Awareness of medication abortion is almost universal among obstetrician-gynecologists in Guatemala, but far smaller proportions know the recommended regimens or have adequate knowledge of the country’s abortion laws.1 More than 90% of the obstetrician-gynecologists who participated in a national study had heard of misoprostol, but just 22–35% knew the dosages required to induce abortion at particular gestational ages. Moreover, although 73% knew that abortion is legal in Guatemala when a woman’s life is in danger, 24–28% mistakenly believed that it is also permitted when a woman’s health is at risk or in cases of fetal anomaly.

Because of Guatemala’s restrictive abortion law—pregnancy termination is legal only to save a woman’s life—as well as the stigma surrounding the procedure, women trying to obtain an abortion often use illegal providers, and unsafe abortion has been the country’s fourth leading cause of maternal death for the past decade. Moreover, one of the two drugs typically used for medication abortion (mifepristone) is unavailable in Guatemala, and the other (misoprostol) is not officially indicated for abortion. Obstetrician-gynecologists have played a key role in introducing and expanding the use of reproductive health services in other countries; to explore whether practi-tioners are in a position to play a similar role in Guatemala, the current study examined providers’ knowledge of and attitudes toward medication abortion.

All members of the Guatemalan Society of Gynecologists and Obstetricians who worked in private practice were recruited for the survey from February to August 2010; nonmember colleagues working at the same sites were also invited to participate. Participants completed a multiple-choice questionnaire that asked about their social, demographic and professional characteristics and assessed their knowledge of medication abortion and its legality; the survey also included questions about their approval of this type of abortion under certain circumstances, such as anembryonic pregnancy (a pregnancy in which the fertilized egg does not develop), severe eclampsia, or fetal anomaly or death. The response rate was 71%. In addition to calculating descriptive statistics, the researchers conducted a multivariate regression analysis to identify provider characteristics associated with approval of certain uses of medication abortion.

Most of the 172 respondents were male (82%) and married (81%), and about half had at least three children and were aged 50 or older (47% each). Three-fifths had at least 20 years of medical experience (61%).

Almost all of the obstetrician-gynecologists knew of misoprostol (92%). However, only small proportions knew what dosages were recommended for abortions administered at less than nine weeks’ gestation (22%) or less than 12 weeks’ gestation (35%), and just one-quarter (25%) had heard of mifepristone. The vast majority of respondents knew that a woman could not obtain a legal abortion solely because she was a rape victim, poor, unmarried or younger than 18 (82–99%). More than seven in 10 providers (73%) knew that abortion performed to preserve a woman’s life is legal in Guatemala, but one in four mistakenly thought it was allowed in cases of severe fetal anomaly (24%) or maternal health endangerment (28%).

Overall, 69% of respondents said they would use misoprostol and mifepristone, if available, to perform legal terminations. However, support of administering these medications in particular cases varied. Nearly nine in 10 (88%) said that they approved of medication abortion in cases of anembryonic pregnancy or of fetal death before 20 weeks’ gestation, while smaller proportions (63–65%) approved of this option before 20 weeks’ gestation if the fetus had multiple severe anomalies or was anencephalic (missing a major part of the brain).

In logistic regression analyses, a provider’s age and number of children were associated with approval of medication abortion in selected instances. The odds of approval in cases of severe eclampsia and fetal death were greater among physicians aged 40–49 than among older providers (odds ratio, 2.0), and greater among respondents who had one or more children than among those who had none (2.2–2.3). Respondents aged 39 or younger were far more likely than those older than 49 to approve of medication abortion when women without eclampsia had a fetal death before 20 weeks’ gestation (6.7). Finally, compared with childless providers, those with one or two children had elevated odds of approving of the procedure for a woman carrying a fetus with anencephaly (2.6).

The investigator acknowledges several study limitations. Providers who declined to participate may have differed from those in the sample. Furthermore, the survey included questions about mifepristone, which is not available in Guatemala, and about medication abortions performed at gestations that differed from those described in World Health Organization guidelines. Nonetheless, given the generally low acceptability of abortion in Guatemala, the researcher notes, it is encouraging that younger providers were more willing than their older peers to consider administering medication for abortion. In addition, if maternal morbidity and mortality are to be lowered, he concludes, Guatemalan obstetrician-gynecologists should make it "a professional and ethical imperative" to augment their skills and increase women’s access to services.

–S. Ramashwar

REFERENCE

1. Kestler E, Obstetrician-gynecologists’ knowledge of and attitudes toward medical abortion in Guatemala, International Journal of Gynecology and Obstetrics, 2012, 116(2):120–123.