Pan American Journal Review of Public Health

Sexual and reproductive rights for contraception in Bolivia, Colombia and Uruguay in the framework of human rights*

Kathya Lorena Cordova-Pozo,1 Graciela Cordova-Pozo,2 Ana Monza,3 Gabriela Píriz,3 Diva Moreno-Lopez4 and Ivan Cardenas4

Suggested citation (original article): Cordova-Pozo KL,Cordova-Pozo G,Monza A, Píriz G,Moreno-LopezD, Cardenas I. Derechos sexuales y reproductivos para la anticoncepción en Bolivia, Colombia y Uruguay en el marco de los derechos humanos. Rev Panam Salud Publica. 2017;41: e140. doi: 10.26633/RPSP.2017.140

ABSTRACT Objective. Compare World Health Organization (WHO) guidelines for contraception in a human rights framework with the existing regulatory frameworks of Bolivia, Colombia, and Uruguay and evaluate which aspects of those regulations need to be developed. Methods. A systematic analysis was based on the WHO analytical framework “Ensuring human rights in the provision of contraceptive information and services: Guidance and recom- mendations” to determine whether the legislation of Bolivia, Colombia, and Uruguay contain general references to the population, specific referen­ces to adolescents, or do not refer to the topic. To this end, 36 documents related to contraception were analyzed: 9 from Bolivia, 15 from Colombia, and 12 from Uruguay. Results. It was confirmed that each country’s legislation complies with several WHO recom- mendations. The three countries have strengths in nondiscrimination and in opportunity for informed decision-making, and have weaknesses in accessibility, quality, and accountability. Acceptability is a strength in Colombia and Bolivia, and confidentiality is a strength in Bolivia and Uruguay. Colombia has weaknesses in avai­lability, confidentiality, and participation. Conclusions. Comparison of national legislation with WHO guidance helps to see the strengths and weaknesses of national regulatory frameworks and to see opportu­nities to improve regulations.

Keywords Contraception; legislation; health legislation; Bolivia; Colombia; Uruguay; adolescent; human rights.

Sexual and reproductive health (defined as 11-19 year olds). Actions Colombia, 13% of adolescent girls are (SRH) is a critical issue for adolescents during this stage can have conse- married, and 20% girls under the age of quences for the rest of their lives, such 18 have already carried a pregnancy to 1 South Group, Cochabamba, Bolivia. Send corre- as adolescent motherhood, and sexu- term (1). In Uruguay, the number of spondence to: Kathya Lorena Cordova-Pozo. ally transmitted infections (STIs), in- births in adolescent mothers is 16.4%; Email: [email protected] 2 Hospital Seton, Cochabamba, Bolivia. cluding human immunodeficiency only 3.6% of mothers are in a favorable 3 Administración de los Servicios de Salud del virus (HIV). The adolescent population economic environment and 22.4% are Estado (ASSE), Montevideo, Uruguay. 4 Ministerio de Salud y Protección Social, Bogotá, is 22% in Bolivia, 18.4% in Colombia mothers are in unfavorable economic Colombia. and 15.3% in Uruguay. In Bolivia and environments (2).

* Non-official English translation revised by the authors. In case of discrepancy between the two versions, the Spanish original shall prevail.

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Rev Panam Salud Publica 41, 2017 1 Review Cordova-Pozo et al. • Sexual and reproductive rights for contraception

