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Dr. Raffaela Schiavon

Mexico

Medical termination of pregnancy

in Latin America

J O IN S E S S IO N 0 4

L a t in A m e r ic a , a d v a n c e s a n d p r o b le m s Index

We will describe the history of medical

termination of pregnancy (Medical Abortion:

MA or ToP) in Latin America and Caribbean

(LAC), and reflect on its impact on the

increasing safety of the procedure, in spite

of still legally restricted settings, on the

growing knowledge and access, the impact

on providers and women, and the remaining

persistent challenges and research gaps.

Overview 1.• WHO estimates* that in LAC region, 6,420.000

abortions take place every year, out of a total of 55,700.000 in the world; while only 23.6% are estimated to be safe, 16.7% are unsafe, and nearly 60% fall into the category of less unsafe procedures.• LAC region has the most restrictive legal frameworks in the world: ToP was completely illegal or extremely restricted (to save women s lives, rarely women s health and exceptionally in case of rape) until only 10 years ago. • Nicaragua, El Salvador and the Dominican Republic, together with Vatican City and Malta, are the only

five countries in the world where abortion is still illegal under any circumstances.* http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31794-4.pdf

Overview 2.• In the last decade, first trimester abortions was

legalized on demand in Mexico City, and five years later in Uruguay; other legal changes took place in Argentina, Brazil, Colombia and lately, Chile. However, implementation of these laws is slow, and access to legal services in the public health system is still limited.

• Medical termination of pregnancy is a relatively new technology that has profoundly changed the way health services and health professionals provide and more so, women have access to, an induced abortion (ToP).

Legal framework

Unsafe abortion

Public Health and Human Right issues

Maternal Mortality and MorbidityHospital care of complications Costs •Health System•Out-of-Pocker

•Criminalization•Social inequities

Preventable suffering

ServicesTechniqueAccessQuality

The history of MA

A double serendipity:

ØMisoprostol: undesired side-effectsØMifepristone: pharmacological research

for Cushing Syndrome

plus women´s defense movement

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ØMisoprostol was “discovered” and used by womenin Brazil to induce abortion, and than disseminatedin LAC.

ØDoses and routes were initially empiricalØOther regimens were also used in the region (i.e:methotrexate alone or with misoprostol)ØControlled clinical trials later evaluated- in legal contexts- optimal doses and routes, aswell as efficacy and safety,alone and in combinationwith mifepristone.

M isop ro sto l

b u ca l

Medical Abortion RegimensImpact of MA on provision of abortion

services 1.

MA had a profound positive effect of the

provision of abortion services in LAC region,

both in terms of the formal health system –

public and private legal services, and the

health professionals in charge of them - as

well as in terms of access to de-medicalized

procedures, including women´s self and

home use of MA, legal or “illegal”.

Impact of MA on provision of abortion services 2.

Experiences in Mexico City and Uruguay documentMA impact within legal services:Ødecreasing complexity of health infrastructures

and level of care required (from hospitals to firstlevel clinics)Øsimplified and shorted care time (home intakeof misoprostol)

Øless need for specialized surgical training andlower cadres of health providers (from ObGynto mid-level providers)

Impact of MA on provision of abortion

services 3.

Most of all, MA most probably contributed to

decrease the stigma for physicians (and other

providers) involved in ToP services: it

minimizes professionals´ role and involvement

in the process of abortion, limiting it to

prescription, counseling and monitoring (risk

reduction), and putting the process itself in the

hand of the woman.

0

5 .00 0

1 0.0 0 0

1 5.0 0 0

2 0.0 0 0

2 00 7 2 00 8 2 00 9 2 01 0 2 01 1 2 01 2 2 01 3 2 01 4 2 01 5Me d ica me n to A ME U /A E E U L U I

The Mexican case

Changes in Technologies

The Mexican case

Changes in Technologies

www.ile.salud.cdmx.gob.mx/wp-content/uploads/Interrupcion-Legal-del-Embarazo-Estadisticas-2007-2017-26-de-abril-2018.pdf

76.5%

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Impact of MA on women s access

to abortion

MA in general (and misoprostol in particular) has

signified increased access to induced abortion for

the women, independently of the laws, and of the

implementations of these laws.

Examples of direct provisions of MA have developed

in LAC region:

Øhotlines & online information

Øonline access and sales (WoW)

Ødirect pharmacy access

Øaccompaniment networks

Zamberlin N, Romero M, Ramos S. Reproductive Health20 2012 129:34https://doi.org/10.1186/1742-4755-9-34

Impact of MA on public health

MA widespread knowledge and use is probably

the single most important factor that

contributed to drastically reduce abortion-

related maternal mortality and complications

due to unsafe abortion in LAC, in spite of the

persistent legally restrictive framework in the

region.

