Latin American women's experiences with medical abortion in settings where abortion is legally ...

12 Pages·2013·0.37 MB·English

Zamberlinetal.ReproductiveHealth2012,9:34
http://www.reproductive-health-journal.com/content/9/1/34
REVIEW Open Access
’
Latin American women s experiences with
medical abortion in settings where abortion is
legally restricted
Nina Zamberlin1*, Mariana Romero2 and Silvina Ramos1
Abstract
Abortion is legally restricted inmost of Latin America where 95% ofthe 4.4million abortions performed annually
are unsafe.
Medical abortion (MA) refersto the useof a drug or a combinationof drugs to terminate pregnancy. Mifepristone
followed by misoprostol is the most effective and recommended regime.In settings where mifepristone is not
available, misoprostol alone is used.
Medical abortion has radically changed abortion practices worldwide, and particularly inlegally restricted contexts.
InLatin America women have been using misoprostol for self-induced home abortions for over two decades.
Thisarticle summarizes the findings of a literature review onwomen’s experiences withmedical abortion in Latin
American countries where voluntary abortion is illegal.
Women’spersonal experiences with medical abortion are diverse and vary according to context, age, reproductive
history, social and educationallevel, knowledge about medical abortion, and the physical, emotional, and social
circumstances linked to thepregnancy.But most importantly, experiences are determined bywhether or not
women have thechance to access: 1) a medically supervised abortion in a clandestine clinic or 2) complete
and accurateinformationon medical abortion. Other key factors are access to economic resourcesand
emotional support.
Women value the safety and effectiveness of MA as well as the privacy thatit allows and the possibility of having
their partner, a friend or a person of their choice nearby during the process. Women perceive MA as less painful,
easier, safer, more practical, less expensive, more natural and less traumatic than other abortion methods. The fact
that it is self-induced and thatit avoids surgery are also pointed out as advantages.Main disadvantages identified
bywomenare that MAis painful and takes time to complete. Othernegatively evaluatedaspectshave to do with
side effects, prolonged bleeding, the possibility thatit might not be effective, and thefact that some women
eventually need to seek medical care at a hospital where theymight be sanctioned for having an abortion and
even reported to the police.
Keywords: Medical abortion, Misoprostol, Latin America
*Correspondence:[email protected]
1CenterfortheStudyofStateandSociety(CEDES)(ExternalResearcher)and
AdolescentHealthFoundation(FUSA),BuenosAires,Argentina
Fulllistofauthorinformationisavailableattheendofthearticle
©2012Zamberlinetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
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Abstract (Spanish)
Elabortoestá legalmente restringido enla mayoría de América Latina donde 95% de los 4.4millones de abortos
que se realizan anualmenteson inseguros.
Elabortocon medicamentoses eluso de una droga ouna combinación de drogas para interrumpi elembarazo.
Mifepristona seguidade misoprostol constituye el regimen más efectivo y recomendado. Enlos lugares donde no
está disponible lamifepristona, se utiiza misoprostol solo.
Elabortocon medicamentosha transformado radicalmente la práctica delabortoa nivelmundial, y
particularmente en loscontextos legalmente restrictivos. EnAmérica Latina, desde hace másde dosdécadas,las
mujeres utilizan elmisoprostol para autoinducirse abortos.
Este artículo resume loshallazgos de unarevisión bibliográfica sobrelas experiencias de las mujeres con elaborto
conmedicamentosen países latinoamericanos donde elabortovoluntarioes ilegal.
Las experiencias personales de las mujeres con elabortocon medicamentosson diversas y varían según el
contexto, la edad, la historia reproductiva, elnivelsocioeconómico y elconocimientoacerca del aborto con
medicamentos así como las circunstancias físicas, emocionales y sociales que rodean a embarazo. Pero
fundamentalmente,las experiencias están determinadas porla posibilidad de las mujeresde acceder a: 1)un
aborto clandestino realizado bajo supervisión médica, o2) información completa y precisa acerca del aborto con
medicamentos. Otros factores clave incluyenel acceso a recursos económicos y elapoyo emocional.
Las mujeres valoranla seguridady efectividad del aborto con medicamentos así como la privacidad que ofrece y la
posibilidad de tenercerca a su pareja, un/a amiga/o, o persona de su confianza durante el proceso. Las mujeres
perciben al aborto con medicamentoscomo menos doloroso,más fácil, más seguro, más práctico, menos costoso,
másnatural y menos traumáticoque otrosmétodos abortivos. Que sea auto-inducido y que evite elprocedimiento
quirúrgico tambiénson señalados como ventajas.Las principalesdesventajas identificadas son que es doloroso y
que lleva tiempo para que se complete. Otrosaspectos evaluados negativamente incluyen los efectos secundarios,
elsangrado prolongado, laposibilidad de que no sea efectivo, y elhecho de que algunas mujeres eventualmente
deban solicitar atención médica enuna institución donde sean sancionadas por haberse practicado unabortoy
hasta denunciadas a la policía.
