Mariana Romero

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America

BACKGROUND Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Unsafe abortion: the preventable pandemic

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving womens health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves womens health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

Womens' opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina.

BackgroundThe results of a qualitative study carried out in four developing countries (Cuba, Thailand, Saudi Arabia and Argentina) are presented. The study was conducted in the context of a randomised controlled trial to test the benefits of a new antenatal care protocol that reduced the number of visits to the doctor, rationalised the application of technology, and improved the provision of information to women in relation to the traditional protocol applied in each country.MethodsThrough focus groups discussions we were able to assess the concepts and expectations underlying womens evaluation of concepts and experiences of the care received in antenatal care clinics. 164 women participated in 24 focus groups discussion in all countries.ResultsThree areas are particularly addressed in this paper: a) concepts about pregnancy and health care, b) experience with health services and health providers, and c) opinions about the modified Antenatal Care (ANC) programme. In all three topics similarities were identified as well as particular opinions related to country specific social and cultural values. In general women have a positive view of the new ANC protocol, particularly regarding the information they receive. However, controversial issues emerged such as the reduction in the number of visits, particularly in Cuba where women are used to have 18 ANC visits in one pregnancy period.ConclusionRecommendations to improve ANC services performance are being proposed. Any country interested in the application of a new ANC protocol should regard the opinion and acceptability of women towards changes.

Latin American women’s experiences with medical abortion in settings where abortion is legally restricted

Abortion is legally restricted in most of Latin America where 95% of the 4.4 million abortions performed annually are unsafe.Medical abortion (MA) refers to the use of a drug or a combination of 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 in legally restricted contexts. In Latin America women have been using misoprostol for self-induced home abortions for over two decades.This article summarizes the findings of a literature review on women’s experiences with medical abortion in Latin American countries where voluntary abortion is illegal.Women’s personal experiences with medical abortion are diverse and vary according to context, age, reproductive history, social and educational level, knowledge about medical abortion, and the physical, emotional, and social circumstances linked to the pregnancy. But most importantly, experiences are determined by whether or not women have the chance to access: 1) a medically supervised abortion in a clandestine clinic or 2) complete and accurate information on medical abortion. Other key factors are access to economic resources and emotional support.Women value the safety and effectiveness of MA as well as the privacy that it 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 that it avoids surgery are also pointed out as advantages. Main disadvantages identified by women are that MA is painful and takes time to complete. Other negatively evaluated aspects have to do with side effects, prolonged bleeding, the possibility that it might not be effective, and the fact that some women eventually need to seek medical care at a hospital where they might be sanctioned for having an abortion and even reported to the police.Abstract (Spanish)El aborto está legalmente restringido en la mayoría de América Latina donde 95% de los 4.4 millones de abortos que se realizan anualmente son inseguros.El aborto con medicamentos es el uso de una droga o una combinación de drogas para interrumpi el embarazo. Mifepristona seguida de misoprostol constituye el regimen más efectivo y recomendado. En los lugares donde no está disponible la mifepristona, se utiiza misoprostol solo.El aborto con medicamentos ha transformado radicalmente la práctica del aborto a nivel mundial, y particularmente en los contextos legalmente restrictivos. En América Latina, desde hace más de dos décadas, las mujeres utilizan el misoprostol para autoinducirse abortos.Este artículo resume los hallazgos de una revisión bibliográfica sobre las experiencias de las mujeres con el aborto con medicamentos en países latinoamericanos donde el aborto voluntario es ilegal.Las experiencias personales de las mujeres con el aborto con medicamentos son diversas y varían según el contexto, la edad, la historia reproductiva, el nivel socioeconómico y el conocimiento acerca del aborto con medicamentos así como las circunstancias físicas, emocionales y sociales que rodean a embarazo. Pero fundamentalmente, las experiencias están determinadas por la posibilidad de las mujeres de acceder a: 1) un aborto clandestino realizado bajo supervisión médica, o 2) información completa y precisa acerca del aborto con medicamentos. Otros factores clave incluyen el acceso a recursos económicos y el apoyo emocional.Las mujeres valoran la seguridad y efectividad del aborto con medicamentos así como la privacidad que ofrece y la posibilidad de tener cerca a su pareja, un/a amiga/o, o persona de su confianza durante el proceso. Las mujeres perciben al aborto con medicamentos como menos doloroso, más fácil, más seguro, más práctico, menos costoso, más natural y menos traumático que otros métodos abortivos. Que sea auto-inducido y que evite el procedimiento quirúrgico también son señalados como ventajas. Las principales desventajas identificadas son que es doloroso y que lleva tiempo para que se complete. Otros aspectos evaluados negativamente incluyen los efectos secundarios, el sangrado prolongado, la posibilidad de que no sea efectivo, y el hecho de que algunas mujeres eventualmente deban solicitar atención médica en una institución donde sean sancionadas por haberse practicado un aborto y hasta denunciadas a la policía.

