Physicians' knowledge and opinions about medication abortion in four Latin American and Caribbean region countries.

To examine physicians' knowledge and attitudes in regard to medication abortion, we conducted focus-group discussions with general practice physicians and obstetrician-gynecologists in Honduras, Mexico, Nicaragua and Puerto Rico. Physicians were familiar with the practice of several types of medication and surgical abortion methods. Medication abortion with misoprostol is most common among women of higher socioeconomic status and is prescribed by physicians, pharmacists or self-administered. Conflicting opinions regarding safety, efficacy, cost, potential for self-medication and acceptability emerged; some participants expressed hope that medical abortion would reduce the risks associated with unsafe abortion, while others contended that drug distribution and self-medication without proper counseling could be problematic. Participants noted a lack of reliable sources of information for both providers and women, and expressed interest in strategic dissemination of information.

Do Mexico City pharmacy workers screen women for health risks when they sell oral contraceptive pills over-the-counter?

CONTEXT: In Mexico, oral contraceptives (OCs) are available to women over-the-counter in pharmacies. While past research has suggested that nonmedical providers, such as pharmacy workers, are capable of screening women for contraindications to OCs, little is known about their practices. METHODS: After selecting a 10% random sample of all pharmacies in Mexico City (n = 108), we surveyed the first available pharmacy worker to learn more about pharmacy workers' screening practices when selling OCs over-the-counter to women. RESULTS: While nearly all of the pharmacy workers surveyed had sold OCs without a prescription, only 31% reported asking women any questions before selling pills. Among those who asked questions, the most commonly asked questions were about other medications a woman was taking, about blood pressure and about alcohol intake. Pharmacy workers did not ask these questions consistently to all clients. CONCLUSION: Training pharmacy workers might be one strategy to improve screening of women for pill contraindications. However, pharmacy workers may lack the time and motivation to carry out such screening. An alternative strategy might be to better inform women to self-screen for pill contraindications.

As often as needed: appropriate use of emergency contraceptive pills.

Previous research has established that emergency contraceptive pills are safe and have the potential to reduce unintended pregnancy; however, policy makers, providers and even women themselves have expressed concern about repeat use of the method. Evidence regarding the safety, efficacy and frequency of repeat use show that the method is safe and effective, even when used multiple times. Reported rates of repeat use are actually lower than would be expected, and needed, based on the frequency of unprotected intercourse and contraceptive failure reported in most countries. Healthcare providers should encourage use of emergency contraceptive pills as a backup after recognizable failure of barrier methods or other hormonal contraceptive methods, and should expect that women may need emergency contraceptive pills multiple times during their reproductive years.

Routine follow-up visits after first-trimester induced abortion.

Routine follow-up visits after abortion are intended to confirm that the abortion is complete and to diagnose and treat complications. Many clinicians also take advantage of the follow-up visit to provide general reproductive health care: discussing contraceptive plans and providing family planning services; diagnosing sexually transmitted infections; performing a Pap test or discussing abnormal Pap results. We reviewed the evidence related to the routine postabortion follow-up visit. Other than mifepristone medical abortion performed at 50 days of gestation or later and methotrexate medical abortion, we found little evidence that mandatory follow-up visits typically detect conditions that women themselves could not be taught to recognize. In addition, the natural history of the most severe complications after abortion-infection and unrecognized ectopic pregnancy-have time courses inconsistent with the usual timing of the follow-up visit. Costs associated with this visit can be great. These include travel expenses, lost wages, child-care expenses, privacy and emotional burdens for women, and scheduling disruptions and the related opportunity costs caused by "no-shows" for the provider. Follow-up appointments should be scheduled for those women likely to benefit from a physical examination. For the remainder of women, simple instructions and advice about detecting complications, possibly coupled with telephone follow-up, might suffice. Although arguably valuable in their own right, counseling, family planning services, or sexually transmitted infection diagnosis and treatment should not be so inflexibly bundled with postabortion care. Protocols that require in-person follow-up after abortion may not make the best use of a women's time or abilities, or of the medical system.

Policy implications of a national public opinion survey on abortion in Mexico.

