Abortos seguros e inseguros: Costos monetarios totales y costos para el sistema de salud de la Argentina en 2018 / Safe and unsafe abortions: Total monetary costs and health care system costs in Argentina in 2018

RESUMEN Durante el primer semestre de 2018, en Argentina se inició un profundo debate sobre la legalización de la práctica del aborto, que puso en evidencia la falta de estudios científicos que aborden la dimensión económica del tema en la Argentina. Este trabajo busca avanzar en la cuantificación de los costos del aborto bajo dos escenarios: el del actual contexto de ilegalidad y los costos potenciales si se aplicaran los protocolos internacionales recomendados, en un contexto de legalización de la práctica. Los resultados de la comparación de los costos monetarios totales en 2018 (privados o de bolsillo y para el sistema de salud) del escenario actual de ilegalidad y práctica insegura del aborto, frente a escenarios potenciales de prácticas seguras, muestran que se podría ahorrar una gran cantidad de recursos si se implementaran los protocolos recomendados. Dichos resultandos, además, se muestran robustos al realizar una serie de ejercicios de sensibilidad sobre los principales supuestos incluidos en las comparaciones.

ABSTRACT During the first semester of 2018, a profound debate on the legalization of the practice of abortion was initiated in Argentina, which exposed the lack of scientific studies addressing the economic dimension of abortion in this country. This work seeks to move forward in the quantification of the costs of abortion under two scenarios: the current context of illegality and the potential costs if the recommended international protocols were applied in a context of legalization of the practice. The results of the comparison between, on the one hand, the total monetary costs in 2018 (private or out-of-pocket expenditure and costs for the health care system) of the current scenario of illegality and unsafe practice of abortion and, on the other hand, potential scenarios of safe practices, shows that a large amount of resources could be saved if the recommended protocols were implemented. These results proved to be robust after carrying out a series of sensitivity exercises on the main assumptions included in the comparisons.

Maus-tratos e discriminação na assistência ao aborto provocado: a percepção das mulheres em Teresina, Piauí, Brasil / Maltreatment and discrimination in induced abortion care: perception of women in Teresina, State of Piauí, Brazil

Resumo O tratamento das complicações do aborto provocado pode ser dificultado por atitudes de discriminação praticadas por profissionais de saúde nos hospitais e serviços de aborto. Este artigo recuperou histórias de violência institucional entre mulheres que provocaram o aborto em condições ilegais e inseguras. Foram entrevistadas 78 mulheres internadas em um hospital público de referência em Teresina por complicações do aborto provocado. Utilizou-se roteiro semiestruturado com perguntas sobre práticas e itinerários de aborto e violência institucional durante a internação. Práticas discriminatórias e de maus-tratos durante a assistência foram relatadas por 26 mulheres, principalmente entre aquelas que confessaram a indução do aborto. Julgamento moral, ameaças de denúncia à polícia, negligência no controle da dor, longa espera pela curetagem uterina e internação conjunta com puérperas foram os principais tipos de violência institucional narrados. As práticas de violência institucional na assistência ao aborto provocado violam o dever de acolhimento do serviço de saúde e impedem que as mulheres tenham suas necessidades de saúde atendidas.

Abstract Treatment of complications resulting from induced abortion may be hampered by discriminatory attitudes manifested by healthcare professionals in hospitals and abortion services. This article retrieved stories of institutional abuse directed at women who had an induced abortion in illegal and unsafe conditions. Seventy-eight women admitted to a public hospital in Teresina for complications after an induced abortion were interviewed. A semi-structured script was used with questions about practices and itineraries of abortion and institutional violence during hospitalization. Discriminatory practices and maltreatment during care were reported by 26 women, especially among those who confessed to induction of the abortion. Moral judgement, threat of filing a complaint to the police, negligence in the control of pain, long wait for uterine curettage, and hospitalization with mothers who have recently given birth were the main types of institutional violence reported by women. Cases of institutional violence in the care of induced abortion violates the duty of the healthcare service and prevents women from receiving the necessary health care.

