Transitar el laberinto: trayectorias de cuidado entre mujeres que deciden abortar en el Ecuador / Traversing the labyrinth: Trajectories of care among women who decide to have an abortion in Ecuador

El acercamiento a las experiencias de mujeres que decidieron abortar en Ecuador, a partir de sus relatos biográficos, nos permitió comprender las trayectorias de cuidado por las que debieron transitar. Se desarrolló una metodología cualitativa, con enfoque biográfico narrativo, con la participación de 19 mujeres mayores de edad, residentes en diferentes provincias del Ecuador, un territorio con medidas restrictivas sancionatorias legales y morales alrededor del aborto. Encontramos que los contextos socio biográficos de las participantes se caracterizaron por la presencia de múltiples formas de violencia; sus decisiones en salud sexual y reproductiva constituyen una carga moral que las responsabiliza y les impone una serie de mandatos sociales en medio de grandes limitaciones y restricciones; sus trayectorias y búsqueda de cuidados se caracterizan por un Estado ausente como garante, lo que las lleva resguardarse en sí mismas o en algunas mujeres que construyen redes de soporte por fuera de la institucionalidad formal de protección, transitando rutas diversas donde el descuido y las violencia vuelven a ser predominantes. Estos hallazgos derivan en una serie de discusiones en torno a la vida de las participantes, como el tránsito por un laberinto donde las violencias que experimentan crean encrucijadas y rodeos difíciles de evadir y superar; por otra parte, la maternidad se presenta como una propuesta que enfrenta a las mujeres a tensiones permanentes, donde la decisión de abortar es una postergación de aquella más que su negación, tensiones como las mutaciones de la religiosidad, que no solo dan soporte del ideal femenino y de su rol básico de la maternidad, sino también un elemento de soporte para la decisión. Se concluye con la propuesta del Cuidado Sororo de la Salud Sexual y Reproductiva (SSR), inspirada en las teorías feministas y en los aportes de las organizaciones sociales que defienden los derechos sexuales y reproductivos de las mujeres. Dicha propuesta se deriva de las narrativas de las mujeres y se centra en su autonomía para reivindicar la importancia del cuidado desde una perspectiva más humanizada, respetuosa, solidaria y empática. (AU)

The approach to the experiences of women who decided to have an abortion in Ecuador allowed us to understand the care trajectories they had to go through, based on their biographical accounts. A qualitative methodology was used with a biographical narrative approach and the participation of 19 women of legal age, residents of different provinces of Ecuador, a territory with restrictive legal and moral sanctioning measures around abortion. We found that the socio-biographical contexts of the participants were characterized by the presence of multiple forms of violence; their sexual and reproductive health decisions constitute a moral burden that makes them responsible and impose a series of social mandates in the midst of great limitations and restrictions; their trajectories and search for care are characterized by an absent State as guarantor, which leads them to take refuge in themselves or in some women who build support networks outside the formal institutionality of protection, going through diverse routes where neglect and violence are once again predominant. These findings lead to a series of discussions about the life of the participants as the transit through a labyrinth, where the violence they experience creates crossroads and detours difficult to avoid and overcome; motherhood as a proposal that confronts women with permanent tensions, where the decision to abort is a postponement of it, rather than its denial and the mutations of religiosity that not only support the feminine ideal and its basic role of motherhood, but also an element of support for the decision. It concludes with the proposal of Sororo Care of Sexual and Reproductive Care (SRH), inspired by feminist theories and the contributions of social organizations that defend women's sexual and reproductive rights. This proposal is derived from women's narratives and focuses on their autonomy, to vindicate the importance of care from a more humanized, respectful, supportive and empathetic perspective. (AU)

Caring for Patients' Reproductive Healthcare During the COVID-19 Pandemic.

Abortion care requires supporting a patient through the decision to end a pregnancy, the process of having an abortion, and how to care for themselves after the decision is made. This process is nuanced in the best of times and has been exacerbated by the COVID-19 pandemic. This article provides a foundation for clergy and mental health providers on some of the issues that patients will experience accessing abortion care, specifically during the pandemic.

