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Colectivamujer y salud: RIGHT HERE RIGHT NOW PLATFORMABORTION STATUS IN THE CARIBBEANA COMPARATIVE ANALYSIS OF COST, RESTRICTIVE LEGISLATION AND BARRIERSAlexandra Viloria & Camila Frías Estrada3/5/2018An overview of the status of abortion within eight Caribbean countries, comparing the different institutional, cultural and legal barriers that restrict access to abortion and their impact in women’s lives and society in general. With the collaboration of:Julio Cesar Mejía, Estimates for Domincan Republic. Maleny Díaz, EditorContents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc508025981 \h 4Methodology PAGEREF _Toc508025982 \h 6Conceptual Inventory and Data Archeology PAGEREF _Toc508025983 \h 7Types of Abortion by the World Health Organization PAGEREF _Toc508025984 \h 7Abortion Methods by the World Health Organization PAGEREF _Toc508025985 \h 8Safe Abortions: A Worldwide Right and Necessity for Women PAGEREF _Toc508025986 \h 8Definition of Safe/Unsafe Abortion according to the World Health Organization PAGEREF _Toc508025987 \h 8Classifications and definitions of Unsafe Abortion according to the World Health Organization PAGEREF _Toc508025988 \h 8Social groups affected by abortion policies in the Caribbean PAGEREF _Toc508025989 \h 9Global Data on adolescent birth rates by the Department of Economic and Social Affairs Population Division (DESA) PAGEREF _Toc508025990 \h 10Definitions of Adolescence/ Young Population by the World Health Organization and Population Reference Bureau PAGEREF _Toc508025991 \h 11Definition of rights to sexual and reproductive health by the European Parliament Forum on Population and Development (EPF) PAGEREF _Toc508025992 \h 11Abortion Policies: Global Overview PAGEREF _Toc508025993 \h 13Abortion Access Inequalities PAGEREF _Toc508025994 \h 15Consequences and cost of unsafe abortions PAGEREF _Toc508025995 \h 16The Sociocultural representation of Abortion Practices in the Caribbean PAGEREF _Toc508025996 \h 18Legal Aspects of Abortion in the Caribbean PAGEREF _Toc508025997 \h 24Regulatory models of abortion: a path to understanding the progress of abortion legislation in the Caribbean PAGEREF _Toc508025998 \h 24Review on Caribbean Countries: government types, legal systems, criminal codes, abortion provisions and historic improvements PAGEREF _Toc508025999 \h 28Criminal Codes based on the British Common Law PAGEREF _Toc508026000 \h 31Criminal Codes based in the Dutch Civil Law PAGEREF _Toc508026001 \h 32Criminal Codes based on the Napoleonic Code PAGEREF _Toc508026002 \h 33Current Discussion of Abortion in the Countries of Study PAGEREF _Toc508026003 \h 33Abortion legislation in Curacao and legal controversies PAGEREF _Toc508026004 \h 33The 1999 Tolerance policy: A controversial progress in Curacao abortion policies PAGEREF _Toc508026005 \h 33Dominican Republic Criminal Code Status PAGEREF _Toc508026006 \h 34The Big Discussion about Las Tres Causales in Dominican Republic –The Three Abortion Exceptions- PAGEREF _Toc508026007 \h 34Abortion status in Jamaica, exceptions, and penalization PAGEREF _Toc508026008 \h 35Legal precedents that allows the abortion practice in Jamaica PAGEREF _Toc508026009 \h 36Safe abortion legislation and repercussions in Haiti’s society and government PAGEREF _Toc508026010 \h 36Suriname, abortion legislation and criminal code provisions regarding the practice PAGEREF _Toc508026011 \h 37Trinidad & Tobago abortion policies PAGEREF _Toc508026012 \h 38Saint Lucia abortion legislation PAGEREF _Toc508026013 \h 38Guyana abortion legislation PAGEREF _Toc508026014 \h 39Summary of penalties and requirements to abortion in the countries studied PAGEREF _Toc508026015 \h 40Impact and Cost of restrictive abortion policies in the Caribbean region PAGEREF _Toc508026016 \h 42Abortion incidence in the Caribbean PAGEREF _Toc508026017 \h 42Women’s health cost PAGEREF _Toc508026018 \h 44Social Cost PAGEREF _Toc508026019 \h 47Economic Cost PAGEREF _Toc508026020 \h 48Mapping of Actors: Who has influence in abortion policies? PAGEREF _Toc508026021 \h 52Guyana PAGEREF _Toc508026022 \h 53Jamaica PAGEREF _Toc508026023 \h 54Suriname PAGEREF _Toc508026024 \h 55Haiti PAGEREF _Toc508026025 \h 56Dominican Republic PAGEREF _Toc508026026 \h 58Conclusions PAGEREF _Toc508026027 \h 61References PAGEREF _Toc508026028 \h 62Introduction In the first decades of 21st century abortion policies and matters relating to women’s reproductive rights are still viewed under the spectrum of conservative religious morals, severe legal punishments and restrictive legislations worldwide. These negative perceptions and pervasive policies towards women continue to operate at a social and legal level, even though international institutions focused on health policies such as the World Health Organization (WHO) define and recognize abortion as a human right. The WHO has established effective recommendations on the relevance of a comprehensive reproductive and sexual health protocol in the implementation of safe abortions. Moreover, the reinforcement of abortion practices in safe environments ensures: women’s health –mentally and physically—, a well-planned socioeconomic development and sociocultural equality. These facts are validated in the low rates of morbidity, maternal mortality and adolescent births in developed countries. Careful consideration of the abovementioned statements determines that access to safe abortions for women must be granted. Brought forth by the promotion and implementation of a legal/societal model based on: the acknowledgement of women’s reproductive and sexual rights, decriminalization of the practice, and access to safe abortions under legitimate conditions. Yet, powerful barriers remain for women and their need to exercise their reproductive and sexual rights in all the countries covered in this report. The core of this report is to unveil the root of moral, legal, and cultural controversies present in Caribbean societies and how these challenges have a deep impact in their national economies.First, this study analyzes how abortion legislation has a crucial impact on the lives, health and socioeconomic outcomes of Caribbean women residing in: Curacao, Dominican Republic, Guyana, Haiti, Jamaica, Trinidad and Tobago and Saint Lucia. Second, we provide an explanatory chart of the economic and social costs of unsafe abortion practices in the countries observed. This section allows us to provide the reader and citizen with a picture of the economic and social impact abortion has when kept at non-regulated and/or unsafe conditions. Third, we have designed an actor’s map constituted by social groups, state institutions and advocacy groups, to show the reader how the dynamics of the stakeholders involved in a public discussion about abortions operate. Fourth, the substantial content is divided in six sections: Conceptual Inventory and Data Archeology, Abortion Policies: Global Overview, The Sociocultural Representation of Abortion Practices in the Caribbean, Legal Aspects of Abortion in the Caribbean, Impact and Cost of Restrictive Abortion Policies and Mapping of Actors: Who has influence in abortion policies? Finally, it is relevant for us to note that stigma, illegality and statistical gaps have inhibited the fact extraction process in many instances of interest, but an effort has been made to get the most detailed perspective on the abortion situation, accessing diverse data bases at local and international agencies, and conducting interviews with key advocacy actors and academic research papers. This work was funded by Colectiva Mujer y Salud as part of the Caribbean Right Here Right Now Platform for the promotion and access of sexual and reproductive rightsMethodology This study is the result of an extensive meta-analysis, qualitative and quantitative methodologies based on: 1. Research related to abortion incidence and estimations, 2. Analysis of legal status of abortion, 3. Cost and impact of access to safe abortions. Interviews were conducted with one expert on the state of abortions and sexual and reproductive rights from six of the eight countries reviewed. The covered countries were: Jamaica, Guyana, Haiti, Dominican Republic and Suriname; an attempt was made to contact key informants for St. Lucia, Trinidad and Curacao but coordination was unsuccessful. Nonetheless we provide an overview on abortion legislation status and social challenges in all countries selected. All experts consulted are representatives of the Right Here Right Now platform in their respective countries. Interviews are focused on each expert’s input regarding the following subjects: legal status of abortion, prevalence of abortion practices and barriers to access safe abortions, perceived values and beliefs around abortion and identification of actors involved in abortion policies in the specific country of origin. An additional interview was conducted with a gynecologist physician in the Dominican Republic to explore the abortion complications present within the Dominican healthcare system. Estimates were calculated to determine an approximate number of abortions and their classification, as either safe or unsafe, in the Dominican Republic. The country was selected because data was quite crystalized by the actor interviewed. The methodology for estimates was based on models proposed by Guttmacher-WHO. A detailed explanation of the model is laid out in the estimates section of the document. The scarcity of abortion cost statistics was one of the marked limitations in this study. All countries had this constraint due to the stigma and illegality of abortion practices. For example, in the case of the Dominican Republic various attempts were made to gather data focused on the after care of abortion services. Applications were submitted to the Ministry of Health and Social Security Institutions, but a response wasn’t obtained. We proceeded to substitute the analysis model for one based on information provided by key informants. Conceptual Inventory and Data Archeology In this section we present a list of concepts accompanied by definitions of international organizations focused on the study and collection of statistics on: healthcare, adolescence data, women’s reproductive rights, public policies and /or legislations on reproductive and sexual rights, human rights, demographic data and socioeconomic indicators at a global and regional level. To define abortion and the complementary concepts that are integrated under this term we use the parameters and definitions implemented by the World Health Organization, the Department of Social and Economic Affairs of the United Nations (Population Division), UNICEF, Guttmacher Institute, The Lancet, European Parliamentary Forum on Population and Development, World Population Database, and the World Bank.Types of Abortion by the World Health OrganizationThe World Health Organization defines abortion as the interruption of pregnancy when the fetus is still not viable outside the mother's womb. Abortion is divided into four types that are differentiated by the intentionality and / or reason for the termination of pregnancy and by the restrictive and / or decriminalizing laws of the countries in which this practice is carried out. There are four types of abortion: spontaneous, induced, legal / therapeutic, and illegal.Spontaneous Abortion/Miscarriage is defined as the loss of pregnancy before 26 weeks, when the fetus is not yet able to survive safely outside the womb. A miscarriage occurs when a pregnancy ends abruptly. Induced Abortion is defined as the result of maneuvers performed deliberately with the intention of terminating the pregnancy. The maneuvers can be performed by the pregnant woman herself or by medical staff and / or assistants. Legal Abortion or therapeutic abortion is recognized as being performed under the decriminalizing laws of the country where it is practiced. Illegal Abortion or Clandestine Abortion is understood as one that is prohibited by law and punishable as a crime. Most of the time it is carried out in unhygienic and non-regulated conditions putting at risk the lives of women who experience complications during the process and preventing them to receive urgent care in a hospital after the procedure.Abortion Methods by the World Health OrganizationAbortion methods are medical / surgical procedures that, with the right technology to practice them and specific medications, make the termination of pregnancy viable and safe. The methods must be adapted in accordance to specific needs of the gestation period. These methods are: surgical abortion and medical (pharmacological chemical) abortion.Surgical abortion is the interruption of pregnancy in the operating room by a surgical technique. The medical (chemical or pharmacological) abortion consists in the intake of various medications to achieve the interruption of the pregnancy.Safe Abortions: A Worldwide Right and Necessity for Women Material conditions, medical practitioner knowledge and their credentials are crucial factors in ensuring the immediate and future wellbeing of the woman who requests or needs an abortion. Therefore, safe environments that follow the application of medical protocols allow for control of the risks of loss of life and health complications after and during abortion procedures. The defining parameters of quality and safety of abortion practices are contemplated in the WHO Safe Abortion Guide. These parameters are based on 1) the material conditions of the abortion centers -technology, drugs and appropriate abortion methods- and 2) the capacity and medical merits of the practitioners. According to the WHO the abortion safety levels are subdivided as safe, insecure, less insecure, and much less insecure.Annually, millions of women in developing countries face health complications due to the lack of access to safe abortions. The causes of this impediment are the criminalization of abortion practice, religious fundamentalisms, fragile health institutions, stigmas, and sociocultural traditions based on patriarchy and machismo. Definition of Safe/Unsafe Abortion according to the World Health Organization Safe Abortion is defined as a medical procedure that follows a method, recommended by WHO (medical abortion, vacuum aspiration, or dilatation and evacuation), that is appropriate to end the pregnancy with the assistance of a person with valid credentials to provide the service. Classifications and definitions of Unsafe Abortion according to the World Health OrganizationThe World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out by persons lacking the necessary skills in an environment that does not follow the minimal medical standards.Unsafe abortion procedures may involve insertion of an object or substance (root, twig or catheter or traditional concoction) into the uterus; dilation and curettage performed incorrectly by an unskilled provider; ingestion of harmful substances; and application of external force.Less Safe Abortion is used if only one of the two criteria were met—i.e., either the abortion was carried out by a trained provider but with an outdated method (e.g., sharp curettage) or a safe method of abortion (e.g., misoprostol) was used but without adequate information or support from a trained individual. Least Safe Abortions occurs if the service was provided/conducted by untrained individuals using dangerous methods, such as ingestion of caustic substances, insertion of foreign bodies, or use of traditional concoctions.Social groups affected by abortion policies in the CaribbeanThis report focuses in the social groups of adolescent and adult women in their reproductive age (15-44 years) living in the countries observed. These groups of women are currently facing economic and educational limitations. The mentioned factors confirm that the social groups observed are more susceptible to being negatively stricken by the absence of legislation or criminalization