Abstract

The use of misoprostol for abortifacient purposes is a phenomenon observed in Brazil since the late 1980s. The drug started to be used at that time for self-induced abortion, when it began to be commercialized for the treatment of peptic ulcer. Its access was restricted from 1998 onwards, but the drug continues to be commercialized illegally. The objective of this article is to summarize the knowledge produced by research in Brazil about induced abortion and the use of misoprostol. An integrative review of original studies carried out in Brazil and published in journals indexed in SciELO, PubMed and Lilacs databases was performed. The search found 68 titles, and 28 articles were included in the review. Most women who induced pregnancy interruption were young and did it before 15 gestational weeks. The rate of misoprostol use ranged from 89% to 36%. This drug is effective for terminating pregnancy in the first trimester and has a low rate of complications. However, the more socially vulnerable the woman is, the greater are the health risks in the abortion process. The conclusion is that the purchase of misoprostol as an abortifacient is facilitated, despite it being prohibited, and its complications are associated with the context of vulnerability of the pregnant woman.

Key words:
Abortion; Misoprostol; Abortifacient agents

Introduction

The use of misoprostol for abortifacient purposes is a phenomenon observed in Brazil since the late 1980s. Due to the context of illegality of abortion in the country, included in the penal code in 1830 and reaffirmed in the penal codes of 1890 and 1940, misoprostol started to be used as an alternative for self-induction of abortion, even though its commercialization was authorized for the treatment of peptic ulcer¹1 Lowy I, Correa MCDV. The "abortion pill" misoprostol in Brazil: women's empowerment in a conservative and repressive political environment. Am J Public Health 2020; 110(5):677-684..

As the drug is a prostaglandin, it is contraindicated for pregnant women because it induces uterine contractions due to its uterotonic action. The knowledge of this collateral effect rapidly spread and between 1986 and 1998 the drug was commercialized in pharmacies to women who wished to interrupt pregnancy. In 1998, its commercialization was forbidden²2 Faúndes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol. Adv Contracept 1996; 12(1):1-9.. Despite the prohibition, the commercialization of the drug is made illegally until the present time³3 Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Cien Saude Colet 2012; 17(7):1671-1681..

Illegality did not cease the practice of abortion, considering that one in every five women until 40 years old has made, at least, one abortion in her reproductive trajectory. Data of a recent study demonstrate that there are annually at least 503 thousand abortions in Brazil, which corresponds to 1,300 women per day⁴4 Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Cien Saude Colet 2017; 22(2):653-660.. The same research found evidence that 48% of the totality of abortions were made with the use of drugs. Studies on this theme found that the rate of misoprostol use varied from 89% a 36%⁵5 Chaves JHB, Pessini L, Bezerra AFSB, Guilhermina R, Nunes, Rui. A interrupção da gravidez na adolescência: aspectos epidemiológicos numa maternidade pública no nordeste do Brasil. Saude Soc 2012; 21(1):246-256.^,66 Silva DFO, Bedone AJ, Faúndes A, Fernandes MAS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. Consequência do uso de misoprostol? Rev Bras Saude Mater Infant 2010; 10(4):441-447..

Women have been using misoprostol for the interruption of pregnancy as one of the options to conduct their decisions about their reproductive life⁷7 Arilha MM. Misoprostol: percursos, mediações e redes sociais para o acesso ao aborto medicamentoso em contextos de ilegalidade no estado de São Paulo. Cien Saude Colet 2012; 17(7):1785-17947.. After the bleeding that results from the use of the drug, half of the women seek hospital care, either to certify the completion of the abortion or for the treatment of complications⁴4 Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Cien Saude Colet 2017; 22(2):653-660.. The literature points out that the doses of misoprostol used are various, demonstrating a gap regarding the access to information about the dose, the ways of administration, contraindications and the necessary care in the post-abortion³3 Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Cien Saude Colet 2012; 17(7):1671-1681..

