Women’s experiences with the use of medical abortion in a legally restricted context: the case of Argentina

Abstract

This article presents the findings of a qualitative study exploring the experiences of women living in Buenos Aires Metropolitan Area, Argentina, with the use of misoprostol for inducing an abortion. We asked women about the range of decisions they had to make, their emotions, the physical experience, strategies they needed to use, including seeking health care advice and in dealing with a clandestine medical abortion, and their overall evaluation of the experience. An in-depth interview schedule was used. The women had either used misoprostol and sought counselling or care at a public hospital (n=24) or had used misoprostol based on the advice of a local hotline, information from the internet or from other women (n=21). Four stages in the women’s experiences were identified: how the decision to terminate the pregnancy was taken, how the medication was obtained, how the tablets were used, and reflections on the outcome whether or not they sought medical advice. Safety and privacy were key in deciding to use medical abortion. Access to the medication was the main obstacle, requiring a prescription or a friendly drugstore. Correct information about the number of pills to use and dosage intervals was the least easy to obtain and caused concerns. The possibility of choosing a time of privacy and having the company of a close one was highlighted as a unique advantage of medical abortion. Efforts to improve abortion law, policy and service provision in Argentina in order to ensure the best possible conditions for use of medical abortion by women should be redoubled.

Résumé

Cet article présente les conclusions d’une étude qualitative de l’expérience d’habitantes de l’Aire métropolitaine de Buenos Aires, Argentine, qui ont utilisé le misoprostol pour provoquer un avortement. Nous avons demandé aux femmes la portée des décisions qu’elles ont dû prendre, leurs émotions, l’expérience physique, les stratégies auxquelles elles ont eu recours, notamment demander des conseils de santé et gérer un avortement médicamenteux clandestin, et leur évaluation globale de l’expérience. Un plan d’entretien approfondi a été utilisé. Les femmes avaient utilisé le misoprostol et demandé des conseils ou des soins dans un hôpital public (n=24) ou bien elles avaient utilisé le misoprostol selon les conseils d’une ligne d’assistance, les informations sur Internet ou les conseils d’autres femmes (n=21). Quatre étapes ont été identifiées dans l’expérience des femmes : comment elles ont décidé d’interrompre la grossesse, comment elles ont obtenu le médicament, comment elles ont pris les comprimés et des réflexions sur l’issue, qu’elles aient ou non demandé des conseils médicaux. La sécurité et la confidentialité sont des facteurs déterminants de la décision de pratiquer un avortement médicamenteux. L’accès aux médicaments était le principal obstacle, nécessitant une ordonnance ou une pharmacie compréhensive. Les informations correctes sur le nombre de comprimés à utiliser et les intervalles de dosage étaient les moins faciles à obtenir et ont suscité des inquiétudes. La possibilité de choisir un moment d’intimité et d’être accompagnée par un proche a été soulignée comme un avantage unique de l’avortement médicamenteux. Il faudrait redoubler d’efforts pour améliorer les lois, les politiques et la prestation de services d’avortement en Argentine afin de garantir les meilleures conditions possibles pour l’utilisation de l’avortement médicamenteux par les femmes.

Resumen

Este artículo presenta los hallazgos de un estudio cualitativo que explora las experiencias de las mujeres que viven en el Ãrea Metropolitana de Buenos Aires, en Argentina, con el uso de misoprostol para inducir un aborto. Les preguntamos a las mujeres acerca de una variedad de decisiones que tuvieron que tomar, sus emociones, la experiencia física, las estrategias que necesitan utilizar, tal como buscar consejos sobre servicios de salud y para lidiar con un aborto con medicamentos clandestino, así como sobre su evaluación general de la experiencia. Se utilizó un programa para entrevistas a profundidad. Las mujeres habían usado misoprostol y buscado consejería o atención en un hospital público (n=24), o habían usado misoprostol basándose en los consejos de una línea local de atención telefónica, información del internet o de otras mujeres (n=21). Se identificaron cuatro etapas en las experiencias de las mujeres: cómo tomaron la decisión de interrumpir el embarazo, cómo obtuvieron el medicamento, cómo usaron las tabletas, y sus reflexiones sobre el resultado independientemente de que hayan o no hayan buscado consejos médicos. La seguridad y privacidad fueron clave para decidir usar el método de aborto con medicamentos. El acceso al medicamento fue el principal obstáculo, que requirió una receta o una farmacia con personal amigable. La información correcta sobre el número de tabletas a usar y los intervalos de dosis fue la manera menos fácil de obtener y causó inquietudes. La posibilidad de escoger un momento de privacidad y estar acompañada de una persona cercana se destacó como una ventaja única del aborto con medicamentos. Es imperativo reduplicar los esfuerzos por mejorar la ley, política y prestación de servicios referentes al aborto en Argentina a fin de asegurar las mejores condiciones posibles para el uso del aborto con medicamentos por parte de las mujeres.

