Unsafe abortion in Brazil: a systematic review of the scientific production, 2008-2018

Rosa Maria Soares Madeira Domingues Sandra Costa Fonseca Maria do Carmo Leal Estela M. L. Aquino Greice M. S. Menezes About the authors

Abstract

This study sought to update knowledge on unsafe abortion in Brazil. We carried out a systematic review with study search and selection on MEDLINE and LILACS, with no language restriction, from 2008 to 2018. We evaluated article quality using the Joanna Briggs Institute instruments. We evaluated 50 articles. The prevalence of induced abortion in Brazil was estimated by a direct method to be 15% in 2010 and 13% in 2016. Higher prevalences were observed in more socially vulnerable populations. There was a decrease in the ratio of induced abortions by 1,000 women of reproductive age in the period 1995-2013, reaching 16 per 1,000 in 2013. Half of all women reported using medications for terminating pregnancies and the number of hospital admissions due to complications from abortion, especially severe complications, decreased from 1992 to 2009. Maternal morbimortality from abortion had a reduced frequency but reached high values in specific contexts. It is likely that maternal deaths from abortion are under-reported. Common mental disorders during pregnancy and postpartum depression were more frequent among women who unsuccessfully attempted to induce an abortion. Findings indicate that abortion is frequently used in Brazil, especially in less-developed regions and by more socially-vulnerable women. Access to safer methods probably contributed to the reduction in hospitalizations due to complications and to the reduction in morbimortality from abortion. However, half of all women still resort to other methods and the number of admissions due to complications from abortion is still high.

Keywords:
Induced Abortion; Systematic Review; Health Surveys


Introduction

Abortions may be classified as safe, less safe or unsafe, depending on the method used to induce them and the professionals responsible for providing them 11. Ganatra B, Gerdts C, Rossier C, Johnson Jr BR, Tunçalp Ö, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet 2017; 390:2372-81.. Between 2010 and 2014, it is estimated that, globally, 35 unsafe abortions occurred per 1,000 women aged between 15 and 44 years 22. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet 2016; 388:258-67. each year. According to another estimate, there were approximately 7 million hospital admissions due to complications from abortions in developing countries in 2012 33. Singh S, Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries. BJOG 2016; 123:1489-98.. With regard to the 1990-1994 period, there was an expressive, though unequal, decrease in unsafe abortions rates. There was a significant decrease from 46 to 27/1,000 in developed countries and a non-significant reduction of 39 to 37/1,000 in developing countries 22. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet 2016; 388:258-67.. Latin America stands out as one of the regions with the highest frequency of unsafe abortions (44/1,000), despite restrictive legislation in most of its countries, with the exception of Uruguay, Colombia and Cuba. In Brazil, abortion is legally allowed in cases of risk to the woman’s life, pregnancy resulting from rape and, since 2012, cases of fetal anencephaly.

In literature reviews of the subject in Brazil, in 2009 44. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. 20 anos de pesquisas sobre aborto no Brasil. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).,55. Menezes G, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204., findings already showed a reduction of abortions between 1991 and 1996, with stabilization until 2005. In 2005, based on hospitalizations recorded in the Brazilian Unified National Health System’s Hospital Information System (SIH/SUS, in Portuguese), it was estimated that around 1 million abortions took place every year in the country, corresponding to a rate of 20.7/1,000 women of reproductive age. Women turned to abortion regardless of socioeconomic position, race/color, age and religion, but unsafe practices were more common among young women with low educational levels, without a partner, who were students or domestic workers 55. Menezes G, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204.. Abortion was the cause of 11.4% of maternal deaths in the only available study, from 2002, conducted in state capitals and the Federal District 66. Laurenti R, Mello-Jorge MH, Gotlieb SLD. A mortalidade materna nas capitais brasileiras: algumas características e estimativa de um fator de ajuste. Rev Bras Epidemiol 2004; 7:449-60.. Regional inequalities were found and black women from the less privileged classes who lived in the peripheries were the most affected 55. Menezes G, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204.. Knowledge gaps identified at the time led to the recommendation of population studies, comparing different regions of the country, rural and urban areas, as well as the investigation of social determinants.

Though not all illegal abortions are unsafe, since they can be performed with adequate methods and by qualified professionals 77. Sedgh G, Filippi V, Owolabi OO, Singh SD, Askew I, Bankole A, et al. Insights from an expert group meeting on the definition and measurement of unsafe abortion. Int J Gynaecol Obstet 2016; 134:104-6., the illegality and clandestine nature of these abortions increases the health risks associated with the procedure. For this reason, we will use the term unsafe abortion to designate abortions not permitted by law. This study seeks to carry out a systematic review of estimates, characteristics of the women associated with unsafe abortions and complications from this practice in Brazil.

Methods

This is a systematic review on legal abortion and unsafe abortion in Brazil. All review stages were independently carried out by two researchers (R. M. S. M. D. and S. C. F.) following the recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 88. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche P, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6:e1000100. in their reporting. Results regarding legal abortions are presented in another article.

Eligibility criteria

We included original scientific articles published between 2008 and 2018 on legal abortion and unsafe abortion, which employed a quantitative methodology, with no restrictions regarding study design. The period was chosen based on the last published review of the subject, which included studies published up to December 2007. For unsafe abortions, we considered as eligible works that investigated estimates of its occurrence, characteristics of women associated with its occurrence and complications. For legal abortion, we considered as eligible all studies that investigated this subject.

We excluded studies that employed a qualitative methodology, non-systematic reviews, theoretical essays, research protocols, methodological articles, theses and dissertations, as well as studies that assessed diagnostic and therapeutic aspects of abortion.

Bibliographical search strategy

We consulted the electronic databases MEDLINE and LILACS. The keywords, which were used in combination, are described in Box 1. Additionally, we included references cited by the selected publications that met inclusion criteria. The electronic searches, with no language restrictions, were initiated in 10/Oct/2017, concluded in 06/Nov/2017 and later updated on 28/Feb/2019.

Box 1
Bibliographic search: descriptors and boolean operators.

Study selection

After manual exclusion of duplicates, we carried out an initial triage based on titles, excluding all those not related to unsafe abortions or legal abortions in Brazil. After reading the abstracts, articles that did not meet eligibility criteria were excluded. Other articles were excluded after being read in full. The entire selection process was carried out independently by two researchers, with the few disagreements being resolved through consensus.

Study quality assessment

Article quality was assessed based on instruments validated in the scientific literature, formulated by the Joanna Briggs Institute 99. Joanna Briggs Institute. Clinical appraisal tools. http://joannabriggs.org/research/critical-appraisal-tools.html (acessado em 10/Jan/2018).
http://joannabriggs.org/research/critica...
, which contemplate the different types of studies included in this review. These instruments, while respecting the specificities of each epidemiological design, value inclusion criteria and population sampling, methods for measuring variables and statistical analysis. Different instruments were used to assess the quality of works that estimated prevalence and verified associated factors. Thus, a study that assessed these two aspects of unsafe abortions may have different limitations for each assessed aspect. We did not exclude works based on quality. We present the main limitations along with the results.

Presentation of results

For each included study, we extracted the following data: authors, year of publication and of study, study design, location, studied population, assessed outcome, methodological limitations and main results.

Results

We identified 749 texts and selected 233 abstracts. Of these, 140 were excluded because they were qualitative studies (30%), theoretical essays (22.1%), analyses of other aspects of abortion (18.6%), reviews (10%), other types of publication (editorial, letters, protocols, methodological articles, theses and dissertations - 19.3%). We then read the remaining 90 articles in full (we were unable to read on article on unsafe abortions) and, after applying the eligibility criteria, 50 studies on unsafe abortions were included in this analysis (Figure 1). Articles on legal abortion (n = 20) are discussed in another publication.

Figure 1
Flowchart of the selection of articles included in the review of unsafe abortion in Brazil.

The 50 included articles presented results from 48 studies. In the analysis, we categorized the articles according to subject: unsafe abortions occurrence estimates; women’s profile and associated factors; complications from unsafe abortions. Some studies discussed more than one subject and were therefore included in more than one Table.

Prevalence and rates of induced abortion in Brazil

Twenty five articles presented data on abortion estimates (Table 1), eight of which had a national scope: two derived from the Brazilian National Survey of Demography and Health (PNDS, in Portuguese), from 1996 and 2006 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.; two from the Brazilian National Abortion Survey (PNA, in Portuguese), conducted in 2010 and repeated in 2016 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.; one from the National Alcohol and Drugs Inquiry (LENAD, in Portuguese) 1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7.; two used secondary data from the SIH-SUS 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.,1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.; and the remaining articles was a survey of maternity hospitals from 24 states 1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29..

