Safe Abortion Saving Lives Respecting Rights A Dissemination
Safe Abortion Saving Lives Respecting Rights A Dissemination Packet for WHO Safe abortion: technical and policy guidance for health systems, Second edition, 2012
Safe Abortion Saving Lives Respecting Rights Global Introduction A Dissemination Packet for WHO Safe abortion: technical and policy guidance for health systems, Second edition, 2012
Sections of this presentation Introduction Public Health & Human Rights Clinical Care Planning & Managing Care Legal & Policy Considerations Introduction
Introduction • Audiences • Method of development • Highlights of new information Introduction
Audiences • Policymakers • Program managers • Service providers • Advocates Introduction
WHO standards & requirements Introduction • Priority questions & outcomes • Evidence retrieval • Assessment & synthesis • • Formulation of recommendations Dissemination, implementation, impact evaluation & updating
Method of development • Literature review • Cochrane and other systematic reviews • GRADE system Introduction
Method of development • Global panel of stakeholders • Companion document: Clinical practice handbook for safe abortion care Introduction
Highlights of new information • • Latest unsafe abortion estimates Recommendations for: o Clinical care o Service delivery & scaling-up • Introduction Human rights framework for policy & legislation
Safe Abortion Saving Lives Respecting Rights Global Module 1: The public health & human rights rationale for safe abortion A Packet to Disseminate WHO Safe abortion: technical and policy guidance for health systems, Second edition, 2012
Sections of this presentation Introduction Public Health & Human Rights Clinical Care Planning & Managing Care Legal & Policy Considerations
Module 1 Public health & human rights rationale
Abortion in Context • All countries & women of all ages • Married and unmarried women • Women with and without children Module 1: Public Health & Human Rights
Planned Pregnancy A woman may want to have a child, but: • Pregnancy may threaten the woman’s health or survival • Fetal abnormality • Partner, family or community pressure Module 1: Public Health & Human Rights
Unintended Pregnancy • Health considerations • Socioeconomic concerns • Cultural reasons • End childbearing or space births • Rape, incest • Other personal reasons Module 1: Public Health & Human Rights
Unintended Pregnancy • 222 million women who do not want to become pregnant but are using no contraceptive method or a traditional method • 33 million accidental pregnancies among contraceptive users Module 1: Public Health & Human Rights
Public Health Context • 85 million • 40 million unintended pregnancies annually in the developing world end in abortion Module 1: Public Health & Human Rights
Public Health Context Number of Unsafe Abortions Annually (Global) 25, 000 20, 000 15, 000 10, 000 5, 000 2003 2008 Module 1: Public Health & Human Rights 0 Unsafe Abortion
Public Health Context Proportion of Unsafe Abortions Annually 50% 49% 48% 47% 46% 45% 1995 2003 2008 44% 43% 42% 41% Module 1: Public Health & Human Rights Unsafe Abortion
Public Health Context Unsafe Abortions Developing Countries: 98% Developed Countries: 2% Module 1: Public Health & Human Rights
Public Health Context Induced Abortions in Developing Countries Unsafe Safe Module 1: Public Health & Human Rights
Public Health Context Unsafe Abortion in Developing Countries Over age 20 Under age 20 Module 1: Public Health & Human Rights
Proportion of abortions that are unsafe Africa 97 Latin America 95 Asia 40 Unsafe Safe Eastern Europe 13 Developed Countries 0. 5 0% Module 1: Public Health & Human Rights 20% 40% 60% 80% 100%
Proportion of abortions that are unsafe South-central Asia 65 61 South-eastern Asia Unsafe Western Asia Eastern Asia Safe 60 0. 5 0% 20% 40% 60% 80% 100%
Proportion of abortions that are unsafe Caribbean 46 Central America 100 Unsafe South America 100 0% Module 1: Public Health & Human Rights 20% 40% 60% 80% 100%
Proportion of abortions that are unsafe South America 100 Central America 100 Caribbean 46 Unsafe Safe Asia Eastern Europe 40 13 0% Module 1: Public Health & Human Rights 20% 40% 60% 80% 100%
Proportion of abortions that are unsafe Southern Africa 58 Eastern Africa 96 Northern Africa 98 Unsafe Safe Middle Africa 100 Western Africa 100 0% Module 1: Public Health & Human Rights 20% 40% 60% 80% 100%
Risk of death due to unsafe abortion LDCs 80 Northern Africa 30 Southern Africa 40 Western Africa 80 Eastern & Middle Africa 100 0 50 100 Deaths (per 100 000 unsafe abortions) Module 1: Public Health & Human Rights 150
Consequences of unsafe abortion • 47, 000 related deaths • 5 million women with disabilities • 220, 000 children motherless Module 1: Public Health & Human Rights