Keywords:

• abortion law and policy
• medical abortion
• women’s perspectives
• misoprostol
• abortion hotlines
• Argentina

Unsafe abortion and related mortality are both higher in countries with narrow grounds for legal abortion.¹ By 2011, 46% of countries in the world (91 out of 192) allowed abortion based only on risk to the woman’s life or health, 29% allowed abortion at a woman’s request (at least in the first trimester of pregnancy), while five countries (Chile, El Salvador, Nicaragua, Malta and Dominican Republic) did not allow abortion under any circumstances.²

In 2006, it was estimated that about one million women were being hospitalized for treatment of complications from unsafe abortion in Latin America.³ In 2008, according to WHO estimates, 95% of the 4.23 million abortions that took place in the region were unsafe.¹ More recently, it was estimated that 12% of all maternal deaths in the regional were due to complications of unsafe abortion.⁴ Most countries have restrictive abortion laws,⁵ but as evidence worldwide shows, legal prohibition does not deter women from seeking an abortion. When faced with an unwanted pregnancy, many women will seek an abortion, despite condemnation and barriers that make it difficult or impossible for them to obtain a safe abortion.⁶

The development of medical technology has made it possible for women to terminate a pregnancy safely, both surgically and medically. In legally restricted contexts, the expansion of access to and use of medical abortion has increased considerably,^7–10 due to the availability of misoprostol over the counter or on the black market. In these settings, different strategies, such as information and referral hotlines, internet purchase, and pre-and post-abortion counselling are increasingly being used – mainly by civil society organizations and women’s groups – to expand women’s access to safe medical abortion.^11,12

Medical abortion provides women with the option of an early abortion that is safe, easily accessible, not invasive, and allows ambulatory care. Studies show that women prefer medical abortion for a range of reasons: it is more natural, it does not involve surgery or anaesthesia, it allows for early abortion, it preserves privacy, and women feel more in control of the abortion process since, among other reasons, it can be organized to fit the woman’s daily routine. For these reasons, in most acceptability studies, almost all the women who have used medical abortion have said they would use it again and recommend it to other women.^8,13–16

In Latin America, women have been using medical abortion for self-inducing abortions at home for several decades.^17,18 Of the two medications recommended by the World Health Organization for medical abortion, mifepristone is still not available in almost any country in the region, but misoprostol has been sold in pharmacies since the 1980s.^19,20 Misoprostol is approved in most countries to prevent gastric ulcers but not for gynaecological or obstetric indications, except in six countries,^* which have registered it for some of these indications though not for abortion.²¹ In spite of the legally restricted context and in the absence of enforcement of the criminal law on abortion, the use of medical abortion by women is reducing the risks of unsafe abortion, thus contributing to the accomplishment of Millennium Development Goal 5a and 5b.²²

A recent literature review focused on the Latin American region found that despite the long tradition of academic and social research in sexual and reproductive health, and a strong women’s movement mobilized around the abortion issue,^23,24 few studies have specifically focused on the medical abortion experience from women’s perspective. This review also showed that legal restrictions on access to abortion and regulatory restrictions on access to medical abortion medications result in women lacking the appropriate information on dosage, symptoms and efficacy of medical abortion. The absence of counselling and support before, during and after the abortion process also results in women using the medication in suboptimal conditions.¹⁸

Abortion in Argentina is restricted by the Penal Code, with exceptions if the woman’s life or health is at risk, or if the pregnancy is the result of rape, including sexual assault of a mentally disabled woman. But even abortions on these grounds are not guaranteed by the health system.²⁵ Despite these restrictions, almost 400,000 abortions per year have been estimated to take place in Argentina, and complications of unsafe abortion have been the leading cause of maternal mortality for the last two decades.^26,27

Legal restrictions and the absence of a culture of abortion provision in public health services –even for the limited grounds provided by law – are the main barriers to accessing safe abortion. The fact that misoprostol is not approved for pregnancy termination adds another barrier. Not only do women face obstacles in obtaining misoprostol, but health professionals also have to deal with the fact that as misoprostol is not registered for abortion they have to resort to using it off-label.

