From Traditional to Medicalized Methods

Women know about a whole range of abortive procedures, or ones that supposedly function as such, even though their effectiveness has not been scientifically proved. Although the abortive capacity of these methods is doubtful, it is a well-known fact that many of them cause serious complications that often require hospitalizing the woman to complete the abortion (Paxman et al., 1993). In many cases, these complications can lead to the woman’s death. To interrupt pregnancy, women resort to midwives, health professionals, or unqualified personnel, or even attempt to terminate the pregnancy themselves. The person that performs an abortion largely determines the method used.

In an article summarizing the practice of abortion in Latin America and the Caribbean, the authors describe the various methods available, ranging from the use of abortive plants to the insertion of a catheter or a metal probe into the uterus (Paxman et al, 1993). They also highlight the frequent use (particularly in Chile) of dilation and curettage (D&C), performed illegally by doctors or midwives. Another study of the same region on abortion in risky situations shows that both adult women and adolescents use various methods for aborting, such a inserting sharp, solid objects into the uterus (such as knitting needles, spoons, catheters, pencils, earrings, clothes hangers, umbrella spokes and so on) or the direct application to the vagina of soap and vinegar, among other substances. They also resort to swallowing various acidic substances, caustic products, or herbal infusions, or even use external physical force to cause direct contusions on the womb (Espinoza and Carillo, 2003).

These practices show that abortive methods range from traditional, occasionally outdated methods to more sophisticated medical methods. This situation is not exclusive to Latin America. The authors of a study conducted in three national capitals in different parts of the world (Lima, Manila and Nairobi) report that abortion methods include the ingestion of chemical products and detergents, plant-based preparations, overdoses of drugs, the introduction of objects into the uterus, and engaging in intense physical effort (Ankomah et al., 1997).

In his analysis of the procedures for interrupting pregnancies in Uruguay, Sanseviero (2003), distinguishes two types of methods: medicalized procedures (performed illegally) and those based on popular knowledge. The former correspond “to procedures whose use is mediated by the intervention of technically qualified third parties (abortion performers), who are either doctors or obstetricians or else by agents with the necessary knowledge/power to be able to perform these procedures (dilation and curettage, manual aspiration, induction of labor, medical abortion through the use of Cytotec or RU-486…). The latter include procedures whose legitimacy is based on knowledge disseminated through an anonymous, collective, popular, usually female actor. The way methods based on popular knowledge are handled varies: they may be self-administered by the woman herself or implemented within the context of networks of female solidarity. These methods include self-administered Cyotec, inserting probes into the uterus, drinking rue, coffee and palm infusions […], douches, inserting potassium permanganate pills [which are made from poisonous substances] into the vagina…” The author adds that women even insert parsley stalks or sharp objects – usually knitting needles – into their uteruses, to tear the membranes and provoke the expulsion of the uterine contents.

A Wide Range of Traditional Methods

A study of abortion in Latin America conducted by The Alan Guttmacher Institute (AGI, 1994) includes an exhaustive list of the abortion methods used in various countries in the region (Brazil, Colombia, Chile, Mexico and the Dominican Republic). The methods are classified into seven groups: folk methods-herbal/natural, folk methods-manufactured, folk methods-physical, medical techniques, pharmaceutical techniques, prayers, and voluntary traumatization (see Table 1).

Plant-based methods are based on pharmacopoeia and traditional and popular knowledge. These methods are sometimes described in the literature as methods “to make women have their periods” rather than as abortion methods (Sobo, 1996). They are purchased in markets or prescribed by folk healers or herbalists and used in the form of potions, douches or plant suppositories (Costa, 1998). Thus in Mexico, where access to abortion is restricted, there is an “informal market” run both by medicinal plant sellers in both markets and by pharmacists. Plants are sold for their abortive properties, since they are known to cause menstruation, encourage contractions or prevent the implantation of an embryo. Among the plants mentioned are tree daisy (montanoa tormentosa) and rue (ruta graveolens), two plants prescribed alone or in association with others (Pick et al., 1999). In this same country, Ehrenfeld (1999) writes that women use teas made from spices (cinnamon and oregano) occasionally mixed with chocolate, as well as tree daisy infusion. With the last infusion two liters are drunk over a period of two hours.