of abortion.To obtain this information about the affected population we used the line of Health Inequities / Contraceptive Prevalence: Modern Methods (WHO, 2015), collected in the Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2007-2014); as a way to verify access to contraceptive methods in women of reproductive status, based on the data reflected on the area of ??residence, educational level and economic level. The area of ??residence did not reflect profound differences between women in urban and rural areas. Of the eight countries selected four did not have data available on Contraceptive Prevalence / Modern Methods of Health Inequities, (WHO, 2015). These countries were Jamaica, Curacao, St. Lucia and Trinidad and Tobago.Teenagers and adult women living in the urban areas of Guyana (2009) were equivalent with 40% use of contraceptive methods for both areas. In the case of Haiti (2012) it was similar, reflecting 31% in both areas. In the case of the Dominican Republic (2007), a prevalence of some use of contraceptive methods was reported in the rural area with 72%. Finally, Suriname (2010) showed that the prevalence of contraceptive use was higher in women who lived in urban areas, reflecting 49%. Based on the data presented by the WHO (2015), it cannot be defined whether the women most affected by lack of access to contraceptive methods or those who make fewer uses of these methods come mostly from urban or rural strata. In this study, half of the countries covered were not included in the data of the line analyzed.However, most women who did have access to some type of traditional or modern contraceptive method had a higher level of education and their income was classified as high. Therefore, the affected group is defined as adolescents and adult women in the reproductive stage, of scarce economic and educational resources.Global Data on adolescent birth rates by the Department of Economic and Social Affairs Population Division (DESA)The?adolescent fertility rate?is?defined?as the number of?births?per 1,000 women aged 15 to 19. Having children so early in life exposes?adolescent?women to unnecessary risks. Their chance of dying is twice as high as that of a woman who waited until her 20s to begin bearing children. (Population Reference Bureau, 2017)The average adolescent birth rate in countries with restrictive abortion policies in 2013 was about three times greater (69 births per 1,000 women aged 15 to 19 years) than in countries with liberal abortion policies (24 births per 1,000 women aged 15 to 19 years). (DESA, 2014) Although, the adolescent fertility rate has decreased over the years, in 2013 76 percent of developing countries expressed a greater concern about adolescent fertility levels and an additional 25 percent expressed a lower concern. Therefore, the percentage of Governments providing direct support for family planning has continued to increase in developing regions, from 82 per cent in 1996 to 93 per cent in 2013. (World Population Policies Database, 2013)In 2012, 94% of Latin American and Caribbean governments implemented concrete measures to increase access to sexual and reproductive health services in the past five years (United Nations Population Fund, 2012). Definitions of Adolescence/ Young Population by the World Health Organization and Population Reference BureauAdolescence is defined as the period of growth and human development after childhood and before adulthood between 10 and 19 years of age. Various biological processes condition this phase of growth and development, as the beginning of the puberty period that marks the passage from childhood to adolescence. Yet in women it is marked by a transition to a new reproductive cycle. Young Population?is a population with a relatively high proportion of children, adolescents, and young adults; a low median age; and thus, a high growth potential.Reproductive Age or Child Bearing Years are the reproductive age span of women, assumed for statistical purposes, to be between 15-44 or 15-49 years of age.Definition of rights to sexual and reproductive health by the European Parliament Forum on Population and Development (EPF)Reproductive health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity, in all matters relating to the reproductive system, its functions and processes. Sexual and reproductive rights are the rights of each individual to make reproductive decisions, including the choice to marry and determine the number and spacing of time to have children. It also includes sexual and reproductive security. Including the right not to suffer sexual violence or coercion.Other aspects that constitute sexual and reproductive rights of women are, being informed and having access to family planning methods of their own choice. Equally important, these must be safe, effective, affordable and acceptable. Given these points, it is important to include in the plan various methods of personal choice to regulate fertility according to the law. In conclusion, family planning includes access to crucial health care services that allow women to safely go through the stages of pregnancy and childbirth; offering couples the best opportunities to have a healthy child. Definition of Family Planning by the Population Reference Bureau and EPFFamily Planning consists of the conscious effort of couples to regulate the number and spacing of births through artificial and natural methods of contraception. Family planning connotes conception control to avoid pregnancy and abortion, but it also includes efforts of couples to induce pregnancy.Family planning is delimited by access to 1) Services to prevent or voluntarily postpone pregnancy, 2) Accurate information to help guarantee choice, 3) the correct use of and satisfaction with a contraceptive method and, 4) Supplies, among other contraceptive things. Definition of Human Rights by the European Parliament Forum on Population and DevelopmentAll human beings are born free and equal in dignity and rights. The rights to life and health are essential for the enjoyment of all other rights and are protected by international law. The promotion of the right to health needs to be included in all the relevant political agenda creation processes, including the policies of poverty reduction and international development.Definition of Gender Equality European Parliamentary Forum on Population and Development Gender equality is defined as the state or condition that affords women and men equal enjoyment of human rights, socially valued goods, opportunities, and resources.Abortion Policies: Global Overview Abortion as a nonguaranteed right of the State –and any other form of government- in all its forms and partial exemptions is a discussion that mirrors the social inequality and legal limitations, specifically the scarce access to medical services, women face on a daily basis at the moment of practicing their reproductive and sexual rights. Induced abortions are a common practice worldwide. Estimates indicate that between 2010 and 2014 25% of all pregnancies ended in an induced abortion (WHO, 2017). The reasons why women seek abortions are varied and can be classified in socioeconomic concerns (including poverty, no support from the partner, and disruption of education or employment); family-building preferences (including the need to postpone childbearing or achieve a healthy spacing between births); relationship problems with the husband or partner; risks to maternal or fetal health; and pregnancy resulting from rape or incest. Related causes include poor access to contraceptives and contraceptive failure (Bankole A, Singh S, Haas T. 1998, cit. by Grimes, Benson, Singh, et. al., 2006). Several international human rights and development committees such as The Program of Action of the International Conference on Population and Development, and the Fourth World Women Conference, CEDAW General Committee, among others, express dispositions on access to legal and safe abortion as a right, for women to preserve their health. Signatory countries are mandated to assure Sexual and Reproductive Rights for Women and specifically to review punitive legislation against women that have abortions done. In this sense, General recommendation No. 35 of the Committee for the Elimination of All Discrimination Against Women states that “Violations of women’s sexual and reproductive health and rights, such as forced sterilization, forced abortion, forced pregnancy, criminalization of abortion, denial or delay of safe abortion and/or post-abortion care, forced continuation of pregnancy, and abuse and mistreatment of women and girls seeking sexual and reproductive health information, goods and services, are forms of gender-based violence that, depending on the circumstances, may amount to torture or cruel, inhuman or degrading treatment”. The international human rights system recognizes that women’s dignity is related to the ability to exercise their sexual and reproductive rights. Yet these rights tend to become highly vulnerable and limited in determined countries. The WHO (2017) indicates that “…barriers to accessing safe abortions include: restrictive laws, poor availability of services, high cost, stigma, conscientious objection of health –care providers. Unnecessary requirements such as: mandatory waiting periods, mandatory counseling, provision of misleading information, third party authorization, medically unnecessary tests”. In fact, several studies stress the correlation between abortion prohibition and the prevalence of unsafe abortion (Gonzales 2011; Sedhg, Bearak, Singh, et al., 2016; WHO, 2017;). Restrictive legislation does not prevent abortions from happening. As seen in table 1, abortion rates are similar between countries with restrictive laws and those with liberal legislation (Sedhg, Bearak, Singh, et al., 2016). Table 1. Abortion rate per 1000 women aged 15–44, and unsafe abortion percentage by grounds under which abortion is legally allowed, 2010–14Type of legislation Abortion Rate (90% UI)Prohibited altogether or to save a woman's life37 (34-51)Physical Health43 (40-53)Women's mental health33 (27-49)Socioeconomic grounds31 (23-47)On request34 (29-46) UI: uncertainty interval. Source: Sedhg, Bearak, Singh, et al., 2016The evidence points out that barriers to safe abortion (legal prohibition among others) ignites and promote unsafe abortions practices. Regarding this matter Johnson, Mishra, Levelanet, et al. (2017) state “the average rate of unsafe abortion is estimated to be more than four times higher in countries with more restrictive abortion laws than in countries with less restrictive laws”. Facts stated above are confirmed by the findings of Ganatra, Gerdts, Rosier, Brooke, Johnson et al. (2017), as seen in table 2. These estimates show that the proportion of safe abortions varies from 25.2% in countries where abortion is restricted to 87.4% in contrast to countries where abortion is available without legal restriction. It can be concluded that more restrictive laws do not impact the incidence of abortions but rather cause women to have them in an unsafe manner. Table 2: Distribution of abortion safety categories for countries grouped by legal status and income levelLegal statusProportion of abortions that are safeProportion of abortions that are less safeProportion of abortions that are least safeRestricted (not allowed or only allowed to save a woman’s life or for physical health)25·2% (14·5–41·0)43·6% (27·6–54·2)31·3% (21·0–41·9)Allowed for mental health or socioeconomic reasons 41·2% (35·9–46·7)40·8% (34·6–47·1)17·1% (13·3–22·0)Abortion without restriction to reason 87·4% (79·2–92·0)11·9% (7·3–19·8)0·7% (0·5–1·8)Note: Data are presented as % (90% uncertainty interval).Source: Ganatra, Gerdts, Rossier, Brooke, Johnson, et al., 2017Moreover the WHO (2017) indicates that even in cases when practiced by medically trained personnel, illegal abortion tend to be unsafe due to the fact that they are done in facilities that don’t meet the proper quality criteria to perform medical procedures, including unsanitary conditions; complications may also result from the lack of access to emergency care, post abortion care may not be available, and women hesitating to seek healthcare due to fear of retaliations. Abortion Access Inequalities Despite formal restrictions to safe abortion faced by millions of women, the youngest populations in reproductive age stand out as the social group most affected by state marginalization. “Worldwide, young women under the age of 20 make up 70 per cent of all hospitalizations resulting from unsafe abortion complications” (PLAN 2007, cited by IPPF, 2014).According to IPPF (2014), the barriers for young women to access abortion can be summarized as the negative and unreal perceptions adults have of this social group. One of the central assumptions is that young women lack the capacity due to the “childish” cultural constructions surrounding young populations. The sociocultural aspect mentioned above, presents young women as powerless and na?ve social actors, without the capacity to make their own decisions regarding sex and sexual health. On the other hand, there is a marked stigma towards sexually active women. Sex is also conceived in many religious countries as a serious matter and a practice of “responsible, married adults”. This cultural and political limitation makes the access difficult for young women due to lack of legislation and political representation in society and its institutions. One of the biggest barriers for accessing safe abortion is the age consent law present in many countries with restrictive abortion laws. Lower income women also seem prone to encountering barriers when in need of safe abortions. In countries where abortion is not restricted the service can become inaccessible due to economic reasons. For example, the service can become unaffordable if is not provided at a free or low-cost price. Limitations are equally present for wealthier women living in countries with restrictive legislation. Although they can afford the abortion service they must access it through clandestine providers or through traveling to other countries with flexible laws and safe conditions. In addition, post abortion care may be more accessible to women with the economic means to access private practices (like having health insurance) or who can afford the cost of post care. In this case, lower income women are more susceptible to suffering post abortion complications without health care treatment, due to economic impediments to pay for the services provided in the private health sector.Accessibility to abortion services can’t be studied without taking into consideration two central facts: the controversial nature of abortion and stigmatization that very often comes from its practice. The effects of these social constructs are very present when women, of high or low income, do not have access to their support network when going through this procedure. Evidence points out that women seek abortions alone, without any parental assistance. Therefore, the request for money from a family member or even a spouse may be out of the question (Vlassoff, Walker, Shearer,Newlands and Singh, 2010). Consequences and cost of unsafe abortionsNegative consequences of unsafe abortion can relate to health, economics and social life. The most common health complications due to unsafe abortions are: hemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs (Grimes et al., 2006). These complications have a huge impact in women’s mortality and morbidity rates. Consequences may be attributed and translated: According to WHO (2017) each year between 4.7% – 13.2% of maternal deaths worldwide can be attributed to unsafe abortion. WHO estimates that in 2008, 47,000 women died from unsafe abortion, translating to 30 unsafe abortion deaths per 100,000 live births (WHO 2011; cit. by Black, Laxminaraya and Temmerman 2016). About 8.5 million women worldwide suffer complications from unsafe abortions annually (Singh, Darroch, and Ashford 2014, cited by Black et. al. 2018) Around 7 million women are admitted to hospitals every year in developing countries, because of unsafe abortion?