Improving Access to Safe Abortion

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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
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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 Africaand
  encourage 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.
Contact Email ipas_publications_at_ipas.org
Web www.ipas.org Email pubs_at_familycareintl.org
Web www.familycareintl.org
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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 Africa
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Unsafe Abortion in Context

• Module 1

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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

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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

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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 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

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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 are 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
Addressing Unsafe Abortion in Africa
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

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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

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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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Other International Commitments

• Protocol on the Rights of Women in Africa
• Adopted July 2003 by African Union
• Calls for states to authorize abortion in
  cases of sexual assault, rape, incest, and where
  the continued pregnancy endangers the mental and
  physical health of the mother or the life of the
  mother or the unborn child.

The protocol will come into force when ratified
by 16 countries
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Other International Commitments

• Maputo Plan of Action
• Seeks to take the continent forward towards the
  goal of universal access to comprehensive sexual
  and reproductive health services in Africa by
  2015
• Built on nine action areas, including unsafe
  abortion
• Areas of action for unsafe abortion
• Advocacy/policy
• Capacity building
• Service delivery

Special Session of the African Union Conference
of Ministers of Health Maputo, Mozambique
September 2006
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Legal Context

• Module 3

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Legal Status andAvailability 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)

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Legal Status of Abortion

• All countries in Africa allow abortion in some
  situations
• To save the womans 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

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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
• 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 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.

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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 byDuration 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
  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

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Involving Different Cadres of Providers

• Mid-level health workers can be trained to
  provide safe early abortion services
• In many African countries, doctors are scarceor
  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

Nurses, midwives, clinical officers,and others
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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 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, and advocate for ratification of the
  Protocol on the Rightsof 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

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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

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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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Thank you!
Addressing Unsafe Abortion in Africa