Unwanted pregnancy: challenges for health policy

Abstract

reaches fertile age without knowing her own afraid of it, it is very difficult to inform her fu!ly about how to regulate her fertility. “Access” to services for all women is critical. Even with full knowledge of the means to avoid pregnancy, women may still have unwanted pregnancies if appropriate and effective methods of contraceotion are DM readily available fr) t&remat the *.-iirn.. +I,-,. ....,J need them. Women in Brazil, for exammle. have very limited contraceptive choices. jhe; relv primarily on surtical sterilization and the pill. Restriciive government policies are a :dndrarce to changing this situaticla. Gnnetheless, because women are highly motiwed to regulate their fertility, contraceptive prevalersc is very high (Table 1).

body, or being

In Lain America, goveromentsfail to retognize that i&rmotion and senvces for sexuality, reproduction and contraception ore essential to women’s health. Governments should adopt comprehensive women’s he&h policit% and prognune to help women avoid unwanted pregnancies that lead to dongerow illegal abortions. This incbrdes ses education, especially for adolescents; contraceptive choices; accessible services; decrimiwlization of abortion and removal o/’ obstacles to legal abortion ze.rv!ces; and sutqort ior women who wirh to carry theirpregnuhsies to iz??. Kwwords: Abortion; Brazil; Health policy; Contraception; Adolescents; Sex educa!ion.

Every unwanted pregnancy represents a failure bv societv to orovide the woman with ways to avoid :6at p~egatwy. These inchtde full information about her body, sexuality, reproduction and contraception, and also access to the various services necessary lo insure that she can act on that knowledge. The failure of families and schools to educate youog people about sex is a primary cattse of unwanted pregnancy. When a girl

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When governments ignore or do not accept that sex education, particularly f&r servicss for fertility adolescents, and

regulation are a very important element in promoting women’s health, the vacuum created by official indifference is often filled by the pharmaceutical industry and private physicians or institutions. In Brazil, women a:e allowed or rye” encouraged to purchssL pills over the counter without screening for contra-indications or to undertake surgical sterilization wtrhout fully understandina its permanency. Private phy&iarts increase iheir earnings by practicing with no other criteris clients to pay for it.

surgkal sterilization than the capacity of

Prhdie organi7ation5, driven by donor criteria, are more interested in the number of new acceptors than in the quality of their services, or in offering real choices among methods. Some might argue that limited availability of methods is better than no method at all, but that is doubtful. With choice limited to pills and surgical sterilization, many women are forced to use an inappropriate contraceptive. with conseauences ranaing from dircornfort and emotional problems io severe c”mdicati”ns and risk of death. The lack of alteriatives leaves mihions of women exposed to the risk of unwanted pregnancy. Moreover, reliance on the private sector, to the virtual exclusion of governrnmt, means that poor women will suffer more than higher income women. Poor women:, who often have more chiiirm and a hieher incidence of medical reasons to avoid- pregnancy, have problems purchasing pills every month and may gel pregnant because they do not have money a: the beginning of a cycle. The availability and the quality of surgical sterilization also defvmds on the capacity to pay. The &bortion experience It is very difficult. if not impossible, to know the exact magnitude of unwanted pregnancies. The little informaiion that exists

refers to the main consequence of unwanted; pregnancy, induced aborlion. In Bra:& the estimates vary from 4 million to 500,OCfl induced abortions annually, without strong basis for any of the estimates. Data from the social security system (INP_MPS) indicate that more than 200,000 women were hospitalized for treatment of abortion complications in 1980. Whether the numbers are in the hundreds of thousands or in the millions is irrelevant. The fact is that a very significant number of women in Brazil, as in the rest of Latin America, are confronted with the personal drama and the physical risks of unwanted pregna-xq. Because induced abortion is legally restricted, many women face the complications of clandestine abortions. Even a woman who is permitted safe abortion berause the pregnancy poses a risk to her life, or because it is the result of rape, may not obtain legal authorization to abort in a public facility; this means she must go through illegal channels. Ahhougb the greatest number of &gal abortions are undertaken by married wolnen in their late twenties or early thirties, with 2 or 3 children, the experience of unwanted pregnancy and illegal abortion may be more severe for singre adolescent girls. They have less social support, greater doubts, less financial capacity to pay for an Interruption and take longer to reahxe that they are pregnant. Consequently, they have more severe complications, a higher rate of infeetion, and greater risk of mutilation and death. The law and medical ethics condemn tbortiott, but millions of abortions are carried out. The name and addresses of the providers are public knowledge, but neither the law nor ethical norms are ever applied, except in cases where the wotnan dies and a link to an abortion can be traced. Maw physicians are strongly agdttst abortion but in certain situations, particularly when the unwanted pregnancy occurs in a member of his/her family or in a close friend, these physicians refer the case to a colleague.

