"That is when I understood everything": Ideological trajectories of pro-choice female doctors in Mexico.

OBJECTIVES: There is little evidence about how physicians become abortion clinicians or advocates. We describe the ideological trajectories of pro-choice female Mexican doctors and the factors that made them pro-choice. STUDY DESIGN: In this qualitative study, we conducted semistructured interviews with members of the Mexican Network of Female Pro-choice Physicians. Participants came from eight diverse states. We used a feminist epistemology approach and analyzed data using inductive coding as well as a priori categories (becoming pro-choice, trajectories, and training). RESULTS: We included 24 female pro-choice physicians. We identified five intersecting factors that influenced becoming pro-choice: feminism, personal experiences, confrontation with the inequalities and violence that women experience, role models, and routine exposure to abortion care. Participants described three ideological trajectories: being pro-choice before studying medicine, not having a specific opinion, and changing from "pro-life" to "pro-choice." Participants described the absence of abortion training in medical schools, stigmatizing training, and the use of alternative training sources. CONCLUSIONS: In the absence of training on abortion during medical education, a combination of intersecting personal as well as work-related experience may turn doctors into pro-choice abortion clinicians and/or advocates. The findings of this study may be used to develop comprehensive medical curricula as well as strategies directed at doctors who have never received training on abortion care, such as promoting interactions with nonmedical abortion providers, education on inequalities and violence against women, moving beyond public health to a human rights and gender perspective, and exposure to routine safe abortion care. IMPLICATIONS: Mexican female doctors become pro-choice clinicians who provide abortion care and/or advocates in spite of their medical education.

["The system is still precarious". Barriers in access to medical abortion: the experience of accompanying persons in three regions of Mexico]. / "Sigue siendo un sistema precario". Barreras de acceso a abortos clínicos: la experiencia de acompañantes en tres regiones mexicanas.

The study aimed to identify the most frequent barriers in access to abortions in both clandestine and legal clinical contexts, from the perspective of accompanying persons, namely feminist activists who accompanied women that opted for voluntary abortions with medication. We performed 14 semi-structured interviews with accompanying persons in three regions of Mexico: Baja California and Chiapas, both of which are restrictive contexts, and Mexico City, where elective abortion is legal up to 12 weeks' gestational age. We identified four categories in which the social vulnerabilities of women who elect to undergo abortion intersect, namely lack of information, persistence of stigma, influence of the legal framework, and flaws in abortion care, including in clinics for legal termination of pregnancy (in Mexico City), and poor quality of the services provided, with verbal abuse, conscientious objection, and healthcare provider complaints, and finally the antichoice groups and their strategies. In the three regions, access to abortion clinics is still a privilege reserved for women with the necessary economic, logistic, and socials resources for the procedure in these settings. The existence of a program for legal termination of pregnancy (Interrupción Legal de Embarazo) in only one entity reveals the existence of a legal and health inequality. The study's findings on accompanying persons for women undergoing abortions provide backing for the Mexican government to improve access to safe abortions for all women, especially now that the country's Supreme Court has decreed the procedure's decriminalization and its imminent nationwide legalization.

El objetivo de esta investigación fue la identificación de las barreras más recurrentes de acceso a abortos en contextos clínicos (clandestinos o legales), desde la perspectiva de acompañantes, activistas feministas que acompañan a mujeres que optaron por abortos autogestionados con medicamentos. Realizamos 14 entrevistas semiestructuradas con acompañantes en tres regiones mexicanas: Baja California y Chiapas, ambos contextos restrictivos, y la Ciudad de México, donde el aborto por voluntad es legal hasta las 12 semanas. Identificamos cuatro categorías en las cuales se entretejen las vulnerabilidades sociales de las mujeres que deciden abortar, la falta de información, persistencia de estigma, y la influencia del marco legal, los fallos en la atención del aborto, incluso en las clínicas de interrupción legal de embarazo (en la Ciudad de México), y mala calidad de los servicios prestados -maltrato, objeción de conciencia y denuncia de los proveedores de salud-, y, por último, los grupos anti-derechos y sus estrategias. En las tres regiones, el acceso a abortos clínicos sigue siendo un privilegio reservado para las mujeres que cuentan con los recursos económicos, logísticos y sociales indispensables para realizarlo en esos espacios. La existencia de un programa Interrupción Legal de Embarazo en solamente una entidad denota la existencia de una desigualdad jurídica y sanitaria. Los hallazgos de este estudio sobre mujeres acompañantes de abortos aportan elementos para que el Estado mexicano mejore el acceso a abortos seguros para todas las mujeres, sobre todo ahora que la Suprema Corte de la Justicia de la Nación decretó la despenalización, y la legalización inminente en todo el país.

