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					Improving Access to Safe Abortion
Guidance on Making High Quality
Services Accessible




   Based on Safe Abortion: Technical and Policy Guidance
    for Health Systems World Health Organization, 2003
                          Improving Access to Safe Abortion
                          Guidance on Making High Quality
                          Services Accessible
                          Prepared by Ipas and Family Care International (FCI) to promote greater
                          understanding of the challenge of unsafe abortion in Africa
                          and encourage measures to make abortion services safe and accessible
*World Health             to the full extent of the law, based on international guidance from the
Organization. Safe
                          World Health Organization (WHO)*. Ipas and FCI are solely responsible
Abortion: Technical and
Policy Guidance for       for the contents of this presentation, which may be used or abstracted
Health Systems.           without prior permission.
Geneva: WHO, 2003.
                          February 2007

                          Contact:
                          Email: ipas_publications@ipas.org         Web: www.ipas.org
                          Email: pubs@familycareintl.org            Web: www.familycareintl.org
                             Introduction



                             This presentation includes modules on:
                             • Context and general information on unsafe
                               abortion
                             • International agreements
                             • Legal issues
                             • Clinical services
                             • Management issues
                             • Overcoming barriers to access
Addressing Unsafe Abortion
in Africa
Unsafe Abortion in Context

Module 1
                             Unsafe Abortion in Africa



                             • African countries have a wide range of laws
                               and practices regarding abortion
                             • Africa has the highest rate of death caused
                               by unsafe abortion of any region (100 deaths
                               per 100,000 live births, resulting in 29,800
                               deaths each year)
                             • In Africa, unsafe abortion accounts for 12%
                               of maternal deaths

Addressing Unsafe Abortion
in Africa

Module 1
                             Unsafe Abortion in Context



                             • Abortions occur in all countries
                             • Unsafe abortions are concentrated in developing
                               countries (around 95%)
                             • Abortions occur in all age groups
                             • Married and unmarried women, with and without
                               children, seek abortions



Addressing Unsafe Abortion
in Africa

Module 1
                             The Context: Wanted Pregnancy




                             A woman may want to have a child, but:
                             • Pregnancy may not be supported by
                               woman’s partner, family or community
                             • Pregnancy may threaten the woman’s health
                               or survival
                             • Foetus may have an abnormality




Addressing Unsafe Abortion
in Africa

Module 1
                             The Context: Unwanted Pregnancy



                             Many women do not want to become pregnant, because of:
                                     •   Personal reasons
                                     •   Health considerations (such as HIV)
                                     •   Socioeconomic concerns
                                     •   Cultural reasons
                                     •   Relationship problems
                                     •   Desire to stop childbearing/space births
                             Yet, 80 million unplanned pregnancies occur each year, because of:
                                      • Lack of access to contraception
                                      • Contraceptive failure
                                      • Rape/coerced sex



Addressing Unsafe Abortion
in Africa

Module 1
                            Legal Status and Demand for Abortion




                            • Legally restricting abortion does not
                              necessarily reduce the number of abortions
Definition: Unsafe
abortion is the
                              that occur in a country
termination of a
pregnancy carried out       • The legal status and availability do affect the
by someone without
the skills or training to
                              safety of abortion; where abortion is legal
perform the procedure         and safe services are available, deaths and
safely, or in a place
that does not meet            disability from abortion are greatly reduced
minimal medical
standards, or both.
(According to WHO, and
endorsed by the UN)




Module 1
                             Abortion Restrictions and
                             Maternal Mortality




Addressing Unsafe Abortion
in Africa
                             McKay, HE, Rogo, KO Dixon, DB. 2001. FIGO society survey: acceptance and use of new ethical guidelines regarding
Module 1                     induced abortion for non-medical reasons. International Journal of Gynecology and Obstetrics 75: 327-336.
                             Impact of Unsafe Abortion



                             • The deaths caused by unsafe abortion
                               are preventable
                             • Abortion performed in sanitary conditions
                               by a skilled provider is an extremely safe
                               procedure
                             • Safe abortion is much safer than childbirth



Addressing Unsafe Abortion
in Africa

Module 1
                             Impact of Unsafe Abortion



                             In addition to death, unsafe abortion in Africa
                             can also lead to:
                             • Significant short- and long-term illness
                               and injury to women
                             • High costs to treat complications
                             • Negative impacts on women, families, children,
                               and communities
                             • Increased likelihood of death among children
                               whose mother has died
Addressing Unsafe Abortion
in Africa

Module 1
International Agreements

Module 2
                             International Obligations



                             International agreements recognise that:
                             • Unsafe abortion is a major public health concern
                             • Abortion should be safe and available to the full
                               extent of the law
                             • Health systems have a responsibility to provide
                               these services