Table 1
Estimates of unsafe abortion prevalence/rates in Brazil, 1993-2016.

Studies based on the 1996 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11. and 2006 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92. PNDS directly estimated - that is, based on interviews with women - a prevalence of induced abortion of 2.4% 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11. and 2.3% 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92., respectively. In both, the Northeastern and Northern regions had the highest values (3.1% and 2.3% in 1996; 3.5% and 4.3% in 2006 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.) while the Southern region had the lowest prevalences (1.7% in 1996 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.; 0.8% in 2006 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.). In 1996, Rio de Janeiro stood out, with a prevalence of 6.5%, higher than the other states 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.. Comparing data from 1996 and 2006, we observed an increase in abortion occurrence in the North and a reduction in the South.

The 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66. and 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. PNA produced direct estimates using the ballot box method. In this method, women deposit self-completed, unidentified questionnaires with questions on induced abortion into a ballot box, with the goal of increasing the confidentiality of the information. These surveys interviewed literate women aged between 18 and 39 years who lived in urban areas of the country 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. The lifetime prevalence of abortion was of 15% in 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66., and 13% in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.; it was higher among women aged 35-39 years (22% in 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66., 18% in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.), women who lived in the North/Central regions (19% in 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66., 15% in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.) and in the Northeastern Region (20% in 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66., 18% in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.), who had low income (17% in 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66. and 16% in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. among women who earned up to the minimum wage) and low educational levels (23% in 2010 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66. and 22% in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. among women with up to 5 years of schooling) and among those who self-declared as black (15%) and indigenous (24%) in 2016 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. (this information was not recorded in 2010). When considering the information on the most recent abortion, and not any abortion over the woman’s life, accounts were more frequent among younger women - 29% among those aged 12-19 years and 28% among those aged 20-24 years - when compared with those aged over 25 years (13%). There were no differences according to religion 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. Use of medication was cited as the main abortive method by half of the women in both years 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. In the 2016 PNA, researchers were able to estimate the occurrence of 503 thousand procedures in the previous year, that is, in 2015 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. Around half of the women reported being hospitalized after an abortion, with a reduction from 55% to 48% from the first to the second study 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60..

The LENAD study, carried out in 2012 with women aged 14 years or older, measured lifetime abortion based on direct interviews. It found the occurrence of unsafe abortions among 16.3% (14.5%-18.3%) of women, and a dose-response effect according to alcohol use. Among women who did not binge drinking (BD), defined as consuming 4 or more drinks in approximately 2 hours, or who did not have an alcohol use disorder (AUD measured by the DSM-5 scale), unsafe abortions prevalence was of 15% (13.2%-17%), reaching 24.9% (16.3%-36.2%) among those with BD and AUD 1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7..

In the studies based on SIH-SUS data, indirect estimates used the Guttmacher Institute’s (AGI) methodology 1818. Guttmacher Institute. Good reproductive health policy starts with credible research. https://www.guttmacher.org/international/abortion (acessado em Nov/2017).
https://www.guttmacher.org/international...
. For Brazil, the first study encompassed the years 1996-2012 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20. and analyzed the time trend of the induced abortions coefficient - unsafe abortions/1,000 women of reproductive age (UA/WRA) - and of the ratio of abortions/100 live births (UA/LB) 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.. It estimated an annual average of 994,465 induced abortions in Brazil, corresponding to a UA/WRA coefficient of 17/1,000 and a ratio of 33.2 induced abortions/100 live births. Researchers found a statistically significant decrease in the UA/WRA between 1996 and 2012 (R2: 94%; p < 0.001) at a national level and in the regions Northeast, Southeast and Central, stability in the South and decrease in the North. The greatest reduction was observed in the Northeast, with an annual reduction of 0.63 unsafe abortions/1,000 women of reproductive age. As for the UA/LB ratio, only the more populated regions, the Northeast and the Southeast, experienced a reduction; in the other regions, there was a constant increase, with stability at the national level. Researchers also detected clusters of high abortion prevalence in the North, Northeast and Southeast 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.. In the second study 1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8., which analyzed a series from 1995 and 2013 1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8., two correction factors were used and researchers also found a reduction in the annual occurrence of abortion in the period. The maximum estimate described a reduction from 1,086,708 annual abortions in 1995 to 865,160; and the minimum, from 864,628 in 1995 to 687,347 in 2013. There was also a reduction in the UA/WRA coefficient (from 27 to 16/1,000 women of reproductive age) in all regions, but it remained higher in the North and Northeast and among women aged 20-29 years (22/1,000 women of reproductive age). The ratio of unsafe aborions/100 live births was reduced from 35 to 30/100 live births, but rose in the Northern and Southern regions 1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.. Lastly, a multi-centric, hospital-based study using a direct estimate based on interviews with women who had given birth in Brazilian maternity hospitals estimated 9.7% of induced abortions in previous pregnancies 1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29..

At a local level, Mello et al. 1919. Mello FM, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saúde Pública 2011; 27:87-93. analyzed hospital admissions in Pernambuco from 1996 to 1006 and Madeiro et al. 2020. Madeiro AP, Rufino AC, Santos IS, Carvalho MS. Estimativas e tendências de aborto provocado no Piauí: um estudo ecológico no período de 2000-2010. Rev Bras Promoc Saúde 2015; 28:168-75. carried out a similar analysis in Piauí for the 2000-2010 period. In Pernambuco, researchers found a high number of admissions due to abortion, with an estimated 621,022 unsafe abortions and a UA/LB ration of 36.1/100 live births 1919. Mello FM, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saúde Pública 2011; 27:87-93.. Findings also showed differences between the state’s health regions, both in the unsafe abortions frequency and in time trends. There was a 7.7% reduction in hospitalizations due to complications from abortion in the state in the period, with a statistically significant decline only in the Recife metropolitan region. The other regions had an increase in the number of unsafe abortions, with two regions more than doubling the number of cases. The Piauí study identified 55,678 hospitalizations due to complications from abortion in the analyzed period, with a reduction of the UA/LB ratio in the state, from 17.6/100 to 13.5/100, with a statistically significant annual decrease of 2.2% 2020. Madeiro AP, Rufino AC, Santos IS, Carvalho MS. Estimativas e tendências de aborto provocado no Piauí: um estudo ecológico no período de 2000-2010. Rev Bras Promoc Saúde 2015; 28:168-75..

Four household surveys in the state of São Paulo estimated the prevalence of abortion among women with a previous pregnancy, which varied between 4.4% 2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87. and 4.5% 2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312. among those who lived in the capital (in 1993 and 2008, respectively) and 6.9% and 18.3% in two favelas 2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.. For the calculation, the studies used different definitions of reproductive age in the denominators. In the 1993 study, conducted in the state capital, authors used two different methods - direct interviews and randomized response technique (RRT) - to estimate the occurrence of unsafe abortions in the previous year, finding a much higher value when using RRT than when using interviews (42 vs. 1 per 1,000) 2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87..

Eleven studies focused on specific populations, using direct estimates, most through interviews. Five of these were conducted on young women and adolescents. In a favela in São Paulo, 6.1% of women and 10.8% of men (discussing their partners’ pregnancies) aged between 15 and 25 years reported a previous experience of abortion 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.. In another favela in the same city, 1.2% of women and 2.8% men aged 15-24 years reported at least one previous abortion 2626. Silva RS, Fusco CLB. Comportamento do aborto induzido entre jovens em situação de pobreza de ambos os sexos - Favela México 70, São Paulo, Brasil, 2013. Reprod Clim 2016; 31:13-21.. The GRAVAD study, a household survey in three Brazilian capitals, found, among young people aged 18-24 years who reported a pregnancy, a termination in 21.5% of cases. This was more frequent in Rio de Janeiro (52.8%) and in Salvador (42.1%), Bahia State, Brazil, than in Porto Alegre (5.1%), Rio Grande do Sul State, Brazil 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.. In a study of students from public and private schools in Maceió, Alagoas State, Brazil aged 12-19 years, using a self-administered questionnaire, 81.9% of students who had been pregnant reported a previous unsafe abortions 2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.. In Porto Alegre and Rio Grande, in the state of Rio Grande do Sul, a study with homeless children, adolescents and youths aged 10-21 years identified a previous pregnancy among 29.3%, with a 15.6% prevalence of unsafe abortions among those with a previous pregnancy and greater experience of abortion (induced and/or miscarriages) among girls than among boys (17.4% vs. 8.8%) 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66..

