A HOSPITAL STUDY OF ILLEGAL IN BOLIVIA1

Pa&i& E. Baidey,,2 Lois Llano Saavedra,3 Lzh Kzm?iner,4 Michael WeZsh,5 and Barbara Janowitzd

INTRODUCTION deaths were related to induced abortion complications (3). Illegal are associated ’s population as of 1986 with high rates of maternal morbidity was estimated at about 6.4 million in- and mortality, and treatment of women habitants. The off&l population policy hospitalized for illegal abortions draws has been to promote growth by encour- upon scarcemedical resources. Hence, in aging immigration and maintaining cur- countries where induced abortions are il- rent levels of fertility. Direct measures legal their adverse consequences consti- have been taken to maintain these fertil- tute a serious public health problem. ity levels by closing family planning clin- Abortion is only permitted in ics (4). No government support is pro- Bolivia when a woman’s physical health vided for family planning services, is threatened by pregnancy or when she making the private sector the primary has been the victim of rape or incest; oth- source of contraception. A 1983 contra- erwise it is illegal (1). However, such ille- ceptive prevalence survey found that gal abortions are commonplace. Indeed, 24 % of the married women 15-49 years in the 1970s the Bolivian Ministry of of age were using contraceptive methods; Public Health estimated that the treat- of these, 14% were using rhythm and ment of complications arising from ille- other traditional methods, while 10% gal abortions accounted for more than were using modern clinical methods. 60% of the country’s obstetric and gyne- cologic expenses (2). In this same vein, a 1983 publication that reported maternal 3 Family Counseling Center (Centro de O&ntaci&z Fa- mortality as being 48 deaths per 10,000 $ m&a), Ia Paz, Bolivia. 2 live births stated that 27% of these 4 Physician, Family Counseling Center, La Paz. . 5 Senior Program Coordinator for Iatin America, Family Health International. 2 6 Associate Director for the Division of Program EvaIua- tion, Family Health International. .g u ’ Support for the project reported here was provided by a Familv Health International under a coooerative aeree- ment &h the U.S. Agency for Interna~onal Deviop- ment (DPE-0537-A-00-4047-00). This article wili also be published in Spanish in the BoLetetinde k Oj;,i,a Sanitati Panamericana, vol. 104. 1988. * Senior Research Analyst in the Division of Program Evaluation. Family Health International, Research Xi- angle Park, North Carolina 27709. USA. 27 Pharmacies and private medical clinics Hospitals within the country’s three were the most commonly reported main geographic regions (the high sources of contraceptive services (,), As plains, valleys, and tropical and subtrop- of 1984, the nation’s crude birth rate was ical plains) were included in this sample. estimated at 40 births per 1,000 popula- Physicians from each partici- tion per year, and women who had fin- pating center were trained to complete ished child-bearing had an average of six questionnaires that included informa- children (5). tion about the patient’s sociodemo- A lack of data on abortion graphic characteristics, obstetric and and its medical sequelae led members of contraceptive history, condition at admis- the Bolivian Society of Gynecologists and sion, medical treatment during hospital- Obstetricians to conduct a study of ization, and reproductive and contracep- women hospitalized for complications of tive plans. abortion. The study’s immediate aims At admission, the attending were to determine these hospitalized medical personnel classified each case of women’s sociodemographic characteris- abortion as definitely or probably spon- tics, the proportion of abortions that taneous, or (alternatively) definitely or were illegally induced, the patients’ probably induced. This classification was symptoms, the complications involved, based upon information reported by the the medical treatment provided and hos- patient and the attending physician. If pital resources used, the patients’ the patient said the abortion was in- patterns of contraceptive use before duced, it was coded as such. If she said it hospitalization, and their subsequent was spontaneous, but there was clinical contraceptive plans. Ultimately, the pur- evidence to the contrary (such as cervical pose was to provide policymakers with lacerations), it was coded as induced-ei- data that would help them design family ther by the physician or at Family Health planning components for maternal International.’ health care programs, so as to reduce the Even so, the final result was rates of unwanted pregnancy and illegal ahnost certainly an underestimate of the abortion. true number of induced abortions. For even when abortion is legal, many women do not wish to admit that they have terminated a pregnancy (61. It is M ATERIALSAND METHODS ’ Family Health International is a nonprofit organization 2 From 1 July 1983 through 30 located at Research Triangle Park in North Carolina, une 1984, data were collected on all USA. that carries out research on maternal and child : Jwomen admitted to a sample of Bolivian health and family planning. The organization is cur- z rently supporting projects throughout the United 2 hospitals for treatment of complications States and in over 40 countries. The computer coding .j$ associated with pregnancy wastage. referred to (transcription of the physicians’ answers) 9, Q These included the 11 major hospitals in was done at Family Health International. 3 the country’s five largest cities (Cocha- bamba, La Paz, Oruro, Santa Cruz, and Sucre). In each city a Ministry of Health 5n, (MOH) and a Social Security (SS)hospital were chosen; and in the case of La Paz 28 two private hospitals were also chosen. therefore likely that there were some a consensual union or married. The per- casesof induced abortion that showed no centage of induced abortions was also overt clinical evidence and that were said higher among the study subjects who by the women involved to be spontane- had been pregnant for the first time ous. If induced abortions (particularly (31% induced) than it was among those these without complications) were who had experienced at least one pre- underreported as a result, then the com- vious pregnancy (22 % induced). The pa- plication rate among induced caseswas tients’ level of education was not associ- probably overestimated. ated with the proportion of abortions induced, nor was their previous abortion experience. Regarding previous abortions, RxWETS a relatively small share (16.5 % ) of the women hospitalized for an earlier abor- Characteristicsof the Patient tion were classified as currently having an Population induced abortion, while a larger share (39.1%) of the women who had not During the year-long study been hospitalized for an earlier abortion period a total of 4,37 1 women were ad- were classified this way (see Table 1). mitted to the participating hospitals with These data are difficult to interpret, be- complications associated with pregnancy causeprevious abortions were not identi- loss. Of these women, 28 % were from La fied as spontaneous or induced. It is evi- Paz, the city with the largest population, dent, however, that nearly half of all the 2 5 % were from Cochabamba, 18 % from women studied had experienced a pre- Santa Cruz, 16% from Oruro, and 13% vious abortion, and that three-quarters from Sucre. Nine hundred and ninety- of those with known prior abortions had two (23%) of the abortions involved also been hospitalized. were classified as illegally induced, and 3,379 (77 % ) were classified as spontane- Patient Complications, ous (Table 1). The share of abortions clas- sified as induced, by city, ranged from ‘Ikatment, Length of Hospital 42 % in Oruro to 15 % in La Paz. Stay, and Mortality The percentage of abortions Table 2 indicates that women classified as induced (see the third col- classified as having a spontaneous abor- z umn of Table 1) was negatively associated tion were admitted with far fewer com- with age, ranging from 39% among plications and generally received less 5 women 17 years of age or younger to treatment than those classified as having 5 18% among women over 29. The per- an induced abortion. Women with in- R centage of induced abortions was much duced abortions were more likely to have 5 higher among women not currently in a fever exceeding 38°C infection, trau- 2 any union than among those who were in matic lesions (such as cervical or vaginal . lesions), and excessive blood loss than s were women with spontaneous abor- ; tions. They were also more likely to re- 3 ceive antibiotics and blood transfusions %t3 (but not anesthesia, IV fluid, or oxy- Q tocins) than those with spontaneous abortions. 29 TABLE1. Percentagedistribution of the patients admitted for treatment following abortionaccording to their age, education,marital status, number of liking children, occurmnceof previouspregnancy, and previousabortion experience. The table also shows the percentageof patients in each gmup who were claMed as having in- duced abortfons.

