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Introduction to Clinical research
Final Research Proposal

1. Title- Whatis the incidence of maternal mortality annually, related

to abortions in the hospital la Maternidad la Altagracia in Santo
Domingo?
2. Abstract- High rates in maternal mortality around the world reveals the inequity to health
access and even points out the disparity between economic status. Almost all mortality
cases correspond to developing countries with a rate of 239 for every 100,000 for the year
2015, in contrast with non-developing countries which presented a rate of 12 for every
100,000 according to the World Health Organization (WHO). The Dominican Republic
accounts for one of the highest ciphers on the Caribbean region with an annual rate of 95
for every 100,000 up to 2013 according to the ministry of health, alarming as it is, rates
are still going higher each year. Women have equal right to access the highest quality of
care there is. This implies the right information adequate to each individual need, the
access to contraceptive methods and the decision when to be a mother, and receiving
early attention with all the quality, dignity and respect from the moment of pregnancy
until the postpartum period. Having such high rate in the country should raise awareness
on how dysfunctional a health system is. Major factors attributing to this fatal number are
cases of preeclampsia, eclampsia, hemorrhages, sepsis or other infections, and due to
complications produced by induced abortion, which according to the “Sistema de
vigilancia epidemiologica” (SINAVE), made up to a thirteen percent of maternal deaths
in the Dominican Republic on 2014. The consequences of unsafe abortions
predominantly affect women, more often in countries with highly restrictive laws, which
are concentrated in developing regions. Information about the incidence of induced
abortions in a country is needed to motivate the formation of new protocols and ways of
management. This research has the objective to find data that motivates the state to create
public policies that asses this problem.
3. Key words- maternal mortality rate, maternal death, abortions, abortion incidence,
induced abortion, clandestine abortion, abortion safety, women rights
4. Problem statement- Our problem can be making representative samples of the post
abortion cases in Santo Domingo, Dominican Republic. Under reports or no reports at all
in the hospital documentation.
5. Objectives- Specific
a. What is the incidence of maternal mortality annually, related to abortions in the
hospital la Maternidad la Altagracia in Santo Domingo?
General
a. How many patients visit the hospital seeking attention after an induced abortion?
b. what are the protocols used for induced abortion patients?
c. Is the data useful to estimate the rate of other hospitals on the area?

6. Background- Maternal death or maternal mortality is defined by the World Health

Organization (WHO) as "the death of a woman while pregnant or within 42 days of termination of

