RESEARCH ARTICLE “No one should be alone in living this process”: trajectories, experiences and user’s perceptions about quality of abortion care in a telehealth service in Chile Sara Larrea ,a Camila Hidalgo,b Constanza Jacques-Aviñó ,c Carme Borrell ,d Laia Palència e a Doctoral candidate, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain; Research Coordinator, Women Help Women, Amsterdam, Netherlands. Correspondence: slarrea80@gmail.com b Associate Academic, Departamento Promoción de la Salud de la Mujer y el Recién Nacido, Facultad de Medicina Norte, Universidad de Chile, Santiago, Chile; Evaluator, Inclusión y Equidad, Santiago, Chile c Researcher, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain; Researcher, Universitat Autònoma de Barcelona, Barcelona, Spain d Associate Professor, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain; Executive Director, Agència de Salut Pública de Barcelona, Barcelona, Spain; Researcher, CIBER Epidemiología y Salud Pública, Madrid, Spain; Institut d’Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain e Senior Public Health Technician, Agència de Salut Pública de Barcelona, Barcelona, Spain; Researcher, CIBER Epidemiología y Salud Pública, Madrid, Spain; Researcher, Institut d’Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain Abstract: Self-managed abortion is a common self-care practice that enables pregnant people to exercise their rights to health, bodily autonomy and to benefit from the advances of science even when living in contexts that do not guarantee these rights. In this interpretative qualitative study, we aimed to understand women’s abortion trajectories, experiences with self-managed abortion and assessments of the quality of care provided by Women Help Women (WHW, an international activist non-profit organisation working on abortion access). Grounded in feminist epistemology and health inequalities approaches, we conducted eleven semi-structured interviews in Santiago, Chile. We found that illegality, stigma and expectations surrounding motherhood and abortion determined women’s experiences. Participants perceived the WHW service as good, trustworthy, fast and affordable, and valued confidentiality and privacy; the quantity and quality of information; having direct, personalised and timely communication with service staff; being treated with respect; and feeling safe, cared for and supported in their decisions. Most participants considered self-managed abortion appropriate and acceptable given their circumstances. Fear was the dominant feeling in women’s narratives. Some participants mentioned missing instant communication, in- person support and professional care. We conclude that support, information and company are key to improving abortion seekers’ experiences and enabling their decisions, particularly in legally restrictive settings. Centring care in pregnant people’s needs and autonomy is fundamental to ensure safe, appropriate and accessible self-care interventions in reproductive health. Social and legal changes, such as public funding for abortion, destigmatisation and decriminalisation, are needed to realise people’s right to higher standards of healthcare. DOI: 10.1080/26410397.2021.1948953 Keywords: quality of care, telehealth, abortion, self-managed abortion, misoprostol, mifepristone, qualitative evaluation, feminism Introduction common self-care practice that enables pregnant Self-managed abortion, the use of pills to inter- people to exercise their rights to health and bodily rupt a pregnancy outside the formal health system autonomy and to benefit from the advances of and without direct medical supervision,1 is a science, even when living in contexts that do not © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group 1 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 guarantee these rights. Seeing this potential, fem- legal grounds, stigma, and a wide definition of inist collectives around the world, and particularly health professionals’ right to conscientious objec- in legally restrictive contexts, have organised to tion that translates into denial of care,7,8 explain provide information and support to those self- why the change in the law has failed to improve managing their abortions. By doing so, these abortion access for most people with unwanted organisations facilitate the rights of populations pregnancies. Socially, abortion is still a contested made vulnerable by unjust laws, neglectful gov- issue: while around 70% of the population agreed ernments and discriminatory societies. To contrib- with decriminalisation under limited circum- ute to a better understanding of how supported stances as included in the new bill, only a small abortion self-care is evaluated and experienced proportion of Chileans support abortion on by people living in legally restrictive settings, in demand.8,9 this article we analyse the experiences of Chilean Despite the difficulties of studying a clandes- women* who accessed abortion through the tine phenomenon, previous research in Chile has Women Help Women (WHW) telehealth service. shown that elective abortion is most common The recent history of abortion regulation in among women with higher socioeconomic status;4 Chile speaks of how this issue has been used as that young women and those with internet access a bargaining chip by administrations of diverse are more likely to access safer methods; and that political tendencies. Therapeutic abortion – the the use of misoprostol to induce abortion interruption of a pregnancy to protect the preg- increased during the last decades.10,11 While mis- nant person’s health and life – was legal from oprostol - and more recently mifepristone - are 1931 to 1989.2 During an eight-month period registered for gynaecological uses,12 distribution under the socialist government of Salvador is restricted to authorised healthcare facilities. Allende (1970–1973), health professionals inter- Therefore, most people access misoprostol alone preted this clause liberally and openly provided from the parallel market, where prices are high abortion and post-abortion care in public hospi- and the authenticity and quality of the medicines tals.3 This practice changed when dictator Augusto are not guaranteed.10 Local feminist organisations Pinochet took power, but