Four studies assessed the occurrence of unsafe abortions among women with HIV/AIDS. Three had a similar methodology, comparing women living with HIV/AIDS (WLHA) who received care at a reference service with women not living with HIV/AIDS (WNLHA) who received care at primary health care services. The first, conducted in 13 municipalities of the 5 Brazilian macrorregions, in 2003-2004, and which used the ballot box method, found a unsafe abortions prevalence of 17.5% among WLHA and of 10.4% among WNLHA (p < 0.001) 3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.. Later, in 2011, in Rio Grande do Sul 3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570. and São Paulo 3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916., in 2013-2014, using direct interviews, researchers found, respectively, a lifetime unsafe abortions prevalence of 13% and 14.1% among WLHA and 4.9% and 3.2% among WNLHA. The fourth study, carried out in a reference center for WLHA in Rio de Janeiro found a unsafe abortions incidence of 2.1% (95% confidence interval - 95%CI: 1.2%-3.0%) per woman/year, from 1996 to 2003, with 31% of pregnancies resulting in unsafe abortions 3333. Friedman RK, Bastos FI, Leite IC, Veloso VG, Moreira RI, Cardoso SW, et al. Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil. Rev Saúde Pública 2011; 45:373-81..

A study of sex workers in Teresina, Piauí, State, which used the ballot box method to provide a direct estimate, revealed a lifetime unsafe abortions prevalence of 52.6%, reaching 71.2% among women aged 35-39 years 3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43.. Lastly, in a cross-sectional study in São Paulo, with adults admitted to a clinic for addiction treatment, 40.7% of women and 23.8% of men reported unsafe abortions over their lives in a direct interview 3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416..

Women’s profile and factors associated with induced abortion in Brazil

Twenty-two studies addressed the characteristics of women who have abortions and/or factors associated with unsafe abortions 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.,1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7.,1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.,2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43.,3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416.,3636. Nader PRA, Macedo CR, Miranda AE, Maciel ELN. Aspectos sociodemográficos e reprodutivos do abortamento induzido de mulheres internadas em uma maternidade de Serra - ES. Esc Anna Nery Rev Enferm 2008; 12:699-705.,3737. Silva DFO, Bedone AJ, Faundes A, Fernandes AMS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. consequência do uso de misoprostol? Rev Bras Saúde Mater Infant 2010; 10:441-7.,3838. Ramos KS, Ferreira ALC, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44:605-10.,3939. Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes R. Abortamento provocado na adolescência sob a perspectiva bioética. Rev Bras Saúde Mater Infant 2010; 10 Suppl 2:S311-9.,4040. Borsari CMG, Nomura RMY, Benute GRG, Lucia MCS, Francisco RPV, Zugaib M. Aborto provocado em mulheres da periferia da Cidade de São Paulo: vivência e aspectos socioeconômicos. Rev Bras Ginecol Obstet 2013; 35:27-32.,4141. Dias TZ, Passini Jr. R, Duarte GA, Sousa MH, Faúndes A. Association between educational level and access to safe abortion in a Brazilian population. Int J Gynaecol Obstet 2015; 128:224-7.,4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30. (Table 2).

Table 2
Characteristics/factors associated with unsafe abortion in Brazil, 1996-2012.

In population studies or in studies carried out in primary health care services, including women of different age groups, the following were found to be positively associated with unsafe abortions: increased age 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570., non-white race/color 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30., low income 2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30., living in rural areas 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11. or being a migrant 4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30., having paid work 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11., not being religious 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11., being single/not living with a partner 2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570., early onset of sexual activity 2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99., have more than one or two partners in the last year 2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19., greater number of sexual partners in life 3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570., use of alcohol 1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7. and illicit drugs 3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.. Two studies found an association between unsafe abortions and low educational level 2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30. and in Campinas, São Paulo State 4141. Dias TZ, Passini Jr. R, Duarte GA, Sousa MH, Faúndes A. Association between educational level and access to safe abortion in a Brazilian population. Int J Gynaecol Obstet 2015; 128:224-7., São Paulo State, and in Rio Grande do Sul 3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570. researchers found a positive association between high educational levels and termination of unwanted pregnancies. The ratio number of children/pregnancies had contradictory results: at times, lack of children 2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33., and at times a greater number of pregnancies/children 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43. were associated with unsafe abortions. A study that assessed the occurrence of unsafe abortions according to the difference between the number of living children and that reported as ideal found higher proportions of unsafe abortions among women who did not yet have the desired number of children, with these values higher among single women (29.5%) than among those who were married (2.9%) 2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87.. Other factors, such as the presence of a sexually transmissible infection 3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99. and a more accepting attitude toward abortion (for different reasons) 2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33. were positively associated with the termination of pregnancy (Table 2).

Three studies interviewed young women and found a positive association between abortion and number of partners 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39., greater number of pregnancies/children 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39., sexual coercion 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39., living in Rio de Janeiro or in Salvador 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39. and having obtained information on sex from people other than the parents 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.. A study with students of Maceió schools found a higher frequency of abortion among adolescents who were in a conjugal union 2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.. In the GRAVAD survey, educational level had a positive gradient with induced abortion among young people 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.. In Maceió, in turn, researchers found a positive association between studying in a public school and having an abortion 2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.. In the São Paulo periphery, abortion was more frequently reported by men (talking about their partners) and among people who lived alone (Table 2) 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19..

Hospital studies in the public network described the characteristics of women admitted due to abortion, with samples varying between 104 and 1,838 users. A study at a maternity hospital that is an HIV reference center for the entire country found an association with young age at first sexual relation, non-white race/color, smaller number of children, sexually transmissible infections, absence of prenatal care for that pregnancy and greater number of partners 1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.. Four studies 3636. Nader PRA, Macedo CR, Miranda AE, Maciel ELN. Aspectos sociodemográficos e reprodutivos do abortamento induzido de mulheres internadas em uma maternidade de Serra - ES. Esc Anna Nery Rev Enferm 2008; 12:699-705.,3737. Silva DFO, Bedone AJ, Faundes A, Fernandes AMS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. consequência do uso de misoprostol? Rev Bras Saúde Mater Infant 2010; 10:441-7.,3838. Ramos KS, Ferreira ALC, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44:605-10.,3939. Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes R. Abortamento provocado na adolescência sob a perspectiva bioética. Rev Bras Saúde Mater Infant 2010; 10 Suppl 2:S311-9. used criteria from the World Health Organization (WHO) to classify abortions 4343. World Health Organization. Studying unsafe abortion: a practical guide. http://apps.who.int/iris/bitstream/10665/63596/1/WHO_RHT_MSM_96.25.pdf (acessado em 10/Jan/2018).
http://apps.who.int/iris/bitstream/10665...
and considered most as certainly or probably induced. They found an association between inducing an abortion and a larger number of children 3838. Ramos KS, Ferreira ALC, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44:605-10., lack of a partner 3636. Nader PRA, Macedo CR, Miranda AE, Maciel ELN. Aspectos sociodemográficos e reprodutivos do abortamento induzido de mulheres internadas em uma maternidade de Serra - ES. Esc Anna Nery Rev Enferm 2008; 12:699-705.,3737. Silva DFO, Bedone AJ, Faundes A, Fernandes AMS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. consequência do uso de misoprostol? Rev Bras Saúde Mater Infant 2010; 10:441-7.,3838. Ramos KS, Ferreira ALC, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44:605-10. and unwanted pregnancy 3636. Nader PRA, Macedo CR, Miranda AE, Maciel ELN. Aspectos sociodemográficos e reprodutivos do abortamento induzido de mulheres internadas em uma maternidade de Serra - ES. Esc Anna Nery Rev Enferm 2008; 12:699-705.. Another study compared unsafe and safe abortions, noting higher frequency of unsafe abortions among wqomen with lower income, educations, with black race/color and migrants 4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30.. A study conducted at an addiction treatment clinic, with 616 users, 82.5% of whom were men, found an association between unsafe abortions and female sex, being single, unemployment, tobacco use, sexual activity in the previous 12 months, irregular condom use, STI history, testing for HIV and emergency contraception use 3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416. (Table 2).

