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- 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. Contact: Email: Ipas_publication@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 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
- 3. 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
- 4. Unsafe Abortion in Context Module 1
- 5. 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
- 6. 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 Asia
- 7. 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 Asia
- 8. 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
- 9. 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
- 10. 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
- 11. 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
- 12. 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
- 14. 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 Asia
- 15. 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 Asia
- 16. 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 Asia
- 17. 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 Asia
- 19. Legal Status and Availability 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 Addressing Unsafe Abortion In Asia
- 20. 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 Addressing Unsafe Abortion In Asia
- 21. 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 Asia
- 22. 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 Asia
- 24. 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 Addressing Unsafe Abortion In Asia
- 25. 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 Asia
- 26. 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 Asia
- 27. 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 methodAddressing Unsafe Abortion In Asia
- 28. 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 Addressing Unsafe Abortion In Asia Success rates have been observed to be 85-90%
- 29. 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 Asia
- 30. 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 Asia
- 31. 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 Asia
- 32. Methods of Abortion by Duration of Pregnancy Module 4 Addressing Unsafe Abortion In Asia Vacuum aspiration (manual/electric) Mifepristone and misoprostol (or gemeprost) Dilatation and curettage (under investigation) (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
- 33. 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 Asia
- 34. 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
- 36. 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 Addressing Unsafe Abortion In Asia
- 37. 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 Addressing Unsafe Abortion In Asia
- 38. Overcoming Barriers to Access Module 6
- 39. 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 availableAddressing Unsafe Abortion In Asia
- 40. Module 6 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 abortionAddressing Unsafe Abortion In Asia
- 41. Creating an Enabling Environment Possible information barriers: • Women are unaware of the circumstances under which abortion services are legal Possible cost barriers: • Abortion services are expensive All barriers can be overcome with dedicated resources and political will. Module 6 Addressing Unsafe Abortion In Asia
- 42. 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 Addressing Unsafe Abortion In Asia
- 43. 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 Asia
- 44. 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 Addressing Unsafe Abortion In Asia
- 45. How Can Advocates Increase Access to Safe Abortion Services? Women’s health advocates can: • Review governmental compliance with international 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 Addressing Unsafe Abortion In Asia
- 46. 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 Addressing Unsafe Abortion In Asia
- 47. 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 Asia
- 48. Thank you! Addressing Unsafe Abortion In Asia
Editor's Notes
- Speaker's Notes: Abortion occurs commonly, yet it is stigmatized and hidden. This presentation describes the problems associated with unsafe abortion in Asia, and outlines strategies to address these problems. I will begin by sharing information about abortion and unsafe abortion, and the international agreements that deal with this issue. Then, I will discus how to offer safe abortion services—specifically focusing on clinical issues, how to organise services, and policy barriers. Recommendations here are based primarily on the World Health Organization’s 2003 document: Safe Abortion: Technical and Policy Guidance for Health Systems. Additional Resources: You should feel free to customise the presentation, selecting modules or slides to best fit the purpose of the presentation and the interests of the audience. Some suggested versions of the slide presentation are available in the User’s Guide, which is included on this CD-ROM. The User’s Guide provides suggestions on which slides to select for health care providers, policymakers, advocates, and media. This is also an appropriate time to inform your audience of rules for the presentation, such as whether questions should be asked at any time or saved until the end of the presentation.
- Speaker’s Notes: The presentation was prepared by Ipas and Family Care International (FCI) to promote greater understanding of the challenge of unsafe abortion and encourage measures to make abortion services safe and accessible to the full extent of the law. Ipas and FCI are solely responsible for the contents of this presentation.
- Speaker's Notes: This presentation contains six modules, covering: Context and general information on unsafe abortion International agreements Legal issues Clinical services Management issues Overcoming barriers to access
- Speaker’s Notes: The next slides review: Regional and global statistics on unsafe abortion; The context in which unsafe abortions take place; Reasons why women may seek abortions for both wanted and unwanted pregnancies; The relationship between legal status and demand for abortion; The links between unsafe abortion and maternal mortality; and Its impact on women, their partners and families, and communities.
- Speaker’s Notes: Asia is perhaps the world’s most diverse region when it comes to laws and practices regarding abortion. In many parts of Asia, women experiencing an unwanted pregnancy face great difficulty in obtaining safe, high-quality abortion services, and must seek abortions performed in clandestine, and often unsafe, conditions. It is estimated about 34,000 women die each year from complications related to unsafe abortion in Asia, accounting for 13% of all deaths from the complications of pregnancy and childbirth. [1] The stigma around abortion makes it difficult to gather data on this issue, however, and numbers may in fact be much higher. It is important to note that almost all deaths from unsafe abortion in this region occur in South, South-Eastern and Western Asia. In Eastern Asia, including China and Vietnam, where abortion is generally legal and safe, abortion services are relatively accessible to most women who seek them, the incidence of unsafe abortion is low and abortion-related deaths are extremely rare. [1] Additional Resources:Of the 46 million abortions that are estimated to take place annually around the world, at least 19 million are unsafe. Nearly 68,000 women die every year from complications related to unsafe abortion throughout the world, accounting for 13% of all maternal deaths [2]. Customising this slide:You can customise this slide (or add an additional slide) with facts such as: Abortion and unsafe abortion rates in your country or region; Anecdotal information on unsafe abortion in your country or region; Percentage of women in main ob/gyn hospitals admitted for abortion-related complications; etc. Regional or national percentages of how many maternal deaths are attributable to unsafe abortion. Reference: World Health Organization, Unsafe abortion: Global and regional estimates of incidence of unsafe abortion and associated mortality in 2000 – Fourth edition (Geneva: WHO, 2004), available at: http://www.who.int/reproductive-health/publications/unsafe_abortion_estimates_04/estimates.pdf World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at: http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf.