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pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from accidental or incidental
causes."[1] The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live
births versus 12 per 100 000 live births in developed countries. There are large disparities between
women with high and low income and those women living in rural versus urban areas. Almost all
mortality cases correspond to developing countries with a rate of 239 for every 100,000 for the
year 2015, in contrast with non-developing countries which presented a rate of 12 for every
100,000 according to the World Health Organization (WHO).[1] According with the vigilance
system of the country on 2013, in the Dominican Republic the maternal mortality rate was of 94.8
deaths for every 100,000 live births.[2] This alarming rate is indicative that human rights, more
specifically, women’s rights, have not being taken into complete consideration, and projects a
major need in society. Although attempts have been made in reducing maternal mortality, there is
much room for improvement, particularly in impoverished region. The Dominican Republic has
been struggling with a high mortality rate, and depict the actions done to assess the problem, the
rate of mortality still on an alarming cipher. Even though numerous contributions in the country
has being made in order to decrease this number of maternal mortality, they haven't achieved a
sustained reduction, there's still work to do to get to the planned goals. Mortal maternity rate is
still elevated even though that access to the services offered from the specialized personal is
universal, 99 percent of women receive prenatal attention, with at least four assistants and a
physician, a gynecologist or a nurse, meanwhile 98.5 percent of the labors took place a health
facility.[2] It's important to mention that frequently, maternal deaths happen in the community
service area, like in hospitals, due to the lack of sufficient medication and insufficient facilities to
offer the necessary attention in cases of high risk. The fact that most maternal deaths occur during
the postpartum period indicates the existence of possible sources of nosocomial infections that
could be prevented with an efficient medical attention that makes sure of the right protocols of
biosafety, an adequate hospital facility, sufficient medication, capacitation of the medical personal
and of paramedics, as the following of the women after birth for a period.[2] The most common
cause of maternal death is by hypertensive syndrome (preeclampsia, eclampsia), infections,
responsible of one out of four of maternal deaths. Mortality due this cause has being the major
cause for the last fifteen years. Followed in frequency by hemorrhages sepsis and puerperal
infections and complications produced by abortions, which according to studies from SINAVE, at
the year 2013 (MSP-DIGEPI, Sistema de Vigilancia Epidemiologica, 2014) makes a thirteen
percent of maternal deaths. [2] Even though the studies shows that abortion plays a high percentage
of contribution to maternal mortality, it is important to recall its ilegal status in the Dominican
Republic. Laws fall along a continuum from outright prohibition to allowing abortion without
restriction as to reason. As of 2017, 42% of women of reproductive age live in the 125 countries
where abortion is highly restricted (prohibited altogether, or allowed only to save a woman’s life
or protect her health). The vast majority (93%) of countries with such highly restrictive laws are
in developing regions. In contrast, broadly liberal laws are found in nearly all countries in Europe
and Northern America, as well as in several countries in Asia.[3] The legality continuum ranges
from category 1, outright prohibition on any ground, to category 6, allowing abortion without
restriction as to reason. The four intermediate categories permit abortion on progressively broader
grounds: to save a woman’s life, to protect a woman’s physical health, to protect her mental health,
and for socioeconomic reasons. Many countries permit abortion on at least one of the following
three additional grounds: if the pregnancy resulted from rape or incest, or if the fetus has a grave
anomaly. These additional grounds do not affect a country’s placement along the continuum, but

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can be meaningful avenues for affording women the possibility of obtaining a safe and legal
abortion. Both components are important and together broadly reflect each country’s commitment
to making safe, legal abortions available.[3] As mentioned earlier, countries may also legally
permit abortion for grounds that are not part of the legality continuum: in cases in which the
pregnancy resulted from rape or incest, or the fetus has a grave anomaly. These grounds are
relevant for countries in the middle-four legal categories, as no country in category 1 allows for
any of these three exceptions (consistent with their prohibition of all abortions), and all countries
in category 6 allow abortion without restriction as to reason. Being part of the first legal category,
as in the Dominican Republic, where the criminal code penalizes women and girls who induce
abortions and anyone who assists them; Under article 317 of the criminal code, doctors, surgeons,
midwives, nurses, pharmacists, and “other medical professionals” who provide abortions face
prison terms of five to 20 years. Pregnant women who induce or consent to abortions, and any
individuals who relay information to pregnant women about obtaining an abortion, if the abortion
occurs, face six months to two years in prison.[4] When abortion is criminalized, pregnant women
and girls often cannot access factual, unbiased, and confidential information from qualified
professionals about a full range of options, leaving them more susceptible to pressure, coercion,
or even abuse from partners or others who may want to control their reproductive health. Induced
abortion is common across the globe. The vast majority of abortions occur in response to
unintended pregnancies, which typically result from ineffective use or nonuse of contraceptives.
Other factors are also important drivers of unintended pregnancy and the decision to have an
abortion. Some unintended pregnancies result from rape and incest. Other pregnancies become
unwanted after changes in life circumstances or because taking a pregnancy to term would have
negative consequences on the woman’s health and well-being.[3] As a result, abortion continues
to be part of how women and couples in all contexts manage their fertility and their lives, regardless
of the laws in their country. Thus, safe abortion services will always be needed. Regionally, the
highest estimated abortion rate is in Latin America and the Caribbean (44 abortions per 1,000
women; and the lowest rates are in Northern America and Oceania (17 and 19 per 1,000,
respectively). Studies found that the prevalence of least-safe abortions increased with increasing
restrictions, from 1% of all abortions in countries in the least-restrictive category to 17% in those
in the moderately restrictive category to 31% in those in the most-restrictive category.
[3] Available data from legally restrictive settings show increases in the use of vacuum aspiration,
which is a less-invasive surgical technique than D&C. Perhaps even more important, use of
misoprostol alone (the second drug in the combination protocol) has risen substantially. In
countries that legally restrict abortion, mifepristone (the first drug) is either prohibitively expensive
or unavailable altogether. Misoprostol, which is widely registered to treat gastric ulcers (and less-
widely registered for obstetric indications), is far less expensive than mifepristone and much more
available. Studies in a few countries show that untrained abortion providers—including
pharmacists or market sellers, who may know little about misoprostol—are usually more plentiful,
easier to find and less expensive than trained and informed ones.[5] The consequences of
clandestine—and often unsafe—abortions predominantly affect women in countries with highly
restrictive laws, which are concentrated in developing regions. Although women seeking to
terminate a pregnancy in these countries are increasingly able to obtain misoprostol to self-induce
an abortion, they still could be at risk of negative health consequences if they cannot get the
necessary information to use the method correctly. In countries with highly restrictive laws where
access to misoprostol is poor, an abortion under unsafe conditions remains the main option
available to many women, especially poor women. But once such countries expand the legal