Abortions Patients classified No. W) inducz (%) Patientage: 14-17years 114 (2.6) (38.6) 18-19 tt 244 (5.6) (30.3) 20-29 // 2,349 (53.7) (24.2) 230 fl 1,658 (37.9) (18.3) Unknown 6 (0.1) -a Education: Non& 418 (9.6) (23.9) Primary 1,693 (38.7) (23.0) 2 secondary 2,254 (51.6) (22.2) Other 4 (0.1) -a Unknown 2 (0.1) -a Marital status: Neverin union 447 (10.2) (46.3) Consensualunion 571 (13.1) (23.6) Married 3,229 (18.0) Divorced,separated, or widowed 124 (2 (54.8) !/umberof living children: 0 697 (15.9) (25.8) 1 897 (20.5) (19.5) 2 896 (20.5) (21.4) 3 678 (15.5) 4 502 (11.5) I;;.;{ r5 701 (16.0) (24:0) First pregnancy: Yes 494 (11.3) (31.3) No 3,877 (88.7) (21.6) Previousabortion: b Yes 1,775 (45.8) (22.3) Hospitalized 1,334 (34.4) (16.5) Not hospitalized 441 (11.4) No 2,102 (54.2) ~YIij Total 4,371 (100.0) (22.7) < CL a Lessthan 25 cases. ry b Includesonly the 3,877women wilh priorpregnancies. -4 R ‘G 9) 3

