Israel_Complications of Unsafe Abortion

8/2/2019 Israel_Complications of Unsafe Abortion

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Postabortion Care:

The Missing Ingredient in ReducingMaternal Mortality

Ellen Israel, CNM, MPH

Pathfinder International

MCHIP Asia Regional Meeting,

Dhaka, May 3-6, 2012


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What is the problem?

Unsafe abortion is one of the

3 leading causes of maternalmortality.. (WHO, 2011).

In 2008, half of all abortions

in the world were unsafe; 98%

occurred in developing

countries.

Severe

bleeding

24%

Infections

15%

Eclampsia

12%Obstructed

labor

8%

Unsafe

abortion

13%

Other direct

causes8%

Indirect causes

20%

Though death from unsafe abortion

fell to 47,000 in 2008 (from 69,000 in 2003),

the proportion of women dying remains stagnant at 13% of maternal

deaths.

Death from unsafe abortion is highest in countries with the most

restrictive abortion policies.

Morbidity and disability caused by unsafe abortion affects women at,

at least, 10 times the mortality rate.


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The problem in Asia

Abortion rates did not decrease between 2003and 2008:

26/1,000 in South Central (e.g., India) and

Western Asia

36/1,000 in Southeastern Asia(compared to 29/1,000 in Africa)

Even in countries where abortion is not restricted,

there are high percentages of substandardprocedures in both public and private facilities

e.g., Nepal, Cambodia, and India; only 2/5 of services

are considered safe in India.


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Why is postabortion care (PAC) neglected

to address maternal mortality?

PAC is usually excluded from maternal health programs and

services largely because of the pervasive stigma attached to

abortion and women who seek them.

PAC being sidelined leads to few or no services, or poor andlimited services, which dont address the root causes of

unsafe abortion.

To ensure universal access to comprehensive PAC, abortion-

related stigma must be addressed.

The root causes of unsafe abortion include barriers to

obtaining and using contraception, and a broad array of

gender and other barriers.


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Political will is fundamental to ensuring

universal access to PAC

Governments signed on to multiple international

agreements over the years that reiterated the public

health imperative and right of women to receive PAC

services without discrimination.

Governments need support and even pressure to live

up to their commitments to ensure PAC as an

integrated maternal health service for all women

who need it.


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What are general solutions?

Mobilize and support governments to address unsafe

abortion and comprehensive PAC services integrated with

maternal and reproductive health.

Decentralize and scale-up services on all facility levels as part

of integrated, one-stop shop services.

Develop networks of stakeholders with interest in womens

health and rights to engage in national assessments of need,

develop standard training and protocols for comprehensive

PAC services, ensure commodity supply lines, and include in

HMIS.

Ensure availability ofmisoprostol for PAC, bringing services

closer to the community (e.g., in health posts). Misoprostol

use makes PAC provision more acceptable for some providers.


7/19

Global Misoprostol Registration by Indication

NEPAL

INDIA

TANZANIA & ZANZIBAR

NIGERIABANGLADESH

ZAMBIA

UGANDA

SUDAN

GHANAKENYA

Last updated: September 2011

*Misoprostol may or may not be registered for gastriculcers

SOMALILAND

MOZAMBIQUE

PAKISTAN

SIERRA LEONE

MALAWI

ETHIOPIA

MALI

BOLIVIA

Registered for postpartum hemorrhage (PPH) & treatment of incomplete abortion*

Registered for PPH and other ob/gyn indication*

Registered for PPH*

Registered for another ob/gyn indication, not PPH*

Registered for gastric ulcers only


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What are general solutions? contd

Within PAC programs, recognize and address thegender constraints/barriers to womens:

Desire to limit or space;

Desire to exercise reproductive control; and

Ability to effectively exercise reproductive control.

Work to address PAC needs ofyoung women and girls.

Emphasize attitude change for providers around thedangerous withholding of reproductive health services

(e.g., contraception and PAC) from young people and

unmarried youth.


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What IS being done that is effective?

National attention to PAC and scale-up. Examples include

Rwanda and Peru.

Advocacy. Holding countries to the task of signed

agreements; involvement from parliament, stakeholder

networks, government ministries, and civil society groups.

Integration. Integrating PAC with, as an equal component

of, maternal health programs and services.

Contraception/family planning (FP). Strengthening

contraception/FP as an essential reproductive health servicein and of itself to reduce unintended pregnancy, unsafe

abortion, and need for PAC services.


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The Postabortion Care

Consortium (PACC)

Pathfinder is the current Chair of the PACC

Initially formed in 1993 by JHPIEGO, IPPF, Pathfinder, Ipas,

and EngenderHealth, in recognition of the unsafe abortion

toll on women and the need to promote PAC as a publichealth imperative.