In Mexico, recent political events have drawn increased public attention to the subject of abortion. In 2000, using a national probability sample, we surveyed 3000 Mexicans aged 15-65 about their knowledge and opinions on abortion. Forty-five per cent knew that abortion was sometimes legal in their state, and 79% felt that abortion should be legal in some circumstances. A majority of participants believed that abortion should be legal when a woman's life is at risk (82%), a woman's health is in danger (76%), pregnancy results from rape (64%) or there is a risk of fetal impairment (53%). Far fewer respondents supported legal abortion when a woman is a minor (21%), for economic reasons (17%), when a woman is single (11%) or because of contraceptive failure (11%). In spite of the influence of the Church, most Mexican Catholics believed the Church and legislators' personal religious beliefs should not factor into abortion legislation, and most supported provision of abortions in public health services in cases when abortion is legal. To improve safe, legal abortion access in Mexico, efforts should focus on increasing public knowledge of legal abortion, decreasing the Church's political influence on abortion legislation, reducing the social stigma associated with sexuality and abortion, and training health care providers to offer safe, legal abortions.

Abortion, contraceptive use, and adolescent pregnancy among first-year medical students at a major public university in Mexico City.

OBJECTIVE: If properly trained, medical students could become future opinion leaders in health policy and could help the public to understand the consequences of unwanted pregnancies and of abortions. The objective of this study was to analyze the frequency of unwanted pregnancies and induced abortions that had occurred among women who were first-year medical students at a major public university in Mexico City and to compare the experiences of those women with the experiences of the general population of Mexican females aged 15 to 24. METHODS: In 1998 we administered a cross-sectional survey to all the first-year medical students at the National Autonomous University of Mexico, which is the largest university in Latin America. For this study we analyzed 549 surveys completed by female students. RESULTS: Out of the 549 women, 120 of them (22%) had been sexually active at some point. Among those 120 sexually active students, 100 of them (83%) had used a contraceptive method at some time, and 19 of the 120 (16%) had been pregnant. Of those 19 women who had been pregnant, 10 of them had had an illegal induced abortion (in Mexico, abortions are illegal except under a small number of extenuating circumstances). The reported abortion rate among the female medical students, 2%, was very low in comparison with the 11% rate for women of similar ages in the Mexican general population. CONCLUSIONS: The lower incidence of abortion among the female medical students indicates that when young Mexican women have access to medical information and are highly motivated to avoid unintended pregnancy and abortion, they can do so.

Abortion, contraceptive use, and adolescent pregnancy among first-year medical students at a major public university in Mexico City / El aborto, el uso de anticonceptivos y el embarazo en la adolescencia en estudiantes de medicina de una importante universidad pública en México, D.F.

OBJECTIVE: If properly trained, medical students could become future opinion leaders in health policy and could help the public to understand the consequences of unwanted pregnancies and of abortions. The objective of this study was to analyze the frequency of unwanted pregnancies and induced abortions that had occurred among women who were first-year medical students at a major public university in Mexico City and to compare the experiences of those women with the experiences of the general population of Mexican females aged 15 to 24. METHODS: In 1998 we administered a cross-sectional survey to all the first-year medical students at the National Autonomous University of Mexico, which is the largest university in Latin America. For this study we analyzed 549 surveys completed by female students. RESULTS: Out of the 549 women, 120 of them (22 percent) had been sexually active at some point. Among those 120 sexually active students, 100 of them (83 percent) had used a contraceptive method at some time, and 19 of the 120 (16 percent) had been pregnant. Of those 19 women who had been pregnant, 10 of them had had an illegal induced abortion (in Mexico, abortions are illegal except under a small number of extenuating circumstances). The reported abortion rate among the female medical students, 2 percent, was very low in comparison with the 11 percent rate for women of similar ages in the Mexican general population. CONCLUSIONS: The lower incidence of abortion among the female medical students indicates that when young Mexican women have access to medical information and are highly motivated to avoid unintended pregnancy and abortion, they can do so.