2 2 n,

30 TAME 2. Condiin and tmafmentof the study patientswith induced and spon- bayous abortions, showing the compliions existing at admission,types of treatmentreceived during hospitalization,number of days hospitalized,and case- fatalll rate.

% of patientswith abortionsclassified as: % of all patients Spontaneous Induced (n = 4,371) (n = 3,379) (n = 992) Compkations: Fever 8.6 3.1 27.7 Infection 12.0 5.7 33.2 Eaxsslveblood loss 34.0 32.0 40.8 Lesions 4.8 0.0 21.2 Treatmentat hospital: Generalanesthesia 95.4 96.3 92.1 Bloodtransfusion 6.2 11.9 IV fluid 6i:i 64.6 65.5 Antibiotics 66.5 60.9 85.8 Oxytocins 71.1 70.6 72.8 No.of dayshospitalzcxf: 0 0.6 0.3 1.8 1 38.9 41.I 31.2 2 35.4 37.2 29.3 3 15.7 13.8 22.0 r4 9.4 7.6 15.7 Casefatality ratea 1.6/1,000 0.3/1,000 6/l ,000

a Numberof deathsdivided by numberof cases.

Hospital stays (perhaps the hospital resourceswas considerable, with best overall indication of resource use) each woman spending an average of 17 were significantly longer for women with days in a hospital. induced abortions. More than a third Seven women died during of those with induced abortions spent their hospitalization, one as a conse- three or more days in a hospital, as com- quence of an incomplete spontaneous pared to 21% of those with spontaneous abortion. The case-fatality rate among abortions. the 992 patients classified as having in- Due to abortion-related com- duced abortions was six per thousand, as plications, 20 women, 16 of whom had compared to 0.3 per thousand among reported induced abortions, received a women classified as having spontaneous total hysterectomy. Of these 20, 15 were abortions. less than 30 years of age and five had no The woman who died from living children. Besides the high per- complications of a spontaneous abortion sonal cost to these women, the use of was 37 years old and had had seven preg- nancies, three of which had terminated in abortion. She was four months preg- nant at the time of admission and had been bleeding for over two weeks. Among the patients who died symptoms for 15 days before seeking from complications associated with in- treatment. She died within three hours duced abortion, one woman 29 years of of arrival, before any surgical interven- age was diagnosed as having an ectopic tion. A third patient, this one 23 years of pregnancy as well as a perforated uterus. age with one child, came to the hospital A hysterectomy was performed, but she with peritonitis plus cervical and uterine died within 24 hours. Another patient perforations. Several surgical procedures was a 35year-old mother of two living were performed during a hospital stay children who arrived at the hospital in a that lasted 50 days. state of septic shock. Her abortion had been induced by a medically untrained ProceduresUsed to Induce person, and she had been suffering Abortion Table 3 provides information about the abortion practitioners used by

TABLE3. Abortionpractitioners cited by 572 of the study women with induced abortions-by age group, maritalstatus, education,pregnancy history, and abor- tion history of the study women.

% abortionsinduced by: Person Person without with Number medical medical Total of Patient training training (%) women Age(in years)? 14-17 6.9 13.8 79.3 100.0 29 18-19 4.2 14.9 80.9 100.0 47 20-29 4.7 31.4 63.9 100.0 341 230 6.5 33.8 59.7 100.0 154 Marital status: Nevermarried 5.0 25.5 69.5 100.0 141 Consensualunion 2.5 40.7 56.8 100.0 81 Married 6.7 27.6 65.7 100.0 315 Divorced,separated or widowed 0.0 40.0 60.0 100.0 35 EducdW None 8.0 48.0 44.0 100.0 50 Primary 5.8 36.3 57.9 100.0 240 2 secondary 4.3 21.1 74.6 100.0 280 First pregnancy? Yes 4.0 17.0 79.0 100.0 100 No 5.5 32.5 62.0 100.0 471 Previousabortion: b Yes 6.5 38.8 54.7 100.0 201 Hospitalized 7.8 27.9 64.3 100.0 129 Not Hospitalized 4.2 58.3 37.5 100.0 72 No 4.8 27.8 67.4 100.0 270 Total 5.2 29.7 65.0 100.0 572

