How do you help homeless alcoholics? Few people would guess that giving them a free glass of wine every few hours is part of the answer. But this is known as the harm reduction approach, a strategy or set of policies that aims to reduce the harms associated with certain behaviors – even if they are illegal – but without necessarily ending or reducing those behaviors.
The idea of treating alcoholics by managing their supply, instead of cutting them off completely, was pioneered in Canada and is now being proposed by health experts in Sydney. Giving indigent chronic alcoholics access to shelter and other services while providing them with alcohol is anticipated not only to lead to improvements in their health (or, at least, a less rapid decline), but also to reduce public costs associated with emergency room visits, police contact, court costs and jail time. It’s the same idea behind initiatives that provide heroin addicts with clean needles to prevent the spread of HIV.
Now experts are asking if the same approach could help lower the number of women who die from unsafe abortions. According to the World Health Organization (WHO), an estimated 22 million unsafe abortions take place every year, resulting in around 47,000 women dying and another 5 million suffering from disabilities. In 2004, a team of Uruguayan professionals including physicians, nurses, midwives, psychologists and social workers established Iniciativas Sanitarias, a nonprofit organization, to address unintended or unwanted pregnancies and their consequences by focusing on sexual and reproductive health as a basic human right. At a time when abortion was illegal in most cases, Uruguay started experimenting with a harm reduction approach in the way doctors dealt with women who were considering terminating their pregnancies. Instead of being treated like criminals, women were offered counseling and post-abortion healthcare. The “Uruguay Model” was so successful that the rate of deaths due to unsafe abortion plummeted. Uruguay went on to become one of the few Latin American countries to loosen its restrictive abortion laws. And some experts are saying the harm reduction approach could work in other countries where strict reproductive laws often force women to have unsafe abortions.
In the Latin America and Caribbean region, according to the Guttmacher Institute, at least 10 percent of maternal deaths result from unsafe abortions. But in Uruguay, unsafe abortion was the leading cause of maternal death in the decade up to 2000. From 1996 to 2001, 47 percent of maternal deaths at the Pereira Rossell Hospital Center, the national hospital for women’s health, resulted from unsafe abortions. To reduce this unacceptably high level of death and injury, Uruguay’s medical professionals and civil society banded together to introduce “safer abortions” through a harm reduction approach.
The point of a harm reduction approach to abortion is to address the issue as a public health concern rather than a moral dilemma. “International organizations have been saying that a harm reduction approach is more closely tailored to public health goals than when countries seek to regulate abortion,” says Charles Abbott, legal adviser for Latin America and the Caribbean at the Center for Reproductive Rights. “The use of criminal law is a very blunt instrument, and it often has corollary effects that worsen the public health outcomes for people. A public health approach for a public health issue, I think, really is important.”
The Uruguayan nonprofit organization Iniciativas Sanitarias won the Pan American Health Organization’s (PAHO) V Best Practices Contest in 2012 for applying a harm reduction approach to incorporate the perspective of gender equality in healthcare. It started by pushing a fundamental conceptual change in the doctor-patient relationship. As abortion had been illegal in Uruguay since 1938 – with the exception of rape or threats to mothers’ life or health – women with unwanted pregnancies were treated poorly by doctors, so much so that many women avoided seeking help until it was too late. Shifting to what Iniciativas Sanitarias refers to as an “ethical commitment to sexual and reproductive health” allowed medical professionals to provide care without focusing on the legality of abortion. The team used a training strategy built around “cognitive conflict” to help healthcare workers to understand better how underlying inequality was leading to patronizing attitudes.
Instead, medical professionals focused on counseling women who were considering having abortions and then providing comprehensive post-abortion care. In a June 2016 New York Times article, Joanna Erdman, assistant director and MacBain Chair in Health Law and Policy at Schulich School of Law, Dalhousie University, says that while doctors instructed women on the correct use of medical abortion drugs, they didn’t give information on how or where to obtain them, because that would have been against the law. “It was not advice. It was not prescribing or promoting,” she says.
The results in Uruguay have been stark. In 2011, Leonel Briozzo, who was then vice minister of public health and an Iniciativas Sanitarias member, says in a U.N. Population Fund (UNFPA) news release, “Today we are proud to affirm that Uruguay is the only Latin America country that didn’t register any maternal deaths from unsafe abortion.”
Since adopting a harm reduction approach to abortion, Uruguay has made safe abortion widely available in the first 12 weeks of gestation (14 weeks in the case of rape). In 2012, parliament passed a law to waive criminal penalties for abortion in the first trimester, with certain procedural requirements, although abortion remains a crime under the criminal code.
Public health officials from Uganda and Tanzania have reportedly been studying the Uruguay Model. “Uruguay has shown a pretty effective model for addressing maternal mortality,” says Abbott of the Center for Reproductive Rights. And some experts have expressed hope that it could help address the renewed interest in women’s reproductive rights in the face of the Zika virus.