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Objective To evaluate whether continuation rates with the 52-mg levonorgestrelreleasing intrauterine system (LNG-IUS) up to 5 years after placement differed between women using the method exclusively for contraception and those using the device for medical reasons alone. Methods A retrospective cohort study was conducted in a family planning clinic with 5,034 LNG-IUS users: 4,287 using the method exclusively for contraception and 747 for medical reasons alone. The continuation rate at 1 to 5 years of use was calculated by life table analysis. Results Initially, the continuation rate was significantly higher in the contraception group: 85.8 versus 83.4 and 77.4 versus 76.0 per 100 women-years in the 1st and 2nd years of use, respectively. There were more discontinuations due to bleeding/spotting in the medical reasons group in the first two years. The discontinuation rate according to reason for use was not significantly different from the third to the fifth year of use. No women discontinued due to amenorrhea in either group. Conclusion The continuation rate was significantly higher in the contraception group in the first two years of use. Amenorrhea was not a reason for discontinuation in either group, suggesting that counselling in this respect was adequate. Nevertheless, counselling could perhaps have been better with regards to the expected long period of bleeding and spotting in the first two years after placement. Resumo Objetivo Avaliar a taxa de continuação até 5 anos de uso do sistema intrauterino liberador de 52-mg levonorgestrel por dia (SIU LNG) -IUS) é diferente entre mulheres que o usam exclusivamente como anticoncepcional que entre as que usam exclusivamente por razões médicas. Métodos Estudo retrospectivo realizado em uma clínica de Planejamento Familiar 5.034 usuárias de SIU LNG, 4.287 que optaram pelo método apenas como anticoncepcional e 747 que o usavamsomente por razoesmédicas. A taxa de continuação de um até cinco ano foi calculada por meio de análise de tabela de vida Resultados No início a taxa de continuação foi significativamente maior no grupo da anticoncepção: 85,8 versus 83,4 e 77,4 versus 76,0 por 100 anos-mulher no 1° e 2° ano de uso, respectivamente. Houve mais descontinuações por sangrado-manchado no grupo de razões médicas nos dos primeiros anos. A taxa de continuação não foi significativamente diferente desde o terceiro até o quinto ano de uso. Nenhuma mulher de ambos os grupos descontinuou por amenorreia. Conclusão A taxa de continuação foi significativamente maior no grupo de anticoncepção durante os dos primeiros anos de uso. Amenorreia não foi motivo de descontinuação em ambos os grupos, sugerindo que a orientação a esse respeito foi adequada. Entretanto, a orientação referente ao longo período de sangramentos irregulares nos dois primeiros anos após a inserção, precisaria ser melhorado.

Objectives: Sexual violence is a problem that affects children and adolescents regardless of social class, age, origin, religion, education level, marital status, race, or sexual orientation. This study aimed to analyze the associations between victim-offender relationships and the victim's age in cases of sexual violence involving female victims. Methods: This cross-sectional, retrospective observational study used data from the Brazilian Ministry of Health’s Department of Public Health Surveillance in Brasília regarding the reportable crime of rape as informed by female victims in the Federal District between January 1, 2012, and December 31, 2018. The age of the victim was classified as

Objective To find out which was the opinion of residents in obstetrics and gynecology about the advantages and disadvantages of medical abortion as compared with surgical procedures. Method Cross-sectional multicenter study among residents in obstetrics and gynecology from 21 maternity hospitals located in 4 different geographical regions of Brazil, using a self-responded questionnaire with 31 questions related to their opinion and experience on providing abortion services. Results Most residents agreed that “being less invasive” (94.7%), “does not require anesthesia” (89.7%), “can be accompanied during the process” (89.1%), “prevents physical trauma” (84.4%) were the main advantages of medical abortion. Conclusion Residents perceived both clinical and personal issues as advantages of medical abortion. Resumo Objetivo Descobrir qual foi a opinião dos residentes em ginecologia e obstetrícia sobre as vantagens e desvantagens do aborto medicamentoso em relação aos procedimentos cirúrgicos. Métodos Estudo multicêntrico transversal entre residentes de ginecologia e obstetrícia de 21 maternidades localizadas em 4 diferentes regiões geográficas do Brasil, utilizando um questionário autorrespondido com 31 questões relacionadas à sua opinião e experiência na prestação de serviços de aborto. Resultados A maioria dos residentes concordou que "ser menos invasivo" (94,7%), "não necessitar de anestesia" (89,7%), "poder ser acompanhado durante o processo" (89,1%), "prevenir trauma físico" (84,4%) foram as principais vantagens do aborto medicamentoso. Conclusão Os residentes perceberam tanto questões clínicas como pessoais como sendo vantagens do aborto medicamentoso.

Buscou-se identificar o grau de adesão dos hospitais de referência ao Protocolo de atendimento às mulheres em situação de violência sexual no Paraná-Brasil, entre 2009 e 2015, associando aos perfis sociodemográficos e às categorias de adesão. Estudo observacional transversal, população composta por todas as mulheres em situação de violência sexual, atendidas por 28 Hospitais do Paraná. Analisaram-se dez itens sobre a taxa de adesão: desde o acolhimento, profilaxias, até encaminhamentos posteriores ao trauma. Encontrou-se que todos os Hospitais fizeram o atendimento agudo às mulheres: 50% aderiram às Profilaxias ISTs, AIDS e hepatites, coletas de secreção e exames sanguíneos; 63% ofereceram contracepção de emergência; 69% encaminharam para acompanhamento ambulatorial. Houve associação entre idade, etnia, escolaridade e estado civil com melhores taxas de adesão ao Protocolo. Entendeu-se que Hospitais de referência se preocupam com atendimentos agudos, mas não aderem integralmente às medidas profiláticas, multidisciplinares e continuadas.

