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Women's Experiences with the Use of Medical Abortion in a Legally

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Women's Experiences with the Use of Medical Abortion in a Legally FEATURE Women’s experiences with the use of medical abortion in a legally restricted context: the case of Argentina Silvina Ramos,a Mariana Romero,b Lila Aizenbergc a Senior Researcher, Center for the Study of State and Society (CEDES), Buenos Aires, Argentina. Correspondence: [email protected] b Senior Researcher, CEDES, and National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina c External Researcher, CEDES, Buenos Aires, Argentina Abstract: This article presents the findings of a qualitative study exploring the experiences of women living in Buenos Aires Metropolitan Area, Argentina, with the use of misoprostol for inducing an abortion. We asked women about the range of decisions they had to make, their emotions, the physical experience, strategies they needed to use, including seeking health care advice and in dealing with a clandestine medical abortion, and their overall evaluation of the experience. An in-depth interview schedule was used. The women had either used misoprostol and sought counselling or care at a public hospital (n=24) or had used misoprostol based on the advice of a local hotline, information from the internet or from other women (n=21). Four stages in the women’s experiences were identified: how the decision to terminate the pregnancy was taken, how the medication was obtained, how the tablets were used, and reflections on the outcome whether or not they sought medical advice. Safety and privacy were key in deciding to use medical abortion. Access to the medication was the main obstacle, requiring a prescription or a friendly drugstore. Correct information about the number of pills to use and dosage intervals was the least easy to obtain and caused concerns. The possibility of choosing a time of privacy and having the company of a close one was highlighted as a unique advantage of medical abortion. Efforts to improve abortion law, policy and service provision in Argentina in order to ensure the best possible conditions for use of medical abortion by women should be redoubled. © 2014 Reproductive Health Matters Keywords: abortion law and policy, medical abortion, women’s perspectives, misoprostol, abortion hotlines, Argentina Unsafe abortion and related mortality are both abortion.4 Most countries have restrictive abor- higher in countries with narrow grounds for tion laws,5 but as evidence worldwide shows, legal abortion.1 By 2011, 46% of countries in the legal prohibition does not deter women from world (91 out of 192) allowed abortion based seekinganabortion.Whenfacedwithanunwanted only on risk to the woman’slifeorhealth,29% pregnancy, many women will seek an abortion, allowed abortion at a woman’s request (at least despite condemnation and barriers that make in the first trimester of pregnancy), while five coun- it difficult or impossible for them to obtain a tries (Chile, El Salvador, Nicaragua, Malta and safe abortion.6 Dominican Republic) did not allow abortion under The development of medical technology has any circumstances.2 made it possible for women to terminate a preg- In 2006, it was estimated that about one mil- nancy safely, both surgically and medically. In lion women were being hospitalized for treatment legally restricted contexts, the expansion of access of complications from unsafe abortion in Latin to and use of medical abortion has increased America.3 In 2008, according to WHO estimates, considerably,7–10 due to the availability of miso- 95% of the 4.23 million abortions that took place prostol over the counter or on the black market. in the region were unsafe.1 More recently, it was In these settings, different strategies, such as estimated that 12% of all maternal deaths in the information and referral hotlines, internet pur- regional were due to complications of unsafe chase, and pre-and post-abortion counselling are Contents online: www.rhm-elsevier.com Doi: 10.1016/S0968-8080(14)43786-8 1 S Ramos et al. Reproductive Health Matters 2014;Supplement(43):1–12 increasingly being used – mainly by civil society results in women using the medication in sub- organizations and women’sgroups– to expand optimal conditions.18 women’s access to safe medical abortion.11,12 Abortion in Argentina is restricted by the Penal Medical abortion provides women with the Code, with exceptions if the woman’s life or health option of an early abortion that is safe, easily is at risk, or if the pregnancy is the result of rape, accessible, not invasive, and allows ambulatory including sexual assault of a mentally disabled care. Studies show that women prefer medical woman. But even abortions on these grounds abortion for a range of reasons: it is more natural, are not guaranteed by the health system.25 it does not involve surgery or anaesthesia, it Despite these restrictions, almost 400,000 abor- allows for early abortion, it