maternal health/mortality


 

By Nyasa Times Reporter

July 3, 2013

Health ministers from several African countries have vowed to tackle the high number of deaths of women due to unsafe and crude abortion by among other efforts, expanding the provision of safe abortion services.

The commitment was made by ministers of health and gender and senior government officials from Ghana, Liberia, Kenya, Malawi, Mali, Nigeria, Sierra Leone, Tanzania, Uganda and Zambia at a regional meeting of ministers on unsafe abortion and maternal mortality in Africa.

The meeting took place on June 18-19, 2013 in Nairobi, Kenya and Malawi was represented by the then deputy ministers of health and gender Halima Daud, and Agnes Mandevu Chatipwa respectively, Lastone Chikoti, the Reproductive Health Officer in the ministry of health and Elsie Tembo the Second Principal Secretary in the ministry of gender.

“We note that unsafe abortion constitutes between 13-30 percent of the unacceptably high rates of maternal deaths in our countries, and acknowledge that concrete and urgent action must be taken to address this challenge if maternal death and injuries are to be effectively reduced.

“We additionally recognize that unsafe abortion constitutes a violation of women’s human rights, and affirm the link between protection, promotion and realization of women’s human rights to the improvement of sexual and reproductive health outcomes for women and girls in our countries,” reads the communiqué by the minister in part.

The ministers mentioned other countries which are providing safe abortion services and simultaneously reduced their maternal mortality rates.

The ministers thus committed themselves to individually and collectively as countries tackle the problem by examining laws, using evidence to raise awareness on issue.

“We will try to integrate evidence and advocacy on the issue of unsafe abortion into the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) and in other efforts to reduce maternal mortality and morbidity in our respective countries.

“We will also encourage our governments to include the issue of unsafe abortion as part of the issue of maternal health in Cooperation Frameworks with donor countries and development partners,” said the ministers.

According to a 2010 ministry of health study called Abortion in Malawi: Results of a Study of Incidence and Magnitude of Complications of Unsafe Abortion, 70,000 Malawian women have abortions every year, which is 24 abortions for every 1000 women aged 15-44. 31,000 Malawian women are treated for complications of unsafe abortion annually.

Approximately 17 percent of maternal deaths in Malawi are attributable to unsafe abortion, making it one of the primary causes of maternal mortality. 30percent of all admissions in country’s gynecological wards are due to unsafe abortion.

 

http://www.nyasatimes.com/2013/07/03/african-health-ministers-agree-to-tackle-unsafe-abortion/

http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?pagewanted=1&_r=1&hp&pagewanted=all&
By JOSHUA LANG
Published: June 12, 2013 807 Comments

S. arrived alone at a Planned Parenthood in Richmond, Calif., four days before Christmas. As she filled out her paperwork, she looked at the women around her. Nearly all had someone with them; S. wondered if they also felt terrible about themselves or if having someone along made things easier. She began to cry quietly. She kept reminding herself that she felt secure in her decision. “I knew that that was going to be the right-wrong thing to do,” she told me later. “I was ready for it.”

After S. urinated in a cup, she was led into a small room. She texted one of her sisters, “Do you think God would forgive me if I were to murder my unborn child?” It was the first time anyone in her family knew she was pregnant.

“Where are you?” her sister asked. “Are you O.K.?”

“I’m at Planned Parenthood, about to have an abortion.”

“God knows your heart, and I understand that you are not ready,” her sister texted back. “I think God will understand.”

The pregnancy had crept up on S. She was a strong believer in birth control — in high school she was selected to help teach sex education. But having been celibate for months and strapped for cash, she stopped taking the pill. Then an ex-boyfriend came around. For months after, she had only a little spotting, but because her periods are typically light, she didn’t think much of it at first. Then she started to worry. “I used to press on my stomach really hard thinking maybe it would make my period come,” she said.

Around Thanksgiving in 2011, S., then 24, took her first pregnancy test — a home kit from Longs Drugs. S. (her first initial) lived alone, with her dog and her parrot, and it was late at night when she read the results. She stared into space, past the plastic stick. She’d never been pregnant before. “I cried. I was heartbroken.” Her ex had begun a new relationship, and she knew he wouldn’t be there to support her or a child. She was working five part-time jobs to keep herself afloat and still didn’t always have enough money for proper meals. How could she feed a baby? She kept the news to herself and made an appointment at Planned Parenthood.

At the clinic, a counselor comforted S. and asked her why she had come, if anyone had coerced her into making this decision. No, S. explained, she was simply not ready to have a child. The woman asked how far along she thought she might be. S. estimated that she was about three months pregnant.

In the exam room, a technician asked her to lie down. She did an ultrasound, sliding the instrument across S.’s stomach: “Oh . . . it shows here that you are a little further along.” She repeated the exam. S., she estimated, was nearly 20 weeks pregnant, too far along for this Planned Parenthood clinic. S. felt numb: “I was thinking, If it is too late here, it is probably too late other places. . . . And I was like, Oh, my God, now what?”

Planned Parenthood gave S. a packet of information, including two pieces of paper — one green, for adoption, and one yellow, for other abortion providers. S. still wanted to have an abortion. She called a clinic in Oakland and took the first available appointment, just after Christmas. “I was a ticking time bomb, running out of days,” she told me. On the Internet, another of S.’s sisters also found a place called First Resort, which provided abortion counseling. S. didn’t know that First Resort’s president once said that “abortion is never the right answer.” (A spokeswoman for First Resort says that while the organization “takes no public stand on legalized abortion,” it “does not provide abortions or abortion referrals.”)

