Abstract
In Latin America, where restrictive laws limit women's access to safe abortion services, misoprostol is being used to induce abortions, often without correct information on dosage or regimens. This study in an unnamed Latin American country aimed to identify appropriate channels through which instructions on misoprostol use could be disseminated to women. In-depth interviews were carried out with physicians, pharmacy staff, women who had had safe abortions and women from the community, as well as focus group discussions with advocates of safe abortion. Participants considered physicians to be the most appropriate source of information and for ensuring confidentiality for both women and provider. Participants considered midwives, pharmacists and women's groups as appropriate referral points, but not providers of information. Legal restrictions and professional risk were the primary reasons why pharmacists rejected this role, though many are selling misoprostol. There was a general lack of information about misoprostol for medical abortion among both health professionals and women. Accurate information about misoprostol use for a wide range of gynaecologic and obstetric purposes, including induced abortion, could be incorporated into training and educational materials for physicians, midwives and other appropriate mid-level providers, as well as pharmacists. Without these alternative information channels, access to information would be severely restricted, especially in rural areas.
Résumé
En Amérique latine, oú la législation limite l'accès aux services d'avortement, le misoprostol est utilisé pour l'interruption de grossesse, souvent sans informations sur le dosage et la thérapeutique. Cette étude dans un pays latino-américain non identifié souhaitait déterminer les réseaux pouvant transmettre aux femmes les instructions sur l'utilisation du misoprostol. Elle a organisé des entretiens avec des médecins, des pharmaciens, des femmes ayant avorté médicalement et des femmes de la communauté, ainsi que des discussions avec des militants pour l'avortement sans risque. Les participants estimaient que les médecins étaient la source la plus appropriée d'information et la meilleure garantie de confidentialité pour les femmes et les prestataires. Les participants considéraient que les sages-femmes, les pharmaciens et les groupes féminins pouvaient servir de conseillers, mais non d'informateurs. Les restrictions juridiques et le risque professionnel étaient les principales raisons pour lesquelles les pharmaciens refusaient ce räle, même si beaucoup vendent du misoprostol. Les professionnels de la santé et les femmes manquaient de renseignements sur le misoprostol pour l'avortement médicamenteux. Des données exactes sur l'utilisation du misoprostol dans diverses indications gynécologiques et obstétriques, notamment l'interruption de grossesse, pourraient être incluses dans le matériel de formation des médecins, des sages-femmes et d'autres prestataires de niveau intermédiaire, ainsi que des pharmaciens. Sans ces autres sources d'information, l'accès á I'information serait gravement restreint, particuliérement dans les zones rurales.
Resumen
En Latinoamérica, donde las leyes limitan el acceso de las mujeres a los servicios de aborto seguro, se utiliza el misoprostol para inducir abortos, a menudo sin la información correcta sobre la dosificación o los regímenes. El objetivo de este estudio, realizado en un país latinoamericano no identificado fue determinar las vías para la difusión de instrucciones sobre el uso del misoprostol. Se realizaron entrevistas a profundidad con médicos, personal de farmacias, mujeres que habían tenido abortos seguros y mujeres de la comunidad, así como discusiones en grupos focales con defensores del aborto seguro. Los participantes opinaron que los médicos son la mejor fuente de información, a fin de garantizar la confidencialidad tanto de las mujeres como de los proveedores. Los participantes consideraban a las parteras, los farmacéuticos y los grupos de mujeres como buenos puntos de referencia, pero no como suministradores de información. Aunque muchos venden misoprostol, los farmacéuticos rechazaron esta función debido a las restricciones jurídicas y al riesgo profesional. Dado que tanto las mujeres como los profesionales de la salud carecían de información sobre el misoprostol para inducir el aborto, debería incorporarse información exacta sobre su uso para una amplia gama de fines ginecológicos y obstétricos, incluida la interrupción del embarazo, en la capacitación y los materiales educativos de médicos, parteras profesionales y otros prestadores de servicios de salud de nivel intermedio, así como farmacéuticos. Sin otras fuentes informativas, el acceso a la información se limitaría en gran medida, especialmente en las zonas rurales.
