Early experiences with Cytotec being used for abortions and endangering women was reported from Brazil. This is an indepth look at the consequences there.

http://www.hsph.harvard.edu/Organizations/healthnet/reprorights/docs/arilha.html

Global Reproductive Health Forum, Harvard University

Cytotec in Brazil: 'At Least It Doesn't Kill'

Margareth Arilha and Regina Maria Barbosa

Misoprostol (brand name Cytotec) is a synthetic analogue of prostaglandin E1, developed by G D Searle & Company in the 1970s for treatment of certain kinds of gastric and duodenal ulcers. It is currently approved and available for this indication in at least 72 developed and developing countries and as of March 1992, 14 other countries were considering applications for similar approval and use. In Brazil, it is sold in packets of 28 tablets, each tablet containing 200 micrograms.

As with all prostaglandins, whether those produced in the body or synthetic analogues, misoprostol has a stimulating effect on smooth muscles, including the uterus, making them contract. In France, it is currently being used in combination with RU486 (mifepristone) to induce abortions up to 49 days of pregnancy.

It was in Brazil, however, that its use as an abortifacient first gained notoriety, both because of its widespread use by women to induce their own abortions and because of the subsequent public condemnation and action taken by the government.

The experience with Cytotec in Brazil points up the contradictions in the illegal situation of abortion in the country. However, when Cytotec became a public issue, instead of confronting the pressing problems women face, the Brazilian Ministry of Health and a number of state government authorities took action to prevent women from obtaining this drug, thereby hoping to avoid a deeper involvement in these problems.

This paper describes how the use of Cytotec spread and the problems it created for the government, how it affected gynaecologists' thinking and practice, how it altered women's experience of clandestine abortion, and the continuing problems that have resulted from the 'solution' of restricting the availability of this drug.

How the use of cytotec spread

Cytotec was approved for sale over the counter in Brazilian pharmacies in August 1986. Its use as an abortifacient spread quickly after its introduction, but with little public notice at first.

It is not possible to identify a sole source responsible for disseminating information about the abortifacient properties of Cytotec. Pharmacies, doctors and women themselves were all part of a large network that grew as time passed. It is interesting to note, however, that although legal abortion is restricted in most of the southern hemisphere, it was only in Brazil that the drug became well known as an abortifacient. More recently, we have learned that it is being used by women in Mexico and Venezuela on a small scale, and in Barbados on an unknown scale.[1]

From 1986 to 1988, the drug was marketed in Brazil by Searle. In 1988, marketing was taken over by the Brazilian company Biolab Laboratories. This would have been of no importance politically, except that the public campaign against the drug in the following years probably had a more direct effect on this nationally-based company than might have been the case with an international one.

In 1988, its use against ulcers was approved in the USA. Even though Searle was not applying to market the drug there for any obstetric or gynaecological purposes, the anti-abortion National Right to Life Committee publicly opposed the granting of the licence. This was reported in the Brazilian press.

Campaigns against the drug

The first campaigning against Cytotec in Brazil took place between mid-1988 and January 1990, probably as a result of the campaign in the USA. In this period, several articles were published which accused the Ministry of Health of irresponsibility and lack of control over the sale of the drug by pharmacies. The government was urged to withdraw Cytotec from the market or restrict its sale to patients with a medical prescription.

Although most drugs in Brazil are sold without a medical prescription by pharmacies, this campaign did not highlight misuse of any other drug. Nor did it call for broader changes in national drug control policy or prescription requirements. Although there were a few vague references to Cytotec as the tip of an iceberg, the rest of the iceberg was never described. Only Cytotec was focused on.

An analysis of the sales of Cytotec shows an increasing trend beginning in January 1989, with sales rising to over 50,000 units per month. Except for some fluctuations in 1990, this trend was maintained until July 1991, when the Ministry of Health imposed its restrictions. After July 1991, sales decreased steadily and still remain at low levels. [2]

Up to 1990, publicity about the drug probably promoted both knowledge of its existence and sales. The fluctuations in sales during 1990 coincided with a new phase in public campaigning against Cytotec, which consisted of statements made in the press and other media and letters sent to the Ministry of Health. This campaign was carried out by consumer defence groups, a few feminists linked with the Feminist International Network against Reproductive and Genetic Engineering (FINRRAGE), and some medical and pharmaceutical institutions such as the Regional Committees of Pharmaceutical Professionals and some Regional Committees of Medicine.

Allegations were made that Cytotec was causing an increase in the number of abortions by making it easier for women to abort themselves, thus encouraging a dangerous and criminal practice. The anti-abortion intent of most of these allegations caused public reaction against the drug to intensify.

