International

1 Journal of Gynecology and Obstetrics (2006) 95, 221–226 L. Briozzo et al.

www.elsevier.com/locate/ijgo

AVERTING MATERNAL DEATH AND DISABILITY

A risk reduction strategy to prevent maternal

deaths associated with unsafe abortion
L. Briozzo a , G. Vidiella a , F. Rodríguez a,⁎, M. Gorgoroso a ,
A. Faúndes b , J.E. Pons a

a
Department of Obstetrics and Gynecology, School of Medicine, University of the Republic, Montevideo, Uruguay
b
Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Campinas, SP, Brazil

Received 10 January 2006; accepted 26 July 2006

KEYWORDS Unsafe Abstract

abortion; Maternal
mortality; Introduction: Worldwide, 13% of maternal deaths are caused by complications of
Risk reduction strategy; spontaneous or induced abortion, 29% in Uruguay and nearly half (48%) in the Pereira
Misoprostol; Rossell Hospital. Purpose: This paper describes a risk reduction strategy for unsafe
Uruguay abortions in Montevideo, Uruguay, where over one-fourth of maternal deaths are
caused by unsafe abortion. Methods: Although abortion is not legal in Uruguay,
women desiring abortions can be counseled before and immediately after to reduce
the risk of injury. Women contemplating abortion were invited to attend a “before-
abortion” and an “after-abortion” visit at a reproductive health polyclinic. At the
“before-abortion” visit, gestational age, condition of the fetus and pathologies were
diagnosed and the risks associated with the use of different abortion methods (based
on the best available scientific evidence) were described. The “after-abortion” visit
allowed for checking for possible complications and offering contraception. Re-
sults: From March 2004 through June 2005, 675 women attended the “before-
abortion” and 495 the “after-abortion” visit, the number increasing over time. Some
women (3.5%) decided not to abort, others were either not pregnant, the fetus/
embryo was dead or the woman had a condition that permitted legal termination of
pregnancy in the hospital (7.5%). Most women, however, aborted. All women used
vaginal misoprostol in the doses recommended in the medical literature. There were
no serious complications (one mild infection and two hemorrhages not requiring

⁎ Corresponding author. Fax: +598 2 7099287.

E-mail address: [email protected] (F. Rodríguez).

0020-7292/$ - see front matter © 2006 International Federation Of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
All rights reserved.
doi:10.1016/j.ijgo.2006.07.013
International
2 Journal of Gynecology and Obstetrics (2006) 95, 221–226 L. Briozzo et al.

transfusion). Conclusion: The strategy is effective in reducing unsafe abortions and

their health consequences.
© 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier
Ireland Ltd. All rights reserved.