This review study aims to synthesise the knowledge produced by empirical researches in the field of health focused on the interruption of pregnancy with the use of the drug misoprostol, specifically in Brazilian studies. Our intention is to provide subsidies to policies and programmes that contribute to the reduction of risks to women’s health. It should be stressed that the search in the literature was performed with the word misoprostol, but this is not the only method used in Brazil for self-induction of abortion; this may represent a bias in relation to other methods that are not the object of this article.

Method

This is a study of integrative literature review of researches conducted in Brazil and published in periodicals indexed on the databases of SciELO (Scientific Electronic Library Online), PubMed (National Library of Medicine) and LILACS (Latin American and Caribbean Health Sciences Literature). The search was carried out on 14 March 2020 using the descriptors abortion and misoprostol on SciELO; abortion, misoprostol and Brazil on PubMed and LILACS databases. The search found 68 titles. The filter of studies conducted in Brazil was applied due to the authors’ interest in analysing the magnitude of the use of the drug for self-induction of abortion in the country, considering that the theme has been investigated since the 1990s.

Of the 68 titles found, 22 duplicates were removed. The remaining 46 titles and abstracts were read and 18 were excluded, according to the criteria: six studied other themes, two were not empirical researches, four were literature reviews, four were researches developed in other countries, one was a title in German, and one study was not found (Figure 1).

The analysis of content of the articles was made by means of the following steps: critical reading and rereading of the texts; search for similarities and divergences; data classification by themes; interpretative synthesis according to the objectives of the study. The articles were classified in five categories: I) sociodemographic and reproductive characteristics of women who interrupted pregnancy; II) abortive trajectory in the context of clandestinity; III) impacts on health of women who interrupt pregnancy; IV) abortive efficacy and teratogenicity of misoprostol; V) misoprostol in the media and the judiciary.

Besides the 28 titles included in the review (Chart 1) and presented in the results, this study added eight articles¹1 Lowy I, Correa MCDV. The "abortion pill" misoprostol in Brazil: women's empowerment in a conservative and repressive political environment. Am J Public Health 2020; 110(5):677-684.^,22 Faúndes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol. Adv Contracept 1996; 12(1):1-9.^,44 Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Cien Saude Colet 2017; 22(2):653-660.^,3333 Swarc L, Vazquez SSF. "Lo quería hacer rápido, lo quería hacer ya": tiempos e intervalos durante el proceso de aborto. Sex Salud Soc 2018; 28:90-115.^,3434 Cardoso BB, Vieira FMSB, Saraceni V. Aborto no Brasil: o que dizem os dados oficiais? Cad Saude Publica 2020; 36(Supl. 1):e00188718.^,3838 Vauzelle C, Beghin D, Cournot MP, Elefant E. Birth defects after exposure to misoprostol in the first trimester of pregnancy: prospective follow-up study. Reprod Toxicol 2013; 36:98-103.

39 Koren G, Schuler L. Taking drugs during pregnancy: how safe are the unsafe? Can Fam Physician 2001; 4(5):951-953.^-4040 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção Humanizada ao Abortamento: norma técnica. Brasília: MS; 2005., one doctoral dissertation³²32 Goes EF. Racismo, aborto e atenção à saúde: uma perspectiva interseccional [tese]. Salavador: Universidade Federal da Bahia; 2018, a book chapter³⁶36 Cook RJ, Dickens BM, Fathalla MF. Saúde reprodutiva e direitos humanos: integrando medicina, ética e direito. 1ª ed. Rio de Janeiro: CEPIA; 2004., data of the Ministry of Health³⁵35 Brasil. Ministério da Saúde (MS). Sistema de Informações sobre Mortalidade. [acessado 2022 jan 23]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/mat10uf.def
http://tabnet.datasus.gov.br/cgi/deftoht... (MS) on mortality from abortion, and an official document of the MS for the introduction and discussion of the theme under study⁴⁰40 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção Humanizada ao Abortamento: norma técnica. Brasília: MS; 2005..

