Bottom‐up advocacy strategies to abortion access during the COVID‐19 pandemic: Lessons learned towards reproductive justice in Brazil

Abstract

In Brazil, abortion is only allowed in cases of rape, serious risk to a woman's life or fetal anecephaly. Legal abortion services cover less than 4% of the Brazilian territory and only 1,800 procedures are performed, in average, per year. During the COVID-19 pandemic, almost half of the already few Brazilian abortion clinics shut down and women had to travel even longer distances, reaching abortion services at later gestational ages. In this paper, we describe three bottom-up advocacy strategies that emerged from difficulties deepened during the COVID-19 pandemic at a single abortion service in Brazil, amidst anti-gender policies from the federal government. Telemedicine abortion, outpatient surgical abortion and the provision of abortion after 20 weeks' gestation are important strategies that may reduce inequalities that impact the most vulnerable populations, such as black and indigenous women, children, adolescents and women experiencing domestic violence.legal abortion, outpatient surgical abortion, second and third trimester abortion, South America, telemedicine | BACKGROUNDIn Brazil, access to legal and safe abortion has been difficult even before the COVID-19 pandemic. Brazil has one of the most restrictive laws on induced abortion in the world. According to the Brazilian Penal Code, abortion is only allowed in cases of rape or serious risk to a woman's life. In 2012, fetal anencephaly was included as a third legal ground to abortion. 1 Although the Brazilian Penal Code is dated from 1940, it was only in 1999 that the Ministry of Health published its first regulations in an attempt to increase the number of legal abortion services throughout the country. 2 Despite such effort, there is still a scarcity of clinics providing access to lawful abortion. In 2019, there were 251 services with at least one abortion performed, covering less than 4% of the Brazilian territory. 3 In these few services, a regimen of suspicion of the sexual violence survivors' narratives is common, and health professionals tend to question the victim's subjectivity in order to decide whether she legitimally holds the right to an abortion. For example, in Brazil, it is common practice to require authorization from three health professionals for the legal ground

Challenges to the implementation of telemedicine in abortion care for victims of sexual violence in Brazil

“…NUAVIDAS protocol included hospital-supplied misoprostol with supervised use, allowing women to self-administer the drug in their households with telemedicine support, in the pandemic ( 37 ). The Federal Public Prosecutor's Office in Uberlandia supported and declared the legality of NUAVIDAS model of telemedicine for abortion care to sexual violence victims ( 26 ).…”

“…The pioneer model of telemedicine for abortion care called NUAVIDAS, was the first public health service to use telemedicine for legal abortion care in the country. This initiative has been studied and documented, with positive results impacting women and adolescents’ health and rights ( 48 ). However, the NUAVIDAS telemedicine for abortion care model to sexual violence victims has been challenged in court.…”

“…The implementation of telemedicine for abortion care for sexual violence victims was an important step to improve effectiveness and availability of legal abortion services in Brazil ( 23 ). This initiative was firstly implemented at the Comprehensive Care Center for Victims of Sexual Assault, also called NUAVIDAS, located at Hospital from the Federal University of Uberlândia, state of Minas Gerais.…”

“…In partnership with the feminist organization Anis Institute, NUAVIDAS health staff developed the Protocol for Legal Abortion via Telehealth in which self-management of misoprostol was allowed at home for pregnancy termination, with remote supervision by health staff outside from the health facility ( 24 ). The protocol adopted by NUAVIDAS followed international human rights standards and best scientific-based evidence available on telemedicine in abortion care, by which pregnant women exercise the right to informed consent, autonomy in decision making and right to privacy in abortion care ( 25 ).…”

“…Some states were not offering a single referral center, and in others, most services were available only in capitals, mainly in the Southeast region ( 9 ). Although any hospital with an obstetric practice should be able to perform legal abortions, during the Covid-19 pandemic it was observed that the number of hospitals offering legal abortion procedures dropped ( 10 ).…”