Failure of the Law to Grant Access to Legal Abortion in Chile.

Introduction: In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant person's life is at risk, (ii) fetal nonviability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile. Methods: Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semistructured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes. Results: We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion. Discussion and Health Equity Implications: Although the 2017 law expanded legal access to abortion in Chile, significant barriers remain. Compounded with social stigma, and the socioeconomic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.

Chilean Medical and Midwifery Faculty's Views on Conscientious Objection for Abortion Services.

CONTEXT: In 2017, Chile reformed its abortion law to allow the procedure under limited circumstances. Exploring the views of Chilean medical and midwifery faculty regarding abortion and the use of conscientious objection (CO) at the time of reform can inform how these topics are being taught to the country's future health care providers. METHODS: Between March and September 2017, 30 medical and midwifery school faculty from universities in Santiago, Chile were interviewed; 20 of the faculty taught at secular universities and 10 taught at religiously affiliated universities. Faculty perspectives on CO and abortion, the scope of CO, and teaching about CO and abortion were analyzed using a grounded theory approach. RESULTS: Most faculty at secular and religiously affiliated universities supported the rights of clinicians to refuse to provide abortion care. Secular-university faculty generally thought that CO should be limited to specific providers and rejected the idea of institutional CO, whereas religious-university faculty strongly supported the use of CO by a broad range of providers and at the institutional level. Only secular-university faculty endorsed the idea that CO should be regulated so that it does not hinder access to abortion care. CONCLUSIONS: The broader support for CO in abortion among religious-university faculty raises concerns about whether students are being taught their ethical responsibility to put the needs of their patients above their own. Future research should monitor whether Chile's CO regulations and practices are guaranteeing people's access to abortion care.

RESUMEN Contexto: En 2017, Chile reformó su ley de aborto para permitir el procedimiento bajo circunstancias limitadas. Explorar las opiniones del personal académico de medicina y partería en relación con el aborto y el uso de la objeción de conciencia (OC) en el momento de la reforma, puede informar sobre los temas que están siendo enseñados a los futuros prestadores de servicios de salud del país. Métodos: Entre marzo y septiembre de 2017, fueron entrevistados 30 miembros del personal académico de las facultades de medicina y partería de universidades en Santiago, Chile. Veinte de ellos enseñaban en universidades laicas y diez en universidades con afiliación religiosa. Se analizaron las perspectivas del personal académico sobre la OC y el aborto, el alcance de la OC, y la enseñanza sobre OC y aborto, mediante el uso de un enfoque de teoría fundamentada. Resultados: La mayoría del personal académico de las universidades laicas y de las de afiliación religiosa apoyó el derecho del personal clínico a rehusarse a proveer servicios de aborto. En general, el personal académico de las universidades laicas pensó que la OC debería limitarse a proveedores de servicios específicos y rechazó la idea de una OC institucional, mientras que el personal académico de las universidades con afiliación religiosa apoyó decididamente el uso de la OC por un amplio conjunto de proveedores y a nivel institucional. Solamente el personal académico de las universidades laicas avaló la idea de que la OC debería ser regulada de tal forma que no obstaculizara el acceso a los servicios de aborto. Conclusions: El amplio apoyo a la OC en relación con el aborto en el personal académico de las universidades con afiliación religiosa genera preocupaciones sobre si se está enseñando a los estudiantes sobre su responsabilidad ética de poner las necesidades de sus pacientes por encima de las propias. Futuras investigaciones deben monitorear si las reglamentaciones y prácticas en materia de OC en Chile están garantizando el acceso de las personas a los servicios de aborto.