Complications associated with induced abortion

Twenty-two studies assessed complications from unsafe abortions (Table 3). Four assessed hospitalizations due to complications, two of which had a national scope - one for the period 1992-2009 4444. Singh S, Monteiro MF, Levin J. Trends in hospitalization for abortion-related complications in Brazil, 1992-2009: why the decline in numbers and severity? Int J Gynaecol Obstet 2012; 118 Suppl 2:S99-106., the other referring to 2006 4545. Mariutti MG, Silva HLR, Costa Jr ML, Furegato ARF. Abortamento: um estudo da morbidade hospitalar no país. Rev Bras Med 2010; 67:97-103. -, while two were local investigations, in Paraná 4646. Veras TCS, Mathias TAF. Principais causas de internações hospitalares por transtornos maternos. Rev Esc Enferm USP 2014; 48:401-8. and Santa Catarina 4747. Bonassa RT, Rosa MI, Madeira K, Simões PW. Caracterização de casos de internação por abortos complicados na Macrorregião Sul Catarinense. Arq Catarin Med 2015; 44:88-100.. All used SIH/SUS data and showed a reduction in hospitalizations due to abortion. The rate of hospitalization due to abortion in Brazil reached 3.1/1,000 women in 2009, a 57% reduction from 1992 4444. Singh S, Monteiro MF, Levin J. Trends in hospitalization for abortion-related complications in Brazil, 1992-2009: why the decline in numbers and severity? Int J Gynaecol Obstet 2012; 118 Suppl 2:S99-106.. A sharper drop (69%) was found for more severe complications, when compared with less severe ones (52%), especially infection and hemorrhage. All studies showed differences between regions and states. Higher rates were observed in the North and Northeast, while lower rates were observed in the South 4444. Singh S, Monteiro MF, Levin J. Trends in hospitalization for abortion-related complications in Brazil, 1992-2009: why the decline in numbers and severity? Int J Gynaecol Obstet 2012; 118 Suppl 2:S99-106.,4545. Mariutti MG, Silva HLR, Costa Jr ML, Furegato ARF. Abortamento: um estudo da morbidade hospitalar no país. Rev Bras Med 2010; 67:97-103.. In 2006, Roraima and Amapá stood out due to the higher rates (101 and 94 per 1,000, respectively) and of the 50 municipalities with the highest values, 17 were located in Bahia 4545. Mariutti MG, Silva HLR, Costa Jr ML, Furegato ARF. Abortamento: um estudo da morbidade hospitalar no país. Rev Bras Med 2010; 67:97-103.. Many municipalities did not record hospitalizations due to abortion in 2006, probably due to under-reporting 4545. Mariutti MG, Silva HLR, Costa Jr ML, Furegato ARF. Abortamento: um estudo da morbidade hospitalar no país. Rev Bras Med 2010; 67:97-103.. In Paraná, hospitalizations due to abortions corresponded to 24.1% of obstetric hospitalizations (ratio 9.1/100 deliveries), with higher values among women aged 35-49 years, respectively, 36.9% and 20.2 abortions/100 deliveries 4646. Veras TCS, Mathias TAF. Principais causas de internações hospitalares por transtornos maternos. Rev Esc Enferm USP 2014; 48:401-8.. In Santa Catarina, there was a reduction in the hospitalization rate from 1999 to 2010, with an average of 2.1/1,000 4747. Bonassa RT, Rosa MI, Madeira K, Simões PW. Caracterização de casos de internação por abortos complicados na Macrorregião Sul Catarinense. Arq Catarin Med 2015; 44:88-100..

Table 3
Complications associated with unsafe abortion in Brazil, 1992-2013.

Six studies assessed complications from abortions. In Maranhão, a case series in two maternity hospitals in São Luís identified 17.5% of unsafe abortions among hospitalizations due to abortions, with 65% of women having used misoprostol, either on its own or in combination with another substance. Complications were mild, especially cramps and bleeding, with an average hospitalization time of 2.5 days 4848. Araújo MCR, Mochel EG. Aborto provocado: fatores associados em mulheres admitidas em maternidades públicas em São Luís, Maranhão, Brasil. Rev Paul Enferm 2008; 27:79-86.. In Maceió, a study with 2,592 students revealed 16.1% of complications and 10.1% of hospitalizations following 149 unsafe abortions 4949. Correia DS, Monteiro VG, Egito ES, Maia EM. Aborto provocado na adolescência: quem o praticou na Cidade de Maceió, Alagoas, Brasil. Rev Gaúcha Enferm 2009; 30:167-74.. In Campinas 3737. Silva DFO, Bedone AJ, Faundes A, Fernandes AMS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. consequência do uso de misoprostol? Rev Bras Saúde Mater Infant 2010; 10:441-7., infectious (10%) and hemorrhagic complications (13%) were significantly more frequent among certainly induced abortions. There was no association between misoprostol use and lower occurrence of complications. Also in Maceió 3939. Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes R. Abortamento provocado na adolescência sob a perspectiva bioética. Rev Bras Saúde Mater Infant 2010; 10 Suppl 2:S311-9., 81.5% of certainly induced abortions were identified among 201 hospitalized adolescents, 77.4% of whom used misoprostol. There were three cases of uterine perforation and eight blood transfusions, all for certainly or probably induced abortions 3939. Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes R. Abortamento provocado na adolescência sob a perspectiva bioética. Rev Bras Saúde Mater Infant 2010; 10 Suppl 2:S311-9.. In 2010, a study on public servants in the State of São Paulo found that abortion was the outcome of 55.7% of unplanned pregnancies. Most abortions were performed by doctors, and this was associated with fewer complications and hospitalizations 4141. Dias TZ, Passini Jr. R, Duarte GA, Sousa MH, Faúndes A. Association between educational level and access to safe abortion in a Brazilian population. Int J Gynaecol Obstet 2015; 128:224-7.. Gomperts et al. 5050. Gomperts R, van der Vleuten K, Jelinska K, Costa CV, Gemzell-Danielsson K, Kleiverda G. Provision of medical abortion using telemedicine in Brazil. Contraception 2014; 89:129-33., in an analysis of the complete records of 307 women who had medication abortions supported by the organization Women on Web in 2011 5050. Gomperts R, van der Vleuten K, Jelinska K, Costa CV, Gemzell-Danielsson K, Kleiverda G. Provision of medical abortion using telemedicine in Brazil. Contraception 2014; 89:129-33. showed that most (76.9%) evolved to a complete abortion; 20.9% of women later had to be submitted to a surgical procedure, and this was more common among pregnancies at 13 weeks or more.

Nine studies investigated severe maternal morbidity and maternal mortality associated with abortion 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.,5151. Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, et al. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet 2012; 119:44-8.,5252. Souza KV, Almeida MRCB, Soares VMN. Perfil da mortalidade materna por aborto no Paraná: 2003-2005. Esc Anna Nery Rev Enferm 2008; 12:741-9.,5353. Souza ML, Ferreira LAP, Burgardt D, Monticelli M, Bub MBC. Mortalidade por aborto no Estado de Santa Catarina: 1996 a 2005. Esc Anna Nery Rev Enferm 2008; 12:735-40.,5454. Figueiredo YMD, Malta DC, Rezende EM. Análise da mortalidade materna no município de Governador Valadares, 2002-2004. REME Rev Min Enferm 2010; 14:376-85.,5555. Martins EF, Almeida PF, Paixão CO, Bicalho PG, Errico LS. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115.,5656. Galvão LP, Alvim-Pereira F, Mendonça CM, Menezes FE, Góis KA, Ribeiro Jr. RF, et al. The prevalence of severe maternal morbidity and near miss associated factors in Sergipe, Northeast Brazil. BMC Pregnancy Childbirth 2014; 14:25.,5757. Madeiro AP, Rufino AC, Lacerda ÉZ, Brasil LG. Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piauí, Brazil. BMC Pregnancy Childbirth 2015; 15:210.,5858. Kale PL, Jorge MHPM, Fonseca SC, Cascão AM, Silva KS, Reis AC, et al. Deaths of women hospitalized for childbirth and abortion, and of their concept, in maternity wards of Brazilian public hospitals. Ciênc Saúde Colet 2018; 23:1577-90., two of which had a national scope 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.,5151. Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, et al. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet 2012; 119:44-8.. Data from the 2006 PNDS indicated an occurrence of complications (especially hemorrhagic and infectious) among women who had abortions two times higher than that among women who had had deliveries 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.. A study conducted in 27 reference hospitals 5151. Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, et al. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet 2012; 119:44-8. verified that, even though only 2.5% of cases of severe maternal morbidity, maternal near miss (a woman who almost died, but survived a severe complication during pregnancy, delivery or up to 42 days after delivery) and maternal death resulted from complications from abortions, when they were present, they were more severe, with a significantly higher proportion of maternal near miss relative to the other obstetric causes. Women’s pre-existing conditions, low maternal weight, admission to the reference service or transferal from other units and any kind of delay in receiving adequate care were associated with maternal near miss in cases of abortion 5151. Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, et al. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet 2012; 119:44-8..

