Perils and possibilities of health exception laws: A narrative review

Forty-seven of the 203 countries with abortion laws detailed by the Center for Reproductive Rights have a health exception (HE) clause, inconsistent in both wording and implementation, even within countries. This narrative review sought to determine the understanding and implementation of the legally permissible HE in different countries, or states, to provide clarification and guidance for strategies that will maximize permitted access to safe abortion within the law and avoid undue delays that harm the lives and health of women and their families. A multimethod approach was used

and social well-being and not merely the absence of disease or infirmity". 1,2rty-seven of the 203 countries with abortion laws detailed by the Center for Reproductive Rights have a HE. 3 The HE clause in abortion laws of different countries is not only inconsistent in its wording but also in its implementation, even within countries, and typically varies according to regulations from the Ministry of Health. 3,4Even countries structured as federations, such as Mexico and the USA, may pass laws at the federal level but have different, even contradictory, legislation at the state level.As a consequence, women, health professionals, administrators, and lawyers may be confused as to the scope of a given HE clause.Some laws require consultation with more than one provider and impose other barriers that delay medical interventions that can be lifesaving.
Importantly, most countries with HEs do not include gestational age limits, reflecting the reality that medical intervention for distinct health risks may be required at any time during pregnancy. 3,4e objective of this narrative review by Global Doctors for Choice (GDC) is to improve the understanding and implementation of legally permissible HE around the world, by exploring barriers and providing legal case examples as well as successful country case studies, for strategic advocacy purposes, to maximize permitted access to safe abortion within the law.

| BACKG ROU N D
Unsafe abortion continues to be a significant and preventable cause of maternal mortality and morbidity globally. 5The WHO and many other professional organizations around the world assert that abortion should be considered a health concern.In fact, comprehensive abortion care is listed in the essential healthcare services published by WHO in 2020, noting that an enabling environment for abortion care includes respect for human rights including a supportive framework of law and policy. 6,7The UN Human Rights Committee's General Comment on the Right to Life recognizes and protects the right to life for all human beings and establishes that the right to life begins at birth.The General Comment stipulates that any regulation on voluntary terminations of pregnancy may not interfere with the right to life or "jeopardize their lives, or subject them to physical or mental pain or suffering". 8WHO further provides a detailed review of key international human rights standards on abortion. 9In a global comparative review of abortion law in 2022, the Council on Foreign Relations noted: "Access to safe abortion has been established as a human right by numerous international bodies, and regional human rights courts, including the European Court of Human Rights, the Inter-American Court of Human Rights, and the African Commission on Human and Peoples' Rights". 10 In most countries of the world, even those where abortion has been liberalized, access to abortion remains embedded in the criminal code. 4Canada is the only country where abortion is considered to be solely a matter of health and is under the jurisdiction of regulatory bodies of health professionals.Some countries' laws permit abortion in cases of rape and fetal anomaly, with inconsistency as to whether a medical or police report is required to obtain abortion in the case of rape.In this narrative review we propose to consider rape as qualifying on mental health grounds, as implemented in Colombia for example.This sidesteps barriers arising from mandated reports to criminal authorities.Similarly, we consider fetal anomaly to fall under the HE both because of associated mental health concerns and because certain anomalies also pose maternal medical risks if pregnancy continues (e.g.anencephaly).
Many advocates for abortion agree that the aspiration goal is for women to have autonomy whenever they decide to end a pregnancy for any reason, along with ready access to the services required.
Decriminalizing abortion means that neither the woman nor her doctor (typically) will face criminal charges for having or providing abortion regardless of the laws/restrictions in the country.Access to abortion on request under the law would be a reasonable expected sequitur.In the last few years, several countries and a few states in the US have made significant progress toward this end.South Korea and Mexico removed abortion from the criminal code federally, although uncertainty regarding access remains due to contradictory laws at the state level in Mexico.New Zealand decriminalized abortion before 20 weeks, providing abortion on request until that threshold.Australia and Colombia decriminalized abortion before 24 weeks and Argentina before 14 weeks. 3,11Criminal law limiting medical management puts clinicians in the impossible situation of failing their professional fiduciary and medical obligations or risking imprisonment or malpractice suits.Conscientious objection is sometimes misunderstood and used by some with concerns about legal risks or stigma from providing abortion services. 12Referring women out of state, as is occurring in the US today, or out of country, causes delays that can lead to death or serious complications.