FIGO established a Working Group on the Prevention of Unsafe Abortion in 2007 and a parallel program or "Initiative" with the same name. The initiative involved 46 FIGO member societies from seven regions: South-Southeast Asia, Eastern-Central Europe and Central Asia, North Africa and Eastern Mediterranean, Eastern-Central-Southern Africa, Western-Central Africa, Central America and Caribbean, and South America. Each society working in collaboration with the corresponding Ministry of Health and other agencies conducted a situational analysis and prepared a plan of action based on the findings. Such plans of action are continuously monitored by annual evaluation of the progress in the implementation at regional workshops. A substantial progress has been achieved in providing legal and safe abortion services, replacing curettage for manual vacuum aspiration or misoprostol and introducing and expanding postabortion contraception with emphasis on long-acting methods, such as IUDs and contraceptive implants.

Global leadership from donors and international professional associations has enabled postabortion family planning services to be scaled up worldwide through preservice education, clinical service delivery, and global health programming.

Esta revisión no sistemática de la literatura tuvo como objetivo describir los cambios que se han producido en la práctica del parto por cesárea desde la antigüedad hasta la actualidad y evaluar las consecuencias de estos cambios para la mujer y para su hijo recién nacido. En la antigüedad, el parto por cesárea solo se realizaba post mortem o perimortem para preservar la vida del feto o para separarlo de su madre muerta. Actualmente, este método de parto es ampliamente utilizado no solo teniendo una indicación médica adecuada, sino también para adaptarse a la comodidad de la mujer embarazada y/o la de su obstetra. Dicha conducta, que ha llevado a un número creciente de procedimientos electivos, puede tener consecuencias negativas para la mujer y para su bebé. Este impacto negativo es contrario a lo esperado cuando la cesárea es indicada correctamente, cuando este procedimiento es un factor importante en salvar la vida de la madre y de su hijo recién nacido.

As many articles in Supplement issue highlight, the topic of “abortion” is extremely controversial and causes reactions rooted in religious, moral, philosophical, legal, health and human rights perspectives. The word abortion carries a heavy stigma that leads people to seek to avoid being connected with it. This essential issue of stigma is presented in many of the articles included in this Supplement. Part of the articles presented in this Thematic Section refer to the situation in some countries in the region, especially Argentina, Uruguay, Brazil and Colombia, as examples of countries in which there is greater or lesser progress in access to safe abortion, but also El Salvador, as an extreme example of restriction and intolerance toward abortion. The articles further describe the cases of European countries that recently changed their legislation, such as Portugal and Ireland.

