Motivations for using misoprostol for abortion outside the formal healthcare system in Colombia: a qualitative study of women seeking postabortion care in Bogotá and the Coffee Axis.

BACKGROUND: In 2006, a Constitutional Court ruling partially decriminalized abortion in Colombia, allowing the procedure in cases of rape, risk to the health or life of the woman, and fetal malformations incompatible with life. Despite this less prohibitive law, some women and pregnant people preferred self-managing their abortions outside the formal healthcare system, often without accurate information. In 2018, we undertook a study to understand what motivated women to self-manage using medications that they acquired informally. Colombia has since adopted a progressive law in 2022, permitting abortion on request through the 24th week of pregnancy. However, the implementation of this law is still underway. Examining the reasons why women chose to informally self-manage an abortion after 2006 may not only highlight how barriers to legal services persisted at that time, but also could inform strategies to increase knowledge of the current abortion law and improve access to services going forward. METHODS: In-depth interviews were conducted in 2018 with 47 women aged 18 and older who used misoprostol obtained outside of health facilities to induce an abortion, and who were receiving postabortion care in two private clinics. Interviews explored what women knew about the 2006 abortion law which was then in effect, and the reasons why they preferred informal channels for abortion care over formal healthcare services. RESULTS: Women's motivations to use misoprostol obtained outside the formal healthcare system were influenced by lack of trust in the healthcare system along with incomplete and inaccurate knowledge of the abortion law. Conversely, women considered misoprostol obtained outside the healthcare system to be effective, affordable, and easier to access. CONCLUSIONS: Obtaining misoprostol outside the formal healthcare system offered a more accessible and appealing prospect for some women given fears of legal repercussion and stigma toward abortion. Though this preference will likely continue despite the more liberal abortion law, strategies should be implemented to broaden knowledge of the recent change in law and to combat misinformation and stigma. This would support knowledge of and access to legal abortion for those who wish to avail themselves of these services.

Aceptación y factores asociados con la anticoncepción moderna posaborto en mujeres atendidas en un hospital público / Acceptance and factors associated with modern post-abortion contraception in women treated in a public hospital

Resumen OBJETIVO: Determinar la frecuencia de aceptación y los factores asociados con la anticoncepción moderna posaborto en pacientes atendidas en un hospital público de Perú. MATERIALES Y MÉTODOS: Estudio observacional y transversal efectuado en pacientes en el posaborto inmediato atendidas de junio a diciembre de 2022 en el servicio de Urgencias del Hospital San Juan de Lurigancho, Lima, Perú, seleccionadas por conveniencia. Se utilizó un cuestionario validado. Se aplicó la prueba χ2 de Pearson con un nivel de significación del 5%. RESULTADOS: Se estudiaron 166 pacientes en el posaborto inmediato de las que el 94% (n = 156) aceptó algún método anticonceptivo moderno; el más frecuente fue el inyectable mensual (44.0%) y el menos aceptado el dispositivo intrauterino (0.6%). Los factores personales asociados con la aceptación del método anticonceptivo moderno fueron: edad (p < 0.01), no tener pareja (p < 0.001) y ésta estuviera de acuerdo con el anticonceptivo elegido (p < 0.001). Los factores institucionales asociados fueron: tiempo de la consejería en planificación familiar (p = 0.047), privacidad-confidencialidad de la consejería (p < 0.001) y satisfacción con la atención ofrecida durante la orientación (p = 0.026). CONCLUSIONES: La edad, carecer de pareja y estar de acuerdo con ésta acerca de la elección del método anticonceptivo posaborto junto con los factores institucionales (tiempo de consejería en planificación familiar, importancia de la privacidad-confidencialidad y percepción de la atención en consejería en planificación familiar) se asociaron, significativamente, con la aceptación de algún método anticonceptivo moderno posaborto.