only at the end of his providing accompaniment and hotlines such as military dictatorship was abortion formally pena- Línea Aborto Libre (Free Abortion Hotline), Con lised in all circumstances, including therapeutic las Amigas y en la Casa (With Friends and at abortion.2 Feminist organisations and social Home) and Miso pa todas (Miso for all) Network, movements advocated for a change in regulation as well as telehealth services such as Women for almost three decades and in 2017, during Help Women and Women on Web, are also com- the second period of Michelle Bachelet’s presi- mon sources of support, information and, in dency, the change finally arrived. Currently, abor- some cases, abortion pills.13,14 tion should be performed by medical Women Help Women (WHW) is an international professionals on three grounds: to save the life feminist organisation that facilitates access to of a pregnant person, for fatal fetal anomalies, medical abortion in restrictive settings. It has and in cases of rape.4 operated in Chile since its foundation in 2014. However, the long-awaited change in regu- People requesting the service fill in an online sur- lations did not improve access substantially. The vey to confirm their eligibility for medical abor- Chilean Ministry of Health reported that only tion (being less than eleven weeks pregnant and 700 legal abortions were performed during without contraindications for medical abortion 2019,5 meaning that the vast majority of the esti- according to WHO guidelines).15 WHW counsellors mated 72,000–140,000 annual abortions in the provide information through email on the logis- country6 are still performed outside the formal tics of the service and the process of the medical health system and the legal indications. Limited abortion as well as emotional support. WHW requests a €75 donation that can be made via international bank transfer or credit card but *People with diverse gender identities, including people who people who cannot donate are still offered the ser- do not self-identify as women may need abortion services. vice. 200 mg of mifepristone and two doses of While we strive to use language that reflects that need, in 800mcg of misoprostol each are sent by mail this study we interviewed cis-women and use the word and take one to two weeks to arrive in Chile. women to refer to them. WHW recommends taking mifepristone orally 2 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 followed 24 hours later by 800 mcg of buccal mis- based on three principles. First, that intersectional oprostol (the second misoprostol dose is meant to gender analysis, that is, the analysis of the inter- be used only if needed, according to WHO guide- action between gender, race and ethnicity, social lines).15 Users are informed that the buccal or sub- class and territories, among other axes of oppres- lingual use of misoprostol would diminish the risk sion, is fundamental to understanding the world. of criminalisation in case of complications (as Second, that the position from which knowledge is opposed to vaginal use where remains of the produced is important to what and how we know. pills can be found in the vagina days after the pro- And third, that the understanding of how the cedure, and could be used as evidence that the world functions is incomplete without social abortion was induced). A follow-up survey is sent action to challenge it.23,24 From these perspec- two weeks after the delivery of the package. tives, our standpoint as feminist activists and WHW counsellors are feminist activists trained in scholars, some of us abortion activists and orig- medical abortion and two specialised doctors inally from settings were abortion is restricted, are available to support them and answer medical informed this study. Having a diverse group of questions. researchers with different relations to the subject Interest in supported self-care interventions, of study allowed a balanced analysis. such as the WHW model of care, has grown in recent years, and has been raised further by Sample and data collection COVID-19.16,17 In this context, strategies that A convenience sample was recruited through the were formerly designed and led by activists, such WHW service. An invitation email was sent to as self-management as an option for abortion people who were living in Santiago and had care, are being increasingly adopted by formal used the service between November 2018 and health systems.18 While extensive knowledge April 2019, so that we could offer the option of about the effectiveness, safety and acceptability in-person interviews. Approximately 10% of the of the use of abortion pills outside formal health- invitees responded to our call. The contact infor- care facilities exists,19,20 research into users’ evalu- mation of voluntary participants was sent to the ations of the quality of these services is more first author, who contacted them by phone to limited. Evaluations of quality of care are impor- arrange for a telephone or in-person interview tant to inform the design of supported self-care (in a private place chosen by the participant). initiatives that aim to facilitate reproductive jus- We used semi-structured interviews to collect tice - that is, people’s right to have or not to data following the rationale of abortion trajec- have children and to do both with dignity and tories. That is, “the processes and transitions support21 – in a variety of contexts. occurring over time for a pregnancy that ends in To contribute to filling these gaps, our aim in abortion”.25 We asked participants about preg- this study was to understand abortion trajectories nancy confirmation, abortion decision-making leading people to use the WHW service in Chile, and service seeking, experiences with medical their experiences with self-managed abortion, abortion, their assessments of the quality of the how they evaluate WHW’s quality of care and WHW service, previous experiences with gynaeco- how they compare it with gynaecological and logical services and their recommendations for obstetric services they have accessed in the past. improvement. We also asked participants to reflect on whether their experience changed their opinions on abortion and for some sociode- Materials and methods mographic characteristics (see supplementary