Women’s use of medical abortion outside of clinical settings has therefore occurred clandestinely both despite legal restrictions and because of them. Given the importance of medical abortion in reshaping the nature of abortion, understanding women’s experiences in legally restricted settings seems to be particularly relevant.²⁸ This article presents the findings of a qualitative study aimed at exploring the experiences of women living in Buenos Aires Metropolitan Area in Argentina with the use of misoprostol for inducing an abortion.

Methodology

This was a descriptive, exploratory study. The sample consisted of women with different medical abortion experiences in terms of the sources of information and counselling they had to resort to. Some of them (n=24 women) had used misoprostol and sought counselling or presented with symptoms of incomplete abortion at a public hospital in the city of Buenos Aires.^† The others (n=21 women) had used misoprostol following the advice of a local hotline, the internet, or other women. All of them had had their abortion at home.

The women were recruited in two ways. Women who had sought counselling at a hospital were approached by a member of the hospital’s health team, before they were discharged, who asked if the research team could interview them. These interviews took place at the hospital. To reach women who did not attend a health care facility, snowball sampling techniques were used. Through women’s organizations in the community and through personal networks, we sought referrals of women who had had a self-induced medical abortion in the previous 12 months. In some cases, the contact person referred more than one woman to us. In other cases, an interviewee referred another woman to us. In each case, the contact person asked the women if the research team could interview them.

An in-depth interview schedule was used to gather information about the woman’s decision to have an abortion and her choice of medical abortion; how the medication was obtained; beliefs about how the medication works; perceptions of safety and efficacy; physical and subjective experience of the abortion process; perceptions of privacy; personal and family costs; and the role of the health service, if any.

The protocol was approved by the WHO Research Ethical Review Committee and by the Comité de Ética en Investigación of CEMIC (Centro de Educación Médica e Investigaciones Clínicas Roberto Quirno, Buenos Aires, Argentina). Informed consent was obtained from all the women. Field work was conducted between October 2011 and July 2012.

Interviews were conducted in Spanish, and analysis was done using the original Spanish text. Coding of the interview transcripts was conducted independently by two members of the research team; discrepancies in coding were discussed and resolved by the research team. The quotes used here were translated into English. All names used are fictitious to protect participants’ anonymity.

Our aim, as described in this paper, was to explore the diversity of women’s experiences, the range of decisions, emotions, and physical accounts and strategies, including seeking health care, that women went through in dealing with a clandestine medical abortion, and their overall evaluation of the experience. We also wanted to find out whether the experience of medical abortion might be different if the woman had received medical advice and care before or after the abortion. We discuss the implications of these findings for women’s health and well-being, and examine how the findings should be used to influence future strategies to improve access to safe medical abortion in legally restricted contexts.

Findings

The 45 women interviewed were aged 18–40 years; 60% had completed basic education (seven or more years of schooling). One third of them were living with their partners at the time of the interview. Sixty per cent of them had children, ranging from one to nine.

We identified four stages in the women’s experiences. Firstly, how the decision to terminate the pregnancy was taken, including the search for information and the reasons for choosing medical abortion. Secondly, how the medication was obtained, including access to a prescription and the purchase of the tablets. Thirdly, how the tablets were used, including the search for information about how to use them (dosage, interval, side effects and danger signs). Finally, the post-abortion stage, once the process was over, whether or not the woman sought medical advice, and the woman’s reflections on what had happened.

The decision to terminate a pregnancy using misoprostol

The choice of medical abortion was the result of the women comparing different options for resolving their pregnancy. In this process, the advantages of using pills for an abortion were a key factor: pills were more comfortable because they could be used at home and with a significant other person at the woman’s side; they were less risky; the medication was safe and more effective; it did not require undergoing a surgical procedure. The cost of the pills compared to the cost of a surgical abortion was not reported as an important barrier or as an advantage.

