Step by Step in Argentina: Putting Abortion Rights into Practice

Abstract

In December of 2020, the Argentine Congress legalized abortion through 14 weeks, vastly increasing access to abortion care in the country. The law’s passage followed years of advocacy for abortion rights in Argentina - including mass public and civil society mobilization, vocal support from an established pool of abortion providers who offered abortion services under specific legal exceptions prior to the new law, and the growth of community groups such as the Socorristas en Red who provide support for people to self-manage abortions. Aided by ample political will, the number of health facilities offering services increased substantially after the law was passed, and the public visibility around the law has helped assure people seeking abortion that it is their right. Proyecto mirar is an initiative focused on both gathering and using qualitative and quantitative data to inform stakeholders about the progress and obstacles of the law’s implementation. In this review, we present an overall summary of the first two years of implementation of the abortion law in Argentina based on proyecto mirar data and contextualized through the historical processes that have contributed to the law’s passage and application. While we see increases in abortion services and improved public perception around abortion rights, inequities in access and quality of care persist throughout the country. Specifically, providers in some regions are well trained, while others create obstacles to access, and in some regions health services provide high quality abortion care whereas others provide substandard care. To be sure, the implementation of public policies does not happen overnight; it requires government support and backing to tackle obstacles and solve implementation problems. Our findings suggest that when new abortion laws are passed, they must be supported by civil society and government leaders to ensure that associated policies are well crafted and monitored to ensure successful implementation.

Keywords:

• abortion
• Argentina
• reproductive health
• policy implementation

Plain Language Summary

In December 2020, the Argentine Congress voted to make abortion legal through 14 weeks, increasing access to abortion care in the country. The approval of this law followed years of advocacy for abortion rights in Argentina - including mass public protests and debate, vocal support of abortion providers who offered abortion services under specific legal circumstances prior to the new law, and the growth of feminist groups who provide support for people to manage an abortion themselves. Aided by the support of the government, the number of health facilities offering services increased substantially after the law was passed, and the public visibility around the law has helped assure people seeking abortion that it is their right. Proyecto mirar is an initiative focused on both gathering and using data to inform stakeholders of the progress and obstacles to how the law is being put into practice in the country. Here we summarize the first two years of implementation of the abortion law in Argentina based on data from proyecto mirar, and we explain how this progress was influenced by the multiple actors and actions that also led to the law being passed. While abortion services increased and public perception about abortion improved, there are still differences in access and quality of care throughout the country. Specifically, providers in some regions are well trained, while others create obstacles to access, and in some regions health services provide high quality abortion care whereas others provide substandard care. Our findings suggest that when new abortion laws are passed, they must be supported by civil society and government leaders to ensure that the policies linked to these laws are put into practice and monitored to ensure they are successful.

Introduction

In December of 2020, the Argentine Congress passed Law 27.610, “Access to Voluntary Interruption of Pregnancy and Post-Abortion Care”, which dramatically changed the legal framework for abortion access in the country. With this law, Argentina transitioned from a country where abortion was criminalized except under certain legal indications, to a context where legal abortion is available on request through 14 weeks’ gestation, and without gestational age limits for specific indications (ie, rape or risk to life or health of the pregnant person).¹ Importantly, the new law was framed using a rights-based approach, guaranteeing access to abortion services free of charge in all health care facilities (both public and private) in all provinces. In addition, while the law did include a provision for conscientious objection by health professionals, it requires all conscientious objectors refer patients to a health service where abortion is provided.^1,2 Argentina’s legal reform represented the first major change to abortion rights laws in the Latin American and Caribbean region since Uruguay expanded abortion in all cases through 12 weeks in 2012. Though abortion laws in the region vary widely, regional trends have unfolded in recent years to increase the provision of abortion under certain legal indications. Since the passage of the Argentine law, abortion rights bills and court decisions have proliferated in the region, with countries such as Mexico and Colombia expanding abortion rights and advocates in other countries pushing for these same rights.³

Argentina is a middle-income country with a federal governance system, high levels of social inequality and poverty, and a decentralized public health system.⁴ The Catholic Church once had a strong political role, though it is diminishing, and extremely conservative evangelical groups have recently emerged and actively fought against movements to promote sexual and reproductive rights in the country.^5,6 Argentina’s strong tradition of political participation, labor organizing, and active social movements -including the women’s rights and feminist movements- have created and maintained a political culture open to debate and social change. The result of this history has been landmark legal changes to recognize gender, sexual, and reproductive rights in the past two decades.^7,8 The passage of the new Argentine abortion law was the culmination of this long history of activism, socially legitimizing abortion, and advancing access under the existing legal exceptions framework.