Case Fatality Rates: Unsafe Abortion All developing regions 220 Latin America 30 Eastern Europe 30 Asia 160 Africa 460 0 200 400 Deaths (per 100 000 unsafe abortions) Module 1: Public Health & Human Rights 600
Regulatory & policy context Maternal mortality from unsafe abortion • Higher in countries with major restrictions to abortion • Lower in countries were abortion is available upon request or under broad conditions Module 1: Public Health & Human Rights
Legal & Policy Considerations Only 19% of developing countries allow abortion based on social or economic circumstances Module 1: Public Health & Human Rights
Grounds on which abortion is permitted by region Percentage of countries 100 80 75% Physical health 60 Mental health 50% 40 Fetal impairment 27% 20 0 Rape/incest 29% Developed Countries Module 1: Public Health & Human Rights Asia Africa LAC Economic or social
Grounds on which abortion is permitted - Asia Percentage of countries 100 80 75% 60 Physical health 50% Mental health Rape/incest 40 29% 27% 20 0 Eastern Asia South-central Asia Module 1: Public Health & Human Rights Western Asia South-eastern Asia Fetal impairment Economic or social
Grounds on which abortion is permitted – Latin America Percentage of countries 100 80 Physical health 60 Mental health Rape/incest 40 Fetal impairment 23% 20 0 Economic or social 25% 8% Caribbean Module 1: Public Health & Human Rights Central America South America
Grounds on which abortion is permitted - Africa Percentage of countries 100 80 Physical health 60 Mental health Rape/incest 40 20 Fetal impairment Economic or social 20% 17% 6% 0 Southern Africa Eastern Africaa Module 1: Public Health & Human Rights 6% Northern Africa 0 Western Middle Africa
Grounds on which abortion is permitted Percentage of countries 100 80 75% Physical health 60 Mental health Rape/incest 40 20 Fetal impairment Economic or social 50% 27% 29% 0 Eastern Southern Eastern ASIA Africaa Module 1: Public Health & Human Rights 6% Northern Western Africa 0 Middle Africa
Liberal abortion laws & policies Lower abortion rates (Geneva: WHO, 2011). Module 1: Public Health & Human Rights
Public Health & Human Rights One in four women who undergo unsafe abortion is likely to develop temporary or lifelong disability requiring medical care Module 1: Public Health & Human Rights
Unsafe abortion is costly • $23 million • $200 million • $930 million • $6 billion minor complications at PHC level out-of-pocket expenses lost income postabortion infertility Module 1: Public Health & Human Rights
Safe abortion is cost saving • $2. 6 million • $1. 7 million cost of unsafe abortion to the Mexico City health system potential annual savings by increasing access to safe abortion Module 1: Public Health & Human Rights
Clear and Unambiguous “As a preventable cause of maternal mortality and morbidity unsafe abortion must be dealt with as part of the MDG on improving maternal health and other international development goals. ” Module 1: Public Health & Human Rights
Public Health & Human Rights “The fulfillment of human rights requires that women can access safe abortion when it is indicated to protect her health. ” Module 1: Public Health & Human Rights
Human Rights • Free and responsible decision • • • making on sexuality and reproductive health including the number, spacing and timing of children Life Equality and non-discrimination Privacy Module 1: Public Health & Human Rights
Human Rights • Freely choose a spouse and enter into marriage only with free and full consent • Enjoy the benefits of scientific progress • Access relevant health information (WHO, 2004) Module 1: Public Health & Human Rights
Human Rights Rationale The new emphasis on human rights can bolster arguments that governments must ensure safe abortion access as part of their commitment to fulfilling international human rights obligations. Module 1: Public Health & Human Rights
Safe Abortion Saving Lives Respecting Rights Global Module 2: Providing Clinical Care to Women Undergoing Abortion A Packet to Disseminate WHO Safe abortion: technical and policy guidance for health systems, Second edition, 2012
Sections of this presentation Introduction Public Health & Human Rights Clinical Care Planning & Managing Care Legal & Policy Considerations Module 2: Clinical Care
Module 2 Clinical Care
Pre-abortion care Determine gestational age Provide information for decisionmaking and voluntary consent Routine use of antibiotics with surgical abortion Module 2: Clinical Care
Not necessary • Routine laboratory tests • Pre-abortion ultrasound scanning • Options counseling, if not desired • Routine follow-up visit Module 2: Clinical Care
Determine Gestational Age Recognition of pregnancy symptoms Bimanual pelvic examination Abdominal examination Module 2: Clinical Care