“It seems less risky to me. Yes, it seems safer, and less.... I don’t know, I feel that maybe [surgical abortion] is too much of an intervention into your body. I used the pills instead, I did it at home, with the people I love, and maybe it is less hard than the curette.” (Laura, 25)

“I picture myself in just any place, with any doctor, not knowing whether he is really a doctor or not, and it seems to me like butchery. I have a friend who did that and she came out totally drugged from anaesthesia, crawling on the floor in an empty apartment, you see, it is really not good, no support at all, you never even know who performed it…” (Lucía, 28)

For most of the women interviewed, the information needed to make the decision whether to use misoprostol was obtained by contacting different sources, primarily friends and relatives. However, the information obtained was often incomplete and did not fully satisfy their expectations, thus making them resort to more than one source until they felt they had received the information necessary to move on. Trust in the method’s safety, instilled by the sources consulted, was the determining factor in deciding to use misoprostol for 18 of the 45 women.

Those women who were able to consult health services that are well known for their commitment to women and quality of care felt particularly comfortable with the abortion process. On top of that, the interaction with friendly providers, who not only gave proper information but also listened to them and paid attention to their concerns in a respectful way, made them feel legitimized in their decision. For several women, the internet played a significant role, mostly for those who accessed a local hotline and its printed materials,^* whose information was a kind of “one-stop shopping”. They described this source as accessible, comprehensive and accurate.

“Once I realized I was pregnant I started asking friends who were older than me if they knew how to end it… They told me about the pills and other methods, but they said: ’If you are going to do it, play it safe!’ So, I did not think about another alternative, I trusted them since they knew what they were talking about.” (Claudia, 21)

“I asked a friend who told me that X hospital was friendly, that she sent girls there… And then there are books, that one from the Lesbians and Feminists who support legal and safe abortion, which I borrowed. I read it, and found it was safe. I already had information from my friends in Chile who had done it. And so, I made the decision.” (Taira, 31)

Getting hold of the medication

It took the women one to two weeks to obtain a supply of the tablets. The complexity of this endeavour depended on getting the prescription needed to purchase it; having contacts who could identify which pharmacy to go to; finding a pharmacy that would sell it; having enough money; and getting the support of friends and/or family.

In Argentina, a filled-in prescription form, handwritten and dated by a health professional, is required to purchase misoprostol. Personal contacts and word of mouth were particularly important in this respect. Given the burden of trying to obtain a filled-in prescription form, many women tried different strategies to get the medication without one. In the end, 21 women obtained a prescription from a public health service well known for providing counselling, while 11 women bought the medication at a pharmacy without a prescription. Six turned to a physician friend or relative who provided the prescription, five got the pills directly from friends or relatives, and two women bought the medication through the internet.

“I went to several pharmacies, together with a friend of mine; we went from pharmacy to pharmacy, and we told the pharmacist: ‘Look I have this problem, I need your help but I do not have a prescription.’” (Yamila, 18)

“The hardest part was getting the prescription… in the end I got it through a friend of a friend who was a doctor… but before that I made several appointments with gynaecologists trying to find a friendly doctor who would give me a prescription.” (Gabriela, 25)

Those who could not get the name of a pharmacy they could rely on consulted the pharmacies in their own neighbourhood as a first step, since knowing the pharmacy staff was perceived as an asset that might make the purchase possible.

Given the fact that misoprostol is not registered for abortion, buying the medication for that purpose requires making an illegal act look as if it were a legal one. For the women in this study, this meant using strategies to avoid any “what is it for” questions on the part of the pharmacist. For example, some of the women asked an older person to purchase the medication, making it sound like they had a gastric ulcer problem. Others asked for the prescription to be written up on behalf of a man.

“A physical therapist wrote a prescription for my partner instead of me. He said: ’ Well, I will go and purchase it with my good neighbour face. I can always say I have tendinitis, or whatever…” (Victoria, 33)

Leaflets, brochures and publications on medical abortion, Argentina, 2014

Even though almost all the women in the study had financial limitations, the cost of the medication was not perceived as an insurmountable problem, particularly when compared to the perceived cost of a surgical abortion. It is worth noting that the women pondered both cost and safety together when deciding for a medical abortion.

