ACCESS to safe abortion services is restricted. Constructing Access to Legal Abortion Services in Mexico City

 2002 Reproductive Health Matters. Published by Elsevier Science Ltd. All rights reserved. Reproductive Health Matters 2002;10(19):86–94 0968-8080/02...
Author: Magdalen Greer
4 downloads 1 Views 115KB Size
 2002 Reproductive Health Matters. Published by Elsevier Science Ltd. All rights reserved. Reproductive Health Matters 2002;10(19):86–94 0968-8080/02 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 0 2 ) 0 0 0 1 8 - 6 www.elsevier.com/locate/rhm

Constructing Access to Legal Abortion Services in Mexico City Deborah L Billings a, Claudia Moreno b, Celia Ramos b, Deyanira Gonzalez de Leon c, Ruben Ramırez d, Leticia Villase~nor Martınez e, Mauricio Rivera Dıaz f a

c

Senior Research Associate, Ipas Mexico, Mexico City, Mexico. E-mail: [email protected] b Programs Coordinator, Ipas Mexico Physician and Associate Professor, Department of Health Care, Universidad Autonoma Metropolitana-Xochimilco, Mexico City, Mexico d Medical Advisor, Ipas Mexico e General Director, Medical and Emergency Services, Department of Health, Federal District, Mexico f Advisor to General Director, Medical and Emergency Services, Department of Health, Federal District, Mexico

Abstract For the last three decades, government and health institutions have recognised that unsafe abortion is an important social and public health problem in Mexico. Although the Penal Code in every state defines at least one situation in which abortion is legal, access to legal abortion services is restricted for women throughout Mexico. In August 2000, the Mexico City Legislative Assembly reformed the Penal Code to include a wider range of grounds on which abortion is legal and added regulations to ensure access to legal abortion services in cases of rape and forced artificial insemination. The Mexican Supreme Court upheld the constitutionality of the reforms in January 2002. This paper describes a collaborative project between Ipas Mexico and the Mexico City Department of Health to provide legal abortions in cases of rape and to ensure that comprehensive health services for survivors of sexual violence are available and accessible. It describes a model of care being introduced into 15 public general and maternal-child health hospitals in Mexico City through a programme of multi-disciplinary consciousness-raising workshops and training courses on sexual violence and legal abortion. Few health care providers have had prior training in service provision for survivors of sexual violence or abortion service delivery. Workshop participants showed a high level of willingness to participate in legal abortion services for survivors of sexual violence when and if they are receive solid institutional support.  2002 Reproductive Health Matters. Published by Elsevier Science Ltd. All rights reserved. Keywords: abortion law and policy; sexual violence and abuse; reproductive health services; training of service providers; Mexico

A

CCESS to safe abortion services is restricted for women throughout Mexico, despite the reality that Penal Codes in every state define at least one situation in which abortion is exempt from penalty. 1 In all 31 states and the Federal Dis1

Abortion is legal in Mexico in cases of rape in all 32 states, accident (imprudencial) on the part of the women in 29 states, 28 when the woman’s life is endangered by the pregnancy, 10 for severe fetal malformation, and 9 when the woman’s health is endangered by the pregnancy. The state of Yucatan is the only state that allows abortion for economic reasons (i.e. the woman already has at least three children).

86

trict (Mexico City), women have the right to an abortion when the pregnancy is the result of rape. At the ICPDþ5 review in 1999, Mexico along with other countries reaffirmed its commitment to take steps to ensure that unsafe abortion would be addressed as an important public health problem. Countries also agreed that ‘In circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible (Paragraph 63iii)’ [1]. In general, however, few resources have been designated for training and equipping health care