Background methods like the insertion of foreign bodies into the
Only 28% of countries –most of them in the developed uterus, drinking toxic solutions, or procedures per-
world– permit abortion upon request.a Unsafe abortion formed by unskilled providers [3,4]. Social and cultural
and related mortality are both highest in countries with beliefs against abortion as well as stigma are other bar-
narrow grounds for legal abortion. An estimated 21.6 riers to safe abortion that make women turn to unsafe
million unsafe abortions took place worldwide in 2008, methods [5]. In addition, fear of ill treatment and legal
almost all in developing countries, resulting in 47,000 reprisals might prevent women from seeking prompt
maternal deaths and millions of women suffering injury, medicalcareafteranabortion [1,6].
illness andlifelong disability[1]. Medical abortion (MA) refers to the use of a drug or a
In Latin America, 95% of the 4.4 million abortions combination of drugs to terminate pregnancy. Mifepris-
performed annually are unsafe. Only Cuba, Mexico City, tone followed by misoprostol is the most effective and
Uruguay and several Caribbean islands have liberal abor- recommended regime. In settings where mifepristone is
tion laws [2]. The World Health Organization (WHO) not available, misoprostol alone is used.b Mifepristone is
estimates that in 2008, 12% of all maternal deaths in the an anti-progestin that blocks the action of progesterone,
region (1,100 in total) were due to unsafe abortion and ahormonenecessary tomaintainapregnancy,andalters
about one million women were hospitalized for treat- the endometrium causing the uterine lining to shed.
mentofcomplications fromunsafeabortion [1,2]. Misoprostol is an analog of prostaglandin E that causes
1
Despite legal restrictions, abortion is widely per- the cervix to soften and the uterus to contract, resulting
formed. When faced with an unwanted pregnancy many intheexpulsionoftheuterinecontents[7].Until63days
women will seek an abortion regardless of its legality. of gestation WHO recommends 200 mg of miefepris-
The safety of a clandestine procedure depends on the tone administered orally followed by 800 mcg of miso-
conditions under which it is performed which are pri- prostol administered vaginally, buccally or sublingually
marilydeterminedbythewoman’ssocioeconomicstatus. 24to48hoursfollowingingestion ofmifepristone[8].In
Women living in vulnerable social conditions who can- the case of misoprostol alone, WHO recommends 800
not afford safe clandestine abortions often turn to risky mcg of misoprostol administered by vaginal or
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sublingualroutes,upto three repeat dosesat intervals of Argentina, Chile, Peru, Ecuador, Venezuela and Mexico
atleastthreehours [8]. there are abortion hotlines that provide information on
Fist trimester medical abortion is a highly safe and ef- how to use misoprostol for early pregnancy termination
fective procedure [8]. Up to 9 weeks gestation effective- based on scientific information published by the World
ness is 98% for the combined regime and between 75% Health Organization and the Latin American Federation
and90%formisoprostol alone[7-9]. ofOBGyN Societies (FLASOG).
The effects of medical abortion are similar to those Some NGOs in legally restrictive settings have clinics
associated with spontaneous abortion and include uter- that provide information, counseling, medication and
ine cramping and prolonged bleeding. Common side health care services at low cost or no cost to women
effects include nausea, vomiting and diarrhea [7-9]. In seeking abortions. Some of these organizations offer
2005, the World Health Organization added mifepris- both medical and surgical abortions performed by physi-
tone and misoprostol to its List of Essential Medicinesc cians,whileothersarerunbytrainednon-medical coun-
for countries where abortion is not against the law. In selors who provide information as well as the
2009 misoprostol was also included for the treatment of medication for the woman to administer herself, and fol-
incomplete abortion. lowupservices[17,18,20,26].
Medical abortion has radically changed abortion prac- In several Latin American countries medical abortion
tices worldwide, and particularly in legally restricted has enabled the implementation of harm reduction pol-
contexts. Women can now access a non-invasive, safe icies. Based onthe right to health,autonomy, confidenti-
and effective method, which is more affordable than sur- ality and information, health professionals provide
gicalmethodsanddoes notrequirethird party participa- women with unwanted pregnancies pre-abortion coun-
tion in the procedure [9,10]. In Latin America women seling including information on how to self-induce a
havebeenusingmisoprostolforself-inducedhomeabor- medical abortion, and postabortion care. Medication is
tions for over two decades [11]. As misoprostol became not provided since it would be against the law, women
more widely used the use of highly unsafe and invasive have to obtain it by their own means. This strategy
abortion methods gradually became less frequent proved highly effective to prevent abortion related ma-
[2,12,13]. ternaldeaths [27].
