Orientador: Aloisio Jose Bedone / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-14T08:07:19Z (GMT). No. of bitstreams: 1 Silva_DanielaForneldeOliveira_M.pdf: 972669 bytes, checksum: 320b3154e074527b3b86e49612602038 (MD5) Previous issue date: 2009 / Resumo: Introdução: O aborto inseguro corresponde a uma das principais causas de mortalidade materna no mundo. Na última década, o acesso a métodos seguros para o aborto, principalmente o misoprostol, tem contribuído para um declínio nos relatos de morbidade relacionada ao aborto. Na cidade de Campinas, a mortalidade materna por aborto, que era uma das primeiras causas de morte na década passada, parece ter-se reduzido consideravelmente. Esses dados podem refletir o maior uso de misoprostol pelas mulheres que optam por induzir o aborto. Objetivos: Verificar a proporção de abortos induzidos com misoprostol e outros métodos, e comparar as complicações observadas. Sujeitos e Métodos: De julho de 2008 a abril de 2009 as mulheres internadas com diagnóstico de aborto em dois hospitais de Campinas foram entrevistadas e submetidas a uma lista de verificação que continha os critérios da OMS para a classificação de abortos induzidos. De acordo com estes critérios, as mulheres foram classificadas como abortos possivelmente, provavelmente e certamente induzidos; as mulheres que não apresentaram qualquer um dos critérios foram classificadas como abortos espontâneos. As pacientes classificadas como aborto possível, provável ou certamente provocado, responderam também a um questionário. Resultados: Das 543 mulheres internadas com diagnóstico de aborto, 5 não tiveram suas entrevistas concluídas e foram identificadas 259 (48%), que possivelmente, provavelmente ou certamente provocaram o aborto: 222 (85,7%), 11(4,3%) e 26 (10,0%), respectivamente. Dentre os 259 questionários aplicados, somente 25 mulheres assumiram ter feito uso de algum método para indução do aborto e dentre estas apenas 9 referiram uso de misoprostol. O número de complicações infecciosas e hemorrágicas observado foi pequeno. Foram observadas diferenças significativas nos índices de complicações entre mulheres que assumiram a indução do aborto em relação àquelas que não assumiram. Entretanto esta diferença não foi significativa entre as mulheres que usaram misoprostol e as que usaram outros métodos. A única variável que esteve relacionada significativamente com tipo de aborto e complicações foi o estado marital: as mulheres sem parceiro fixo apresentaram maior índice de abortos provavelmente e certamente induzidos e de complicações hemorrágicas. Oitenta por cento das mulheres que disseram não desejar a gravidez estavam usando métodos contraceptivos. Conclusão: Houve um número pequeno de abortos confessadamente induzidos e uma baixa incidência de complicações. A coincidência do estudo com notícias de perseguição policial a mulheres que abortaram pode ter interferido na disposição dessas pacientes em relatar manobras, enquanto o uso de misoprostol exclui sinais da indução. Os dados confirmam o conceito generalizado de ter havido uma redução na freqüência e gravidade das complicações associadas à prática do aborto; entretanto não permitem verificar até que ponto o uso de misoprostol é responsável por essa redução, como observada em outros estudos. Será necessário esperar algum tempo até que essas notícias de perseguição policial às mulheres que abortaram saiam da mídia e fiquem esquecidas, para se tentar obter informações mais verídicas. Além disso, faz-se necessário repetir estudos mais apurados sobre mortalidade materna que permitam verificar se efetivamente a mortalidade materna associada ao aborto é tão baixa como aparece nas estimativas oficiais. / Abstract: Introduction: The unsafe abortion corresponds to one of the major causes of maternal death in the world. During the last decade, the access to safer methods to abortion, mainly misoprostol, has contributed to decrease of abortion morbidity. In Campinas, the maternal mortality by abortion seems to have fallen considerably. This can have occurred because of the great use of misoprostol by women who chose to induce the abortion. Objectives: Verify the proportion of induced abortion with misoprostol and other methods, and to compare the complications observed. Subjects and methods: From July 2008 until April 2009, the women who had an abortion and were admitted to two hospitals in Campinas were interviewed, a check-list with the WHO criteria of induced abortion was used to verify if the abortion was induced or not. To obtain more information about women whose abortion was classified as possible, provable or certainly induced a structured pre-tested questionnaire was applied. Results: Among 543 women hospitalized due to abortion, 5 women din't finish their interview and 259 women (48%) had their abortion classified as possible, probable or certainly induced: 222 (85,7%), 11(4,3%) e 26 (10,0%), respectively. Only 25 women (among 259 questionnaires obtained) assumed to have induced abortion and only 9 of these reported the use of misoprostol. The incidence of infection and hemorrhagic complications was small. There was a significant difference between complications rates in women that assumed have induced abortion and in women that didn't assume it. However, there was no significant difference between complications in women that used misoprostol and in women that used other methods. The marital status was the only sociodemographic characteristic that demonstrated some relation with abortion classification and with complications: women without a partner had a superior rate of probable and certainly