Abstract OBJECTIVE: To determine the frequency of acceptance and factors associated with modern postabortion contraception in patients attended at a public hospital in Peru. MATERIALS AND METHODS: Observational and cross-sectional study conducted in immediate postabortion patients attended from June to December 2022 at the Emergency Department of the Hospital San Juan de Lurigancho, Lima, Peru, selected by convenience. A validated questionnaire was used. Pearson's test c2 was used with a significance level of 5%. RESULTS: We studied 166 patients in the immediate postabortion period, of whom 94% (n = 156) accepted some modern contraceptive method; the most common was the monthly injectable (44.0%) and the least accepted was the intrauterine device (0.6%). Personal factors associated with modern contraceptive method acceptance were age (p < 0.01), no partner (p < 0.001), and partner's agreement with the chosen contraceptive method (p < 0.001). Associated institutional factors were agreeing with the time of family planning counseling (p = 0.047), considering the importance of privacy-confidentiality of counseling (p < 0.001), and agreeing with the care offered during counseling (p = 0.026). CONCLUSIONS: Age, lack of a partner, and agreeing with the partner about the choice of postabortion contraceptive method along with institutional factors (time of family planning counseling, importance of privacy-confidentiality, and perception of care in family planning counseling) were significantly associated with acceptance of some modern postabortion contraceptive method.

Contraception and abortion in times of crisis: results from an online survey of Venezuelan women.

Introduction: In the last decade, Venezuela has experienced a complex humanitarian crisis that has limited access to healthcare. We set out to describe Venezuelan women's experiences accessing sexual and reproductive health services, including abortion, which is heavily restricted by law. Methods: We fielded an online survey in July of 2020 among Venezuelan women recruited through social media advertisements. We conducted descriptive statistical analyses using Excel and STATA SE Version 16.0. Results: We received 851 completed survey responses. Almost all respondents experienced significant hardship in the last year, including inflation (99%), worries about personal safety (86%), power outages (76%), and lack of access to clean water (74%) and medications (74%). Two thirds of respondents used contraception in the last two years, and almost half (44%) of respondents had difficulty accessing contraception during that same time period. About one fifth of respondents reported having had an abortion; of these, 63% used abortion pills, and 72% reported difficulties in the process. Half of those who had an abortion did it on their own, while the other half sought help - either from family members or friends (34%), from providers in the private health sector (14%), or from the Internet (12%). Conclusions: Venezuelan women who responded to our survey describe a harsh context with limited access to sexual and reproductive health services. However, they report relatively high rates of contraceptive use, and abortion seems to be common despite the restrictive legal setting.

Associations between contraceptive availability and rate of subsequent legal abortions in Colombia: A historical cohort analysis.

OBJECTIVE: To describe factors associated with subsequent abortions in Colombia and evaluate whether high-efficacy contraceptive availability (IUD) post-index abortion was associated with higher efficacy contraceptive initiation and fewer subsequent abortions within 2 years. METHODS: The study population comprised patients aged 15-44 years who underwent index abortion in 2017 at four clinics in Bogotá, Colombia. Using charts, we conducted a retrospective cohort study with 2-year follow-up (2017-2019) after the index abortion for outcomes of contraceptive initiation and subsequent abortion. We evaluated associations between demographic or clinical characteristics and outcomes using Pearson chi-square and multivariate logistic regression. RESULTS: Of 9175 patients with index abortion, 3409 (37.2%) initiated an intrauterine device (IUD) and 467 (5.1%) had a subsequent abortion within the study period (2017-2019). IUD availability (adjusted odds ratio [aOR], 1.64; 95% confidence interval [CI], 1.39-1.93) and insurance use (aOR, 5.03; 95% CI, 4.37-5.78) were associated with high-efficacy contraceptive initiation; medication abortion was inversely associated (aOR, 0.24; 95% CI, 0.22-0.27). Initiation of no (aOR, 4.94; 95% CI, 3.59-6.80) or moderate-efficacy (injection: aOR, 4.21 [95% CI, 3.14-5.62]; oral contraceptive pill: aOR, 4.60 [95% CI, 3.21-6.59]) methods were associated with subsequent abortion. CONCLUSION: Subsequent abortion is inversely associated with initiated postabortion contraceptive efficacy, which is modifiable on a systems level by improving access to effective postabortion contraception.

Legal termination of pregnancy as an opportunity for expanding postabortion contraception: Experience at the Pereira Rossell Hospital, Montevideo, Uruguay.