The PACC strives to ensure universal access to

comprehensive PAC services everywhere in the world.

The PACC is committed to assisting any and all governments,

groups, and individuals in the development and

implementation of PAC programs and services, including

community engagement, that address unsafe abortion.


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The PACC, contd

Specific priorities of the PACC for the next two years:

Ensuring Youth-friendly PAC services everywhere

Ensuring misoprostol for PAC to increase access and to

bring services closer to the community

Addressing the lack of MVA equipment, misoprostol and

other necessary supplies for PAC services

Working within countries, with government and civilsociety, to ensure PAC programs that address holistically

women with incomplete abortion, including capacity

building and scale-up of PAC nationally


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The 5 Essential Elements of PAC

In 2002, after much discussion and refining, the PACC

endorsed the 5 essential elements of PAC.

1. Community and service provider partnerships

2. Counseling

3. Treatment of incomplete abortion and complications

4. Contraception and family planning services

5. Reproductive and other health services (e.g., referrals)

The 5 elements reflect critical areas that all PAC programs

should address to be fully effective. Each element requires

specific attention.


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The PACC Contd

The PACC has and is forming Task Forces to develop resourcesto fill gaps: Youth, Misoprostol, Essential Supplies, Quality

Service Delivery (including contraception and infection

prevention), and Community engagement and partnerships.

The PACC sees itself as closely allied with and complementary

to USAIDs PAC Connection. For example, the PACC is able to

address sustainability of MVA equipment and promotemisoprostol to complement the PAC Connections excellent

work on improving universal post-PAC contraception within

communities and facilities.


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Lack of policies/guidelines

Lack of organized services to

provide FP Limited method mix

Lack of IEC materials

Stock-outs of contraceptives

Lack of counseling on FP

methods and availability

Additional charges for FP

Barriers to FP Provision in PAC Services

National Norms/Policies

Some cadres not allowed to

provide PAC services

Limitations on who can receive

FP (age, # of pregnancies)

Poor location of PAC services

No FP commodities in budget

Health System Barriers

Negative provider attitude

Lack of knowledge about rapid

return to fertility

Little to no FP counseling

Lack of referral for FP methods (if

cannot be provided on-site)

Religious concerns

EMONC/BMONC training only

focuses on emergency treatment

Provider

Client

Other


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WHO Recommendations

Follow WHOs recommendations to prevent ill-effects of

unsafe abortion:

Making safe abortion services available and accessible

where abortion is not restricted by law or policy

Ensuring that permitted reasons for abortion are

supported by the national legislative process and health

systems;

Granting access to services for the management of

complications from unsafe abortion, or PAC

Providing post abortion counseling and provision of

contraceptives which help avoid repeat abortion.


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Recommendations on how to ensure

integration of PAC with maternal health

Ensure integration by including PAC in language, protocols,programming, budgets, and data collection for maternal

health. Dont allow it to be separated or diminished.

Include PAC in adolescent and youth sexual and reproductive

health and youth-friendly maternal health programs.

Conduct values clarification and attitude change exercises

starting at the top with policymakers, health care managers,

providers, community opinion makers and members, etc

Ensure post-PAC contraceptive services are of high quality, and

provided immediately, on-the-spot.


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Recommendations, contd

Work with the rights and health networks in your country

along with government to ensure maximum access to

comprehensive PAC services.

Ensure access to misoprostol to increase access to PAC

Ensure access to young and unmarried women to PAC

services without discrimination

Work with the PAC Consortium to gain strength throughexperience and tool sharing for problem solving.


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Resources and references Facts on Induced Abortion Worldwide, Guttmacher Inst. Jan. 2012

Unsafe abortion: Global and regional estimates of the incidence of unsafe

abortion and associated mortality in 2008, WHO

Induced Abortion: Incidence and Trends Worldwide from 1995-2008, Gilda

Dedgh et al., in the Lancet, Jan. 2012

Unsafe Abortion: The Missing Link in Global Efforts to Improve MaternalHealth, Guttmacher Policy Review, Spring 2011

Essential Elements of Post-abortion Care: Origins, Evolution and Future

Directions, Corbett, M. and Turner, K, Intl Family Planning Perspectives,

Sept. 2003

Womens Demand for Reproductive Control: Understanding and

Addressing Gender Barriers, McCleary-Sills, J., et al.Intl Center for

Research on Women, Feb. 2012

Facts on Induced Abortion in Pakistan, Guttmacher In Brief, May 2009


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Thank youEllen Israel: [email protected]

PAC Consortium: www.pac-consortium.org
mailto:[email protected]://www.pac-consortium.org/http://www.pac-consortium.org/http://www.pac-consortium.org/http://www.pac-consortium.org/mailto:[email protected]

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