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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
0020-7292/$ - see front matter © 2006 International Federation Of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
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doi:10.1016/j.ijgo.2006.07.013
tion programs which offered needle exchange to Strategi pengurangan risiko bertujuan
illicit drug users. This paper describes how the untuk meminimalkan efek negatif dari
program was implemented and its impact during the perilaku sosial tertentu yang
diketahui berbahaya, tetapi
first 15 months of its application.
dipraktekkan oleh sekelompok orang
yang sangat rentan untuk terlibat
Sebagian besar, jika tidak semua, dalam praktik semacam itu. Menerapkan
aborsi yang diinduksi di Uruguay konsep itu
adalah klandestin, karena aborsi telah
menjadi kejahatan sejak itu
1938. Hukum Uruguay menyatakan semua to unsafe abortion, a group of obstetrician/gyne-
aborsi sukarela selalu ilegal. Namun cologists founded an NGO called “Iniciativas Sani-
demikian, di bawah keadaan khusus,
tarias” and developed the “Sanitary Initiatives
hakim berwenang untuk tidak menerapkan
Against Unsafe Abortion” (SIAUA).
hukuman. Namun dalam prakteknya,
The planning and organization of the SIAUA
meskipun aborsi tidak dikenakan
hukuman ketika dilakukan dalam keadaan started in July 2001. The group is a “health
khusus (untuk mencegah kematian professional association” and included members of
perempuan atau morbiditas yang serius, the Faculty of Medicine of the University of the
kemiskinan ekstrim, kehamilan ekstra- Republic; the Medical Union, the Society of Obste-
atau pranikah, atau ketika kehamilan trics and Gynecology and the Association of Mid-
adalah hasil dari perkosaan), hanya wives of Uruguay. It acknowledges induced abortion
aborsi yang luar biasa. dilakukan di as illegal and, hence, pregnancy termination is not
rumah sakit umum. Perubahan politik, part of the care provided by the health system.
seperti membuat undang-undang aborsi Nevertheless, induced abortion has a “before” and
jauh lebih terbatas, dapat mengurangi “after” period. The intervention focussed on those
kematian yang terkait dengan aborsi, “before” and “after” periods, recommending that
tetapi reformasi hukum seperti itu women planning abortion have at least one medical
membutuhkan waktu untuk menjadi visit before and another after the abortion. The
efektif. Baru-baru ini, undang-undang public health clinic in which the program was
kesehatan seksual dan reproduksi introduced is in the Pereira Rossell Hospital as a
sebelum Senat tidak dapat memperoleh subdivision of the Reproductive Health Polyclinic.
suara yang diperlukan untuk pengesahan
All women who were uncertain about the direc-
dan, dalam kasus apa pun, Presiden
tion they wanted to take with their pregnancy and
Republik mengancam akan memvetonya.
Dalam menghadapi kenyataan itu, those who had already decided to abort were
strategi baru pengurangan risiko referred to the polyclinic. Some women were
diadopsi oleh para profesional referred by colleagues and others are self-referred.
kesehatan yang bekerja di Pereira A public information campaign was conducted. At
Rossell Hospital. Strategi ini the before visit, the pregnancy would be confirmed,
terinspirasi oleh pengalaman women would be informed of possible alternatives
pencegahan HIV / AIDS. to abortion and of the risks associated with the
different means used in Uruguay to induce abor-
program tion yang menawarkan tions. The purpose was not to try to influence the
pertukaran jarum untuk pengguna women's decisions, but to inform them about the
narkoba terlarang. Makalah ini
menjelaskan bagaimana program itu untuk aborsi yang tidak aman,
dilaksanakan dan dampaknya selama 15 sekelompok ahli kebidanan / gyne-
bulan pertama penerapannya. kologis mendirikan sebuah LSM yang
disebut "Iniciativas Sani- thasas" dan
mengembangkan "Inisiatif Sanitasi
Terhadap Aborsi yang Tidak Aman"
2. Methods (SIAUA).
Perencanaan dan pengorganisasian SIAUA
dimulai pada Juli 2001. Kelompok ini
2.1. The strategy adalah "asosiasi profesional
kesehatan" dan termasuk anggota
The strategy of risk reduction aims to minimize the Fakultas Kedokteran Universitas
negative effect of certain social behaviors that are Republik; Serikat Medis, Perkumpulan
known to be dangerous, but are practiced by a group Kejiwaan dan Ginekologi, dan Asosiasi
of people that are particularly vulnerable to Bidan di Uruguay. Itu mengakui aborsi
engaging in such practices. Applying that concept yang diinduksi sebagai ilegal dan,
International
5 Journal of Gynecology and Obstetrics (2006) 95, 221–226 L. Briozzo et al.
means of social support that exist in the country, karena itu menghindari kebutuhan untuk
legal issues and other issues of which many women menggunakan metode yang lebih
may not have been aware. berbahaya.
