Opinions and attitudes among abortion clients
Attitudes towards abortion and women who have abortions
While some women believe that Uruguay continues to be a conservative country where abortion is still taboo, others said they saw major progress in social attitudes, including the fact that decriminalization had been achieved. Almost all interviewees felt that abortion is their right and that they have the prerogative to decide what to do with their bodies and their lives. In general, abortion is seen as an individual experience that is only incumbent on the person who has to get one. Although most spoke with their partner, family members, or friends, a few did not share the experience with anyone other than the legal abortion team that provided care during the process.
“I have nothing to say; what needed to be said got said and that’s that. I did it, I’m fine, and ciao.” (Age 23).
“I didn’t talk about it with my husband, or my sister, or my friends, or with anybody. The topic is now closed, that’s that.” (Age 34).
Religious ideas were almost nonexistent in interviewees’ discourse. However, they all reported some level of guilt, describing “pangs of conscience,” and other feelings, such as “a non-physical pain,” shame, sadness, anger, depression, and loneliness, and some referred to themselves as selfish. All interviewees shared the idea that the abortion was an experience that marked them for life:
“[…] I think I’m going to carry this until I die.” (Age 23).
“I think it is a trauma that one does not get over, even though one learns to live with it […] this guilt is going to be lifelong.” (Age 22).
“When I think about going to the gynecologist and they are going to ask me about my medical history, I’m ashamed to have to tell them that I just had an abortion.” (Age 38).
Still, one abortion client expressed positive feelings about having access to a legal abortion as compared to an unsafe option:
“It was strange because it was a new experience, but it was a lifesaver. You avoid the trauma of doing it in a clandestine place where they can do anything to you and where no one is going to take responsibility for anything.” (Age 29).
Despite recurring feelings of guilt, none of the participants said they regretted their abortion. However, these clients experienced their process as something that they do not want to have to go through again. In fact, all of them said that, until discovering an unwanted pregnancy, they saw abortion as a very remote possibility, something that they would not have to go through or that they would not be capable of doing.
“[…] I had sworn to myself that I would never have an abortion and I ended up doing it. It was kind of ironic and I was surprised to find myself contradicting myself about something that I said I wouldn’t do.” (Age 23).
“[…] I said it would never happen to me and it happened.” (Age 34).
Several of them said they were against abortion even after having terminated a pregnancy, while others expressed a change of opinion prompted by the experience.
“I’m against abortion, so it was a very difficult decision to make and to this day it still weighs on me.” (Age 31).
“[..] I was against abortion until it was my turn.” (Age 22).
“In line with my upbringing, I had always been against it; I imagined it to be pretty cruel because of what they say and they tell you.” (Age 27).
They all confirmed that it was the best decision they could make, given that it was not the right time to have a child because of various reasons: poor economic or health situations, instability with a partner, or because they already had several children.
Interestingly, with the exception of one interviewee, participants harshly judged other women who have abortions, and even more severely those who have more than one. Although they fully justified their own abortion saying things like “I didn’t want to do it, but of course my situation wasn’t easy” (Age 27), they saw other women’s abortions as acts of irresponsibility, selfishness, and immaturity.
“If you already did it once, why are you going to do the same thing again? Once is fine, but those who do it two, three, four times, [it’s] like they kind of do it just for fun.” (Age 22).
“I see many women who do it like just for fun […] people who say: ‘well, I got pregnant and I can do it one, two, and even three times.’” (Age 31).
“[…] others get pregnant real easy and have abortions [as easily/often as] they change their jeans.” (Age 23).
“[…] there are other cases of women where it’s like they don’t care if they get pregnant and abort and go back and repeat the story […] it’s different for those who want to come every year to do it, but for women whose case is like mine, it’s okay.” (Age 38).
“I think there should be limits because they’re going to get pregnant ten times and they’re going to take the life of an innocent being […] Names and record numbers should be recorded and tell them ‘look, there’s a limit, you can’t get pregnant five times and get rid of it every time you feel like it.’” (Age 22).
Attitudes towards abortion health professionals and services
For the women interviewed, the most common feelings before visiting facilities to request an IVE or legal abortion service were shame, fear of rejection, or fear of undergoing a procedure that could endanger their health.