| Notes on terminology
Because terminology varies around the world, we use the term "abortion" in this article synonymously with the terms voluntary abortion, induced abortion, evacuation of the uterus, and termination of pregnancy.All of these terms can be used interchangeably and refer to purposefully ending a pregnancy with the intention of avoiding a live birth.The procedure can be accomplished by medications, manual vacuum aspiration, dilation and suction curettage, dilation and sharp curettage (D&C), and dilation and evacuation (D&E).
Although it is not the current recommended standard of care, D&C is included here because it is used for abortion care in many parts of the world.
We also use the term clinician interchangeably with the terms health or medical practitioners and healthcare providers.These broad categories encompass physicians as well as midwives, physician assistants, nurse practitioners, surgical extenders, among others.Related terminology is found in Appendix 1.
Although this resource uses female pronouns as well as the terms "women and girls" in our discussion of abortion, we recognize that people who do not identify as women may also need access to abortion.

| ME THODS
We employed a mixed methods approach comprising health and legal literature reviews, key informant interviews, compilation of emblematic cases, and country case studies of two positive countrybased examples.

| Literature review
We searched for peer-reviewed published quantitative and qualitative research explicitly addressing the HE for legal abortion and found few such publications in English or Spanish published prior to our search in November 2022, or November 2023.We expanded the search by adding additional key terms such as therapeutic abortion, human rights, legal frameworks, qualifying conditions, and case studies of implementation, and included research pertaining to conditions often associated with HEs, such as cancer during pregnancy and fetal anomalies.We searched for studies under the following categories: Health Exception/Grounds-Based Approaches, Indications and Qualifying Conditions for Health Exception, and Laws and Policies Related to Health Exception, and excluded those that did not mention abortion when discussing fetal anomalies.

| Desk review
We used the WHO's Global Abortion Policies Database to determine the comparative legal landscape regarding abortion as it allows for a country-by-country comparison. 4Country data that seemed ambiguous were confirmed with research into that individual country's penal code and abortion regulations.We investigated the requirement for "police reports" for certain exceptions to some countries' abortion bans at the individual country level.
We employed the definitions used by the WHO for legal and unsafe abortions 6 and expanded upon the WHO's use of legal terms like "criminalization" by also incorporating generally accepted definitions for technical terms in legal practice.

| Emblematic cases
In legal terms, emblematic cases refer to "cases that… lead to court decisions that are emblematic of systematic patterns of human rights violations or structural discrimination". 13We consider emblematic cases to be those that brought failures to provide abortion care under the HE into public focus and had an impact on the continued fight for accessible abortion through resulting legislative changes or increased public awareness and outcry.Emblematic

| Key informant interviews
We sought to interview doctors, administrators, and activists who were geographically diverse and had a breadth of experience with HEs, and interviewed 15 representatives from 14 countries across four continents (Latin America, Africa, Europe, and Asia).Interview questions were developed by HE committee members and covered use and interpretation of the HE, related laws and policies, health worker knowledge and comfort, general population knowledge, and data and monitoring.Questions were intentionally open-ended and designed to solicit the maximum information possible from interviewees.Each interviewee was contacted by email and provided their consent for interview and anonymized collated information.
We did not seek Institutional Review Board approval because this was primarily a literature and desk review.The key informants were interviewed in their organizational not personal capacities, without identifying information.Interviews were conducted via Zoom in either English or Spanish.They lasted between 30 and 60 min and inquired about availability of guidelines regarding HE, what clinicians know and if/how they provide care falling within the HE, what women understand about the HE, and how the HE law functions.
Interviews were recorded, transcribed, and thematically analyzed.

| Country case studies
We provide two country case studies from Ghana and Colombiacountries that expanded their interpretation of the HE in ways that facilitated access to abortion and related service.

| Limitations
The available health-related literature was sparse so we reviewed peer-reviewed articles that explicitly addressed the HE, indications, and qualifying conditions, as well as related laws and policies, even if their samples sizes were too small or insufficiently representative to permit conclusions.Although we aimed to include geographically diverse investigations, the majority were from Europe and the Americas.Our interview sample was chosen in order to include diverse countries and continents and on the basis of the interviewee's general knowledge of the field and willingness to participate and is not representative of physicians in that country.We selected one emblematic case to highlight each medical category.Emblematic cases derive from strategic litigation tactics which in turn reflect availability of activist lawyers and are not distributed according to frequency of occurrence.While each component of this mixed method approach had limitations, they complemented one another and led to the identification of key themes and strategic approaches toward our objective.

