Asia

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

Contact:

Email: [email protected] Web: www.ipas.org

Email: [email protected] Web: www.familycareintl.org

Prepared by Ipas and Family Care International (FCI) to promote greater understanding of the challenge of unsafe abortion in Asia and measures to make abortion services safe and accessible to the full extent of the law, based on international guidance from the World Health Organization (WHO)*. Ipas and FCI are solely responsible for the contents of this presentation, which may be used or abstracted without prior permission.

February 2007

*World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2003.

Improving Access to Safe Abortion

Guidance on Making High Quality Services Accessible

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 Asia

Unsafe Abortion in Context

Module 1

Unsafe Abortion in Asia

• Asian countries have a wide range of laws and practices regarding abortion

• Asia has the highest number of deaths caused by unsafe abortion of any region (about 34,000 each year, over 90 each day)

• In Asia, unsafe abortion accounts for 13% of maternal deaths

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


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


The Context: Unwanted Pregnancy

Module 1

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

Definition: Unsafe abortion is the termination of a pregnancy carried out by someone without the skills or training to perform the procedure safely, or in a place that does not meet minimal medical standards, or both. (According to WHO, and endorsed by the UN)

Module 1

Legal Status and Demand for Abortion

• Legally restricting abortion does not necessarily reduce the number of abortions that occur in a country

• The legal status and availability do affect the safety of abortion; where abortion is legal and safe services available, deaths and disability from abortion are greatly reduced

Abortion Restrictions and Maternal Mortality

McKay, HE, Rogo, KO Dixon, DB. 2001. FIGO society survey: acceptance and use of new ethical guidelines regarding induced abortion for non-medical reasons.

International Journal of Gynecology and Obstetrics 75: 327-336.Module 1

Module 1

Impact of Unsafe Abortion

• The deaths caused by unsafe abortionare preventable

• Abortion performed in sanitary conditions by a skilled provider is an extremely safe procedure

• Safe abortion is much safer than childbirth

Module 1

Impact of Unsafe Abortion

In addition to death, unsafe abortion in Asia 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

International Agreements

Module 2

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 providethese services



ICPD…In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion.

Paragraph 8.25Programme of Action, International Conference of Population and Development, Cairo, 1994

Module 2



ICPD +5…In circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health.

Paragraph 63(iii)

Module 2

Key Actions for the Further Implementation of the ICPD Programme of Action, 21st United Nations General Assembly Special Session, New York, 1999


Millennium Development Goals

MDG 5 Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio

• In some settings, reducing unsafe abortion may be technically the easiest way to reduce maternal deaths as mandated by MDG 5

• Unsafe abortion can be reduced through comprehensive sexual and reproductive health education, high quality contraceptive services, and safe abortion services

The MDGs were approved by U.N. memberstates following the Millennium Summit, held in 2000.

Module 2


Legal Context

Module 3

Legal Status andAvailability of Abortion

Asia 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

Module 3


Legal Status of Abortion

All countries in Asia allow abortion in some situations:

• To save the woman’s life – 100% of Asian countries

• To preserve physical and mental health – 63% of Asian countries

• In cases of rape or incest – 48% of Asian countries

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

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

Module 3


WHO Provides Leadership and Guidance

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

Module 3

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


Clinical Services

Module 4

Clinical Services

Module 4

The WHO Guidance specifies that abortion services should be:

•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


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


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


Module 4

Preferred Methods of Abortionup 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


Misoprostol is widely available, at low cost. WHO does not yet have a recommendation for a preferred treatment regimen.

Two expert groups provide recommendations for misoprostol use exist.

These documents recommend between 2 and 3 doses, repeated every 6-24 hours:

• Until 12 weeks, use 800 mcgs vaginally.• Between 13-15 weeks, use 400 mcgs vaginally.• Between 16 and 20 weeks, use 200 mcgs vaginally.

Misoprostol Alone for Induced Abortion through 9 weeks

Module 4


Success rates have been observed to be 85-90%

Preferred Methods of Abortionbetween 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

Module 4


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


Module 4

Preferred Methods of AbortionAfter 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


Methods of Abortion by Duration of Pregnancy

Module 4


Vacuum aspiration (manual/electric)

Mifepristone andmisoprostol (or gemeprost)

Dilatation and curettage

(underinvestigation)

(by specially trained providers)

Dilatation and evacuation

Mifepristone and repeated doses of misoprostol or gemeprost

Vaginal prostaglandins (repeated doses)

Hypertonic solutions

Intra/extra-amniotic prostaglandins

Figure 2.1 Methods of abortion

Completed weeks since last menstrual period

Preferred methods

Other methods

222120191817161514131211104 95 6 7 8

Clinical Issues for Abortion

Module 4

Pain management and emotional support should be offered to all women

• Comfort and support

• Tranquilizers

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

• Analgesics

• Anaesthetics


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 Asia

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 willbe 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 services, and other provider obligations

Module 5


Involving Different Cadres of Providers

• Mid-level health workers* can be trained to provide safe early abortion services

• In many countries, doctors are scarce or not well distributed in rural areas

• Offering abortion at the primary and secondary levels can make services more accessible

• MVA and medical methods of abortion can be used at all levels of the health system

*Nurses, midwives, clinical officers,and others

Module 5


Overcoming Barriers to Access

Module 6

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


Module 6


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



Possible information barriers:

• Women are unaware of the circumstances underwhich abortion services are legal

Possible cost barriers:

• Abortion services are expensive

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

Module 6


Influencing Policy and Practice

Many groups and individuals have a role in 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

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

Module 6


Module 6

How Can Health-Care WorkersIncrease 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


How Can Advocates Increase Access to Safe Abortion Services?

Women’s health advocates can:

• Review governmental compliance withinternational agreements

• Clarify legal grounds for abortion

• Advocate to remove administrative and regulatory barriers to safe services

• Inform women about the abortion law and available services

Module 6


Module 6

How Can the Media & ProfessionalGroups 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


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 providersin 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

Module 6


Thank you!


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