S. went to First Resort the day before her appointment in Oakland, unsure what to expect. It provided a free ultrasound. The nurse asked S. if she wanted to see the baby and turned the monitor toward her: “Look! Your baby is smiling at you.” S. was shaken, convinced she also saw the baby smiling. The nurse told her that she was at least a week further along than the Planned Parenthood estimate (ultrasound estimates can be off by several days either way). S. sobbed all the way to her car and called the clinic in Oakland, giving it the First Resort estimate. If it was correct, they told her, she would be past its deadline. S. never made it to the Oakland clinic and in a matter of days gave up looking for another clinic that could perform a later procedure. She was out of gas money, hadn’t eaten a decent meal in weeks and resigned herself to the fact that, no matter what she wanted or how it would affect her life, she was going to have a baby.

When Diana Greene Foster, a demographer and an associate professor of obstetrics and gynecology at the University of California, San Francisco, first began studying women who were turned away from abortion clinics, she was struck by how little data there were. A few clinics kept records, but no one had compiled them nationally. And there was no research on how these women fared over time. What, Foster wondered, were the consequences of having to carry an unwanted pregnancy to term? Did it take a higher psychological or economic toll than having an abortion? Or was the reverse true — did the new baby make up for any social or financial difficulties?

“It’s not that the study was so hard to do,” Foster says. But no one had done it before. Since Roe v. Wade was decided in 1973, the debate over abortion has focused primarily on the ramifications of having one. The abortion rights community maintains that abortion is safe, both physically and psychologically — a position most scientists endorse. Those on the anti-abortion side argue that abortion is immoral, can cause a fetus pain and leads to long-lasting negative physical and psychological effects in the women who have the procedure. There is no credible research to support a “post-abortion syndrome,” as a report published by the American Psychological Association in 2008 made clear. Yet the notion has influenced restrictive laws in many states. In Alabama, women who seek an abortion must have an ultrasound and be offered the option to view the image; in South Dakota, women must wait at least 72 hours after a consultation with a doctor before having the procedure. “The unstated assumption of most new abortion restrictions — mandatory ultrasound viewing, waiting periods, mandated state ‘information,’ ” Foster says, “is that women don’t know what they are doing when they try to terminate a pregnancy. Or they can’t make a decision they won’t regret.” Lost in the controversy, however, is the flip side of the question. What, Foster wondered, could the women who did not have the abortions they sought tell us about the women who did?

Most studies on the effects of abortion compare women who have abortions with those who choose to carry their pregnancies to term. It is like comparing people who are divorced with people who stay married, instead of people who get the divorce they want with the people who don’t. Foster saw this as a fundamental flaw. By choosing the right comparison groups — women who obtain abortions just before the gestational deadline versus women who miss that deadline and are turned away — Foster hoped to paint a more accurate picture. Do the physical, psychological and socioeconomic outcomes for these two groups of women differ? Which is safer for them, abortion or childbirth? Which causes more depression and anxiety? “I tried to measure all the ways in which I thought having a baby might make you worse off,” Foster says, “and the ways in which having a baby might make you better off, and the same with having an abortion.”

Foster began by gathering data locally. She ran the study out of her office at U.C.S.F. (I am a student in the U.C. Berkeley-U.C.S.F. Joint Medical Program but did not know Foster before reporting this article.) When the counselors at a nearby abortion clinic received a woman who was too far along to terminate her pregnancy, they called Foster, who would run over and arrange to interview the patient. Given the stigma attached to seeking an abortion later in pregnancy, Foster expected that many women would be reluctant to be part of her study. But four out of five women agreed to participate. “Sometimes, if you tell them that their experience is valuable, that it might help other people in their situation, they will come through,” she says.

Initially, Foster’s study was confined to women whose pregnancies were in a narrow band of time on either side of this particular clinic’s gestational limit — two weeks under or three weeks over. (In California, state law allows an abortion up to what a physician considers viability, but clinics can set their own limits.) Eventually Foster received multiple foundation grants that allowed her to hire additional staff and recruit more subjects. The study, which is ongoing, encompasses 30 clinics from 21 states across the country. The clinics’ gestational limits vary from 10 weeks to the end of the second trimester, with a vast majority falling in the second trimester, typically defined as Weeks 14 to 26 of pregnancy. Women turned away from these “last stop” clinics had no other options within 150 miles. Of some 3,000 women who were asked to participate, 956 have completed a baseline interview and agreed to follow-up interviews every six months. Of those women, 452 were within two weeks of their facility’s cutoff and received an abortion, and 231 missed the cutoff by up to three weeks and were turned away. About 20 percent of the turnaways received an abortion elsewhere. Foster compared the remaining women who carried their pregnancies to term with the near-limit abortion patients. (The 273 other women in the study received a first-trimester abortion and acted as a control group. In the United States, 88 percent of abortions occur in the first 12 weeks, and Foster wanted to be sure that the near-limit abortion patients did not differ significantly in their outcomes from first-trimester abortion patients.) Of the turnaways in Foster’s study who gave birth, 9 percent eventually put their children up for adoption.

There are many reasons women are turned away from an abortion clinic — lack of funds (many insurance plans don’t cover abortion) or obesity (excess weight can make the procedure more complicated) — but most simply arrive too late. Women cite not recognizing their pregnancies, travel and procedure costs, insurance problems and not knowing where to find care as common reasons for delay. These are the women for whom “society has the absolute least sympathy,” Foster acknowledges. While a majority of Americans (53 percent) agree with Roe, many of those who support abortion rights draw the line at later stages of pregnancy. And the law reflects this view. Roe v. Wade guarantees a woman’s right to abortion only up to the “viability” of a fetus, with exceptions for danger to a woman’s health. (Viability varies depending on the medical expert you ask, typically at 23 weeks or more.) But the widespread discomfort with abortions near viability is reflected in recent bans on so-called partial-birth abortions. And many clinics, reacting to state law, set their own gestational limits — often 20 to 22 weeks — making later-term abortion more difficult to find in some states than in others. (In the U.S., 87 percent of counties have no abortion provider at all.)