| Literature review
We reviewed 23 papers: 7 specifically on HE, 13 on Indications and Qualifying Conditions, and 3 on Laws and Policies.The crosscutting themes that emerged included the range of definitions and interpretations of risk, the barriers to implementation of HE laws, and successful strategies for expanding access to abortion care through the HE.
Ramos et al. 14 published a study regarding the implementation of the legal and safe abortion policy in Argentina and determined that most healthcare practitioners lacked information on the legal framework ("restrictive understanding of both health and rape indicators") and noted that only a few doctors were willing to provide an abortion, even though most were in favor of it under the Penal Code grounds.Although the Colombian 2006 abortion law had legalized abortion in cases of risk to the mother's physical or mental health, fetal abnormalities incompatible with life, and in the case of rape or incest, Stefani et al. 15 reported that very few qualifying abortions were subsequently provided.The authors identified issues with interpretation of the law, lack of government oversight in provision of abortion care, and a general lack of knowledge about the law as reasons for the low numbers of legal abortions. 15o publications provided comparative analyses regarding access to abortion under the HE law.Küng et al. 16 looked at interpretation and implementation of the law and consequences for access to legal abortion in Britain, Colombia, and Mexico.The authors identified five factors that influence the application of HE laws: "(1) the definition of health, with explicit mention of mental as well as physical health; (2) a strong public health sector that provides abortion services; (3) knowledge of the HE law, including clear guidelines for physicians; (4) dissemination of information about the HE law; and (5) a history of court cases that protect women and clarify the HE law". 16nzález Vélez 17 compared interpretations of the HE in Latin America, particularly Colombia, Argentina, and Mexico, and focused on the distinction between risk of bodily harm and occurrence of bodily harm.The author evaluated the advocacy work of a group of allies in Latin America who had promoted broader understanding of the HE in order to improve its full implementation and considered their efforts to have been quite successful in helping providers interpret the HE policy. 15,17,18In addition to the findings cited above, they highlighted the focus on human rights, provisions to account for conscientious objection, and lack of gestational age limit as significant strengths of the law. 15,18e authors recommend "The key concepts of the HE are to do with the meaning of risk, of health as an integrated concept, the use of the HE for adolescents, and the relationship between risk to health, rape and fetal malformation".15,17,18 A consensus document by several experts and organizations in Latin America provides justification why the HE is a human right, the principles and ethical parameters that should be taken into consideration while applying this right, 19 criteria for interpreting the HE exception, and a guide for problem solving when it comes to misinterpretation of the HE.
The most recent WHO guidelines on abortion published in March 2022 recommend against laws and other regulations that restrict abortion by grounds. 6De Londras et al. 20 reviewed the evidence as to whether or not grounds-based approaches sufficiently meet the international human rights law stipulation that abortion be available where the pregnant person's life is at risk.They determined that grounds-based approaches delay access to care, narrow availability of abortion care, have a chilling effect on providers' willingness to provide abortion care, can lead to further limitations to abortion, and are insufficient to meet states' human rights obligations.Thus, they concluded that the negative impacts on pregnant people and providers from grounds-based approaches result in violations of human rights.

| Key informant interview findings (Supporting information S1)
We interviewed 15 key informants from 14 countries: Argentina, Bolivia, Brazil, Colombia, Ecuador, Mexico, Peru, Uruguay, Ghana, Kenya, South Africa, South Korea, Ireland, and the UK.Key informants included representatives from GDC partner organizations as well as governmental and nongovernmental organizations.A majority of interviewees were abortion providers themselves and spoke about their experiences providing care under the HE as well as their general understanding of the HE in their country.
The consensus among all our interviewees was that legal abortion under the HE was not being provided to the full extent of the law.The reasons behind this underutilization differed but in all 14 countries there were clear opportunities to increase utilization of the HE as a means to improving access to abortion care.The reasons cited for underutilization of the HE included narrow definitions of "health", lack of medical guidelines for provision of care under the HE, confusion among clinicians and women regarding qualifying conditions, stigma and conscientious objection by clinicians, and lack of education on the HE for both providers and those seeking abortion.Moreover, implementation of the HE is often not monitored.
Another commonly cited barrier to utilization of the HE was lack of medical guidelines or poorly developed or incomplete guidelines for provision of abortion under the HE.While most countries represented in our interviews had some established medical policies or guidelines, their quality and utility varied widely.Some medical guidelines for provision of abortion under the HE had been authored by medical providers, but many interviewees reported that guidelines had been authored by lawyers or other government personnel with minimal understanding of abortion care.Interviewees reported a need for evidence-based guidelines for provision of abortion care specifically pertaining to the HE written with input from medical providers.

| Desk review
Laws and regulations pertaining to the HE vary widely with regard to the definition of health used and whether or not that definition encompasses health in all its dimensions, including physical, mental, and social health.The United Nations Human Rights Committee clearly articulates a directive on abortion and interpretation of the right to life, noting the State may regulate voluntary abortion (Table 1). 8 general, countries that have more liberal access to abortion through multiple pathways (i.e. on request early in pregnancy as well as HE later on) are more likely to use a broader definition of health akin to the WHO definition.Narrow interpretation of the concept of health and inaccurate concepts of "risk" or "threat" to the pregnant woman's health and life resulting in a restrictive interpretation of the HE are more common in countries with less access to abortion overall.Lack of a clear definition of "health" or "risk" can be strategic to dissuade attempts to access or provide abortion care through the HE.Explicit inclusion of mental health also varies widely with some countries allowing for self-report or physician attestation of mental health impacts and some countries requiring involvement of mental health professionals such as psychologists to verify presence of mental health symptoms.

| Emblematic cases
The HE often comes into public consciousness when an emblematic case 13 clearly demonstrates the harm that can arise from restrictive abortion laws, confused interpretation of the law, and lack of legislation around provision of care.
The examples of high-profile cases included in Boxes 1-5 illustrate the lack of clarity regarding implementation of the HE clause in the abortion law of the country.These cases constitute real-world examples of how the legal landscape is applied to the unique facts in each individual woman's case since their legal standing has been established.

