been to and (iv) abortion if doubts or contractual (iii) access prevent not may facility the within treatment; or entities other with of conflicts administrative interruption unjustified of the omissions entail or that actions from obligations refrain must services abortion provide state; that the facilities by guaranteed (ii) be must and manner ongoing and regular a in provided must be services abortion (i) that: recommends principle this of application The manner. Continuity passed. already has procedure the with compliance for regulations the in established period time the if of services refusal abortion the justify to used be followed been not has procedure a that fact the may delays making create it toimpossible the the perform would abortion, procedure shall be In or omitted. no case woman, a of health or life the endangers extent fullest the to procedure other any or judicial legal, administrative, any pursuing When requirements. unnecessary or additional imposing from prohibited are employees their and facilities furthermore, possible; as quickly as performed is abortion the that ensure to necessary help the all with women provide shall abortions perform Facilitiesthat care. immediate Promptness 122 121 12 0

The following sources were consulted for the definition of this principle: Comisión Nacional de Seguimiento de de Seguimiento de Nacional Comisión principle: this of definition the for consulted were sources following The of The decisions following the Court of Constitutional Guidance for Health Systems. Health for Guidance and org/pdf/esp_pub_Aborto_seguro.pdf); Imperative. Health Public A Center for Rights Reproductive (2005) chasque.net/frontpage/comision/dossieraborto/cap2_2.htm); seguro? Uruguay), in médicamente Health aborto and un (Woman hace Uruguay se en ¿Cómo Salud y Mujer y Beijing) Monitor to Committee (National Beijing T–1198Case T-170 2003, of 2006. of T-837 and 2002 of archivolegaldigital/directiva2003/RM–N1216–2003–SADM.pdf). Peru Mnseil eouin 26 f 03 (www.minsa.gob.pe/portal/06Transp–AccesoInf/01InformacionInst/ 2003 of 1216 Resolution Ministerial . : Abortion services should be provided in conditions of optimal security for for security optimal of conditions in provided be should services Abortion : 121 : Health services must be : must provided in Health services an ongoing and uninterrupted, regular : Women who request or require an abortion are guaranteed prompt and and prompt guaranteed are abortion an require or request who Women :

Briefing Paper, New York: Center for Reproductive Rights (www.reproductiverights. Rights Reproductive for Center York: New Paper, Briefing Geneva: WHO. Geneva: 12 0 World Health Organization (2003) (2003) Organization World Health

(How to perform a safe medical abortion), abortion), medical safe a perform to (How Colombia were consulted for the of definition this principle: Safe Safe Abortion: 122

Technical and Policy Technical and Policy Uruguay Safe Safe Abortion: (www.

128 127 126 125 124 123 social of expansion the on based cultural and change. social to promote actions including networks, be support can consolidation service addition, In disaster. migrants in general and populations, migrants in crisis situations, for displaced example in the wake reasons: of a natural transitory other for services accessing difficulties have that is critical for also populations leaders involvement The of community services. need brigades health and educational include may measures These populations. isolated most the for is but not limited that access urban to,and which promote ruralentails, measures areas, country, the throughout services of availability the includes recommendation This 1. I. to pay. ability her not and need her with accordance in provided be must services and services, abortion accessing fewer resources. with those subsidize resources greater with individuals those which in systems promote Solidarity services. abortion of provision the guarantee to and for financing provide Co-responsibility

of services organization the to related barriers reduce to Measures care and with appropriate referral and counter-referral systems and referral appropriate with and care Create and/or consolidate service networks throughout the country at allof at levels country the throughout networks service consolidate and/or Create elh evcs hud olw diitaie iiin (eeal crepnig o egahc iiin) f each of divisions) geographic to corresponding (generally divisions administrative follow should services Health principle: this of definition the for consulted were sources following The The usefulness of this principle depends on the geopolitical organization of each country, the level of autonomy autonomy of level the country, each of organization geopolitical the on depends principle this of usefulness The text, constitutional Proposed principle: this of definition the for consulted were sources following The that are very isolated, where the population’s mobility is severely limited or where several communities with with communities several where or limited severely concentrated. is are services health to access mobility limited population’s the where isolated, very are that country. The names of these divisions differ by country: for example municipalities, states. boroughs, departments, 44-48. pages on is issue this of analysis comparative The (www.eclac.cl/prensa/noticias/discursossecretaria/3/20963/DeterminantesSalud18MarzoFinal.pdf). 2005) March 18 Chile, Santiago, (ECLAC, Health of Caribbean the Determinants Social and on Commission America the of launch Latin for official the at Commission (ECLAC), Economic the of Secretary Executive Machinea, Luis Remarks José Caribbean, by the and America Latin for (www.eclac.cl/publicaciones/xml/8/24058/LCW63_ReformasSalud_ALC_Cap2.pdf). Commission Documents Project Economic principles); security social on impact Caribbean: Caribe: el y Latina system. insurance health the and actors the of http://canciller.blogia.com/2007/050601–principios-de-coordinacion-concurrencia-y- subsidiaridad.php). and 0del%20MAS.doc (http://constituyenteyautonomias.enlared.org.bo/Archivo/Docs/TEXTO%20CONSTITUCIONAL%20ultimo%2 ‘Brigades’ refer to a system of providing health services extramurally. In other words, health teams travel to areas areas to travel teams health words, other In extramurally. services health providing of system a to refer ‘Brigades’ 128 : In order to pricing policies achieve shall toaccess universal services, abortion and reliance on community toleaders improve access in areas where women 125

su impacto en los principios de la seguridad social social seguridad la de principios los en impacto su : The state and all other levels of government shall work together to together work shall government of levels allother and state The : In no circumstance shall In no a circumstance woman’s toinability pay prevent her from (Health reforms in Latin America and the the and America Latin in reforms (Health Las reformas de salud en América América en salud de reformas Las 126 123 , 124 127 Bolivia

in

V. Recommendations for developing regulations that 161 guarantee access to abortion services V. Recommendations for developing regulations that 162 guarantee access to abortion services to prevent unwanted pregnancies in the future. These types of services are generally generally to decide who women are assist also must at lower provided levelsystem This facilities. care services of types These future. the in pregnancies unwanted prevent to services and counseling necessary the receive women that and care of level higher a at to is ensure that goal abortion do services not their end with care; the procedure integrated when it of has been performed part fundamental a are counter-referrals Likewise, facility. appropriate to the referrals timely to and make care to play a role in abortion allowthat pharmacies to create mechanisms important is it referrals, of concept conventional this to addition In system. health the treatment does when not capacity the exist at necessary the or woman’s point of determined intoentry been has health her to risk additional an when care of levels higher to woman a of transfer timely the guarantee to is referrals of goal the sector, health the sectors. other as well as system health the include must systems These access. Finally, developing referral and counter-referral is systems critical to removing barriers to rural areas. or in remote living available are that women for services include also should They home. the outside and/or in tasks for responsible are women that fact takethat intothe of operation account hours appropriate include must measures These pregnancy. in the later abortions or of complications because care necessary of when levels across referrals appropriate including care, of levels all at developed be in trimester. the terminations toencourage first However, be performed must capacities facilities, care level lower by provided be should Because abortion is a simple procedure, in most it cases, is to important note that services for country. of the areas geographic in different these services provide responsible facilities which is and spheres who private and public establish the in clearly services providing to obligation the include must Regulations 131 129 evidence). medical to take forensic (for the organizations or with reports police to transfer for example required, is involvement its (when interface system legal service that organizations social or adoption) include chooses may woman a when system example, this in involved sectors Other care. to necessary access them to guarantee in order pregnancies their continue 13 0

(2003) (2003) Organization Health World cases.» complicated more for referral effective and procedures first-trimester provide «The initial priority «Themight be to priority initial train in those and in including rural equip lower at areas, staff level facilities to least See See See Norway Colombia Safe Abortion: Safe . and and Norway

Technical and Policy Guidance for Health Systems Health for Guidance Policy and Technical . Service networks at all levels, organization of services. of organization levels, all at networks . Service 13 0 preferably in outpatient settings, to settings, outpatient in preferably 129 . Geneva: WHO. . Geneva: 131 Within Within 139 138 137 136 135 134 133 132 (Pap cancer cervical for screening include care abortion with conjunction in provided model. the of part central a as support and counseling of inclusion the and measures) (favoringpromotion of health issues inclusion the health-related reproductive Comprehensive care has two essential components: 2. ( ( ( ( ( ( ( ( ( ( ( ( ( The following key factors are considered in the model proposal and recommendations:

HIV/AIDS) and populations (adolescents) as well as post-abortion care post-abortion well as as (adolescents) HIV/AIDS) populations and (violence, situations to special attention with policies, health reproductive and sectors. service of social Involvement judiciary. of the Involvement sectors. private and public the across mechanisms coordinating Implement of clients. referrals timely for pharmacies with Alliances counter-referralReferral systems. and all for facilities. of operation hours Appropriate care. specialized need that cases for Ensure availability of mid and high level care to institutions manage complications or possible. where setting, inoutpatient an services Provide units. health mobile Include models. care health in developing leaders Involve community networks. support social Strengthen the in country. of the divisions geopolitical different services provide that facilities of lists available make to mechanisms Create are sector, health the by authorized country. the available throughout facilities, certified and services that Ensure Adopt integrated care models for abortion services within a framework of sexual of sexual aframework within services abortion for models care integrated Adopt See See An important element of element An important See be should that criteria or measures important most the synthesize category each in points bullet the general, In guide women receiving health care in decision making and self-care. and making decision in care health receiving women guide 48-57. pages on is issue this of analysis comparative The needs. client’s the meet cannot providers health Brazil pregnancies. unwanted preventing and methods contraceptive on counseling for systems counter-referral Mexico states. departments, regions, boroughs, municipalities, country: by differs which country, model. this by proposed as aregulation, creating when considered h tr ‘epltcl iiin rfr t te diitaie n gorpi ognzto o te ertr o a of territory the of organization geographic and administrative the to refers division’ ‘geopolitical term The Italy Colombia 139 , for example, provides for referrals to feminist non-governmental organizations and women’s groups if if groups women’s and organizations non-governmental feminist to referrals for provides example, for , , Services for other sexual and reproductive health-related issues that can be be can that issues health-related reproductive and sexual other for Services Spain . . , Puerto

Rico Brazil , Brazil ’s support model is that it establishes that one of the objectives of counseling is to of counseling that one of the objectives is that it model establishes ’s support and 136 Colombia 137 135 establish referral systems. 133

services services for other sexual and 134 Colombia and Guyana 138 also establish

132

V. Recommendations for developing regulations that 163 guarantee access to abortion services V. Recommendations for developing regulations that 164 guarantee access to abortion services 141 14 prioritizemust the of needs each woman in order to provide adequate care. professional a by provided assistance the one; rigid a or format only the is format this that assumed be it should time no at essential, is counseling the content in included what be should of discussion Although pregnancy. the continue to decides woman the reduction risk abortion, and unsafe for pregnancy of termination safe from ranging options provide also must They women. dissuade to seek not do and making decision autonomous women’s that encourage support and counseling include and health promote must models These of models require services, of abortion specialized care. for issues prevention need other the with the for conjunction in provisions support that, include that and policies pregnancies, health unwanted/unplanned reproductive and sexual Legal abortion services should be provided within a framework of comprehensive services. abortion for aprerequisite or to access barrier In should an become the no ofadditional provision of circumstances services types these of action. course any particular from them to dissuade seek not and making decision voluntary and autonomous women’s encourage should services these models, to and counseling support respect With violence. for gender-based services and support smear) 143 142 0

Countries with models of care for abortion in situations of in of models with violence: situations Countries care for abortion For example, the Protocol of Hospital Belén de Trujillo establishes that the medical examination before an abortion before an abortion that examination the de medical Belén Trujillo of the establishes Protocol For example, Hospital See See is especially detailed. especially is de Práctica Clinica de Práctica Health, Publicof Ministry forabortions. need theconsequently and future the in pregnanciesunwanted of number the decrease to is service counseling the of goal ultimate The that they receive thecare necessary both before and after an procedure,abortion including access to contraception. procedure. The goal is to bring women with unwanted or unplanned pregnancies into the health andsystem ensure the before 24hours antibiotics of administration prophylactic as such issues other as well as abortion, ofunsafe methods and safe discuss to her with meets team medical a pregnancy, her end to voluntarily decides woman If the options. different explore Argentina.women help in to counseling and and Uruguay information inof provision the mortality include maternal regulations of The cause main the the abortion, decrease unsafe to to aims due decision deaths of This number pregnancies. their end to decide who women to counseling provide sectors private and public the in physiciansthatmandating resolution a via regulations its in initiative this included Health of UruguayantheMinistry 2004, unwanted unplannedIn pregnancies.and/or with women tocomprehensive care Sanitarias Iniciativas to empower women seeks and communities through increasing the commitment efforts. of health professionals to provide such of example pioneering a is in Sanitarias) initiated (Iniciativas professionals project health of reduction group harm The framework. legal the of irrespective mortality, maternal is an opportunity to take a Pap smear and conduct other tests that aid in diagnosing sexual and reproductive reproductive and sexual diagnosing in aid that tests issues. other health conduct and smear Pap a take to opportunity an is Some countries are implementing initiatives to reduce risks associated with unsafe abortion in order to decrease decrease to order in abortion unsafe with associated risks reduce to initiatives implementing are countries Some 14 Brazil 0 and breast cancer, testing for HIV and other sexually transmitted infections, infections, transmitted sexually other and HIV for testing cancer, breast and ’s and Peru (Health care regulations and clinical practice guidelines). Ordinance 369 of 2004.

