Women's experiences using drugs to induce abortion acquired in the informal sector in Colombia: qualitative interviews with users in Bogotá and the Coffee Axis.

In 2006, abortion in Colombia was decriminalised under certain circumstances. Yet some women continue to avail themselves of ways to terminate pregnancies outside of the formal health system. In-depth interviews (IDIs) with women who acquired drugs outside of health facilities to terminate their pregnancies (n = 47) were conducted in Bogotá and the Coffee Axis in 2018. Respondents were recruited when they sought postabortion care at a health facility. This analysis examines women's experiences with medication acquired outside of the health system for a termination: how they obtained the medication, what they received, how they were instructed to use the pills, the symptoms they were told to expect, and their abortion experiences. Respondents purchased the drugs in drug stores, online, from street vendors, or through contacts in their social networks. Women who used online vendors more commonly received the minimum dose of misoprostol according to WHO guidelines to complete the abortion (800 mcg) and received more detailed instructions and information about what to expect than women who bought the drug elsewhere. Common instructions were to take the pills orally and vaginally; most women received incomplete information about what to expect. Most women seeking care did not have a complete abortion before coming to the health facility (they never started bleeding or had an incomplete abortion). Women still face multiple barriers to safe abortion in Colombia; policymakers should promote better awareness about legal abortion availability, access to quality medication and complete information about misoprostol use for women to terminate unwanted pregnancies safely.

What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis.

INTRODUCTION: In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them. METHODS: A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews. RESULTS: Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications. CONCLUSIONS: As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.

'I felt the world crash down on me': Women's experiences being denied legal abortion in Colombia.

BACKGROUND: In 2006, Colombia's constitutional court overturned a complete ban on abortion, liberalizing the procedure. Despite a relatively liberal new law, women still struggle to access safe and legal abortion services. We aimed to understand why women are denied services in Colombia, and what factors determine if and how they ultimately terminate pregnancies. METHODS: We recruited women denied abortion at a private facility in Bogota. Twenty-one participants completed an initial interview and eight completed a second longer interview. Two researchers documented themes and developed and applied a codebook to transcripts using ATLAS.ti. RESULTS: Participants faced barriers, such as lack of knowledge of service availability and delayed pregnancy recognition, leading to denial. Five out of eight participants ultimately received abortions in public hospitals, due to support from partners and a robust referral system; nevertheless, they received poor care. Those who continued pregnancies endured stigmatizing events and inaccurate medical counselling at referral facilities. Several women contemplated illegal abortion though were afraid to attempt it. CONCLUSION: We propose the following recommendations: 1) increase awareness about availability and legality of abortion services to prevent delay and consequent denial; 2) provide counseling and referral upon denial; and 3) train providers in interpersonal quality abortion care.

Health consequences of unsafe abortion in Colombia, 1989-2008.

The number of Colombian women hospitalized for the treatment of induced abortion complications increased from 57 679 in 1989 to 93 336 in 2008; the hospitalization rate also rose: from 7.2 to 9.1 cases per 1000 women aged 15-44 years. Factors that likely underlie the increase include improved access to postabortion care (although 1 in 5 women still do not obtain the care they need) and the growing role of misoprostol, often used incorrectly and to some extent replacing the use of surgical abortion by doctors. Efforts are evidently needed to improve access to safe abortion and effective contraception.

Estrategia FIGO para la prevención del aborto inseguro: experiencia en Colombia / Experience in Colombia regarding the FIGO strategy for preventing unsafe abortion