Conditions occurring as a result of the pregnancy (case 1)
Conditions occurring as a result of the pregnancy fall into several subcategories.They may derive from pregnancies gone awry such as spontaneous abortions or ectopic pregnancies, or comprise medical complications of pregnancy such as pre-eclampsia, or medical conditions that are aggravated by pregnancy, such as cardiomyopathies or certain mental health conditions.Emptying the uterus in the case of a placental separation, inevitable abortion (miscarriage/spontaneous abortion), or removing an ectopic pregnancy is standard medical management for failure of pregnancy.The HE should apply in such cases.Even in countries where abortion is completely banned, treatment should not be denied as the pregnancy is not viable.A TA B L E 1 United Nations Human Rights Committee directive on abortion.

United Nations directive
Abortion 8 Health of the pregnant woman 8 • Must provide safe and legal abortion where the life and health of the woman is at risk • Must provide safe and legal abortion where carrying a pregnancy to term would cause the woman substantial pain and suffering • Must provide safe and legal abortion where the pregnancy is the result of rape or incest • Must provide safe and legal abortion where the pregnancy is not viable Life 8 • Begins at birth; therefore, human rights only begin after birth • Right to life is the entitlement to live free from acts or omissions causing unnatural or premature death, as well as, right to enjoy life with dignity Criminalization 8 • Criminalization of abortion or pregnancy of unmarried women could be a violation of women's right to life • Criminalization of medical professionals conducting abortions could be a violation of women's right to life Obligations of states

Existing conditions worsened by pregnancy (case 2)
There are numerous medical conditions that can be aggravated by pregnancy including lupus, cardiac disease, respiratory disease, mental health, kidney disease, liver disease, autoimmune disease, hypercoagulability, and multiple sclerosis among many others.
Continuation of a pregnancy in women with such conditions can pose serious risks to their current and future health.In situations where the continuation of a pregnancy would aggravate existing conditions and pose a significant risk to a women's health, provision of abortion care under the HE is appropriate.Alicja Tysiąc's case is the example provided here of a woman whose pregnancy aggravated her existing eye condition to the point of near blindness (Box 2). 22nditions that require treatment that might result in fetal harm (case 3) Another common situation is denial of care for conditions unrelated to pregnancy that require treatment that might result in fetal harm or miscarriage, such as chemotherapy or radiotherapy.
In such cases, termination of pregnancy is not the goal but unin- to potential harm to the fetus, such as in the case of Ana Maria Acevedo (Box 3). 23ltiple exceptions, including risk to health (case 4) Sometimes the abortion is requested because the pregnancy resulted from rape or because there is a fetal anomaly.
Continuation of pregnancy and motherhood in such conditions may result in damage to women's mental, social, or physical health that women should be allowed to avoid wherever the HE, even if rape or fetal anomaly exceptions are not specified by the law.Such is the case of L.C. who was denied an abortion despite having been impregnated from a rape at a very young age and having attempted suicide subsequently (Box 4). 24Although there were multiple possible pathways to accessing abortion through different exceptions to the restrictive abortion law, she was denied care through all of them.

Possibility of future harm (case 5)
Risk to health of continuing a pregnancy when there is the potential for harm in the future or when the risk is to mental or social health is often underestimated.Too often physicians fail to understand that the HE should be invoked if the pregnant woman does not want to put her health at risk by continuing the pregnancy.One example of a case where the potential for future harm was not considered was the case of Adiela Orozco Loaiza, who was denied preventative treatment for cervical cancer because she was pregnant (Box 5). 15ese emblematic cases illustrate situations where the HE clause in the law (or multiple exceptions) could have been used and was not.
These specific examples have reached the national/regional courts Acevedo that although radiotherapy was the appropriate treatment for her cancer, the hospital could not provide it to her as pregnancy was a contraindication for radiotherapy given the negative effects it would have on the fetus.
Acevedo was denied both a therapeutic abortion and radiotherapy and only received treatment for her pain.Her health rapidly declined, she underwent a cesarean section at 22 weeks because she was in a "pre-mortem state" marked by respiratory distress and organ failure.Her baby died within 24 h and Acevedo died a few weeks later.
Impact: Following Acevedo's death, her family gave permission to a group of lawyers, Multisectorial de Mujeres, to represent them in criminal proceedings against the doctors involved in her care.The Court charged the doctors involved for noncompliance with civil servants' duties and held them responsible for the injuries suffered.This decision was the first of its kind in Argentina and set a precedent that the denial of a legal abortion constituted a crime.
Acevedo's story was widely publicized and adopted by the Argentinian feminist movement as a rallying cry for legal abortion.its law to allow women to access abortion care in the case of rape or incest, review its strict interpretation of "therapeutic abortion," establish a mechanism for ensuring that abortion services are available when indicated, and guarantee access to abortion care when a woman's life and physical and mental health are in danger.
on the grounds of violation of human rights and failure to obtain legal abortion under the country's HE clause.There are many other similar cases that have not reached regional courts or have not been formally reported.

