FINAL Africa

Improving Access to Safe Abortion: 

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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Contact: Email: ipas_publications@ipas.org Web: www.ipas.org Email: pubs@familycareintl.org Web: www.familycareintl.org 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 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. September 2005 *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: 

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: 

Unsafe Abortion in Context Module 1

Unsafe Abortion in Africa: 

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 Module 1 Addressing Unsafe Abortion in Africa

Unsafe Abortion in Context: 

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

The Context: Wanted Pregnancy: 

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

The Context: Unwanted Pregnancy: 

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 Module 1 Addressing Unsafe Abortion in Africa

Legal Status and Demand for Abortion: 

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 are available, deaths and disability from abortion are greatly reduced

Abortion Restrictions and Maternal Mortality: 

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 Addressing Unsafe Abortion in Africa

Impact of Unsafe Abortion: 

Module 1 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

Impact of Unsafe Abortion: 

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

International Agreements: 

International Agreements Module 2

International Obligations : 

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

International Obligations: 

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 Module 2 Addressing Unsafe Abortion in Africa

International Obligations: 

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 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 Addressing Unsafe Abortion in Africa

Millennium Development Goals: 

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. member states following the Millennium Summit, held in 2000. Module 2 Addressing Unsafe Abortion in Africa

Other International Commitments: 

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 Module 2 Addressing Unsafe Abortion in Africa

Legal Context: 

Legal Context Module 3

Legal Status andAvailability of Abortion: 

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) Module 3 Addressing Unsafe Abortion in Africa

Legal Status of Abortion: 

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 Module 3 Addressing Unsafe Abortion in Africa

Barriers to Access: 

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 Addressing Unsafe Abortion in Africa

WHO Provides Leadership and Guidance: 

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 Addressing Unsafe Abortion in Africa

Clinical Services: 

Clinical Services Module 4

Clinical Services: 

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 Module 4 Addressing Unsafe Abortion in Africa

Before the Procedure: 

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

Information and Counselling: 

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

Preferred Methods of Abortionup to 9 Completed Weeks: 

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

Misoprostol Alone for Induced Abortion through 9 weeks: 

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%. Module 4 Addressing Unsafe Abortion in Africa

Preferred Methods of Abortionbetween 9 and 12 Completed Weeks: 

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 Module 4 Addressing Unsafe Abortion in Africa

Abortion After 12 Weeks: 

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

Preferred Methods of AbortionAfter 12 Weeks: 

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

Methods of Abortion byDuration of Pregnancy: 

Methods of Abortion by Duration of Pregnancy Module 4 Addressing Unsafe Abortion in Africa

Clinical Issues for Abortion : 

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 Addressing Unsafe Abortion in Africa

Follow-up Care for Abortion : 

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

Management Issues: 

Management Issues Module 5

National Norms and Standards: 

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 Module 5 Addressing Unsafe Abortion in Africa

Involving Different Cadres of Providers: 

Involving Different Cadres of Providers Mid-level health workers* can be trained to provide safe early abortion services In many African 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 medication abortion can be used at all levels of the health system *Nurses, midwives, clinical officers, and others Module 5 Addressing Unsafe Abortion in Africa

Overcoming Barriers to Access: 

Overcoming Barriers to Access Module 6

Creating an Enabling Environment: 

Module 6 Creating an Enabling Environment 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

Creating an Enabling Environment: 

Module 6 Creating an Enabling Environment 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

Creating an Enabling Environment: 

Creating an Enabling Environment Information barriers Women are unaware of the circumstances under which abortion services are legal Cost barriers Abortion services are expensive All barriers can be overcome with dedicated resources and political will. Module 6 Addressing Unsafe Abortion in Africa

Influencing Policy and Practice: 

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 Module 6 Addressing Unsafe Abortion in Africa

How Can Policymakers Increase Access to Safe Abortion Services?: 

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 Addressing Unsafe Abortion in Africa

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

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

How Can Advocates Increase Access to Safe Abortion Services?: 

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 Module 6 Addressing Unsafe Abortion in Africa

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

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

What Can Be Done?: 

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 Module 6 Addressing Unsafe Abortion in Africa

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