Objetivo. Con entrenamiento adecuado, los estudiantes de medicina pueden convertirse en líderes de opinión con futura injerencia sobre las políticas de salud, así como ayudar al público a entender las consecuencias de los embarazos indeseados y del aborto. El objetivo del presente estudio ha sido examinar la frecuencia del embarazo indeseado y del aborto provocado en mujeres de primer año de la carrera de medicina en una de las principales universidades de México, D.F., y comparar las experiencias de esas mujeres con las de la población general de mujeres mexicanas entre los 15 y 24 años de edad. Métodos. En 1998 hicimos una encuesta transversal de todas las estudiantes de primer año de medicina de la Universidad Autónoma de México, que es la universidad más grande de América Latina. Examinamos un total de 549 encuestas. Resultados. De las 549 mujeres encuestadas, 120 (22%) habían tenido actividad sexual en algún momento. De esas 120 estudiantes que habían sido activas sexualmente,100 (83%) habían usado un método anticonceptivo alguna vez y 19 de las 120 (16%) habían estado embarazadas. De estas últimas 19 mujeres, 10 se habían sometido a un aborto ilegal (en México el aborto siempre es ilegal salvo en circunstancias extenuantes muy contadas). La frecuencia declarada de aborto entre las estudiantes de medicina, que fue de 2%, fue muy baja en comparación con la frecuencia de 11% hallada en mujeres de la misma edad en la población mexicana en general. Conclusiones. La menor incidencia del aborto entre las estudiantes de medicina revela que cuando las jóvenes mexicanas tienen a su alcance información de orden médico y el firme propósito de evitar el embarazo indeseado y el aborto, lo pueden lograr

Knowledge and attitudes about the differences between emergency contraception and medical abortion among middle-class women and men of reproductive age in Mexico City.

Two reproductive technologies--emergency contraception and medical abortion--have the potential to reduce unintended pregnancy significantly in Latin America. Lack of knowledge and negative attitudes about the methods may limit their impact, however. Results from focus group discussions with middle-class men and women of reproductive age residing in Mexico City indicate that knowledge about emergency contraception and medical abortion is low. After being informed about both methods, participants supported emergency contraception but tied their support for medical abortion to its legal status. Participants remained concerned about the methods' efficacy, mechanism of action, and potential to encourage sexual risk-taking. While almost all desired greater dissemination of information about and access to both methods in Mexico, participants cited religious and cultural concerns, as well as barriers in communication with providers and within families, as significant challenges. Participants hoped, however, that both emergency contraception and medical abortion might play important roles in preventing unwanted pregnancy and abortion-related morbidity and mortality in Mexico in the future.

Emergency contraception in Mexico City: knowledge, attitudes, and practices among providers and potential clients after a 3-year introduction effort.

Emergency contraception (EC) has the potential to reduce unwanted pregnancy significantly, in Mexico as elsewhere. Recent years have seen tremendous growth in programs and research devoted to expanding access to emergency methods worldwide. In Mexico City, we conducted a pre-intervention/post-intervention research study of one way to introduce EC. Following a baseline survey of family planning providers and clients in 1997, we organized and implemented a three-year program of training for health care providers and a multi-faceted information campaign for the general public, including a national toll-free hotline and website. In 2000, we again surveyed family planning clinic providers and clients, using instruments similar to those employed in the baseline study. EC awareness increased significantly from 13% of clients to 32%, and support jumped from 73% to 83%. Providers at study clinics improved method recognition from 88% to 100%.

Information campaign and advocacy efforts to promote access to emergency contraception in Mexico.

Emergency contraception (EC) has the potential to reduce unwanted pregnancy significantly, in Mexico as elsewhere. Recent years have seen tremendous growth in programs and research devoted to expanding access to emergency methods worldwide. In Mexico we developed a comprehensive model introduction effort that included four components: provider training, public information (through a dedicated hotline and website, free media, paid radio and TV spots, participation in talk shows, and alternative media channels), collaboration with the public sector to include EC in the official family planning norms, and assistance to partner with commercial firms to register a dedicated EC product. Ongoing efforts to combat misperceptions and overcome opposition are crucial to informing the public and ensuring greater access to the method.

Prevalence of battering among 1780 outpatients at an internal medicine institution in Mexico.

Violence against women has recently drawn attention in the medical community as a leading cause of preventable morbidity and mortality. Specific algorithms designed to identify women at risk can be applied to create an opportunity for screening, diagnosis and treatment during medical care initiated for common conditions. This study investigated the incidence and history of battering among women seeking general medical care, and looked for potential risk factors and associations with presenting symptoms. We used a self-administered, anonymous survey to question 1780 adult female outpatients visiting a tertiary care internal medicine teaching hospital in Mexico City. We calculated current abuse (physical and/or sexual abuse by a partner within the past year), abuse during pregnancy, childhood abuse, and lifetime abuse. We found levels of violence against women in Mexico comparable to those reported from other countries. 152 women (9%) reported current physical and/or sexual abuse. An identical number also reported abuse during pregnancy. Lifetime prevalence was 41%. Women currently or previously abused reported more physical symptoms in the last six months than did non-abused participants. Pelvic pain, depression, headache and substance abuse were frequent among abused women. Currently abused women also scored higher (p<0.01) on indicators of depression. Current abuse correlated strongly with a childhood history of physical and/or sexual abuse, with low educational level of the victim, with substance abuse by the partner or by the woman herself, and with higher parity.