Termination of pregnancy for fetal anomalies: Parents' preferences for psychosocial care.

OBJECTIVE: To investigate, from the perspective of women and partners, at what stage of a termination of pregnancy (TOP) for fetal anomalies psychosocial care (PSC) is most meaningful, what topics should be discussed, and who should provide PSC. METHOD: A cross-sectional retrospective cohort study was conducted with a consecutive series of 76 women and 36 partners, who completed a semi-structured online questionnaire. RESULTS: Overall, women expressed a greater need for PSC than their partners. Parents expressed a preference for receiving support from a maternal-fetal medicine specialist to help them understand the severity and consequences of the anomalies found and to counsel them in their decision regarding termination. Parents showed a preference for support from mental healthcare providers to help with their emotional responses. Forty-one percent of the women visited a psychosocial professional outside of the hospital after the TOP, indicating a clear need for a well-organised aftercare. CONCLUSION: Different disciplines should work together in a complementary way during the diagnosis, decision making, TOP, and aftercare stages. Parents' need for PSC should be discussed at the beginning of the process. During aftercare, attention should be paid to grief counselling, acknowledgement of the lost baby's existence, and possible future pregnancies.

The patient perspective: perceptions of the quality of the abortion experience.

PURPOSE OF REVIEW: Abortion services are essential in sexual and reproductive health and should be held to the same standards as other health services. Patient (or person)-centeredness is a key dimension of healthcare quality that incorporates the perspectives of patients in care provision. The purpose of this review is to summarize studies published in the last year examining women's experiences with abortion care and to describe facilitators and barriers to person-centered care. RECENT FINDINGS: Considering person-centeredness in abortion care using dimensions of dignity, autonomy, privacy, communication, social support, supportive care and health facility environment allows for critical evaluation of data describing women's experiences with abortion and postabortion services. Review of the available literature shed light on the impact of social stigma, health policy and abortion restrictions on women's abortion experiences. SUMMARY: Considering multiple domains and varied settings, current data suggest abortion services worldwide generally fail to provide person-centered care. Institutions and providers may be limited in their ability to provide patient-centered abortion care because of deeply embedded social stigma, institutional regulations and legal restrictions.

Evaluating the impact of a quality management intervention on post-abortion contraceptive uptake in private sector clinics in western Kenya: a pre- and post-intervention study.

BACKGROUND: Integration of family planning counselling and method provision into safe abortion services is a key component of quality abortion care. Numerous barriers to post-abortion family planning (PAFP) uptake exist. This study aimed to evaluate the effect of a quality management intervention for providers on PAFP uptake. METHODS: We conducted a pre- and post-intervention study between November 2015 and July 2016 in nine private clinics in Western Kenya. We collected baseline and post-intervention data using in-person interviews on the day of procedure, and follow-up telephone interviews to measure contraceptive uptake in the 2 weeks following abortion. We also conducted semi-structured interviews with providers. The intervention comprised a 1-day orientation, a counselling job-aide, and enhanced supervision visits. The primary outcome was the proportion of clients receiving any method of PAFP (excluding condoms) within 14 days of obtaining an abortion. Secondary outcomes were the proportion of clients receiving PAFP counselling, and the proportion of clients receiving long-acting reversible contraception (LARC) within 14 days of the service. We used chi-squared tests and multivariate logistic regression to determine whether there were significant differences between baseline and post-intervention, adjusting for potential confounding factors and clustering at the clinic level. RESULTS: Interviews were completed with 769 women, and 54% (414 women) completed a follow-up telephone interview. Reported quality of counselling and satisfaction with services increased between baseline and post-intervention. Same-day uptake of PAFP was higher at post-intervention compared to baseline (aOR 1.94, p < 0.001), as was same-day uptake of LARC (aOR 1.72, p < 0.001). There was no overall increase in uptake of PAFP 2 weeks following abortion. Providers reported mixed opinions about the effectiveness of the intervention but most reported that the supervision visits helped them improve the quality of their services. CONCLUSIONS: A quality management intervention was successful in improving the quality of PAFP counselling and provision. Uptake of same-day PAFP, including LARC, increased, but there was no increase in overall uptake of PAFP 2 weeks after the abortion.