(Singh 2006, 2010; Singh and others 2009, cit. by WHO 2017)These health complications have an impact in countries total health expenditure and in family finances. The annual cost of treating major complications from unsafe abortion is estimated at US$ 553 million (WHO 2017). ?Social consequences are harder to measure but evidence suggests that stigma causes direct harm to women’s wellbeing while becoming a barrier for women to access healthcare. Stigma seems to be harder on younger and unmarried women because of the shame that is commonly attached to sexually active unmarried women. In addition, these groups of women tend to be more inexperienced and have fewer economic resources (Grimes et al., 2006).Finally, maternal deaths leave a toll of broken families and orphaned children who may often face a life of hardship. The Sociocultural representation of Abortion Practices in the Caribbean In this section we focus on how bio politics and systemic violence operate on the female body within the observed Caribbean cultures. We start from the variations of systemic violence, the normative functions of patriarchy over the female body and the range of social values ??assigned to it by different social groups.The analysis focuses on four central actors/ powers: the patriarchal state, civil society, health ministries, and the church. To develop this analysis, we based ourselves on three key theories to understand the functions of power and its normative apparatus on female bodies. These theories are: 1) the bio politics proposed by Michel Foucault (1976), 2) the systemic violence developed by the Slovenian thinker Slavoj Zizek (2008), and 3) the theory of cultural representation systems exposed by the Jamaican cultural theorist, Stuart Hall (1997). 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VALUE="ko">Korean</OPTION><OPTION VALUE="ku">Kurdish</OPTION><OPTION VALUE="ky">Kyrgyz</OPTION><OPTION VALUE="lo">Lao</OPTION><OPTION VALUE="la">Latin</OPTION><OPTION VALUE="lv">Latvian</OPTION><OPTION VALUE="lt">Lithuanian</OPTION><OPTION VALUE="lb">Luxembourgish</OPTION><OPTION VALUE="mk">Macedonian</OPTION><OPTION VALUE="mg">Malagasy</OPTION><OPTION VALUE="ms">Malay</OPTION><OPTION VALUE="ml">Malayalam</OPTION><OPTION VALUE="mt">Maltese</OPTION><OPTION VALUE="mi">Maori</OPTION><OPTION VALUE="mr">Marathi</OPTION><OPTION VALUE="mn">Mongolian</OPTION><OPTION VALUE="ne">Nepali</OPTION><OPTION VALUE="no">Norwegian</OPTION><OPTION VALUE="ny">Nyanja</OPTION><OPTION VALUE="ps">Pashto</OPTION><OPTION VALUE="fa">Persian</OPTION><OPTION VALUE="pl">Polish</OPTION><OPTION VALUE="pt">Portuguese</OPTION><OPTION VALUE="pa">Punjabi</OPTION><OPTION VALUE="ro">Romanian</OPTION><OPTION VALUE="ru">Russian</OPTION><OPTION VALUE="sm">Samoan</OPTION><OPTION VALUE="gd">Scottish Gaelic</OPTION><OPTION VALUE="sr">Serbian</OPTION><OPTION VALUE="sn">Shona</OPTION><OPTION VALUE="sd">Sindhi</OPTION><OPTION VALUE="si">Sinhala</OPTION><OPTION VALUE="sk">Slovak</OPTION><OPTION VALUE="sl">Slovenian</OPTION><OPTION VALUE="so">Somali</OPTION><OPTION VALUE="st">Southern Sotho</OPTION><OPTION VALUE="es">Spanish</OPTION><OPTION VALUE="su">Sundanese</OPTION><OPTION VALUE="sw">Swahili</OPTION><OPTION VALUE="sv">Swedish</OPTION><OPTION VALUE="tg">Tajik</OPTION><OPTION VALUE="ta">Tamil</OPTION><OPTION VALUE="te">Telugu</OPTION><OPTION VALUE="th">Thai</OPTION><OPTION VALUE="tr">Turkish</OPTION><OPTION VALUE="uk">Ukrainian</OPTION><OPTION VALUE="ur">Urdu</OPTION><OPTION VALUE="uz">Uzbek</OPTION><OPTION VALUE="vi">Vietnamese</OPTION><OPTION VALUE="cy">Welsh</OPTION><OPTION VALUE="fy">Western Frisian</OPTION><OPTION VALUE="xh">Xhosa</OPTION><OPTION VALUE="yi">Yiddish</OPTION><OPTION VALUE="yo">Yoruba</OPTION><OPTION VALUE="zu">Zulu</OPTION></SELECT>" MACROBUTTON HTMLDirect These theories will allow us to provide an analysis of how the normative system of State institutions operate, how its policies influence the realities of legitimately marginalized female bodies and which variables are present in the systems of sociocultural representation around the roles of the female body.-958854225925Figure 1: An approach to representation and mental maps of the female body, motherhood and abortion in the Caribbean Source: Own elaboration based on interviews with key informantsLet us start with the definitions raised by Michel Foucault about the body in his works: Punishment and Discipline and the Birth of Bio-Politics, works the French philosopher uses to deconstructs the body as a pluridimensional and plurisignificative object that functions as 1) support for symbols of fear, 2) a place of conflict between the individual and society, 3) a metaphor for social organization, 4) the center of the institutions of control, and 5) the object that allows us to identify a model of social identity.Basing ourselves on Foucault’s concepts and complementing them with the theory on Representation by Stuart Hall, we try to identify the mental maps constructed around the Caribbean female body taking two central points of analysis 1) the feminine biological dimension associated with the idea, function and value of selfless and virginal motherhood and, 2) the opposite (but parallel) perception that rejects, criticizes and regulates the reproductive dimension of women and their right to access safe abortion services.Both analytical approaches allow us to understand, based on how the female body conforms to different moral values/perceptions in different cultures, how certain actors attribute meaning to the female body (in different stages) through language / practice, the relevance and visibility that is given to the issue of legal and safe abortion, and social stigmas activated at the time of the woman opting for termination of a pregnancy.The map of perceptions is the result of a series of interviews conducted in 2018 with advocacy group actors working on reproductive rights and sexual health organizations. In Table 1 we classify the general access limitations to safe abortion services in each country interviewed. Only five countries, of the 8 under observation, participated of these interviews: Haiti, Dominican Republic, Jamaica, Guyana and Suriname. Table 3. Anti-abortion perceptionsCountries Social Stigma Individual Religious BeliefsDisinformationFear of legal prosecutionSilencing of safe abortion agendas and public discussionsAnti-abortion institutions/ The ChurchGuyanaXXXHaitiXXDominican RepublicXXXXSurinameXXJamaicaXXXXDeconstructed perceptions about abortion by interviewed actors The country with the most negative perceptions of women and abortion is the Dominican Republic. The interviewed actor indicates that the main abortion issues are rooted in the government’s institutions and the general population’s double standards towards the practice. One of the common perceptions towards women who have gone through abortions is their libertine characterization. This negative description is not only used to describe women with the necessity of an abortion service but is also implemented to relate the immoral aspect of women that exercise their sexual and reproductive rights. In this cultural scenario, sexual and reproductive empowerment represent a threatening activity that transforms the maternal/virginal/resignation figure into a body of sin/ frivolity and promiscuity. Furthermore, the actor exemplifies this case with the radical moral views exercised by conservative women, due to religious beliefs, when it comes to the approval of abortion exceptions as the case of pregnancies caused by rape. This population perceives that the baby (symbol of surrender) should live and have the opportunity to be raised by the mother. Nonetheless, the mother’s conditions and sufferings are made invisible and non-existent. It is interesting to note that the actor interviewed in the Dominican Republic does not mention a central fear of government power or punitive laws -one of the most restrictive in the region-, but it does highlight the population "ignorance" factor about the improvements that would follow the legalization of safe abortion or the approval of the three exceptions. Perhaps the fact that the government is not mentioned as a body of control and total regulation is given because of what the actor understands as "the Dominican double standards on unsafe abortion" projected into the government mechanisms of objective violence towards women’s reproductive rights.Jamaica is the second country with the highest scores on the level of negative perceptions and barriers surrounding the practice of abortion. Two of the causes mentioned by the actor interviewed were based on the fear of normative and religious institutions. Women were afraid to: 1) commit a crime (perhaps fear of abusive police authorities, a fear very present in Jamaican society) and, 2) fear of the power of religious institutions (another institution of great power and influence in the country). In Jamaica’s scenario, two institutions of power shape up the overall perceptions of the female body: the government and the church. Abortion in Jamaica represents fear of government but does not impede the practice. This is confirmed in the approval percentage of safe abortion representing a 50% of the Jamaican population. However, the interviewed actor indicates that society mistrusts state institutions and has no hope that abortion will be legalized since "if a legalization of abortion is proposed, the church would do everything possible to prevent it". The distrust of Jamaican society towards the institutions is highly marked. This fact, not only represents an effect of objective violence towards women reproductive rights but also a subjective violence in which “the bad ones” are embodied/ represented by government and religious institutions or groups with the power to exercise direct sanctions/punishments/violence towards nontraditional and/ or progressive social groups. Guyana is one of the three countries in the Caribbean region (the only one of all 8 under observation in this report) with abortion fully legalized upon the request of women. Nonetheless, the female body is still perceived as a body / object that loses value in the moment women take over their reproductive rights by accessing abortion services.The interviewed actor indicates women feel that abortion condemns them to the category of "bad woman". It is not indicated in the interview the kind of badness it refers to. In addition, she stresses that the lack of information encourages women to doubt the effects of abortion as a medical practice, agreeing that the procedure can lead to infertility. Another important perception is the invisibility of safe abortion as part of the governmental public agenda. It’s been more than two decades since abortion is legal in Guyana, yet the government is still struggling to include safe abortions as a service in the public health system. Nonetheless the discussion about abortion in Guyana does not seem to be going backwards or forward but has stagnated. In this case, the promotion and visibility of public agendas focused on sexual health, family planning and reproductive rights, has been overshadowed by LGBTIQ advocacy groups public discussion. In the case of Suriname, the actor interviewed underlines the lack of government regulation on a concrete implementation plan that stipulates how, when and where safe abortion services should be requested and delivered. The actor stressed that there’s confusion about the health-related protocols to be followed by the medical personnel who carry out the abortions. The state of things hasn’t improved since the last revision of the penal code. The actor notes, the abortion public discussion is muted or does not seem relevant within the country's health policy. In this case, there is no negative perception about women or abortion, but rather a governmental abandonment and invisibility of transparent health care protocols and public agendas promoting the legal practice of safe abortions. The silence exercised by Surinamese government towards women reproductive rights functions as a temporary unaccountable permission that can be denied at any time, making the practice unstable and a non-granted right. Furthermore, the actor informs that fear is a big barrier, specifically, in terms of reviving the public discussion of legal and safe abortion. The main reason is fear of government and its power to possibly annul the current advances as a form of punishment (after all, it can do so because abortion is not decriminalized). This perception may be a sign of unjustified fear and illegitimate exercises of power by government institutions. In addition, it shows a high sense of control over women’s reproductive rights/ bodies leaving the abortion practice in a grey area where it operates more like a privilege than a human right. It may well represent a defense mechanism implemented by the government in order to stay unaccountable from relevant health reforms and regulation investments when it comes to the structure needed to safely provide abortion services in the country. Finally, normalizing the irregular practice while not reinforcing its safety (medically and legally) is part of the objective/direct violence faced by Surinamese women when it comes to the access safe abortions. Haiti is the country with the least negative perceptions, yet religious beliefs have an important relevance in everyday practice. According to the consulted actor the Haitian population recognizes the social necessity for safe abortion services. Currently, a law is being evaluated in the new penal code reviews. The interviewed actor mentioned the case of a doctor with marked religious affiliations who referred a patient to a different physician because they were presenting an unsafe post abortion complication. The body, in this case, under religious precepts becomes a sign of illness and immorality. The religious morality exercises its power of punishment by rejecting the body of the sinner. In the case of Haiti, women are still highly rejected and punished within State institutions, as is the case of the ministries of health and its personnel. Finally, the interviewed actor exemplifies the direct effect of objective violence (by making a self-evident social problem invisible) towards women by stating, “we have the prohibition law, but everyone knows that women get abortions everyday”. Table 4 summarizes the cultural constructions around women’s roles in society, fear and absence of government, and personal values about abortions that impede liberal policies for each country. The first cell gathers countries with weak abortion implementations. In the second cell the negative stereotypes about women requesting or going through abortions are identified. The third cell shows which conservative/traditional perceptions are based on the religious role of maternity. The fourth cell is used to identify actor’s perceptions towards the abuse of power in government institutions. Finally, the fifth cell serves to mark the myths towards abortion as a medical malpractice. Table 4. Negative practices and fears that mediate abortion practices in the CaribbeanCountries Irregular abortion practices based on weak implementations by governmentNegative stereotypes of women requesting abortion servicesConservative representations based on maternity idealsFear of government Myths about infertility GuyanaXXXXHaitiXDominican RepublicXXXSuriname XXJamaicaXXXXSource: Own elaborationLegal Aspects of Abortion in the Caribbean Regulatory models of abortion: a path to understanding the progress of abortion legislation in the CaribbeanIn this Report on the Situation of Abortion in the Caribbean, the regulatory systems of abortion are based on the comparative law analytic text Abortion and Reproductive Justice: a Look at Comparative Law, (Bergallo, 2011). The regulatory models analyzed by Bergallo are 1) total penalty model, 2) model of permits or exceptions, 3) model of permits with and without implementation, 4) repeal model, and 5) assessment model.Based on these regulatory models, we present below a table in which legal abortion regulations, following Bergallo's regulatory models scheme, are adapted to the countries covered by this report. Nonetheless, we have added the section “Improvements regarding liberalization of abortion laws” in order to explain public discussions and criminal code improvements over the years. Table 5. Summary: Abortion Regulation Models Regulation ModelsRegulation Models qualitiesRegulation Models applied by CountryLast revision of Criminal CodesImprovements regarding liberalization of abortion lawsTotal Penalty ModelsUnder this regulation model, abortion is totally penalized. 