Improving Access to Safe Abortion

1
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
2
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 Europe 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

Contact Email Ipas_publication_at_ipas.org Web
www.ipas.org Email pubs_at_familycareintl.org Web
www.familycareintl.org
World Health Organization. Safe Abortion
Technical and Policy Guidance for Health Systems.
Geneva WHO, 2003.
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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 Europe
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Unsafe Abortion in Context

• Module 1

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Unsafe Abortion in Europe

• In most countries of Europe, abortion is
  available on broad legal grounds and is usually
  performed by trained health-care providers
• In Europe, about 300 women die every year due to
  complications from unsafe abortions
• Unsafe abortion accounts for 20 of maternal
  deaths

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Unsafe Abortion in Context

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

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The Context Wanted Pregnancy

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

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The Context Unwanted Pregnancy

• Many women do not want to become pregnant,
  because of
• Personal reasonsHealth 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

Module 1
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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

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
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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
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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
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Impact of Unsafe Abortion

• In addition to death, unsafe abortion in Europe
  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

Module 1
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International Agreements

• Module 2

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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

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International Obligations

• 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 8.25

Programme of Action, International Conference of
Population and Development, Cairo, 1994
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International Obligations

• 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 womens health.
• Paragraph 63(iii)

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

• Module 3

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Legal Status andAvailability of Abortion

• Europe 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

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Legal Status of Abortion

• Almost all countries in Europe allow abortion in
  some situations
• To save the womans life 98 of European
  countries
• To preserve physical and mental health 95 of
  European countries
• In cases of rape or incest 93 of European
  countries
• Countries should offer safe abortion services in
  all circumstances permitted by law

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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, including formal and informal fees
• Societal, cultural and religious attitudes,
  including stigma
• Where safe abortion is not available, women seek
  unsafe services

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WHO Provides Leadership and Guidance
Available athttp//www.who.int/reproductive-heal
th/publications/safe-abortion/safe-abortion.html
In response to the international mandate, WHO
developed Safe Abortion Technical and Policy
Guidance for Health Systems
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Clinical Services

• Module 4

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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

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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

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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

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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

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Misoprostol Alone for Induced Abortion

• 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.

Success rates have been observed to be 85-90
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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

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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

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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

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Methods of Abortion by Duration of Pregnancy
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Clinical Issues for Abortion

• 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

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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.

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Management Issues

• Module 5

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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 services, and other provider
  obligations

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Involving Different Cadres of Providers

• Non-specialists can be trained to provide safe
  abortion services
• In many countries, ob-gyns and other 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

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Overcoming Barriers to Access

• Module 6

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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 DC)
  are still used
• Drugs needed for medical abortion are not
  approved or available

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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

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Creating an Enabling Environment

• 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.

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Influencing Policy and Practice

• Many groups and individuals have a role in making
  policies and practices more responsive to
  womens needs
• Ministry of health policymakers
• Health-care providers
• Medical and health associations
• Legal professionals
• Womens advocacy groups
• Media
• Academic institutions and professional groups
• National and international non-governmental
  organizations
• Religious groups

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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

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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

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How Can Advocates Increase Access to Safe
Abortion Services?

• Womens 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

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How Can the Media 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

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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

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

• Thank you!

Addressing Unsafe Abortion InEurope