Results and discussion

Most of the studies was developed with quantitative methods (n = 15), nine investigations used a qualitative approach, three used a combination of qualitative and quantitative methods, and one study is a case report. Of the 15 quantitative studies, 11 were cross-sectional researches, two studies were case control, one was a clinical essay, and one was a case study. Of the nine qualitative investigations, one was conducted using documental research and interviews, one using analysis of narrative, and seven using interviews. Most of the articles was published in the 2010s (n = 19). Five articles are from the 1990s, only two articles were published in the decade of 2000, and two articles in 2020/2021. In relation to the geographic region, the results show that nine investigations were multicentre, 13 were conducted in the Northeast region, four in the Southeast region, and two were conducted in the South region.

Sociodemographic and reproductive characteristics of women who interrupted pregnancy (Category I)

Six studies were included only in category I and two articles were considered as category I and category III, hence category I totalized eight studies. The investigations made evident that the majority of women who interrupted pregnancy was young⁹9 Ramos KS, Ferreira ALCG, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44(3):605-610.^,1010 Fonseca W, Misago C, Freitas P, Santos FL, Correia LL. Características sociodemográficas, reprodutivas e médicas de mulheres admitidas por aborto em hospital da Região Sul do Brasil. Cad Saude Publica 1998; 14(2):279-286.^,1111 Fonseca W, Misago C, Correia LL, Parente JAM, Oliveira FC. Determinantes do aborto provocado entre mulheres admitidas em hospitais em localidade da região Nordeste do Brasil. Rev Saude Publica 1996; 30(1):13-18.^,2727 Misago C, Fonseca W, Correia L, Fernandes LM, Campbell O. Determinants of abortion among women admitted to hospitals in Fortaleza, North Eastern Brazil. Int J Epidemiol 1998; 27(5):833-839.^,2929 Coêlho HL, Teixeira AC, Cruz Mde F, Gonzaga SL, Arrais PS, Luchini L, La Vecchia C, Tognoni G. Misoprostol: the experience of women in Fortaleza, Brazil. Contraception 1994; 49(2):101-110.^,3131 Araújo MCR, Mochel EG. Aborto provocado: fatores associados em mulheres admitidas em maternidades públicas em São Luis/MA. Rev Paul Enferm 2007; 27(2):79-86. and did the procedure before 15 weeks of pregnancy⁵5 Chaves JHB, Pessini L, Bezerra AFSB, Guilhermina R, Nunes, Rui. A interrupção da gravidez na adolescência: aspectos epidemiológicos numa maternidade pública no nordeste do Brasil. Saude Soc 2012; 21(1):246-256.^,99 Ramos KS, Ferreira ALCG, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44(3):605-610.. The identification of induced interruption presented variation between 25% and 94% of the cases studied in the investigations⁸8 Nader PRA, Blandino VRPM, Maciel ELN. Características de abortamentos atendidos em uma maternidade pública do Município da Serra-ES. Rev Bras Epidemiol 2007; 10(4):615-624.^,2828 Nunes Md, Madeiro A, Diniz D. Histórias de aborto provocado entre adolescentes em Teresina, Piauí, Brasil. Cien Saude Colet 2013; 18(8):2311-2318.. In the present days, it is still not easy to identify the induction of pregnancy interruption, due to the criminalization of abortion in the country.

Ramos et al. (2010)⁹9 Ramos KS, Ferreira ALCG, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44(3):605-610., in a study conducted in Recife, state of Pernambuco (PE), with 160 women admitted to hospital with characteristics of abortion until the 20th week, made evident that the majority of them was between 20 and 29 years old (48.9%) and had eight or more years of education (72%). Only ten per cent did not have a partner. Regarding the knowledge of contraceptive methods, the totality of the participants knew the contraceptive pill and the male condom.

Chaves et al. (2012)⁵5 Chaves JHB, Pessini L, Bezerra AFSB, Guilhermina R, Nunes, Rui. A interrupção da gravidez na adolescência: aspectos epidemiológicos numa maternidade pública no nordeste do Brasil. Saude Soc 2012; 21(1):246-256., in a study conducted in Maceió, state of Alagoas (AL), with 201 adolescents admitted to a maternity, corroborate Ramos⁹9 Ramos KS, Ferreira ALCG, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44(3):605-610. regarding the gestational age lower than 15 weeks that prevails in cases of provoked abortion. Moreover, provoked abortion happened mostly in adolescents without children and with stable partners. In most cases, the interrupted pregnancy had not been planned.