Our interpretative qualitative study was grounded data). As the data collection process evolved, we in health inequalities and feminist epistemology focused on enquiring into issues that emerged in approaches. The term “health inequalities” refers previous interviews, such as the feeling of fear, to unfair, avoidable and systematic differences in why they chose the WHW service when other the health status of population groups. They are options were available and why they did not con- socially produced by the unequal distribution of tact the WHW service during the abortion. resources and power and are marked by social, We conducted seven phone-based and four in- economic, geographical and demographic person interviews in Santiago, Chile between May lines.22 By feminist epistemology, we refer to the and June 2019. Average duration was 30 min. All critical perspective of knowledge production interviews were conducted in Spanish, audio 3 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 Table 1. Participants’ sociodemographic characteristics, number of children and number of previous abortions Number of Is in a Employment Number of previous Pseudonym* Age relationship status Level of education children abortions Miriam 25 Yes Unemployed University complete 0 0 Fernanda 30 Yes Employed Technical education 1 1 Nora 31 Yes Employed University complete 0 0 Killa 36 Yes Unpaid domestic University 4 1** work incomplete Cristina 23 Yes Freelance worker Technical education 0 0 Antonia 34 No Employed University complete 0 0 Iliana 36 Yes Employed University complete 0 0 Janet 26 Yes Employed University complete 0 0 Carla 23 No Student + University 0 0 Employed incomplete Valeria 25 Yes Employed University complete 0 0 Manuela 31 No Employed University complete 1 Missing data *In order to protect participants’ anonymity, a pseudonym was assigned to each of them. **For medical reasons. recorded and transcribed verbatim. Table 1 pre- version of the codebook that included categories sents participants’ personal characteristics. Age and one of us used it to code the next four inter- ranged from 23 to 36 years; around half the par- views; a second member reviewed the coded tran- ticipants were 30 years or younger. Most partici- scripts and provided input. Next, we created a pants were in a relationship at the time of the table that contained categories, sub-categories, interview, had higher education and were work- codes and direct quotes exemplifying each subca- ing. Three had children and two had had previous tegory. We also developed a map that summarised abortions. categories and relations between them. Finally, we met to discuss the data and agree on the struc- Data analysis ture of the manuscript. Quotes presented in the manuscript were extracted from the analysis Data analysis was conducted by three of the table and are identified with a pseudonym to pro- authors. First, one team member read all the tect participants’ anonymity, and their age. interviews for familiarity and selected two inter- views that represented different points in the spectrum of responses. Then the three of us Ethical issues coded these interviews separately and met to dis- The study was approved by the Drug Research cuss codes and pre-analytic categories. A first Ethical Committee CEIm -Parc de Salut MAR, Bar- codebook was created as a result of this triangu- celona (Code: 2018/8145/I), as a sub-study of a lation. Two members of the team used it to code PhD thesis about feminist medical abortion ser- the next five interviews separately and then dis- vices. We adhered to the Ethical Principles for cussed interpretation. We then created a second Human Research defined by the 1964 Declaration 4 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 of Helsinki. Participants consented to participate developed into a crisis for the couple, that ended in the study and for the interviews to be audio with the relationship. Other participants were recorded. They provided written consent for in- forced by the situation to disclose the preg- person interviews and verbal consent (audio nancy. One had first decided to continue with recorded) for telephone ones. All identifiable the pregnancy, so she disclosed it widely and data were shared through secure channels, stored then said she had a miscarriage. Another partici- in encrypted devices and deleted immediately pant, who needed medical care for an abortion after the interview. Interview recordings and tran- complication, told her religious family she did scripts were identified with an anonymised code. not know she was pregnant, because she feared their reaction. Women identified a link between legal restric- Results tions, social punishment and taboos around abor- Trajectories to WHW service: decision-making, tion and mentioned these as reasons to keep both disclosure and access to abortion pills their pregnancy and the abortion a secret. Some, Most participants identified pregnancy symptoms like Manuela (31), shared stories of being judged and then confirmed the pregnancy with a urine by their loved ones when disclosing their decision: test or an ultrasound. Several mentioned that “My mom even told me not to do it, that she was they got pregnant while using contraception or never going to forgive me […] it’s like if you want explained the reasons why they were not taking to have an abortion you’re … I don’t know … a precautions. Many of them referred to contracep- bad woman or a devil, so, that’s why I wanted to tion as their personal duty and felt guilty and irre- face it alone, because people are still very preju- sponsible for getting pregnant unintentionally. diced against it”. Only a few participants thought the abortion decision was theirs to make. Most participants Others said they did not feel safe approaching referred to abortion as a “couple’s decision”, but the formal health system for information or described different levels of partner involvement: support. some partners proposed the abortion, others par- Most interviewees supported abortion decrimi- ticipated in the decision-making process and nalisation before deciding to abort, only one others just accepted a decision that was made thought abortion was “an irresponsible decision” by the woman. but changed her mind when she faced an While many interviewees