Prevalence and sociodemographic characteristics of women with induced abortion in a population sample of São Paulo, Brazil

Milena Goulart Souza Carmen L. B. Fusco Solange A. Andreoni Rebeca de Souza e Silva About the authors

Abstracts

Objectives:

This study aims at estimating the prevalence of women with induced abortion among women of childbearing age (15-49 years) who had any previous pregnancy, in the city of Sao Paulo, Brazil, in the last quarter of 2008, and identifying the sociodemographic characteristics (SC) associated with it.

Methods:

A cross-sectional survey was carried out. The dependent variable was dichotomized as: no abortion and induced abortion. The independent variables were: age, paid work/activity, familial monthly income, schooling, marital status, contraceptive use and number of live births. Statistical analysis was performed using log-binomial regression models with approximation of Poisson to estimate the prevalance ratios (PR).

Results:

Of all women with any previous pregnancy (n = 683), 4.5% (n = 31) reported induced abortion. The final multivariate model showed that having now between 40 and 44 years (PR = 2.76, p = 0.0043), being single (PR = 2.79, p = 0.0159), having 5 or more live births (PR = 3.97, p = 0.0013), current oral contraception or IUD use (PR = 2.70, p = 0.454) and using a "non effective" (or of low efficacy) contraceptive method (PR = 4.18, p = 0.0009) were sociodemographic characteristics associated with induced abortion in this population.

Conclusions:

Induced abortion seems to be used to limit fertility, more precisely after having reached the desired number of children. The inadequate use or non-use of effective contraceptive methods, and / or the use of contraceptives " non effective", exposed also the women to the risk of unintended pregnancies and, therefore, induced abortions. In addition, when faced with a pregnancy, single women were more likely to have an abortion than married women.

Abortion; Induced abortion; Epidemiology; Public Health; Reproductive Health; Prevalence Ratio


INTRODUCTION

Abortion is defined as discontinuation, voluntary or not, from pregnancy until the 20th week or with a conceptus weighing less than 500 grams, according to criteria established by the World Health Organization (WHO) 1 Andalaft Neto J, Rocha MIB. Sexo e vida: panorama da saúde reprodutiva do Brasil. In: Berquó ES, editor. A questão do aborto: aspectos clínicos, legislativos e políticos. São Paulo: Universidade Estadual de Campinas; 2003. p. 257-318. , 2 World Health Organization. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008 [Internet]. Geneva: World Health Organization; 2011 [cited 2013 Jan 14]. Available from: http://whqlibdoc.who.int/publications/2011/9789241501118_eng.pdf
Available from: http://whqlibdoc.who.int...
. Some obstetricians delimit the time of gestation to define abortion as up to 22 weeks of pregnancy 3 Rezende J, Montenegro CAB. Obstetrícia fundamental. 11a ed. Rio de Janeiro: Guanabara Koogan; 2008. .

It is called abortion the process that threatens pregnancy and miscarriage the product removed from the conception, however, it is common to reference both, process and product, as abortion 1 Andalaft Neto J, Rocha MIB. Sexo e vida: panorama da saúde reprodutiva do Brasil. In: Berquó ES, editor. A questão do aborto: aspectos clínicos, legislativos e políticos. São Paulo: Universidade Estadual de Campinas; 2003. p. 257-318.. As for the type, the abortion may be spontaneous (natural) or provoked, also known as voluntary or induced.

The incidence of induced or provoked abortion (IA) worldwide varies between regions and among subgroups of women. In addition, there are countries where the laws are permissive towards abortion, namely where abortion is legal, and others, such as Brazil, whose laws are restrictive, outlawing the IA in almost all conditions. In the latter, the majority of abortions are induced in a clandestine manner, generating the need to estimate their incidence and prevalence that will not be fully available in official data, due to under-reporting.