O aborto medicamentoso ou farmacológico tem demonstrado ser um meio eficaz para a interrupção da gravidez. Entretanto, o treinamento de provedores no uso do misoprostol tem sido limitado. O presente artigo tem como objetivo identificar o grau de conhecimento dos médicos residentes em Ginecologia e Obstetrícia sobre aborto medicamentoso. Realizou-se um estudo transversal multicêntrico com residentes regularmente inscritos no programa de residência em Ginecologia e Obstetrícia de vinte e um hospitais de ensino. Foi utilizado um questionário de autorresposta. As respostas corretas a cada uma das alternativas foram identificadas e uma variável de resposta binária (≥ P70, < P70) foi definida pelo percentil 70 do número de perguntas sobre o misoprostol. Quatrocentos e sete médicos residentes devolveram o questionário, sendo que 404 estavam preenchidos e três em branco. A maioria (56,3%) dos residentes tinha até 27 anos de idade, era do sexo feminino (81,1%) e não vivia junto com um(a) companheiro(a) (70%). A maior proporção (68,2%) estava cursando o primeiro ou segundo ano da residência. Apenas 40,8% dos participantes acertaram 70% ou mais das afirmativas. Na análise múltipla, cursar o terceiro ano de residência ou superior (OR = 2,18; IC95%: 1,350-3,535) e ter participado do atendimento a uma mulher com abortamento induzido ou provavelmente induzido (OR = 4,12; IC95%: 1,761-9,621) mostraram-se associados a um maior conhecimento sobre o tema. Entre os médicos brasileiros residentes em Ginecologia e Obstetrícia, o conhecimento sobre o aborto medicamentoso é muito reduzido e constitui um obstáculo para o bom atendimento dos casos de interrupção legal da gestação. El aborto con medicamentos o farmacológico ha demostrado ser un medio eficaz para la interrupción del embarazo. No obstante, la capacitación de los médicos en el uso del misoprostol ha sido limitada. El objetivo de este artículo es identificar el grado de conocimiento de los médicos residentes en Ginecología y Obstetricia sobre el aborto con medicamentos. Se realizó un estudio transversal multicéntrico con residentes regularmente inscritos en el programa de residencia en Ginecología y Obstetricia de veintiún hospitales de enseñanza. Se utilizó un cuestionario de autorrespuesta. Las respuestas correctas de cada una de las alternativas fueron identificadas y una variable de respuesta binaria (≥ P70, < P70) se definió por el percentil 70 del número de preguntas sobre el misoprostol. Cuatrocientos siete médicos residentes devolvieron el cuestionario, siendo que 404 estaban cumplimentados y tres en blanco. La mayoría (56,3%) de los residentes tenía hasta 27 años de edad, eran de sexo femenino (81,1%); no vivía junto a un(a) compañero(a) (70%). La mayor proporción (68,2%) estaba cursando el primero o segundo año de residencia. Solamente un 40,8% de los participantes acertaron un 70% o más de las afirmaciones. En el análisis múltiple, estar en el tercer año de residencia o superior (OR = 2,18; IC95%: 1,350-3,535) y haber estado implicado en la atención a una mujer con aborto inducido o probablemente inducido (OR = 4,12; IC95%: 1,761-9,621) se mostraron asociados a un mayor conocimiento sobre el tema. Entre los médicos brasileños residentes en Ginecología y Obstetricia, el conocimiento sobre aborto con medicamentos es muy reducido y constituye en obstáculo para una buena atención de los casos de interrupción legal de la gestación. Medical or drug-induced abortion has been proven as an effective means for termination of pregnancy. However, training of providers in the use of misoprostol has been limited. The current article aims to identify the degree of knowledge on medical abortion among Brazilian medical residents in Gynecology and Obstetrics. A multicenter cross-sectional study was performed with residents regularly enrolled in residency programs in Gynecology and Obstetrics in 21 teaching hospitals. A self-responded questionnaire was used. Correct responses to each of the alternatives were identified, and a binary response variable (≥ P70, < P70) was defined by the 70th percentile of the number of questions on misoprostol. Four hundred and seven medical residents returned the questionnaire, of which 404 were completed and three were blank. The majority (56.3%) of the residents were 27 years or younger, females (81.1%), and single or not living with a partner (70%). Two-thirds (68.2%) were in the first or second year of residency. Only 40.8% of the participants answered 70% or more of the questions correctly. In the multivariate analysis, enrollment in the third year of residency or greater (OR = 2.18; 95%CI: 1.350-3.535) and having participated in treatment of a woman with induced or probably induced abortion (OR = 4.12; 95%CI: 1.761-9.621) were associated with better knowledge on the subject. Among Brazilian medical residents in Gynecology and Obstetrics, knowledge on medical abortion is very limited and poses an obstacle to proper care in cases of legal termination of pregnancy.

Purpose: To investigate the opinions of Brazilian medical residents in Obstetrics and Gynaecology on abortion legislation according to their personal beliefs.Material and methods: A multicentre cross-sectional study. Residents at 21 university teaching hospitals completed a self-report questionnaire on their opinions in abstract terms, and about punishing women who abort in general and women they know.Results: In abstract terms, 8% favoured allowing abortion under any circumstances (fully liberal); 36% under socioeconomic or psychological constraints (broadly liberal); 75.3% opposed punishing a woman who has aborted (liberal in general practice); and 90.2% opposed punishing women they knew personally (liberal in personal practice). Not having a stable partner and not being influenced by religion were factors associated with liberal opinions. In personal practice, however, 80% of those who are influenced by religion were liberal. The percentage of respondents whose opinions were liberal was significantly greater among those who believed that abortion rates would remain the same or decrease following liberalisation.Conclusions: Judgements regarding the penalisation of women who abort are strongly influenced by how close the respondent is to the problem. Accurate information on abortion needs to be provided. Although about one third of the respondents were broadly liberal, the majority oppose punishment.

OBJECTIVE To evaluate residents' knowledge about the evolution of abortion rates in countries where abortion has been legalized, and to assess whether such knowledge correlates with residents' sociodemographic characteristics and experience in abortion care. METHODS A multicenter, cross-sectional study was conducted in 21 Brazilian hospitals with 404 medical residents in obstetrics and gynecology. Data collection occurred during February 2015 through January 2016. Data were collected through a self-administered, anonymous questionnaire. The χ2 test, Fisher exact test, and multiple logistic regression analysis were performed. RESULTS Of residents, 60% believed that the abortion rate would increase after legalization; 82% had been involved in the care of women with incomplete abortion and 71% in the care of women admitted for legal abortion. Associations were found between knowledge of the evolution of the abortion rate after legalization and region of birth, region of medical school, and importance attached to religion. Multiple regression confirmed that studying medicine in the south/southeast of Brazil and attaching little importance to religion were associated with knowing that legalization does not lead to an increase in abortion rate. CONCLUSION Information relating to abortion in medical schools and during residency is very limited and should be improved.

Approximately 47 000 women die each year worldwide as a result of the complications of unsafe abortion, almost exclusively in low- and middle-income countries with restrictive abortion laws. In these countries, very few women who comply with the conditions imposed by the law can access safe abortion services in the public health system. The main obstacle is the unwillingness of gynecologists and obstetricians to provide abortion services by claiming conscientious objection, which is often used to hide their fear of the stigma associated with abortion. This happens because many colleagues are unaware that without access to legal services these women will resort to an unsafe abortion and its consequences. This violates the statement from FIGO's Committee for the Ethical Aspects of Human Reproduction and Women's Health, which asserts that: "The primary conscientious duty of obstetrician-gynecologists is at all times to treat, or provide benefit and prevent harm, to the patients for whose care they are responsible. Any conscientious objection to treating a patient is secondary to this primary duty."