- Speaker’s Notes: Regardless of legal status or other factors, abortions take place worldwide. The injustice is that almost all unsafe abortions take place in developing countries (and countries “in transition,” such as those in Eastern Europe and the former Soviet republics). Indeed, almost no unsafe abortions take place in developed countries, where safe abortion is generally more available under the law. [1] There is no “typical abortion seeker”—abortions occur in all age groups, and a wide range of women, married and unmarried, with and without children, seek abortions.. Additional Resources: Abortions occur in all age groups: “[Based on studies from 56 countries] the highest proportion of abortions occurs among women aged 20-24 and 25-29.” [2]. However, this pattern reflects in large part lower fertility rates among women who are either younger than 20 years of age or are older than 30. When those younger and older women do get pregnant, they are more likely to seek abortions, and therefore have a higher ratio of abortion per pregnancy, although a lower rate of abortion overall. Both married and unmarried women, with and without children, may seek abortion: A diverse range of women seek abortions; generally, the profile tends to vary by region, and depends on a number of factors, including average age of marriage, prevalence of pre-marital sexual activity, access to contraception, preferred family size, and so on. There are many reasons why a married woman might want to terminate a pregnancy (see next slide) [2]. Definitions: Abortion Rate: The number of abortions out of a total number of women of reproductive age. Abortion Ratio: The number of abortions out of a total number of pregnancies. Customising this slide: Use local studies to illustrate the situation in your country. Often, audiences have preconceived ideas about who is affected by abortion (such as primarily adolescents or unmarried women), so it can be useful to demonstrate that a wide range of women have abortions. References: 1. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at:http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf. 2. Bankole, A., S. Singh and T. Haas, “Characteristics of Women Who Obtain Induced Abortion: A Worldwide Review,” International Family Planning Perspectives 25 (June 1999), available at: http://www.agi-usa.org/pubs/journals/2506899.html.
- Speaker’s Notes: Women may wish to terminate wanted and unwanted pregnancies. For example, even when a woman wants a child, she may feel the need to end the pregnancy because it threatens her health or survival; or the foetus has an abnormality. Or, she may feel pressured by shame, stigma, disapproval from her partner, family or community, or even government policies. Additional Resources: Wanted pregnancy: Pregnancy may not be supported by the woman’s family or community. Certain women – such as those who are young, old, unmarried, in school, and/or with children already – may find that their parents, community members, religious institutions, and even their partners do not approve of their pregnancies. In these circumstances, they may feel pressured to end the pregnancy. In some Asian countries, such as China, Bangladesh, and Korea, where the preference for sons is strong and the technology for determining the sex of the fetus is available, sex-selective abortion may be relatively common. [1] Pregnancy may threaten the woman’s health or survival. For instance, she may have a health condition such as diabetes, malaria, renal problems, or some types of heart disease, that could be made worse by carrying the pregnancy to term. Customising this slide: This slide can be customised according to the situation in your country or region. References: Bairagi, R., “Effects of Sex Preference on Contraceptive Use, Abortion and Fertility in Matlab, Bangladesh” International Family Planning Perspectives 27 (September 2001), available at http://www.agi-usa.org/pubs/journals/2713701.html.
- Speaker’s Notes: Many women do not want to get pregnant, for a wide range of reasons. Yet, millions of unplanned pregnancies occur each year, because: women do not have access to or use contraception. This may be because of lack of supplies, poor information, and other factors; contraceptive methods sometimes fail, even when they are used correctly; many women experience forced or coerced sex which results in pregnancy. Adolescents are particularly vulnerable to unwanted pregnancy because they tend to have less information about sexuality and contraception, less access to services, and fewer resources to manage their health care. [1, 2] Additional Resources: 120-150 million women worldwide want to delay or limit childbirth but do not use contraception. This figure comes from Demographic and Health Surveys and reflects those women (in union or married) who state that they either want no more children or want to delay having their next child, but are not using a method of family planning (that is, they have an “unmet need for family planning”). They may not be using family planning for a variety of reasons, such as: A lack of access to family planning services (particularly affordable, culturally appropriate services). More than 350 million women around the world do not have access to family planning services; Beliefs that contraceptive methods are unsafe or unsuitable for them; The cost of family planning; or Opposition to family planning from their partners or other family members, among other factors. [1] “In the majority of African and Middle Eastern countries studied and in a large number of countries in Asia, Latin America, and the Caribbean, at least 20 percent of married women of reproductive age had an unmet need for contraception. The countries with the highest percentage of women with unmet need are in Sub-Saharan Africa: Rwanda (37 percent), Malawi (36 percent), and Kenya (36 percent).” [2] Contraceptive methods fail. It is estimated that, globally, over 26 million pregnancies occur in couples using contraception each year. [3] Many women experience forced or coerced sex. Representative data are hard to come by, but it is clear from numerous small studies in countries around the world that rape and sexual coercion are all too common. Most victims already know the person attacking or coercing them. Some estimates suggest that as many as one in four women will experience sexual violence at the hands of an intimate partner during her lifetime. Rape is also common in situations of war or ethnic conflict. [4] Customising this slide: This slide can be customised according to the situation in your country or region by adding DHS data on fertility, preferred family size, and unmet need. [5] You can also include/discuss unique circumstances contributing to abortion-seeking, such as strong bias towards boy children, etc. References: 1. Johns Hopkins University Center for Communications Programs, “Meeting Unmet Need: New Strategies,” Population Reports XXIV/1 available at http://www.infoforhealth.org/pr/j43edsum.shtml. 2. RAND Corporation, The Unmet Need for Contraception in Developing Countries, Population Matters Policy Brief (Santa Monica, CA: Rand, 1998), available at http://www.rand.org/publications/RB/RB5024/. 3. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at: http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf. 4. World Health Organization, The World Report on Violence and Health (Geneva: WHO, 2002), available at http://www.who.int/violence_injury_prevention/violence/world_report/en/. 5. DHS reports are available online at www.measuredhs.com; you can also order hard copies of DHS reports from the web site or from MEASURE DHS+, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA.