Clandestine abortions occur, almost always, in risk conditions, which increases maternal morbimortality which, in its turn, is numerically insignificant when it comes legal and safe abortions 2 World Health Organization. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008 [Internet]. Geneva: World Health Organization; 2011 [cited 2013 Jan 14]. Available from: http://whqlibdoc.who.int/publications/2011/9789241501118_eng.pdf
Available from: http://whqlibdoc.who.int...
. The abortion that takes place in inadequate or risk conditions, therefore unsafe, causes, globally, about 70,000 deaths per year (13% of all maternal deaths) 4 International Planned Parenthood Federation. Morte e negação: abortamento inseguro e pobreza. New York: International Planned Parenthood Federation; 2006. .

Monitoring the trends to the occurrence of IA is of crucial importance to assess maternal health and progress towards Goal 5, Target 6, of the Millennium Development Goals to reduce maternal mortality and achieve universal access to reproductive health 5 Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012; 379(9816): 625-32.. In 2003, the maternal mortality ratio in Brazil, obtained from reported deaths, was 51.7 maternal deaths per 100,000 liveborn infants (li), and the official and adjusted maternal mortality ratio was 72.4 per 100,000 li, corresponding to 1,572 maternal deaths 6 Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Manual dos comitês de mortalidade materna [Internet]. Brasília: Ministério da Saúde; 2007 [citado 2011 Jul 24]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/comites_mortalidade_materna_3ed.pdf
Disponível em: http://bvsm...
. Because abortion is considered a crime under the Criminal Code and of other deficiencies in the notification system of maternal deaths there is massive under-reporting of these, although the maternal death has been declared of compulsory notification in 2003 6 Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Manual dos comitês de mortalidade materna [Internet]. Brasília: Ministério da Saúde; 2007 [citado 2011 Jul 24]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/comites_mortalidade_materna_3ed.pdf
Disponível em: http://bvsm...
, 7 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(4):709-19..

Despite the sharp decrease in maternal mortality in Brazil of 21% in 2011, referred by the Ministry of Health 8 Laboissière P. Mortalidade maternal no Brasil teve queda de 21% de 2010 para 2011 [Internet]. 2012 [citado 2011 Jul 25]. Disponível em: http://agenciabrasil.ebc.com.br/noticia/2012-05-25/mortalidade-materna-no-brasil-teve-queda-de-21-de-2010-para-2011
Disponível em: http://agen...
, the country is still far from achieving the proposed target of reducing by 3/4 (three quarters), between 1999 and 2015, the maternal mortality ratio 9 United Nations. The Millennium Development Goals Report [Internet]. New York: United Nations Department of Public Information; 2005 [cited 2011 Jul 28]. Available from: http://unstats.un.org/unsd/mi/pdf/MDG%20Book.pdf.
Available from: http://uns...
. The maternal mortality indicator shows currently 68 maternal deaths for 100,000 liveborn infants (68/100,000 li), with 8% of these being caused by unsafe abortion.

On the other hand, abortion is the 4th leading cause of maternal mortality in Brazil, being admitted by the Criminal Code, from 1940, in only two cases* * On 04/12/2012, the Federal Supreme Court (STF) has approved the termination of pregnancy of anencephalic fetus, also called therapeutic anticipation of delivery : (i) if there is no other way of saving the mother's life, and (ii) if the pregnancy results from rape 10 10 Brasil. Código Penal: Decreto lei n. 1.004, de 21 de outubro de 1969 . 4a ed. São Paulo: Saraiva; 1971.. The lack of a specific policy - with counseling about risks and precautions to illegal abortion -, coupled with the clandestinity of the act, considered a crime under Brazilian law, contributes decisively to the mortality of the mother 11 11 Adesse L. O ponto crítico do aborto. J Ciênc [Internet]. 2012. Disponível em: http://www.jornaldaciencia.org.br/Detalhe.jsp?id=82958
Disponível em: http://www.jo...
.

