UNWANTED PREGNANCY AND UNSAFE ABORTION

Transcription

Women and Health Learning Package
Developed by The Network: TUFH Women and Health Taskforce
Third edition, September 2007
Support for the production of the Women and Health Learning Package (WHLP) has been
provided by the Global Knowledge Partnership, by Global Health through Education,
Training and Service (GHETS), and by The Network: Towards Unity for Health (The
Network: TUFH). Copies of this and other WHLP modules and related materials are
available on The Network: TUFH website at http://www.the-networktufh.org/publications_
resources/trainingmodules.asp or by contacting GHETS by email at [email protected], or by
fax at +1 (508) 448-8346.
About the authors
Deyanira González de León Aguirre, MD, MPH
Department of Health Care, Division of Biological and Health Sciences
Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
Dr González de León graduated from the Faculty of Medicine, National Autonomous
University of Mexico (UNAM), and holds a post-graduate degree from the Institute of Health
Development, Havana, Cuba. She began work at the Metropolitan Autonomous University,
Xochimilco Campus (UAM-X) in 1981, and has been a full professor since 1992. Her
academic interests include health promotion and education, gender studies and women’s
sexual and reproductive health. She was the coordinator of the Research Unit on Education
and Health, and responsible for the project “Abortion care in Mexico: Physicians’ attitudes
towards abortion”. She also conducted the project “Women and the medical profession in
Mexico”, and has collaborated in other research projects at the UAM-X. She teaches subjects
related to women’s sexual and reproductive health in both undergraduate and postgraduate
university programs. Dr González de León served as an external advisor to Ipas Mexico, a
non-profit agency working to improve women’s lives by focusing on reproductive health
from 2001-2002. While with Ipas, she collaborated on a project to support medical and
nursing schools in incorporating new perspectives on reproductive health and abortion care
into curricula, as well as participated in a project to create legal abortion services for victims
of sexual violence in Mexico City. Dr González de León has been a member of The Network:
TUFH Taskforce on Women and Health since 2002. Email: [email protected] /
[email protected]
Deborah L. Billings, PhD
Senior Associate, Research and Evaluation
Ipas Mexico, Mexico City, Mexico
Dr Billings develops research, assessment, and evaluation strategies to advance Ipas’ work in
Mexico and throughout Latin America. She also serves as one of Ipas Mexico’s liaisons to
the steering committee of the Alianza por el Derecho a Decidir (ANDAR) [Alliance for the
Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion
http://www.the-networktufh.org
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Right to Decide]. Dr Billings is a graduate of the University of Michigan with a PhD in
Sociology. She has been the Co-Principal Investigator on several operations research projects
related to post-abortion care in Mexico, Bolivia, Ghana, and Kenya, and also participated in the
design and analysis of an anthropological study documenting traditional midwives’ attitudes
and practices regarding abortion in Morelos, Mexico. In addition, Dr Billings has provided
research guidance to the Menstrual Regulation Training and Services Program (MRTSP) in
Bangladesh; the State Workers’ Health System (ISSSTE) in Mexico; and projects in Mexico
examining the intersection of unwanted pregnancy, HIV/AIDS, and unsafe abortion among
adolescents. She currently leads research initiatives in Mexico and Bolivia, focused on the
sexual and reproductive health of adolescents and comprehensive care to survivors of sexual
violence. Before moving to Mexico City, Dr Billings served as Deputy Director of Health
Systems Research and as a Senior Research and Policy Fellow. She is currently a Senior
Research Associate and Coordinator of Research and Evaluation in Ipas Mexico. She is also an
Adjunct Assistant Professor (Maternal and Child Health) in the University of North Carolina,
School of Public Health. Email: [email protected]
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INTRODUCTION
Medical and nursing schools have the responsibility to collaborate with health systems to
provide women with comprehensive healthcare services. In many countries, however,
medical and nursing students face restrictions and difficulties in acquiring knowledge about
subjects related to sexual and reproductive health. Among these subjects are unwanted
pregnancy and unsafe abortion, which are often considered to be hard to handle by many
faculty members.
Unwanted pregnancies are common events worldwide, and abortion has long been a highly
controversial matter in all cultures and societies. The current debate on these topics involves
issues related to women’s human and sexual and reproductive rights, legislation, politics and
ethics. The debate also involves important issues related to the provision of sexual and
reproductive healthcare services aimed at women.
This module seeks to increase students’ awareness about the complexity of the issues related
to unwanted pregnancy and unsafe abortion. The authors have experience in implementing
the module as a workshop, but teachers may decide how to use the module according to their
own possibilities and needs. The basic content to be included in a workshop can be seen in
Appendix II.
GLOBAL OVERVIEW
In almost all developing countries women’s access to procedures for safe abortion is
restricted by the law, which results in high rates of preventable complications and deaths.
Over the last decades, the adverse consequences of unsafe abortion have been a serious
concern of women’s rights advocates and global organizations. The World Health
Organization (1992) defined unsafe abortion as:
A procedure for terminating an unwanted pregnancy carried out either by a person
lacking the necessary skills or in an environment that does not conform to minimal
medical standards, or both.
The 4th International Conference on Population and Development (ICPD), held in Cairo in
1994 and attended by representatives from 179 countries, was the first global forum where
agreement was reached that unsafe abortion should be recognized and addressed as a relevant
public health matter.
The ICPD gave voice to proposals to improve women’s health that for a long time had been
held by feminist organizations, supportive medical professionals, lawyers and legislators,
human rights activists and academics all over the world. The recommendations of the ICPD
were a starting point in a new orientation of population policies for developing countries, and
were also very useful in providing a new reference framework for the analysis of sexual and
reproductive health from an integrated and progressive viewpoint. The ICPD fully recognized
sexual and reproductive rights as part of fundamental human rights, and called for universal
access to sexual and reproductive health services by 2015. Since 1994, government health
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systems and non-government organizations have implemented programs based on the model
of sexual and reproductive health, which addresses the socioeconomic and cultural
determinants of women’s health and stresses on the need to promoting gender equity and
women’s empowerment.
The Program of Action of the ICPD clearly stated the necessary actions that government
health systems should follow in order to reduce the adverse consequences of unsafe abortion
on women’s health:
All governments and relevant intergovernmental and non-governmental
organizations are urged to strengthen their commitment to women’s health, to deal
with the health impact of unsafe abortion as a major public health concern and to
reduce the recourse to abortion through expanded and improved family planning
services. Prevention of unwanted pregnancies must always be given the highest
priority, and every attempt should be made to eliminate the need for abortion.
Women who have unwanted pregnancies should have ready access to reliable
information and compassionate counselling. Any measures or changes related to
abortion within the health system can only be determined at the national or local
level according to the national legislative process. In circumstances where abortion
is not against the law, such abortion should be safe. In all cases, women should have
access to quality services for the management of complications arising from
abortion. Post-abortion counselling, education and family planning services should
be offered promptly, which will also help to avoid repeat abortions (United Nations
General Assembly, 1994; par. 8.25).
Five years later, during the first review of the ICPD implementation (Cairo+5), governments
reaffirmed their commitment and called for health systems to make safe abortion services
accessible to women:
In circumstances where abortion is not against the law, health systems should train
and equip health-service providers and should take other measures to ensure that
such abortion is safe and accessible. Additional measures should be taken to
safeguard women’s health (United Nations General Assembly, 1999; par. 63iii).