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grounds for abortion and implement access to safe and legal abortion services, recourse to
clandestine and unsafe abortions usually goes down. In societies where restrictive laws and stigma
persist, however, women tend to prioritize secrecy over health—with consequences that
reverberate at the individual, family and national levels. The prevalence and severity of these
consequences vary across settings, and also by women’s economic resources and social
circumstances.[6] The pattern of inequity in access to safe abortion, as seen through the lens of
urban-rural residence and poverty status, is consistent across countries where abortion is highly
legally restricted.Women and girls described using a variety of methods to try to end pregnancies,
including taking or inserting pills (most commonly misoprostol, often called by the brand name
Cytotec); using teas, beverages, and other home remedies; trying to induce poor health, for
example by denying themselves food or water; taking prescription medications contraindicated
during pregnancy; or trying to induce physical trauma that ends the pregnancy.[4] The riskiest
abortions—i.e., those performed by untrained providers or self-induced not using misoprostol—
are estimated to account for much higher proportions of procedures among poor and rural women
(62% and 55%) than among non-poor and urban women (36% and 38%).114 In addition, this
inequity is intensified when access to postabortion care is considered, because the disadvantaged
women who can least afford the costs of treating complications from unsafe abortion are the ones
most likely to develop complications and need care.[7] Severe, untreated complications from
unsafe abortion can be life-threatening. In the Dominican Republic, complications from abortion
or miscarriage account for at least eight percent of maternal deaths, according to the Ministry of
Public Health.[4] The country’s total abortion ban has devastating consequences. Women and girls
facing unplanned or unwanted pregnancies—including those resulting from rape or incest, or when
the fetus will not survive—are forced to choose between clandestine abortion or continuing their
pregnancies, even if they do not want to and even if they face serious health risks, including death.
The longer they remain untreated, the worse the outcome; thus, much of the mortality associated
with induced abortion can be attributed to treatment delays. Recommended standards of
postabortion care incorporate the following key elements: immediate treatment of complications,
including pain management; provision of contraceptive counseling and services, and STI/HIV
care; and mobilization of community partnerships to improve services and spread information
about their availability.[8] Even in countries with restrictive abortion laws, the provision of
postabortion care is generally accepted by governments and health care providers as part of
standard women’s health care, consistent with the Cairo Programme of Action, which was agreed
to by all countries.[9]Global efforts stressing the importance of postabortion care to save lives have
led some legally restrictive countries to issue laws that make provision of postabortion care
obligatory. In many countries with highly restrictive abortion laws, however, the quality of
postabortion care falls far short of WHO’s guidelines. Delaying care for an incomplete abortion
can make a mild problem much worse, because doing so can lead to sepsis, shock and even death.
An unknown level of risk is borne by women who forgo care altogether, which likely occurs most
often among those disadvantaged by their lower socioeconomic status: According to surveys of a
wide variety of health professionals in 14 countries with recent abortion incidence studies,
forgoing needed care is estimated to be far more common among rural poor women than among
urban nonpoor women: Whereas, on average, an estimated 49% of rural poor women who need
care from complications do not obtain it, only 21% of similar urban nonpoor women forgo such
care.[9] Although abortion in the Dominican Republic is completely illegal, a study on female
university students have found that more than half of the students interviewed agreed that abortion
should be permitted in cases where the women’s health is critical. 74.5 percent believes that

