Reflections from an abortion policy conference in Costa Rica, October 2022

Keywords:

• safe abortion
• abortion policy
• reproductive justice
• activism

On 1–2 October 2022, in commemoration of International Safe Abortion Day, Costa Rica hosted its first National Conference on Abortion Policy. The conference sought to bring together people from across the country and the region to discuss experiences, challenges, and knowledge about abortion and the right to choose. The aim was to co-develop through an intersectional, collective, and participatory approach an agenda and roadmap for action, and thus build a stronger network of people across disciplines and organisations with the common goal of achieving “aborto legal, seguro y gratuito” (legal, safe, and free abortion) in Costa Rica. The event was organised by ACCEDER, a local human rights non-profit, Aborto Legal Costa Rica, a local grassroots movement, Peras del Olmo, a local feminist association, and Women’s Link Worldwide, an international non-profit. These organising entities were also supported by Ipas, a global reproductive justice organisation, the Center for Reproductive Rights, a global human rights organisation, Colectiva por el Derecho a Decidir, a Costa Rican pro-choice collective, and CLACAI, a Latin American consortium working to end unsafe abortion.

Costa Rica’s abortion policy is categorised by the Center for Reproductive Rights as allowable “to preserve health”.¹ Since 1970, the Penal Code states in Article 121 that an abortion practised with the consent of a woman by a doctor or an authorised obstetric nurse is not punishable by law, when it has been conducted with the aim to avoid a risk to the life or health of the mother and this could not be avoided by other means.² However, despite this being codified in the Penal Code, there have been no guidelines or policies for implementation within health systems. There is no clear definition as to what constitutes “risk to the life or health of the mother”, nor what the allowable procedures or timeframes are in cases where abortion is permitted by law.

Due to this lack of clarity, advocates for abortion rights fought for the operationalisation of Article 121 into concrete guidelines for practice and implementation. In 2019, the Costa Rican president claimed to have honoured his campaign promise in signing the “Norma Técnica” (technical guidelines) to operationalise therapeutic abortions.³ Nonetheless, this document still does not provide enough detail, accountability, or enforcement mechanisms that would lead to true access to abortion “to preserve health”. The guideline states that each health centre will define their own protocols to guarantee implementation of therapeutic abortions but outlines no mechanisms for accountability. The determination of whether a case qualifies for authorisation to end the pregnancy relies on a committee of three physicians who will review the available evidence and decide. If the committee rules that an abortion is not needed, the pregnant person can appeal the decision only once. The document also includes clauses for conscientious objection on behalf of providers. Not surprisingly, this new legal document did little to change the landscape of abortion access in Costa Rica. In the year 2022, only six women requested abortions, of which only two had the procedure authorised by their assigned medical committee.⁴ This likely speaks to issues related to conscientious objection, as well as lack of training and understanding of abortion by Costa Rican medical providers. To date, in 2023, several years after the guidelines were signed and approved, the obstetrics and gynaecology residency programme in Costa Rica still provides no educational modules, lectures, readings, resources, nor training on the provision of abortion care.⁵

In 2022, a new conservative president was elected and, fulfilling an election promise, created a new committee a few months after stepping into office to re-assess the already limited-in-scope technical guidelines. Further, in February of 2023, The Committee on the Elimination of Discrimination Against Women (CEDAW) will be reviewing Costa Rica and it is likely that abortion policies will weigh heavily on the topics that the session discusses. All of these have been a force behind the organisation of the first National Conference on Abortion Policy in the country.

I was invited to the conference to present findings from my research on global abortion policy reform and share ideas on how this evidence base could be leveraged by activists and organisers. I am a Costa Rican primary care physician and I have practised medicine in rural and urban areas of the country. Since I left Costa Rica nine years ago, I have worked in the field of sexual and reproductive public health and health policy. I have been interested in abortion policy ever since I started seeing patients in situations where I found my hands to be tied. I remember from my internship year a woman who came to the emergency room to ask to be induced to deliver her baby who had been diagnosed as anencephalic months prior, and all I could think about was how the system and policies had failed this woman, and so many before her. I also remember another instance where a woman was brought in with a perforated uterus from a failed coat-hanger abortion – and the resident on call that night called the police. In 2018, when the news of the Irish referendum circled the globe, I remember thinking about how it came to be that a small, very Catholic country, not too different from Costa Rica, was able to succeed in its campaign for abortion rights. This thought is what I then used as my driving force behind my dissertation research question. My conference presentation was framed around the findings from a scoping review of the literature to assess for drivers of abortion policy reform described in the academic literature since the year 2000.

For a long time, I have struggled with how inaccessible academia is; academic research is vast and rich, but published research is barricaded behind journal paywalls, jargon-ridden prose, and complex database search strategies. Further, in my academic endeavours in the disciplines of medicine, public health, and policy analysis, I have been taught that for the sake of objectivity, research, advocacy, and activism need to be distinctly separate. Attending this conference was my personal form of protest against this widely accepted norm, and I was deliberately trying to engage in science-based advocacy, defined as “ensuring that the best science is in the right hands, at the right time and in the right format”.⁶

However, part of engaging in science-based advocacy requires also learning how to listen to the people on the ground who work on these issues day in and day out, to inform and guide us in our academic endeavours. Over the course of the two-day conference, I paid attention to choices of words, use of personal experiences, how activists drew from evidence sources available to them, gaps in knowledge and strategy that were highlighted, and relationships with the academic sector. Here, I share some of my personal reflections from that weekend.