In most Latin American countries, stringent laws limit women's access to safe abortion services. In much of the region, physicians can legally conduct abortions only to save a woman's life or in cases of rape, incest, or fetal abnormality. Citation1 As a result, most of the four million induced abortions in Latin America each year are considered illegal and many are conducted in unsafe conditions, leading to complications that account for 17% of Latin America's maternal mortality. Citation2 In order to decrease the complications associated with unsafe abortion, health care providers and women need information about safe, available abortion options.
One such option is misoprostol, a prostaglandin drug that was approved almost 20 years ago for prevention and treatment of gastric ulcers. Citation3 Because the drug causes uterine contractions and cervical softening, it is being used for a growing range of off-label obstetric and gynaecologic indications, including for pregnancy termination both with the drug mifepristone or on its own. Citation3Citation4Citation5Citation6
For pregnancy termination early in the first trimester, mifepristone followed by misoprostol is very effective. Citation7Citation8Citation9 However, mifepristone is not registered for use in any Latin American country. Misoprostol used alone (with repeat intravaginal doses) for pregnancy termination in the first trimester has complete abortion rates of 88-93% in clinical studies, Citation10Citation11Citation12Citation13Citation14 although lower success rates have been documented in actual practice in one Latin American clinic. Citation15 Misoprostol is relatively inexpensive in comparison to other abortion methods, it does not require refrigeration and in many countries, it is available over the counter at pharmacies without a prescription. Citation16 For these reasons, misoprostol alone is an option for women seeking safe abortion in Latin America and other legally restricted settings. Citation15Citation17Citation18
Many women in Latin America, Africa, and Asia have used misoprostol to induce abortions without guidance from health care providers. Interviews with women who sought care for perceived complications revealed that many of the women lacked information on what to expect, on how to determine if their abortion was complete, and whether and when to seek emergency care. Hence, they were unable to determine whether their symptoms were normal and whether or not a complete abortion had occurred.Citation16 In contrast, results from research with women using misoprostol in Latin America under clinical supervision illustrate that most women felt prepared for and supported throughout the experience by the health care provider. Citation15Citation19
In 2003, an expert group developed instructions for the use of misoprostol alone for pregnancy termination through nine weeks of pregnancy LMP (last menstrual period). Citation20 The best means for reaching health care providers and women with this information, however, has not yet been determined. To address this need, we conducted an exploratory study in one Latin American country to identify appropriate channels through which instructions on misoprostol use could be disseminated to women without causing legal risk to individuals or restrictions on the availability of the drug. To ensure protection for the individuals involved in this research, the country where the research was conducted is not named.
As in other Latin American countries, access to safe abortion services is limited in this country. Health care is physician-dominated, whereby physicians are seen as the bearers of health-related knowledge and command a high level of authority in the provision of health care. Citation21Citation22Citation23Citation24Citation25 In contrast, mid-level providers are often viewed as lacking authority or expertise, even though they are the most common providers of health care and health information for women in some settings. Citation26
Methods
We conducted 33 in-depth interviews to solicit attitudes and perspectives about providing information to women for the safe off-label use of misoprostol for abortion. We identified and recruited participants using purposive sampling techniques to ensure a high degree of trust and safety between participants and researchers. They included the following:
nine general practitioners, family physicians, or obstetrician-gynaecologists with at least five years of experience. They were either from the private sector and providing safe abortion services, including misoprostol, and linked with a national network of health care providers working to reduce the impact of unsafe abortion, or public sector physicians who were providing treatment for abortion complications;
nine pharmacists or pharmacy staff, from pharmacies certified by the Ministry of Health, and recommended by the national family planning association as “user friendly” , that is, they had received family planning training, sold contraceptives at low prices and served young people in order to reduce unintended pregnancies. Some pharmacies were contacted directly when referrals were not available;
six women, aged 18-45, who had received safe abortion care at a private facility within the previous 30 days, who were referred by their physicians; and
nine women from the community, aged 18-45, who were referred by local women's networks and NGOs.