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 women should have the right to stop her pregnancy. Also 72.7 percent favors decision taking of
stopping the pregnancy when its complicated by malformations incompatible with life.[10]
Substantial gaps in knowledge about abortion remain, however. To fill such gaps, like the purpose
of this research, other researchers are developing and applying innovative approaches to better
document the incidence of abortion and to better understand its causes, conditions and
consequences. This report calls to examine the current state of abortion across legal settings and
socioeconomic contexts, and considers abortion in light of factors known to influence its safety
and incidence. The benefits of expanding legal grounds for abortion begin to accrue as soon as
women no longer have to risk their health by resorting to clandestine abortion. Although legality
is the first step toward safer abortion, legal reform is not enough in itself. It must be accompanied
by political will and full implementation of the law so that all women— despite inability to pay or
reluctance to face social stigma—can seek out a legal, safe abortion. This study aims to gather
further information on abortion incidence in order to raise awareness to the community for the
hopes of new policies and laws, where the women’s legal sexual and reproductive rights are taken
into account. Legality alone does not guarantee access, and vigilance is required to prevent
backsliding where onerous restrictions that are not based on safety erode the availability of safe
and legal abortion services. Highly restrictive laws do not eliminate the practice of abortion, but
make those that do occur more likely to be unsafe.[3]
7. Ethical considerations- the research ensures quality and integrity; The study will seek
informed consent; respect the confidentiality and anonymity of respondents; ensure that
participants will participate in study voluntarily; will avoid harm to participants; and show that the
research is independent and impartial.
8. Methodology- The Abortion Incidence Complications Method (AICM) uses an estimate
of the number of women receiving post-abortion care, taken from a survey of healthcare facilities,
multiplied by the inverse of the estimated proportion of abortions that lead to treated
complications, taken from a survey of knowledgeable informants. The modified AICM uses
women’s abortion reports to estimate the proportion of abortions that lead to treated complications
and should improve our chances of capturing self-induced abortions. Using medical records,
hospital data from abortion cases and a survey to maximize and include self induce abortion rates.
9. Timeline- The study is planned to recollect data for a whole year in order to gather enough
information and estimate regional, and national levels of abortion incidence.
10. References-

[1]
MORTALIDAD MATERNA
In-text: (1)
Your Bibliography: Mortalidad materna [Internet]. Who.int. 2018 [cited 21 April 2019]. Available from:
https://www.who.int/es/news-room/fact-sheets/detail/maternal-mortality
[2]
ORTEGA, G., GOMEZ, F., BARDAJI, G. AND RAMIREZ, A.
Retos y necesidades sobre mortalidad materna y neonatal
In-text: (2)
Your Bibliography: 1 Ortega G, Gomez F, Bardaji G, Ramirez A. Retos y necesidades sobre mortalidad
materna y neonatal [Internet]. Dominicanrepublic.unfpa.org. 2017 [cited 20 April 2019]. Available from:
https://dominicanrepublic.unfpa.org/sites/default/files/pub-pdf/Analisis%20SituacionPoblacional_RD%20-
%20Web_0.pdf
[3]
ABORTION WORLDWIDE 2017: UNEVEN PROGRESS AND UNEQUAL ACCESS
In-text: (3)