All women were also invited to attend an “after
visit”, regardless of their final decisions on continu- Activities were initiated in the Pereira Rossell
ing their pregnancies. We consider the attendance Hospital in March 2004, after a relatively long period
at the “after” consultation to be a benchmark of the of preparation that allowed for clear definition of
effectiveness of the “before” consultation. the activities to be included in the intervention and
This program was called: “Counseling for a safe the instruments to evaluate its results. A few months
motherhood—intervention to protect women from after its initiation, in August of the same year, it
unsafe induced abortion”. While some abortions became an official policy of the Ministry of Health.
may be averted, those who do abort will do it with An intense information campaign for health
the least possible risk and, in some cases, pathologic professionals was implemented, based on bioethical
conditions may be identified that would lead to a principles, legal medicine, medical professionalism
legal medical intervention in the hospital. and concepts of sexual and reproductive health with
Another purpose of the “before” visit is to create a gender perspective. The gynecology clinics of the
friendlier environment for women, preventing psy- Medical University of the Republic function in the
chological aggression or denunciation to police Pereira Rossell Hospital and the commitment to the
authorities and stimulating the return for follow-up program of the senior staff of these clinics has been
as recommended. The public perception of the of enormous importance.
program has been highly satisfactory and the pre- Before starting the program, its organizers
liminary results show this. Inclusion of this at-risk contacted the network of primary health clinics of
population in the health system generates feelings of Montevideo. Health personnel of the clinics were
calmness and safety in the users, because it avoids informed about the program and were asked to
the need to resort to more dangerous methods. refer to the Pereira Rossell Hospital any pregnant
women with an unwanted pregnancy and who could
sarana dukungan sosial yang ada di be at risk of unsafe abortion. As time passed, women
negara tersebut, masalah hukum dan told others and word of mouth became the main
isu-isu lain yang banyak perempuan mechanism of dissemination of information on the
mungkin tidak sadar. existence of the program.
Semua wanita juga diundang untuk Kegiatan dimulai di Rumah Sakit
menghadiri "setelah kunjungan", Pereira Rossell pada Maret 2004,
terlepas dari keputusan akhir mereka setelah periode persiapan yang relatif
untuk melanjutkan kehamilan mereka. panjang yang memungkinkan definisi
Kami menganggap kehadiran pada yang jelas tentang kegiatan yang akan
konsultasi “setelah” menjadi tolok dimasukkan dalam intervensi dan
ukur keefektifan konsultasi “sebelum”. instrumen untuk mengevaluasi hasilnya.
Program ini disebut: "Konseling untuk Beberapa bulan setelah inisiasi, pada
ibu yang aman - intervensi untuk bulan Agustus tahun yang sama, itu
melindungi wanita dari aborsi yang menjadi kebijakan resmi Departemen
tidak aman". Sementara beberapa aborsi Kesehatan.
dapat dihindari, mereka yang melakukan Kampanye informasi yang intensif untuk
aborsi akan melakukannya dengan risiko para profesional kesehatan
yang paling mungkin dan, dalam dilaksanakan, berdasarkan pada
beberapa kasus, kondisi patologis prinsip-prinsip bioetika, pengobatan
dapat diidentifikasi yang akan hukum, profesionalisme medis dan
mengarah pada intervensi medis hukum konsep kesehatan seksual dan
di rumah sakit. reproduksi dengan perspektif gender.