“At first, I was a little afraid of the whole procedure. After the counseling, I felt safe and calm. I felt confident.” (Age 29).
Overall, women had positive experiences with the health care teams at the facility where they received their service. Almost all said that they did not feel judged by the interdisciplinary team. Rather, they said they were surprised by the thorough information they received and that they felt welcomed and well-understood.
“I thought they would be a little more hostile, because of the fact that one is killing a person, but no, everything [was] just fine.” (Age 22).
“You arrive afraid that you’re going to be judged by the same doctors whose job is to save lives, but it was nothing like that, everything super good, marvelous, in fact, they protect you.” (Age 29).
Only one of the clients reported having felt rejected by one of the health professionals who treated her:
“When I came in for the ultrasound, the person who was doing it looked at me and said ‘I don’t do IVE and they looked me up and down. When I gave them the paper, they looked at it and said that the doctor didn’t do IVE and the other went and told them: ‘it doesn’t matter, she’s a patient and you have to take care of her’. She went and took her the paper and the woman came and told me to my face, ‘I don’t do IVE. There were a lot of people outside the examining room and even though not everyone knows what IVE is, it was like […] they were judging me.” (Age 38).
During the interview, women were asked about a hypothetical doctor refusing to provide abortion services. Even though they talked about how disappointing and upsetting it would be for a doctor to disapprove of their decision and said they might have changed their minds had they encountered something like this, they did agree that health professionals should be allowed to object to providing abortion services.
All abortion clients in our sample had a medicated abortion. Despite having expressed a high level of satisfaction with the overall service, many of the women said they would have liked to have been able to choose between a medicated and surgical procedure. Two women said they would have preferred a surgical abortion because they perceived the hospital to be a safer place to have the procedure.
“I thought they were going to do the procedure here, not that it had to be in my home. I was very scared. If I had been given a choice, I would have liked to be admitted because I would have felt calmer” (Age 22).
“When they sent me home to take the pill I thought it was risky and that it would be much better to be seen in a hospital” (Age 22).
Opinions on the Uruguay abortion law
Almost all the women interviewed knew about decriminalization of abortion from seeing it on television or in the press, which suggests that the issue had been present in the public discourse. Most found the facility where they obtained abortion services by searching online. All said they were relieved that they did not have to have an illegal or clandestine abortion and saw decriminalization as a major advance with regard to the rights of women in Uruguay. Further, they believed that decriminalization had contributed to changing Uruguayans’ overall attitude towards abortion.
“Since there’s the law, more [people] are in favor [of women’s right to choose].” (Age 22).
“Hopefully no one stops this law, it saves us all, it’s a choice so that one can live as one wants, as one likes. It makes no sense to have children to keep them deprived. It’s a choice they give us to live well.” (Age 29).
These abortion clients became aware of the details of the law and the service—such as the gestational age limit and the abortion method specified in the medical guides—during their first visit to the health care center. When asked about their opinion about the specific aspects of the law, almost all felt that the twelve-week limit was appropriate. Some even felt that it should be earlier due to preconceived—and sometimes inaccurate—views that they held regarding the risks involved and the state of development of the fetus.
“Up to 12 weeks is okay and that is already a lot, because the baby [sic] is already formed and it’s somewhat traumatic, it gives you quite a shock, it had everything: its fingers were formed, even the features on its face. I say that eight weeks would be okay.” (Age 29).
However, the majority of those interviewed were in disagreement with the required five-day reflection period, calling it excessive, unnecessary, and torturous.
“Those five days were endless for me, because when you are sure and you want to be done with it, you want it to be now.” (Age 38).
“If it is already a difficult decision and they make you wait, it becomes torture.” (Age 22).
“You want to be done with it. When they give you that requirement, they don’t strictly consider it to be five days. In my case, it was fifteen days.” (Age 29).
For these women, there was nothing to think over since they had made up their minds before setting foot in the facility for the first time.
Opinions and attitudes among health professionals who participate in abortion services
Attitudes towards abortion and women who have abortions
In general, health professionals who participate in abortion services in Uruguay had positive opinions about the right to choose and they supported women and their choices. Although each health professional has their own limits with regard to the different aspects of the process, all felt that their perspectives should not influence the care they give their patients. The health professionals interviewed said that they saw abortion as a woman’s right and that the decision to terminate a pregnancy is her own business. They believe that each woman has her reasons, that these reasons are worthy, and that their role as medical professionals is not to judge.