Changes to abortion laws in other countries have proven difficult to implement, with historical and new obstacles causing challenges in implementation.^9–11 In Argentina, the new law has the potential to improve access and quality of abortion services and to reduce the risks of unsafe abortion and other harms to health and wellbeing. However, structural challenges and some barriers to implementation must be urgently addressed in order to make abortion a safe and accessible option to all those seeking it throughout the country.^1,2 In this review, we present an overall summary of the first two years of the implementation of the abortion law in Argentina, contextualized within the historical context of the law, its passage, and implementation.

Methods for Monitoring the Implementation of the Law

To understand how and to what extent a law is being implemented and to advocate for any necessary adjustments, it is crucial to track the process and results from the outset. Monitoring the implementation of an abortion policy helps sexual and reproductive rights advocates determine their advocacy strategies for expanding access and improving care. Additionally, policymakers can use this evidence to identify and tackle implementation problems, while advocates in other parts of the world who are working to implement laws and policies to ensure access to legal abortion can learn from this evidence and experience. For the past two years the authors of this article have worked on an initiative, proyecto mirar (“Looking forward”), whose objective is to monitor how the Argentine abortion law is being implemented.¹² Proyecto mirar utilizes a dual approach of gathering/analyzing qualitative and quantitative data and employing the results to inform stakeholders about the progress of the law’s implementation which can contribute to public debate, public policy decisions, and advocacy strategies. We also convene stakeholders across Argentina to discuss the data and how it can be utilized to improve the law’s implementation while requesting input on what data is needed to further analyze the policies supporting the new abortion law.

We have developed a comprehensive system to monitor and evaluate key aspects of the law, including a framework that outlines key indicators to track. In our development of this framework we also reviewed other monitoring initiatives from the region. Several other initiatives in Latin America are also dedicated to monitoring the implementation of new regulations to expand abortion access: the organization Mujeres y Salud en Uruguay in Uruguay tabulates sexual and reproductive health indicators and produces reports on abortion access, and La Mesa por la Vida y la Salud de las Mujeres in Colombia has focused on barriers to access following recent Court decisions to expand abortion rights in the country.^13,14 Proyecto mirar is the only initiative to use a comprehensive framework (described below) and regularly report on indicators related to abortion with a focus on quality and access to abortion services.

When designing our monitoring framework, we used the Monitoring Results for Equity System (MoRES), a framework developed by UNICEF.¹⁵ The framework is a multi-step, multifaceted process that includes monitoring key indicators that lead to health equity. These indicators fit into four main dimensions: Enabling environment, supply, demand, and quality. Though this framework has been used in a variety of contexts and for multiple health conditions, to our knowledge it has not been used in the context of abortion care. We have adapted this framework and within each of these dimensions defined key indicators related to abortion which are reflected in the framework.

To monitor indicators in these four dimensions, we continually gather qualitative and quantitative data which inform us of the progress of the policy’s implementation. Every six months we gather data from publicly-available sources and request data from national and provincial public health departments when it is not publicly available. We also gather publicly-available quantitative data produced by non-governmental organizations that produce studies or annual reports regarding their own services. While the quantitative data allow us to numerically track the progress of key indicators nationally and explore inequalities across jurisdictions, we also recognize the importance of qualitative data to better understand how the new policies are being implemented and why the implementation is happening as it is, as well as illuminate us to key information that may not yet be recorded quantitatively. To that end, we conduct interviews with key informants who fit in the following categories: policymakers at the national and provincial level, activists/advocates, and abortion providers. To assess how the public agenda is framed and evolves, proyecto mirar also monitors national and local news outlets, primarily newspapers, to understand trends in the amount, type, and themes of media coverage of abortion. We then present this gathered qualitative and quantitative information through annual and biannual publications, our project website (www.proyectomirar.org.ar), social media, the press, and provincial meetings with stakeholders, with the goal of reaching diverse audiences who can use the information to improve abortion access and quality of care.¹⁶

