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UNSAFE ABORTION AND CONTRACEPTION
IN GHANA
EMMANUEL SK MORHE
MB.ChB, FWACS, FGCS, MPH 8/9/2012
Unsafe abortion and contraception
Outline of presentation
8/9/2012
Definition
Unsafe abortion a public health problem
Value of contraception in the management
Outline the way forward
Capacity building for advocacy, training, service provision
and research in integrating contraception into maternity
and abortion care
Definitions
8/9/2012
Unsafe Abortion is a procedure for terminating an
unwanted pregnancy, carried out either by a person
lacking the necessary skills or in an environment lacking the
minimal medical standards, or both.
Contraception simply means prevention of pregnancy.
A contraceptive is a medication or device that is used to
prevent pregnancy.
Unsafe Abortion
8/9/2012
A major Public health problem in Ghana
Major cause of maternal and child morbidity and mortality
12% of maternal deaths in KBTH and KATH
Commonest cause of admissions to emergency Gynaecology wards (~40 %).
A lot of man-hours, hospital ward space and supplies go into managing abortion complications.
Huge economic cost to individuals, families and the nation.
.
8/9/2012
.
010
20
30
40
FR
EQ
UE
NC
Y
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
YEAR
Haemorrhage Hypertensive diseases
Abortions Genital tract infections
Obstructed labour/ Ruptured uterus Ectopic pregnancy
TRENDS IN DIRECT CAUSES OF MATERNAL DEATHS-KATH(1998-2007)
Kwawununu et al, 2011
Abortion Morbidity
In KBTH of 212 induced abortions
17.6% had blood transfusions,
56% spent 1-3 days
24.3% spent 7 days or more in hospital (Lassey, 1995)
In KATH of 252 cases
21.0% had blood transfusions,
26.2% had pelvic or generalized peritonitis,
5.6% impaired organ function,
1.2% perforated uterus ( Damalie, 2010 )
8/9/2012
Complications of unsafe abortion in Ghana
Incomplete abortion
Vaginal bleeding /Hypovolaemic shock
Visceral injuries:
lacerations, perforation of uterus, bladder, intestines
Sepsis
Septicaemia/septic shock
Peritonitis /Pelvic abscess
Acute poisoning (Pesticides)
Multiple organ failure
Death
Pelvic pain and dyspareunia
Tubal Infertility
Cervical weakness Recurrent spontaneous abortions
Preterm labour
Ectopic pregnancy
Vesicovaginal or rectovaginal fistula
Anxiety and Depression
Psychological trauma
8/9/2012
Acute clinical complications Chronic clinical complications
Methods employed in unsafe abortion
8/9/2012
Foreign bodies e.g. sticks and metal objects.
Drinking herbal concoctions and poisonous chemicals.
Vaginal insertion of herbal preparations or chemicals. which are often corrosive.
Taking high doses of over-the-counter medications.
Conventional methods
Misoprostol (Cytotec) (currently most common)
Surgical dilation and curettage/MVA by untrained personnel
Intra-amniotic injection of concentrated salt solution
NB: Methods vary across the country
Who are the providers of unsafe abortion?
chemical sellers/
pharmacist38%
Nurse/midwife
20%
Physicians12%
Self-induced
11%
'Quack' doctors
16%
Others)3%
Distribution of induced abortion by provider in Southern Ghana
0
10
20
30
40
50
60
70
80
%
8/9/2012 Ahiadeke, 2001
Source of data: Damalie 2010
Who are victims?
0
10
20
30
40
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Age Group
Distribution of abortion by age at last induced abortion
Women with less formal
education
Married< not married;
Parous<nulliparous;
Diverse religious
backgrounds
Christians/Moslems/Afric
an Traditionalist
Diverse cultural and
ethnic background
8/9/2012
Ahiadeke 2001, Konney et al, 2009; Srofenyo and Lassey, 2003; Turpin et al, 2002
perc
enta
ges
Factors contributing to unsafe abortion in Ghana (I)
8/9/2012
Social Stigma of abortion
practitioners, clients and civil society
Religion and cultural believes and norms
Lack of committed leadership/political will
Many years of restrictive laws.