Two local population studies assessed maternal mortality using data from the Braziliam Mortality Information System (SIM). In Paraná, data from the State Committee to Prevent Maternal Mortality showed stability in the Maternal Mortality Ratio (MMR) for abortion/100,000 live birth in the trienniums 1997-1999 (3.7), 2000-2002 (4.3) and 2003-2005 (3.6). In the last triennium, 59% of deaths from abortion were a result of infectious complications 5252. Souza KV, Almeida MRCB, Soares VMN. Perfil da mortalidade materna por aborto no Paraná: 2003-2005. Esc Anna Nery Rev Enferm 2008; 12:741-9.. In Santa Catarina State, from 1996 to 2005, the MMR for abortion, according to SIM data (excluding cases of ectopic pregnancy, hydatidiform mole and other abnormal products of conception) was of 1.5 per 100,000 live births, with a variation from 1.3 to 5.1 in the six state regions. Researchers observed a greater proportion of deaths among women aged 20-29 years (45.2%) with 1-8 years of schooling (38.7%) and who were married (51.6%) 5353. Souza ML, Ferreira LAP, Burgardt D, Monticelli M, Bub MBC. Mortalidade por aborto no Estado de Santa Catarina: 1996 a 2005. Esc Anna Nery Rev Enferm 2008; 12:735-40.. In Governador Valadares, Minas Gerais State, only five maternal deaths were recorded in the triennium 2002-2004, three of which resulted from complications from abortion 5454. Figueiredo YMD, Malta DC, Rezende EM. Análise da mortalidade materna no município de Governador Valadares, 2002-2004. REME Rev Min Enferm 2010; 14:376-85.. A time series of maternal mortality, from 2000 to 2001, in Minas Gerais State 5555. Martins EF, Almeida PF, Paixão CO, Bicalho PG, Errico LS. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115., identified a 38% increase in deaths from abortion, when associated causes - and not only the underlying cause of death - were included; 44% of new deaths identified in the study had not been classified as maternal in the underlying cause 5555. Martins EF, Almeida PF, Paixão CO, Bicalho PG, Errico LS. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115..

Three local, hospital-based studies assessed maternal morbimortality. In Sergipe State, researchers found that abortion was the cause of 11.8% of maternal deaths from 2011 to 2012 5656. Galvão LP, Alvim-Pereira F, Mendonça CM, Menezes FE, Góis KA, Ribeiro Jr. RF, et al. The prevalence of severe maternal morbidity and near miss associated factors in Sergipe, Northeast Brazil. BMC Pregnancy Childbirth 2014; 14:25., and in Piauí an investigation carried out in 2012-2013 showed that infected abortion was the most frequent isolated cause of maternal death (30%) 5757. Madeiro AP, Rufino AC, Lacerda ÉZ, Brasil LG. Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piauí, Brazil. BMC Pregnancy Childbirth 2015; 15:210.. Both studies also assessed the occurrence of maternal near miss, with previous abortion being associated with maternal near miss for that pregnancy in Sergipe 5656. Galvão LP, Alvim-Pereira F, Mendonça CM, Menezes FE, Góis KA, Ribeiro Jr. RF, et al. The prevalence of severe maternal morbidity and near miss associated factors in Sergipe, Northeast Brazil. BMC Pregnancy Childbirth 2014; 14:25.. In the Piauí study, only cesarean delivery in the current pregnancy was associated with maternal near miss 5757. Madeiro AP, Rufino AC, Lacerda ÉZ, Brasil LG. Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piauí, Brazil. BMC Pregnancy Childbirth 2015; 15:210.. Lastly, a study conduced in hospitals in the municipalities of Rio de Janeiro, Niterói and São Paulo with 7,845 women identified only one maternal death, which was not associated with abortion 5858. Kale PL, Jorge MHPM, Fonseca SC, Cascão AM, Silva KS, Reis AC, et al. Deaths of women hospitalized for childbirth and abortion, and of their concept, in maternity wards of Brazilian public hospitals. Ciênc Saúde Colet 2018; 23:1577-90..

We also identified studies that assessed mental health outcomes. One such study, which had many methodological limitations, assessed women’s depression and anxiety scores 30 days after abortion, using the Hospital Anxiety and Depression scale. It found a significantly higher mean of depression (8.3 vs. 6.1, p < 0.05) and anxiety (11.0 vs. 8.7, p < 0.05) among women with unsafe abortions, when compared with those with miscarriages 5959. Benute GR, Nomura RM, Pereira PP, Lucia MC, Zugaib M. Abortamento espontâneo e provocado: ansiedade, depressão e culpa. Rev Assoc Med Bras 2009; 55:322-7.. Two articles 6060. Ludermir AB, de Araújo TV, Valongueiro SA, Lewis G. Common mental disorders in late pregnancy in women who wanted or attempted an abortion. Psychol Med 2010; 40:1467-73.,6161. Ludermir AB, Araya R, Araújo TV, Valongueiro SA, Lewis G. Postnatal depression in women after unsuccessful attempted abortion. Br J Psychiatry 2011; 198:237-8. from a longitudinal study assessed the mental health of women in Recife interviewed in the third trimester of pregnancy. In the baseline, the global prevalence of common mental disorders (CMD), assessed using the SRQ-20, was 43.1%, while among those who reported having attempted an abortion (13.7%), the occurrence was of 63.6% 6060. Ludermir AB, de Araújo TV, Valongueiro SA, Lewis G. Common mental disorders in late pregnancy in women who wanted or attempted an abortion. Psychol Med 2010; 40:1467-73.. In the follow-up interviews, conducted, on average, 8.1 months after delivery, an abortion attempt was associated with postpartum depression, using the Edinburgh Scale6161. Ludermir AB, Araya R, Araújo TV, Valongueiro SA, Lewis G. Postnatal depression in women after unsuccessful attempted abortion. Br J Psychiatry 2011; 198:237-8..

Discussion

Approximately one fourth of the scientific production on unsafe abortions in the period was composed of quantitative studies that analyzed the three aspects addressed in this review. Direct estimates of usafe abortions prevalence in national-scope studies varied between 2.3% 1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92. and 16.3% 1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7.. In local studies, these estimates varied between 1.2% among women aged 15-24 years 2626. Silva RS, Fusco CLB. Comportamento do aborto induzido entre jovens em situação de pobreza de ambos os sexos - Favela México 70, São Paulo, Brasil, 2013. Reprod Clim 2016; 31:13-21. and 81.9% among sexually active girls aged 12-19 years who had been pregnant 2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.. The estimated occurrence varied between 865,000 1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8. and 503,000 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. abortions in the country from 2013 to 2015.

This large variation may be explained in large part by the different methodological approaches used and the different populations studied. Some works included the total of women of reproductive age (with different age limits) 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.,1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.,1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7.,1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.,1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.,1919. Mello FM, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saúde Pública 2011; 27:87-93.,2020. Madeiro AP, Rufino AC, Santos IS, Carvalho MS. Estimativas e tendências de aborto provocado no Piauí: um estudo ecológico no período de 2000-2010. Rev Bras Promoc Saúde 2015; 28:168-75.,2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19., and others focused only on young women 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2626. Silva RS, Fusco CLB. Comportamento do aborto induzido entre jovens em situação de pobreza de ambos os sexos - Favela México 70, São Paulo, Brasil, 2013. Reprod Clim 2016; 31:13-21.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76., or women with a previous pregnancy 1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33., or a specific population group 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,3333. Friedman RK, Bastos FI, Leite IC, Veloso VG, Moreira RI, Cardoso SW, et al. Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil. Rev Saúde Pública 2011; 45:373-81.,3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43.,3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416.. Studies with direct methods employed face-to-face interviews 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92.,1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7.,1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.,2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2626. Silva RS, Fusco CLB. Comportamento do aborto induzido entre jovens em situação de pobreza de ambos os sexos - Favela México 70, São Paulo, Brasil, 2013. Reprod Clim 2016; 31:13-21.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,3333. Friedman RK, Bastos FI, Leite IC, Veloso VG, Moreira RI, Cardoso SW, et al. Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil. Rev Saúde Pública 2011; 45:373-81.,3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416., self-administered questionnaires 2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76., ballot box method 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43. or the RRT 2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87., the latter with lower possibility of under-reporting. Indirect estimates 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.,1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.,1919. Mello FM, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saúde Pública 2011; 27:87-93.,2020. Madeiro AP, Rufino AC, Santos IS, Carvalho MS. Estimativas e tendências de aborto provocado no Piauí: um estudo ecológico no período de 2000-2010. Rev Bras Promoc Saúde 2015; 28:168-75., in turn, used the AGI methodology, with parameters for the correction of miscarriages, abortions that do not result in hospitalization and abortions with hospitalization in the private sector, which are not captured by the SIH database, which is restricted to hospitalizations with public funding. These parameters are subject to imprecision and have been the object of debates. It is worth noting that, due to the illegality and the stigma surrounding abortion, imprecisions occur regardless of the chosen method and technique 6262. Menezes G, Aquino EML, Domingues RMSM, Fonseca SC. Aborto e saúde no Brasil: desafios para pesquisas quantitativas em um contexto de ilegalidade. Cad Saúde Pública 2009; Suppl 2:S193-204..