The opinions of Brazilian women regarding vaginal delivery and cesarean sections was studied.Six hundred and fifty-six women who had given birth in seven hospitals in São Paulo and Pernambuco, using the Public Health Service, were interviewed. The opinions of women who had delivered only by cesarean section was compared with those of women who had had at least one vaginal delivery.Significantly more women who had experienced at least one vaginal delivery considered this to be the best way of giving birth (90.4% vs. 75.9% among C-section-only women). Similar proportions in both groups (45.5% and 42.8%) stated that vaginal labor is better because it causes less pain and suffering for the woman. Significantly more women who had experienced a vaginal labor (47.1% vs. 30.3%) reported that it had no disadvantage. More women who had only had cesarean sections referred not having contractions/pain as an advantage of this method (56.7% vs. 41.7%).Apparently, pain and women's perception of pain were the characteristics which differentiated women with history of vaginal delivery from those with cesarean sections in the sample studied. However, the opinion that vaginal delivery is better than cesarean section was expressed independently of the recognition that pain could be its main disadvantage.

OBJETIVO: Avaliar a proporção de serviços de saúde (SSs) que preenchem a notificação compulsória e quais os principais obstáculos para o preenchimento de tal documento. MÉTODOS: Realizou-se um estudo com abordagem mista. Para a abordagem quantitativa, foi realizado um estudo de corte transversal, com coleta de dados por telefone. Foram identificados 291 SSs no Estado de São Paulo que referiam dar atendimento a mulheres que sofrem violência sexual. A amostra foi composta por 172 serviços que referiram prestar atendimento de emergência às mulheres. Na abordagem qualitativa realizaram-se estudos de casos, com amostra intencional e de conveniência. Foram escolhidos seis municípios, nos quais foram entrevistados profissionais de dois SSs. Realizaram-se 45 entrevistas semiestruturadas. Para os dados quantitativos, realizou-se uma análise descritiva simples. Para os dados qualitativos, realizou-se análise temática do conteúdo das entrevistas. RESULTADOS: A proporção de serviços que referiram sempre preencher a ficha de notificação em casos de violência sexual foi de 79,1%. Mais da metade (53,5%) referiu dificuldades relativas às mulheres atendidas, um terço referiu motivos referentes à ficha e 29,7% reportaram dificuldades relacionadas aos profissionais. Na etapa qualitativa, as dificuldades mais referidas foram o tamanho da ficha, os problemas para se obter as informações da mulher e a dificuldade do profissional em obter essas informações. CONCLUSÃO: Embora a maior parte dos SSs tenha referido preencher a ficha de notificação compulsória, mencionou também várias dificuldades para fazê-lo, especialmente relacionadas à sobrecarga de trabalho dos profissionais e à incompreensão acerca da importância dessa notificação no contexto da atenção integral às mulheres que sofrem violência sexual. OBJECTIVE: To evaluate the proportion of health services that fill out the compulsory notification and what the main difficulties to fill it out are. METHODS: A study was carried out with two different approaches. For the quantitative approach, a cross sectional study was performed, with telephone data collection. In the state of São Paulo, 291 health services that had reported providing care to women who suffer from sexual violence were identified. The sample was composed of 172 services that reported providing emergency care to women. In the qualitative approach, case studies were conducted. Six cities were chosen by intention and convenience. For each of them, professionals from two health services were invited to participate. Forty-five semi-structured interviews were conducted. For quantitative data, a descriptive analysis was carried out. For qualitative data, a thematic analysis of content was performed. RESULTS: The proportion of health services which reported always filling out the notification in cases of sexual violence was 79.1%. More than half (53.5%) reported difficulties concerning the assisted women, one third reported reasons related to the form, and 29.7%, to the professionals. In the qualitative approach, the main difficulties were the size of the form, the problems to obtain the information about the woman and the difficulty for the professional to obtain this information. CONCLUSION: Although most health services claimed to fill out the compulsory notification, they also mentioned several difficulties to do so, especially with regard to the workload of professionals and the misunderstanding about the importance of the notification in the context of comprehensive care to women who suffer from sexual violence.

Objective To evaluate long-acting reversible contraceptive (LARC) uptake immediately after abortion at Lusaka University Teaching Hospital, Zambia in the period following an intervention to increase the acceptance of LARC. Methods The present retrospective, observational study reviewed the clinical records of all patients admitted to the Lusaka University Teaching Hospital for an incomplete abortion or for a legal induced abortion between January 1 and December 31, 2016. The primary outcome measure was the proportion of adult women (aged 20-44 years) and adolescents (aged 10-19 years) who were already using an available contraceptive method at the time of hospital discharge. Contraceptive use was compared with historical data from the same institution before the intervention to increase LARC acceptance was performed. Results Data from 3858 patients (587 adolescents and 3271 adults) were included. LARC use was recorded among 108 (18.4%) and 409 (12.5%) adolescents and adults, respectively. This compared with rates from 2011 of less than 1% and less than 4%, respectively. Conclusion The rate of LARC use at discharge following incomplete or induced abortion had increased when compared with historical control data from before the intervention program was performed; however, there remains room for improvement.