One of the Millennium Development Goals, formulated in 2001 by the United Nations, called
for global efforts to reduce maternal mortality by three quarters around 2015. But unsafe
abortion continues to be a serious public health matter and a major obstacle to reducing the
high rates of maternal mortality in the developing world (Crane & Hord-Smith, 2006).
Unwanted pregnancies, which are the most common cause of induced abortion around the
world (Guttmacher Institute, 1999), are defined as those that occur at an inopportune time, as
a result of unfavourable circumstances, or among women who do not want to have children
(Langer, 2002). Unwanted pregnancies present an important social problem all over the
world, but are more frequent in developing countries. The lack of access to health services
and modern contraception is one of the major causes of unwanted pregnancies, but there are
many other elements that complicate the matter.
Opportunities to use effective contraception depend heavily on the availability of sexual and
reproductive health services, but in many contexts these services do not always meet the
individual needs of women who want to avoid pregnancy or control spacing between births.
In many societies, cultural and religious beliefs limit women’s ability to make their own
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decisions about sexuality and reproduction and poor and less-educated women, as well as
adolescents, usually find it difficult to gain access to contraception. Thousands of women
become pregnant because of sexual violence, which is a serious and often-neglected problem
throughout the world. Besides, all known contraceptives can fail and women may become
pregnant even when they are using modern methods properly; in other cases, unwanted
pregnancies may be the result of consensual but unplanned and unprotected sexual
encounters. Women may also become pregnant due to stigmatization of unmarried women
using contraceptives, because they use ineffective traditional contraceptive methods, or
because their sexual partners reject any kind of contraception (Guttmacher Institute, 1999;
United Nations Population Fund, 2000; Langer, 2002; World Health Organization, 2004;
Crane & Hord-Smith, 2006; Warriner, 2006).
Another important cause of unwanted pregnancy is the lack of access to emergency
contraception -also known as the morning-after pill or post-coital contraception. Although
emergency contraception is now widely available in most developed countries, it is generally
less known and less used by women in developing countries. When used within the first five
days after unprotected sex, emergency contraceptive pills may reduce a woman’s individual
chance of pregnancy by 60-90%. Emergency contraception is a safe recourse for all those
women who have had unprotected sexual intercourse, including cases of rape or accidents
when using condoms or pills, and the World Health Organization has called for greater access
to this method in all countries (International Consortium for Emergency Contraception, 2003;
World Health Organization, 2005).
When faced with unwanted pregnancies, many women choose abortion as their recourse.
Experiences from all over the world have shown that women who have terminated their
pregnancies give very similar reasons for making their decision (see Appendix I, Table 1).
These reasons include the desire to stop or delay childbearing; adverse socioeconomic
conditions; conflictive couple relationships; age and marital status; working conditions and
unemployment; educational and personal expectations; maternal and foetal health conditions;
rape or incest; and sexual partner or parental coercion (Guttmacher Institute, 1999).
Accurate information on the real incidence of abortion is difficult to obtain. In all of those
contexts with highly restrictive laws, rates are estimated according to the number of women
hospitalized for the treatment of abortion-related complications. Therefore, a large number of
women having abortions, both safe and unsafe, are excluded from official statistics. In many
places of the developing world providers often refuse to admit that they perform abortions
and women are usually unwilling to report that they have undergone the procedure. Available
data show, however, that the incidence of abortion is high. More than one-quarter of women
worldwide who become pregnant have either an abortion or an unwanted birth. By the end of
the 20th Century, 36% of all pregnancies in developing countries were unplanned and 20%
ended in abortions. Currently, 46 million women worldwide have induced abortions each
year, of which 27 million are legally performed and 19 million take place outside the legal
system. Nearly 80% of women who voluntarily terminate their pregnancies live in developing
countries (Guttmacher Institute, 1999; World Health Organization, 2004).
Global estimates indicate that 19 million unsafe abortions were carried out around the year
2000. Almost all of these unsafe abortions, or 18.4 million, took place in developing regions.
Most women who interrupt their pregnancies already have children and are married or live in
stable unions, but an increasing number of women having abortions worldwide are single
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adolescents. More than 60% of all unsafe abortions in developing countries occur among
women 15-30 years old, with almost 14%, or 2.5 million, among women under 20 years
(World Health Organization, 2004).
Complications of unsafe abortion are one of the major causes of hospital admissions in
countries with restrictive laws, which cause a significant drain on scarce material and
financial resources in public hospitals facilities (World Health Organization, 2004). A
significant proportion of beds at urban public maternal hospitals are daily occupied by
women suffering complications of unsafe abortion -including tears in the cervix, perforation
of the uterus, fever and infection, septic shock, and severe hemorrhage-, and its treatment
may consume up to one half of the total financial resources for obstetric care. A growing
number of developing countries have incorporated post-abortion care models into public
hospitals, but in many places women still leave obstetric care services without comprehensive
counseling and contraceptive protection (Guttmacher Institute, 1999; United Nations
Population Fund, 2004).
Post-abortion care models include the treatment of women with complications of abortion
using manual vacuum aspiration; general counseling to meet women’s emotional and
physical needs; contraceptive counseling to help women to avoid repeat unwanted
pregnancies and abortions; and access to other reproductive health services. The
implementation of this model requires changes in providers’ attitudes and practices so that
women receive prompt and humane healthcare (Billings et al., 2007)
According to data from the World Health Organization (2004) complications of unsafe
abortions account for 13% of all maternal deaths, and nearly 68,000 women died around the
year 2000 following unsafe abortions (see Appendix I, Table 2). Global estimates indicate the
mortality associated with unsafe abortion in the developing world is significantly higher than
in developed countries (see Appendix I, Table 3).
Under safe medical conditions the risk of suffering complications of abortion is very low, and
deaths are extremely rare events. In most developed countries abortion is a legal procedure
and women have access to qualified comprehensive services. In many countries services are
provided at government health facilities and most abortions are performed early in
pregnancy, in hygienic settings, by well-trained providers, and with effective surgical or
medical procedures (Guttmacher Institute, 1999; Berer, 2002; World Health Organization,
2004). Surgical abortion (using manual or electric vacuum aspiration) and medical abortion
(induced through the use of drugs such as mifepristone and misoprostol) are currently the
standard methods recommended by the World Health Organization to terminate early
pregnancies. Both methods can be provided in primary healthcare facilities, and their use has
substantially contributed to improving the quality of abortion care (Guttmacher Institute,
1999; Baird & Flinn, 2001; Berer, 2005; World Health Organization, 2006; Warriner, 2006).
Safe abortion services provided by qualified practitioners do exist in big cities of developing
countries with restrictive laws, but they are usually expensive and inaccessible to most
women. In these contexts, many women resort to unskilled clandestine practitioners and
many others opt for self-induced abortions using hazardous or ineffective means. As a rule,
poor women who undergo unsafe abortions are much more likely to face difficulties in
obtaining access to prompt emergency care, and many of these women do not receive the care
they need. On the other hand, in most developing countries access to safe abortion is limited
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even in circumstances permitted by the law. Government services to provide legal abortions
are scarce, women are usually unaware about their existence, and requirements to authorize
the procedure are often long and bureaucratic. Besides, a poor understanding of the law is
common among doctors and many of them refuse to perform abortions because of moral and
religious objections (Guttmacher Institute, 1999; Berer, 2002; Billings et al., 2002; Cook et
al., 2003; World Health Organization, 2004; Warriner, 2006).