induced abortion and hemorrhagic complications. Eighty percent of women who didn't desire the gestation were using contraceptives methods. Conclusion: There was a small number of assumed induced abortions and a low incidence of complications. The coincidence of this study with news of police prosecution of women suspected of induced abortion may have interfered on women willingness to be sincere, while the use of misoprostol prevents any sign of induction. The data confirm the opinion that the frequency and severity of abortion complications had gone down, but do not allow to verify which role misoprostol played in that process. It will be necessary to wait some time until those news of police prosecution disappear from the headlines to then be possible to obtain more reliable data. Besides that, it is necessary to execute detailed studies about maternal mortality, which allow us to verify if the rate of maternal mortality related with abortion is as low as the national statistics rate. / Mestrado / Tocoginecologia / Mestre em Tocoginecologia

Women of child-bearing age sometimes fail to plan for pregnancies. Often they discover that they are pregnant and are not prepared or cannot afford to raise the child. Before 1996 there was no choice for women as regards pregnancies, all pregnancies must be carried to term and delivered except on health grounds and with stringent conditions. However after the TOP act was enacted in 1996, women were allowed a choice of TOP up to and including 20 weeks of pregnancy.<br /> <br /> Regardless of the availability of choice of TOP, some pregnant women still present late (after 12 weeks) for TOP when the risks of complications and costs are higher. Women who present late for TOP usually have to be admitted to a district or regional hospital and managed. The costs at such institutions are high. TOPs before 12 weeks (early TOP) are done in a primary health care (PHC) facility (TOP center) and no admission is required hence less cost. Complications of early TOP are also very mild and rare. In Lejweleputswa district there is only one TOP Center (Kopano TOP Clinic) and this serves both Lejweleputswa and the Northern Free State districts. Early TOPs (less than 12 weeks) are done and completed at this center. Late TOPs (above 12 weeks but not more than 20 weeks) are initiated at this TOP center and referred to district or regional hospitals nearest to the patient&rsquo / s home, in both districts for completion.<br /> <br /> Problems - An increasing number of women are seeking TOP service at late stages of pregnancies and the incidence of severe complications like severe bleeding, retained placenta, infection, amniotic fluid embolism, death etc, are increasing. The hospital&rsquo / s bed space and budget are stretched to the limit due to the influx of late term TOP to the hospitals. Lack of manpower, especially doctors, in these hospitals also create some problems, as the few doctors available have to attend to other ill patients as well. Sometimes bleeding TOP patients are transfused with blood and placed on a waiting list for theatre and this often increases the risk of complications. The emotional effect of late TOP on hospital staff (doctors and nurses) are enormous as the expelled fetus are much more developed than in early TOP where no fetus is seen at evacuation with simple Manual Vacuum Aspiration (MVA).<br />

The primary objectives in this study were to gain a deep level of understanding of Kenyan women’s experiences of seeking abortion, both safe and unsafe, and to explore how social and legal issues impact their choices and the routes they take to obtain abortion. I explored the contexts and interpreted 49 in-depth narratives of women’s emic experiences of abortion in Mombasa city and the Kilifi district, Kenya, using a qualitative form of inquiry conducted between April and July 2005. Ethical Review Committees granted ethical clearance to this study. This emic work revealed gender inequity consistent with developing feminist theory and thus how women conceive gendered relationships is introduced in this analysis of women's narratives. The findings provide new insights as well as useful confirmatory knowledge, gleaned from detailed empirical evidence within Kenyan women’s social contexts. The women have revealed the evidence through their narratives; such an approach is largely missing in existing abortion literature. The prominent finding is that women do not abort motherhood, but they do abort particular pregnancies to protect motherhood; to avoid a difficult motherhood likely to compromise the quality of care they envisage for their potential and existing children. This includes ensuring the best nurturing environment, paternal and religious identity, social legitimacy. The abortion decision is difficult to make and thoroughly considered. The married women make a consultative decision with their ‘breadwinners’ having the upper hand. Legal barriers cannot bar abortion but entrench inequities in abortion care access, heighten secrecy, stigma, and hamper prompt comprehensive post abortion care seeking. Thus, financial resources, peers, geographical remoteness, and knowledge significantly influence the type of abortion accessed. Consequently, unsafe abortion threatens motherhood of the most vulnerable groups of women. The foremost recommendation is that public health law must ensure healthy, enjoyable, dignified motherhood for the women; hence safe early abortion (first trimester) must become accessible to alleviate existing health care inequities. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2013.