Ghana Abortion law prior to HE change being initiated
The abortion law was restricted and criminalized in the

Impact: In response to the denial of treatment, Orozco
Loaiza filed a protective action before a judge arguing that her right to health and life is being violated.The judge ruled that because the hysterectomy constituted an abortion she could not have the surgery.The judge also noted that not all physicians consider her diagnosis to be an injury with malignant potential and that therefore denying her a hysterectomy did not pose a serious risk to her health or life.

Subsequently, this case was instrumental in guiding the
Colombian Constitutional Court's correct interpretation of "risk" post-revision of the law in 2006.

Subsequent evolution of HE law and implementation
The 1990's Safe Motherhood initiative focused on access to legal and safe abortion services within the HE as a right, with emphasis placed on engaging service providers to more widely interpret the HE.A policy review conducted in 2003 expanded fully the interpretation of the three exceptions under which abortion could be performed legally: • Rape, incest, defilement, etc.
• On the grounds of endangered maternal health if the pregnancy should continue.
This policy review provided the basis for the Ghana Health Service to incorporate these exceptions and wider interpretation into the Reproductive Health Strategy of 2003. 25 2006 a Comprehensive Abortion Care Guideline was operationalized that enabled capacity building of health workers to provide safe abortion services, and critically expanded safe abortion services in Ghana and thus tackling the problem of unsafe abortions. 26e postabortion policy and the guidelines placed emphasis on the management of incomplete abortion and family planning support without any attempt to verify if abortion was client initiated or not, with emergency clinicians mandated to provide care.

Reasons for change
The exceedingly high contribution of unsafe abortion

Initiation of the change
The postrevolutionary military government in the1980s wanted to make a swift shift from most traditional norms.
This meant that there was a clear role for well-respected organizations such as UNFPA, IPAS, Marie Stopes, CSOs, and health policy makers notable among them the late Professor Fred Sai, professional associations such as the Society of Obstetricians and Gynecologists of Ghana (SOGOG), and GDC.

Allies involved in the advocacy work
Allies involved in this advocacy work included IPAS, UNFPA, and GDC working with the Ministry of Health and the Ghana Health Service, as well as women's groups.

The most effective component[s] of advocacy
Effective advocacy resulted from the use of evidence generated by health workers and highly placed professionals like OBGYNs, health directors, and midwives.Credible voices of physician leaders from government and GDC members were equally very powerful.

Interpretation of the new terms for HE
The expanded interpretation of the exceptions and the new terms came through the implementation of the Comprehensive Abortion Care program, particularly from 2008.This was rolled out nationwide.Continuous advocacy was equally critical.

Colombia Abortion law prior to HE change being initiated
Colombia had an absolute ban on abortion until 2006.
Women resorted to clandestine abortion, often facing severe complications, abuse, imprisonment, and death.

Subsequent evolution of HE law and implementation
In 2006, in response to a constitutional challenge against the total prohibition of abortion, the Colombian Constitutional Court established three exceptions in which abortion should be granted: • Risk to life or health.
• Pregnancy resulting from sexual abuse.

Allies involved in the advocacy work
Civil society led the change, mainly the feminist movements and Women's Link Worldwide, with many others involved in the implementation, including La Mesa por la Vida y la Salud de las Mujeres (La Mesa), professional groups, academic societies, the Grupo Médico por el Derecho a Decidir (GMDD/ GDC), and the Federación Colombiana de Obstetricia y Ginecología (FECOLSOG).

