Abstracts

INTRODUCTION

Unsafe abortion represents a controversial and challenging question, which incorporates social justice aspects in low and middle income countries, ⁷7  Cook RBB, Tathala M. Saúde reprodutiva e direitos humanos: integrando medicina, ética e direito. Rio de Janeiro: Cepia; 2004. involving a complex network of legal, economic, social, and psychological factors. ⁷7  Cook RBB, Tathala M. Saúde reprodutiva e direitos humanos: integrando medicina, ética e direito. Rio de Janeiro: Cepia; 2004. ^{, 17}17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... Unsafe abortion is defined as the interruption of a pregnancy performed by persons/professionals without the necessary technical abilities and/or in environments without adequate sanitary standards. ^aa World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva; 2003 [cited 2013 Jan 10]. Available from: http://whqlibdoc.who.int/publications/2003/9241590343.pdf On the other hand, abortion that is considered safe is that which performed in situations set forth in law, making it possible to provide women with the necessary and qualified treatment on behalf of structured health services. These services should offer psychosocial assistance at the moment of decision and guarantee the quality of health care necessary for the treatment and monitoring of the event. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, a}a World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva; 2003 [cited 2013 Jan 10]. Available from: http://whqlibdoc.who.int/publications/2003/9241590343.pdf

Unsafe abortions occur mainly in countries where the laws are restrictive to the procedure or in those where it is legal, but women’s access to health services is hampered. ¹²12  Faúndes A. Strategies for the prevention of unsafe abortion. Int J Gynaecol Obstet . 2012;119(Suppl 1):68-71. DOI:10.1016/j.ijgo.2012.03.021
https://doi.org/10.1016/j.ijgo.2012.03.0... As a consequence, unsafe abortion is one of the main causes of maternal morbidity and mortality in these countries. ¹1  Ǻhman E, Shah IH. New estimates and trends regarding unsafe abortion mortality. Int J Gynaecol Obstet. 2011;115(2):121-6. DOI:10.1016/j.ijgo.2011.05.027
https://doi.org/10.1016/j.ijgo.2011.05.0... ^{, 10}10  Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Cienc Saude Coletiva . 2010;15Suppl 1:959-66. DOI:10.1590/S1413-81232010000700002 
https://doi.org/10.1590/S1413-8123201000... ^{, b}b Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion worldwide: a decade of uneven progress. New York: Guttmacher Institute; 2009 [cited 2013 Jan 10]. Available from: http://www.guttmacher.org/pubs/Abortion-Worldwide.pdf In 2008, it is estimated that 22 million unsafe abortions occurred around the world, 97.0% in developing countries. ²²22  Shah I, Ǻhman E. Unsafe abortion in 2008: global and regional levels and trends. Reprod Health Matters . 2010;18(36):90-101. DOI:10.1016/S0968-8080(10)36537-2
https://doi.org/10.1016/S0968-8080(10)36... ^{, 23}23  World Health Organization. Unsafe Abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. Geneva; 2011[cited 2013 Jan 10]. Available from: http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241501118/en/index.html
http://www.who.int/reproductivehealth/pu... Approximately 13.0% of maternal deaths in the world are related to unsafe abortion, resulting in 47,000 deaths of women each year, mainly in Latin American countries. ²²22  Shah I, Ǻhman E. Unsafe abortion in 2008: global and regional levels and trends. Reprod Health Matters . 2010;18(36):90-101. DOI:10.1016/S0968-8080(10)36537-2
https://doi.org/10.1016/S0968-8080(10)36... ^{, 23}23  World Health Organization. Unsafe Abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. Geneva; 2011[cited 2013 Jan 10]. Available from: http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241501118/en/index.html
http://www.who.int/reproductivehealth/pu...