We also conducted three focus group discussions (8-10 participants each) with advocates for safe abortion who were from civil society organisations or providing abortions in the private sector. These were used to solicit views on viable and non-threatening strategies for reaching women with misoprostol information and whether there was consensus or disagreement about these. Prior research conducted by one of the research partners had demonstrated that this mix of participants was both effective and feasible for discussing such topics. Citation27
While this sample is not intended to be representative, it does capture a diverse group of participants with experience in the provision of or access to abortion services and information.
Rural participants came from a small town in one of the most rural regions of the country, characterised by large indigenous communities, high rates of poverty and illiteracy, and poor access to health services. Urban participants were from the capital city and another large city where reproductive health services and information are more accessible to the population. We expected to find distinct perspectives related to the preferred channels for information provision in each of these settings. For example, we expected rural participants to prefer non-physician channels due to geographic and/or cultural barriers limiting their access to physicians.
We asked participants about: women's sources of reproductive health information, knowledge of abortion laws and sources for abortion services and information, knowledge of misoprostol, and benefits and limitations of providing misoprostol information through specific channels and communication methods. All interviews and focus group discussions were tape-recorded with the consent of the participants, except for two participants, who declined to be recorded. Tape recordings were transcribed and textual data were coded by hand by the interview team, using a theme-based content analysis approach. All interviews and analyses were conducted in Spanish. The study team consisted of seven researchers located in Latin America and the United States.
To ensure participant anonymity, we did not record names or other identifying information during the study and used a verbal consent process; interviewers verified in writing that consent had been obtained from each participant. This study protocol was approved by PATH's Human Subjects Protection Committee.
Our use of purposive sampling methods enabled us to identify participants who had experience in safe abortion or who were open to addressing the question of how best to reach women with misoprostol information. While the majority of the participants were sympathetic to the need for safe abortion care, several pharmacy employees expressed moral or religious opposition to abortion. This may have occurred because some pharmacies were sampled without prior referral.
To avoid asking respondents to reveal their personal experiences, they were not asked about actual use or provision of misoprostol, but only about the benefits and limitations of their preferred channels for information dissemination - physicians, midwives, pharmacists, community networks, friends or family - and how the information should be presented, verbally or in writing.
Information channels about misoprostol for pregnancy termination
Physicians
There was consensus among all groups interviewed that physicians were the most appropriate channel for providing women with instructions on misoprostol use. Nearly all participants described physicians as the most trustworthy source of medical information; their medical training was often cited as the key factor for ensuring that instructions could be conveyed clearly and correctly. Numerous participants emphasised their concern that women's bodies could respond differently to misoprostol and that they might require individualised instructions based on their medical history.
“I try to not get involved…I don't know the person, her past, or her medical history, nor do I know how she is going to use it, or what she is going to take. I prefer to say: ‘It's best that you go to your physician so that he can check you.’” (Pharmacist)
Participants from the urban focus groups agreed that physicians in both public and private health facilities could effectively provide misoprostol information, although they needed to be chosen carefully since many could impose their own anti-abortion stance on women and act as barriers to information. Participants in one urban focus group reported that physicians in their region do not openly admit to performing abortions, although it is widely known that some do so for high fees. Such physicians were not viewed as appropriate for providing misoprostol information, given that they might encourage women to undergo more costly procedures.
Although physicians included in this study felt they could discuss misoprostol with women in the privacy of a medical consultation, several said they could not talk openly about it. One physician cautioned that if information on misoprostol use became too public, anti-abortion activists could try to have misoprostol pulled from the market. This concern was echoed by focus group participants.
“There are medications going around that can cause an abortion, but they are not legalised for this type of procedure…If in private practice, I start to use this type of medication, I can have problems - legal problems. I am putting at risk my integrity; I am putting at risk my legality; I am putting at risk my professionalism.” (Physician, public sector facility, rural region)
Physicians from the rural region raised the issue of accessibility, noting that many women in rural areas do not go to physicians due to cost or geographic inaccessibility, and would therefore not benefit from contact with a physician. This concern was reiterated by the women from rural communities.
Several physicians noted that other health professionals could provide misoprostol information. One mentioned trained health educators and nurses and another noted that only nurses or physicians should provide the information as both have the background in anatomy and physiology to explain the drug's effects.