To determine the association between mode of delivery and maternal complications in patients with severe preeclampsia.A prospective cohort study was conducted with 500 pregnant women with severe preeclampsia. The mode of delivery, vaginal or caesarean section, was considered the exposure, while the postpartum maternal complications and severe maternal morbidity were the outcomes. Logistic regression analysis was performed to determine the adjusted risk and 95% confidence intervals (95% CI) of maternal morbidity.Labour was spontaneous in 22.0% and induced in 28.2%, while 49.8% had an elective caesarean section. Ninety-five (67.4%) of the patients in whom labour was induced delivered vaginally. Total Caesarean rate was 68.2%. The risk of severe maternal morbidity was significantly greater in patients submitted to Caesarean section (54.0% versus 32.7%) irrespective of the presence of labour. Factors that remained associated with severe maternal morbidity following multivariate analysis were a diagnosis of HELLP syndrome after delivery (OR = 3.73; 95% CI: 1.55-9.88) and having a caesarean (OR = 1.91; 95% CI: 1.52-4.57).Caesareans are often performed in patients with severe preeclampsia and are associated with significant postpartum maternal morbidity. Induction of labour should be considered a feasible option in these patients.

Contraceptive vaginal rings (CVR) offer a new, effective contraceptive option, expanding the available choices of hormonal contraception. Various ring prototypes have been evaluated: progestin-only rings and combined progestin-estrogen rings, as well as different combination of progestins and estrogens. The progestin-only ring is intended for continuous use, whereas the combined ring has been designed for cyclic 3-week in/1-week out use, although several studies have explored alternative schemes of extended use. However, only two ring designs have reached the market: NuvaRing, a 1-month combined ring that releases etonogestrel and ethinylestradiol, and Progering, a 3-month progesterone-releasing ring for use in lactating women. A one year Nestorone/ethinyl estradiol CVR is approaching the final stages of development, as the Population Council is preparing to submit a new drug application to the Food and Drug Administration. The main advantages of CVRs are their effectiveness (similar or slightly better than the pill), ease of use without the need of remembering a daily routine, user ability to control initiation and discontinuation, nearly constant release rate allowing for lower doses, greater bioavailability and good cycle control with the combined ring, in comparison with oral contraceptives. Current prototypes in development include rings releasing progesterone receptor modulators, which would provide estrogen-free contraception, as well as combined rings releasing estradiol, instead of ethinyl-estradiol, providing a safer profile. Furthermore, intensive efforts towards developing dual protection rings, providing both contraception and protection against reproductive tract infections, offer hope that this greatly needed technology will soon undergo clinical testing and will be in the hands of women worldwide in the near future.

Unsafe abortions remain a major public health problem in countries with very restrictive abortion laws. In Brazil, parliamentarians - who have the power to change the law - are influenced by "public opinion", often obtained through surveys and opinion polls. This paper presents the findings from two studies. One was carried out in February-December 2010 among 1,660 public servants and the other in February-July 2011 with 874 medical students from three medical schools, both in São Paulo State, Brazil. Both groups of respondents were asked two sets of questions to obtain their opinion about abortion: 1) under which circumstances abortion should be permitted by law, and 2) whether or not women in general and women they knew who had had an abortion should be punished with prison, as Brazilian law mandates. The differences in their answers were enormous: the majority of respondents were against putting women who have had abortions in prison. Almost 60% of civil servants and 25% of medical students knew at least one woman who had had an illegal abortion; 85% of medical students and 83% of civil servants thought this person(s) should not be jailed. Brazilian parliamentarians who are currently reviewing a reform in the Penal Code need to have this information urgently.

The provision of abortion care represents a great ethical challenge to physicians, particularly in countries where the law states that abortion is a crime. The concept that it is a crime carries a stigma that is worse than that associated with other acts qualified by law as crimes. This stigma leads to at least two different kinds of unethical behavior. One is the refusal to provide safe abortion services to women who comply with the legal requirements, alleging conscientious objection, and the other is to discriminate against women with complications of induced abortion. Both unethical behaviors may be associated with severe consequences for the health of women whose care was refused or delayed. Less attention is given to the ethical obligation to prevent induced abortion from recurring by offering postabortion contraception to comply with the ethical obligation of preventing harm to the patients for whose care they are responsible.

Access to contraception reduces maternal deaths by preventing or delaying pregnancy in women who do not intend to be pregnant or those at higher risk of complications. However, not all unintended pregnancies can be prevented through increase in contraceptive use, and access to safe abortion is needed to prevent unsafe abortions. Despite not preventing the problem, provision of emergency care for complications can help prevent deaths from such unsafe abortions. Safe abortion in early pregnancy can be provided at primary care level and by non-physician providers, and the risks of mortality associated with such safe, legal abortions are minimal. Although entirely preventable, unsafe abortions continue to occur because of numerous barriers such as legal and policy restrictions, service delivery issues and provider attitudes to abortion stigma. Overall, the provision of contraception and safe abortion is important not just to prevent maternal deaths but as a measure of our ability to respect women's decisions and ensure that they have access to timely, evidence-based care that protects their health and human rights.