a Includesonly 570 or 571women because information on one or Iwo womenwas missing in eachcase. b Includesonly the 471 women with priorpregnancies. the patients classified as having induced pared to 55 % of those who reported a abortions. In all, 420 (42 % ) of these pa- previous abortion. Regarding these latter tients either declined to give information women with previous abortions, 64 % of concerning the practitioner or did not ac- those who were previously hospitalized knowledge to attending medical person- appeared to have chosen an abortion nel that they had had an induced abor- practitioner with medical training, as tion. All of these 420 were excluded from compared to only 38 % of the women Table 3. with prior abortions who were not hospi- Of the remaining 572, 65% talized. reported that their abortion had been Able 4 provides information initiated by a person with some medical about procedures used to initiate rhe in- uaining; only 5 % had self-induced abor- duced abortions. The method most com- tions. Women under 20 were the most monly cited was insertion of a foreign ob- likely to seek medically trained person- ject into the vagina (26%), followed by nel; and the higher the woman’s educa- curettage (23%) and administration of tion, the more likely she was to have the an oral (7%). However, abortion induced by a person with medi- many of the patients (38%) declined to cal training. Also, 79% of the women specify the method used. who were pregnant for the first time The method of induction var- chose someone with medical training, as ied considerably with the type of practi- compared to only 62 % of the parous women. In addition, 67 % of the parous women with no chose a person with medical training, as com-

TABLE4. Proceduresused to induce abortion in the 992 study women classifiedas having induced abtins-by the type of abortion practitfonerinvolved.

Abortioninduced by: Person Person Unknown- without with patient medical medical declinedto Patient training training answera Total Procedureused (n = 30) (n = 170) (n = 372) (n = 420) (n = 992) Insertionof foreign object(%) 3.3 56.5 34.1 9.0 26.4 Curettage(%) 0.0 11.2 51.3 3.3 22.6 Administrationof oral abortifacient(%) 83.3 19.4 1.9 1.2 7.1 Injection(W) 3.3 0.0 3.8 Other(%) 3.3 2 38:: 0.2 2.4 Patientdeclined to answer(%) 6.7 2.9 1.3 86.2 37.7

Total(%) 100.0 100.0 100.0 100.0 100.0 a includes67 caseswithout data. 33 tioner. Among practitioners with some classified as induced involved at least one medical background, more than half diagnosable complication, and more used curettage, while another third used than a quarter had three or four. insertion of a foreign object. Only 11% Insertion of a foreign object of the practitioners without medical was associated with a greater number of training used curettage; over half used complications than curettage. Overall, insertion of a foreign object. When a 37 % of the women whose abortions were woman initiated her own abortion she induced by insertion of a foreign object most frequently took an oral aborti- had three or more complications as com- facient . pared with 28% of those induced by cu- Table 5 shows how complica- tions and the number of days hospital- ized varied with the method of induc- tion. More than half of the 992 abortions

TABLE5. Numbers of complications,types of complications,and days of hospitalizationexperienced by patients whose abortionswere induced, by inductionmethod.