Addressing Unsafe Abortion
in Africa

Module 2
                             International Obligations




                             ICPD
Programme of Action,
International Conference
                             …In circumstances where abortion is not against the
of Population and            law, such abortion should be safe. In all cases, women
Development, Cairo, 1994
                             should have access to quality services for the
                             management of complications arising from abortion.
                                                                      Paragraph 8.25




Addressing Unsafe Abortion
in Africa

Module 2
                              International Obligations




                              ICPD +5
Key Actions for the Further
Implementation of the ICPD
                              …In circumstances where abortion is not against the
Programme of Action, 21st     law, health systems should train and equip health-
United Nations General
Assembly Special Session,     service providers and should take other measures to
New York, 1999                ensure that such abortion is safe and accessible.
                              Additional measures should be taken to safeguard
                              women’s health.
                                                                    Paragraph 63(iii)


Addressing Unsafe Abortion
in Africa

Module 2
                             Millennium Development Goals



                             MDG 5
The MDGs were                Reduce by three-quarters, between 1990 and 2015, the
approved by                  maternal mortality ratio
U.N. member
                               • In some settings, reducing unsafe abortion may be
states following
the Millennium                   technically the easiest way to reduce maternal deaths as
Summit, held                     mandated by MDG 5
in 2000.                       • Unsafe abortion can be reduced through comprehensive
                                 sexual and reproductive health education, high quality
                                 contraceptive services,
                                 and safe abortion services
Addressing Unsafe Abortion
in Africa

Module 2
                             Other International Commitments



                             Protocol on the Rights of Women in Africa
                             • Adopted July 2003 by African Union
The protocol will
come into force              • Calls for states to “authorize … abortion in cases
when ratified                  of sexual assault, rape, incest, and where the
by 16 countries
                               continued pregnancy endangers the mental and
                               physical health of the mother or the life of the
                               mother or the unborn child.”




Addressing Unsafe Abortion
in Africa

Module 2
                             Other International Commitments



                             Maputo Plan of Action

Special Session of the
                             • Seeks to “take the continent forward towards the
African Union                  goal of universal access to comprehensive sexual
Conference of                  and reproductive health services in Africa by 2015”
Ministers of Health
                             • Built on nine action areas, including unsafe
Maputo, Mozambique
September 2006                 abortion
                             Areas of action for unsafe abortion
                               • Advocacy/policy
                               • Capacity building
                               • Service delivery
Addressing Unsafe Abortion
in Africa

Module 2
Legal Context

Module 3
                             Legal Status and
                             Availability of Abortion



                             Africa has a wide range of legal scenarios:
                             • Abortion is legally allowed and safe services
                               are available
                             • Abortion is legally allowed but safe services
                               are difficult to access
                             • Abortion is legally restricted and safe services
                               are difficult to access (majority of region)



Addressing Unsafe Abortion
in Africa

Module 3
                             Legal Status of Abortion



                             All countries in Africa allow abortion in some situations:
                              • To save the woman’s life – 100% of African countries
                              • To preserve physical and mental health –
                                51% of African countries
                              • In cases of rape or incest – 23% of African Countries
                              • In three countries (6%), abortion is legal without restriction
                                as to reason.

                             Countries should offer safe abortion services in all
                             circumstances permitted by law

Addressing Unsafe Abortion
in Africa

Module 3
                             Barriers to Access



                             Many women are unable to exercise their
                             legal right to safe abortion services because of:
                              • Inadequacies in the health system
                              • Policy, administrative, and regulatory issues
                              • Lack of knowledge on the part of women, communities,
                                and health care providers
                              • Cost
                              • Societal, cultural and religious attitudes, including stigma
                             Where safe abortion is not available, women seek
                             unsafe services
Addressing Unsafe Abortion
in Africa

Module 3
                             WHO Provides Leadership and
                             Guidance

                             Available at:
                             http://www.who.int/reproductive-health/publications/safe-abortion/safe-abortion.html




In response to
the international
mandate,
WHO developed
Safe Abortion:
Technical and
Policy Guidance
for Health Systems




Addressing Unsafe Abortion
in Africa

Module 3
Clinical Services

Module 4
                             Clinical Services



                             The WHO Guidance specifies that abortion services
                             should be:
                             • Available and accessible to the full extent of the law
                             • Safe and of high clinical quality
                             • Respectful and confidential, with adequate
                               counselling, information, and support

                             The Guidance specifies basic equipment
                             and procedures

Addressing Unsafe Abortion
in Africa

Module 4
                             Before the Procedure



                             Confirm pregnancy and desire to terminate, and
                             estimate duration to help determine possible
                             methods of abortion
                             • Patient history and bimanual pelvic exam usually adequate
                             • Ultrasound is not routinely necessary
                             Screen for pre-existing conditions