The Ministry of Health was put under increasing pressure to control the abortifacient use of Cytotec. A number of non-governmental institutions, state and county government representatives, members of parliament, pharmacists, religious groups and branches of the Justice Department all made representations to the Ministry. Curiously, the Catholic Church as an institution was absent from this campaign, at least in public. However, the Church very commonly brings pressure behind the scenes in such a situation, and it is not unlikely that it did so in this case too.

Pressure began to come from all over the country, and most of those taking an active part demanded that Cytotec be included in the list of strictly controlled drugs, and only sold to bearers of special prescriptions or for hospital use. Importantly, Biolab Laboratories put a lot of pressure on the Ministry of Health to take a position because of concern about the company's public image.

Although there were health professionals and others who did not agree with this campaign and even a few who raised the broader issue of abortion legislation, they rarely spoke out or only did so very timidly, and they received little press coverage. These included the Brazilian Federation of Gynaecologists and Obstetricians (FEBRASGO) who, in the first half of 1991, took a position in favour of research on and use of prostaglandins for a number of gynaecological and obstetric purposes, in line with international practice.

We are not aware of any discussion of this issue in the women's health movement in Brazil until after we became involved in the research project that is reported below. Almost no information existed on the safety and efficacy -- or otherwise -- of Cytotec as it was being used in the Brazilian situation. In the absence of well-articulated, national political action in support of safe, legal abortion, almost no one came forward to defend the use of Cytotec.

Instead, state government authorities decided to intervene and events began to move very quickly. In May 1991, the state of Rio de Janeiro restricted the use of Cytotec to hospitals only. On 4 July, the state authorities in Ceará imposed a total ban on the sale of Cytotec in the state, which has been maintained to date. They also initiated legal action against the federal government for its lack of action, a move that was publicised in all the newspapers.

On 17 July, the Ministry bowed to this pressure. They required that any purchase of Cytotec must be accompanied by a double-copy prescription from a physician, containing the physician's name, with one copy retained by the pharmacy. Further, they made an agreement with Biolab Laboratories that the company would reduce the availability of the drug.

In the second half of 1992, the use of Cytotec in Minas Gerais was restricted to hospitals, while in the state of São Paulo its gynaecological use was forbidden in September 1992 and its sale to the public was restricted to authorised pharmacies registered with local government authorities.

With all the negative publicity that the drug was receiving, it appears that many pharmacies stopped stocking the drug or reduced the quantity they carried. As a result of all these factors, sales decreased rapidly after July 1991. However, women can still buy Cytotec on the black market, including in Ceará. More recently, this black market has expanded, especially in São Paulo, with the illegal entry of Cytotec from other countries, mainly from Argentina and the USA.

Extent of cytotec use

A number of studies have tried to assess the extent of Cytotec use by women to terminate unwanted pregnancies. However, it must be stressed that Cytotec did not appear in Brazil in a vacuum. Before Cytotec came on the market, women were already inducing their own abortions or going to illegal abortionists or private doctors to terminate unwanted pregnancies. They were drinking herbal teas and drug cocktails, injecting themselves with drug preparations, introducing caustic substances, instruments and objects such as catheters and sharp objects into the cervix and uterus, or using abdominal pressure or violent exercise, often with fatal results.

Just before Cytotec became a significant factor, it was estimated that there were between one and four million induced abortions every year in Brazil and that women were having between one and three abortions in their lifetimes. [3] Practically all abortions were and are done illegally [4] and complications are common. Abortion was one of the major causes of maternal deaths in Brazil before Cytotec came on the scene. [5]

The only way to estimate the extent of use of Cytotec, apart from sales figures, is by focusing on women admitted to hospitals with abortion-related complications. In 1990, research conducted in public maternity hospitals in the northeastern cities of Recife and Fortaleza confirmed that Cytotec was being used as an abortifacient. An analysis of the admission records of two hospitals in Recife revealed that of the 8,744 cases of abortion admitted during the period October 1987 to October 1990, 10 per cent were recorded as induced. Of these, 73 per cent were induced using some kind of drug. Cytotec was named in 50 per cent of these cases. As these figures were not broken down by year, no trend can be identified. [6]

In Fortaleza (Ceará), of a total of 164 cases with abortion-related complications attended in 1988 at the Assis Chateaubriand Maternity Hospital, 12 per cent were induced with Cytotec. In 1989, this proportion increased to 50 per cent of a total of 249 cases and, in 1990, 72 per cent of 715 cases. These figures indicate a rising prevalence of this type of abortion among the cases admitted to the hospital, both in relative and absolute terms.6