preserves privacy, tions per year have been estimated to take place and women feel more in control of the abortion in Argentina, and complications of unsafe abor- process since, among other reasons, it can be tion have been the leading cause of maternal 26,27 organized to fit the woman’s daily routine. For mortality for the last two decades. these reasons, in most acceptability studies, Legal restrictions and the absence of a culture almost all the women who have used medical of abortion provision in public health services – abortion have said they would use it again and even for the limited grounds provided by law – recommend it to other women.8,13–16 are the main barriers to accessing safe abortion. In Latin America, women have been using The fact that misoprostol is not approved for medical abortion for self-inducing abortions at pregnancy termination adds another barrier. home for several decades.17,18 Of the two medica- Not only do women face obstacles in obtaining tions recommended by the World Health Organi- misoprostol, but health professionals also have zation for medical abortion, mifepristone is still to deal with the fact that as misoprostol is not not available in almost any country in the region, registered for abortion they have to resort to using it off-label. but misoprostol has been sold in pharmacies ’ since the 1980s.19,20 Misoprostol is approved in Women s use of medical abortion outside of clinical settings has therefore occurred clan- most countries to prevent gastric ulcers but not destinely both despite legal restrictions and for gynaecological or obstetric indications, except because of them. Given the importance of medi- in six countries,* which have registered it for cal abortion in reshaping the nature of abortion, some of these indications though not for abor- 21 understanding women’s experiences in legally tion. In spite of the legally restricted context restricted settings seems to be particularly rele- and in the absence of enforcement of the crimi- vant.28 This article presents the findings of a nal law on abortion, the use of medical abortion qualitative study aimed at exploring the experi- by women is reducing the risks of unsafe abor- ences of women living in Buenos Aires Metropoli- tion, thus contributing to the accomplishment 22 tan Area in Argentina with the use of misoprostol of Millennium Development Goal 5a and 5b. for inducing an abortion. A recent literature review focused on the Latin American region found that despite the long tradition of academic and social research in Methodology sexual and reproductive health, and a strong This was a descriptive, exploratory study. The women’s movement mobilized around the abor- 23,24 sample consisted of women with different medi- tion issue, few studies have specifically cal abortion experiences in terms of the sources focused on the medical abortion experience of information and counselling they had to resort from women’s perspective. This review also to. Some of them (n=24 women) had used miso- showed that legal restrictions on access to abor- prostol and sought counselling or presented with tion and regulatory restrictions on access to symptoms of incomplete abortion at a public medical abortion medications result in women hospital in the city of Buenos Aires.† The others lacking the appropriate information on dosage, (n=21 women) had used misoprostol following the symptoms and efficacy of medical abortion. advice of a local hotline, the internet, or other The absence of counselling and support before, women. All of them had had their abortion at home. during and after the abortion process also †The name of the hospital is not provided for confidentiality *Argentina, Brazil, Colombia, Mexico, Peru and Uruguay. reasons. 2 S Ramos et al. Reproductive Health Matters 2014;Supplement(43):1–12 The women were recruited in two ways. Women findings for women’s health and well-being, and who had sought counselling at a hospital were examine how the findings should be used to influ- approached by a member of the hospital’shealth ence future strategies to improve access to safe team, before they were discharged, who asked if medical abortion in legally restricted contexts. the research team could interview them. These interviews took place at the hospital. To reach women who did not attend a health care facility, Findings snowball sampling techniques were used. Through The 45 women interviewed were aged 18–40 years; women’s organizations in the community and 60% had completed basic education (seven or through personal networks, we sought referrals more years of schooling). One third of them were of women who had had a self-induced medical living with their partners at the time of the inter- abortion in the previous 12 months. In some view. Sixty per cent of them had children, ranging cases, the contact person referred more than from one to nine. one woman to us. In other cases, an interviewee We identified four stages in the women’sexperi- referred another woman to us.
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