While mifepristone is unlikely to be available in coun- There is evidence that shows that in countries where
tries with restrictive abortion laws, misoprostol is avail- voluntary abortion is not legal, increased use of med-
able in most of Latin America. It is generally approved ical abortion over other methods has increased the
to prevent gastric ulcers and not for gynecological and safety of self-induced procedures by reducing complica-
obstetric indications, except for four countries in the tions related to unsafe abortion [12,13,28-32]. Miso-
regiond which have it registered for some obstetric indi- prostol and mifepristone are valuable resources that
cation [14,15]. It is usually available in 200 mcg oral have great potential to expand access to safe abortion
tablets and in some countries it is associated with an and therefore reduce maternal morbidity and mortality.
anti-inflammatory. It has been available in pharmacies However, the efficacy and safety of MA in legally
sincethe late1980se[16]. restricted settings depends strongly on its adequate use
Information about medical abortion spreads mostly by in terms of dosage and gestational age, and the avail-
word of mouth and through the Internet [17-19]. Phar- ability and accessibility of quality postabortion care ser-
macies usually dispense misoprostol despite the fact that vices [12,13].
regulations in most countries require that it be sold only Globally,mostresearchonmedicalabortionissituated
under prescription [20-23]. Medical abortion drugs are in legal abortion contexts and focuses on trials of medi-
also accessed through providers in informal settings or cation regimes and cost-effectiveness analyses of medical
on the Internet [19,24,25]. Local and international vs surgical abortion. Less attention has been paid to
women’sgroups andNGOsalsodisseminateinformation women’s experiences, perspectives and preferences [33].
on medical abortion through the Internet, printed mate- Given the importance of medical abortion in reshaping
rials and hotlines that provide instructions on how to the nature of abortion in legally restrictive settings, it is
self-perform a medical abortion [19]. “Women on web”, crucial to have a deep understanding of women’s experi-
an international digital community, provides on-line ences withthis method.
medical abortion services in different languages to This article summarizes the findings of a literature re-
women living in countries where there are no safe abor- view on women’s experiences with medical abortion in
tion services. Women complete a medical consultation Latin American countries where voluntary abortion is il-
through an interactive web-based questionnaire and if legal. Itincludes studiesfocused onwomen’sperceptions
there are no contraindications they are sent a MA kit regarding knowledge, access and use of medical abortion
(mifepristone+misoprostol) by postal mail.f In as well as the physical and subjective experience of
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undergoing a clandestine medical abortion. The article ofBrazilwhereoverhalfadozenarticleswerepublishedin
has a dual aim: to consolidate available evidence about the early and mid 1990s. Brazil was the first country to
the experiences of women who havea MA, and to foster report the use of misoprostol for self-induced clandestine
the political and academic debate around unsafe abor- abortions,andmostresearchaddresseswomenhospitalized
tion in Latin America and the key role that MA has in forpostabortioncare[12,34-38].
makingabortion safer. Few studies focus exclusively on medical abortion,
while the rest address medical abortion within a wide
Methodology variety of issues related to the abortion event such as
The review focused on studies produced in Latin America reasons for seeking an abortion, the decision making
since 1990 to June 2011. Evidence in Spanish, Portuguese process, or attitudes towards abortion and include
andEnglishwasidentifiedthroughtwodifferentmethodolo- women who used medical abortion as well as women
gies: 1) automatic searches of data bases (Lilacs,g Medline,h who resorted to other means of pregnancy termination.
PubmedCentral,iPoplinejandCochranek).2)Grayliterature In these cases, we only selected the information which
search for unpublished or non-peer-reviewed sources by could shed light onthe experienceofundergoing amed-
contactingkeyinstitutionsthatconductresearchonabortion icalabortion.
issuesintheregion,reviewingcongressesabstracts,meeting Studies differ in the time elapsed between the abortion
summaries and news bulletins from pertinent networks.l and the moment data was collected. Some only included
Keywords used include: abortifacient agents; misoprostol; women who had had an abortion in the previous six
methotrexate; mifepristone; abortion (abortion applicants; months or in the previous two years, while others en-
induced abortion; voluntary abortion; therapeutic abortion); compassmuchlongerperiodsoftime, upto20years.
interviews; stressful events; experiences; perception and Selected studies can be classified in the following cat-
opinion,connectedbyBooleanoperatorsavailableinthedif- egories according to the study population and sample
ferent data bases. Additional file 1: Table S1 which can be usedasshown onAdditionalfile2:Table S2.
