ABSTRACT

In recent decades, decisive events shaping the political and social context surrounding abortion in Argentina culminated in the passing of the Voluntary Termination of Pregnancy (IVE in Spanish) Law in December 2020. The objective of this article is to explore the main barriers to accessing legal abortions in the public health system faced by women during 2019 and 2020 in two Argentine jurisdictions: Rosario and the Autonomous City of Buenos Aires. Based on an adaptation of the “three phases of delay” framework, surveys and semi-structured interviews with 117 women were conducted. Study participants reported difficulties in accessing information about the places and people to turn to for abortions, and most stated that pregnant individuals lack information regarding their legality. Although the majority of interviewees reported positive experiences with health services, they also identified some administrative and institutional barriers.

KEY WORDS:
Abortion; Health Services Accessibility; Argentina

INTRODUCTION

Over the last decades, Argentina saw a process of gradual visibilization and legitimation concerning the right to abortion, and a process of an increasing demand for access to abortion on certain grounds under the statutory framework in force since 1921. These advances are evidenced in successive documents and technical guidelines elaborated by Argentina’s National Ministry of Health since 2007,¹1. Ministerio de Salud de la Nación. Guía técnica para la atención de los abortos no punibles [Internet]. 2010 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/579v2xrx .
https://tinyurl.com/579v2xrx... ^,22. Ministerio de Salud de la Nación. Protocolo para la Atención Integral de las personas con derecho a la interrupción legal del embarazo [Internet]. 2015 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2p89xv9z .
https://tinyurl.com/2p89xv9z... ^,33. Ministerio de Salud de la Nación. Protocolo para la atención integral de las personas con derecho a la interrupción legal del embarazo: Actualización 2019 [Internet]. 2019 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2s4y9r7a .
https://tinyurl.com/2s4y9r7a... ⁾ as well as the rules adopted in various jurisdictions to establish the conditions required to have access to abortion, under the provisions contained in the Penal Code, the rulings by the Supreme Court of Justice, and the technical guidelines issued by the World Health Organization (WHO) for safe abortion care.⁴4. Gebruers C. El aborto legal en Argentina: la justicia después de la sentencia de la Corte Suprema de Justicia en el caso “F.A.L.” [Internet]. Buenos Aires: REDAAS; 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/bde5fat3
https://tinyurl.com/bde5fat3...

In this context, which was referred to as a “procedural turn,”⁵5. Bergallo P. La lucha contra las normas informales que regulaban el aborto en Argentina. En: Cook R, Erdman J, Dickens B, (editores). El aborto en el derecho transnacional: Casos y controversias. México: Fondo de Cultura Económica; 2016.⁾ no prior court authorizations were required to have access to a legal termination of pregnancy (hereinafter, ‘ILE’) [Interrupción Legal del Embarazo], and progress was made toward access to legal abortion on statutory grounds, but with unequal realities for each province.

Despite this greater openness, there were still obstacles and resistances to guarantee access to legal termination of pregnancy within the health system. These barriers included, for example, court actions against national and provincial protocols, or imposing limits to abortion provision according to arbitrary criteria and intentions of health authorities and/or health care workers.⁶6. Hopp C. El caso “pro familia”: militancias y resistencias en torno al aborto legal. Derecho PCP. 2009;63:95-138.⁾

Other processes converged to enable a progressively broader access to abortion. On the one hand, experiences of health care approaches in different jurisdictions⁷7. Teppaz D. Las interrupciones legales de embarazos como práctica integrada en los servicios del sistema de salud [Internet]. Buenos Aires: REDAAS; 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/vcfvbyke.
https://tinyurl.com/vcfvbyke.... ; dissemination of self-managed abortion encouraged by women groups like Lesbians and Feminists for Abortion Decriminalization [Lesbianas y Feministas por la Descriminalización del Aborto]⁸8. Lesbianas y Feministas por la Descriminalización del Aborto. Todo lo que querés saber sobre cómo hacerse un aborto con pastillas. Ciudad Autónoma de Buenos Aires: Ediciones Madres de Plaza de Mayo; 2012.⁾ and Socorrismo⁹9. Socorristas en Red. Sistematización de acompañamientos a abortar [Internet]. 2020 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/3z8aautk .
https://tinyurl.com/3z8aautk... ; creation of professional networks within the public sector committed to guaranteeing the right to legal abortion, like Access to Safe Abortion Network (REDAAS) [Red de Acceso al Aborto Seguro] and Professionals for the Right to Choose Network [Red de Profesionales por el Derecho a Decidir]; and commercial availability of misoprostol for induction of labor as authorized by the Federal Department of Health, which can be sold upon prescription filed with pharmacies following a special filing mechanism and can be used in public health services - Resolution No. 6726/2018 adopted by the National Administration of Drugs, Foods, and Medical Devices (ANMAT) [Administración Nacional de Medicamentos, Alimentos y Tecnología Médica] -, as well as the production of 200 micrograms misoprostol by a state-owned laboratory.