Gender-based violence and Gender-based HIV are examples of such issues. ’s models. 142 o elh ae o penny n cidit, n aoto if adoption and childbirth, and pregnancy for care health to Uruguay Brazil . Normativa de Atención Sanitaria y Guiasy Atención Sanitariade Normativa , Mexico and Colombia 143 . Brazil’s model . model Brazil’s Uruguay Finally, it y a by 141

144 ( ( ( recommendations: and proposal model in the considered are following keyThe factors need. they support the receive women that to ensure issues emotional or or counseling should Post-abortion also violence include a space to address any lasting psychological gender-based for services support example, services). of HIV, appropriate other management or (for situations warranted certain if treatment by and consultation for referred be also should pregnancies) and counseling, unwanted/unplanned future prevent (to Finally, within the integrated care model, women should receive post-abortion counseling care. health and counseling they to seek decide when – way positive a in always not – decisions their in of interfere can beneficiaries who the adults usually are Adolescents systems. health within status their of out only the model of care, but not also related issues to account costs and other into barriers to take access arising must population this to services providing when Considerations factors. related other and parents, with or setting care in ahealth openly speaking of the difficulties use, contraceptive negotiating about difficulties the development), of stage this during common risks other with associated (often pregnancies unplanned people: or unwanted preventing of young and difficulties the include these adolescents of stage developmental the to specific characteristics the of consideration and professionals for training special require care of models These for needs specific their of development. tostage their appropriate care of health because also but systems) health in limited often is (which holders rights autonomous as status their of because only not is This population. tothis specific care of model a within provided be should services abortion it, with associated aspects has many and young particular people for provision adolescents service Because later. discussed as resources), and to procedures example, for relates, (which information and process) making decision the in support emotional to relates (which counseling provide to need the between differentiate to important is

Inclusion of abortion care in special cases as part of comprehensive care models: care of comprehensive part as cases in special care of abortion Inclusion issues. health reproductive and sexual for care and prevention promote and pregnancies unwanted for options of range wide a the provide that care of and models Comprehensive services abortion include that abortion. of unsafe prevention policies health reproductive and Sexual See See Norma del Instituto Materno Perinatal Perinatal Materno Instituto del Norma (Regulations of the Perinatal Maternal Institute) Maternal Perinatal the of (Regulations 144 as well as contraceptive contraceptive as well as of of Peru .

V. Recommendations for developing regulations that 165 guarantee access to abortion services V. Recommendations for developing regulations that 166 guarantee access to abortion services 154 153 152 151 149 148 147 The World Health Organization has stated that the medical personnel who provide provide who personnel medical and midwives general aides, medical physicians. should include the nurses, services abortion that stated has Organization Health World The circumstances. in what and services abortion provide can who state explicitly requirements. relevant the with comply who and well-trained are who areas) geographic across located (adequately professionals health of number In order to guarantee the provision of abortion it services, is to necessary have a sufficient 3. ( ( ( ( ( ( ( 146 145 to services abortion restrict to circumstances any in necessary not is it words, other In 15 0

Psychosocial support. Psychosocial consultation. the decision about postponing a whenever possible contraceptive for method a later after the abortion, including information on emergency contraception, emergency on information including abortion, the after permanent) and (temporary methods contraceptive of range wide a of Availability adolescents. for health reproductive and to sexual related problems of other treatment and Care to buildtrust. in order consultation of the and of information Counseling for that adolescents includes an explicit explanation about confidentiality systems. health within holders rights as adolescents for Protection hours. appropriate and locations accessible adolescents: for of care Model support and process. making decision the during women for counseling counseling comprehensive a of Provision ii. i. Appropriate professionals to perform abortions to perform professionals Appropriate See, among others, the psychosocial support provided to women in to women provided support psychosocial the others, among See, example, for See, See See in rights reproductive and sexual for model care integrated the example, for See, See The comparative analysis of this issue is on page 57. page on is issue this of analysis comparative The procedure. the of understanding abetter offer to partner Colombia approaches. detailed most the of one includes (2006) See obligatory provisions in in provisions obligatory See The The See

Incorporate abortion services in comprehensive care models for sexual sexual for models care HIV. for care in comprehensive services abortion Incorporate comprehensive in violence. services abortion Incorporate Brazil Peru Brazil Manual de Orientación y Consejería en SSR SSR en Consejería y Orientación de Manual , , . Colombia , for example, includes prevention of sexually transmitted infections and HIV/AIDS, among others. among HIV/AIDS, and infections transmitted sexually of prevention includes example, , for Colombia 15 145 Colombia 0 , , Norway Peru 152 Norway , , which establishes the option of developing ‘adolescent-friendly services’. ‘adolescent-friendly developing of option the establishes , which Italy , South , Guyana and and

Africa Colombia , Norway and and Sxa ad erdcie elh oneig manual) counseling health reproductive and (Sexual Brazil on entities that provide abortion services. services. abortion provide that entities on and and . Panama 153 Guyana . and, at the woman’s request, to her woman’s at request, the and, 146 147 154 Peru model, that includes includes that model, Regulations should should Regulations . 149 151 148 avoiding

of

Peru

4. 159 158 157 156 155 of care. to evaluating quality the record. Above all, it is to important recognize that timeliness in service provision is critical medical the in included be must delay the for reasons manner, the timely a in provided obligatory. be must and access to obstacles additional create not should limits time These women. to services provide must facilities include must Regulations ( ( ( recommendations: and proposal model in the considered are following keyThe factors of agynecologist. presence the may require situation, to help even forcan example a high-risk cases, specific situation. Some evaluate that women’s socio-economic and procedure, the after and during before, needs, emotional not toalso but only to that their teams can respond women’s needs physical disciplinary physicians. specialized or physicians 16 0

Promptness in providing services in providing Promptness professionals: non-medical includes team professionals. appropriate other and workers social psychologists, multi-disciplinary the that Ensure necessary. when obstetricians and gynecologists Include abortion. medical for and complications without cases for midwives and aides medical nurses, trained appropriately and/or general physicians services: who can provide abortion Establish In In pregnancy. Panama 65. page on is issue this of analysis comparative The Brazil 2007. Ipas. Advisor, a System of Health Senior PhD. support MSPH, ObGyn, the León, de Ponce with Gómez well Rodolfo specialist. perfectly need this meet can providers training level of Mid level procedures. same the abortion have surgical to for as need necessarily not do who but complications, of symptoms recognizing in trained by personnel process abortion of the supervision appropriate and counseling pre-abortion on appropriate 12 before weeks. abortion Systems Health for Guidance Policy and Technical (2003) et al et (1993).al (1986),Organization Greenslade (Freedman Health World From aspiration vacuum perform to trained be can insertion, IUD as such procedure transcervical a perform to and pregnancy of Health personnel […who] have demonstrated ability to perform a bimanual pelvic examination to diagnose signs signs diagnose to examination pelvic bimanual a perform to ability […who] demonstrated have personnel Health Medical abortion Medical with abortion and mifepristone provides misoprostol a new on perspective provision service that is centered South ’s ‘support’ model provides for multi-disciplinary teams that include social workers and psychologists. and workers social include that teams multi-disciplinary for provides model ’s ‘support’ , Africa Mexico , for example, a registered and appropriately trained nurse or midwife is allowed to perform an an perform to allowed is midwife or nurse trained appropriately and registered a example, for , and and 156 Colombia , 157 clearly defined maximum time limits time maximum defined clearly emphasize the importance of providing care to women in the early stages of of stages early the in women to care providing of importance the emphasize 155 159 In addition, the ideal strategy is to create multi- create to is strategy ideal the addition, In . Geneva: WHO. p.60. WHO. . Geneva: Whenever services are not not are services Whenever 16 0 within which which within Safe Abortion: Safe 158

V. Recommendations for developing regulations that 167 guarantee access to abortion services V. Recommendations for developing regulations that 168 guarantee access to abortion services information about services to clients – both at the level of public awareness raising raising awareness public of level the at both – clients of to dissemination services systematic about the information and consent, informed to related measures such, As of care. ahighquality to sustain necessary rights fundamental in grounded are quality to related barriers reducing for below described measures the and of each – care linked inherently are of services health within clients quality of rights the guaranteeing Ensuring rights. human ensure fundamental to women’s quality of of protection standards the conventional beyond go must the process that care demonstrate of to quality intended is guidelines and norms and delivery process care service of adequate quality robust a guaranteeing to related measures of group This II. brin i cutis hr aoto i lgly etitd r s lea: hi rgt to rights their illegal: is or restricted legally is abortion where countries in abortions have who women to example, for extends, right This privacy. to right clients’ ensure to Finally, measures related to protecting confidentialityand privacy are essential components clinical techniques. adequate using by professionals manner well-trained in delivered a timely and effective are abortion legal for required services the that ensure to measures Such right life. and the health of protection the to linked closely measures are professionals, health for delivery guidelines and as requirements, wellinfrastructure as training and accreditation In the addition, the adoption rules ofobjection, about conscientious protocols or service health. their about decisions autonomous make and can informed clients that ensure to essential is information timely autonomy.Clear, and and information truthful to clients of right fundamental the to respond – level individual the at and campaigns . . . . I. standards quality and rights guaranteeing quality: service to related barriers eliminate to Measures Measures to reduce barriers related to the organization of organization toservices the related barriers to reduce Measures Promptness in providing services in providing Promptness abortions to perform professionals Appropriate management care post-abortion as well as (adolescents) populations and HIV/AIDS) situations (violence, special to attention framework with policies, a health within reproductive and services sexual of abortion for models care comprehensive Adopt care and with appropriate referral and counter-referral systems Createand/or consolidate service networks throughout the country at all levels of

162 161 to addition in factors include that considered be making decision regulate to systems alternative that requires concept this in implicit children’sautonomy of recognition The balanced with the obligation to protect them as children. autonomy their and holders rights as children of recognition the between equilibrium counselingpointforof aguidance conceptestablish and toreduced.helpsThe becomes need the that – result a as responsibilities– and livestheir assume affecting themselvesdecisions make to to and capacity their increase turn, in must, competencies greater Child.the of Rights the Conventionon1989 the of 5 article internationalin recognizedlawby was concept A useful tool to regulate the consent of minors is the concept of ‘evolving capacities’. This of her representatives. possible discrepancy between the desires of the minor or disabled woman and the desires a disability in the decision making process and to refer to existing mechanisms to resolve a it is important to determine the value assigned to the desires of the minor or woman with and informedresponsible free,manner. a For in the decisionconsent of her makeminors or can women woman who pregnant are the not thatable to so availablegive consent, alternativesandassistancethewell asas consequenceseffects andprocedures,the risks, compulsory obligation, provided objective, truthful, sufficient and timelywoman the who requests of informationor writing, requires a in legal about agreement, abortion once voluntary the health the facility as has, as consent part of define its regulations Mexico The care. of comprehensive part form that topics other as well as procedure the about information complete and timely factual, of basis on the by makes decision woman the which fully and a informed free an action be must Consent woman. the of consent informed the be must services abortion all of basis The 5. client. of each situation particular to the corresponds that treatment toright receive the particularly equality, to right the protecting of part cultural important of an is account considerations Taking confidential. and private strictly remains provider the and the client between and any still informationbemust preserved discussed confidentiality