“Usually the only difference between making it and not is just realizing you are pregnant,” Foster says. “If you’re late, abortion gets much harder to find. All the logistic concerns snowball — money, travel, support.” Women who seek abortions tend, in general, to be less well off than those who don’t, and those seeking second-trimester abortions tend to be “particularly vulnerable,” given the difficulties of finding an appropriate clinic and the higher cost of a later procedure.

As the argument that abortion harms women gains political traction, it is especially critical to look at how turnaways fare. “All past studies of women denied abortion in the United States have been hospital-specific and local, focusing on a brief amount of time, without a control group,” says Roger Rochat, former director of the division of reproductive health at the C.D.C. and a professor of global health and epidemiology at Emory University. “Foster’s turnaway study had a sample across the United States that she followed over a long period of time. It is the best science we have ever done on the subject. ”

Foster’s study does have a precedent — of a sort. In 1957, Czechoslovakia liberalized its abortion laws, while maintaining significant restrictions. Women were required to apply to an abortion commission and could be denied for a host of reasons — if they were past 12 weeks’ gestation, presented “false or insufficient” reasons or had had an abortion too recently. Women denied by the first commission could appeal to regional review boards. Some were denied twice and thus carried their pregnancies to term.

An eminent American psychologist, Henry David, took note of this and embarked on a pioneering study. Between 1961 and 1963, 24,989 Czech women applied for abortions; 638 of the applications were denied after initial application and appeal. With a team of Czech colleagues, David enrolled 220 of the women who were twice denied the abortion they sought and 220 women who never pursued an abortion. For the next 35 years, he followed their children, making regular inquiries and comparisons between the two groups.

The first results examined the children at age 9. David reported that the children born of unwanted pregnancies had significant disadvantages. They were breast-fed for shorter periods; were slightly but consistently overweight; had more instances of acute illness and lower grades in Czech. They seemed less capable in socially demanding situations; they were less popular among peers and teachers and even, if sons, with their own mothers. David concluded that “the child of a woman denied abortion appears to be born into a potentially handicapping situation.” After David published his first round of data, Czechoslovakia made first-trimester abortion available on demand.

In the course of interviewing the mothers about their children, David’s research suggested that whether the mother wanted the child was a significant predictor of the child’s future negative qualities, independent of the effect of the mother’s personality. But he did not have a proper control group to determine if a child’s unwantedness rather than a poor family environment was the source of the trouble. David called it “the Achilles’ heel” of his work.

Foster’s study, by contrast, seeks to isolate the impact of abortion by comparing two groups of very similar women: there are few differences in their educational and socioeconomic backgrounds, and they all sought an abortion. Only 6.6 percent of near-limit patients in the study and 5.6 percent of turnaways finished college (18 percent of adult American women have a bachelor’s degree). One in 10 were on welfare, and approximately 80 percent reported not having enough money to meet basic living needs. A majority, in both groups, already had at least one child.

Foster hoped that their similarities would allow her to answer more fully how abortion affects women’s mental health and emotional states. The A.P.A. report from 2008 concluded that, among adult women with unplanned pregnancies, the “relative risk of mental-health problems is no greater if [women] have a single elective first-trimester abortion than if they delivered the pregnancy.” But it did not go beyond the first trimester. It also noted the “complexity of women and their circumstances” and suggested that further study was needed to “disentangle confounding factors and establish relative risks of abortion compared to its alternatives.”

Foster saw that most abortion studies failed to acknowledge that women seeking abortions are likely to have mixed emotions — regret, anger, happiness, relief. They also often failed to separate the reaction to pregnancy from the reaction to the abortion. She has designed her study to do both, relying on a series of questions and periodic interviews, and initial results, to be published in the fall, show that the emotion that predominates right after an abortion is relief.

When she looked at more objective measures of mental health over time — rates of depression and anxiety — she also found no correlation between having an abortion and increased symptoms. In a working paper based on her study, Foster notes that “women’s depression and anxiety symptoms either remained steady or decreased over the two-year period after receiving an abortion,” and that in fact, “initial and subsequent levels of depressive symptoms were similar” between those who received an abortion and those who were turned away. Turnaways did, however, suffer from higher levels of anxiety, but six months out, there were no appreciable differences between the two groups.

Where the turnaways had more significant negative outcomes was in their physical health and economic stability. Because new mothers are eligible for government programs, Foster thought that they might have better health over time. But women in the turnaway group suffered more ill effects, including higher rates of hypertension and chronic pelvic pain (though Foster cannot say whether turnaways face greater risk from pregnancy than an average woman). Even “later abortions are significantly safer than childbirth,” she says, “and we see that through lower complications and low incidence of chronic conditions.” (In the National Right to Life’s five-part response to preliminary findings of Foster’s study, which were presented at the American Public Health Association conference last year, the group noted that the ill effects of abortion — future miscarriage, breast cancer, infertility — may become apparent only later. Reputable research does not support such claims.)

Economically, the results are even more striking. Adjusting for any previous differences between the two groups, women denied abortion were three times as likely to end up below the federal poverty line two years later. Having a child is expensive, and many mothers have trouble holding down a job while caring for an infant. Had the turnaways not had access to public assistance for women with newborns, Foster says, they would have experienced greater hardship.

Though S. is not part of Foster’s turnaway study, she is in many ways typical. The same month that she realized she would be having her baby, she was confronted with a host of financial hurdles. She couldn’t move in with her parents because they’d lost their home to foreclosure. By late March, S., exhausted by the pregnancy, had stopped working. Everyone moved into her older sister’s house — a three-bedroom, one-bathroom — where now seven people would be living. There was a family meeting. S. and her baby would take one room; her sister’s daughter would move into the small playroom; the parents would move into the garage. Their parents brought 20 years of belongings with them; S. sold, gave away or threw out everything she could but brought her parrot and her dog.