Women with safe abortion experience from both urban and rural regions expressed the concern that physicians could abuse their authority by acting as gatekeepers of the information, and that women in need who distrusted the medical establishment might not turn to physicians. As one woman noted, the disadvantage with only physicians having misoprostol information was that they would have to want to share it.
Both community women and those with safe abortion experiences mentioned some physicians' poor treatment of women. One woman from an urban region said that her experience of physicians was that they “insult, assault, offend, lecture and scold people.” She said that physicians must treat women with dignity and respect if they are to be effective channels for misoprostol information.
Midwives
Most participants felt that midwives would be appropriate as referral sources but not as providers of misoprostol information. Physicians and pharmacists, primarily from the rural area, cited the important role midwives play in rural communities in relation to pregnancy and reproductive health and that they are often the most trustworthy source of information in their communities. However, both they and women in the community cited midwives' lack of medical training as the main limitation on their ability to provide accurate instructions for misoprostol use, as they feared that not having a medical background could prove “fatal for patients” .
Women from the rural area who had received safe abortion care differed; they considered midwives appropriate providers of misoprostol information.
“They explain things to us well, they take good care of us; they even tell us how we can take care of ourselves.” (Woman with abortion experience)
Rather than an emphasis on the technical aspects of misoprostol use, this respondent highlighted the importance of being taken care of, feeling cared for and receiving the information needed to care for herself.
Pharmacists
All pharmacists and pharmacy employees rejected the idea of providing information on misoprostol use, due to the illegality of induced abortion, and thought that only trained physicians should provide it. Many of the pharmacists said they preferred to avoid selling misoprostol to “avoid getting involved in problems” . However, when asked if they were currently selling the drug, six of the nine were doing so but did not say if it was for gastric ulcers or pregnancy termination.
Pharmacists did not view themselves as having the proper medical training to give instructions on misoprostol use and said they referred women to physicians whenever they had requests for abortion assistance.
“I send them to the physician…I can't give them other information, for ethical and legal reasons, and because the Ministry of Health tells us that we can only sell prescribed medications. That's it.”
All the pharmacists were concerned about professional risk. Some of them also expressed opposition to abortion and that it was “unethical” to provide women with the drug or information on its use. Others suggested that providing women with the information would lead to abuse of the drug and “irresponsible” family planning decisions.
“…We're not physicians and this medication has many consequences. If they take the wrong dose and bleed too much or they have an incomplete abortion and go to the hospital and tell them that the pharmacy gave them the medication and [told them] how to use it…there is no benefit whatsoever [to pharmacies].”
“You're seeing an abuse of it now, but the abuse would get worse because of how easy it would be: ‘Oh, I won't get injections and I won't take the pill, after all there is this thing [misoprostol] if I end up pregnant, and I already know the dosage.’”
All the other groups interviewed agreed that pharmacists could be good referral points for women seeking misoprostol information since so many go to pharmacies to purchase the drug, but they also agreed that pharmacists should not serve as a channel for instructions on use. They cited reasons such as pharmacists not having medical training, their role as salespeople who are not interested in educating people or providing information, and did not consider them trustworthy information sources. As one woman with safe abortion experience noted,
“They give you another [drug] and sell it to you for the same price as Cytotec. That is to make you suffer for a while, and nothing else. They don't give you advice for what you want, so they are very, very bad sources of information.”
Focus group participants from all three regions concurred and cautioned against pharmacies providing misoprostol information, warning that this would likely trigger a strong backlash, whether from the government or anti-abortion groups, that could affect availability of and access to the drug.
Despite all these objections, however, when asked if they would be interested in receiving accurate information on misoprostol use, nearly all pharmacists said yes and that they would like to be better informed.
Community networks, friends and family
Participants thought that use of misoprostol carried a large responsibility and that instructions on correct dosage, side effects, danger signs and other specific medical information should come from trained medical providers. While community networks, friends and family members were all considered important first-tier referral points, they felt it would be “too risky” to have them provide misoprostol instructions because they could unintentionally provide incorrect information that could result in harmful effects.