Informed consent Informed child, appropriate direction and guidance in the exercise by the child of the rights recognized in the present present the in recognized rights the of child the by exercise Convention. the in the guidance of and capacities evolving direction the other with appropriate or consistent child, manner guardians a legal in provide, custom, to child, local the by for for responsible provided legally as persons community or family extended the of members the 66. page on is issue this of analysis comparative The Article 5: States Parties shall respect the responsibilities, rights and duties of parents or, where applicable, applicable, where or, parents of duties and rights responsibilities, the respect shall Parties States 5: Article 162 161 This concept recognizes that children’sincreasinglyrecognizesthatacquisitionconceptof This

V. Recommendations for developing regulations that 16 guarantee access to abortion services 9 V. Recommendations for developing regulations that 170 guarantee access to abortion services 163 provided be informationmust (i) rights:followingminimum the least at respect should disability, of type some with women For children. of their spacing and number the things, other among choose, and rights reproductive and sexual their enjoy to capacity the have therefore exposed. children are they which to health their to risks prevent to manner responsible a in acting are infections, transmitted sexually and AIDS pregnancies, unwanted from that minors who are sexually active, and seek information and ways to protect themselves finds capacities evolving of concept the field, rights reproductive and sexual the Within ( ( ( models: regulatory alternative some suggests Child the of Capacities Evolving case. each in minor the of maturity the account into take and age 166 165 164

only for those rights that are at risk of being abused or neglected by adults, and and adults, by rights.» to other neglected respect with of competence age apresumption limits or introducing abused of being of risk at are establishment that rights the those for and only rights can specific who among child differentiation a Legal entitles but age-limits includes age. earlier an at right to the acquire competence demonstrate that model a of Introduction achild’s rights. Alternatively, to restrict in order incapacity todemonstrate adults right. on onus the particular with competence of any presumption a introduce exercise could law the to competence determine to which «Removal of all substituting age-limits, a framework of individual assessment through The publication, publication, The establish if a minor has the capacity to make a decision relating to the termination of her pregnancy: pregnancy: her of termination the to to relating and make to adecision cases capacity the has aminor if specific establish evaluate to criteria as definitions eventually appropriate adopted be of could and that several personnel suggests trained It of competency. of lack the is concept this applying to limitations main the of Article 3, which establishes establishes which 3, Article must rules for be making when for in decision considered establishing to women relation with disabilities abortion. Rights. Reproductive Adolescents’ X: Chapter Rights, York: Reproductive for Center New (2006) Rights Reproductive for Center and advantages the model. each of for disadvantages following and 71 page See alternatives. four these of analysis extended an for 12 page ( ( ( ( Landsdown, G (2005) (2005) G Landsdown, The The «Ability a decision.» Achievement implications. long-term and short the and involved risks the her, or him affect will they how action, of courses different of consequences Ability themselves. for issues the through thinking of capable be and manipulation or coercion without choice Ability questions. relevant ask and concerns articulate apreference, express alternatives, available the United Nations Convention on the Rights of Persons with Disabilities (2006) Disabilities with Persons of Rights the on Convention Nations United to to to think assess

understand p.xi. The Evolving Capacities of the Child the of Capacities Evolving The of and a the fairly h Eovn Cpcte o te Child. the of Capacities Evolving The choose potential General and stable communicate with set Principles, , published by the UNICEF Innocenti Research Centre, Centre, Research Innocenti UNICEF the by published , for Gaining Ground. A Tool for Advancing Reproductive Rights Law Reform Law Rights Reproductive Advancing for Tool A Ground. Gaining some of benefit, values. degree relevant states: «(a) Respect for inherent dignity, individual autonomy autonomy individual dignity, inherent for Respect «(a) states: 166 The child needs to have some value base from which to which from maketo base value have needs child some The risk , by the UNICEF Innocenti Research Centre, notes that one one that notes Centre, Research Innocenti UNICEF the by , of h sse rgltn ifre consent informed regulating system the independence. and information. Florence: UNICEF Innocenti Research Centre. See See Centre. Research Innocenti UNICEF Florence: harm. The child must be able to understand the the understand to able be must child The The child needs to be able to understand The child needs to a be to needs able child The exercise defines some of the rights that that rights the of some defines 163 165 The report, report, The 164

These These The The .

168 167 ( ( recommendations: and proposal model in the considered are following keyThe factors the designated person be someone who is in direct conflict with her interests. accordance with the woman’s right and her clinical condition. take into consideration the circumstances of the situation, the alternative which is most in conscientiousobjector, must afamily spouse)member, notguardian or is who doctor (a her provideforconsenttolaw designated by person will, theher express towomanthe for impossible is it if (iii) pregnancy; the regardingdesires her express to her enable to exhausted be must measures possible all and pregnancy, the continue or terminate to clear;(ii) providers attend first must to determining whether the disabled woman desires the information is understood, that the procedures, effects and alternative treatments are appropriatetheirlimitations,most todisabilitiesformwithwomenensuring thatato in

case of minors, the pregnant adolescent should be recognized as a rights holder holder accepted. rights be the a should desires as in her recognized and be example, should for adolescent pregnant consideration; the into minors, of taken case be must situation individual The woman’s the save life. to decision is a make may professional a writing where situations (in urgent in except paramount sufficient), are desires woman’s the consent, of issues to relation In See See the See article 23 provides for respect for the autonomy of persons with disabilities to make decisions relating to sexual sexual entitled to provision, This health. relating and reproductive decisions make to disabilities with persons of autonomy the for respect for provides 23 article be shall to 12, the to degree proportional article Reinforcing safeguards the which and such rights person’s affect interests.» measures The body. judicial or authority impartial and independent competent, a by review regular subject to are and possible time shortest the for apply circumstances, person’s the to tailored and proportional are and undue influence, of interest are of free of conflict the person, and will preferences the rights, respect capacity legal of exercise the accordance to in relating measures abuse that ensure shall prevent safeguards to Such law. rights safeguards human international effective with and appropriate for provide capacity legal of exercise the recognition 12 titled This Article article, making of abilities. decision to alludes the persons’ Convention disabled directly Additionally, Convention.» present the in out exercise set the freedoms fundamental them and rights human the of guaranteeing enjoyment and of purpose the for women, full of the empowerment ensure to and measures advancement appropriate development, all take shall Parties States «2. and freedoms» fundamental and rights and to in by shall take this ensure the regard of full measures them and all equal enjoyment human discrimination, 6 Article particular persons….» of independence and choices, own one’s make to freedom the including woman. provided…» be must rights these exercise to necessary means the and recognized, are education planning family and of reproductive spacing and information, number age-appropriate to the access have to and on children their responsibly and freely decide to disabilities with persons of rights The (b) that… all ensure to as so in others, with basis equal an on disabilities relationships, with and parenthood family, persons marriage, to relating against matters discrimination eliminate to measures appropriate and effective take shall they Brazil are South , entitled to Africa South before women African : «1. States Parties recognize that women and girls with disabilities are subject to multiple multiple to subject are disabilities with girls and women that recognize Parties States «1. : the with regulations, which explicitly prohibit requesting additional consent other than from the the from than other consent additional requesting prohibit explicitly which regulations, and and law 167 disabilities , states in paragraph 4: «States Parties shall ensure that all measures that relate to to relate that measures all that ensure shall Parties «States 4: paragraph in states , Guyana , where minors are the ones to make the decision. make to the ones the are minors , where to ensure Respect 168 the Every attempt should be made so that the the that so made be should attempt Every full for enjoyment the home and of

Under no circumstances may the the rights family, and states: «1. states: Parties States freedoms defines

to which rights Equal

V. Recommendations for developing regulations that 171 guarantee access to abortion services V. Recommendations for developing regulations that 172 guarantee access to abortion services 170 due to the dictates of his or her conscience, regardless of how removed such argumentsany individual are professes in order to abstain from complying with the mandates of the law no political or religious organization can abrogate the ‘certification’ of the arguments that the concept of conscience does not depend on mechanism adherencewhereby this tofreedom is anyput into religiouseffect... It cannot becreed emphasized andenough thattherefore legal or social considerations governing their circumstances. Conscientious objection is the one person’s rights extend to the point where another’s begin – and their theirprinciplesindividual overcriteria all– within the basic laws governing coexistence, which establish that assert topeopleall facultyof the asunderstood Firstly,consciencebe «freedomofmust regulations. in abortion addressed be should that main elements the well as as objection conscientious of concept the both defines section this access, women’s to the as barriers critical of most the one is and complex, is constitutions this issue Because right of individuals. many by recognized is which objection, conscientious address to measures concrete include exception, without must, regulations pregnancies, their end In order for regulations to guarantee to services women who have voluntarily decided to 6. ( ( 173 172 171 169 objection. It is the right only of natural persons; importanttonotethat neither thestatenorlegal entities have theright toconscientious C-355 Case In from the concept of conscience of the person evaluating them.»

provide it. provide to able not are who individuals of consent the obtain to procedure clear a Establish representative. of her and minor the of consent the between discrepancies resolve to mechanism special a Establish of violence. a victim pregnancies. unwanted or is adolescent the unplanned whether identify to attempt also should adults future possible, Wherever avoid to order in information and education of provision the reinforce to serves guardian or parent(s) of involvement Conscientious objection Conscientious In this situation, responses In should be to this responses at obtained situation, Can the least: questions, following anyone the besides woman In In See Castillo, E (2005) Objeción de conciencia (Conscientious objection). objection). (Conscientious conciencia de Objeción E(2005) Castillo, 78. page on is issue this of analysis comparative The handled? be disabilities severe will How opinion? physician’s or of who the for cares person more the weight? woman carry How much weight should be given to the attending representative woman’s legal of the opinion the Does designated? been person that has how and abortion about make a can decision Who representation? have legal not does woman the if happens What abortion? the request Mexico Italy . and other countries the term ‘individuals’ is also used. also is ‘individuals’ term the countries other and , 170 hc dciiaie aoto i tre icmtne i Clmi, t is it Colombia, in circumstances three in decriminalized abortion which 171 169 173 therefore clinics, hospitals, health centers Espacio Libre Espacio 172 , No. 10. Bogotá: PROFAMILIA. 10., No. Bogotá: 181 18 179 178 177 176 175 174 ( ( ( ( ( recommendations: and proposal model in the considered are following keyThe factors procedures. these with assisting or performing from that exempt be to facilities desire their to indicate must apply services who abortion provide professionals Medical procedures. abortion of provision facility, or unit including hospital bythe required tasks and obligations the with comply to prepared are employees new that employment of condition a it make professionals, government of level the each throughout country, personnel appropriate are there that possible, as much as ensure, To and relevant according to the mechanisms established by the medical profession. legitimatewasconscientiousobjection the whether to prejudiceas subsequentwithout must immediately refer the woman to another professional who can perform the abortion,fundamental rights.physicianTherefore,a ifprofessesconscientious she objection,or he whether or not the physician agrees with abortion nor does it permit objectionignorance refersof towomen’s a well-establishedconscientious mentioningthatreligious worth is conviction,it persons,naturaland For therefore abortion. to regardis with not a question of orany other entity, regardless of what it is called, 0

and abortion nor hide information nor limit a woman’s options in order to change change to order in options woman’s a limit nor information hide nor abortion and rights women’s about information provide to refuse not may facilities and Providers facility. to appropriate an or facility same the within objector conscientious a not is who professional toa manner timely a in woman the to refer required is she or he objector, conscientious a is professional health a When objectors. conscientious Facilities must guarantee an appropriate number of health who professionals are not invoked awoman’s be lifein danger. is when cannot objection Conscientious to natural persons. applies objection Conscientious A See See See universities. or associations professional as such groups even or facilities Health order to comply with the requirements on service availability in different parts of the country. the of parts different in availability service on requirements the with comply to order Norway in regulations conscientious also of See rights 2008). no of have T-209 (Decision institutions other objection and clinics hospitals, that stating objection, relating conscientious systems to care health and hospitals of providers, duties legal the clarifying decision a new issued recently County, state, departmental, etc. departmental, County, state, From Case C-355 of 2006 of the Constitutional Court of Colombia. The Constitutional Court of Colombia Colombia of Court Constitutional The Colombia. of Court Constitutional the of 2006 of C-355 Case From Colombian Mexico Italy Norway allows employment conditions to stipulate that medical personnel may not be conscientious objectors in objectors may not be conscientious personnel that medical to stipulate conditions employment allows and and and and . regulation establishes the guarantees granted to women in response to conscientious objection. conscientious to response in women to granted guarantees the establishes regulation Colombia Brazil . . 18 0 177 176 can, when advertising job openings for health health for openings job advertising when can, 174 Colombia cannot claim conscientious objection 178 181 and and Mexico . 175 179