How safe is emergency contraception?

Emergency contraception is used to prevent pregnancy after unprotected sex but before pregnancy begins. Currently, women can use emergency contraception by taking higher doses of the active ingredients found in ordinary oral contraceptive pills [either combined estrogen-progestogen (progestin) or progestogen-only formulations], or by having providers insert copper-bearing intrauterine devices (IUDs). The antiprogestogen mifepristone also has an excellent efficacy and safety profile as emergency contraception, but it is currently available for this indication only in China. Many studies have documented providers' and women's fears about the individual and public health safety risks of emergency contraception. Some of these concerns include potentially increased risks of cardiovascular events (including arterial and venous disease), worries about possible effects on future fertility, feared teratogenic consequences following method failure or inadvertent use during pregnancy, exaggerated or extreme fears of adverse tolerability, and concerns about drug interactions with other medications. Wider public health questions include feared reductions in the use of ongoing, more effective contraception, possible 'abuse' of emergency contraception through overly frequent use, and potential increases in risky sexual encounters (owing to the existence of a back-up, postcoital method) and therefore in rates of sexually transmitted infections, including HIV/AIDS. These fears can each be generally allayed. Direct and indirect investigations of emergency contraception in the biomedical and social science literature, the extensively documented safety profile of ordinary oral contraceptives, and more than 30 years of clinical experience since hormonal emergency contraception was first described, give strong evidence for its safety. This review confirms declarations by the World Health Organization and the US Food and Drug Administration, and shows that emergency contraception has an excellent safety profile in nearly all women. Finally, emergency contraception allows women a second chance to avoid unwanted pregnancies. Whether pregnancy is carried to term or terminated, the condition has inherent risks that are greater than any posed by emergency contraception.

Policy climate, scholarship, and provision of emergency contraception at affiliates of the International Planned Parenthood Federation in Latin America and the Caribbean.

Emergency contraception (EC) has great potential to decrease the incidence and resulting consequences of unwanted pregnancy, including unsafe abortion. We conducted this study to understand EC practices in Latin America and the Caribbean (LAC). We contacted 43 International Planned Parenthood Federation affiliates in LAC to interview them about EC availability. We collected family planning norms and researched registered EC products in LAC. We searched English- and Spanish-language sources to compile EC literature reviews. Thirty-seven affiliates (86%) responded to the survey, and 62% offer EC. Central and South American affiliates are more likely to offer EC than are Caribbean affiliates. Of those offering EC, 96% offer cut-up packets of oral contraceptives, whereas six affiliates offer dedicated products. Of those not offering EC, 79% believe it constitutes abortion. EC availability and support for the method appear to be increasing in LAC, and clearer distinctions between EC and abortion in medical and policy guidelines should increase acceptance further.

Anticoncepción de emergencia: un método simple, seguro, efectivo y económico para prevenir embarazos no deseados / Emergency contraception: a simple, safe, cheap method and effective to prevent unwanted pregnancies

En el presente artículo, se revisa la información más actualizadas sobre los métodos utilizados en anticoncepción de emergencia (AE), definidos éstos como aquellos que previenen el embarazo en un periodo no mayor de tres días después del coito no protegido, de una falla del método o de la violación de la persona. En caso de métodos no hormonales, como el dispositivo intrauterino (DIU), la ventana de intervención se amplía hasta cinco días después de la relación sexual. Se revisan, también, los esquemas actuales de tratamiento, las indicaciones, la efectividad anticonceptiva, los efectos colaterales y el perfil de seguridad, los posibles mecanismos de acción, así como los elementos de la consejería. Se enfatizan los posibles beneficios sobre la salud reproductiva derivados del conocimiento amplio y difuso, así como del acceso fácil y no restringido a esta metodología, además de anexarse la bibliografía actualizada sobre el tema.