Temporal trends and spatial distribution of unsafe abortion in Brazil, 1996-2012 / Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012 / Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012

OBJECTIVE To analyze temporal trends and distribution patterns of unsafe abortion in Brazil. METHODS Ecological study based on records of hospital admissions of women due to abortion in Brazil between 1996 and 2012, obtained from the Hospital Information System of the Ministry of Health. We estimated the number of unsafe abortions stratified by place of residence, using indirect estimate techniques. The following indicators were calculated: ratio of unsafe abortions/100 live births and rate of unsafe abortion/1,000 women of childbearing age. We analyzed temporal trends through polynomial regression and spatial distribution using municipalities as the unit of analysis. RESULTS In the study period, a total of 4,007,327 hospital admissions due to abortions were recorded in Brazil. We estimated a total of 16,905,911 unsafe abortions in the country, with an annual mean of 994,465 abortions (mean unsafe abortion rate: 17.0 abortions/1,000 women of childbearing age; ratio of unsafe abortions: 33.2/100 live births). Unsafe abortion presented a declining trend at national level (R2: 94.0%, p < 0.001), with unequal patterns between regions. There was a significant reduction of unsafe abortion in the Northeast (R2: 93.0%, p < 0.001), Southeast (R2: 92.0%, p < 0.001) and Central-West regions (R2: 64.0%, p < 0.001), whereas the North (R2: 39.0%, p = 0.030) presented an increase, and the South (R2: 22.0%, p = 0.340) remained stable. Spatial analysis identified the presence of clusters of municipalities with high values for unsafe abortion, located mainly in states of the North, Northeast and Southeast Regions. CONCLUSIONS Unsafe abortion remains a public health problem in Brazil, with marked regional differences, mainly concentrated in the socioeconomically disadvantaged regions of the country. Qualification of attention to women’s health, especially to reproductive aspects and attention to pre- and post-abortion processes, ...

OBJETIVO Analisar tendências temporais e padrões de distribuição espacial do aborto inseguro no Brasil. MÉTODOS Estudo ecológico realizado com base nos registros das internações hospitalares de mulheres por abortamento no Brasil, no período de 1996-2012, obtidos do Sistema de Informações Hospitalares do Ministério da Saúde. Estimou-se o número de abortos inseguros segundo local de residência, utilizando-se técnicas de estimativas indiretas. Foram calculados os indicadores: razão de aborto inseguro por 100 nascidos vivos e coeficiente de aborto inseguro por 1.000 mulheres em idade fértil. As tendências temporais foram analisadas por regressão polinomial e a distribuição espacial utilizando os municípios brasileiros como unidade de análise. RESULTADOS Foram registradas 4.007.327 internações hospitalares por abortamento no Brasil no período. Estimou-se um total de 16.905.911 abortos inseguros, com média anual de 994.465 abortos (coeficiente médio de aborto inseguro de 17,0 abortos/1.000 mulheres em idade fértil e razão de 33,2 abortos inseguros/100 nascidos vivos). O aborto inseguro apresentou tendência de declínio em nível nacional (R2: 94,0%; p < 0,001), com padrões desiguais entre as regiões. As regiões Nordeste (R2: 93,0%; p < 0,001), Sudeste (R2: 92,0%; p < 0,001) e Centro-Oeste (R2: 64,0%; p < 0,001) apresentaram tendência de declínio, enquanto a região Norte (R2: 39,0%; p = 0,030), tendência de aumento, e a região Sul (R2: 22,0%; p = 0,340), de estabilidade. A análise espacial identificou a presença de clusters de municípios com altos valores de abortos inseguros, localizados especialmente em estados das regiões Norte, Nordeste e Sudeste. CONCLUSÕES O aborto inseguro se mantém ...

Complicated illegal induced abortions at a tertiary health institution in Nigeria

Globally it is estimated that 26-53 million induced abortions occur annually. An estimated 20 million of these are unsafe especially in countries with restrictive abortion laws. Approximately 48% of all abortions worldwide were unsafe and more than 97% of these are in developing countries. Our objective was to find out complications of illegal induced abortions in a tertiary care institution. All cases of complicated induced abortion, seen over a 5 year period were reviewed. Relevant data relating to the socio-demographic profile of the patients, clinical presentation, abortion service providers and facilities and mode of termination of pregnancy were extracted. One hundred and nineteen patients, constituting 3.4% of gynaecological admissions were studied. The mean age of the patients was 23.5 +/- 6.6 years with over 80% single. The mean gestational age at abortion was 12.8 +/- 4.1 weeks. Incomplete abortion and postabortal sepsis formed the major indication for admission. About a fifth of the cases had abdominal visceral involvement. Twenty [18%] had laparotomy and 10[9%] had renal dialysis. Over 75% of patients were discharged in stable state. This study highlights the pressing need for an organised program for reproductive health education especially for the adolescents and unmarried who were most affected by abortion complications. In addition training and continuing medical education for doctors favourably disposed to abortion services is highly indicated from this study