In Brazil, the illegality of unsafe abortion obscures its real magnitude and repercussions. The practice of abortion is considered a crime in the country, being permitted by law in cases of sexual violence (rape) or maternal risk of life ⁸8  Diniz D. Quem autoriza o aborto seletivo no Brasil? Médicos, promotores e juízes em cena, Brasil. Physis . 2003;13(2):13-34. DOI:10.1590/S0103-73312003000200003
https://doi.org/10.1590/S0103-7331200300... ^{, c}c Decreto-lei no 2.848, de 7 de dezembro de 1940. Código penal. Diario Oficial Uniao . 31 dez 1940:2391. and, more recently, in cases of pregnancies of anencephalic fetuses. ²¹21  Pacagnella RC.Novamente a questão do aborto no Brasil: ventos de mudança? Rev Bras Ginecol Obstet. 2013;35(1):1-4. DOI:10.1590/S0100-72032013000100001
https://doi.org/10.1590/S0100-7203201300... Against the difficulties of registering the number of abortions, the estimates are based on hospital admissions due to abortion recorded in the Brazilian Unified Health System (SUS). ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... It is estimated that between 729,000 and 1.25 million unsafe abortions are performed annually. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... It is additionally estimated that by the end of reproductive life, one in five women in Brazil will have had an abortion. ¹⁰10  Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Cienc Saude Coletiva . 2010;15Suppl 1:959-66. DOI:10.1590/S1413-81232010000700002 
https://doi.org/10.1590/S1413-8123201000... Post abortion curettage is the second most frequent obstetrician procedure in the public health system. Around 240,000 hospital admissions are performed annually for treatment of complications arising from abortions in the SUS, generating annual costs of approximately 45 million reais. ^dd Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2005. Besides this, abortion-related indicators reveal strong social and regional inequalities. States in the North and Northeast regions present higher abortion rates ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... and constitute the main cause of maternal death in some capitals of these states. ^dd Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2005.

Knowledge of the magnitude and trends of unsafe abortion is necessary to monitor the progress in the direction of improving maternal health care and access to family planning. Furthermore, it can contribute to the development of public policies that promote the discussion, prevention, and integral and humanized care for women in abortion situations. ¹⁴14  Juarez F, Singh S, Garcia SG, Olavarrieta CD. Estimates of induced abortion in Mexico: what’s changed between 1990 and 2006? Int Fam Plan Perspect . 2008;34(4):158-68. DOI:10.1363/3415808
https://doi.org/10.1363/3415808... ^{, 17}17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... Due to the difficulties of obtaining data, indirect estimates have been important tools, and various methodologies have been developed and tested. ²2  Alan Guttmacher Institute. Clandestine abortion: a Latin American reality. New York: Alan Guttmacher Institute; 1994. ^{, 11}11  Diniz D, Corrêa M, Squinca F, Braga KS. Aborto: 20 anos de pesquisas no Brasil. Cad Saude Publica . 2009;25(4):939-42. DOI:10.1590/S0102-311X2009000400025
https://doi.org/10.1590/S0102-311X200900... ^{, 14}14  Juarez F, Singh S, Garcia SG, Olavarrieta CD. Estimates of induced abortion in Mexico: what’s changed between 1990 and 2006? Int Fam Plan Perspect . 2008;34(4):158-68. DOI:10.1363/3415808
https://doi.org/10.1363/3415808...

The objective of this study was to analyze time trends and spatial distribution patterns of unsafe abortion in Brazil, from1996 to 2012.

METHODS

Ecological study of time-series and spatial analysis, utilizing secondary data of hospital admissions due to abortion occurring in Brazil, from 1996 to 2012. A database was compiled based on the number of hospital admissions due to abortion, the number of live births and the population of women aged 10 to 49. The data were obtained from the Sistema de Informações Hospitalares (SIH – Brazilian Hospital Information System) and the Sistema de Informações sobre Nascidos Vivos (SISNAC – Brazilian Live Birth Information System), from the Departamento de Informática do SUS (DATASUS – Brazilian Unified Health System Information Technology Department) ^ee Ministério da Saúde, Departamento de Informática do SUS. DATASUS. Brasília (DF): 2013 [cited 2013 Oct 13]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=02 and the Brazilian Institute of Geography and Statistics (IBGE). ^ff Instituto Brasileiro de Geografia e Estatística. População Residente. 2013 [cited 2013 Dec 15]. Available from: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popuf.def The population data were collected from the Brazilian Population Demographic Census (2000 and 2010), Population Counting (1996) and population estimates for inter census years (1997-1999, 2001-2009 and 2011-2012). ^ff Instituto Brasileiro de Geografia e Estatística. População Residente. 2013 [cited 2013 Dec 15]. Available from: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popuf.def The data of live births were obtained from the live birth declarations (DN), standardized nationwide (data available until 2011). ^ee Ministério da Saúde, Departamento de Informática do SUS. DATASUS. Brasília (DF): 2013 [cited 2013 Oct 13]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=02 The information about hospitalizations due to abortion were obtained from the Autorização de Internação Hospitalar (AIH – Hospital Admission Authorization) recorded from 1996 to 2012, ^ee Ministério da Saúde, Departamento de Informática do SUS. DATASUS. Brasília (DF): 2013 [cited 2013 Oct 13]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=02 according to place of residence. Abortion and its complications correspond to the codes O00-O08 (Pregnancy with abortive outcome), of Chapter XV – Pregnancy, childbirth and puerperium, of the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). ^gg Word Health Organization. Statistical Classification of Diseases and Related Health Problems (ICD): 10th rev. Geneva; 2007 [cited 2013 Jan 10]. Available from: http://apps.who.int/classifications/apps/icd/icd10online/

