Several Brazilian studies were undertaken in the 1990's to evaluate the effects of misoprostol which was used, for a limited period of time as an abortificient. One study interviewed 1603 women with abortion-related complications (mostly incomplete abortion) who were admitted to seven public hospitals in Rio de Janeiro, Brazil between April-December, 1991. Abortions were classified as induced if the women admitting terminating the pregnancy or if there were signs of intervention such as cervical laceration, perforation, foreign bodies or evidence of chemical burns. Based on this evaluation, 803 women were classified as having had an induced abortion. Among the women classified as having had an induced abortion, 20% were age 18 or younger, 38% were 19-24, 23% were 25-29, 13% were 30-34, 5% were 35-39 and 1% were age 40 or more. Fifty-six percent (56%) of the women were single and were living alone, 10% were married, and 34% were cohabiting. Twenty-nine percent (29%) had no children, 51% had one or two children, 15% had three or four children and 6% had five or more children. In regard to educational status, 5% were illiterate, 31% had completed 1-4 primary grades, 41% had completed 5-8 primary grades and 23% had incomplete secondary education or more. 26% of the women were repeating abortion.
Some 57% of the women had used misoprostol alone or along with other methods, 13% had used oral drugs, 11% had used herbal teas, 9% intramuscular injections, 4% catheter insertion, 3% abortion clinics, 2% abdominal pressure and 1% intravaginal potassium permanganate. Heavy bleeding was observed in 19% of misoprostol cases compared with 16-25% for other abortion methods except abortion clinics which was only 5%. Infection was observed in 17% of the misoprostol cases compared to 18-21% for oral drugs, teas or injections, 43% for abortion clinics and 50% for catheter insertion. Blood transfusions were required in 1% of misoprostol cases compared to 11% for catheter insertion, 5% for herbal teas, and 2% of oral drugs and none for other abortion methods. Curettage was required in approximately 85% of the cases except for women who had abortions in abortion clinics where it was 60%. Systemic collapse occurred in 1% of misoprostol abortions compared to 2% for other oral drugs, 5% if herbal teas were used, 3% for catheter insertions, and 10% for abortions in abortion clinics32.
| Demographic Data: Latin American Postabortion Women | ||||||||
| Location | Year | No. of Women | Under Age 20 % | Single % | Nulliparous % | Repeating Abortion % | Education None % | Education Primary Only % |
| San Paul, Brazil | 1978-82 | 2588 | 16 | --- | --- | 44.4(a) | --- | --- |
| Boliva | 1983-84 | 990 | 12 | 21 | 18 | 47 | 10 | 39 |
| Mexico | 1980-88 | 156 | 14 | 49 | 61 | 15 | --- | --- |
| Lima, Peru | 1993 | 225 | --- | 21 | 29 | --- | --- | 26 |
| Rio de Jaeiro(d), Brazil | 1991 | 803 | 20(b) | 56 | 29 | 26 | 5 | 72 |
| Fortaleza(d), Brazil | 1992-93 | 102 | 17 | 46 | 25 | 36 | --- | 58 |
| Fortaleza(d), Brazil | 1990-92 | 593 | 31(c) | 70 | --- | --- | --- | --- |
| a) 62% under age 20 and 42% over age 20 were repeating abortion b) Under age 19 c) Under age 21 d) Misoprostol abortions | ||||||||
Another study of 1840 women who were treated for complications of abortion at the Instituto Materno-Infantil de Pernambuco in Brazil during 1988-1992, found that serious infections defined as tubal/ovarian abscess or septicemia were lower in women who had attempted abortion with misoprostol (0.8%) compared to other unspecified types of induced abortion (14.6%) . Women age 24 or under were less likely to have a serious infection (1.4%) compared to women age 25 or more (3.1%), Women who were nulliparous were more likely to have a serious infection (2.5%) compared to women of parity one or more (1.5%), and women with a gestational age of 10 weeks or less were less likely to experience serious infection (1.4%) compared to women at 11 or more gestational weeks (3.0%). Approximately 30% of the women in this study were considered anemic by having a hemoglobin level of 8 g/dl or less or had hemorrhagic shock33.
A World Health Organization (WHO) study published in 1985, reported that overall 41% of pregnant women in Latin America were anemic (hemoglobin of less than 11.0 g/dl) compared to 9% of pregnant women in more developed countries. If this study had utilized the WHO definition of anemia, a considerably greater number of women in this study would have been considered anemic. Anemia during pregnancy significantly increases the risk of pregnancy-related death. One study found that an anemic woman is five times more likely to die of pregnancy-related causes compared to a woman who is not anemic34. The WHO has estimated that 2067c of maternal deaths in Africa are directly due to anemia with additional deaths caused indirectly by anemia, especially obstetric hemorrhage35.