A study carried out by Fonseca et al. (1998)¹⁰10 Fonseca W, Misago C, Freitas P, Santos FL, Correia LL. Características sociodemográficas, reprodutivas e médicas de mulheres admitidas por aborto em hospital da Região Sul do Brasil. Cad Saude Publica 1998; 14(2):279-286. in Florianópolis, state of Santa Catarina (SC), with 620 women admitted to hospital care with a diagnosis of pregnancy interruption reinforces data found by Ramos⁹9 Ramos KS, Ferreira ALCG, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44(3):605-610. regarding the prevalence of age between 20 and 29 years. A research conducted in Fortaleza, state of Ceará (CE), with 4,359 women demonstrated a majority in the same age group¹¹11 Fonseca W, Misago C, Correia LL, Parente JAM, Oliveira FC. Determinantes do aborto provocado entre mulheres admitidas em hospitais em localidade da região Nordeste do Brasil. Rev Saude Publica 1996; 30(1):13-18.. In the study in Florianópolis¹⁰10 Fonseca W, Misago C, Freitas P, Santos FL, Correia LL. Características sociodemográficas, reprodutivas e médicas de mulheres admitidas por aborto em hospital da Região Sul do Brasil. Cad Saude Publica 1998; 14(2):279-286., 53.9% of the women did not use a contraceptive method, whereas 20.6% referred the use of contraceptive pill and 5.7% the use of condom. The motives for not using contraceptive methods among women without a stable partner included: neglect, lack of expectation of having a sexual relation, and fear of adverse effects. The unavailability of contraceptive methods was mentioned by less than 5% of the interviewees. In the investigation conducted in the Northeast region of Brazil¹¹11 Fonseca W, Misago C, Correia LL, Parente JAM, Oliveira FC. Determinantes do aborto provocado entre mulheres admitidas em hospitais em localidade da região Nordeste do Brasil. Rev Saude Publica 1996; 30(1):13-18. with 4,359 women, the unavailability of contraceptive methods was mentioned by 8% of the participants.

A population research of national scope demonstrated that abortion rates were higher among women with low education level (until the fourth grade) (22%), total family income until one minimum wage (16%), and yellow, black, brown, and indigenous (from 13% to 25%) women, rather than among white women (9%)⁴4 Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Cien Saude Colet 2017; 22(2):653-660..

When looking into race/ethnicity data, a study conducted in the Northeast region with 2,640 women made evident that “the interruption of pregnancy occurred belatedly among black women (15.4% vs. 11.1% among brown and 11.4% among white)” (p. 69)³²32 Goes EF. Racismo, aborto e atenção à saúde: uma perspectiva interseccional [tese]. Salavador: Universidade Federal da Bahia; 2018.

Abortive trajectory in the context of clandestinity (Category II)

The ten studies included in this category evidenced the following phases of the process of abortion with misoprostol: 1) the news of pregnancy; 2) making the decision of abortion; 3) seeking information and establishing bonds; 4) obtaining the drug; 5) using the drug; 6) eliminating and certifying the completion of abortion³³33 Swarc L, Vazquez SSF. "Lo quería hacer rápido, lo quería hacer ya": tiempos e intervalos durante el proceso de aborto. Sex Salud Soc 2018; 28:90-115.. The trajectory undergone by women who induced abortion with misoprostol can be exemplified by the course described by Porto and Sousa (2017)¹⁶16 Porto RM, Sousa CHD. "Percorrendo caminhos da angústia": itinerários abortivos em uma capital nordestina. Rev Estud Fem 2017; 25(2): 593-616., in which the medicament was used at home and seeking hospital care happened after the appearance of symptoms related to the drug’s effects, such as pain and bleeding.