“The reasons are worthy; no one can decide what a woman should do or what is best for her.” (Physician).
“Every woman has the right to terminate a pregnancy for whatever reason. I don’t think that it’s right or wrong.” (Physician).
“One doesn’t stop being a person, but my feelings don’t matter when I’m supporting the women. If a woman comes in who is using contraceptives, lives alone, has four children, does not have a pension, and gets pregnant, of course we’ll feel more empathy than for a woman who does not take care of herself, who doesn’t care whether she gets pregnant; but regardless of my feelings and opinions, the decision is the woman’s.” (Physician).
All participants felt that their professional duty was strictly to provide information and services. One health professional expressed this recurrent feeling eloquently by explaining that their professional duty is defined in terms of how they can support the patient’s needs:
“What matters most to me is to support the patient; that’s why I became a gynecologist.” (Physician).
In general, health professionals saw abortions as difficult situations for women; as an experience that no woman wants to have to begin with, and certainly as one that none would want to repeat. Thus, they see abortion overall as a watershed experience in their lives.
“The experience is an abortion in general, whether medicated or surgical. The experience marks a before and an after.” (Physician).
In terms of their opinion of abortion itself, several health professionals saw it simply as one more sexual and reproductive health service; as a routine procedure in their daily professional life, the same as a gynecological exam or a pelvic exam on a pregnant woman. With regard to repeat abortions, most saw them as a result of errors of a medical system that is unable to provide effective training on contraception and the Uruguayan mentality that still sees sexuality as a taboo. But nonetheless, they did not believe that women use abortion as contraception.
“It’s mostly the system’s fault, due to a lack of understanding, time, or information. It is not an ideal situation; it’s not that I like it, but I don’t place the blame on the patient.” (Physician).
We did not find a clear trend regarding health professionals’ preference about whether or not to talk about providing abortion services outside the workplace. Some health professionals talk about it openly:
“I talk about my job with everyone. Family, friends, colleagues. At the family level, sometimes there are differences on the subject of principles or religious values.” (Physician).
While others prefer discretion, noting that they only “talk about [their] job with few people.” (Midwife).
In general, these health professionals expressed great satisfaction with the increase of legal abortion services in the country, without denying that abortion stigma still exists in Uruguayan society. When asked directly about its existence, the interviewed health professionals described this stigma in the following ways:
“[…] it shows in abortion clients’ fear, and is manifested quietly, with rejection and with indifference.” (Physician).
“[…] it exists. I don’t know if it’s to such an extent as to produce consequences. When the law was being defended, a segment of society demonstrated their opposition.” (Physician).
“Many patients who do terminate [pregnancies] want to keep it a secret for fear of what others might say. Where I work, it’s a small town; people gossip about this and are judgmental. These comments affect patients emotionally.” (Physician).
“Uruguay is a stigmatizing society around abortion and a number of other issues.” (Psychiatrist).
Attitudes towards health professionals who participate in abortion services
In general, health professionals said they were comfortable with their work teams and believe that their experiences since decriminalization have been positive. Only one health professional reported difficulties in the social context where they work, which is not in the city of Montevideo:
“Since it’s a small town, people ask questions and try to judge, but we try to maintain confidentiality.” (Physician).
One of the most common complaints was that there is great demand for abortion services and few service health professionals:
“[…] the greatest obstacle is patient demand where sometimes we feel a little overloaded; more human resources are needed and more time given to visits.” (Physician).
High demand sometimes hinders the process:
“Delays in the process make [some] women still prefer clandestine abortions. The process is very long; so they prefer to do it outside.” (Midwife).
Although all of those interviewed respected the right of other health professionals to object, they see objection as a significant obstacle, since it can affect women’s decisions and hinder overall service. Some health professionals also mentioned health centers that have not been able to put together abortion teams because in some cases there is a scarcity of gynecologists who are willing to prescribe the abortion medication.
Health professionals felt that administrative staff within hospitals also needed further training, given that, together with the objectors, when they manifest stigmatizing views they too constitute a substantial barrier that negatively impacts the quality of abortion services.