With regards to HIV, 31.5% of the were collected and reviewed; nine from cultural diversity (16). Raising aware- study population in Bolivia and 26% in Bolivia, 15 from Colombia and 12 from ness of adolescent health and training in Colombia know about HIV, 8.9% in the Uruguay (Annex 1). The analysis was differentiated services are also promoted urban area and 17.6% in rural areas. The multidisciplinary and per country; con- (17). Colombia’s sexuality policy is artic- prevalence of HIV in the population ducted, by a Bolivian political economist ulated within national and international aged 15-24 years is 0.3% in Bolivia and and a medical doctor; by a Colombian norms on sexuality and SRHR (11), 0.5% in both Colombia and Uruguay (1). adolescent technical leader and a special- which helps to achieve common objec- The prevalence of modern methods of ized professional of the Ministry of tives in other laws (Primary Health Care, contraception is 33.7% in Bolivia, 72.7% Health and Social Protection; and by a the Ten-year Public Health Plan 2012- in Colombia and 74.8% in Uruguay; con- Uruguayan psychologist and a gynecolo- 2021, the General System of Social Secu- doms being the least popular method: gist from the SRH area of the​​ public rity in Health (GSSS, Law 100/93). This 4% in Bolivia, 7% in Colombia, and 30.8% system. regulates the Plan of Basic12Attention in Uruguay (1). These statistics are simi- and STI/HIV and unwanted pregnancy lar throughout South American coun- RESULTS prevention programs through informa- tries, with differences between regions, tion, education, communication and use rural-urban areas, and socio-economic The results are presented in numerical of the male condom, guaranteeing the contexts, since South America has high order under the WHO’s analytical frame- free access of adolescents to contracep- levels of inequality that hinder social in- work, entitled “Human Rights Respect tive services (18-21). Uruguay focuses on clusion and sustainable growth (3). when providing contraceptive informa- creating contraceptive and fertility treat- The Montevideo Consensus urges tion and services: guidance and recom- ment protocols for the population (13). Governments to change their legislation mendations” (WHO, 2014) (Table 1)a1. in order promote of sexual and reproduc- 2) Availability of contraceptive tive health and rights (SRHR) (4). This 1) Discrimination in the provision information and services [2.1] Consensus is a strategic framework for of contraceptive information and advancing the Program of Action of the services [1.1-1.2] Bolivia provides yearly a planning for International Conference on Population provision and storage based on a pro- and Development in Cairo in 1994 and The three countries have regulations to grammatic goal for each health facility the Latin American and Caribbean Con- ensure access to contraceptive information and is added at the municipal, local, de- sensus on Population and Development and services without discrimination [1.1]. partmental, and national levels (8) to adopted in Mexico in 1993. In Bolivia all healthy adolescents are eligi- strengthen the National Single Supply The aim of this manuscript is to com- ble for any contraceptive method after System and the Medicines Logistics Ad- pare the recommendations of the World guidance and counseling, and the guide- ministration Subsystem and Inputs, Health Organization (WHO) (5) to pro- lines recommend designing of friendly es- which ensure the provision of materials, vide contraceptive information and ser- tablishments that take care of regional and medicines and contraception (16). No vices with the normative framework of cultural particularities to favor the access specific regulations were found for Col- Bolivia, Colombia and Uruguay, evaluat- and use of contraceptives by multiple us- ombia. Uruguay has regulations for pur- ing contraceptive legislation and high- ers, including adolescents (8,9). Colombia chases that revise, consolidate and lighting the aspects necessary to develop guarantees SRHR, freedom of violence, estimate needs annually, based on the and achieve respect for human rights. equality, autonomy and without discrimi- previous consumption coordinated by nation due to sex, age, ethnicity, sexual ori- the SRH departments, ensuring access METHODS entation, gender identity, disability, and quality of care (22, 23). religion or victims of armed conflict (10,11). A systematic analysis and evaluation Colombia detects and addresses risk fac- 3) Accessibility of contraceptives was carried out based on the analytical tors, promotes protective factors for ado- information and services [3.1-3.10] framework, circumscribed in the WHO lescents (12). Uruguay recommends the document ¨Respect of human rights when universalization of primary care in sexual The three countries meet 4/10 sub-rec- providing contraceptive information and and reproductive health (SRH) with inte- ommendations but there is a lack of im- services: guidance and recommendations¨ grality, quality, opportunity, and commit- proved access for displaced populations (2014) (Table 1). The legislation of Bolivia, ment of human resources and adequate and those living in crisis [3.4]. There is Colombia and Uruguay were reviewed to information systems, guaranteeing univer- also a lack of mobile services for those see if they contain general references to sal access to contraception (13,14). facing geographical barriers [3.8]. the population, specific references for ad- All three countries support laws and The three countries have regulations olescents, or no reference to these recom- policies with established programs [1.2]. for comprehensive sexuality education mendations. Similar studies have already Bolivia focuses on discrimination-free (CSE), indicating that educational insti- been carried out under this methodology services (15) and is based on basic princi- tutions and health centers are required (6,7). The analysis only presents the exist- ples of the right to life such as physical for education, SRH guidance, and re- ing legislation and not its degree of integrity, gender and generational eq- sponsible and SRHR-free exercise [3.1]. implementation. uity, participation, solidarity, social For Bolivia, HIA must be consistent with Thirty-six documents including laws, justice and reciprocity with respect to decrees, resolutions, policies, guidelines 1 This program frames both the Collective a In this manuscript the numbers in brackets refer Intervention Plan (PIC) and the Obligatory Health and manuals related to contraception to the item listed in table 1. Plan (POS)