1) Dominican Republic2) Suriname1) 1997; 2006; 2012, 2) 19931) Yes. Improvements took place in 2012 when three exceptions were approved under the New Criminal Code. Yet, the Constitutional Court rejected the new Criminal Code due to irregularities in the approval process. 2) No. Under the 1993 revised Criminal Code abortion is illegal. Although, women do have access to abortion because Article 309 isn’t directly applied to women. The Surinamese government calls the Article “dead letter law”.Models of Permits or Exceptions/ Modality without ImplementationIn this model legislation includes a menu of non-punishable abortion options (exceptions). However, this model has its variables: 1) exceptions without implementation and 2) exceptions with implementation.1) Jamaica 2) Haiti1) 1864 2) 1810 1) Jamaica’s has had legal precedents in the past, based in the British Common Law case Rex vs. Bourne (1938). This case made it possible to approve abortion under the exception to preserve the physical and mental health of the pregnant woman. Yet, abortion is illegal in Jamaica under the Offences Against the Person Act. But no revision regarding abortion legislation has been made to the Criminal Code since 1864.No implementation Modality: legislation includes the exceptions, but it does not contemplate an action plan that allows pregnant women to have easy access to abortion services2) In 2016 Haiti’s Ministry of Justice announced the creation of a five-year Commission that will review and reform the penal laws of the country. Pro-abortion and reproductive rights Advocacy groups have requested a reevaluation of abortion exceptions approved in the ongoing revisions of the Criminal Code.Permission Model with ImplementationThis model represented a new regulatory reality. Since traditional non-punishability cases were specified, generous permits appeared allowing administrative regulations to be implemented by defining: type of practitioners and clarifying how, when and where abortion services should be provided.1) Trinidad and Tobago 2) Curacao 3) St. Lucia1) 1925 2) 1999 3) 2004No. Trinidad & Tobago hasn’t revised or improved the Criminal Code since the first decades of the 20th. Century. Abortion is illegal under the Offences Against the Person Act. Yet, abortions are allowed in case to preserve the life or health of the pregnant woman.Yes. Since 1999 the Curacao Government established a Tolerance Abortion Policy. Nonetheless, abortion is an illegal practice and legal penalties are more focused on the pregnant women. However, it protects the medical practitioner from legal prosecution. Yes. St. Lucia Criminal Code was revised in 2004 and abortions are allowed in case to protect the pregnant woman’s life, physical and mental health, and in case of rape or incest. Nonetheless, abortion is illegal in different scenarios. Derogation Model or Repeal ModelThis model suppresses the penalty of abortion in early pregnancy (first trimester).GuyanaMedical Termination of Pregnancy Act No. 7 of 14 Junes 1995 Yes. In 1995 abortion was made legal without restriction as to reason during first 8 weeks of pregnancy, and thereafter on broad grounds between 8 and 12 weeks of pregnancy, and thereafter on specific grounds. Previously, abortion was illegal according to the Criminal Code. Assessment ModelThis model establishes a regulation standard that would allow North American States to abandon the detriments mechanism to regulate in a demanding manner different pre-requisites for access to abortion, including a very complete advice on the practice and its harmful effects on the fetus.N/AN/AN/ASource: Caribbean RHRN Advocacy Focus Areas; Bergallo, 2011 The detailed classifications above, allows us to understand abortion as a right attached to different models adopted/practiced by each county studied. During this section we found a marked discrepancy in the implementation process in cases were exceptions to the law were permitted. For example, profound incongruences were highlighted in countries classified under the “permission model without implementation” as is the case of Jamaica and Haiti. In these scenarios, women had access to abortion through one or two exceptions, yet they weren’t supported by effective implementations. In those cases, women were granted the abortion right without knowing where and how this service should be provided or requested under safe conditions. Suriname was another example of law and implementation discrepancy. The abortion law is nationally known as “dead letter law” because it is tolerated and non-punishable by the government. Nonetheless, the practice remains illegal. In addition, although abortion is tolerated, it is not regulated under any legitimate health standards. Table 7. Approved exceptions for abortions Abortion ExceptionsTo save the pregnant woman’s life To protect the woman’s health during high-risk pregnanciesTo protect the mental and physical health of the pregnant womanTo protect the woman in case of a pregnancy caused by a rape or incest To protect the woman in case of poor fetal developmentIn case of a woman’s socioeconomic limitationsCuracao---XX---X---GuyanaXXXXXXHaitiX---------------JamaicaX---XXX---Saint. LuciaX---X---------Suriname------------------Dominican Republic------------------Trinidad & TobagoX---------------Sources: CEPAL 2011; Caribbean RHRN Advocacy Focus Areas, 2017.Review on Caribbean Countries: government types, legal systems, criminal codes, abortion provisions and historic improvements In this part of the report we have organized the types of governments, legal systems, criminal code origins, abortion provisions and historic improvements on abortion law liberalization. This overview has the purpose of providing the reader with a wider view of similarities and contrasts regarding legislations in each country; we highlight distinctions between enacted laws in contrast to governments plans of action and penalty application. Additionally, we feature the circumstances (legal and social) in which women gain access to abortion in countries with incongruent laws and sanctions. Finally, we present the regulatory models and abortion laws per country observed; taking into consideration that all the countries under observation were in the past or are currently colonies of the Netherlands, Spain, France and Great Britain. Table 6. Government Types, Criminal Codes, and Ratified Treaties CuracaoGuyanaHaitiJamaicaSaint Lucia SurinameDominican RepublicTrinidad & TobagoGovernment TypesParliamentary Representative Democratic part of the Netherlands KingdomPresidential Democratic RepublicSemi-Presidential RepublicParliamentary Democracy based on the United Kingdom Westminster system.Parliamentary Constitutional Monarchy?Presidential RepublicUnitarian Republic with a civilian, democratic and representative government.Parliamentarian RepublicLegal SystemBased on the Dutch Civil LawBased on the British Common LawBased on the Napoleonic Codes of 1804-1810Based on the British Common-LawBased on the British Common LawBased on the Dutch Civil LawBased on the Napoleonic Codes of 1804-1810Based on the British Common LawCriminal Code and abortion provisionsCriminal Code of 1988 (Act No. 23)And revised Criminal Code 2010Abortion is ilegal Abortion is legal since 1995. Under Medical Termination of Pregnancy Act No. 7 of 14 June 1995Criminal Code based on the 1810 French Napoleonic CodeAbortion is illegal under Criminal Code, Art. 262Abortion is illegal under Offences Against the Person Act. Sections 72 and 73 Abortion is illegal under Revised Criminal Code of 2004 Art. 66Abortion is illegal and penalized in the Article 309, paragraphs 355-358 of the Surinamese Criminal Code 1911. Abortion is illegal under Constitution Art. 37 and Art. 317 under the Criminal Code of 1844. Abortion is illegal under the Offences Against the Person Act of April 3, 1925Ratified Human Rights TreatiesN/ACEDAWCEDAW-OPCRCCESCRCERDCCPRCRC:OPSCCRC:OPACCERDCCPRCESCRCEDAWCRCCRC:OPSCCRPD *CRPD-OPCERDCCPRCESCRCEDAWCRC:OPSCCRC:OPACCMWCRPD CERDCEDAWCRCCRC:OPSCCRC:OPACCERDCCPRCESCRCEDAWCRCCRC:OPSCCERDCCPRCESCRCATCEDAWCEDAW-OPCRCCRC:OPSCCRC:OPACCRPD *CRPD-OPCERDCCPRCESCRCEDAWCRCCRPD *As seen in table 6, all eight countries have democratic governments either with a presidential or parliamentarian structure. In all cases, except for Guyana, the legal instruments that regulate abortion exist as a legal colonial legacy. Specific penal codes studied in this report have gone through reform while others have not. Those that did not present any reforms express the views and needs of the 19th century colonial territories. All eight countries observed have ratified the human rights treaty of the Convention for the Elimination of All Forms of Discrimination Against Women (CEDAW). Under this treaty the abortion criminalization is defined as a form of gender violence and therefore against women’s human rights. In fact, by signing this treaty all countries make a commitment regarding liberalization of policies and its decriminalization according to international human rights standards. Countries like Dominican Republic, Haiti and Jamaica have shown no progress or liberalization in abortion policies although they have ratified the CEDAW.Table 7 below gives us a summary of the different instances where abortion is allowed in the countries studied. Table 7. Approved exceptions for abortions in the Caribbean Countries of Study Abortion ExceptionsTo save the pregnant woman’s life To protect the woman’s health during high-risk pregnanciesTo protect the mental and physical health of the pregnant womanTo protect the woman in case of a pregnancy caused by a rape or incest To protect the woman in case of poor fetal developmentIn case of a woman’s socioeconomic limitationsCuracao---XX---X---GuyanaXXXXXXHaitiX---------------JamaicaX---X---------Saint. LuciaX---XX------Suriname------------------Dominican Republic------------------Trinidad & TobagoX---------------Sources: CEPAL 2011; Caribbean RHRN Advocacy Focus Areas, 2017.Criminal Codes based on the British Common LawFormer British colonies have Criminal Codes based on the British Common-Law, which still mostly implements the Offences Against the Person Act without modifications or under a new enacted criminal code. Four countries fall under this category: Guyana, Jamaica, Trinidad and Tobago, and Saint Lucia. Guyana, of the four former British colonies, is the only one that has decriminalized abortion under all circumstances. However, the other three, Trinidad and Tobago, Jamaica and Saint Lucia, penalize abortion but grant two exceptions: 1) to save the woman’s life and, 2) protect her mental and physical health. The mentioned exceptions take place because of the legal precedent based on the British Common Law, Rex vs. Bourne, 1938. In this example, the colonial legacy of the British Common Law does have positive flexibilities in regard to abortion legislation in Jamaica, Saint Lucia, and Trinidad and Tobago. Nonetheless, Jamaica doesn’t have any effective implementations regarding abortion medical protocols which ensure how the procedure should be conducted and which medical personnel is needed during the procedure. Neither one clarifies the type of healthcare facilities in which abortions should be provided. In Jamaica’s case the abortion exception doesn’t have a strong implementation although granted by law. In the cases of Saint Lucia and Trinidad and Tobago, these countries do have a health protocol which stipulates how and where abortion services can be delivered or provided. However, the abortion exception has a discriminatory implementation because it doesn’t allow public hospitals to provide abortion services. This presents a limitation for pregnant women of limited economic resources or living under the poverty line. Criminal Codes based in the Dutch Civil LawThe countries with Criminal Codes based on the Dutch Civil Law, as is the case of Curacao and Suriname have mixed levels of restriction towards abortion. Suriname doesn’t have any exception available under its criminal code, but Curacao has three exceptions approved. Yet, their criminal codes application has certain flexibilities towards the practice, allowing pregnant women to have access to abortion services under secrecy or avoiding the non-enforced penalties stated in each criminal code. In the Curacao scenario, a Tolerance Policy has been implemented since 1999. However, this policy doesn’t legally protect pregnant women, but does protect medical practitioners from legal prosecution. As a matter of fact, the Tolerance Policy allows pregnant women to get this service in healthcare professional facilities following the law exceptions and on women’s request. Yet if the abortion is under the pregnant woman’s request, and without honoring the exceptions, the access to this service makes them regular patients but infringers of the law at the same time. This type of legal and social contradictions may nurture an environment of confusion and fear among pregnant women, because the legal restrictions do not protect their status as legitimate patients requesting a service.The Suriname case is even more distinctive due to an apologetic government position towards abortion practices while still having strict laws against them. In Suriname, abortion is illegal, but sanctions aren’t implemented and stipulations in the criminal code are openly avoided. In 2002, the Surinamese Government stated in the Reproductive Health paragraph of the CEDAW that women have access to abortion because the criminal code is not applied. The government referred to the law as ‘dead letter law’. (Caribbean RHRN Advocacy Focus Areas, 2017). In both cases, Curacao and Suriname, implementation of abortion laws is incongruous and non-transparent. The discriminatory tolerance policy and inconsistent practices between law, action and sanctions, leave women unprotected by the law although they have access abortion services. These types of legal contradictions may nurture an environment of confusion and fear among pregnant women, because the legal restrictions are still valid and therefore do not protect their rights and needs as patients requesting a service. Abortion operates more like a privilege than a granted human right. Criminal Codes based on the Napoleonic Code The countries with criminal codes based on the Napoleonic Code (1810), of the French System, are Dominican Republic and Haiti. These two nations have the highest level of restrictions towards abortion practices. Dominican Republic is one of the five countries in the Latin American and Caribbean region that prohibits abortion in all circumstances. Haiti’s case is a bit more flexible because it approves one exception when required to save the pregnant woman’s life. Nonetheless, Haiti does not have any healthcare protocols or detailed conditions stating where and how the abortion should be conducted. As for the Dominican Republic, there’s no protocol or detailed condition stipulating how and where the procedure should be conducted because