Dr. Nelson Soucasaux, Brazilian gynecologist
Despite its amazing technological and scientific progress, from the cultural, social and political standpoints Brazil continues to be a country "underdeveloped by conviction" - as I used to say when I was still a young adult, at the end of the 60's and beginning of the 70's. Now I'm 56 and the situation hasn't changed very much. Brazil is a country that doesn't recognize some of the most elementary individual rights and, among them, women's rights to their own bodies (despite a shameful and increasing growth of "populism" and demagogy).
Regarding the recognition of women's right to abortion in most European countries, the U.S.A. and Canada, abortion tragically remains radically prohibited in Brazil (except in very few situations). Even so, fortunately, there are and there have always been lots of clandestine abortion clinics where all women who can afford the cost of the procedure can safely have an abortion within correct medical and technical standards. But disgracefully not according to the present-day preferential method - which is, as almost all well-informed people in Europe and North America know -, medicinal abortion by making use of the mifepristone-misoprostol association (mostly along the first 7 or even up to 9 weeks of pregnancy).
As far as I know as a gynecologist who has always struggled for the recognition of women's right to abortion in cases of unwanted pregnancies (see Note 1, below) and who constantly deals with the problem, the few clandestine abortion clinics I have noticed tragically insist on practicing the old, outdated and invasive surgical method (intra-uterine vacuum-aspiration under slight general anesthesia). To find a place that makes use of the modern mifepristone-misoprostol association has been impossible - at least up to this moment, and I live and work in Rio de Janeiro. Needless to say, mifepristone and misoprostol are forbidden in Brazil.(see Note 2, below).
I know that here you might ask: if, despite the prohibition, clandestine abortion clinics do function in Brazil without major problems, why do they not make use of the modern medicinal abortion (since acquiring the medicines in Europe and North America must be an easy task)? Though I don't have the exact answer and don't want to accuse anybody, I do have strong reasons to suppose that Brazilian abortion clinics insist on the exclusive use of the old surgical procedure just for making more money - that is, for greed. Everybody knows that, regrettably, surgical procedures are always much more expensive than the clinical ones (though personally I fully disapprove of that difference and do think that surgeons charge extortionate prices for their work ). In this way, considering that even "well-informed" Brazilian women still ignore the existence of mifepristone and how it works (see Note 3, below) and that we live in a context in which abortion is not only illegal but also a taboo, it is quite understandable that, for abortion clinics that necessarily work clandestinely, it is very easy to continue using the surgical method. Sadly, it's much more profitable.
As here in Brazil the abortive effect of the anti-progesterone mifepristone associated with the prostaglandin-analog misoprostol is not publicly discussed - even in our ob-gyn journals !!! -, Brazilian women don't have the right to choose between a medicinal or a surgical abortion. The final result is that, here, in practice, the only way to safely get rid of an undesired pregnancy is to undergo the old instrumental, surgical abortion in a clandestine clinic. And all of this is the cruel outcome of a vicious circle involving non-recognition of women's rights to their bodies, stubborn insistence on criminalizing abortion plus intentional and official disinformation!
Of course, some ads of mifepristone and/or misoprostol can be found on the Web here, but there are several reasons to suspect that some of these medicines may be false or, at least, non-reliable. The same may happen to those directly sold in the black-market. Which ones of them are real? Which are fakes? How can we know? And I'm informed that the same thing happens all over the world, even in countries where abortion is legal!
The efficacy and safety of medicinal abortion was established worldwide approximately 10 years ago after a very long period of careful research and experimentation. For decades and up until that time, the only way a woman had for having an abortion in the first trimester was uterine vacuum-aspiration, and the advent of vacuum-aspiration was preceded by many, many decades of uterine curettage, which was by far much more aggressive and risky than aspiration.
Though being invasive and implying some risks - as all surgical medical procedures -, uterine vacuum-aspiration is safe whenever well-performed by experiencd doctors. But the advent of medicinal abortion with the mifepristone-misoprostol association brought about the greatest and the most important shift in the abortion techniques. Now, in the first 7 or even up to 9 weeks of pregnancy women can have an abortion with 90-95% of success only by taking these medicines. Despite some unpleasant side-effects easily controlled with symptomatic medication (see Note 3, below), the whole thing became incomparably much easier, safer and less-aggressive. Women no longer have to undergo an intra-uterine procedure under general anesthesia for having an abortion in the first 7 to 9 weeks of gestation (except for the 5-10 percent of cases in which medicinal abortion fails and has to be completed by vacuum-aspiration ).