2 Rev Panam Salud Publica 41, 2017 Cordova-Pozo et al. • Sexual and reproductive rights for contraception Review

TABLE 1. Comparative analysis of legislation under the WHO analytical framework “Ensuring human rights in the provision of contraceptive information and services” (WHO, 2014)

Summary of the WHO Recommendations Bolivia Colombia Uruguay 1. Non-discrimination 1.1 Guarantee access to information and services 1.2 Legal and political support to the established programs 2. Availability 2.1 Available supply of medicine and contraception 3. Accessibility 3.1 Provision of comprehensive sexual education 3.2 Eliminating financial barriers 3.3 Interventions to improve access to users with difficulties 3.4 Interventions to improve access to displaced populations 3.5 Information and services as part of HIV test and treatment 3.6 Provision of contraception as part of antenatal and postpartum care 3.7 Integrate the provision of contraception with abortion/post-abortion care a 3.8 Mobile outreach services to populations that face geographical barriers 3.9 Eliminating third-party or spousal authorization requirements b b 3.10 Eliminating parental authorization for adolescents 4. Acceptability 4.1 Include gender-sensitive counselling, skill building tailored to needs 4.2 Priority to follow-up services and side-effects c 5. Quality 5.1 Quality assurance processes 5.2 Insertion and removal services, counselling on side-effects 5.3 Competency-based training and supervision of health-care personnel d d d 6. Informed decision-making 6.1 Scientific evidence for informed choice 6.2 Informed choice without discrimination 7. Privacy and confidentiality 7.1 Confidentiality and privacy of individuals 8. Participation 8.1 Participation in the programme and policy design, implementation and monitoring. 9. Accountability 9.1 Effective accountability mechanisms, remedies and redress: individual/ systems Evaluating and monitoring to guarantee the highest quality and respect 9.2 to human rights Legend: orange specific normative guidance pertaining to general population and to adolescents; yellow specific normative pertaining to general population only;green specific normative guidance pertaining to adolescents only; gray normative guidance for that recommendation is not present in the country legislation. a Abortion is illegal in Bolivia b Colombia and Uruguay have legal provisions but the normative tells that consent has to be requested. c Uruguay has no legislation on side-effects management d Bolivia, Colombia and Uruguay have no legislation to monitoring personnel Source: Comparative analysis based in the WHO document, 2014

physical and psychological development autonomy for responsible exercise of information and services for the general (17), the families must also be educated SRHR and life as a couple, and the social population and adolescents [3.2]. These (16). Colombia promotes self-knowl- security system offers specialized ser- services include intrauterine devices edge, self-esteem, and expression sexual vices for adolescents (25). Uruguay fo- (IUD), oral contraception (including identity while being treated with fair- cuses on training teachers in schools and emergency contraception, which in Bo- ness, respect, and allowance of a harmo- SRH services for counseling and preven- livia is only available at pilot centers) nious family life and according to tion of STIs in all age groups (13,14). Uru- and condoms. Implants are not univer- psychological, physical needs as appro- guay promotes reduction of unwanted sally available (8,13). In Bolivia, contra- priate for age (24,25). Where the family pregnancies through teaching about ception is free, part of the family planning and school are obliged to the formation, proper condom use (26,27). and HIV/AIDS/STI programs (16), pre- orientation and stimulation of the exer- All three countries guarantee free, se- venting the cost of service and contra- cise of rights, responsibilities and cure and reliable access to contraceptive ception from limiting the options