The liberalisation of abortion laws has been a major factor in the reduction of maternal
mortality rates in many countries and has had a decisive influence on women’s general wellbeing and health conditions. Around the world, more than 60% of people live in countries
where abortion is either permitted without restrictions or is allowed on broad grounds,
including socioeconomic and personal reasons. However, more than one quarter of all people
still reside in countries where abortion is permitted only to save the woman’s life or is not
allowed under any circumstances (see Appendix I, Table 3). A number of countries have
substantially reformed their abortion laws in the last decades, by including new
circumstances under which abortion could be permitted, by broadening gestational limits or
eliminating parental authorizations in cases of minors who request abortions. In many
countries legislation explicitly admits abortion when pregnancy results from rape or incest,
and when there is a high probability of foetal impairment (Cook et al., 2003; Center for
Reproductive Rights, 2005; Grupo de Información en Reproducción Elegida, 2005).
Abortion is a highly controversial procedure in much of the world, and even in countries
where abortion is legal on broad grounds, laws can set restrictions in terms of gestational
periods, health facilities and providers, consent requirements, or counselling and waiting
periods. On the other hand, in some countries where abortion is only permitted to save the
woman’s life or to preserve her mental or physical health, laws may allow the procedure
under a few exceptions; abortion may be authorized, for example, in cases of pregnancy
resulting from rape or incest, as well as in those of foetal impairment (Guttmacher Institute,
1999; Cook et al., 2003).
The high incidence of complications and deaths resulting from unsafe abortions has a clear
association with restrictive laws. In Romania, for example, the removal of liberal abortion
laws in 1966 led to a substantial increase in the number of abortion-related deaths. The figure
rose from 20 deaths/100,000 live births in 1965 to 150/100,000 live births in 1983. Abortion
laws were liberalized again in 1989, and one year later maternal deaths attributed to unsafe
abortions declined to around 60/100,000 live births (World Health Organization, 2004).
Legal abortions are necessary to prevent the adverse consequences of unsafe procedures.
However, the liberalization of abortion laws does not guarantee by itself that safe procedures
are available for all women. The case of India, one of the few developing countries with
liberal abortion laws, clearly shows that legality does not always coincide with safety.
Abortion is legal under a wide range of medical and social grounds since 1971, but unsafe
abortion remains a relevant public health matter; government abortion services are scarce,
and bureaucratic and cultural barriers make it difficult women’s access to safe procedures.
The number of unsafe abortions in India is extremely high and accounts for 9 to 20% of all
maternal deaths (Ganatra & Elul, 2003).
Unsafe abortion remains a relevant public health matter in developing countries, as well as a
social justice and human rights issue. One of the key elements to reduce the necessity for
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abortions is the prevention of unwanted pregnancies by improving access to qualified
reproductive health services and contraception and providing sexuality education. However,
it is well known that even in contexts where modern contraception is widely available not all
unwanted pregnancies and abortions can be prevented. Experiences around the world have
shown that restrictive laws, socioeconomic disparities and gender inequities are closely
related to the adverse consequences of unsafe abortion. Therefore, all societies should
guarantee the right to comprehensive care for all those women who voluntarily decide to
terminate their unwanted pregnancies. Today the public and all healthcare professionals
should keep in mind that:
Abortion properly performed is no longer a threat to the physical or mental health of
the woman, and can be performed humanely and without economic exploitation.
The medical profession needs therefore to act with reason, moral sensibility and a
profound sense of social responsibility. Supported by available scientific
knowledge, the medical profession can face squarely its professional and personal
obligations (Villarreal, 1989).
REGIONAL OVERVIEW: MEXICO 1
Since the early 1970’s, abortion has been widely recognized as a relevant social and public
health matter in Mexico. However, the most conservative religious and political circles have
generated confusion and misinformation about abortion. The Catholic Church and powerful
conservative groups have blocked the debate on the initiatives to update the laws, which have
been presented at different moments by women’s groups linked to the feminist movement
and by certain actors within the government. Most legislators, political leaders and healthcare
authorities have evaded the responsibility of discussing the repercussions of abortion laws,
which favours the clandestine practice of abortion (González de León y Billings, 2001).
The political context of the country has been marked by significant changes since the middle
of the 1980’s and the demand to liberalize abortion laws has gained an increasing interest
among the civil society and the support of many key, progressive social actors. As a result of
many efforts, in recent years the legal framework of abortion has begun to substantially
change in Mexico.
In 2000, the Mayor of Mexico City presented a bill to broaden the bases on which legal
abortion could be obtained in the capital city of the country. Previous legislation dated from
the early 1930’s and did not penalise abortion in cases of pregnancy resulting from rape, to
save the life of the woman, and in cases of pregnancy resulting from an accident beyond the
woman’s control. The bill was passed by a majority in the Federal District Legislative
Assembly and included four indications for which abortion would not be penalized: when the
pregnancy presents grave risk to the health of the woman (including the risk of death), in the
case of severe congenital foetal malformation, and in the case of artificial insemination
performed without the consent of the woman. In addition, and for the first time in the
country, the legislation clearly defined the responsibilities of the judicial and health sectors in
the provision of abortion services and the steps that need to be followed to ensure women’s
access to safe abortion services in the case of rape or artificial insemination without consent
(Asamblea Legislativa del Distrito Federal, 2000; Lamas & Bissell, 2000).
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A general profile of the Mexican population is presented in the Appendix I, Table 7.
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A more relevant advance took place in April 2007, when the Democratic Revolution Party
presented a bill to decriminalize abortion during the first 12 weeks of pregnancy in the
Federal District of Mexico City. The bill was fully supported by the Mayor of Mexico City
and all authorities of the local Ministry of Health and it was passed by a majority of local
representatives. Under this new progressive legislation, abortion is allowed on request for all
women within the first trimester of pregnancy. The new legislation requires the local Ministry
of Health to provide free of charge safe, legal abortions, as well as to prevent unwanted
pregnancies by promoting sexuality education and assuring a wide availability of modern
contraceptive methods (Asamblea Legislativa del Distrito Federal, 2007; Grupo de
Información en Reproducción Elegida, 2007a; Ipas, 2007).
With this last legislative reform the Federal District of Mexico City has, after Cuba and
Guyana, one of the most progressive abortion legislations in the Latin-American region. This
landmark reform will serve as an example for other Mexican states to review and liberalize
their laws and will support further proposals to decriminalize abortion at the national level.
In all other 31 states of the country abortion laws remain highly restrictive. Laws vary from
one state to another and penal codes include at least two circumstances in which abortion is
exempt from penalty; all over the country abortion is permitted when the pregnancy is the
result of rape (see Appendix I, Table 4). Yet most states penal codes lack of accurate
procedures for laws to be accomplished, which presents important barriers for women’s
access to safe medical services in cases of rape or any other circumstances admitted by the
laws (Grupo de Información en Reproducción Elegida, 2007b).
The bureaucracy and fragmentation of government health and legal agencies do not always
facilitate and expedite legal abortions; the public, in general, has a poor understanding on the
laws; and the availability of legal abortion services at public hospitals is limited (Billings et
al., 2002; Becker et al., 2002; Lara et al., 2003).
Physicians’ attitudes regarding abortion present another important barrier for women’s access
to safe abortion. Eminent medical professionals have contributed to the analysis of the public
health consequences of unsafe abortion, giving weight to the movement to modify restrictive
laws. However, most Mexican physicians take a conservative stance on the issue of abortion
and have remained at the margins of public debate on the topic. In general, doctors do not
understand the laws and many refuse to perform abortions under any circumstances; in other
cases, abortion-related stigmas and moral and religious beliefs play an important role on their
attitudes regarding abortion.