“Improving access to the different services and the interaction among them, for example, with the administrative side, nursing, medical staff, laboratory, they should have periodic meetings to fine-tune issues. Administrators and doctors see voluntary termination of pregnancy in totally different ways.” (Physician).
“Not a single administrator works with us [the IVE teams]; there is a lot of turnover in receptionists and they aren’t trained.” (Midwife).
“Very good work is done on logistics, on timing, coordination. The only detail is with the sonographers, because this needs special handling and technicians are not always trained and can intimidate patients.” (Physician).
The majority of the health professionals who participate in legal abortion services reported having received training before the law went into effect. However, all participants expressed interest in receiving further training in abortion service delivery, including some who want to be trained in vacuum aspiration procedures or care for complications from incomplete abortions.
Health professionals mentioned the bias that exists in the type of abortion procedure they provide, which is almost always medicated abortion. They all confirmed that women are not given a choice between a surgical and medicated procedure. One reason they preferred to provide medicated abortion was because they perceived surgical abortion to have more complications and to cost more.
“It is an option that suits all parties: the woman, because she can do it at home in a setting that is not unfamiliar and if we talk about it as a law, that abortion is medicated and not surgical, it serves the state itself and the different institutions, and health professionals. It’s more economical than hospitalizing all those women.” (Physician).
Others explain the preference for medicated abortion in terms of training, in other words, many health professionals have not been trained to provide aspiration abortions. But in general, most are quite pleased with the widespread use of medicated abortion. Some health professionals also described preference for providing the pills because they could avoid being present during expulsion. Some even said that if they had to perform aspiration abortions they would become objectors.
“If the woman requests the surgical method, I withdraw. I wouldn’t have my colleagues’ support. The situation would get messy. I believe that the woman has to accept that she is the one who is terminating the pregnancy.” (Physician).
“I always say what I do, and that I don’t have to actively participate in the termination. If I had to participate actively I would conscientiously object. I had a very bad experience with a fetus when I was a resident, and I said that I wouldn’t do that again because it was very traumatic.” (Physician).
However, several health professionals believe that patients should be able to choose their preferred abortion method and that health professionals should adhere to their role of providing complete and accurate information on the available options. For most, their primary concern was to not endanger the woman’s life and to prevent complications in order to minimize the risk of empowering their opponents:
“We take care of the woman and we take care of the law because if a complication occurs the opponents will take advantage of it.” (Physician).
Opinions on the Uruguay abortion law
Some health professionals believed that following decriminalization in 2012, attitudes in the medical community changed and that the right to choose is increasingly being seen in a better light.
“Yes, I have seen colleagues who were not very convinced that this is a right […], and there are others who are conscientious objectors. But in general, the attitude [towards abortion] is more open now.” (Physician).
“Discussion about the issue is a little more fluid and open; even though you may or may not agree, the woman’s decision is respected.” (Physician).
“Colleagues who were very negative seem calmer now.” (Physician).
Almost everyone believes that implementation of legal abortion services has been very successful across the country. However, the health professionals interviewed outside the capital thought that this success is more obvious in Montevideo and that women outside the capital continued to experience much more difficulty in accessing services.
Opinion was divided on the five-day reflection period. Some think that rather than being a time for reflection, the five days are disrespectful to the patient and stigmatize her, because they challenge a decision that has already been made.
“I don’t think it’s advisable, I think it’s more a contradiction: we say that we respect the patient and then we tell her to go think about her decision.” (Physician).
“Most women have already thought about it and they come in to terminate; very few decide to continue with the pregnancy after counseling.” (Physician).
“There shouldn’t be a set time period. For some it simply does more harm. The person already thought about it before coming to the clinic.” (Midwife).
Some health professionals would prefer to have this requirement removed. Other health professionals believe that it is an adequate period, as long as the wait does not result in exceeding the legal gestational age limit. Others believed that the five days were critical because they enabled women to think without pressure and, in some cases, to continue their pregnancies.
There was consensus that the gestational age limit was appropriate although some believe the limit should be lowered to ten weeks. This is due to the overall view that “[t]he more weeks that go by, the greater the risk to the patient.” (Physician).