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

providers in public health systems to offer legal abortion services. This article focuses on the results of the first stage of a project carried out by Ipas Mexico and the Department of Health of Mexico City aimed at preparing public hospitals to provide legal abortion services. In August 2000, the Mexico City Legislative Assembly modified the Penal Code to include a wider range of grounds on which abortion is not penalised. Progressive changes were also made to the regulations to be followed by the judicial and health sectors on women’s access to legal abortion services in case of rape and forced artificial insemination [2]. This paper describes the development and implementation of a comprehensive model of care that includes legal abortion services for women survivors of sexual violence in public hospitals in Mexico City. Sexual violence and forced pregnancy in Mexico City Mexico City’s penal code defines rape as copulation with a person of either sex through the imposition of physical or ‘‘moral’’ (e.g. threats) violence. It also includes the forced introduction of objects or instruments other than the penis into the vagina or anus. Rape is committed when either of these actions occurs with a person who is younger than 12 years of age, with a person who does not have the capacity to comprehend the significance of the act or who, for whatever reason, could not refuse or stop the act. Rape can also take place within marriage and carries the same penalty as rape outside marriage [3]. The average number of rapes reported each day in Mexico City, three to four, has remained fairly constant from 1993 to 2001 [4]. Yet the true extent of the problem is not reflected in official statistics. Mexican non-governmental organizations (NGOs) estimate that only 10% of rapes are ever reported [5] due to widespread lack of confidence in the judicial system, lack of information among the general public about rape and the high incidence of sexual violence committed by family members and others who are known to the victim. Rape committed by known persons tends to be repetitive, often escalates over time and is often linked to economic dependency, familial ‘‘honour’’, fear, shame, lack of knowledge that it is a crime or that avenues for recourse exist, and social stigma, all of which make publicly exposing the violence difficult. These

dynamics also help to explain, in part, why many women who become pregnant from rape do not seek legal abortion services. Of 345 women seeking care in a public health clinic in Mexico City from February through March 1998, 11% reported having been raped at some time in their lives and 20% reported sexual violence in the context of an intimate relationship [6]. Numerous studies show that the majority of victims are young women who know the rapist [7,8]. One study of survivors of sexual violence attended by the Centre for Care for Intrafamilial and Sexual Violence in Mexico City (CAVIS) from 1990 to 1996 found that 86% of 531 sexual violence victims were female, 50% under the age of 20. All of the perpetrators were men and 62% were known to the victims, including close family members, partners and neighbours. Thirteen percent became pregnant after rape and 54% wanted an abortion [8]. According to reports from the Centre for Therapeutic Support for Victims of Sex Crimes (CTA) 2 in Mexico City, more than 65% of all sexual violence is committed by persons known to the victims [5]. A study published in 1999 reported that among adolescents treated in one clinic in Mexico City, 54% knew the aggressor, 20% had some form of sexually transmitted infection and 10% became pregnant after the rape [7]. Among 11 women aged 14–28 who became pregnant after rape who sought care at the CTA [9], five terminated the pregnancy while the other six women continued the pregnancy and kept the child. All the women who decided to abort had been raped by men unknown to them and reported the attack to police within an average of 19 days, while women who did not abort had been raped by family members, friends and in one case the woman’s boss. These women did not report the rape until almost nine months after the attack. This may be significant as it represents a move to protect the newborn whereas protection was not sought for themselves. Forced motherhood and unsafe abortion in Mexico The 1995 Platform for Action of the UN Women’s Conference condemns forced motherhood 2 The CTA, under the authority of the Attorney General’s Office of Mexico City (PGJDF), is the only existing public sector centre providing legal and psychological support to victims of sexual crimes and referral for medical care.

87

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

as a violation of women’s human rights. Cook and Dickens emphasize that in no other circumstance are people required to use their bodies for the sustenance of others against their will. Legal scholars have argued that to require women to use their bodies against their will in this way constitutes sex discrimination [10]. Forced pregnancy and motherhood are in direct violation of Article 4 of the Mexican Constitution, which states that all persons have the right ‘‘to decide in a free, responsible and informed manner about the number and spacing of their children’’, yet they are a common life experience of women in Mexico [11,12]. Feminists in Mexico have used the concept of ‘‘voluntary motherhood’’ since the 1970s to advocate for comprehensive sexuality education, access to effective contraceptive methods, eradication of forced sterilisation of women and provision of legal abortion as a last resort for women with unwanted pregnancy [13]. For the last three decades, government and health institutions have recognised that unsafe abortion is an important social and public health problem in Mexico, e.g. in the 1973 General Population Law. Estimates of national prevalence of induced abortion vary, with the National Council on Population (CONAPO) calculating approximately 200,000 induced abortions between 1993 and 1995 [14]. Many women are forced to resort to unsafe abortions, resulting in a high number of preventable complications, as well as deaths [15]. Unsafe abortion is the fourth most common cause of maternal mortality in Mexico [16]. In 1994, about a third of women required hospitalization for emergency care following unsafe abortions [17]. An analysis of maternal mortality in Mexico found that women living in marginalized areas were twice as likely to die from abortion complications as women living in other regions [18]. These figures do not take into account the increased usage of misoprostol by women to self-induce abortions which, as seen in Brazil, will most likely result in fewer complications, less severe morbidity and fewer deaths [19,20].