Community clinic with health services for women, Peru, 1999
Other dissemination channels mentioned or discussed by participants included health workshops for university student groups and training sessions/courses in schools of social work, medicine and nursing (including information in their curricula) as well as television and radio programmes. While none of these channels garnered support across participant groups, the benefits of reaching target audiences such as youth were cited and should be explored.
Communication methods
All study participants were asked about the benefits and limitations of five different formats for conveying misoprostol information. The formats were brochures, posters, verbal communication, the internet and photo-novellas. As the majority of discussion and consensus revolved around verbal communication and brochures, only these findings are presented here. However, participants did cite benefits associated with each of the other formats, which should be explored further.
The majority of participants identified verbal communication through physician-patient consultations as the best method for conveying misoprostol use instructions to women. Physicians and women with abortion experience considered this method the safest for ensuring confidentiality for both providers and women, and for reducing legal risk to the physician's practice or clinic. Physicians, women with abortion experience and women from the community all highlighted the importance of this dialogue, so that women could ask questions. In most rural regions, the tradition of passing information orally from one person to another is culturally appropriate and logistically feasible, given the numerous indigenous languages and low literacy levels.
The main limitations associated with verbal communication was the possibility of women forgetting or confusing the instructions and the need for the instructor to be well trained and a good communicator. Some participants suggested that written instructions accompany verbal communication to ensure proper and effective use.
The main benefit of brochures, cited by all groups, was that women could keep the information, refer to it later and share it with others. Focus group participants agreed that written information is considered reliable, especially if backed by a respected institution. However, they said written instructions should not take the place of individualised verbal instructions but complement them.
Physicians were the main group to mention limitations associated with written instructions. Several said they could not include their contact information, as this could put both them and women at risk. Several physicians also voiced the concern that women would use the written information without any medical supervision, increasing the chance that their questions would go unanswered or that they would use the drug improperly. One physician voiced the concern that misoprostol use is already widespread, and that providing women with more information would only lead to more induced abortions. All participants from the rural region emphasised the low literacy rates in their population, for whom written instructions would have little value.
Focus group participants often suggested small, wallet-size information cards as the format for written information. Views regarding the inclusion of contact information or a provider's phone number differed. Participants in the rural region felt they should not be included to avoid putting providers at risk; the urban focus groups agreed that women should be given a phone number or address where they could get more information or follow-up care.
Discussion
The findings of this study reflect the highly medicalised, physician-dominated setting. The view that physicians were the best source of information was shared consistently across the groups, even among advocates of safe abortion, who we had anticipated might prefer other information channels. However, it was the advocates who stressed the importance of preventing anti-choice physicians from blocking access to information because of their opposition to abortion. These views may reflect a legitimate fear of engaging in an illegal activity. By suggesting physicians as the providers of information about misoprostol, the other groups might have been seeking to remove their own professions from any explicit role. This provides other groups, such as pharmacists, with an opportunity to request misoprostol information without compromising their professional responsibilities.
The study uncovered a general lack of information about misoprostol and medical abortion among both health professionals and women of reproductive age. The concern that women's bodies could react in such different ways to misoprostol, with potentially fatal consequences, reflects a lack of information about the safety and efficacy of misoprostol, Citation28Citation29 not just a belief in the need for physicians to give information.
The belief that physicians are the most trustworthy sources of medical abortion information has also been found in other studies in Latin America. Middle-class men and women in one study said they would believe medical abortion was safe and efficacious only if a doctor had told them so. They also thought doctors were the most effective educators on such matters. Citation30
Physicians who are interested in broadening women's access to safe abortion will be critical to ensuring women's access to misoprostol informatio.Citation31 However, if they were women's only source of information, access to the method would be severely restricted, not least because good counselling and information-sharing skills are not emphasised in medical education or rewarded or recognised in professional practice. Moreover, women in this Latin American country face cost constraints and geographic and cultural barriers to accessing physicians.