                             • Routine use of antibiotics at the time of abortion reduces
                               post-procedural risk of infection
                             • However, abortion should not be denied where
                               prophylactic antibiotics are not available
Addressing Unsafe Abortion
in Africa

Module 4
                             Information and Counselling



                             Complete and accurate information must be
                             provided in a respectful, confidential environment

                             Clients should be counselled on three main topics:
                             • Their decision to seek an abortion; verify that
                               it is free of coercion
                             • What to expect during the abortion procedure
                             • Post-abortion contraception and other reproductive
                               health services

Addressing Unsafe Abortion
in Africa

Module 4
                             Preferred Methods of Abortion
                             up to 9 Completed Weeks


                             As feasible, a choice of methods should be available
                             Preferred methods up to 9 completed weeks
                             of pregnancy:
                              • Medication methods of abortion
                                (mifepristone followed by a prostaglandin)
                              • 200 mg mifepristone followed after 36-48 hours
                                by a prostaglandin
                              • Manual vacuum aspiration (MVA)
                              • Electric vacuum aspiration
                             Dilatation and curettage is not recommended and
                             should be replaced with another method

Addressing Unsafe Abortion
in Africa

Module 4
                             Misoprostol Alone for Induced Abortion
                             through 9 weeks



                             Misoprostol is widely available, at low cost.
                             • WHO does not yet have a recommendation for a
                               preferred treatment regimen.
                             • 2003 consensus statement for misoprostol-only
                               protocol through 9 weeks:
                             • 800 mcgs vaginally, repeated after 24 hours.
                             • Using this protocol, success rates have been
                               observed to be 85-90%.

Addressing Unsafe Abortion
in Africa

Module 4
                             Preferred Methods of Abortion
                             between 9 and 12 Completed Weeks



                             Preferred methods between 9 and 12
                             completed weeks of pregnancy:
                             • Manual vacuum aspiration (MVA)
                             • Electric vacuum aspiration


                             Dilatation and curettage is not recommended
                             and should be replaced with another method



Addressing Unsafe Abortion
in Africa

Module 4
                             Abortion After 12 Weeks



                             Where legal, abortion services should be available
                             after 12 weeks. Women may:
                             • Develop problems in pregnancy that threaten their
                               health or survival
                             • Discover foetal abnormalities
                             • Experience a change in their life situation that makes
                               continuation of the pregnancy problematic
                             • Seek abortion after 12 weeks for other reasons

Addressing Unsafe Abortion
in Africa

Module 4
                             Preferred Methods of Abortion
                             After 12 Weeks



                             After 12 completed weeks of pregnancy,
                             WHO recommends:
                             • Mifepristone followed by repeated doses
                               of a prostaglandin
                             • Dilatation and evacuation, using a method
                               of cervical preparation and vacuum aspiration (should
                               be used only in settings where highly skilled,
                               experienced medical providers are available)
                             • Vaginal prostaglandins alone


Addressing Unsafe Abortion
in Africa

Module 4
                             Methods of Abortion by
                             Duration of Pregnancy



                             Figure 2.1 Methods of abortion
                             Completed weeks since last menstrual period
                               4     5       6   7     8         9   10     11    12    13     14    15     16     17     18   19   20   21   22
                             Preferred methods

                                      Vacuum aspiration (manual/electric)              (by specially trained providers)


                                                                                       Dilatation and evacuation


                                      Mifepristone and           (under                Mifepristone and repeated doses of misoprostol or gemeprost
                                      misoprostol (or gemeprost) investigation)
                                                                                       Vaginal prostaglandins (repeated doses)

                             Other methods

                                      Dilatation and curettage


                                                                                       Hypertonic solutions


Addressing Unsafe Abortion                                                             Intra/extra-amniotic prostaglandins
in Africa

Module 4
                             Clinical Issues for Abortion



                             Pain management and emotional support should be offered to all
                             women
                                 • Comfort and support      • Analgesics
                                 • Tranquilizers            • Anaesthetics
                             General anaesthesia is usually not recommended for abortion
                             and increases the clinical risks

                             Cervical priming can be offered for a first trimester abortion,
                             although it can increase the time requirement and the cost of
                             treatment

                             Universal precautions reduce risk of infection to patients and
                             medical staff

Addressing Unsafe Abortion
in Africa

Module 4
                             Follow-up Care for Abortion



                             Women should receive clear information on:
                              • Follow-up visits needed
                              • What to expect after the procedure
                              • How to take care of themselves
                              • Return to fertility (as early as 2 weeks)
                              • STI prevention and contraception, if wanted
                             The recovery period will vary depending on pregnancy
                             duration and type of abortion procedure