The most effective component[s] of advocacy
Regional fora, led by La Mesa and several national and The interviews with key informants and the literature review suggest focusing on broad interpretations of the HE law to encompass rape, young age, and fetal anomaly even if they are not specified as grounds for exceptions, as these all have health consequences.In the case of multiple exceptions, using the least onerous exception for the patient was recommended.For example, if a patient qualifies for both health and rape exceptions, the HE should be used, as that avoids barriers such as required reports to the police.
Key informants from Latin America also interpreted the HE to refer to physical, psychological, and social health and noted that the possibility of future harm is key to considering risk to health and life as that it is impossible and dangerous to create a comprehensive and finite list of every condition that could affect a pregnant woman threatening her life or health. 27eating public awareness of deaths due to lack of access to safe abortion in countries with restrictive laws has played an increasingly important role in changing those laws.The "green wave" involving public outcry and demonstrations demanding access to safe abortion, especially when supported by health professionals and the Ministry of Health has proven effective in some Latin American countries.Such public awareness and outcry in Malta and worldwide over the treatment of an American tourist in June 2022, with the same pregnancy complication that Savita had in Ireland, 21 recently led the government of Malta to introduce a draft law that would have legalized abortion in situations of serious risk to the health of a pregnant woman.But in June 2023, amendments to the Bill curtail access to abortion access solely to situations where a pregnant woman's life is at risk, continuing to prohibit abortion in all other circumstances. 28notable development has been the prosecution of doctors for the failure to provide care.In Italy, four doctors were found guilty of

Other factors
The Ministry of Health and international agencies also led training and technical assistance programs for health teams across the country.Centers such as Fundación Oriéntame set an example to the health system as it had been providing comprehensive outpatient postabortion care since the 1970s and thus normalized abortion as a health service, and as a right, not a crime.They trained health professionals and advised policy makers.The Zika virus epidemic and the COVID-19 pandemic also brought attention to the importance of guaranteeing abortion services under the HE as a right and an essential health service.○ In countries with restrictions on abortion, the HE refers to a legally permissible abortion when there is risk to a woman's health if the pregnancy continues.

Law in Colombia: 2022
○ For our research on HEs, we used the following definition based on the United Nations Human Rights Committee's General Comment on the Right to Life: • Abortion is a human right and governments must provide safe and legal abortion where the life and health of the woman is at risk, where carrying a pregnancy to term would cause the woman substantial pain and suffering, where the pregnancy is the result of rape or incest, or where the pregnancy is not viable. 8 Risk ○ The potential for an adverse outcome or the potential that a specific action, exposure or continued exposure will give rise to a negative health outcome.
○ Risk refers to the possibility of harm not the probability.Risk is a subjective measure; for the pregnant woman must decide the degree of risk she is willing to take on.
• The Federación Latinoamericana de Sociedades de Obstetricia y Ginecología (FLASOG) states that "When the country's legislation does not condemn abortion in cases of risk to the life and health of the woman, the woman's opinion as to how much risk she is willing to take should be a determining factor in the decision to terminate the pregnancy". 30

Health
○ A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. 6○ These terms can be used interchangeably and refer to purposefully ending a pregnancy with the intention of avoiding a live birth. 6The procedure can be accomplished using medications; manual vacuum aspiration (MVA); dilation and suction curettage (D&C); or dilation and evacuation (D&E).

Therapeutic abortion
○ Intentionally ending a pregnancy through medical or surgical intervention when the continuation of pregnancy endangers the pregnant woman's health, and the woman decides not to take the risk. 6The procedure can be done using one of the following methods: manual vacuum aspiration (MVA); suction curettage, dilation and curettage (D&C), or D&E.