The number of hospitalizations due to abortion (NIH – internações hospitalares por abortamento ) subsidized the calculation of estimates of unsafe abortions (NAI – número de abortos inseguros ) by year and place of residence. To achieve this, the methodology of Alan Guttmacher ²2  Alan Guttmacher Institute. Clandestine abortion: a Latin American reality. New York: Alan Guttmacher Institute; 1994. was used, based on the following formula:

NAI = (5)*(1.125)*(0.75) NIH

This methodology estimates the number of unsafe abortions, considering: 20.0% of hospital admissions due to abortion complications (one admission for every five abortions); parameter of 12.5% as an estimate of underreporting (admissions performed outside SUS) and a discount of 25.0% of abortions due to spontaneous causes. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... The following indicators were calculated: unsafe abortion rate per 1,000 women of childbearing age (10 to 49), a measurement that describes the number of unsafe abortions in a female population in reproductive age, and the unsafe abortion ratio per 100 live births (2000-2011), that indicates the probability of a pregnancy ending in unsafe abortion instead of a live birth. ²³23  World Health Organization. Unsafe Abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. Geneva; 2011[cited 2013 Jan 10]. Available from: http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241501118/en/index.html
http://www.who.int/reproductivehealth/pu...

Data analysis was performed in two stages. In the first, the time trends of unsafe abortion indicators were analyzed using the five geographic regions (North, Northeast, Central-West, South and Southeast) and the 27 states as units of analysis. Time trends analysis was performed using the polynomial regression method, ¹⁵15  Kleinbaum DG, Kupper LL, Nizam A, Muller KE. Applied regression analysis and other multivariable methods.4th ed. Boston; Duxbury Press; 2007. with the objective of identifying the curve that best adjusted to the data, in order to describe the relationship between the dependent variable Y (unsafe abortion indicator) and the independent variable (year of study). To avoid the autocorrelation between the terms of the regression equation, an artifice of centralizing the year variable was used, transforming it to calendar year minus the mid-point of the historic series. The following models were tested: first order (simple linear) (Y = β₀ + β₁X), second order (Y = β₀ + β₁X + β₂X²), third order (Y = β₀ + β₁X + β₂X² + β₃X³), where β₀ is the period average rate and β₁, β₂ and β₃ represents the average annual increment. The choice of the best model was based on the best function according to scatterplot, best adjustment by the analysis of residuals, greatest statistical significance and greatest determination coefficient (R²). In the case of similar statistical models, the simpler one was chosen. The trends were considered statistically significant when the models presented a p-value < 0.05.

In the second stage, the spatial distribution patterns of unsafe abortion in Brazil were analyzed using the municipalities of residence (5,565; territorial division of 2010) as unit of analysis. Methods of spatial analysis and GIS techniques were used to evaluate the geographic distribution and spatial dependence of unsafe abortion indicators in Brazil.

Two strategies were used as the basis for the construction of thematic maps. To correct the random fluctuations and provide greater stability of unsafe abortion rates, especially in municipalities with small populations, the average rates were estimated in three sub-periods (1996-2000, 2001-2006 and 2007-2012) and total period (1996-2012). The unsafe abortion rates were again estimated (smoothed rates) through the Local Empirical Bayesian method. ⁵5  Assunção RM, Barreto SM, Guerra HL, Sakurai E. Maps of epidemiological rates: a Bayesian approach. Cad Saude Publica . 1998;14(4):713-23. DOI:10.1590/S0102-311X1998000400013
https://doi.org/10.1590/S0102-311X199800...

The presence of global spatial dependence was analyzed using the Global Moran’s I index on crude rates. ⁶6  Cliff AD, Ord JK. Spatial processes: models & applications. London: Pion; 1981.  The local autocorrelation (LISA – Local Index of Spatial Association) was assessed by the Local Moran’s index. ³3  Anselin L. Local indicators of spatial association-LISA. Geogr Anal . 1995;27(2):93-115. DOI:10.1111/j.1538-4632.1995.tb00338.x
https://doi.org/10.1111/j.1538-4632.1995... To identify critical or transition areas, we used the Moran scatterplot based on the Local Moran’s index. ³3  Anselin L. Local indicators of spatial association-LISA. Geogr Anal . 1995;27(2):93-115. DOI:10.1111/j.1538-4632.1995.tb00338.x
https://doi.org/10.1111/j.1538-4632.1995... For spatial representation of the Moran scatterplot, we used the Moran Map that considers only the mapping of municipalities with statistically significant differences (p < 0.05).