accessed at http://cedes.org.ar/Rmw_oms_cedes_Table1.pdf Studies include both qualitative and quantitative
includes details of keywords used, search strategies by data approaches that applied different data collection techni-
base and number of articles identified. Figure 1 shows the ques: 1) in-depth interviews focused on the narrative of
processofapplyingtheselectioncriteriatotheitemsidenti- the abortion experience; 2) review of medical records
fiedinthesearch. and surveys of women hospitalized for postabortion care
to describe socio-demographic characteristics, previous
Results use of contraception, abortion method used and inci-
Theliteraturereviewidentified27articles/paperswhichare dence of complications (these studies do not analyze in
highly diverse in terms of methodological approaches, data depth the experience around self-inducing the abortion);
collectiontechniques,design,inclusioncriteria,andsample and3)literaturereviews.
methods.m Most studies were carried out between 2005 Despite the diverse approaches, all articles address
and 2011. Earlier production is scarce, except for the case critical aspects of the medical abortion experience. The
Figure1Summaryofthefindingsofdatabasesearch.
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following section summarizes the main dimensions have more positive experiences. In this sense, counseling
present in the evidence reviewed which include: know- by a health care professional or a qualified counselor is
ledge and information about medical abortion; choice vital forthewhole abortion process[4,13,25,39].
of method; obtaining the medication; the medical
abortion process: the physical and the psychological Choiceofmethod
experience. As with most abortion matters within legally restricted
settings, the experience of undergoing a medical abor-
tion is primarily determined by social class. Lower in-
Knowledgeandinformationaboutmedicalabortion come women do not have an array of safe methods to
Women usually learn about MA when they have an un- choose from according to their needs and preferences
intended pregnancy. Previous knowledge is scarce and [39,49], but they do perceive that using medication is
superficial, often limited to knowing about the existence safer than introducing objects or other traditional unsafe
of “abortion pills” that sometimes are confused with methods [12,24]. Preference for MA is also expressed
emergencycontraception[17,30,39-41]. based on fear of unsafe medical procedures or because
Decidingto haveanabortion anddoing so isnot alin- they associate it more with a menstrual regulation
ear process, particularly in legally restricted settings, not process. However, cost and accessibility are key factors
only because women might face ambivalence and per- for deciding for a MA, more than personal preferences
sonal, familial and social conflict, but also because they or a balance of its advantages and disadvantages.
might take several different “small actions” which do not Women make pragmatic decisions regarding the
follow a sequential or organized pattern [42]. Faced with abortion method based on their possibilities that are
anunwantedpregnancy,womenstart searching for solu- not necessarily “real choices” [17,18]. In the absence of
tions that might eventually lead to a MA. Many find out financial constraints some would prefer a surgical abor-
about MA only after unsuccessfully trying other sup- tion performed by a physician or a medically supervised
posedly abortifacient methods such as herbal infusions procedure[35,39,49].
andhormonalinjectables [17,18,25,26,30,39,43]. Women value the safety and effectiveness of MA as
Clandestinity implies that information about MA is well as the privacy that it allows and the possibility of
not openly and publicly available but that it rather having their partner, a friend or a person of their choice
flows through hidden informal or “underground” chan- nearby during the process. Women perceive MA as less
nels. Female relatives, friends, neighbors and the sexual painful, easier, safer, more practical, less expensive, more
partner, are the ones who provide information or help to natural and less traumatic than other methods. The fact
identify sources of information such as women who that it is self-induced and that it avoids surgery is also
had abortions in the past or who have been close to pointed out asanadvantage [11,17,18,24,35,44].
women in a similar situation, women’s health organiza- Main disadvantages identified by women are that MA
tions, health professionals, pharmacies and Internet sites is painful and takes time to complete. Other negatively
[11,24,35,36,39,43,44]. evaluated aspects have to do with side effects, prolonged
Women who reach harm reduction services often find bleeding, the possibility that it might not be effective,
out about MA through the counseling provided [25]. In and the fact that some women eventually need to seek
some cases men lead the search for information resort- medical care at a hospital where they might be sanc-
ing to other men who can provide advice [12,45,46] tioned for having an illegal abortion and even reported
whilewomenadoptamorepassivestance [47]. tothepolice[11,17,18].
