1. Panel:“Medical abortion pills: how and where do women get them.” Midwife Ana Labandera Monteblanco Director Iniciativas Sanitarias - Uruguay Risk and Harm reduction Model

2. Population: 3.3 million Maternal Mortality: 23 / 100.000 live births Abortion penalized by law since 1938. Exceptions: Preserve life of the woman Rape Extreme poverty Unsafe Abortion was the leading cause of maternal mortality in 2001. 10/25/2015 Uruguay

3. In 2001, an NGO, Iniciativas Sanitarias (IS), developed a program to decrease maternal morbidity and mortality from unsafe abortion and the incidence of unsafe abortion 10/25/2015 This program is part of the Sexual & Reproductive Health Law since 2008 This program is part of the Sexual & Reproductive Health Law since 2008 Iniciativas Sanitarias – Health Initiatives

4. ICPD Paragraph 8.25 and ICPD+5 Paragraph 63i. “Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling” Our Model follows this important recommendation.

5. Risk and Harm Reduction Strategy –Philosophical education strategy without moral opinion about risk behaviors (Unsafe abortion) Professional Values – medical and health care team values. – Vocation – Discipline – Competence – Commitment Bioethics Approach –Respect and promote autonomy –Beneficence –Non maleficence –Justice Human Rights approach –Right to Health care assistance –Right to information of scientific progress Legal Issues and Local Context –Professional Secrecy - Confidentiality The framework of the model emphasizes

6. 1- TO DIMINISH MATERNAL MORBIDITY AND MORTALITY 2- TO DECREASE THE NEED TO HAVE AN ABORTION, AND THUS, THE OVERALL ABORTION RATE 1- THE OBJECTIVE

7. ABORTION ILLEGALABORTION BEFOREBEFORE AFTER AFTER THE NEW APPROACH OF “Iniciativas Sanitarias” PROGRAM THE NEW APPROACH OF “Iniciativas Sanitarias” PROGRAM 10/25/2015

8. We speak with the woman, face to face, in a horizontal relationship, taking our time to listen to her instead of censoring her, trying to clarify the reason between the two of us: why she thinks she needs an abortion, and what she really feels, deep in her heart. It is necessary to align the “thinking and the feeling”, to avoid women feeling guilty or depressed later. We allow them some time to reflect, and decide with freedom. This is reinforced with a multidisciplinary consultation with the gynecologist or the midwife, (or either of them) with the psychologist. BEFOREBEFORE

9. Carrying out a situation diagnosis Evaluating risk and protection factors Assessing decision level of the users Carrying out therapeutic interventions Identifying the indicators pointing to possible post-abortion mental health increased damages. Referring the patient, or carrying out a follow up, when necessary. 10/25/2015 Ob-gyn or Midwife + psychologist Appointment

10. ABORTION ILLEGAL DENIEDABORTION ILLEGAL DENIEDBEFORE 1- Counseling regarding alternatives to abortion 2- Information about abortion methods and their risks: empowerment. (including Misoprostol) 3- Epidemiological analysisBEFORE 1- Counseling regarding alternatives to abortion 2- Information about abortion methods and their risks: empowerment. (including Misoprostol) 3- Epidemiological analysis AFTER POST-ABORTION CARE 1- Damage Prevention 2- Integral rehabilitation 3- Future contraception (Diminishing the abortion rate)AFTER POST-ABORTION CARE 1- Damage Prevention 2- Integral rehabilitation 3- Future contraception (Diminishing the abortion rate) THE GUIDELINES 10/25/2015

11. NUMER OF USERS ASSISTED UNDER THE MODEL: 3215  PERIOD March/2004 – July/2009 METHODOLOGY IMPLEMENTATION OF HEALTH INITIATIVES RISK-REDUCTION MODEL IN THE MAIN WOMEN THIRD LEVEL HEALTH CENTER OF URUGUAY 10/25/2015 Project supported by: F.I.G.O IPAS SAAF IPPF OMS UNFPA

12. METHODOLOGY Data was collected using a pre-designed form for the “before-abortion” and “after-abortion” visit, filled by the professionals and identified with a number IMPLEMENTATION OF HEALTH INITIATIVES RISK-REDUCTION MODEL 10/25/2015 PEREIRA ROSSELL HOSPITAL: MAIN WOMEN THIRD LEVEL HEALTH CENTER OF URUGUAY PEREIRA ROSSELL HOSPITAL: MAIN WOMEN THIRD LEVEL HEALTH CENTER OF URUGUAY

13. Age distribution 10/25/2015 Less than 15 16 to 19 20 to 34 more than 35 No data

14. 84,9 % before 13 weeks “Gestational Age” in patients who required our service.