Women in the higher socioeconomic strata determined to abort can do so in tbe best medical facilities. The lower the finaxial capaciry, the w’oi6c:he :xhnical and psychological conditions in which abortion can be obtained. The poorest women will pay a few dollars to hwe someone cause infection and/ or bleeding that will justify hospitalization in the same public facility that will not provide a safe abortion, even to a woman who meets legal conditions. But in addition to severe morbidity or death, many other physical, gsycho:ogical and social risks confront the we’nau wno has an unwanted pregnancy. These include the anguish and uncertainty of being or not being pregnant, the traumatic decision to abort, componnded by the sinister environment in which illegal abortions are provided. particularly for those who are not rich. For adolescents, unwanted pregnancy and abortion often result in eviction from home and/or school, early and unhappy marriage, and loss of opportunities for the rest of their lives. The psychological consequences are difficult to evaluate. It seems that the decision to abort is almost never easy and without pain. All unwanted pregnancy is a failure, but psychological conseqaewes seem to be worse rk Wer in gestation the abortion is carried out and tile less the support from family and ffier?s ]12]. The lack of formal social acceptance of abortion makes the wcrilan who aborts an outcast. Even the male partner or the m&her may not be supportive. and most of me time the pregnant woman feels that the entire burden is on her shoulders. Forced marring<. sing!: motherhood, giving the baby up for adoption or adding an unwanted child to the family are all stressful and traumatic solutions. Although some unwanted pregnancies may culminate in a loved child, the very large number of “street children,” millions in Rrazil alone, is a clear testimony to one of the most dramatic consequences of unwanted pregnancies. It is thus very unfortunate that many

goveru~.znts have been ia:ifferent to the contraceptive izds of women. Governments may be far better olacr-’ t^ meet women’s reproductive health needs than & pr;vate sector in Third World countries. Their tider coverage of the population, mu!tiple levels of health care (from basic to tertiarvk defined standards, ‘&d potential for -providing comprehensive services are great advantages. As yet. however, the Brazilian health system concentrates on orenatal care and deliverv services.

Unti! Third World governments realize that prevention of unwanted pregnancies is more effective and less expensive than caring for the complications of clandestine abortions, and that women will be better served by such a policy, the high incidence of unsafe Induced abw:)cn will continue.

ThecRalleoges for policy Actions to relieve the drama of unwanred pregnancy and abortion ?re undoubtedly needed with great urgency. The Lz_^?w are known, but the w!ltical will is missing. The two main lines of action needed are to prevent unwanted pregnancy and to reduce the risk of death from abortion. Sex education and provision of good quality contraceptive services are two different but complementary aud esser.:iaI approaches to the prevention of unwanted plignancy. ;iex education that provtdes information about anatomy and the physiology of reproduction, and liberates males and females from myths and stereotypes about sexuality from early childhood, is required. Such education teaches children and adults to lose the shame and fear of one’s own body, and discusses openly sexual aud reproductive responslblhtles. Such information will a! least help to avoid many of the pregnancies that result from ignorance, from curiosity, or

from “unexpected” encounters. Particular

emphasis should bc placed on the w&s of preventing pregnancy until it is wanted. Within this context anortion can be objectively discussed. Sex educ;!ion should go hand in hand with general education, which also enables girls

and women to avoid unwanted pregnancy. An educated woman may be more ‘capable of avoiding the severe consequences of unintended gestation, and the risks of con.plicatlon and death if a:. abortion is inducea. i-, emotion of general education may seem too ambitious, but it should be a long term objective. It is perfectly possible, if the po!;tlca commitment is present as has been shown in a number of low income courttries. Prevention of unwanted pregnancy also requires universal access to good quality qudity” contraceptive services. “Good services offer accurate ioformation, appropriate and compassionate counselings -and a choice of the contraceptive methods presently available in the world and accepted by the most prestigious medical authorities, usuatly represented by WH@ scientific groups. Good quahty contraceptive services should include a wide range of women’s health services, within the capacity of basic health care in the country, and an attitude of understanding and disposition to listen to women’s worries and priorities. A strategy to establish integrated women’s health programs that include contraception is being demonstrated in the State of SBo Paula, Brazil. A concept of integral health services for women was deveiooed at the Denartment of Obstetrics and Gynecology of the State Universitv of Camcinas. under the direction ot one bi he ikioi;. Initiatby, sevc:a! venicai programs to care for particular women’s health problems were imolemented with reasonab!e success. It became evident. however, that separate care for different organs or situations related to the same woman was inappropriate. Over time, an approach to services that considers the woman as a whole person, who may have multiple health problems, was developed.