A study conducted with 122 women in five state capitals of Brazil found some common characteristics in the first abortion: age under 19 years, women with children, and black. Abortion started at home and was concluded at a hospital. Teas, liquids and herbs were used with the purpose of regulating the menstruation. Misoprostol was used in over half of the cases of induced abortion (52%), isolated or in association with teas, liquids and herbs. Curettage in private clinics was made in over a third of the interviewed women (36%). Most of the women was not attended in hospitals (64%)³3 Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Cien Saude Colet 2012; 17(7):1671-1681., which demonstrates a low search for health services to certify the completion of the abortion.

Another relevant fact regards the ill-treatment received when looking for health services. Moral sanctions, threat of denouncement and long waiting are examples of situations faced. Older women, in general, omitted the induction, with the purpose of protecting themselves from denouncement and ill-treated²⁰20 Zordo S. The biomedicalisation of illegal abortion: the double life of misoprostol in Brazil. Hist Cienc Saude Manguinhos 2016; 23(1):19-36..

The fear of facing this type of situation has been evidenced in a study conducted in the Northeast of the country with 2,640 women, in which the fear reported by black women when seeking care in the post-abortion was referred to by 13% of the participants, more than twice in relation to white women (5.9%)³²32 Goes EF. Racismo, aborto e atenção à saúde: uma perspectiva interseccional [tese]. Salavador: Universidade Federal da Bahia; 2018.

Another investigation conducted in the Northeast found discriminatory situations undergone by women when seeking assistance. “The nurse made me look at the foetus”, recalled in an interview with researchers an adolescent who used misoprostol, and continued, “she insisted with me to see it. I found this terrible.”²⁸ (p. 2316). The authors of this research also indicated that in cases when health professionals notice the abortion induction, there might occur institutional violence, as exemplified in the case of an adolescent:

In an investigation conducted by Arilha (2012)⁷7 Arilha MM. Misoprostol: percursos, mediações e redes sociais para o acesso ao aborto medicamentoso em contextos de ilegalidade no estado de São Paulo. Cien Saude Colet 2012; 17(7):1785-17947., it was demonstrated that when deciding to make the abortion with misoprostol, factors such as price, safety, preservation of the identity and privacy are taken into consideration, besides the fact of not having to inform personal data to make the abortion in a private clinic. About making the abortion in a private clinic, one participant of the study mentioned: “There are places that are very precarious, it is dangerous…” (p. 1789). However, buying the medicament is not simple, and it counts with the participation of men. Different strategies can be used in the process of purchase and factors such as social networks in which women are inserted and mediators are involved usually influence the outcome. To buy misoprostol it is necessary to know the correct codes, in a place of possible commercialization. Not knowing such a place means that the search for the medicament becomes slow and anguishing. To induce an abortion, it is a race against time, considering that the sooner the abortion is performed, the greater the chances of it being concluded without complications for the woman¹⁶16 Porto RM, Sousa CHD. "Percorrendo caminhos da angústia": itinerários abortivos em uma capital nordestina. Rev Estud Fem 2017; 25(2): 593-616.^,2222 Arcanjo FCN, Ribeiro AS, Teles TG, Macena RHM, Carvalho FHC. Uso do misoprostol em substituição à curetagem uterina em gestações interrompidas precocemente. Rev Bras Ginecol Obstet 2011; 33(6):276-280..

It is important to stress that the commercialization of misoprostol in the illegal market, due to its unlawful circulation, can present a wide variation of prices. In a consultation with a supplier in the Southeast region of Brazil, the price of each tablet was R$137.50 in January 2022, plus the delivery fee. The consultation was made by a person who needed the medicament for an abortion in January 2022. The supplier sent the price by WhatsApp message.

Impacts on health of women who interrupted pregnancy (Category III)

Three articles were included only in this category, in addition to two studies classified in two categories, I and III. The studies highlighted that the impacts on the health of women who use misoprostol vary according to the social context. In these studies, no obits related to abortion were found.