It is estimated that the annual sum of clandestine and unsafe abortions in Brazil lies between 750,000 and 1.5 million, considering only hospitalization data within the Single Health System (SUS), in 2000, if applied to Brazilian data the methodology proposed by the Alan Guttmacher Institute (1999), and remembering that most of them do not reach hospitals. For Latin American and Caribbean, the same institute attained the value of 4 million clandestine abortions, and unsafe, per year 12 12 Rede Nacional Feminista de Saúde e Direitos Reprodutivos. Dossiê aborto inseguro: direito de decidir sobre o aborto: uma questão de cidadania e democracia. Saúde da mulher e direitos reprodutivos Belo Horizonte: Rede Nacional Feminista de Saúde e Direitos Reprodutivos; 2001..

The deaths from abortion in Brazil consist mostly of poor, young, black and low education level women, which indicates high rate of social injustice and health inequities 7 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(4):709-19. , 13 13 Adesse L, Monteiro FG, Levin J. Panorama do aborto no Brasil. Radis 2008; 66(11): 10-15.. Abortion must be addressed as a matter of public health and human rights, keeping in mind that, when unsafe, it is a preventable cause of maternal death 13 13 Adesse L, Monteiro FG, Levin J. Panorama do aborto no Brasil. Radis 2008; 66(11): 10-15..

The information on prevalence and global and regional rates and trends as well as local, may also help to identify gaps in contraceptive use 5 Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012; 379(9816): 625-32..

In Brazil, the 9263/96 law, that deals with Family Planning 14 14 Brasil. Lei nº 9.263, de 12 de janeiro de 1996. Regula o § 7º do art. 226 da Constituição Federal, que trata do planejamento familiar, estabelece penalidades e dá outras providências. Diário Oficial da República Federativa do Brasil [Internet]. Brasília (DF); 1996 jan 15 [citado 2011 Jul 25]. Disponível em: http://www.planalto.gov.br/ccivil_03/Leis/L9263.htm
Disponível em: http://www....
, was considered a significant advance in terms of sexual and reproductive rights of Brazilian men and women. In Article 9, it states that "to the exercise of the right to family planning all the methods and techniques of conception and contraception which are scientifically accepted and do not endanger the life and health of the people will be offered, guaranteed freedom of choice". Although the law ensures, in its 1st Article, that the "family planning is the right of every citizen", the deployment of services aimed at him, their distribution and performance fall way short, not being, in most cases, even made feasible.

Given the illegality of IA and subsequent clandestinity, which lead to unsafe abortion, studies clarifying the conditions of occurrence are still necessary in Brazil. Thus, the present study seeks to estimate the prevalence of women with IA among the women of childbearing age (15 to 49 years old) who have had some pregnancy, living in the city of São Paulo, Brazil, as well as to better characterize the IA health damage in terms of some sociodemographic characteristics associated with it.

METHODOLOGY

This is a cross-sectional study for which we performed a field survey in the months of October, November and December of 2008 in the city of Sao Paulo. For this, 120 streets were randomly selected, whose listing was made using the SEPLAN (Department of Planning and Development) map. In each street, 10 houses were drawn - the house next door would serve as a substitute to the chosen home after three visits, if there was no female resident available to answer the questionnaire for any reason. The interviews were conducted directly, on the home of the interviewee, by female interviewers, college students previously trained specifically for the use of the research instrument. We used a structured questionnaire consisting of 55 different questions on SDC and reproductive health of this population. In total, 861 women were interviewed, aged between 15 and 49 years. For this analysis, we have selected the group of women who had a previous pregnancy, totaling 683 subjects.

For the data analysis, the dependent variable abortion was categorized in IA and no abortion (NA or WA). The independent variables included were: age at the time of the interview, divided into quinquennial age groups (15 - 20; 20 - 25; 25 - 30; 30 - 35; 35 - 40; 40 - 45; 45 - 50); paid activity (yes or no); family income (divided into: up to 0.5 minimum wage (MW); from 0.5 to 1 MW, from 1 to 1.5 MW, from 1.5 to 2 MW, from 2 to 2.5 MW, from 2.5 to 3.5 MW, from 3.5 to 7 MW, from 7 to 10 MW, above 10 MW and "do not know or refused to answer"); schooling (illiterate, elementary school I incomplete/complete, elementary school II (middle school) incomplete/complete, high school incomplete/complete and higher education incomplete/complete); marital status (single, married/attached, separated or divorced and widowed); use, or no use, of one or more contraceptives (pill or intrauterine dispositive (IUD), sterilization, non-effective methods (or of low efficacy) and not using any contraceptive method).