- Speaker’s Notes: Many people believe that if abortion is made more available, more abortions will take place. If we look at countries around the world, however, we see that this is generally not the case. Abortion rates are much more likely to be linked to desired family size and the availability and effectiveness of contraception. In fact, many countries with restrictive abortion laws also have high abortion rates. In fact, many countries with restrictive abortion laws also have high abortion rates. For instance, the highest rates of unsafe abortion in the world occur in the countries of South America, where abortion is illegal under most circumstances. In this region, there is more than one unsafe abortion for every three live births, compared to one in seven globally. The legal status of abortion, however, does affect the safety of abortion. In countries where abortion is legal and available, it is more likely to be safe, and deaths and disabilities from abortion have been shown to decrease dramatically. There are, however, several countries where abortion is legal but safe services are not widely available because of a lack of training, equipment, awareness of the law, or political will. And, in almost all countries with restrictions on abortion, services are unavailable even for legal indications, such as rape. Legal issues will be discussed later in my talk. Additional Resources: The legal status of abortion has little or no impact on rates of abortion For example, in countries where abortion is legal, the abortion rate varies from 6.5 per 1,000 women (Netherlands) to 8.6 (Tunisia) to 83 (Vietnam). (The rate of abortion is the number of women of reproductive age who have an abortion in one year, out of 1,000 women of reproductive age.) [1] In most of the 25 countries that liberalized their abortion laws between 1975 and 1996, the abortion rate increased immediately after legalization, partly because statistics now reflected the true number of abortions, and partly because of increased demand for safe abortions. Abortion rates usually then decreased as contraceptive use increased over time. Generally, where couples used contraception effectively, abortion declined to moderate levels. Where contraceptive use was not widely practiced but there was strong motivation for small families, abortion levels sometimes increased for some time after liberalization. [1] The legal status does affect the safety of abortion; where abortion is legal, deaths and disability from abortion are greatly reduced. In Romania, abortion was legalized in December 1989. In 1990, the number of maternal deaths due to abortion dropped abruptly by more than half. [1] 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) References: Guttmacher Institute, Sharing Responsibility: Women, Society and Abortion Worldwide (New York: Guttmacher Institute, 1999).
- Speaker’s Notes: This graph shows that most of the countries with low maternal mortality—the column on the left—permit abortion for non-medical reasons. Of the 37 countries with the highest maternal mortality ratio, only one allows abortion for non-medical reasons. Reference: McKay, H.E., K.O. Rogo and D.B. Dixon, “FIGO society survey: acceptance and use of new ethical guidelines regarding induced abortion for non-medical reasons,” International Journal of Gynecology and Obstetrics 75 (2001): 327-336.
- Speaker’s Notes: Deaths from unsafe abortion are preventable. When abortions are performed in sanitary conditions by skilled providers, abortion is one of the safest medical procedures in the world. In fact, safe abortion, both vacuum aspiration and medical abortion, is much safer than childbirth. In contrast, the risk of death following complications of unsafe abortion procedures is several hundred times higher than that of an abortion performed professionally under safe conditions. [1] Reference: World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at: http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf.
- Speaker’s Notes: Unsafe abortion has other negative effects on women. For instance, unsafe abortion can result in significant short- and long-term illness and injury. For every death resulting from unsafe abortion, there are countless women who live with pain, infection, and possible infertility. The costs of treating the complications from unsafe abortion are enormous. In some countries as many as two out of three maternity beds in large urban public hospitals are occupied by women hospitalized for treatment of abortion complications, and as much as one-half of obstetric care budgets is spent treating abortion complications. [1] Injuries and deaths caused by unsafe abortion don’t only harm women—they have numerous ill-effects on families, children and communities. For example, a study of maternal mortality in Bangladesh found that children whose mother had died were between three and 10 times more likely than other children to die in the next two years, and a study of HIV-related mortality in Tanzania found that in households where an adult woman had died, children were half as likely to attend school [2]. Additional Resources: Other impacts of injuries and deaths from unsafe abortion on families: Higher likelihood of malnutrition, illness, and death among children whose mother has died; Curtailing of educational opportunities for children in families with high medical expenses; Diminished capacity of the mother to contribute to household income. [2] Customising this slide: You can customise this slide (or add an additional slide) with facts such as: Abortion and unsafe abortion rates in your country or region; Anecdotal information about unsafe abortion in your country or region; Percentage of women in main ob/gyn hospital admitted for abortion complications, etc; Regional percentages of maternal deaths attributable to abortion. You may wish to ask your audience for suggestions of negative impacts. References: 1. Guttmacher Institute, Sharing Responsibility: Women, Society and Abortion Worldwide (New York: Guttmacher Institute, 1999). 2. Inter-Agency Working Group on Safe Motherhood, Safe Motherhood Fact Sheets (New York: FCI, 1998), available at www.safemotherhood.org.
- Speaker’s Notes: This module reviews international agreements related to unsafe abortion and describes the obligations of governments to provide safe abortion services to the fullest extent of the law.
