Africa

Improving Access to Safe
Abortion
Guidance on Making High Quality
Services Accessible
Based on Safe Abortion: Technical and Policy Guidance
for Health Systems World Health Organization, 2003

Contact:
Email: 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.
February 2007
*World Health
Organization. Safe
Abortion: Technical and
Policy Guidance for
Health Systems.
Geneva: WHO, 2003.
Improving Access to Safe
Abortion
Guidance on Making High Quality
Services Accessible

Introduction
This presentation includes modules on:
• Context and general information on unsafe
abortion
• International agreements
• Legal issues
• Clinical services
• Management issues
• Overcoming barriers to access
Addressing Unsafe Abortion
in Africa

Unsafe Abortion in Context
Module 1

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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
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
in Africa

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
in Africa

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 diedAddressing Unsafe Abortion
in Africa

International Agreements
Module 2

Module 2
International Obligations
International agreements recognise that:
• Unsafe abortion is a major public health
concern
• Abortion should be safe and available to the
full extent of the law
• Health systems have a responsibility to
provide
these services
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

Other International
Commitments
Maputo Plan of Action
• Seeks to “take the continent forward towards
the goal of universal access to comprehensive
sexual and reproductive health services in
Africa by 2015”
• Built on nine action areas, including unsafe
abortion
Areas of action for unsafe abortion
• Advocacy/policy
• Capacity building
• Service delivery
Module 2
in Africa
Special Session of the
African Union
Conference of
Ministers of Health
Maputo, Mozambique
September 2006

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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 availableAddressing Unsafe Abortion
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

Module 4
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
in Africa

Methods of Abortion by
Duration of Pregnancy
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
Module 4
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

Overcoming Barriers to Access
Module 6

Module 6
Creating an Enabling
Environment
Possible health system barriers:
• Public health facilities do not provide safe
abortion services to the extent allowed by
law
• Unnecessary medical procedures are
mandated
• Outdated and less safe procedures
(such as D&C) are still used
• Drugs needed for medical abortion are not
approved or availableAddressing Unsafe Abortion
in Africa

Module 6
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 Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

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
in Africa

Thank you!
in Africa

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