Keywords
abortions - therapeutic - hospitals - training - participants
Palavras-chave
abortos - terapêutico - hospitais - treinamento - participantes
Introduction
There are 73 million abortions reported worldwide every year. Approximately 45% of
these are considered unsafe. In developing countries, this percentage increases to
56%.[1] In Latin America, 10 to 16% of maternal deaths are caused by unsafe abortions.[2]
In developing countries, suboptimal access to abortion services is a serious problem.
Women from low socioeconomic groups and other vulnerable women are disproportionately
affected by the lack of information and lack of access to family planning services.[3] Therapeutic abortion must be aligned within a context of respect for sexual and
reproductive rights, a fundamental part of human rights.
In Peru, “an abortion can be performed by a doctor with the pregnant woman's consent
when it is the only way to save the patient's life or to avoid a serious long-term
illness in her health.”[4] Despite the progress made by approving the national guideline for therapeutic abortion,
women still experience inadequate access to this service. This inadequate access results
in high rates of maternal mortality.[4]
[5] Annually, ∼ 376,000 unsafe abortions are performed in this country.[6]
[7]
There have been several initiatives to promote the use of guidelines for therapeutic
abortion and to provide specialized training to doctors.[8] Nevertheless, there are still significant gaps. Training in the management of therapeutic
abortions is not routine in several residency programs in the United States. The inappropriate
methodology used, the absence of simulators, and limited legal support for the institutions,
also limit training.[9]
[10] Turk et al.[9] performed a survey of residency program directors around the United States to describe
their perspective of support for and resistance to abortion training. Almost 75% of
them reported at least some institutional or government restriction, with an average
of 3 types of restrictions. They reported that hospital policy restrictions were common,
followed by state law restrictions.[9]
In 2016, Távara Orozco et al.[8] reported the status of safe therapeutic abortion in Peru based on interviews and
data collection from 10 hospitals. They found that the rate of therapeutic abortions
was still low, with lethal fetal abnormalities being the most common indication.[8]
There is no data on the main barriers to adequate training of specialists in the management
of therapeutic abortion care in Peru. Our objective is to identify the barriers to
provide adequate physician training and to perform therapeutic abortions for women
in public hospitals in Peru.
Methods
We performed a descriptive cross-sectional survey-based study. We invited 400 participants,
obstetrics and gynecology specialists from 7 academic public hospitals in Lima and
8 from other regions of Peru. We included obstetrics and gynecology specialists that
worked in these 15 hospitals, and we excluded participants who were not routinely
assigned to clinical duties or did not complete the survey. We developed our survey
based on previously published surveys.[8]
[9] Our survey evaluated the support systems and limitations for the training and performance
of therapeutic abortions. It consisted of a total of 43 questions.
The validation of the instrument was performed in two phases: content validity followed
by instrument reliability phase. Six Peruvian experts performed the content validity.
They had to meet the following criteria: work experience in the subject, original
research on this subject, and have an academic master's or doctor's degree. The concordance
index, according to the Kappa index, was 0.61. For the instrument reliability phase,
we performed a pilot test with the participation of 30 gynecologists. The total reliability
was 0.77.
The questionnaires were sent to the participants by email and reminder phone calls
from May to November 2020. The data processing and analysis were performed using estimates
to calculate absolute and relative frequencies using IBM SPSS Statistics for Windows,
version 22 (IBM Corp., Armonk, NY, USA).
The Faculty of Medicine of the Universidad Nacional Mayor de San Marcos Research Ethics
Committee approved the research project.
Results
We enrolled 160 participants who completed the survey and met the inclusion criteria.
The characteristics of the participants are shown in [Table 1]. Almost half of the participants reported that their hospital did not provide therapeutic
abortions, but > 80% support the idea of this procedure and thought it should be provided.