We used SPSS software version 15.0 in the preparation of polynomial regression and scatterplots. ArcGIS software version 9.3 (Environmental Systems Research Institute, ESRI, Redlands, CA, USA) and TerraView version 4.2 (INPE – Instituto Nacional de Pesquisas Espaciais, Sao José dos Campos, SP, Brazil) were used for processing, analysis and presentation of cartographic data, calculation of autocorrelation spatial indicators and construction of thematic maps.

Since this is an ecological study using secondary data available to the public without identifying individuals, there was a waiver of the submission to the Ethics Research Committee.

RESULTS

Between 1996 and 2012, 4,007,327 hospital admissions due to abortion were recorded in SIH/SUS, with an average annual of 235,725 hospital admissions. We estimated 16,905,911 unsafe abortions in Brazil, with an average annual of 994,465 (95%CI 961,767; 1,027,163).

Hospital admissions due to abortion, estimates of unsafe abortion and unsafe abortion indicators by regions and states are shown in Table 1 . The average annual unsafe abortion rate was 17.0 abortions/1,000 women of childbearing age, while the unsafe abortion ratio was 33.2 abortions/100 live births. The highest proportion of cases of hospital admissions and unsafe abortions was recorded in the Southeast region (39.2%), especially in the state of Sao Paulo (19.0%). The Northeast region presented the highest values of unsafe abortion indicators (rate: 21.6 abortions/1,000 women of childbearing age; ratio: 39.7 abortions/100 live births). Most states in the North (6/7) and Northeast (6/9) regions, and the states of Federal District and Rio de Janeiro, had higher unsafe abortion rates than the national average, while most states in the Northeast (6/9) and Southeast (3/4) regions, as well as the states of Amapá, Acre and the Federal District, presented unsafe abortion ratio values higher than the national level ( Table 1 ). The state of Amapá had the highest unsafe abortion rate (35.9 abortions/1,000 women of childbearing age) and the state of Bahia, the highest unsafe abortion ratio per live births (53.6 abortions/100 live births) ( Table 1 ).

Trends of unsafe abortion indicators, grouped by regions and states, are presented in Tables 2 and 3. The unsafe abortion rate presented a trend of significant and steady decline in the country (R²: 94.0%; p < 0.001) (linear model), with distinct patterns among the regions and states. Similar to the national pattern observed, the Northeast (R²: 93.0%; p < 0.001), the Southeast (R²: 92.0%; p < 0.001) and Central-West (R²: 64.0%; p < 0.001) regions presented trend of significant and steady decline in the period (linear model). The largest decrease was observed in the Northeast region, with an annual reduction of 0.63 abortions/1,000 women of childbearing age. In contrast, the North region (R²: 39.0%; p = 0.030) showed a trend of significant and not constant increase (second order model), while the South region (R²: 22.0%, p = 0.340) showed a stable trend ( Table 2 ). Most states (16/27) showed a decline trend in the unsafe abortion rates in the period. The states of Amazonas, Amapá, Tocantins, Maranhao, Paraíba and Rio Grande do Sul showed significant increase trends over the period ( Table 2 ).

In contrast to the pattern of decline observed in the unsafe abortion rate, the unsafe abortion ratio/live births presented a stable trend at the national level (R²: 46.0%; p = 0.052). The North (R²: 60.0%; p < 0.001), South (R²: 78.0%; p < 0.001) and Central-West (R²: 23.0%; p = 0.006) regions presented trends of significant and steady increase in the period (linear model). The North (R²: 57.0%; p = 0.001) and Southeast (R²: 25.0%; p = 0.047) regions presented trends of significant and steady decline of this indicator (linear model) ( Table 3 ). Over 40.0% of the states (12/27) presented increase trends in the period. The states of Rondônia, Amazonas, Roraima, Amapá, Tocantins, in Northern Brazil, Paraiba, Northeastern Brazil, Paraná, Rio Grande do Sul, Southern Brazil, Mato Grosso and Goiás, Central-Western Brazil, presented trends of steady increase (linear model) ( Table 3 ).