The rate of 16 unsafe abortions/1,000 women of reproductive age in 2013 1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8., estimated using an indirect method, is inferior to global estimates for the 2010-2014 period, with a similar value to that observed in North America (17/1,000), Western European countries (18/1,000) and Oceania (19/1,000) 22. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet 2016; 388:258-67.. The 2016 PNA estimate, of 503 thousand abortions in 2015, corresponding to approximately 17.5% of births in that year, is also inferior to global estimates of 25% of abortions among pregnancies from 2010 to 2014, and is similar to those of North America (17%), Oceania (16%) and countries from all regions of Africa 22. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet 2016; 388:258-67.. However, there are persistent differences between the country’s regions, states and municipalities 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.,1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.; social inequalities, with higher rates among black women 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19. and among women with low income and educational levels 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.; and among specific populations, such as young people in the beginning of their reproductive lives 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.; children, adolescents and youths living on the street 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66., sex workers 3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43., alcohol 1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7. and illicit drug 3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416. users and WLHA 3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,3333. Friedman RK, Bastos FI, Leite IC, Veloso VG, Moreira RI, Cardoso SW, et al. Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil. Rev Saúde Pública 2011; 45:373-81..

With regard to previous reviews 44. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. 20 anos de pesquisas sobre aborto no Brasil. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).,55. Menezes G, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204., there was an increase in population studies and in studies in the Northeastern Region, investigating factors associated with unsafe abortions. The determinants of abortions should be cautiously interpreted due to the methodological limitations we identified, such as: broad use of the cross-sectional design, less appropriate for causal inferences; distinct ways of measuring unsafe abortions; lack of explicit theoretical models; and measuring variables and the moment of the interview and not at the time when the unsafe abortions occurred. Additionally, the use of selected populations and small samples reduces the potential for generalization of results. Taking these caveats into account, unsafe abortions was nonetheless associated with low income 2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30., non-white race/color 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,4242. Fusco C, Akerman M, Drezett J, Silva RS. Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion. Reprod Clim 2016; 31:22-30. and being single 2121. Silva RS, Vieira EM. Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil. Cad Saúde Pública 2009; 25:179-87.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416.,3636. Nader PRA, Macedo CR, Miranda AE, Maciel ELN. Aspectos sociodemográficos e reprodutivos do abortamento induzido de mulheres internadas em uma maternidade de Serra - ES. Esc Anna Nery Rev Enferm 2008; 12:699-705.,3737. Silva DFO, Bedone AJ, Faundes A, Fernandes AMS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. consequência do uso de misoprostol? Rev Bras Saúde Mater Infant 2010; 10:441-7.,3838. Ramos KS, Ferreira ALC, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44:605-10., corroborating the vulnerability of segments of women who have unsafe abortions in Brazil, just as in other low- and middle-income countries 6363. Chae S, Desai S, Crowell M, Sedgh G, Singh S. Characteristics of women obtaining induced abortions in selected low- and middle-income countries. PLoS One 2017; 12:e0172976.,6464. Aghaei F, Shaghaghi A, Sarbakhsh P. A systematic review of the research evidence on cross-country features of illegal abortions. Health Promot Perspect 2017; 7:117-23.. Although the peak of having an abortion is situated between 20 and 29 years, in most studies, unsafe abortions occurrence increased with age 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570., which can be explained by the longer time of exposure to unplanned pregnancies. Likewise, there was a positive association with a larger number of pregnancies and/or living children 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,2222. Souza MG, Fusco CLB, Andreoni SA, Souza e Silva R. Prevalência e características sociodemográficas de mulheres com aborto provocado em uma amostra da população da Cidade de São Paulo, Brasil. Rev Bras Epidemiol 2014; 17:297-312.,2424. Santos TF, Andreoni S, Souza e Silva R. Prevalência e características de aborto induzido - Favela México 70, São Vicente - São Paulo. Rev Bras Epidemiol 2012; 15:123-33.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43.,3838. Ramos KS, Ferreira ALC, Souza AI. Mulheres hospitalizadas por abortamento em uma Maternidade Escola na Cidade do Recife, Brasil. Rev Esc Enferm USP 2010; 44:605-10., suggesting the use of abortion as a way of regulating procreation, in the absence or failure of contraception 6565. Stover J, Winfrey W. The effects of family planning and other factors on fertility, abortion, miscarriage, and stillbirths in the Spectrum model. BMC Public Health 2017; 17 Suppl 4:775.,6666. Brandão ER, Cabral CD. Da gravidez imprevista à contracepção: aportes para um debate. Cad Saúde Publica 2017; 33:e00211216.. Having a sufficient number of children was the main reason for having an unsafe abortions in a systematic review of the subject 6464. Aghaei F, Shaghaghi A, Sarbakhsh P. A systematic review of the research evidence on cross-country features of illegal abortions. Health Promot Perspect 2017; 7:117-23..

Sexuality and reproduction in adolescence involve complex, singular issues, dependent on socioeconomic context 6767. Alves CA, Brandão ER. Vulnerabilidades no uso de métodos contraceptivos entre adolescentes e jovens: interseções entre políticas públicas e atenção à saúde. Ciênc Saúde Colet 2009; 14:661-70.,6868. Vieira EM, Bousquat A, Barros CRS, Alves MCG. Gravidez na adolescência e transição para a vida adulta em jovens usuárias do SUS. Rev Saúde Pública 2017; 51:25.,6969. Munakampe MN, Zulu JM, Michelo C. Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review. BMC Health Serv Res 2018; 18:909.. In this review, the analysis of young populations did not find consistent results regarding age and having an abortion 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,2828. Correia DS, Cavalcante JC, Egito ES, Maia EMC. Prática do abortamento entre adolescentes: um estudo em dez escolas de Maceió - AL, Brasil. Ciênc Saúde Colet 2011; 16:2469-76.. A single study which assessed educational level in this population found a positive and growing association with the number of years of schooling 2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.. Access to contraception is higher among those with higher income and educational levels, a segment in which an unplanned pregnancy competes with educational, professional and career projects, leading to its termination 6969. Munakampe MN, Zulu JM, Michelo C. Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review. BMC Health Serv Res 2018; 18:909.,7070. Menezes G, Aquino EML, Silva D. Induced abortion during youth: social inequalities in the outcome of the first pregnancy. Cad Saúde Pública 2006; 22:1431-46.. Additionally, it is likely that these adolescents have greater access to resources for terminating pregnancies in safe conditions, with a higher likelihood of surviving an abortion and, therefore, being able to report it.

The number of partners was also associated with abortion 1717. Machado CJ, Lobato AC, Melo VH, Guimarães MD. Perdas fetais espontâneas e voluntárias no Brasil em 1999-2000: um estudo de fatores associados. Rev Bras Epidemiol 2013; 16:18-29.,2323. Fusco CLB, Silva RS, Andreoni S. Unsafe abortion: social determinants and health inequities in a vulnerable population in São Paulo, Brazil. Cad Saúde Pública 2012; 28:709-19.,2727. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570., probably because pregnancies occur in less-established relationships in which contraception may be less regular and in which the acceptance of a child project is less likely 7171. Bajos N, Ferrand M. l'équipe Giné: de la contraception à l'avortement: sociologie des grossesses non prévues. Paris: Institut National de la Santé et de la Recherche Médicale; 2002.. It is worth noting that men’s role in trajectories leading up to abortion is a gap pointed out by previous reviews of the subject 44. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. 20 anos de pesquisas sobre aborto no Brasil. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).,55. Menezes G, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204. and that persists in this review. Only three recent studies included men 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2626. Silva RS, Fusco CLB. Comportamento do aborto induzido entre jovens em situação de pobreza de ambos os sexos - Favela México 70, São Paulo, Brasil, 2013. Reprod Clim 2016; 31:13-21.,2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66., all from adolescent and young populations, addressing only the account of the experience of abortion. In two of these 2525. Silva RS, Andreoni S. Fatores associados ao aborto induzido entre jovens pobres na cidade de São Paulo, 2007. Rev Bras Estud Popul 2012; 29:409-19.,2626. Silva RS, Fusco CLB. Comportamento do aborto induzido entre jovens em situação de pobreza de ambos os sexos - Favela México 70, São Paulo, Brasil, 2013. Reprod Clim 2016; 31:13-21., reports of abortions were more frequent among men than among women in the study population, which may be explained by lesser embarrassment in declaring it or the greater number of affective-sexual relationships susceptible to unwanted pregnancies.