At the same time, mid-level health care providers, health educators and midwives were mentioned as appropriate sources for conveying information about misoprostol use by a limited number of participants in this study. Other studies have demonstrated the ability of trained mid-level providers to provide good quality care, as well as information and counselling. Citation32Citation33 With training, this cadre of providers could also give women misoprostol information. Although pharmacists have been important sources of information in many Latin American settings on contraceptive methods and emergency contraception, Citation34 participants in this study did not consider pharmacies to be an appropriate source of instructions for misoprostol use. Legal restrictions, moral objections and professional risk were the primary reasons why pharmacists rejected this role, and why they preferred not to sell misoprostol. However, several of these same pharmacists said they were currently selling misoprostol, and previous research in Latin America has found that many pharmacies are selling misoprostol. Citation16Citation35 One of these studies found that the vast majority (83%) of those selling misoprostol were recommending ineffective regimens or ones that would cause unnecessary side effects. Citation35 Hence, where pharmacies are the primary source of misoprostol for women, pharmacy staff should have accurate information on the drug, the best regimens, side effects and danger signs Citation16 and be trained to refer women to appropriate physicians.
Ideally, accurate information about misoprostol use for a wide range of gynaecologic and obstetric purposes - including pregnancy termination - could be incorporated into training and educational materials for physicians, midwives and other mid-level providers of reproductive health care, as well as pharmacists. In countries where abortion is legally restricted, alternative channels for reaching women with misoprostol information including women's, are necessary and should be explored in more depth.
Misoprostol is an important option for women seeking pregnancy termination in legally restrictive settings. With proper instructions on its use, health care providers and women alike can use this drug in the safest and most effective ways possible.
Acknowledgements
The authors are grateful to the study participants for sharing their time and perspectives. We also appreciate the work of Soraya Vásquez and Selina Espinoza and their contributions to this study. This research was made possible through the financial support of the William and Flora Hewlett Foundation, the Channel Foundation, Ipas and an anonymous donor.
References
- D Wulf, S Singh. An Overview of Clandestine Abortion in Latin America. 1996; Alan Guttmacher Institute: New York. At: <www.guttmacher.org/pubs/ib12.html. >. Accessed 18 May 2005.
- World Health Organization. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000. 4th ed, 2004; WHO: Geneva. At: <www.who.int/reproductive-health/unsafe_abortion/. >. Accessed 12 August 2005.
- YS Chong, LL Su, S Arulkumaran. Misoprostol: a quarter century of use, abuse, and creative misuse. Obstetrical and Gynecological Survey. 59(2): 2004; 128–140.
- AU Lokugamage, H El Refaey, CH Rodeck. Misoprostol and pregnancy: ever-increasing indications of effective usage. Current Opinion in Obstetrics and Gynecology. 15(6): 2003; 513–518.
- M Burns. Misoprostol use in obstetrics and gynecology. Outlook. 21(4): 2005; 1–8.
- S Clark, J Blum, K Blanchard. Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States. International Journal of Gynecology and Obstetrics. 76(1): 2002; 65–74.
- PW Ashok, GC Penney, GMM Flett. An effective regimen for early medical abortion: a report of 2000 consecutive cases. Human Reproduction. 13(10): 1998; 2962–2965.
- EA Schaff, SL Fielding, C Westhoff. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: a randomized trial. Journal of the American Medical Association. 284: 2000; 1948–1953.
- K Abuabara, J Blue. Providing medical abortion in developing countries: an introductory guidebook. Results of a team residency at the Bellagio Study and Conference Center. 2004; Gynuity Health Projects: New York.
- JL Carbonell, L Varela, A Velazco. The use of misoprostol for abortion at less than or equal to 9 weeks' gestation. European Journal of Contraception and Reproductive Health Care. 2(3): 1997; 181–185.
- JK Jain, KR Meckstroth, DR Michell Jr. Early pregnancy termination with intravaginally administered sodium chloride solution-moistened misoprostol tablets: historical comparison with mifepristone and oral misoprostol. American Journal of Obstetrics and Gynecology. 181(6): 1999; 1386–1391.
- JL Carbonell, J Rodriguez, S Aragon. Vaginal misoprostol 1000 micrograms for early abortion. Contraception. 63(3): 2001; 131–136.