- Speaker’s Notes: Numerous international agreements have called for improvements in abortion access and care. These 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. Important international agreements include the Programme of Action of the International Conference on Population and Development (ICPD) and ICPD+5. Statements by international federations such as the International Federation of Gynecology and Obstetrics (FIGO) are also useful tools to advocate for improved access to safe abortion services. Additional Resources: You may wish to provide your audience with handouts containing the text of the relevant agreements, listed below and on the next three slides. International Federation of Gynecology and Obstetrics (FIGO) Ethics Statement: “In summary, the Committee recommended that after appropriate counseling, a woman had the right to have access to medical or surgical induced abortion, and that the health care services had an obligation to provide such services as safely as possible.” [1] References: International Federation of Gynecology and Obstetrics (FIGO), Guidelines produced by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health (London: FIGO, 2000), available at: http://www.figo.org/docs/Ethics%20Guidelines.pdf
- Speaker’s Notes: In 1994, at the International Conference on Population and Development in Cairo, governments recognized that abortion was an important women’s health issue, stated that it should be safe where legal, and called for postabortion care to treat the complications of abortion in all settings. Additional Resources: Programme of Action of the International Conference on Population and Development (ICPD PoA), Paragraph 8.25: “In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. 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. Post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortions.” [1] References: Programme of Action of the International Conference on Population and Development, Cairo, 5-13 September, 1994 (New York: United Nations, 1994). (Available at: http://www.unfpa.org/icpd/icpd_poa.htm)
- Speaker’s Notes: In 1999 at the five-year review of the Programme of Action of the International Conference on Population and Development, at a Special Session of the UN General Assembly, governments reiterated the language of Paragraph 8.25, and pledged to “train and equip health-service providers and take other measures to ensure that [legal] abortion is safe and accessible.” In 2002, the regional 10-year review of ICPD implementation in Asia reiterated these commitments. A civil society event held in August 2004 to mark ICPD+10 also reiterated the Cairo commitments and noted that WHO’s Technical Guidance should serve as a basis for both public and private health services. Additional Resources: Full Text of ICPD+5, Paragraph 63: (i) In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public-health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. 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. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions. (ii) Governments should take appropriate steps to help women avoid abortion, which in no case should be promoted as a method of family planning, and in all cases provide for the humane treatment and counselling of women who have had recourse to abortion. (iii) In recognizing and implementing the above, and 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. [1] References: 1. Key Actions for the Further Implementation of the ICPD Programme of Action, 21st United Nations General Assembly Session, June 30 – July 2, 1999 (New York: United Nations, 1999). (Available at: http://www.unfpa.org/publications/detail.cfm?ID=276 2. www.countdown2015.org
- Speaker’s Notes: The Millennium Development Goals (MDGs) were developed following the adoption of the Millennium Declaration by 189 world leaders assembled at a special UN General Assembly session held in September 2000, called the Millennium Summit. [1] Based on a number of international conferences held in the 1990s, the MDGs commit member states and the international community to fight poverty and promote human development. These goals are now seen as the primary framework or “road map” for reducing poverty around the world. The fifth of the eight goals calls for the world’s governments to reduce the maternal mortality ratio by three-quarters between 1990 and 2015. A target on reproductive health services was agreed upon in 2006. Of the various direct and indirect causes of maternal deaths, including obstructed labor, sepsis, haemorrhage, and conditions such as malaria that can worsen during pregnancy, unsafe abortion may be technically the easiest to address in some settings. In some countries, unsafe abortion is estimated to cause half of maternal deaths; in these cases, MDG 5 cannot be met unless unsafe abortion is addressed. Additional Resources: The Millennium Development Goals are: Eradicate extreme poverty and hunger; Achieve universal primary education; Promote gender equality and empower women; Reduce child mortality; Improve maternal health; Combat HIV/AIDS, malaria and other diseases; Ensure environmental sustainability; Develop a global partnership for development. [2] References: 1. United Nations Millennium Declaration, Millennium Assembly of the United Nations, Sept. 6-8, 2000 (New York: United Nations, 2000). Available at: http://www.un.org/millennium/summit.htm 2. Road Map towards the Implementation of the United Nations Millennium Declaration, Report of the Secretary-General (New York: United Nations, 2001).
- Speaker’s Notes: The following three slides describe legal issues related to abortion.
- Speaker’s Notes: In Asia there is a wide range of abortion-related legislation, from countries where abortion is highly legally restricted to where it is legal with few or no restrictions. Similarly, the availability of safe abortion services varies widely. There is not always a correlation between whether abortion services are available under the law and whether they are safe and accessible. [1] In some countries, such as Vietnam and China, abortion is legally allowed and safe services are available; In India and Cambodia, abortion is legally allowed but safe services are difficult for some women to obtain; And in countries such as the Philippines and Thailand, abortion is legally restricted and safe services are difficult to obtain. In all countries, even those in this last category, governments have an obligation to make safe services available for all reasons permitted by law. Additional Resources: Legal interpretation varies greatly from country to country. For instance, both “danger to physical or mental health” and “fetal impairment” can be interpreted widely. The United Nations Population Division notes that “[i]n some countries, no definition exists, while in others, most of them Commonwealth countries, mental health is defined to include emotional distress caused to children of the marriage or emotional distress caused to the pregnant woman as a result of her environment.” [2] Clarifying these legal terms can be an important first step in addressing the availability of safe abortion services within the framework of each country’s laws. Customising this slide: You can customise by providing information on the laws or policies for abortion in your country. Emphasize the conditions for which it is legal. [2, 3] References: 1. Guttmacher Institute, Sharing Responsibility: Women, Society and Abortion Worldwide (New York: Guttmacher Institute, 1999). 2. United Nations Population Division, Abortion Policies: A Global Review (New York: United Nations, 2002), available at http://www.un.org/esa/population/publications/abortion. This is a good resource on legal issues relating to abortion, listing all the world’s countries: click on the country you are interested in to see laws related to abortion, a background summary, and an overview of general reproductive health context, including government policies and recent statistics. 3. The following website at Harvard University has the full text of many abortion laws: http://cyber.law.harvard.edu/population/abortion/abortionlaws.htm.