Provide Information • Essential for quality abortion services • Clear, accurate, easily understood, easy to recall • May help the individual woman to decide: whether to have an abortion which method of abortion Module 2: Clinical Care
Provide Information • • Abortion methods available What will be done & length of procedure What woman will likely experience Pain management Risks and complications When normal activity can resume Any follow-up care Module 2: Clinical Care
Options Counseling • Not mandatory for women who have already decided • Can be important for women considering their options • Should be: Module 2: Clinical Care timely, voluntary, confidential, non- directive provided by a trained person
An essential part of abortion care Contraceptive information, counseling & services, including Hormonal contraception IUDs Voluntary surgical methods Module 2: Clinical Care
Cervical preparation 12 -14 weeks Methods: • Oral mifepristone • Misoprostol administered sublingually • Misoprostol administered vaginally • Laminaria placed intracervically Module 2: Clinical Care
Pain management Medication for pain management should always be offered for both medical and surgical methods of abortion • • Provide without delay upon request • General anesthesia not routinely recommended Analgesics (not paracetamol), local anesthesia Module 2: Clinical Care
Clinical recommendations Women should have a choice of abortion method Surgical Module 2: Clinical Care Medical
Surgical Methods Up to 12 to 14 weeks Manual vacuum aspiration (MVA) Electric vacuum aspiration (EVA) Replace D&C (sharp curettage) with MVA or EVA Module 2: Clinical Care
Surgical Methods After 12 to 14 weeks Dilatation and evacuation (D&E) Replace D&C (sharp curettage) with D&E Module 2: Clinical Care
Routine use of antibiotics with surgical abortion • Provide pre- or peri-operatively • If not available, the abortion can still be performed Module 2: Clinical Care
Clinical recommendations Women should have a choice of abortion method Surgical Module 2: Clinical Care Medical
Clinical recommendations Medical Abortion Mifepristone followed by misoprostol Module 2: Clinical Care Misoprostol alone when mifepristone is unavailable
Medical Abortion up to 9 weeks Mifepristone & Misoprostol Up to 7 weeks* Mifepristone 200 mg Oral Wait 24 -48 hours Misoprostol 800 mcg Vaginal OR Buccal OR Sublingual Misoprostol 400 mcg Oral 7 -9 weeks* Module 2: Clinical Care Mifepristone 200 mg Oral Wait 24 -48 hours Misoprostol 800 mcg Vaginal OR Buccal OR Sublingual Flowchart design: Nathalie Kapp, 2012
Medical Abortion 9 -12 weeks Mifepristone & misoprostol 9 -12 weeks (63 -84 days) Mifepristone 200 mg Oral Wait 36 -48 hours Misoprostol 800 mcg Vaginal Additional Misoprostol 400 mcg Vaginal or Sublingual every 3 hours for maximum of 4 further doses In a health facility Module 2: Clinical Care Flowchart design: Nathalie Kapp, 2012
Medical Abortion over 12 weeks up to 24 weeks Mifepristone & misoprostol Greater than 12 weeks (more than 84 days) Mifepristone 200 mg Oral Wait 36 -48 hours Misoprostol 400 mcg Oral OR 800 mcg Vaginal Additional Misoprostol 400 mcg Vaginal or Sublingual every 3 hours for maximum of 4 further doses In a health facility Module 2: Clinical Care Flowchart design: Nathalie Kapp, 2012
Clinical recommendations Medical Abortion Mifepristone followed by misoprostol Module 2: Clinical Care Misoprostol alone when mifepristone is unavailable
Medical Abortion up to 12 weeks Misoprostol Alone Up to 12 weeks Misoprostol 800 mcg (up to 84 days) Vaginal or Sublingual REPEAT Misoprostol every 3 -12 hours for up to 3 doses until expulsion Return for confirmation of completed abortion in 7 -14 days Module 2: Clinical Care Flowchart design: Nathalie Kapp, 2012
Managing complications • Ongoing pregnancy • Incomplete abortion Risks low when performed by trained provider • Infection • Uterine perforation • Anesthesia-related complications • Uterine rupture Module 2: Clinical Care
Infection prevention & control • Hand-washing & protective barriers • • Cleaning Safe disposal of waste Safe handling and disposal of ‘sharps’ Proper disinfection of equipment after use Module 2: Clinical Care
Care after abortion Following uncomplicated abortion, no medical need for a follow-up visit Adequate information on care postabortion & regarding complications Contraceptive information & supplies Follow-up visit, if the woman needs or desires Module 2: Clinical Care
Medical Abortion Misoprostol for incomplete abortion Single dose: Misoprostol 600 mcg orally Misoprostol for incomplete abortion Single dose: Misoprostol 400 mcg sublingually Module 2: Clinical Care Flowchart design: Nathalie Kapp, 2012