More recently, in spite of the restrictions imposed by the federal government in 1991, a study conducted in seven public hospitals in Rio de Janeiro between April and December 1991 found that Cytotec was used on its own by 45 per cent of the women hospitalised with abortion-related complications, used with other methods by an additional 12 per cent, and may have been used by a further 13 per cent who could not identify the drug they had taken by name but who had similar complications to the Cytotec users. [7]

Clearly, the use of Cytotec was becoming more and more common as the 'method of choice' in a situation where safe choices were not available. However, as we will show below, Cytotec changed much more than the method of abortion that women used. It also reduced the risk to health and life women had faced with the more dangerous forms of clandestine abortion. Lastly, it influenced how both women and gynaecologists viewed abortion and the willingness of health professionals to attend women with complications sympathetically.

The views of gynaecologists in São Paulo

In June 1992, we conducted two focus group discussions with obstetrician/ gynaecologists working in the São Paulo public health system, one group consisting of eight women and the other of six men. They were recruited by a professional agency by phone from a long list of those working in the field in different parts of the city, so we did not know their identities in advance. They were invited to come to discuss different aspects of women's health.

The participants in these focus groups confirmed that women and some doctors were using Cytotec as a means of getting around the law on abortion. They also talked about the uses of Cytotec that FEBRASGO had defended, and said that Cytotec had been found to be a valuable therapeutic resource for both obstetric and gynaecological purposes. For example, Cytotec was being used in hospitals for uterine evacuation in cases of incomplete spontaneous abortions and fetal death and also for inducing labour. The participants did not specify different dosages for these three indications. The only dosage mentioned was two tablets given orally every six hours for 24 hours with two tablets inserted vaginally. However, they said that it had now become more difficult to use the drug in these cases.

Both groups were concerned about the potential health problems associated with the use of Cytotec as an abortifacient, but their impression was that it had contributed to a decrease in the rate of maternal mortality and morbidity:

'We used to have two hysterectomies a week, now we have one every six months.'

Although complications such as severe bleeding or strong cramps did occur, their experience was that the use of Cytotec did not present the same level of risk as abortions provoked by quacks or by the women themselves with other, commonly used methods. On the other hand, they were worried about what they called 'bad' or 'indiscriminate' use of the drug, that is, in cases where the risks incurred by the woman were high. The examples they gave of this included:

• cases of women over 28 weeks of pregnancy who took Cytotec to try to provoke an abortion and who brought on a premature birth instead.
• cases of women who had had a recent caesarean section, had become pregnant again and had used Cytotec to try to abort.
• cases of women who used 30 or more tablets to ensure they would abort.

All of the participants were concerned that the situation of illegality made it impossible to obtain reliable scientific information about what an adequate dosage should be in relation to the body weight of the woman and the duration of pregnancy -- whether for abortion or for the other uses being practised. They talked about different dosages and routes of administration being used, sometimes orally and vaginally at the same time, and sometimes only orally or vaginally. In their experience, intense bleeding, when it occurred, was associated with high dosages as well as low ones. They also knew of cases of complete abortion with very little bleeding. Because of their own lack of information, they were unable to explain these differences in the women they treated in hospital.

Our impression with regard to Cytotec was that women doctors were more willing to help a woman with an unwanted pregnancy than male doctors. None of the participants admitted to knowing of doctors who gave the drug directly to women. But they did say that some doctors were informing women that the drug existed, and also telling women they could take it at home and then come to the hospital for help afterwards. The majority who did this, however, apparently did not explain anything to women about what it would be like when they took the drug.

Another observation these gynaecologists made was that the women who used Cytotec to abort felt less guilty about their abortions than those who used other methods. They said that the women they encountered in the hospital and in post-abortion consultations often described what they had done as bringing on a late period rather than as an abortion.

Further, they were of the opinion that doctors also felt less prejudiced against women who had aborted with Cytotec. This seemed to be because the doctors felt more capable of saving the women's lives than they did with other clandestine methods, since the complications were less severe. Thus, the tension and insecurity they felt was diminished. In addition, neither the woman nor the fetus caused such a terrible visual impact when Cytotec was used, compared with other methods:

'There are patients who provoke an abortion by introducing a knitting needle or a catheter. If the fetus is big, it may come out badly damaged, for example with a hole in the head or the eye or the shoulder. With Cytotec that doesn't happen ... When you see a fetus that is intact, it's different from when there are injuries all over it. You don't feel so much rage.'

