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Panel:“Medical abortion pills: how and where do women get them.”
Midwife Ana Labandera Monteblanco Director Iniciativas Sanitarias -
Uruguay
Risk and Harm reduction Model
• Population: 3.3 million
• Maternal Mortality: 23 / 100.000 live births
• Abortion penalized by law since 1938.
Exceptions: • Preserve life of the woman• Rape• Extreme poverty
• Unsafe Abortion was the leading cause of maternal mortality in 2001.
04/21/23
Uruguay
In 2001, an NGO, Iniciativas Sanitarias (IS), developed a
program to decrease maternal morbidity and mortality from unsafe
abortion and the incidence of unsafe abortion
04/21/23
This program is part of the Sexual & Reproductive
Health Lawsince 2008
Iniciativas Sanitarias – Health Initiatives
ICPD Paragraph 8.25 and ICPD+5 Paragraph 63i.
• “Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling”
Our Model follows this important recommendation.
• Risk and Harm Reduction Strategy– Philosophical education strategy without moral opinion about risk
behaviors (Unsafe abortion)
• Professional Values – medical and health care team values.– Vocation – Discipline – Competence – Commitment
• Bioethics Approach– Respect and promote autonomy– Beneficence – Non maleficence – Justice
• Human Rights approach– Right to Health care assistance– Right to information of scientific progress
• Legal Issues and Local Context– Professional Secrecy - Confidentiality
The framework of the model emphasizes
1- TO DIMINISH MATERNAL MORBIDITY AND MORTALITY
2- TO DECREASE THE NEED TO HAVE AN ABORTION, AND THUS, THE OVERALL ABORTION RATE
1- THE OBJECTIVE
ABORTIONABORTION
ILLEGALBEFOREBEFORE AFTERAFTER
THE NEW APPROACH OF “Iniciativas Sanitarias” PROGRAM
04/21/23
• We speak with the woman, face to face, in a horizontal relationship, taking our time to listen to her instead of censoring her, trying to clarify the reason between the two of us: why she thinks she needs an abortion, and what she really feels, deep in her heart.
• It is necessary to align the “thinking and the feeling”, to avoid women feeling guilty or depressed later.
• We allow them some time to reflect, and decide with freedom.
• This is reinforced with a multidisciplinary consultation with the gynecologist or the midwife, (or either of them) with the psychologist.
BEFOREBEFORE
• Carrying out a situation diagnosis• Evaluating risk and protection factors• Assessing decision level of the users• Carrying out therapeutic interventions• Identifying the indicators pointing to possible
post-abortion mental health increased damages.• Referring the patient, or carrying out a follow up,
when necessary.
04/21/23
Ob-gyn or Midwife + psychologistAppointment
ABORTIONABORTION
ILLEGAL
DENIED
BEFOREBEFORE1- Counseling regarding alternatives to abortion
2- Information about abortion methods and their risks: empowerment. (including Misoprostol)
3- Epidemiological analysis
AFTERAFTERPOST-ABORTION CARE
1- Damage Prevention
2- Integral rehabilitation
3- Future contraception(Diminishing the abortion rate)
THE GUIDELINES
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NUMER OF USERS ASSISTED UNDER THE
MODEL: 3215
PERIOD March/2004 – July/2009 PERIOD March/2004 – July/2009
METHODOLOGY
IMPLEMENTATION OF HEALTH INITIATIVES RISK-REDUCTION MODEL IN IMPLEMENTATION OF HEALTH INITIATIVES RISK-REDUCTION MODEL IN THE MAIN WOMEN THIRD LEVEL HEALTH CENTER OF URUGUAYTHE MAIN WOMEN THIRD LEVEL HEALTH CENTER OF URUGUAY
04/21/23
Project supported by:
•F.I.G.O•IPAS•SAAF•IPPF•OMS•UNFPA
METHODOLOGY
Data was collected using a pre-designed form for the “before-abortion” and “after-abortion” visit, filled by the
professionals and identified with a number
IMPLEMENTATION OF HEALTH INITIATIVES RISK-REDUCTION MODEL
04/21/23
PEREIRA ROSSELL HOSPITAL: MAIN WOMENTHIRD LEVEL HEALTH CENTER OF URUGUAY
Age distribution
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0%
10%
20%
30%
40%
50%
60%
70%
menor de 15 16 a 19 años 20 a 34 años 35 o mas sin dato Less than 15 16 to 19 20 to 34 more than 35 No data
84,9 % before 13 weeks
“Gestational Age” in patients
who required our service.
CONTRACEPTION AND CONTRACEPTION AND UNWANTED PREGNANCYUNWANTED PREGNANCY
““BEFORE” VISITS (n: 2206)BEFORE” VISITS (n: 2206)
04/21/23
REASON N %
INTERFERENCE WITH HER LIFE PROJECT
851 38,6%
ECONOMICS PROBLEMS 873 39,6%
NO PARTNER 272 12,3%
SEXUAL VIOLENCE 23 1,0%
TOO MANY CHILDREN 167 7,6%
OTHERS 243 11,0%
Main reasons given when looking for an abortion
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0%
5%
10%
15%
20%
25%
30%
35%
Acceso Salud Falla No tiene Muerte
ADOLESC.
ADULTS
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The main fears that women express PRE-ABORTION
Accessto misoprostol Health Failure of misoprostol No Fears Death
RESULTSRESULTSIN RELATION WITH IN RELATION WITH
THE USE OF THE USE OF MISOPROSTOL MISOPROSTOL
IIHome use of misoprostol to interrupt
pregnancy
Use of misoprostol in the sample analysed. Use of misoprostol in the sample analysed.