Different surveys (González de León & Billings, 2001; Billings et al., 2002; Lara et al., 2004)
have shown that most physicians –including residents and specialists in obstetrics and
gynaecology, and general and family medicine practitioners- do not oppose pregnancy
termination in cases of rape, in cases of grave risk to the woman’s health or life, and in those
of severe foetal impairment. All of these circumstances are included in different states’ penal
codes, but they do not coincide with the most common reasons why women seek abortions in
Mexico (see Appendix I, tables 5 and 6). It is clear that much work has to be done within
medical schools, health services and professional associations to modify physicians’ attitudes
regarding abortion, since the position taken by the medical community plays a central role in
the application of liberal abortion laws and therefore in women’s access to safe services.
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On the other hand, neither moral condemnation nor the threat of legal penalties has impeded
the practice of abortion in many private facilities, through which physicians generate
significant earnings. Few doctors provide private safe abortion services because of an ethical
commitment to protect the health of women who request the termination of an unwanted
pregnancy. Due to social and economic disparities few women can afford the costs of safe
procedures performed by well trained physicians. The vast majority of women, who lack of
economical resources and information, are forced to risk their health, and even their lives, by
resorting to dangerous methods or practitioners who are not properly trained. Clandestine
practices to terminate unwanted pregnancies often result in complications of unsafe abortions
that could have been prevented (González de León & Billings, 2001).
As in other countries where abortion is restricted by the laws, in Mexico statistical data about
induced abortion and its consequences are uncertain and outdated. According to one study, in
1990 the annual number of induced abortions in the country was estimated around half a
million (Guttmacher Institute, 1999). For the same period government agencies estimated a
lower number, with approximately 200,000 induced abortions per year between 1993 and
1995 (Consejo Nacional de Población, 1999).
The number of women who experience complications of unsafe abortions in Mexico is
unknown. Most available data are obtained from public hospital records and it does not allow
distinction between spontaneous and induced abortions, nor among safe or unsafe abortions.
However, estimates indicate that by the middle of the 1990’s one-third of women required
emergency care following unsafe procedures (López, 1994). In 2005, complications of
abortion were the fifth most common cause of hospital stays at all public hospitals throughout
the country (Secretaría de Salud, 2007). In Mexico City, within hospital facilities of the local
Ministry of Health, this kind of complications were the fourth most common cause of
hospital morbidity between 2000 and 2005 (Gobierno del Distrito Federal, 2005). Recent
estimates at the national level indicate that the average annual number of women who are
hospitalized due to complications of abortion is around 167,000 (Schiavon et al., 2007).
In 2002, abortion was the third most common cause of maternal mortality at the national level
(Secretaría de Salud, 2004). The number of women who die following complications of
unsafe abortions is underestimated, since many of the maternal deaths reported as obstetric
haemorrhages could in fact be attributed to unsafe abortions (Langer, 2002; Langer, 2003b).
A recent analysis on statistical data about abortion-related mortality shows that 21,464
maternal deaths were reported at the national level between 1990 and 2005; of these maternal
deaths, 1,537 were attributed to complications of abortion, representing 7.2% of all maternal
deaths. Almost half, or 45%, occurred in women aged 20-29, and nearly two thirds, or 64%,
in women without social security; 281 abortion-related deaths took place at the homes of
women, with 77% occurring in rural areas (Schiavon et al., 2007).
A high number of induced abortions in Mexico are due to unwanted and unplanned
pregnancies. Around 1990 almost one half of all pregnancies in Mexico, or 40%, were
unplanned, with 17% ending in induced abortions and 23% in unwanted births (Guttmacher
Institute, 1994). Government policies in both fields of population and health address that the
best way to prevent unwanted pregnancies is the use of modern contraception. The use of
contraceptives has substantially increased over the last decades, but it is still limited for
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certain groups of women. Data from a national survey indicate that in 2003 virtually all
Mexican women of reproductive age knew at least one method to prevent pregnancy, and
three quarters of those sexually active and living with their sexual partners were using
contraceptive methods (Secretaría de Salud, 2005). However, lower levels of contraceptive
use are still found in adolescents, with less than 40%; in women who lack of education, with
57%; and in those pertaining to indigenous groups, with 52% (Schiavon et al., 2007).
Unwanted pregnancy and unsafe abortion are relevant problems among adolescents. The
incidence of adolescent pregnancy has declined, but it has been estimated that 40 to 70% of
pregnancies in this group are unplanned (Schiavon, 2003). In 2005, more than 17% of all
births throughout the country occurred in women under the age of 20 (Instituto Nacional de
Estadística, Geografía e Informática, 2007). On the other hand, national data from hospital
facilities of the federal Ministry of Health indicate that abortion was the second cause of
hospital stays among adolescents aged 15-19, and the fifth among girls aged 10-14
(Secretaría de Salud, 2003).
In 1994 the Mexican government was a signatory of the ICPD agreements and reaffirmed its
commitment to ensure that unsafe abortion would be addressed as a relevant public health
matter during the ICPD review in 1999. However, it is still much to be done to reach the
ambitious goals of the ICPD in Mexico. An important advance for the prevention of
unwanted pregnancies took place in 2004, when the federal Ministry of Health authorized the
use of emergency contraceptive pills. Despite the strong opposition from conservative groups
this method is currently available over the counter and can be prescribed at all health
facilities across the country.
The major government health institutions have accumulated experiences in implementing
post-abortion care services at hospital facilities in some states of the country, but the
decentralization of public health services, its size and diversity have presented challenges to
fully institutionalizing post-abortion care (Billings et al., 2007). In addition, in recent years
fewer efforts and resource have been directed by the federal government to ensure women’s
access to safe abortion when it is not against the law; to equip and train physicians and nurses
to provide comprehensive services for women suffering complications of unsafe abortion;
and to incorporate innovative, safe, cost-effective technologies into obstetric health facilities.
The lack of political and financial support has contributed to an unequal, slow progress in the
protection and promotion of sexual and reproductive health in many countries of the
developing world (Haberland & Measham, 2002; Langer, 2003a; Stewart & cols, 2004;
Burke & Shields, 2005; Glasier et al, 2006)). In the case of Mexico, government financial and
logistical limitations have impeded efforts to expand and improve primary healthcare services
and family planning programs, or to strengthen the strategies to decrease maternal mortality
and the high rates of cervical cancer. On the other hand, financial and socio-cultural barriers
have inhibited the reinforcement of programs to end violence against women and girls, to
implement effective programs for the prevention of sexually transmitted infections and AIDS,
or to better respond to adolescents’ sexual and reproductive health needs.
In recent years, the public has been increasingly involved in the debate of national issues and
different social actors –non-government organizations linked to feminist groups, progressive
health professionals, lawyers and human rights advocates, academics, legislators and
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government progressive agents- have intensified their efforts for the recognition of sexual and
reproductive rights and in support of women’s abilities to exercise these rights.
These social actors have succeeded in making abortion more visible, through initiatives to
modify existing norms and laws, by organizing opinion polls on this issue, and by publicizing
individual cases and supporting survivors of rape who have been denied legal abortion
services through the media. Some non-government organizations have played a decisive role
in the promotion of emergency contraception and have collaborated with the major
government health institutions in introducing innovative models for the comprehensive
management of women suffering complications of unsafe abortions and victims of sexual
violence. All over the country, many groups are currently advocating for better sexuality
education; for the universal access to effective contraceptive methods; for the recognition of
adolescents’ right to contraception and informed consent; and for the reinforcement of public
policies to promote gender equity and to eliminate violence against women.