Sociodemographic determinants of complicated unsafe abortions in a semi-urban Nigerian town: a four-year review / Determinantes sociodemográficas de abortos inseguros complicados en un poblado semiurbano de Nigeria: una revisión de cuatro anos

BACKGROUND: Abortions performed by persons lacking the requisite skills or in environments lacking minimal medical standards or both are considered unsafe. It is estimated that over 20 million unsafe abortions are performed annually and about 70 000 women die globally as a result, with the majority occurring in the developing world. This study aims to determine the sociodemographic factors involved in complicated unsafe abortions. SUBJECTS AND METHODS: The study is a four-year retrospective evaluation of all cases of complicated unsafe abortions managed at the Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state, Nigeria between January 1, 2007 and December 31, 2010. RESULTS: The incidence of unsafe complicated abortions over the study period was 4.10% of total deliveries and contributed 14.0% of gynaecological admissions: 34.92% occurred in adolescents less than 20 years of age, of which the majority (55.55%) were secondary school students. There were 55.45% of patients who were nulliparae, 60.32% were unemployed and 69.80% were unmarried. A total of 87.30% had never used any form of contraceptive. Abortion mortality rate was 256/100 000 deliveries and the case fatality was 4.76%. It constituted 30.0% of all gynaecological deaths and 17.64% of maternal deaths during the study period. The commonest cause of death was septicaemia (66.66%). CONCLUSION: Unfavourable sociodemographic factors are major determinants of the high incidence of unsafe abortion in the Niger Delta despite strict abortion laws. Concrete measures must be put in place to address these, as unsafe abortion and its complications are a major cause ofmaternal morbidity and mortality in the environment.

ANTECEDENTES: Los abortos realizados por personas que no poseen las habilidades requeridas o en circunstancias en las quefaltan las normas médicas mínimas, o ambas, son considerados inseguros. Se estima que se realizan encima de 20 millones de abortos inseguros anualmente y aproximadamente 70 000 mujeres mueren globalmente como resultado, presentándose la mayoría de estos casos en el mundo en vías de desarrollo. Este estudio se propone determinar los factores sociodemográficos involucrados en los abortos inseguros complicados. SUJETOS Y MÉTODOS: El estudio es una evaluación retrospectiva de cuatro anos de todos los casos de abortos inseguros complicados tratados en el Hospital Docente Universitario de Niger Delta, Okolobiri, estado de Bayelsa, Nigeria, entre el 1ero de enero de 2007y el 31 de diciembre de 2010. RESULTADOS: La incidencia a lo largo del periodo de estudio fue 4.10% y contribuyó el 14.0% de los ingresos ginecológicos: 34.92% ocurrieron en los adolescentes de menos de 20 anos de edad, de los cuales la mayor parte (55.55%) eran estudiantes de escuela secundaria. Hubo 55.45% pacientes nulí-paras, 60.32% desempleadas y 69.80% solteras. Un total de 87.30% nunca había usado contraceptivo alguno. La mortalidad por aborto fue 256/100 000 partos, y la fatalidad de casos fue 4.76%. Ello constituyó el 30.0% de todas las muertes ginecológicas. La causa más común de las muertefue la septicemia (66.66%). CONCLUSIÓN: Los factores sociodemográficos desventajosos constituyen determinantes principales de la alta incidencia del aborto inseguro en Niger Delta, a pesar de sus estrictas leyes en contra del aborto. Deben tomarse medidas concretas para abordarlos, ya que el aborto inseguro y sus complicaciones constituyen una de las mayores causas de morbosidad maternal y mortalidad en el ambiente.