Information about MA is mostly spread by word of
mouth and it is therefore highly diverse and fragmented, Obtainingthemedication
particularlywhenitcomesfromlaypeople,butpharmacy In most cases women have to procure the medication by
staff and health professionals also provide highly hetero- themselves, except those who access MA through an in-
geneous information that in some cases differs signifi- stitutionorahealth professionalthat provides misopros-
cantly from scientific standards[19-21,23,30,39,44,48]. tol. Risk reduction services offer information on medical
Complete and correct information about how to abortion as a way to avoid higher risk methods but
use and what to expect from MA, including dosage, women must obtain the drug on their own. Some
routes of administration, mechanism of action, effective- women feel highly frustrated when they learn that abor-
ness, contraindications and side effects is crucial in tions are not practised nor is misoprostol provided by
determining the outcome of the process and the such services [25].
woman’s experience. Women who receive accurate and In many Latin American countries pharmacies are
complete information on how the medical abortion widely used as a source of medical advice, especially by
process will develop and what is and what is not normal lower income populations, and women havetraditionally
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resorted to pharmacies in search for drugs to bring on Accessing the drug will depend on the woman’s eco-
menstruation when they have a delayed menstrual nomiccapacity,socialnetwork,personalskills,andsupport
period [13,21]. Misoprostol is purchased at retail phar- from others. Male partners who are involved in the abor-
macies either as the entire package or by the pill, tion decision usually have an active role in obtaining the
usually without prescription despite the fact that medication, particularly in contributing economically and
government regulations require sale under prescrip- searchingforwheretobuyit[12,25,46].
tion [11,20-22,34]. Pharmacy staff often recommend
misoprostol for pregnancy termination but their
knowledge about dosage, route of administration, side Themedicalabortionprocess:thephysicalexperience
effects complications and effectiveness is often poor Like the majority of abortions, most medical abortions
in quality [20,21]. They usually advise to seek medical take place within the first 12 weeks of pregnancy
care once bleeding starts [22]. [11,12,32,39,40]. Women generally understand that earl-
Different levels of difficulty exist in obtaining miso- ier abortions are safer, but sometimes the abortion is
prostol related to the local regulation of the drug and delayedbecausetimeisspent seekinginformation,trying
the level of government control over pharmacy sales. ineffective methods, searching for the medication and
Stricter control makes access more difficult, pushing raising the money to buy it [30,39]. Second and even
women to the black market where prices are higher third trimester self-induced home abortions with miso-
[25,48,50]. prostol have been reported [11,34]. These situations can
In settings where misoprostol is sold only under pre- beextremely risky.
scription women display a variety of strategies to either For most women, getting ready for a medical abortion
obtain a prescription or to buy the drug without one. means preparing for something unknown, an unexper-
These include paying for a prescription, claiming that ienced event that can trigger unexpected consequences
the drug is not for ObGyn purposes either by obtaining [39,49]. They must decide when and where to do it, if
and presenting a prescription from a non-ObGyn spe- someone will be with them at that moment and who
cialist, or asking a man or an older woman to buy the they want that person to be. If they have children they
drug for themarguingthatisfortheirown use[22]. must arrange for someone to look after them and
Internet is extensively used to search for information organize thedomestic chores[17,18,39].
on MA and to a lesser extent to buy misoprostol. The Women appreciate the privacy that medical abortion
qualityandauthenticityofmisoprostolsoldontheInter- allows them. In some circumstances they conceal the
netbyindividualswithlucrative purposesisquestionable abortion from other people. There are testimonies of
since it is sometimes not provided in its original pack- women who went through a MA without altering their
aging and can be fake [19,50,51]. The studies reviewed daily lives and surrounded by relatives, or even their
do not report use of telemedicine websites or hotlines partner, who were unaware of their condition. In other
for obtaining MA medication among Latin American cases, hiding the abortion from other household mem-
women.n bersisdifficultandproblematic [17,26,44].
Prices vary widely, and depend on where the medica- Women often prefer to use the pills during the night as
tion is purchased [16,39,40]. Even if medical abortion is theyperceiveittobesafer,withfewchancesofbeinginter-
considerably less expensive than surgical methods, it is rupted, and they are usually at home whileothers are rest-
still unaffordable for poor women and adolescents who ing[12,17,39].Thenightmightalsofeellikeamoreprivate
do not have ready access to cash. Women implement andprotectedtimefordoingsomethingillegal[39].
different strategies to gather the moneyto buy the medi- It is not uncommon for women to use misoprostol to-
cation: borrowing money from friends and relatives, ask- gether with other methods, mostly ineffective ones like
ing for a salary advance, working overtime, selling teas and other infusions, and injections bought in phar-
valuable objects [25,39,49]. One study even refers to macies[12,51,52].
women travelling or contacting people in neighboring Few of the women who obtain the medication outside
countriestoobtainthemedication[39]. clinical settings can specify the name of the medication
Sometimes women who bought the whole package they used for pregnancy termination [17,39,40,44,49,53]
and have pills left after completing the abortion and cannot precise if they were antibiotics, analgesics or
either offer them or sell them to other women in need tranquilizers [17].
of misoprostol as a way of female solidarity or cost- The information that women receive outside clinical
recovery[22,39]. settings about how to use misoprostol is highly di-
Obtaining the drug implies not just having the money verse, consequently, women use misoprostol in a var-
but entering the circuit of irregular sale of misoprostol. iety of ways [24,35,51] with doses ranging between 4
Internetisthemain source ofthiskindofinformation. and 16 tablets, and much higher doses in extreme
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cases [11,35,54,55]. However the median dose is usu- In some cases attempts to terminate pregnancy with
ally 800 mcg, the adequate dosage for early abortion misoprostol are not successful and pregnancy continues.