Maternal Mortality in Argentina: A Closer Look at Women Who Die Outside of the Health System

Objectives To assess maternal mortality among women who died outside health institutions. To use the technique of verbal autopsy to identify maternal deaths and to obtain qualitative information about the determinants of maternal death using the “three delays” model. Methods Subjects were women aged 10–49 who died outside of a health institution during 2002 in five Argentine provinces with maternal mortality ratios above the national average. Cases were identified through the national and provincial registries, and data were collected using verbal autopsies, where the relatives of the deceased are interviewed. Results Of 252 completed verbal autopsies, 15 maternal deaths and five late maternal deaths were found. Hemorrhage was the most common cause of maternal death. Seventy-nine percentage of women who died of maternal causes experienced at least one delay in accessing care, with delays in seeking assistance as the most common, followed by delays in accessing and receiving quality care. Conclusions Maternal causes of death are equally prevalent among women who die outside the health system as among those who die within it, but avoidable deaths are still a problem. Interventions to improve understanding of “alarm signals” (serious symptoms) and improved access and quality of care are necessary to reduce maternal mortality.

Anticoncepción y aborto en Argentina: perspectivas de obstetras y ginecólogos

OBJETIVO: Reflexionar sobre el rol de los tocoginecologos/as en torno a las politicas publicas en salud reproductiva en Argentina. MATERIAL Y METODOS: Combinacion de metodos cuantitativos (encuesta, n=467) y cualitativos (entrevista semiestructurada, n=35; grupos focales, n=6). RESULTADOS: Para los profesionales, el aborto y la anticoncepcion son problemas muy relevantes. Siete de 10 otorgaron maxima prioridad a implementar servicios de planificacion familiar y consejeria anticonceptiva pos-aborto. Uno de 2 propuso promover el debate social sobre aborto. La gran mayoria acordo que despenalizar el aborto contribuiria a disminuir la mortalidad materna y que la ley no deberia penalizarlo ante riesgo de vida o salud, violacion o incesto y malformacion incompatible con la vida extrauterina. CONCLUSIONES: Las cuestiones mas criticas del campo de la salud reproductiva forman parte de la agenda de los medicos. Las acciones de abogacia deben profundizar una vision integral de la salud y destacar la responsabilidad social de estos actores.

Women’s experiences with the use of medical abortion in a legally restricted context: the case of 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. Résumé Cet article présente les conclusions d’une étude qualitative de l’expérience d’habitantes de l’Aire métropolitaine de Buenos Aires, Argentine, qui ont utilisé le misoprostol pour provoquer un avortement. Nous avons demandé aux femmes la portée des décisions qu’elles ont dû prendre, leurs émotions, l’expérience physique, les stratégies auxquelles elles ont eu recours, notamment demander des conseils de santé et gérer un avortement médicamenteux clandestin, et leur évaluation globale de l’expérience. Un plan d’entretien approfondi a été utilisé. Les femmes avaient utilisé le misoprostol et demandé des conseils ou des soins dans un hôpital public (n=24) ou bien elles avaient utilisé le misoprostol selon les conseils d’une ligne d’assistance, les informations sur Internet ou les conseils d’autres femmes (n=21). Quatre étapes ont été identifiées dans l’expérience des femmes : comment elles ont décidé d’interrompre la grossesse, comment elles ont obtenu le médicament, comment elles ont pris les comprimés et des réflexions sur l’issue, qu’elles aient ou non demandé des conseils médicaux. La sécurité et la confidentialité sont des facteurs déterminants de la décision de pratiquer un avortement médicamenteux. L’accès aux médicaments était le principal obstacle, nécessitant une ordonnance ou une pharmacie compréhensive. Les informations correctes sur le nombre de comprimés à utiliser et les intervalles de dosage étaient les moins faciles à obtenir et ont suscité des inquiétudes. La possibilité de choisir un moment d’intimité et d’être accompagnée par un proche a été soulignée comme un avantage unique de l’avortement médicamenteux. Il faudrait redoubler d’efforts pour améliorer les lois, les politiques et la prestation de services d’avortement en Argentine afin de garantir les meilleures conditions possibles pour l’utilisation de l’avortement médicamenteux par les femmes. Resumen Este artículo presenta los hallazgos de un estudio cualitativo que explora las experiencias de las mujeres que viven en el Ãrea Metropolitana de Buenos Aires, en Argentina, con el uso de misoprostol para inducir un aborto. Les preguntamos a las mujeres acerca de una variedad de decisiones que tuvieron que tomar, sus emociones, la experiencia física, las estrategias que necesitan utilizar, tal como buscar consejos sobre servicios de salud y para lidiar con un aborto con medicamentos clandestino, así como sobre su evaluación general de la experiencia. Se utilizó un programa para entrevistas a profundidad. Las mujeres habían usado misoprostol y buscado consejería o atención en un hospital público (n=24), o habían usado misoprostol basándose en los consejos de una línea local de atención telefónica, información del internet o de otras mujeres (n=21). Se identificaron cuatro etapas en las experiencias de las mujeres: cómo tomaron la decisión de interrumpir el embarazo, cómo obtuvieron el medicamento, cómo usaron las tabletas, y sus reflexiones sobre el resultado independientemente de que hayan o no hayan buscado consejos médicos. La seguridad y privacidad fueron clave para decidir usar el método de aborto con medicamentos. El acceso al medicamento fue el principal obstáculo, que requirió una receta o una farmacia con personal amigable. La información correcta sobre el número de tabletas a usar y los intervalos de dosis fue la manera menos fácil de obtener y causó inquietudes. La posibilidad de escoger un momento de privacidad y estar acompañada de una persona cercana se destacó como una ventaja única del aborto con medicamentos. Es imperativo reduplicar los esfuerzos por mejorar la ley, política y prestación de servicios referentes al aborto en Argentina a fin de asegurar las mejores condiciones posibles para el uso del aborto con medicamentos por parte de las mujeres.

