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Study of Illegal Abortion in Bolivia1

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Study of Illegal Abortion in Bolivia1 A HOSPITAL STUDY OF ILLEGAL ABORTION 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 abortions are associated Bolivia’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 cause previous 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.
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