12
APPENDIX I
Table 1: Why women choose abortion
To stop childbearing
•
•
•
I have already have as many children as I want
I do not want any children
My contraceptive method failed
To postpone childbearing
•
•
My most recent child is still very young
I want to delay having another child
Socio-economic conditions
•
•
•
I cannot afford a baby now
I want to finish my education
I need to work full-time to support (myself or) my children
Relationship problems
•
•
•
•
I am having problems with my husband (or partner)
I do not want to raise a child alone
I want my child to grow up with a father
I should be married before I have a child
Age
•
•
•
•
I think I am too young to be a good mother
My parents do not want me to have a child
I do not want my parents to know I am pregnant
I am too old to have another child
Health
•
•
•
•
The pregnancy will affect my health
I have a chronic illness
The foetus may be deformed
I am infected with HIV
Coercion
•
•
•
I have been raped
My father (or other male relative) made me pregnant
My husband (or partner) insists that I have an abortion
Source: Guttmacher Institute (1999). Sharing responsibility: Women, society &
abortion worldwide. New York: AGI, p. 17.
13
Table 2: Global and regional estimates of unsafe abortions and maternal deaths
due to unsafe abortions, around the year 2000*
Number of
unsafe
abortions
(thousands)
Number of
maternal
deaths due to
unsafe
abortion
% of all
maternal
deaths
Unsafe
abortion
deaths to
100 000 live
births
World
Developed countries **
Developing countries
19 000
500
18 400
67 900
300
67 500
13
14
13
50
3
60
Africa
Eastern Africa
Middle Africa
Northern Africa
Southern Africa
Western Africa
4200
1700
400
700
200
1200
29 800
15 300
4900
600
400
8700
12
14
10
6
11
10
100
140
110
10
30
90
Asia **
Eastern Asia
South-central Asia
South-eastern Asia
Western Asia
10 500
***
7200
2700
500
34 000
***
28 700
4700
600
13
***
14
19
6
40
***
70
40
10
Europe
Eastern Europe
Northern Europe
Southern Europe
Western Europe
500
400
10
100
***
300
300
***
<100
***
20
26
4
13
***
5
10
***
1
***
Latin America and the
Caribbean
Caribbean
Central America
South America
3700
100
700
2900
3700
300
400
3000
17
13
11
19
30
40
10
40
North America
***
***
***
***
Oceania **
30
<100
7
20
Regions
* Figures may not add up exactly because of rounding.
** Japan, Australia and New Zealand have been excluded from the regional estimates, but are included in the
total for developed countries.
*** No estimates are shown for regions where the incidence is negligible.
Source: World Health Organization (2004). Unsafe abortion: Global and regional estimates of the incidence of unsafe
abortion and associated mortality in 2000. Geneva: WHO (modified).
14
Table 3: Circumstances under which abortion is permitted around the world, in
percentages of population and number of countries, 2005
Circumstances
% of world’s
population
Number
of countries
To save the woman’s life or prohibited all together
26
72
To preserve physical health (also to save the woman’s life)
10.1
35
To preserve mental health (also to save the woman’s life and
physical health)
2.7
20
Socioeconomic grounds (also to save the woman’s life, physical
health and mental health)
20.7
14
Without restriction as to reason
40.5
54
Source: Center for Reproductive Rights (2005). The world’s abortion laws. New York: CRR.
Table 4: Circumstances under which abortion is permitted in Mexico
Circumstances
Number of states
(n =32)
Pregnancy resulting from rape
32
To save the life of the pregnant woman
27
Pregnancy resulting from an accident beyond the woman’s control
29
Foetal impairment
13
Pregnancy presenting grave risk to the health of the woman
9
Artificial insemination performed without the consent of the woman
8
Socioeconomic reasons (for women with 3 and more children)
1
On request *
1
Source: Grupo de Información en Reproducción Elegida (2007b). Leyes del aborto en México
(hoja informativa). México: GIRE (modified).
*Since April 2007 in the Federal District of Mexico City.
15
Table 5: Circumstances under which ob-gyn residents’ in Mexico City accept the
practice of abortion *
Circumstances
(%)
(n = 121)
Fetal malformation incompatible with extra-uterine life
94
Pregnancy poses risk to the life of the woman
91
89
Woman has severe heart condition
59
Woman has AIDS or is HIV positive
52
Fetal malformation compatible with extra-uterine life
48
Woman with psychological problems, or at risk of, because of the pregnancy
26
Woman or partner with poor socioeconomic conditions
19
Women, married or single, who does not want to be pregnant
15
Woman with children whose partner died or abandoned the family
12
Adolescent without the means to support a family
12
Contraceptive method failure
11
Woman who is studying and can not attend to a child
8
Source: González de León D, Billings D (2001). Attitudes towards abortion among medical trainees in
México City public hospitals. Gender and Development, 9 (2), 87-94.
* Ob-gyn residents were practicing in seven public hospitals in Mexico City
16
Table 6: Circumstances under which Mexican physicians accept abortion *
Circumstances
%
86
To save the life of the pregnant woman
93
Pregnancy presenting grave risk to the health of the woman
87
Severe foetal impairment
83
Artificial insemination performed without the consent of the woman
56
Socioeconomic reasons
13
In cases of single mothers
8
In cases of minors (less than 18 years)
13
Contraceptive failure
15
On request
20
Source: Lara D, Goldman L, Firestone M (2004). Opiniones y respuestas. Resultados de una encuesta de
opinión a médicos mexicanos sobre el aborto. México: Population Council.
* The survey included a sample of 1,206 physicians working at health facilities of the federal Ministry of Health
and the private sector in urban areas throughout the country.
17
Table 7: General profile of the Mexican population
Total population (millions), 2005
107.0
Average population growth rate (%), 2005
Urban population (%), 2003
1.2
76
Life expectancy of women, 2005
Life expectancy of men, 2005
78.0
73.6
Total fertility rate, 2005
2.27
Contraceptive prevalence, 2002
All methods
Modern methods
68
60
Maternal mortality ratio per 100,000 live births, 2003
Infant mortality rate per 1,000 live births, 2005
Mortality rate of girls under the age of 5, 2005
Mortality rate of boys under the age of 5, 2005
Births per 1,000 women aged 15-19, 2000-2005
Births with skilled attendants (%), 2004
83
19
20
25
67
86
GNI per capita, 2003
Public health expenditures (% of GDP), 2003
US$ 8,950
2.7
Source: United Nations Population Fund (2005). State of world population 2005: The
promise of equality. Gender equality, reproductive health and the Millennium
Development Goals. New York: UNFPA.
18
APPENDIX II
IMPLEMNTING THE MODULE AS A WORKSHOP
As mentioned before, the module has been implemented as a workshop. Content includes the
basic information that all medical and nursing students should receive about unwanted
pregnancy and unsafe abortion. Resources to cover all contents of a workshop can be found
in three sections of this module: Bibliography, Suggested Reading and Recommended
Websites.
