Journal name: Pragmatic and Observational Research Article Designation: ORIGINAL RESEARCH Year: 2017 Volume: 8 Pragmatic and Observational Research Dovepress Running head verso: Ortiz-Prado et al Running head recto: Overall mortality and morbidity rates due to abortion in Ecuador open access to scientific and medical research DOI: http://dx.doi.org/10.2147/POR.S129464 Open Access Full Text Article ORIGINAL RESEARCH Abortion, an increasing public health concern in Ecuador, a 10-year population-based analysis Esteban Ortiz-Prado1–4, Objectives: To describe the epidemiology of abortion in Ecuador from 2004 to 2014 and Katherine Simbaña5,6, Lenin compare the prevalence between the public and the private health care systems. Gómez5,6, Anna M Stewart- Methods: This is a cross-sectional analysis of the overall mortality and morbidity rate due to Ibarra4,7, Lisa Scott8, abortion in Ecuador, based on public health records and other government databases. Gabriel Cevallos-Sierra9 Results: From 2004 to 2014, a total of 431,614 spontaneous abortions, miscarriage and other 1OneHealth Research Group, Faculty of types of abortions were registered in Ecuador. The average annual rate of abortion was 115 Medicine, Universidad De Las Americas, Quito, per 1,000 live births. The maternal mortality rate was found to be 43 per 100,000 live births. Ecuador; 2Department of Cellular Biology, Physiology and Immunology, Institute of Conclusions: Abortion is a significant and wide-ranging problem in Ecuador. The study sup- Biomedicine, Universitat de Barcelona, Spain; 3Department of Physiology, Faculty of Medicine ports the perception that in spite of legal restrictions to abortion in Ecuador, women are still For personal use only. “Eugenio Espejo”, Universidad Tecnologica terminating pregnancies when they feel they need to do so. The public health system reported Equinoccial, Quito, Ecuador; 4Department of Medicine, College of Medicine, 5Center for >84% of the national overall prevalence. Global Health and Translational Science, Upstate clandestine abortion, private vs public health system, misoprostol, therapeutic Medical University, State University of New York, Keywords: Syracuse, NY, USA; 6Faculty of Medical Science, abortion, metrotexate, misoprostol School of Medicine, Universidad Central del Ecuador, 7Prometeo Program, SENESCYT, Quito, Ecuador; 8Graduate College of Biomedical Sciences, Western University of Health Sciences, Introduction 9 Lebanon, OR, USA; School of Public Health, 1 University of Heidelberg, Heidelberg, Germany Every minute there are on average 255 births worldwide from around 210 million pregnancies annually. Eighty million of those pregnancies are unplanned or unwanted Video abstract and 1 in 2 of these are terminated before birth, representing more than 41 million abortions a year.2–5 About 47,000 women die every year due to complications from unsafe abortions, 86% of which occur in developing countries.6–8 Unsafe and clan- destine abortions represent a great risk for women and therefore are an urgent public Pragmatic and Observational Research downloaded from https://www.dovepress.com/ by 54.70.40.11 on 10-Dec-2018 health matter. Studies have shown that banning elective termination of pregnancy is associated with an increase in clandestine abortion practices and associated medical complica- tions that arise when abortions are performed under unsafe conditions.6,9 In some South American countries, such as Ecuador, Peru and Colombia, elective abortion is criminalized under most circumstances.10,11 However, there are a few Latin American Point your SmartPhone at the code above. If you have a countries and territories, such as Puerto Rico, Cuba, Uruguay and Mexico, where there QR code reader the video abstract will appear. Or use: are legal grounds that allow women to terminate unwanted pregnancies.12,13 In South http://youtu.be/L0EQ1CpMiSY America, the rates of unsafe abortion are one of the highest in the world.14 Restrictive laws for abortion and clandestine and unsafe practices to terminate Correspondence: Esteban Ortiz-Prado pregnancy become even more relevant in the current Zika virus outbreak. Zika virus One Health Research Group, Universidad de las Américas, Calle de los Colimes y Avenida De los has been linked to severe neurological malformations in babies born from infected Granados, Quito 170137, Ecuador mothers. This has increased the demand for pregnancy termination in Latin American Tel +593 99 576 0693 15–17 Email [email protected] countries. Clandestine and unsafe abortions are more common in poor and very submit your manuscript | www.dovepress.com Pragmatic and Observational Research 2017:8 129–135 129 Dovepress © 2017 Ortiz-Prado et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://dx.doi.org/10.2147/POR.S129464 