In another study between July, 1992 and February, 1993, 102 women residing in Fortaleza, in Northeast Brazil with a known history of misoprostol use for induced abortion were interviewed. These women were known by the researchers or were acquaintances of women who were interviewed. Seventeen percent (17%) were age 16-19, 57% were age 20-29, 25% were age 30-39, and 2% were age 40-49. Forty-six percent (46%) were never married, 15% had been married and 39% were currently married. Twenty-four percent (24%) had 0-3 years education, 34% had 4-7 years, 28% had 8-10 years and 14% had high school or more. Twenty-five percent (25%) had no live born children, 60% had 1-3 children, 15% had 4-12 children and 16% reported between one to five dead children. Seventy-seven percent (77%) were rated as being in low social classes and 81% were Catholic. Twenty-two percent (22%) were the head of a family, 39% were wives, 26% were daughters, 12% shared their home with friends, and 2% were live-in housemaids.
Sixty-four percent had no induced abortions prior to misoprostol use, 20% had one previous induced abortion, 10% had two previous abortions and 6% had from three to eleven previous induced abortions. Seventy-two percent (72%) of the women said they would accept the right to abortion but only 52% were favorable to misoprostol. Fifty-seven percent (57%) had not used any contraceptives. The most frequent stated reasons for abortion were rape, no stable partner and poor economic conditions. The researchers believed that abortion reform legislation was needed to accommodate new fertility control technologies, such as abortifacient pills36.
An earlier study of 2588 Brazilian women treated for post-abortion complications at the Hospital of Santo Andre, State of San Paulo, during 1978-1982, compared the characteristics of women who were under 20 years of age with those who were age 20 or more. Sixteen percent (16%) of the women in the study were under age 20. Those who were under 20 were more likely to have a greater gestational age, were more likely to have had a pregnancy end in abortion, and were more likely to have had one or more previous abortions (62.2% v 42.2%) compared to women over age 20. Women under age 20 were also more likely to be maritally unstable with many women working in domestic service as maids. It was noted that these women often had no legally recognized employment status, live in worse conditions, and experience less job stability, which might result in an abortion if pregnancy occurs.
Seventy-seven percent (77%) of the women had their menarche before the age of 14, and 81.4% had started their sexual life before they had reached the age of 14. The beginning of sexual relations at younger ages was found to lead to a tendency to have a first pregnancy at an earlier age. The author concluded that the incidence of abortion, especially among adolescents was unacceptably high and that abortion was being used as a contraceptive method in the absence of efficient and efficacious reproductive planning37.
Whether or not contraception will reduce the high incidence of induced abortion, and particularly repeat abortion, is problematical. In an attempt to determine whether or not counseling women to use contraceptives following induced abortion would reduce the incidence of repeat abortion, a study was undertaken of more than 3000 women who were admitted to hospitals with complications of induced or spontaneous abortion. Researchers in Kenya, Zimbabwe, Zambia, Nigeria and Mexico divided women into two groups. One group participated in a single session of contraceptive counseling after treatment for their complications, and the other group had no counseling session. One year later, researchers interviewed the women to determine contraceptive use and the incidence of repeat pregnancy and abortion. It was found that the counseling did not significantly reduce the rate of repeat abortion38. A recent study of 1661 French Canadian women found that non-compliance with scheduled follow-up visits for contraceptives following abortion was as high as 50% with younger women and women repeating abortion among those least likely to return39.
The reasons why Latin American women have abortions are similar to many of the reasons why U.S. women have abortions, i.e. relationship problems, can't afford baby, or too young or immature40. Based upon limited available studies, it also appears that Latin American women experience the same type of psychological reactions to abortion as U.S. women.
The attitude of the Latin American male and the quality of the relationship as to whether or not he offers financial and emotional support to his pregnant partner in support of childbirth is an important factor in determining the outcome of a pregnancy. Because a large number of abortions are for socioeconomic reasons, many Latin American women who become pregnant and have an abortion appear to have desired to carry the child to term. By resorting to abortion, many of these women appear to have violated their moral or religious beliefs in the process.
A wide variety of illegal abortion techniques were identified. Although definitions of complications were frequently imprecise and the number of studies limited, it appeared that the complications from illegal abortion among hospitalized Latin American women were less life-threatening compared to hospitalized African women41. However, one Brazilian study of women with abortion complications reported a high incidence of anemia which would indicate an increased risk of pregnancy-related death.