'Before, we used to go through a revolting process with the patient because she was presenting us with a disgusting mess. Nowadays, cases seem to be more benign, and the patient is thankful to have a curettage done.'

Another very relevant change that was described in these discussions was the effect on gynaecologists who, in the past, had had nothing to do with abortions. In Brazil, there has always been a complete separation between the doctors who perform abortions and the ones who do not. The two do not mix, not least because those who perform abortions have to pay the police in order to obtain a corrupt form of authorisation to function without fear of arrest and imprisonment. Further, women would only go to an 'abortion doctor' when they needed an abortion, and not as patients with 'normal pathologies'.

Cytotec has changed this situation, because now even doctors who carry out a 'more noble' practice can also make an abortion possible. Some have chosen to give women Cytotec or tell them to use it, and then send or take them to a good clinic or hospital where a decent curettage can be performed if necessary. This can be done without getting mixed up with the police because there is no evidence that the doctor is involved. For the women, it becomes unnecessary to go to a quack or an 'abortion doctor'.

Finally, they said that women will go to see a gynaecologist in his/her private clinic after having used Cytotec, just to find out 'if everything is OK'. In these cases, it is common to confirm by ultrasound that the abortion was complete.

We do not know how much the more 'noble' doctors were/are charging for these services nor how 'abortion doctors' feel about it, though in the case of the latter we can imagine that they may have lost many patients during the period when Cytotec was easily available. These changes and the potential financial interests involved are illustrated in the following statement by one of our focus group members:

'There are colleagues now who are not abandoning their patients anymore. Before, the woman paid for her appointment and you diagnosed the pregnancy, and then the one who performed the abortion made $300 or $500. You didn't make anything. With Cytotec, the doctor keeps his patient. He attends her in all the moments of her life, even in dealing with an undesired pregnancy. I think that my colleagues have this option now.'

Women's experience of Cytotec
In-depth interviews

In order to study the use of Cytotec from women's point of view, we carried out in-depth interviews with a group of 14 women aged 18 to 40 from different social classes, all of whom had had an abortion using Cytotec. We recruited them by asking women we knew if they knew of women who had used Cytotec, and made contacts through the referrals we were given. The interviews took place 6 to 18 months after they had used the drug. This was not a representative sample and their experiences are not necessarily representative of the women who have used Cytotec.

Four of the 14 women had had induced abortions before; the other ten had not. Most of them had heard about Cytotec from friends. Because Cytotec is being used clandestinely, little reliable information about it has been disseminated and women have administered it in a wide variety of ways. They have taken it orally or inserted it vaginally only, or combined oral and vaginal use in order to enhance its effectiveness. Intravaginally, they have inserted whole tablets or crushed them into a gynaecological cream and inserted the mixture.

There are also huge differences in the doses of the drug that women have used. In Recife and Fortaleza, this was found to vary from an average of four to 16 tablets.6 There seems to be a preference for a dosage of four tablets, two taken orally and two administered intravaginally. But quantities of up to 84 tablets were reported in the study in Rio. Sixty-two per cent of the women in that study used doses of two to 28 tablets at one time, while many of those who used massive doses spread this over several days.7 (Table 1)

Table 1. Total doses of misoprostol reported in Rio de Janeiro

This data is only from women who were hospitalised, however. A similar range of doses was mentioned by the doctors in our focus groups, as well as by the women we interviewed. However, no data on dosage has been published for women who did not attend a hospital, whether or not their pregnancies were successfully terminated or their abortions were complete.

In general, attempts to interrupt pregnancy with Cytotec occur during the first trimester. However, as the drug is active throughout the nine months of gestation, it has been used at later stages with sometimes dramatic results. One of the women we interviewed reported taking 64 tablets over a period of four months. When her menstruation was first delayed, this woman took 30 tablets and had heavy bleeding. Thinking that she was no longer pregnant, she began taking oral contraceptives. Then she began thinking that she was pregnant again, and she started taking Cytotec again until she finally aborted at home. She was about 16 weeks pregnant by that time.