This project, derived from the Public Notice 22 funded by the National Research Council (CNPq), was organized by the Department of Preventive Medicine of Universidade Federal de São Paulo (UNIFESP) in 2008 and approved by the Ethics and Research Committee of the institution, under the number 1927/09.

Data Analysis

The data were summarized using descriptive measures appropriate to the type of variable: number and percentage for qualitative variables, mean and standard deviation for the quantitative ones.

The prevalence of women with IA was assessed through generalized linear models, using the Poisson distribution with logarithmic link function and robust variance to approximate the binomial distribution 15 15 Barros AJD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol [Internet]. 2003 [cited 2011 Jul 25];3(21). Available from: http://www.biomedcentral.com/1471-2288/3/21
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according to each feature separately. The choice of this method is due to the suggestion of the literature 15 15 Barros AJD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol [Internet]. 2003 [cited 2011 Jul 25];3(21). Available from: http://www.biomedcentral.com/1471-2288/3/21
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for the purpose of describing the Prevalence Ratios (PR) of events considered "rare". To identify which characteristics were more strongly associated with IA, multiple regression analysis of the PR of the factors investigated was done, using a strategy of selecting variables by the backward method and grouping the categories statistically closer. Finally, we built a final model for the PR of women with IA who had previous pregnancy.

Throughout the analysis, we used a significance level of 5% (p < 0.05) and a 95% confidence interval (95%=CI).

RESULTS

In this study, 683 women aged at the moment of the interview between 15 and 49 years referred having had a pregnancy in the course of life and, of these, 31 reported an induced IA.

In Table 1, the sociodemographic data colected, regarding these 683 women, are presented according to: age, engage in paid activity, family income, schooling, current marital status and current use of contraceptive.

Table 1
Sociodemographic data of the women studied. Sao Paulo. 2008.

Among these women, it was observed that, in terms of age at the time of the interview, the distribution of interviewed women was not even, with apparent underestimation, in the proportions of respondents who have been pregnant at least once, in the age groups that correspond to young women. The current age average of all women who have had a pregnancy, in the study population, was 36.1 years, with a higher percentage of women (20.9%) in the current age group of 30 to 35 years and around 20% in the 40 to 45 years range (Table 1).

In the same table, we noticed that, regarding paid activity, 51.7% of the women reported receiving some monthly salary. The income reported by the majority was 1 to 2.5 MW. As for schooling, only 1% of the women who have already been pregnant were illiterate, 38% had up until elementary I, incomplete or complete (13.3%) or elementary II, incomplete or complete (24.7%), 47% had high school, incomplete or complete, and 13.9% had higher education, incomplete or complete.

In relation to marital status, 87.7% of respondents in this group reported being, at the time of the interview, married or cohabiting consensually.

Regarding the use of contraceptive methods, the higher proportion of women with a previous pregnancy appears among those who used low-efficacy or "non-effective" (30.3%) contraceptive methods; followed by the ones who declared non-use of contraceptives (24.5%), those who reported current use of "the pill" or IUD (25.6%) and, lastly, those who were already sterilized (19.6%) at the time of interview.

In Table 2, we have the distribution of women with prior pregnancy according to miscarriage caused by SDC and their PR for IA (crude analysis). As stated above, of the 683 women who experienced pregnancy, 31 (4.5%) declared IA. The distribution of women with IA, according to SDC, in percentages, is shown in Table 3.

Table 2
Distribution of women with previous pregnancy according to induced abortion by sociodemographic characteristics and prevalence ratio in the crude analysis. Sao Paulo. 2008.

Table 3
Distribution of women with previous pregnancy according to induced abortion by sociodemographic characteristics in percentages. Sao Paulo. 2008.