Studies with specific populations, such as homeless children, adolescents and youths 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66., patients undergoing addiction treatment 3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416. and WLHA 3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916. identified an increased vulnerability in these populations, with early sexual initiation 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,7272. Heywood W, Patrick K, Smith AM, Pitts MK. Associations between early first sexual intercourse and later sexual and reproductive outcomes: a systematic review of population-based data. Arch Sex Behav 2015; 44:531-69., illicit drug use 3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416., greater number of sexual partners 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99.,3131. Pilecco FB, Teixeira LB, Vigo A, Dewey ME, Knauth DR. Lifetime induced abortion: a comparison between women living and not living with HIV. PLoS One 2014; 9:e95570.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416., sex in exchange for money 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916., irregular condom use 3535. Diehl A, Pillon SC, Santos MA, Laranjeira R. Abortion and sex-related conditions in substance-dependent Brazilian patients. Cad Saúde Pública 2017; 33:e00143416. and physical and/or sexual violence 3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916.,7373. Hall M, Chappell LC, Parnell BL, Seed PT, Bewley S. Associations between intimate partner violence and termination of pregnancy: a systematic review and meta-analysis. PLoS Med 2014; 11:e1001581., resulting in early pregnancies 2929. Neiva-Silva L, Demenech LM, Moreira LR, Oliveira AT, Carvalho FT, Paludo SDS. Pregnancy and abortion experience among children, adolescents and youths living on the streets. Ciênc Saúde Colet 2018; 23:1055-66.,3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916. that are unplanned/unwanted 3232. Pinho AA, Cabral CDS, Barbosa RM. Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare. Cad Saúde Pública 2017; 33:e00057916. and more frequent unsafe abortions. A national survey also found a dose-response effect between alcohol use and unprotected sex, pregnancy before the age of 20 and having an unsafe abortion at some point in life 1414. Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Braz J Psychiatry 2019; 41:131-7..

A relevant finding that is consistent with previous reviews is the trend of a sharp reduction of hospitalizations from abortion between 1995 and 2013 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.,1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.,1919. Mello FM, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saúde Pública 2011; 27:87-93.,2020. Madeiro AP, Rufino AC, Santos IS, Carvalho MS. Estimativas e tendências de aborto provocado no Piauí: um estudo ecológico no período de 2000-2010. Rev Bras Promoc Saúde 2015; 28:168-75.,4444. Singh S, Monteiro MF, Levin J. Trends in hospitalization for abortion-related complications in Brazil, 1992-2009: why the decline in numbers and severity? Int J Gynaecol Obstet 2012; 118 Suppl 2:S99-106.,4545. Mariutti MG, Silva HLR, Costa Jr ML, Furegato ARF. Abortamento: um estudo da morbidade hospitalar no país. Rev Bras Med 2010; 67:97-103.,4646. Veras TCS, Mathias TAF. Principais causas de internações hospitalares por transtornos maternos. Rev Esc Enferm USP 2014; 48:401-8.,4747. Bonassa RT, Rosa MI, Madeira K, Simões PW. Caracterização de casos de internação por abortos complicados na Macrorregião Sul Catarinense. Arq Catarin Med 2015; 44:88-100., especially for severe complications 4444. Singh S, Monteiro MF, Levin J. Trends in hospitalization for abortion-related complications in Brazil, 1992-2009: why the decline in numbers and severity? Int J Gynaecol Obstet 2012; 118 Suppl 2:S99-106.. A 2012 estimate of hospitalizations due to complications from unsafe abortions among women aged 15-44 years in developing countries found rates varying between 2.4 to 14.6 per 1,000, with the lower rate observed in Brazil 33. Singh S, Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries. BJOG 2016; 123:1489-98.. Regional inequalities, with higher values in the North and Northeast, however, remained both in direct 1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.,3030. Barbosa RM, Pinho AA, Santos NS, Filipe E, Villela W, Aidar T. Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil. Ciênc Saúde Colet 2009; 14:1085-99. and indirect 1515. Martins-Melo FR, Lima MS, Alencar CH, Ramos Jr. AN, Carvalho FH, Machado MM, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20.,1616. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.,4545. Mariutti MG, Silva HLR, Costa Jr ML, Furegato ARF. Abortamento: um estudo da morbidade hospitalar no país. Rev Bras Med 2010; 67:97-103. estimates.

Since national studies with direct estimate did not show a reduction in unsafe abortions prevalence - 2.4% and 2.3% in the two PNDS, which were ten years apart 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.,1111. Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Jr. EF, et al. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet 2011; 112:88-92., 15% and 13% in the 2010 and 2016 PNA 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. - a possible explanation for the reduction in hospitalizations is the lower occurrence of complications from unsafe abortions resulting from the use of safer methods, among which misoprostol 7474. Arilha MM. Misoprostol: percursos, mediações e redes sociais para o acesso ao aborto medicamentoso em contextos de ilegalidade no Estado de São Paulo. Ciênc Saúde Colet 2012; 17:1785-94.. In both PNA 1212. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Ciênc Saúde Colet 2010; 15 Suppl 1:959-66.,1313. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60., approximately half of the women used medications to terminate pregnancy, a finding confirmed by local studies 3434. Madeiro AP, Rufino AC. Aborto induzido entre prostitutas: um levantamento pela técnica de urna em Teresina - Piauí. Ciênc Saúde Colet 2012; 17:1735-43.,3939. Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes R. Abortamento provocado na adolescência sob a perspectiva bioética. Rev Bras Saúde Mater Infant 2010; 10 Suppl 2:S311-9.,4848. Araújo MCR, Mochel EG. Aborto provocado: fatores associados em mulheres admitidas em maternidades públicas em São Luís, Maranhão, Brasil. Rev Paul Enferm 2008; 27:79-86.,5858. Kale PL, Jorge MHPM, Fonseca SC, Cascão AM, Silva KS, Reis AC, et al. Deaths of women hospitalized for childbirth and abortion, and of their concept, in maternity wards of Brazilian public hospitals. Ciênc Saúde Colet 2018; 23:1577-90.. Medication abortion is a safe and efficient method when employed in the first gestational trimester 7575. Raymond EG, Harrison MS, Weaver MA. Efficacy of Misoprostol alone for first-trimester medical abortion: a systematic review. Obstet Gynecol 2019; 133:137-47.. In this review, in the only study that did not find an association between misoprostol and the reduction of complications, there seems to have been an under-reporting of the medication’s use; in any case, women who used other abortive methods had higher proportions of hemorrhagic and infectious complications 3737. Silva DFO, Bedone AJ, Faundes A, Fernandes AMS, Moura VGAL. Aborto provocado: redução da frequência e gravidade das complicações. consequência do uso de misoprostol? Rev Bras Saúde Mater Infant 2010; 10:441-7..

Despite the reduction in the hospitalization rate, the absolute number of hospitalizations from complications from usanfe abortions is high, estimated at approximately 110,000 in 2012, with costs for the health system 33. Singh S, Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries. BJOG 2016; 123:1489-98.. Hypotheses for this high number include unmet contraceptive needs, especially among women with greater social and economic vulnerability 7676. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher - PNDS 2006: dimensões do processo reprodutivo e da saúde da criança. Brasília: Ministério da Saúde; 2009.; still limited access to safe methods to terminate pregnancy 7777. Heilborn ML, Cabral CS, Brandão ER, Faro L, Cordeiro F, Azize RL. Itinerários abortivos em contextos de clandestinidade na cidade do Rio de Janeiro - Brasil. Ciênc Saúde Colet 2012; 17:1699-708.,7878. Silveira P, McCallum C, Menezes G. Experiências de abortos provocados em clínicas privadas no Nordeste brasileiro. Cad Saúde Pública 2016; 32:e00004815.,7979. Souza ZCSN, Diniz NMF, Couto TM, Gesteira SMA. Trajetória de mulheres em situação de aborto provocado no discurso sobre clandestinidade. Acta Paul Enferm 2010; 23:732-6., including inadequate use of misoprostoll 8080. Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81.,8181. Nunes MD, Madeiro A, Diniz D. Histórias de aborto provocado entre adolescentes em Teresina, Piauí, Brasil. Ciênc Saúde Colet 2013; 18:2311-8.,8282. Diniz D, Madeiro A. Cytotec e aborto: a polícia, os vendedores e as mulheres. Ciênc Saúde Colet 2012; 17:1795-804.; and local health care practices of hospitalizing women before the abortion is completed. Studies on women’s trajectories indicate that they are instructed to go to a hospital as soon as they start bleeding 8080. Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81.,8181. Nunes MD, Madeiro A, Diniz D. Histórias de aborto provocado entre adolescentes em Teresina, Piauí, Brasil. Ciênc Saúde Colet 2013; 18:2311-8.. In the accounts from cases from the organization Women on Web, researchers also found a high proportion of curettages for finalizing abortion in Brazil, which may be related to local practices for managing abortion, since a small proportion of women had complications compatible with the use of this surgical procedure 5050. Gomperts R, van der Vleuten K, Jelinska K, Costa CV, Gemzell-Danielsson K, Kleiverda G. Provision of medical abortion using telemedicine in Brazil. Contraception 2014; 89:129-33..