profile of mortality and morbidity outcomes of illegal abortions in Lahore

To evaluate the morbidity, mortality and sociodemographic characteristics of illegally induced, unsafe abortion and their relationship with different modes of management. This descriptive study was conducted in Department of Gynae/Obs; Social Security Hospital, Lahore from June 2009 - November2010. A total of 105 cases admitted in the hospital with complications of unsafe abortion that fulfilled the inclusion criteria. The patients/their female attendants were interviewed by doctors. The patients were examined in detail, investigated and managed accordingly. A structured proforma was used to collect data. The data were analyzed. Out of 105 cases, 68[64.8%] were below 30 years. Eighty six [81.9%] were married and rest 19[18.1%] were unmarried females. Forty seven [44.8%] women were illiterate. About 2/3[rd] women were from lower socioeconomic [SE] class and 1/3[rd] from lower middle SE class. Only 63 patients [60.5%] were having some knowledge of contraceptives. Thirty eight [36.2%] abortions were conducted by Doctors [outside the public hospital], 34[32.4%] by untrained birth attendants and 33[31.4%] by Nurses/ lady health visitors [LHVs]. Forty [38.1%] women were managed conservatively, 38[36.2%] by D and C and 27[25.7%] by laparotomy. Significantly higher number of patients [41%] underwent laparotomy whose abortion was conducted by untrained providers. Ninety five [90.5%] patients recovered while 10[9.5%] expired due to serious complications. Illegal abortions are more common among lower socioeconomic class and are associated with significant mortality and morbidity especially provided by unskilled providers. Further studies to assess social, cultural, legal and health system correlates are indicated

Arming the witches-a betrayal of professionalism

It is harvesting season of crop sowed in the last decade under the umbrella of Prime Minister Health Program as we are facing the complications of illegal abortions done by the health workers .It is to emphasize to the health workers and Health Program organizers to disengage from the practice objectives are to; estimate the frequency of its complications, discuss types of complications encountered with its mortality and morbidity and demonstrate the ways of its notification and prevention. All patients admitted with peritonitis due to illegal abortions were included in the study during one year period. Results showed alarming increase of illegal abortions complications [53% of total peritonitis cases] with most common injuries to colon or small bowel. Mortality was 6% and morbidity 94%. Conclusion were made that extensive technical and ethical training of health workers and surgeons are needed along with resurrection of regional ethical committee to look after the affairs

Complications chirurgicales des avortements clandestins: à propos de 51 cas observés dans deux hôpitaux de Yaoundé

Le but de cette étude était de décrire les complications des avortements provoqués dans la clandestinité et imposant un traitement chirurgical. Il s'agit d'une étude rétrospective transversale portant sur les malades opérés dans les services de Chirurgie de l'Hôpital central et du Centre Hospitalier Universitaire de Yaoundé du 1er Janvier 2004 au 31 Décembre 2008. Les variables d'étude étaient l'âge, le statut matrimonial, les antécédents gynécologiques, les antécédents d'avortement antérieur, le mode, l'indication chirurgicale et l'état général des patientes; les lésions découvertes en peropératoire, leur traitement et l'évolution postopératoire. Cinquante une patientes ont été retenues pour cette étude menée pendant une durée de quatre ans, soit une moyenne de 12,7 cas par an. L'âge des patientes variait entre 15 ans et 41 ans avec une moyenne de 30 ans; 33 patientes (64,7%) avaient un âge situé entre 15ans et 25 ans. 6 patientes (11,7%) étaient multipares et 4 patientes étaient primipares (7,8%). Treize patientes (25,42%) avaient déjà subi une interruption volontaire de grossesse sans complication. Quarante-neuf patientes (96%) étaient arrivées avec un tableau de péritonite ; 43 patientes (84,22%) étaient classées ASA III (American Association of Anesthesiologists). Les lésions chirurgicales étaient à type de perforations ou de déchirures utérines dans 20 cas (39,21%), annexielles dans 9cas (17,64%), digestives dans 16 cas (31,37%) et urinaires dans 4 cas. Le traitement a associé au traitement de la péritonite, les sutures utérines, digestives et vésicales ; les gestes d'exérèse comprenaient deux hystérectomies et cinq salpingectomies. Il a été réalisé des gestes de dérivation dont deux cystostomies et deux colostomies. La mortalité était de 15,6%. L'étude recommande une éducation des femmes en matière de contraception et de planning familial, et surtout une politique sociale permettant de réduire le nombre des avortements clandestins