At table 3, once again, concerning age, the distribution of women with IA denotes a underrepresentation of the younger. The higher proportion of women who had induced abortion was aged, at the time of interview, between 40 and 45 years (35.5%), followed by the group of women between 30 and 35 years (22.5%), percentage close to the age group between 35 and 40 years (19.3%). In this research, we were not informed at what age exactly each woman induced abortion, but we can conclude that between 30 and 45 years most of the women who provoked an abortion (77.3%) had already done so at least once 16 16 Cecatti JG, Guerra GVQL, Sousa MH, Menezes GMS. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet. 2010;32(3): 105-11..

The family income reported by most women with IA (80.6%) ranged between 0.5 and 2.5 MW, but with 19.4% of them having a less than 1 MW income 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011.. Among the women who reported IA, 51.6% declared having a paid job.

Regarding schooling, among women with IA, 12.9% declared having elementary school I (incomplete to complete), 38.7% elementary school II (incomplete or complete), 38.7% high school (also incomplete or complete) and 9.6% (3 M) reported having initiated higher education (Table 3). Despite the similarity in the proportions of women with IA in elementary II and high school, we see from Table 2 that the prevalences are quite distinct, 12/169 for elementary II and 12/321 for high school, showing a preponderance of the prevalence of women with IA with elementary school II, complete or incomplete, over the women with IA with high school. Comparing Tables 1 to 3, the presence of a first filter in the schooling of the woman when she becomes pregnant and a second one at the onset of IA is noticed, particularly in relation to high school and higher education 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011. , 18 18 Fusco CLB. Aborto inseguro: frequência e características sociodemográficas associadas, em uma população vulnerável - Favela Inajar de Souza, São Paulo [dissertação de mestrado]. São Paulo: Universidade Federal de São Paulo; 2006..

As to marital status, the same phenomenon can be seen in the results regarding the difference between proportions and prevalence. There is a higher proportion of women with IA who referred being married or cohabiting at the moment of the interview, yielding a higher proportion of women with IA with that marital status (67.8%) (Table 3). However, when looking at the prevalences, marital status shows a higher prevalence (7/69) of single women, 10.1%, while the women with IA that reported married/united marital status have a prevalence of 3.9%.

Concerning the use of contraceptive methods, most women with IA (51.6%) referred the current use of "non-effective (or low efficacy) contraceptive", while 16.1% of them do not use any contraceptives, amounting a total of 67.7% of women without basic protection against an unintended pregnancy 7 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(4):709-19.. In addition, 25.8% reported using "the pill" (oral contraceptive) or IUD currently and 6.5% had already underwent elective tubal ligation (Table 3).

The proportion of women with IA associated to the number of children born alive is thus distributed: 74.2% have one to four children; 16.1% already have more than 5 children and 9.7% did not have any children (Table 3). Again, the prevalences must be observed, because the prevalence of women with 5 or more children (5/35), 14.3%, ends up being the largest among them (Table 2).

Categorized variables, that in Table 2 had statistical significance, were: unmarried marital status (p = 0.020), "non-effective" current contraceptive (p = 0.026) and liveborn infants (p = 0.003 for 5 or more children and p = 0.068 - marginally significant - for no LI).

Finally, in Table 4 we have the final result of the regression analysis for prevalence ratio of IA among women with prior pregnancy with their significances.

Table 4
Final model of the regression analysis for prevalence ratio of induced abortion for women with previous pregnancy. Sao Paulo. 2008.

The variable categorized with the largest PR was "use of non-effective contraception (or low efficacy)", with a PR = 4.18, which also showed a strong statistic significance (p < 0.001), which demonstrates that women who, among others, used non-effective or low-efficacy contraceptives were 4.18 times more likely of having an abortion in relation to the reference category, and proceeding to it. On the other hand, the "current use of pill or IUD" presented a PR = 2.70, with p = 0.046, not being informed if such use was already made, and was inadequate, at the time of the pregnancy terminated in IA.