abortion is completely penalized.Current Discussion of Abortion in the Countries of StudyAbortion legislation in Curacao and legal controversiesThe progress of safe abortion laws and the reinforcement of transparent policies in Curacao have shown little improvement in the last two decades. Even though the island counts on a new Constitution since 2010, safe abortion by women request is still illegal by law. Under the 1999 Tolerance Policy abortion is pardoned/tolerated as a medical practice. This policy only protects general practitioners from being legally prosecuted. Therefore, the tolerance policy doesn’t apply to pregnant women requesting an abortion service. The Tolerance Policy shows a huge controversy between the law restrictions: the policy only protects one party (General Practitioner) while it discriminates against the other (women requesting safe abortion services). The 1999 Tolerance policy: A controversial progress in Curacao abortion policiesDespite the fact that abortion is illegal in Curacao, this service can still be provided upon the request of women and conducted by General Practitioners in hospitals. Nonetheless, women face serious challenges such as 1) hospital bureaucracy, 2) lack of information from the medical staff and, 3) scarce medical staff. The last point is confirmed by gathered data in 2009, which shows that three of eight abortions were provided by a hospital facility (Boersma, 2011).The study conducted by Boersma in 2009, equally shows that the first trimester -illegal TOP- (Termination of Pregnancy) upon request is carried out by 11 of the 102 general practitioners. There is a lack of information by Public Health Services about TOP and not all para-medical practitioners will make referrals to a TOP providing General Practitioner because of anti-abortion motives, causing postponement of the desired procedure at times. (Boersma, 2011).The 1999 Tolerance Policy promulgated by the Public Prosecutor may be the only advance in the abortion policies matter in Curacao. Even so, the “tolerance” deeply discriminates against women requesting and making use of abortion services. These restrictive laws and contradictory policies can also mirror oppressive policies, remnants of Catholic beliefs, and patriarchal views of females in Curacao society. Dominican Republic Criminal Code Status The Dominican Republic Criminal Code does not ponder any of the six exceptions for abortion practices in a special or high-risk situation during an unintended pregnancy. Moreover, Constitution Article 37 proclaims the supreme prevalence of the right to live in cases of life and death rejecting any type of life suppression. The laws against abortion positions the Dominican Republic as one of the five countries of the Latin American and Caribbean region with a regulatory model based on total prohibition. Since the decade of 1990’s few modifications have been introduced to the Dominican Republic Criminal Code through the executive and legislative branches. Yet it was an evident fact that the judiciary branch needed (and still needs) to upgrade and adapt the criminal code to 21st century necessities of Dominican society. Accordingly, a new process of revision and upgrade of the Criminal Code was put to action by the Chamber of Deputies in 2012.The Big Discussion about Las Tres Causales in Dominican Republic –The Three Abortion Exceptions- In 2014 Dominican president Danilo Medina proceeded with accurate observations regarding the Criminal Code under review. The first executive remarks were directed at the non-existent abortion provisions under three exceptional cases he considered relevant to grant in special situations: 1) to save or protect the woman/mother’s life, 2) to protect women’s health during high-risk pregnancies, and 3) to protect the women in case of poor fetal development. Later that year the Chamber of Deputies approved Medina’s observations under the enactment of a new criminal code. Nonetheless, by January 2015 the Constitutional Court (Tribunal Constitutional) presented three unconstitutional resources, content defects and irregularities in the ongoing approval period. The Court rejection was based in the Code’s qualities, alleging its design was closer to an Organic Law than a Criminal Code. By extension, the Code’s approval required a different qualified majority of votes equal to 119 votes and not 93, as it was the real number on December 2015. As a result, the Criminal Code went back to the Senate for further reviews that did not violate the legal basis and the process required for the reform of a modified punitive Code.In 2016 president Medina proceeded with new observations advocating the approval of the three abortion exceptions requested before. Medina noted his concern of the new Criminal Code revision, highlighting that the new Code didn’t have any of the abortion provisions it once did in 2014. Due to this process, the president expressed the following argument publicly:“The proposed observations are not intended to impose on the pregnant woman, in such extreme circumstances, the obligation to choose the termination of pregnancy. But to allow her in safety conditions, to decide without fear of criminal sanction. It is about allowing her to be accompanied by her decision, with the assistance of capable and specialized medical staff, to overcome the tragedy experienced”Presently, the legal issue regarding the three abortion exceptions hasn’t been clarified in the Dominican Republic Criminal Code; although 28 countries in the Ibero-American region, and part of the Caribbean have approved at least one of these three exceptions abiding the human rights treaties ratified by their governments. The CEDAW, CESDR, CRC Committees have presented profound observations on the Dominican Criminal Code modifications regarding abortion legislation. These observations are included in the World Health Organization, Global Abortion Policies Database, 2017. Abortion status in Jamaica, exceptions, and penalization Abortion is illegal in Jamaica under the Offences Against the Person Act of 1963, which is based on the 1861 English Act. In sections 71 and 72, abortion is completely penalized by law. Jamaican abortion penalties are more severe towards women than practitioners and/or medicine providers. In the case of women practicing unsafe abortions they face: partial prison life sentence with or without hard labor. Yet, practitioners or providers will face a strict three-year prison sentence with or without hard labor. Although, these sanctions may be flexible towards practitioners, the criminalization of abortion shows an impediment for entitled medical staff to provide the service due to fear of imprisonment. This factor is notorious as well in women going through unintended pregnancies, the fear of legal prosecution and the violation of their private character (in case of pregnant adolescents under 16) are big barriers for accessing this service in safe environments that honor their private characters. Despite the detailed punishments under sections 71 and 72, exceptions exist in Jamaica for lawful abortion in the following situations: 1) to save the life of the woman, and 2) to preserve their physical and mental health. Yet in both cases the spouse’s consent is required (depending on the situation). Yet pregnant women must obtain the approval of two specialists to be provided with a safe abortion on the grounds of mental health, fetal impairment, rape or incest (ONU, 2001). The tiresome bureaucratic processes may result in problematic and unhealthy delays when adult and adolescent Jamaican women need immediate abortion services in exceptional situations.Legal precedents that allows the abortion practice in JamaicaUnder the Jamaica General Criminal Law of Necessity abortion is permitted only to preserve the life of a pregnant woman. This means that exceptions, to the active laws against abortion, can be made without applying legal sanctions (either to medical staff or women). The second legal abortion exception, to preserve the pregnant woman’s physical and mental health, is rooted in 1938 Britain’s legal precedent Rex vs. Bourne. In this case, the Court ruled in favor of the lawfulness of abortion because it was the product of rape and it had been performed to prevent the woman from becoming a “physical and mental wreck”. Rex vs. Bourne established a precedent for future abortion cases in Jamaica because its legal system is rooted on the British Common-Law. Nonetheless, the systemic violence and structural invisibilization of women’s reproductive rights in Jamaica obstructs the reinforcement and transparency of these exceptions granted by law. This fact can be connected to the lack of political representation for women in the Jamaican Parliament; as of 2015 women only held 16.7 seats.Safe abortion legislation and repercussions in Haiti’s society and governmentThe ongoing situation in Haiti regarding the progress and reinforcement of Women’s Reproductive Rights legislation is necessary but critical. Abortion is considered a crime in Article 262 of Haiti’s 1810 Criminal Code. Yet this procedure is only permitted under the criminal law principle of necessity in the case of preserving the pregnant woman’s life.Although abortion is permitted by the criminal law principle of necessity, this practice is restricted by law and is often viewed negatively by the local patriarchal culture, and a population with deep religious beliefs. In the same fashion, the government does not count with strong institutions to dispose economic resources directed to promoting or reinforcing contraceptive agendas for women as is the purpose of family planning agendas.The absence of safe abortion legislation in Haiti’s legal system is well rooted in the insufficient access to health services, strong patriarchal social system, strict criminal sanctions against abortion, state economic crisis, and deep social stigma towards abortion practices.Given the facts above, the CEDAW Committee expressed its concern regarding the negative and discriminatory stereotypes of Haitian women’s roles and behavior (2016). The Haitian population’s social practices tend to promote gender inequality and female disempowerment over women’s reproductive rights.In spite of this fact, a presidential Commission was set up in 2015 by former President Michel J. Martelly to draft a law on abortion in the new Penal Code. In this document, Articles 340, 341 and 342 decriminalize abortion (Profamile, IPPF, 2017). The proposed articles read as follow: Art. 340. Termination of pregnancy with the free and informed consent of the pregnant, and practiced according to the requirements of medical science, is always permitted. It is the same when the physical or mental health of the woman is in danger or when the pregnancy results from rape or incest.When it takes place without the consent of the pregnant woman, she is liable to imprisonment of five (5) to seven (7) years and a fine of 50,000 gourdes at 100,000 gourdes Is punishable by the same penalty anyone, by food, drink, drugs, will have caused the abortion of a pregnant woman without her consent.The penalty is the same if abortion is caused by physical force. Physicians, surgeons, other health officers and pharmacists who will have indicated or administered these means, will be sentenced to the same penalty of the abortion followed.Art. 341. When the termination of pregnancy takes place under conditions that endangering the health of the pregnant woman, by an unqualified person, in a different place that a public or private health institution recognized by the Ministry responsible for health care, or beyond the period of twelve (12) weeks, the perpetrator shall be liable to imprisonment from seven (7) to ten (10) years and a fine of 75000 gourdes to 150,000 gourdes.Art. 342. The person who intentionally practices the sterilization of a woman without his knowledge, while there is no medical or surgical justification, is punishable by imprisonment of three (3) to five (5) years and a fine of 75,000 Gourdes at 150,000 gourdes. The doctor's license will be suspended for one (1) year.(Proposed articles on abortion for the new penal code in Haiti)The latest version of the drafted law was modified by the demands of Haitian feminist organizations. The main reason was based on the restrictive recommendations made by Haiti’s Health Ministry in which decriminalization was limited in cases to save a woman’s life, fetus malformation, rape or incest. Total decriminalization was proposed in this new version of the legal draft showing great advancement toward a liberal agenda on Haitian women’s reproductive rights. However, this proposal is still waiting for parliamentary vote. It is not considered a law at this moment. Suriname, abortion legislation and criminal code provisions regarding the practiceAccording to the Surinamese legal system based on the Dutch Civil Law, abortion can only be permitted in the case of safeguarding the life of the pregnant woman. This exception is possible under the legal principle of criminal necessity. Suriname’s criminal code penalizes the person for up to three years of imprisonment or with a fine of up to three thousand guilders. If the person has acted out of profit, or has acted professionally or regularly, or is a medical practitioner, midwife or pharmacist, the penalty may be increased by one third (United Nations, 2002). Abortion is illegal in Suriname but tolerated as a practice. Abortions are performed by doctors at an economic cost and without official regulations to control quality of services. The Elimination of all Forms of Discrimination against Women Committee (CEDAW, 2007), expressed concerns and demanded improvements for, 1) high maternity rate, 2) High teenage pregnancy, 3) Increasing infection of HIV/AIDS among women and girls and, 4) Lack of health care access in rural communitiesTrinidad & Tobago abortion policiesAbortion is illegal in Trinidad and Tobago and is only approved when the life of the pregnant woman is in danger. Abortions can be conducted based on the law, but the service is not provided in public hospitals only by private clinics.The sanctions of abortion are included in the Offences Against the Person Act of April 3, 1925. Under Articles 56 and 57, any person who tries to induce the miscarriage of a woman, unlawfully administers to her any noxious thing or unlawfully uses any means is subject to four years’ imprisonment. A woman who undertakes the same act with respect to herself is subjected to the same penalty. In addition, any person who unlawfully supplies means to procure an abortion knowing that it is intended for that purpose is subject to two years’ imprisonment. According to the information presented above, sanctions apply for the pregnant woman, providers/practitioners and assistants. Yet, under general criminal law principles of necessity, an abortion can be legally performed to save the life of a pregnant woman because, Trinidad and Tobago, like other Commonwealth countries, whose legal system is based on the English common law, follows the holding of the 1938 English Rex v. Bourne decision determining whether an abortion performed for health reasons is lawful. Saint Lucia abortion legislation Saint Lucia revised its criminal code in 2004, as a result the grounds on which abortion was permitted were to save the life of a woman and to preserve her physical health. The law specifically states that “an act performed in good faith and without negligence for the purposes of medical or surgical treatment of a pregnant woman is justifiable although it causes or is intended to cause abortion or miscarriage” (United Nations, 2001). The new dispositions contemplate that abortion is allowed to save a woman’s life, to preserve her physical or mental health, and if the pregnancy is product of rape or incest. Considering the restrictions faced in other Caribbean countries, St. Lucia has stipulated a legal framework