Safe Abortion Saving Lives Respecting Rights Global Module 3: Planning and Managing Care A Packet to Disseminate WHO Safe abortion: technical and policy guidance for health systems, Second edition, 2012
Sections of this presentation Introduction Public Health & Human Rights Clinical Care Planning & Managing Care Legal & Policy Considerations Module 3: Planning and Managing Care
Module 3 Planning and Managing Care
Health systems planning for safe abortion services • National standards and guidelines • Capacity building of health personnel, including midlevel providers • Financing • Policy and programme development Module 3: Planning and Managing Care
Constellation of services • Integrated • Medically accurate information • Non-directive counseling • Timely service delivered without delay • Contraceptive information and services Module 3: Planning and Managing Care
Standards & Guidelines • Evidenced-based, up-to-date, operationalized • Types of abortion services available • Requirements for equitable access & adequate quality • Rights of clients and providers; providers’ obligations Module 3: Planning and Managing Care
Standards & Guidelines Where Which levels of the health system Who Categories of health care staff What Methods/ procedures, required authorization, if any How Training, quality assurance, supplies, equipment Referrals To which levels and/or facilities for safe abortion, follow-up for complications, and/or resupply or LAPMs of contraception Rights Informed consent, confidentiality and privacy Module 3: Planning and Managing Care
Not necessary • Mandatory decisionmaking/options counseling • Routine laboratory tests • Pre-abortion ultrasound scanning • Routine follow-up visit Module 3: Planning and Managing Care
Services & information • Readily available and affordable to all women to the full extent of the law o Young women o Adolescents • Decentralized to primary-care level o Provision by midlevel providers o Referral systems for all required higher-level care Module 3: Planning and Managing Care
Financing Account for: • Costs to the health system • Affordability & ready availability to all women Adding safe abortion to existing health services is likely to be low cost relative to the costs of treating complications of unsafe abortion. Module 3: Planning and Managing Care
Financing & budgeting • Equipment, supplies medications • Information, client materials • Staff time • Training and supervision • Infrastructure upgrades • Record keeping • Monitoring & evaluation Module 3: Planning and Managing Care
Decisions provide quality & reduce cost • Switch dilatation and sharp curettage to vacuum aspiration or medical abortion • Provide information to come in early for abortion • Provide postabortion contraception Module 3: Planning and Managing Care
Affordability of services • Ensure equitable access regardless of ability to pay • Fees should be based on ability to pay o Exempt poor and adolescents from paying • No denial, delay or informal charges Module 3: Planning and Managing Care
Planning & Managing: Major Strategic Steps Implement on small Assess scale & Plan Advocate & Mobilize Module 3: Planning and Managing Care Assess & scale up
Scaling-up • • Systematic planning Management Guidance and support Sufficient human and financial resources Module 3: Planning and Managing Care
Safe Abortion Saving Lives Respecting Rights Global Module 4: Legal and Policy Considerations A Packet to Disseminate WHO Safe abortion: technical and policy guidance for health systems, Second edition, 2012
Sections of this presentation Introduction Public Health & Human Rights Clinical Care Planning & Managing Care Legal & Policy Considerations Module 4: Legal and Policy Considerations
Module 4 Legal & Policy Considerations
Deaths attributable to unsafe abortion, by legal grounds for abortion Module 4: Legal and Policy Considerations
Grounds on which abortion is permitted by region Percentage of countries 100 80 80% Physical health 60 Mental health 39% 40 Fetal impairment 18% 20 0 Rape/incest 8% Developed Countries Module 4: Policy and Legal Considerations Asia Africa LAC Economic or social
Key international agreements • International Conference on Population and Development+5 • Millennium Development Goals Module 4: Legal and Policy Considerations
International Obligations ICPD • Abortion, when not against the law, should be safe • In all cases, women should have access to quality services for the management of complications arising from abortion Module 4: Legal and Policy Considerations
ICPD + 5 and +10 Where abortion is not against the law, health systems should: § Train and equip § Take other measures to ensure that abortion is safe and accessible § Safeguard women’s health Module 4: Legal and Policy Considerations