Then we have the "number of children of 5 or more", with PR = 3.97 and p = 0.001. It had already been pointed out that 74.2% of women with IA have 1 to 4 children and 16.1%, over 5 children 19 19 Souza e Silva R. Patterns of induced abortion in urban area of Southeastern region, Brazil. Rev Saúde Pública. 1998; 32(1): 7-17.. The latter had an almost four times higher chance than the previous of inducing an abortion.

The "single status on the marital status category" has PR = 2.79, with p = 0.015, meaning that unmarried or single women, of the analyzed group, resorted to abortion almost 3 times more than the others.

The "current age category, or stratum, of 40 to 44 years", shows PR=2.76 and p=0.004, which demonstrate that this age group had, at the time of the interview, in this population, a prevalence of women with IA 2.7 times higher than the age stratum taken as a reference.

DISCUSSION

Globally, 40% of all pregnancies are unintended or unplanned 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97.. Women faced with an unintended, or unplanned, or even inappropriate pregnancy have only two choices: facing an unwanted birth or interrupting pregnancy 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97.. In Brazil, as in many poor or developing countries, this option is made difficult by restrictive laws toward voluntary abortion, leading to clandestine abortion.

Women in social circumstances of disadvantage are more likely to experience an unintended gestation than women with greater financial and social resources 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97.. Family income declared by the women in this study demonstrates, once again, the influence of a low income on the occurrence of induced and unsafe abortion 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011..

The vulnerability to unwanted pregnancies is strongly influenced by access and use, or no use, of effective contraception, besides exposure to unwanted sex, early marriage and sexual violence 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97.. Contraceptive use is closely associated with the level of education of the woman; the more educated women are, the more knowledge they have about contraceptive methods and their use, may choose the most effective, unlike the less educated, who are more likely to mention lack of knowledge about sexual and reproductive health, including family planning. Women who are more educated have, besides more acquired knowledge, greater autonomy and greater choice making capacity 7 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(4):709-19. , 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97..

As we've seen, in the population surveyed, more than half of the women with IA report the current use of non-effective contraceptives, or low efficacy, and another part does not use contraceptives, leading to a significant proportion of women without protection against an unplanned pregnancy 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97.. It can be noted that these women, if this situation is maintained, continue to be candidates for new IA 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011..

Although we do not have accurate knowledge about the type of access to health services of these women (how many are SUS users, how many have health insurance and so on), it can be deduced that the "family planning" stated by law does not satisfy the required demands of contraceptives. The Brazilian population, especially SUS users, does not have yet regular access to contraceptives 21 21 Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Área Técnica de Saúde da Mulher . Assistência em Planejamento Familiar: Manual Técnico/Secretaria de Políticas de Saúde, Área Técnica de Saúde da Mulher - 4ª edição - Brasília: Ministério da Saúde, 2002. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/0102assistencia1.pdf
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. In Brazil, the National Family Planning Policy was created in 2007. In 2009, this policy was enlarged, providing greater access to definitive methods of contraception, such as tubal ligation and vasectomy, as well as condoms and other contraceptives 22 22 Ministério da Saúde (BR). Saúde da Mulher/Planejamento Familiar. Portal Brasil. Brasília (DF): Ministério da Saúde;2010. Disponível em: http://www.brasil.gov.br/sobre/saude/saude-da-mulher/planejamento-familiar
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.

To the women who have access to contraceptives, often lacks the possibility of choosing the method or the medicine most appropriate and effective, particularly in the SUS. On other occasions, the failure is in the lack of appropriate information by a multidisciplinary team, as required by the technical standards of care in family planning of the MH 21 21 Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Área Técnica de Saúde da Mulher . Assistência em Planejamento Familiar: Manual Técnico/Secretaria de Políticas de Saúde, Área Técnica de Saúde da Mulher - 4ª edição - Brasília: Ministério da Saúde, 2002. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/0102assistencia1.pdf
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, especially for less educated women. These standards recommend at least three types of activity in contraceptive assistance: educational activities, counseling and clinical activities that, on the other hand, must be developed in an integrated manner and in a process that goes beyond contraception, aiming to support comprehensive women health 21 21 Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Área Técnica de Saúde da Mulher . Assistência em Planejamento Familiar: Manual Técnico/Secretaria de Políticas de Saúde, Área Técnica de Saúde da Mulher - 4ª edição - Brasília: Ministério da Saúde, 2002. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/0102assistencia1.pdf
Disponível em: http://bvsms....
. In practice, this level of complexity of actions has not yet been reached.