Several studies have proved the ineffectiveness of traditional methods. One of these was conducted on pregnant women in Brazil to determine the effectiveness of certain substances traditionally used to induce menstruation. In this study, 41% of women that reported having used various drugs for this purposes said that they used teas prepared with herbs (Mengue et al., 1998). In rural parts of Jamaica, a wide range of plants are known and used for their properties in causing menstruation and abortions (Sobo, 1996). Fort (1993), referring also to rural zones, although in this case to Peru, highlights the use of plants as abortive methods. He too notes that they are extremely ineffective.

Likewise, in a study conducted in six countries: Brazil, Colombia, Chile, the Dominican Republic, Mexico and Peru, Singh and Deidre (1994) confirm the frequent use as abortive products of plant-based preparations (infusions and teas) despite their proven inefficacy. In Uruguay, Sanseviero (2003) found that nearly 80% of clandestine abortions were performed by health professionals. The service they provided varied enormously: whereas some performed abortions with a purely commercial attitude, with no consideration towards their patients, others regarded it as a service, the fees for which depended on the resources of the women, whom they treated with special deference. This same author notes that the remaining 19% of abortions were carried out through practices based on popular wisdom, or self-administered by the women themselves. Again, various products were used which, although not actually abortive, often had major effects on women’s health. These included manufactured products, such as detergents, methylene blue, bleach or chlorine, and acidic products, such as lemon. Also used were white alcohol, wine, vinegar or other liquids containing alcohol. Sugary products such as cola drinks, used either as beverages or injected into the vagina, were also used for this purpose (Singh and Deidre, 1994; Ankomah et al., 1997; Brito de Marti, 1994).

Certain pharmaceutical products are also reputed to have abortive properties. The unrestricted sale of these products contributes to their massive use, although they are actually prescribed for a purpose other than interrupting gestation. They are products that are medically inadvisable during pregnancy and which, when used for abortive purposes, are employed in higher than normal doses. These include anti-malaria pills (Nivaquine and quinine), hormones (such as Crinex and Synergon), aspirin or acetaminophen, antibiotics, laxatives, etc. (Bonnema and Dalebou, 1992; Rocha, 1993; Costa, 1998). In Mexico, pharmacy employees sell women products that are assumed to be abortive, yet which do not necessarily cause abortions, although they do have side effects. Among them the most frequently used include Metrigen and quinine (Pick et al., 1999).

In Paraguay, pharmacy assistants also sell injectable hormones as abortive products (Krayacich de Oddone et al., 1991). Sobo (1996) notes that in Jamaica, hormone overdoses are commonly used to cause abortions. In the aforementioned study conducted in Brazil (Mengue, et al., 1998), 30% of the female participants reported having used estrogen or progesterone in higher than usual doses.

The case of misoprostol or Cytotec will be dealt with later on, since it is a product occasionally prescribed by doctors as an abortive product, although it is also commonly sold over the counter.

Physical abortion methods consist mainly of inserting objects into the vagina, such as plant stalks or roots, sharp metal or plastic objects, crushed glass, bicycle spokes, catheters, etc. (Singh and Deidre, 1994; Ankomah et al., 1997; Brito de Marti, 1994; Costa, 1998). In Sao Paulo, Rocha notes, like Sanseviero, that women use knitting needles and metal spokes, aside from medicine sold at pharmacies to abort (Rocha, 1993). These techniques often perforate the uterus or cause hemorrhages and may even cause the woman’s death. Other techniques include massages and manipulations of the uterus, violent physical effort, blows and falls. In Bolivia, too, physical effort is described as a risk for causing an abortion (Network, 1994).