1 The Relationship of Abortion to Trends In Contraception and Fertility in Brazil, Colombia and Mexico, S Singh, G Sedgh, Int'l Family Planning Perspectives 23(1):4, March 1997 [Back]
2 Health in the Amencas. 1998 Edition, Volume 11, Pan American Health Organization: Washington DC, p. 183, 246, 416. [Back]
3 The Prevalence of Domestic Violence Among Women Seeking Abortion, SL Gladner et al, Obstet Gynecol 91 :1002, 1998 [Back]
4 Health in the Americas, 1998 Edition, Volume 11, Pan American Health Organization: Washington DC, p. 243, 404. [Back]
5 Expenencia sexual anticoncepcion en jovenes en algunos paises de America Latina, presented at the XII Latin American Gynecology and Obstetrics Congress, Guatemala City, Guatemala, Oct 25-30, 1987 as cited in Reproductive Health in the America, Ed. AR Omran et al, Pan American Health Organization PAHO/WHO, 1992. p. 124 [Back]
6 Conducta sexual y anticonceptiva en jovenes solteros. E Garcia et al, Ginecologia y Obstetacia de Mexico 49:343,1981 as cited in Reproductive Health in the Americas, 1992, p. 124 [Back]
7 Gender Differences in Sexual Practices and Sexually Transmitted Infections Among Adults in Lima, Peru, J Sanchez et al, Am J Public Health 86:1098,1996 [Back]
8 A Hospital Study of Illegal Abortion in Bolivia. PE Bailey et al, PAHO Bulletin 22(1):27, 1988 [Back]
9 Abortion Decision Making: Some Findings from Colombia, Carole Browner, Studies in Family Planning 10(3):96, March 1979 [Back]
10 La practice del aborto en las mujeres de sectores populares de Buenos Aires, J Llovet, S Ramos, Documento CEDES No.4. Buenos Aires: Centro de Estudios Sociales (1988) as cited in The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America, JM Paxman et al, Studies in Family Planning 24(4):205, July/Aug 1993 [Back]
11 Induced Abortion in Chile, with references to Latin American and Caribbean countries, M Weisner, paper presented at the annual meeting of the Population Association of America, Toronto. Canada, May 3-5, 1990 as cited in Reasons Why Women Have Induced Abortions: Evidence from 27 Countries, A Bankole, Int'l Family Planning Perspectives 24(3):117, 1998 [Back]
12 El aborto: enfoque psicosocial y de salud publica, M Kennedy, paper presented at the Meeting of Researchers on Induced Abortion in Latin America and the Caribbean, Bogota, Colombia, Nov 15-18, 1994 as cited in Reasons Why Women Hae Induced Abortions, 1998 [Back]
13 Illegal Abortion in Mexico: Client Perceptions, S Pick De Weiss, HP David, Am J Public Health 80(6):715, June, 1990; Abortion in the Americas, H David, S Pick de Weiss in Reproductive Health in the Americas, Ed. AR Omran et al, Pan American Health Organization PAHO/WHO, 1992, pp. 335-337 [Back]
14 Embarazo Indeseado y Aborto, JV Mejia, MM Telez, Bogota, Colombia: Editorial Presencia, 1992 as cited in Reasons Why Women Hae Induced Abortions, 1998 [Back]
15 Reasons Why Women Have Induced Abortions: Evidence from 27 Countries, A Bankole et al, Int'l Family Planning Perspectives 24(3):117, 1998, p.l21-122 [Back]
16 Misoprostol and illegal abortion in Rio de Janeiro, Brazil, SH Costa and MP Vessey, The Lancet 341:1258, May 15, 1993 [Back]
17 Misoprostol and illega1 abortion in Fortaleza, Brazil, H Coelho et al, The Lancet 341:1261, 1993 [Back]
18 Misoprostol: The experience of women in Forialeza, Brazil, HL Coelho et al, Contraception 49:101, 1994 [Back]
19 Reproductive Health in the Americas, Ed. AR Omran et al, Pan American Health Organization PAHO/WHO, 1992, p 341 citing several studies [Back]
20 Abortion in Cuba, M Soza et al, Paper presented at the Population Council Workshop, Toronto, May 2, 1989 as cited in Reproductive Health in the Americas. (1992) p. 334 [Back]
21 Unsafe Abortions: Methods Used and Characteristics of Patients Attending Hospitals in Nairobi, Lima, and Manila, A Ankomah et al, Health Care for Women International 18:43, 1997 [Back]