What’s in the law doesn’t necessarily translate into real-world access

Years of activism and organised efforts went into having President Alvarado sign the “Norma Técnica” in 2019, only to then realise that this did not in fact expand access to safe abortion in Costa Rica. This means that in practical terms, there is little difference between Costa Rica and a country where abortion is prohibited altogether, like Nicaragua or Honduras. They may be colour-coded differently on the Center for Reproductive Rights global map, but the real-life access is the same in both countries: women cannot easily or readily procure a safe abortion through the health system in cases of risks to their health or life. The fact that the law does not reflect the real outcomes is not news to most; however, when it comes to strategising, most movements focus specifically on changing a law or regulation, and do not think about how to leverage movement in different parts of the system to create change. For example, given that there is a provision for conscientious objection in the Costa Rican guidelines, it may be a strategy worth pursuing to more actively engage physicians and educate them on matters related to abortion, instead of sidelining them and viewing them as the obstacle to overcome. In the conference there were only two medical doctors: myself, and a colleague I had encouraged to register and attend. Throughout the weekend, many activists expressed feelings of doctors being a “lost cause” and there was a general sense of antipathy towards doctors in general.

Many people feel like the pro-choice movement is not a welcoming space for them

Feminist activists have struggled for a long time with breaking the patterns that have excluded and marginalised certain groups. In 1989 Kimberlé Crenshaw coined the term “intersectionality” as a way to explain how people have different and overlapping identities which may compound inequality, leading to different types of experiences depending on each person’s array of identities. As a result, more mindful attempts have been made to include experiences across race, ethnicity, sexual orientation, and gender identities. During the conference in Costa Rica, several participants shared that they considered that a lot of the pro-choice rhetoric was very anti-religion and anti-Christianity. Thus, they did not feel that there was a welcoming environment for spiritual people like themselves who were also pro-choice. Examples that were shared during the conference were posters and chants used at rallies, marches, and protests, where messaging ranged from “keep your rosaries out of my ovaries” to more offensive language and graffitied images of the Pope and religious symbols. This means that the movement is missing out on a lot of perspectives and participation that could strengthen current efforts. A large part of the work that activists do is educating the public and spreading awareness about how abortion rights are an integral part of human rights. However, to sway public opinion, you need people to be willing to give you a chance and listen to what you have to say. Since people are more likely to listen to like-minded people and may tend to avoid information that contradicts their positions and values, having spiritual and religious activists front and centre and available for these conversations and outreach processes is critical to engaging people who could not otherwise be reached. The religious participants at the conference made a call to activists to be mindful of language, posters, and messaging and to focus on rationales related to personal autonomy, human rights, compassion, and health, rather than anti-religious rhetoric.

The United States should look beyond its borders more

Countries in Latin America have leaned into each other’s experiences and leveraged resources and strategies. The “Marea Verde” (Green Tide) is a feminist social movement that began in Argentina in response to the alarming rates of gender-based violence and femicide in the region. Shortly after, the movement reframed its legislative demands around women’s autonomy and rights, which included the decriminalisation and legalisation of abortion. The Green Tide has been credited as instrumental to the success seen in countries such as Argentina, Colombia, and Mexico. For decades, the United States (US) was one of only two countries in the Americas that protected legal access to abortion (the second country being Canada), while the rest of the continent, specifically the Latin American region, had some of the most restrictive abortion policies in the world. Now, countries in Latin America that allow abortion on request include Mexico, Colombia, Argentina, Uruguay, Cuba, Guyana, and French Guyana.¹ Further, countries that used to be extremely restrictive have yielded on certain areas of the policy, leading to small, incremental change. For example, the 2012 Brazilian Supreme Court issued a ruling to authorise abortions in cases of fetal anencephaly.⁷ Despite the wealth of social movements and concrete gains in Latin America, activists in the US seem not to look outside their borders for support, ideas, or collaboration. This is not unique to abortion activists; this form of American exceptionalism permeates through most of medicine, public health, and public policy, where many consider evidence to be truly valid only if it was generated in the US, given that the US is so inherently different from any other country. After the Supreme Court Dobbs decision in the US and the gains made in many Latin American countries, this order has shifted. This is an opportunity to look beyond US borders and study movements in other regions that could help advances in the areas that have unfortunately regressed. It is important to look also at where there have been losses in the region. Nicaragua, prior to 2006, did not have an absolute prohibition on abortion.⁸ Studying cases like this can also provide valuable insights as to what potentially caused the shift towards more restrictive policies and start to anticipate and strategise on how to mitigate those factors in other countries.

Overall, what impressed me the most was the energy, passion, and vitality of the activists at the conference. I leave this conference committed to becoming a better listener and a better reproductive health policy advocate to help co-construct the evidence base and other support that reproductive justice activists need to succeed in their campaigns.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Pardee RAND Graduate School: Doris Dong Dissertation Award 2021-2022.