OBJECTIVE: To determine to what extent women adopted highly effective contraceptive methods after a legal abortion. METHODS: The data available during a period before and another period after liberalization of the abortion law were reviewed. The data gathering was incomplete and reliable only during certain periods, which were used in the study. RESULTS: There was an increase in the proportion of women who returned for contraception and in the proportion who used any method and long-acting methods; however, no contraception was administered immediately after abortion and only 16% of all women treated started to use a long-acting method during the period after the law was liberalized. CONCLUSION: The proposed objective was not being achieved, the recommended guidelines were not being followed, and data gathering was incomplete. Good intentions are not enough and it is always necessary to evaluate the performance of a program. The results indicate that immediate reforms are necessary in postabortion contraception services.

Las pesadillas como un síntoma clave para el diagnóstico de la psicopatología posaborto / Nightmares as a key symptom in diagnosing post-abortion psychopathology

Reactions to severe stress and adjustment disorders may go unnoticed if their symptoms are not related to the original traumatic situation; they may be masked by different psychosomatic complaints or mistaken for other mental disorders. If the disorder goes undiagnosed, the treatment and the psychotherapeutic approach will not be effective, resulting in chronicity and treatment resistance. Therefore, in order to achieve the desired diagnosis, besides the comprehensive assessment of disturbances, it was of great help to explore a symptom which, although frequently reported by patients, can go unnoticed in the psychopathology of these disorders: distressing dreams or nightmares. We consistently noticed that distressing dreams or nightmares in women with various affective and behavioral disorders would appear to be a premonitory symptom of the post-abortion traumatic origins of the condition and a call to consider such hypothesis. The conclusion is that nightmares are very sensitive and specific indicators of the presence of post-traumatic disorders. Therefore, in order to reach the desired efficiency in the diagnosis and treatment of post-abortion psychopathology, we postulate that, in all affective or adjustment disorders, in addition to a comprehensive assessment of their disturbances, the presence of abortion-related persistent nightmares should be taken into account or investigated, since they are often the key symptom in identifying post-abortive reactivity within the disorde

Las reacciones al estrés grave y los trastornos de adaptación pueden pasar inadvertidos, enmascarados por diferentes quejas psicosomáticas o confundidos con otras alteraciones mentales, si sus síntomas no se relacionan con el trauma que los originó. Si el trastorno queda sin diagnosticar, su tratamiento y abordaje psicoterapéutico no serán efectivos, dando lugar a la cronicidad y resistencia de la afección. Pero para llegar a dicho diagnóstico, además de la evaluación integral de las alteraciones, nos fue de gran ayuda la exploración de un síntoma que, aunque referido frecuentemente por las pacientes, puede pasar desapercibido en el conjunto psicopatológico de estos trastornos: los sueños angustiosos o pesadillas. De forma repetida fuimos comprobando que los ensueños angustiosos o pesadillas, en mujeres con diversos trastornos afectivos y conductuales, parecían ser un síntoma premonitorio del origen traumático posabortivo de la sintomatología y una llamada de alerta que obligaba a tener en cuenta dicha hipótesis, llegando finalmente a la conclusión de que las pesadillas son indicadores muy sensibles y específicos de la presencia de alteraciones postraumáticas. Por ello, para lograr la deseada eficiencia en el diagnóstico y tratamiento de la psicopatología posabortiva, postulamos que, ante todo trastorno afectivo o conductual-desadaptativo, aparte de una evaluación integral de sus alteraciones, se tenga muy en cuenta -o se investigue en su caso- la presencia de pesadillas persistentes sobre temas abortivos, por ser éstas muchas veces el síntoma clave en la identificación de la reactividad posabortiva de los trastornos

The cost of post-abortion care in developing countries: a comparative analysis of four studies.