Epidemiology and management of intra-abdominal injuries due to criminal abortion

To collect data about different aspects of epidemiology of intra-abdominal injuries due to criminal abortions and devise a plan of management for various categories of intra-abdominal injuries. This observational case series study was carried out in Surgical unit 2, Bahawal Victoria hospital, Bahawalpur, from January 2006 to December 2007. A total of 40 consecutive patients were studied. All patients of abdominal injuries due to criminal abortion were included in the study. Patients of criminal abortion having only gynaecological complications i.e. per vaginal bleeding, septicaemia and acute renal failure were excluded from the study and only the patients with abdominal injuries were included. Relevant history and appropriate physical examination was performed and necessary investigations were done. Exploratory laparotomy was performed and injuries were treated accordingly. The most common age group developing intra-abdominal injury due to criminal abortion was of 25-34 years [77.5%]. Most of these abortions were in first trimester [70%], in women belonging to poor socio-economic status [80%]. Sixty five percent of these abortions were induced by semi-skilled persons, mostly by dilatation and curettage [70%]. The most common clinical presentation was painful abdominal distention [57.5%]. On laparotomy, gut injury was found in 20 [50%] cases, out of which 12 [60%] cases underwent gut exteriorisation. Isolated uterine injury was observed in 13 [32%] cases, out of which 12 [92%] patients underwent primary uterine repair. Intra-abdominal injuries due to criminal abortions are a definite entity. They usually present as acute abdomen. Exploratory laparotorny is mandatory; viscera most commonly injured are gut and uterus

El derecho a la objecion de conciencia en el supuesto del aborto / The right to the objection of conscience in the assumption of aAborto

La objeción de conciencia consiste en el incumplimiento de una obligación de naturaleza legal, cuya realización produciría en el individuo una grave lesión de la propia conciencia. Desde los mismos orígenes del Estado de Derecho, el respeto a la libertad de conciencia ha sido considerado uno de los derechos más fundamentales, ya que se presupone que la libertad y la dignidad humanas se encuentran por encima del mismo Estado.El derecho a la objeción de conciencia puede entenderse como la dimensión externa de la libertad ideológica y de conciencia. Este derecho, pilar esencial en todo Estado de Derecho, posee especial relevancia en el debate bioético, al tratarse de una vía muy adecuada para solucionar, en un sistema democrático, los inevitables conflictos que genera la tensión entre legalidad y justicia.En las últimas décadas, el derecho a la objeción de conciencia ha desarrollado toda su virtualidad en aquellos países en los que se han aprobado leyes despenalizadoras del aborto. Las profesiones sanitarias tienen un horizonte y un sentido claros: el cuidado y el respeto de la vida, la salud y la integridad de todos los seres humanos. En consecuencia, cuando una norma legal vulnera o contradice este principio, surgen sólidas razones para fundamentar el derecho a la objeción de conciencia de los sanitarios

Tetanus in adult population: uncommon modes of transmission

To document and evaluate various injuries leading to tetanus in adults. Retrospective study involving indoor patients with tetanus. Tetanus section of medical Ward of Mayo Hospital, /K.E.Medical College, Lahore. Ninety one patients admitted in the ward in the year 1997. Main outcome measures: Some unreported wounds possibly leading to tetanus in adults. There was male preponderance [M:F = 1.5:1] Majority [93.4%] were be low the age of 60 years and 75 patients [82.4%] were below the age of 50 years. Fifty six [61.5%] patients were from urban slums and 35 [38.5%] were from rural areas and none from posh localities. Eighty six [94.5%] were not vaccinated and 5 [5.5%] were not sure of having vaccination against tetanus. Commonest site of the wound was on foot and leg [46.1%] followed by uterus and vagina [26.4%], other sites being arm [12.1%] hand, [11%] nose, head, thigh and back 1.1% each. Commonest type of wound was roadside accident [37.3%], illegally induced abortions, delivery and post delivery handling [26.4%]. Other unusual wounds were nail injuries [7.7%] elective surgery [5.5%] firearms and crackers [4.4%]. I/M. injections [4.4%] thorn [3.3%] electiricshock [2.2%] scratch of hen paw [2.2%], dog bite [1.1%]. No cause found in 5 [5.5%] patients. Mean stay in the ward was 33.6 +/- 19.2 days. Fifty [55%] patients recovered completely and were discharged home. The mortality was 42.8% and 2.2% left the ward against medical advice. Besides common injuries, that can lead to tetanus, uncommon wounds of firearms and crackers, illegally induced abortions [dai] mis-handling, tubal ligation, IUCD etc. have not been reported in the past to cause tetanus, and should not be overlooked. Most of the survivors had longer incubation period. Severe and fatal tetanus was noted in patients with shorter incubation period

Illegal abortion: from gravity of complications to judicial consideration

We live at a time in wich abortion is legalized in a great number of western countries. In our country, the laws forbid abortion have not prevented its clandestine practice leading not only to medical problems but to social and ethical ones too. We present here the histories of 4 patients each of whom have presented grave complications of clandestine abortion [3 deaths and one with favorable evolution after a stay of 62 days in intensive care unit]; at the light of this, we have tried to analyse incriminated factors and remind the evolution Morrocan legislation in that field