Tujuan lain dari kunjungan "sebelum" Klinik ginekologi dari Universitas
adalah membuat a Kedokteran Republik berfungsi di Rumah
lingkungan yang lebih ramah bagi Sakit Pereira Rossell dan komitmen
perempuan, mencegah agresi psikologis untuk program staf senior klinik ini
atau penolakan terhadap otoritas telah sangat penting.
kepolisian dan menstimulasi kembalinya Sebelum memulai program,
tindak lanjut seperti yang organisatornya menghubungi jaringan
direkomendasikan. Persepsi publik klinik kesehatan primer Montevideo.
terhadap program ini sangat memuaskan Tenaga kesehatan dari klinik
dan hasil pra-liminer menunjukkan hal diberitahu tentang program dan diminta
ini. Penyertaan populasi berisiko ini untuk merujuk ke Rumah Sakit Pereira
dalam sistem kesehatan menghasilkan Rossell setiap wanita hamil dengan
perasaan tenang dan aman di pengguna, kehamilan yang tidak diinginkan dan
A risk
224 reduction strategy to prevent maternal deaths associated with unsafe abortion L. Briozzo 224
et al.
yang bisa berisiko aborsi tidak aman. with information that guarantees that they will be
Seiring berlalunya waktu, para wanita in a better position to take the best decisions,
memberi tahu yang lain dan dari mulut according to their own situations, environment and
ke mulut menjadi mekanisme utama values.
penyebaran informasi tentang During the “before visit”, confirmation of preg-
keberadaan program.
nancy and of gestational age by ultrasound is carried
out, as well as an evaluation of potential maternal or
embryonic pathologies. Women may choose to see or
2.2. The “before visit”
not to see the ultrasonic image in real time or in
photography. When a normal pregnancy is confirmed,
The “before visit” is an opportunity for women to be
ample opportunity is given to the many women who
seen as citizens, with rights, who should be provided
would like to have the chance to explain why they
"Kunjungan sebelum" adalah kesempatan
must consider the possibility of termination. They are
bagi perempuan untuk dilihat sebagai
warga negara, dengan hak, yang harus informed that the health team is there to help them
disediakan (within the law), not to judge them. Also they are
informed of all possible options such as giving up the
newborns for adoption, and the possibility of a
pregnancy termination in the hospital if she has any
of the conditions in which termination is permitted
under Uruguayan law. There is no pressure to adopt
any of the alternatives, which are presented as
neutrally as possible.
best available evidence and includes unsafe proce- 2.3. The “after visit”
dures commonly used in Uruguay and in many other
developing countries, and the safe procedures used The main condition of this “after visit” is absolute
in the countries where abortion is legal. Medical confidentiality. The health care team is perfectly
abortion with misoprostol is included among the clear that breaking confidentiality would be a
safer procedures. (Mifepristone is not mentioned serious legal and ethical transgression in their
because it is completely unavailable in Uruguay.) All practice.
the scientific information and the legal status of
misoprostol is provided (dose, routes, symptoma-
tology, side effects, mechanism of action, effec- Kondisi utama "kunjungan" ini adalah
tiveness, Moebius syndrome, problems of use at late kerahasiaan mutlak. Tim perawatan
gestational ages that might cause premature birth, kesehatan sangat jelas bahwa melanggar
etc.). Restrictive laws prevent us from giving kerahasiaan akan menjadi pelanggaran
information on where to buy the appropriate drugs. hukum dan etis yang serius dalam
All women attending the before visit are invited praktik mereka.
to an “after visit”, for either antenatal or post-
abortion care, depending on their decision. If a
woman is Rh negative, she is advised to get the anti-
Rh immunization which is provided by the hospital.
When a woman reports she has had an abortion, The associations of the women's characteristics
the provider avoids either judging or belittling the and gestational age with the outcome of pregnancy
problem. Every woman has the support of a multi- at the “after visit” were analyzed. The independent
disciplinary team that provides medical, psycholo- variables were age, marital status, employment
gical and social care and support. A major status, history of previous pregnancies and abor-
component of the care is the provision of an tions, and gestational age. The dependent variable
effective contraceptive method, according to the was the outcome of pregnancy at the “after visit”.
freely informed decision of each woman.
If women have an incomplete abortion, we 4. Results
provide uterine aspiration (manual or electric).
