The impact of misoprostol availability on abortion safety
Aníbal Faúndes1, Leonel Briozzo2, Gonzalo Vidiella2
1Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP),
Campinas, SP, Brazil, 2Department of Obstetrics and Gynecology, School of Medicine. University of the
Republic. Montevideo, Uruguay.
In developing countries with restricted abortion laws, poor women have a very high rate of
unsafe abortions, which are usually induced by the introduction of sharp objects through
the cervix, causing infection and hemorrhage. Consequently, unsafe abortion is a main
cause of maternal deaths, up to being the first cause in Argentina and Uruguay in recent
years. Misoprostol became available in the 1980s. The label explained that it could not be
used during pregnancy, as it could cause abortion. That information was used by
pharmacy’s clerks, to respond to the demand of women requesting a remedy for delayed
menses. In a few years, from the late 1980’s to the early 1990’s, most abortions in Brazil
were induced with misoprostol. The same was observed in other Latin American countries
the following years. Initially women used excessive dosage and some severe
complications and death (rupture uterus) were reported. In a short time, however, women
learnt to use misoprostol more effectively and safely. Coincidentally, physicians throughout
Latin America noticed a reduction in severe post-abortion complications and during the last
decade several studies confirmed the positive impact of the availability of misoprostol on
safety of abortion, by reducing septic complications, but also severe bleeding. Studies
have shown a temporary association between increases in the sales of Misoprostol and
reduction in the complications of unsafe abortion. Other studies have compared
complications of clandestine abortions induced with misoprostol and by other unsafe
means, showing the much greater safety of abortions induced with misoprostol. An
interesting social intervention was evaluated in Uruguay. Physicians from the largest
maternity hospital that attends one quarter of all deliveries in the country were alarmed by
the maternal deaths resulting from unsafe abortion. Based on the risk reduction strategy, a
special outpatient clinic for women who wanted to abort was open. Women are diagnosed,
offered alternatives to abortion and given the available evidences on the risks of different
form abortion induction, including different doses and routes of misoprostol administration.
Virtually all women who persisted in the intention to abort used misoprostol. Since then, no
maternal deaths have been observed compared with an average of 4 deaths a year during
the preceding three years. In addition, the severity of post-abortion complications have
been dramatically reduced, showing the capacity of misoprostol to save life in
environments where abortion legislation is still very restrictive.
The FIGO initiative - How providers are making a difference
State University of Campinas, Sao Paulo, Brazil
The FIGO Initiative on Prevention of Unsafe abortion was created in 2007, under the leadership of Dorothy Shaw, with the purpose of reducing the burden of unsafe abortion for women, particularly in countries with restrictive abortion laws. Because abortion is often stigmatised, it was a subject mostly ignored by the obstetric and gynecology societies in those countries and the first task of the FIGO initiative was to bring unsafe abortion and its consequences to the fore and propose strategies for prevention. The obstetrics and gynecology societies and an increasing proportion of their members have become involved in the implementation of these strategies. Of particular relevance is that eleven countries with abortion laws that are not totally restrictive where the law has never, or almost never, been applied started to provide safe abortion using the full extent of the law. In addition, four of the five obstetrics and gynecology societies from countries where abortion is not permitted in any circumstance are actively involved in promoting less restrictive abortion laws.
One of the countries participating in the FIGO initiative (Uruguay) succeeded in the approval of a law that now allows abortion without restrictions (with regard to the cause) with the very important participation of the obstetrics and gynecology society and its members. This activity of the Uruguayan colleagues started long before the FIGO initiative was created but FIGO helped to disseminate the application of the new law, facilitating access to safe abortion services in the whole country. The FIGO initiative has also contributed to committing many of our colleagues to become involved in replacing surgical curettage with manual vacum aspiration or misoprostol and in the installation or expansion of post abortion contraception services.
Timid progress in Africa and Latin America
State University of Campinas, Sao Paulo, Brazil
In 2008, when the FIGO Initiative on Prevention of Unsafe Abortion started, twelve countries from Sub Saharan Africa participated and only South Africa and Ethiopia officially offered safe abortion services, although in every country abortion is permitted at least in some circumstances. In 2016, out of the same twelve countries only Tanzania, Cameroon and Gabon do not include the expansion of safe abortion services within the limits of the law in their plan of action. This progress, which may appear as quite impressive, it is still timid because it is still limited to a few larger, usually University, Hospitals. The potential for rapid expansion has not yet occurred with the exception of Ethiopia. The situation in Latin America is even worse. Only Cuba, out of the 17 countries participating in the FIGO Initiative, had liberal abortion law and access to safe legal abortion that is universal. Brazil was the other country where legal abortion after rape was being offered, although limited to a few larger hospitals. Five of these 17 countries have totally restrictive legislations, and abortion is not permitted in any circumstance. Uruguay changed its legislation to a liberal stance and access to safe legal abortion is close to universal. Several other countries are now offering access to safe legal abortion within the limits of the law: for example Brazil, Argentina, Bolivia, Peru and Colombia and the process is in continuous expansion. In addition, proposals for slightly more liberal legislations are being discussed in the five countries where abortion is currently not permitted in any circumstances.