described the unwanted pregnancy. Most participants also had decision as easy, fast or “already made” (Manuela, some previous information about medical abor- 31), because they knew they did not want to tion. They generally perceived it as a safe pro- parent at all or at that moment, for others it cedure that could be managed without medical was complex, difficult or took time. For instance, support. Only a few participants had beliefs that two women mentioned first deciding to keep the reflected the erroneous information that circu- pregnancy and then changing their minds. Gener- lates in the parallel market, for example, that ally, the moment in life was a decisive factor in the different pills should be used with different abortion choice. Work, education, economic hard- administration routes and that women die using ship, a couple’s projects and already having chil- abortion medication. dren were some of the situations that led them We identified two major ways of seeking for to decide to interrupt the pregnancy. Wishes and abortion information and services: searching feelings around motherhood also played an online and asking other women (acquaintances important role. Some interviewees wanted to be who have had abortions and feminist activists). “more prepared to be a mom” (Nora, 31) and others The time it took them to find WHW by searching wanted to be able to take care of their children. online varied; one woman said it was because Most participants handled the pregnancy as a “you have to distinguish between what is reliable secret and disclosed it only to their partners, and what is not, it is not so easy” (Janet, 26). Find- though a few talked about it with other family ing WHW seemed to be easier for the ones who members or friends. Some felt their partner’s started by asking other women, particularly support was fundamental and others were disap- those who were part of feminist networks, as pointed about the role they played. Two women one participant explained: “it’s all about friends mentioned that the pregnancy and the abortion and support networks” (Killa, 36). 5 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 Most participants considered several services and four hours, and several mentioned feeling and sources of pills before contacting WHW, their perception of time was distorted by the including other feminist organisations and ven- intensity of the pain, so they felt that the abortion dors in the parallel market. One woman had an process “took forever” (Cristina, 23). Most partici- unsuccessful abortion attempt with misoprostol pants were able to identify the moment of the she got from the parallel market before contacting expulsion and said pain diminished after that. WHW, and another requested support from sev- One of the participants who reported severe eral feminist organisations simultaneously. For pain did not use painkillers because she was the others, WHW was their first choice. Only two afraid it would interfere with the abortion. mentioned approaching health professionals Four participants reported complications. One while seeking abortion care; one of them got a had a haemorrhage a couple of days after the referral to WHW and a local organisation and abortion and passed out. She attributed it to the the other got mistreated by her gynaecologist. fact she had to take care of her small children Women mentioned fearing to be scammed in too soon after the abortion. Another woman the parallel market, receiving contradictory infor- identified a haemorrhage the same day she took mation from online vendors, affordability, and misoprostol. Both went to the hospital and, feeling more secure about the authenticity of based on WHW information, said they did not the pills as the reasons to choose the WHW service. know they were pregnant, so were diagnosed for a miscarriage and got treated according to their Abortion experience: information, emotions, needs. Both said they were treated well by the time and company staff because they did not mention having Logistical arrangements for the abortion process induced the abortion. Two other women had included taking time off work, searching for a intermittent abundant bleeding that lasted more place to take the pills and finding childcare and than a month. For both, a complication was company. Most women were accompanied by ruled out when they sought medical care several their partners, others by their female friends, weeks after the abortion. Others mentioned fear- one by her mother and aunt and others were ing they had a complication during the abortion alone. Several participants highlighted the impor- process, because the pain was too strong or the tance of having company during the process and bleeding too abundant, but also being able to many mentioned feeling lucky because they had recognise this as a normal part of the medical more support than other women, as Killa (36) abortion based on the information they had. explained: Participants described having diverse emotions during the abortion process. Some felt “calmed”, “I felt more comfortable with the process at home, “emotionally stable” or “not very affected”, and with my husband accompanying me all the time several of them attributed it to knowing what to […] I felt I could handle it. But I think in the expect based on the information they got. Others same situation, alone, it must be terrible. Because mentioned unpleasant emotions such as sadness, of the pain, because of the discomfort, because of loneliness and guilt or said the process was everything. I think that no one should be alone in “emotionally heavy” (Antonia, 34). Across the inter- living this process”. views, fear was the most mentioned emotion. Generally, women followed WHW instructions Among those who were fearful, criminalisation, to take the pills and all of them used misoprostol social judgment and “something going wrong” buccally or sublingually. They described having during the abortion process (including the pills cramps, bleeding and common side effects such not working, having long term consequences as diarrhoea and chills. While some described from the abortion and dying during the process) the abortion as a “fast”, “painless” or “not very were most common. Fear of criminalisation and intense” process, others said it