Methodused to induceabortion: Unknown- Insertion patient of foreign Oral declinedto object Curettage abortifacient Injection Other specify Total (n = 262) (n = 224) (n = 70) (n = 38) (n = 24) (n = 374) (n = 992) % of patientswith indicatednumber of complications(%): 0 0.4 2.2 0.0 0.0 16.7 2.1 1 35.9 50.9 91.4 89.5 50.0 5:.; 53.6 .-I 26.3 18.3 4.3 2.6 20.8 11:5 16.3 3’ 23.3 17.9 4.3 7.9 8.3 24.6 20.3 4 14.1 10.7 0.0 0.0 4.2 3.7 7.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 % of patients with indicatedcompkations at admission(%): co Fever 37.0 25.9 7.1 7.9 12.5 29.0 27.7 3Y Infection 40.5 42.9 4.3 10.5 12.5 31.3 33.2 -; Bleedinga 98.5 93.3 100.0 100.0 79.2 96.8 96.4 CL Lesions 38.9 22.9 1.4 0.0 29.2 13.2 21.2 2 % of patients with .g indicatednumber of days hospitalized: d 0 3.8 1.8 0.0 0.0 0.0 1.1 1.8 3 1 27.1 30.8 35.7 18.4 25.0 35.0 31.2 26.0 23.2 41.4 36.8 37.5 31.8 29.3 $ : 26.3 21.4 18.6 36.8 25.0 18.2 22.0 a, r4 16.8 22.8 4.3 7.9 12.5 13.9 15.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 34 a Mined as any bleeding. rettage. This difference is statistically sig- both contraceptive and modern method nificant (p < 0.01). To be more specific, use for the women with induced abor- significantly more patients had fever, tions were similar to the rates found for bleeding, or lesions if a solid object was urban Bolivia by the 1983 contraceptive inserted into the uterus than if curettage prevalence survey-which found 39% of was employed; however, no significant the women surveyed to be using contra- difference was observed between the two ceptive methods and 17% to be using groups with regard to infection. modern clinical methods. Because insertion of a foreign All study women not using object was associatedwith a greater num- contraception during the month before ber of complications and higher propor- conception were asked why they had not tions of most symptoms, one would have been using a method. The reasons they expected longer hospital stays for these gave, which are listed in Table 7, may be women. However, hospitalization was classified into the following four catego- not consistently longer for the women ries: (1) reasonsrelated to desire for preg- whose abortions were induced with solid nancy, (2) failure to recognize a need, (3) objects. lack of knowledge and/or accessibility of Women whose abortions were methods, and (4) personal reasons. Re- initiated by oral or injec- gardless of the type of abortion subse- tions generally had only one complica- quently involved, the highest percentage tion, and this was usually bleeding. Not of study women cited reasons related to surprisingly, these women were the least knowledge or accessibility of methods. likely to stay four or more nights. The percentage lacking knowledge might actually be higher than that PreviousContraceptive Practices shown, since women who cited other rea- and Reproductive Plans sons may also have lacked knowledge. For women with spontaneous abortions, As Table 6 shows, the rate of the second most important reason was contraceptive use among the study popu- that they desired the pregnancy. As lation during the month before concep- might be expected, only 2% of the tion was low. Twenty-three percent of all women with induced abortions gave this the women hospitalized for treatment reason. However, many (27 % ) of the following abortion reported using some women with induced abortions said they method, but only 7% were using mod- did not recognize a need for contracep- ern clinical methods (oral or injectable tion, either because they did not think it contraceptives, IUDs, or barrier meth- was necessary or because of infrequent ods), while 13 % were using the rhythm sexual activity. method. Table 7 does not convey a The rate of contraceptive complete picture regarding women who practice was higher among those with in- did not want their pregnancies. Of the duced abortions than among those with women with spontaneous abortions, spontaneous abortions (40% versus 19 % 37% said they did not want the preg- were using some form of contraception). Regarding use of modern clinical meth- ods, 17% of those with induced abor- tions had been using such methods, as compared to 4 % of those with spontane- ous abortions. In general, the rates of 35 TABLE6. Percentagesof women practicing contraceptionamong the 4,371 study subjects (classified by type of abortion)during the month of conceptionand among 2,166 contraceptiveprevalence survey (CPS) subjects, showingthe types of contraceptivemethods used.

% of patientswith % of urban abortionsclassified as: % of womensurveyed Contraceptivepractice during total Spontaneous Induced by 1983CPSa monthof conception (n = 4,371) (n = 3,379) (n = 992) (n = 2,166) Useda method: 23.4 18.6 39.8 38.6 Periodicabstinence 73.1 12.8 14.2 19.5 Sferiization - - 4.4 IUD.9 3.2 1.2 10.3 6.3 Hormonalsb 7.6 1.2 2.7 5.4 Barriermethods, spermicides 1.9 1.2 4.2 1.3 Withdrawal,lactation, other 3.6 2.7 8.3 1.7 Didn’tuse a method 76.6 81.4 60.2 61.4 Total 100.0 100.0 100.0 100.0 a Unpublishedpreliminary results for currentlyor previouslymarried women 15-49 yearsof age. b Oralcontracepttves. injectables.

TABLE7. Reasonsgiven for not using contraceptionby the 3,347 study womenwho were not using contraceptionduring the month beforeconception-by type of abortion.