“The reason why I would recommend it is because of the greater possibility of economic accessibility, compared to the cost issue with surgical abortion. You can choose between this [medical abortion] and other clandestine kinds of abortions, which are riskier. That makes a difference. I can tell you that at the level of the poor middle class, or whatever it is that we are, we know that surgical abortions are currently risky because of the conditions in which they are performed. This is a cheaper and safer possibility.” (Yamila, 21)

At the end, half of the women had to rely on contacts in their personal networks to finally get hold of the medication.

“My sister got me the pills. She works in a social organization that provides the pills for women who want to have an abortion. The organization gets the pills through another organization which, as far as I know, has a contact with someone who works in a laboratory.” (Camila, 22)

“A friend of mine knows because a friend of hers knows. I said to her: ’Please, when you talk to her, ask where she bought them.’ She did me this favour, she asked her and she said she had bought the pills from a lady. And off we went, she just walked in, bought them and gave them to me.” (Norma, 30)

Using the medication

The restricted legal context in which abortions take place in the country influences the type and quality of information available.¹⁸ Half of the women felt confident about how to use the pills, mostly those who had been advised by a health provider before the abortion or had obtained information through the web and/or the hotline. Nevertheless, the interviews showed that the women’s knowledge of what to expect and how the medication works was incomplete and fragmented, and even physicians were not always perceived as reliable sources.

“Doctors themselves give different information. I received very different information. One said that I had to take only 4 pills and that would cause the abortion, another said that I should take all 12 of them; another said that I should take 4 pills and maybe 24 hours later the other 4. And that worried me.” (Norma, 30)

“A friend of mine asked different feminist organizations and she got information but piece by piece… People were scared to give her the information directly and they found it hard to give her a phone contact. Or they told her that there was a pill and it was not illegal to get it. All the information they gave her was wrong. Then, I found a website where I found a very useful book about abortion with pills, where to get it and the steps to follow.” (Gabriela, 25)

Routes of administration used were vaginal, oral, or a combination of both. Physicians sometimes recommended not using the vaginal route so that there will be no trace of the medication afterwards if the woman is examined, e.g. if she has complications of any kind. Women reported different regimens but the most frequent one was 4 pills every 3 hours. Women were particularly concerned about the number of pills and the interval between doses, which was the least clear information they could obtain.

“My main doubt was when to repeat the dose … whether I was losing it or not because the information I had said that if you had a big loss and you had to use two menstrual pads every half hour then you had to go to hospital. But I had a normal period so I was not sure. Then, I bled for 15 days so I went to a clinic and the ultrasound showed I still had something inside, so I repeated the dose, I used 4 pills.” (Andrea, 33)

All the women took the medication at home, on a day and at a time of day most convenient for them, which made them felt more at ease. They chose the night time, when children were asleep, or weekends when they had some time to rest, and interferences and demands were reduced.

“I used it during the weekend, because [the doctor] told me that in two days, three at most, it would be done. So, I said, on the third day, I will be ready to go back to work.” (Gabriela, 43)

Two-thirds of the women went through the abortion process in the company of someone close to them (partner, friend or relative), who they trusted. This was particularly highlighted by them as a unique advantage of medical abortion.

“You can do this at home, it allows you to have somebody there that you trust and can get support from.” (Lucía, 28)

The physical experience

For most of the women the abortion itself was experienced either as a normal menstruation or a more intense one. This created the perception that the abortion was close to a “natural process” and made them cope better with their anxiety and fears.

“It was like a normal menstruation. You think it will be like heavy bleeding or something like that, but it was very light and then it stopped… I was worried whether everything would turn out fine, I didn’t know how my body would handle it… but no, it was actually great.” (Karina, 36)

The bleeding and expulsion were recognized as key signs. In fact, 16 women said that through the bleeding they could confirm that the abortion process had started and was ongoing. Women also reported other physical symptoms, such as pain (24), expelling blood clots (9), contractions (5), chills (3), vomiting (3), buzzing in their ears (1), and diarrhoea (1). Though the women felt less pain than expected, dealing with it depended on whether they had been previously informed about the side effects, and whether somebody kept them company.

