Abortion practice in the northeast Caribbean: "Just write down stomach pain"

Small island exigencies and a legacy of colonial jurisprudence set the stage for this three-year study in 2001-2003 of abortion practice on several islands of the northeast Caribbean: Anguilla, Antigua, St Kitts, St Martin and Sint Maarten. Based on in-depth interviews with 26 physicians, 16 of whom were performing abortions, it found that licensed physicians are routinely providing abortions in contravention of the law, and that those services, tolerated by governments and legitimised by European norms, are clearly the mainstay of abortion care on these islands. Medical abortion was being used both under medical supervision and through self-medication. Women travelled to find anonymous services, and also to access a particular method, provider or facility. Sometimes they settled for a less acceptable method if they could not afford a more comfortable one. Significantly, legality was not the main determinant of choice. Most abortion providers accepted the current situation as satisfactory. However, our findings suggest that restrictive laws were hindering access to services and compromising quality of care. Whereas doctors may have the liberty and knowledge to practise illegal abortions, women have no legal right to these services. Interviews suggest that an increasing number of women are self-inducing abortions with misoprostol to avoid doctors, high fees and public stigma. The Caribbean Initiative on Abortion and Contraception is organising meetings, training providers and creating a public forum to advocate decriminalisation of abortion and enhance abortion care.     

Abortion, social inequity, and women's health: obstetrician-gynecologists as agents of change.

Unsafe abortion persists as a serious health problem for women. It is rooted in poverty, social inequity, and denial of women's basic human rights. As experience from Latin America and other regions demonstrates, obstetrician-gynecologists can be leaders in supporting reproductive rights and access to safe abortion, through their professional societies and also by way of their roles as providers, academicians, and advocates. Ob-gyns are often most effective when working in partnership with women's organizations, lawyers, and other stakeholders.     

The reality of unsafe abortion in a rural community in South India

Though the law in India has permitted medical termination of pregnancy on broad legal grounds for over two decades, unsafe abortions carried out by unqualified providers show no signs of decreasing. A community-based study was undertaken in rural South India to determine the prevalence of induced abortion, women's reasons for seeking abortion, who was providing abortions and whether the procedures were safe or unsafe. A cross-sectional study design was used that included focus group discussions with 88 women and a quantitative survey with 195 married women who had a birth interval of two or more years since their last pregnancy. There was a high prevalence of induced abortion (28 per cent) among the study population, mainly among women who were not using contraception. Most abortions were carried out in the first trimester of pregnancy and unqualified practitioners performed 65 per cent of terminations. The preference for illegal, untrained providers in a country where abortion is legally available exposes the ambiguity in the status of abortion and how inadequacies in legal service provision have served to promote and sustain unsafe providers and practices. An integrated approach to family planning and reproductive health which includes abortion is imperative if the reproductive health status of Indian women is to be improved. The poor utilisation of existing government facilities suggests the need for improving the quality of services, expansion of abortion facilities and the introduction of safer methods of abortion. To do this, a re-examination and re-framing of aspects of the 1971 abortion law is needed.     

Does methotrexate confer a significant advantage over misoprostol alone for early medical abortion? A retrospective analysis of 8678 abortions

Objective  The objective of this study was to compare efficacy for four medical abortion regimens used in one clinic setting: (1) misoprostol alone, (2) oral methotrexate + buccal misoprostol, (3) oral methotrexate + vaginal misoprostol, and (4) intramuscular methotrexate + vaginal misoprostol.
Design  Retrospective analysis of data from clinical records.
Setting  An anonymous women's health centre in Latin America, providing medical abortion services since 2001 in a highly restrictive setting.
Population  A total of 8678 women with gestations <56 days, who sought a medical abortion between April 2002 and December 2004.
Methods  Chi-square test was performed to compare patient characteristics by abortion outcome (success/failure). The impact of selected variables on method success was explored through logistic regression. A second regression analysis was conducted with a subsample ( n = 4022), for which data on parity and previous abortion(s) were available.
Main outcome measure  Abortion outcome (success/failure) at 2-week follow up.
Results  Success rates for the three methotrexate regimens ranged from 81.7 to 83.5% and did not differ significantly; misoprostol-alone regimen had a success rate of 76.8%. Efficacy was significantly higher for the three combined methotrexate regimens compared with misoprostol alone and remained so in the multivariate model (OR = 1.35). In the final regression, lower gestational age, being nulliparous, and having no previous abortions were positively correlated with method success.
Conclusions  In this real-use setting, methotrexate appears to confer a significant advantage over misoprostol alone for early medical abortion. This finding is important for settings where mifepristone remains unavailable. Additional factors such as gestational age limits and patient preference should be considered in regimen selection.     