1. Introduction tion programs which offered needle exchange to

illicit drug users. This paper describes how the
Objective 5 of the Millenium Development Goals program was implemented and its impact during the
states that maternal mortality should be reduced by first 15 months of its application.
75% between 1990 and 2015. Actions to achieve this
goal must include prevention of abortion-related
maternal deaths; as globally, about 13% of these 2. Methods
deaths are caused by unsafe abortions. It is also a
cause of maternal death that can be relatively 2.1. The strategy
easily reduced with the right interventions.
In the case of Uruguay, the adoption of appro- The strategy of risk reduction aims to minimize the
priate strategies to reduce unsafe abortions is negative effect of certain social behaviors that are
especially important, because in this country the known to be dangerous, but are practiced by a group
proportion of maternal deaths due to abortion of people that are particularly vulnerable to
reached 28.7% during the period 1991–2001 [1]. engaging in such practices. Applying that concept
The situation is even worse in the main public to unsafe abortion, a group of obstetrician/gyne-
maternity hospital in the country, Pereira Rossell cologists founded an NGO called “Iniciativas Sani-
Hospital, where about one-fourth of all deliveries in tarias” and developed the “Sanitary Initiatives
the country are attended. In that hospital, which Against Unsafe Abortion” (SIAUA).
cares for women of low socio-economic status, The planning and organization of the SIAUA
almost half of all maternal deaths (48%) were due to started in July 2001. The group is a “health
abortion. Such a high proportion of maternal deaths professional association” and included members of
resulting from unsafe abortion calls for a response the Faculty of Medicine of the University of the
from the professionals responsible for women's care Republic; the Medical Union, the Society of Obste-
in Uruguay and particularly those from the Pereira trics and Gynecology and the Association of Mid-
Rossell Hospital [2]. wives of Uruguay. It acknowledges induced abortion
Most, if not all, induced abortions in Uruguay are as illegal and, hence, pregnancy termination is not
clandestine, as abortion has been a crime since part of the care provided by the health system.
1938. Uruguayan law declares all voluntary abortion Nevertheless, induced abortion has a “before” and
always illegal. Nevertheless, under extenuating “after” period. The intervention focussed on those
circumstances, judges are authorized not to enforce “before” and “after” periods, recommending that
penalties. In practice, however, even though abor- women planning abortion have at least one medical
tion is not penalized when performed in extenuating visit before and another after the abortion. The
circumstances (to prevent women's death or serious public health clinic in which the program was
morbidity, extreme poverty, extra- or premarital introduced is in the Pereira Rossell Hospital as a
pregnancy, or when pregnancy is the result of rape), subdivision of the Reproductive Health Polyclinic.
only exceptionally are abortions carried out in public All women who were uncertain about the direc-
hospitals. Political changes, such as making abortion tion they wanted to take with their pregnancy and
laws far less restrictive, may reduce abortion- those who had already decided to abort were
related deaths, but such legal reforms take time to referred to the polyclinic. Some women were
become effective. Recently, a sexual and reproduc- referred by colleagues and others are self-referred.
tive health law before the Senate was unable to gain A public information campaign was conducted. At
the necessary votes for passage and, in any case, the the before visit, the pregnancy would be confirmed,
President of the Republic threatened to veto it. women would be informed of possible alternatives
In face of that reality, a new strategy of risk to abortion and of the risks associated with the
reduction was adopted by health professionals different means used in Uruguay to induce abor-
working at the Pereira Rossell Hospital. The strategy tions. The purpose was not to try to influence the
was inspired by the experience of HIV/AIDS preven- women's decisions, but to inform them about the
A risk
223 reduction strategy to prevent maternal deaths associated with unsafe abortion L. Briozzo 223
et al.

means of social support that exist in the country, with information that guarantees that they will be
legal issues and other issues of which many women in a better position to take the best decisions,
may not have been aware. according to their own situations, environment and
All women were also invited to attend an “after values.
visit”, regardless of their final decisions on continu- During the “before visit”, confirmation of preg-
ing their pregnancies. We consider the attendance nancy and of gestational age by ultrasound is carried
at the “after” consultation to be a benchmark of the out, as well as an evaluation of potential maternal or
effectiveness of the “before” consultation. embryonic pathologies. Women may choose to see or
This program was called: “Counseling for a safe not to see the ultrasonic image in real time or in
motherhood—intervention to protect women from photography. When a normal pregnancy is confirmed,
unsafe induced abortion”. While some abortions ample opportunity is given to the many women who
may be averted, those who do abort will do it with would like to have the chance to explain why they
the least possible risk and, in some cases, pathologic must consider the possibility of termination. They are
conditions may be identified that would lead to a informed that the health team is there to help them
legal medical intervention in the hospital. (within the law), not to judge them. Also they are
Another purpose of the “before” visit is to create a informed of all possible options such as giving up the
friendlier environment for women, preventing psy- newborns for adoption, and the possibility of a
chological aggression or denunciation to police pregnancy termination in the hospital if she has any
authorities and stimulating the return for follow-up of the conditions in which termination is permitted
as recommended. The public perception of the under Uruguayan law. There is no pressure to adopt
program has been highly satisfactory and the pre- any of the alternatives, which are presented as
liminary results show this. Inclusion of this at-risk neutrally as possible.
population in the health system generates feelings of All women with normal pregnancies, with no
calmness and safety in the users, because it avoids legal or medical grounds for in-hospital induced
the need to resort to more dangerous methods. abortion, are informed about the risks involved in a
Activities were initiated in the Pereira Rossell clandestine pregnancy termination, according to
Hospital in March 2004, after a relatively long period the gestational age and the means used. The
of preparation that allowed for clear definition of information on risk by method used is based on the
the activities to be included in the intervention and best available evidence and includes unsafe proce-
the instruments to evaluate its results. A few months dures commonly used in Uruguay and in many other
after its initiation, in August of the same year, it developing countries, and the safe procedures used
became an official policy of the Ministry of Health. in the countries where abortion is legal. Medical
An intense information campaign for health abortion with misoprostol is included among the
professionals was implemented, based on bioethical safer procedures. (Mifepristone is not mentioned
principles, legal medicine, medical professionalism because it is completely unavailable in Uruguay.) All
and concepts of sexual and reproductive health with the scientific information and the legal status of
gender perspective. The gynecology clinics of the misoprostol is provided (dose, routes, symptoma-
Medical University of the Republic function in the tology, side effects, mechanism of action, effec-
Pereira Rossell Hospital and the commitment to the tiveness, Moebius syndrome, problems of use at late
program of the senior staff of these clinics has been gestational ages that might cause premature birth,
of enormous importance. etc.). Restrictive laws prevent us from giving
Before starting the program, its organizers information on where to buy the appropriate drugs.
contacted the network of primary health clinics of All women attending the before visit are invited
Montevideo. Health personnel of the clinics were to an “after visit”, for either antenatal or post-
informed about the program and were asked to abortion care, depending on their decision. If a
refer to the Pereira Rossell Hospital any pregnant woman is Rh negative, she is advised to get the anti-
women with an unwanted pregnancy and who could Rh immunization which is provided by the hospital.
be at risk of unsafe abortion. As time passed, women
told others and word of mouth became the main
mechanism of dissemination of information on the 2.3. The “after visit”
existence of the program.
The main condition of this “after visit” is absolute
2.2. The “before visit” confidentiality. The health care team is perfectly
clear that breaking confidentiality would be a
The “before visit” is an opportunity for women to be serious legal and ethical transgression in their
seen as citizens, with rights, who should be provided practice.
A risk
224 reduction strategy to prevent maternal deaths associated with unsafe abortion L. Briozzo 224
et al.

