UNWANTED PREGNANCY AND UNSAFE ABORTION 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 1 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] Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 2 UNWANTED PREGNANCY AND UNSAFE ABORTION 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion 3 http://www.the-networktufh.org 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 4 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 5 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 6 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 7 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). 1 A general profile of the Mexican population is presented in the Appendix I, Table 7. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 8 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 9 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 10 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 11 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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). Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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 Pregnancy resulting from rape 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 16 Table 6: Circumstances under which Mexican physicians accept abortion * Circumstances % Pregnancy resulting from rape 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.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 Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.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/ Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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? Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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? Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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? Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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? Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org 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. Women and Health Learning Package: Unwanted Pregnancy and Unsafe Abortion http://www.the-networktufh.org Tutor’s Notes
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