V. Recommendations for developing regulations that 173 guarantee access to abortion services V. Recommendations for developing regulations that 174 guarantee access to abortion services 7. 185 184 183 182 rights women’s violates information this Revealing clients. their relationship with professional the from originating information all confidence in seek maintain women that ensure to physician-patient to physician a of obligation legal and ethical the is it elements critically, manner.Here, timely a in services important most most the of and, one is information confidentiality, of confidentiality Maintaining ( ( ( ( 187 186

Confidentiality, medical confidentiality and privacy of services of privacy and confidentiality medical Confidentiality, available to women. consistently are services that so an appropriate number of physicians who are at not facilities objectors conscientious are that facilities services. abortion private provide to and authorized public of list a available make to guidelines Create afacility; within objector Regulations must include a formal procedure, in writing, to register as a conscientious Conscientious objection does not extend to pre- or post-abortion activities. post-abortion or to pre- extend not does objection Conscientious objection. Individuals who are not directly involved in the procedure cannot invoke conscientious any. are if there alternatives management abortion or options therapeutic her decision. Neither may or professionals facilities deny a woman information about More information on clients’ rights can be found in before a case he or she might attend, instead of having to indicate in advance his or her reasons behind the the behind objectors. conscientious not reasons are her or his advance or are personnel in their whether about them guides and indicate personnel over control to some facilities having gives This of objection. instead attend, might she or he case a before Norway Norway Spain Service Delivery Guidelines for SexualDelivery and Service Health Services Reproductive 83-86. pages on is issue this of analysis comparative The General Ministry’s the to annually 2007). of 0031 reported (Order Quality be Service on should Office and services these require who clients for available and gynecological–obstetric complexity be kept current must information This high services. and abortion to provide willing those medium have that personnel and those low, Quality services provide Service to on authorized Office network General the Ministry’s within the to facilities refer must Offices Health District and Departmental facility. the in place prominent a in displayed be to Pregnancy B). of Termination Supplement Medical Legal 4, Act, (Art. institution the of director or owner the and institutions approved all the register, Government official the in list to 1975). Pregnancy, of Termination concerning Act the of Implementation 1986). (Art. abortions to that a perform publish and of units list facilities municipalities the hospital Abortions, Legal of Performance the for Reporting centers of abortion lists publish accredited periodically See See Italy , Norway . , and and Italy 182 Norway and and , Guyana Mexico . Without these procedures, a physician can invoke conscientious objection immediately immediately objection conscientious invoke can physician a procedures, these Without . and and

The same regulation requires the certificate granting approval to perform abortions abortions perform to approval granting certificate the requires regulation same The . Colombia 184 however, the facility should not promote this option. this promote however, not should facility the have provisions along these lines. lines. these along provisions have Gazette, International Planned Parenthood Federation (2004)

Finally, in in Finally, ( 185 Art. and in a Guyanese newspaper, the name and address of of address and name the newspaper, Guyanese a in and This mechanism must help to maintain maintain to help must mechanism This

2, on Royal Centers and Decree Accredited Mandatory Norway Colombia . Third edition. London: IPPF. Chapter 1. has established the obligation of county county of obligation the established has , the Health Promotion Entities and the the and Entities Promotion Health the , Guyana Spain requires the Ministry of Health Health of Ministry the requires 186 requires health authorities to to authorities health requires 187

19, to privacy and and privacy to

Regulation for the Regulation 183 Medical Medical and 191 189 188 ( ( recommendations: and proposal model in the considered are following keyThe factors couldhave awoman’s it on life. many ofimplications the because rape of case inthe important particularly is Privacy service. the providing is who professional in offered a way that inspires the woman’s confidence in thephysical facilitiesand in the mark of for the respect woman and her decision to end the pregnancy. Privacy should be a as childbirth and pregnancy for services from separately services to provide important especially is it abortion, of case the In privacy. guarantees which and safe feel patients where area separate designated a in private, in provided be should services health All records. of medical evaluation quality of and the monitoring permits that mechanism a be also must there and required, where evidence, judicial provide to needed as records to access allows that mechanism a be must there time, same the At records. medical of management the for guidelines have to important is it patient, the privateabout information containing documents to applies also confidentiality Because confidentiality. patient maintain to required are physicians, just not professionals, health all that note instruments. rights human international by recognized as health 19 0

of harm. type other any patient a cause or prosecution criminal to patient a expose may that information any report or reveal to not physicians on obligation explicit an Create confidentiality. Maintain See See woman for the crime of voluntary abortion after she was reported by the physician she consulted. See also the the also See consulted. she physician the by reported was she after abortion voluntary of crime the for woman medical and confidentiality. confidentiality on FEMI) Federation, Medical Ethics (Domestic the Interior and del SMU) Médica Uruguay, Federación of the of Union Board (Medical Uruguay del Médico Sindicato the of Tribunal Arbitration the of Interruption Voluntary the for Care on Pregnancy). Regulation Technical Service, of Characteristics 6, abortion for care (Art. health provide procedures» or of aware are that In team health 2005). the of Care, members are who Abortion «Persons to Humane applies for Regulations Technical Ethics, Professional 5. of Abortion, and Aspects Ethics Legal Professional (II. and professionals to health physicians applies confidentiality (Art. person another benefit to or benefit own their for any information use may not individuals these that and procedure to the relating issues and documents of the confidentiality maintain to facility approved an to access legal having or at, working or by employed person any requires any medical professional, authorized medical professional, owner or director of an approved establishment, (Art acquired of information all the confidentiality to observe is required cases abortion in examining involved person and every Norway Ipas. Managua: care). post-abortion and confidentiality place: (2004) Ipas This point and the following are from the Declaration of the Faculty of Medicine of the University of the Republic, Republic, of the University of the of Medicine Faculty of the Declaration the from are following the and point This Mexico , Guyana 191 Entre la espada y la pared: la y espada la Entre , Brazil . 189 11, Act No. 50 concerning Termination of Pregnancy, 1975, with amendments, 1978 amendments, with 1975, Pregnancy, of Termination concerning 50 No. 11,Act Uruguay , , Brazil Guyana . 2007. This Declaration was in response to the prosecution of 16 May 2007 of a young young a of 2007 16May of prosecution the to response in was Declaration 2007.. This and and and and Colombia 19 Norway 0

el secreto profesional y la atención posaborto atención la y profesional secreto el have provisions along these lines. lines. these along provisions have .

14, Medical Termination of Pregnancy Act, 1995). Act, Pregnancy of Termination 14,Medical Norway 188 (Between a rock and a hard hard a and rock a (Between has established that each each that established has Colombia It is important to important is It , confidentiality confidentiality , ).

In Guyana

Brazil ,

V. Recommendations for developing regulations that 175 guarantee access to abortion services V. Recommendations for developing regulations that 176 guarantee access to abortion services 8. 198 197 196 195 194 193 192 available. Information circumstances are those in guarantee access to services necessary thisandawareness creation theleadtomustrights frameworka of thatensuresthat the professionalsmadeawarebemust – that abortioncrime nota iscertainin circumstances, mechanismstoexercising for thoserightswithinhealththe system keyresponsibilityensuretheirthatwomenaknowhavetorightsaccess state andthe of awarenessabout their rights under the laws ofeach country. Access tosuch information is In the context of abortion, the main objective of providing informationA tobasic women premiseis to raiseof public health is the prevention of health problems and their complications. 9. patient’s the in communicate can who groups. ethnic or communities specific for language professionals of availability the Guarantee ( ( ( ( ( ( (

and provision of information to individual clients to of information individual provision and Cultural considerations Privacy is an essential part of the model of care for rape victims. obstetrics. from separate physically be should services Abortion for provider. and awoman privacy between conversations provide to areas other from separate rooms examination of use Make it. access cannot confidentiality must be appropriately protected so that information, individuals of who are confidentiality not for obligated to responsible are maintain facilities that Establish preventing not time, same reasons. legitimate other for or quality to evaluate service access the at while, appropriately records medical Maintain Establish ethical and administrative sanctions if confidentiality is violated. is if confidentiality sanctions administrative and ethical Establish effect. to this instructions issue must facilities and confidentiality respects provide services to a patient must ensure that the entire team of medical professionals who professionals medical and physicians confidentiality, to maintaining addition In Systematic dissemination of information to promote services to the general public public general to the services to of information promote dissemination Systematic See See 188. footnote See In See Technical Regulation on Care for the Voluntary Interruption of Pregnancy, Appendix 2. Appendix Pregnancy, of Interruption Voluntary the for Care on Regulation Technical See The comparative analysis of this issue is on page 87. page on is issue this of analysis comparative The 86. page on is issue this of analysis comparative The information. of confidentiality maintain to required are establishment, the of owner or director Peru versus Flores Cruz ( acts of medical and criminalization on of Court confidentiality Human Rights of the Inter-American decision African South Guyana Brazil , Technical Regulations for Humane Abortion Care. Abortion Humane for Regulations , Technical , for example, in addition to those who have contact with the patient, all employees, including the the including employees, all patient, the with contact have who those to addition in example, for , , Guyanese Uruguay , 18 November 2004, FJ 96-103). 2004, , 18 November and and Declaration. 196 Norwegian 194 models. 195 197 198 . Women – and healthandWomen – Colombia 192 193 . which which De De la 199 ( ( ( recommendations: and proposal model in the considered are following keyThe factors risks, procedures, the procedure. the after to expect what and minimum, risks of those consequences a at address, must women to provided health. information reproductive and sexual women’s for barrier an cultural constitute that enormous inequalities gender the dismantle to help can facilities care negotiating health change, for about vehicle a as problems information Using issues. violence, related other and gender-based use contraceptive in manifest often which and women men, between relationships power unequal address to opportunity an important offer can procedure abortion the about information providing consideration, first provided. is information basic the that ensuring and focus rights a guaranteeing information: providing when considerations important two are There effectively. duties counselors, when and who are their an link essential in care, perform information, the provision abortion of comprehensive provides procedure the performing professional medical other or physician the when both exists opportunity This information. quality the entire process of care and a offers to to unique opportunity provide reliable, critical timely and is woman individual an and professional health a between consultation The thereby contributing to women’s empowerment. professionals(asdiscussedbelow) appropriatethatfoster an responsewomen’sto needs, information campaigns must be conducted in conjunction with campaigns targeting healthmanner andmusthelp toreduce therisks ofunsafe abortion andcomplications.its Public which in circumstances and servicesare available. services encouragemust aboutIt information women includetoseek servicestimely ain must public general the to provided 2 2 2 0 0 00 1 2