Legal framework for safe abortion in Mexico City In recent years, political life in Mexico has been marked by significant change, in which the public has been increasingly involved in the discussion 88

of problems and issues. Feminist groups, academics and NGOs have intensified their struggle for the recognition of sexual and reproductive rights and in support of women’s abilities to exercise these rights. They have succeeded in making the complex issues of abortion and violence against women more visible, through initiatives to modify existing laws and norms, by publicising individual cases and supporting women such as Paulina del Carmen Ramirez Jacinto who have been denied legal abortion services [21], whose case is being taken by NGOs to the Inter-American Commission on Human Rights. Penalisation of abortion is covered in the 1931 Penal Code for the Federal District, in which abortion is legal when pregnancy results from rape, to save the life of the woman or when abortion results from an accident (such as falling down the stairs). In August 2000 the interim Mayor of Mexico City Rosario Robles presented a bill to broaden the grounds for a legal abortion in Mexico City [22]. 3 The bill, known as the Robles Law, added three indications for legal abortion; it was passed by a majority in the Federal District Legislative Assembly [2]. The exemption ‘‘to save the life of the woman’’ was replaced with a broader indication – ‘‘when the pregnancy presents a grave risk to the health of the woman’’. Although not specified in the law as such, many legal scholars support a broad interpretation of this clause to include both physical and mental health [23]. In addition, abortion was made legal in cases of severe fetal malformation or artificial insemination without the woman’s consent, and the maximum prison sentence for women who have illegal abortions has been reduced from five to three years. A significant advance in this legislative reform was the clear definition of responsibilities of the judicial and health sectors, including physicians, and the procedures they are to follow in the provi3

Cortes and Bissell emphasize the key events upon which the Penal Code reform was based include the Secretary of Health’s statement in July 1998 that the issue of abortion should be debated publicly, sparking coverage in the media over the course of several weeks; and the activism of the ‘‘Campaign for Access to Justice for Women’’ (comprised of 40 NGOs with a core group of activists) that presented information to government officials, political party leaders and the media about domestic and sexual violence, the rights of children, young people and victims of violence, the right to freedom from discrimination, and the right to abortion as part of the right to health [22].

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

sion of legal abortion services following rape or non-consensual insemination [2,24,25]. Such enabling regulations are notably absent from legislation in most Mexican states, presenting an important barrier to women’s access to safe services. Thus, for a woman to get a legal abortion following rape: • she must report the rape to the Public Prosecutor’s Office and state that she is pregnant; • the pregnancy must be confirmed by a health institution; • there must be evidence to allow the Public Prosecutor’s Office to declare that the pregnancy is the result of rape (court proceedings or sentencing of an alleged perpetrator are not required); • she must request an abortion. If these conditions are met, the Public Prosecutor’s Office is obliged to authorize an abortion within 24 hours. In response to the misinformation given to Paulina and her mother regarding the minimal risks that accompany safe abortion, language was added to the reform that states that physicians must provide the pregnant woman with objective, truthful, sufficient and opportune information about the abortion procedure, including its ‘‘risks, consequences and effects’’. Physicians must also provide the woman with information about ‘‘support and alternatives’’, so that she can make a decision in a free, informed and responsible manner. Information should be provided to the woman immediately and the physician should not attempt to influence or delay her decision. A month after the reforms were passed, the conservative National Action Party (PAN) and the Mexican Green Ecological Party (PVEM) argued that abortion for fetal malformations was unconstitutional. In January 2002, in a groundbreaking judgement, the Mexican Supreme Court upheld the law, and declared that the Public Prosecutor’s office could authorize abortions in cases of rape and forced insemination. In response, Mexico City’s Health Secretary, Dr. Asa Cristina Laurel announced that the city’s public hospitals would offer legal abortion services to women [26]. The ruling was a critical one, in that it recognised that the fundamental rights of women may in some circumstances prevail over those of the fetus and that religious values can and should be put aside when determining secular legal matters.

