A Lesson from Uruguay: Evading the Consequences of Unsafe Abortion Ahead of Legislative Change
“Christina Allain is a student of International Health at the BU School of Public Health since September 2009. She graduated from Boston University in 2006 with a bachelor’s degree in biochemistry and molecular biology and currently works as a research scientist in drug discovery for a pharmaceutical company in Cambridge, Massachusetts while she pursues her MPH.”
Each year worldwide, 67,000 women lose their lives to complications from unsafe abortion. Accounting for 13% of all maternal deaths, low-income countries shoulder an alarming proportion of this burden with over 97% of unsafe procedures occurring in the developing world. (1,2) The legal status of abortion is a major determinant of mortality, which has been shown to decrease, if not disappear, where abortion is legalized. (3) Indeed, when performed by trained personnel and under hygienic conditions, it is one of the safest procedures in modern medicine. Twenty-six percent of the world’s population, however, lives where abortion is considered criminal or is only allowed to save the woman’s life, as is the case in 72 countries. Although these deaths and complications are entirely preventable, they go unrecognized and unaddressed. (4) This paper will discuss the strengths and weaknesses of one program that aims to support women facing unplanned pregnancy in a setting where abortion is severely restricted by law.
Unsafe abortion is defined by the World Health Organization as ‘‘a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.’’ (5) The International Congress on Population and Development (ICPD) identified it as a leading target in the effort to reduce maternal mortality worldwide and in 1994 named it a Millennium Development Goal for 2015. (6) The ICPD went further five years later, reemphasizing the critical role of women in the family unit, to insist that even where abortion is illegal governments must provide family planning, support and medical care for post-abortion complications. (7) To date, few steps have been taken to achieve this. (8)
One notable exception, however, is that of Uruguay. As in other Latin American countries, abortion is only permitted if the pregnancy threatens the woman’s life or health or occurs because of rape. (9) As of 2003, Uruguay was among the countries with the highest rates of maternal mortality due to unsafe abortion in the world, where 25.8% of maternal deaths were attributed to abortion-related complications from 1997 to 2001 nationwide. During the same period at the Pereira Rossell Hospital in Montevideo, which serves the lowest-income population in the country, abortion-related complications accounted for 46.1% of all maternal deaths. (10)
In the face of such disturbing statistics, Uruguay’s medical community decided to act. With the Millennium Development Goals in mind and no changes in the legal status of abortion foreseeable, an NGO run by medical professionals founded the “Sanitary Initiatives Against Unsafe Abortion” (SIAUA) program at the Pereira Rossell Hospital. The program was designed to provide information, counsel, and clinical services to women at risk for unsafe abortion and it specifically targeted the country’s lowest-income population.
Operating within the law, the program took advantage of the “before” and “after” periods surrounding an illegal induced abortion. Women who expressed either uncertainty about the outcome they wanted with their pregnancy or decisiveness about termination were referred to a dedicated clinic where their pregnancy and gestational age would be confirmed, any maternal or embryonic pathologies evaluated, and they would have the chance to discuss why they felt it necessary to consider termination. In some cases, the pregnancy was found to be false or conditions existed that permitted an in-hospital abortion. In others, when the pregnancy was normal and the woman expressed a determination to end it nonetheless, clinicians provided information on all of the available options, from adoption and other social support services to the risks associated with illegal abortion induced by methods commonly used in Uruguay. Misoprostol in particular was one method discussed at length, in terms of its proper dosage, routes, symptomatology, side effects, mechanism of action, effectiveness, complications, and risks of use at late gestational ages. Prescribed as treatment for gastric ulcers, the drug is inexpensive, widely available in developing countries, and triggers uterine contractions if used during pregnancy. (11) No information was supplied on where to obtain drugs, however, and all women were urged to return for a follow up visit for either antenatal or post-abortion care.
As might be expected in a setting where abortion is heavily restricted by law, the most important condition of the “after” visit was confidentiality. With that assurance, any woman reporting having induced abortion outside the hospital was offered privacy, medical, psychological, and social care, and uterine aspiration in the event of an incomplete abortion. All women were provided with an effective contraceptive method as well.
Over the course of the program’s fifteen-month evaluation period, the SIAUA saw a steady increase in participation, roughly 75% of enrolled women return for follow-up, and 439 women out of 495 report having induced abortion outside the hospital, all of whom reported the method used as misoprostol. One case of post-abortion infection, two cases of hemorrhage, and no maternal deaths or severe complications occurred among participants; additionally, no abortion-related maternal deaths and only two cases of post-abortion sepsis occurred at the Pereira Rossell Hospital as a whole during the study period. This compares to an average of four deaths per year and ten cases of post-abortion sepsis occurring in each of the preceding three years. (12)
The Uruguay SIAUA program demonstrates that the burden of unsafe abortion can be alleviated ahead of relaxation of abortion law, and it can serve as a useful model for supporting women facing unplanned pregnancy. Its applicability to other contexts, however, is unclear. It is possible that some of the very factors that made the SIAUA approach successful could manifest as barriers elsewhere. A major determinant of the Uruguayan success, for example, was the leadership of the medical community. Senior medical staff commitment to the program ensured primary care provider cooperation, a critical point, as these were the front line contacts of at-risk women and whose responsiveness stood to have a major impact on the outcome. The Ministry of Health sanctioned the SIAUA after six months, which enabled clinicians to keep records without fear of participants’ prosecution and in turn allowed for more rigorous program assessment. Finally, the guarantee of confidentiality at follow up, perhaps the most important element of the program, protected participants and created a rapport of trust.
In sad contrast, other countries’ medical communities have not similarly led the way on this issue. Given that reproductive and sexual health are human rights of women and maternity is not a disease, Fathalla considers the role of the medical community in this battle and argues that obstetricians must be part of the solution as they have a social obligation to protect women from maternal death for the very reason that maternity is not a disease. (13) This is the underlying reason for success in Uruguay: the mobilization of the Uruguayan medical community in response to this pandemic, which necessarily preceded the establishment of a program as comprehensive and effective as the SIAUA. By viewing sexual and reproductive health through a lens of bioethics, professional commitment, and scientific evidence, obstetricians and the medical community at large are in a unique position to drive medical professionalism forward and protect women’s human rights. (14)
The Uruguayan success implies that much can be done to alleviate the harm of unsafe abortion even where abortion is illegal. Only a persistent and stubborn refusal to acknowledge the problem stands in the way. It is essential to the preservation of families and societies that women have available alternatives to unsafe abortion or access to reliable post-abortion care. The SIAUA in Montevideo provides both and demonstrates the gains that can be made. While the medical community cannot directly effect legislative change, it cannot wait for it to address this issue and, arguably, it has a responsibility to find a way to alleviate the problem until such time as safe abortion is widely available. The power of an attitude like that of the Uruguayan medical community is immense, is demonstrated convincingly by the SIAUA results, and can be measured in the number of lives saved and injuries evaded that would otherwise be the cost each year of continuing to ignore unsafe abortion.
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