During the period, 99.9% (5,560/5,565) of municipalities recorded at least one case of hospitalization due to abortion. The distribution of average unsafe abortion rates among municipalities ranged from zero to 124.5 abortions/1,000 women of childbearing age, while the smoothed rates ranged from 0.4 to 122.3. Figures 1 and 2 show maps of the spatial distribution of average crude and adjusted (smoothed) unsafe abortion rates, respectively. In general, both maps show municipalities and/or clusters of municipalities with high unsafe abortion rates (> 20 abortions/1,000 women of childbearing age) in almost all states, located mainly in North, Northeast, Southeast and Central-West regions ( Figures 1 and 2 ). The Northeast and North regions concentrate most of these municipalities, covering important areas with high rates in all states ( Figures 1 and 2 ). Furthermore, important clusters of municipalities with high rates in west of Mato Grosso do Sul, south of Mato Grosso, east of Goiás, the Federal District and north of Minas Gerais were found ( Figures 1 and 2 ).

The Global Moran’s I index for the entire period and sub-periods showed positive (ranging from 0.18 to 0.28) and significant (p < 0.01) values, indicating global spatial autocorrelation with similar patterns in Brazil. Figure 3 shows the clusters of municipalities identified according to the Local Moran’s index for the unsafe abortion rates and visualized by Moran Map. During this period, were identified clusters of municipalities with high rates (high/high) located from the north and east of Sao Paulo, extending to north of Ceará and east of Piauí. An important concentric cluster covered municipalities in south, east and northeast of Bahia, covering most municipalities of the states of Alagoas, Sergipe and Pernambuco and bordering the south of the states of Paraíba and Ceará. In the North region, four other areas with high values of this indicator were identified, highlighting the cluster which covers almost the entire state of Acre and northwest Pará ( Figure 3 ). Clusters of municipalities with low values (low/low) were found covering almost the entire South region, large part of the Central-West region and the state of Maranhao, as well as in isolated areas in the North, Northeast and Southeast regions ( Figure 3 ).

DISCUSSION

This national population-based study provides a comprehensive overview of unsafe abortion and measures its magnitude as a public health problem in Brazil. Although unsafe abortion shows a national decline trend, there are different patterns among the regions. Unsafe abortion has a widespread geographic distribution in the country, with records in almost all municipalities. Furthermore, the existence of clusters of municipalities with high values of unsafe abortions has been identified, especially in states of the North, Northeast and Southeast regions.

A network of high complexity of determinants and conditioning factors, including social, cultural, religious, moral, and legal aspects, inhibits women from declaring their abortions, compromising the existence of more accurate information, thus hindering identification of its real magnitude. ^hh Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011. The situation of illegality in which abortion is performed in Brazil affects the reliability of the statistics that could potentially subsidize the implementation of more precise policies for the different regional realities and age groups. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... ^{, h}h Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011.

Despite the illegality of abortion in Brazil, as in other countries with restrictive laws, ¹1  Ǻhman E, Shah IH. New estimates and trends regarding unsafe abortion mortality. Int J Gynaecol Obstet. 2011;115(2):121-6. DOI:10.1016/j.ijgo.2011.05.027
https://doi.org/10.1016/j.ijgo.2011.05.0... ^{, 22}22  Shah I, Ǻhman E. Unsafe abortion in 2008: global and regional levels and trends. Reprod Health Matters . 2010;18(36):90-101. DOI:10.1016/S0968-8080(10)36537-2
https://doi.org/10.1016/S0968-8080(10)36... ^{, 23}23  World Health Organization. Unsafe Abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. Geneva; 2011[cited 2013 Jan 10]. Available from: http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241501118/en/index.html
http://www.who.int/reproductivehealth/pu... ^{, a}a World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva; 2003 [cited 2013 Jan 10]. Available from: http://whqlibdoc.who.int/publications/2003/9241590343.pdf ^{, b}b Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion worldwide: a decade of uneven progress. New York: Guttmacher Institute; 2009 [cited 2013 Jan 10]. Available from: http://www.guttmacher.org/pubs/Abortion-Worldwide.pdf a high number of hospital admissions for abortion was observed. The criminalization of abortion does not prevent women from interrupting an unwanted or unplanned pregnancy. It only exposes the indiscriminate, unsafe, dehumanized practices with high risk of death, that generate high economic, political and social costs. ⁹9  Diniz D. Aborto e a saúde pública no Brasil. Cad Saude Publica. 2007;23(9):1992-3. DOI:10.1590/S0102-311X2007000900001
https://doi.org/10.1590/S0102-311X200700... ^{, 20}20  Olinto MTA, Moreira-Filho DC. Fatores de risco e preditores para o aborto induzido: estudo de base populacional. Cad Saude Publica . 2006;22(2):365-75. DOI:10.1590/S0102-311X2006000200014
https://doi.org/10.1590/S0102-311X200600...