The number of children born alive is another important variable to determination of the outcome IA. The average number of children per woman in the study population was 2.17. With inadequate or irregular use of contraceptives, with use of low efficacy contraception, or without the use of any contraceptive method, women of childbearing age end up having more children than the number desired by them. Several studies 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011. , 23 23 Silva RS. O aborto provocado frente à contracepção e o declínio da fecundidade na Cidade de São Paulo. Rev Saúde Pública 2005; 1(9): 9-29. point to this issue as one of the main factors that lead women to choose abortion, especially among low-income women without access to family planning services. As mentioned above, the law on family planning in Brazil 14 14 Brasil. Lei nº 9.263, de 12 de janeiro de 1996. Regula o § 7º do art. 226 da Constituição Federal, que trata do planejamento familiar, estabelece penalidades e dá outras providências. Diário Oficial da República Federativa do Brasil [Internet]. Brasília (DF); 1996 jan 15 [citado 2011 Jul 25]. Disponível em: http://www.planalto.gov.br/ccivil_03/Leis/L9263.htm
Disponível em: http://www....
was considered a breakthrough in the area of sexual and reproductive rights, but in practice, its application still is precarious. Thus, the higher the number of unwanted children, the greater the chance of occurrence of IA 7 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(4):709-19. , 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011. , 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97. - the prevalence being four times higher for women with more children born alive in the population under study corroborates this fact. It can be noted that in São Paulo in 2002 the fertility rate was 1.88 children per woman, value below the replacement level 24 24 Yazaki LM. Fecundidade da mulher paulista abaixo do nível de reposição. Estud Av 2003; 17(49): 65-86., falling to 1.7 in 2012. Once again it is evidenced the IA use for fertility control, as already shown in other studies 7 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(4):709-19. , 18 18 Fusco CLB. Aborto inseguro: frequência e características sociodemográficas associadas, em uma população vulnerável - Favela Inajar de Souza, São Paulo [dissertação de mestrado]. São Paulo: Universidade Federal de São Paulo; 2006. , 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97..

The mean age at the time of the interview for the total of women in the group of women who have had a pregnancy was 36.1 years, with an uneven age distribution in this sample and under-representation of young women belonging to the first two five-year periods (15 to 19 and 20 to 24 years). We were not informed of the age at the time of pregnancy or abortion. These facts, as discussed above, prevent the study of the behavior of the IA according to age group among women below 24 years old. Surveys show an increased vulnerability to abortions among teenagers and young females 25 25 Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia . Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde). Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_aborto.pdf
Disponível em: http://bvsms....
, although it is necessary to have further discussions on social determinants and even on the experiences of pregnancy and abortion in these stages of life 26 26 Menezes G, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25: s193-s204..

There was not, in the crude analysis, significant difference between age groups. It is known that several studies show a higher prevalence of women with IA among young women 17 17 Fusco CLB. Aborto Inseguro: determinantes sociais e iniquidades em saúde em uma população vulnerável Favela Inajar de Souza, São Paulo, SP, Brasil [tese de doutorado]. São Paulo: Universidade Federal de São Paulo; 2011. , 21 21 Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Área Técnica de Saúde da Mulher . Assistência em Planejamento Familiar: Manual Técnico/Secretaria de Políticas de Saúde, Área Técnica de Saúde da Mulher - 4ª edição - Brasília: Ministério da Saúde, 2002. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/0102assistencia1.pdf
Disponível em: http://bvsms....
, 27 27 Cabezas-García E, Langer-Glass A, Alvarez-Vázquez L, Bustamante P. Perfil sociodemográfico del aborto inducido. Salud Pública Méx 1998; 40(3): 264-71., but some studies indicate abortion reports in ascending order according to the age of the women, with higher prevalence among those of 35 years and older 16 16 Cecatti JG, Guerra GVQL, Sousa MH, Menezes GMS. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet. 2010;32(3): 105-11.. In agreement with the latter, and respecting the limitations of the sample, in this population the current age group with the higher prevalence of women with IA was 40 to 44 years. One can think of omission in the statements of the young women, but it should also be considered that "the higher the age, the longer the exposure period to pregnancy and abortion" 16 16 Cecatti JG, Guerra GVQL, Sousa MH, Menezes GMS. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet. 2010;32(3): 105-11..