Medical management of abortion

Medical abortion care encompasses the management of various clinical conditions including spontaneous and induced abortion (both viable and non-viable pregnancies), incomplete abortion and intrauterine fetal demise, as well as post-abortion contraception. Medical management of abortion generally involves either a combination regimen of mifepristone and misoprostol or a misoprostol-only regimen. Medical abortion care plays a crucial role in providing access to safe, effective and acceptable abortion care. In both high- and low-resource settings, the use of medical methods of abortion have contributed to task shifting and sharing and more efficient use of resources. Moreover, many interventions in medical abortion care, particularly those in early pregnancy, can now be provided at the primary-care level and on an outpatient basis, which further increases access to care. Medical abortion care reduces the need for skilled surgical abortion providers and offers a non-invasive and highly acceptable option to pregnant individuals.

A cross-sectional analysis of Kenyan postabortion care services using a nationally representative sample.

OBJECTIVE: To assess quality of postabortion care (PAC) offered by Kenyan healthcare facilities. METHODS: A cross-sectional survey was conducted using data from the Incidence and Magnitude of Unsafe Abortions study, conducted among 326 PAC-providing healthcare facilities throughout Kenya from March 13 to June 30, 2012. Descriptive results with weighted proportions and an ordered probit model were used. RESULTS: Overall, 408 (41.8%) first-trimester PAC cases were treated using appropriate technology versus 826 (82.6%) second-trimester cases. Private healthcare facilities lagged behind public healthcare facilities on the use of appropriate technology: 264 (47.5%) public and 144 (33.1%) private facilities used such technology for first-trimester abortion, and 664 (89.6%) public versus 162 (68.8%) private for second-trimester abortions). Most healthcare facilities (251, 70.7%) had at least one provider trained in PAC. A total of 273 (80.7%) healthcare facilities reported offering contraception to all PAC patients, mainly short-acting methods. Delivery of PAC services depended on the availability of separate evacuation room (public level 2-3: odds ratio [OR] 22.93; public level 4-6: OR 77.14), and the number of family planning methods offered within the facility (public level 2-3: OR 1.38; public level 4-6 OR 1.57; private level 2-3: OR 2.27; private level 4-5: 4.89). CONCLUSION: Effective monitoring of PAC services, particularly among private healthcare facilities, might improve overall quality of services.

Integrating postabortion care, menstrual regulation and family planning services in Bangladesh: a pre-post evaluation.

BACKGROUND: In Bangladesh, abortion is restricted except to save the life of a woman, but menstrual regulation is allowed to induce menstruation and return to non-pregnancy after a missed period. MR services are typically provided through the Directorate General of Family Planning, while postabortion care services for incomplete abortion are provided by facilities under the Directorate General of Health Services. The bifurcated health system results in reduced quality of care, particularly for postabortion care patients whose procedures are often performed using sub-optimal uterine evacuation technology and typically do not receive postabortion contraceptive services. This study evaluated the success of a pilot project that aimed to integrate menstrual regulation, postabortion care and family planning services across six Directorate General of Health Services and Directorate General of Family Planning facilities by training providers on woman-centered abortion care and adding family planning services at sites offering postabortion care. METHODS: A pre-post evaluation was conducted in the six large intervention facilities. Structured client exit interviews were administered to all uterine evacuation clients presenting in the 2-week data collection period for each facility at baseline (n = 105; December 2011-January 2012) and endline (n = 107; February-March 2013). Primary outcomes included service integration indicators such as provision of menstrual regulation, postabortion care and family planning services in both facility types, and quality of care indicators such as provision of pain management, provider communication and women's satisfaction with the services received. Outcomes were compared between baseline and endline for Directorate General of Family Planning and Directorate General of Health Services facilities, and chi-square tests and t-tests were used to test for differences between baseline and endline. RESULTS: At the end of the project there was an increase in menstrual regulation service provision in Directorate General of Health Services facilities, from none at baseline to 44.1% of uterine evacuation services at endline (p < 0.001). The proportion of women accepting a postabortion contraceptive method increased from 14.3% at baseline to 69.2% at endline in Directorate General of Health Services facilities (p = 0.006). Provider communication and women's rating of the care they received increased significantly in both Directorate General of Health Services and Directorate General of Family Planning facilities. CONCLUSIONS: Integration of menstrual regulation, postabortion care and family planning services is feasible in Bangladesh over a relatively short period of time. The intervention's focus on woman-centered abortion care also improved quality of care. This model can be scaled up through the public health system to ensure women's access to safe uterine evacuation services across all facility types in Bangladesh.