There was significant heterogeneity of estimated unsafe abortions among Brazilian regions and states. The North and Northeast regions showed the highest values of the indicators analyzed. The distribution of the indicators by state is consistent with the regions with high indicators, mainly in the North and Northeast. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... The unsafe abortion rates showed decline nationally and in most regions (Northeast, Southeast and Central-West), while in the North region there was an increasing trend. The estimated number of unsafe abortions was equivalent to 33.2% of total live births. This indicator showed a stable trend at national level and increase in North, South and Central-West regions. The observed pattern suggests that, despite the decline of unsafe abortion in relation to the population of women of reproductive age in most regions and states, in some of these geographic areas there is an increase in the number of pregnancies that result in abortions rather than births. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro...

The reduction in the number of unsafe abortions can be explained by better access to modern and effective contraception, declining fertility rates, increased medication abortion (misoprostol) and expansion of the jurisprudence in cases of legal abortions provided by law. ¹²12  Faúndes A. Strategies for the prevention of unsafe abortion. Int J Gynaecol Obstet . 2012;119(Suppl 1):68-71. DOI:10.1016/j.ijgo.2012.03.021
https://doi.org/10.1016/j.ijgo.2012.03.0... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... ^{, h}h Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011. Currently, women suffering sexual violence can turn to public health services to carry out the termination of pregnancy in an assisted and safe manner. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... Regional differences can be attributed in part to increased access and adherence to contraception in regions/states with the lowest indicators of unsafe abortions. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... It is emphasized the possible effect of increased use of misoprostol for induction of abortion, reducing the frequency of complications and consequently resulting in lower number of hospital admissions, which could partly explain the reduction in the period studied. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... The National Survey of Abortion in Brazil, conducted in 2010, found that misoprostol was the method of choice most cited by women for induction of abortion. ¹⁰10  Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Cienc Saude Coletiva . 2010;15Suppl 1:959-66. DOI:10.1590/S1413-81232010000700002 
https://doi.org/10.1590/S1413-8123201000... Misoprostol reduces the frequency of complications caused by the use of methods associated with high rates of infection, such as foreign bodies from entering and use of other invasive techniques for inducing abortion. ¹⁹19  Nader, PRA, Blandino, VRP, Maciel, ELN. Características de abortamentos atendidos em uma maternidade pública do Município da Serra - ES. Rev Bras Epidemiol . 2007;10(4):615-24. DOI:10.1590/S1415-790X2007000400019
https://doi.org/10.1590/S1415-790X200700... However, additional studies are needed to assess the impact of the use of misoprostol for the induction and incidence of abortion in Brazil. ¹⁰10  Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Cienc Saude Coletiva . 2010;15Suppl 1:959-66. DOI:10.1590/S1413-81232010000700002 
https://doi.org/10.1590/S1413-8123201000... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... The highest fertility rates can make the female population more vulnerable to unsafe abortion risks. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... Although the fertility rates have declined in all Brazilian regions between 2000 and 2010, there are still significant regional differences, with higher levels of fertility in the North and Northeast regions. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro...

It is undeniable that there have been improvements in access to family planning, mainly to the expansion of the National Family Planning Policy, as well as the quantitative availability of some effective contraceptive methods distributed for free by the SUS. ⁱi Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. PNDS 2006: Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher. Brasília (DF); 2008. However, there was little change in the diversity in options for contraception used by women with lower socioeconomic status. ²¹21  Pacagnella RC.Novamente a questão do aborto no Brasil: ventos de mudança? Rev Bras Ginecol Obstet. 2013;35(1):1-4. DOI:10.1590/S0100-72032013000100001
https://doi.org/10.1590/S0100-7203201300... In 2006, the main methods used by the population with greater social and economic vulnerability were female sterilization and oral contraception. ⁱi Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. PNDS 2006: Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher. Brasília (DF); 2008. The results of this study suggest that there are still important gaps in the provision of reproductive health services and that greater efforts to improve access and adherence to the use of contraceptives are needed. ¹⁸18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro...