[34,35,37]. Intervals between doses also vary widely Women who access medical services that perform abor-
[24]. tions can resort to a surgical abortion [17,18,26]. But
Women use misoprostol vaginally, orally or a combin- women who lack thisalternativeareleftwith nooptions.
ation of both routes [24,35-37] and seem to prefer oral The possibility of having a surgical procedure depends
rather than vaginal administration [13]. Some women on their economic capacity. These are critical situations
dislikeorareuncomfortable withthe vaginaladministra- marked by anxiety and distress, particularly when
tion of tablets, or are not sure they can insert them women are aware of the possible teratogenic effects of
correctly by themselves. Several authors relate oral themedication[39].
preference to the idea of menstrual regulation, while
vaginal insertion is culturally more linked to abortion
[12,17]. Thepsychologicalexperience
After inserting or taking the pills women wait for Having a medical abortion means a direct and vivid
something to happen. When possible, they stay home physical experience which triggers strong emotions, fan-
and rest. Others continue with their daily routines. In tasies and fears. Few of the articles reviewed refer to the
some cases expulsion or heavy bleeding took them by psychological aspects of the MA experience, which are
surprise whilethey wereat schooloratwork [17,49]. closely related to the physical experience, the informa-
Bleeding usually starts few hours after the first dose tion the woman has received, and the availability or lack
and is most abundant at 6 to 12 hours after insertion ofmedical andemotional support[17,18,39,45,49].
[44] but can also take much longer [24,35]. Bleeding can Some women relate MA to a menstrual regulation
last between 1 and 60 days [24]. Several studies report process or something akin to getting their period, which
testimonies of heavy bleeding, or bleeding more abun- reduces emotional distress and helps them to cope with
dant than what women had expected [30,40]. Often the process [11,17,18,44]. On the other hand, many
women areunabletodeterminewhether theirsymptoms women go through a MA feeling that it is an unknown
are normal or abnormal or whether a complete abortion process of which they have no full control [39]. Com-
hasoccurred [30]. mon feelings are fear of the negative reactions in the
Common side effects include chills, diarrhea, nausea, body, and concern linked to pain and bleeding. Women
headache, dizziness and fever. These are usually well tol- are very anxious about heavy vaginal bleeding and fear
erated [17,40]. Most women experience pain of different they can bleed to death or suffer long lasting health
intensity and duration [24,40,44]. Generally the most se- complications including infertility [25,43,51]. Women
vere pain takes place the first day after inserting/taking who have legal medical abortions in a medically con-
the pills, particularly after 5 to 7 hours, and later trolled settingarelessconcerned aboutbleeding[56].
diminishes [44]. Some women report unbearable sus- Testimonies also reflect uncertainty and anxiety about
tained pain for several hours [17,25,26]. Those who have how long the process will last, when they will be able to
medicalsupervision are recommended to take pain relief return to their daily life and whether or not certain ac-
medication[17]. tivities are safe to do (working, swimming, bathing,
Some women start and finish the MA process at physicalactivity,sex) [17].
home. Others do not wait enough to complete the abor- Women who have medical supervision and/or receive
tion alone and seek medical assistance in health care detailed information from a qualified source and know
institutions where a surgical uterine evacuation proced- whattoexpectintermsof bleeding,painandsideeffects
ure is usually performed. Some women seek medical report more positive experiences with less anxiety and
care shortly after bleeding starts, either because they are fear, feel more in control and tend to remain calm [29].
afraid that something bad will happen to them, or be- In addition, previous experience with pregnancy and de-
cause they were told to do so by the person who liveryseemstocontribute toabetter management ofthe
instructed them on how to use the medication situation [17].
[12,20,22,30,35,36,44,45]. Many women, but particularly those who undergo the
As information on MA becomes more widespread and process with no counseling or supervision, have emo-
women gain more experience they make better use of tionally draining experiences marked by fear of negative
misoprostol[11,35].Evidencecollectedfromhospitalized consequences, anxiety and concern. These are mostly
postabortion women shows that prevalence of severe elicited by the clandestine context and the lack of med-
complications is lower among women who used miso- ical back-up in moments when women feel extremely
prostol than among those who used other methods vulnerable and out of control of the situation [39,45].