Singh S et al, BJOG 123, Issue 9, August 2016

Winikoff et al, Int Persp Sex Reprod Health Vol 38, N 3, Sept 2012

2

3

4

5

6

7

8

9

2 0

2 5

3 0

3 5

4 0

4 5

5 0

5 5

6 0

2 00 0 2 00 2 2 00 4 2 00 6 2 00 8 2 01 0 2 01 2 2 01 4 2 01 6

T as a de M or ta li da d* T as a de A te nc ió n* *

* Mortality Rate x 100,000 women attended due to abortion in public health services** Utilization of Health Services Rate: women attended in public health services per 1,000 women in population

Mortalityrate

Healthcare Rate

The Mexican case

Abortion mortality and morbidity:

National

y = 38.74e-0.054xR² = 0.4739

y = 56,893e-0,031xR² = 0,695

1 0

1 5

2 0

2 5

3 0

3 5

4 0

4 5

5 0

5 5

6 0

2 00 02 00 12 00 22 00 32 00 42 00 52 00 62 00 72 00 82 00 92 01 02 01 12 01 22 01 32 01 42 01 52 01 6

C DM X N a cio n al (s in C D MX )

•Mortality Rate x 100,000 women attended due to abortion in public health services

Unpublished data

Letalidad

Abortion M orta lity rate

National vs. M exico C ity 2000-2016

y = 33,783e-0,095x

R² = 0,474

y = 40,961e-0,015x

R² = 0,3239

1 0

1 5

2 0

2 5

3 0

3 5

4 0

4 5

5 0

2 00 7 2 00 8 2 00 9 2 01 0 2 01 1 2 01 2 2 01 3 2 01 4 2 01 5 2 01 6

C DM X N ac io n al ( sin C D M X )

*/ Rate x 100,000 women 15-44 ys. attended due to ALL abortions in public health services

Unpublished data

Abortion M orta lity rate

National vs. M exico C ity 2007- 2016

Abortion M orta lity rate

M exico C ity 2000-2006 vs. 2007-2016

y = 33,783e-0,095xR² = 0,474

20 0 720 0 820 0 920 10 20 11 20 12 20 13 20 14 20 15 20 16

y = 24,936e0,0595xR² = 0,4216

10

15

20

25

30

35

40

45

50

20 0 0 20 0 1 20 0 2 20 0 3 20 0 4 20 0 5 20 0 6 20 0 7

Tasa por 100 mil

*/ Rate x 100,000 women 15-44 ys. attended due to ALL abortions in public health services

Unpublished data

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Safe and Legal Abortion in Mexico

Ø Abortion safety has improved in all Mexico,

probably due to MA (misoprostol) increased

knowledge and use

Ø Abortion safety has increased even more

significantly in Mexico City due to MA (mife plus

miso) increased use AND to the new legal

framework.

Remaining challenges 1.

There are key gatekeepers that modulate MAability to improve access and safety of abortion

(including ToP) or all women in need:

1) information that is comprehensible and

accessible for all, particularly related toawareness of gestational age, of abortion

completeness and serious complications and

need for referral;

2) access to MA drugs, that includes sanitary

registration in all countries

3) No unnecessary prescription requirements

Remaining challenges 2.

3) good quality and accessible cost of drugs,

both in legal and “illegal” settings

4) up-to-date medical care of any incomplete

abortion complications for all women

5) elimination of their criminalization.

Abortion: not only legal and safe

Quality is usually defined as: 1 ) in te rp e rso n a l q u a lity o r th e h e a lth ca re in te ra ct io n

2 ) te ch n ica l q u a lity, w h e th e r p ro v id e rs m e e t n o rm a t iv e sta n d a rd s fo r

a p p ro p r ia te ca re o r e v id e n ce -b a se d c r ite r ia .

How can it be assessed ?P a t ie n t o r c lie n t e xp e r ie n ce ca n a sse ss

in te rp e rso n a l a n d te ch n ica l q u a lity

c lie n t-ce n te re d n e ss o f c a re

su b je c t iv e e xp e r ie n ce s (p a in co n tro l)

o b je c t iv e e xp e r ie n ce s (w a it in g t im e s)

o b se rv a t io n s o f s ta ff b e h a v io r (d o c to r p ro v id e d in fo rm a t io n ).

Legal framework

Safe and Legal abortion

Public Health and Human Right issues

Maternal Mortality and MorbidityHospital care of complications Costs •Health System•Out-of-Pocker

•Criminalization•Social inequities

Suffering prevented

ServicesTechniqueAccessQuality

Take-home messages

• Medical Abortion (MA) widespread knowledge

and use is probably the single most important

factor that contributed to drastically mitigate

the toll in maternal mortality and

complications due to unsafe abortion in LAC,

in spite of its persistent restrictive laws.

• LAC continues to be the ideal place to build a

research agenda on MA able to nurture

evidence-based policies in the region and in

the whole world.

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Dr. Raffaela Schiavon

schiavonraffaela1@gmail.com

Köszönöm szépen

Muchas gracias

Thanks

Grazie