“I was with my partner, he was with me because as far as I understood it, you cannot take the medication if you are alone, just in case, you know… that is what my doctor told me…. It was different from what I had expected, less tragic… I thought that the pain was going to be stronger and that I was going to be even more worried.” (Lucía, 25)

Only 12 of the 45 women used painkillers, mostly those who had been previously advised to do so by a health professional. Fear about stopping the abortion process, as well as the belief that the pills already contained a painkiller, were the main reasons why women rejected the use of analgesics.

Despite having some notion about what symptoms they should expect after taking the pills, and how to move on consequently, many of the women lacked information about how the drug acts and what it does in the body. These ideas were expressed as:

“Whatever is there is dissolved/unfastened.”

“There are little pieces of tissue.”

“It has to do with chemical reactions that make the body expel the embryo.”

“It produces contractions.”

“It dilates the uterus.”

“It changes your hormones.”

“Pills get there and explode.”

“I had a revolution in my belly.”

“The pills cut the oxygen.”

The emotional experience

Although all the women had decided to have an abortion, all of them went through the process with negative emotions, even those who were confident about the medication. Fear of heavy bleeding (8), guilt and remorse (8), uncertainty of not knowing whether the medication had been correctly taken (6), dread of becoming infertile (6), careless for getting pregnant (6), sadness (5), annoyed about having to deal with health care providers and confessing the abortion (4), fear of dying (3), worries about coping with daily routine (2), shame for killing a baby and neglecting their kids, (3) were all part of women’s accounts.

On the other hand, relief and satisfaction with having solved the problem, and a feeling of self-confidence about the decision taken were positive emotions associated with the abortion experience for some women. For these women, having information on fetal growth, and the practical sense of “having solved” a vital problem counterbalanced guilt and remorse, which appeared to be underlying emotions for almost all the women interviewed.

“The first fear, maybe the strongest one, is that of guilt. It is this idea of killing a life, let’s say, this thing that results from a Christian upbringing, which actually I didn’t have. But also, I had a feeling of relief, of being able to do it. You can never say that it is a joy, it cannot be said that you are happy when doing what you have to do, but there is this idea that I wanted this, that I wanted to do it.” (Natalia, 33)

Fears and anguish were also better handled when women had a support network, including a health care provider who would be responsive to doubts or a significant person who would stay by her throughout the abortion process.

“What I remember is my partner’s company, we were living together and my house was the place we chose to do it. He was there; he took care of me and also took care of my physical pain… I never felt that things were out of control.” (Natalia, 33)

The experience with the health service

Previous consultation with the hospital where some of the women were contacted for the study shaped their expectations about medical abortion. Those who had received counselling there were above all pleased and very surprised by the fact that a public health facility was willing to guide them through the process, give relevant information, ask no questions, provide comfort, reassure them of the safety of the method, and support their decision. All these features were pointed out as especially valuable and made them feel more at ease with their decision to abort and the abortion process itself.

“To feel comforted, to feel guided about what to do next, about where to get the medicine, to have the prescription problem solved, to receive information on the price, all these issues… and not being condemned, looked after… these truly mattered to me.” (Laura, 25)

“At first I was scared to come to the hospital… I had already experienced going to public hospitals to ask for the morning-after pill or to ask for condoms and being treated like a murderer… but once there, the easiest thing was being able to talk to the women doctors. They are very friendly women; it was easy talking to them. I thought it would be harder. These ladies are very nice and you can trust them and tell them anything, because they will not make a big deal out of it. And for me that was really essential.” (Lucia, 23)

“They opened the door for me. I was very nervous, I had an ultrasound, they said how long I was pregnant… that I had time to think it over, they calmed me down and reassured me everything would go fine, that the method was effective, and that the risk of dying was very, very low. They advised me to come back; that they would be waiting for me.” (Debora, 23)

For three of the women who had had no previous counselling from a health professional, what they thought were alarming symptoms — fever, heavy or lengthy bleeding, unbearable pain, absence of bleeding – triggered the decision to go to hospital. All three expected a negative response from the hospital, based on their own and other women’s experiences. They assumed the health service would not be receptive to their needs because of what they had done. Fear about being mistreated and/or reported to the police were overcome by the even stronger fear of dying, however. Once they were admitted, these expectations were replaced by the distressing reality of being left alone in a room or being put into the same room as women in labour or women with their newborn babies next to them, because the hospitals do not have a separate space for women with abortion complications.