% of patientswith abortionsclassified as: % of total Spontaneous Induced Reasonsgiven (n = 3,347) (n = 2,750) (n = 597) Pregnancydesired 29.1 34.9 2.3 Recognitionof need: 14.2 11.4 26.8 Didn’t think use necessary 9.5 7.8 17.4 Little sexual activity 4.7 3.6 9.4 Knowledge/accessibility: 42.7 41.I 49.9 Didn’t know about contraception 41.1 39.6 47.7 Methodsnot available/tw wstly 7.6 1.5 2.2 Personalreasons: 11.7 10.6 16.9 Fear of side-effects 7.9 7.5 9.9 Objectionsof partner; famih or religion 3.8 3.1 7.0 Other 1.8 1.4 3.4 cc2 Unknown 0.5 0.5 0.7 .j$ Total 100.0 100.0 100.0 9) a 23 2

3R

36 nancy, and 20% were uncertain whether they intended to use some contraceptive they wanted it or not. In contrast, 90 % method, and 66% said they intended to of those with induced abortions said they use a modern clinical method.8 While did not want the pregnancy, and only the percentage of women intending to 7% were uncertain. Overall, half of the use modern clinical methods was much total study population not using contra- higher than the percentage reporting use ception said the pregnancy was not de- of those methods before pregnancy, the sired, while 17 % were uncertain. percentage intending to use traditional Regarding the stated intent of methods (particularly the rhythm study subjects to use or not use contra- method) was considerably lower than the ception following their abortions, the percentage reporting use of those meth- percentage saying they intended to use a ods before pregnancy. This was especially method in the future was higher than true for the group of patients with in- the percentage saying they had used a duced abortions. method during the month before con- Women who said they did not ception (T&ble 8). Nearly half the women intend to use any contraceptive method hospitalized for complications associated after their abortion were asked why not. with spontaneous abortions said they in- As Table 9 indicates, the reason given tended to use a method, and 34 % said most frequently by women with sponta- they intended to use a modern clinical neous abortions was that they wanted to method. More emphatically, over three- get pregnant again. (The next most fre- fourths of the women hospitalized for quent reason among this group was lack complications of induced abortion said

8 Defined as use of hormonals, IUDs, condoms, spermi- tides, or sterilization. The category “other” was com- prised largely of women who wished to consult further with a physician before deciding which method to use.

TABLE8. Statadintentions of 4,363 study subjjcts to use or not use contraceptfvemethods followingaborlfon, by type of abortion. Informationwas missingfor eight of the 4,371 study subjacts.

% of patientswith abortionsclassified as: % of total Spontaneous Induced Plansfor contraceptiveuse (n = 4,363) (n = 3,377) (n = 986) Patientsstating intent to use: 55.6 49.4 77.0 /LIDS 26.6 23.0 38.7 HOrmonalS 12.1 8.7 23.6 Periodicabstinence 5.2 6.1 2.7 Withdrawal 3.8 3.8 4.1 Steriiization 2.5 2.2 3.7 f?aniermethods, spermicides 0.5 0.5 0.4 Other 4.9 5.1 4.3 Patientsstating intent not to usecontraception 44.4 50.6 23.1 Total 100.0 100.0 100.0 TABLE9. Reasonsgiven for intendingnot to use contraceptionby the 1,939 study subjects who said atter their abortionsthat they intendedto use no contraceptionin the future. % of patientswith abortioosclassified as: Reasonsgiven for intending % of notto usecontraception - total Spontaneous Induced in the future (n = 1,939) (n = 1,711) (n = 228) Pregnancydesired 52.4 57.9 11.4 Intendsto discontinuesexual relations 9.1 6.0 32.5 Noknowledge of contraception 28.2 27.6 32.9 Personalreasons 6.7 7.1 21.5 Fear of side-effects 4.7 4.6 5.7 Objectionsof partnec fan@ or re/igion 4.0 2.5 75.8 1.1 1.1 1.3 Unknown 0.4 0.4 0.4 Total 100.0 100.0 100.0