Over the last five years, comprehensive national surveys of the cost of post-abortion care (PAC) to national health systems have been undertaken in Ethiopia, Uganda, Rwanda and Colombia using a specially developed costing methodology-the Post-abortion Care Costing Methodology (PACCM). The objective of this study is to expand the research findings of these four studies, making use of their extensive datasets. These studies offer the most complete and consistent estimates of the cost of PAC to date, and comparing their findings not only provides generalizable implications for health policies and programs, but also allows an assessment of the PACCM methodology. We find that the labor cost component varies widely: in Ethiopia and Colombia doctors spend about 30-60% more time with PAC patients than do nurses; in Uganda and Rwanda an opposite pattern is found. Labor costs range from I$42.80 in Uganda to I$301.30 in Colombia. The cost of drugs and supplies does not vary greatly, ranging from I$79 in Colombia to I$115 in Rwanda. Capital and overhead costs are substantial amounting to 52-68% of total PAC costs. Total costs per PAC case vary from I$334 in Rwanda to I$972 in Colombia. The financial burden of PAC is considerable: the expense of treating each PAC case is equivalent to around 35% of annual per capita income in Uganda, 29% in Rwanda and 11% in Colombia. Providing modern methods of contraception to women with an unmet need would cost just a fraction of the average expenditure on PAC: one year of modern contraceptive services and supplies cost only 3-12% of the average cost of treating a PAC patient.

Efficacy of early induced medical abortion with mifepristone when beginning progestin-only contraception on the same day.

OBJECTIVES: To investigate whether starting progestin-only contraception immediately after mifepristone reduced the efficacy of early medical abortion with a mifepristone-misoprostol regimen. METHODS: A review of patient records from October 1, 2012 to March 31, 2013 from four Marie Stopes Mexico clinics in Mexico City was conducted. Patients were eligible for inclusion if they had undergone a medical abortion with mifepristone-misoprostol at no later than 63days of pregnancy, had a recorded outcome, and had either started progestin-only contraception immediately after mifepristone administration or had not started contraception. The primary outcome-successful induced abortion-was defined as the complete evacuation of uterine contents without the need for further intervention. A secondary outcome was the number of induced abortions completed without the need for manual vacuum aspiration. RESULTS: Records from 2204 patients were included; 448 (20.3%) patients had started progestin-only contraception, and 1756 (79.7%) had not. Patients not taking progestin-only contraception were significantly more likely to be primigravidas and nulliparous. Medical abortion success did not vary between the two groups; 1890 (85.8%) were successful and 2085 (94.6%) were completed without the need for manual vacuum aspiration. Different methods of progestin-only contraception did not affect medical abortion outcomes. CONCLUSION: Beginning progestin-only contraception immediately following mifepristone for early medical abortion was not associated with reduced medical abortion effectiveness.

Legal termination of pregnancy as an opportunity for expanding postabortion contraception: Experience at the Pereira Rossell Hospital, Montevideo, Uruguay.

OBJECTIVE: To determine to what extent women adopted highly effective contraceptive methods after a legal abortion. METHODS: The data available during a period before and another period after liberalization of the abortion law were reviewed. The data gathering was incomplete and reliable only during certain periods, which were used in the study. RESULTS: There was an increase in the proportion of women who returned for contraception and in the proportion who used any method and long-acting methods; however, no contraception was administered immediately after abortion and only 16% of all women treated started to use a long-acting method during the period after the law was liberalized. CONCLUSION: The proposed objective was not being achieved, the recommended guidelines were not being followed, and data gathering was incomplete. Good intentions are not enough and it is always necessary to evaluate the performance of a program. The results indicate that immediate reforms are necessary in postabortion contraception services.

Medical abortion and manual vacuum aspiration for legal abortion protect women's health and reduce costs to the health system: findings from Colombia.

The majority of abortions in Colombia continue to take place outside the formal health system under a range of conditions, with the majority of women obtaining misoprostol from a thriving black market for the drug and self-administering the medication. We conducted a cost analysis to compare the costs to the health system of three approaches to the provision of abortion care in Colombia: post-abortion care for complications of unsafe abortions, and for legal abortions in a health facility, misoprostol-only medical abortion and vacuum aspiration abortion. Hospital billing records from three institutions, two large maternity hospitals and one specialist reproductive health clinic, were analysed for procedure and complication rates, and costs by diagnosis. The majority of visits (94%) were to the two hospitals for post-abortion care; the other 6% were for legal abortions. Only one minor complication was found among the women having legal abortions, a complication rate of less than 1%. Among the women presenting for post-abortion care, 5% had complications during their treatment, mainly from infection or haemorrhage. Legal abortions were associated not only with far fewer complications for women, but also lower costs for the health system than for post-abortion care. We calculated based on our findings that for every 1,000 women receiving post-abortion care instead of a legal abortion within the health system, 16 women experienced avoidable complications, and the health system spent US $48,000 managing them. Increasing women's access to safe abortion care would not only reduce complications for women, but would also be a cost-saving strategy for the health system.