“The fear I felt was because I was in a room alone, and in the next room there were women giving birth. There was this girl who was giving birth and I heard everything. I told myself: ’I want to die.’ There was a clock there, I kept staring at it, my sister called me every 50 seconds because they only let them come in for a second. They were not allowed to visit me.” (Lucia, 28)

“You are in the same room with all the mothers. They keep talking about the baby, about the belly, blah blah blah… So I was fine, but it was impossible not to feel anguish.” (Andrea, 21)

The “abortion is over”: assessment of the experience

At the end of the interview, women were asked to assess their experience as a whole and its positive and negative aspects, the impact it had on them and how they saw it for women in general. Some of the women touched on aspects of the method itself and what it allows and also the circumstances in which their abortion experience had taken place, which they felt needed to be understood together. Many of them mentioned both good aspects and negative ones, recognising the ambivalence in both the situation and the experience.

“If you know the risks, if you have good information, and someone by your side, the pills allow you to keep the experience private. The decision is always a private one, and using the pills means that you are able to do it in your own way, when you want, with the people you want, and that is priceless. But not all women have access to these conditions… and sometimes another method is chosen — because life is different for each woman.” (Ana, 29)

“The method doesn’ t matter as long as it is safe and it is backed by someone, by a professional. The method doesn’t matter; it does matter how you reached it, what matters is to know what to expect and to have information…” (Claudia, 24)

“With [the pills] you don’t take any risks, as you do when you are in the hands of someone you don’t know, who will charge you lots of money because he doesn’t care… you are not cared for in such hands and you can even catch something.” (Lucía, 28)

“When I decided to do it, I thought: ’It’s relatively cheap, you are at home, you can be with someone, and you are not in a clandestine place. Afterwards, it took so long that I thought that I should have decided otherwise. Because with that other way, you end it in the same day, you leave and that’s it. Begins and finishes the same day, you get checked, but when that shitty moment passes, it’s over. But this way it keeps going on and you don’t know whether to repeat the pills or not.” (Andrea, 21)

The circumstances in which the abortion took place, the clandestine conditions and the consequent risks, and the quality of information they could get, were particularly significant for some of the women.

“Other options are more complicated because you need a physician to intervene, a physician who is committing a felony; you are engaged in a perverse relationship because you are bribing him to put his license at risk… so in that sense, pills are a million times better.” (Victoria, 33)

“I know women who it failed for. For me it depends on how you manage it and what you know beforehand… I know people who tried with the pills over and over and nothing happened. Luckily for them, the babies were fine because there was the chance for something to happen. Information really matters.” (Claudia, 24)

Finally, women talked about choice and the autonomy to make decisions. The option of a private process for pregnancy termination, with the interference of no one else, was particularly valued.

“The pills can change your life, being able to decide what you want to do with your body… I think they are like birth control pills, you take them and you don’t have to explain why you take them, they give you autonomy and a privacy which even the loneliest of women in the world, even one who has nobody she can trust, can still do it. So I believe this aspect, autonomy, is essential because, after all, it is your body. I think the other options always include a third party with whom you have to negotiate and whenever you have to negotiate, there is something to lose… Once you have the pills in your hands you can do whatever you want.” (Victoria, 33)

Conclusions

This study explored women’s experience with medical abortion in a legally restricted setting. As with a number of other countries in Latin America, the situation related to abortion in Argentina has been changing in recent years due to judicial rulings in favour of women’s access to abortions that are legal on existing grounds of risk to life or health, and rape, and the introduction of certain public policy changes, particularly norms issued to regulate access to legal abortion on these grounds.^23,29,30 At the same time, the alternative of home use of misoprostol, coming from women’s groups, social organizations and health teams at certain public health services, has reached women with unwanted pregnancies. Supporting this are local hotlines and websites providing accurate and gender-sensitive information and counselling, as well as referrals to friendly health services;³¹ community-based organizations carrying out educational activities and providing informational materials, reaching out to women and providing support;³² public health services counselling women using a harm-reduction approach;³³ an open cultural climate for debate on abortion;^34–36 and the more extensive use of misoprostol for pregnancy termination, often discovered by women through word of mouth.^33,36

The findings reported here should therefore be interpreted in the light of this changing context. The unprecedented window of opportunity created by misoprostol use sits side by side with the historical barriers to access safe abortion, legally or not. Women are benefiting from the new scenario but still live with the deeply rooted cultural background of illegality, which makes them suffer from social stigma and emotional barriers that limit their acceptance of the decision to have an abortion.