Addressing Unsafe Abortion
in Africa

Module 4
Management Issues

Module 5
                             National Norms and Standards



                             Norms and standards should outline:
                             • Where – what levels of the health system should offer
                               abortion services
                             • Who – what categories of health care staff can provide
                               abortion services
                             • How – what training, supplies, and equipment will
                               be needed
                             • What authorization procedures, if any, are required
                             • The rights of patients to informed consent, confidentiality and
                               privacy
                             • Referral requirements for providers who refuse to provide abortion
Addressing Unsafe Abortion
                               services, and other provider obligations
in Africa

Module 5
                             Involving Different Cadres
                             of Providers



                             • Mid-level health workers* can be trained to
                               provide safe early abortion services
*Nurses, midwives,
clinical officers,           • In many African countries, doctors are scarce
and others                     or not well distributed in rural areas
                             • Offering abortion at the primary and secondary
                               levels can make services more accessible
                             • MVA and medication abortion can be used at all
                               levels of the health system
Addressing Unsafe Abortion
in Africa

Module 5
Overcoming Barriers to Access

Module 6
                             Creating an Enabling Environment



                             Possible health system barriers:
                             • Public health facilities do not provide safe
                               abortion services to the extent allowed by law
                             • Unnecessary medical procedures are mandated
                             • Outdated and less safe procedures
                               (such as D&C) are still used
                             • Drugs needed for medical abortion are not
                               approved or available

Addressing Unsafe Abortion
in Africa

Module 6
                             Creating an Enabling Environment



                             Possible administrative barriers:
                             • Signatures by several doctors are required and
                               are time-consuming or difficult to obtain
                             • Spousal authorization, or parental notification or
                               consent is required
                             • A limited number and type of health personnel
                               are authorized to provide abortion services
                             • Unnecessary restrictions are placed on facilities
                               that provide abortion
Addressing Unsafe Abortion
in Africa

Module 6
                             Creating an Enabling Environment



                             Possible information barriers:
                             • Women are unaware of the circumstances under
                               which abortion services are legal

                             Possible cost barriers:
                             • Abortion services are expensive

                             All barriers can be overcome with dedicated
                             resources and political will.

Addressing Unsafe Abortion
in Africa

Module 6
                             Influencing Policy and Practice



                             Many groups and individuals have a role making
                             policies and practices more responsive
                             to women’s needs:
                             •   Ministry of health policymakers
                             •   Health-care providers
                             •   Medical and health associations
                             •   Legal professionals
                             •   Women’s advocacy groups
                             •   Media
                             •   Academic institutions and professional groups
                             •   National and international non-governmental organizations
                             •   Religious groups
Addressing Unsafe Abortion
in Africa

Module 6
                             How Can Policymakers Increase
                             Access to Safe Abortion Services?



                             Policymakers can:
                             • Clarify legal grounds for offering safe
                               abortion services
                             • Remove administrative and regulatory
                               barriers to safe services
                             • Establish or improve national norms
                               and standards
                             • Broaden the definition of providers who
                               can offer services
Addressing Unsafe Abortion
in Africa

Module 6
                             How Can Health-Care Workers Increase
                             Access to Safe Abortion Services?




                             Health care workers and managers can:
                             • Establish and maintain high quality services
                             • Monitor and evaluate abortion services
                             • Supervise health care personnel providing abortion
                             • Determine training needs
                             • Address cost issues, including setting
                               reasonable user fees


Addressing Unsafe Abortion
in Africa

Module 6
                             How Can Advocates Increase
                             Access to Safe Abortion Services?



                             Women’s health advocates can:
                             • Review governmental compliance with
                               international agreements, and advocate for ratification
                               of the Protocol on the Rights
                               of Women in Africa
                             • Clarify legal grounds for abortion
                             • Advocate to remove administrative and regulatory
                               barriers to safe services
                             • Inform women about the abortion law
                               and available services

Addressing Unsafe Abortion
in Africa

Module 6
                             How Can the Media and Professional Groups
                             Increase Access to Safe Abortion Services?




                             Media can:
                             • Disseminate accurate information
                             • Inform public opinion
                             • Educate the general public about safe services

                             Academic institutions and professional groups can:
                             • Train health professionals
                             • Advocate for clear norms and policies

Addressing Unsafe Abortion
in Africa

Module 6
                             What Can Be Done?



                             Depending on the national situation, priorities for action
                             may include the following:

                              • Establish national (clinical and procedural) norms or
                                guidelines for all legal indications of abortion
                              • Identify and remove barriers in existing policies or practices
                              • Train existing providers and/or new categories of providers
                                in clinical and interpersonal skills
                              • Ensure sustainable equipment and drug supply
                              • Authorize additional reproductive health professionals
                                as abortion providers
                              • Inform women about their rights under the law

Addressing Unsafe Abortion
in Africa

Module 6
                             Thank you!




Addressing Unsafe Abortion
in Africa

				
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