Medical Abortion

Objective: to review medical abortion with emphasis on studies using methotrexate and misoprostol.Data Sources: a MEDLINE search and bibliographies from relevant articles were used. Only studies in English and French with medical abortion using mifepristone, methotrexate and misoprostol were reviewed.Data selection: only studies using mifepristone with 100 or more women were included. All studies using methotrexate and misoprostol alone or in combination were reviewed.Results: in early pregnancy, combinations of mifepristone with prostaglandin or methotrexate with misoprostol are effective for pregnancy termination. When misoprostol is used to augment mifepristone or methotrexate, its vaginal application appears to be superior to the oral route. Vaginal misoprostol (800 μg) is more effective applied five to seven days after the methotrexate than three days after. For inevitable or incomplete abortions, misoprostol alone may be used effectively to avoid surgery. When surgical abortion fails, medical abortion is an excellent back-up treatment.Conclusion: medical abortion with mifepristone or methotrexate plus misoprostol is a safe and effective method of pregnancy termination. Because the complete abortion rate with medical abortion is less than with vacuum aspiration, surgery cannot be completely avoided. Commitment on behalf of both physician and patient is necessary to ensure safety. If mifepristone becomes available in Canada, studies comparing its use to methotrexate will be of paramount importance to help to determine the best method. Further research into medical abortion is important to women’s health as this method is highly acceptable and has the potential to increase access to safe abortion.     

Abortion in a Restrictive Legal Context: The Views of Obstetrician–Gynaecologists in Buenos Aires, Argentina

In Argentina, unsafe abortions are the primary cause of maternal mortality, accounting for 32% of maternal deaths. During reform of the National Constitution in 1994, the women's movement effectively resisted the reactionary government/church position on abortion. Health professionals, including obstetrician–gynaecologists, played conflicting roles in this debate. This article presents results from a study carried out in 1998–1999 of the views of 467 obstetrician–gynaecologists from public hospitals in Buenos Aires and its Metropolitan Area, focus group discussions with 60 of them, and interviews with heads of department from 36 of the hospitals. The great majority believed abortion was a serious public health issue; that physicians should provide abortions which are not illegal; that abortion should not be penalised to save the woman's life, or in cases of rape or fetal malformations; and that women having illegal abortions and abortion providers should not be imprisoned. Some 40% thought abortion should not be penalised if it is a woman's autonomous decision. Those who were better disposed towards the de-penalisation of abortion cited a combination of public health reasons and the need for social equity. The women's health and rights movement should do advocacy work with this professional community on women's needs and rights, given the prominent role they play in reproductive health care provision and in the public sphere.     

Unsafe abortion and postabortion care - an overview

Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.     

Decentralizing postabortion care in Senegal with misoprostol for incomplete abortion

Objective

To expand access to postabortion care (PAC) services in Senegal by introducing misoprostol as a first-line treatment at the community level.

Methods

The present prospective study enrolled 481 women seeking treatment for incomplete abortion at 11 community health posts in Senegal between September 2011 and August 2012. Participants were given 400 μg of sublingual misoprostol and asked to return to the clinic 1 week later to confirm clinical status. At study completion, all women were asked to respond to a series of questions regarding their experience with this method. All care was provided by nurse midwives.