OBJECTIVES: the prevalence of gender and sexual violence, its association with gender and ethical attitudes and the experience of suffering and perpetration of violence were evaluated among students at a public university in Brazil. METHODS: a cross-sectional study analyzed the answers given by 2430 students to a questionnaire sent by internet. RESULTS: among girls, 56.3% had been subjected to some kind of violence and 9.4% to sexual violence since university admission; 29.9% of men reported having perpetrated some kind of violence, 11.4% gender and 3.3% sexual violence. Multivariate analysis showed that living with parents/relatives was a protective factor for women being subjected to and men perpetrating sexual violence but not for "any type of violence". Lower scores for ethical attitudes were associated with a greater likelihood of men perpetrating any kind of or gender violence. Student for whom religion was important had a lower risk of being a perpetrator of any type and of sexual violence, but not gender violence. CONCLUSIONS: the findings may be useful for the discussion of this problem and to propose interventions to prevent or minimize the problems of gender and sexual violence on campus. Further studies in other university contexts need to be carried out to increase knowledge and explore possibilities for intervention. OBJETIVOS: avaliar a prevalência de violência de gênero e sexual e sua associação com atitude de gênero e ética e a experiência de sofrer e perpetrar violência, entre alunos de uma universidade pública no Brasil. MÉTODOS: estudo transversal que analisou as respostas de 2430 alunos a um questionário enviado por internet. RESULTADOS: entre as alunas, 56,3% sofreram algum tipo de violência e 9,4% sofreram violência sexual desde seu ingresso na universidade; 29,9% dos homens declararam ter perpetrado algum tipo de violência; 11,4% violência de gênero e 3,3% violência sexual. Análise multivariada apontou que viver com pais/parentes foi um fator que protegeu as mulheres de sofrerem e os homens de perpetrarem violência sexual, mas não "qualquer tipo de violência". Baixa pontuação no escore de atitude em ética esteve associada a alta probabilidade dos homens perpetrarem "qualquer tipo de violência" e violência de gênero. Os alunos que davam importância à religião tiveram risco menor de serem perpetradores de "qualquer tipo de violência" e de violência sexual, mas não de violência de gênero. CONCLUSÕES: os achados podem ser úteis para a discussão desse problema e para propor intervenções para prevenir ou minimizar os problemas de violência de gênero e sexual no campus. Além disso, requerem-se mais pesquisas para ampliar o conhecimento e as possibilidades de intervenção.

The Zambian Association of Gynecology and Obstetrics is one of the International Federation of Gynecology and Obstetrics (FIGO) member societies participating in the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences from the East, Central, and Southern Africa region. The activities included in this country’s plan of action were to provide access to safe abortion within the full extent of the law to women receiving care at the University Teaching Hospital in Lusaka, and to increase the proportion of women leaving the hospital with a contraceptive method. Zambian law regarding abortion is liberal, but in general it was not applied until very recently. The proportion of legal terminations of pregnancy among patients receiving abortion care at the hospital increased from 3.2% in 2009 to 7.7% in 2011, while the percentage of women leaving the hospital with a contraceptive method increased from 25.3% to 69.4% over the same period.

In Brazil, Resolution 196/96 on research involving human subjects created the National Council of Ethics in Research (CONEP) with a mandate to stimulate the creation of institutional review boards (IRBs) throughout the country, provide guidelines, and regulate their structure and operation. A descriptive study was carried out in 2007. The coordinators of all 508 IRBs registered in CONEP in 2006 were invited to participate; 502 accepted (response rate = 99%) and responded to a structured questionnaire conducted via telephone. Prior to the publication of Resolution 196/96, IRBs were created at an average rate of 1.7 per year. In contrast, an average of 47.3 IRBs per year were created between 1997 and 2006. The percentage of IRBs with their own physical space and telecommunication equipment was higher among older IRBs compared to more recently established IRBs. A significantly greater proportion of IRBs created prior to the year 2000 provided services for other institutions, offered courses, and produced tex...

The Working Group of the International Federation of Gynecology and Obstetrics (FIGO) on the Prevention of Unsafe Abortion and its Consequences received a mandate to contribute to reduce the number of women who have to resort to induced abortion and the maternal mortality and morbidity associated with unsafe abortion by minimizing unintended pregnancies, improving access to safe abortion services, and increasing the quality of and access to post-abortion care, including post-abortion contraception. A project proposal was prepared and approved by an anonymous donor, funding a structure headed by a general coordinator, the Chair of the Working Group, together with 6 regional coordinators and 1 assistant regional coordinator, plus 43 focal points nominated by the participating societies. A situational analysis of induced/unsafe abortion for each country was prepared by the focal points with the technical support of the Guttmacher Institute, and a plan of action based on the findings of the analysis. The situational analysis and plans of action were discussed at 7 regional workshops held between June and August, 2008. Fifty-four member societies nominated a focal point, 48 attended the regional workshops, and 43 had a plan of action approved by their governments and respective societies. The plans of action are currently in the process of implementation, with the collaboration of a number of national and international agencies and organizations.