O objetivo dessa pesquisa era identificar as barreiras mais recorrentes no acesso a abortos em contextos medicalizados (clandestinos ou legais), desde o ponto de vista de acompanhantes, ativistas feministas que acompanham mulheres que optaram por abortos autogeridos com medicamentos. Realizamos 14 entrevistas semiestruturadas com acompanhantes em três regiões mexicanas; Baja California e Chiapas, ambas com legislações restritivas, e Cidade de México, onde o aborto voluntário é legal até 12 semanas de gestação. Identificamos quatro categorias nas quais se mesclam as vulnerabilidades sociais das mulheres que decidem abortar, a falta de informação, a persistência de estigma, e a influência do marco legal, as falhas no atendimento para o aborto, inclusive nas clínicas de interrupção legal de gravidez (na Cidade de México), e a baixa qualidade dos serviços prestados - maus tratos, objeção de consciência e denúncia contra os profissionais de saúde -, e, por último, os grupos antiaborto e suas estratégias. Nas três regiões, o acesso a abortos medicalizados continua sendo um privilégio reservado as mulheres que dispõem dos recursos económicos, logísticos e sociais imprescindíveis para realizá-lo naqueles espaços. A presença de um programa de interrupção legal de gravidez (Interrupción Legal de Embarazo) em apenas uma entidade denota a existência de uma desigualdade jurídica e sanitária. Os resultados desse estudo sobre mulheres acompanhantes de abortos trazem elementos para que o Estado mexicano melhore o acesso a abortos seguros para todas as mulheres, sobre tudo agora que a Suprema Corte de Justiça do México decretou a descriminalização e que a legalização é iminente no país como um todo.

Locating Autonomous Abortion Accompanied by Feminist Activists in the Spectrum of Self-Managed Medication Abortion.

Diverse models of self-managed medication abortion exist-ranging from some interaction with medical personnel to completely autonomous abortion. In this commentary, we propose a new classification of self-managed medication abortion and describe the different modalities. We highlight autonomous abortion accompanied by feminist activists, called "acompañantes," as a community- and rights-based strategy that can be a safe alternative to clinical abortion services in clandestine as well as legal settings. To improve access, abortion needs to be decriminalized and governments must acknowledge and facilitate the diversity of safe abortion options so women may choose where, when, how, and with whom to abort.

"Becoming the woman she wishes you to be": A qualitative study exploring the experiences of medication abortion acompañantes in three regions in Mexico.

OBJECTIVES: Acompañantes are activists who accompany women who have medication abortions outside of clinical settings. We describe models of accompaniment across 3 states in Mexico with diverse abortion laws, access, and acompañantes, and describe how acompañantes conceptualize the benefits and challenges of their work. STUDY DESIGN: In this exploratory, qualitative study, we conducted semi-structured interviews with 14 participants about their experiences as acompañantes, in 2 states with restrictive abortion legislation (Baja-California, Chiapas) at the time of research and Mexico City, where abortion is legal upon request in the first trimester. We used a feminist ethnography approach and analyzed data using a priori categories which included perceived benefits of and challenges of the accompaniment model. RESULTS: Participants described similar steps and general characteristics of the accompaniment process regardless of the setting, supporting the concept of an overarching definition of the holistic accompaniment model for these acompañantes. Holistic accompaniment is a horizontal model that involves trusting women, not asking for the reasons for their abortion, preventing criminalization, economic support, respecting autonomy, emotional accompaniment, and being flexible. Participants described perceived advantages, including safety, even in settings otherwise unsafe, such as where women may be stigmatized and / or criminalized. Participants described benefits of autonomous abortion compared to in-clinic medication abortion or surgical abortion, and benefits specifically related to accompaniment, such as the potential to make the abortion a positive experience. CONCLUSIONS: We describe components of a holistic accompaniment model in Mexico which has specific characteristics that may benefit women who opt for out-of-clinic abortion. IMPLICATIONS: We describe specific characteristics of a holistic accompaniment model in Mexico; this description facilitates learning across models and could be used to better understand the similarities and differences among accompaniment models, other self-managed medication abortion models, and provider-led abortion services.

"Sigue siendo un sistema precario". Barreras de acceso a abortos clínicos: la experiencia de acompañantes en tres regiones mexicanas / "The system is still precarious". Barriers in access to medical abortion: the experience of accompanying persons in three regions of Mexico / "Continua sendo um sistema precário". Barreiras no acesso a abortos medicalizados: a experiência de acompanhantes em três regiões mexicanas