Basic content of the workshop:
Unwanted pregnancy, unsafe abortion, and women’s health
•
•
•
•
•
•
Unwanted pregnancy, abortion, and women’s sexual and reproductive health and
rights
Global, regional, and local estimates on unwanted pregnancy and unsafe abortion
The role of culture and poverty on the incidence of unwanted pregnancy and unsafe
abortion
Abortion laws and their implications for women’s health
Ethical aspects involved in the termination of pregnancy
Attitudes of healthcare providers towards induced abortion
New alternatives for the prevention of unwanted pregnancy: emergency contraception
•
•
•
Emergency contraception methods
The use of emergency contraception for victims of sexual violence
The use of emergency contraception for adolescent women
Comprehensive abortion care
•
•
Woman-centred abortion care
Models of post-abortion care
Current options for the termination of early pregnancies
•
•
Manual vacuum aspiration (MVA)
Medical abortion (medication abortion): with Mifepristone and Misoprostol; with
Methotrexate and Misoprostol; with Misoprostol alone
19
REFERENCES
Asamblea Legislativa del Distrito Federal (2000). Decreto por el que se reforman y
adicionan diversas disposiciones del Código Penal y el Código de Procedimientos Penales
para el Distrito Federal. México, DF: Gaceta Oficial del Distrito Federal, décima época, No.
148, 24 de agosto.
Asamblea Legislativa del Distrito Federal (2007). Decreto por el que se reforma el Código
Penal para el Distrito Federal y se adiciona la Ley de Salud para el Distrito Federal. Gaceta
Oficial del Distrito Federal, décima séptima época, No. 70, 26 de abril.
Baird TL, Flinn SK (2001). Manual vacuum aspiration: expanding women’s access to safe
abortion services. Chapel Hill, NC: Ipas.
Becker D, Garcia SG, Larsen U (2002). Knowledge and opinions about abortion law among
Mexican youth. International Family Planning perspectives, 28(4), 205-213.
Berer M (2002). Making abortion a woman’s right worldwide. Reproductive Health Matters,
10 (19), 1-8.
Berer M (2005). Medical Abortion: A fact sheet. Reproductive Health Matters, 13(26), 2024.
Billings D, Moreno C, Ramos C, Gonzalez de León D, Ramírez R, Villaseñor L, Rivera M
(2002). Constructing access to legal abortion services in Mexico City. Reproductive Health
Matters, 10 (19), 86-94.
Billings D, Crane BB, Benson J, Solo J, Fetters T (2007). Scaling-up a public health
innovation: A comparative study of post-abortion care in Bolivia and Mexico. Social Science
& Medicine, 64(11): 2210-2222.
Burke AE, Shields WC (2005). Millennium Development Goals: Slow movement threatens
women’s health in developing countries (Editorial). Contraception, 72, 247-249.
Center for reproductive Rights (2005). The world’s abortion laws (fact sheet). New York:
CRR.
Cook RJ, Dickens BM, Fathalla MF (2003). Reproductive health and human rights:
Integrating medicine, ethics, and law. New York: Oxford University Press.
Consejo Nacional de Población (1999). Ejecución del Programa de Acción de la Conferencia
Internacional sobre la Población y el Desarrollo. México: CONAPO.
Crane BB, Hord-Smith C (2006). Access to safe abortion: An essential strategy for achieving
the Millennium Development Goals to improve maternal health, promote gender equality,
and reduce poverty. Chapel Hill, NC: Ipas / Millennium Project.
Ganatra B, Elul B (2003). Legal but not always safe: three decades of a liberal abortion
policy in India. Gaceta Médica de México, 139 (suppl. 1), 103-108.
20
Glasier A, Metin A, Schnid GP, García C, Van Look P (2006). Sexual and reproductive
health: A matter of life and death. The Lancet (Series on Sexual and Reproductive Health 1),
368, 1595-1607.
Gobierno del Distrito Federal (2005). Sistema Automatizado de Egresos Hospitalarios, 2005.
México: GDF/SSA.
González de León D, Billings D (2001). Attitudes towards abortion among medical trainees
in México City public hospitals. Gender and Development, 9 (2), 87-94.
Grupo de Información en Reproducción Elegida (2005). El derecho a la salud y al aborto
seguro en los compromisos internacionales del gobierno de México (hoja informativa).
México: GIRE.
Grupo de Información en Reproducción Elegida (2007a). La Ciudad de México a la
vanguardia en Latinoamérica (press communication). Mexico: GIRE. Available on line:
www.gire.org
Grupo de Información en Reproducción Elegida (2007b). Leyes del aborto en México (hoja
informativa). México: GIRE.
Guttmacher Institute (1994). Aborto clandestino: una realidad latinoamericana. New York:
GI.
Guttmacher Institute (1999). Sharing responsibility: Women, society & abortion worldwide.
New York: GI.
Haberland N, Measham D, eds. (2002). Responding to Cairo: Case studies of changing
practice in reproductive health and family planning. New York: Population Council.
Instituto Nacional de Estadística, Geografía e Informática (2007). Estadísticas de natalidad.
México: INEGI.
International Consortium for Emergency Contraception (2003). Improving access to
emergency contraception (policy statement). New York: ICEC.
Ipas (2007). In historic vote, Mexico City decriminalizes early abortion (press interview with
Dr. Rafaela Schiavon, Director of Ipas Mexico). Available on line: www.ipas.org
Lamas M, Bissell S (2000). Abortion and politics in Mexico: context is all. Reproductive
Health Matters, 8(16).
Lara D, Goldman L, Firestone M (2004). Opiniones y respuestas. Resultados de una encuesta
de opinión a médicos mexicanos sobre el aborto. México: Population Council.
Langer A (2002). El embarazo no deseado: impacto sobre la salud y la sociedad en América
Latina y el Caribe. Revista Panamericana de Salud Pública/Pan American Journal of Public
Health, 11 (3), 192-204.
21
Langer A (2003a). Salud sexual y reproductiva: dónde estamos a casi una década después de
El Cairo. In: Bronfman M, Denman C (editors, 2003). Salud reproductiva. Temas y debates.
México: Instituto Nacional de Salud Pública.
Langer A (2003b). Embarazo no deseado y aborto inseguro: su impacto sobre la salud en
México. Gaceta Médica de México, 139 (Supplement 1), 3-7.
Lara D, Klein L, García S, Becker D (2003). Abortion in Mexico (fact sheet). Mexico:
Population Council.
López R (1994). El aborto como problema de salud pública. In: Elu MC, Langer A, eds.
Maternidad sin riesgo en México. México: IMES, 85-90.
Raymond EG, Trussell J, Polis CB (2007). Population effect of increased access to
emergency contraceptive pills. A systematic review. Obstetrics and Gynecology, 19(1), 181188.
Schiavon R (2003). Problemas de salud en la adolescencia. In: López P, Rico B, Langer A,
Espinosa G, (editors). Género y política en salud. México: Secretaría de Salud / UNIFEM.
Schiavon R, Polo G, Troncoso E (2007). Aportes para el debate sobre la despenalización del
aborto. México: Ipas.
Secretaría de Salud (2003). La salud de adolescentes en cifras. Salud Pública de México, 45
(suppl. 1), 153-166.
Secretaría de Salud (2004). Estadísticas de mortalidad relacionada con la salud reproductiva:
México 2002. Salud Pública de México, 46 (1), 75-88.
Secretaría de Salud (2005). Salud: México 2004. Informe para la rendición de cuentas.
México: SSA.
Secretaría de Salud (2007). Sistema Nacional de Información en Salud. México: SSA /
SINAIS. www.sinais.salud.gob.mx
Stewart FH, Shields WC, Hwang AC (2004). Cairo goals for reproductive health: Where do
we stand at ten years? (Editorial). Contraception, 70, 1-2.