The sociodemographic characteristic "marital status" is one of the possible definers of the occurrence or not of an induced abortion in the existence of an unplanned pregnancy 7 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(4):709-19. In the population studied, the PR for the categorized variable "single", as shown in Results, indicates that the officially sigle women (until the moment of the interview) induced about three times more abortions than the married/united ones 28 28 Silva RS, Andreoni S. Aborto induzido: uma comparação entre mulheres casadas e solteiras residentes na cidade de São Paulo em 2008. Rev Ciência&Saúde Coletiva 2012; 17(7): 1725-33.. These women also had a higher incidence of paid activity, lower household income, and lower schooling 7 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(4):709-19. , 28 28 Silva RS, Andreoni S. Aborto induzido: uma comparação entre mulheres casadas e solteiras residentes na cidade de São Paulo em 2008. Rev Ciência&Saúde Coletiva 2012; 17(7): 1725-33., factors that contribute to the choice of IA along with the fact that they find themselves alone facing an unintended pregnancy 18 18 Fusco CLB. Aborto inseguro: frequência e características sociodemográficas associadas, em uma população vulnerável - Favela Inajar de Souza, São Paulo [dissertação de mestrado]. São Paulo: Universidade Federal de São Paulo; 2006. , 20 20 Malarcher S, Olson LG, Hearst N. Unintended pregnancy and pregnancy outcome: equity and social determinants. In: Blas E, Kurup AS, editores. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 177-97..

In a worldwide review of induced abortion 29 29 Bankole A, Singh S, T. H. Características de mulheres que obtêm aborto induzido: uma revisão a nível mundial. Perpect Int Planej Fam 2001; Spec: 10-9., published in 2001, which included countries in which abortion was legalized and countries where it is restricted by law, developed countries and developing countries, it was concluded by the authors: "In more than half of the analyzed countries, married women have a higher percentage of abortions that single women. Once pregnant, however, the single woman is more likely to choose abortion than the married one" 29 29 Bankole A, Singh S, T. H. Características de mulheres que obtêm aborto induzido: uma revisão a nível mundial. Perpect Int Planej Fam 2001; Spec: 10-9.. One could think that these findings justify the higher prevalence of single women with IA in the present study.

CONCLUSIONS

Of the 683 women interviewed who had already experienced a pregnancy, aged between 15 and 49 years, living in the city of São Paulo, 31 reported at least one IA. The categorized variables corresponding to the main SDC studied that showed PR significantly associated with the occurrence of IA were: current age between 40 and 44 years old, use of non-effective or low efficacy contraceptives and/or inappropriate use of contraceptive methods, number of children born alive equal or superior to 5 and single marital status.

In this article, we discussed the main implications of these findings that, once again, along with their overlapping with others SDCs or variables such as income, schooling and changes in the participation of modern women in society, lead to the urgency of implementing effective family planning services, the need for equity in health and the legalization of abortion.

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  • *
    On 04/12/2012, the Federal Supreme Court (STF) has approved the termination of pregnancy of anencephalic fetus, also called therapeutic anticipation of delivery

History

  • Received
    04 Feb 2013
  • Reviewed
    01 Dec 2013
  • Accepted
    11 Dec 2013
  • Publication
    June 2014
Associação Brasileira de Pós -Graduação em Saúde Coletiva São Paulo - SP - Brazil
E-mail: revbrepi@usp.br