Medical abortion
○ Use of medications to end a pregnancy.Medication abortion does not involve surgery or anesthesia, although analgesia is generally used to alleviate discomfort from uterine cramping. 6The recommended protocol involves ingestion of mifepristone followed by misoprostol and is endorsed by international medical bodies and WHO.This regimen has been demonstrated to be safe and effective during the first 12 weeks of pregnancy, and thereafter under medical supervision, adjusting dosage.Misoprostol can also be used alone to terminate a pregnancy. 6 Surgical abortion ○ Use of transcervical procedures for terminating pregnancy, including vacuum aspiration, and dilatation and evacuation (D&E).6 8. Spontaneous abortion (miscarriage) ○ Spontaneous loss of a pregnancy prior to 24 weeks gestation, that is, before the fetus is usually viable outside the uterus.The spontaneous abortion is termed "complete" or "incomplete" depending on whether or not tissues are retained in the uterus.An incomplete spontaneous abortion may require medical or surgical intervention to complete the process. 6 Incomplete abortion ○ Clinical presence of an open cervical os and bleeding indicating that not all products of conception have been expelled from the uterus, or the expelled products are not consistent with the estimated duration of pregnancy.
Common symptoms include vaginal bleeding and abdominal pain.Uncomplicated incomplete abortion can result after an induced or spontaneous abortion (i.e.miscarriage).If untreated without spontaneous resolution, an incomplete abortion can lead to excessive blood loss or infection. 6.Inevitable abortion ○ A threatened spontaneous abortion without hope of recovery and continuation of the pregnancy, for example rupture of membranes prior to fetal viability. 6.Ectopic pregnancy ○ The implantation of a fertilized egg/blastocyst outside of the uterus, most commonly in the fallopian tube.As the fallopian tube can neither accommodate nor sustain a growing embryo, it will either resolve and resorb, or rupture, which can pose a life-threatening hemorrhagic emergency.
An ectopic pregnancy is another example of a non-viable pregnancy. 31. Serious and nonviable fetal anomalies ○ Nonviable fetal anomalies are those with no known longterm survivors (e.g., anencephaly).Serious fetal anomalies are those requiring extensive medical and surgical intervention for survival or survival with compromise associated with lifetime dependency.
cases provide compelling stories about individual women and can prove instrumental in navigating HE laws in the countries where they arise.We provide examples of high-profile cases (Section 4.4) that illustrate the lack of clarity regarding implementation of the HE clause in the abortion law of the country.The examples fall into five broad medical categories: 1. Conditions occurring as a result of pregnancy.2. Existing conditions worsened by pregnancy.3. Conditions that require treatment that might result in fetal harm.4. Multiple exceptions, including risk to health. 5. Possibility of future harm.
tentional fetal harm or fetal demise could occur as a result of the treatment needed to preserve the woman's health.These cases should fall under the HE as preventing women from receiving needed treatment puts their health and life at risk.Medical care for conditions such as cancer has been denied or postponed due Conditions occurring as a result of pregnancy Background: In 2012, Savita Halappanavar, a 31-year-old married dentist with a desired pregnancy suffered a premature rupture of membranes early in the second trimester that would lead to an inevitable abortion (spontaneous miscarriage).Despite the inevitable pregnancy loss, clinicians refused to terminate her pregnancy because her 17week fetus still had a detectable heartbeat.After being denied care, Halappanavar developed sepsis and died.An investigation following her death determined that confusion over Ireland's abortion law, and the lack of legislation outlining the limited circumstances in which abortion was allowed, contributed to her death.Impact: Halappanavar's death sparked widespread outrage over the Eighth Amendment which had effectively banned abortion in Ireland and, in Halappanavar's case, prevented clinicians from providing standard care that would have saved her life.Her death led to protests in Ireland and abroad and widespread condemnation of the restrictive Irish abortion law by human rights organizations including Amnesty International.The public outcry about the harm caused by the Eighth Amendment galvanized public support for a campaign that continued until its successful repeal in 2018.First-trimester abortion is now freely available, however the HE is rarely used thereafter.Existing conditions worsened by pregnancy Background: Alicja Tysiąc is a Polish woman with a severe visual impairment.Tysiąc became pregnant in 2000 with her third pregnancy and consulted with her doctors to assess the risk to her eyesight posed by carrying the pregnancy to term.Three ophthalmologists determined that pregnancy and delivery posed a serious risk to her health and the preservation of her eyesight but refused to issue the certificate needed to terminate the pregnancy and instead recommended that she deliver via cesarean section.Tysiąc was finally able to obtain the necessary certificate from a general practitioner; however the head of the Obstetrics and Gynecology Department at the Warsaw hospital to which she had been referred declined to terminate the pregnancy citing the lack of medical grounds for a therapeutic abortion.Tysiąc was unable to appeal the decision or obtain a timely abortion, was forced to carry the pregnancy to term and deliver via cesarean section.Tysiąc's vision seriously deteriorated to the point of near blindness.Impact: In 2001, Tysiąc filed a criminal complaint against the OBGYN who declined to terminate her pregnancy but her complaint was dismissed after a panel of experts determined that her pregnancy and delivery had not contributed to the deterioration of her eyesight.Subsequently in 2005, the Center for Reproductive Rights along with Tysiąc filed a case at the European Court of Human Rights alleging violations of the European Convention on Human Rights.In 2007, the Court ruled that the Polish government had failed to fulfill its obligations under Article 8 of the European Convention on Human Rights that ensure respect for private life.
Conditions that require treatment that might result in fetal harm Background: In 2006, Ana María Acevedo, a 19-year-old mother of three presented at a hospital in Santa Fe, Argentina complaining of a toothache.Clinicians discovered a facial tumor, diagnosed cancer, and referred her to another hospital for radiotherapy where it was discovered that she was pregnant.The radiotherapist informed Multiple exceptions including risk to health Background: Starting at the age of 11, L.C. was repeatedly raped by a 34-year-old man and eventually became pregnant.Upon learning she was pregnant, L.C. attempted suicide by jumping off a roof.She survived the attempt and ended up in the hospital with a severe spinal cord injury and in need of emergency surgery.The hospital declined to perform the emergency surgery based on potential risk to the pregnancy and also refused to perform an abortion despite a Peruvian HE clause that allowed for therapeutic abortion in case of irreversible and severe damage to health.L.C. ended up paralyzed from the neck down and miscarried as a result of her injuries.Impact: In 2009, the Center for Reproductive Rights along with the Center for the Promotion and Defense of Sexual and Reproductive Rights filed a human rights petition on L.C.'s behalf claiming that Peru's failure to provide L.C. with essential reproductive health in a timely manner violated both the Peruvian Constitution as well as international treaty obligations.The UN Committee on the Elimination of Discrimination Against Women (CEDAW) upheld the claim and requested that Peru provide L.C. with reparations including physical and mental rehabilitation, amend