Finally, although they correspond to another type of method of a very different nature, to which abortive effects are also attributed, there are prayers, talismans and amulets, which are certainly far less damaging to a woman’s health.

Studies carried out in the 1990s on women hospitalized for complications from abortions performed in Chile, Colombia and Bolivia highlight the importance of self-induced abortions and the fact that they are often caused by inserting objects into the uterus (such as probes, catheters or blunt objects) (Paxman et al., 1993).

A compilation on abortive methods (Artuz and Restrepo, 2002) shows that ignorance of the effects of the substances used to interrupt pregnancies may have fatal consequences for women. The authors say women often consume herbs like mint, whose active properties, in excessive doses, can cause vascular collapses or other serious health problems.

The different methods are sometime combined to guarantee greater “effectiveness”. Thus, in a study undertaken in Chile, Weisner (1990) describes the variety of methods used by a particular woman to provoke an abortion. The woman in question gave herself two injections of methergine (a hormonal product) and then swallowed a drink based on red wine boiled with herbs together with nine aspirins and then another drink based on cement. The procedure ended with the insertion of a catheter. The immediate, frequent consequence of the use of these methods is the risk of congenital malformations for the women’s babies, if the pregnancy continues, and grave risk to women’s health and even lives.

The choice of abortive methods depends, as mentioned earlier, on women’s socio-economic status, which often depends on their educational attainment: the poorest women and those with less schooling use risky methods, such as plants sold by herbalists while others, with more financial resources, use health services that offer greater security (Espinoza and López Carrillo, 2003). Thus, women’s socio-economic status determines their exposure to risky abortions.

In a study on unwanted pregnancies in Latin America and the Caribbean, Langer (2002) agrees with this, stressing the fact that in cities, womenwhot can afford to pay high medical fees have access to less risky abortions. Conversely, poor urban women have no choice but to resort to abortions that they either perform on themselves or that are performed by unqualified personnel. These latter procedures are performed with dangerous methods and usually take place in the women’s homes in unhygienic conditions (Costa, 1998). In Mexico, for example, access to risk-free clandestine abortions is usually reserved for women that can afford expensive procedures, with the guarantee that their confidentiality will be preserved (Ehrenfeld, 1994; Ortiz–Ortega et al., 2003). This situation illustrates and confirms the fact that income continues to be a key factor in access to abortion in countries where it is illegal. An identical situation occurs in Bolivia, where women from the upper classes abort with the help of medical personnel, while those from social groups with fewer resources undergo abortions in risky, unhygienic conditions (Pereira Morato, 1991).

In his study on abortion in Uruguay, Sanseviero (2003) shows the link between women’s financial situations and the conditions in which their abortions are performed. Women of a higher socio-economic level have safe, medicalized abortions, while poor women tend to resort to the risky popular practices. This author believes that these practices reflect a profound “social injustice” since they are the only choice for women in situations of extreme personal and social vulnerability.

Medical abortion

These medication methods are currently based on three types of drugs: methotrexate (marketed as Ledertrexate), mifepristone (also known as RU-486), and misoprostol (sold commercially as Cytotec) (Schiavon, 2003). These medications can be used on their own or in combination with others (Espinoza, 2002). The conditions for the prescription and use of these products are closely linked to the legal status of abortion and their availability in each country.

The literature shows that there has been a considerable increase in the use of these methods in countries in the region, whether “under medical supervision or through the acquisition of medication at pharmacies or through informal vendors” (Lafaurie et al., 2005; Ferrando, 2002; Rodríguez, 2004; Espinoza et al., 2004; Lara et al., 2004).

The safety, effectiveness and acceptability of medical abortion are fairly good, according to a study conducted in Cuba. Moreover, women that used these methods were more satisfied than those that were treated with clinic or surgical methods (68.5% as opposed to 54.4%) despite the presence of certain side effects (Cabezas, 1998).

