Reducing unsafe abortion: An introduction to the Safe Abortion Care (SAC) approach for designing and monitoring services

Maternal Mortality and Unsafe Abortion Unsafe abortion accounts for 13% of pregnancy-related deaths globally Where abortion is safe and accessible, abortion deaths and injuries are rare (South Africa, Romania, Western Europe, US) Maternal mortality reduction goals (MDG5) will not be met without safe abortion services.

Do EmOC programs include abortion-related needs? EmOC partially addresses abortion- related needs (i.e. treat complications) EmOC does not prevent or help women manage unwanted pregnancies

SAC Approach Package of SAC Services –Safe induced abortion for all legal indications –Treatment of abortion complications –Postabortion contraception Signal Function Performance Seven SAC Indicators

SAC Signal Functions 6 signal functions for basic SAC facilities administer essential antibiotics administer intravenous fluids administer uterotonics perform removal of retained products for uterine sizes ≤12 weeks provide postabortion contraception perform induced abortion for uterine sizes ≤12 weeks for all legal indications

SAC Signal Functions (continued) 4 additional signal functions for comprehensive SAC sites perform removal of retained products for uterine sizes >12 weeks perform blood transfusion perform laparatomy perform induced abortion for uterine sizes >12 weeks for all legal indications

SAC monitoring indicators describe: Availability and distribution of SAC services (by signal function performance) Utilization of SAC services Quality of SAC services

Availability: SAC Indicator 1 DEFINITION: Amount of facilities providing basic and comprehensive SAC services RECOMMENDATION: 5 SAC facilities/500,000 population At least 1 Comprehensive SAC facility (perform 6 basic + 4 comprehensive signal functions) 4 Basic SAC facilities (perform 6 basic signal functions)

Distribution: SAC Indicator 2 DEFINITION: Number of facilities providing basic and comprehensive SAC in sub-national areas RECOMMENDED LEVEL: 100% of sub-national areas have adequate levels of SAC per Indicator 1 (i.e. 5 facilities/500,000 pop. at least one of which provides comprehensive SAC)

SAC Indicators 1 and 2 Assumption that once a country (or portion of a country) achieves 5/500,000 coverage and equitable distribution, the population’s minimum need for abortion care is met.

Utilization and Quality: SAC Indicators 3-7 These Indicators use facility caseload information: Obstetric complications Abortion complications Induced abortions UE methods used Post-abortion contraception

Utilization Indicator 3: Proportion of women treated for obstetric complications that are abortion-related Indicator 4: Proportion of women treated for abortion complications that are serious

Utilization (continued) Indicator 5: Proportion of women receiving abortion services that are induced procedures

Quality Indicator 6: Proportion of uterine evacuations performed with recommended technology Indicator 7: Proportion of women receiving abortion services who obtain contraception

Key assumption of SAC model If indicators show that SAC services are: available in sufficient quantity well-distributed utilized by women of adequate quality WE CAN ASSUME THAT SERVICES ARE PREVENTING ABORTION-RELATED DEATHS