In this article we present key findings from two years of proyecto mirar’s work monitoring the law, including a synthesis of relevant quantitative data we have collected from publicly-available and requested sources (including data requested from national and local governments and other non-governmental organizations), and analyses of media reports. The Federal government did not begin collecting statistics regarding the number of abortions provided until the law was implemented in 2021; thus, we do not have centralized data from years prior to the law, however some provinces did collect their own data regarding abortion provision and the Federal government did report some data on the number of facilities providing abortion and the number of medication treatments distributed prior to 2021. When applicable, we report on those data as well. We also present quotes from key informants interviewed for our yearly reports, in 2021 and 2022, on the law; all quotes shared here were already published in those reports.^17–19 The interviewees were chosen purposively to ensure perspectives from different fields and regions of the country. They were asked about topics relating to the progress and challenges of implementing the law and quality of abortion care in Argentina. Because these key informants were asked about topics related to monitoring this new policy and were not asked about their personal experiences but rather their perspectives on the law, we did not seek human subjects review. All key informants gave permission for their quotes to be used verbatim in the reports. In this review we explain how the history and enabling environment that existed before the law, detailed above, has contributed to the data we currently observe related to supply, demand, and quality of care, and explain the progress and obstacles to full implementation of the law.

Organizing and Advocacy Lead to Increased Public Support for Abortion Rights and Paved the Way for Implementation Successes

The passage of the abortion law received strong support from providers, activists, policymakers, and the public at large, and was accompanied by an immediate increase in the number of public health facilities providing abortion services in the country. We attribute the advances made during this initial implementation of the law to: a) The history of long-term mobilizations and advocacy which continued after the law was implemented, b) The public policies that existed before the law which, based on a broad interpretation of legal indications, allowed the growth of networks of health professionals providing abortion, c) The existence of community groups such as the Socorristas en Red who provided abortion support outside of clinics, and d) The political will at the time of passage of the law which provided an enabling environment where the federal government supported the initial implementation.

Long-Term Mobilizations and Advocacy

Argentina has a long history of feminist organizing and social mobilization, which resulted in important legal changes to recognize various gender, sexual, and reproductive rights in the past decades.²⁰ The fight for legal abortion grew from these movements and expanded substantially in 2005 with the formation of the National Campaign for Safe and Legal Abortion (“the Campaign”), a diverse coalition of stakeholders dedicated to advocating for nationwide abortion rights. The Campaign regularly introduced bills to legalize abortion in Congress since 2006 and implemented communications strategies to legitimize abortion rights. In 2018, the campaign introduced a bill to legalize abortion and the first-ever debate on abortion rights was heard in Congress.^7,21,22 The bill was passed in the Lower Chamber but was rejected in the Senate. This process, which included several months of televised Congressional debates, also resulted in mass mobilizations in the streets, led by members of the Campaign, and ample media coverage. This movement is considered the beginning of what is referred to as the “marea verde” (Green Wave), which is now a regional mobilization for abortion rights throughout Latin America, and is symbolized by the green bandanas worn to demonstrate support for abortion rights.^8,22–24 The Campaign, along with other civil society organizations, continue to advocate today for improved access and quality abortion services, and are responsible for much of the social surveillance which helps maintain political focus on the law’s implementation.