This happens in 30% of the cases who used The total number of women attending the “before
misoprostol. (More recently, as we acquire more visit” during the 15 months of this evaluation was
experience with misoprostol, having now cared for 675. It increased steadily from 20 during the first
more than 4000 women, the proportion needing 3-month period, March–May 2004, to 59 in June–
uterine evacuation has declined to 18%.) August and to 220 in September–November. The
number of women attending the program stabi-
Ketika seorang wanita melaporkan dia lized, between 149 and 224 during the two
telah melakukan aborsi, penyedia following 3-month periods. The number of “after
menghindari baik menilai atau visits” also increased at a similar rate, from 17 in
meremehkan masalah. Setiap wanita
memiliki dukungan dari tim
multidisiplin yang memberikan
perawatan dan dukungan medis, 3. Evaluasi
psikologis dan sosial. Komponen utama
perawatan adalah penyediaan metode Dari Maret 2004 hingga Agustus 2004,
kontrasepsi yang efektif, sesuai yaitu, selama periode sebelum itu
dengan keputusan bebas informasi dari menjadi kebijakan resmi Departemen
setiap wanita. Kesehatan, perawatan diambil untuk
Jika wanita memiliki aborsi yang tidak tidak mencatat informasi apa pun yang
lengkap, kami memberikan aspirasi akan memungkinkan identifikasi para
uterus (manual atau listrik). Ini wanita, karena takut itu dapat
terjadi pada 30% kasus yang digunakan untuk penuntutan pidana. Baru
menggunakan misoprostol. (Baru-baru setelah Departemen Kesehatan menyetujui
ini, karena kami memperoleh lebih program itu sebagai resmi, dimulai pada
banyak pengalaman dengan misoprostol, September 2004 hingga Juni 2005, kami
setelah sekarang merawat lebih dari mencatat karakteristik perempuan yang
4000 wanita, proporsi yang membutuhkan berpartisipasi dalam program, diagnosis
evakuasi uterus telah menurun hingga akhir mereka saat pendaftaran, usia
18%.) kehamilan, penggunaan kontrasepsi
sebelumnya. metode dan riwayat
obstetrik. Hasil kehamilan dan adopsi
3. Evaluation kontrasepsi setelah aborsi juga dicatat
untuk para wanita yang menghadiri
From March 2004 through August 2004, that is, "setelah kunjungan". Jumlah perempuan
during the period before it became an official policy yang hadir sebelum dan sesudah
of the Ministry of Health, care was taken not to kunjungan didaftar sejak awal program.
record any information that would allow identifica- Asosiasi karakteristik perempuan dan
tion of the women, for fear it could be used for usia kehamilan dengan hasil kehamilan
criminal prosecution. It was only after the Ministry pada "setelah kunjungan" dianalisis.
of Health sanctioned the program as official, Variabel independen adalah usia, status
starting in September of 2004 until June 2005, perkawinan, status pekerjaan, riwayat
that we recorded the characteristics of women kehamilan sebelumnya dan aborsi, dan
usia kehamilan. Variabel dependen
participating in the program, their final diagnosis at
adalah hasil kehamilan pada "setelah
enrollment, gestational age, previous use of contra-
kunjungan".
ceptive methods and obstetric history. The out-
come of the pregnancy and the adoption of 4. Hasil
contraception after abortion were also recorded
for those women who attended the “after visit”. Jumlah total perempuan yang menghadiri
The number of women who attended the before "sebelum kunjungan" selama 15 bulan
and the after visits was registered from the evaluasi ini
beginning of the program.
A risk
227 reduction strategy to prevent maternal deaths associated with unsafe abortion L. Briozzo 227
et al.
675. Terus meningkat dari 20 selama the first 3 months to 172 in the third 3-month
yang pertama period. After that, it decreased to 72 and 126 in
Periode 3 bulan, Maret – Mei 2004, the following periods (Fig. 1).
menjadi 59 di bulan Juni– Agustus dan Almost 75% of the women who attended the
220 pada bulan September – November. “before visit” returned for the “after visit” or were
Jumlah wanita yang menghadiri program
resolved at the hospital (495/675 = 73.4%). Among
ini stabil, antara 149 dan 224 selama
those for whom there was information 439, or
dua periode 3 bulan berikutnya. Jumlah
88.9%, had an induced abortion outside the hospital
"setelah kunjungan" juga meningkat
pada tingkat yang sama, dari 17 di and 3.5% returned for antenatal care. The remain-
ing 7.5% were not pregnant, had blind ova, a dead
embryo/fetus or met a requirement for legal
abortion in the hospital.