Objetivo: analizar la situación del aborto inseguro en Colombia para establecer: consecuencias, factores determinantes y calidad de la atención e identificar los puntos susceptibles de intervención, para elaborar un plan de acción tendiente a reducir los embarazos no deseados, abortos provocados y sus consecuencias. Materiales y métodos: estudio cualitativo con un componente de revisión de material bibliográfico y otro de consenso de expertos. Se llevó a cabo en dos fases. En la fase 1, de análisis situacional, se recolectó información mediante el formato elaborado por el grupo de trabajo de FIGO (Federación Internacional de Ginecología y Obstetricia). En la fase 2, de elaboración del plan de acción utilizando un marco lógico, se reunieron los representantes de OPS (Organización Panamericana de la Salud), UNFPA (Fondo de Población de las Naciones Unidas), filiales de IPPF (Federación Internacional de Planificación Familiar), ONG locales y agencias del gobierno. Resultados: el análisis situacional se resume en tres ejes: embarazo no deseado, intervenciones para su prevención y aborto. En el plan de acción se definieron cuatro objetivos específicos: mejorar el acceso a los servicios de salud sexual y reproductiva; facilitar el acceso a la interrupción voluntaria del embarazo acorde con la Sentencia C-355 de 2006; promover el acceso al misoprostol para usos ginecoobstétricos; y mejorar la información sobre tasas y complicaciones asociadas al aborto inseguro. Conclusión: a pesar del avance en Colombia con la Sentencia C-355 de 2006, aún persisten grandes retos, tales como reglamentar opciones de fácil acceso al servicio de interrupción voluntaria del embarazo para mujeres víctimas del conflicto armado, protocolos de investigación al interior de los tribunales de ética médica para los asuntos relacionados con objeción de conciencia, clarificar la autonomía y capacidad de menores de catorce años.

Objective: analyzing the situation regarding unsafe abortion in Colombia for establishing its consequences, determinant factors and the quality of attention as well as identifying susceptible intervention points for preparing a action plan aimed at reducing unwanted pregnancies, provoked abortions and their consequences. Materials and methods: this was a qualitative study, having a bibliographic material review component and another regarding expert consensus. It was carried out in two phases: 1. A situational analysis: information was compiled by using a form drawn up by the International Federation of Gynecology and Obstetrics (FIGO) working group; and 2. Preparing an action plan using a logical framework. A meeting was held with representatives from the Pan-American Health Organization (PAHO), the United Nations Population Fund (UNFPA), International Planned Parenthood Federation (IPPF) affiliates, local NGOs and government agencies. Results: the situational analysis revealed three areas of interest: unwanted pregnancy, prevention interventions and abortion. Four specific objectives were defined in the action plan: a) Improving access to sexual and reproductive health services; b) Facilitating access to voluntary interruption of pregnancy according to ruling C-355/2006; c) Promoting access to misoprostol for gynecobstetric use; and d) Improving information about unsafe abortion associated rates and complications. Conclusion: in spite of advances having been made in Colombia via ruling C-355/2006, there are still great challenges to be faced, such as establishing regulations for female victims of armed conflict, options for gaining easy access to the voluntary interruption of pregnancy service, research protocols within medical ethics’ tribunals for matters related to conscientious objection, clarifying the autonomy and ability of minors aged less than fourteen.

Oriéntame: preventing and solving problems related to unwanted pregnancy for 25 years in Colombia.

For over 25 years, the Oriéntame Foundation in Bogotá, Colombia, has been providing reproductive health services to women, regardless of their socio-economic or marital status, race, age or religious affiliation. Oriéntame started by focusing primarily on unwanted pregnancy and treatment for incomplete abortion, which has contributed to the reduction of maternal mortality in Bogotá. Oriéntame now provides comprehensive sexual and reproductive health services, including sexual health education, Pap smears, gynaecological problems, STIs and sexual violence, with a continuing emphasis on unwanted pregnancy, treatment for incomplete abortion and post-abortion care. The women that come to Oriéntame, some 18,000 per year in recent years, are from all socio-economic levels, and are increasingly more informed. The services are regularly re-evaluated so as to accommodate their changing needs. There is a sliding scale of fees, so that the 40% of women patients with higher incomes subsidize the 60% with lower incomes; this also allows the clinics to be self-supporting. Services are offered in an atmosphere of respect for women and their decisions, with professional staff who are trained to take care of both the medical and emotional needs of each woman. Since 1992, Oriéntame has also been doing outreach to the slum areas of Bogotá, providing education and information, to contribute to the empowerment of the poorest inhabitants of the city.