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“We Are Putting Our Reproductive Age at Risk”

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“We Are Putting Our Reproductive Age at Risk” “We are Putting our Reproductive Age at Risk” Influencing Factors, Experiences and Reflections on How it is to Manage Cases of Abortions and Obstetric Emergencies with Pregnancy Loss as an Obstetrician-Gynecologist in El Salvador Emma Stenbacka Master Thesis, 30 credits Medicine Program, 330 credits Supervisors: Professor Birgitta Essén & Professor Solveig Jülich Department of Women’s and Children’s Health & Department of History of Science and Ideas Examinator: Professor Matts Olovsson Department of Women’s and Children’s Health 2019-01-17 Note on the title: “We are putting our reproductive age at risk” is a quote from one informant, when she broadly reflected on how the El Salvadorian health care system fails the patients of reproductive age by sometimes not providing adequate health care. 2 Table of Contents Abstract ............................................................................................................................................. 4 Populärvetenskaplig Sammanfattning ........................................................................................... 5 Abbreviations ................................................................................................................................... 6 1. Background ................................................................................................................................... 7 1.1. Sexual and Reproductive Health and Rights ........................................................................... 7 1.2. The Pregnancy ......................................................................................................................... 8 1.2.1. Pregnancy Related Problems and the Loss of a Pregnancy ........................................... 9 1.2.1.1. In Early Pregnancy: Focusing on Abortions ......................................................... 9 1.2.1.2. In Late Pregnancy: Focusing on Obstetric Emergencies with Pregnancy Loss .. 11 1.3. Maternal Health Problems Globally and in Latin America .................................................. 12 1.4. The El Salvadorian Context .................................................................................................. 13 1.4.1. Legal and Ethical Aspects and the Role of the Physician ........................................... 14 1.4.2. The Patients and Prosecuted Women .......................................................................... 16 1.5. Theoretical Framework: Reproductive Governance ............................................................. 17 1.6. Objective and Questions at Issue .......................................................................................... 18 2. Material and Methods ............................................................................................................... 20 2.1. Medical Humanities .............................................................................................................. 20 2.2. Study Design ......................................................................................................................... 20 2.2.1. Selection: Purposive and Snowball Sampling ............................................................ 20 2.2.2. The Informants ............................................................................................................ 21 2.2.3. The Interview Guide and In-Depth Interviews ........................................................... 21 2.3. Transcription ......................................................................................................................... 22 2.4. Thematic Analysis ................................................................................................................. 23 2.5. Ethical Considerations .......................................................................................................... 24 2.6. The Researchers Preunderstanding ....................................................................................... 25 2.7. Concepts ................................................................................................................................ 25 3. Results ......................................................................................................................................... 27 3.1. The Influencing Factors and How They Influence ............................................................... 27 3.1.1. Ethical Principles and Conflicting Laws ...................................................................... 27 3.1.2. The Catholic Church .................................................................................................... 29 3.1.3. Environment of Polarization, Judgmental Attitudes and Hierarchy ............................ 30 3.2. Experiences and Reflections… ............................................................................................. 32 3.2.1. …Concerning Abortions .............................................................................................. 32 3.2.2. …Concerning Obstetric Emergency With Pregnancy Loss ......................................... 34 4. Discussion .................................................................................................................................... 37 4.1. The Circumstances of Reporting a Patient or Not ................................................................ 37 4.2. Prioritizing of the Religious and Moral Values .................................................................... 39 4.3. Unprofessional Management and The Loss of Rights of the Pregnant Woman ................... 41 4.4. Conclusion ............................................................................................................................ 42 4.5. Strengths and Limitations and Potential Sources of Bias ..................................................... 43 4.6. Implications for Future Research .......................................................................................... 44 5. Acknowledgement ...................................................................................................................... 46 6. References ................................................................................................................................... 47 7. Appendix ..................................................................................................................................... 51 7.1. Attachment 1: Information About the Study and Informed Consent .................................... 51 7.2. Attachment 2: The Interview Guide ...................................................................................... 53 7.3. Attachment 3: The Interview Guide for the Case ................................................................. 56 3 Abstract In El Salvador, where induced abortion is prohibited on all grounds, women are condemned to aggravated homicide, with the prison sentence up to 40 years, also for other pregnancy outcomes such as spontaneous abortions and other obstetric emergencies with pregnancy loss. The physicians managing the cases have to consider ethical principles and conflicting laws, making it impossible to keep them all and many times the woman goes directly from the hospital to the prison. The purpose of the report was to gain deeper understanding and knowledge about the influencing factors on the clinical management, and obstetrician-gynecologists’ experiences and reflections on managing cases with abortion and obstetric emergencies with pregnancy loss. More Broadly, the goal of the report was to contribute to the field of medical humanities by demonstrating how in these cases non-medical and -biological factors influence on the clinical management. This was done using a qualitative approach, thematically analyzing five semi-structured in-depth interviews with obstetrician-gynecologists in El Salvador with the help of the theoretical framework of reproductive governance. The results showed that the main influencing factors on the clinical management of abortion and obstetric emergencies with pregnancy loss were the ethical principles and conflicting laws, the Catholic Church and the environment of polarization, judgmental attitudes and hierarchy. Depending on the individual prioritization of the factors, influenced by both the private and work environment and done either deliberately or not, they had all created an individual framework for managing the cases and hence also to weigh the rights between the woman and the unborn in different situations. In practice, there is no consensus on how to clinically manage the cases of abortion and obstetric emergencies with pregnancy loss and the management depends on both the obstetrician-gynecologist’s individual framework and the particular circumstances at hand. From this conclusion one might question the equal right to health care and the patient safety for pregnant women in El Salvador. 4 Populärvetenskaplig Sammanfattning I El Salvador är abort totalförbjudet och kvinnor kan bli dömda för mord med fängelsestraff upp till 40 år också för att ha fått ett sent missfall. Idag sitter 26 kvinnor i fängelse dömda för detta.. Läkarna som tar hand om fallen måste överväga etiska principer och motsägande lagar, vilket i många situationer innebär att minst en lag måste brytas. Ofta åker kvinnan dessutom direkt från sjukhuset till fängelset då det är vårdpersonalen som anmäler henne. Syftet med den här rapporten var att få större förståelse för vilka faktorer som påverkar
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