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Ortiz-Prado et al Dovepress young women who lack access to medical services and, Statistics Deaths and Births Databases from 2004 to 2014, unfortunately, these women are also the ones who might be Hospital Discharges Database from 2004 to 2014 and the most affected by the Zika outbreak.14,15 Population Census of the National Institute of Census and Ecuador has prohibited any form of induced abortion Statistics (INEC) from 2010. Data includes annual hospital since 1837, when the first Penal Code of Conduct was cases, mortality, and number of live births. Demographic published.18 This code stated that abortions could not be characteristics of women including age, province of resi- requested by women for any economic, social or personal dency and type of establishment were analyzed. The number reason. Furthermore, abortions were considered illegal of units of off-label abortive drugs sold was obtained from regardless of fetal wellbeing.19 In January 2014, the Penal local purchase of medications retrieved from government Code of Conduct was ratified and therapeutic abortion was pharmaceutical company Enfarma EP, up to 2015. approved under specific circumstances that were limited to We used the following terms to retrieve the information mentally ill or incompetent women who had been raped or corresponding to the International Classification of Diseases cases where the woman’s physical or mental health was in 10th revision (ICD-10): Medically Justified abortion (ICD direct danger as a result of the pregnancy itself.19,20 O04), spontaneous abortion (ICD O03) and other pregnancies A study published in 1990 by The Bull Institute shows that that resulted in abortion (ICD O00-O02, O05-O08). there was a notable increase in the overall rate of abortions in The data used is public, anonymized, thus the local regula- Ecuador from 1964 to 1988.21 However, the lack of data from tory agency does not require an IRB approval or ethics review. that period makes it difficult to ascertain whether the increase We performed a Pearson correlation in order to find if was due to an incremental rise in the number of miscarriages there is any correlation between the use of the misoprostol or induced abortions, or simply to an improvement in data off-label abortive pill with the rate of abortion in Ecuador, collection. The study identified social determinants that were assuming the distribution of abortion rate and of misoprostol linked to abortion. It showed that most unwanted pregnan- were both normally distributed. The raw data was analyzed, cies occurred in the rural, mountainous regions of Ecuador, saved and managed within the Microsoft Excel™ software For personal use only. typically within low-income families.22 The validity of these and episheet stat open source statistical software was used findings is difficult to prove, due to widespread underreport- for descriptive and frequency analyses. References cita- ing of intentionally induced abortions, most likely due to the tion and retrieval were managed by Zotero Open Source legal consequences previously described.4,6,23 Software version 4.0.11. Spatial analysis was performed Although there are legal constraints that limit access to using QGIS 2.8. abortion services in Ecuador, access to some drugs such as misoprostol, an off-label abortive pill, is possible. Misopro- Results stol is a prostaglandin E1 analog with regulatory approval in Prevalence of abortion in Ecuador Ecuador to treat gastroduodenal ulcers but can also be used to Between 2004 and 2014, a total of 431,614 miscarriages and induce abortion, either as oral pills or by vaginal placement.24 abortions that met any of the ICD-10 abortion classifications Misoprostol and its off-label indications as an abortive pill (spontaneous abortion, justified medical abortion or other Pragmatic and Observational Research downloaded from https://www.dovepress.com/ by 54.70.40.11 on 10-Dec-2018 works when taken before the 63rd day of gestation, having a pregnancies that ended in abortion) were reported in Ecuador reported success rate for pregnancy termination higher than within the national Hospital Discharges Database (Table 1). 90% if done within this time frame.24–29 The number of annual spontaneous and induced The aim of this study is to describe the epidemiology of abortion registrations combined ranged from 33,132 in abortion in Ecuador from 2004 to 2014 as well as to describe 2004 (108/1,000) to over 40,256 (124/1,000) in 2013 and its current trends. At the same time, we compared the preva- decreased to 35,711 (112/1,000) in 2014 when the abortion lence of abortion between the public and private health care ban was ratified.