- Speaker’s Notes: Abortion is permitted by law in at least some circumstances in all of Asia’s 46 countries. All Asian countries allow an abortion to be performed to save a woman’s life, and many permit abortion on broader grounds. [1] International consensus documents require that governments offer safe abortion services in all circumstances permitted by law. Reference: United Nations Population Division, Abortion Policies: A Global Review (New York: United Nations, 2002), available at:http://www.un.org/esa/population/publications/abortion.
- Speaker’s Notes: Women are often unable to exercise their legal right to abortion because laws are misunderstood, interpreted inconsistently, or put into practice erratically. In many countries, there is a difference between what the law states and what is actually practiced. These barriers can be caused by: Inadequacies in the health system, including lack of trained providers, equipment, and resources; Policy issues, including judicial, administrative, and regulatory barriers; Information gaps: women, communities, and health care providers lack knowledge of the law; Cost: fees for abortion-related services are often prohibitively high; Societal attitudes, affected by religious or cultural beliefs that stigmatize abortion. Barriers can particularly affect certain groups, notably poor, illiterate, and/or rural women. For example, information gaps are more likely to affect women with lower levels of education and literacy, cost barriers are more likely to affect poor women, and health systems barriers may more severely affect rural women or those without access to tertiary health care. Where women cannot access safe abortion services, they often seek out unsafe services, with the dire impacts to their health, lives, and families that I have already presented. Customising this slide: To customise this slide for your audience, you can add detail on how the laws are enforced or ignored in your country or region. For instance, is it legal for women who have been raped to receive abortion services? Can they in fact receive those services?
- Speaker’s Notes: In response to the international mandates, WHO developed this new Guidance on safe abortion for health systems. It urges each country to meet the obligation to provide abortion within its legal framework for all reasons permitted by law, and provides guidance on clinical and service delivery issues. The Guidance is available in PDF format on your CD-ROM or on the WHO website. The CD-ROM includes the Guidance in English, French, Spanish, Russian, and Portuguese. WHO will also provide a limited number of copies free of charge to those in developing countries.
- Speaker’s Notes: The next set of slides cover clinical issues related to abortion, including preferred methods of abortion according to gestational age, pre- and post-abortion counseling, pain management, and follow-up care.
- Speaker’s Notes: Let’s talk about the recommendations in the WHO Guidance. WHO 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, offering adequate counselling, information and support The Guidance includes recommendations for basic equipment (most routinely available) and procedures. Abortion services should meet the same high standards as other health services in terms of privacy, confidentiality, accessibility, promptness, affordability, and flexibility.
- Speaker’s Notes: A number of steps should be taken before the abortion procedure. Most important are confirming the pregnancy and the woman’s desire to terminate it, and estimating its duration. This information is critical for determining the best method of abortion, and can usually be accomplished by taking a patient history to determine last menstrual period, and conducting a bimanual pelvic examination. Ultrasound is not necessary for the provision of early abortion, but can be helpful in some cases, such as in detecting ectopic pregnancies. Before the abortion, women should be screened for other conditions, such as reproductive tract infections, which can increase the risk of post-procedural infection. If an infection is suspected, it should be treated immediately with antibiotics and abortion can then be carried out; testing and treatment need not delay the abortion procedure, however. In some settings, antibiotics are provided to all women receiving abortion. Such treatment has been shown to reduce post-procedure infections by half. However, abortion should not be denied where prophylactic antibiotics are not available. Customizing this slide: You can add information about services available in your settings, as well as local norms and protocols.
- Speaker’s Notes: Counselling is a critical part of abortion services, but is often not provided. Women deserve full information and supportive counselling to ensure that the decision to seek an abortion is made freely and that they understand what to expect during and after the procedure. They should be offered a choice of methods (such as vacuum aspiration or medical/pharmaceutical methods) if possible and appropriate. Additionally, women who are seeking abortion may want to avoid a subsequent pregnancy. They may also have other reproductive health or social needs. Abortion services ideally should include counselling on self-care and contraception. Where possible, they should also be able to link women with other services they may need, such as legal advice and counselling in cases of rape or domestic violence. Customizing this slide: If appropriate for your audience, you could add information about what counselling is currently provided in your country.