S., who had never seriously considered adoption, was overwhelmed when Baby S., a healthy girl, was born in May 2012. “It was like, whoa!” S. recalled. “That first night was terrible. I was tired, and she was so hungry, and she had a very loud cry. They don’t tell you how hard it is to nurse your baby. You don’t know how painful it is for something to eat off you, and it’s pulling your skin.” She developed plugged ducts, a condition in which the breasts become painfully engorged with milk.

It’s not unusual for new mothers to have trouble breast feeding, but S. felt overwhelmed in other ways too. “This baby is such a crybaby, and I didn’t know what was going on,” she said. “I felt like she didn’t love me, like maybe she was mad at me.” S. watched bitterly as her family members held a contented Baby S. When S. held her, the baby would begin to cry. It went on like that for weeks. S. sometimes buried her head in her pillow, crying, when the baby cried. “Her tone was negative,” one of S.’s sisters remembers. “She would become angry, saying she wished the baby would shut up.”

S. wanted to be a good mother, so she kept trying to nurse even when she began to develop sores on her breasts. Perhaps because of S.’s difficulty breast-feeding, Baby S. wasn’t gaining weight. Her physician threatened to call social services. Through a federal program — Women, Infants and Children (W.I.C.) — S. found a lactation consultant, who rented her a breast pump and provided her with information on baby formula. Once she stopped breast-feeding, Baby S. began to gain weight.

One day, when Baby S. was nearly 3 months old, S. left her on a pillow at the center of her bed while she went to the bathroom. She was gone for about a minute. When she came back, Baby S. was on the floor, lying face up, whimpering softly. S. and her mother took the baby to the hospital. It turned out nothing was wrong, but like many new parents in that situation, S. was terrified. The thought of losing Baby S. made her sick. From that point on, she no longer buried herself under the pillow when her baby cried. She didn’t let Baby S. out of her sight.

S. now says that Baby S. is the best thing that ever happened to her. “She is more than my best friend, more than the love of my life,” S. told me, glowingly. There were white spit-up stains on her green top. “She is just my whole world.”

When I told Foster S.’s story, she wasn’t surprised that S. ended up bonding with her baby. “That would be consistent with our study,” Foster said. “About 5 percent of the women, after they have had the baby, still wish they hadn’t. And the rest of them adjust.” S.’s experience is also consistent with one of the most striking statistics from Henry David’s Czech study. David found that nine years after being denied abortions, 38 percent of women said they never sought one in the first place.

Some would use these data as justification to further restrict abortion — women rarely regret having a child, even one they thought they didn’t want. But as Katie Watson, a bioethicist at Northwestern University’s Feinberg School of Medicine, points out, we tell ourselves certain stories for a reason. “It’s psychologically in our interest to tell a positive story and move forward,” she says. “It’s wonderfully functional for women who have children to be glad they have them and for women who did not have children to enjoy the opportunities that afforded them.”

Yet it is still true that being denied an abortion resulted in some measurable negative effects for S. She had to give up work and her apartment, and her precarious finances became more precarious. When women seek abortion, you have to ask yourself, Foster says, what is the alternative they are trying to avoid? And how might the life of a turnaway look if she’d had the abortion she sought? “You would need to look at the people who managed to get the abortion and find whether a woman who started out similarly is now in school, building a stable relationship, career or, possibly, that later she had a baby she was ready for.”

Talking with Foster, I was reminded of a woman I met at a “last resort” clinic in New Mexico. J., as I will call her, lived in Kansas with her partner and teenage son. She was 38, one of the long-term unemployed, and struggling to support the child she had. She thought she was too old to become pregnant. When she missed her period, she and her partner drove to a nearby abortion clinic, in Oklahoma, knowing that they couldn’t afford another baby. The clinic estimated that J. was five weeks pregnant, but when they tried to perform an abortion, the procedure was not successful.

Two weeks later, J. and her partner went to a more specialized clinic in Tulsa and were told that J. was actually 23 weeks pregnant, past the clinic’s gestational limit. J. cried in the parking lot. She and her partner drove to Texas, where she missed the gestational limit again. Finally, in New Mexico, J. was able to terminate her pregnancy. A month later J. got a job operating heavy machinery at a manufacturing plant for $15 an hour. She had been applying for the past six months. If she had had the baby, she said, she wouldn’t have been able to take the job. “They wouldn’t have even looked at me.”

Given some of the negative outcomes for turnaways, Foster’s study raises an uncomfortable question: Is abortion a social good? Steven D. Levitt, a University of Chicago economist and co-author of the book “Freakonomics,” famously argued that the passage of Roe v. Wade led directly to a sharp drop in crime during the early ’90s: women who were able to plan their families gave birth to better-adjusted children. The study was widely criticized, but the extent to which it was discussed shows the intensity of the desire to understand abortion’s effect on society. “It’s offensive,” Foster said of the Levitt study. “Let people have abortions or they will breed criminals?” If there is a social good to abortion, Foster prefers to frame that good in terms of positive alternatives. “Maybe women know what is in their own and their family’s best interest,” she said. “They may be making a choice that they believe is better for their physical and mental health and material well-being. And they may be making a decision that they believe is better for their kids — the kids they already have and/or the kids they would like to have when the time is right.”

S.’s baby turned 1 on May 13. She still qualifies for W.I.C. benefits and is still living with her sibling and parents, working two days a week. Of her living arrangement, S. says: “We have had family talks and pretty much come to the conclusion that we are trying to move by the end of the year. But we haven’t really found a place to go.” What will happen when she leaves her sister’s house and she has to support herself and her baby? And what about Baby S.? Will Henry David be right that being “born unwanted” is a predictor of poor development?