for abortion that honors women’s health in critical situations. Nevertheless, bureaucratic barriers still exist when abortion is permitted by a law exception. One of the crucial barriers to access lawful abortion in St. Lucia is the permit process request. For example, if an abortion is requested upon the cause of rape or incest, the woman must present the medical practitioners with a copy of a police report stating the date and time the incident occurred and the confirmation of an ongoing police investigation of the case. This situation may expose women to double stigma. One based on being a rape victim and the other rooted in the inconsiderate delay of a traumatic pregnancy product of violence. Another observed barrier in the exception implementation protocol of St. Lucia law is the obligatory 48 hours counseling session women must go through before an abortion. This process may nurture the fear of stigma and the violation of privacy in women. Even though the penal code states that women should be advised to inform their partners in case of getting an abortion, a partner’s permission is not required for the abortion to take place. This gives St. Lucia’s women more liberty to decide on their own. Guyana abortion legislation Abortion is legal in Guyana under the Medical Termination of Pregnancy Act No. 7. Of June 14, 1995. In 2008, the Government theoretically cleared the way for public hospitals to perform abortion, but public hospitals only provided abortions to women with ongoing complications like incomplete abortions. It wasn’t until recent years that medical abortion was made somewhat accessible in the country. The situation changed because Guyana’s Responsible Parenthood Association submitted a demand to the Higher Court in 2015 to allow, on the basis of the Medical Termination Act, that second level care professionals could administer medical abortions. Specifically, the Court Order of 15 January 2016 states: “It is hereby ordered that the Guyana Responsible Parenthood Association be and is hereby granted a declaration of its right on the true construction of section 5(1) of the Medical Termination of Pregnancy Act 1995, Act No 7 of 1995 to enable the administration of treatment for the termination of pregnancy of not more than eight weeks duration by any lawful and appropriate method other than a surgical procedure on its behalf of medexes, midwives, nurses, pharmacists and any other appropriately trained and registered mid-level member of the health profession under a process supervised by a medical practitioner provided that once a client decides on Medical Abortion (MA) the medical practitioner is to be notified immediately…” Before this ruling, public health ministries did not offer abortion services, these were limited to certain private clinics at a high cost. In 2016 The Guyana Responsible Parenthood Association started to offer medical abortions as part of their program. Summary of penalties and requirements to abortion in the countries studied Finally, table 8 provides an overview of the penalties and barriers that each country disposes to control abortions, Table 8. Penalties and requirements for abortions in the countries studied. Countries Exceptions to Access AbortionsPenalty ScopeDetermination requirement by medical personnelDominican RepublicNone/total prohibition3 to 6 years for women, medical staff, and assistantsNone/ totally prohibitedCuracao1999 Tolerance Policy (for medical practitioners)/ Illegal for women seeking abortions/Socially tolerated upon women requestNot SpecifiedYes. Procedure must be done by a general/medical practitionerHaitiTo save the pregnant woman’s lifePrison/ Hard LaborNot specified, yet is widely practice under unsafe conditionsSt. LuciaSave the woman’s life or physical or preserve mental health, or as result of rape or incest.14 years of prison. For the woman who performs it herself or allows it to be performed by another party. The same sentence applies to the abortionist.Yes. Procedure is only performed in private clinics.JamaicaTo save the woman’s life and to preserve her physical and mental healthLife prisonPrisonForced Laborwoman, medical practitioner and assistantsNo.Trinidad & TobagoTo save the woman’s life 4 years for practitioner and woman. 2 years for aiding in the process of finding someone to perform an abortion Yes. Procedure is only performed in private clinics SurinameNone3 years for the woman. 4 years for the doctor/practitionerNo. Tolerated in private practice. Impact and Cost of restrictive abortion policies in the Caribbean region The experts consulted during this study and the available data suggest that general opinion in the region is shifting towards the acceptance of liberal abortion policies. Yet a mindset change takes time to translate into the lifting of barriers to safe abortion. Abortion in the Caribbean maintains its controversial quality in which traditional values and religious morals clash against liberal agendas, progressive social practices and access to equal healthcare for women. Given the points above, the cost of restrictive legislation cannot be analyzed without a gender perspective and the complex role women are playing in Caribbean societies. This chapter covers the prevalence of unsafe abortions in the region and the specific costs faced by each country’s economies and the challenges faced by women unable to access services. Abortion incidence in the CaribbeanThe Caribbean is the UN sub region with the highest incidence of unsafe abortions. Only a low percentage of abortions are delivered in safe conditions (Ganatra et al., 2017). Estimates for abortion incidence in the Caribbean region is 60 out of every 1000 women aged 15-44 in one year. 904240-1905Source: Ganatra et al., 2017Graph 1 shows that only 25.4% of abortions can be classified as safe. This data exposes a marked contrast to the Northern American region, in which 100% of abortions are safe. According to abortion classifications most abortions in the Caribbean region are classified as less safe. This phenomenon reveals an important fact: that self-induced abortions are becoming a common practice in the Caribbean because the misoprostol drug has become more available (Ganatra et al. 2017; Boersma, 2011). The fact stated above is also validated in the countries covered by this study. All five consulted informants expressed that misoprostol was the preferred method of abortion. Yet, least safe methods persist. Among these methods were the use of herbs and beverages, clandestine surgical methods, and self-administered invasive procedures. Abortion statistics and methods by specific countriesSuriname has an estimated 5.000 to 10.000 abortions per year. This translates to an abortion rate of 43 to 86 per 1.000 women between the ages of 15 to 44. The abortion prevalence showed, that 7% of all women pregnant, self-administered misoprostol drug as the common method of abortion (MICS, 2010)In the same manner, other indicators showed how often Surinamese teenage girls opted for self-induced medical abortions (Suriname Beijing Report, 2016). According to our informants this practice is possible by the assistance of general practitioners and gynecologists that offer medical abortions per women’s request. In 2012, the abortion prevalence in Haiti was 4% of women to ever get pregnant (EMMUS, 2012). According to experts, this number should be considered the bottom value of prevalence since abortion is often a subject of shame and a lot of women do not report it. Among abortion methods used by women were: misoprostol (39 %), dilatation and curettage/aspiration (36 %), herbs or beverages (26%) and injections or pills non-specified (25%). In Curacao, a total of 1,126 abortions were registered for an estimated abortion rate of 38 per 1000 for women between 15 to 44 years of age. Of 666 registered abortions, 59.3% were medical (misoprostol) and 40.7% were surgical. Boersma’s research states that weak state funding and social shame are substantial factors that promote ‘non-medical’, illegal abortion practices. In the illegitimate Curacao circuit, misoprostol can be purchased in the black market and other traditional methods like the local herbs as yerba di lagadishi, lumbra blancu, shimarucu machu, jerba di kabritu and basora pretu. (Boersma, 2011). The Responsible Parenthood Association, based in Guyana, provided between?6,614 and 8,319 safe medical abortion services in 2016 and 2017. Exact numbers are not available for abortions carried out outside this service. Nonetheless, a 27% increase in the number of delivered abortions in one year reflects how widespread the demand for abortions is becoming. The Guyana informant indicated that unsafe abortions are still common in the country because there is a high proportion of unmet family planning. According to the WHO, in 2009 a 28.5% of married women had access to Family Planning. In Guyana, abortion is commonly used as a contraceptive method. This activity responds to existing barriers like limited territorial health coverage and misinformation about the availability of safe abortion services. In 2013, Dominican Republic had an estimate of 114,000 induced abortions, 43 per 1000 women between 15 to 49 years. Estimates agree that between 75% to 82% of abortions are unsafe and under the method of self-administered misoprostol. Correspondingly, less common methods are still present among Dominican women. Such as clandestine surgical procedures and the use of traditional beverages. Abortion statistics for Saint Lucia, Trinidad and Tobago and Jamaica were not available when requested for this study. Women’s health costData suggest a strong correlation between restrictive abortion laws and higher rates of maternal deaths (Johnson, et al. 2017). Estimates for Latin America and the Caribbean show that 9.9% of maternal deaths are caused by abortions. The sub-Saharan Africa region has a similar rate at 9.6%, in both regions abortion tends to be restricted. However, in Asia where access to abortion is generally restricted, this cause only accounts for in 0.8% of maternal deaths (Say, Johnson, Gimmil et al. 2014). Table X shows the countries of interest for the present study, and apart from Guyana, Haiti, Suriname and the Dominican Republic abortions have more restrictive legislation along with higher maternal deaths. Maternal death is a multidimensional phenomenon, where the quality of the health care system structure plays a major role. For the countries studied only St. Lucia and Trinidad fall below the Sustainable Development Goal of less than 70 maternal deaths per 100,000 women. Table 9. 2015. Maternal Death Ratio, total number of deaths CountryMaternal death ratio (per 100,000 women)2015Curacao..Dominican Republic92Guyana229Haiti359Jamaica89St. Lucia48Suriname155Trinidad and Tobago63Source: WHO Health Indicators Database, 2017In 2013, Dominican Republic official records show that 13% of maternal deaths were caused by abortions (MEPyD, 2016). While in Haiti, this statistic accounts for up to 30% (EMMUS-V, 2012). In Guyana abortion is legally permitted since 1995 yet only medical doctors and specialists were permitted to carry out the procedure until 2015. Medical personnel are still scarce in comparison with the country’s population. Moreover, abortion services were not available in Guyana’s public hospitals. For this reason, our consulted expert states that unsafe abortions had an important role in maternal mortality. Currently it is expected that access to safe abortions service will become available, this may impact the proportion of maternal deaths. Guyana’s case illustrates how barriers are not only limited to legislation, other factors remain as relevant obstacles. Among these are 1) policies that limit provisions of abortion care to obstetricians and gynecologists working at high-level care facilities 2) a conscientious objection by health-care providers 3) bureaucratic requirements for third-party authorization(s) 4) unnecessary medical tests 5) mandatory counseling and, 6) mandatory waiting periods that can lead to high risk unsafe practices (Johnson, et al. 2017). A maternal mortality study in Suriname concluded that between 2010 and 2014 illegal abortion accounted only for 1.5% of deaths reported. Although abortion is prohibited by law, in Suriname it is a tolerated practice. Nonetheless, it remains a common activity for women, who went through self-induced abortions with misoprostol, to seek safe surgical evacuation in hospitals by certified or in training gynecologists. The same study notes that the illegality of the practice is the main cause for underreported abortions. (Kodan, Verschueren, Roosmalen, et. al. 2017) Maternal Death Cases Below we include some references to cases of maternal deaths linked the current analysis Curacao: “A recent example is the death of a young woman in 2007 due to complications of a self-induced abortion, leaving behind her one year old daughter.” (Boersma, 2011)Jamaica “I recall a case when I was a medicine resident student. A woman visited a health facility to get an abortion. The time of pregnancy was underestimated and serious complications arose from the procedure. The patient was advised to stay in a hospital overnight. Yet she refused because she did not want her family to know what she was doing. Finally, she went home and her condition deteriorated. Afterwards she died of post abortion complications” (Dr. Michael Abrahams for The Gleaner, 2017)Dominican RepublicMassiel was twenty-four years old and the mother of a five-year-old girl when she took abortion pills. Afterwards, she presented post abortion complications yet she did not reach appropriate healthcare immediately because of fear-based reasons. Once the pain became insufferable Massiel visited two health centers and a private doctor. After the medical consults she was only prescribed with pain relief medications. She tried to look for a third opinion and therefore ended up in a public maternity hospital where she was informed that required exams for her condition were not available within hospital services. Once more, she seeks for an additional opinion. Massiel went to a private clinic to be assisted with the medical required procedures. Diagnose was informed: the only way to cure her infection was by amputating her legs. Sadly, Massiel ended up dying just a couple of days later. ( Colectiva Mujer y Salud and Womens Link, 2017)Trinidad and Tobago achieved the millennium development goal when it comes to battling maternal mortality rates. The civil society of Trinidad and Tobago has made it a priority that all births in the country must be delivered by skilled personnel. Furthermore, antenatal and reproductive health services are widely available, except for abortions, which remain illegal in most cases (Commonwealth Foundation, 2013). Fatal complications caused by unsafe abortions are very present in the public health ministries covered in this study. Numerous life stories point out that women suffering from these complications are seen daily in public hospitals. After auditing a gynecology department in Curacao, it was found that in one year fourteen women were admitted in the hospital with complications of TOP: six after instrumental and eight after medical termination of pregnancy. Of these eight, three women had induced abortion themselves with misoprostol. Two ectopic pregnancies were detected after provision of TOP by a GP: one after a TOP, the other after a medical TOP. The complications were pain and/or prolonged blood loss, sometimes with significant fall in hemoglobin levels; in two cases, blood transfusions were required. Curettage was performed on all these women, except in one case where there was a wait and see policy after a medical TOP. In one woman the abortion debris was infected. (Boersma, 2011)In 2014, the Victoria Jubilees Hospital located in Jamaica completed a study focused on attempted termination of pregnancies. Their findings show that 