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Your Bibliography: Abortion Worldwide 2017: Uneven Progress and Unequal Access [Internet].
Guttmacher.org. 2017 [cited 20 April 2019]. Available from:
https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf
[4]
“IT’S YOUR DECISION, IT’S YOUR LIFE” | THE TOTAL CRIMINALIZATION OF ABORTION IN
THE DOMINICAN REPUBLIC
In-text: (4)
Your Bibliography: “It’s Your Decision, It’s Your Life” | The Total Criminalization of Abortion in the
Dominican Republic [Internet]. Human Rights Watch. 2018 [cited 21 April 2019]. Available from:
https://www.hrw.org/report/2018/11/19/its-your-decision-its-your-life/total-criminalization-abortion-
dominican-republic
[5]
POWELL-JACKSON, T., ACHARYA, R., FILIPPI, V. AND RONSMANS, C.

Delivering Medical Abortion at Scale: A Study of the Retail Market for Medical Abortion in Madhya
Pradesh, India
In-text: (5)
Your Bibliography: Powell-Jackson T, Acharya R, Filippi V, Ronsmans C. Delivering Medical Abortion at
Scale: A Study of the Retail Market for Medical Abortion in Madhya Pradesh, India. PLOS ONE.
2015;10(3):e0120637.
[6]
SEDGH, G., BEARAK, J., SINGH, S., BANKOLE, A., POPINCHALK, A., GANATRA, B.,
ROSSIER, C., GERDTS, C., TUNÇALP, Ö., JOHNSON, B. R., JOHNSTON, H. B. AND ALKEMA,
L.

Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends
In-text: (6)
Your Bibliography: Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B et al. Abortion
incidence between 1990 and 2014: global, regional, and subregional levels and trends. The Lancet.
2016;388(10041):258-267.
[7]

SEDGH, G., FILIPPI, V., OWOLABI, O. O., SINGH, S. D., ASKEW, I., BANKOLE, A., BENSON, J.,
ROSSIER, C., PEMBE, A. B., ADEWOLE, I., GANATRA, B. AND MACDONAGH, S.

Insights from an expert group meeting on the definition and measurement of unsafe abortion
In-text: (7)
Your Bibliography: Sedgh G, Filippi V, Owolabi O, Singh S, Askew I, Bankole A et al. Insights from an
expert group meeting on the definition and measurement of unsafe abortion. International Journal of
Gynecology & Obstetrics. 2016;134(1):104-106.
[8]

ZIRABA, A. K., IZUGBARA, C., LEVANDOWSKI, B. A., GEBRESELASSIE, H., MUTUA, M.,
MOHAMED, S. F., EGESA, C. AND KIMANI-MURAGE, E. W.

Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated
factors
In-text: (9)
Your Bibliography: . Ziraba A, Izugbara C, Levandowski B, Gebreselassie H, Mutua M, Mohamed S et al.
Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated
factors. BMC Pregnancy and Childbirth. 2015;15(1).
[9]

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 PROGRAMME OF ACTION OF THE INTERNATIONAL CONFERENCE ON POPULATION
DEVELOPMENT. ACTION 7.6
In-text: (9)
Your Bibliography: Programme of Action of the International Conference on Population Development.
Action 7.6 [Internet]. Un.org. 2014 [cited 21 April 2019]. Available from:
http://www.un.org/en/development/desa/population/publications/ICPD_programme_of_action_en
[10]
CAIRO, L., FIGUEROA, J., SANGIOVANNI, G., FLORES, M. AND SALETA, C.

Situación del aborto en República Dominicana

In-text: (10)
Your Bibliography:. cairo l, figueroa j, sangiovanni g, flores m, saleta c. Situación del aborto en República
Dominicana [Internet]. Profamilia.org.do. 2016 [cited 22 April 2019]. Available from:
http://profamilia.org.do/wp-content/uploads/2017/08/Situaci%C3%B3n-del-aborto-en-RD-min.pdf