[29,34,35]. Some women refrain from seeking medical care out of
Zamberlinetal.ReproductiveHealth2012,9:34 Page8of11
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fear that they will be mistreated, penalized or given expressed by women in legal abortion settings [33,57-59]
medicationtoretainthepregnancy [43]. The major difference lies in the confidence that legal-
Affective support and company are vital during the ity provides and the reassurance that the heath system
MA process, particularly for adolescents who are more accompanies them and cares for them during the abor-
vulnerable than older women in the same situation tion process.
[25,26]. Women are usually accompanied by their part- Women who have MAs in legally restricted settings
ner, female relatives (mother, sister) or female friends access mostly misoprostol and they tend to use it in ra-
who help to minimize discomfort or simply stay bythem ther adequate doses. The literature reviewed over a
[17,25,39,49]. Having the support of their close ones 20 year period shows that recent studies report more
gives women not only the possibility of sharing doubts proper use of misoprostol while older studies refer to
and fears, and not feeling alone -which is reassuring and more “anarchic use” including excessive doses. Also,
helpsthemtoremaincalm-butalsoimpliesthepossibil- most side effects described are similar to those reported
ity of accessing economic resources or having someone in clinical trials [8]. This could be indicating that
who will take care of their children if they have any information on MA is becoming more widespread in
[25,39]. Women who go through the process alone or theregion.
conceal the abortion from other household members The information on the psychological experience of
usually haveemotionallydifficult situations[17,25,47]. women who have medical abortions in legally restricted
settings does not allow to make comparisons with
Conclusions the abortion experience in general. However, using a
Women’s personal experiences with medical abortion self-induced method in the privacy of their homes
are diverse and vary according to context, age, repro- seems to reduce the stress related to the illegal character
ductive history, social and educational level, knowledge ofabortion.
about medical abortion, and the physical, emotional, and Latin America has a long tradition of academic pro-
social circumstances linked to the pregnancy. But most duction and social research in sexual and reproductive
importantly, experiences are determined by whether or health and a strong women’s movement mobilized
not women have the chance to access: 1) a medically around the abortion issue [60,61]. However, the litera-
supervised abortion in a clandestine clinic, or 2) ture review shows that there are few studies in the re-
complete and accurate information on medical abortion. gion that specifically focus on the medical abortion
Other key factors are access to economic resources and experience from the woman’s perspective. Furthermore,
emotionalsupport. several countries have no research production on this
The experiences of women who access medical abor- field at all. Research on abortion in legally restricted
tion under clinical supervision or who receive qualified settings implies additional ethical and logistical
counseling vary significantly from those who use miso- obstacles to a naturally socially sensitive issue
prostol on their own or with the help of laypeople. which affect the possibility of exploring the issue and
Women who access MA services provided by trained obtaining valid information, particularly when it
personnel have the most positive experiences. They are involves approaching women who have had illegal
assured genuine medication, have medical backup in abortions [61,62].
case of complications and can resort to a surgical pro- The evidence reviewed is highly heterogeneous and
cedure in case of medical abortion failure or incomplete was produced by different approaches and methodolo-
abortion.Womenwhodonotaccessthistypeofservices gies; therefore a comparative analysis is not possible.
are on their own during the whole process, including Most available research is based on samples of women
finding alternative solutions if the attempts with miso- hospitalized after an abortion or women who accessed
prostol are not successful. Their experiences are charac- risk reduction services. Only a minority of studies in-
terized by anxiety and fear of negative consequences to clude women who completed the MA process alone,
their health. Doing something illegal and acting in a without preabortion counseling and/or postabortion
clandestine way is a major cause of distress that makes care. Adolescent women are underrepresented in the
women feel vulnerableandunprotected. Thepresenceof available studies and the experience of those under age
significant others and social networks are helpful during 15iscompletely absent.Weknownothingabout women
thewholeprocess. who had failed medical abortions and continued on with
Overall women find MA acceptable even though it their pregnancy, and very little about those who had a
might not be their first choice if they had the possibility legal abortion within the health care system or those
toselectbetweensurgicalormedical methods.Theposi- who received misoprostol for postabortion care. In
tive and negative attributes of MA perceived by women addition, most literature comes from large urban set-
in legally restricted contexts are very similar to those tings, and few studies include rural or indigenous
Zamberlinetal.ReproductiveHealth2012,9:34 Page9of11
http://www.reproductive-health-journal.com/content/9/1/34
women [18]. More and updated scientific evidence on teratogenicity if the method fails and the pregnancy is not
medical abortion in Latin American is needed in order interrupted[8].
for researchers, activists, policy makers and health care cThe WHO List of Essential Medicines contains those
providers to have a better and more comprehensive medicines which are considered to satisfy the priority
understandingofitsimpactonwomen’slivesandhealth. health needs of the population of developing countries,
Given the results of this literature review, it is clear and which have been selected on the basis of their effi-
that the research agenda on women’s experiences with cacy, safety andcost-effectiveness.
medical abortion is not yet fully developed in the Latin dBrazil, Peru, Mexico[14]andArgentina[15].