When a woman reports she has had an abortion, the first 3 months to 172 in the third 3-month
the provider avoids either judging or belittling the period. After that, it decreased to 72 and 126 in
problem. Every woman has the support of a multi- the following periods (Fig. 1).
disciplinary team that provides medical, psycholo- Almost 75% of the women who attended the
gical and social care and support. A major “before visit” returned for the “after visit” or were
component of the care is the provision of an resolved at the hospital (495/675 = 73.4%). Among
effective contraceptive method, according to the those for whom there was information 439, or
freely informed decision of each woman. 88.9%, had an induced abortion outside the hospital
If women have an incomplete abortion, we and 3.5% returned for antenatal care. The remain-
provide uterine aspiration (manual or electric). ing 7.5% were not pregnant, had blind ova, a dead
This happens in 30% of the cases who used embryo/fetus or met a requirement for legal
misoprostol. (More recently, as we acquire more abortion in the hospital.
experience with misoprostol, having now cared for The odds of having an induced abortion outside
more than 4000 women, the proportion needing the hospital were not significantly different by
uterine evacuation has declined to 18%.) age, occupation, or number of previous pregnan-
cies or abortions (Table 1). Single women had twice
3. Evaluation the odds of having an abortion compared with
those with a stable partner, but the confidence
limits included 1.00. The only variable highly
From March 2004 through August 2004, that is,
associated with having an abortion was gestational
during the period before it became an official policy
age. Those whose pregnancy was 10–12 weeks had
of the Ministry of Health, care was taken not to
one-third of the odds of aborting compared with
record any information that would allow identifica-
those with a pregnancy of < 10 weeks. Women with
tion of the women, for fear it could be used for
a pregnancy of > 13 weeks had one-tenth the odds
criminal prosecution. It was only after the Ministry
of aborting compared with the reference group
of Health sanctioned the program as official,
(Table 1).
starting in September of 2004 until June 2005,
All of the women who returned for the “after
that we recorded the characteristics of women
visit” and who had had an abortion said it was
participating in the program, their final diagnosis at
carried out it with misoprostol. There was only one
enrollment, gestational age, previous use of contra-
case of mild post-abortion infection and two cases
ceptive methods and obstetric history. The out-
of hemorrhage that did not require blood transfu-
come of the pregnancy and the adoption of
sion. There were no maternal deaths or severe
contraception after abortion were also recorded
complications due to abortion registered among the
for those women who attended the “after visit”.
women who participated in the program, and in
The number of women who attended the before
fact, there was no maternal death caused by
and the after visits was registered from the
abortion complications during the project period
beginning of the program.
in the Pereira Rossell Hospital, compared with an
The associations of the women's characteristics
average of four deaths a year during the preceding
and gestational age with the outcome of pregnancy
3 years. The number of cases of post-abortion sepsis
at the “after visit” were analyzed. The independent
had been 10 per year during 2001 through 2003 and
variables were age, marital status, employment
status, history of previous pregnancies and abor-
tions, and gestational age. The dependent variable
was the outcome of pregnancy at the “after visit”.