We asked the women why they had chosen Cytotec. For all the women we interviewed, regardless of social class, price was a decisive factor. Many of them had considered other ways of inducing the abortion, but gave up pursuing these when they became aware of the cost. '... I went to a clinic, but it would have cost a little more than my salary, so I thought: What now? I won't be able to do it that way ...'
(Marcia, age 23)

The women gave three other main reasons why they had chosen this method, according to their different life situations. The first was that Cytotec had made the decision to have an abortion easier. This was a reason common to all the women who were less than 20 years old, who did not want to have a child but did not have the courage to go to a clinic for an abortion. For this group, the drug allowed the abortion to take place without the conscious planning that going to a clinic requires. Cytotec was usually purchased or obtained with the help of relatives, friends or boyfriends, before these young women had definitely decided whether to take it. Then, using it or not became a decision that was made on the spur of the moment. The drug was taken and the abortion carried out within a context of ambiguity:

'My mother had already bought the drug, but I still hadn't decided. Every day, when I got home, she asked. I kept putting it off until one day when I went out, I had gone to a Karaoke (night club), when I got home and I had something to eat, I took it ... I think if I'd had to go to a clinic, I wouldn't have done it, I wouldn't have been able to. Since I really didn't want to, it was like this. I got home and said, "I'm going to take it now." If I had had more time I wouldn't have done it.'
(Mirna, age 17)

'I never saw it as an abortion. Using Cytotec felt more like postponing pregnancy at the time, waiting a little longer for a new life to appear. Because if I had gone to a clinic, I would never have forgiven myself. I was already doing this with a lot of regret, with a tight heart, full of insecurity. I wouldn't have been able to face a clinic, not physically or psychologically. I was never in favour of the abortion. I always thought that if I had an abortion, I would carry it with me for the rest of my life.'
(Nilce, age 18)

'... I thought about going to a clinic, but it was too expensive and I would have had to plan it, go there, set the date, pay on the date. But not with the medicine, it's there in front of you, either you take it or you don't, and at least at that moment I had decided. I had very big doubts, so I did it very quickly. It's like I said, one moment I thought I was going to do it and the next I thought I wouldn't ...'
(Dilma, age 19)

The second main reason the women gave for taking Cytotec was that it would make the abortion process itself easier. This was said by all of the middle class women, some of whom also said they thought Cytotec would permit more privacy.

Often the decision to abort cannot be shared with partners or relatives, who may be opposed to the idea, sometimes to the point of not allowing the woman to make her own decision whether to have the baby. Normally, it is only friends who are involved in the decision-making process, if anyone. At other times, the need for silence is associated with not leaving 'signs' on the body. Some said they did not want health professionals to be able to see that there had been an abortion. Any evidence of abortion might cause a gynaecologist, whose future services the woman may depend on, to change her/his attitude and not look after her any longer.

'... I was thinking especially about privacy. Using Cytotec is something that is yours, nobody has to know what you did or didn't do, no one invades your privacy. Even the gynaecologist I went to later didn't know that I had had an abortion.'
(Ana Cristina, age 31)

'... I didn't want him [boyfriend] to know, and I didn't have the money, even though that wasn't the main reason. I wanted something fast and safe. In fact, I didn't even think of going to a clinic because I'd just got pregnant and I thought that there would be no problem with Cytotec ...'
(Fatima, age 27)

Some of the middle class women thought that Cytotec would be less invasive than other methods and so would be less traumatic. These women were aware that other forms of clandestine abortion carry more risks to women's health and lives, and can be both physically and psychologically traumatic. Cytotec was attractive because it would remove the more dangerous risks from the scenario.

'I think that the effects of abortion, even though you are in favour of it, have always bothered me. It's traumatic, it's a real operation. That's what counted. Cytotec was less traumatic.'
(Rosana, age 25)

'It's less traumatic, a lot less. You know what the sensation is? The sensation you have is that your period is late and so you take medicine for it to come. That is the feeling I had. I can lie to myself if I want, but I won't. I did it feeling good. I am not a liar to say such a thing, that I simply took some medicine, that I didn't cause an abortion.'
(Fatima, age 27)

Another consideration for the middle class women was that it would speed up the process, by reducing the waiting time between the decision to abort and the onset of abortion. For some women, an undesired pregnancy creates a need to 'get rid of it quickly'. In such cases, there was a feeling that Cytotec could do this best.

'I couldn't wait for the thing to get too far advanced. When I found out, the pregnancy was already ten days along, so I said, the sooner we solve this problem the better it is for everybody. I'll take Cytotec.'
(Ana Cristina, age 31)

For all of the low-income women we interviewed, the main reason given for using Cytotec was that it would not kill them. Their fear of dying from an abortion is the fruit of concrete experience - of abortion procedures carried out in very precarious circumstances - and part of the reality of their lives.

'... At least Cytotec doesn't kill. I've never heard that it's killed anybody, I've never heard anything like that, not even a friend of mine who got rid of a five-month-old pregnancy.'
(Sandra Lucia, age 34)

All the women we interviewed chose Cytotec because they perceived that it had distinct advantages or because it brought the decision and the actual abortion more closely together. However, this 'ideal' picture of abortion with Cytotec fell apart for the ones who had negative experiences with it.