The findings show that women perceive many advantages to medical abortion. As many other studies in the Latin American region have shown, the women in this study greatly appreciated the possibility of keeping their abortions private; of being able to choose the day, place and time to use the pills; the safety of having the abortion without the intervention of unknown people; the secure feeling of going through a physiological process; and the chance of being looked after by someone they chose.

The fact that the women had to rely on themselves in a clandestine setting meant that information and counselling were critical.^16,26 The women accessed information from different sources and were particularly concerned when those sources did not provide the same information, or it was fragmented or inaccurate. The information they managed to obtain made them trust the method enough to go forward with it but, at the end of the day, they sometimes felt that the knowledge they had was not enough, causing a distressing sense of uncertainty. Although more information is available now compared to the past,¹⁶ it still seems to be much less than women need. In addition, it does not speak about the wide range of aspects of the abortion process that women are concerned about: the extent of the bleeding, whether and when to repeat the dosage or not, how to assess the clots, how to cope with fear, anxiety, pain and guilt, among other aspects.

Women actively searched for counselling to support them to make a decision and/or carry out the abortion. They found it from various sources: a hotline, relatives and friends, printed material, and also health professionals.⁸ The particularities of the method, combined with the legal restrictions on health professional involvement, puts the abortion in women’s hands. The diversity of groups and individuals currently committed to supporting safe abortion also makes counselling, which is essential, more available.

At the same time, the hotline and its information materials were highly valuable resources, particularly for those women who seemed more assertive and resourceful in using the internet and managing with printed materials. For women who felt more vulnerable, face-to-face contact and reassurance from a friendly health care provider better suited their needs. Moreover, the “moral authority” of health care providers helped to dissipate their distress and bring legitimacy to their situation and decisions.

Our findings show that the women involved and relied on partners, family and/or friends during the abortion process. The “nature” of medical abortion and the women’s wish to have someone by their side was nurturing for them.^8,26,37

Although recent studies in Latin America argue that women use medical abortion because they have no other alternative, we have shown that the women in this study chose medical abortion after a thoughtful process of decision-making.^8,37,38 The final decision was taken once the advantages and safety of the pills were clear.

Although this study was small and cannot be taken as representative, the findings show that despite the legally restrictive setting, women were accessing information, counselling and misoprostol, and at the end, deciding whether to have an abortion and able to act on their decision, whether or not they had health professional support. They found this method challenging but also acceptable and affordable. Nevertheless, they also expressed many doubts and uncertainties, not all explained by the clandestine environment. The fact that the use of medical abortion in this setting was in their own hands put a heavy burden on some of them. A lot of self-confidence would be needed to go through this process without hesitation.

Efforts to improve abortion law, policy and service provision in Argentina in order to ensure the best possible conditions for use of medical abortion by women should be redoubled. The availability of mifepristone as well as misoprostol should be approved and an enabling environment created. At the same time, since not all women and not all life experiences and circumstances are the same, choice of abortion method and information sources should be a priority.

Acknowledgements

The authors acknowledge the technical and financial support from HRP (UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). We are grateful to all the women who shared their experiences and trusted us in reporting such a significant moment of their lives. We want to thank the Chief of Service and staff of the hospital that introduced us to women. Without their help the study would not have been possible. We greatly appreciate the commitment and sensitivity of Ana Aguilera, Sonia Ariza, Paula Bilder and Tamar Finzi in conducting the interviews.

Notes

* Argentina, Brazil, Colombia, Mexico, Peru and Uruguay.

† The name of the hospital is not provided for confidentiality reasons.

* We refer to “Todo lo que querés saber sobre cómo hacerse un aborto con pastillas”, Lesbianas y Feministas por la Descriminalización del Aborto. http://www.editorialelcolectivo.org/ed/index.php?option=com_content&view=article&id=176:todo-lo-que-queres-saber-sobre-como-hacerse-un-aborto-con-pasillas&Itemid=1.