RÉSUMÉ Contexte: En 2017, le Chili a réformé sa législation de l'avortement, autorisant l'intervention dans des circonstances limitées. Létude de l'opinion du corps professoral des facultés de médecine et des écoles de sages-femmes concernant l'avortement et le recours à l'objection de conscience (OC) au moment de la réforme peut éclairer la manière dont ces sujets sont enseignés aux futurs prestataires de soins de santé du pays. Méthodes: Entre mars et septembre 2017, 30 professeurs et enseignants de facultés et écoles de médecine et de sages-femmes à Santiago (Chili) ont été interviewés; 20 enseignaient dans des universités laïques et 10, dans des universités de confession religieuse. Leurs points de vue sur l'OC et l'avortement, la portée de l'OC et l'enseignement relatif à l'OC et à l'avortement ont été analysés selon l'approche de la théorie ancrée. Résultats: Pour la plupart, le corps professoral des universités laïques et de confession religieuse reconnaissait le droit des cliniciens à refuser la prestation de soins d'avortement. Les professeurs d'universités laïques estimaient généralement que l'OC devrait être limitée à certains prestataires spécifiques et rejetaient la notion de l'OC institutionnelle, alors que ceux des facultés et écoles de confession religieuse soutenaient fermement le recours à l'OC par un large éventail de prestataires et au niveau institutionnel. Seul le corps professoral laïc souscrivait à l'idée que l'OC doit être réglementée de manière à ne pas entraver l'accès aux soins d'avortement. Conclusions: Le soutien plus large de l'OC à l'avortement parmi le corps professoral d'universités de confession religieuse soulève des questions quant à savoir si les étudiants sont sensibilisés à leur responsabilité éthique de faire passer les besoins de leurs patientes avant les leurs. La recherche future devra surveiller si la réglementation et la pratique de l'OC au Chili garantissent l'accès aux soins d'avortement.

"Obviously there is a conflict between confidentiality and what you are required to do by law": Chilean university faculty and student perspectives on reporting unlawful abortions.

BACKGROUND AND OBJECTIVES: While Chile recently decriminalized abortion in cases of rape, lethal fetal anomaly, and to save a woman's life, most abortions are still criminalized. We assessed medical and midwifery school faculty and students' views on punishing and reporting people involved in unlawful abortion, and their understanding of their obligation to protect patient confidentiality and to report unlawful abortions. METHODS: We interviewed 30 medical and midwifery school clinician faculty from seven public, private, secular and Catholic-affiliated universities, all located in the metropolitan region of Santiago, Chile. Medical (n = 239) and midwifery (n = 79) students at these same seven universities completed an online survey. We coded faculty interview transcripts, and analyzed codes related to maintaining patient confidentiality and reporting unlawful abortion. We summarized student views related to reporting and imprisoning people involved in unlawful abortion, and used general estimating equation (GEE) models to identify the factors associated with support for criminalization. RESULTS: Faculty and students generally did not support reporting or imprisoning anyone involved in an unlawful abortion and believed that protecting patient information takes precedence over reporting. Yet, faculty described pressures to report in the public sector and several cases where they or their colleagues were involved in reports. Most students somewhat/strongly agreed (78%) that patient information concerning an unlawful abortion should be kept confidential; 35% strongly/somewhat agreed that a clinician involved in an unlawful surgical abortion should be imprisoned, and 18% agreed that the woman involved should be imprisoned, with students from secular universities being significantly less likely to support reporting and punishing people involved in unlawful abortion, than students from Catholic universities. DISCUSSION: There is a need to clarify clinicians' ethical obligations in abortion care, in particular in Catholic universities, so that they can ensure that their patients have access to high quality confidential health care services.

Medical and midwifery students' views on the use of conscientious objection in abortion care, following legal reform in Chile: a cross-sectional study.

BACKGROUND: In August 2017, Chile lifted its complete ban on abortion by permitting abortion in three limited circumstances: 1) to save a woman's life, 2) lethal fetal anomaly, and 3) rape. The new law allows regulated use of conscientious objection (CO) in abortion care, including allowing institutions to register as objectors. This study assesses medical and midwifery students' support for CO, following legal reform. METHODS: From October 2017 to May 2018, we surveyed medical and midwifery students from seven universities located in Santiago, Chile. Universities included 4 secular (2 public and 2 private) and 3 private religiously-affiliated universities; all offering medical degrees with a specialization in obstetrics and gynecology (ob-gyn) and five offering midwifery degrees. We used generalized estimating equations (GEE) to identify characteristics associated with student support for CO, intentions to use CO to refuse to care for someone seeking abortion, and support for CO at the institutional level. RESULTS: 333 of the 413 eligible students who opened the survey, completed the questions on conscientious objection; 26% were seeking medical degrees with an ob-gyn specialty, 25% were seeking midwifery degrees, and 49% were seeking medical degrees and had not yet decided their specialty. While nearly all endorse requirements for conscientious objecting clinicians to inform (92%) and refer (91%) abortion-seeking patients, a minority (18%) would personally use conscientious objection to avoid caring for a patient seeking abortion (12% secular and 39% religious university students). About half of religious-university students (52%) and one-fifth of secular-university (20%) students support objections at the institutional level. CONCLUSIONS: Most students support the regulated use of CO which preserves patients' access to abortion care. Religious-university student views on the use of conscientious objection in abortion care are discordant with those of their institutions which currently support institutional-level objections.