A research conducted in Salvador, state of Bahia (BA), with twenty women who were assisted at a public maternity revealed that the majority was black and young. Abortion induction began with herbs, which in most cases have no efficacy. Misoprostol was then used in a dosage between one and four tablets, both orally taken and introduced in the vagina. The search for medical care occurred when bleeding and pain became intense. Due to the high price, misoprostol is not always accessible, thus exposing women to less safe methods. A health professional reported that because poverty permeates the lives of people in the region, women act desperately when discovering a pregnancy that they do not want to bring to completion, and therefore use dangerous methods, as for instance the insertion of “chumbinho” in the vagina²⁰20 Zordo S. The biomedicalisation of illegal abortion: the double life of misoprostol in Brazil. Hist Cienc Saude Manguinhos 2016; 23(1):19-36..

Chaves (2012)⁵5 Chaves JHB, Pessini L, Bezerra AFSB, Guilhermina R, Nunes, Rui. A interrupção da gravidez na adolescência: aspectos epidemiológicos numa maternidade pública no nordeste do Brasil. Saude Soc 2012; 21(1):246-256. stresses that abortion is a common practice in women’s reproductive lives, regardless of social class, age, religion and marital status. However, the availability of financial resources interferes directly in the risks to which the adolescents submit themselves. Besides, even if the abortion induction is made with misoprostol, high doses might put women’s health and lives in danger, due to the risk of uterine rupture⁶6 Silva DFO, Bedone AJ, Faúndes A, Fernandes MAS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. Consequência do uso de misoprostol? Rev Bras Saude Mater Infant 2010; 10(4):441-447..

An investigation conducted by Silva et al (2010)⁶6 Silva DFO, Bedone AJ, Faúndes A, Fernandes MAS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. Consequência do uso de misoprostol? Rev Bras Saude Mater Infant 2010; 10(4):441-447. in Campinas, state of São Paulo (SP), assessed the complications in women admitted at hospital from abortion (n = 259). The researcher found infectious (10%) and haemorrhagic (13%) complications. No cases were found of severe infection and bleeding that resulted in hysterectomy during the period of the study.

A research conducted in Recife with 1,840 women revealed the rate of 9.5% of infections in pregnancies interrupted until the 24th week and of 23% after the 25th week. In relation to severe infections, the rate was of 1.4% in pregnancies interrupted until the 24th week and of 3.1% after the 25th week. When the rate of complications was compared with the type of abortion and the method used, data demonstrated a rate of 7.9% of infections and 0.9% of severe infections for the cases of spontaneous abortion; 4.2% of infections and 0.8% of severe infections for the cases of abortion induced with misoprostol; and 49.4% of infections and 14.6% of severe infections for the cases induced with other methods. Thus, among women who induced abortion, those who made it with misoprostol presented twelve times lower chance of infection²2 Faúndes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol. Adv Contracept 1996; 12(1):1-9..

An investigation conducted in the Northeast of the country with 2,640 women in post-abortion care, identified that black and brown women presented proportions twice as high of regular, severe or very severe conditions, in comparison with white women when arriving at the hospital. Black women reported greater institutional barriers in comparison with brown and white women when seeking post-abortion care³²32 Goes EF. Racismo, aborto e atenção à saúde: uma perspectiva interseccional [tese]. Salavador: Universidade Federal da Bahia; 2018.

It should also be highlighted that between 2006 and 2015, the obits resulting from abortion were more frequent in the age group between 20-29 years. The maternal mortality ratio (MMR) specific for abortion according to skin colour was higher in black women from 2006 to 2012. In 2013 and 2014, the indigenous women had higher MMR³⁴34 Cardoso BB, Vieira FMSB, Saraceni V. Aborto no Brasil: o que dizem os dados oficiais? Cad Saude Publica 2020; 36(Supl. 1):e00188718..

Considering that there is no specific code for induced abortion in the International Classification of Diseases (ICD-10), this review study extracted from Datasus (Brazilian National Health Information System) the data on obits from indirect forms of abortion, with the selection of cases of non-specified abortion (category O06 of ICD-10), other types of abortion (O05), and failure in the attempt of abortion (O07). Between 2015 and 2019, the obits from these causes in black and brown women (N=135) were more than double the number in relation to white women (n = 70)³⁵35 Brasil. Ministério da Saúde (MS). Sistema de Informações sobre Mortalidade. [acessado 2022 jan 23]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/mat10uf.def
http://tabnet.datasus.gov.br/cgi/deftoht... .