Only three of the 14 women described favourable and trouble-free experiences. In all three cases, the pregnancy was very early, with menstruation no more than two weeks late. These women were more informed than the others, and none of them had to go to hospital for a curettage or any other treatment. One had bleeding for 15 days and one for 30 days, while the third had pain, diarrhoea and vomiting, but all three said these effects were tolerable. A gynaecologist was with one of them when she took the drug. Another was a nurse herself and carried out the procedure with the support of her husband, who is also a nurse. The third had her boyfriend with her and also had the help of a friend.

For the 11 women who described the experience as negative, it was the unforeseen and unexpected characteristics of the process - caused by an almost total lack of information - that made the experience so negative. They were frightened, and their lack of knowledge prevented them from assessing whether or not they needed medical help for what was happening. They described this stage as filled with intense physical pain, anguish and fear, including death fantasies:

'... I kept thinking that I would have a haemorrhage, like that other girl. I had this feeling ... I thought, I'm doing this because I have to, but I'm also risking my life. I knew that if I had problems, I would be in trouble, but if it had to happen it would happen...'
(Nilce, age 18)

'... I was imagining that I would feel dizzy, feel sick, end up in hospital and not know what to say to my parents. I was afraid my body would reject something. I was afraid I would die instantly ...'
(Marcia, age 23)

'... My worry was with the pills that I put inside, because the oral pills had less effect. But the others would go into the ovary, the uterus, and they could harm me... Besides this, there was the risk of dying that I only found out about later.'
(Rosana, age 28)

Independent of social class, all the women knew how to take the drug, but they had no information about the maximum number of tablets they could take, the time it took from onset to completion of the abortion, or even under what circumstances to seek help. Pharmacists, doctors and friends had a wide variety of opinions and recommendations on these points.

Generally, the women used the drug at night without anybody else knowing, and for them, privacy was transformed into loneliness. Help from other people was sought only when pain and bleeding became intolerable. To assess the seriousness of the effects and decide what to do about them, whether to stay at home or go out in search of medical help, whether to tell family, partners or friends, were decisions taken largely in isolation. The process ended up being a lot longer and more complicated than most of the women had expected when they started it. Thus, except for the price, few of their expectations corresponded to their actual experience, especially among the middle class users.

None of them had thought they would have to go to hospital, since most had chosen Cytotec to avoid a curettage. Three of them did not seek medical help, but felt insecure about this decision. Eight did go to hospital.

Paradoxically, the existence of this drug allowed some of the women to abort very early, while others felt able to postpone doing anything or denied the need to recognise the pregnancy and make a decision about it. Thinking that they could abort 'at any time' without going to a clinic, many of them ended up in a higher risk situation because they waited to take the drug until a more advanced stage of pregnancy. Three of the women in this situation delivered the fetus and cut the umbilical cord themselves at home, and only went to hospital later for a curettage.

'I made the delivery by myself. It was awful. I was all covered with blood. I thought I was going to die because of all the blood. The thing just fell out, I cut the cord, I took the fetus into my hand, it was awful. I shiver when I remember. It makes my blood run cold. I went to the bathroom, had a bath, wrapped the baby in paper, it was a boy, a four-month pregnancy. It was horrible. There was no place in the hospital, and they sent me to the Capao Redondo for a curettage. I went by ambulance, with the fetus in a plastic bag with the placenta. I didn't open my mouth to say anything about the Cytotec. In Capao, the hospital was very dirty. I was disgusted, I was horrified. There were about ten women in the same situation as I was. Everybody is taking it. I think that it is really very dangerous. The thing is, I'm very healthy. They made the curettage and I left, I ran away from the hospital.'
(Angela, age 37)

'...When I looked down, there was a little leg coming out. Then I called him, I told him to take it out. I didn't want to keep that thing. He looked for some scissors and cut. I don't even know what he did, I washed and left. I knew there would be problems because the placenta hadn't come out. I went to the hospital and the doctor said I had provoked an abortion. I insisted that I hadn't, that I had slept in a tight skirt and that when I woke up, this had happened. When I arrived, the doctor said: "It's an infected abortion, you can't go home, you risk having a haemorrhage and dying on the way. She insisted that I couldn't leave: You are a minor, unaccompanied, with an infected abortion. I can't let you leave" ...'
(Nilce, age 18)

'... I saw the doctor at the USP and he was angry with me and said: "Look, mother, you are pregnant, and we are here to take care of mothers who want children, not those who don't." So what could I do? I left and went home and just bled all night.'
(Sandra Lucia, age 34)

Generally speaking, most of the women interviewed were in favour of abortion as an important alternative for an unwanted pregnancy. However, the positive view they had had of Cytotec was destroyed, and most of them said they now thought curettage was a safer and more appropriate method, especially those who had already had a previous abortion, and including the low-income women.