Changes in the use of manual vacuum aspiration for postabortion care within the public healthcare service network in Honduras.

Honduras is one of the 17 priority countries included in the International Federation of Gynecology and Obstetrics (FIGO) Initiative for the Prevention of Unsafe Abortion and its Consequences. The priority category enables the country to request emergency funding to acquire services or commodities that could contribute toward achieving the objectives laid out in its plan of action. These objectives include improving postabortion care by increasing the use of manual vacuum aspiration (MVA) as an outpatient procedure with minimal human and material resources. Since the Ministry of Health lacked funding, use of the emergency fund was approved for the purchase and distribution of MVA kits nationwide to ensure continuity and the hope of increasing MVA use. Eleven hospitals participating in this initiative provided data for analysis of the outcome. These data show no increase in MVA use; however, as discussed in the article, further investigation provided valuable information on the reasons behind these results.

Síndrome post-aborto: reacciones psicológicas post-aborto / Post-abortion syndrome

El efecto que el aborto produce en la salud mental de la mujer que lo vivencia, sobre todo si es provocado, es un tema preocupante. Numerosas investigaciones y la experiencia clínica demuestran que las reacciones psicológicas varían de una mujer a otra, pero que en ningún caso es inocuo. Las distintas investigaciones y la experiencia clínica describen desde reacciones ansiosas, depresivas, sentimientos de vacío y dolor, hasta un síndrome específico, el síndrome post-aborto, el cual presentaría casi las mismas características del estrés pos-traumático.

The effect that abortion produces on the mental health of woman who have experienced one, especially if provoked, is a topic of concern. Numerous investigations and clinical experience demonstrate that psychological reactions differ from one woman to another, but in no case is it innocuous. Different research and clinical experience describe a range from anxiety, depressive reaction, feelings of emptiness and pain up to a specific syndrome, post-abortion syndrome, which presents almost the same characteristics as post-traumatic stress.

Latin American hospitals improve postabortion care. Maternal health.

PIP: Approximately 4 million women undergo illegal abortions each year in Latin America and the Caribbean, and hundreds of thousands of women with postabortion medical emergencies or incomplete abortions seek hospital care. Once in an emergency ward, a woman may await treatment for 24 hours, bleeding, frightened, and in pain. A woman in such a situation may also experience nurses who chastise her for becoming pregnant or committing a sin, be examined with several staff members observing, undergo unexplained treatment without anesthesia, and/or leave the service facility without knowing whether she is still fertile or how to avoid pregnancy. INOPAL, Population Council's operations research program on family planning and reproductive health in the region, is working to find the best ways, medically and financially, for hospitals to deliver high-quality, comprehensive services to postabortion patients. Most maternal deaths and injuries could be prevented by access to family planning services and information about contraceptive use. The Population Council and colleagues from hospitals, governments, and nongovernmental organizations are conducting studies in Guatemala, Peru, and Mexico on the emergency treatment of incomplete abortions with the goal of improving and standardizing postabortion services.^ieng

Post-abortion services in Bolivia.

PIP: Third World women with complications from an illegally induced abortion tend to postpone seeking medical treatment, because of both a lack of knowledge about the signs of infection or hemorrhage and a fear of moral and legal sanctions. At admission, hospital policies require that women be questioned repeatedly until they acknowledge whether their symptoms are a result of induced or spontaneous abortion. In Bolivia, women hospitalized for abortion-related complications also face financial sanctions. They are charged 450 Bs (US$105) for dilatation and curettage); social security coverage is denied as is eligibility for sliding scale fees based on ability to pay. Interviews with 12 patients and 14 staff members at 4 Bolivian hospitals revealed substantial variation in the postabortion care women receive. Care seemed to be more dependent on the personal ethics of staff members than definite policies. In general, however, these women did not receive the moral support needed to help them overcome their feelings of ambivalence, guilt, and depression. Rather, a double standard prevails, where women alone bear responsibility for the pregnancy and then are blamed for seeking termination under illegal conditions.^ieng

Postabortion contraception: few family planning services available.