The use of Cytotec, or misoprostol, is a good example of this. In certain countries where abortion is legal, such as Cuba or Puerto Rico, Cytotec is used in places authorized to perform abortions. It is prescribed according to extremely precise protocols: it is used orally or vaginally, at a specific point in the pregnancy, either alone or in combination with other medication, such as methotrexate. It has proved to be effective and does not have very many side effects (Cabezas, 1998; Rodríguez Cárdenas and Velasco Boza, 2003).

Misprostol’s effectiveness has led to its growing use. In Peru and other Latin American countries, counseling services are provided to show women how to use misoprostol properly to interrupt a pregnancy (Chávez, 2005).

The authors of a study conducted in Cuba on 120 women scheduled to undergo an abortion between the 10th and 12th week of pregnancy underline the effectiveness and safety of using misoprostol vaginally. The rates of effectiveness of the product reached 94% among white Cubans and 74% among black women, whether or not they were originally from Cuba (Carbonell Esteve et al., 1998). Likewise, another study conducted in a hospital in Havana on 141 women that were less than 70 days pregnant, with an average age of 24, 52% of whom were single, half of whom had no children and nearly 60% of whom had had previous abortions, showed the same proportion of effectiveness (94%) as well as a lack of complications from using different doses of this product vaginally (Rodríguez Cárdenas and Velasco Boza, 2003,). In another study, these same authors showed how the effectiveness of these methods declined when lower doses of the drug were used (Rodríguez Cárdenas and Velasco Boza, 2003). A study conducted in Cuba also confirms the effectiveness of medical abortion accomplished by combining methotrexate administered orally with misoprostol administered vaginally (Carbonell, 1998), or with mifepristone (Winikoff et al., 1997; Cabezas, 1998; Prine et al., 2003).

On the other hand, in a survey applied in the United States, Brazil and Jamaica, the gynecologists consulted emphasized the effectiveness of misoprostol and noted its high acceptance among the women they treated, which varied between 80% and 90% (Clark et al., 2002).

In other countries, Cytotec is generally used illegally. This medicine, initially commercialized to treat gastric or duodenal ulcers, acquired a certain “notoriety” because of its abortive properties, whether it was administered orally or vaginally (Barbosa and Arilha, 1993). It is distributed through various channels, both official and otherwise, since it is used at health centers, sold at pharmacies or other types of establishments, sometimes clandestinely, and in parallel or informal markets (Arilha and Barbosa, 1993). Doctors, pharmacy employees and all kinds of people also spread information on the abortive properties of Cytotec (Sherris et al., 2005). In Rio de Janeiro, Brazil, 84% of the women that used this product had been told about it by friends, colleagues or acquaintances, while 10% had been directly informed by pharmacy employees (Costa and Vessey, 1993).

Brazil is a good example of the diversity of situations in the dissemination of this product. Since its introduction in 1986, sales have rapidly increased (Coelho et al., 1993). Thus, in the city of Goiânia, sales of the product tripled between 1987 and 1989 (Costa, 1998). Since 1988, however, its use has been the subject of controversial debates for the following reasons: a) because this product was used more for its abortive properties than for treating ulcers, b) because gynecologists wanted the product to be available for their use, particularly in the treatment of incomplete abortions and c) because its use contributed to an increase in the number of abortions (Barbosa and Arilha, 1993). These debates contributed to the establishment of restrictions, and sometimes even prohibitions on the sale of this product. Since 1991, the Brazilian government limited the conditions of its sale to reduce its use as an abortive product. These restrictions, which were fairly severe, were applied according the legal regulations of each state (compulsory medical prescription, exclusive use in hospitals or other authorized facilities). Although these limitations contributed to the reduction of Cytotec’s official sales, they also led to the product being sold on the black market, at very high prices (Coelho et al., 1993).