Since the beginning of the use of misoprostol for abortion purposes in Brazil, in 1989, women’s deaths decreased due to the use of less invasive methods, with a reduction of 83.3% of death risks between 1990 and 2012, although maternal mortality data are underdiagnosed³⁴34 Cardoso BB, Vieira FMSB, Saraceni V. Aborto no Brasil: o que dizem os dados oficiais? Cad Saude Publica 2020; 36(Supl. 1):e00188718.. However, although the maternal mortality rate from abortion has decreased, it does not mean that the process of abortion has the expected safety, because the studies evidenced situations of precariousness in hospital care after the realization of self-induced abortion. Furthermore, the posture of the State in not recognizing the magnitude of the utilization of medicaments for abortion has sustained the position of not providing an integral care to women who induce abortion.

The General Assembly of the International Federation of Gynaecology and Obstetrics (FIGO) adopted in 2000 the Resolution on Reproductive and Sexual Health as women’s rights, affirming that “improvements in women’s health need more than better science and health care; they require state action to correct injustices to women”³⁶36 Cook RJ, Dickens BM, Fathalla MF. Saúde reprodutiva e direitos humanos: integrando medicina, ética e direito. 1ª ed. Rio de Janeiro: CEPIA; 2004..

Abortive efficacy and teratogenicity of misoprostol (Category IV)

One apprehension about using misoprostol for self-induction of abortion was related to the fear of causing harm to the newborn’s health in case of failure in the attempt to abort. There are scarce studies on the abortive efficacy and teratogenicity of misoprostol in Brazil. Four articles were included in this category.

Regarding the abortive efficacy, Arcanjo et al. (2011)²²22 Arcanjo FCN, Ribeiro AS, Teles TG, Macena RHM, Carvalho FHC. Uso do misoprostol em substituição à curetagem uterina em gestações interrompidas precocemente. Rev Bras Ginecol Obstet 2011; 33(6):276-280. conducted a clinical essay with misoprostol for uterine emptying after foetus loss, which presented an efficacy rate of 80.3%. However, the number of participants was relatively small. A meta-analysis conducted by Raymond (2019)³⁷37 Raymond E, Harrison MS, Weaver MA. Efficacy of misoprostol alone for first-trimester medical abortion: a systematic review. Obstet Gynecol 2019; 133(1):137-147. concluded that the administration of misoprostol for the interruption of pregnancy in the first trimester was efficacious and presented a low rate of complications. Nevertheless, the authors highlight the importance of monitoring its use to detect failures, besides the need to collect complementary data on the dose and administration route.

Regarding the teratogenicity of misoprostol, two investigations evidenced the possible association of its use to eight cases of congenital malformation²³23 Bernardi P, Graziadio C, Rosa RFM, Pfeil JN, Zen PRG, Paskulin GA. Fibular dimelia and mirror polydactyly of the foot in a girl presenting additional features of the VACTERL association. Sao Paulo Med J 2010; 128(2):99-101.^,2424 Opaleye ES, Coelho HLL, Faccini LS, Almeida PC, Santos EC, Ribeiro AJV, Costa FS. Avaliação de riscos teratogênicos em gestações expostas ao misoprostol. Rev Bras Ginecol Obstet 2010; 32(1):19-35.. Vauzelle et al. (2013)³⁸38 Vauzelle C, Beghin D, Cournot MP, Elefant E. Birth defects after exposure to misoprostol in the first trimester of pregnancy: prospective follow-up study. Reprod Toxicol 2013; 36:98-103. found a rate of around 2% of congenital malformations in newborns and foetuses exposed to misoprostol.