Previous Policies and Abortion Provision

In 2012, the Supreme Court clarified that rape was an exception under which all individuals could obtain a legal abortion and instructed the national and provincial governments to follow key quality standards for abortion provision. This was a landmark decision given the legal and symbolic importance that this ruling had in moving the legalization process forward. Following this decision, health professionals began to interpret the indications under which abortion was legal, especially those stating abortion was legal for the health of the pregnant person, more broadly, to include both mental and physical health. Health professional networks such as the Access to Safe Abortion Network (REDAAS) and the Health Professionals Network for the Right to Decide, started publicly expressing their commitment to guaranteeing access to safe and legal abortions, and contributed to expanding access and strengthening a critical mass of health workers who supported abortion provision and pushed for legal change. Alongside this process, the Ministry of Health developed protocols for the provision of abortion services, which outlined the regulatory frameworks for care and evolved over time to include broader health grounds for abortion access within the existing legal framework. Consequently, the number of abortion providers legally offering abortion care under a framework of legal indications grew, with over 900 health facilities offering abortion care immediately prior to the law. These practices helped establish a robust network of health professionals who supported abortion access, advocated for the law, and were prepared to respond to the new law.^21,25,26

Feminist Movements Supporting Self-Management of Abortion

While the National Campaign was gaining strength, and providers were expanding abortion access under the existing legal framework, feminist organizations increased the visibility of their work supporting people by providing socioemotional support and information about how to use medications for abortion on their own, without clinical supervision (“self-management of abortion”). One particular collective of feminist organizations, the Socorristas en Red, steadily expanded since 2012, ensuring more individuals knew about and could access support and information to self-manage abortions outside of the medical sector.²⁷ These same activists also collaborated with the healthcare system to help people access care in cases where they could not or did not want to self-manage.^28–30 This model of abortion care and support contributed to advocacy efforts by raising awareness about safe and effective medication abortion, helping to empower people seeking abortion, destigmatizing abortion, and ultimately contributing to the wave of support for abortion rights.³¹

Political Will and Public Visibility

The mass mobilizations of 2018 in support of the failed attempt to pass an abortion law helped to bolster public visibility about abortion, “socially de-penalize” the topic, and forced the Congress to engage in an unprecedented debate about the topic, requiring politicians to express their arguments publicly. In 2019 a new government was elected, and the 2020 abortion bill was introduced by the Executive office. In addition to the evolving and expanding abortion protocols being produced by the government, the introduction of the bill by the Executive branch demonstrated a strong political commitment to abortion rights which then extended to supporting the law's implementation.^22,32

Progress and Obstacles to Full Implementation

Previous literature and many key informants interviewed by proyecto mirar suggested that the debates, public support, and publicity during the 2018 and 2020 debates about abortion legalization created a “destigmatization” scenario for abortion rights and an enabling environment for the beginning of the implementation process. This visibility meant that the policy, when enacted, was top of mind for policymakers, service providers, and civil society who were ready and willing to support the implementation:

One thing that has helped is the public status the law had. It wasn’t a law that was passed that people were unaware of. People are unaware of laws that pass all the time. But in this instance, the enormous publicity that the debate had, which was a product of the fight and everything that the ‘marea verde’ produced, from the approval, the implementation, to the enactment. (Sexual and Reproductive Health Program Officer, provincial level).¹⁸

This active engagement from civil society, policymakers, and service providers that contributed to its implementation helped increase access nationwide to abortion services: in 2021, 73,487 abortions were provided in the public sector while the Socorristas en Red continued to accompany individuals who chose to self-manage their abortions; reporting a total of 9,172 accompanied self-managed abortions in 2021.^33,34 In 2022, 96,664 abortions were provided in the public sector (data from the Socorristas for 2022 are yet to be published, and health facilities outside the public center are not required to report).³⁵ Despite these promising trends in service provision, inequities remain and more information on quality of care is needed to ensure full implementation.

Remaining Structural Challenges

Despite the advances that have been made in abortion access following the passage of the law, which we will detail below, challenges rooted in Argentina’s political and cultural history persist. Many of these challenges stem from the history of health care provision in Argentina, where, in a fragmented and decentralized healthcare system, many providers and local health systems operate independently as they choose.^4,36,37 At the same time, Argentina’s federal system of governance means that provinces, and the Ministries of Health within those provinces, are responsible for the implementation and enforcement of the law and related public health policies and choose whether and how to implement them.^37,38

Increased Supply of Key Goods and Services, Though Unevenly Spread Within and Across Provinces