In Brazil, this medicine is widely known as a method used in illegal abortions, often in incorrect doses. Despite the restrictions imposed, it is very commonly used, as shown by the results of various surveys. Although the sale of Cytotec was prohibited from 1992 to 1996 in the cities of Fortaleza, Goiânia and Recife, between 40% and 78% of women hospitalized were admitted as a result of abortions caused by this product (Costa, 1998). A study conducted at a maternity ward in Fortaleza (in the northeast region) showed an increase in the use of misoprostol in inducing abortions, which rose from 12% in 1988 to a rate of over 70% in the 1990s (Costa, 1998). In the maternity ward of the university hospital of this same city, between 1990 and 1992, 73% of the women admitted to hospital had used misoprostol to induce an abortion. In 1991, of the 593 women admitted to hospital, 75% had used misoprostol, while 16% had used a different form of medication (Schonhofer, 1991; Coelho et al., 1993). Likewise, in the case of Fortaleza, two thirds of the women admitted to hospital for abortion-related complications reported having used misoprostol vaginally and/or orally, either alone (29%) or in combination with other products (37%). Some of the remainder of women in this study had used medicinal plants (14% consumed them in the form of teas), pharmaceutical products (often applied through intramuscular injections) or blends of hormonal products, used by 17% of women (oxytocin, and neostignine, prostigmine…). The rest of the women resorted to inserting objects into their vaginas, using catheters or aspiration (Fonseca et al., 1996; Misago et al., 1998; Misago and Fonseca, 1999). The authors quoted stress that most of the women tried various different methods of aborting.

In the study by Mengue and other researchers undertaken in Brazil with the participation of over 6,000 women at prenatal clinics, 16% used Cytotec (Mengue et al., 1998). At the same time, at the Florianópolis hospital, between 1993 and 1994, half of all the women admitted for abortion complications had used Cytotec, either alone or in combination with other methods (Fonseca, 1998). In Rio de Janeiro, according to a study undertaken on hospitalized women, 57% reported having used Cytotec, 13% admitted having employed a product whose name they did not know (which may also have been Cytotec) while 18% admitted having used other methods (such as herbs or the insertion of objects) (Costa, 1993). In Sao Paulo, over 50% of abortions were caused by Cytotec, often followed by hospitalizations to complete these abortions (Rocha, 1994; Paxman et al., 1993).

One can infer from the above that misoprostol plays a major role as an abortive product, particularly among poor women in urban zones in Brazil (Coelho et al., 1993). The results of a study on pharmacy sales show that this method is required or proposed in over 50% of all cases (Coelho et al., 1991).

Cytotec also acquired a certain popularity for other reasons. According to a study conducted in Brazil, it is widely accepted by women since, compared with other illegal abortive methods, it costs very little, which makes it easier to interrupt a pregnancy by using this product than to go to a clinic to have an abortion. This is much appreciated by young women for whom access to abortion is usually quite difficult. Middle-class women also stress the advantage of this medicine, since it enables them to perform abortions directly in their homes, without being subjected to delays at clinics. Finally, another advantage commented on by women from the most disadvantaged social classes, who traditionally used methods that are dangerous to health, was that Cytotec is perceived as a “safe method that does not kill women” (Barbosa and Arhila, 1993).

All the gynecologists surveyed in this country mention another significant advantage of Cytotec: complications are less serious than those caused by other procedures like inserting objects into the uterus, meaning that its use hinders doctors’ work less when they have to deal with complications arising from the interruption of a pregnancy. Due to its effectiveness, and despite the fact that Brazilian authorities had previously tried to restrict its use, misoprostol was eventually included in the health regulations of this country. In Brazil, MEA and Cytotec have been used in abortion services since the 1990s and were recommended in the Technical Health Guidelines (1998) on violence against women. The technical guidelines in force for “Prevention and Treatment of Damage Resulting from Sexual Violence against Women and Adolescents” (Ministerio de Saúde, 2005) and “Humanized Abortion Care” (Ministerio de Saúde, 2005), both established in 2005, include these methods and specify the conditions for their use (personal communication from María Isabel Baltar de Rocha).