As part of this process, in the year 2018, a fundamental change in the political and social context took place, which was marked by the first debate on decriminalization and legalization of abortion held in Argentina’s Congress. That debate promoted the circulation of information and arguments coming from the legal, social, and health research spheres to the whole society.¹⁰10. Karstanje M, Ferrari N, Verón Z, Gherardi N, Romero M, Ramos M. De la clandestinidad al Congreso: Un análisis del debate legislativo sobre la Ley de Interrupción Voluntaria del Embarazo en Argentina [Internet]. Buenos Aires: REDAAS; 2019 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2s3hmv2h .
https://tinyurl.com/2s3hmv2h... Moreover, the feminist and women movement was established as a key actor in the political scenario and public debate, being in the spotlight even in spheres where the topic had not been addressed within the media and the public opinion. In addition, social mobilization called large sectors of society in favor of a legal change and increased the bases of support, engaging the youth and new allies in the ordinary political world. This whole experience led to a counterattack by the conservative sectors, articulated around new health, legal, and ethical arguments, as well as new strategies of incidence and social mobilization, with a visible level of organization.¹¹11. Karstanje M, Ferrari N, Verón Z. Posverdad y retrocesos. Un análisis de las estrategias discursivas de los grupos antiderechos en el debate legislativo sobre aborto en Argentina [Internet]. Buenos Aires: REDAAS; 2019 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/4huzj7mv .
https://tinyurl.com/4huzj7mv... ⁾

The confluence of these changes, together with the continuous demand for women movements, resulted in the passage of Act No. 27610 on access to Voluntary Termination of Pregnancy (hereinafter, ‘IVE’) [Interrupción Voluntaria del Embarazo] in December 2020.

The new scenario after such an enactment required new strategies and arguments that consider the obstacles to access abortion that had been observed in the scenario existing before this new piece of legislation. Bearing this in mind, the aim of this article is to identify the barriers faced by pregnant individuals to have access to legal and safe abortion in the public health system in two Argentine jurisdictions: Rosario and the Autonomous City of Buenos Aires, during 2019 and 2020. These jurisdictions were chosen because they both have a long trajectory in public policies regarding access to legal termination of pregnancy before the passage of the above-mentioned act.¹²12. Fernández Vázquez S. Políticas públicas de aborto en transición: de las consejerías pre y post aborto a las interrupciones legales del embarazo en el Área Metropolitana de Buenos Aires. Revista de Bioética y Derecho. 2018;43:145-160.^,1313. Ministerio de Salud de la Ciudad de Buenos Aires. Salud sexual y reproductiva en la ciudad de Buenos Aires: Situación y respuesta 2019 [Internet]. 2020 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2p9sc5f6 .
https://tinyurl.com/2p9sc5f6... ^,1414. Romero M, Moisés S. El aborto en cifras [Internet]. Buenos Aires: REDAAS; 2020 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2xzjhc7u .
https://tinyurl.com/2xzjhc7u... ^,1515. Honorable Concejo Municipal de Rosario. Ordenanza No, 8.186 [Internet]. 2007 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/4mbxm72u .
https://tinyurl.com/4mbxm72u...

Considering the political process in Argentina over the last years, and particularly the outcome that was the legalization of abortion at the end of 2020, the results of this study are intended to offer a situation diagnosis prior to the passage of the act, as a baseline for the barriers in access to abortion. In this way, our goal is to contribute to the follow-up of the implementation of the public policy flowing from Act No. 27610 and provide empirical research that can be used in upcoming studies on the impact of the new piece of legislation.

CONCEPTUAL FRAMEWORK

Based on the barriers identified in literature dealing with abortion,¹⁶16. La Mesa por la Vida y la Salud de las Mujeres. Barreras de acceso a la Interrupción Voluntaria del Embarazo en Colombia [Internet]. 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/3hdfruwf .
https://tinyurl.com/3hdfruwf... ^,1717. DePiñeres T, Raifman S, Mora M, Villarreal C, Foster DG, Gerdts C. ‘I felt the world crash down on me’: Women’s experiences being denied legal abortion in Colombia. Reproductive Health. 2017;14(1):133.^,1818. Baum S, DePiñeres T, Grossman D. Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion. International Journal of Gynaecology and Obstetrics. 2015;131(3):285-288.^,1919. Erdman JN. Harm reduction, human rights, and access to information on safer abortion. International Journal of Gynaecology and Obstetrics. 2012;118:83-86.⁾ we adapted the “three phases of delay”²⁰20. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Sciences & Medicine. 1994;38:1091-1110.⁾ framework to discuss from an analytical perspective the obstacles encountered by women to access legal abortion services. According to this model, the factors hindering access to health care services can be chronologically identified in the following way based on the stages to access and use health services:

According to this model, it is understood that the search and provision of health care does not depend only on the lack of financial or human resources of the person seeking medical attention, but on multiple cross-linked factors.²⁰20. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Sciences & Medicine. 1994;38:1091-1110.⁾ If we consider that not having access to legal and safe abortion in a timely manner exposes women to potential complications of pregnancy or of abortion in risky conditions, the possibility of tackling barriers/delays can be key.