Expanding access to legal abortion in the public health sector In 1995, the national Ministry of Health and the Public Prosecutor’s Office of Mexico City signed an agreement to create clinics for comprehensive care for victims of sexual violence in three public hospitals in different zones in Mexico City [27]. A key component of the agreement is that women rape survivors are referred from the Public Prosecutor’s Office to the CTA for psychological and legal support and then to one of the three hospitals for medical care, including legal abortion if requested by the woman. In one of the hospitals an ethics committee was also established, to review all cases in which a legal abortion is requested. This has proven to be a barrier to women’s access to legal abortion services and is unnecessary since the Public Prosecutor’s Office now authorizes the abortion procedure. Several Mexican NGOs developed strong links with the three hospitals included in the agreement and sponsored workshops aimed at developing improved communication between the judicial and health sectors. However, direct training for providing comprehensive care was not instituted, nor was a model of care developed to guide service provision. The delivery of legal abortion services in the three hospitals has not been consistent. Services have been ongoing since 1995 in one of the three hospitals but are provided in an inconsistent manner in another, depending on the medical director’s personal attitudes. The third hospital only recently began to provide services to women victims of sexual violence in a systematic way, but does not offer legal abortion services. Thus, despite past agreements, access to safe, legal abortion services continues to be extremely limited. Approval of the Robles Law provided a more solid foundation from which to carry out the work of implementing legal abortion services in the public sector. While the reforms apply only to public services in Mexico City, their impact has been nationwide in terms of opening up public debate on legal abortion in Mexico. Since August 2000, new strategies have been developed and implemented by several NGOs that aim to broaden women’s access to legal abortion services. One strategy is the organization of prestigious national and international conferences aimed at physicians, particularly obstetricians and 89

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

gynaecologists, that focus on the impact of violence against women and propose ways in which they can help to prevent, diagnose and treat the effects of domestic and sexual violence, including safe, legal abortion services. That services should be provided free of cost in the public sector is highlighted in the Monterrey Declaration 2000 following a three-day symposium on ‘‘Violence: ethics, justice and health for women’’ [28]. Legal abortion was also one of the key themes of a three-day special session on violence against women in 2001 by the Mexican Federation of Gynecology and Obstetrics (FEMEGO) and the International Federation of Gynecology and Obstetrics (FIGO). Mexican civil society organizations participated in these groundbreaking meetings, where the linkages between sexual violence and legal abortion were discussed openly by physicians and proposals for future action at the local, state and national levels developed.

A model to enhance access to comprehensive services for survivors of sexual assault In Mexico City, Ipas Mexico and the Mexico City Department of Health initiated a collaborative project in August 2000 that aims to establish comprehensive care that includes legal abortion services for survivors of sexual violence. Experience in Mexico and throughout the world was drawn upon to develop a model of care and a strategy for implementing it. Particularly relevant was the Brazilian experience, where a growing number of hospitals perform legal abortions and provide specialist services for survivors of sexual violence [29,30]. The model of care was reviewed and refined in collaboration with health care providers from hospitals throughout the city in consciousness-raising workshops. It has three basic premises: • Care should be women-centred with the needs of survivors of sexual violence placed at the centre of care. Services should be organized in such a way that women can receive care during different phases in their life related to the sexual violence. • Health care facilities are key locales and health care professionals key actors in the prevention and treatment of violence again women. Many times the only formal assistance or care that 90

women seek is from health care professionals, and their visit may or may not be directly related to the violence, depending on the severity of harm. • Comprehensive care includes specialized medical services, while also emphasizing women’s need for psychological and legal support. Overall, the model promotes access to a range of services – legal, medical and psychological – to which women have a right. The model is designed for use in health centres and hospitals, with the full range of services outlined below offered in secondary level hospitals. Personnel in health centres, on the other hand, can focus on promotional and educational activities, detection of violence in women’s lives, provision of first contact medical attention (including emergency contraception and referral to hospitals) and follow-up with women and their families when appropriate.