Millennium Development Goals Reducing unsafe abortion one of the most direct ways to reduce maternal deaths as mandated by MDG 5 comprehensive sexual & reproductive health education, high quality contraceptive services, & safe abortion services Module 4: Legal and Policy Considerations
Key International Human Rights Treaties • International Covenant on Civil and Political Rights (ICCPR) • International Covenant on Economic, Social and Cultural Rights (ICESCR) • Convention on the Elimination of All forms of Discrimination Against Woman (CEDAW) • Convention on the Rights of the Child (CRC) Module 4: Legal and Policy Considerations
Examples of UN Treaty Body Recommendations to States • Take action to prevent unsafe abortion, including by amending restrictive laws that threaten women’s, including adolescents’, lives. • Provide legal abortion in cases where the continued pregnancy endangers the health of women, including adolescents. • Provide legal abortion in cases of rape and incest. • Amend laws that criminalize medical procedures, including abortion, needed only by women and/or that punish women who undergo those procedures. Module 4: Legal and Policy Considerations
Legal grounds for abortion • When there is threat to a woman’s life • When there is threat to a woman’s health • When pregnancy is the result of rape or incest • Where there is fetal impairment • For economic and social reasons • On request Module 4: Legal and Policy Considerations
Legal, regulatory and administrative barriers • • • Restrictive interpretation of legal grounds 3 rd party authorization from additional medical professionals, courts, parents or partners Conscientious objection without referral requirements Module 4: Legal and Policy Considerations
Legal, regulatory and administrative barriers • Restrictions on: § Available methods of abortion § Range of service providers • • Mandatory waiting periods • Requiring names of service providers Lack of confidentiality and privacy Module 4: Legal and Policy Considerations
Eliminate access barriers • High fees • Distance • Information gaps • Lack of trained providers, equipment, supplies • Stigma Module 4: Legal and Policy Considerations
Essential information for women • Accurate, complete, timely • Easily understood & recalled • Respecting dignity, needs, perspectives • Facilitating free and informed consent Module 4: Legal and Policy Considerations
Creating an enabling environment • Review list of barriers & determine enabling factors and resources to ensure safe abortion • Examine existing policies to identify gaps and/or areas in need of improvement Module 4: Legal and Policy Considerations
Policy considerations • Human rights of women • Positive health outcomes for women • Legality of & access to safe abortion • Good-quality contraceptive information & services • Needs of the poor, adolescents, rape & incest survivors, & women living with HIV/AIDS Module 4: Legal and Policy Considerations
Sections of this presentation Introduction Public Health & Human Rights Clinical Care Planning & Managing Care Legal & Policy Considerations Module 4: Legal and Policy Considerations
Main Sources • World Health Organization. (2012) Safe Abortion: technical and policy guidance for health systems, second edition, (Geneva: WHO, 2012). Available at: http: //apps. who. int/iris/bitstream/10665/70914/1/9789241548434_eng. pdf • World Health Organization. (2011) Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, sixth edition (Geneva: WHO, 2011). Available at: http: //whqlibdoc. who. int/publications/2011/9789241501118_eng. pdf • WHO safe abortion guidance: Updates and recommendations. Ipas, July, 11, 2012. • World Health Organization. (1998) Unsafe abortion: global and regional estimates of incidence of and mortality due to unsafe abortion with a listing of available country data. Geneva, World Health Organization. (WHO/RHT/MSM/97. 16) • World Health Organization. (2007) Unsafe abortion, authors. Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2003. 5 th ed. Geneva: World Health Organization; 2007. Available at: http: //www. who. int/reproductivehealth/publications/unsafeabortion_2003/ua_estimates 03. pdf • WHO Safe Abortion Guidance: Ipas Fact Sheet on 2 nd Edition, Ipas, July 2012. • Sedgh, Gilda; Singh, Susheela; Shah, Iqbal H. ; Ahman, Elisabeth; Henshaw, Stanley K. ; Bankole, Akinrinola. Induced abortion: Incidence and trends worldwide from 1995 to 2008; 2012. Lancet, 379 (9816): 625 -632. • Kapp, Nathalie, “Revised guidelines for safe abortion” (Power. Point presentation), World Health Organization, Department of Reproductive Health Research, August 29, 2012. • Improving Access to Safe Abortion: Guidance on Making High Quality Services Accessible, Ipas and Family Care International (FCI), 2005
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