Among these delays, account was taken of the obstacles and barriers faced by women seeking legal abortion. Barriers can be classified into five groups:

In addition, several studies that analyze the reasons that lead people to seek abortion services outside of the formal health system (in the community-based health care system) also report the existence of institutional barriers.²¹21. Aiken ARA, Guthrie KA, Schellekens M, Trussell J, Gomperts R. Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain. Contraception. 2018;97(2):177-183.^,2222. Doran FM, Hornibrook J. Barriers around access to abortion experienced by rural women in New South Wales, Australia. Rural Remote Health. 2016;16(1):3538.⁾ These barriers include such situations as delays in accessing abortion services (waiting long weeks), a bad past experience, criticism from health care providers,²¹21. Aiken ARA, Guthrie KA, Schellekens M, Trussell J, Gomperts R. Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain. Contraception. 2018;97(2):177-183. and delays caused by medical prescription of several tests,²²22. Doran FM, Hornibrook J. Barriers around access to abortion experienced by rural women in New South Wales, Australia. Rural Remote Health. 2016;16(1):3538. among others.

It should be noted that although the conceptual framework on barriers considers lack of information to be a personal barrier, this does not imply that the lack of information should be seen as an individual responsibility. On the contrary, we want to emphasize that public health policy officials are primarily responsible for guaranteeing access to information on sexual and reproductive health.

METHODOLOGY

Design and sampling

This is an exploratory research study aimed at identifying the barriers faced by pregnant individuals seeking legal abortion in two Argentine jurisdictions: the Autonomous City of Buenos Aires and the city of Rosario. Data was collected through surveys and semi-structured interviews.

We used a non-probability sampling with people capable of becoming pregnant that had access to grounds-based legal abortion, between July 1, 2019 and the March 31, 2020, in five health care facilities: Hospital Álvarez and Centro de Salud Y Acción Comunitario No. 34 (CESAC 34) [Heath Care and Community-based Centre No. 34] located in the Autonomous City of Buenos Aires; Centro de Especialidades Médicas Ambulatorias de Rosario (CEMAR) [Center of Outpatient Medical Specialties of Rosario], Maternidad Martin [Martin Maternity Hospital], and Hospital Roque Sáenz Peña in the city of Rosario. Individuals were invited to take part in the study by the health care professionals of the institutions participating in the research while preserving professional secrecy and confidentiality. If the person agreed to participate, they were contacted by an interviewer or surveyor from the team, who applied the process of informed consent to take part in the study. After obtaining consent, the next step was to conduct the survey or the semi-structured interview.

We started with an initial sample of 191 women that expressed their intention to participate in the study. Right after being contacted by a member of the research team, 117 women (61%) did agree to take part in the study. The main reasons to change their minds between the first and the second contact stage had to do with lack of privacy, difficulties in finding time to complete the interview, overload of household and caregiver tasks, and the emotions evoked from telling their abortion experiences (see Figure 1). Regarding group assignment purposes, for the interviews, priority was given to gestational age (13 weeks or more) in order to have enough participants in this group. Once this requirement was satisfied, we started to conduct interviews with a group, and surveys with the other group, until the list of available contacts was fully checked up.

Interviews and surveys were conducted by telephone given mobility restrictions imposed by the Mandatory Preventive Social Isolation (ASPO) [Aislamiento Social Preventivo Obligatorio] due to COVID 19 pandemic. This context likely contributed to the reduced number of individuals willing to take part in the study.

With respect to phone interviews, some women may feel more comfortable in this type of interview than during in-person interviews, mainly when it comes to sensitive topics like abortion. This statement is based on previous experiences of the team.²³23. Ramos S, Romero M, Aizenberg L. Women’s experiences with the use of medical abortion in a legally restricted context: the case of Argentina. Reproductive Health Matters. 2015;22(44 suppl 1):4-15.

DATA COLLECTION TOOLS

The tools were organized around dimensions related to the barriers to accessing legal abortion services, based on an adaptation of the “three phases of delay” framework²⁰20. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Sciences & Medicine. 1994;38:1091-1110. explained in more detail in the conceptual framework section.

Data collection tools included surveys and semi-structured interviews. For the survey, 92 questions were prepared, 83 with a pre-established list of answers and nine with open-ended answers, organized in eight blocks: 1) sociodemographic data, 2) information on the last pregnancy that led to abortion, 3) the process followed to terminate pregnancy, 4) the first consultation, the experience in the 5) public or 6) community-based health care system, and one last block on 7) women’s opinion and 8) perception regarding the barriers existing in society to access abortion services. Some of the blocks were mutually exclusive depending on the participant’s trajectory (first consultation in the public, private, or community-based health care system).

Regarding the semi-structured interview, it was chosen because it is a type of guided but flexible interview in which the interviewer leads the conversation with questions and cross-questions, and the interviewee gives answers by expanding and using their own words.²⁴24. Adams W. Conducting Semi-Structured Interviews. En: Handbook of Practical Program Evaluation. Hoboken: John Wiley & Sons; 2015.⁾ For the interview, a list of open-ended questions, cross-examination, and probes was prepared for collecting qualitative information related to the same dimensions described for the survey. Both tools had been previously tested.

Data analysis

The surveys were paper-based to avoid inconsistencies. Then we entered the information on an Excel database for later statistical processing. The audio semi-structured interviews were transcribed. Information was reduced according to theme blocks and dimensions of the tool used. We used an Excel spreadsheet in which the verbatim transcription of the information provided by the interviewees for each dimension was entered. The dimensions and themes used to analyze the information, as well as the inductively created categories, were discussed by the research group in order to agree on the operating definition and the way of using them when analyzing the data.