Cohort Records Study of 19,655 Women Who Received Postabortion Care in a Tertiary Hospital 2010-2013 in China: What Trends Can Be Observed?

The retrospective cohort epidemiological study was to investigate the characteristics of women who underwent induced abortion. Data were retrospectively collected from women who underwent induced abortions (n = 19,655) at the Xiamen Maternity and Child Health Care Hospital (2010-2013). The characteristics of women who underwent induced abortions included mean age, unmarried status, no previous deliveries, first pregnancy, ≥2 abortions including the current one, and a history of caesarian section. From 2010 to 2013, mean age increased and declines were observed in the ratio of induced abortions to live births, the proportion of induced abortions among women of 15-24 years, those who were unmarried, had their first pregnancy, or had no history of delivery. However, the rates of induced abortions increased among women who were lactating, had a history of caesarian section, or had an interpregnancy interval of <6 months. This snapshot of induced abortions in China might suggest that the numbers are increasing but the ratio to live births has fallen. Methods should be improved to prevent unwanted pregnancies and reduce the number of induced abortions in China. It must be emphasized that differences in mentality and culture between countries might limit the representativeness of these results.

[Quality assessment of treatment associated with abortion: a prototype questionnaire for health services users]. / Avaliação da qualidade da atenção ao aborto: protótipo de questionário para usuárias de serviços de saúde.

Little research in Brazil has focused on the quality of care following unsafe abortion. This article presents the first step in the development of an instrument to assess hospital care provided by the Brazilian Unified National Health System in three cities of Brazil. Along with related criteria, four key dimensions of care were defined: wellcome and guidance, technical quality of care, continuity of care, and supplies and physical environment. The authors performed a cross-cultural adaptation of a set of items proposed by the World Health Organization. Following an assessment of the dimensions and criteria not captured by this set, the researchers decided to adapt questions from related studies and to add others developed by the research team itself. The questionnaire was pretested in 52 patients from three cities to assess the acceptance, understanding, and time of application and to make final adjustments. The instrument totaled 55 items organized according to different stages of care. Its expanded use depends on subsequent psychometric assessments, currently underway.

Unusual synechia at hysterosalpingography: intrauterine fallopian tube after surgical abortion.

We report a patient who had uterine perforation with incarceration of the fallopian tube after surgical abortion. The diagnosis was made during hysteroscopy, realized after hysterosalpingography, and treated by laparoscopy.

Septic shock due to Klebsiella pneumoniae after medical abortion with misoprostol-only regimen.

OBJECTIVE: To report a case of a healthy woman who was admitted to the hospital with septic shock caused by a common uropathogen after self-administration of misoprostol for pregnancy termination. DESIGN: Case report. SETTING: Tertiary hospital. PATIENT(S): A 38-year-old woman, gravida 5, para 3, who developed septic shock after medical termination of pregnancy. INTERVENTION(S): Suction curettage, antibiotic treatment, plasma and platelet transfusions. MAIN OUTCOME MEASURE(S): Klebsiella pneumoniae was isolated from blood samples. RESULT: Ten days after her admission she was discharged home in good condition on oral antibiotics. CONCLUSION(S): Severe infections leading to septic shock from common pathogen bacteria can occur after medical termination of pregnancy, independently of the regimen used.

[Effect of Qinggong Zhixue Granule on low immunity mice].