15. CONTRACEPTION AND UNWANTED PREGNANCY “BEFORE” VISITS (n: 2206) 10/25/2015

16. REASONN% INTERFERENCE WITH HER LIFE PROJECT 85138,6% ECONOMICS PROBLEMS 87339,6% NO PARTNER 27212,3% SEXUAL VIOLENCE 231,0% TOO MANY CHILDREN 1677,6% OTHERS 24311,0% Main reasons given when looking for an abortion 10/25/2015

17. The main fears that women express PRE-ABORTION Access to misoprostol Health Failure of misoprostol No Fears Death

18. RESULTS IN RELATION WITH THE USE OF MISOPROSTOL RESULTS

19. II Home use of misoprostol to interrupt pregnancy II Home use of misoprostol to interrupt pregnancy Use of misoprostol in the sample analysed. Method usedN% Misoprostol 44889,6 Misoprostol + LEC 30,6 Total misoprostol 45190,2 Other 40,8 Total 45591

20. II Home use of misoprostol to interrupt pregnancy II Home use of misoprostol to interrupt pregnancy Self-administration of misoprostol Route of administration N% Muccal mucosa 5111,3 Oral 112,4 Vaginal 32572,1 Combined6013,3 USE OF MISOPROSTOL451

21. II Home use of misoprostol to interrupt pregnancy II Home use of misoprostol to interrupt pregnancy Misoprostol dose used Dose Used (mcg) N% 400265,8 600122,7 80036781,4 900-1500143,1 1.600102,2 > 160071,6 USE OF MISOPROSTOL451 81,4 % 1 or 2 doses

22. II Home use of misoprostol to interrupt pregnancy II Home use of misoprostol to interrupt pregnancy Time between self-administration of misoprostol and expulsion. Time use/expulsionN% menos de 6 horas16235,9 6 to 11 hours13930,8 12 to 23 hours224,9 66,7 % under 12 hours USE OF MISOPROSTOL451

23. II Home use of misoprostol to interrupt pregnancy II Home use of misoprostol to interrupt pregnancy Post-use Complications of misoprostol ComplicationsN% Other mild 122,4 Mild infectious 71,6 Milb bleeding leves 102,0 NO COMPLICATIONS 42384,6 USE DE MISOPROSTOL451 84.6 WITHOUT COMPLICATIONS

24. Most women come to us after having decided to undergo an abortion Most common reasons for abortion: life PROJECT and economic problems 10% of women did not end up with illegal abortion 55% did engage in abortion but under safer conditions 21% continued with pregnancy Misoprostol (self-administered and in the context of the health program) is very effective and safe. CONCLUSIONS AND PERSPECTIVES

25. In the black market. Some women help others when they have extra pills. In friendly pharmacies. Through internet. Using cell phones in public restrooms at shopping malls. Very high prices. HOW AND WHERE

26. At the professional associations level, we are working for the Ministry of Public Health to enforce Act 18426 of Sexual and Reproductive Health Rights, and for it to regulate the ambulatory use of misoprostol to treat incomplete abortions. To prescribe or not to prescribe? Professionals as guarantors of sexual and reproductive rights HOW AND WHERE

27. CONCLUSIONS AND PERSPECTIVES Since 2004, Uruguay has been a country that, in spite of a restrictive abortion law, provides comprehensive health care services to women with unwanted pregnancies Maternal mortality has declined in recent years in hospital and throughout the country Patients visit the Service in earlier stages of pregnancy 10/25/2015

28. 5- PERSPECTIVES AND CHALLENGES EXPAND THIS SUCCESSFUL MODEL IN URUGUAY SHARE THE MODEL IN LATIN AMERICA AND BEYOND INCREASE PROFESSIONAL COMMITMENT WITH SEXUAL AND REPRODUCTIVE RIGHTS TRANFORM THE PROFESSIONAL – PATIENT RELATIONSHIP TO: –EMPOWER WOMEN –DEVELOP PROFESSIONAL VALUES

29. agl@montevideo.com.uy

32. ADMITED TO THE ICU DUE TO UNSAFE ABORTION COMPLICATIONS