American region. More research is needed in order to eIn the case of Brazil, in the late eighties misoprostol
get a comprehensive picture. Different subpopulations was available over the counter in pharmacies and be-
and issues need to be addressed and other study designs came a popular abortifacient method. In 1991 the gov-
and methodologies implemented. The experience with ernment severely restricted its sale and in some states it
medical abortion and its results and impact on adoles- was completely banned. Currently it is sold exclusively
cents, rural and indigenous women, and women acces- for hospital use. However, misoprostol continues to be
sing legal abortions within restrictive legal contexts need soldinthe blackmarket[16,34].
to be better understood. Issues such as the experience of fIn 2008 Gomperts et al. published a study based on
successful use of medical abortion by women who use it 484 women from 33 different countries who contacted
with no medical supervision needs to be better assessed Women on Web and received a medical abortion kit
given the potential of medical abortion as a self-used (mifepristone+misprostol) by postal mail. Results show
technology. As for study designs, general population is that women seem capable of self-administering MA
still not in the pictureand it should be. In order to over- when proper information and instructions are provided
come the limitations of the widely used convenience through Internet and additional interactive online con-
sampling methods, respondent-driven sampling (RDS) sultationsandemailcorrespondence [64].
needs to be assessed as a probabilistic sampling strategy gLatin American and Caribbean Health Sciences
to study this specific hard-to-reach population [63]. Information.
Additionally, comparative analysis among countries hU.S.National LibraryofMedicine.
needs also to be developed not only to understand the iU.S.NationalInstitutesofHealth.
use of this new technology in different cultural and so- jJohn's HopkinsBloombergSchool ofPublic Health.
cial contexts but also to get a more robust understand- kThe Cochrane Collaboration.
ing of its impact on women’s experiences in legally and lIn 2009, the Latin American Consortium against Un-
culturallyrestrictive environments. safe Abortion (CLACAI) carried out a literature review
Women in developing countries where abortion is le- on Latin American women’s experiences with medical
gally restricted have a great need for safe, affordable and abortion coordinated by Nina Zamberlin which included
simple abortion methods. Misoprostol is a very import- designing a methodology for data collection [65]. In
ant contribution which has facilitated women better ac- 2010 CLACAI created RepoCLACAI, a repository on
cess than ever before to an effective and safe method for abortion that systematizes research studies, technical
early self-induced pregnancy termination. This has had a documents and guidelines produced in the Latin Ameri-
positiveimpactontheirhealth. Womenneedtohaveac- can region(www.clacaidigital.info).
cess to detailed and complete information on MA mStudies were not quality assessed and therefore none
through a wide array of communication channels, as wasexcludedonsuch basis.
well as pre and post abortion services to optimize the nGomperts et al. analyze access and use to MA through
great potential that MA has to make abortions safer in WomenonWeb(www.womenonweb.org)bywomenin33
legally restrictivesettings. different countries where abortion is legally restricted, but
dataisnotdisaggregatedbycountryorregion[64].
Endnotes
a98% of countries in the world allow abortion to save a
woman’s life, most of them also permit one or several fur- Additional files
ther conditions. However, in many settings legal abortions
arehardtoaccessandarerarelyofficiallypracticed[1]. Additionalfile1:TableS1.Descriptionofsearchstrategiesfor
identificationofarticles.
bMethotrexate has also been used in combination with
Additionalfile2:TableS2.Selectedarticles.
misoprostolasamedicalmethodforearlyabortioninsome
countries where mifepristone is not available. However, a
WHO toxicology panel recommended against the use of
Abbreviations
methotrexate for inducing abortion, based on concerns of MA:Medicalabortion;WHO:WorldHealthOrganization.
Zamberlinetal.ReproductiveHealth2012,9:34 Page10of11
http://www.reproductive-health-journal.com/content/9/1/34
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Lima:CLACAI;2011.
17. LafaurieMM,GrossmanD,TroncosoE,BillingsD,ChávezAlvaradoS,
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NZcarriedouttheselectionofstudiesbasedontheinclusioncriteria,read, ExperienciasdelasMujeresenMéxico,Colombia,EcuadoryPerú.:Population
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discussedthefindingsanddrafts,andcontributedtothefinalarticle.All perspectivesonmedicalabortioninMexico,Colombia,Ecuadorand
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