Abortion as a human right: The struggle to implement the abortion law in Colombia

In 2006, a Colombian Constitutional Court decision legalized abortion in cases of risk to a woman's physical or mental health, fetal malformation incompatible with life, or rape or incest. This decision resulted from legal action brought by feminist groups, and frames abortion as a human right. Advocates played a key role in implementing the new law by educating providers and the public about its broad interpretations. Healthcare providers and facilities did not have an organized response to the new law. Nonprofit organizations filled this gap, and provide a majority of legal abortions throughout the country. Civil society facilitated implementation of the new law by providing legal accompaniment to women facing barriers to accessing abortions. Despite these efforts, few legal abortions are performed each year, and clandestine, often unsafe abortions continue to prevail. Lack of information about the new law, stigma, and fluctuating political will remain key barriers.


| CONTEXT
Prior to 2006, abortion was illegal in Colombia under all circumstances. Unsafe abortions were common and were the second leading cause of maternal mortality in the mid-1990s. 3 A new Constitution in 1991 emphasized the fundamental rights of the individual and established the "tutela," a mechanism enabling citizens to demand that every law or decision be in accordance with the protection of these rights. 4 In 2006, the Colombian Constitutional Court issued a landmark decision (C-355) liberalizing the country's abortion law; the decision came in response to a constitutional challenge filed as part of a concerted strategic litigation effort led by Women's Link Worldwide in alliance with other women's and legal advocacy groups. 5,6 After 2006, advocacy efforts continued and were key in ensuring implementation of the law. For example, La Mesa por la Vida y la Salud de las Mujeres (henceforth, LaMesa), a group of nonprofit organizations and individuals, provided advice and support to women who had been denied or had difficulty obtaining legal abortions, and documented these experiences. 7 Such advocacy efforts led the Court to issue at least 15 other decisions to protect Colombian women's access to abortion. Particular features of the Colombian healthcare system are key to understanding successes and barriers in the implementation of the new abortion law. In 1993, a national health system was established that aimed to provide universal access to health care, now considered a right of all Colombians. This is a public-private system financed primarily through contributions from employers and workers and includes a subsidized regime for the poor and unemployed who receive services for small or no fees. All citizens are entitled to receive the same basic package of healthcare services.
An element of an earlier health system reform was to decentralize the provision of health services, which are now provided at the local level. 8 The health management information system was also decentralized. 3 The reform has resulted in remarkable increases in healthcare coverage (from 23% of the population in 1990 to 97% in 2015), decreases in out-of-pocket spending, improvement in overall health status, and reductions in maternal and infant mortality rates. 8 Despite these successes, inequities persist: rural and poor urban people have much lower coverage rates, and quality of care can vary dramatically. 9 The high number of people displaced due to long-standing internal conflict (one of the world's highest at 6.4 million) came mostly from rural areas, which further aggravated geographical health inequities. 8

| INNOVATION
The Colombian abortion law was groundbreaking in that it was one of the first judicial decisions to uphold abortion rights on the grounds of equality and human rights. 5 This decision came in response to a constitutionality challenge that was based on the premise that a total prohibition of abortion was against women's fundamental rights, including the right to life, health, and physical integrity; the right to equality and nondiscrimination; and the right to dignity, reproductive autonomy, and development of personality. 10 As a result of decision C-355, abortion is not a crime under three conditions: if a woman's life or health (understood as a complete state of physical and mental well-being) is at risk, which must be certified by a physician or psychologist; when there are fetal malformations incompatible with life, which must be certified by a physician (not necessarily a specialist); and when pregnancy is a result of criminal acts that have been officially reported (which includes rape, incest, or if the pregnancy is a result of unwanted artificial insemination or implantation of a fertilized ovum). Importantly, there are no gestational age limits for abortions provided within these guidelines. 10 This topic became a subject of debate among implementers after the law was passed. As one interviewee explained:

| RECIPIENTS
The main recipients of the new law are Colombian women, whose rights are protected by the Constitutional Court. Colombia is a large country with a heterogeneous population, high levels of socioeco-  Bogotá, 97% of abortions in Colombia are provided by these two clinics (62% by manual vacuum aspiration and 36% with medication). 16 These organizations were also essential in registering misoprostol for use in medical abortion, and in introducing mifepristone in the country. As one interviewee summarized:

| REMAINING CONCERNS
The most important concern about the implementation of abortion services in Colombia is that few legal abortions are being performed, and that illegal ones still prevail. 22 Importantly, it is difficult to quantify  Fluctuating political will has also been a key barrier to establishing abortion services in Colombia. Respondents cited several examples of specific health sector initiatives that were established to increase access to abortion, but which were later dismantled owing to changes in political leadership. One such case involved a public hospital in Bogotá in which women's health services including abortions had been established, but these were closed with the arrival of a new mayor who did not prioritize the implementation of abortion services.
Interviewees explained that support for the new law changed based on leadership within the Ministry of Health, and that without strong central support, abortion opponents blocked many initiatives to establish services. As one respondent explained: Another remaining concern is provider resistance to providing abortion services due to conscientious objection. While conscientious objection is well defined in Colombian law, and abortion advocates have made efforts to educate providers and the public, the constraints on it are not enforced. 24  status. Another concern is the application of updated clinical protocols. While protocols were written in accordance with existing WHO guidelines and some efforts were made to train healthcare providers, there have been no centralized concerted efforts to ensure that the guidelines are followed across the national territory. Formal statistics regarding the types of procedures performed are lacking, but respondents expressed concern that many service providers are still performing abortion by dilation and sharp curettage rather than by manual or electric vacuum aspiration or medical abortion.
According to statistics by the Health Department of Bogotá, 16 of the 3% of abortions performed in the public sector, 58% were by sharp curettage, which imposes risk and has not been the recommended standard of care for several years. 25 According to one interviewee, one barrier to using manual vacuum aspiration is that the equipment itself is stigmatized as something only used for induced abortion. In addition, physicians do not receive training in manual vacuum aspiration during their undergraduate or graduate medical education.
Training in dilation and evacuation (D&E) for second trimester abortions is also scarce. Second trimester terminations are performed by induction of labor, except at Oriéntame where providers were trained abroad to perform D&E.

| LESSONS LEARNED
The Colombian law is exemplary in its focus on human rights, its provisions on conscientious objection, and its lack of gestational age limits. In Colombia, civil society played a catalytic role in obtaining legal change and implementing the new law. Feminist groups used legal advocacy to obtain legal access to abortion on specified grounds and promoted implementation by strategically educating providers and the public about the Constitutional Court's broad interpretation of the law, and particularly of the health exception.
They also provided ongoing legal support to women who were being denied abortions, thus identifying barriers to obtaining abortions and leading to further legal protections for Colombian women seeking abortions.
However, implementation of the law has been limited by a complex public-private healthcare system with inadequate government oversight. Despite being mandated by law, many hospitals and clinics have failed to establish abortion services. Civil society groups, including some physician advocates, have stepped up and played a leadership role, as nonprofit organizations were quick to launch services and now provide a majority of abortions throughout the country.
Despite these efforts, the 2006 Colombian abortion law has not led to equitable access to safe abortions. There is no accurate registration of abortions in Colombia, since a centralized monitoring system was not included in the initial planning strategies. Further efforts are needed to ensure that these data are available while maintaining patient confidentiality. However, it is known that the number of legal abortions being performed remains relatively small, and that clandestine, often unsafe abortions are common. Lack of information about the law and lack of political commitment to ensure that it is implemented remain important barriers to accessing abortion services.

AUTHOR CONTRIBUTIONS
BMS: Contributed to the initial proposal, interview instrument, conducted Colombia interviews, wrote the first draft of the paper, and

CONFLICTS OF INTEREST
Laura Gil Urbano, Ana Cristina González Vélez, and Cristina Villarreal Velásquez functioned as key informants, were interviewed, and served as coauthors of this case study. The authors have no conflicts of interest to declare.