The material gathered was saved electronically with limited access by the research team. Paper-based versions were kept in a safe place that could be accessed only by the research team.

Study limitations

As to study limitations, it should be noted that, although the sample was selected before the legalization of abortion (December 2020), the interviewed and surveyed individuals were exposed to a social and political environment where the subject of abortion gained relevance on the public agenda, particularly, after the first legislative debate in 2018. This context could have affected the perception of the interviewees in this research in respect to barriers to accessing abortion services, and also of their right to access abortion. Therefore, the results presented here should be read taking into account the social and political scenario of those years, which was completely immersed in the public debate over abortion.

Another limitation to consider is that the sample is made of women that managed to access legal termination of pregnancy (ILE). Therefore, there could be barriers for women that did not access a legal termination of pregnancy that could not be identified in this study. The same can be said regarding women that did not agree to take part in the survey or the interview, who could give account of various experiences and barriers not included in the present study.

Ethical aspects

All women participating in this study accepted the terms of the informed consent. The study was approved by the Ethics Committee of the Center of Perinatal Studies in Rosario [Centro Rosarino de Estudios Perinatales], by the Ethics Committee in Research under the Secretary’s Office of Public Health of the Municipality of Rosario, and by the Teaching Committees of the health care facilities taking part in the study.

In order to protect the identity of women that took part in this investigation, fictional names are used.

RESULTS

To report the results, we used the term women and not pregnant individuals because the interviewed individuals identified themselves as cisgender women. Therefore, our intention is not to exclude trans or non-binary pregnant individuals; the manner to refer to the group of individuals who completed the interviews and the surveys has to do with the characteristics of the sample.

The number of women that took part in the study was 117 (23 interviews and 94 surveys). Out of the total of the interviewed women, 14 resided in Rosario and nine in the Autonomous City of Buenos Aires, and 13 were women that a second-trimester abortion. Table 1 shows the profile of both samples.

Differences can be observed in the profile of the interviewed and surveyed women (interviewed women have a higher educational level and most of them do not have children). These differences cannot be explained by the type of service chosen, since both interviews and surveys were conducted in all the institutions participating in the study. Non-probability sampling and self-selection to take part in the study could explain some of the identified differences.

First delay

Subjective and social aspects directly linked to the person, but also to institutional factors, are involved in women’s pathways to seek abortion services. Taking into account both personal resources as well as the resources provided by the health care system itself is fundamental to understand the obstacles - and, consequently, the delays - faced by abortion seekers. At the beginning of the process, the delays in recognizing the pregnancy due to irregular menstrual periods, denial of pregnancy, or absence of an adequate diagnosis of pregnancy made by health care professionals were some of the factors that generated delays and put off seeking medical attention. Once pregnancy was confirmed, six out of ten surveyed and interviewed women reported emotional aspects like anguish, fear, and uncertainty about what to do as factors present at this stage of the process:

Almost half of the surveyed women (48.7%) reported that they did not know where they could go or to whom they could turn to have an abortion. The interviewed women did not know where to go to seek abortion services, and in many cases, they lacked information on legal termination of pregnancy:

These testimonies match the opinion of the surveyed women: 60% stated that almost none of them know when an abortion is legal.

Friends were the main source of information on where to go to have an abortion (four out of ten surveyed women), followed by health care institutions (three out of ten women). Internet (one out of ten) and relatives (one out of ten) were less common sources.

Despite not being significant delays - the average gestational term of weeks at the time of choosing to have an abortion was 7 weeks -, five out of ten surveyed women reported that the decision to have an abortion was difficult to make. The testimonies of the interviewees coincided with this view:

These difficulties link up with women’s perceptions of their opportunities to access abortion: seven out of ten commented that, once the decision was made, access to abortion was going to be a little or very difficult:

The interviewees linked this difficulty with lack of information on legal abortion and on the facilities that they could resort to, but also with social barriers. These included lack of supportive family environment, gender-based violence situations, and persistence of abortion stigma:

Despite these difficulties, nine out of ten surveyed women could talk about abortion with somebody and eight out of ten received support in their decision-making. Most of the surveyed women did not talk about the subject with their parents, but they did with their partners and/or friends. The testimonies of the interviewees show that the people with whom they shared the decision were close and trusted people:

In addition to the personal, subjective, and social aspects noted above, our intent is to focus on the barriers encountered within the health system. Some of the obstacles identified by women are labeled as institutional barriers: women commented that when it came to having a medical test or ultrasound scanning to confirm pregnancy and determine gestational age, they had to go through situations of symbolic violence exerted by health care workers, as well as delays in attention due to scarce availability of appointments. These situations have an impact on women’s emotionality and entail delays in access to abortion in a timely manner. Some interviewees stated:

Second delay

After women learned about their pregnancy and decided to seek medical attention within the health system, they encountered several barriers that fall within the second delay. At this stage of the process, just like in the first, there are subjective and institutional factors.

Personal barriers identified in the first delay persisted: anxiety, panic, and fear linked at this stage with not knowing if they would access health care services to have the abortion procedure performed. At the same time, lack of information on the legal status of abortion determined the way that some people related with the institutions that they attended to request abortion services:

The interaction between women and health care services was also determined by the fear of finding professionals against abortion or by fears deriving from past experiences - whether their own or someone else’s - of mistreatment in private or public health care services. It should be noted that, nevertheless, some women attended the public health care services to have a first consultation precisely after having been well treated in previous experiences or because of the recommendation of friends and/or information available on the Internet about facilities where the procedure is performed.