Various studies show that the use of this method has led to a reduction of serious complications, such as infections, perforations and haemorrhages (which are frequent with certain clandestine methods, especially the introduction of objects into the uterus), as well as a reduction in the morbi-mortality associated with abortion (Barbosa and Arhila, 1993; Espinoza et al., 2004; Costa and Vessey, 1993; Lima, 2000; Rocha, 1994). In this respect, as Billings (2005) notes in a study on the use of this drug for abortions during the first three months of pregnancy, misoprostol is a good choice in places where abortion services are not very accessible and in places where the interruption of pregnancy significantly contributes to maternal mortality. Although the author highlights the effectiveness of this method, she warns that it should only be used under the prescription of qualified medical personnel. Another study evaluating the effectiveness and safety of the intrauterine application of misoprostol in pregnancies deferred and less than 12 weeks in Panama concluded that despite the positive results, the study did not confirm the intrauterine use of this product as a safe, effective alternative for deferred abortions. It adds that nearly all the women (92%) were satisfied with the procedure and that they preferred this technique to D&C (Campos et al., 2001).

Although Cytotec is perceived as a method with fewer risks, there are a number of possible complications that can be caused by use of this product in inaccurate doses. This problem tends to occur when women abort on their own, without any medical assessment (Barbosa and Arhila, 1993). In fact, due to the lack of precise information or because they fail to observe the recommended doses or methods of administration, women often use Cytotec in either too low or extremely high doses, which explains the complications. An overdose may cause side effects such as nausea, vomiting, diarrhea or fever, whereas an insufficient dose will translate into an incomplete or failed abortion (Clark, 2002). In the event of an incomplete abortion, treatment is required to end it, and if the pregnancy continues, there are risks of congenital malformations (González, et al., 1998; Lima, 2000; Rocha, 1993; Pastuszak et al., 1998). In Argentina, a study on the improper use of misoprostol in pregnant adolescents showed that the drug is very well known among women of childbearing age. This would explain the increase in the number of women that end up being hospitalized for metrorrhagia (a uterine hemorrhage that occurs outside the menstrual period) caused by the use of misoprostol in unsuitable amounts (Vázquez and Gutiérrez, 2004).

At the same time, the widespread use of Cytotec in Brazil contrasts with that in other countries in the region, where its use is far less common. In the case of Mexico, there is astonishingly little knowledge of Cytotec as an abortive product. A study of middle-class men and women shows little knowledge of the methods for aborting using drugs, despite such methods offering the advance of reduced morbid-mortality (Gould et al., 2002). Only 49% of Mexican doctors are aware of the advantages of Cytotec in treating incomplete abortions (García et al., 2003). Since pharmacy employees in Mexico appear not to know of the abortive properties of Cytotec, it is usually only sold to treat ulcers, as shown in the study by Pick et al. (1999).

Several guidelines have been drawn up to reduce the risks of using misoprostol, either alone or in combination with other medicine. These include the leaflet published by Ipas and the Latin American Federation of Obstetrics and Gynecology Societies (FLASOG) on the safe interruption of pregnancy during the first three months with this drug (FLASOG and Ipas, 2005). In addition, the July 2005 issue of the journal Outlook (2005) is devoted to misoprostol use. The Faúndes manual is a detailed guide on the use of misoprostol for various uses, including abortion (Faúndes, 2003).

Another text, The Provision of Medical Abortion Services in Developing Countries: An Introductory Guide, Blumenthal et al., (2004) offers specific information on the use of methotrexate and misoprostol, as well as mifepristone, for countries whose legislation permits the use of this last, very effective drug.

On the Caribbean island of Guadeloupe, where abortion is legal at the woman’s request, the RU-486 pill is commonly used either alone or in combination with misoprostol, an abortive procedure that has also proved effective (Guengant and Bangou, 2000). In St. Martin, where French legislation also applies, abortions are also performed with this medicine. It also appears that in most Caribbean islands, misoprostol is widely used either under medical control or self-administered by women (Petherson and Azize, 2005).