Rev Panam Salud Publica 41, 2017 3 Review Cordova-Pozo et al. • Sexual and reproductive rights for contraception available to adolescents (28). Colombia health, including for girls (35). In Uru- Regarding follow-up services and side aims for the prevention of STIs/HIV and guay, voluntary abortion is decriminal- effects [4.2]: Bolivia has the following unwanted pregnancies with free distri- ized and post-event contraception priority tracking services for contracep- bution of reversible methods of contra- counseling is provided (34). tive side effects: a) eight week follow-up ception to the population in health None of the countries have regulations post initial consultation and further fol- facilities, in the social security system on mobile services to reduce geographi- low-up every three months for consulta- and where sexual acts are performed cal barriers [3.8]. tion on consistency of method use, and (brothels) (18-20,29). Elimination of authorization of the side effects; b) twelve months later for a Uruguay has universal access to safe spouse or third parties [3.9]: In Bolivia, pelvic examination, cervical cancer or and reliable reversible contraception. any woman or man can undergo long- STI screening, , and assessing for side ef- Permanent contraceptives are reserved term or permanent sterilization in a safe fects of each method (8.28). Colombia, on for persons over 18 or married, divorced manner, prior to counseling and in- the other hand, focuses a follow-up of or widowed women. (13-14); in private formed consent, without consent of their adolescents vulnerable to method adher- clinics condoms are given for twelve partner (8); co-responsibility is encour- ence (20). Uruguay promotes follow-up months for a small fee (26). Adolescent aged for adolescents, but if they attend with a gynecologist three months after access the method and a promotion and alone, they must give the necessary in- starting a contraceptive method (39) but prevention consultation in SRH, is dis- formation and can choose the desired has no regulations for the management tributed by vending machines (26). Fe- method, even if their partner has not of side effects. male condoms can also be distributed consented (28). Colombia and Uruguay from vending machines (27,30). emphasize free decision and autonomy, 5) Quality of contraceptive None of the countries have regulations although they refer to the fact that it is information and services [5.1-5.3] to improve access to the rural and urban common practice to ask the authoriza- poor [3.3]. Colombia and Uruguay pro- tion of the partner for consent in the case Bolivia and Colombia do not have vide information and access to adoles- of female sterilization, but not for male norms in quality assurance processes cents on contraception and condom use sterilization (11,34). [5.1]. In Uruguay, the Ministry of Health as part of the vulnerable population The three countries have regulations for defines contents, plans awareness activi- (20,26). Colombia focuses on improving not requiring parental consent for the ado- ties and training references for profession- the health of vulnerable groups, adoles- lescent; age is not a medical reason for de- als to improve the quality of care (13). cents and those who have scarce re- nying SRH counseling or access to In the case of Bolivia and Uruguay, sources (31). contraception [3.10] (21,26,28,36). All three they do not show norms for IUD inser- None of the countries studied have offer reversible methods on request. Bo- tion and removal services or implants regulations to improve access for the dis- livia pays special attention to the provision [5.2] nor for advice on side effects. Col- placed or those in crisis scenarios [3.4]. of non-reversible methods (28). Colombia ombia offers the application and removal The three countries have regulations for also guarantees access to information and of the IUD and insert of the implant and universal access to prevention and com- education (20,37). Uruguay offers some advises on side effects (29). prehensive treatment of STIs and HIV/ services respecting the progressive auton- All three countries have staff training AIDS, providing information, counsel- omy of the adolescent (13,38). based on competencies [5.3]. Bolivia fo- ing and delivery of condoms, with test- cuses on providing guidance and care ing and treatment of the general 4) Acceptability of contraceptive with qualified personnel for the under- population and adolescents [3.5] (8,18,19, information and services [4.1-4.2] standing, and management of current 26,27). Bolivia promotes the use of con- contraceptive policies and standards, its doms to avoid STI transmission (8). Col- All three countries have regulations to application in the promotion of SRHR ombia focuses on STI counseling and provide acceptable information and ser- and access to counseling and services (8) treatment for pregnant women (21). Uru- vices based on needs, gender-sensitive for adolescents. Staff should have train- guay contextualizes adolescents, gender counselling, particularly for adolescents ing in communicating with adolescents, and their sexual practices (27). [4.1] (12,13,28). Bolivia indicates orienta- families, and the general to ensure ac- All three countries have regulations tion and listening based on the adoles- ceptable comprehensive care, and to en- for contraception to prevent unwanted cent’s concerns to use a contraception, sure impartiality without making value and postnatal pregnancy [3.6] fosters co-responsibility, generates nego- judgments (28). Colombia indicates that (8,20,26,32,33). Uruguay focuses on tiation skills, reports on effectiveness and medical or nursing professionals should counseling of adolescents, instructions side effects, follows-up consultations, be trained in IUD insertion and removal, on the correct use of condoms and other and provides services for both married counseling and obtaining informed con- recommendations to prevent recurrence and single individuals (8,28). In Colom- sent (29). Uruguay focuses on the ade- of unwanted pregnancies (26). bia, adolescents are a cross-cutting part quate training of technical aspects, All three countries have regulations of their policy and the social determi- information provision, skills for commu- for the provision of post-abortion contra- nants to eradicate discrimination based nication and treatment provision; psy- ception [3.7] (8, 20,34). In Bolivia, abor- on gender, STI and HIV/AIDS, and dis- chologist, and sexual assault services tion is illegal, except in the cases of rape, crimination based on sexual orientation (13), orientation training, and condom incest, or to protect the woman’s health. or gender identity (12). Uruguay focuses delivery (26). Bolivia, Colombia and Abortion is legal in Colombia in the case on the training of health personnel for Uruguay do not have regulations for per- of rape, incest, or to protect the woman’s informed choice (13). sonnel supervision.