Health care providers' opinions on abortion: a study for the implementation of the legal abortion public policy in the Province of Santa Fe, Argentina.

BackgroundIn Argentina, abortion has been decriminalized under certain circumstances since the enactment of the Penal Code in 1922. Nevertheless, access to abortion under this regulatory framework has been extremely limited in spite of some recent changes. This article reports the findings of the first phase of an operations research study conducted in the Province of Santa Fe, Argentina, regarding the implementation of the local legal and safe abortion access policy.MethodsThe project combined research and training to generate a virtuous circle of knowledge production, decision-making, and the fostering of an informed healthcare policy. The project used a pre-post design of three phases: baseline, intervention, and evaluation. It was conducted in two public hospitals. An anonymous self-administered questionnaire (n = 157) and semi-structured interviews (n = 27) were applied to gather information about tacit knowledge about the regulatory framework; personal opinions regarding abortion and its decriminalization; opinions on the requirements needed to carry out legal abortions; and service’s responses to women in need of an abortion.ResultsFirstly, a fairly high percentage of health care providers lack accurate information on current legal framework. This deficit goes side by side with a restrictive understanding of both health and rape indications. Secondly, while a great majority of health care providers support abortion under the circumstances consider in the Penal Code, most of them are reluctant towards unrestricted access to abortion. Thirdly, health care providers’ willingness to perform abortions is noticeably low given that only half of them are ready to perform an abortion when a woman’s life is at risk. Willingness is even lower for each of the other current legal indications.ConclusionsFindings suggest that there are important challenges for the implementation of a legal abortion policy. Results of the study call for specific strategies targeting health care providers in order to better inform about current legal abortion regulations and to sensitize them about abortion social determinants. The interpretation of the current legal framework needs to be broadened in order to reflect a comprehensive view of the health indication, and stereotypes regarding women’s sexuality and abortion decisions need to be dismantled.

La calidad de la atención posaborto: un desafío para la salud pública y los derechos humanos

Amelioration of postabortion care seeks to reduce morbidity and mortality related to unsafe abortion and prevent the reoccurrence of unwanted pregnancy through beneficial technologies and a woman-centered approach. This article reports changes in postabortion care in a public hospital in the city of Buenos Aires. A quasi-experimental design was applied to evaluate the changes associated to the intervention. In both stages of the study the following data collection techniques were applied: survey of women during postabortion hospitalization, self-administered survey of heath care team, nonparticipant observation of care process. Within the observed results, changes were noticed in the time women had to wait to receive care and to have the procedure performed, and in the provision of contraceptive counseling and methods before the medical discharge. Even though the health care team showed a strong preference for manual vacuum aspiration (MVA) and widely recognized its benefits, the adoption of such technique was not generalized after the intervention.