Juana Fernandez* was a university student and in the first few months of a new relationship when she discovered she was pregnant.

She was not ready to become a mother in her early 20s, so Fernandez, from Montevideo, decided to have an abortion. At that time, abortion was illegal in Uruguay so she was forced to undergo a clandestine termination. It was a stressful time.

Since then, Uruguay has undergone a seismic shift. In 2012, it decriminalised abortion to allow terminations during the first 14 weeks of pregnancy, making the country the most progressive in Latin America for women’s reproductive rights. For activists in neighbouring states, who are fighting to overturn some of the world’s most restrictive abortion laws, Uruguay has become a model to aspire to.

Apart from Uruguay, only Cuba and Guyana in the region allow elective abortions. In Argentina a bill to allow abortion during the first 14 weeks of pregnancy was voted down in August.

“The [decriminalisation of abortion] was a historic moment – it helped break the stigma,” says Fernandez, now 35. “It’s easier to talk with friends upfront about abortion, and the general public can see that this is a public health concern.”

It has also helped “level out” social inequality. “In the past, only wealthier women could access safe clandestine abortions in clinics,” she says. The less affluent would have to resort to more dangerous methods, such as using wire.

However, she adds: “The most difficult thing now is making abortion seem like a human right.”

Uruguay’s transformation from a country where unsafe abortion was the biggest cause of maternal deaths to one that is leading the way on reproductive rights has taken decades of hard work to change policy and minds. The approach focused on recognising and reducing the harm caused by unsafe abortions and making the issue a public health concern.

In 2001, Leonel Briozzo and colleagues at Iniciativas Sanitarias, a member association of the International Planned Parenthood Federation, launched a programme in the capital city that provided before and aftercare, information and emotional support for women who had undergone clandestine abortions or were considering doing so. At that time abortion was only permitted in very limited circumstances, such as if a woman’s life was in danger.

The programme took a “risk- and harm-reduction” approach. Healthcare professionals operated within the law to reduce injury and death from botched terminations. The method worked. In 2000, unsafe abortion was responsible for an estimated 40% of maternal deaths in Uruguay. By 2015, this figure had fallen to 8%. Uruguay now has the second lowest maternal mortality rate in the Americas, after Canada but above the US, which comes in fifth.

The model, along with a free contraceptive programme, was expanded throughout the country by 2010 and laid the foundations for decriminalisation two years later.

“The Uruguay model is one that other countries in Latin America and developing countries should follow. In my experience, its implementation is often followed by a change in legislation,” says Briozzo, who went on to become Uruguay’s vice minister for public health.

He adds that while the situation has improved and is better than in other countries in the region, there is still social stigma around abortion and several obstacles to accessing services.

When a woman decides she wants to have an abortion, she must meet with a team, including a social worker and psychologist, who are supposed to help her make an informed choice. There is then an obligatory five-day period of reflection, before a gynaecologist will prescribe medication or refer her for a surgical termination.

On top of that, many gynaecologists are conscientious objectors. A gynaecologist who objects to abortion, for reasons of personal morality or religion, is legally required to refer a patient on to someone who doesn’t.



Paysandú is a city on the banks of the Uruguay River, 235 miles north-west of Montevideo and with a population of more than 76,000. It has just one gynaecologist who is not a conscientious objector.

Lucia Olivares, 32, is a macramé artist from Paysandú. She terminated an unplanned pregnancy this year after an 18-day process. Photograph: Michael Vince Kim

Lucia Olivares, a 32-year-old macramé artist, underwent an abortion in the city in May. She remembers the process as long and stressful.



“I wish I’d had my decision respected from the beginning,” she says. “I didn’t need five days to think about it … I felt like my life was on hold and I suffered from anxiety for 18 days because staff didn’t seem to know – or wilfully ignored – the official steps.”

Healthcare professionals are not supposed to influence a woman’s decision, though Olivares felt her wishes were challenged repeatedly.

“During an ultrasound, a consultant told me about the heartbeat of the foetus, while showing me everything on a large screen, without asking me. As I left, they gave me photos of the foetus, which are usually souvenirs for [a prospective parent] who is looking forward to having a child. I sat in a park and cried. I didn’t regret my decision – I just felt very vulnerable and unsupported by medical professionals.”



Olivares plans to submit a formal complaint about her experience. “I think that things can change here, but slowly. It’s necessary for women like me to file complaints and show the cracks in the law where it’s failing. I’m 32, I was really sure of my decision. But a 15-year-old can easily have her mind changed, especially when dealing with social pressure, stigma, parents’ influence, and the romanticism surrounding maternity.”



About 75 miles north of Paysandú, next to the Argentine border, is Salto, a city with 100,0000 inhabitants. Salto has been notoriously resistant to abortion. Soon after abortion was decriminalised, all gynaecologists registered as conscientious objectors, which meant that women had to travel miles to access legal and safe abortions in the capital.



In recent years, the situation has improved in Salto: the city now has three gynaecologists who aren’t conscientious objectors. Yet women say that social stigma still persists.



Margarita Da Rosa, 43, a sociology professor and mother of two, had an abortion in 2015.



“[The multidisciplinary team] tried to make me feel guilty and asked me whether I was really sure about my decision several times. I was getting separated at the time after 23 years of marriage. I was sure. It also felt as if they were constantly trying to delay the process. Uruguay is ahead. But culturally it still has a long way to go in some regions.”

Federica Chalar, 22, who lives in Salto with her four-year-old daughter, says that Uruguay “is on the right track”, but more needs to be done to educate young people about sex.

Federica Chalar, 22, is a trainee teacher and local women’s rights activist. She lives in Salto with her four-year-old daughter. Photograph: Michael Vince Kim

“Abortion is not a contraceptive method, it’s not a situation any woman wants to find herself in,” says Chalar, a trainee teacher and member of Waslala, a local feminist collective that campaigns for legal and safe abortion.

“Family planning services and contraceptives are good and accessible here, but adolescent sex education is so important,” she says, describing current provision for secondary school students as superficial.

Massimo Montes, 17, says: “The assumption is that we already know how to use [contraceptives], that we are well-informed and responsible for our decisions, which is not always the case. At least in my family, no one speaks about contraceptives – perhaps out of embarrassment.”

Last year, at a secondary school in Salto, a sex education class turned into an unauthorised anti-choice session. Student Celina Silvera, 16, says flyers showing pictures of the Virgin Mary holding foetuses were handed out. “This was a class for biology baccalaureate electives, some of whom may go on to become future doctors,” she says.

“Legally, Uruguay is a pioneer, but there isn’t always a correlation between law and cultural progress. Sex education needs to improve.

“We’re getting there as a country. Change starts among small groups of friends, among colleagues and in the family. We have to stop staying quiet and putting up with the small injustices, and justifying violence. We have to speak loudly when things are not all right and seek solutions collectively. We have to inform ourselves and others about the current problems.

“I believe in my generation and its potential to generate lasting change through these collective movements.”

*Some names have been changed to protect identities