Table 1
Characteristics of the Participants
|
Variables
|
n
|
%
|
|
Age (years old) (mean ± SD)
|
46.8 (±12)
|
|
|
Male
|
109
|
68.1
|
|
Female
|
51
|
31.9
|
|
Married
|
107
|
66.9
|
|
Single
|
41
|
25.6
|
|
Divorced
|
9
|
5.6
|
|
Widow
|
3
|
1.9
|
|
Hospital region
|
|
|
|
Lima
|
120
|
75
|
|
Other region
|
40
|
25
|
|
Religion
|
|
|
|
Catholic
|
141
|
88.1
|
|
None
|
11
|
6.9
|
|
Other
|
8
|
5
|
|
Position
|
|
|
|
Faculty
|
141
|
88.1
|
|
Department director
|
15
|
9.4
|
|
Department chairman
|
4
|
2.5
|
|
Does your hospital provide therapeutic abortion?
|
|
|
|
No
|
76
|
47.5
|
|
Yes
|
84
|
52.5
|
|
Do you think that therapeutic abortions should be provided?
|
|
|
|
No
|
28
|
17.5
|
|
Yes
|
132
|
82.5
|
[Table 2] described the barriers identified by the participants to train and provide therapeutic
abortion at their institution.
Table 2
Barriers to train physicians and to provide therapeutic abortion
|
n
|
%
|
|
Training in therapeutic abortion is limited as a result of:
|
|
Peruvian law
|
73
|
45.6
|
|
Institutional policies
|
53
|
33.1
|
|
No relationship with an institution that provides abortion
|
23
|
14.4
|
|
Lack of medications/equipment
|
11
|
6.9
|
|
Providing therapeutic abortion is limited as a result of:
|
|
Peruvian state law
|
80
|
50.0
|
|
Institutional policies
|
43
|
26.8
|
|
No relationship with an institution that provides another type of abortion
|
24
|
15.0
|
|
Lack of expert physicians
|
13
|
8.1
|
Most of the participants consider that the position of the Peruvian government' regarding
therapeutic abortion is indifferent or deficient ([Fig. 1]).
Fig. 1 Position of the Peruvian government regarding therapeutic abortion.
Regarding training at their institution, 63.7% of the respondents stated that the
hospital does not offer abortion training. Also, 46.9% reported that the training
is performed in other institutions, such as scientific societies, universities, or
private institutions. [Table 3] describes the levels of support at their institution for training in therapeutic
abortion.
Table 3
Level of support for training
|
Lot of support
|
|
Support
|
|
Neutral
|
|
Limitations
|
|
Lot of limitations
|
|
None
|
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Department leadership
|
12
|
7.5
|
50
|
31.3
|
47
|
29.4
|
28
|
17.5
|
16
|
10
|
7
|
4.4
|
|
Hospital director
|
9
|
5.6
|
33
|
20.6
|
70
|
43.8
|
22
|
13.8
|
16
|
10
|
10
|
6.3
|
|
Nurses
|
14
|
8.8
|
53
|
33.1
|
61
|
38.1
|
9
|
5.6
|
12
|
7.5
|
11
|
6.9
|
|
Anesthesiologist
|
5
|
3.1
|
40
|
25
|
61
|
38.1
|
25
|
15.6
|
19
|
11.9
|
10
|
6.3
|
|
Medical staff and equipment
|
18
|
11.3
|
52
|
32.5
|
42
|
26.3
|
25
|
15.6
|
13
|
8.1
|
10
|
6.3
|
|
Interaction with other specialties
|
8
|
5
|
60
|
37.5
|
53
|
33.1
|
19
|
11.9
|
10
|
6.3
|
10
|
6.3
|
|
Residents
|
49
|
30.6
|
52
|
32.5
|
37
|
23.1
|
12
|
7.5
|
9
|
5.6
|
1
|
0.6
|
More than half of the participants (56.3%) thought that abortion training should be
integrated into the residency program, while 20% thought it should be part of family
planning rotation. Two-thirds had availability for abortion training 1 to 3 days per
week, and 22.5% between 4 and 6 days per week. The personal reasons not to participate
in therapeutic abortion training were religious reasons in 17.5% and to avoid legal
problems in 8.1%.