43 per cent of expectant mothers who were admitted with complications had attempted abortion. Furthermore, in October 23rd and 27th of 2017 five of 18 women who presented themselves to the Early Pregnancy Unit, admitted to having attempted a termination of pregnancy. Findings also exposed doctor’s involvements in four of the five abortion attempts (The Gleaner, 2017).The consulted expert in Suriname stressed the unsettling situation of an increasing number of teenage girls visiting the emergency rooms due to abortion complications. Maternity hospitals in Dominican Republic perform about nine procedures of uterus evacuation as treatment for incomplete abortions daily. According to the hospital?s management about 25% of women that go through the procedure are adolescent girls. (Listin Diario, 2016). Social CostSeveral cases of obstetric violence and medical personnel mistreatment have been reported from health civil society groups in the Dominican Republic. This issue has become a normalized activity that targets women requesting post care services in public health ministries after unsafe abortions complications. The local informant recalls how frequent the “threatening the patient” practice has become from nurses with the sole purpose of making a woman confess to having an abortion. In several scenarios, Dominican medical personnel use intimidation and shaming to punish women after an empowered decision to terminate a pregnancy. The “make her feel guilty” mechanism is one of the rituals that promotes the stigma within public state health institutions. Women in Jamaica are taught that abortion equals to crime. In the same manner, the woman who seeks an abortion service is considered a child killer. Although, Jamaican law does not penalize abortions resulting from rape or incest, the only hospital that offered these exceptional services was closed in the 90’s. The available data for Dominican Republic, Haiti and Jamaica is consistent with the fact that 20 to 21% of women have been victims of physical and/or sexual violence by an intimate partner. (UN Women Global Database on Violence Against Women, 2018)Physical violence is the main and most frequent type of violence faced by Dominican women daily. The numbers point out that being victim of sex abuse results in a higher risk for women to suffer from physical/mental health disorders. It is also a direct cause and result of unwanted pregnancies. Table 10. Lifetime Physical and/or Sexual Intimate Partner Violence *Jamaica20%(2008)Haiti21 % (2012)Dominican Republic20% (2013)Source: UN Women Global Database on Violence Against Women, 2018*Data was only available for mentioned countriesRural women in Guyana use abortions as contraceptive methods. There is a stigma towards abortion because women will be perceived as “bad women”. In Catholic circles the stigma is heavier. In the Dominican Republic Christianity remains the predominant religion. A majority of the population is Christian, for women admitting to an abortion, especially young unmarried women, it means they will be considered promiscuous and without control of their lives.Social and reproductive health is taboo in Haiti, young people don’t have access SHR services, quality education on SHR or family planning. In Haiti women recall the shame that comes from having abortions, which is something that rich women who can travel overseas for the service do not have to confront. A frequent social tragedy is the maternal deaths connection to orphaned children; considering that childcare is one of the central roles appointed by patriarchal Caribbean societies. When a child grows up without mother and without economic means it translates to be socially left out and unprotected. In a study done on maternal death in the Dominican Republic, out of the seven cases reported all women left orphan children, most of which were disengaged from the protection of core family members. Economic CostThis section of costs is based on the economic process of how much women pay to get abortions. Guyana is the only country that provides abortion services without a significant economic cost. In all the other countries studied abortion has a monetary cost because insurance companies do not cover this medical service. Another influencing factor is the variety of pricing depending on the abortion method. If the abortion method consists in the self-administering misoprostol pills, the cost is relatively cheap. Yet, if women try to get the medicine through clandestine clinics the cost is much higher. According to Haiti informants, a clandestine abortion provider or “charlatan” can cost from US$50 to US$100. Is important to highlight that this practice is related to a higher rate of complications. In Dominican Republic a clandestine abortion clinic charges from US$150 to US$200. While beverages or misoprostol pills go from zero to US$10. In Curacao, under the Tolerance Policy, recognized practitioners can provide safe abortion services. Nonetheless, the main barrier is gaining access to professional care without economic costs. According to Boersma, this economic limitation becomes the main reason why for women in Curacao less safe abortions are frequent.Once abortions are performed, safe or unsafe, health complications may arise, however, when safe legal abortions are performed by trained professionals and under hygienic conditions less than 0.3% lead to complications that require facility-based care (Henshaw, 1999 cited by Prada, Singh, Remez, et. al. 2011). Equally important, unsafe abortions are the cause of unexpected costs at different levels (see figure 2). Many women will look for attention in the healthcare system but others because of restrictions and diverse barriers will look for solutions elsewhere. (Vlassof et al. 2010) A comprehensive estimation of cost should include the expenditures that women and their families experience in the long term, including the loss of productive days because of physical and mental health complications, but studies that consider this scope of impact are not available. A more focused approach is to measure the cost generated within the formal health care systems, taking into account how much money the states and people spend receiving attention after abortion complications. Figure 2. Analytical framework for estimating the economic cost of serious complications from unsafe abortions, by Vlassof et. al. (2010). In the Dominican Republic a gynecologist from one of the busiest maternal hospitals in Santo Domingo, who was consulted for this study, stated that direct cost of post abortion care for the public service is around US$50 to US$120 for treating bleeding and incomplete abortions. Between US$280 to US$330 for the treatment of sepsis and up to US$470 for uterine perforation. These services offered for free in public hospitals tend to be more precarious than in private clinics. It is also common that some services are not available inside the hospital in some instances, patients need to get them through private providers (for example specialized imaging and laboratory testing is often not available in public hospitals) which adds an out of pocket cost. The anecdotic amounts obtained for the Dominican Republic are aligned with a study performed in Colombia, where the average cost of post abortion care was US$136 for treatment in secondary facilities, and US$151 for tertiary facilities, this study also added that costs were highest for perforations ($609) and shock ($512), followed by sepsis ($355) and lacerations ($203). Estimates of Vlassof et al. (2010) found the average per-patient cost of post abortion care in Latin America in 2006 was US$94; when considering the overall cost for Latin America, the Regional estimates of the annual number of post-abortion cases treated and health care system costs (2006 US$) ranges from $70,000,000 to $135,000,000 (Vlassof et. al. 2010). It is important to note that less costly and less severe complications are far more common than the more serious more expensive complications, in the report for Colombia incomplete abortions accounted for the vast majority of treated complications (86%) followed by shock (9%), sepsis (4%) while laceration and perforation accounted for less than 1% (Prada, Maddow-Zimmet, Juarez, 2013). The number of abortions resulting in complications that require medical care is unknown for the Caribbean countries considered, however taking the Colombia data as a parameter, an estimated 33% of women with abortion complications will need medical assistance (Guttmacher, 2013) and an estimated 15–25% of all women who have unsafe abortions will not seek care (Singh, 2006 cited by Vlasoff et al., 2010), if considering that this proportion is applicable to our countries, we could infer that the burden, both in women’s pockets and in the states, is significant. One last observation is that women also face more limitations than men when it comes to economic opportunities. Taking the differences in unemployment rate between males and females (see table 11) it can be observed how, in the countries studied, men getting their own income is more plausible than women. This lack of financial resources for women leads to less safe abortion practices and less possibilities to receive the needed care, especially those women living in poverty. Table 11. Unemployment rate by country and sex, 2016CountryFemale Male CuracaoNANADominican Republic21.49.1Guyana15.69.4Haiti15.711.9Jamaica17.59.7St. Lucia28.518.3Suriname13.65.4Trinidad and Tobago4.83.3Source: World Bank Gender Data PortalMapping of Actors: Who has influence in abortion policies?-827405207645For the mapping of actors, we have used the Stakeholder Salience Analysis proposed by Mitchell, R. K., Agle, B. R. and Wood. D. J. (1997). This analysis considers the relation of three characteristics: Power, Legitimacy and Urgency, these may overlap and are represented in a Venn diagram where the considered actors can be mapped in one of the following areas: Dormant Stakeholder: Possess power to impose their will through coercive, utilitarian or symbolic means, but have little or no interaction /involvement as they lack legitimacy or urgency.?Discretionary Stakeholder: Posses legitimacy but it has no urgency or philanthropy. Demanding Stakeholder: Those with urgent claims, but no legitimacy or power. Dominant Stakeholder: The group that many theories position as the only stakeholders of an organization or project. Likely to have a formal mechanism in place acknowledging the relationship with the organization or project.Dangerous Stakeholder: Those with powerful and urgent claims will be coercive and possibly violent. Dependent Stakeholder: Stakeholders who are dependent on others to carry out their will, because they lack the power to enforce their stake. Advocacy of their interests by dominant stakeholders can make them definitive stakeholders.Definitive Stakeholder: An expectant stakeholder who gains the relevant missing attribute. Often dominant stakeholders with an urgent issue, or dependent groups with powerful legal support. (Taken from )When it comes to the liberalization of abortion there is a clear pattern of actors in all the countries consulted. The general scenario is that religious groups lead the opposition of legal access to abortion. Political leaders tend to have a more neutral approach that varies depending on the influence that religious groups may have on partisan politics, while women’s rights groups, in many cases associated with the health sector, are the voices that advocate for legal and safe abortions. Nonetheless the urgency on the subject for each actor varies from country to country. It is important to stress that, as appointed in the anthropological analysis, restrictive gender roles play against the quest for legal and safe abortions; the value of motherhood in women, and the inequalities of power in public life that affect women are a barrier to put women’s health and reproductive needs in the center of a rational discussion, instead of dominant patriarchal values. Guyana Dominant stakeholdersGuyana’s government is ruled by the coalition party A Partnership for National Unity (APNU) in which conservative sectors that have more ties to a specific anti-abortion religious group can be found, even when Guyana has 6 officially recognized religions; at the moment there is no action by the Guyanese government towards changing the abortion legislation. The American and Brazilian branches of the evangelical church have a lot of power and legitimacy in Guyana, they have presence and supporters in the whole Guyanese territory and have a lot of resources as well. These churches have very conservative points of view when it comes to women’s role and their reproductive rights, and they are also part of the mainstream culture. These groups are the main opposition when it comes to accessing abortions, according to our informants. In recent times there have been protests from evangelical groups in the border clinics of the Responsible Parenthood Association because abortions are performed there, but these protests were not systematic and were considered one-time occurrences rather than part of an ongoing agenda. The focus of the most conservative religious groups in Guyana has been the persecution of sexual diversity and the anti LGBT manifestations, as abortion became legal in Guyana the discussion of its penalization is out of the public conversation. The Catholic Church is also a dominant stakeholder but there are factions inside this institution that accept the need of abortion in certain circumstances. Back in 1995, when the Medical Termination of Pregnancy Act in Guyana was issued, the catholic church was the main opponent, since then this institution stopped advocating on the matter and shows no urgency in establishing more restrictive legislation, there are parties inside the catholic church that opposed abortions, but these are not being vocal on the subject. Demanding StakeholderWomen in Guyana are in a demanding position, there is a need among them to access all types of sexual and reproductive health services. Women in Guyana have gained consciousness of their rights and needs, but the country is still a male dominated society, with big influence from conservative religious groups. Many women are prohibited to use contraception either by their partners or their church, so it’s a challenge for Guyanese women to speak publicly about their need for reproductive services, including the need of safe abortions. Definitive stakeholdersAdvocacy groups for women’s rights and for sexual and reproductive rights are definitive stakeholders when it comes to access to safe abortions in Guyana. Organizations like Guyana Responsible Parenthood Association (GRPA) were at the frontline of activism for the legalization of abortion that resulted in the Medical Termination of Pregnancy Act. GRPA submitted a subpoena to Guyana’s Supreme Courts in 2014 requesting permission for providers in the second level of care (medexes, midwives, nurses and pharmacist providers) to be able to perform medical abortion procedures; by law abortions were only allowed to be performed by doctors (third level of care) but these professionals are scarce in Guyana, especially in rural areas. It was also GRPA who offered free abortion services starting in 2016, so even though abortion has been legal since 1995. It is only recently that it has become a relatively accessible service, and it is so as a result of the efforts of GPRA, with the support of other local organizations and international networks like IPPF and Women on Waves. Men population in Guyana are also a definitive stakeholder because they have a dominant voice in their families and communities and a lot of agency, not many men speak about abortion, but those who do, speak against it. Especially in certain ethnic groups abortions and contraception are seen by men in a negative way because to them they are a symbol