Women of child-bearing age sometimes fail to plan for pregnancies. Often they discover that they are pregnant and are not prepared or cannot afford to raise the child. Before 1996 there was no choice for women as regards pregnancies, all pregnancies must be carried to term and delivered except on health grounds and with stringent conditions. However after the TOP act was enacted in 1996, women were allowed a choice of TOP up to and including 20 weeks of pregnancy.<br /> <br /> Regardless of the availability of choice of TOP, some pregnant women still present late (after 12 weeks) for TOP when the risks of complications and costs are higher. Women who present late for TOP usually have to be admitted to a district or regional hospital and managed. The costs at such institutions are high. TOPs before 12 weeks (early TOP) are done in a primary health care (PHC) facility (TOP center) and no admission is required hence less cost. Complications of early TOP are also very mild and rare. In Lejweleputswa district there is only one TOP Center (Kopano TOP Clinic) and this serves both Lejweleputswa and the Northern Free State districts. Early TOPs (less than 12 weeks) are done and completed at this center. Late TOPs (above 12 weeks but not more than 20 weeks) are initiated at this TOP center and referred to district or regional hospitals nearest to the patient&rsquo / s home, in both districts for completion.<br /> <br /> Problems - An increasing number of women are seeking TOP service at late stages of pregnancies and the incidence of severe complications like severe bleeding, retained placenta, infection, amniotic fluid embolism, death etc, are increasing. The hospital&rsquo / s bed space and budget are stretched to the limit due to the influx of late term TOP to the hospitals. Lack of manpower, especially doctors, in these hospitals also create some problems, as the few doctors available have to attend to other ill patients as well. Sometimes bleeding TOP patients are transfused with blood and placed on a waiting list for theatre and this often increases the risk of complications. The emotional effect of late TOP on hospital staff (doctors and nurses) are enormous as the expelled fetus are much more developed than in early TOP where no fetus is seen at evacuation with simple Manual Vacuum Aspiration (MVA).<br />

Department of Advanced Nursing Science / PhDH / Background: Despite measures to curb unwanted pregnancies and to sustain and expand abortion services, a high number of complications and deaths still occur. The failure of these measures is evidenced by the high number of women who are admitted to the public hospitals of KwaZulu-Natal Province with complications from induced abortions. KwaZulu-Natal Department of Health has repositioned Family Planning to a key priority in its health program in order to improve the situation for women. However, in order to improve the situation, it is necessary to understand the underlying causes. This study sought to identify challenges that affect women's access to Post Abortion Care (PAC) services in KwaZulu-Natal Province, South Africa. It also sought to shed light on the challenges faced by those who render PAC services, as well as assess the skills of those workers as observed while they provided PAC services. After conducting the research on challenges related to access and rendering of post abortion care services, the researcher identified a need to develop guidelines for management of unsafe and induced abortion complications, with the aim to improve the life expectancy of women and prevent maternal deaths. Therefore, an outcome of the study was the development of a PAC management guideline. Purpose: The purpose of the study was two-fold: Phase 1: to explore the challenges faced by women when accessing PAC, and the health care workers who render PAC services, and to assess the PAC skills of the health care workers; Phase 2: to use the findings of Phase 1 to develop guidelines for post abortion care management at selected Hospitals of KwaZulu-Natal Province, South Africa. Methods: The design of the study was guided by the Andersen model of Health Care Utilization. The model focuses on the contextual factors - enabling factors, predisposing factors and need factors - that influence the individual's utilization of health care services. Five districts of KwaZulu-Natal Province, South Africa were selected for the study. A convergent parallel mixed method was used to collect and interpret the data. A qualitative study was used to explore perceptions and challenges of women when accessing PAC; this was carried out by means of in-depth interviews with 23 women who accessed PAC services. Five Focus Group Discussions (FGD) were carried out with 50 health care workers to explore the challenges they experienced when managing abortion complications. A quantitative approach was used for direct skills observation of 92 health care workers. Thematic analysis was used to analyse the qualitative data; descriptive statistics were used to analyse the quantitative data. Results: From the in-depth interview data, several main themes were identified. Women who accessed PAC identified a lack of facilities that offered PAC service, distance from the community to the hospital that provided PAC service, lack of transport, shortage of staff, unskilled staff, shortage of equipment, long waiting queues, stigma and discrimination as challenges associated with delay or avoidance of access to post abortion care services. The main themes raised by the health care providers were lack of support from the management, shortage of staff, lack of training, burnout, unavailability of the guidelines or protocols and shortage of equipment. The quality of PAC services was perceived as poor by both the women seeking care and the health care workers. The main concerns raised by the women were lack of respect, lack of privacy, sharing of bed and insufficient time with the health care provider. The results confirmed that guidelines are needed for the management of post abortion care services. The findings from the qualitative and quantitative parts of the study were used by an expert group to develop PAC management guidelines. The development of the guidelines was in accordance with the WHO models, PICOS & GRADES. The guidelines were validated by the group using a close-ended checklist, analysed with simple descriptive statistics. Conclusion: This study concludes that access to comprehensive quality post abortion care must be provided for all women at times of need. Quality PAC services should be rendered by skilled health care workers in a facility which is accessible and well equipped with functional equipments and updated guidelines. Recommendations: The study therefore recommends that measures should be taken to ensure the provision of quality PAC services. The PAC services should be accessible with the increased number of facilities, adequate trained health care workers with functional equipment and guidelines. Health care workers must receive training and management support to enhance quality PAC services. Privacy and respect must be maintained during provision of PAC services to ensure quality of care and increase demand. There must be continuous community awareness about PAC services which will encourage early-seeking behavior, and reduce fear of stigma and discrimination by the providers of PAC services before the complications arises. This study did not cover all the districts to identify the challenges on delaying PAC service. Therefore, this study recommends additional clinical, operations and community research which will give broader details and understanding on the challenges that cause delay for seeking immediate post abortion care services. / NRF