Introducing the Dilation and Evacuation Technique in Brazil: Lessons Learned From an International Partnership to Expand Options for Brazilian Women and Girls

Abstract

Dilation and evacuation (D&E) is the recommended surgical procedure for uterine evacuation in the second trimester. Despite its established safety record, it is not routinely available in most countries around the world. In this paper, we describe the multi-phase capacity-building project we undertook to introduce D&E in Brazil. First, we invited a highly motivated obstetrician-gynecologist and abortion provider to complete an observership at an established D&E site in the United States. We then organized a month-long clinical training for two experienced gynecologists in Brazil, followed by ongoing remote mentorship. Almost all patients we approached during the training opted for D&E, and all expressed satisfaction with their experience. Despite the restrictive legal setting and prevailing abortion stigma in Brazil, our training was well-received, and we did not experience any overt resistance from hospital staff. We learned that obtaining institutional support is essential; and that presenting scientific evidence during dedicated didactic times was an important strategy to obtain buy-in from other local healthcare providers. An important challenge we encountered was low case volume given the restrictive legal setting. We addressed this by partnering with nearby hospitals and non-profit organizations for patient referrals. We also rescheduled, adapted and optimized this project for implementation in the midst of the COVID-19 pandemic. Despite the challenges we faced, this project led to the successful introduction of D&E up to 16–18 weeks at two sites in Brazil. In the future, we plan additional training to increase capacity for D&E at more advanced gestational ages.

Clinical analysis of prophylactic uterine artery embolization combined with double balloon catheter for second-trimester pregnancy termination in cases of complete placenta previa: A retrospective study

“…Dilation and evacuation is one of the most common invasive surgeries and can be performed on a pregnant or nonpregnant patient and be either diagnostic or therapeutic around the world. [7,28–30] Patients seeking elective termination or managing a missed, incomplete, or inevitable abortion with <14 weeks of estimated gestational age could opt for these surgical procedures or medical management. Dilation and evacuation is generally not recommended for patients with an estimated gestational age >14 weeks, [28] as these procedures are associated with pain, hemorrhage, DIC and other side effects.…”