- Speaker’s Notes: Up to 9 completed weeks of pregnancy, WHO recommends manual vacuum aspiration, electric vacuum aspiration, and medication abortion (also known as medical abortion or pharmaceutical abortion), specifically mifepristone (originally known as RU-486) followed by a prostaglandin. The mifepristone/misoprostol regimen has been included in the WHO’s essential medicines list since 2005. D&C, or dilatation and curettage, is no longer recommended and should be replaced with another method. The drugs needed for medication abortion, specifically mifepristone and misoprostol or gemeprost, are not yet widely available in many Asian countries. Medication abortion methods have the potential to greatly expand access to safe legal abortion, and health systems should seek to approve and make these methods available. Additional Resources: MVA and medication abortion, specifically mifepristone followed by misoprostol, have comparable rates of effectiveness and low rates of complications. The two methods have different service delivery requirements, and result in different experiences for women. Surgical abortion cab be quicker, involve fewer visits, and result in less bleeding and nausea. Medical abortion may be more private, and some women find it more “natural” and may feel more in control with this method. Customising this slide: If appropriate for your audience, you could add information about what methods of abortion are available in your country. Reference: World Health Organization, Frequently asked clinical questions about medical abortion (Geneva WHO: 2006). Available at: http://www.who.int/reproductive-health/publications/medical_abortion/faq.pdf
- Speaker’s Notes: Misoprostol is widely available, at low cost, in much of the world. The WHO Guidance notes that further research is needed on misoprostol when used alone for abortion. WHO has not made a recommendation for a preferred protocol using misoprostol alone. Two expert sources of information exist to guide use of misoprostol alone for abortion. In 2003, an expert group, convened by Gynuity Health Projects and the Reproductive Health Technologies Project, created a consensus statement on the use of misoprostol alone for induced abortion, through nine weeks after the last menstrual period (LMP). [1] In 2005 and 2007, the Latin American Federation of Societies of Obstetrics and Gynecology (FLASOG) issued guidelines for the use of misoprostol for a range of obstetric and gynecologic indications, including abortion. These guidelines recommend that misoprostol can safely be used alone for abortion through 20 weeks gestation. [2] The recommended regimen supported by these two documents is: Until 12 completed weeks of pregnancy: Give 800 mcgs of vaginal misoprostol, repeat every 6-24 hours, until the abortion is complete, up to three doses, or until complete, whichever is first (preferred). Alternatively, in pregnancies up to 9 completed weeks, you may give 800 mcgs of sub-lingual misoprostol, repeat every 3-4 hours up till three doses or until complete, whichever is first. From 13 to 15 weeks of pregnancy: Give 400 mcgs of vaginal misoprostol, repeat once between 6 and 12 hours, if there has been no response. If there is no response at 24 hours, give double the initial dosage (800 mcgs). Repeat again 12 hours later if there is no evidence that the abortion process has been started, for a maximum of four doses (maximum of two 400 mcg doses and two 800 mcg doses). From 16 to 20 weeks of pregnancy: Give 200 mcgs of vaginal misoprostol, repeat once if there is no response, between 6 and 12 hours. If there is no response at 24 hours, give double the initial dosage (400 mcgs). Repeat again 12 hours later, if there is no evidence that the abortion process has been started, for a maximum of four doses (maximum of two 200 mcg doses and two 400 mcg doses). References: Gynuity Health Projects and Reproductive Health Technologies Project, Instructions for Use: Abortion Induction with Misoprostol in Pregnancies through 9 Weeks LMP (New York: Gynuity Health Projects, 2003). Faúndes A, Cecatti J, Conde-Agudelo A, Escobedo J, Rizzi R, Távara L y Velasco A.- Uso de misoprostol en obstetricia y gynecologia - FLASOG Segunda- Edición, Marzo 2007 Clark, W., C. Shannon and B. Winikoff, “Misoprostol for uterine evacuation in induced abortion and pregnancy failure,” Expert Reviews in Obstetrics and Gynecology, 2(1), 67-108 (2007).
- Speaker’s Notes: Between 9 and 12 completed weeks of pregnancy, the mifepristone/prostaglandin method is still under investigation, and only vacuum aspiration (manual or electric) is recommended. Again, it should be noted that D&C, or dilatation and curettage, is not recommended and should be replaced with another method.
- Speaker’s Notes: There are numerous reasons women may seek to terminate a pregnancy after 12 weeks, and where legal, all levels of the health system should be able to refer women to facilities that have the capacity to perform later abortions safely. Reasons include health problems that develop during pregnancy and foetal abnormalities that typically cannot be identified until after 12 weeks, as well as personal issues. Also, financial, psychological, cultural, political and/or service-delivery factors may create barriers and delays, which can result in the need for a later abortion. Many countries legally permit some abortions after 12 completed weeks of pregnancy. For instance, some countries' abortion laws do not specify limits on when abortions can be performed, while other countries’ laws set gestational limits. Laws that include gestational limits usually permit abortion later in pregnancy under certain conditions, such as threat to the woman’s life or health. Customizing this slide: If appropriate, you can put this slide in context by referring to the current practice or law in your setting or country.
- Speaker’s Notes: For pregnancy termination after 12 completed weeks, both medical and surgical methods are appropriate, depending on the local context. Medication methods of abortion, specifically mifepristone, are effective and recommended, but as of 2007, their availability is still limited. Dilatation and evacuation (D&E) is the safest, most effective surgical technique; it must be performed by highly skilled, experienced providers. Vaginal prostaglandins alone are also recommended. Both gemeprost and misoprostol have been studied; further research is needed to identify the optimal regimen of misoprostol alone. Customising this slide: If appropriate, you can put this slide in context by referring to the current practice or law in your setting or country.
- Speaker’s Notes: This chart summarizes the methods of abortion that WHO recommends according to the duration of the pregnancy. The dotted lines indicate that regimens during these timeframes are still under investigation. Those methods listed at the bottom of the chart should only be used if preferred methods are not available.
- Speaker’s Notes: Most women report pain with abortion, and therefore all should be offered pain management. Pain can be caused by anxiety, cervical dilation, and uterine cramping. Three types of drugs can be used, alone or in combination: Analgesics can reduce pain during and after the procedure, tranquilizers can reduce anxiety among women undergoing surgical abortion, and local anaesthetics can reduce pain during cervical dilation. General anaesthesia is usually not recommended for abortion and increases clinical risks. All health services, including abortion, should be offered in a respectful, supportive environment. Verbal support can help reduce anxiety and help women feel more comfortable; if feasible, women may find it comforting to have a friend, family member, spouse, or other person with them during the procedure. Cervical priming is recommended by WHO for nulliparous women with pregnancies over nine completed weeks, for women under 18, and for all women with pregnancies over 12 completed weeks. Infection prevention procedures are critical to prevent the transmission of infections, including HIV, to patients and health care providers. Universal precautions include hand-washing and use of protective barriers (such as gloves); proper cleaning of equipment, linens, floors, etc; safe disposal of contaminated waste; and safe handling and disposal of “sharps.” Customising this slide: This slide can be customised by adding details on the guidelines and/or current practices in place in your country or setting, if available.