OBJECTIVE: To probe into the pharmacological mechanism of the Chinese medicinal compound Qinggong Zhixue Granule (QGZXG), which has an effect of replenishing qi to activate blood and expelling stasis to stop bleeding, in treating irregular vaginal bleeding after medical abortion. METHODS: Healthy female KM mice and mice with immunodeficiency caused by cytoxan (CTX) were chosen as experimental subjects. The effects of QGZXG on the phagocytization of the mice's monocytes (by using the method of carbon particles expurgation), the delayed type hypersensitivity caused by 2,4-dinitrochlorobenzene (DNCB) and the content of antibody of hemolysin in the mice's serum were observed. RESULTS: (1) QGZXG improved the ability of the liver and spleen of immunodeficient mice to expurgate carbon particles. There was an significant statistical difference between the CTX treated group and the low dose group as well as the high dose group (P < 0.01) and a statistical difference between the CTX treated group and the medium dose group (P < 0.05). (2) QGZXG boosted the cellular immunity of immunodeficient mice. The ear swelling of mice in low, medium and high dose group was more obvious than that in the CTX treated group, and this difference was significant in statistics (P < 0.01). (3) QGZXG raised the content of the antibody of hemolysin in the serum of immunodeficient mice. A statistical difference occurred between the high dose group and the CTX treated group. The low and medium dose also had a tendency of such effect. CONCLUSION: QGZXG can improve both the specific and non-specific immunity of the immunodeficient mice, and therefore accelerate the recovery of the whole body and endometrium after parturition and abortion. In consequence, it leads to shorter duration and less quantity of vaginal bleeding after medical abortion.

Driving forces maps: case studies of a tool for implementing change strategies.

In this article, driving forces mapping, a technique derived from business strategy, is applied to five different client situations: an AIDS support organization, a men's bereavement group, an individual managing grief after abortion following diagnosis of a fetal anomaly, an individual dealing with an HIV diagnosis, and a couple who wanted to increase marital satisfaction. The technique was found to be helpful in goal definition, contracting and developing mutuality, and it was less helpful in introspective work. The article describes the work in ways that allow the reader to understand the process and apply the technique.

[Expert evaluation of temporary disability with regard to pregnancy, abortion and labor]. / Ekspertiza vremennoi netrudosposobnosti v sviazi s beremennost'iu, abortom i rodami.

PIP: Characteristic features of expert evaluation of temporary disability during pregnancy and after abortion and labor adopted in the USSR are outlined. At the earliest stages of pregnancy, women should be assigned to the work not associated with potential exposure to hazardous factors. Women with pregnancy complications should undergo comprehensive examination, preferably in a hospital setting: average length of stay is 20 days for threatened abortion, 21 days for premature labor (28-37-week pregnancy), 16 days for hypertension, 14 days for vomiting or nephropathy, 17 days for anemia, and 14 days for Rhesus-incompatibility. After abortion on demand or abortion for medical indications, a woman should be given a sick leave. The length of sick leave depends upon the pregnancy term (56 days for pregnancy longer than 28 weeks). Women with normal pregnancy and labor can receive a leave for 112 calendar days (56 days during the prelabor period and 56 days for the postpartum period). In the case of labor complications or multiple pregnancy, duration of the postpartum leave should be increased to 70 days. Indications for a 70-day postpartum leave include preeclampsia or eclampsia; cesarean section or vacuum-extraction; profuse hemorrhage during labor requiring blood transfusions; tears of the cervix uteri; postpartum endometritis, thrombophlebitis, septicemia, and suppurative mastitis; history of heart valve disease or congenital heart defects; and premature labor.^ieng

[Endocrinological aspects of rehabilitating women following induced abortion]. / Endokrinologicheskie aspekty reabilitatsii zhenshchin posle iskusstvennogo preryvaniia beremennosti.

PIP: A total of 107 patients were followed up after uncomplicated induced abortion performed prior to 12 weeks gestation. Daily measurements of luteinzing hormone, estrogens, and pregnanediol showed that the menstrual function and the pituitary-ovarian association were recovered within the 1st 3 cycles after the abortion by vacuum aspiration. Pituitary-ovarian disorders persisted in 10.2% of the patients. A set of rehabilitation procedures is proposed on the basis of the findings for women in need of pregnancy termination. (author's)^ieng