Surveyed women, in turn, stated to have had, in general, a good experience with health services during their first consultation: 71.3% said that it proved easy or very easy for them to find a place to have an abortion while 77.1% highlighted that they were attended during the first consultation. Most of them had high-quality abortion care: eight out of ten women stated that they were given information about abortion as a right, seven out of ten said they received information on abortion methods, eight out of ten received the information that they expected or better, and eight out of ten said the staff manners were as expected or better.

The information from the interviews was useful to explore more in depth women’s experience in the public health care services and to identify the problems that they had to face. Their narratives suggest that, despite having good experiences, they also encountered administrative and institutional barriers that hindered both the identification and access to a health care facility.

Administrative barriers include deficient and inadequate referral systems, failures in notices and offered information, non-compliance with the patient’s confidentiality, and lack of specific places for consultations and access to legal termination of abortion (‘ILE’), as described by some of the interviewees:

Administrative barriers, at this stage, are linked with lack of availability and organization of services (resources and appointments); however, the interviewees’ experiences with state-owned institutions show that they also encountered institutional obstacles related to episodes of mistreatment by health care workers and/or administrative workers, an assumption about the desire to have children and/or having no respect for their autonomy:

Finally, when interacting with health care services, they also identified logistic barriers, related with the geographic distance to get to facilities providing abortion services and with difficulties in reconciling work schedules and household care with available appointments. Out of the surveyed women, 44.7% said that they had to quit important household tasks or that they had to leave work outside of their homes to make it for the consultation and, within this group, 42.9% indicated that it proved difficult or very difficult to do so. The narratives of the interviewees focus on the same issue:

The experiences of the interviewed women also demonstrate their difficulties to reach health care services to access abortion:

Third delay

The third stage refers to delay in obtaining adequate and timely treatment, that is to say, in accessing legal termination of pregnancy with quality standards as indicated by the norms that regulate this service in Argentina.³3. Ministerio de Salud de la Nación. Protocolo para la atención integral de las personas con derecho a la interrupción legal del embarazo: Actualización 2019 [Internet]. 2019 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2s4y9r7a .
https://tinyurl.com/2s4y9r7a... As noted above, the present investigation is based on the so-called three phases of delay approach; however, it should be recalled that said approach has been adapted in order to describe a phenomenon that does not follow the ordinary care pattern. In the case of abortion, the third delay includes, many times, having to pay several visits to health care facilities, for example, to access ultrasound scanning prior to performing an abortion, to obtain a prescription or tablets in the case of abortion with medication or to have post-abortion tests.

In this sense, the overwhelming majority of the surveyed women had medication abortion at home, after receiving tablets at a hospital or a health care facility (72.3%) and 30.9% had an abortion performed at hospital, most of them using Manual Vacuum Aspiration (MVA).

A factor that is observed throughout the whole process, since the woman suspects that she is pregnant until the abortion is performed, are feelings of fear, nervousness, and anxiety, that in the third delay are related to potential negative consequences for their health, both before and during the procedure. This continuity is summarized by one of the interviewees:

Again, personal barriers had an impact on the way that women interacted with health services. Despite their feelings and fears, the interviewees highlighted the importance of feeling reassured as they were supervised and accompanied by health care professionals, in particular where abortion required hospitalization:

This same trust in health care professionals was also described by those who performed abortion at home although, in these situations, the fact of not receiving support from family and close friends during the procedure was identified as a difficulty.

The narratives of women give account of situations related to social barriers like taboo and silence on abortion, as well as fearing judgment:

Women also mentioned such institutional barriers as situations of mistreatment and misogynistic comments from health care professionals:

In addition, lack of adequate facilities for performing abortions (for instance, places where abortion seekers did not have to share the space with pregnant women or women in labor) and administrative barriers like scarce availability of services were also highlighted.

As with the two previous stages, in the third delay logistic barriers are also identified and linked with difficulties in abandoning caregiver duties related to children or aging adults, in being absent from work out of the home or in reconciling health care service schedules with formal work, as well as distances from hospitals or health care facilities:

DISCUSSION

This article aimed at describing the barriers faced by women seeking abortion in the public sector health services within two jurisdictions of Argentina - Rosario and the Autonomous City of Buenos Aires - in the year prior to the passage of Act No. 27610. To achieve this, we used an adaptation of “three phases of delay” framework, which presents both advantages and challenges. One of the potentialities of the approach, which has been largely used in literature on maternal mortality,²⁵25. Moran AC, Charlet D, Madhavan S, Aruldas K, Donaldson M, Manzi F, et al. Methodology for a mixed-methods multi-country study to assess recognition of and response to maternal and newborn illness. Journal of Health, Population and Nutrition. 2017;36(1):1-8.^,2626. Mgawadere F, Unkels R, Kazembe A, van den Broek N. Factors associated with maternal mortality in Malawi: application of the three delays model. BMC Pregnancy Childbirth. 2017;17(1):219.^,2727. Mohammed MM, El Gelany S, Eladwy AR, Ali EI, Gadelrab MT, Ibrahim EM, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy Childbirth. 2020;20(1):585.^,2828. Maharjan N, Tuladhar H, Malla K, Tumbahangphe K, Budhathoki B, Karkee R, Shrestha JR, Merriel A, Manandhar DS. Maternal near miss analysis in three hospitals of Nepal: An assessment using three delays model. Journal of Nepal Health Research Council. 2021;19(2):264-269. is that it incorporates the time dimension into the analysis of obstacles to access health care services, facilitating the identification of critical moments during the process. However, some challenges are faced when adapting this model to the particular features of the decision-making process and abortion care. Some obstacles can be “overlapped” among delays or can be difficult to classify. For example, barriers to access ultrasound scanning could fall within the first delay (need to confirm pregnancy to make a decision) or the third delay (confirmation of gestational age to offer the adequate procedure).