Results

All but three of the study women (99.4%; 474/477) had successful complete abortion after taking misoprostol. Almost all women were satisfied or very satisfied with the treatment (99.6%; 469/471), would select the method again if needed (98.9%; 465/470), and would recommend the method to a friend (99.8%; 468/469).

Conclusion

The results provide further evidence that 400 μg of misoprostol is highly effective for first-line treatment of incomplete abortion. Furthermore, this regimen can be fully provided by nurse midwives, and can be easily and successfully introduced in community health settings where other methods of PAC may not previously have been available. Clinicaltrials.gov: NCT01939457     

Women's perspectives on medical abortion in Mexico, Colombia, Ecuador and Peru: a qualitative study

In Latin America, where abortion is almost universally legally restricted, medical abortion, especially with misoprostol alone, is increasingly being used, often with the tablets obtained from a pharmacy. We carried out in-depth interviews with 49 women who had had a medical abortion under clinical supervision in rural and urban settings in Mexico, Colombia, Ecuador and Peru, who were recruited through clinicians providing abortions. The women often chose medical abortion to avoid a surgical abortion; they thought medical abortion was less painful, easier or simpler, safer or less risky. They commonly described it as a natural process of regulating their period. The fact that it was less expensive also influenced their decision. Some, who experienced a lot of pain, heavy bleeding or a failed procedure requiring surgical back-up, tended to be more negative about it. Regardless of legal restrictions, medical abortion was being provided safely in these settings and women found the method acceptable. Where feasible, it should be made available but cost should not have to be women's primary reason for choosing it. Psychosocial support during abortion is critical, especially for those who are more vulnerable because they see abortion as a sin, who are young or poor, who have limited knowledge about their bodies, whose partners are not supportive or who became pregnant through sexual violence.     

Making Abortions Safe: A Matter of Good Public Health Policy and Practice

Globally, abortion mortality constitutes at least 13% of maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing abortion mortality and morbidity in countries where they remain high is a matter of good public health policy, based on good medical practice, and an important part of initiatives to make pregnancy safer. This paper examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands: changes at national policy level; abortion training for service providers; the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.     

Induced abortions among adolescent women in rural Maharashtra,India

In a study in rural Maharashtra, India, adolescents constituted 13.1% of the 1717 married women who had an induced abortion during an 18-month period in 1996-1998. The 197 adolescents who were subsequently interviewed had a lesser role in the decision-making process on abortion than women older than them. Most abortions were obtained in the private sector. Though spacing was the main reason for adolescents seeking abortion, prior contraceptive use among them was low. Additionally, they were less likely to receive post-abortion contraceptive counselling or to adopt contraception. Sex selection accounted for more than a fifth of abortions among adolescents. Additional qualitative data from 43 never-married and separated adolescents seeking abortion showed that non-consensual sex made many pregnancies unwanted, and cost, limited mobility, lack of family and partner support and the need for privacy to prevent stigma led many to go to traditional providers, even though safer options existed. Family planning programmes need to address the contraceptive needs of newly married adolescent women as well as unmarried adolescents. Informing adolescents of their legal rights, sensitising providers to adopt an empathetic attitude, and exploring innovative ways of increasing access to safe services for unmarried adolescents are all recommended.     

Making legal abortion available in Brazil: Partnership in pratice

This article describes the participation of feminist groups who work in the area of women's reproductive health and rights in campaigns for the provision of legal abortion in public hospitals in Brazil. Brazilian criminal law permits therapeutic abortion in cases where pregnancy is the result of rape orposes a serious risk to the life of the woman. Today, as a result of the combined efforts of feminists, health professionals and policymakers, more than 20 hospitals in Brazil are officially permitted to perform therapeutic abortions within the existing law. A model programme has also been developed to train service providers to do legal abortions, where the agreement of a hospital board can be obtained. This training has also improved care for illegally obtained, incomplete abortions in those hospitals but not in hospitals where doctors have not been trained. Problems with lack of access and concerns about the lack ofpublic acceptance of abortion remain. Women not only need the right to abortion but also more services and health professionals who are trained to perform abortions across the whole country.     