Almost half of the participants (45%) did not receive training on abortions, 10% received
training only in early failed pregnancies, and 45% received training for the management
of therapeutic abortions. Almost half of the physicians (44.4%) stated that they did
not perform any therapeutic abortions during residency, and only 16.9% did > 10 procedures.
On the other hand, 85% stated that they had competencies for the management of abortion
complications. The major barriers to providing therapeutic abortions included Peruvian
law (53.8%), hospital policies (18.8%), and lack of experts (10.6%). [Figures 2] and [3] describe the internal and external barriers to adequately incorporate therapeutic
abortion services in their institution.
Fig. 2 Internal barriers to provide therapeutic abortions.
Fig. 3 External barriers to provide therapeutic abortions.
Regarding conferences that provide wellbeing resources for physicians who perform
abortion, 30.6% reported that they participate once every year, while 36.3% more than
once per year. The remaining did not participate in such sessions during the last
years. A total of 40.6% of the participants were unaware of tools to handle emotions
during and after performing therapeutic abortions.
Discussion
To improve women's health, women's rights, and health promotion, interventions should
be supported.[5]
Our study showed that almost half of the specialists do not provide therapeutic abortions
at their institution, although most of them support the idea of therapeutic abortion
care. Access to safe abortion is crucial in the care of women's health.[11] In Latin America, each county has different laws; some limit access to safe abortion,
while others make this procedure widely available for their population.[12]
[13] To provide safe abortion to a population, the availability of a significant number
of institutions and doctors with training in this service is required.[14] The majority of physicians report limited exposure to therapeutic abortion during
residency training. The lack of doctors trained in performing abortions is a problem
described not only in Peru. Prior studies have reported limited access to abortions
in obstetrics and gynecology training programs.[15]
[16] The lack of doctors trained for this procedure leads to limited or no access to
safe abortion. This lack of access can lead to clandestine abortions or pregnancies
carried to term despite the risk they may pose to women.
For example, in the United States, most abortions performed occur in nonacademic institutions,
limiting the exposure of residents to these types of procedures. Academic institutions
in that country must make different efforts to ensure the exposure of their residents
to training in safe abortion.[17]
As in other countries, legal regulations are one of the main barriers that limit the
exposure to this procedure during specialty training. These legislative barriers are
pronounced in training centers, which are public hospitals with government funding.
Also, many academic centers require procedures that make the abortion process difficult;
for example, consents that must be signed a few days before the procedure can be performed.
These common barriers to providing safe therapeutic abortion in academic centers are
consistent with the responses of the participants in our study.
In a study published by Freedman et al.,[18] most doctors who wanted to provide abortion services to their community did not
perform it, mainly due to legal barriers or to the institution where they worked.
A study in Latin America showed that most doctors who provided services in public
hospitals were not aware of the grounds on which abortion is not punishable. In this
study, > 60% favored decriminalizing abortion, while only 1 in 5 had performed a therapeutic
abortion in their medical practice.[19] One study in Brazil, where it is legal to perform abortions in the case of rape
based on a woman's statement, showed that 82% of the physicians required police reports
or judicial authorization. This requirement is a major barrier for these women to
access safe abortions.[20]
Access to therapeutic abortions in public institutions in Peru is limited, with just
a few public hospitals providing this service. A study published in 2016 reported
that in the 10 hospitals where this procedure is performed in Lima, only 257 procedures
were performed in the previous 5 years.[8] A survey conducted with doctors from public hospitals in Lima showed that 44% of
them did not agree with some of these legal limitations since they violate the right
to doctor-patient confidentiality.[21]
The impact of religion on access to training in therapeutic abortion has also been
described. The fact that the institution is associated with a religious entity limits
the ability to train residents in therapeutic abortion.[2]
[22] In our study, > 80% of the participants considered themselves catholic. However, < 20%
of the participants reported that religion was a reason for not participating in therapeutic
abortion training.