Mass media and public awareness activities. awareness public and media Mass the availability of services. and abortion legal emphasizing rights reproductive and sexual on Campaigns public. general the at directed activities health public include should Policies The The that focus on sexual and reproductive health, and emphasize legal abortion. legal emphasize and health, reproductive and sexual on focus that about campaigns the new law in Mexico City. In fatherhood. and motherhood responsible and rights, reproductive health, reproductive a also is There situation. a violent The Guidelines). Institute Maternal (Perinatal understood be should In In With the recent decriminalization of abortion in in abortion of decriminalization recent the With Mexico Colombian Peruvian , the government is required to promote and implement integrated training policies on sexual and and sexual on policies training integrated implement and promote to required is government the , regulations establish not only what information should be provided, but also that the information information the that also but provided, be should information what only not establish regulations regulations require that counseling includes specific information for women with HIV/AIDS or in in or HIV/AIDS with women for information specific includes counseling that require regulations 2 0 2 Brazilian abortion regulation addressing women victims of violence. of victims women addressing regulation abortion Colombia Mexico , it is mandatory for the Assembly to conduct outreach outreach conduct to Assembly the for mandatory is it , , nationwide mobilization activities are being , activities conducted mobilization nationwide 199

In relation 2 00 The basic basic The 2 0 to 1 the

V. Recommendations for developing regulations that 177 guarantee access to abortion services V. Recommendations for developing regulations that 178 guarantee access to abortion services 2 10. 2 level of care, and so on. so and level of care, also indicate what of type health for is professional procedures, recommended different access to information and contraceptive and methods) pre- management, pain (including counseling post-abortion prophylaxis, antibiotic pregnancy, examinations, post-abortion of weeks to according to procedure is abortion care for requirements minimum with appropriate the most for specifying technical guidelines implement health compliance professionals guarantee to way best The ( ( ( ( ( guarantee: must basis individual an on of information provision The ( ( ( 2 2 protocols: creating for point starting and Policy Guidance for Health Systems guidelines, published Organization Health World the 2003, In 2 2 0 0 0 0 0 0 7 3 5 6 8 4

Understanding of women’s cultural Understanding Establishment of counseling models that of rape. in cases with into contact come encourage women’s empowerment. be provided. of that the for women legal representatives system example, services, legal abortion must about information provide to that society of of information sectors other of obligation the Emphasize amount minimum the of Identification contraception. emergency and condoms methods, contraceptive permanent and temporary about information including after-effects, and its the procedure and information truthful about Timely awoman’s for decisions. Respect change. legal for support public to generate Actions networks. support social to strengthen Activities services of use in pregnancy. early increase and rights about awareness raise to activities Community Adopting protocols or technical guidelines for care for guidelines technical or protocols Adopting See See In medical abortion), other issues related to abortion procedures (control and prevention of infections, management management of infections, and prevention (control procedures to abortion related issues other abortion), medical analysis, tissue methods, other evacuation, and dilatation curettage, and dilatation aspiration, vacuum abortion, status, surgical management, pain cervix, of the isoimmunization/Rh (preparation methods pregnancy, abortion counseling), and smear, Pap information ectopic infections, conditions, pre-existing ultrasound, tests, laboratory Services Health Reproductive and Sexual for Guidelines Delivery Service and Medical 92-106. pages on is issue this of analysis comparative The Brazil More information on contraceptive methods can be found in International Planned Parenthood Federation (2004) (2004) Federation Parenthood Planned be in found can International methods on contraceptive information More Protocols Protocols should address the following topics, as a minimum: care pre-abortion (medical history, physical examination, Brazil Brazil ’s support model encourages providers to adapt to the woman’s cultural frame of reference. of frame cultural woman’s the to adapt to providers encourages model ’s support , one component of counseling is forrespect the woman’s decisions, no matter what they may be. ’s support model. ’s support 2 2 0 0 , which explores all these issues and is an important 3 8 2

0 5 and intellectual situations. intellectual and 2 0 7 and other Guidelines issues. should 2 0 6 Safe Abortion: Safe . Third edition, London: IPPF. London: edition, . Third 2 0 4

Technical 21 2 ( ( ( ( ( 213 212 211 providers Some of pregnancy. six weeks about beyond pregnancies of ectopic the detection aid can ultrasound available, is it Where 2000). (RCOG the abortion for early of necessary provision not is scanning Ultrasound transfusion…. blood require might that provided be where should feasible, typing especially at group blood higher (Rh) level Rhesus referral and centres, ABO in for case Tests of procedure. complications abortion the to at initiatethe occurs time if and treatment of be prepared haemorrhage or following or provider the enables prevalent is it where in areas anaemia haemoglobin to detect levels haematocrit Measuring evacuation. uterine delay or hinder not should tests such and present the provider is the unsure whether woman However,is pregnant. obtaining clearly not are pregnancy of signs typical the unless needed, be not may pregnancy for physical examination to confirma from the and pregnancy record and woman’s estimate the its from length. obtained Laboratory information testing the require only providers the World testing, Health Regarding laboratory Organization «in has stated: cases, most 0 0 9

In no circumstances should any test be required in order to perform an abortion. an to perform in order required be any test should circumstances no In health providing in involved everyone sectors. private and public the in both country, in the services for mandatory be must guidelines These stages of pregnancy entail different different at abortionslevels of as risk. meet should procedure each needs what appropriate and most are methods which gestation, of weeks determine, according to to important danger,additionalinisgestationalan becomebarrier. reason,itislimitscanthis For abortions. request women and that reasons different the account into take medication mustGestational limits combines that chart a to alleviate provide pain. pain support emotional to For important care. is post-abortion it and management complications managing pain procedures, perform examinations, can professionals pre-abortion health which care, of levels procedures, prophylaxis, antibiotic management, abortion on information Include care. for guidelines technical Implement An explicit prohibition such as this is found in the the in found is this as such prohibition explicit An (2003) Organization Health World See WHO. Chapter: Abortion Methods. Methods. Abortion Chapter: WHO. South Colombia Abortion: (2003) Organization Health World evaluation. decision and monitoring mechanisms, performance, referral and training provider services, making), of (type implementation service (recovery), follow-up complications), of For detailed care guides: World Health Organization (previous footnote), footnote), (previous Organization Health World guides: care detailed For See See Colombia

Africa

Technical and Policy Guidance for Health Systems. Health for Guidance Policy and Technical , Peru 211 and and , which does not establish gestational limits. For systems that consider the circumstances, see see circumstances, the consider that systems For limits. gestational establish not does which , For example, in cases of fetal malformation, or when the woman’slifethemalformation, fetal when of or cases example, in For and and Guyana Brazil . . Safe Abortion: Safe 21 Colombian 0

2 Technical and Policy Guidance for Health Systems Health for Guidance Policy and Technical 0 9 Geneva: WHO. WHO. Geneva: regulation. 212 Colombia , Brazil and and Peru . . Geneva: Geneva: . 213 Safe Safe

V. Recommendations for developing regulations that 17 guarantee access to abortion services 9 V. Recommendations for developing regulations that 180 guarantee access to abortion services 214 facilities outpatient in performed be can complications) large a Consequently, professionals. are no there when trained pregnancy, of weeks first the during (especially of abortions number appropriately by performed is it when The World Health Organization has stated that, in general, abortion is a simple procedure 11. ix. viii. vii. vi. v. iv. iii. ii. i. protocols. biosecurity include also must care for Guidelines of stages at later procedures pregnancy.» abortion during or before helpful technology the find 219 218 217 216 215 include: these 22

0

Cleaning and disinfection areas. disinfection and Cleaning instruments. of reusable Decontamination objects. sharp other and syringes of needles, Disposal based on the proposed educational requirements educational proposed the on based system accreditation of the content and professionals of (certification) accreditation procedure. the after and before personnel for guidelines Hygiene Determining the infrastructure necessary to provide services, mechanisms for the the for mechanisms services, to provide necessary infrastructure the Determining Elimination waste. of contaminated Personnel’s use of protective garments (gloves, goggles, materials. other and Storage of instruments masks, gowns). –sterilization. level disinfection High Antisepsis before the procedure. the before Antisepsis This requires mechanisms to monitor compliance. monitor to mechanisms requires This South In tests. certain require countries Some (2003) Organization Health World WHO. p.24. WHO. individual, such as consultations, therapies, imaging, urgent care, laboratory tests, and so on. According to some some to According on. so and tests, laboratory care, urgent imaging, therapies, consultations, as such individual, the of ‘admission’ require not do that services of group a for care of method the to refer to term the use systems 106-112. pages on is issue this of analysis comparative The Latin in IPPF/WHR. Pregnancy. Unwanted Abortion for and Services Comprehensive of Pregnancy Quality Unwanted the Evaluating of Caribbean. and Management America Integrated the Address to Project Multi-country etc. masks, gloves, of use the on standards international following recommends Regulations on the Operations and Functioning of Health Facilities in Puerto Rico). Care). Abortion Humanefor TechnicalRegulations women the forVoluntary Rh-negative CareInterruption on of Regulation forTechnical Pregnancy). 6.4.2, 6.4.1.3 immunoglobulinand (Art. Rh anti–D determine to administeringtest the not required: but recommended, is is transfusion a case in typing blood Outpatient services are Outpatient services those that services do not require a Some hospital infrastructure. health certification services International Planned Parenthood Federation/Western Hemisphere Region (2007) (2007) Region Hemisphere Federation/Western Parenthood Planned International Africa 214 217 , for example, has developed a guide on the reuse of manual vacuum aspiration equipment and and equipment aspiration vacuum manual of reuse the on guide a developed has example, for , , 215

ae Abortion: Safe Brazil Colombia, : offering blood typing, syphilis and HIV testing (4. Clinical Abortion Care,

Puerto

it is obligatory to provide the option of an HIV test and for and test HIV an of option the provide to obligatory is it ehia ad oiy udne o Hat Systems. Health for Guidance Policy and Technical

Rico requires an Rh and antibody test (Art. H, General H, (Art. test antibody and Rh an requires 218 , 219 22 0 that comply with minimum with comply that 216 The most important of important most The rmtn Ra Otos A Options: Real Promoting New York: New Geneva: Geneva: 222 221 level university professionals medical facilities work. where the the training at ongoing at and education include education of types important most two The cultural and barriers. to help eliminate stereotypes also can and levels various at provided be should Education issues. social and ethical addresses that and women’s empowerment that encourages perspective rights and a gender with care health of delivery the on also but procedures abortion on only not – training and education specialized receive should services abortion providing in involved personnel In order to provide integrated care that truly encourages the exercise of allrights, health 12. III. reproductive and sexual services. health outpatient other for required those to similar requirements . 0. . . . . . II.