Some of the women said that certain conditions of Cytotec use should be specified, for example, that it should be used only in the first month of pregnancy or only by adult women. In the case of adolescents, they recommended medical attendance. Some felt that it should not be taken alone at home by anyone.

The majority said they would not recommend Cytotec to other women, nor would they take it again themselves. Only four of them, the three who had had uneventful experiences and Sandra Lucia in spite of her negative experience, said they would take Cytotec again if necessary.

Data from Rio de Janeiro

The study in Rio referred to above [7] provides quantitative data that help to contextualise the individual experiences of the women we interviewed. That study examined 803 cases of induced abortion who were matched for age and parity with 803 women delivering to term from April to December 1991 in seven public hospitals in the city. Of those women with induced abortions, between 57 and 70 per cent used Cytotec alone or with another method.

Most (84 per cent) of the Cytotec users learned about the method from friends, relatives or colleagues, while 10 per cent heard about it from a pharmacist. Seventy per cent obtained the drug from a pharmacy but only about half of these were given advice there on how to use it.

For 25 per cent of the women, Cytotec was the only method they knew about. Eleven per cent had previously used it as an abortifacient. Twenty-eight per cent said they had chosen it because it was the most accessible method, 14 per cent because it was safer than other methods, and 13 per cent because it was the cheapest. Seventy-four per cent used it before 16 weeks of pregnancy and 8 per cent at 20 weeks or later.

Bleeding started within 12 hours of taking the drug for 52 per cent of the women and between 12-24 hours for 13 per cent. Nineteen per cent had to wait between 2 and 10 days, and 16 per cent for more than 10 days, including five women who waited for more than a month. The proportion reporting onset of bleeding within 12 hours increased with gestational age and among those who used the tablets both orally and vaginally rather than orally only.

Vaginal bleeding and uterine cramps were the most frequent reasons given for seeking hospital care (80 per cent and 78 per cent, respectively). Eight per cent reported vomiting and diarrhoea as the reason.

Of the 454 women who used Cytotec for whom information was recorded, only 4 per cent had complete abortion, 72 per cent had incomplete abortion, 21 per cent had threatened, inevitable or missed abortions, and 3 per cent were judged to be in premature labour. Eighty-five per cent needed curettage. Surprisingly, the proportion requiring curettage decreased significantly with duration of gestation, from 89 per cent at 12 weeks of pregnancy or less, to 50 per cent at 20 weeks and over. Morbidity among those who used Cytotec was substantial but less severe than among women who had catheter insertion or other invasive methods. (Table 2)

There were three deaths recorded among women who had reportedly used Cytotec, two from sepsis and one from ruptured uterus. The latter was 32 years old and was said by her sister to have used Cytotec at 16 weeks gestation in her second pregnancy.

Thirty-five per cent of the 803 controls delivering at term said that they had wanted to terminate their pregnancies; 18 per cent had made attempts and of these, 6 per cent had taken Cytotec unsuccessfully. Another 5 per cent reported taking an abortifacient drug that they could not identify, which could have been Cytotec, so the exposure rate could have been as high as 11 per cent. [7]

Discussion

Public discussion about Cytotec has virtually stopped. The Ministry of Health said that the measures taken in July 1991 would be re-discussed after six months but nothing has happened. Not surprisingly, they prefer to 'forget it'. In one sense, this may be better, because at least the drug has not been banned totally. However, we have the impression that Biolab Laboratories are no longer interested in Cytotec and may further reduce availability of the drug in Brazil. This will put pressure on the black market and make the drug even less accessible and more expensive than it has probably become already.

Recently, the state of Ceará and the Ministry of Health showed themselves to be very efficient in banning another drug which women in Ceará were starting to use to provoke abortion after Cytotec was banned. This drug has the brand name Dicorantil (Sarsa Laboratories) and is indicated for cardiological problems. One woman who used it as an abortifacient is known to have died. Unlike with Cytotec, abortifacient use of this drug apparently carries a high risk of death. Information about this situation was made public by the Group for the Prevention of Improper Use of Medicines, the same group whose study of Cytotec in Ceará in 1990 led to its banning there.

Women's experience with Cytotec in the clandestine context of Brazil illustrates the extent of the lack of information, help and other resources that women need to deal with the abortion process in a safer and less traumatic way. It also indicates that when faced with unsafe options only, women will choose overwhelmingly for the least unsafe method available.