A recent study by Turk et al.[9] showed that the most common constraints to physician training identified by directors
of residency programs in the United States included institutional or legal policies.
The directors of programs that included this training as an integral part of the residency
identified fewer restrictions than the directors of programs where they did not train
in abortions.[9]
More than 60% of the participants reported that the hospital where they practice does
not offer training in therapeutic abortion, and < 50% have trained under the responsibility
of another institution. On the other hand, almost 50% of the participants did not
carry out a therapeutic abortion during their training, while only 17% performed > 10
procedures. The model of inclusion of abortion training during medical residency has
an important impact.
The American College of Obstetricians and Gynecologists (ACOG)[14] reports three types of abortion training models in gynecology and obstetrics residencies
in the United States. The first is known as “opt-out,” in which the academic center
has an abortion program integrated into its curriculum. It is standard for residents
to regularly perform this procedure, except for residents who opt out due to religious
or moral objections. The second is the “opt-in,” in which the academic center provides
training only if the resident requests to be trained in that procedure. And the third
type of residency is that without abortion training. Turk et al.[15] demonstrated that residents who were trained in “opt-out” residency programs had
a greater number of abortions, greater exposure to abortion procedures, and felt more
comfortable in their abilities to perform this procedure. On the other hand, residents
of residency programs of the “opt-out” type had the same results as residents of hospitals
where this training was not performed.[15] Other studies have shown that residents graduated from “opt-out” training feel more
confident in their abilities, not only to provide abortions, but also to manage other
procedures and counseling in gynecology and obstetrics.[22]
[23]
[24]
The training of residents in therapeutic abortion should be comprehensive and should
include training in patient counseling, 1st-trimester ultrasound, pain management, cervical dilation, as well as medical and
surgical management.[14] Many studies have shown that graduates of training centers where family planning,
including abortion, was an integral part of the program, have greater skill in handling
not only the procedure, but also all the other aforementioned aspects.[15]
[21]
[22]
[25]
It is crucial to be able to make changes to improve the training of physicians in
family planning, including therapeutic abortion. The ACOG[14] recommends continuing efforts to stop stigmatizing abortion and include it in medical
training. They suggest that some measures are to include sexual education and therapeutic
abortion in the curriculum of medical schools, as well as to improve exposure to residents
for this procedure. Allen et al.[26] showed that the factor most strongly associated with whether the obstetrician-gynecologist
provides abortion service was whether the provider was interested in training in it
before starting residency. This is why it is vitally important to be able to expose
medical students to these topics during their undergraduate studies.[26]
Our study is the first to evaluate the perceptions of therapeutic abortion of a significant
number of physicians from academic institutions in Peru. There are many barriers to
training and access, and our study describes the most common and prevalent in Peru.
For the development of our survey, we used tools previously used by other authors.
In addition, we describe the different possible barrier areas such as leadership,
resources, and support from other specialties, among others.
Our study also has limitations. The main limitation of our study is that the vast
majority of the participants work in Lima, so it is possible that these results do
not apply to different areas of Peru. Our study has a few limitations due to its design,
such as the possibility of non-honest answers, different interpretations of the questions
for each participant, and the possibility that some answers may be guided by the moral
and/or religious position of the respondent regarding abortion treatment. Despite
its limitations, the present study contributes significantly to knowledge about therapeutic
abortion training in Latin America and plays a role in this important public health
measure.
Conclusion
Most doctors support therapeutic abortions and show interest in improving their skills;
however, not all hospitals offer adequate training and education. During training,
therapeutic abortion procedures are performed in a limited number. Also, lack of knowledge
of the law and of institutional policies are common, making fear of ethical, legal,
and religious repercussions the main barriers.