El objetivo de esta investigación fue la identificación de las barreras más recurrentes de acceso a abortos en contextos clínicos (clandestinos o legales), desde la perspectiva de acompañantes, activistas feministas que acompañan a mujeres que optaron por abortos autogestionados con medicamentos. Realizamos 14 entrevistas semiestructuradas con acompañantes en tres regiones mexicanas: Baja California y Chiapas, ambos contextos restrictivos, y la Ciudad de México, donde el aborto por voluntad es legal hasta las 12 semanas. Identificamos cuatro categorías en las cuales se entretejen las vulnerabilidades sociales de las mujeres que deciden abortar, la falta de información, persistencia de estigma, y la influencia del marco legal, los fallos en la atención del aborto, incluso en las clínicas de interrupción legal de embarazo (en la Ciudad de México), y mala calidad de los servicios prestados -maltrato, objeción de conciencia y denuncia de los proveedores de salud-, y, por último, los grupos anti-derechos y sus estrategias. En las tres regiones, el acceso a abortos clínicos sigue siendo un privilegio reservado para las mujeres que cuentan con los recursos económicos, logísticos y sociales indispensables para realizarlo en esos espacios. La existencia de un programa Interrupción Legal de Embarazo en solamente una entidad denota la existencia de una desigualdad jurídica y sanitaria. Los hallazgos de este estudio sobre mujeres acompañantes de abortos aportan elementos para que el Estado mexicano mejore el acceso a abortos seguros para todas las mujeres, sobre todo ahora que la Suprema Corte de la Justicia de la Nación decretó la despenalización, y la legalización inminente en todo el país.

The study aimed to identify the most frequent barriers in access to abortions in both clandestine and legal clinical contexts, from the perspective of accompanying persons, namely feminist activists who accompanied women that opted for voluntary abortions with medication. We performed 14 semi-structured interviews with accompanying persons in three regions of Mexico: Baja California and Chiapas, both of which are restrictive contexts, and Mexico City, where elective abortion is legal up to 12 weeks' gestational age. We identified four categories in which the social vulnerabilities of women who elect to undergo abortion intersect, namely lack of information, persistence of stigma, influence of the legal framework, and flaws in abortion care, including in clinics for legal termination of pregnancy (in Mexico City), and poor quality of the services provided, with verbal abuse, conscientious objection, and healthcare provider complaints, and finally the antichoice groups and their strategies. In the three regions, access to abortion clinics is still a privilege reserved for women with the necessary economic, logistic, and socials resources for the procedure in these settings. The existence of a program for legal termination of pregnancy (Interrupción Legal de Embarazo) in only one entity reveals the existence of a legal and health inequality. The study's findings on accompanying persons for women undergoing abortions provide backing for the Mexican government to improve access to safe abortions for all women, especially now that the country's Supreme Court has decreed the procedure's decriminalization and its imminent nationwide legalization.

O objetivo dessa pesquisa era identificar as barreiras mais recorrentes no acesso a abortos em contextos medicalizados (clandestinos ou legais), desde o ponto de vista de acompanhantes, ativistas feministas que acompanham mulheres que optaram por abortos autogeridos com medicamentos. Realizamos 14 entrevistas semiestruturadas com acompanhantes em três regiões mexicanas; Baja California e Chiapas, ambas com legislações restritivas, e Cidade de México, onde o aborto voluntário é legal até 12 semanas de gestação. Identificamos quatro categorias nas quais se mesclam as vulnerabilidades sociais das mulheres que decidem abortar, a falta de informação, a persistência de estigma, e a influência do marco legal, as falhas no atendimento para o aborto, inclusive nas clínicas de interrupção legal de gravidez (na Cidade de México), e a baixa qualidade dos serviços prestados - maus tratos, objeção de consciência e denúncia contra os profissionais de saúde -, e, por último, os grupos antiaborto e suas estratégias. Nas três regiões, o acesso a abortos medicalizados continua sendo um privilégio reservado as mulheres que dispõem dos recursos económicos, logísticos e sociais imprescindíveis para realizá-lo naqueles espaços. A presença de um programa de interrupção legal de gravidez (Interrupción Legal de Embarazo) em apenas uma entidade denota a existência de uma desigualdade jurídica e sanitária. Os resultados desse estudo sobre mulheres acompanhantes de abortos trazem elementos para que o Estado mexicano melhore o acesso a abortos seguros para todas as mulheres, sobre tudo agora que a Suprema Corte de Justiça do México decretou a descriminalização e que a legalização é iminente no país como um todo.

[Dysphagia in a young woman from Somalia]. / Dysfagie bij jonge vrouw uit Somalië

BACKGROUND: Multidrug-resistant tuberculosis is increasing worldwide. The determination of possible resistance is essential for adequate treatment. Tuberculosis is common amongst immigrants from Somalia and extra-pulmonary localisation is often seen. CASE DESCRIPTION: A 21-year-old woman from Somalia presented with progressive dysphagia and severe weight loss. Endoscopy revealed two ulcers in the mid-oesophagus. A chest x-ray showed enlarged lymph nodes in the right hilar and mediastinal regions. The Ziehl-Neelsen stain and PCR for mycobacteria were negative. Sputum samples and oesophageal biopsies were cultured. Quadruple tuberculostatic therapy was started empirically. After five weeks, a sputum culture grew Mycobacterium tuberculosis, which was resistant to rifampicin and isoniazid. She was treated with second-line anti-tuberculous therapy and eventually recovered. CONCLUSION: Tuberculosis can manifest in many ways. It is important to obtain patient material for culture; not only to confirm the diagnosis but also for the determination of possible resistance which is necessary for adequate therapy.