- Speaker’s Notes: The follow-up visits required will vary depending on gestational age and what type of abortion procedure (surgical or medical) has been used. Women should know that they can contact the health facility before their follow up visit if necessary. Women should be told about the normal range of pain and bleeding that they can expect, and should be encouraged to contact the facility if their symptoms are more severe or of longer duration than expected. They should also be given information on how to take care of themselves, and when they can return to normal activities. It is important for women to know that fertility can return as soon as two weeks following the procedure, even before the next menstrual period. In addition, women should be given information about protecting themselves from sexually transmitted infections and unwanted pregnancy. There are several contraceptive methods that can be used immediately following abortion, and emergency contraception is an important option that women should know about. Customising this slide: You can include information on the policies and norms for post-abortion follow-up care in your setting.
- Speaker’s Notes: The next two slides discuss issues that should be considered when defining or clarifying national norms and standards on abortion.
- Speaker’s Notes: Besides offering clinical services, another key aspect of making safe abortion services available within the law involves establishing or clarifying national norms and standards. The next few slides will discuss some of the policy issues that may need to be addressed in some settings. Without clear standards, health care providers and others often feel unsure of their obligations and rights under the law. Health care managers and providers should understand and comply with norms and standards. Norms and standards should protect the rights of clients and providers, and specify providers’ legal and ethical obligations. It is important that norms and standards detail the “where, who and how” of any service. For instance: Where: MVA and medical abortion can be safely provided at lower levels of the health system. Who: Mid-level providers can safely provide MVA. How: Are there supplies or equipment that need to be registered in-country and added to official equipment lists? Other issues that specifically relate to abortion services include possible third-party authorization procedures (that is, whether other health care providers, judges, parents, spouses or others must agree to the procedure). National norms and standards should also protect women’s reproductive rights in line with international human rights standards. These include the right to make fully informed decisions free of violence or coercion and to autonomy in decision-making, as well the rights to confidentiality and privacy. Policies regarding abortion services may also need to include mechanisms to take into account health care providers’ personal views. Women should not be denied the services they need because of providers’ personal beliefs. In these cases, national norms and standards should provide clear guidance for when such refusal is permitted (sometimes known as a “conscience clause” or an “opt-out clause”) and what referral to other providers or sites is required. Public health care facilities do not have the right to opt out; they must staff appropriately to offer services that are legal. [1] In general, in circumstances where abortion is allowed under the law, efforts should be made to keep services accessible, and not create barriers for women. Customising this slide: Describe the norms and standards in place in your country or region (such as a national population or reproductive health policy, regulations established by professional associations, and/or MOH service delivery guidelines for maternal health services). You could ask the audience how many of them are familiar with these norms and standards. Reference: Rebecca J. Cook and Bernard M. Dickens, Considerations for Formulating Reproductive Health Laws (Geneva: WHO, 2000) Available at http://www.who.int/reproductive-health/publications/rhr_00_1/considerations_for_formulating_reproductive_health_laws.pdf
- Speaker’s Notes: An important issue for many countries in Asia is the involvement of mid-level providers. This is because in East Asia and the Pacific there are only 13 doctors for every 10,000 people, compared to 38 per 10,000 people in Europe. Even in settings with higher proportions of doctors, they may be concentrated in urban areas or the private sector. Research has clearly shown that midwives and other mid-level health professionals can provide high quality manual vacuum aspiration. Both MVA and medical methods of abortion can be used at lower levels of the health system, with adequate back-up and referral. Bangladesh leads Asia in training and authorizing paramedical professionals to perform uterine evacuation. As mentioned earlier, properly provided abortion services are safer than many other medical procedures, including childbirth. Customising this slide: Provide local data for your setting on the availability of different levels of providers in different regions. For instance, in some settings, doctors are scarce outside of big cities. In others, doctors are more widely available, but only specialists (ob/gyns) are authorized to perform abortions or provide postabortion care. Sub-Saharan Africa: One doctor for every 10,000 people East Asia and the Pacific: 13 doctors for every 10,000 people Latin America and the Caribbean: 16 doctors for every 10,000 people Europe: 38 doctors for every 10,000 people You can also provide information on whether mid-level providers are authorized to provide abortion and if not, what the steps might be for such authorization. References: 1. Warner IK, Merik O, Hoffman M, et al, “Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised cotrolled equivalence trial,” Lancet (2006). 2. Ipas, “Deciding women's lives are worth saving: Expanding the role of midlevel providers in safe abortion care,” Issues in Abortion Care 7 (2002). 3. United Nations Population Division, Abortion Policies: A Global Review (New York: United Nations, 2002), available at http://www.un.org/esa/population/publications/abortion.
- Speaker’s Notes: The next section outlines what we can do to overcome some of the many barriers to legal abortion and the roles that different groups can play to ensure that safe abortion is available and accessible to the full extent of the law.