OBJECTIVES: To explore the use of the neonatal near miss concept as a tool to evaluate the quality of neonatal care as 3 million early neonatal deaths occur every year around the world and the majority of these deaths are avoidable and take place in developing countries. METHODS: This is a secondary analysis of the 2005 WHO Global Survey on Maternal and Perinatal Health a cross-sectional study using data from 19 randomly selected Brazilian hospitals. A pragmatic definition of neonatal near miss was developed and tested. Near miss indicators were calculated. RESULTS: Among the 15169 live born infants included in this analysis 424 presented at least one of the following conditions: very low birth weight less than 30 gestational weeks at birth or an Apgar score at the 5th minute of life less than 7. According to the operational definition these survivors from life-threatening conditions were considered neonatal near miss cases. The early neonatal mortality rate was 8.2/1000 live births the neonatal near miss rate was 21.4 neonatal near miss cases/1000 live births. Substantial variations in the mortality among neonates with life-threatening conditions at birth were observed suggesting intra-hospital quality of care issues. CONCLUSION: The near miss concept and indicators provided information that could be useful to evaluate the quality of care and set priorities for further assessments and health care improvement for newborn infants.

OBJECTIVE: To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternalfactors and perinatal outcomes. METHODS: In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter's association with maternal characteristics and perinatal outcomes. FINDINGS: Of the 97 095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. CONCLUSION: Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

OBJETIVO: Avaliar a prevalência de cesariana em hospitais brasileiros. MÉTODOS: Estudo transversal com dados do Sistema Global de Dados para a Saúde Materna e Perinatal, da Organização Mundial da Saúde, para os estados de São Paulo, Pernambuco e Distrito Federal. Analisaram-se dados de 15.354 mulheres que tiveram parto entre setembro/2004 e março/2005, segundo características sociodemográficas e reprodutivas e do hospital. Foram realizadas análises bivariada - com cálculos de razões de prevalência e respectivos intervalos de confiança- e multivariada por regressão de Poisson. RESULTADOS: A razão de prevalência de cesarianas foi significativamente maior entre mulheres com maior idade, entre as casadas/unidas, e com maior índice de massa corporal. As condições apresentadas durante a gravidez ou parto, como diagnóstico de HIV da parturiente, maior peso e perímetro cefálico do recém-nascido, e maior número de consultas de pré-natal, se associaram à maior razão de prevalência de cesariana. Na análise de regressão mostraram associação direta com o desfecho: maior idade e escolaridade da parturiente; presença de hipertensão/eclâmpsia, doenças crônicas e de outras condições médicas; maior perímetro cefálico do recém-nascido, ser primípara, ter tido cesariana na última gravidez, e ter recebido analgesia peridural ou raquidiana durante o trabalho de parto. Embora a proporção de cesarianas tenha sido maior nos hospitais com índice de complexidade alto, a diferença não foi estatisticamente significante, assim como para as demais características dos hospitais. CONCLUSÕES: As condições da gravidez, do recém-nascido e as características sociodemográficas e reprodutivas da parturiente associaram-se independentemente à realização de cesariana. O índice de complexidade hospitalar não esteve associado, provavelmente pela homogeneidade da amostra de hospitais. OBJECTIVE: To assess the prevalence of cesarean sections in Brazilian hospitals. METHODS: A cross-sectional study was carried out with data from the World Health Organization's Global Data System for Maternal and Perinatal Health, for the Brazilian states of São Paulo, Pernambuco and the Federal District. Data relating to 15,354 women who gave birth between September/2004 and March/2005 were analyzed, according to sociodemographic, reproductive, and hospital-related characteristics. Bivariate analyses - with calculations of the prevalence ratios and respective confidence intervals - and multivariate Poisson regression analyses were performed. RESULTS: The prevalence ratio of cesarean sections was significantly higher among older women, who were married/living with a partner and with higher body mass index. The following conditions during pregnancy or birth were associated with higher cesarean section prevalence ratio: parturient being diagnosed as HIV-positive, heavier weight and greater head circumference of the newborn, and more prenatal consultations. In regression analysis, the following variables showed direct association with the outcome: parturient being older and with higher schooling level, presence of hypertension/eclampsia, chronic condition or some other medical condition, newborn's greater head circumference, being primiparous, having had a cesarean in the last pregnancy and having received an epidural block or rachidian analgesic during labor. Although the proportion of cesareans was higher in hospitals with a high complexity index, the difference was not statistically significant, as well as for other characteristics of hospitals. CONCLUSIONS: The conditions of the pregnancy, newborn and the sociodemographic and reproductive characteristics of the parturient were independently associated with cesarean delivery. The hospital complexity index was not associated with cesarean delivery, probably due to the homogeneity of the hospital sample. OBJETIVO: Evaluar la prevalencia de cesárea en hospitales brasileros. MÉTODOS: Estudio transversal con datos del Sistema Global de Datos para la Salud Materna y Perinatal, de la Organización Mundial de la Salud, para los estados de Sao Paulo, Pernambuco y Distrito Federal de Brasil. Se analizaron datos de 15.354 mujeres que tuvieron parto entre septiembre/2004 y marzo/2005, según características sociodemográficas reproductivas y el hospital. Fueron realizadas análisis bivariado- con cálculos de razones de prevalencia y respectivos intervalos de confianza – y multivariado por regresión de Poisson. RESULTADOS: La razón de prevalencia de cesáreas fue significativamente mayor entre mujeres con mayoría de edad, entre las casadas/unidas, y con mayor índice de masa corporal. Las condiciones presentadas durante la gravidez o parto, como diagnóstico de HIV de la parturienta, mayor peso y perímetro cefálico del recién nacido, y mayor número de consultas de pre-natal, se asociaron a la mayor razón de prevalencia de cesárea. En el análisis de regresión mostraron asociación directa con el facto: mayor edad y escolaridad de la parturienta; presencia de hipertensión/eclampsia, enfermedades crónicas y de otras condiciones médicas; mayor perímetro cefálico del recién nacido, ser primípara, haber tenido cesárea en la última gravidez, y haber recibido analgesia peridural o raquidiana durante el trabajo de parto. A pesar de la proporción de cesáreas haber sido mayor en los hospitales con índice de complejidad alta, la diferencia no fue estadísticamente significativa, así como a las demás características de los hospitales. CONCLUSIONES: Las condiciones de la gravidez, del recién nacido y las características sociodemográficas y reproductivas de la parturienta se asociaron independientemente a la realización de cesárea. El índice de complejidad hospitalaria no estuvo asociado, probablemente por la homogeneidad de la muestra de hospitales.

