"I wrote the prescription; the patient did the abortion": Preparation of gynecologists for abortion services in Montevideo before and after 2004 Open Access

EtShalom, Yonah (2015)

Permanent URL: https://etd.library.emory.edu/concern/etds/7d278t76x?locale=en
Published

Abstract

Background: Unsafe abortion causes 13% of all maternal deaths worldwide (WHO, 2011b). In Uruguay, prior to 2001, unsafe abortion caused ~30% of maternal mortality (Briozzo et al., 2004). In 2004-2012, nationwide implementation of a harm reduction model coincided with a steady reduction in abortion-related death. In 2012, 1st-trimester abortion was decriminalized with several restrictions. No data were available on the extent of gynecologist training in the abortion, to help determine the degree to which lack of training is a cause of decreased access to safe abortion under the new law.

Purpose: To determine, 18 months after the decriminalization of abortion, the extent to which gynecologists practicing in Montevideo, Uruguay are trained, willing, and confident about providing abortion services - and which kinds of abortions they are trained to provide. We also sought to measure what proportion of gynecologists have provided abortions, and to capture reasons for denial of abortion services.

Methods: Cross-sectional structured survey using convenience/snowball sampling of 40 gynecologists (37 in-person surveys, 3 via online survey) totaling 42% of gynecologists currently practicing in in the public sector in Montevideo (approx. 90). Montevideo was chosen because, as the capital city of Uruguay, its metro area is home to 51% of the country's population.

Primary Results: Of the respondents, 95% were trained in induced abortion and 97.5% in managing incomplete miscarriage; 97.5% had managed incomplete miscarriage surgically and 95% medically (using misoprostol). Eighty-nine percent of abortion providers reported having denied patients abortions due to gestational age based on legal gestational age restrictions.

Conclusions: Based on the very high prevalence of abortion training amongst respondents, it appears that lack of training is not a major barrier to access. Montevideo gynecologists appear to be trained in both medical and surgical techniques of abortion care, whether through abortion training or miscarriage management training/experience. Because 85% of respondents reported having seen an abortion patient with advanced gestational age, barriers to early access to abortion as well as to contraception should be further researched and extending the gestational limit should be explored.

Table of Contents

Abstract…………………………………………………………………….…………………….4

Acknowledgements………………………………………………………..……….…………….6

Chapter 1: Introduction…………………………………………………………….…………….9

Chapter 2: Background and Literature Review…………………………...……….…………….14

Chapter 3: Methodology and Results……………………………………..……….…………….35

Chapter 4: Discussion, Conclusion and Recommendations……………………….…………….65

References………………………………………………………………...……….…………….76

Appendices……………………………………………………………….……….……………..81

A. Survey………………………………………………………...……….……………..81

B. Ley 18.987 (Original Spanish text of law)…………………... ……….…………….86

C. Law 18.987 (Unofficial English translation of law)…………. ……….…………….92

Tables

1. Selected facilities' number of births annually compared to national and citywide totals …………………………………………………………………………………….……..39

2. Demographics of Montevideo gynecologist respondents……………………………….43

3. Characteristics of Montevideo healthcare facilities employing gynecologist survey respondents, based on convenience sampling survey data……………………………...46

4. Frequency and proportion of sample of Montevideo gynecologists reporting experience managing incomplete miscarriages by miscarriage management method………………………………….47

5. Frequency and proportion of sample of Montevideo gynecologists reporting receiving training in abortion, by abortion method……………………………………………………………………49

6. Self-reported level of confidence in ability to safely provide abortion care amongst providers reporting < 10 abortions in prior month (n=17)………………………………56

7. Self-reported level of confidence in ability to safely provide abortion care amongst providers reporting 10 or more abortions in prior month (n=7)……………………...….56

8. Frequency and proportion of sample of Montevideo abortion providers reporting having ever denied abortion services based on legal restrictions on abortion………………………………...59

9. Descriptive statistics on timing intervals between medical school graduation, first abortion training, and first abortion provision, in years…………………………………60

10. . Mean interval between graduating medical school and first abortion training, by abortion provision status and quantity…………………………………………………..61

Figures

1. Barriers to safe abortion (based on WHO, 2011b); emphasis indicates barriers addressed in this project…………………………………………………………………………….12

2. Maternal deaths per 100,000 live births in Uruguay 1991-2014 (based on WHO, 2015b)

……………………………………………………..…………………………………….16

3. Steps in abortion services outlined in IS' harm reduction model………………………..19

4. Steps in abortion services delineated in Law 18.987……………………………………21

5. Photograph, © 2012 Manuela Aldabe.………………………………………………..…23

6. Barriers to safe abortion (based on WHO, 2011b)………………………………………29

7. Distribution of respondents' age by gender (n=40)……………………………………...44

8. Distribution of medical school graduation years for study sample of Montevideo gynecologists (n=39)…………………………………………………………………….45

9. Methods of abortion taught to Montevideo gynecologists, by year of first abortion training (n=36)…...……………………………………………………………………..50

10. Montevideo gynecologists' first abortion training, by year, by motivation for training: Required, recommended by employer, or by personal initiative? (n=36)………………52

11. Montevideo gynecologists' motivation for obtaining first abortion training, by timing of training (n=36)…………………………………………………………………………..52

12. Montevideo gynecologists' abortion provider status, by age group……………………..54

13. Cumulative distribution of Montevideo gynecologists' first abortion provision, by year (n=22)……………………………………………………………………………………54

14. Resources used to guide Montevideo gynecologists' abortion care (n=27)……………..55

15. Reasons for obtaining abortion training among respondents who provided 10 or more abortions in prior month (n=7)………………………………………………………….62

16. Reasons for obtaining abortion training among respondents who provided fewer than 10 abortions in prior month (n=17)…………………………………………………………62

17. Cumulative distribution of medical school graduation, first abortion training, and first abortion provision as a function of time………………………………………………....64

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