BRAZIL – Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil
by Thália Velho Barreto de Araújo, Estela M L Aquino, Greice M S Menezes, Maria Teresa Seabra Soares de Britto e Alves, Maria-da-Conceição C Almeida, Sandra Valongueiro Alves, Liberata Coimbra, Oona M R Campbell
Cadernos de Saude Publica 2018 Jun 25;34(6):e00168116. DOI: 10.1590/0102-311X00168116 (free full text)
Around 18 million unsafe abortions occur in low and middle-income countries and are associated with numerous adverse consequences to women’s health. The time taken by women with complications to reach facilities where they can receive appropriate post-abortion care can influence the risk of death and the extent of further complications. All women aged 18+ admitted for abortion complications to public sector hospitals in three capital cities in the Northeast of Brazil between August-December 2010 were interviewed; medical records were extracted (n=2,804). Nearly all women (94%) went straight to a health facility, mainly to a hospital (76.6%); the rest had various care-seeking paths, with a quarter visiting 3+ hospitals. Women waited 10 hours on average before deciding to seek care. 29% reported difficulties in starting to seek care, including facing challenges in organising childcare, a companion or transport (17%) and fear/stigma (11%). A few did not initially recognise they needed care (0.4%). The median time taken to arrive at the ultimate facility was 36 hours. Over a quarter of women reported experiencing difficulties being admitted to a hospital, including long waits (15%), only being attended after pregnant women (8.9%) and waiting for a bed (7.4%). Almost all women (90%) arrived in good condition, but those with longer delays were more likely to have (mild or severe) complications. In Brazil, where access to induced abortion is restricted, women face numerous difficulties receiving post-abortion care, which contribute to delay and influence the severity of post-abortion complications.
Additional information from the text:
- All 19 eligible hospitals (8 in Recife, 7 in Salvador and 4 in São Luís) participated. A total of 3064 women were eligible, of whom 2.7% refused to participate and 5.8% were discharged or died (2 women) before they could be interviewed, leaving 2,804 women interviewed.
- Fifty-eight percent of women were in Salvador, 27.1% in São Luís, and 13.9% in Recife. Most women (91.7%) were under 30 years of age, with a mean age of 27.6 years and were mostly (88.6%) married, cohabiting or in a stable relationship. The majority (89.1%) declared themselves as non-white, but 0.4% did not classify themselves. Nearly two-thirds (64.3%) had eight years of education or more. A third (35.5%) were not working, but only 7% had never worked.
- Women’s means of transport for their first care-seeking attempt were private car (family, boyfriend, friend or neighbour’s car) (32.5%), public transport (32.2%), taxi (18%) ambulance (7.8%), on foot (5%), or by bicycle or motorbike (0.9%). Over three-quarters (76.6%) of women went to a hospital first (of which 97% were public hospitals), however, only about half (47%) remained there for the entirety of their care. Nearly a quarter of women (23%) did not go to an appropriate facility level, although 16% sought care within the health system, going first to a health facility (outpatient clinic or primary health unit) for the care they needed. The percentage whose first care-seeking venue was outside the health system (i.e. a drugstore, use of traditional medicine at home, or a visit to a traditional birth attendant or other) was less than 7%.
- Just under half of all women went to one hospital only, while a quarter went to 2 hospitals, and the remainder went to 3 or more, up to a maximum of 8 hospitals. The complex care-seeking combinations involved other health levels and other non-health sector provision as well.
- Almost all women arrived at their ultimate hospital in good condition (92%), while 5% arrived in serious or very serious condition. Women who went to only one hospital were slightly more likely to have arrived in serious or very serious condition. 84.3% of women reported that abortion occurred up to 8 weeks and 97.2% up to 12 weeks of gestation.
- Women hospitalised for abortion complications took nearly 10 hours from first symptoms to decide to seek care. Comparable research in other settings is scarce, but this is shorter than in Kenya, where 54% waited over a week, or Mexico where a qualitative study found most women waited two+ days.
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