22 Aborto provocado: Estudio antropologico en mujeres jovenes de sectores populares, Monica Weisner in Actas del Primer Congreso Chileno de Antropologia: Santiago, Chile: Sociedad Chilena de Antropologia (1988) as cited in The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America, JM Paxman et al, Studies in Family Planning 24(4):205, July/Aug 1993 [Back]
23 Testing a Model of the Psychological consequences of Abortion, Warren B Miller et al in The New Civil War The Psychology. Culture. and Politics of Abortion. Ed. Linda J. Beckman, S Marie Harvey, American Psychological Association (1998) pp. 235-267 [Back]
24 Psychiatric Morbidity and Acceptability Following Medical and Surgical Methods of Induced Abortion, DR'Urquhart, AA Templeton, Br J Obstet Gynecol 98:396, April 1991; Coping With Abortion, L Cohen, S Roth. Journal of Human Stress, Fall, 1984 p.l40-145; Grief and Elective Abortions: Breaking the Emotional Bond?, L Peppers, Omega 18(1): 1, 1987-88; The Effects of Termination of Pregnancy: A Follow-up Study of Psychiatric Referrals, R Schmidt, RG Priest. Br J Medical Psychology 54:267, 1981 [Back]
25 En Defensa del Aborto en Venezuela, G Nlachado, Caracas: Editonal Ateneo, 1979 as cited in The Clandestine Epidemic (1993) [Back]
26 Psychological responses after abortion, N Adler et al. Science 248:41, 1990 [Back]
27 Induced abortion in Chile with references to Latin American and Caribbean countries, HM Weisner, Paper presented at Population Council Workshop, Toronto,1990 as cited in Reproductive Health in the Americas (1992) p.332 [Back]
28 Illegal induced abortion: a study of 74 cases in Ife-Ife, Nigeria, FE Okonofua et al, Tropical Doctor 22:75, 1992 [Back]
29 Psychological Problems of Abortion for the Unwed Teenage Girl, Cynthia Martin, Genetic Psychology Monographs 88:23, 1973; Follow-up After Therapeutic Abortion in Early Adolescence, MG Perez-Reyes, R Falk, Arch Gen Pschiatry 28:120, 1973 [Back]
30 Illegal Abortion in Mexico: Client Perceptions, S Pick de Weiss, HP David, Am J Public Health 80(6): 715, 1990; Abortion in the Americas, HP David, S Pick de Weiss in Reproductive Health in the Americas, Eds AR Omran et al, Pan American Health Organization PAHO/WHO, 1992, p.323-354 [Back]
31 A Hospital Study of Illegal Abortion in Boliia, PE Bailey et al, PAHO Bulletin 221): 27, 1988 [Back]
32 Misoprostol and illegal abortion in Rio de Janeiro, Brazil, SH Costa, MP Vessey, The Lancet 341:1258, May 15, 1993 [Back]
33 Post-abortion complications aher interruption of pregnancy with misoprostol, A Faundes et al, Advances in Contraception 12:1, 1996 [Back]
34 The Consequences of Iron Deficiency and Anaemia in Pregnancy on Maternal Health, the Foetus and the Infant, FE Viten, SCN News 11:1418, 1994 [Back]
35 The Aetiology of Anaemia in Pregnancy in West Africa, N van den Broek, Tropical Doctor 26:5, January. 1995 citing World Health Organization studies [Back]
36 Misoprostol: The experience of women in Fortaleza, Brazil, HL Coelho et al, Contraception 49:101, Feb 1994 [Back]
37 Abortion and Adolescence: Relation Between the Menarche and Sexual Activity, N Schor, Int'l Journal of Adolescent Medicine & Health 6(3-4):225, 1993 [Back]
38 Meeting Women's Needs for Post-Abortion Family Planning Report of a Bellagio Technical Working Group, M Wolf, J Benson, Int'l J Gynecology & Obstetrics 45, Suppl:S3-S24, 1994 [Back]
39 Les facteurs associes au non-retour a visite de suivi precoce post-avertement, I Ntaganira et al, Can J Public Health 89(1):62, Jan/Feb 1998 [Back]
40 Why Do Women Have Abortions?, A Torres, JD Forrest, Family Planning Perspectives 20(4):169, July/Aug 1988 [Back]
41 Pregnancy-Related Deaths of African Women, II. Hospital and Community Based Studies, TW Strahan, Association for Interdisciplinary Research in Values and Social Change 13(3):1-8, Mar/Apol, 1999 [Back]
1, 2,