- Speaker’s Notes: I mentioned earlier that despite laws that permit abortion in at least some circumstances, women encounter numerous barriers in trying to obtain safe and legal abortion services. Sometimes these barriers are written into laws, sometimes into Ministry of Health guidelines, and other times, they are imposed by providers because of their personal beliefs or because they lack knowledge about what is actually required. For the next few slides, I will discuss some possible barriers to safe abortion services—and, more important, solutions. It is important to bear in mind that each of these barriers can be overcome, if there is a commitment from key groups. Let’s start with health system barriers, which are probably the most common. Many countries in Asia are not yet providing abortion services to the extent the law permits through the public health system. As guidelines are developed to implement the law, many countries have a tendency to over-medicalise abortion, which is a simple procedure, by requiring general anaesthesia, sonograms, and other medically unnecessary steps. Outdated and less safe procedures, such as dilation and curettage, may still be used, or the drugs needed for medication abortion may not be available. Customising this slide: Customise this slide with information from your own country or region on why women have difficulty obtaining abortion within the law, for instance: Health care providers do not receive training in abortion techniques. If you are using PowerPoint, this slide can be customized using the animation feature to “hide” the solution until the presenter hits the “enter” button on the computer. The presenter can use this feature to present an example of a barrier, then facilitate the group coming up with a solution, before bringing up a solution on the screen. Ask the audience to come up with solutions to these common health system barriers: Few health facilities provide abortion to the extent allowed by law. Unnecessary medical procedures are mandated (e.g. general anaesthesia).
- Speaker’s Notes: Administrative barriers can be well-intentioned but result in significant obstacles for women trying to obtain safe abortion services. For instance, some laws or policies require signatures by several doctors before an abortion can be performed. For some women, obtaining these signatures is time-consuming or impossible. Many countries permit only physicians, or only ob-gyn specialists, to perform abortions. Given the severe shortage of physicians in rural areas, this requirement unnecessarily limits the number of service delivery sites where safe abortions can be made available. Requiring consent from another person, such as a spouse or a parent, can create significant barriers for some women and does not respect their rights to confidentiality and autonomy in decision-making. And, sometimes unnecessary restrictions are placed on facilities that provide abortion, such as requiring equipment that is not necessary for abortion. Customising this slide: Ask the audience to propose ways to eliminate the following administrative and regulatory barriers: Signatures by several doctors are required and are time-consuming or difficult to obtain. For example, in Saudi Arabia, a legal abortion must be performed in a government hospital. A panel of three medical specialists appointed by the hospital director must sign a recommendation before an abortion can be performed and written consent must be obtained from the woman and her husband or her guardian. A limited number and type of health personnel are authorized to provide abortion services.
- Speaker’s Notes: When abortion laws are restrictive, women and, often, health professionals, may be unaware of exactly what the law permits. Studies in some countries have also shown that women are unaware of when and how they get pregnant, making it difficult for them to recognize the signs early in pregnancy. This can lead to delays in seeking abortion until after the time when the procedure can be carried out most easily and at lowest risk (i.e., the first 12 weeks). Cost is a significant barrier for poor, rural women throughout the world. In some cases, other reproductive health services are available at low cost or are free, but abortion remains expensive; such a pricing disparity is financially punitive to women seeking abortion. All of the barriers that we have just discussed can be overcome with the commitment of a wide range of allies, along with political will and adequate resources. Customising this slide: Customise this slide with information from your own country or region on why women have difficulty accessing abortion within the law, for instance: Information barrier: Where abortion is legal in cases of rape, services for rape survivors do not provide information on abortion. Cost barrier: Abortion and postabortion care prices are high in order to discourage women from seeking them, rather than being based on their true cost.
- Speaker’s Notes: Given the guidance from WHO and the obligation to make safe abortion accessible where allowed by law, how can these recommendations be made practical? In the next few slides, I will talk about the role of various groups in increasing access to safe abortion services where legal, including policymakers, health care workers and managers, safe abortion advocates, media, academic institutions, and professional groups.
- Speaker’s Notes: Policymakers have a very important role. They can: Clarify legal grounds for offering safe abortion services, Remove administrative and regulatory barriers to safe services, Establish or improve national norms and standards, and Broaden the definition of providers who can offer services. Customising this slide: Customise the slide and discussion based on who is in your audience. For instance, if Ministry of Health personnel are in attendance, point out the importance of MOH-approved guidelines and the critical role in some countries of MOH supply lists for drugs and equipment. Ask the audience to think of other examples of things policymakers could do, within your legal framework. Are there any examples of actions policymakers have taken within your country, on this issue?
- Speaker’s Notes: Health care workers and managers also have a key role to play as the front line in providing services. They can ensure that services are available to the extent allowed by law: Establish and maintain high quality services; Monitor and evaluate abortion services to establish accountability and ensure continued quality; Supervise health care personnel providing abortion; Determine training needs; and Address cost issues, including setting reasonable user fees.
- Speaker’s Notes: Women’s health advocates can do several things to help ensure that women have access to safe abortion services within the law of their country. They can: Review governmental compliance with international agreements; Clarify legal grounds for abortion in their country to women and communities who are not aware of the details in the law; and Advocate to remove administrative and regulatory barriers to safe services; Inform women about the abortion law and available services.
- Speaker’s Notes: The media and professional groups also have important roles to play. The media can take the responsibility to disseminate accurate information in what can often be an emotional and confusing area of discussion. They can ensure that the realities of women’s lives are represented in the media, and educate the public about safe services, if they are available. Professional groups, such as ob/gyn societies, legal societies, and medical colleges, can speak out for services to be made available under the law, and can ensure that health professionals are trained and prepared to offer high quality, safe abortion services within the country’s laws.
- Speaker’s Notes: In conclusion, it is possible to reduce the terrible toll that unsafe abortion takes upon women, families, communities and nations worldwide. There are a number of steps that can be taken – involving input and commitment from various groups. We can all make a difference. Some key steps, depending on the local situation, include: 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; Authorise additional reproductive health professionals as abortion providers; and Inform women about their rights under the law. There are certainly other steps that can be taken, but the important thing is to begin to act. Thank you for your time. Customizing this slide: You could ask your audience to identify ways that their group can work to make abortion safer and more accessible under the laws of their country.