Despite the reduction of hospitalizations and severe complications, avoidable morbimortality persists in the country. The studies we analyzed show that abortion represents a small proportion of maternal near miss. However, women with severe maternal morbidity caused by abortion had a higher proportion of maternal near miss than those with severe maternal morbidity due to other pregnancy outcomes 5151. Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, et al. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet 2012; 119:44-8.. In the 2006 PNDS, pregnancies that ended in abortion had twice the complications of those that ended in deliveries 1010. Cecatti JG, Guerra GV, Sousa MH, Menezes GM. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11.. Unsafe abortions, when compared with safe abortions, also had a significantly higher number of complications from infections in a national survey 5151. Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, et al. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet 2012; 119:44-8.. The proportion of maternal deaths from abortion and the rate of specific maternal mortality from abortion vary, reaching high values in specific locations, such as Governador Valadares 5454. Figueiredo YMD, Malta DC, Rezende EM. Análise da mortalidade materna no município de Governador Valadares, 2002-2004. REME Rev Min Enferm 2010; 14:376-85.. Abortion as a cause of maternal morbimortality, both among adults and adolescents, has been reported in low- and middle-income countries 8383. Adler AJ, Filippi V, Thomas SL, Ronsmans C. Incidence of severe acute maternal morbidity associated with abortion: a systematic review. Trop Med Int Health 2012; 17:177-90.,8484. Neal S, Mahendra S, Bose K, Camacho AV, Mathai M, Nove A, et al. The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literature. BMC Pregnancy Childbirth 2016; 16:352.,8585. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2:e323-33.. The most recent estimate indicates abortion to be the cause of 9.9% (95%CI: 8.1%-13.0%) of maternal deaths in Latin America and the Caribbean 8585. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2:e323-33., with the possibility of under-reporting 8585. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2:e323-33.,8686. Gerdts C, Vohra D, Ahern J. Measuring unsafe abortion-related mortality: a systematic review of the existing methods. PLoS One 2013; 8:e53346.. In this review, a study showed a 38% increase of abortion as a cause of maternal mortality when the multiple causes criterion was used 5555. Martins EF, Almeida PF, Paixão CO, Bicalho PG, Errico LS. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115..

Delays in adequate obstetric care are associated with a higher occurrence of severe maternal outcomes 8787. Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, et al. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth 2014; 14:159.. Taking into consideration the illegality of abortion, one may assume that these delays occur either because women delay seeking services due to lack of social support 8888. Araújo TVB, Aquino EML, Menezes GMS, Alves MTSSB, Almeida MCC, Alves SV, et al. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública 2018; 34:e00168116., fear of admitting an illegal practice 82 or due to the stigma associated with abortion 8888. Araújo TVB, Aquino EML, Menezes GMS, Alves MTSSB, Almeida MCC, Alves SV, et al. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública 2018; 34:e00168116.,8989. Gelman A, Rosenfeld EA, Nikolajski C, Freedman LR, Steinberg JR, Borrero S. Abortion stigma among low-income women obtaining abortions in Western Pennsylvania: a qualitative assessment. Perspect Sex Reprod Health 2017; 49:29-36.; or because of the difficulty accessing health care services or a timely offer of care 8888. Araújo TVB, Aquino EML, Menezes GMS, Alves MTSSB, Almeida MCC, Alves SV, et al. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública 2018; 34:e00168116.. Studies conducted in the Northeast showed low quality of the care offered to women hospitalized due to complications from abortion, measured through an analysis of the service structure and of women’s perception of the care they received 9090. Aquino EML, Menezes G, Barreto-de-Araújo TV, Alves MT, Alves SV, Almeida MC, et al. Qualidade da atenção ao aborto no Sistema Único de Saúde do Nordeste brasileiro: o que dizem as mulheres? Ciênc Saúde Colet 2012; 17:1765-76.,9191. Carneiro MF, Iriart JAB, Menezes GMS. "Largada sozinha, mas tudo bem": paradoxos da experiência de mulheres na hospitalização por abortamento provocado em Salvador, Bahia, Brasil. Interface (Botucatu) 2013; 17:405-18.,9292. Madeiro AP, Rufino AC. Maus-tratos e discriminação na assistência ao aborto provocado: a percepção das mulheres em Teresina, Piauí, Brasil. Ciênc Saúde Colet 2017; 22:2771-80.. The delay in seeking care and the occurrence of delayed complications from induced abortion increase the distance between the death and the abortion itself, which may contribute to its omission as an underlying cause in the death certificate, favoring its under-reporting as a cause of maternal death 5555. Martins EF, Almeida PF, Paixão CO, Bicalho PG, Errico LS. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115..

Lastly, negative mental health outcomes were found among women with unsuccessful termination attempts, even after adjusting for prior mental disorder 6060. Ludermir AB, de Araújo TV, Valongueiro SA, Lewis G. Common mental disorders in late pregnancy in women who wanted or attempted an abortion. Psychol Med 2010; 40:1467-73.,6161. Ludermir AB, Araya R, Araújo TV, Valongueiro SA, Lewis G. Postnatal depression in women after unsuccessful attempted abortion. Br J Psychiatry 2011; 198:237-8.. A systematic review of the association between abortion and mental health outcomes, including studies published between 1995 and 2009, estimated that women who had induced abortions had an 81% higher risk of presenting negative outcomes of several types, including use of illegal drugs, suicidal behavior, alcohol use, depression and anxiety 9393. Coleman PK. Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009. Br J Psychiatry 2011; 199:180-6.. However, recent prospective studies on the voluntary termination of pregnancy in the United States and Sweden did not show an association between depressive symptoms 9494. Gomez AM. Abortion and subsequent depressive symptoms: an analysis of the National Longitudinal Study of Adolescent Health. Psychol Med 2018; 48:294-304. or post-traumatic stress 9595. Wallin Lundell I, Georgsson Öhman S, Frans Ö, Helström L, Högberg U, Nyberg S, et al. Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study. BMC Womens Health 2013; 13:52. and abortion of unwanted pregnancies. Women with post-induced abortion post-traumatic stress symptoms were, are a higher proportion, young, with low educational levels, higher levels of anxiety and depression and greater need for counseling than those who did not develop symptoms 9595. Wallin Lundell I, Georgsson Öhman S, Frans Ö, Helström L, Högberg U, Nyberg S, et al. Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study. BMC Womens Health 2013; 13:52.. In the United States, women who were denied abortions had higher anxiety levels at the beginning of follow-up than those who had abortions 9696. Horvath S, Schreiber CA. Unintended pregnancy, induced abortion, and mental health. Curr Psychiatry Rep 2017; 19:77.. In the Brazilian context, in which abortion is illegal and women who seek clandestine abortions are subjected to unsafe methods, it is to be expected that an unwanted pregnancy represents an even greater psychological and emotional stress, aggravated by the stigma surrounding abortion in health services.

Some limitations of the review must be addressed. The review protocol was not registered. There is a possibility of publication bias because there were no searches beyond those of the MEDLINE and LILACS databases, complemented by references cited in the articles. Although we used many combinations and keywords, related articles may have escaped the search. It is worth noting that the only article selected based on its abstract, but not included, estimated unsafe abortions prevalence among sex workers, a population addressed by another study included in the review. Another possible limit could be a consequence of the instrument we used to assess the articles’ quality. The blind, independent assessment by two researchers, as well as the resolution of disagreements by consensus, sought to minimize classification bias.

Conclusions

Abortion is frequently used in Brazil, especially in less developed regions and by more socially vulnerable women. Access to safer methods for terminating pregnancy probably contributed to the reduction of complications, hospitalizations and morbimortality from abortion. However, the MMR from abortion, while potentially avoidable, remains high in specific contexts, and may be underestimated in the country due to under-reporting. Half of all women still resort to non-medication methods and the number of hospitalizations is high. The scientific production with quantitative data is small and lacks methodological adequacy. There are few studies conducted outside of capitals and large centers, in private clinics or out of the public network. Finally, the effects of stigma and racism in the increase of women’s vulnerabilities to unsafe practices and lower quality of health care must be contemplated in future investigations.

Acknowledgments

This review was funded by the Global Health Strategies, Rio de Janeiro, Brazil.

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Publication Dates

  • Publication in this collection
    10 Feb 2020
  • Date of issue
    2020

History

  • Received
    02 Oct 2018
  • Reviewed
    13 Aug 2019
  • Accepted
    28 Aug 2019
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br