was “not that posi- of social judgment often led these women’s tive”, or even “traumatic”. Some said the pain was decisions on how to manage their abortions. For “severe but tolerable”, but most described the example, one participant stopped her psychiatric medical abortion as a very painful process. Two treatment because she feared she would be participants thought information did not prepare judged by her psychiatrist and others decided them for the intensity of the pain. Generally, par- not to seek medical care despite having compli- ticipants said the intense pain lasted between one cation signs because they feared being mistreated, 6 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 reported at the hospital, or denied care. Janet (26), which made them trust the service; and knowing who was living in a small city at the time of the they were accessing the method used in countries abortion, stated that “The place where I live has with liberal abortion laws, as Miriam (25) stated: an institutional conscientious objection. So I ima- “The website and everything, it’s as if they were try- gined that I was going to get there and I was ing to normalise a little, as if they were not judging going to be left out, unattended.” Other fears you, […] since there it is not a crime as it is here, included not having enough time to wait for the and the vision is different. […] it was as if it was pills to come from abroad, being scammed something like … more normal than how it’s seen when using a credit card, getting incorrect pills here”. and doses, not having medical backup in case of a complication, receiving an invasive treatment Most participants said WHW exceeded their if they went to the hospital, and regretting the expectations because they approached it to abortion. “buy” the pills and did not expect to receive sup- Despite the fears, several participants said that port and care during the process. One participant being able to choose the place and the company said she thought that her contact with WHW would for the abortion was ideal for them. They men- be “a more clandestine thing, like drug trafficking” tioned comfort, privacy and not having to and was surprised she felt comfortable and trea- approach doctors as the reasons for this prefer- ted “like a friend” (Killa, 36). On the other hand, ence. As Cristina (23) expressed, “I am grateful one participant said she was expecting to be that I was able to do this quietly, alone in my referred to a doctor who would perform the abor- home, and not with a doctor.” On the contrary, tion and was given no choice but to self-manage. others self-managed their abortion because “it Participants described the interpersonal was the only alternative” (Nora, 31). Some partici- relationship with WHW staff as close, empathic, pants would have preferred to be supported by a professional and without judgment. They said health professional and one said it was unfair to WHW staff were welcoming, treated them with have to self-manage an abortion as states should care and respect and made them feel they were support women’s reproductive decisions. One par- not alone, as Valeria (25) summarised: “They are ticipant mentioned she felt good about not having not meddlesome but not indifferent either”. Others to see anyone during the abortion process only said that follow-up emails and questions made because she feared disclosing the abortion in a them feel cared for and many valued receiving context such as Chile. referrals to local services. Most participants Participants also described how their beliefs described WHW communication as fast or immedi- about abortion changed after their experience. ate, and only one said she experienced a slight Several said they now think abortion medication delay in responses. Generally, women said they should be readily available; others felt more had good, personalised, direct, and timely com- motivated to join the struggle for abortion rights munication with WHW and assessed email – the and to share their abortion stories and accompany main WHW communication tool – as private, other women with unwanted pregnancies. fluid and direct. However, a few women perceived email as distant and interrupted. One of them said Assessing WHW quality of care: abortion she would have liked to have in-person support, normalisation, interpersonal relations, timely as she felt written communication was insuffi- communication and pills affordability cient. Most participants did not contact WHW All participants considered WHW’s service to be of during the abortion process because they did good quality and said they would recommend it. not need more information, or because they had They described it as timely, comfortable, fast, dis- support from other feminist organisations, creet, and efficient. Several participants said they acquaintances who had had abortions and trusted felt safe while contacting WHW. Their reasons health professionals, with whom they could com- included WHW normalising abortion, which municate via instant phone messaging. made them feel they were approaching “a legal The majority of our participants had higher form of the illegal” (Fernanda, 30); receiving the education and personal incomes they could pills in their original blister (as pills in the parallel decide how to spend. Thus, when asked about ser- market are often sold unpacked); accessing evi- vice accessibility, most women felt that accessing dence-based, clear and complete information, the service was easy for them but would be hard 7 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 for others in less privileged situations. Several par- comparison did not make sense given the legal ticipants mentioned that access to the WHW ser- restrictions in Chile. vice is mediated by resources not everyone has, Several participants shared experiences of long such as contacts, internet access, previous infor- waiting times, judgment and mistreatment in the mation, and a credit card. Like Killa (36), many formal health system when trying to access legally expressed that the amount of the donation was available services such as contraception. For “a lot of Chilean money”, but seemed affordable example, one said she was on a waiting list for a because the price of the pills in the parallel mar- tubal ligation for