Medical and psychosocial training/education psychosocial and Medical The comparative analysis of this issue is on page 114. page on is issue this of analysis comparative The period care. a outpatient for considered is it 24 than hours, treatment less is period surgical time the If 24 than hours. and/or greater medical receive to hospital a into entrance means admission definitions, Continuing training is the responsibility of facilities that provide abortion services. abortion provide that facilities of responsibility the is training Continuing professionals health of training and education the to related barriers eliminate to Measures quality standards quality and rights guaranteeing quality: totorelated eliminateservice barriers Measures system based on the proposed educational requirements educational proposed the on based system for mechanisms the (certification)accreditation ofand professionals content of theaccreditation services, provide to necessary infrastructure the Determining care for guidelines technical or protocols Adopting general the to services clients to information individual providing and public promote to information of dissemination Systematic Cultural considerations services of privacy and confidentiality medical Confidentiality, objection Conscientious consent Informed 221 222

Professional

V. Recommendations for developing regulations that 181 guarantee access to abortion services V. Recommendations for developing regulations that 182 guarantee access to abortion services ( ( ( ( recommendations: and proposal model in the considered are following keyThe factors customary attitudes and practices that education and training can help to eliminate. about a woman’s decision to end a pregnancy, are just two of the stereotypes and harmful woman’s decision. Requiring a husband or partner’s consent, or making moral judgements differentoptionsunwantedonfor a for pregnancy, withrespect emotionaland support counseling with women provide personnel that ensure should focus gender and rights A violence.gender-based as suchsituations special address and detect can they that so to reduce or eliminate gender stereotypes in health care but must also sensitize personnel shouldreceive training ongender, rights, bioethics andempowerment. Training canhelp In addition, physicians, midwives, nurses, counselors, social workers and administrative the require staff services teams. organized in multi-disciplinary of professionals of arange involvement abortion clear, make recommendations these As provision). pre- and prophylaxis, antibiotic and (surgical complications, abortion examinations procedures and managing counseling post-abortion (including contraceptive counseling abortion management, include pain must medical), training technical minimum, a As the professionals who provide abortion services meet medical accreditation requirements. associations are ideal for these types of initiatives. 226 225 224 223 ( ( (

dcto ms peae elh rfsinl t poie mtoa spot to support emotional provide to professionals health prepare must Education aspects. technical health as well as focus rights for and gender a include training must training and Education and education continuing professionals. encourage must hospitals, and universities with collaboration in divisions, departmental other and Municipalities work. professionals facilities where the at education Ongoing and comprehensive abortion care in their academic programs. academic in their care abortion comprehensive and Involve faculties of medicine so that they incorporate health sexual and reproductive services. to provide teams of multi-disciplinary creation the Encourage limit or harmful are that rights. of their women's exercise practices and attitudes eliminate to help must Training women. Professional associations should play an important educational role in many areas on this issue: academic debate, debate, academic issue: this on areas many in role educational important an play should associations Professional The The in training personnel See Italy with compliance monitoring providers, on. so and Congress, for training reports writing regulations, certification, provider for criteria defining argument, scientific Italian : Regulation for the Social Protection of Motherhood and Voluntary Interruption of Pregnancy (1978). Pregnancy of Interruption Voluntary and Motherhood of Protection Social the for : Regulation 225 regulations identify universities, among others, as responsible for training health personnel. health training for responsible as others, among universities, identify regulations 224 Brazil , which emphasizes sensitization. emphasizes , which 223 Education and training must ensure that 226 227 and services improve to used be should – research or evaluations records, medical from enquiry that would undoubtedly help to improve abortion care. All information – whether rape and its relationship to as wellabortion, as are other issues, just some of the areas of of problem the of magnitude the abortions, request who women the of circumstances the services, abortion safe of benefits and costs the on Research complications. reduce to help can services legal to access timely how determine particular,to in and, abortion about knowledge expand to tool essential an as encouraged be should Finally, research services. evaluating abortion of component essential an is received has she care health the of evaluation client’s the including on), so and records, medical of management appropriate collection, data of oversight example, (for facilities health at practice routine a be may evaluations care of quality of care issues and the evaluation of both facilities and providers. Although quality address must regulations abortion and crucial is quality service dilemmas, attendant its which are and critical in this Infield.as asprovisionan abortion, complex area ofservice Data management must also draw on other sources, including service quality evaluations, client data. socio-demographic and provision service to barriers on information comprehensive include also should it complications; and procedures on statistics to reduced be not should reporting However, women. to provided of services the timeliness and quality to inservice monitor order complications as – mechanisms and include – reporting of procedures for monitoring part system the codifying epidemiological must management Data country. each in systems collection data care health existing the in included are statistics abortion-related that crucial is it current data. Given this concern, and the difficulties of collectingdata relating to Good public health can decisions only abortion, be made when they are on based high quality and 13 IV. . III. .

Data management Data systems oversight and monitoring collection, data to related barriers eliminate to Measures The comparative analysis of this issue is on page 118. page on is issue this of analysis comparative The Measures to eliminate barriers related to the education and training of health health of training professionals and education the to related barriers eliminate to Measures Medical and psychosocial training/education psychosocial and Medical 227

V. Recommendations for developing regulations that 183 guarantee access to abortion services V. Recommendations for developing regulations that 184 guarantee access to abortion services 14. ehnss n lc ta esr cmlac wt te euain ad i particular, in and, regulations the with compliance ensure that place in mechanisms put therefore, must, officials health level Senior system. health the within entities and regulations individuals all However, from compliance guarantee to mechanisms services. effective without abortion useless are of provision the for requirement important extremely an is services abortion of aspects psychosocial and technical the Regulating ( ( ( ( ( ( ( ( ( following: the include systems management of information Key elements others. among of rights, exercise the for conditions improved and standards, quality improved mechanisms, compliance and regulations of improvement including levels, various on change create to tool a as 233 232 231 229 228 ( ( recommendations: and proposal model in the considered are following keyThe factors services. abortion to legal access timely guarantee 23 0

Monitoring, compliance and oversight systems of individual facilities of individual systems oversight and compliance Monitoring, audits. clinical and monitoringlegible), and complete is it that (so recorded is information includingwhatrecords, medical appropriate ofmanagementfor systems Implement overall and services. quality ofClient provider evaluations full decisions. their and women for including respect services, of timeliness and quality the and themselves evaluate they how and conditions, working their view they how quality: of evaluations Provider standards. quality with facilitiescomply that to ensure Systems accurate. reliable and availabletransparent, information that is public toEnsure the basis. aregular on information of this dissemination Public Information should be sent to a central statistical system complications Reporting data. service abortion collecting for System Establish which entities or officials will conduct oversight activities. oversight will conduct officials or entities which Establish services. to abortion related requirements and of activities Establish data management systems to periodically collect information on compliance See See deaths. maternal Including Guyana 121. page on is issue this of analysis comparative The Spain Colombia Spain (Order of 16 June 1986, Art. 1). Art. 16 of 1986, June (Order , Colombia , where the format is annual reports. annual is format the , where , Guyana and and , Spain Spain , South have done so. done have 229

Africa and infections to monitoring systems. to monitoring infections and Colombia and and Norway (Circular 0031 of 2007). 2007). of 0031 (Circular . 228 23 0 for timely decision making. 231 233 232 24 239 238 237 236 235 234 boards. ethics medical by prohibited be should which of confidentiality, which or law by create allowed a burden disproportionate on women. those These penalties must also address violation than other requirements of imposition the and delay Penalties should be defined by lawand address failure toprovide services, ( ( ( ( ( ( ( ( . . IV. 0

Establish mechanisms to begin proceedings to impose penalties. to impose proceedings to begin mechanisms Establish or failure to comply. services denial of for penalties Define of Health. Ministry over the away tooversight as maintain body legislative parliament the to reporting obligatory establish to mechanisms Create facilities. and services of health monitoring community for mechanisms Create providers. abortion Establish measures to eliminate employment or social discrimination against resort. of last body the as board governing other or deny that decisions against services appeal to facilities health within mechanisms Create provision. of service timeliness Monitor services. delay would that requirements administrative additional of imposition the preventing in vigilant Be See the the See See See note 188. 188. note See Colombia Italy asuperior. to sent immediately is case the denied, is abortion Norway See Decree 4444 of 2006 of 4444 Decree See systems Measures to eliminate barriers related to data collection, monitoring and oversight Monitoring, compliance and oversight systems of individual facilities of individual systems oversight and compliance Monitoring, management Data Mexico . Colombian has the broadest appeal mechanism. One of its most interesting aspects is that it is automatic: when an an when automatic: is it that is aspects interesting most its of One mechanism. appeal broadest the has 234 . Art. 7 of Decree 4444 of 2006. of 4444 Decree 7of . Art. , Guyana with higher authorities, up to and including the highest health officials officials health highest the including and to up authorities, higher with Uruguay , Guyanese , Colombia Declaration. . Colombia 235 , Norwegian , Peru . , Brazil , Brazilian and and Norway and and . Mexican models. 237 238 24 239 0

236 unnecessary

or other

V. Recommendations for developing regulations that 185 guarantee access to abortion services V. Recommendations for developing regulations that 186 guarantee access to abortion services ( ( ( ( ( recommendations: and proposal model in the considered are following keyThe factors health. reproductive and of sexual in matters holders rights and to to that create adolescents recognizeguarantee mechanisms free services them as to revised be also should adolescents for policies Payment care. expensive more require of the needs – clients not should clients medical inbe more charged if other words, they – and if should fees, establish any, in accordance with ability to pay and not based on the country each in allowed as – sectors private and public the to apply must policy fee The option. an is resources fewer with women subsidize to resources greater with women require that cross-subsidization and fees scale sliding although all, to free be ideally should Services payment (fees, coupons, sliding scale fees, vouchers) co-pays, relationship, levels, socio-economic cost-benefit lowest the at women high for free a have services abortion Because 15. V. 243 242 241 246 245 244

funding costs: to related barriers reduce to Measures medical needs of the clients. of the needs medical the not and pay to ability with accordance in scale sliding a on be should fees Any rights to access. abarrier becoming from costs to prevent mechanisms Develop reproductive and sexual as holders. adolescents recognize to mechanisms Create adolescents. for services free Provide women. poorest the for services free Provide Create a fee policy afee Create Timely and safe abortion care has numerous positive impacts both on health systems and on women. In contrast, contrast, In on women. and systems on health both impacts positive numerous has care abortion safe and Timely These recommendations on costs should also be applied to the provision of contraceptive methods after an an equity. increase to seek after that reforms sector health of methods principle a basic is This contraceptive of provision the to applied be also should costs on recommendations These These are some of the terms used for the (out-of-pocket) payments women must make in return for services. for return make in must women payments (out-of-pocket) the for used terms the of some are These abortion in order to decrease unwanted or unplanned pregnancies, repeated abortions and complications. and abortions repeated pregnancies, unplanned or unwanted decrease to order in abortion Mexico 2000. DC, Washington Bank, World the at given aspeech From Brasilia. of University (by system health the at the of Economics for and of Brazil, Professor Brasilia, Governor Buarque, Former Cristovan costs complications). of reducing reduction a and abortions) unsafe to due deaths protection the avoiding in (by lives results human care of abortion providing Consequently, levels. various at costs act creates to greater failing avoid that of to result way the order are in a costs in those action’: act omitted to the of Failing ‘costs called is costs. what in enormous results impacts creates positive manner timeliest the in provided not is that care 128. page on is issue this of analysis comparative The and and Colombia specifically provide free services for poor women at public hospitals. public at women poor for services free provide specifically 241 246 243 and in no circumstance should should circumstance no in and 244 be a barrier to access. 242

they should 245 be

25 249 248 247 of just name to number consent, party third and a committees ethics creating professionals, by medical authorization examinations, medical forensic authorization, judicial Additional mayrequirements include filingcriminal charges (whenis abortion not legal), 17 women. on burdens to disproportionate or services barriers additional impose to attempt not does that environment an facilitate and occurring from situations of types these prevent therefore must regulations Abortion services. to access limit to arguments ‘scientific’ using by complex more them make or access regulate to services. provisions to administrative issue institutions health and authorities health national both services, abortion access can women when govern laws Although VI. be should care. but health providing for used mechanisms general services, abortion receiving population the classify specifically to need do not mechanisms These and which should pay should receive free for services services. pay as determined by an a called system SISBEN. As to services. ability population’s a for on based is pay Colombia in pay to services abortion of afford cost to the example, cannot capacity who women populations’ to preference specific give to identify order to in used be should instruments These 16. . . V. . 0

of different populations of different Avoid additional requirements for abortion services abortion for Avoid requirements additional Creating and implementing instruments to identify the socio-economic situation situation socio-economic the to identify instruments implementing and Creating See Chapter IV of the comparative analysis for the definition of SISBEN on page 130. page on SISBEN of definition the for analysis comparative the of IV Chapter See each in system financing system’s health the of performance the on depends measure this of usefulness The The comparative analysis of this issue is on page 130. page on is issue this of analysis comparative The 130. page on is issue this of analysis comparative The country. individual barriers administrative reduce to Measures Measures to reduce barriers related to costs: funding to costs: related barriers to reduce Measures of different populations of different situation socio-economic the to identify instruments implementing Creating and policy afee Create

These measures often attempt to restrict the legal grounds for abortion abortion for grounds legal the restrict to attempt often measures These 247 , 248 249 This identifiessystem which populations 25 0