There is a chance, of course, that S. and her baby will thrive. How Foster’s turnaway subjects will be affected long-term is still unclear. In assessing how women like S. and J. fare over time, Foster plans to look at several variables: mother-child bonding; whether women who carry unwanted pregnancies to term face lasting economic difficulties; how the children of turnaways compare with children who are born later to women who once had abortions. The purpose of Foster’s study is not to set policy by suggesting new or uniform gestational limits. She notes, however, that there are ways to reduce the number of women seeking abortion at an advanced gestational age by improving access to reproductive health care. But Foster sees herself as a scientist, not an advocate. She did not set out, she says, to disprove that abortion is harmful. “If abortion hurts women,” she says, “I definitely want to know.”

Joshua Lang is a student in the U.C. Berkeley-U.C.S.F. Joint Medical Program.

Editor: Sheila Glaser

A version of this article appeared in print on June 16, 2013, on page MM42 of the Sunday Magazine with the headline: Unintentional Motherhood.

 

by Francine Coeytaux, Public Health Institute (PHI)

and Elisa Wells, Independent Consultant

May 28

 

http://rhrealitycheck.org/article/2013/05/28/why-arent-we-taking-advantage-of-the-potentially-game-changing-drug-misoprostol/  

 

Misoprostol: Have you heard about this small, inexpensive, and most importantly available pill that can save women’s lives? Pragmatic Brazilian women first discovered the potential of misoprostol (or Cytoteca, in their parlance) in the 1980s. According to the label on this widely used peptic ulcer drug, it was not to be taken during pregnancy as it could induce bleeding. Living in a country with very restrictive policies and little access to safe abortion services, they recognized the opportunity to circumvent the system and, by word of mouth, spread the word to other women about this easily obtainable pill that could help them safely end an unwanted pregnancy.

 

Thirty years later, women in countries around the world are beginning to do the same-continuing to spread the word, talking to each other about misoprostol, and trying to get their hands on these pills. The women who are accessing the drug in their communities and taking it by themselves have shown us that there are relatively few health risks involved with misoprostol. What began in Brazil as a natural public health experiment has been validated by rigorous clinical studies conducted by international groups such as the World Health Organization and Gynuity. These studies have shown that the use of misoprostol for abortion is very safe, especially when taken early on in the pregnancy; while not as effective as when taken in combination with mifepristone (another abortion pill), misoprostol taken alone will safely terminate 75 to 90 percent of early pregnancies when taken as directed.

 

Misoprostol has also been proven to have numerous other lifesaving properties, including the ability to prevent and treat postpartum hemorrhage and to induce labor. It is registered in more than 85 countries, usually as an anti-ulcer medication, and is used off-label by clinicians around the world for numerous reproductive health indications. In addition to these clinical uses, we are beginning to see positive public health outcomes from community-based use of misoprostol. In countries where abortion is restricted and women are using misoprostol, we have seen a reduction in infections. And in under-served communities, where women delivering at home are taught to take misoprostol immediately after delivery, postpartum hemorrhage is significantly reduced.

 

If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide-postpartum hemorrhage and unsafe abortion-why have we not taken more advantage of this exciting technology? Given the global attention being paid to meeting the fifth Millennium Development Goal (MDG 5)-that of reducing maternal mortality-it is difficult to fathom why we continue to squander the opportunity misoprostol offers us.

 

The public introduction of any new technology takes time and is not easy; the introduction of emergency contraception is just one of the latest examples. Reproductive health advocates have been working for decades to increase women’s access to this safe, effective, and non-abortifacient technology. While much progress has been made around the world, the recent action of the Obama administration to prevent full over-the-counter access in the United States is a sad illustration of the hurdles women face in accessing reproductive health technologies. The hurdles we face in introducing misoprostol will be even higher given three inherent characteristics:

It has multiple indications, including abortion.

It is only “second best” to existing drugs, competing with a “gold standard.”

It can be used by women without the assistance of a provider.

The Challenge of Multiple Indications

Misoprostol’s greatest clinical asset-the fact that it can be used for numerous reproductive health indications-also poses enormous challenges for implementation. As mentioned, misoprostol has many uses: to both prevent and treat postpartum hemorrhage, to induce labor, to induce abortion, and for post-abortion care. But these multiple indications pose two major challenges for implementation, one political and the other educational.

 

The political challenge lies in overcoming the stigma of abortion. A survey we conducted in 2010 of organizations that were working with misoprostol for postpartum hemorrhage revealed that the second biggest barrier to the introduction of misoprostol was its association with abortion. To quote one respondent who was asked about the challenges and opportunities for its introduction: “Hypersensitivity of misoprostol as an abortifacient [is a barrier]. We see this in clinical providers, government officials, even donors-a disproportionate concern that if misoprostol were to be made available for PPH prevention and treatment, it would be used for abortion. This is a major obstacle in accepting misoprostol for other OB/GYN indications-the abortion stigma.”

 

This political fear is strong, despite the evidence that all indications of misoprostol use are potentially life-saving. And because of this fear, there is a great deal of sidestepping going on as organizations begin to introduce misoprostol at the community level for postpartum hemorrhage while trying to stay clear of its potential use for abortion. “We feel there is tremendous promise for use of misoprostol for [postpartum hemorrhage], so we do not want to jeopardize that application by highlighting the other indications,” said another respondent.

 

The political controversy only exacerbates the programmatic challenge of informing women, their partners, and their health-care providers of the different doses and the proper timing of administration needed for different indications. This is usually facilitated by the registration and labeling of products in appropriate doses for each of misoprostol’s various indications.  

 

But because the vast majority of misoprostol use is currently done “off-label”(it’s being used for an indication other than the one the product is registered for) there is an urgent need to find ways to get women accurate information about how to use it for the different reproductive health purposes. Mobile technologies are beginning to open the information door to some women, but challenges remain. We need to find ways of achieving a broader level of knowledge about correct use, and to help women differentiate between the proper uses for each indication, including abortion.

 

The Challenge of Competing Against a “Gold Standard”

For both indications-abortion and postpartum hemorrhage-misoprostol is the second best option, up against another drug long considered the “gold standard.” For abortion, the most effective medical abortion regimen is mifepristone combined with misoprostol; when used together, the success rate is 93 percent, and when misoprostol is used alone it is 78 percent successful. Thus, where mifepristone is available, such as in the United States, it is the drug of choice.