Even today the law criminalizes abortion.
Ignorance of the existing laws.
practitioners and general population
Factors contributing to unsafe abortion (II)
8/9/2012
Late policy development on CAC.
CAC standards and protocols came in 2006
Poor implementation of health policies.
Poor health services infrastructure
Lack of trained personnel
Inadequate contraceptive services
Lack of empowerment of women.
Poverty, deprivation and socio-cultural norms
How do we address the problem of unsafe abortion?
8/9/2012
Prevent unwanted pregnancy
Contraception/HTSP
Manage unwanted pregnancy
CAC model
Manage complications of unsafe abortion
PAC model
Contraception is of central value
(1)PAC model: Treat unsafe abortion complications
8/9/2012
Promote PAC as an effective public health strategy
Emergency treatment: EOU/Antibiotics/Transfusion
Counselling psychosocial or emotional support
Postabortion family planning.
provide family planning on the gynecologic w ard
Link to other reproductive health services
Screening and treatment of STIs, cervical cancer.
Community and Service Provider Partnerships
In treatment, prevention and advocacy efforts including
mobilization of resources
Address emotional and physical health needs of women PAC in Action, 2002, No. 2
(2) CAC model: Manage unsafe abortion
8/9/2012
Includes all components of PAC model.
Plus elective abortion care by trained personnel (to
the extent allowed by law).
The law:
I. To protect life of the woman
II. To protect physical and mental health of the woman
III. Rape, defilement or incest
IV. For fetal malformation incompatible with life
CAC is based on evidence
Evidence in support of CAC: Abortion Mortality: Abortion is safer the earlier in pregnancy it is performed
0.6
1.7
3.4
8.9
0.40.1 0.2
7.1
0
2
4
6
8
10
<9 9–10 11–12 13–15 16–20 21+ All
abs.
Births
Sources: All births and abortions: Grimes DA, 2006;
Abortion by gestation: Bartlett et al., 2004 (1988–1997 data)
Deaths per 100,000
Abortions by gestation
Some CAC implementation principles in Ghana
8/9/2012
I. CAC is an integral part of RH care
II. Right to access service.
III. Thorough clinical evaluation and procedural
documentation required.
IV. Right to privacy and confidentiality.
V. Partner or spousal consent may be encouraged
but not mandatory.
VI. A method of contraception should be accepted or
acceptable to the client.
CAC: Specific Policies
8/9/2012
I. Abortion is not and shall not be used as family
planning method in Ghana
II. For Rape, defilement or incest legal evidence not
required for abortion care.
III. Pregnancy in a minor <16 years is considered as a
result of statutory rape.
IV. A parent or an adult acting in loco parentis can give
consent on behalf of the minor <18 years.
V. No psychiatric assessment required to establish
mental or emotional distress.
Policies: Conscientious Objection
8/9/2012
Refusal to carry out procedure based on moral, religious or ethical grounds.
Only those directly involved in performing abortion procedure can claim conscientious objection.
A service provider claiming conscientious objection has the duty of care to refer the client to an accessible provider.
No provider has the right to conscientious objection in an
emergency situation.
No individual may claim conscientious objection if the client
is below 18 years ( Children’s Act 1998, Act 560).
Elective abortion care:
Surgical method
8/9/2012
MVA: Recommended up to 12 weeks
EVA: Recommended < 12 weeks
D&E for second trimester terminations
Need osmotic dilators e.g. laminaria/dilapan (not
available in Ghana)
D&C no longer recommended, reserved for well
trained providers.