United Nations General Assembly (1994). Program of Action of the International Conference
on Population and Development. New York: UN.
United Nations General Assembly (1999). Key actions for the future implementation of the
program of action of the ICPD. New York: UN.
United Nations Population Fund (2000). State of world population 2000: Lives together,
worlds apart: men and women in a time of change. New York: UNFPA.
22
United Nations Population Fund (2002). State of world population 2002: People, poverty and
possibilities. New York: UNFPA.
United Nations Population Fund (2004). State of world population 2004: The Cairo
consensus at ten. Population, reproductive health and the global effort to end poverty. New
York: UNFPA.
United Nations Population Fund (2005). State of the world population 2005: The promise of
equality. Gender equality, reproductive health and the Millennium Development Goals. New
York: UNFPA.
Villarreal J (1989). Commentary on unwanted pregnancy, induced abortion, and professional
ethics: a concerned physician’s point of view. International Journal of Gynecology and
Obstetrics, (Supplement 3), 51-45.
Warriner IK (2006). Unsafe abortion: An overview of priorities and needs. In: Warriner IK
(editor 2006). Preventing unsafe abortion and its consequences. Priorities for research and
action. New York: The Allan Guttmacher Institute.
World Health Organization (1992). The prevention and management of unsafe abortion.
Report of a technical working group. Geneva: WHO/MSM.
World Health Organization (1997). Unsafe abortion: Global and regional estimates of
incidence of and mortality due to unsafe abortion with a listing of available country data.
Geneva: WHO/RHT/MSM.
World Health Organization (2004). Unsafe abortion: Global and regional estimates of the
incidence of unsafe abortion and associated mortality in 2000. Geneva: World Health
Organization (written by E. Ahman and I. Shah).
World Health Organization (2005). Levonorgestrel for emergency contraception (fact sheet).
Geneva: WHO.
World Health Organization (2006). Frequently asked clinical questions about medical
abortion. Geneva: WHO
23
SUGGESTED READING
Association of Reproductive Health Professionals (2000). Reproductive health model
curriculum. Second edition. Washington: APGO. Available on line: www.apgo.org
Bearinger LH, Sieving RE, Ferguson J, Sharma V (2007). Global perspectives on the sexual
and reproductive health of adolescents: Patterns, prevention, and potential. The Lancet
(Second Series on Adolescent Health), 369, 1220-1231.
Berer M (2002). Making abortions safe: a matter of good public health policy and practice.
Reproductive Health Matters, 10 (19), 31-44.
Baird DT (2000). Mode of action of medical methods of abortion. Journal of the American
Medical Women’s Association, 55 (3), supplement.
Crane BB, Hord-Smith C (2006). Access to safe abortion: An essential strategy for achieving
the Millennium Development Goals to improve maternal health, promote gender equality,
and reduce poverty. Chapel Hill, NC: Ipas / Millennium Project. Available on line:
www.ipas.org
Cook RJ, Dickens BM, Fathalla M (2003). Reproductive health and human rights. Integrating
medicine, ethics, and law. New York: Oxford University Press Inc.
Davis V, Free MJ (2002). Using technology to reduce maternal mortality in low–resource
settings: challenges and opportunities. Journal of the American Medical Women’s
Association, 57 (3), 149-153.
De Bruyn M (2002). Human rights, unwanted pregnancy & abortion related care: Reference
information and illustrative cases. Chapel Hill, NC: Ipas. Available on line: www.ipas.org
De Bruyn M (2003). Violence, pregnancy and abortion. Issues of women’s rights and public
health. A review of worldwide data and resources for action. Chapel Hill, NC: Ipas.
Available on line: www.ipas.org
Dixon D (2001). Preventing unsafe abortion: A call to action for health providers. Chapel
Hill, NC: Ipas. Available on line: www.ipas.org
Espey E, Ogbun T, Chavez A, Qualls C, Leyba M (2005). Abortion education in medical
schools: A national survey. American Journal of Obstetrics and Gynaecology, 192, 640-643.
Gogna M, Romero M, Ramos S, Petracci M, Szulik D (2002). Abortion in a restrictive legal
context: the views of obstetrician-gynaecologists in Buenos Aires, Argentina. Reproductive
Health Matters, 10 (19), 128-137.
Guttmacher Institute (1998). Into a new world: Young women’s sexual and reproductive
lives. New York: AGI.
Haslegrave M, Olatunbosun O (2003). Incorporating sexual and reproductive health care in
the medical curriculum in developing countries. Reproductive Health Matters, 11 (21), 49-58.
24
Hessini L (2004). Advancing reproductive health as a human right: progress toward safe
abortion care in selected Asian countries since ICPD. Chapel Hill, NC: Ipas. Available on
line: www.ipas.org
Hord C, Baird T, Billings D (1999). Advancing the role of midlevel providers in abortion and
post-abortion care. Issues in Abortion Care 6. Chapel Hill, NC: Ipas.
International Planned Parenthood Federation (2006). Death and denial: Unsafe abortion and
poverty. London: IPPF. Available on line: www.ippf.org
Joffe C (2006). Morality and the abortion provider (Editorial). Contraception, 74, 1-2.
Available on line: www.arhp.org/editorials
Maine D, Chavkin W (2002). Maternal mortality: global similarities and differences. Journal
of the American Mediacal Women’s Association, 57 (3), 127-130.
Medical Students for Choice/American Medical Women’s Association. A medical student’s
guide to improving reproductive health curricula. Alexandria VA: MSC/AMWA. Available
on line: www.ms4c.org
Radhakrishna A, Gringle RE, Greenslade FC (1997). Identifying the intersection:
adolescents, unwanted pregnancy, HIV / AIDS and unsafe abortion. Carrboro, NC: Ipas.
Available on line: www.ipas.org
Rodríguez P, Shields WC (2005). Religion and medicine (Editorial). Contraception, 71, 302303. Available on line: www.arhp.org/editorials
Stewart FH, Wells E, Flinn SK, Weitz TA (2001). Early medical abortion: Issues for
practice. San Francisco: Center for Reproductive Health Research & Policy, University of
California. Available on line: www.reprohealth.ucsf.edu
Teklehaimanot KI (2002). Using the right to life to confront unsafe abortion in Africa.
Reproductive health Matters, 10 (19), 143-150.
United Nations Population Fund (2006). Ending violence against women. New York:
UNFPA. Available on line: www.unfpa.org
Warriner, IK, Shah, IH (2006). Preventing unsafe abortion and its consequences. Priorities
for action. New York: Guttmacher Institute.