Another study, conducted in Cuba, corroborates the great effectiveness of RU-486 in combination with other vaginally applied medicine (ONO802) to interrupt pregnancy at early stages (Gómez et al., 1995).

Marta Lamas considers that with RU-486 “abortion no longer depends on a third party, becoming a much simpler, more affordable procedure.”  “Its use,” adds the Mexican anthropologist, “allows women to have full responsibility for a private decision” (Lamas, 2005).

The use of this medicine has reduced the number of women admitted to hospitals with complications from abortions performed in risky conditions (Coeytaux, 2002), which is noticeably reflected in existing records and estimates on this practice.

Manual Aspiration and Curettage: two surgical methods for the practice of abortion

Surgical abortions are generally performed by D&C or manual endouterine aspiration (MEA). The choice between these two methods depends on the time of pregnancy and the degree of training of those that can perform them, and also on whether or not the procedure is legal. Instrumental uterine curettage is sometimes performed by people with insufficient training, particularly in the case of illegal abortions, with the risk of causing women infections, hemorrhages or gynecological consequences that may affect later pregnancies.

The aspiration method is often used when abortion is authorized. It is a less traumatic method than curettage, and performed under local or sometimes general anesthetic until 12 twelve weeks of pregnancy. Complications rarely arise with this method, which is increasingly used for treating post-abortion complications, and in many countries it has already been introduced into health programs (Rayas and Catotti 2004; Rayas et al., 2004). Certain clandestine clinics are staffed by doctors specializing in gynecology who offer this method responsibly and sometimes at affordable prices for the majority of the population. This procedure is also offered by private specialists, who charge high fees that are only affordable for part of the female population, i.e. the economically privileged.

The surgical methods above require the intervention of health professionals and normally offer women greater safety. But in countries where these methods are used by unqualified or barely qualified personnel in an unsuitable health environment, women still face numerous risks. The places where these abortions are performed vary: they can be hospitals, private clinics or simply the homes of the women that resort to this method, without any guarantees in terms of hygiene or asepsis.

Several studies provide testimony on the use of curettage. In Peru, for example, it is performed by doctors (Fort, 1993). A study performed in six countries shows that women with sufficient financial resources go to clinics to have abortions by curettage or aspiration (Singh y Deidre, 1994).

In the literature, the practice of these two methods is primarily described as “interventionist” due to the fact that they are often used to deal with post-abortion complications, rather than to perform abortions themselves. Discussions usually focus on the advantages and disadvantages of the two. According to Johnson et al. (1993), curettage is the most commonly used method for dealing with incomplete abortions, although programs are being implemented to replace this practice with manual aspiration, which is less costly in terms of treatment, personnel and length of time spent in hospital.

A study undertaken in Panama at hospitals in four different parts of the country showed, for example, that aspiration requires less use of resources than curettage, both as regards type of medicine and input  and length of hospital stay (Lacayo et al., 2003).

Mexico experienced a reduction in maternal morbi-mortality after the introduction of aspiration for dealing with abortion complications, as well as a reduction in treatment costs and an improvement in the installed capacity of health units (Quiroz-Mendoza et al., 2003). According to the authors, the cost of post-abortion care fell from $264 to $180 USD when this method was used instead of curettage. Mexico, they add, introduced manual aspiration as part of the authorities’ plan to introduce new technologies and comply with the International Pact of Social, Economic and Cultural Rights. The pact, sponsored by the United Nations, stipulates that individuals are entitled to enjoy all forms of scientific progress and their applications.

Manual aspiration procedures are fairly well known in Mexico, since approximately 60% of doctors in public hospitals are trained in them, as well as in post-abortion family-planning services (Reproductive Health Matters, 2002). However, Rayas et al. (2004) estimate that in Mexico, 60% to 70% of surgical abortion procedures used still involve curettage.