of knowledge.) For women with induced abortions, the two most commonly cited D ISCUSSION reasons were lack of knowledge about contraception and intent to discontinue The foregoing results cannot sexual relations. However, 21.5 % cited be applied generally to all Bolivian personal reasons, especially objections of women experiencing abortions, since the their partner, family, or religion to con- study sample included only those women traceptive use. who sought medical attention and were Those who said they intended admitted to certain hospitals. Women to use a modern clinical method were who suffered only minor complications asked where they intended to obtain or none at all would have been less likely their contraception. As indicated by the to seek hospital care. In addition, some figures in Table 10, nearly 80% of the women, especially in rural areas, had women in the induced group and over limited accessto hospitals. Nevertheless, 90% of those in the spontaneous group becauseof the difficulties involved in ob- 3 said they would obtain their contracep- taining data on abortions outside of hos- 2 tion in the private sector. pital settings, the data obtained provide i important information about abortion 2 (\1 despite their limitations, -4 Clearly, the physical and psy- -8 u chological costs of abortion to some aa women and their families were very high. Seven women died; and 20, some 2 of whom were young and unmarried, had hysterectomies. The cost to hospitals of treat- ing these women was also high. The pa- 38 tients occupied a substantial number of TABLE 10. Intended sources of modern conbxqtive methods, as reported by study women who said after their abortionsthat they plannedto use such methods:

% of patientswith abortionsclassified as: % of total Spontaneous Induced Intendedsource of method (n = 1,817) (n = 1,162) (n = 655) Privateclinic/physician 62.3 70.1 48.4 Pharmacy 24.6 21.3 30.4 Healthcenter/government clinic 7.4 2.5 16.1 Returnto hospital 4.0 4.8 2.6 Receivedmethod before discharge 1.5 0.9 2.4 Other 0.1 0.2 Unknown 0.1 0.1 i:; Total 100.0 100.0 100.0