Immediately after the law was passed abortion providers began offering legal abortions without the need for prior approval. The support from the Ministry of Health, along with providers’ previous experiences with abortion care provision under the indications in the pre-existing law allowed for this rapid implementation in health services. The existence of multiple networks of trained health professionals meant that experienced providers could support others in expanding their abortion services. At the same time, stakeholders have noted that the law itself and the social de-stigmatization of abortion has encouraged some providers, who may have been hesitant to provide under the previous legal indications, to be trained and offer abortion services outside of the large cities where services were typically offered:

Abortion became more visible not only because of the law itself, but because it had been a taboo topic. If we were to leave the large cities you can see this a lot more in different provinces and town, the interest that increased among many health providers that we thought weren’t interested or didn’t want to participate. And the law showed that there were many more providers who wanted to participate that we didn’t know about before. (Doctor, Obstetrics & Gynecology).¹⁷

The political will of many health authorities also contributed to the increased number of health facilities providing abortion services:

The other key element was the dedication and conduct of the Ministry [of Health], a commitment that they had had previously and was reinforced with the law. This helped a lot, there was a lot of support in those first meetings with the team. And this political support is key because it provides legitimacy. (SRH Program coordinator, provincial level)¹⁸

The National Ministry of Health as well as some local and provincial health administrators published clear protocols outlining how services were to be administered and establishing clear guidelines that all health providers could follow. To encourage this new provision, some service providers, civil society organizations and local and provincial governments as well as the federal government focused on training providers and support staff in abortion practices, including the first-ever virtual training course facilitated by the Ministry of Health and supported by the reproductive health organization Ipas, which enrolled approximately 800 health professionals.¹⁷

The Ministry of Health also ensured that access to supplies of key medications for abortion were guaranteed, contributing to increased services. Once the new abortion law was in place, the National Department of Sexual and Reproductive Health (DNSSR) increased the number of misoprostol treatments it distributed to health centers, from 18,500 treatments in 2020 to 74,071 in 2021 and 62,323 in 2022.^33,35,39 The DNSSR also began distributing combined treatments of mifepristone and misoprostol under a special waiver, as mifepristone was not officially registered yet in the country. This distribution was possible thanks to donations from the NGO Fòs Feminista and purchasing support from UNFPA. Simultaneously, two public laboratories started producing misoprostol for use at public health facilities and the government distributed donations from Ipas of manual vacuum aspiration (MVA) kits, which providers began to use more frequently.¹⁷

This experience and support from already-existing providers and the Ministry of Health facilitated the rapid increase in public health facilities offering abortion services: from 907 health facilities offering abortion services in 2020 to 1,793 in 2022.^33,35 To monitor the progress of the implementation, the National Ministry of Health produced reports on abortion services provided beginning in 2021, with several provinces producing reports even prior to the law. This allowed for the government and civil society to track the implementation of the law publicly and demonstrated the government’s commitment to ensuring transparent data processes and accountability efforts.^33,40 Civil society organizations, most of which had been a part of the National Campaign, also continued to monitor abortion provision and support people in their abortion-seeking to ensure services were provided in a timely, high-quality manner:^41–43

Something else that helped a lot, at a local level, was a very organized civil society: to have colleagues in other provinces who would call and say, ‘there’s a woman admitted here, and they won’t see her, they’re giving her poor treatment.’ These ties that were constructed in provinces during the ‘marea verde’ happened a lot, they put a lot of pressure on the secretaries of health in the provinces, on the hospital directors. The permanent presence of those colleagues who were organized was an important support for local implementation. (Director of SRH programs, provincial level)¹⁸

While there are strong signs of improved availability of abortion services, there are inequities in the availability of those services throughout the country. In 2022 the number of public health centers offering abortion in Argentina per capita was 0.16 health centers per 1000 women of reproductive age, however inequities are seen by province, with the provinces of Chaco, Mendoza, and Santiago del Estero with the lowest rates at 0.03 per 1000 women of reproductive age, and the province with the highest rate, La Pampa, having 0.45 public health facilities per 1000 women of reproductive age.³⁵ One of the primary reasons for these differences is the lack of physicians who can provide abortion in certain regions of the country, in particular those who provide abortions after 14 weeks, where there are already a limited number of providers nationwide. Additional reasons include continued abortion stigma and a lack of institutional financial resources.^17,18 Some progress is, however, being made: while midwives are currently not allowed to provide abortion services in most provinces, a bill is moving through the National Congress which allows midwives to provide abortion care in the first trimester, which if approved will increase the availability of providers throughout the country.^44–46