A case report published in Brazil by Bernardi et al. (2010)²³23 Bernardi P, Graziadio C, Rosa RFM, Pfeil JN, Zen PRG, Paskulin GA. Fibular dimelia and mirror polydactyly of the foot in a girl presenting additional features of the VACTERL association. Sao Paulo Med J 2010; 128(2):99-101. discusses the disruptive vascular effect caused by misoprostol, which may lead to foetal malformations related to craniofacial structures and in body members. The spectrum of malformations of the report suggests an association with teratogenicity in the period of foetal organogenesis. However, more studies are needed on this issue.

Malformation in newborns occur in 1% to 3% of the general population and any malformation is rare, which hinders the attribution of malformation to a medicament or substance. Children born with Moebius syndrome are thirty times more likely to have been exposed to misoprostol inside the uterus, when compared to newborns with other malformations. Even though the probability is higher than thirty times, Moebius syndrome is rare (one case in every 50 thousand to 100 thousand births), thus there is a low risk of malformation³⁹39 Koren G, Schuler L. Taking drugs during pregnancy: how safe are the unsafe? Can Fam Physician 2001; 4(5):951-953..

Misoprostol in the media and the judiciary (Category V)

Three studies were included in this category. The approach of Brazilian media to misoprostol is mostly related to the apprehension of illegally commercialized medicaments. There has been no identification in journalistic texts of information that misoprostol is considered by the World Health Organization (OMS) as an essential medicament. Physicians perform a double role, at times helping women, at times as agents who denounce them¹⁷17 Diniz D, Castro R. O comércio de medicamentos de gênero na mídia impressa brasileira: misoprostol e mulheres. Cad Saude Publica 2011; 27(1):94-102.. It is noteworthy that women are the target of the news when the emphasis changes to abortion provoked by medicaments.

In an analysis of six police investigations and four criminal proceedings, Diniz e Madeiro (2012)¹²12 Diniz D, Madeiro A. Cytotec e aborto: a polícia, os vendedores e as mulheres. Cien Saude Colet 2012; 17(7):1795-1804. identified three cases of denouncements against women who induced abortion at home and ended up in a public hospital in the Federal District, demonstrating how a health institution can be a place of threat to women. According to the Technical Norm of the Ministry of Health, “in face of spontaneous or provoked abortion, the physician or any health professional cannot communicate the fact to the authorities ‒ police, judicial, or Public Prosecution Office ‒ because the professional secrecy in the practice of health care is a legal and ethical duty”⁴⁰ (p. 14). The study by Diniz e Madeiro (2012)¹²12 Diniz D, Madeiro A. Cytotec e aborto: a polícia, os vendedores e as mulheres. Cien Saude Colet 2012; 17(7):1795-1804. demonstrated the breach of recommendation about secrecy preconized by the Technical Norm, with the violation of the right to secrecy of women who were denounced.

An investigation of 331 court decisions about misoprostol revealed that in 77.6% of the cases, the crime associated to the medicament was against public health. The crime of drug traffic corresponded to 9.9% of the cases and smuggling was cited in 6.9% of the cases. The crime of abortion was associated to the medicament in 8.4% of the cases²⁵25 Assis MP. Misoprostol on trial: a descriptive study of the criminalization of an essential medicine in Brazil. Cad Saude Publica 2021; 37(10):e00272520..

Final considerations

Abortion is a common event in women who were young, married or single, with gestational age inferior to 15 weeks, but with belated interruption in black women. The use of misoprostol for the interruption of pregnancy was frequent and it was an alternative sought due to price and safety. Around half of the women who used the medicament needed hospitalisation for the completion of the abortion, finding hindrances in obtaining hospital care and undergoing ill-treatment.

It is noteworthy that the use of misoprostol has decreased mortality from abortion in Brazil. However, the induction of abortion with the medicament is a painful and unsafe process for women, especially for those who live in contexts of greater vulnerability, as the young, black and brown, and with low education level. To these aspects should be added gender inequities and the criminalization of abortion.

Misoprostol is an object of journalistic reports and juridical decisions. In the media, the emphasis is mostly related to the illegal commercialization of the medicament and it is a target of police news, with stress on suppliers of the medicament and input apprehension. In the juridical sphere, most of the decisions are categorised as crime against public health.

References

Publication Dates

History