Wolf M (2002). Deciding women’s lives are worth saving: Expanding the role of midlevel
professionals. Issues in Abortion Care, number 7. Chapel Hill, NC: Ipas/IHCAR. Available
on line: www.ipas.org
25
RECOMMENDED WEBSITES
Advocates for Youth
http://www.advocatesforyouth.org
American Medical Women’s Association
http://www.amwa-doc.org
Association of Professors of Gynecology and Obstetrics
http://www.apgo.org
Association of Reproductive Health Professionals
http://www.arhp.org
Center for Reproductive Health Research & Policy
http://www.reprohealth.ucsf.edu
Center for Reproductive Rights
http://www.crlp.org
Engender Health
http://www.engenderhealth.org
Family Care International
http://www.familycareintl.org
Family Health International
http://www.fhi.org
Global Health Council
http://www.globalhealth.org
Human Rights Watch
http://www.hrw.org
Ibis Reproductive Health
http://www.ibisreproductivehealth.org
International Center for Research on Women
http://www.icrw.org
International Consortium for Emergency Contraception
http://www.cecinfo.org
International Consortium for Medical Abortion
http://www.medicalabortionconsotium.org
International Federation of Gynecology and Obstetrics
http://www.figo.org
26
International Women’s Health Coalition
http://www.iwhc.org
Ipas (International Projects Assistance Services)
http://www.ipas.org
Latin American and Caribbean Committee for the Defense of Women’s Rights
http://www.cladem.org
Medical Students for Choice
http://www.ms4c.org
Medication Abortion
http://www.medicationabortion.com
National Abortion Federation
http://www.prochoice.org
National Association of Nurse Practitioners in Women’s Health
http://www.npwh.org
Pacific Institute for Women’s Health
http://www.piwh.org
Pan American Health Organization
http://www.paho.org
Planned Parenthood Federation of America
http://www.plannedparenthood.org
Population Action International
http://www.populationaction.org
Population Council
http://www.popcouncil.com
Population Reference Bureau
http://www.prb.org
Reproductive Health Gateway
http://www.rhgateway.org
Reproductive Health Outlook
http://www.rho.org
Safe Motherhood Initiative
http://www.safemotherhood.org
27
The Access Project
http://www.theaccessproject.org
The Alan Guttmacher Institute
http://www.agi-usa.org
United Nations Population Fund, Reproductive Health
http://www.unfpa.org/rh/index.htm
Women’s Global Network for Reproductive Rights
http://www.wgnrr.org
Women’s Health Project
http://www.wits.ac.za/publichealth
Women Watch
http://www.un.org/womenwatch
World Health Organization, Reproductive Health and Research
http://www.who.int/reproductive-health
World Health Organization, Gender and Women’s Health
http://www.who.int/gender/documents/en/
28
CASE STUDIES
Case Study 1: Soledad
Soledad is a single, 27-year old woman. She was born in Cuetzalan, a small rural town in the
state of Puebla, Mexico, and came alone to Mexico City 10 years ago. She did not finish her
primary education. Currently, she and her 6 year-olds daughter live with an aunt in a
suburban, marginalized area. She lost contact with her daughter’s father 4 years ago.
Soledad works as a waitress in a restaurant in downtown Mexico City. She became sexually
active when she was 16 years old and has had three sexual partners. She arrives at your
private practice with a positive pregnancy test that was done at a private lab. She notes that
the pregnancy is the result of rape. About eight weeks ago, she was raped by a man that she
met some time ago, and who invited her to go dancing. Afterwards she refused to have sexual
intercourse, but he used physical violence and verbal threats to force her to have sex. She has
not yet reported the rape to the police. Soledad is very worried, and she asks you to interrupt
the pregnancy.
Students’ Guide
1. What is your legal responsibility to this woman?
2. What type of information would you offer to her regarding the steps required for her
to obtain a legal abortion?
3. What type of information would you offer to her regarding the possible impact of this
pregnancy on her health?
4. What are the ethical principles that apply in this case?
5. What would you do if you were a conscientious objector to abortion?
Case Study: Soledad
Case Study 2: Elena
Elena, a 33 year-old woman, arrives at your private practice in Mexico City. She works as a
primary school teacher and has a good socio-economic status. She has two children.
Elena’s menstrual cycles are regular (every 28 to 30 days), and she has never had any serious
health problems. Her last period came eight weeks ago, and during the last eight months she
and her husband have had sex only sporadically. They have been separated during the last six
months and plan to divorce, but approximately four weeks ago she did have unprotected sex
with him. Yesterday she picked up a pregnancy exam from a nearby lab, indicating a positive
result. Given her situation, she does not want to have another child and is very worried. She
tells you frankly that she wants to have an abortion and asks for your help.
Students’ Guide
1.
2.
3.
4.
What options would you present to this woman?
What type(s) of information would you offer to this woman?
What are the ethical principles that apply in this case?
What would you do if you were a conscientious objector to abortion?
Case Study: Elena
Case Study 3: Bertha
Bertha is 38 years old. She was born in the state of Puebla, but moved to Mexico City two
months ago. She finished her high school education; she married when she was 22 years old,
and currently she is a housewife. She has two healthy adolescent daughters and a good
relationship with her husband. She arrives alone at your office in a public maternal hospital
and reports to you that she is 16 weeks pregnant. Bertha is very sure about the date of her last
menstrual period and says that her pregnancy was planned. She had a miscarriage two years
ago, when she was 15 weeks pregnant. She has never had any serious health problem.
Considering Bertha’s age, you decide to request some specific prenatal diagnostic tests:
maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol.
The lab reports the following results: a high level of alpha-fetoprotein, and normal levels of
human chorionic gonadotropin and unconjugated estriol. Given these results, you request an
ultrasound scanning and its findings confirm your suspicions of anencephaly.
Students’ Guide
1.
2.
3.
4.
How do you classify Bertha’s health conditions?
What are the legal options for Bertha in this case?
What kind of information would you offer to Bertha?
If Bertha decides to terminate her pregnancy, what would be the legal requirements to
do so?
5. What would you do if you were a conscientious objector to abortion?
Tutor’s Notes
Case Study 4: Andrea
Andrea is 16 years old, a high school student. She was born in Mexico City where she lives
with her parents in a middle class neighbourhood.
Andrea has never been pregnant; she began to be sexually active when she was 14 years old,
and has had only one sexual partner. She arrives at the Ministry of Health clinic near
Zihuatanejo, Guerrero, accompanied by her partner, where you work as a physician doing
your social service. The young woman and her boyfriend are spending some of their summer
vacation here on the beach with their friends. They tell you that they had unprotected sex the
night before. Usually, the couple uses condoms correctly on a regular basis, but the night
before they were on the beach and they forgot to bring the condoms. The young woman tells
you that she has heard her friends talking about some type of pills that can be taken the day
after having unprotected sex. The couple would like you to tell them more about this kind of
medication.
Students’ Guide
1. What is your legal responsibility to this couple?
2. Given her age, do you think that the young woman can make her own decisions about
contraception and give her informed consent?
3. What information would you offer to the couple?
4. What are the ethical principles that apply in this case?
5. What would you do if this couple returns with the same problem in two weeks?
Tutor’s Notes
Case Studies – Tutor’s Notes
These case studies were developed by Jennifer Unger, Deyanira González de León, and
Deborah L. Billings.
The case studies were designed according to the perspective of problem-base learning in
order to help students to develop their analytical and problem-solving skills, as well as to
allow them to put the concepts presented during the workshop into use. The cases include
details of hypothetical patients’ situations that students may face in practice.
Each one of the cases provides students with the case scenario and a series of questions. The
exercise must be carried out with students working together in small groups.
The results of each one of the small groups will be shared and discussed in a general session
conducted by one or more tutors. Students have to play an active role in presenting and
discussing the cases, so tutors must intervene as little as possible in order to allow them to
take the leading role in the general session. However, tutors must be sure to motivate all
students to share their views and queries on the cases presented.
Tutors should guide students to focus the discussion on the most relevant elements of the
cases. Please keep in mind that the main goal of the session is to help students understand the
underlying social and cultural issues involved in each case.
Tutor’s Notes

UNWANTED PREGNANCY AND UNSAFE ABORTION

Transcription

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