The obstacles identified in the results of this investigation can be interpreted in line with other local, regional, and international studies addressing this topic. In this sense, a previous study conducted by this research team,²⁹29. Ramos S, Romero M, Ramón Michel A, Tiseyra MV, Vila Ortiz M. Experiencias y obstáculos que enfrentan las mujeres en el acceso al aborto [Internet]. Buenos Aires: REDAAS; 2020 [citado 4 abr 2022]. Disponible en: https://tinyurl.com/yc5ezcsf.
https://tinyurl.com/yc5ezcsf... in which the same data-collection tool was used but with a different sample, was useful to create evidence to provide information to the debate held in Argentina’s National Congress in 2020 and in the media, and was relevant to describe the barriers in access to abortion even in specific situations permitted by law and to define the horizon of necessary improvements to ensure access to abortion in a timely and appropriate manner.²⁹29. Ramos S, Romero M, Ramón Michel A, Tiseyra MV, Vila Ortiz M. Experiencias y obstáculos que enfrentan las mujeres en el acceso al aborto [Internet]. Buenos Aires: REDAAS; 2020 [citado 4 abr 2022]. Disponible en: https://tinyurl.com/yc5ezcsf.
https://tinyurl.com/yc5ezcsf...

Taking this background into account, the present study shows results that highlight the diversity of women’s experiences in health care facilities where they could access abortion services. The participants reported obstacles with respect to the service delivered at health care facilities; however, most of them claim to have had a positive experience, a situation that matches the research studies carried out in Brazil, Argentina, and Mexico.³⁰30. Carneiro MF, Iriart JAB, Menezes GMS. “Left alone, but that’s okay”: paradoxes of the experience of women hospitalized due to induced abortion in Salvador, Bahia, Brazil. Interface (Botucatu). 2013;17(45):405-418.^,3131. Zamberlin N, Romero M, Ramos S. Latin American women’s experiences with medical abortion in settings where abortion is legally restricted. Reproductive Health. 2012;9:34.^,3232. Olavarrieta CD, Garcia SG, Arangure A, Cravioto V, Villalobos A, AbiSamra R, Rochat R, Becker D. Women’s experiences of and perspectives on abortion at public facilities in Mexico City three years following decriminalization. International Journal of Gynaecology and Obstetrics. 2012;118(Suppl 1):S15-S20. In line with this general positive evaluation, during the interviews, women highlighted the accompaniment by health care professionals in the process and affirmed that they felt “safer” having the procedure performed in a health care facility. A study conducted in Argentina on medical abortion had already highlighted that women praise the safety of facility-based abortions.³¹31. Zamberlin N, Romero M, Ramos S. Latin American women’s experiences with medical abortion in settings where abortion is legally restricted. Reproductive Health. 2012;9:34.⁾ In the present study, most of the surveyed participants stated that they had a good experience with the public health system when it comes to finding services, the quality of attention, and the information received. These data suggest willingness from health care professionals to offer adequate information, which is an aspect that contributes significantly to the reduction of unsafe abortion practices.³³33. Erdman JN. Harm reduction, human rights, and access to information on safer abortion. International Journal of Gynaecology and Obstetrics. 2012;118(1):83-86. It should be made clear that these data can also be the result of the fact that, unlike other regions, the jurisdictions chosen for this study have long trajectories in public policies dealing with access to legal abortion.¹²12. Fernández Vázquez S. Políticas públicas de aborto en transición: de las consejerías pre y post aborto a las interrupciones legales del embarazo en el Área Metropolitana de Buenos Aires. Revista de Bioética y Derecho. 2018;43:145-160.^,1313. Ministerio de Salud de la Ciudad de Buenos Aires. Salud sexual y reproductiva en la ciudad de Buenos Aires: Situación y respuesta 2019 [Internet]. 2020 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2p9sc5f6 .
https://tinyurl.com/2p9sc5f6... ^,1414. Romero M, Moisés S. El aborto en cifras [Internet]. Buenos Aires: REDAAS; 2020 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/2xzjhc7u .
https://tinyurl.com/2xzjhc7u... ^,1515. Honorable Concejo Municipal de Rosario. Ordenanza No, 8.186 [Internet]. 2007 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/4mbxm72u .
https://tinyurl.com/4mbxm72u...