so long that she had several ket can be three or four times the WHW requested kids while waiting. Another explained that in her donation. Only one participant thought “anyone university the only contraceptive method for could access WHW service” (Nora, 31). which information is available is sexual absti- Several participants mentioned that constant nence and another described being mistreated communication with WHW helped them cope by a gynaecologist while requesting information with the anxiety they felt while waiting for the about a vasectomy for her partner. Participants package to arrive. Participants were generally sat- also mentioned low quality care when approach- isfied with the delivery, which for most of them ing the formal health system with abortion- took one week, and for others two to three related needs. Janet’s (26) gynaecologist tried to weeks. One of the women who received the pack- dissuade her from her decision when she men- age in two weeks said the time for delivery was too tioned wanting to have an abortion. Valeria (25) long. had prolonged bleeding and went to the hospital Three participants mentioned having technical one month after taking the pills. Her gynaecolo- problems when accessing the website from a cell gist – who ruled out a complication – told her phone. When asked for recommendations to that “her uterus could fall down” because she improve the service, women proposed imple- waited too long to get medical treatment. While menting more immediate and personal communi- some women normalised the mistreatment in cation means, such as instant messaging, phone health facilities or justified it because of the calls or in-person encounters. Others rec- legal restrictions, others interpreted the general- ommended making the website more visible, ised lack of quality in sexual and reproductive focusing attention towards younger women, creat- health services as the formal health system “for- ing opportunities for collective experience shar- cing women to be mothers” (Killa, 36). ing, and providing more information on how to Some participants also shared their good make the decision and disclose it to others. Sev- experiences with feminist health professionals, eral participants mentioned the legal situation and with a “trusted gynaecologist”. These experi- of abortion in Chile as a justification for the ser- ences included professionals normalising abortion vice limitations. and offering confidentiality about their conversa- tions, providing information and referrals to access abortion outside the health care system Comparing supported self-care with the and adequately informing about other sexual formal health system: searching for humane and reproductive health issues. services and non-judgmental care Previous experiences with sexual and reproductive health services contextualise these women’s Discussion assessments of WHW quality of care. Compared We found that women’s trajectories to the WHW with formal care they had received in the past, service and their experiences with self-managed participants mentioned WHW advantages such as abortion were determined by illegality, stigma, staff being “more humane”, providing more infor- expectations around motherhood and abortion, mation and showing actual concern and willing- as well as by personal circumstances. In line ness to help. Several participants highlighted the with previous analysis about self-managed abor- emotional support, non-judgmental care and rap- tion trajectories in the region,26–28 including pre- port, which they perceived as uncommon features vious studies in Chile,10,11 our results in formal health services. As Antonia (34) stated: demonstrate that illegality and stigma do not “Doctors only care about the medical, not about deter women from deciding to interrupt a preg- me as a person”. Two participants thought the nancy, but make their abortion trajectories and 8 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 experiences harder and more demanding. WHW’s fulfil the aims of guaranteeing rights and achiev- work in Chile inserts itself into the Latin American ing acceptability. feminist tradition of supporting self-care to enable However, our in-depth analysis of the quality of reproductive autonomy and improve abortion the WHW model also allowed us to understand the access,29 and has outcomes similar to those of limits of what a high-quality service can achieve in other feminist initiatives in the region.14,28,30 For a stigmatising and criminalising context. Abortion example, our results confirm that information, stigma is a social process by which a negative attri- accompaniment and ready access to abortion bute is ascribed to those associated with abortion pills improve self-managed abortion (people who have abortions, their partners and experiences.10,11,26,30 providers), grounded on their violation of social By focusing on perceptions about WHW’s qual- expectations.33 For people who have had abor- ity we add fresh data about how its model of care tions, stigma comes from the social belief that impacts abortion trajectories and experiences in they fall short of the ideals of womanhood.34 In specific ways. This information is relevant for dis- practice, stigma translates into barriers for abor- cussions on how self-care could improve access to tion access, fear, silence and shame.33,34,36 Abor- sexual and reproductive health care in the context tion stigma is often compounded by of fragmented legal landscapes, growing global criminalisation, but it can also survive liberalisa- inequalities and formal health systems collapsed tion of abortion laws, as the Uruguayan and by the COVID-19 pandemic. Our results show Colombian cases show.35,36 Previous studies have that, despite legal restrictions, several options to found that fear of being criminalised determines access abortion pills are available in Chile and experiences and narratives around abortion in women chose WHW because they perceived it as Chile.10,11 Our findings add that despite accessing trustworthy, fast and affordable. Participants con- a service that normalises abortion, the centrality sidered WHW a good service and valued the quan- of stigma and fear persists. tity and quality of information; having direct, We also found that while most participants personalised