4 Rev Panam Salud Publica 41, 2017 Cordova-Pozo et al. • Sexual and reproductive rights for contraception Review

6) Informed decision-making 7) Privacy and confidentiality [7.1] through Information Analysis Commit- [6.1-6.2] tees in Bolivia (16), Social Protection In- Bolivia and Uruguay have regulations formation System in Colombia, and the The three countries have regulations to regulate and respect privacy and con- incidence and mechanisms of HIV/STI/ that promote information and advice on fidentiality (13,16,31,40). Bolivia focuses AIDS transmission in Uruguay (13). contraception in order to allow users to on adolescents (28) while Uruguay fo- Bolivia focuses on knowledge for reas- make their own informed choice, giving cuses on guaranteeing the quality and signing budgets and achieving goals adolescents the freedom to choose after privacy of individuals (13). Colombia fo- (17). Colombia focuses on ensuring re- receiving information on available con- cuses on confidentiality and privacy in spect for freedom of thought, free expres- traception, advantages, disadvantages, general, not explicitly pertaining to con- sion in sexuality and reproduction, and consequences of so that an individual traception for adolescents (31). minimizing judgments in health care can choose based on their needs [6.1] processes through political, religious or (8,11,30). Bolivia focuses on unwanted 8) Participation [8.1] cultural positions (11). Uruguay has su- pregnancy prevention, the spacing of pervision of institutions providing SRH children (16) and comprehensive ado- In Bolivia, there are norms for partici- with Coordinating Teams of Reference to lescent care (9). Colombia values per​​ - pation in health and SRH with local guarantee benefits established in Law sonal decision as the maximum youth councils and social control groups 18,426 with monitoring and evaluation, expression of individual and citizen to guarantee the quality of services (31). with identification of barriers, facilita- freedom in lay contexts with knowl- The standard provides training for tors, coordination and users to monitor edge, reason, discernment, will, as- young people to exercise their rights, de- benefits and elaborate evaluation mecha- sumption of limits and consequences of cision making, and self-management of nisms (43). decisions (11). For adolescents, focus is their health and life projects. on systematic use of a chosen contracep- The contraceptive standard promotes DISCUSSION tive method (20). Uruguay focuses on community participation in the promo- age, lifestyle, values, pattern of sexual tion of SR&R and intersectoral activities, This study verified that the legisla- activity and acceptability of the method indicating that participation and co-re- tion of the three countries complies while highlighting safety, efficacy, com- sponsibility are shared between the State, with a number of WHO recommenda- fort and accessibility (30). This is based society and youth for the creation, execu- tions for contraceptive information and on gender, rights and diversity for the tion and control of social transformation services in the framework of human exercise of a pleasurable, free and re- political, economic and cultural policies, rights (5). All three countries have sponsible sexuality (26). (31). Colombia has a regulation to orga- strengths in non-discrimination [1] and The three countries have regulations nize an intersectoral National Commis- spaces for informed decision-making for free decision making on the correct sion to promote and guarantee research [6]. Its weaknesses are in accessibility use of contraception, tolerance and im- and development comprised of govern- [3], quality [5] and accountability [9]. provement in their quality of life for ment units, not including adolescents or Acceptability [4] is a strength for Col- adolescents and the general population the general population (41). Uruguay ombia and Bolivia; confidentiality [7] is [6.2]. Bolivia focuses on intercultural promotes inter-institutional coordination for Bolivia and Uruguay. Colombia has adaptation and respect for women’s with the participation of social networks weaknesses in availability [2], confi- self-determination, where the WHO in- and users to exchange information, dentiality [7] and participation [8] (Ta- tervenes to facilitate the exercise of health education and solidarity support ble 1). rights over the use of contraception, and active participation in the imple- The challenges of these countries lie in recognizing and respecting their ability mentation and monitoring of actions in reforming the laws to optimize contra- to make decisions (8,16). Any adoles- SRH (13,42). ceptive provision in a human rights cent can have a contraceptive consulta- framework and to make contraception tion; the health services must respect 9) Accountability [9.1-9.2] inclusive of the general population and that right and help evaluate the deci- adolescents (Table 2). Improving legisla- sion of the professional, individual, or No country has accountability mecha- tion must address an articulated envi- couple (28). For Colombia, informed nisms with respect to contraceptive in- ronment based on weaknesses and consent means that people can say they formation and services provided, strengths of the national context and of were told and know about reversible including means of compensation to the the health, education, economy and com- and contraceptive long-term effects, individual. munity system so that it can be effec- and can freely choose or change their All three countries have evaluation tively and equitably implemented (3). decision before the procedure without and supervision systems to guarantee This review is built on similar analyses consequence (20). Uruguay leaves the quality, but only Colombia has an evalu- in Paraguay and South Africa (6,7). To- choice of the method to the adolescent ation and supervision system to guaran- gether with Paraguay, Bolivia, Colombia and the professional advises and ac- tee human rights. In Bolivia, Colombia, and Uruguay, they recognize that adoles- companies this process explaining the and Uruguay, regulations were found to cents have special needs and require spe- reasons that support or discourage the strengthen management, monitoring, cific legislation on contraception from the use of the method based on evidence evaluation, implementation control, and perspective of human rights from which (26). policy objectives through data collection the population also benefits. The four share