V. Recommendations for developing regulations that 187 guarantee access to abortion services V. Recommendations for developing regulations that 188 guarantee access to abortion services

that when a medication (misoprostol, in many countries, for example) is registered, but but registered, is example) for countries, many in (misoprostol, medication a when that countries various of experiences the from clear is it decision, this make cannot facilities health individual Although grounds. health public on process registration the begin to In countries where these medications are not registered, mechanisms should be established 19. grounds. of these application broader a equality for allow to be gender should criteria such and of objective justice The perspective. social rights, human a from manner comprehensive and interpret to in or a (the maytemporary) grounds broad latter be structural professionals health or socio-economic health help that criteria define to important therefore is It of illness. absence the merely not and well-being social and mental physical, of state a as health of definition Organization’s Health World the with accordance in be or whole a as woman a at look may not that of pathologies list a become often exception health of the Interpretations 18. request, woman’s requirements. any other without the at performed be should abortion an weeks, 12 first the During of services. provision the delay that boards or professionals multiple of involvement the avoid and requirements and few. a 254 253 252 251 initiate to mechanisms the expand the necessary indication and guarantee its availability should authorities health obstetrics, and gynecology include not do usages indicated its

World Health Organization, particularly misoprostol and mifepristone and misoprostol particularly World Organization, Health are required for a legal abortion alegal for required are Create conditions for the use of medications recommended for abortion by the by the abortion for recommended of medications use the for conditions Create grounds such when abortion, for grounds of the interpretations Avoid restrictive In In The comparative analysis of this issue is on page 141. page on is issue this of analysis comparative The broader Organization’s Health health. of World definition the to according restrictive are that grounds health on definitions include 139. page on is issue this of analysis comparative The rape. of cases in report apolice or specialization) specifying (without certificate Colombia Peru 251 In all cases, it is important to favor the implementation of simple procedures procedures simple of implementation the favor to important is it cases, all In , for example, the Protocol of Hospital Belén de Trujillo and the Perinatal Maternal Institute Guidelines Guidelines Institute Maternal Perinatal the and Trujillo de Belén Hospital of Protocol the example, for , ’s model is one of the simplest in terms of the requirements established by the court case: medical medical case: court the by established requirements the of terms in simplest the of one is model ’s 253 252 254

258 257 256 255 less or costs higher consistent of basis the on complementary as listed be also may and/or facilities, monitoring training are needed. specialist and/or care, medical or specialist diagnostic specialized which for diseases, priority for medicines. list complementary essential the of on misoprostol included has Organization Health World The effects.’» and use product’s of the records to base its use on firmscientific rationale and onsound medical evidence, and to maintain product, the about well informed to be have responsibility they the labelling, approved the in not indication their an for product a to use physicians If judgement. according and knowledge best drugs... available legally use physicians that interests require best patient the the of and practice medical ‘Good that: Drug stated and has Food which States Administration, United the by example, for fairly accepted, is is and approved practice, those the common than of other contractions indications for producing drugs in of effective use [However,] and uterus…. heat-stable cheap, is it by that for accounted fact be the may popularity Its (46%). labour induce to and (57%) abortions it to of in used evacuate death (61%),intrauterine fetal case the uterus of in missed case they that replied physicians countries, three in conducted America. misoprostol of Latin use on in survey obstetricians and gynaecologists by use wide in currently is of and in Gynecology Misoprostol Obstetrics of edition in the latest FLASOG, this recommendation. Health Organization support World the and Societies/FLASOG) Gynaecology and Obstetrics of Federation American y de Both Obstetricia Ginecología de the (Latin Latino Sociedades Americana Federación hemorrhage. of obstetrics-related procedures. abortion for

In the Explanatory Notes, the Notes, Explanatory the In Faúndes, Faúndes, A (ed) (2007) C-355 Case in for provided circumstances the in abortion for of the Welfare, use in of Social authorized the of misoprostol Office Ministry Health request Public the National Health Organization. Health treatment. for safe and cost-effective and potential relevance, health public future and estimated of current on basis the conditions. are selected conditions priority for Priority medicines cost-effective and safe efficacious, most the listing system, care health basic a The medicines. classifying lists of types two the defines FLASOG. Societies/ Gynaecology and Obstetrics of hemorrhage. obstetrics-related gynecology/obstetrics. INVIMA. than other purposes for laboratory a by previously registered product a of indication the broadening of concept the used and reasons health public on based was request Ministry’s The The use of this medicine should be encouraged for gynecology/obstetrics indications other than abortion, such as such abortion, than other indications for gynecology/obstetrics encouraged be should medicine of this use The In Colombia , the Review Committee of the National Institute for Drug and Food Surveillance (INVIMA), at the the at (INVIMA), Surveillance Food and Drug for Institute National the of Committee Review the , Use of in Misoprostol and Obstetrics Gynecology. 258 255 World Health Organization Model List of Essential Medicines Essential of List Model Organization Health World «The Indicated usages should include the general management management general the include should usages Indicated

The complementary list defined in notes is defined these list by also managed the World The complementary 256 opeetr list complementary , stated: , «Therestated: is no doubt that misoprostol core , which decriminalized abortion in some circumstances. some in abortion decriminalized which list presents a list of minimum medicine needs for for needs medicine minimum of list a presents Second Edition. Latin Federation American presents essential medicines medicines essential presents

In case of doubt medicines medicines of doubt In case (revised March 2005) 2005) March (revised

Act 20 of 2007. of 20 Act 257

In Use Use a

V. Recommendations for developing regulations that 18 guarantee access to abortion services 9 1 9

V. Recommendations for developing regulations that 0 guarantee access to abortion services 21. 20. medicines. of essential World Organization’s the Health on list included are Antioxytocics. and Oxytocics 22, 22.1) (Number section in list complementary Oxytocics the on appear respectively), 200µg and 200mg of settings.» (composed misoprostol and mifepristone and 25µg), of variety a in cost-effectiveness attractive 259 . 0. . . . VI.

judiciary the and media, education, including key other with sectors, Involve coordinate and efforts rolein prevention their to strengthen in order pharmacies targeting campaigns information conduct should authorities Health services. seeking women for facility health to appropriate an referrals timely and accurate information Establish mechanisms and strategies to convert pharmacies into allies that provide into provide alliesthat pharmacies to convert strategies and mechanisms Establish It is worth noting that it is the only medicine to appear with the notation: «Where permitted under national law law national under permitted «Where notation: the with appear to medicine only the is it that noting worth is It and where culturally acceptable.» culturally where and for women seeking services. Health authorities should conduct information information conduct prevention in role should their strengthen to order in authorities pharmacies targeting campaigns Health services. seeking that women allies for into pharmacies convert to provide accurate information and timely strategies referrals to an appropriate health facility and mechanisms Establish mifepristone and misoprostol particularly World Organization, Health the by abortion for recommended medications of use the for conditions Create abortion alegal for required are of when such Avoidinterpretations the grounds for grounds abortion, restrictive services abortion for Avoid requirements additional barriers administrative to reduce Measures the judiciary the and media, education, including sectors, key other with coordinate and Involve efforts 259 Health professionals should be trained in the use of all medicines that that ofall medicines use the in trained be should professionals Health

iorso (aia tbe of tablet (vaginal Misoprostol ( ( followingsteps: the include strategy in any advocacy keySome elements particularly decriminalized. is it where in circumstances divisions, abortion false to avoid access foster different that to strategies and abortion discuss of legalization order the for strategies to in between rights important women’s is advance it to addition, strategies In regulations. such with compliance enforcing and creating for commitment political of level the determine to country each in the situation towards the analyze working must are regulations that abortion Groups comprehensive of reproduction. implementation to limited not are that rights - sexuality of area the in rights women’s of breadth the expand to seeking region the in groups for resource a as serve can publication this strategies, advocacy to respect With providers. for asolid framework and certainty provide to and access, to ensure that women can exercise their sexual and rights, reproductive regulations for services: abortion recommendations on the many measures that should be considered when creating health the information provided in the comparative analysis, this tool also includes a model with those that as serve barriers or create burdens on disproportionate women. In addition to wellas features as highlighting information their in on best regulations countries, other clear providing by makers decision for tool reference a as serve to aims publication This other and providers. care health nurses include doctors, of should associations which professional local strategies, with advocacy alliances developing clear establish to and groups society with closely civil work to critical equally is It policy-making. favorable encourage will that information to access have officials health that toensure important is it reason, this For agenda. health public the within issues these This services. abortion safe there when is to social and address political pressure strengthened is commitment often to access timely enable that conditions the create to and rights reproductive and sexual clear women’s a support to requires officials health ones from existing commitment improving or regulations health effective Establishing note Final and his or her position on abortion regulations. abortion on position her or his and influence actor’s can the of who extent the levels: two determine least at and on based involved issue the influence actors different the of characteristics the Map of rights. exercise the encourage Analyze the country context and a establish path for securing health regulations that

measures to measures help eliminate barriers and promote 1

V. Recommendations for developing regulations that 9 guarantee access to abortion services 1 1 9

V. Recommendations for developing regulations that 2 guarantee access to abortion services right to safe and legal abortion to use these tools. tools. these to use abortion legal and toright safe encourages decision makers IPPF/WHR and committed to advocates women’s supporting ( ( ( efforts to advocate for the implementation of abortion regulations. of abortion implementation the for to advocate efforts in obstetricians) and midwives (including associations professionals’ health Involve services. of denial abortion or negligence Involve legal ininterested professionals high impact litigation to respond to claims of debate. of the focus the as code, penal the not health, public emphasize abortion; decriminalize to on aspects legal on work work that those and that access of movement aspects medical the women’s the of parts those among coordination Foster Index of laws and regulations Index of laws and regulations

Country Law or regulation Source Topic

Bolivia1 Penal Code (1972) Government Establishes conditions for access Seguro Universal Materno Infantil (2002) Congress No information relevant to the topic Protocolo para la Atención de la Mujer Embarazada Ministry of Health Incomplete and septic abortion care Paquete de Servicios Mujer Embarazada Ministry of Health Incomplete and septic abortion care Brazil2 Norma técnica: Atenção humanizada ao abortamento Ministry of Health Medical care for all types of abortions, including legal (2005) abortion: consent, procedures, privacy, etc Norma Técnica: Prevenção e tratamento dos agravos Ministry of Health Medical care for abortion in cases of sexual violence resultantes da violência sexualcontra mulheres e adolescentes (2005) Norma Técnica: Prevenção e tratamento dos agravos Ministry of Health Medical care for abortion in cases of sexual violence resultantes da violência sexual contra mulheres e adolescents (2002) Portaria nº 48 de 13 de Agosto de 2001 (Inclusão para Ministry of Health Includes manual vacuum aspiration procedures for reembolso pelo SUS) reimbursement Canada R versus Morgentaler (1988) Supreme Court of Canada Decriminalization of abortion Tremblay versus Daigle (1989) Supreme Court of Canada Women’s autonomy Civil Liberties Association versus British Columbia Supreme Court of British Economic issues (1988) Columbia Morgentaler versus Prince Edward Island (1995) Supreme Court of Prince Edward Economic issues Island Colombia Decreto que reglamenta Aspectos de Salud Sexual y Ministry of Social Welfare Availability of services, establishes that technical Reproductiva (2006) regulations are compulsory, conscientious objection, prohibition against discrimination, sanctions Resolución que adopta Norma Técnica (2006) con Ministry of Social Welfare Enacts the technical regulations, codifies procedures, data Anexos collection, oversight and professional education Norma Técnica IVE (2006) Ministry of Social Welfare Methods, intake and follow-up Acuerdo CNSSS que incluye procedimientos (2006) National Council on Social Includes procedures in the health system Security in Health Circular 031 de 2007 con Información sobre la provisión Ministry of Social Welfare Reporting of approved and available institutions, clarifies de servicios seguros de interrupción voluntaria del some data collection issues embarazo, no constitutiva del delito de aborto (2007) Acta de aprobación uso de medicamentos (2007) See National Institute for Drug and Approves misoprostol point 2.9.39 Food Surveillance (INVIMA) Guyana Medical Termination of Pregnancy Act (1995) All aspects of termination of pregnancy Medical Termination of Pregnancy Regulations (1995) Counseling, approval of facilities, medical authorization, data Italy3 Norme per la tutela sociale della maternita’ e Congress Access, privacy, gestational limits sull’interruzione volontaria della gravidanza (1978) Mexico Penal Code (2004) – see amendments below Requirements in accordance with grounds for abortion and right to information Modificación Código Penal (2007) Mexico City Legislative Allows abortion before 12 weeks Assembly Código de Procedimiento Penal (2004) Permission in cases of rape or non-consensual insemination and right to information Ley de Salud Pública (2004) – see amendments below Mexico City Legislative Access to services at public facilities, informed consent, Assembly conscientious objection Modificación Ley de Salud Pública (2007) Mexico City Legislative Clarifies that services are free, sexual and reproductive Assembly health policies Index of laws and regulations