Apart from these positive points, participants also reported obstacles related to health care services. These can be split into two types, following the classification used by the “Group for Women’s Life and Health” [“La mesa por la Vida y la Salud de las Mujeres”] in Colombia ¹⁶16. La Mesa por la Vida y la Salud de las Mujeres. Barreras de acceso a la Interrupción Voluntaria del Embarazo en Colombia [Internet]. 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/3hdfruwf .
https://tinyurl.com/3hdfruwf... : obstacles related to the attitude of health care professionals and obstacles that have to do with the administrative level. Among the first group, some participants reported mistreatment from health care professionals and lack of specific facilities for legal termination of pregnancy (‘ILE’) and voluntary termination of pregnancy (‘IVE’) procedures. Mistreatment and comments about maternity, as well as the provision of abortions in spaces shared with other practices (for example, maternity rooms), affect women in a negative way and contribute to arousing such feelings as guilt, repentance, and discomfort. These results largely coincide with the literature developed in our region. In Colombia, attitudes of health care professionals have been analyzed, which are intended to prevent access to legal abortions¹⁷17. DePiñeres T, Raifman S, Mora M, Villarreal C, Foster DG, Gerdts C. ‘I felt the world crash down on me’: Women’s experiences being denied legal abortion in Colombia. Reproductive Health. 2017;14(1):133.⁾ or to create barriers and substantial delays.¹⁸18. Baum S, DePiñeres T, Grossman D. Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion. International Journal of Gynaecology and Obstetrics. 2015;131(3):285-288.⁾ Another aspect that was identified was the abuse suffered by women from health care workers aimed at making women change their minds with respect to their abortion decision,¹⁶16. La Mesa por la Vida y la Salud de las Mujeres. Barreras de acceso a la Interrupción Voluntaria del Embarazo en Colombia [Internet]. 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/3hdfruwf .
https://tinyurl.com/3hdfruwf... ⁾ the discomfort generated by careless health workers in abortion facilities,³⁰30. Carneiro MF, Iriart JAB, Menezes GMS. “Left alone, but that’s okay”: paradoxes of the experience of women hospitalized due to induced abortion in Salvador, Bahia, Brazil. Interface (Botucatu). 2013;17(45):405-418.⁾ and the need to count on a more understanding health care staff.³²32. Olavarrieta CD, Garcia SG, Arangure A, Cravioto V, Villalobos A, AbiSamra R, Rochat R, Becker D. Women’s experiences of and perspectives on abortion at public facilities in Mexico City three years following decriminalization. International Journal of Gynaecology and Obstetrics. 2012;118(Suppl 1):S15-S20.⁾ In Uruguay, research studies have revealed the need for a comprehensive training of health care professionals delivering abortion services, since training in technical aspects does not in itself guarantee a respectful attention when it comes to abortion.^(34.35)

As regards administrative obstacles, some women reported a deficit in the information provided, lack of available appointments, and inadequate referral mechanisms among institutions, among others. These results are aligned with the findings of research studies in other Latin American countries that highlight the existence of unexcused delays in rendering services and failures in the referral system,¹⁶16. La Mesa por la Vida y la Salud de las Mujeres. Barreras de acceso a la Interrupción Voluntaria del Embarazo en Colombia [Internet]. 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/3hdfruwf .
https://tinyurl.com/3hdfruwf... ^,1818. Baum S, DePiñeres T, Grossman D. Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion. International Journal of Gynaecology and Obstetrics. 2015;131(3):285-288.⁾ as well as the need reported by women for receiving comprehensive information about the abortion procedure from health care staff.³²32. Olavarrieta CD, Garcia SG, Arangure A, Cravioto V, Villalobos A, AbiSamra R, Rochat R, Becker D. Women’s experiences of and perspectives on abortion at public facilities in Mexico City three years following decriminalization. International Journal of Gynaecology and Obstetrics. 2012;118(Suppl 1):S15-S20.

One of the results that needs highlighting was the lack of information on the legal framework, a barrier reported as much in the surveys as in the interviews. This obstacle is reported in literature as a factor that has an impact on access to abortion.¹⁶16. La Mesa por la Vida y la Salud de las Mujeres. Barreras de acceso a la Interrupción Voluntaria del Embarazo en Colombia [Internet]. 2016 [citado 4 abr 2022]. Disponible en: Disponible en: https://tinyurl.com/3hdfruwf .
https://tinyurl.com/3hdfruwf... ^,1919. Erdman JN. Harm reduction, human rights, and access to information on safer abortion. International Journal of Gynaecology and Obstetrics. 2012;118:83-86.^,3636. Ramos S. Investigación sobre aborto en América Latina y el Caribe: Una agenda renovada para informar políticas públicas e incidencia (resumen ejecutivo). Estudios Demográficos y Urbanos. 2016;31(3):833-860.⁾ However, existing evidence in the region is still scarce. Having evidence about the information and the knowledge that women have on the legal framework is key to better understand their attitude and willingness to seek health care services, and to overcome obstacles to access abortion. Similarly, knowledge on these factors could contribute to designing and strengthening plans and communication strategies offering information adequate to the context to make it easy to access abortion and to demand high-quality medical attention.