Implementation strategy A step-by-step strategy is being followed to implement this model of care in the Department of Health’s 15 general and maternal-child health hospitals in Mexico City. First, information and consciousness-raising workshops are carried out with all relevant health service providers, students and administrative personnel who work in the participating hospitals. These address the main legal, psychological and medical aspects of comprehensive services for victims of sexual violence. Health care providers participating in workshops are being asked to fill in self-administered questionnaires to understand the training, experiences and attitudes of the participants in relation to sexual violence and abortion and to aid in identifying participants for the health teams and allies in each hospital. To date, these steps have been carried out successfully in all 15 of Mexico City’s Department of Health hospitals and initiated in selected hospitals in the states of Mexico and Hidalgo. Future work includes implementation of the methodology in other areas of Mexico as well as completion of the following steps of the implementation strategy in hospitals where this work has already begun. In collaboration with relevant health institutions, health teams in each hospital (including doc-

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

A Model for Comprehensive Care for Victims of Sexual Violence: Essential Components 1. Promotion and dissemination of information about available services Information about the services should be clearly displayed in posters in health care facilities 2. Detection of violence in women’s lives • Health care providers should have the necessary skills to detect situations of violence • Look for indicators of violence • When violence is suspected, take the woman to a private place in the facility where confidentiality can be ensured • Talk about the subject of violence; ask direct questions • Seek the assistance of specialists 3. Specialized information and counselling If a woman is identified as a victim of violence, she should be referred to specialists who form part of a specially trained health team that will: • Engage in crisis management • Provide general and legal information about pregnancy resulting from rape, including the woman’s right to a legal abortion and the steps required with the Public Prosecutor’s Office (report the rape and provide evidence that the pregnancy is the result of rape) and the health sector (confirm pregnancy) for a legal abortion to be authorized

tors, nurses, social workers, psychologists where available and administrative personnel) will be trained in the hospitals to provide comprehensive services to women victims of sexual violence. A system for monitoring the quality of services will also be developed, as will a referral system to specialized psychological support services, including those located outside the hospital. Further, we will seek to foster the formation of discussion groups among health professionals providing these services, so that they feel supported and are not overwhelmed, and to create an incentive system for health teams. Lastly, we will be assisting in formalizing collaborative

• Inform the woman she can continue the pregnancy, put the baby up for adoption or have an abortion • Evaluate risks in collaboration with the woman to assess her safety • Help the woman construct a safety plan • Document in a detailed manner the signs of violence, both physical and psychological, as well as any actions taken 4. Medical services Appropriate medical treatment will depend on when the woman attends the facility to receive support (particularly before or after 72 hours) and should include: • Comprehensive evaluation and treatment of injuries • Gathering legal evidence and documenting findings in the woman’s medical file • Prevention of pregnancy: emergency contraception • Prevention of and treatment for STIs, including post- exposure prophylaxis against HIV • Legal abortion services 5. Referral and follow-up • Referral for psychological support and care (in the hospital or elsewhere) • Referral for legal support • Follow-up and accompaniment of the woman throughout her treatment, with special attention to pregnant women and women with HIV

relationships between the justice and health sectors.

Positive responses from health care professionals The consciousness-raising workshops have been successful in increasing awareness of and interest in the model of care proposed and helped to identify health care providers who want to be part of the multi-disciplinary teams providing these services. The workshop programme involves a total of 12 hours over three working days, using three 91

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

modules: one on the legal framework of sexual violence and abortion and the others on the psychological and medical aspects of care. Each half-day session has two parts: conceptual and theoretical aspects and group exercises that put concepts into practice through the construction of case studies, based on participants’ own experiences in treating survivors of sexual violence. As of February 2002, a total of 468 health service providers from all 15 participating hospitals in Mexico City and 39 participants from the central office of the Department of Health had participated in workshops. During the first day of the workshops, a selfadministered questionnaire was distributed, to find out participants’ knowledge, attitudes and practices related to care for survivors of sexual violence and legal abortion. A total of 365 (78% of 468) participants responded. Confidentiality was ensured through informed consent; the questionnaires were anonymous and returned in unmarked envelopes. Participants frequently mentioned the need to better understand the legal framework of sexual violence and abortion, and to have legal backing if they provide these services. Many hospitalbased participants had questions about the exact procedures to be followed when the hospital received authorization to perform a legal abortion from the Public Prosecutor’s Office. They also expressed concerns about what to do if a minor requests a legal abortion and her parents oppose the decision. Slightly over half the physicians, nurses and social workers said they had received information about violence and sexual violence during medical, nursing or social work school, but less than a quarter had been trained in clinical or psychological aspects of care for survivors of sexual violence and the same percentage in the legal framework of abortion. Fewer than half had been trained in the use of emergency contraception and only 34% of physicians had been trained to use manual vacuum aspiration for the treatment of abortion complications or to perform safe abortions. Overall, prior to the workshops, only 30% of physicians, nurses and social workers and 11% of psychologists had felt prepared to provide comprehensive services to survivors of sexual violence. The majority of participants (65–98%) believed women should have access to legal abortion on all the grounds in the revised Penal Code for Mexico City. More than 90% of physicians accepted abortion in these situations. The fact remains, how92