 

In the case of postpartum hemorrhage, injecting oxytocin is the first line of treatment because, when oxytocin is at full potency, it is more effective than misoprostol. But oxytocin, unlike misoprostol, needs to be refrigerated. As a result, the quality of the drug is easily compromised by exposure to heat-a problem in many Global South countries. Finally, the administration of oxytocin requires that the women deliver in a health-care facility, another “gold standard” established by the medical community.

 

In reality, in many places in the world, we are not meeting these “gold standards,” in spite of decades of trying to do so. Mifepristone is far from universally available, oxytocin stock-outs are common in many places and/or the quality has been compromised, and many women continue to deliver at home, without skilled attendants. In these situations, misoprostol is a very good alternative and even has the advantage of being in pill form, making home use possible and safe.

 

Which brings us to the third challenging characteristic…

 

Women Can Use it Without the Assistance of a Provider

Another survey respondent summed it up nicely: “This is a gender issue. Misoprostol faces this unbelievable barrier because it is a drug for women.”

Therein lies both the greatest opportunity and the greatest challenge.  

 

Misoprostol has the potential to be a game-changer when it comes to maternal health precisely because it can be used safely and effectively by women themselves. The foremost obstacle to achieving MDG 5 is the weak health-care infrastructures of many countries. Misoprostol offers the opportunity to circumvent this obstacle for two of the three principal causes of maternal mortality-postpartum hemorrhage and unsafe abortion. Yet despite growing evidence that women can safely and effectively take misoprostol by themselves, in their homes, for both uses, health-care practitioners are insisting on controlling access to the drug, viewing it as an important addition to their clinical tool kit and a service only they can “provide” instead of as a pill that can be used by women, to help themselves, with little or no assistance from a health-care provider. The failure to relinquish control over the use of misoprostol not only gets in the way of women who are intent on helping themselves, it risks negating the most attractive aspect of this new technology: it’s self-use properties. To quote another respondent to our survey: “Many people are more concerned about what might happen with an intervention (i.e., side effects) than what might happen without an intervention (i.e., maternal death). In this case, women are more likely to be harmed by omission of the intervention than from any danger posed by the intervention itself.”

 

Obviously, as we work to make misoprostol available at the community level we need to acknowledge that it is a powerful drug and that incorrect use can lead to serious consequences-such as uterine rupture during labor induction. While some would use this as an argument for placing restrictions on access, we see this as a call to put accurate and comprehensive information about its safe use into the hands of women.

 

The Way Forward

This week policy makers from around the world are gathering in Malaysia at the third Women Deliver Conference to continue to share ways of reducing maternal mortality. Misoprostol is the single-best opportunity to do just that. But the true potential of this simple and cost-effective technology lies in our willingness to abandon our “provider” frame and put the pills directly in women’s hands. Our challenge is to let women be the shapers and the users of this new technology, not the beneficiaries of what we can provide or what we think they need. Can we stop worrying about women’s “misuse” or “abuse” of misoprostol and show that we truly trust women with their own reproductive health care? Let us remember that it was women who discovered this drug in the first place, specifically to circumvent the weakness of the health-care system. Let us give them back this powerful tool and get out of their way.  Our responsibility is to ensure that women have easy access to the pills and all the knowledge necessary to use them effectively and safely.

 

http://cdn.thejournal.ie/media/2013/04/protection-of-life-during-pregnancy-bill-plp-30-04-13-10-30.pdf

 

Summary and comment, Marge Berer, Reproductive Health Matters

 

This bill manages to allow abortion if a woman’s life is at risk while at the same time protecting the life of the fetus, as required in the Irish Constitution, and at the same time, meeting the conditions laid down by the European Court to legislate clearly on matters arising from previous court cases.

 

The bill allows abortiononly if there is a real and substantial risk to the life of the mother”, for example arising from a physical illness. It says that it is “not necessary for medical practitioners to be of the opinion that the risk to the woman’s life is inevitable or immediate, as this approach insufficiently vindicates the pregnant woman’s right to life”. However, it repeats often that there must be a real and substantial risk to the life of the mother.

 

It also says: “In circumstances where the unborn may be potentially viable outside the womb, doctors must make all efforts to sustain its life after delivery. However, that requirement does not go so far as to oblige a medical practitioner to disregard a real and substantial risk to the life of the woman on the basis that it will result in the death of the unborn.”

 

This appears to take particular account of what happened to Savita Halappanavar, as does the name of the bill.

 

It creates separate conditions for what to do if the woman is threatening suicide, including requiring at least three medical opinions as to whether to allow an abortion on this ground.

 

It makes it clear that legal abortion will be very rare. It allows a woman to appeal a decision against her but makes it extremely difficult to do so.

 

It allows for conscientious objection by individuals but NOT by institutions, which is important, and requires anyone objecting to find another medical professional to refer the woman to.

 

The bureacracy for medical professional control of the decision to allow an abortion is prodigious and possibly even unworkable in practice if a woman’s life is at risk. It potentially requires many medical professionals to be involved to agree an abortion is legal, far more than in any other country. The numbers required to agree to an abortion in case of a threat of suicide appear to say it is hard to believe any woman would actually commit suicide and so she must be examined by many to prove it. It requires any abortion to take place in an obstetric hospital unless it is a medical emergency, which also has specific conditions attached.

 

It makes it very clear that there is no restriction on travelling to another country for an abortion where it is legal. It almost invites women to continue doing so rather than go through this process.

 

Last, and not least, it says that anyone found providing or having an illegal abortion will be subject to punishment of up to 14 years in prison. This is very serious. In my opinion, it is perhaps the worst aspect of this bill from Irish women’s point of view.