- JK Jain, B Harwood, KR Meckstroth. Early pregnancy termination with vaginal misoprostol combined with loperamide and acetaminophen prophylaxis. Contraception. 63(4): 2001; 217–221.
- JK Jain, C Dutton, B Harwood. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of pregnancy. Human Reproduction. 17(6): 2002; 1477–1482.
- D Billings. Misoprostol alone for early medical abortion in a Latin American clinic setting. Reproductive Health Matters. 12(24 Suppl): 2004; 57–64.
- J Sherris, A Bingham, MA Burns. Misoprostol use in developing countries: results from a multicountry study. International Journal of Gynecology and Obstetrics. 88(1): 2005; 76–81.
- AE Pollack, RN Pine. Opening a door to safe abortion: international perspectives on medical abortifacient use. Journal of American Medical Women's Association. 55(3 Suppl): 2000; 186–188.
- K Blanchard, S Clark, B Winikoff. Misoprostol for women's health: a review. Obstetrics and Gynecology. 99(2): 2002; 316–332.
- MM Lafaurie, D Grossman, E Troncoso. Women's perspectives on medical abortion: an exploratory, qualitative study in Mexico, Colombia, Ecuador and Peru. Reproductive Health Matters. 13(26): 2005; 75–83.
- NM Philip, B Winikoff, K Moore. A consensus regimen for early abortion with misoprostol. International Journal of Gynecology and Obstetrics. 87(3): 2004; 281–283.
- VE Faria. Government policy and fertility regulation: unintended consequences and perverse effects. Brazilian Journal of Population Studies. 1: 1997; 1–29.
- JM Belizan, F Althabe, FC Barros. Rates and implications of caesarean sections in Latin America: ecological study. British Medical Journal. 319: 1999; 1397–1400.
- A Castro. Commentary: increase in caesarean sections may reflect medical control not women's choice. British Medical Journal. 319: 1999; 1401–1402.
- Silva M. Physicians and abortion: a study of the willingness to provide legal abortion due to rape in Mexico. PhD dissertation (defended 6 September 2005). Tulane University, Department of International Health and Development, New Orleans, LA.
- I Torres Escobar. Actitud de los médicos tratantes de los abortos que se presentan en los hospitales del Distrito federal. GIRE: Investigación preparada para Population Council/Ipas. México. 1993
- GL Jenkins. Burning bridges: policy, practice, and the destruction of midwifery in rural Costa Rica. Social Science & Medicine. 56(9): 2003; 1893–1909.
- SE Aguilar, O Ortiz. Preprueba del tríptico informativo: aborto médico temprano con misoprostol. Unpublished report to Ipas. 2004
- Consensus Statement: Instructions for use - Abortion induction with misoprostol in pregnancies through nine weeks LMP. Expert meeting on misoprostol. Reproductive Health Technologies Project, Gynuity Health Projects. Washington DC, 28 July 2003.
- K Blanchard, T Shochet, K Coyaji. Misoprostol alone for early abortion: an evaluation of seven potential regimens. Contraception. 72(2): 2005; 91–97.
- H Gould, C Ellertson, G Corona. Knowledge and attitudes about the differences between emergency contraception and medical abortion among middle-class women and men of reproductive age in Mexico City. Contraception. 66(6): 2002; 417–426.
- HL McNaughton, EMH Mitchell, MM Blandon. Should doctors be the judges? Ambiguous policies on legal abortion in Nicaragua. Reproductive Health Matters. 12(24 Suppl): 2004; 18–26.
- FA Althaus. Work in progress: the expansion of access to abortion services in South Africa following legalization. International Family Planning Perspectives. 26(2): 2000; 84–86.
- Ipas, IHCAR. Deciding women's lives are worth saving: expanding the role of midlevel providers in safe abortion care. Issues in Abortion Care 7. 2002; Chapel Hill: Ipas.
- J Beitz. Increasing access to reproductive health services through pharmacists. Outlook. 21(2): 2004; 1–8.
- Lara D, Abuabara K, Grossman D, et al. Pharmacist provision of medical abortifacients in Mexico City. Abstract presented at American Public Health Association Annual Meeting, Washington DC, 8 November 2004.