ever, that these are not the most common reasons why women seek abortion, and in general, there was a low level of acceptance of abortion in circumstances other than those in the Penal Code. Hence, most women may still not gain access to legal abortion services. These findings are consistent with an opinion survey carried out in Mexico in 2000 with a nationally representative, random sample of 3000 men and women aged 15–65. More than half of the respondents supported access to abortion when the life of the woman was endangered (80%), when the pregnancy presented a serious health risk to the woman (75%), in case of rape (64%) and when there are serious physical or mental fetal malformations (52%) [31]. The results are also consistent with findings from a study in 2000 with 121 medical residents in obstetrics and gynaecology working in public hospitals in Mexico City [32]. The majority of health care providers participating in the workshops were of the opinion that all public hospitals should have the capacity to provide legal abortion services. More physicians supported this statement (87%) than nurses (65%). This finding also is consistent with the findings from the national level survey and the study with medical residents, where 76% and 75% respectively of respondents agreed that all public hospitals should offer legal abortion services [31,32]. The majority of workshop participants (80%) indicated that they would be willing to participate in or carry out legal termination of pregnancy in cases of rape. These findings are very positive indeed. About half the nurses (41%) and social workers (56%), who participated indicated an interest in having more in-depth training in comprehensive care for survivors of sexual violence, but only 17% of physicians. In many ways, physicians remain the gatekeepers to a range of health care services and strategies need to be developed with those who are interested to encourage more of their colleagues’ to become involved in future. This project has documented a high level of interest in the topics of sexual violence and legal abortion and high levels of support for providing legal abortion in case of rape. Health professionals are aware of the need for further training, which needs to be addressed both in medical school curricula and in-service training. The model of care and the methodology for implementing it have been met with enthusiasm by both health care providers and policymakers as they seek to implement the

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94

Robles Law. Among the strengths pointed out by many participants in the workshops was the fact that legal abortion has been placed within a context of comprehensive care for survivors of sexual violence rather than isolated as a separate service. Such an approach may also be successful for other legal indications of abortion and should be explored as one way to make abortion services an integrated component of reproductive health services.

Acknowledgements Many thanks to Nadine Gasman, Laura Villa, Ricardo Barreiro, Nancy Martınez, Corina Martınez, Samuel Salinas and Charlotte Hord for reviewing this paper and for support and guidance throughout the project. We also acknowledge the excellent work of the workshop instructors: Rocıo Zepeda, Adriana Ortiz Ortega, Ver onica Rodrıguez and Armando Valle Gay.

References 1. UN General Assembly. Key actions for the future implementation of the Programme of Action for the ICPD. 1999. 2. Asamblea Legislativa del Distrito Federal. Decreto por el que se reforman y adicionan diversas disposiciones del c odigo penal para el Distrito Federal y del c odigo de procedimientos penales para el Distrito Federal. Gaceta Oficial del Distrito Federal, Mexico 2000;148:2–3. 3. Codigo Penal para el Distrito Federal. Art. 265, 266. Mexico DF: Editorial Sista; 2000. p. 92. 4. Procuradurıa General de Justicia del Distrito Federal. Available from: www.pgjdf.gob.mx/estadisticas/ vi.html. Accessed 20 February 2002. 5. Available from: www.unam.mx/rompan/40/rf40rep.html. Accessed 4 December 2001. 6. Ramos-Lira L, Saltijeral-Mendez MT, Romero Mendoza M, et al. Violencia sexual y problemas asociados en una muestra de usuarias de un centro de salud. Salud P ublica de Mexico 2001;43(3):182–91. 7. Martınez-Ayala H, Villanueva LA, T orres C, et al. Agresi on sexual en adolescentes: estudio epidemiol ogico. Ginecologıa y Obstetricia de Mexico 1999;67(9):449–53. 8. Garza-Aguilar J, Diaz-Michel E. Elementos para el estudio de la violaci on sexual. Salud P ublica de Mexico 1997;39:539–45. 9. Ehrenfeld N. Circunstancia difıcil, entrevista difıcil: estudio de usuarias del programa de atenci on a vıctimas. Unpublished final report for Ipas Mexico, 1999.