Logistic obstacles, in particular the time required to travel to reach a health care facility or the impossibility of quitting work or caregiver duties, were also reported as barriers. This coincides with the evidenced described in other research studies carried out in the region³⁷37. Friedman J, Saavedra-Avendaño B, Schiavon R, Alexander L, Sanhueza P, Rios-Polanco R, et al. Quantifying disparities in access to public-sector abortion based on legislative differences within the Mexico City Metropolitan Area. Contraception. 2019;99(3):160-164.^,3838. Becker D, Diaz-Olavarrieta C, Juarez C, Garcia SG, Sanhueza Smith P, Harper CC. Sociodemographic factors associated with obstacles to abortion care: findings from a survey of abortion patients in Mexico City. Women’s Health Issues. 2011; 21(3):16-20.⁾ that place special emphasis on the restrictions of socioeconomic conditions as access determinants. This adds to women’s difficulties to be absent from work and reconcile appointment schedules with caregiver duties for their children or aging adults - an aspect that was revealed in other research studies.¹⁸18. Baum S, DePiñeres T, Grossman D. Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion. International Journal of Gynaecology and Obstetrics. 2015;131(3):285-288.

The importance of friends (in the first place) and of health care facilities (in the second place) as sources of information in respect of where to go to have an abortion was reported both in the surveys and the interviews. This does not amount to an exclusive finding of this study; friends have already been identified in literature as the main source of information.³⁹39. Romero M, Gomez Ponce de Leon R, Baccaro LF, et al. Abortion-related morbidity in six Latin American and Caribbean countries: findings of the WHO/HRP multi-country survey on abortion (MCS-A). BMJ Global Health. 2021;6(8):e005618.^,4040. Ramos S, Romero M, Aizenberg L. Women’s experiences with the use of medical abortion in a legally restricted context: the case of Argentina. Reproductive Health Matters. 2015;22(44):4-15.⁾ However, it is interesting to observe that the information shared among friends and the trust that some of them had in the health system, as well as the demand for and greater knowledge of their rights in the presence of health care professionals reported by the participants could be demonstrating some aspects of this phenomenon that is necessary to keep on investigating. Although the subject of abortion continues to be considerably sensitive for women, since stigma or silence remains,⁴¹41. Zamberlin N. El estigma asociado al aborto como objeto de Estudio: los primeros pasos en América Latina. En: Investigación sobre aborto en América Latina y El Caribe: una agenda renovada para informar políticas públicas e incidencia. Buenos Aires: CLACAI; 2015. as also highlighted by the participants of this study, the greatest social visibility of the topic could constitute a window of opportunity to lay out strategies with a view to the implementation of Act No. 27610 on Access to Voluntary Termination of Pregnancy (‘IVE’) [Interrupción Voluntaria del Embarazo], thus contributing to tumbling down social barriers and the persistent stigma in connection with abortion.

Account should be taken of the limitations of this study. First, the sample only includes women that actually managed to access a legal termination of pregnancy (‘ILE’) within the health system. In this sense, other barriers could exist and still not be identified due to the characteristics of the sample. Secondly, among those women who accessed the health care system, but finally decided not to take part in the study, there could also be experiences and different barriers that could not be identified.

One of the strengths of this study is that it provides empirical and systematized information on the barriers in access to legal abortion in two jurisdictions of Argentina, explored in a context of significant social, political, and legal changes. Although at present Argentina has a piece of legislation that ensures access to voluntary termination of pregnancy, barriers in access to abortion possibly exist, some of which can be similar to the barriers reported in this study.

CONCLUSION

Before the new scenario that emerged after the passage of Act No. 27610 and the ensuing cessation of mobilizations of various sectors within civil society and of the public debate held in previous years, the barriers identified in the present study become more relevant when it comes to strengthening the process of access to abortion in Argentina. It is important, in turn, to interpret the findings in the light of the local context. The jurisdictions chosen for this study have a long trajectory in public policies on access to legal termination of pregnancy (‘ILE’), prior to the passage of the above-mentioned statute. This could explain, at least in part, the fact that most of the participants in the study reported that they had a good experience with health services. In addition, account should be taken of the fact that some the most significant barriers were identified in the first delay, before women got to health care facilities. Among these obstacles, feelings of anguish and fear, lack of information on places where to turn to, and lack of knowledge on legal abortion were reported.

Women lacking information in relation to legal abortion, even in jurisdictions with public policies on legal termination of pregnancy, could be due to the absence of communication campaigns launched by governmental agencies. In this sense, one should wonder whether mass or focused communication strategies could correct this situation and facilitate access to voluntary termination of pregnancy (‘IVE’) or legal termination of pregnancy (‘ILE’).

Thus, to continue producing data and evidence on the barriers in access to abortion proves indispensable in order to disclose information about the implementation of the public policy flowing from Act No. 27610, taking into account not only the difficulties encountered by women within the health services, but also at previous stages of the process, in such a way to introduce corrections when and where detected.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the contributions of Dr. Edgardo Abalos (CREP-Maternidad Martin), Dra. Florencia Aimo (Hospital Roque Saenz Peña), Dra. Paula Botta (CEMAR), Lic. Karina Cammarotta (CESAC Nº 34), Dra. Gilda Diego (Hospital Gral. de Agudos Dr. Teodoro Álvarez), Anahí Farjí Neer (CONICET/ IIGG-UBA), Vanina Landra; Mirna Lucaccini (CONICET/ IIGG-UBA), Eva Panaro (IIGG-UBA), Marina Salomón, and Martín Babino, who was in charge of the quantitative data processing.

References

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