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about 30%) to maternal deaths and morbidity, particularly for young girls, was an incentive, further driven by the push to achieve the Millennium Development Goal (MDG) and Sustainable Development Goal (SDG) targets for maternal mortality in a favorable sociopolitical climate.In addition, improved, safe methods for abortion became available, especially medication abortion and manual vacuum aspiration.The increasing awareness of preventable maternal deaths and morbidity by civil society organizations, policy makers, and healthcare workers amplified the voices calling for change.

Following
Colombia's long-standing and violent internal conflict, a Constitutional High Court was created with the power to oversee the protection of fundamental rights after constitutional reform in 1991.The reform allowed for strong accountability mechanisms, such as the possibility of legally challenging existing laws if a citizen considered any component to be inconsistent with the protection of fundamental rights.This unique provision may have been key to success as the partial decriminalization of abortion did not result from legal reform susceptible to political negotiations and forces, but from recognition of abortion as a right (at least in those particular three situations).
regional organizations and experts resulted in a consensus: "La Causal Salud, Interrupción Legal del Embarazo, Ética y Derechos Humanos"15 that provided extensive legal, ethical, and evidence-based medicine arguments enabling a broad and human rights-based interpretation of the HE.Courageous women and girls who experienced barriers to abortion came forward as emblematic cases that yielded new Constitutional Court rulings that reaffirmed and clarified the scope of the right to abortion.Another component was the expert testimonies in cases in which abortion had been denied, from allies such as GMDD/GDC.FECOLSOG included the implementation of the HE and national protocols in its conferences as well as the correct exercise of conscientious objection, juxtaposing respect for different points of view with the duty to disseminate accurate scientific concepts and to comply with the law's commitment to the protection of the rights of women and girls.Advocacy was also assisted by clear policies from the Ministry of Health, ensuring that only evidence-based concepts and WHO recommendations were included in any decision-making progress related to abortion regulation.A national protocol with technical and legal guidance was reassuring for providers and allowed for the expansion of services.The national guidelines for maternal and perinatal care included a chapter on the HE as part of the continuum of care, which provided clear guidance to broadly interpret the social and mental health risks within the HE and clarified the healthcare provider's responsibility to certify the existence of a risk and the pregnant woman's right to decide how much risk to take when continuing a pregnancy.Although the 2022 WHO guidelines on abortion recommend against laws and other regulations that restrict abortion by grounds, these laws currently exist at the country level.Therefore, our review has focused on navigating HE laws, in order to achieve incremental improvements in access.Article 6 from the UN Human Rights Committee General Comment 36 on the Right to Life stipulates that any regulation on voluntary terminations of pregnancy may not interfere with the right to life or "jeopardize their lives, or subject them to physical or mental pain or suffering".8Further, "States parties must provide safe, legal and effective access to abortion where the life and health of the pregnant woman or girl is at risk, or where carrying a pregnancy to term would cause the pregnant woman or girl substantial pain or suffering, most notably where the pregnancy is the result of rape or incest or where the pregnancy is not viable".8WHO is similarly clear about the autonomy of women, that access to safe abortion is an essential health service enabled by respect for human rights including a supportive framework of law and policy.However, human rights of the pregnant woman are often not aligned with country-based abortion laws, nor are standards of evidence-based care always recognized in guidelines of professional societies and the comprehensive standards of WHO on abortion.The inconsistent wording and interpretation of HE clauses create confusion for clinicians and the public as noted in our informant interviews.A clinician's willingness to provide abortion is affected by this lack of understanding as well as fear of potential consequences.Through collation of the findings in our review, several opportunities emerged for potential strategies to use the HE more broadly to improve access to safe abortion.
has been successfully implemented in Colombia, but required significant advocacy, dialogue with clinicians focused on the correct exercise of conscientious objection, and addressing infrastructural barriers that impede access to care in general.Tactical use of HE laws after changes in law and policy was also successful in Argentina and Ghana.Having a physician Minister of Health proved very helpful in Ghana where comprehensive abortion care, including postabortion care, was implemented due to that physician's concern about high maternal mortality from unsafe abortion.Task-sharing in Ghana and other countries where physicians are in short supply assuages physician shortages.The compelling stories about individual women in the emblematic cases section can also prove instrumental in navigating HE laws in country and in advocacy globally.Noting the broad categories in our framework and even a few examples, it becomes obvious, as noted by the American College of Obstetricians and Gynecologists,