10. Cook RJ, Dickens BM. Considerations for Formulating Reproductive Health Laws, 2nd ed. Occasional Papers 3, WHO/RHR/00.1. Geneva: World Health Organization; 2000. 11. Rosas Ballinas MI. Aborto por Vioticos y Jurıdicos. laci on: Dilemas E Lima: Population Council; 1997. 12. Fundaci on Sı Mujer. Embarazo por Violaci on: la Crisis M ultiple. Cali: Sı Mujer, ISEDER; 2000. 13. Lamas M. The feminist movement and the development of political discourse on voluntary motherhood in Mexico. Reprod Health Matters 1997;5(10): 58–67. 14. Consejo Nacional de Poblaci on. Ejecuci on del Programa de Acci on de la Conferencia Internacional sobre la Poblaci on y el Desarrollo. Mexico: CONAPO; 1999. 15. Langer A. Planificaci on familiar y salud reproductiva o planificaci on familiar vs. salud reproductiva. Desafıos para llevar el paradigma de la salud reproductiva de la ret orica a la practica. In: Bronfman M, Castro R, editors. Salud, Cambio Social y Polıticas: Perspectivas desde America Latina. Mexico City: Edamex: Instituto Nacional de Salud P ublica; 1999. p. 135–49. 16. Lezana MA. Evoluci on de las tasas de mortalidad materna en Mexico. In: Elu MC, Santos Pruneda E, editors. Una Nueva Mirada a la Mortalidad Materna en Mexico. Mexico City: UNFPA, Population Council; 1999. p. 53–70. 17. L opez Garcıa R. El aborto como problema de salud p ublica. In: Elu MC, Langer A, editors. Maternidad sin

18.

19.

20.

21.

22.

23.

24.

25.

Riesgos en Mexico. Mexico City: IMES; 1994. p. 85–90. Lozano R, Hernandez B, Langer A. Factores sociales y econ omicos de la mortalidad materna en Mexico. In: Elu MC, Langer A, editors. Maternidad sin Riesgos en Mexico. Mexico City: IMES; 1994. p. 43–52. Costa SH. Commercial availability of misoprostol and induced abortion in Brazil. Int J Gynecol Obstet 1998;63:S131–9. Pollack AE, Pine RN. Opening a door to safe abortion: international perspectives on medical abortifacient use. JAMWA 2000;55(3):186–8. Poniatowska E. Las mil y una. . . (la herida de Paulina). Mexico City: Plaza y Janes Editores; 2000. Cortes A, Bissell S. August 2000 reforms to Mexico City abortion legislation: the long, hard struggle. In: Klugman B, Budlender D, editors. Advocating for Abortion Access: Eleven Country Studies. Johannesburg: Witwatersrand University Press; 2001. Cook RJ, Dickens BM, Bliss LE. International developments in abortion law from 1998–1999. Am J Public Health 1999;89:579–86. Lamas M, Bissell S. Abortion and politics in Mexico: context is all. Reprod Health Matter 2000;8(16): 10–23. Ortiz Ortega A. El aborto legal en Mexico. Paper presented at: Taller de capacitaci on jurıdica legal para trabajadores del sector salud y otras instancias involucradas respeto a la interrupci on legal del embarazo, 21– 22 September, 2000. Hospital General de Mexico, Mexico City.