Country Law or regulation Source Topic

Lineamientos Generales de Organización y Operación de Mexico City Health Department Requirements based on grounds for abortion, medical los Servicios de Salud relacionados con la Interrupción personnel, conscientious objection, facilities, procedures, del Embarazo en el Distrito Federal (2006) que modificó informed consent, relationship to other departments una circular anterior (2002) – see amendments below Reforma Lineamientos Generales de Organización y Mexico City Health Department Defines some concepts, requirements to access abortion, Operación de los Servicios de Salud relacionados con la reports, requirements for facilities, waiting times, medical Interrupción del Embarazo en el Distrito Federal (2007) files, confidentiality Acuerdo para Procedimiento en caso de Violación Attorney General of Mexico City Procedure to obtain permission from the Ministry in cases of (2006) que reformó acuerdo anterior (2002) rape, procedure for minors not in agreement with parents Norway Termination of Pregnancy Act (1975, amended in 1978) Grounds and duration of pregnancy, facility and professional that may perform abortions, informed consent, administrative procedures, conscientious objection Regulation for the Implementation of the Act concerning Administrative procedure for abortions Termination of Pregnancy (1975) Panama4 Penal Code (1982) Congress Requirements for abortion: grounds, professionals, permission from the National Multidisciplinary Commission on Therapeutic Abortion Oferta de Servicios de Salud del Sistema de Protección Ministry of Health Post-abortion treatment, oversight and follow-up (does not Social (2005) indicate what care consists of) Resuelto Nº 02007 de agosto 2 de 1988 del Ministerio Ministry of Health Orders the creation of the National Multidisciplinary de Salud (1988) Commission on Therapeutic Abortion Resolución 1 de abril de 1989 de la Comisión National Multidisciplinary Requirements for abortion access, consent, waiting times, Multidisciplinaria Nacional de Aborto Terapéutico (1989) Commission on Therapeutic professionals that may perform abortions, facilities where Abortion abortions may be performed, when the commission meets and its powers Peru5 Penal Code (1924) Congress Grounds for abortion, requirement for informed consent and that a doctor performs the abortion Guía de Atención Integral en Salud Sexual y Ministry of Health Post-abortion care (treatment of obstetric hemorrhages Reproductiva (2004) associated with abortion), treatment of incomplete abortion with different complications (includes family planning counseling), also includes treatment for women with incomplete abortion Manual de Orientación/Consejería en Salud Sexual y Ministry of Health Post-abortion counseling, content of counseling (p.23), Reproductiva (2006) specialized counseling for adolescents that does not explicitly include abortion (p.31) Plan General de la Estrategia Sanitaria Nacional de Ministry of Health Chapter on adolescents’ sexual and reproductive rights, Salud Sexual y Reproductiva (2004) including integrated abortion care with specific services (p.6); care for adults, which only includes post-abortion care (p.7); one objective is to improve incomplete abortion care (p.8); special sexual and reproductive health services for adolescents, which only includes incomplete abortion and complications Estrategia Sanitaria Nacional de Salud Sexual y Ministry of Health Does not address abortion Reproductiva Directiva del Instituto Materno Perinatal (2007) National Perinatal Maternal Therapeutic abortion Institute (repealed) Protocolo de Manejo de Casos para la Interrupción Legal Hospital Belén de Trujillo Therapeutic abortion del Embarazo (2006) Gynecology Department Informe técnico Misoprostol General Office of Medications, Approves purchasing of medications by the Pharmacological Supplies and Drugs Commission of the Perinatal Maternal Institute for missed and incomplete abortion Index of laws and regulations

Country Law or regulation Source Topic

Resolución Directorial 1988 (2003) General Office of Medications, Authorization of Prostokos Supplies and Drugs, Ministry of Health Guía de Práctica Clínica de Emergencias Obstétricas, Ministry of Health Procedures for complete abortion, inevitable/incomplete según nivel capacidad resolutiva (2007) abortion, missed abortion and infected abortion relating to equipment, tests and procedures, manual vacuum aspiration protocol; post-abortion counseling (although it does not address legal abortion, only incomplete abortion) Puerto Reglamento General para la Operación y Government of Puerto Rico, Requirements for medical facilities and doctors, availability Rico6 Funcionamiento de las Facilidades de Salud en Puerto Health Department for emergencies, facilities’ authority to create their own Rico (1999) protocols, anesthesia, tests ) Ley de Facilidades de Salud (1965) Authority of the Health Department to regulate ‘places where abortions are performed’ Proyecto para Reglamentar el Licenciamiento, Operación Health Department Health facility licenses, facilities’ statistics, inspection, y Mantenimiento de Facilidades de Salud Ambulatorias internal organization and regulations, medical personnel, (Centros de Planificación Familiar y Terminaciones de tests, requirements for health facilities, infection control, Embarazo) program to improve quality, and data collection and management South Africa Choice on Termination of Pregnancy Act (1996) Parliament Circumstances and conditions when pregnancy can be terminated, places where abortions can be performed, personnel authorized to perform abortion, information, consent of minors Amendment (2004) Parliament Authorities and personnel that can perform abortions Circular H97/2000 (2000) Health Department Primary care, referrals, information, procedures, conscientious objection, medical personnel, post-abortion management, counseling, infection control, biosecurity standards, information systems Spain7 Penal Code (1985) Congress Gestational limits, specialists, consent, authorization Ley General de Consentimiento Informado (2002) Congress Informed consent Real Decreto sobre Centros Acreditados y Dictámenes Ministry of Health Requirements for access Preceptivos para la Práctica de Abortos Legales (1986) Orden de 16 de junio de 1986 sobre Estadística e Ministry of Public Health and Collection of abortion data Información Epidemiológica de las Interrupciones Consumer Affairs Voluntarias del Embarazo realizadas conforme a la Ley Orgánica 9/1985 (1986) Resolución de 4 de febrero de 2000, de la Subsecretaría, Ministry of Public Health and Forms for data collection sobre Estadística e Información Epidemiológica de las Consumer Affairs Interrupciones Voluntarias del Embarazo realizadas conforme a la Ley Orgánica 9/1985, de 5 de julio (2000)

1 Abortion is legal in cases of sexual violence, incest, rape, health or life of the woman. Maternal infant insurance (SUMI) is a comprehensive medical care package. 2 Abortion is legal only to save the life of the woman and in cases of rape or incest. Authorization is on a case by case basis when fetal malformations incompatible with life are present. 3 Before 90 days for health, life of the mother, familial socio-economic conditions, circumstances of the conception or fetal problems. After 90 days: life of the mother and fetal malformation. 4 In Panama, there are two important health laws – the Health Code and the Health Policy – which could possibly address termination of pregnancy but do not include any provisions on the topic. 5 In Peru, there are extensive health regulations on sexual and reproductive health, especially emergency contraception. 6 Abortion is legal in the same circumstances as in the USA. Services are free in cases of rape or incest. 7 Abortion is allowed to save the life or health of the woman, fetal malformations or rape. Index of documents

Index of documents

Title Author Topic

Health systems and the right to health: an assessment of 194 Backman, Gunilla; Hunt, Paul; Khosla, Rajat; et al. Right-to-health features of health countries. The Lancet. 372(9655), pp.2047–2085 (2008). systems, health service indicators Invoking Conscientious Objection in Reproductive Health Care: Casas, Lidia C Conscientious objection in Latin America Evolving Issues in Latin America. Thesis for the degree of Master of Laws, Graduate Department of Law, University of Toronto (2005). Objeción de conciencia médica. Bogotá (2005). Castillo Vargas, Elizabeth Conscientious objection in Colombia La objeción de conciencia al aborto: su encaje constitucional. Cebría García, María Conscientious objection in Spain Gaining Ground. A Tool for Advancing Reproductive Rights Law Center for Reproductive Rights Sexual and reproductive rights and Reform. Chapter X: Adolescents’ Reproductive Rights (2006). adolescents Implementing Adolescent Reproductive Rights Through the Center for Reproductive Rights Sexual and reproductive rights, Convention on the Rights of the Child (1999). adolescents and access to services Transparency in the delivery of lawful abortion services. Canadian Cook, Rebecca Government obligations, transparent Medical Association Journal. 180(3), pp.272-273 (2009). access to legal abortion services Human rights dynamics of abortion law reform. Human Rights Cook, Rebecca and Dickens, Bernard Abortion law reform, health and human Quarterly. 25, pp.1-59 (2003). rights Declaración sobre secreto médico. Uruguay (2007). Faculty of Medicine of the University of the Reiteration of obligation on physicians Republic, the Arbitration Tribunal of the Sindicato and health personnel to maintain Médico del Uruguay (SMU) and the Ethics Board of medical confidentiality the Federación Médica (FEMI) Uso del Misoprostol en obstetricia y ginecología. Federación Latino Faúndes, Aníbal (editor) Misoprostol use in Latin America Americana de Sociedades de Obstetricia y Ginecología (2007). Uso del Misoprostol en Obstetricia y Ginecología. Federación Latino Federación Latino Americana de Sociedades de Misoprostol doses in different cases Americana de Sociedades de Obstetricia y Ginecología (2007). Obstetricia y Ginecología Instructions for Use of Misoprostol for Treatment of Incomplete Gynuity Health Projects and Reproductive Health Misoprostol doses Abortion and Miscarriage. Gynuity Health Projects and Technologies Project Reproductive Health Technologies Project (2004). Medical and Service Delivery Guidelines for Sexual and International Planned Parenthood Federation Sexual and reproductive health issues: Reproductive Health Services (2004). contraception, sterilization, fertilization, HIV, safe abortion and others Entre la espada y la pared: el secreto médico y la atención pos McNaughton, Heathe Luz; Padilla, Karen Z; Physicians reporting women who have aborto. Ipas Centroamérica. Nicaragua (2004). Hernández, Emilia; de Hernández, Patricia; Ramírez, abortions in El Salvador Patricia Misoprostol use in obstetrics and gynecology. Outlook. 21(4) (2005). PATH. Herdman, Cristina (editor) Misoprostol in the United States Penal Code Norway (1902). Legal classification of sexual abuse Too Far to Walk: Maternal Mortality in Context (1994). Thaddeus, Sereen and Maine, Deborah. Published in Study on factors that affect maternal Social Science and Medicine mortality in developing countries The Evolving Capacities of the Child (2005). UNICEF Innocenti Research Centre Comprehensive study on the concept, application and models on the evolving capacities of children to encourage them to make their own decisions Convention on the Rights of Persons with Disabilities (2006). United Nations Declaration of the rights of persons with disabilities Safe Abortion: Technical and Policy Guidance for Health Systems. World Health Organization Abortion care protocol Geneva (2003). WHO Model List of Essential Medicines, 14th edition (March 2005). World Health Organization List of essential medications Challenges and possibilities for innovative praxis in health and Yamin, Alicia Ely Human rights approach to service human rights: reflections from Peru. Health and Human Rights. 6(1), delivery pp.35-62 (2002). International Planned Parenthood Federation / Western Hemisphere Region 120 Wall Street, 9th Floor, New York, NY 10005 Tel 212 - 248 - 6400, Fax 212 - 248 - 4221 Email [email protected], Web www.ippfwhr.org