Despite the clear parameters within the new law, an additional barrier to access is that both providers and institutions still resort to conscientious objection for a wide range of reasons, contributing to the shortage of abortion providers in some settings throughout the country. This practice has not received substantial oversight from local, provincial, and national health authorities, meaning many providers can claim conscientious objection without following the regulations associated with it, such as ensuring individuals are quickly referred elsewhere.^47,48

Increased Abortion-Seeking in Public Health Facilities in the Context of Confusing Bureaucracies and a Lack of Information

The cultural change of social de-penalization of abortion due to increased public visibility, accompanied with a stated right to abortion through the law itself, created an environment where people felt more comfortable accessing and providing care. Stakeholders reported a marked increase in the number of people seeking abortion services at health facilities after the law. They also reported that people seeking abortion appeared more comfortable asking about and discussing abortion services, as well as considering abortion a right. The “social de-penalization” of abortion, though perhaps not for everyone, seems to have bolstered individuals’ comfort to seek abortion services:

Now, we can say to people we help [during their abortion], ‘If you want to go to the health system it’s your right and you can demand it, and they have to guarantee it for you.’ It seems so important at a human level, this power…to know you have power and you can demand your rights. (Feminist activist)¹⁸

Just as the availability of abortion providers varies by province and region, there are also inequities reported in the ability to access abortion by geography and for certain marginalized communities: while 96,664 abortions were carried out in the public health sector in 2022, translating to a national abortion rate of 8.36 abortions per 1000 women of reproductive age, this rate varied substantially by province: from 3.93 in Corrientes, to 13.23 in Buenos Aires City.³⁵

Qualitative interviews describe inequities in care for certain populations. For example, though there has been an emphasis on ensuring care for people under the age of 18, with the Ministry of Health developing clear guidelines and protocols, stakeholders report continued challenges in many areas of the country to ensuring this care, including challenges in guaranteeing confidentiality in cases of minors where abuse is required to be reported. Likewise, people in rural areas do not have continued access to abortion providers, who are primarily located in larger cities.¹⁷

Additionally, while the law mandates free services, there are many reports of people having to pay for extra services related to their abortion, such as the ultrasound. In the private medical system, despite the law mandating that abortion be offered for free in all healthcare facilities, some facilities do not offer care or require payment for it. This forces individuals to seek care at public institutions (where they can also access care under the law regardless of their insurance) or community-based services after their initial consultation in the private system, delaying their process.⁴⁹ To date, the National Ministry of Health does not require any reporting from clinics and hospitals outside of the public health system, which make up 63% of all registered health services in the country (though they may provide fewer abortion services, given the denials and barriers reported in our qualitative research and the universal coverage of the public health system).⁵⁰ Because these health facilities are not required to report on their abortion provision to date, the number of abortions provided in these healthcare systems, as compared to the public sector, cannot be determined and constitute a major obstacle to accountability. Without comprehensive monitoring to ensure enforcement of the law, these denials and charges for abortion care in the public and private sectors continue and create barriers to care.^17,18

In addition to confusion regarding payment for abortion services, there are reports of a lack of information about the law itself and confusing procedures to access services.⁴⁹ Data from interviews with key stakeholders demonstrate that public information about the law itself is lacking; no public informational campaign has yet been implemented in the country and any information campaigns about the law have primarily been led by advocacy organizations with smaller budgets and challenges scaling their campaigns nationally.^17,18 In some cases, institutions feel they cannot publicize their services for safety reasons.¹⁹ Once an individual knows their rights and begins to seek abortion care, they often encounter confusing bureaucracies in the health system itself where they are not sure of the route of care and receive confusing information by health system staff.^17,18