Jose Barzelatto first distinguished himself as a leader with a vision in his years as a medical student. Later, principally as Director of the Reproductive Health Program at the World Health Organization and of the Ford Foundation program for women's sexual and reproductive rights, he contributed immensely toward the recognition of women's sexual and reproductive rights as part of their basic human rights. Jose Barzelatto's vision on abortion reflects his drive to promote social justice and respect individual rights, respect diversity, and promote a social consensus for a peaceful society. He believed that the fetus has moral value and did not accept abortion as a method of fertility control, but understood that abortion is a social phenomenon that cannot be changed with legal or moral condemnation. He accepted that condemning women who abort does not prevent abortion, is unfair, and causes great human suffering at a high social cost. Jose proposed nine points to form the basis for an overlapping consensus on abortion, on which to base a practical consensus that would allow societies to reduce the number of abortions and minimize their consequences. If we can agree on all or most of those points we would achieve the common objectives of: fewer women confronting the dilemma of how to deal with an unwanted pregnancy; fewer induced abortions; and fewer women suffering the consequences of unsafe abortion.

membranes (25.3%) and elective induction (28.9%). The success rate of vaginal delivery was very similar for oxytocin (69.9%) and misoprostol (74.8%), with an overall success rate of 70.4%. Induced labour was more common in women over 35 years of age. Maternal complications included higher rates of perineal laceration, need for uterotonic agents, hysterectomy, ICU admission, hospital stay >7 days and increased need for anaesthetic/analgesic procedures. Some adverse perinatal outcomes were also higher: low 5-minute Apgar score, very low birthweight, admission to neonatal ICU and delayed initiation of breastfeeding. Conclusions In Latin America, labour was induced in slightly more than 10% of deliveries; success rates were high irrespective of the method used. Induced labour is, however, associated with poorer maternal and perinatal outcomes than spontaneous labour.

The International Congress on Population and Development (ICPD) Programme of Action urged governments and intergovernmental and nongovernmental organizations to reduce women's recourse to abortion through improved family planning services; reliable information and counseling should be readily accessible to women who have unwanted pregnancies; where abortion is legal, it should be safe; and in all cases, quality services for management of abortion complications should be accessible. Review of the extent to which these recommendations have been implemented over the last 15 years shows that, with few exceptions, little attention has been given to this serious problem. Because of its political and religious implications, abortion is mostly ignored. Those with the power to promote change have an obligation to raise the issue of abortion from the darkness in which it is currently hidden, and bring it into the public light as a human drama and a health problem that is not difficult to solve if the ICPD recommendations are taken seriously.

This paper describes an evaluation of possible changes in sexual behavior in adolescents who participated in a school-based sex education program in selected public schools in four municipalities in the state of Minas Gerais, Brazil. The program is inserted within the context of reproductive rights, deals with risks involved in unsafe sexual practices and focuses on the positive aspects of sexuality. A quasi-experimental design with pre and post-tests and a non-equivalent control group was used to evaluate the intervention. A total of 4,795 questionnaires were included in this analysis. The program succeeded in more than doubling consistent condom use with casual partners and in increasing the use of modern contraceptives during last intercourse by 68%. The intervention had no effect on age at first intercourse or on adolescents' engagement in sexual activities. The sex education program was effective in generating positive changes in the sexual behavior of adolescents, while not stimulating participation in sexual activities. Este artigo descreve a avaliação de possíveis mudanças no comportamento sexual de adolescentes que participaram de um programa de educação sexual implementado em escolas públicas selecionadas em quatro municípios de Minas Gerais, Brasil. O programa está inserido no contexto dos direitos reprodutivos, discute os riscos de práticas sexuais inseguras e enfoca os aspectos positivos da sexualidade. Utilizou-se um desenho quase-experimental com pré e pós-teste e grupo controle não-equivalente. Foram incluídos 4.795 questionários na análise dos resultados. O programa conseguiu dobrar o uso consistente do preservativo com parceiro casual e aumentar em 68% o uso de métodos anticoncepcionais modernos na última relação sexual. A intervenção não teve efeito sobre a idade da primeira relação sexual ou na prática de atividades sexuais. Concluindo, o programa foi eficaz em gerar mudanças positivas no comportamento sexual de adolescentes sem antecipar ou estimular a prática sexual.