In this study, spatial patterns of rates among municipalities were assessed, identifying clusters of municipalities with higher unsafe abortion rates in states in the North, Northeast and Southeast regions. Analyses revealed a pattern of extreme concentration of municipalities with higher unsafe abortion rates in geographic range that runs from the north of Sao Paulo to the north of Ceará, as well as clusters in areas of the North regions. These findings reiterate the marked regional differences in the occurrence of unsafe abortion in Brazil, and show a larger impact in municipalities with poor socioeconomic and access to health care conditions. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro...

Abortion performed in unsafe conditions is among the main causes of maternal mortality in Brazil ¹⁶16  Laurenti R, Jorge MHPM, Gotlieb SLD. A mortalidade materna nas capitais brasileiras: algumas características e estimativa de um fator de ajuste. Rev Bras Epidemiol . 2004;7(4):449-60. DOI:10.1590/S1415-790X2004000400008
https://doi.org/10.1590/S1415-790X200400... and it is an important cause of institutional discrimination and violence against women in health services. Violence represented by the delay of care, lack of easy access and quality care, or explicit discrimination with negative, prejudiced and judgmental attitudes, ⁴4  Aquino EML, Menezes G, Barreto-de-Araújo TV, Alves MT, Alves SV, Almeida MCC, et al. Qualidade da atenção ao aborto no Sistema Único de Saúde do Nordeste brasileiro: o que dizem as mulheres. Cienc Saude Coletiva . 2012;17(7):1765-76. DOI:10.1590/S1413-81232012000700015
https://doi.org/10.1590/S1413-8123201200... besides the negligence of preventive actions of recurrence of abortions. ^hh Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011.

Despite Brazil being a signatory to international agreements, the impact of unsafe abortion on maternal morbidity and mortality hinders the achievement of targets of the Millennium Development Goals (MDG) and does not guarantee, in its entirety, sexual and reproductive rights of women. ^hh Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011. Addressing this problem touches upon deep questions of social justice, ethics, civil legislation and citizenship. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... Regardless of the legal question that encompasses the abortion, the importance of ensuring access and qualified care to maternal health is emphasized. ¹²12  Faúndes A. Strategies for the prevention of unsafe abortion. Int J Gynaecol Obstet . 2012;119(Suppl 1):68-71. DOI:10.1016/j.ijgo.2012.03.021
https://doi.org/10.1016/j.ijgo.2012.03.0... ^{, 21}21  Pacagnella RC.Novamente a questão do aborto no Brasil: ventos de mudança? Rev Bras Ginecol Obstet. 2013;35(1):1-4. DOI:10.1590/S0100-72032013000100001
https://doi.org/10.1590/S0100-7203201300... Strategies for prevention of unsafe abortions and consequently, resulting deaths, involve integrated actions at all levels of prevention in the health services network, such as: reduction of unwanted pregnancies, quality health care during the abortion procedure, recognition and appropriate management of complications and pre-and post-abortion family planning. ¹²12  Faúndes A. Strategies for the prevention of unsafe abortion. Int J Gynaecol Obstet . 2012;119(Suppl 1):68-71. DOI:10.1016/j.ijgo.2012.03.021
https://doi.org/10.1016/j.ijgo.2012.03.0...

The need for timely care is imperative, given the difficulty for women to recognize signs of possible complications, combined with factors that may delay seeking care. From the perspective of comprehensiveness of care, health professionals must not only provide immediate individualized care for women in abortion situations, but also provide contraceptive alternatives, avoiding the resource of repeated abortions, and involve the family, especially the partners. ^hh Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011. For women with spontaneous abortions and wishing new pregnancies, suitable care for their needs must be guaranteed. The desired quality of care includes aspects related to its humanization, encouraging health professionals, regardless of their moral and religious precepts, to show an ethical posture, ensuring respect for women’s human rights. ^hh Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção humanizada ao abortamento: norma técnica. Brasília (DF); 2011.

Public policies will only be effective when guided by greater knowledge of the causality chain of unsafe abortion, which can be achieved through a larger number of studies with specific methodology. There is a need for studies with direct estimation techniques to determine the real magnitude of unsafe abortion. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... Moreover, there is clear need to expand efforts to develop research to better analyze the real impact of unsafe abortion on women, families, and the health sector. ¹⁴14  Juarez F, Singh S, Garcia SG, Olavarrieta CD. Estimates of induced abortion in Mexico: what’s changed between 1990 and 2006? Int Fam Plan Perspect . 2008;34(4):158-68. DOI:10.1363/3415808
https://doi.org/10.1363/3415808...