Further, it reveals the enormous unmet need for abortion in Brazil. The Rio study showed that many women who carried their pregnancies to term did not want them, and that a substantial proportion of these women had attempted to abort but were unsuccessful. Studies in Fortaleza support this. [6,8]

When Cytotec was freely available, more pregnant women may well have attempted to abort, as the campaigners against the drug alleged. This does not mean that the number of unwanted pregnancies increased, however. Instead, it means that the number of unwanted children who were born decreased, if only briefly.

Table 2. Morbidity from induced abortion reported in Rio (%)

* Of the 57 per cent, 45 per cent used Cytotec alone and 12 per cent with other methods. (Totals vary because information was not always recorded in the notes). 7

The biggest question is: what are Brazilian women, who would have tried to abort with Cytotec and can no longer get hold of it, doing about unwanted pregnancies now? For example, there was a decrease in the number of women attending hospital for abortion complications in Fortaleza after Cytotec was banned. [8] This implies that many have gone back to carrying their pregnancies to term.

We need more research to find out what is happening now with Cytotec in different parts of the country. Our own empirical observations indicate that some women are returning to the old methods to provoke abortions and are again experiencing more serious complications.

The uneventful experiences with Cytotec of three of the women we interviewed, in spite of the clandestine situation, are similar to those that women in France and other countries have had with the combined use of RU486 and prostaglandin. The negative experiences of the majority of the women we interviewed were almost all a direct consequence of the clandestine situation. The banning and restriction of Cytotec has not helped women, but has allowed the problems to continue and possibly made them worse.

Given the apparent willingness of more Brazilian gynaecologists to be involved with abortions induced by a non-invasive method, the ideal situation would be for RU486 to be introduced in Brazil for use with Cytotec, as it is being used in France. Given the unwillingness of Roussel Uclaf to release RU486 in any country with restrictive abortion legislation, this is clearly impossible. At the least, women need to be given accurate information about induced abortion, including about the use of Cytotec.

In the meantime, many more women in the women's health movement are beginning to organise politically around the issue of abortion in Latin America. In this context, doctors and feminists need to work more closely together. If Brazilian gynaecologists had been willing to speak out and admit that they were involved with the use of Cytotec, perhaps the situation would be different today.

As it is, we do not see the situation in Brazil changing soon. What we see is that many women are carrying unwanted pregnancies to term because they have no choice, and that others -- in spite of the illegality of abortion and with different degrees of success -- are trying to find ways to terminate unwanted pregnancies safely and to exercise their right to decide whether and when to have children.

Note

An earlier version of this article appeared under the title 'The Brazilian experience with Cytotec' in the July/August 1993 issue of Studies in Family Planning, 24(4):236-240. Information from the study in Rio de Janeiro is included with the kind permission of The Lancet.

References and notes

1. Re Mexico and Venezuela: Personal communication from a feminist doctor in Mexico. Re Barbados: 'Cytotec in the Caribbean'. Women's Health Journal. 1993; 2:37.
2. Data from Biolab Laboratories, 1993.
3. Faúndes, Anibal et al, 1992. Aborto provocado no contexto da Assistência Integral à Saúde da Mulher. CEMICAMP (Centro de Pesquisas e Controle das Doenças Materno-Infantis de Campinas). Campinas. (Mimeo)
4. The law in Brazil permits abortion only when the mother's life is in danger or when the pregnancy is the result of proven rape or incest. However, practically no legal abortions were performed in Brazilian hospitals until 1991, when Maria José Araujo de Oliveira, the then Director of Women's Health of the São Paulo Health Department, finally convinced one hospital in São Paulo to begin providing legal abortions within the terms of the existing law. This was after two years of trying to convince all the hospitals in the city to do this.
5. Laurenti, R, 1988. Mortalidade de mulheres de 10 a 49 anos no município de São Paulo, com enfase na mortalidade materna. CBDC/PAHO, São Paulo. (Mimeo)
6. Barros, J A C, 1991. A medicalizaçao da mulher no Brasil, O Marketing da Fertilidade. Ed. I Wolffers et al. Hucitec, São Paulo.
7. Costa, Sarah H and Vessey, Martin P, 1993. Misoprostol and illegal abortion in Rio de Janeiro, Brazil. Lancet. 341:1258-61.
8. Coêlho, Helena Lutéscia Luna et al, 1993. Misoprostol and illegal abortion in Fortaleza, Brazil. Lancet. 341:1261-63.

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