4. Results

The total number of women attending the “before

visit” during the 15 months of this evaluation was
675. It increased steadily from 20 during the first
3-month period, March–May 2004, to 59 in June–
August and to 220 in September–November. The
number of women attending the program stabi-
lized, between 149 and 224 during the two
following 3-month periods. The number of “after Figure 1 Number of before and after visits by 3-month
visits” also increased at a similar rate, from 17 in periods.
A risk
225 reduction strategy to prevent maternal deaths associated with unsafe abortion L. Briozzo 225
et al.

Table 1 Odds ratios for abortion among women with Obstetrician/gynecologists, other medical spe-
different characteristics cialists, midwives and other health providers have

Percent (N) Odds 95% confidence an important role in providing services and showing
ratio limits the scientific evidence to policymakers and health

Age authorities. Decriminalization of abortion, however,

< 19 85.7 (72/84) 1.00 falls beyond the control of the health sector and we
20–29 90.3 (215/238) 1.56 0.69–3.48 cannot depend on the health sector to change the
≥ 30 88.4 (152/172) 1.27 0.56–2.90 law.

In Uruguay, the Society of Obstetrics and Gyne-

Marital status
Stable partner 81.7 (85/104) 1.00 cology, the Medical Union, the Medical Faculty of
Unstable partner 89.6 (95/106) 1.93 0.82–4.62 the University of the Republic, have been strong
Single 90.0 (153/169) 2.14 0.99–4.64 supporters of liberalizing abortion law, so far with-
out success. This strategy of risk reduction within
Occupation
the climate of restrictive laws is an intermediate
Housewife 86.5 (141/163) 1.00
Student 89.5 (137/153) 1.34 0.64–2.80 step on the road to approval of a law of sexual and
Employed 88.7 (102/115) 1.22 0.94–1.12 reproductive rights. It has never been the intention
Unemployed 95.5 (21/22) 3.28 0.43–68.59 to modify or delay our objective, which is the
Gravidity
abortion laws, which is immediately accessible to
0 91.2 (166/182) 1.00
1–2 86.5 (160/185) 0.67 0.32–1.38 obstetricians/gynecologists, is the strategy of risk
≥3 89.8 (106/118) 0.85 0.36–2.01 reduction described here, following the example of
similar strategies adopted in HIV control programs
Previous abortions [5,6].
0 88.8 (373/420) 1.00 Our results show a good and improving reception
≥1 89.6 (60/67) 1.08 0.44–2.75
among women vulnerable to complications of
Gestational age unsafe abortion. The increasing number of women
≤ 9 weeks 94.7 (304/321) 1.00 attending the “before visit” suggests that the
10–12 weeks 86.0 (80/93) 0.34 0.15–0.79 friendly and neutral approach adopted by the
≥ 12 weeks 61.4 (35/57) 0.09 0.04 – 0.19 program is successful in reaching the women at
Total differ by characteristic because information is missing risk of an unsafe abortion.
on some clients. The approach presented here reduces abortion
complications by several different mechanisms.
First, we found that some women were not even
there were only two in 2004, none among the
pregnant, which may have made clandestine inter-
women participating in the program.
ventions to evacuate the uterus even more danger-
ous. Second, some women had embryonic or fetal
5. Discussion death; which justified in-hospital emptying of the
uterus. Third, some women met the requirement for
Maternal deaths due to unsafe abortion can be pregnancy termination within the law, which could
drastically reduced by making all abortions safe. In be carried out safely in the public hospital. Fourth,
countries where abortion laws are very restrictive, as after counseling, some women took the free and
is the case in Uruguay and most countries in Latin voluntary decision to continue their pregnancies
America and Africa, the clandestine nature of although it was not intended to influence the
abortion is the underlying cause of their lack of safely. women's decision in any way.
The experience of Romania in the 1960s to the But the most important mechanism of risk
1990s shows the dramatic increase in abortion- reduction appears to be providing scientifically
related mortality and of general maternal mor- based information on the risks associated with
tality when abortion was made illegal in 1965. It different means to induce abortions. It clearly
also shows the even more dramatic drop in prevented the use of dangerous means to induce
abortion-related deaths when the abortion law abortion, such as the introduction of sharp, unster-
became more permissive in 1990 [3]. The experi- ile objects into the pregnant uterus, toxic infusions,
ence in several other countries confirms that etc.
decriminalization of abortion is the most effective It was no surprise that women preferred to use
means to reduce maternal deaths, on the condi- misoprostol to induce their abortions. Although
tion that safe abortion services became available under adequate conditions vacuum aspiration can
[3,4]. be as safe or safer, it was not accessible to the
A risk
226 reduction strategy to prevent maternal deaths associated with unsafe abortion L. Briozzo 226
et al.