Method used N %
Misoprostol 448 89,6Misoprostol +
LEC3 0,6
Total misoprostol
451 90,2
Other 4 0,8Total 455 91
IIHome use of misoprostol to interrupt
pregnancy
Self-administration of misoprostol
Route of administratio
nN %
Muccal mucosa 51 11,3Oral 11 2,4
Vaginal 325 72,1Combined 60 13,3
USE OF MISOPROSTOL 451
IIHome use of misoprostol to interrupt
pregnancy
Misoprostol dose used
Dose Used (mcg)
N %
400 26 5,8600 12 2,7800 367 81,4
900-1500 14 3,11.600 10 2,2
> 1600 7 1,6
USE OF MISOPROSTOL 451
81,4 % 1 or 2 doses
II Home use of misoprostol to interrupt
pregnancy
Time between self-administration of misoprostol and expulsion.
Time use/expulsion N %
menos de 6 horas 162 35,9
6 to 11 hours 139 30,8
12 to 23 hours 22 4,9
66,7 % under 12 hours
USE OF MISOPROSTOL 451
IIHome use of misoprostol to interrupt
pregnancy
Post-use Complications of misoprostol
Complications N %
Other mild 12 2,4
Mild infectious 7 1,6
Milb bleeding leves 10 2,0
NO COMPLICATIONS
423 84,6
USE DE MISOPROSTOL 451
84.6 WITHOUT COMPLICATIONS
• Most women come to us after having decided to undergo an abortion
• Most common reasons for abortion: life PROJECT and economic problems
• 10% of women did not end up with illegal abortion
• 55% did engage in abortion but under safer conditions
• 21% continued with pregnancy
• Misoprostol (self-administered and in the context of the health program) is very effective and safe.
CONCLUSIONS AND PERSPECTIVES
• In the black market.
• Some women help others when they have extra pills.
• In friendly pharmacies.
• Through internet.
• Using cell phones in public restrooms at shopping malls.
• Very high prices.
HOW AND WHERE
• At the professional associations level, we are working for the Ministry of Public Health to enforce Act 18426 of Sexual and Reproductive Health Rights, and for it to regulate the ambulatory use of misoprostol to treat incomplete abortions.
• To prescribe or not to prescribe?
• Professionals as guarantors of sexual and reproductive rights
HOW AND WHERE
CONCLUSIONS AND PERSPECTIVES
• Since 2004, Uruguay has been a country that, in spite of a restrictive abortion law, provides comprehensive health care services to women with unwanted pregnancies
• Maternal mortality has declined in recent years in hospital and throughout the country
• Patients visit the Service in earlier stages of pregnancy
04/21/23
5- PERSPECTIVES AND CHALLENGES
• EXPAND THIS SUCCESSFUL MODEL IN URUGUAY
• SHARE THE MODEL IN LATIN AMERICA AND BEYOND
• INCREASE PROFESSIONAL COMMITMENT WITH SEXUAL AND REPRODUCTIVE RIGHTS
• TRANFORM THE PROFESSIONAL – PATIENT RELATIONSHIP TO:– EMPOWER WOMEN – DEVELOP PROFESSIONAL VALUES
GRAFICO 5- MORTALIDAD MATERNA EN URUGUAY Y EN EL CHPR (2000- 2007)
0
20
40
60
80
100
120
2000 2001 2002 2003 2004 2005 2006 2007 2008
AÑOS
TA
SA
M.M
. / 1
00.0
00 R
NV
URUGUAY
CHPR
Lineal (CHPR)
Lineal (URUGUAY)
GRAFICO 5- MORTALIDAD MATERNA EN URUGUAY Y EN EL CHPR (2000- 2007)
0
20
40
60
80
100
120
2000 2001 2002 2003 2004 2005 2006 2007 2008
AÑOS
TA
SA
M.M
. / 1
00.0
00 R
NV
URUGUAY
CHPR
Lineal (CHPR)
Lineal (URUGUAY)
GRAFICO 6- MORTALIDAD MATERNA POR APCR URUGUAY Y CHPR
0
10
20
30
40
50
60
70
80
2000 2001 2002 2003 2004 2005 2006 2007 2008
AÑOS
FR
EC
UE
NC
IA R
EL
AT
IVA
DE
M.M
. PO
R A
.P.C
.R.
URUGUAY
CHPR
Lineal (URUGUAY)
Lineal (CHPR)
GRAFICO 6- MORTALIDAD MATERNA POR APCR URUGUAY Y CHPR
0
10
20
30
40
50
60
70
80
2000 2001 2002 2003 2004 2005 2006 2007 2008
AÑOS
FR
EC
UE
NC
IA R
EL
AT
IVA
DE
M.M
. PO
R A
.P.C
.R.
URUGUAY
CHPR
Lineal (URUGUAY)
Lineal (CHPR)
INGRESO A C.T.I. POR COMPLICACIONES DEL ABORTO INSEGURO
0
2
4
6
8
10
12
14
16
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
AÑO
FR
EC
. RE
LA
TIV
A D
E IN
GR
ES
O A
C.T
.I.
C.H.P.R.INGRESO A C.T.I.PORCOMPLICACIONDEL A.P.C.R.
Lineal (C.H.P.R.INGRESO A C.T.I.PORCOMPLICACIONDEL A.P.C.R.)
ADMITED TO THE ICU DUE TO UNSAFE ABORTION COMPLICATIONS