Medical Abortion:< 9 weeks
Misoprostol and
Mifepristone
Misoprostol alone
800ug Misoprostol
Vaginally
Repeat after 3-6 hours
Up to 3 doses
8/9/2012
200 mg Mifepristone
800ug Misoprostol
vaginally
400ug Misoprostol
orally
36-48 hrs. later plus
Efficacy 96-98% Efficacy 88%
or
(3) Prevent unwanted pregnancy:
Family planning & contraception in Ghana
8/9/2012
First introduced in Ghana in early 1960s by the
Christian council of Ghana
Modern contraception by PPAG/IFPP in 1966
Funded by USAID
National population policy in 1969
Focus on population growth and GDP for development
Research e.g. UG, Danfa and later Navrongo
Amended in 1994 to reflect actions plans on RH at ICPD
Cairo 1994
Evidence based message for HTSP:
Return to fertility after pregnancy
8/9/2012
A woman can become pregnant before her menses
returns after pregnancy
If not on contraception,
as early as 4 weeks postpartum when not breastfeeding;
as early as 6 weeks postpartum if she regularly
breastfeeds and also gives her baby other food on
regular basis;
From 6 months after delivery if she practices LAM
As early as 2 weeks after first trimester abortion or
miscarriage
Target Audience for HTSP
contraceptive message ?
8/9/2012
Adolescents Avoid pregnancy before 18 years of age
Newly married couples Should plan when to become pregnant
Pregnant women Should plan birth control while pregnant
Postpartum Women Choose a method
Postabortion women Go home with a method
Source : Contraceptive Technology Update Series
8/9/2012
Source : Contraceptive Technology Update Series
8/9/2012
Challenges of contraception and abortion care
8/9/2012
• Lack of capacity
Sustainability of procurement and resupply of
MVA instruments and Contraceptives
• Ensuring high-quality and accessible services
Social, religious, policy and legal restrictions.
Provider bias in offering contraception after pregnancy
Inadequate state investment in contraception
Way forward
We need leaders with vision and passion
Public-private partnerships in building capacity
Services by public and private
Contraception and PAC/CAC
Training
Middle level staff
Physicians/Specialists/Fellows (IFPFP/GCPS)
Research
Intervention projects (IFPFP)
Good record keeping
Advocacy
Key partners: MOH, GHS, Teaching Hospitals, GCPS,
IFPFP, ACNM, R3M partners:
Use health services research evidence to improve family
planning services
Inadequate RH services
8/9/2012
Pong Tamale Health Center • 10 deliveries/month • Staffed by 2
midwives • Refer 100% of
PAC/CAC • LARC provision
Tamale Teaching Hospital • 2006-2007: sepsis leading
cause of death • 1 death/month from abortion
related complications • Received 20 referrals for
PAC/month
Savelugu Hospital • Labor/delivery unit • Recently added c-sections • Staffed by 7 midwives, 1 MD • Referral of almost all PAC • Referral of 100% CAC • No LARC provision
IFPFP baseline needs assessment, 2010
Integration of GCPS Family Planning Fellowship/IFPFP
with other reproductive health projects in Ghana
ACNM in Kumasi, 2010 FP fellows teach midwifery students
Private midwives as preceptors for FP
and CAC Queen mothers association
Summary: Positive national RH policies and initiatives
8/9/2012
• National contraception protocols
• Wide range of contraceptives are available
• Abortion law liberalized since 1985
• Abortion care to be provided to full extent as
permitted by law in 2003
• CAC abortion standards and protocols
developed in 2006
• Midwives included in abortion care to
increase capacity
Summary
8/9/2012
Total population is 24 million
Modern Contraceptive prevalence rate, 17%
Unmet need for contraception 35%
Pregnancies unwanted or mistimed 40%
MMR 350/100,000 live births
59% of births assisted by skilled attendants
Maternal deaths from unsafe abortion 12%
GDHS 2008, GMHS 2007
http://www.justmaps.org/maps/africa/ghana/
Conclusions
8/9/2012
We cannot continue to ignore the fact that
women die everyday from unsafe abortion and many more
severe ill-health
The options for unwanted pregnancy are difficult choices that
may be painful and may hurt the woman physically,
emotionally and spiritually.
Unwanted pregnancy is often a consequence of bad choice of
not using effective contraception.
We need dispassionate deliberations, careful planning
and resolute implementation of evidence based
interventions to address the problem.
Recommended