and timely communication with ser- valued confidentiality and privacy and felt they vice staff; being treated with respect; and feeling had adequate support during the abortion pro- safe, cared for and supported in their decision. cess, many of them identified fears of social judg- Most participants considered self-managed abor- ment and criminalisation as reasons for keeping tion appropriate and acceptable given their cir- their abortion secret. As Sheldon has indicated cumstances. While the generally positive in her analysis of the relation between abortion assessment of self-management as an option of pills, empowerment and privacy in the Republic care may be explained by the Chilean restrictive of Ireland, secrecy and silence may be functional legal environment, WHW’s most valued service in perpetuating stigma and for states to continue features are indicative of the elements that to neglect their responsibilities for reproductive every good abortion service should have. Timely health.37 In our interviews we found that information, emotional support, rapport, and women who accessed abortion through WHW’s respect for women’s choices emerged as key service may be more willing to talk about their elements in abortion care. In contrast, our partici- abortion experience and join the struggle for pant’s assessments of gynaecological services pro- abortion decriminalisation. However, at the indi- vided legally in Chile show how formal care can vidual level, the self-protection strategy of silence fall short in some of these important aspects of and secrecy may still endanger women’s well- quality. Similarly, studies conducted in contexts being as it makes them fear seeking medical with more liberal abortion laws, where home care when needed, as some of our participants administration of medical abortion is offered by mentioned and as Horgan has documented in the formal health system, have found that abor- Northern Ireland.38 tion self-management is sometimes seen as It is well known that those who suffer the worst inferior to in-hospital care because of perceived consequences of criminalisation and lack of abor- lack of information and follow-up, limited access tion access come from marginalised groups.10,11,28 to health professionals, and insufficient pain man- Other authors have also established that abortion agement.31,32 We argue that many of the features trajectories and decision-making are differen- of the WHW model of care could be introduced to tiated by socioeconomic status.27 It is thus impor- self-care initiatives led by formal health systems to tant to note that most of our interviewees had 9 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 university education, access to the internet and and emergency care should also be available for support networks. While our participants said those who want it or need it. In terms of politics, that the WHW service was accessible for them, abortion-related regulations should fulfil their they worried it would not be the case for aim to protect people’s health, rights and well- women with fewer resources. Coinciding with being; thus total abortion decriminalisation and this concern, a previous analysis of a national sur- public funding for abortion are needed in Chile. vey that included a representative sample of However, none of this will happen without a pro- women aged 15–29 in Chile, found a socioeco- found change in social beliefs about abortion and nomic gradient on abortion incidence. As com- the role of women and gender non-conforming pared to young women with low socioeconomic people in society. status, those with higher status had almost five times the odds of having induced an abortion, Strengths and limitations and those with middle status had 1.8 higher Our study design allowed us to contribute new odds.4 The higher presence of relatively privileged information on an under-studied and clandestine women in our study as well as the higher inci- phenomenon and our results have the potential to dence of abortion in this group in the Chilean sur- improve the quality of abortion services, including vey, may be explained by women with more supported self-care interventions, in a variety of resources being more empowered to act on their contexts. Moreover, our qualitative approach reproductive desires,39 or to disclose their abor- enabled us to interview women with diverse tra- tion for research purposes, but it could also jectories and experiences and to understand mean that many women with lower socioeco- their assessments of quality of care in relation to nomic status have no choice but to take unwanted some structural and contextual determinants. pregnancies to term because they are unable to However, our study has some limitations. Our access abortion services. While the nature of our sample was small and fairly homogeneous in study did not allow us to assess if access to WHW terms of socioeconomic status and geography, is determined by socioeconomic status, it does which may have hindered our ability to see a shed light on the qualitative aspects of accessibil- wider array of abortion trajectories. Recruiting ity. We show that support networks facilitate users through the service may have limited the access, that previous knowledge and access to possibility of interviewing unsatisfied users and international payment methods have a mediating understanding the nuances of satisfaction and effect on access and that the perception of afford- acceptability. It is possible that participants ident- ability is related to the price of the pills in the par- ified the interviewer as a member of WHW, which allel market. Further studies aiming to understand may have influenced responses. Finally, it is poss- the different meanings and expectations around ible that our participants were more empowered motherhood and abortion and their relation to than other women in the same context to talk social class and religion are warranted. Also, about abortion, which would soften the effects further research into service utilisation, that of stigma and criminalisation in users’ includes those who do not access abortion ser- experiences. vices, would improve understanding of how struc- tural inequalities operate on abortion access in contexts like Chile, and whether remote support Conclusion