a Definedas homonals,IUDs. condoms, spmicides, or sterilization. hospital beds, and 25% stayed three cies to those desired. Indeed, even nights or more. Virtually all received cu- among the women with abortions classi- rettage while under general anesthesia, fied as spontaneous, the level of contra- even though is the ceptive use was low. That is, over half preferred procedure for treating an in- said they had not wanted the pregnancy complete abortion (7). Since vacuum as- or had not been sure they wanted it. By piration tends to produce less trauma these criteria, the women in both groups than curettage and can be used on an (with induced and spontaneous abor- outpatient basis, it appears that hospital tions) who reported that their pregnan- costs could be reduced by substituting cies had been unwanted (as well as some vacuum aspiration for curettage. Also, of these who reported not being certain) many of the abortions studied could were in need of effective contraceptive have been avoided if counseling, sex ed- methods. ucation, and family planning services The paucity of sex education had been available. provided in the schools and at home is g Overall, a considerable pro- reflected in the large percentage of study g portion of the women studied said they women who cited lack of knowledge as a 5 had not wanted their pregnancies. As reason for not using contraception dur- was to have been expected, higher pro- ing the month before conception. This 5 portions of women with induced (as information problem was also found R compared to spontaneous) abortions said among the women who said they were 3 their pregnancies were not wanted and not planning to practice contraception 2 had been using conuaceptives during the . month before conception. It thus ap- GP pears that among the women with in- s duced abortions, in many casesthe con- z. traceptive methods used were not effective or were not being used correctly. Also, it appears that the level of contra- ceptive use was too low to limit pregnan- 39 after discharge, nearly a third of whom as a result, the prevalence of sterilization said they lacked knowledge of contra- is much lower in Bolivia than in other ception. Latin American countries. Physicians The extent to which patients may be reluctant to recommend and per- hospitalized with complications from form sterilization, and women may not abortions are counseled on family plan- perceive it as an option. ning probably varies with the institution, In countries where highly the clinical staff attending them, and the qualified personnel and financial re- patients themselves. However, it appears sources are limited, it has been found that postabortion counseling, as well as that family planning services are a cost- prior sex education, would offer an im- effective component of integrated mater- portant way of helping these women nal health care (10). This finding is sup- help themselves. ported in a negative sense by the study Although a high percentage reported here, which identified a group of the study women said they intended of Bolivian women whose needs were not to use some contraceptive method after being met-needs that were expressed discharge, the actual level of contracep- by the risks and costs entailed in the ter- tive use will probably be lower. One rea- mination of unwanted pregnancy. son for this could be a lack of available services, especially since no family plan- ning services are provided by the public sector. In this vein, there would appear SUMMARY good reason for health care providers and The extent to which deliber- program planners to respond to the high demand for modern clinical methods. ate pregnancy wastage (induced abor- tion) is practiced in Latin America is dif- More than half of the study patients in- ficult to determine because of its illegal tending to use a method said they status. Until now, no estimates have wanted to use an oral contraceptive or IUD. Since the insertion of an IUD re- been available for Bolivia. However, over quires medical training, if there were no a twelve-month period, beginning in legal hindrances hospital personnel July 1983, data were collected at 11 hos- pitals in five Bolivian cities on 4,37 1 could offer interested women insertion before discharge. Studies have shown women in need of medical treatment fol- that postabortal IUD insertion does not lowing spontaneous or illegally in- duced abortions. Twenty-three percent of significantly increase the rate of subse- these abortions were illegally induced. quent complications (8). The women who deliberately terminated Also, sterilization is one of their pregnancies were more apt to be the most popular contraceptive methods young, nulliparous, and single (not mar- in much of Latin America. However, ried or in a consensual union) than those even when female sterilization is well- whose abortions were spontaneous. known, obstacles often exist within the delivery system (9). In this study, more than 1,800 women said they wanted no more children. Although there is no spe- cific legislation in Bolivia that mentions sterilization, any medical procedure that affects the normal functioning of the re- productive organs is prohibited. Perhaps Of the illegally induced cases, 65 % were induced by medically trained Ft.EFERENCES practitioners, most of whom employed curettage; the other 35%, induced by 1 Tietze, C. Induced Abortion, A Wodd Re- people without medical training or by view, 198.3 ct;Fh ed.). The Population Coun- the women themselves, were initiated cil, New York, 1983. most commonly by inserting a foreign 2 Population Reports. Heahh: The Famdy Plan object in the vagina. In general, the ning Factos SeriesJ, No. 14. Baltimore, 1977. more educated women were more apt to seek out medically trained practitioners. 3 Murillo, A. de la G., and J. de1 Castillo. Mor- talidad matema. Rev&a de l’a Sociedad de Also, women whose abortions were in- GinecoLogiiay Obstetricia (1): 1, 1983. duced by curettage were less likely to ex- perience fever and lesions but had longer 4 Population Division of the United Nations Department of International Economic and average hospital stays. Social Affairs and the United Nations Fund for Sixty-two percent of the Population Activities. Popdation Policy Com- women studied said they had not been pendium (Bohti). New York, 1979. using contraception during the month 5 Consultora Boliviana de ReproducciBn Hu- before conception; 48 % of these nonus- mana. Encuesta de Prevalencia de Medicamen- ers cited lack of knowledge as their rea- tos: Informe Preliminar. La Paz, 1984. son for nonuse. After medical treatment, 6 Szabady, E., A. Klinger, and G. Acsadi. The 77 % said they planned to use contracep- Hungarian Fertility and Family Planning tion, the IUD being the most commonly Study of 1965-66: Preventive Medicine and Family Plannin . In: International Planned cited method. Parenthood Fe1 eration. Proceedings of the Seven of the hospitalized Fifth Conference of the Europe and Near East women studied lost their lives and 20 re- ~.q&on. of the ZPPF in Copenhagen. London, ceived total hysterectomies as a result of abortion-related complications. Of the 7 Kleimnan, R. L. (ed.). Abortion: C~asszj%a- latter, I5 were less than 30 years old and tion and Techniques. IPPF Central Medical five had no living children. In addition, Committee, London, 1974. substantial scarcemedical resources were 8 Goldsmith, A., R. Goldberg, H. Eytaguirre, needed to treat abortion-related prob- S. Lucero, and L. Lizana. IUD Insertion in the Immediate Postabortal Period. In: Goldsmith, lems, as suggested by the fact that over a A., and R. Snowden (eds.). Famdy Planning third of the women with induced abor- Research Conference: A Mdtidiscibhnarv Ab- tions were hospitalized for three or more proacb. Excerpta Medica, Amst&dam: The days. Overall, the results of this study in- Netherlands, 1972, pp. 59-67. dicate a clear need to improve the deliv- 9 Janowitz, B., J. Nufiez, D. L. Covington, and ery of family planning servicesin Bolivia. C. Colven. Wh women don’t get sterilized: A follow-up oY women in Honduras. St& Fam PIann 16(2), 1985. 10 Nortman, D. L., J. Halvas, and A. Rabago. A Cost-Benefit Analysis of the Family Planning Program of the Mexican Social Securitv Ad- mi&tration. Paper presented at the General Conference of the International Union of the Scientific Study of Population held at Flor- ence, Italy, in 1985.