Medical and midwifery student attitudes toward moral acceptability and legality of abortion, following decriminalization of abortion in Chile.

OBJECTIVE: Soon after Chile decriminalized abortion under three limited circumstances in 2017, we assessed medical and midwifery students' attitudes about abortion morality and legality when compared to national opinions. STUDY DESIGN: We administered an anonymous, online survey to medical and midwifery students from seven secular and religiously-affiliated universities in Santiago, Chile. We compared student responses to a nationally representative public opinion survey. MAIN OUTCOME MEASURES: We examined three main outcomes related to abortion attitudes: (1) moral acceptability of abortion and legal support for abortion in (2) one or (3) all listed circumstances. We used general estimating equations to examine whether university type, field of study, and other student characteristics are associated with each outcome and compared student views toward abortion legality with those of the general public. RESULTS: Among the 369 student respondents, most agreed that abortion can be a good thing for some women in some situations (82%). When compared to the general public, a larger proportion of students supported decriminalizing abortion in at least one (83% and 97%, respectively) or all (17% and 51%, respectively) seven listed circumstances. While secular university students held significantly more favorable views about abortion morality and legality than students from religiously-affiliated universities, the majority of students from both university types supported abortion in the three cases in which it was recently decriminalized. CONCLUSIONS: Medical and midwifery students from not only secular but also religiously-affiliated universities are very supportive of the recent decriminalization of abortion, which presents training opportunities for both types of universities.

Future health providers' willingness to provide abortion services following decriminalisation of abortion in Chile: a cross-sectional survey.

OBJECTIVE: To assess Chilean medical and midwifery students' attitudes and willingness to become trained to provide abortion care, shortly after abortion was decriminalised in 2017. DESIGN: We fielded a cross-sectional, web-based survey of medical and midwifery students. We used generalised estimating equations to assess differences by type of university and degree sought. SETTING: We recruited students from a combination of seven secular, religiously-affiliated, public and private universities that offer midwifery or medical degrees with a specialisation in obstetrics and gynaecology, located in Santiago, Chile. PARTICIPANTS: Students seeking medical or midwifery degrees at one of seven universities were eligible to participate. We distributed the survey link to medical and midwifery students at these seven universities; 459 eligible students opened the survey link and 377 students completed the survey. PRIMARY AND SECONDARY OUTCOMES: Intentions to become trained to provide abortion services was our primary outcome of interest. Secondary outcomes included moral views and concerns about abortion provision. RESULTS: Most students intend to become trained to provide abortion services (69%), 20% reported that they will not provide an abortion under any circumstance, half (50%) had one or more concern about abortion provision and 16% agreed/strongly agreed that providing abortions is morally wrong. Most believed that their university should train medical and midwifery students to provide abortion services (70%-79%). Secular university students reported higher intentions to provide abortion services (beta 0.47, 95% CI: 0.31 to 0.63), more favourable views (beta 0.52, CI: 0.32 to 0.72) and were less likley to report concerns about abortion provision (adjusted OR 0.47, CI: 0.23 to 0.95) than students from religious universities. CONCLUSION: Medical and midwifery students are interested in becoming trained to provide abortion services and believe their university should provide this training. Integrating high-quality training in abortion care into medical and midwifery programmes will be critical to ensuring that women receive timely, non-judgemental and quality abortion care.

Diffusion basis functions decomposition for estimating white matter intravoxel fiber geometry.

In this paper, we present a new formulation for recovering the fiber tract geometry within a voxel from diffusion weighted magnetic resonance imaging (MRI) data, in the presence of single or multiple neuronal fibers. To this end, we define a discrete set of diffusion basis functions. The intravoxel information is recovered at voxels containing fiber crossings or bifurcations via the use of a linear combination of the above mentioned basis functions. Then, the parametric representation of the intravoxel fiber geometry is a discrete mixture of Gaussians. Our synthetic experiments depict several advantages by using this discrete schema: the approach uses a small number of diffusion weighted images (23) and relatively small b values (1250 s/mm2), i.e., the intravoxel information can be inferred at a fraction of the acquisition time required for datasets involving a large number of diffusion gradient orientations. Moreover our method is robust in the presence of more than two fibers within a voxel, improving the state-of-the-art of such parametric models. We present two algorithmic solutions to our formulation: by solving a linear program or by minimizing a quadratic cost function (both with non-negativity constraints). Such minimizations are efficiently achieved with standard iterative deterministic algorithms. Finally, we present results of applying the algorithms to synthetic as well as real data.