Working Towards Person-Centered Quality of Care

There are qualitative reports of good quality standards during abortion provision, which includes person-centered care at some health care facilities in some provinces, including care that integrates self-management of abortion with provider-supported abortion. Many of these health services had developed robust abortion care protocols and worked with local activists to ensure good care prior to the law, and have been able to expand their services since the law.^17,51,52 Additionally, activists from the Socorristas en Red and the networks of health professionals are collaborating to train providers in high-quality, person-centered, abortion provision.^53,54

However, in many regions and certain clinics substandard quality of care is reported. In some places, providers and health services continue to use outdated practices that go against current recommendations. For example, key informants reported that methods that are no longer recommended, such as curettage, are still used in some places, and that providers do not know how to appropriately administer the medication abortion regimen. In other cases, providers require an ultrasound even when it is not medically indicated, delaying a person when they are trying to promptly access abortion services. Given the history and common use of medications for abortion prior to the law, medication abortion accounts for most abortions in the country, while the use of MVA has been less common: of the five jurisdictions that report the distribution of abortion method, all jurisdictions reported that more than 85% of all abortions were only with medication.¹⁷ This means fewer providers trained and offering the option, even though the WHO standards of quality abortion care suggest people seeking abortion should have a choice in their abortion method.¹⁷

There are still problems with enormous resistance from some health teams to incorporating scientifically valid techniques into their work. Since abortion was always considered a marginal topic, where in the best of cases someone did the best they could do with what they had, what they knew, it wasn’t a central topic for scientific conferences, no one was famous for being an expert in the topic. In the first trimester, people should be able to decide if they’d prefer medication abortion taken at home, or if they’d prefer to take it in the hospital, or if they’d like MVA, MVA with a local anesthetic or a general anesthetic. The possibility to think about giving people the option to choose, this is still far from what the health teams are thinking about. (SRH Program officer, provincial level)¹⁸

Though, to date, there are no quantitative data on people’s experiences with the quality of abortion care in Argentina after the law, research pre-law and our stakeholder interviews identified that people seeking care desire empathy, respect, and support in their abortion care process.^17,51,55 The National Campaign and their partner organizations continue to monitor issues of quality and conscientious objection and advocate for better quality services.^41,56,57 Meanwhile, the Socorristas en Red have worked to identify cases where people were denied access or received poor care and advocate for better services.⁵⁸ Key informant interviews and these reports from civil society suggest that while some individuals provide high-quality, compassionate care that respects an individuals’ autonomy and right to confidentiality, there is still a need to train all providers to consider these important aspects of quality of care:

The most difficult is transforming the power relations…I think there have been huge advances and that abortion has influenced other things. Because when you start to speak about transparency, accompaniment, there start to be things that change among the health providers, when you do a training with people at the clinics and hospitals, it starts with abortion, but it really has to do with any medical practice where the patient has to make a decision. (Director of SRH programs, provincial level)¹⁷

Conclusions

The feminist, human rights, and health providers movements that led the way for the new abortion law in Argentina, and encouraged mass participation in support of the law, are at present advocating for better access and higher quality abortion services. Meanwhile, the tracking of the law’s implementation by local and national ministries of health, as well as civil society, is focused on monitoring whether the law is making a difference in this large and unequal country.

As we have described in this article, the political will in support of the law and the focus on accountability has allowed providers to quickly ramp up their services after the abortion law was passed in Argentina. Meanwhile, social destigmatization due to activism and support from politicians has encouraged people to seek abortion services and perceive them as their right. However, the experience of implementation thus far in Argentina suggests that quality of abortion care, both technical and socioemotional, vary widely and more efforts are necessary to train providers in high quality abortion provision.

Abortion policy implementation is a complex technical and political process which does not just depend on financial and human resources and available technologies. It is also dependent on the political support and institutional capacity of health authorities to guarantee its success. Despite the strengths we have observed in these two years of abortion policy implementation, inequities in access and quality of care continue throughout the country: while in some regions providers and health services are well-trained and provide quality care, others create obstacles to access and provide substandard care, often due to poor enforcement by local authorities, lack of resources, stigma, and resistance to abortion. Many of these implementation challenges in Argentina stem from the federal political system along with the decentralized health system which allows for individuals at the local and health services levels to implement policies as they see fit, with little enforcement from health authorities.