PIP: The Association for Voluntary Surgical Contraception (AVSC) investigated the linkages between induced abortion and family planning services in a qualitative research project conducted in Colombia, India, and Turkey. Study methodologies included interviews with abortion and family planning service providers, record review, observation, and discussions with policy-makers. In general, abortion and family planning services were entirely separate. Although postabortion clients clearly wanted to avoid another unwanted pregnancy, they generally failed to receive family planning information and services. Abortion providers tended not to view contraceptive provision as their responsibility and, in many cases, had negative attitudes toward abortion patients. Services for abortion and family planning often were not available on the same day or in the same location. In some areas in India, where abortion patients were provided with contraception (IUD and sterilization), its provision was coerced as a condition for abortion. AVSC is working to raise awareness of the need to integrate service links between abortion and family planning programs.^ieng

[Salpingoclasia by minilaparotomy following spontaneous abortion]. / Salpingoclasia por minilaparotomía postaborto espontáneo.

PIP: 200 cases of bilateral tubal occlusion by minilaparotomy after noninfected spontaneous abortion and 1 year follow-up were reviewed. 45% of the patients had a previous abortion. Tubal occlusion was carried out using the same anesthesia for uterine curettage and Pomeroy's technique. Complications may arise in abortions with an IUD in situ, with failure to use a uterine mobilizer in the intrapelvic uterus, obesity, and lack of experience on the part of the surgeon. There was 1 case of pregnancy which occurred, indicating a 0.5% failure rate. Postabortion sterilization should be included in all family planning programs. (author's)^ieng

[Prevalence of anemia in women attending family planning clinic in Durango (author's transl)]. / La prevalencia de anemia en mujeres asistentes a servicios de planificación familiar en la Ciudad de Durango.

PIP: This study investigates the prevalence of anemia in a group of 500 women requesting contraception for the first time at the Health Center in Durango, Mexico. 92% of women were between 15-34, with the majority in the age group 20-24; most had parity 1-4. The average hemoglobin level was 13.04 g/dl, with SE of 0.08. There were 70 anemic women with hemoglobin level below 12 g/dl, which gave a percentage of 14%. 90% of anemic women presented iron deficiency. 16.8% of the total number of women were within the 1st 6 weeks postpartum or postabortion; of these 32% were anemic. Of the 82.4% of women beyond this period of time only 10.4% were anemic. There was no increase in the prevalence of anemia in women with higher parity; among the 174 obese women the percentage of anemia was 86%. The relatively high prevalence of anemia in women seeking contraception compels the doctor to consider very seriously the type of contraception to be prescribed. In Mexico there is an important difference in the geographic distribution of anemia, which seems to be most common in the province of Yucatan, and which is probably caused by alimentary iron deficiency.^ieng

[Permanent control of female fertility by surgical methods]. / Control permanente de la fertilidad femenina por método quirúrgicos.

PIP: The results of 1393 cases of female sterilization are presented in the article. Several techniques of tubal ligation were employed, postpartum and postabortum minilaparotomy, Pomeroy method, and fimbriectomy. Operative procedures are given in details for every technique. Main reason for sterilization was permanent contraception; 92% of patients belonged to low socioeconomic classes, were about 34 years old, with parity over 5, and most with antecedents of abortion and of cesarean section. There were no complications; late morbidity was only 1.47%, and mainly caused by transvaginal surgery. Minilaparotomy was found to give better results than conventional laparotomy; average time for the procedure was 10'. Hospital stay was 3.2 days, and paracervical block was used in over 92% of cases.^ieng

[Postabortion intrauterine device]. / Dispositivo intrauterino postaborto.

PIP: 433 patients were selected by social workers for postpartum insertion of Lippes Loop. Of these only 261, or 60.27%, were available for followup 10 months after insertion. At that time, 177 patients, or 67.81%, were still wearing the IUD and were satisfied with it. 19, or 7.2%, expelled it, and 40, or 15.32% had it removed for different reasons, such as bleeding or pain. 11 patients asked for definitive contraception, and 14, or 5.36%, became pregnant with the device in situ, a percentage certainly higher than that of 1.9% reported by other authors.^ieng