人工流产后保健

人工流产包括手术流产和药物流产,我国每年人工流产数量庞大,其中重复流产者占比高,年轻未孕的女性比例也非常大,而人工流产后女性在内分泌、子宫、卵巢功能等方面均发生急剧变化,心理上也可能出现焦虑抑郁等问题,因此应重视人工流产后保健.医务工作者应对患者及其家属在术后饮食、休息、卫生及性生活、心理恢复方面给予指导;重视女性术后...     

Supportive counseling before and after elective pregnancy termination

Midwives are likely to encounter women seeking care before or after an elective abortion. National estimates of abortion rates suggest that 43% of women in the United States will have at least one abortion by the time they are 45 years old. By not asking women about abortion experiences, providers risk perpetuating women's guilt, shame, and silence. This article describes the emotional consequences of elective abortion, identifies women at high risk for negative reactions, and offers approaches to counseling about the psychosocial effects of abortion both before and after the procedure. Through the provision of counseling for women who have abortions, providers will be able to assist with coping, identify women who might be at greater risk for psychological sequelae, and offer referrals to those in need.     

Women’s perceptions about abortion in their communities: perspectives from western Kenya

Unsafe abortion in Kenya is a leading cause of maternal morbidity and mortality. In October 2012, we sought to understand the methods married women aged 24–49 and young, unmarried women aged ≤ 20 used to induce abortion, the providers they utilized and the social, economic and cultural norms that influenced women’s access to safe abortion services in Bungoma and Trans Nzoia counties in western Kenya. We conducted five focus groups with young women and five with married women in rural and urban communities in each county. We trained local facilitators to conduct the focus groups in Swahili or English. All focus groups were audiotaped, transcribed, translated, computerized, and coded for analysis. Abortion outside public health facilities was mentioned frequently. Because of the need for secrecy to avoid condemnation, uncertainty about the law, and perceived higher cost of safer abortion methods, women sought unsafe abortions from community midwives, drug sellers and/or untrained providers at lower cost. Many groups believed that abortion was safer at higher gestational ages, but that there was no such thing as a safe abortion method. Our aim was to inform the design of a community-based intervention on safe abortion for women. Barriers to seeking safe services such as high cost, perceived illegality, and fear of insults and abuse at public facilities among both age groups must be addressed.     

Acceptability and feasibility of medical abortion with mifepristone and misoprostol in Nigeria

Objective

To examine the acceptability and feasibility of medical abortion in Nigeria.

Methods

In total, 250 women who were eligible for legal pregnancy termination with a gestational age of up to 63 days since last menstrual period were enrolled in Benin City and Zaria between May 2005 and October 2006. Participants received 200 mg of oral mifepristone in the clinic and then took 400 μg of oral misoprostol 2 days later—choosing to either return to the clinic or take it at home. Women returned 2 weeks later for an assessment of abortion status.

Results

The vast majority (96.3%) of women had successful complete abortions. Ultrasound was used to determine outcome in less than one-third (28.9%) of participants. Most women (83.2%) took the misoprostol at home. Almost all (96.2%) participants were satisfied or very satisfied with the abortion method.

Conclusion

The introduction of medical abortion with mifepristone and misoprostol could greatly expand current method options and improve the quality of reproductive health care in Nigeria and other settings in which access to legal abortion services is limited.     

WHO guidelines and the role of the physician in task sharing in safe abortion care

Globally, many women undergo unsafe abortion, although abortion is extremely safe when done in accordance with recommended guidelines. Hence, many women suffer from abortion-related complications, and unsafe abortion remains a major cause of maternal mortality. The high percentage of unsafe abortion is attributed to the inability of women to access safe abortion services. A critical barrier to access is the lack of trained providers. To address this problem, task sharing and the expansion of health worker roles in abortion care have become a public health strategy to mitigate health worker shortages and reduce unsafe abortion. This chapter provides an overview of the WHO guidance on task sharing in safe abortion care, discusses the special role of physicians, and highlights the complexity of implementing task sharing by analyzing the findings from six country case studies.