clientele of the Pereira Rossell Hospital, most of abortion is legally restricted. It reduces the number
whom had limited economic resources. It was of induced abortions through neutral information
reassuring that, after counseling, none of them and counseling, prevents the risk of unnecessary
used any of the riskier methods, such as the termination procedures, and identifies medical
introduction of sharp objects through the cervix. problems that require attention, as well as cases
Misoprostol could not be and was not prescribed where abortion is within the local laws. Even more
by the attending physicians. Women were only important, it reduces suffering and complications to
provided with the evidence-based information on women and the cost of treatment to the public
misoprostol efficacy, risks, side effects, dosage and health service.
route of administration, the same way as it is done
with all other alternatives for abortion induction. 6. Recommendation
The drug is not approved for induced abortion in
Uruguay, but is sold for the treatment and preven-
We hope that the description of this initiative will
tion of peptic ulcer. It appears that women adopted
stimulate others to adopt or adapt the model to
several different strategies to obtain the drug and
their own situation. The implementation and
frequently several women worked together to
evaluation of this strategy by others will allow us
purchase a bottle of 28 tablets sharing the cost.
to confirm or not whether this model can contribute
It appears that our strategy is achieving its
to achieving objective 5 of the Millennium Devel-
purpose of reducing maternal complications and
opment Goals.
deaths associated with unsafe abortion, through the
several mechanisms described above. As death is a
rare event, it will take time before it will be possible References
to verify a statistically significant reduction in
abortion-associated maternal mortality. The fact [1] Briozzo L, Vidiella G, Vidarte B, Ferreiro G, Cuadro JC, Pons
that the rate of complications was minimal among JE. Induced abortion under unsafe conditions. Health
emergencies and maternal mortality in Uruguay. The current
the women participating in the program and that not
situation and medical initiatives for safe motherhood.
a single death after abortion has occurred since the Revista Medical de Uruguay 2002;18:4–14.
program started is suggestive, but not conclusive. [2] Briozzo L, Rodriguez F, Leon I, Vidiella G, Ferreiro G, Pons JE.
What is perfectly clear, however, is that women Unsafe abortion in Uruguay. Int J Gynecol Obstet 2004;85
who had to go through the difficult and stressful (1):70–3.
[3] Stephenson P, Wagner M, Badea M, Serbanescu F. Commen-
process of deciding to abort and carrying it out, felt
tary: the public health consequences of restricted induced
better cared for and safer, after participating in the abortion. Lessons from Romania. Am J Publ Health 1992;82
program. The exponential increase in consultations (10):1328–31.
indicates to us an increase in confidence in the [4] Tietze C, Pakter J, Berger GS. Mortality with legal abortion in
service. New York City, 1970–1972. J Am Med Assoc 1973;225
(5):507–9.
The program has not been free of external
[5] Hahn RA, Onorato IM, Jones TS, Dougherty J. Prevalence of
criticism. The SIAUA team's strength is based on HIV infection among intravenous drug users in the United
the conviction that the program follows basic States. JAMA 1989;261(18):2677–84.
principles of bioethics and recommendations of [6] Needle RH, Coyle SL, Normand J, Lambert E, Cesari H. HIV
the Latin American Federation of Societies of prevention with drug-using populations—current status and
future prospects: introduction and overview. Public Health
Obstetrics and Gynecology (FLASOG) and from the
Rep 1998;113(Suppl 1):4–17.
Ethical Committee of FIGO [7]. [7] Schenker JG, Cain JM. FIGO Committee for the Ethical
We believe that the strategy of the SIAUA is Aspects of Human Reproduction and Women's Health. Int J
creative, effective and feasible in countries where Gynecol Obstet 1999;64:317–22.