Women’s groups made an important contribution to this new approach. They criticized the highly technical manner in which their he&h oroblems were viewed dd this led to the ibclusion of psychosocial riintecsions of care. The importance of a woman’s understanding of her own body, her sexuality and her ability to decide about her fertility became an important part of the concept and led to the addition of good quality contraceptive services. The success of this comprehensive approach at the State University of Campinas lad us to pursue adoption of an integrated women’s k:alth policy for the State of S%o Paulo. The first step was to evaiuato the quality of care that was already available to women in state services. Health services were narrowly directed to prenatal and delivery services, and even these were not necessarily adequate or equally accessible to all women. Family planning services were erratic and cancer control very weak. With this clear picture in mind, the concept of integrated health care and all its implications was widely discussed with women and experts in ihe field. A Program for Integrated Women’s Health Care (PAISM) was initiated. The general goal of the program is to decrease mortality and morbidity among women. More specifically, the program seeks to reduce maternal mortality and mortality due to gynecological cancer; correct inadequacies in the provision of contraception: and diminish the incidence of sexually transmitted diseases. The program recognizes that health problems, such as high maternal mortality and cancer mortality, for example, as well as inadequacies in health services, are the resuit of a chaio of multifactorial causes, including those outside the health sector, that start at the beginning of a woman’s life. Both supply of and demand for services require stimulation. The resouxe needs of each municipality wire surveyed. Mass media were used to motivate women to seek out public services and to make them aware of the need to care properly for themselves. Also, at

the time of mass vaccination campaigns for children, mothers were provided with informational matsri;; and !he opportnn?,.y to set up a gynecological consultation at the nearest health center. In the future, such opportunities can also be used to ask women about cot:tiaceptive use and misuse and to provide correct infxmation about contraceptive choices available to them that arc suited to their individual needs. The strategy for action includes standardizing procedures and extensive in-service training to make health profcssiottafs aware of the importance of their role as health educators during every patient contact. The most significant challenge we face is the reluctance of mauy health care providers to recognize family planning as a legitimate component of women’s 0vemU health care and not as an imposition by foreign cocntries that want to control Brazilian population growth. We must also challenge the traditionally “paternalistic” attitudes of physicians during their interaction with women patients. Similarly, we must change physicians’ attitudes about abortion to assure that those abortions allowed by law can be safety provided by the public health service. We need also to assum high quality training for those who care for women’s health through training centers that are models of quality care. Presently, such standards are not necessarily the rule. Women’s groups are the conscience of society during this process, challenging health providers to improve the quality and extend the range of health services for all women. Withcut their involvement, as beneficiaries, the progrm will certainly fail.

The risks of abortion resuh not from medical factors but from its illegality. Thcrrefore, the logical step to prevent deaths among women who have an unwanted pregnancy is to decriminalize abortion. For many countries. Brazil included, this may seem

difficult, and may take much longer to accomplish t&n t&5 urgent action the problem xq~uires. To change mstrictive legislation. iye must at least start to inzcase awareness and stimulate discussion of the

problem. Meaowhile. it is imperative to eliminate tbe obstacles to legal abork? for those women who meet the legal req&ements. This requires changes in bureaucratic procedures to be followed and in the attitudes af ph+ cianr, gynecologists in particular, who often close their eyes to the dramatic rrali~ of illegal abortion and deny women their legal right to a safe procedure. Given that society often advances more rapidly than do its formal laws, means shculd be explored to replace sordid, emotionally and physicaby traumatic clandestine abortion cleaner, with socially-controlled and sociahy supported abortion. Only a few examples exist ia Latin America (outside Cuba, where safe abortion has been made fuhy accessible), where courageous groups of physicians interpret existing laws broadly. A ‘iioman who does not have the physical, emoiiOnal or social ability to carry 3 pregnancy, and does not have means to pay for a clean abortion, is highly Likely to risk her hfe at the hands of an abortiom~t: she thus meets one of the key criteria for he,-al abortion: “to save the life of the woman.~;i~~ ok% countries. there may be other ‘ways to interpret the la& in favor-of providing asafe service. Gruups in several Latin American countries have taken such initiatives, which set examples of what can be done. Additional alternative actions to reduce the consequences of unwanted pregnancies shoiild include counseling and sock4 support for women who decide to carry the pregnancy to term. Presently, for example, a single working woman who gets pregnant has very kttle, if any, social support if she decides !o carr the pregnancy to term. The right of this woman to have her baby in the best possible conditions, if ihat is her wish, shouid be pro-

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t&led. That necessarily means that mechanisms to make that possible should be estabdshed, including maternal leave, day ix? centers for the baby, and mother’s homes for those who cequirc s;lch a facility. References ,

Amdo 34. a.<:shn. N. M.-JrriCL. FIrrar EA: Pcsquim nas,o,ld sob+ saude ina:err.o.infmtil e planejamsnro familiar - 1986. (National invesligalion On ma,ernd.child health and family planning Km.,