In Fortaleza, Brazil, the introduction of manual aspiration instead of D&C for treating incomplete first trimester abortions led to a 77% reduction in the length of hospital stays and a 41% reduction in the resources used in treating these cases (Fonseca et al., 1997). This procedure, like abortion with medicine, is known to reduce the morbidity and deaths associated with these practices (Misago and Fonseca, 1999).

A study conducted in various Latin American countries notes the 89% reduction in the cost of treatment for incomplete abortions through the introduction of the manual aspiration method, as well as a 33% reduction in the duration of hospital stays (King and Benson, 1998).

Likewise, in a study conducted in the Mexican state of Oaxaca, the authors showed that the aspiration method led to a 32% reduction in treatment costs, as well as a reduction of over 10 hours in hospital stays. They also observed an increase in post-abortion contraceptive prevalence from 29% to 57% (Population Council, Latin America et al. 1998; Langer et al., 1998). In Bolivia, costs were $94 USD and a 35% reduction in hospitalization time was observed (Brambila et al., 1998).

In Peru, aspiration procedures, compared with curettage, helped achieve a reduction in hospital stay duration from 33.3.to 6.4 hours, while costs were reduced from $119 to $45 USD. As a complement to these interventions, family planning counseling services increased the proportion of contraceptive method users between 31% and 64% (Benson et al., 1998; Reproductive Health Matters, 2000). These procedures led to major savings in the health centers responsible for performing safe abortions (Guzmán et al., 1995).

In Cuba, where, as already mentioned, abortion is legal, manual aspiration without anesthetic is practiced up to 45 days after amenorrhea at the clinics in a municipality in Havana (Álvarez Vázquez et al., 1999). Likewise, notes Sanseviero (2003), in Uruguay, a significant number of clandestine clinics use MEA. However, he adds, this method is not commonly used for dealing with incomplete abortions at health centers that function legally, where curettage is more common.

The authors of a study conducted in a Latin American country where abortion is illegal describe how clandestine abortions are performed using manual aspiration. They also note that complication rates are very low (Strickler et al., 2001).

In El Salvador, two studies point to an 11% to 13% reduction in costs and a 27% reduction in hospitalization times due to the use of manual aspiration instead of curettage (Foster-Rosales et al., 2003; Koontz et al., 2003). In Nicaragua, 20% of health services only perform curettage even though doctors have been trained in the aspiration technique. Likewise, in Uruguay, aspiration is used less than curettage (Rayas and Catotti 2004; Rayas et al., 2004).

The introduction of manual aspiration procedures undoubtedly constitutes a great step forward in abortions. Several countries have made a great effort to promote this method: in Bolivia and Brazil, re-imbursement for these two procedures (aspiration and curettage) is provided through the social security system in equal proportions (Rayas and Catotti 2004; Rayas et al., 2004).

It is worth mentioning another method that, despite not being specifically recommended in abortions, is often used in certain countries. Known as menstrual regulation, it is a medical procedure that, as Faúndes and Barzelatto (2005), explain, “consists of emptying the uterine contents of a woman with a slight delay in menstruation (usually of just over 2 weeks) without determining whether or not she is pregnant”. The method, add the authors, “originated with the introduction of vacuum aspiration, at a time when there were no laboratory examinations permitting the early diagnosis of pregnancy.” Likewise, they say, the use of menstrual regulation may be due to the fact that the pregnant woman “may prefer to remain in a state of doubt and persist, for moral, religious and cultural reasons, in the belief that it is simply that their period is late”. In addition to the women, doctors also prefer this method “for legal reasons in countries with restrictive legislation.” Over the years, the period during which a woman could resort to menstrual regulation was extended “to eight or even twelve weeks’ gestation, provided it can be carried out by vacuum aspiration and local anesthetic”. In Cuba, it is estimated that abortions performed using this method constitute 50% to 60% of the total number of cases (Álvarez, 1994; Cortés et al., 1999).

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