93

DL Billings et al. / Reproductive Health Matters 2002;10(19):86–94 26. Patin L. Mexico high court opens door to abortion rights. Ewomen’s News, 8 February 2002. Available from www.womensenews.org. Accessed 9 February 2002. 27. Secretarıa de Salud, Procuradurıa General de Justicia del Distrito Federal. Convenio para Clınica para la atenci on integral de las vıctimas de abuso sexual, Diciembre 1995. 28. Granados Shiroma M, Ortiz Mariscal JD, Campos Gonzalez L. Declaraci on

Monterrey 2000 sobre violencia familiar y sexual hacia la mujer. Monterrey, Nuevo Le on: Ipas Mexico; 2001. 29. Vieira Villela W, de Oliveira Araujo MJ. Making legal abortion available in Brazil: partnerships in practice. Reprod Health Matter 2000;8(16): 77–82. 30. Drezett J. Programa de assistencia integral as vitimas de violencia sexual. Paper presented at: Violencia: etica,

sume  Re Depuis trente ans, le Gouvernement et les institutions sanitaires reconnaissent que l’avortement non medicalise est un important probleme social et de sante publique au Mexique. Bien que dans tous les Etats, le code penal definisse au moins un cas d’avortement legal, l’acces aux services d’interruption de grossesse est restreint pour les femmes dans tout le pays. En ao^ ut 2000, l’Assemblee legislative de Mexico a reforme le code penal pour y inclure davantage de cas o u l’avortement est legal et l’assortir d’une reglementation garantissant l’acces a des services d’avortement legal en cas de viol ou d’insemination forcee. En janvier 2002, la Cour supr^eme mexicaine a confirme la constitutionnalite des reformes. Cet article decrit un projet de collaboration entre Ipas Mexique et le Departement de la santede Mexico pour fournir des avortements legaux en cas de viol et s’assurer que les victimes de violences sexuelles disposent de services complets de sante. Il decrit un modele de soins introduit dans 15 h^ opitaux publics generaux et de sante maternelle et infantile a Mexico gr^ace a un programme d’ateliers et de cours de sensibilisation multidisciplinaire sur les violences sexuelles et l’avortement legal. Peu de prestataires de soins de santeont suivi une formation prealable sur les services destines aux victimes de violences sexuelles, ou sur l’avortement. Les participants aux ateliers etaient pr^ets a participer a des services d’avortement legal pour les victimes de violences sexuelles pour autant qu’ils recßoivent un soutien institutionnel solide.

94

justicia y salud para la mujer, 24–26 August 2000, Monterrey, Nuevo Le on, Mexico. 31. Garcia S, Becker D. Que piensan y opinan las y los mexicanos sobre el aborto? Mexico City: Population Council, Grupo IDM; 2001. 32. Gonzalez de Le on Aguirre D, Billings DL. Attitudes towards abortion among medical trainees in Mexico City public hospitals. Gender Develop 2001;9(2):87–94

Resumen ltimas tres decadas, las instituciDurante las u ones gubernamentales y de salubridad han reconocido que el aborto practicado en condiciones de riesgo es un importante problema social y de salud p ublica en Mexico. Si bien el C odigo Penal en cada estado define por lo menos una situaci on en que el aborto es legal, el acceso a servicios de aborto legal esta restringido para las mujeres en todo el pais. En agosto 2000, la Asamblea Legislativa de la Ciudad de Mexico adopt o una reforma al C odigo Penal que incluyera una gama mas amplia de causas por las cuales el aborto es legal, y agreg o regulaciones para asegurar el acceso a servicios de aborto legales en casos de violaci on e inseminaci on forzada. En enero 2002 la Corte Suprema Mexicana confirm ola constitucionalidad de las reformas. Este artıculo describe un proyecto de colaboraci on entre IpasMexico y el Departamento de Salubridad de la Ciudad de Mexico para proveer abortos legales en casos de violaci on y asegurar la disponibilidad y accesibilidad de servicios integrales de salud para los y las sobrevivientes de violencia sexual. Describe un modelo de atenci on que se esta introduciendo en 15 hospitales p ublicos generales y de salud materno-infantil en la Ciudad de Mexico mediante un programa de talleres multidisciplinarios de sensibilizaci on y cursos de capacitaci on en violencia sexual y aborto legal. Pocos proveedores de atenci on en salud han recibido capacitaci on anterior en la provisi on de servicios para sobrevivientes de violencia sexual o servicios de aborto. Los participantes en los talleres mostraron una alta disposici on a participar en los servicios de aborto legal para sobrevivientes de violencia sexual siempre y cuando reciban un s olido apoyo institucional.

Suggest Documents