But pathetically it is just here, in Brazil, one of the countries where abortion remains forbidden, that all the advances and benefits of medicinal abortion are not easily and safely available to women. To my view, here lies the present-day drama regarding the abortion issue in Brazil. As I said before and as far as I know, the few clandestine abortion clinics which I have noticed only make use of the outdated uterine vacuum-aspiration and, though I cannot prove it, I believe they insist on doing that for making more money with the surgical procedure. (Though there is also the argument that, as medicinal abortion demands that patients go to the clinic at least 3 times and everything here has to be hidden, clandestine abortion clinics may prefer the instrumental method because it requires only one "session" with 100 percent efficacy.)
Besides all of this and as I also observed, attempts to acquire mifepristone and misoprostol on the black-market may be very risky, due to the high possibility of the use of fake or non-reliable products.
So, just in our era of current use of medicinal abortion, that's how I can describe and denounce the entirely absurd, cruel and pathetic situation faced by almost all Brazilian women who presently need to have an abortion. And, to make things worse, only a few of these women know about that! (They do know about misoprostol, but ignore mifepristone.)
As in the still recent past the only medically existing abortion method was uterine vacuum-aspiration, all we had to do as gynecologists was provide the patients with all medical and psychological support and recommend that they seek a safe clandestine abortion clinic. But now that women finally have the much better option of medicinal abortion, it is revolting and heart-breaking that, due to the apparent absence of clinics offering medicinal abortion and the difficulty of acquiring safe and reliable mifepristone and misoprostol within a context in which abortion remains illegal and treated as a case for police, patients still have to clandestinely undergo the outdated surgical procedure.
Note 1: As to my point of view regarding abortion in general, see my articles (in English) "Undesired Pregnancies and Women's Right to Abortion" (http://www.nelsonginecologia.med.br/womenrightabort_engl.htm) and "The Possibility of Becoming Pregnant and its Implications for Women" ( http://www.nelsonginecologia.med.br/possibengrav_engl.htm ), both excerpts from my book "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology"). These articles are also published here, at the MUM.
Note 2: Regarding misoprostol, since it can be used in obstetrics for the induction of labor, it is officially available in Brazil but only for use in hospitals. It is not sold in drugstores. So, here women only can acquire misoprostol (Cytotec) on the black market. Nevertheless, the use of misoprostol alone for medicinal abortion requires very high doses, resulting in stronger side-effects and, over and above all, very often fails in producing a complete abortion.
Note 3: Mifepristone, originally produced in France in 1980 under the name Ru-486, is a potent anti-progesterone. As progesterone is the main hormone responsible for the maintenance of pregnancy, the use of a single dose of mifepristone interrupts pregnancy by antagonizing progesterone's effect. Nevertheless, even causing the death of the egg, mifepristone alone rarely completes the abortion. So the process has to be completed with the use of misoprostol. As a prostaglandin-analog, misoprostol causes strong uterine contractions which, together with an also induced heavy bleeding, finally expels the egg and completes the abortion. The side-effects of medicinal abortion are not serious and are due to misoprostol's action. Basically they consist of strong uterine cramps (treated with analgesics) and intense bleeding. Nausea, vomiting, diarrhea and headache are also reported, only requiring symptomatic medication. Usually women consider these symptoms entirely tolerable and prefer to have a medicinal abortion than a surgical one.
P.S.: As this article is much more political than medical and intends to denounce to the world the present-day situation existing in the country where unfortunately I live and practice gynecology, I want to make it clear that the responsibility for it is exclusively mine. This article expresses my opinion, and not necessarily that of the MUM.
Copyright Nelson Soucasaux 2007
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Nelson Soucasaux is a gynecologist dedicated to clinical, preventive and psychosomatic gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade Federal do Rio de Janeiro, Brazil, he is the author of several articles published in medical journals and of the books "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") and "Os Órgãos Sexuais Femininos: Forma, Função, Símbolo e Arquétipo" ("The Female Sexual Organs: Shape, Function, Symbol and Archetype"), published by Imago Editora, Rio de Janeiro, 1990, 1993. He has been working in his private clinic since 1975.
Web site (Portuguese-English): www.nelsonginecologia.med.br
Email: [email protected]