Rev Panam Salud Publica 41, 2017 5 Review Cordova-Pozo et al. • Sexual and reproductive rights for contraception similar challenges in accessibility [3], qual- TABLE 2. Opportunities to strengthen the legislation in Bolivia, Colombia and ity [5], participation [8] and accountability Uruguay [9] and being signatories of the Montevi- deo Consensus could work in multina- Availability [2], accessibility [3] of contraceptive information and services: tional consensuses to improve these areas. - Col: Integrate contraception within the essential medicine supply chain to increase availability [2.1] One limitation of this study is that it - Bol: Create interventions for the rural residents, urban poor [3.3] analyzes the normative framework and - Bol / Col / Uru: Include interventions to displaced populations and in crisis settings [3.4] not its implementation. Actions taken to - Bol / Col / Uru: Include mobile services to reduce geographical barriers [3.8] improve contraceptive services and in- - Col / Uru: Explicitly state that no spousal authorization is needed [3.9] formation, as well as the challenges that Acceptability [4], quality [5], confidentiality [7] of contraceptive information and services: each country faces due to its health sys- - Uru: Include normative for side-effects management [4.2] tem, socioeconomic situation, taboos, de- - Bol / Col: Include quality assurance processes [5.1] gree of implementation of laws - Bol / Uru: Include the provision of long-acting reversible contraception, insertion and removal [5.2] and non-recognition of the rights can - Bol / Col / Uru: Explicitly include normative for supervision [5.3] make a country comply with the WHO - Col: Include normative to respect confidentiality and privacy of individuals [7] recommendations. Future studies could Participation [8] and accountability [9] of contraceptive information and services: carry out the analysis of the implementa- - Col: Include participation in the programme and policy design, implementation and monitoring. [8] tion and the limitations for comprehen- - Bol / Col / Uru: Include accountability mechanisms, remedies and redress [9.1] sive contraceptive provision. - Bol: Include evaluation and monitoring to respect human rights [9.2] It is concluded that the comparison of Bol., Bolivia; Col., Colombia; Uru., Uruguay the national legislation of Colombia, Bo- Each number in square bracket can be compared with table 1 livia and Uruguay with the WHO guide Source: Based on the WHO (2014) document and the review of legislation to contraception shows strengths and weaknesses in the national and regional commitment on development promotes Declaration. The opinions expressed normative framework to find opportuni- good practices towards a quality service. in this manuscript are the responsibility ties to strengthen legislation. A norma- of the author and do not necessarily tive framework that guarantees respect Conflicts of interest. None stated by ­reflect the criteria or the policy of the for human rights endorses the political the authors RPSP / PAJPH and / or PAHO