This study has some limitations that should be taken into account in the interpretation of the results. The application of the indirect estimation technique depends on the data quality of hospital admissions. ¹⁴14  Juarez F, Singh S, Garcia SG, Olavarrieta CD. Estimates of induced abortion in Mexico: what’s changed between 1990 and 2006? Int Fam Plan Perspect . 2008;34(4):158-68. DOI:10.1363/3415808
https://doi.org/10.1363/3415808... ^{, 17}17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... The use of secondary data may have inconsistencies in the quantity and quality of the information. ¹⁹19  Nader, PRA, Blandino, VRP, Maciel, ELN. Características de abortamentos atendidos em uma maternidade pública do Município da Serra - ES. Rev Bras Epidemiol . 2007;10(4):615-24. DOI:10.1590/S1415-790X2007000400019
https://doi.org/10.1590/S1415-790X200700... We used data from the SIH, which records the procedures performed in hospitals linked to the SUS, not considered admissions by abortion performed in hospitals not affiliated with the SUS. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... Additionally, this information system may not detect inconsistencies in the classification of the cause of hospital admission recorded, i.e., faults in the coding of cause of hospital admission may interfere in the results, requiring careful interpretation. Due to the stigma associated with the procedure and the illegality of abortion, there may have been underreporting of the occurrences of abortion by women and providers of health services, even when they are directly involved in the care. ¹³13  García SG, Tatum C, Becker D, Swanson KA, Lockwood K, Ellertson C. Policy implications of a national public opinion survey on abortion in Mexico. Reprod Health Matters . 2004;12(24 Suppl):65-74. DOI:10.1016/S0968-8080(04)24003-4
https://doi.org/10.1016/S0968-8080(04)24... Indirect methods for estimating the magnitude of unsafe abortion through secondary data are approximate and are based on assumptions for performing the calculation. ¹³13  García SG, Tatum C, Becker D, Swanson KA, Lockwood K, Ellertson C. Policy implications of a national public opinion survey on abortion in Mexico. Reprod Health Matters . 2004;12(24 Suppl):65-74. DOI:10.1016/S0968-8080(04)24003-4
https://doi.org/10.1016/S0968-8080(04)24... We used the method developed in 1994 ²2  Alan Guttmacher Institute. Clandestine abortion: a Latin American reality. New York: Alan Guttmacher Institute; 1994. and previously used in large-scale studies in Brazil. ¹⁷17  Mello FMB, Sousa JL, Figueroa JN. Magnitude do aborto inseguro em Pernambuco, Brasil, 1996 a 2006. Cad Saude Publica . 2011;27(1):87-93. DOI:10.1590/S0102-311X2011000100009
https://doi.org/10.1590/S0102-311X201100... ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... This technique assumes that 20.0% of abortions resulted in hospital admissions recorded by the SUS. ²2  Alan Guttmacher Institute. Clandestine abortion: a Latin American reality. New York: Alan Guttmacher Institute; 1994. ^{, 18}18  Monteiro MFG, Adesse L. Estimativas de aborto induzido no Brasil e Grandes Regiões (1992-2005). Rev Saude Sex Reprod [periódico na Internet]. 2006[citado 2012 dez 10];26. Disponível em: http://www.abep.nepo.unicamp.br/encontro2006/docspdf/ABEP2006_252.pdf
http://www.abep.nepo.unicamp.br/encontro... However, this parameter may not be valid, especially because of regional and temporal variations of the admissions by abortions, the increased use of misoprostol, and the decreased fertility occurred in recent years. Despite these limitations, this study provides rough estimates that contribute to the knowledge, even if still insufficient, of the distribution of unsafe abortion in Brazil.We conclude that unsafe abortion, despite the decline at a national level, still constitutes an important public health problem and is a neglected event in Brazil. Expansion of access to care, qualification and humanization of assistance for women in abortion situations, including post-abortion contraceptive counseling services are needed.

HIGHLIGHTS

The results presented in this article show that unsafe abortion is a significant public health problem, characterized as a neglected event in this country. Although there was a decline over the period studied, there are still significant differences between regions, with higher concentrations in the socioeconomically poorer regions.

The scale and social relevance of the problem indicate the need to create strategies to deal with it.

The context of inequality indicates the need for reinforcing health care actions in the areas of highest risk, offering safe alternatives.

The health care system urgently needs to increase access, qualify care and humanize health care actions for women, especially with regards to reproductive and pre- and post-abortion aspects.

Professor Rita de Cássia Barradas Barata Scientific Editor

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