of promiscuity in women. JamaicaDominant Stakeholders The ruling political class. This social group has the power legitimacy to assume policies to legalize abortions, yet the issue has no urgency in their agendas. The informant reached for this study states that Jamaican politicians would rather not confront religious groups. Instead they just adopt more conservative measures to avoid controversy. Abortion is not a matter of discussion among Jamaican politicians but in several occasions government officials, like Health Minister Dr. Christopher Tufton, have addressed it. The politician declared the importance of having a national dialogue to address the dangers of unsafe abortions (The Gleaner, 2017). Nonetheless, Dr. Tufton’s declarations didn’t advocate directly to the liberalization of abortions but rather stated that the matter should be brought up to the public opinion because of a wide prevalence of morbidity produced by unsafe abortions.Religious groups such as Catholics and other Christians, Rastafarians and Muslim communities are antiabortion. These groups have a lot of influence over people and the government which gives them power and legitimacy. Currently, changing the abortion legislation is not a topic in Jamaica’s public opinion discussions, so keeping abortion restrictive laws is not an urgent matter among religious groups. However, if the matter is brought up to discussion the perception is that these groups will take a stand against the legalization of abortions. Discretionary StakeholdersWomen groups like Family Planning Jamaica, Jamaica for Justice and others have gained legitimacy and some power but are still in a discretionary position when it comes to abortions. These groups have a louder voice in subjects like violence against women or violence against children for which they have participated in consultations and policy making with the government. The need for access to legal and safe abortions is recognized by this actor but there is not an advocacy agenda on the legalizations of induced abortion right now. Another discretionary stakeholder is most of the male population in Jamaica which, according to our informants, is against abortion in most cases, as per request of the woman. They are more prone to accept under certain circumstances like saving a woman’s life or to preserve physical and mental health. Culturally, Jamaican men value having a lot of children and there is still the belief that men should have control of the bodies of their women partners. Jamaican men have dominant voices in their communities and families plus they are a majority in the country’s parliament, however Jamaican men do not seem to be active in the discussions about abortions. Women are similarly attached to their gender role, which in this case is being good mothers and caregivers, not necessarily decision makers. Even though Jamaican women do get abortions daily, these are done silently, and there is not an expressed urgency from the Jamaican female citizens to start a reform on abortions. Women have gained a voice as active participants of their communities and their families but it’s hard to transform that legitimacy into power when they are not organized in platforms or institutions. SurinameDominant StakeholdersSuriname Men have been positioned as dominant stakeholder because it is men who dominate big institutions. It is also perceived that they have no urgency on the abortion matter as they see it as woman’s issue, unless they are personally affected by an unwanted pregnancy in which case they will support that the woman gets an abortion, but there is no clear, strong position of Suriname men on the subject. Political actors in Suriname have a conservative anti-abortion position in their majority since the political class has ties with religious groups. There have been some voices claiming the legalization of abortion in the government, but these have been shot down by the pressure of conservative allies. There is no urgency by the political actor to commit to a specific agenda either pro or against the legalization of abortions. The Pentecostal church is very influential and has many supporters in Suriname, but as in the Guyana case, their urgency when it comes to abortions is not currently relevant because their focus is in fighting against the acceptance of sexual diversity or orientation rights. Demanding StakeholdersSuriname is a very religious country with a Christian majority, so the main public discourse is rejection of abortion, but in fact abortions are widely practiced. Yet, women who get them carry a considerable burden of guilt. Still, Suriname women believe they are the ones to decide if they will get an abortion even if their male partner does not agree with it. But when it comes to public life their influence is minor, high political authorities are still dominated by men with only 14% of women in the parliament. Discretionary StakeholdersWomen groups in Suriname have partnered with the government to gather data and analyze the state of rights for Surinamese women. They play an important role as consultants for the political class that sets the basis for their legitimacy; however, these groups lack access to final decision making. Although institution like the LOBI foundation have addressed publicly the importance of legalization and a lift of barriers to access safe abortions, there’s a feeling that there are other priorities in the public agenda, like the improvement of the healthcare system, which is being affected by a profound crisis that if not contemplated; even if abortion was to be made legally available it would represent an important barrier to access it in a safe manner. HaitiDormant StakeholdersIt is important to stress that most Haitians, including most politicians agree that abortion should be available to save a woman’s life or if the pregnancy is a product of rape. When it comes to seeing abortion as a right to choose, over an unwanted pregnancy, opinion is divided (Profamille, IPPF, 2017). In this discussion Haitian politicians, the president and the parliament, have a dormant role because of their power to change the law, although there is also an important amount of distrust for the government by Haitian people (only 18% of the electorate participated in 2016 elections). The Haitian government lacks real urgency on the matter of abortions according to the experts, the discussion about abortion legalization has been in the public sphere for a long time. In 2015 a presidential commission was appointed and proposed the new penal code in which abortion was made legal at the request of a woman, this was a result of the pressure of the feminist organizations. This proposal is still up for discussion and no decision has been made accordingly. Dominant StakeholdersThe Catholic and Protestant churches are both together in the anti-abortion position, these groups have a lot of power and influence in the Haitian government, many parliamentarians and career politicians are very religious so both churches have important political allies. However, there is not a specific movement from these churches trying to push and anti-abortion agenda, instead these groups tend to react whenever legalization of abortion is up to discussion. It is also perceived that even though these churches have a lot of influence it’s still in the power of the political ruling class which has shown a liberal approach to the management of public issues. Haitian men are also dominant stakeholders, because they have a lot more power than women when it comes to decision making at the family and government levels. Most men are part of the consensus that abortion should be allowed when the life of a woman is at risk, or in case of rape or incest. But it’s a common position among men to disagree that abortion should be available at the request of a woman, the most liberal men will only agree that a woman shouldn’t make the decision of abortion without consulting her male partner. Dependent Stakeholders Feminist groups like SOFA, and sexual and reproductive rights organizations like Profamile have been very active in the demand of legal and safe abortion for Haitian women; currently the platform “Collective pour la Depenalisation du Avortement” is doing active advocacy to get the more liberal legislation approved. These groups have gained legitimacy as respectable authorities in the matter of women rights and sexual and reproductive rights. An example of this is their work in 2015 with the presidential commission in charge of proposing amendments to the penal code regarding abortion, their influence caused that the most permissive proposal that included abortions at the request of the women for pregnancies up to 12 weeks was the one adopted by the commission and proposed to parliament as opposed to the proposal submitted by the Ministry of Health and Population that included legalization of abortion only to save a woman’s life or in case of rape. However, demands for legal safe abortions have not been met in Haiti, no matter the circumstances, and advocates for this cause still struggle for government officials to make a stand toward it. Demanding StakeholdersMost women in Haiti are very sensible to arguments that allow abortions because of socioeconomic challenges, those who don’t agree tend to be influenced by religious beliefs. It has been found that a common critic among Haitian women about the current state of the law is that rich Haitian women can easily go to the United States or to Quebec to privately get an abortion without getting their reputation affected, while poor women must take the risks carried by clandestine abortions (Profamile, 2017). When it comes to having the voices of these women heard there are limitations, since men control the political power, it’s hard for Haitian women who are not organized to claim for their rights. Dominican RepublicDominant StakeholdersThe President of the Dominican Republic has the power and the legitimacy to influence current policy, and in this issue has acted as a dominant stakeholder. In representation of the executive branch of government, the Dominican Republic’s current president, Danilo Medina, has twice vetoed the promulgation of a new penal code that totally prohibits abortion without considering any exemptions to a woman’s wellbeing. It was the president’s office that introduced specific recommendations for the new penal code to include the three exemptions on which abortion should be performed (1.When the mother’s life is at risk due to the pregnancy, 2.When the fetus has a condition that makes it incompatible with life and 3.When the pregnancy is the result of rape or incest) Due to diverse situations a new penal code is still on hold and abortion is still completely prohibited. Even though the president has exercised his power to promote a more liberal abortion legislation, he’s not considered to be an actor with urgency because his support has come in specific and critical moments rather than as a continuous effort to promote a realistic public policy when it comes to abortions. Men population is in a dominant position because men are leaders inside their families and are a great majority in political power. The male voice also has a lot of legitimacy, and even though men have expressed a positive opinion when it comes to allowing abortion in the three exemptions that are being discussed in the Dominican Republic, there is not an active demand when it comes to access to safe abortions. Discretionary StakeholderHealth authorities have the legitimacy to express the problems that arise because of the lack of access to safe abortions. In many cases both public health authorities and doctor’s associations have expressed their concerns, mostly because of the costs health systems carry as a cause of the morbidity associated to unsafe abortions. However, these groups have not shown a level of urgency that matches the consequences they are against because of the total abortion prohibition, for example according to the current penal code, the sentence for a woman who gets an abortion can be up to two years but the sentence to a doctor that assists in doing the abortion can be up to twenty years. Demanding StakeholderWomen groups like Colectiva Mujer y Salud and sexual and reproductive rights advocacy organizations have been the frontline for the legalization of abortion in Dominican Republic, their advocacy efforts have gained weight in public opinion, impacting the acceptance of abortion as a need, at least in certain circumstances. However, women’s groups don’t have the leverage to impact political decisions and their major support comes from middle class sectors of the country’s capital, this means that rural and lower income women do not necessarily feel represented by these organizations. Women population in this country also acts as a demanding stakeholder, they have a private urgency in accessing safe abortions, but it is not translated into public activism. Additionally, the power of women in public life is limited since even though advancements have been made, political power is still dominated by men. Instead women have a voice, an agency at the community level and it is at this level where solutions for the women that seek abortions are found. Dominican women’s legitimacy in the abortion matter is affected by the stigma that comes from single women exercising their sexuality, the dominant idea is that they need abortions because they were promiscuous. Definitive StakeholderThe Dominican Congress is a definitive stakeholder because it is the institution that has the power to change the current legislation and has the legitimacy of being the public representative of the Dominican people. However, abortion is not the most urgent topic in these politicians’ agenda, it has been a major item of discussion in the attempts to reform a dated penal code that demands to be updated to a 21st century reality. The position in both chambers of congress towards the matter of abortion has been ambiguous, but the last time the matter was discussed the majority of congressmen and women in the lower chamber decided that they would not pass a penal code with a total prohibition of abortion and that exemptions should be taken into account. Conclusions Only one of the eight countries studied (Guyana) has abortions available upon request of the women, all others present restrictive legislations, the Dominican Republic and Suriname being the only two in which legislation does not contemplate any legal exemptions for abortions. Barriers for safe abortions in the countries studied are not limited to restrictive legislation, cultural barriers like fear of shame and stigma, fear of enforcement, lack of knowledge, lack of policies to make services available, unfriendliness of available personnel, and monetary cost of safe abortions also push many women to rely on unsafe abortions. Restrictive legislation is the norm but abortion is a very common practice, evidence strongly points out that the Caribbean countries studied have higher incidence of abortions than in countries with more liberal laws. Restrictive policies and legislation only seem to increase the number of unsafe abortions. The severity of abortion legislation varies from country to country but in general abortion is accepted as a daily practice that happens behind closed doors, however, social shame and stigmatization still cause an important social burden on women. Unsafe abortions are an important cause of health complications for women, which can become fatal, evidence suggest that abortion causes maternal deaths each year for almost all countries studied, causing up to 30% of all maternal deaths in Haiti. Complications of unsafe abortion are an important financial burden for women and their families because of out of pocket expenditure, they are also a burden for public healthcare institutions. 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