Every social movement context and every abortion law implementation process are unique as they are deeply rooted in national political culture and dynamics. However, there are important lessons to be drawn from the Argentinian experience. As we see shifts in abortion policies throughout the region, with a specific trend in liberalization of abortion laws, there are several key takeaways from the Argentinean experience that could serve other countries:

• Legal indications can lay a solid foundation for abortion provision pre-law. Even in restrictive contexts, creative implementation of existing abortion policies could expand access. This not only expands current access but ensures providers who are willing and able to offer abortion services when a law is passed and builds a political scenario for which abortion provision is part of the public health policy.

• Capitalizing on the political will of the government at the beginning of the policy implementation can create a solid foundation of access and quality. Political will can be dependent on the government in power; however taking advantage of the positive support at the inception of a law’s implementation can aid in ensuring proper budget, enforcement of the law, and guidelines for provision are put into place early, creating a strong foundation for implementation. Though the government of Argentina has demonstrated much political will and support, further support from the government is needed to conduct widespread information campaigns and enforce provisions in the bill such as conscientious objection provisions.

• Independent monitoring and social accountability is key to ensuring successful implementation. The initial enthusiasm and attention to an abortion law will inevitably recede, and yet it is clear there are continued and new challenges that require adjustments in public policies. Generating data and disseminating it for advocates and policymakers provides evidence to make needed changes. Independent monitoring of the law through data generation, and social accountability which focuses attention on the continued needs of individuals to ensure abortion access, helps maintain pressure on the topic. This surveillance also strengthens new societal expectations for what access and quality of care should be, ensuring that the public also demand their rights and advocate for improvement in services.

• Accountability mechanisms should be designed from the beginning, and ideally within the law, to ensure proper compliance with the law. In Argentina we have seen that many inequities exist due to a lack of enforcement which allows providers and institutions to choose whether and how to provide abortion services.⁵⁹ Governmental reporting on abortion provision and key indicators, as the Argentinean government is doing, is crucial for accountability and enforcement. However, unlike Ireland, where abortion was recently legalized and a review of the law after 3 years is mandated, the Argentinean law does not include any reporting or review requirements, meaning that the government could choose not to share or report key data used for monitoring.⁶⁰ Ensuring that the government continues to report out is crucial for continued monitoring of the law by internal government actors and external civil society organizations, as well as for enforcement of the law by the government.

• Inequities should be anticipated in federalist systems with fragmented health systems. Many of the inequities we see in Argentina pre-dated the law and continue to be challenges which need to be addressed. In other settings with new or anticipated laws, these inequities need to be taken into consideration and addressed from the beginning of the implementation process. This includes a focus on inequities when planning budgets, trainings, geographical foci and in the monitoring of the implementation.

The trajectory of the Argentinean abortion law demonstrates the critical importance of mass, long-term mobilizations not only in support of the passage of the law itself but also in the creation of independent monitoring systems by civil society that increase transparency and accountability of the law’s implementation. These efforts, and the political will of a wide range of politicians and policymakers have created an environment in which abortion access has rapidly expanded in many areas of the country, however we continue to see inequities in access. With continued monitoring efforts, implementation of abortion laws in Argentina can adjust to improve access and quality to better address abortion seekers’ needs and expectations. Additionally, other countries implementing new laws can learn from this experience, focusing on equitable service delivery and monitoring from the beginning, to work towards guaranteeing abortion access and quality of care for those who seek it.

Data Sharing Statement

All data reported in this manuscript are publicly available and cited within the manuscript.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Agustina Ramón Michel, Silvina Ramos, and Mariana Romero participate on the Advisory Committee to the Argentinean Department of Sexual and Reproductive Health. The authors report no other competing interests in this work.

Acknowledgments

We would like to thank Narela Benegas for their continuous intellectual and administrative contributions to proyecto mirar. We would like to thank Daniela Guberman, Edgardo Ábalos, and Silvina Molina for their assistance in the analysis of proyecto mirar data.

Additional information

Funding

Proyecto mirar is supported by the Wellspring Philanthropic Fund.