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Rev Panam Salud Publica 41, 2017 7 Review Cordova-Pozo et al. • Sexual and reproductive rights for contraception

RESUMEN Objetivo. Realizar una comparación entre las Directrices de la Organización Mundial de la Salud (OMS) para la anticoncepción en el marco de los derechos humanos (DDHH) con el marco normativo existente en Bolivia, Colombia y Uruguay y evaluar Derechos sexuales y los aspectos que son necesarios desarrollar en la normativa. reproductivos para la Métodos. Se realizó un análisis sistemático con base al marco analítico de la OMS ¨Respeto de los DDHH cuando se proporciona información y servicios de anticoncep- anticoncepción en Bolivia, ción: orientación y recomendaciones¨ para determinar si la legislación de Bolivia, Colombia y Uruguay en el Colombia y Uruguay contienen referencias generales a la población, referencias marco de los derechos específicas para los adolescentes o no hacen referencia. Para este fin, se analizó un total de 36 documentos relacionados con la anticoncepción: 9 de Bolivia, 15 de Colombia y humanos 12 de Uruguay. Resultados. Se verificó que la legislación de cada país cumple con varias recomenda- ciones de la OMS. Los tres países tienen fortalezas en la no discriminación y el espacio para las decisiones informadas; sus debilidades están en la accesibilidad, la calidad y la rendición de cuentas. La aceptabilidad es una fortaleza para Colombia y Bolivia; la confidencialidad es para Bolivia y Uruguay. Colombia tiene como debilidad la dis- ponibilidad, la confidencialidad y la participación. Conclusiones. La comparación de la legislación nacional con la guía de la OMS ayuda a ver las fortalezas y las debilidades en el marco normativo nacional y ver opor- tunidades para mejorar la normativa.

Palabras clave Anticoncepción; legislación; legislación sanitaria; Bolivia; Colombia; Uruguay; adoles­ cente; derechos humanos.

RESUMO Objetivo. Comparar as diretrizes da Organização Mundial da Saúde (OMS) para contracepção como parte dos princípios dos direitos humanos com os enquadramen­ tos regulamentares existentes na Bolívia, Colômbia e Uruguai e avaliar os elementos Direitos sexuais e destes enquadramentos que precisam ser melhorados. reprodutivos de Métodos. Realizou-se uma análise sistemática segundo a metodologia analítica des­ crita no documento da OMS ¨Respeito aos direitos humanos ao prestar informações e contracepção na Bolívia, serviços sobre contracepção: orientação e recomendações com o propósito de verificar Colômbia e Uruguai como se as legislações da Bolívia, Colômbia e Uruguai fazem referências gerais à população, parte dos princípios dos referências específicas aos adolescentes ou não fazem referências. Ao todo, 36 docu­ mentos sobre contracepção foram analisados: 9 provenientes da Bolívia, 15 da direitos humanos Colômbia e 12 do Uruguai. Resultados. Verificou-se que as legislações dos três países cumprem com diversas recomendações da OMS. Não discriminação e oportunidade para decidir de forma esclarecida são os pontos fortes e acessibilidade, qualidade e prestação de contas são os pontos fracos. A aceitabilidade é um ponto forte na Colômbia e Bolívia e a confiden­ cialidade, na Bolívia e Uruguai. Disponibilidade, confidencialidade e participação são os pontos fracos na Colômbia. Conclusão. A comparação das legislações nacionais com o guia da OMS possibilita identificar os pontos fortes e fracos no enquadramento regulamentar nacional e encon­ trar oportunidades para melhorar.

Palavras-chave Anticoncepção; legislação sanitaria; Bolívia; Colômbia; Uruguai; adolescente; direitos humanos.

8 Rev Panam Salud Publica 41, 2017