 

I believe this bill is extremely successful at doing exactly what the European Court required, to clarify the law when a pregnant woman’s life is at risk, and not a step further. For all the easy criticism we can make of every word of it, it is a gift to the politicians who must have felt (no matter what their personal views) that their political lives were not worth having this fight. They can now say “We did exactly what we were told to do by the European Court” and no more. It will be impossible to oppose it – in those terms – from any point of view. The person/people who drafted it deserve a gold star for compliance with the political necessity involved.

REQUEST FOR SOLIDARITY

 

El Salvador: woman denied life saving medical intervention

 

From: Amnesty International, 15 April 2013

 

http://www.refworld.org/docid/5177d9574.html

 

Beatriz is a 22-year-old woman with a high risk pregnancy who is being denied access to

life saving medical treatment that she urgently needs in El Salvador. Her life is at risk and

she is suffering cruel, inhuman and degrading treatment.

 

Beatriz suffers from health problems that put her life at risk while she is pregnant. She has a history of lupus, a

autoimmune disease in which the body’s immune system attacks the person’s own tissue. She also has other

medical conditions, including kidney disease related to the lupus, and she suffered serious complications during

her previous pregnancy. Beatriz has been diagnosed as being at high risk of pregnancy-related death if she

continues with the pregnancy. Three scans have confirmed that the foetus is anencephalic (lacking a large part of

the brain and skull). Almost all babies with anencephaly die before birth or within a few hours or days after birth.

 

Beatriz has been requesting the recommended medical intervention for over a month. Beatriz wants to live and has

requested an abortion. She is now 4 and a half months pregnant. The medical professionals have not acted in

accordance with her wishes as yet because they feel unable to terminate her pregnancy without the express

assurance from the Salvadoran government that they will not be prosecuted for administering the life saving

treatment she needs. Abortion is criminalised in all circumstances in El Salvador. Under Article No. 133 of the

Penal Code, anyone who provides, or tries to access, abortion services can face lengthy prison sentences.

 

The health professionals responsible for Beatriz’s care have requested permission from the authorities to proceed

with the treatment. As yet no response has been given. Anxiety and suffering increase for Beatriz and her family

every day as concerns for her survival grow. Beatriz has a one year old son. The physical and mental anguish she

is experiencing is contributing to her health condition.

 

Please write immediately in Spanish or your own language:

·           Calling on the authorities to prevent any further denial of treatment and ill-treatment and order the immediate

unfettered access by Beatriz to the life saving treatment she needs, in accordance with her wishes and the

recommendations of medical staff;

·           Urging them to immediately ensure that the health professionals are enabled to provide the treatment necessary

to save Beatriz’s life without the threat, risk or fear of criminal prosecution for doing so in accordance with Beatriz’s

wishes.

·           Urging them to decriminalise abortion in all circumstances and ensure safe and legal access by women and

girls to abortion services necessary to preserve their life or health, or if they are pregnant as a result of rape.

 

PLEASE SEND APPEALS BEFORE 27 MAY 2013 TO:

Minister of Health

Dra. María Isabel Rodríguez

Ministerio de Salud

Dirección postal: Calle Arce No.827,

San Salvador, El Salvador

Fax: +503 2221 0991

Email: mrodriguez@salud.gob.sv

Salutation: Dear Minister/Estimada

Ministra

 

President

Mauricio Funes

Presidente de la República de El

Salvador

Dirección postal: Alameda Dr. Manuel

Enrique Araujo, No. 5500,

San Salvador, El Salvador

Fax +503 2243 6860

Salutation: Dear Mr/ Estimado Sr

 

And copies to:

The Citizens Group for the

Decriminalisation of Therapeutic,

Ethical and Eugenic Abortion

Fax: +503 2226 0356 (say “tono de fax”)

Email: agrupacionporladespenalizacion@gmail.com

 

Also send copies to diplomatic representatives accredited to your country.

The website www.doctorsforchoiceireland.com has just gone live.

Doctors for Choice is an alliance of independent medical professionals and students advocating for comprehensive reproductive health services in Ireland, including the provision of safe and legal abortion for women who chose it.

We believe that women should be supported to make their own decision regarding their sexual and reproductive health and to manage their own fertility, with doctors and nurses providing expert advice and care without judgment, recourse to the law or fear of criminal sanction.

We welcome your support. If you are a doctor or a medical student we will gladly welcome you into membership. You can contact us at doctorsforchoice@gmail.com

Follow them on Twitter and Facebook.

 

e: doctorsforchoice@gmail.com

t:  @doctors4choice

f:   Doctors For Choice Ireland

w:  www.doctorsforchoiceireland.com

http://www.nwci.ie/news/2013/03/22/suicide-in-pregnancy-is-much-rarer-now-thanks-to/

Suicide in Pregnancy is much rarer now ‘thanks to legal abortion’

22 Mar 2013

PeadarOGradyfBDr Peadar O’Grady, Doctors for Choice speaking at seminar “Abortion – The Lives and Health of Women”

Article by Dr Peadar O’Grady, Consultant Child and Adolescent Psychiatrist and member of Doctors for Choice

It is important in discussing the relevance of suicide in the current abortion debate that good medical practice does not come second place to legal arrangements for certification. Maternal mental health matters because of the effects on the mother of mental distress, self-harm and the catastrophe of a completed suicide, but also because of the devastating effects any and all of these can have on any children involved. It is often observed that during pregnancy the incidence of mental health problems and suicidal ideas is high but the risk of completed suicide is lower than usual for comparable women. Even so, because the total of maternal deaths in pregnancy is low, suicide is still one of the top 4 causes of maternal deaths in developed countries.