and self-care interventions such as WHW’s are suf- Women’s trajectories, experiences and assess- ficient to guarantee the rights of the populations ments of quality of abortion care are determined at most risk. by the intersection of structural, contextual and Our study demonstrates that not only support individual factors. Support, accompaniment and for abortion self-care, but also high-quality abor- information are key to improving pregnant tion care, are possible despite legal restrictions. people’s experiences and enabling their decisions, It also highlights the need for social, political particularly in legally restrictive settings. Develop- and legal changes to fully realise reproductive jus- ing models of care centred in pregnant people’s tice. From a service perspective, more emphasis needs and autonomy, including complete and on normalising reproductive choices and huma- evidence-based information, direct and timely nising relationships within health care are key. communication and good interpersonal relation- In-person attention and access to professional ships, is fundamental to ensure that self-care 10 S Larrea et al. Sexual and Reproductive Health Matters 2021;29(3):1–13 interventions in reproductive health are safe and Disclosure statement appropriate. However, social and legal changes – SL was working as a paid staff member at WHW such as public funding for abortion, destigmatisa- when this study was conducted. Authors declare tion and decriminalisation – are needed to enable no other conflict of interest. the full realisation of people’s right to access the highest standard of healthcare. ORCID Sara Larrea http://orcid.org/0000-0002-9206- Contributions 8656 SL designed the study and the data collection Constanza Jacques-Aviñó http://orcid.org/0000- tools, CB and LP supervised the design and con- 0001-8506-780X tributed to it. SL and CH coded the interviews Carme Borrell http://orcid.org/0000-0002-1170- and CJ participated in the analysis. SL drafted 2505 the first version of the manuscript and all authors Laia Palència http://orcid.org/0000-0002-3726- contributed to it. 9893 References 1. Wainwright M, Colvin CJ, Swartz A, et al. 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Sexual and Reproductive Health Matters 2021;29(3):1–13 Résumé Resumen L’avortement autogéré est une pratique d’auto- La autogestión del aborto permite a las personas prise en charge qui permet aux personnes embarazadas ejercer sus derechos a la salud, a la enceintes d’exercer leurs droits à la santé, à l’au- autonomía corporal y a beneficiarse del progreso tonomie corporelle ainsi que de bénéficier des científico aun cuando viven en contextos que no progrès de la science, même quand elles vivent garantizan estos derechos. En este estudio cualita- dans des contextes qui ne garantissent pas ces tivo interpretativo, nuestro objetivo fue entender droits. Dans cette étude qualitative interprétative, las trayectorias de aborto, las experiencias con la nous souhaitions comprendre les trajectoires autogestión del aborto y las evaluaciones de la d’avortement des femmes*, leur expérience de calidad de la atención entre usuarias del servicio l’avortement autogéré et les évaluations de la de Women Help Women (WHW, organización acti- qualité des soins prodigués par Women Help vista internacional sin fines de lucro que trabaja Women (WHW, une organisation militante inter- para ampliar el acceso al aborto). Basándonos nationale à but non lucratif travaillant pour en los enfoques de la epistemología feminista y l’accès à l’avortement). Nous fondant sur les las desigualdades en salud, realizamos once entre- approches de l’épistémologie féministe et des iné- vistas semiestructuradas en Santiago, Chile. galités de santé, nous avons mené 11 entretiens Encontramos que la ilegalidad, el estigma y las semi-structurés à Santiago du Chili. Nous avons expectativas en torno a la maternidad y el aborto constaté que l’illégalité, la stigmatisation et les determinaban las experiencias de las mujeres. Las attentes entourant la maternité et l’avortement participantes valoraron positivamente el servicio y avaient déterminé l’expérience des femmes. Les mencionaron características clave para un buen participantes ont jugé que les services de WHW servicio de aborto. La mayoría consideró la auto- étaient bons, dignes de confiance, rapides et gestión de su aborto como adecuada y aceptable d’un coût abordable, et elles ont apprécié la con- dadas sus circunstancias. A pesar de esto, el fidentialité et le respect de la vie privée; la quan- miedo fue el sentimiento dominante en las narra- tité et la qualité des informations; le fait d’avoir tivas de estas mujeres. Concluimos que el apoyo, des communications directes, personnalisées et la información y la compañía mejoran las experi- ponctuelles avec le personnel chargé des services; encias de quienes buscan un aborto y facilitan sus le traitement respectueux qui leur a été réservé; et decisiones, en particular en entornos restrictivos. le sentiment de sécurité, de prise en charge et de Centrar la atención en las necesidades y autono- soutien dans leurs décisions. La plupart des parti- mía de las personas embarazadas es fundamental cipantes considéraient l’avortement autogéré para garantizar intervenciones de autocuidado adapté et acceptable compte tenu de leurs circon- reproductivo que sean seguras, adecuadas y stances. La peur était le sentiment dominant dans accesibles. les récits des femmes. Certaines participantes ont mentionné que la communication instantanée, le soutien en personne et les soins professionnels leur avaient manqué. Nous en concluons que l’ap- pui, l’information et l’accompagnement sont essentiels pour améliorer l’expérience des femmes souhaitant avorter et permettre leurs décisions, en particulier dans les environnements juridiquement restrictifs. Il est fondamental de centrer les soins sur les besoins et l’autonomie des personnes enceintes pour garantir des inter- ventions d’auto-prise en charge sûres, appropriées et accessibles dans le domaine de la santé repro- ductive. Des changements sociaux et juridiques, comme le financement public pour l’avortement, la déstigmatisation et la dépénalisation, sont nécessaire pour réaliser le droit des personnes à des normes plus élevées de soins de santé. 13