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
5. Discussion
5. Diskusi
clientele of the Pereira Rossell Hospital, most of the women participating in the program and that not
whom had limited economic resources. It was a single death after abortion has occurred since the
reassuring that, after counseling, none of them program started is suggestive, but not conclusive.
used any of the riskier methods, such as the What is perfectly clear, however, is that women
introduction of sharp objects through the cervix. who had to go through the difficult and stressful
Misoprostol could not be and was not prescribed process of deciding to abort and carrying it out, felt
by the attending physicians. Women were only better cared for and safer, after participating in the
provided with the evidence-based information on program. The exponential increase in consultations
misoprostol efficacy, risks, side effects, dosage and indicates to us an increase in confidence in the
route of administration, the same way as it is done service.
with all other alternatives for abortion induction. The program has not been free of external
The drug is not approved for induced abortion in criticism. The SIAUA team's strength is based on
Uruguay, but is sold for the treatment and preven- the conviction that the program follows basic
tion of peptic ulcer. It appears that women adopted principles of bioethics and recommendations of
several different strategies to obtain the drug and the Latin American Federation of Societies of
frequently several women worked together to Obstetrics and Gynecology (FLASOG) and from the
purchase a bottle of 28 tablets sharing the cost. Ethical Committee of FIGO [7].
We believe that the strategy of the SIAUA is
Itu tidak mengherankan bahwa wanita creative, effective and feasible in countries where
lebih suka menggunakan misoprostol
untuk menginduksi aborsi mereka.
Meskipun dalam kondisi vakum aspirasi
yang memadai dapat menjadi aman atau
lebih aman, itu tidak dapat diakses
oleh
abortion is legally restricted. It reduces the number biaya pengobatan untuk layanan
of induced abortions through neutral information kesehatan masyarakat.
and counseling, prevents the risk of unnecessary
termination procedures, and identifies medical
problems that require attention, as well as cases 6. Recommendation
where abortion is within the local laws. Even more
important, it reduces suffering and complications to We hope that the description of this initiative will
women and the cost of treatment to the public stimulate others to adopt or adapt the model to
health service. their own situation. The implementation and
evaluation of this strategy by others will allow us
Tampaknya strategi kami mencapai to confirm or not whether this model can contribute
tujuannya untuk mengurangi komplikasi to achieving objective 5 of the Millennium Devel-
dan kematian ibu yang terkait dengan opment Goals.
aborsi yang tidak aman, melalui
beberapa mekanisme yang dijelaskan di
atas. Karena kematian adalah peristiwa 6. Rekomendasi
yang jarang terjadi, akan diperlukan
waktu sebelum kemungkinan untuk Kami berharap bahwa uraian inisiatif
memverifikasi penurunan yang ini akan merangsang orang lain untuk
signifikan secara statistik dalam mengadopsi atau mengadaptasi model
kematian ibu terkait aborsi. Fakta tersebut ke situasi mereka sendiri.
bahwa tingkat komplikasi sangat minim Implementasi dan evaluasi strategi ini
di antara para wanita yang oleh orang lain akan memungkinkan kami
berpartisipasi dalam program dan bahwa untuk mengkonfirmasi atau tidak apakah
tidak ada satu kematian pun setelah model ini dapat berkontribusi untuk
aborsi telah terjadi sejak program mencapai tujuan 5 dari Tujuan
dimulai adalah sugestif, tetapi tidak Pembangunan Milenium.
konklusif.
Namun, yang sangat jelas adalah bahwa References
perempuan yang harus melalui proses
yang sulit dan penuh tekanan untuk [1] Briozzo L, Vidiella G, Vidarte B, Ferreiro G, Cuadro JC, Pons
memutuskan untuk membatalkan dan JE. Induced abortion under unsafe conditions. Health
melaksanakannya, merasa lebih emergencies and maternal mortality in Uruguay. The current
situation and medical initiatives for safe motherhood.
diperhatikan dan lebih aman, setelah
Revista Medical de Uruguay 2002;18:4–14.
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diinduksi melalui informasi dan
konseling netral, mencegah risiko
prosedur penghentian yang tidak perlu,
dan mengidentifikasi masalah medis
yang memerlukan perhatian, serta
kasus-kasus di mana aborsi berada
dalam hukum setempat. Bahkan yang
lebih penting, mengurangi penderitaan
dan komplikasi bagi perempuan dan