Groups at higher risk of suicide are those with an unwanted pregnancy, particularly teenage mothers and those on low incomes. In its 2009 report on Maternal Mental Health, the UN’s World Health Organisation (WHO) has highlighted the increased risk of mental health problems in, “unintended pregnancy especially among adolescent women”. The WHO emphasises the further risk from factors such as poverty and lack of support, “in contexts in which there are strong, gendered role restrictions on women including lack of reproductive rights”. ‘Reproductive rights’ for women means the right to decide whether or not they want to have children and, if so, how many and when.  To be vindicated this right requires access to abortion services but also access to good quality obstetric, contraceptive and STD services as well as sex education and information. In his 2011 journal article ‘Suicidal Mothers’, Salvatore Gentile agreed that maternal suicide attempts during pregnancy were increased where there was: “teen age, unplanned pregnancy, unmarried status or recent divorce, unemployment, and difficult access to safe abortion service(s).”

It has also been observed that suicide in pregnancy (and the year after delivery, known as the ‘puerperium’) has become much less common with access to legal abortion services. Professor Robert Kendell summarised this conclusion in the title of his 1991 review in the British Medical Journal: ‘Suicide in pregnancy and the puerperium, much rarer now: thanks to contraception, legal abortion and less punitive attitudes’. It is therefore clear from the WHO and peer-reviewed research that restricting access to abortion, that is, denying women ‘the right to choose’, raises the risk of suicide in pregnancy.

Despite this the opposing notion that choosing an abortion increases the risk of mental health problems, and even suicide, persists. This false conclusion is a misreading (often deliberate and repeated) of the fact that there is often a higher incidence of mental health problems found in people who have had abortions than among those giving birth. However ‘correlation is not causation’. When previous mental health and unwanted pregnancy are taken into account there is no higher rate after an abortion. This makes abortion a ‘risk indicator’ rather than a ‘risk mediator’. As we have seen the likely mediators are unwanted pregnancy and previous mental health problems. It is also well known that, following abortion, mental health problems are more common where the woman has had a negative attitude to abortion before and a negative reaction after, especially when she has been under pressure to have an abortion. The ‘right to choose’ must be without pressure to choose a certain way. Good counselling and practical support before and after this decision is the key to supporting women with unwanted pregnancies.

A similar example of prejudice clouding judgement is the observation that LGBT individuals are at higher risk of mental health problems. One conclusion (by many of the same fundamentalist Christians who populate the anti-choice lobby) is that homosexual or transgendered people should be ‘cured’ from this presumed ‘disease’. The modern psychiatric approach, based on evidence, has been to reject the notion of homosexuality or transgender as diseases by identifying the high incidence of bullying and discrimination as causative factors, or ‘risk mediators’, for mental health problems in this group.

When the allegation, that abortion leads to mental health problems or suicide, is systematically investigated, it is found to be false. In the US the American Psychological Association in 2008 found there was no credible evidence that choosing to have an abortion raised the risk of mental health problems. In the UK the National Collaborating Centre for Mental Health’s review in 2011 reached the same conclusion. Where there the choice of legal abortion services is available there is no increase in suicide (or mental health problems) caused by choosing an abortion with informed consent.

Anti-choice proponents have emphasised that ‘Abortion is not a treatment for suicide’ and ignored the fact that there is no such narrowly-defined thing as a ‘treatment’ for suicide. However, abortion, for those who choose it with proper supports, can be as much a ‘treatment’ for the risk of suicide as blood pressure tablets are a ‘treatment’ for the risk of a heart attack. Both can be preventive, lowering the impact of a relevant risk factor; that is, the distress of an unwanted pregnancy and high blood pressure respectively. The ‘treatment’ for unwanted pregnancy is ‘non-directive counselling’ and the ‘treatment’ for suicidal risk in unwanted pregnancy is ‘risk-reduction’, which includes facilitating the choice of accessing abortion services.

In Ireland, abortion, and even access to information on abortion, is heavily restricted with a criminal sanction, confirming the ‘punitive attitude’ Prof Kendell referred to over 20 years ago. Women are forced to travel, usually alone or with a very restricted support network because of the costs of travel. As a result, in this Irish context, the restriction of access to abortion services is mediated by restrictions on travel. The following groups, whose ability to travel is compromised, are therefore at an increased risk of restricted access to abortion and hence at an increased risk of suicide:

  • Women too sick to travel
  • Adolescents and young women
  • Women with young children
  • Migrant women
  • Women with Disabilities
  • Women with no or low incomes
  • Women whose pregnancy, involves a fatal foetal malformation
  • Women pregnant as the result of rape or child sexual abuse.

The obvious solution to these risk factors is to end the unnecessary, dangerous, and, for the most part, ineffective legal restrictions on abortion services. This is the very successful approach taken in Canada for the last 25 years. Abortion there is subject to healthcare guidelines and not criminal law; just like every other medical service. It is an ongoing absurdity that pregnant women are in some way considered to be exceptions to the usual rules of capacity to make a decision.

It seems likely however that, instead of the Canadian model, emergency legislation in Ireland will deal only with the risk to just some of those whose ability to travel is restricted. The ‘need’ to distinguish between, and medically certify, a risk to the life, as opposed to the health, of pregnant women has put an emphasis on suicide that shows little concern for either crisis pregnancy or suicide.

In summary, in terms of mental health concerns, it is important to stress that unwanted pregnancy and previous trauma or mental health problems are the most relevant risk factors for mental health in pregnancy and that women on low incomes and child and adolescent mothers are at particular risk; the focus should be on care and support. Restriction of access to abortion increases suicide risk and supported choice reduces suicide risk. While there is no medical need for aspecial legal framework for abortion, doctors are perfectly capable of certifying the need to support a woman’s choice of abortion services to reduce her risk of mental health problems and suicide.

Doctors for Choice is an organisation of doctors who wish to promote choice in reproductive healthcare. This means advocating for informed consent as the basis for decision making within the doctor-patient relationship. The NWCI and Doctors for Choice recently organised a Seminar on “Abortion – The Lives and Health of Women”, see presentations from the seminar.

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