Safe abortion: technical and policy guidance for health systems 16 April, Tiraspol Safe abortion: technical and policy guidance for health systems Ronald Johnson, PhD Gunta Lazdane, MD PhD

WHO working to eliminate unsafe abortion globally and locally Mapping evidence Improving technologies Testing interventions Eliminate unsafe abortion Developing norms, tools, guidelines Technical support to countries 2 2 Filename

The Challenge of unsafe abortion 85 Unintended pregnancies million 22 million Unsafe abortions 23000 Deaths million 5 million+ 44 In 2008, there were approximately 85 million unintended pregnancies and 44 million abortions, half of which were unsafe. In 2010, there were an estimated 23,000 abortion-related deaths (7.9% of total maternal deaths of 287,000). Disabilities Abortions Billions of $$$ in financial costs

WHO Safe abortion guidelines Safe abortion care: the public health and human rights rationale Clinical care for women undergoing abortion Planning and managing safe abortion care Legal and policy considerations

Safe abortion care: the public health and human rights rationale Safe abortion: technical and policy guidance for health systems Safe abortion care: the public health and human rights rationale Filename

WHO Global Reproductive Health Strategy The strategy is grounded in international human rights treaties and global consensus declarations that call for the respect, protection and fulfilment of human rights, including: the right to the highest attainable standard of health; the right to decide freely and responsibly the number, spacing and timing of children and to have the information and means to do so; the right to have control over, and decide freely and responsibly on matters related to sexuality, including sexual and reproductive health – free of coercion, discrimination and violence; the right to enjoy the benefits of scientific progress and its applications. Eliminating unsafe abortion is one of the key components of the WHO Global Reproductive Health Strategy. The strategy is grounded in: international human rights treaties and global consensus declarations that call for the respect, protection and fulfilment of human rights, including: the right of all persons to the highest attainable standard of health; the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so; the right of women to have control over, and decide freely and responsibly on, matters related to their sexuality, including sexual and reproductive health – free of coercion, discrimination and violence; the right of every person to enjoy the benefits of scientific progress and its applications. To realize these rights, and to safe women’s lives, programmatic, legal and policy aspects of the provision of safe abortion need to be adequately addressed. Filename

Clinical care for women undergoing abortion Safe abortion: technical and policy guidance for health systems Clinical care for women undergoing abortion Filename

Decision-making and counselling Providing information and offering counselling can be very important in helping a woman consider her options and ensuring that she can make a decision that is free from pressure. However, Many women have made a decision to have an abortion before seeking care, and this decision should be respected without subjecting a woman to mandatory counselling. Provision of counselling to women who desire it should be voluntary, confidential, non-directive, and by a trained person. Guidance on counselling (page 36). 8 Filename Filename

Methods of abortion Dilatation and sharp curettage should be replaced with vacuum aspiration and use of combination mifepristone and misoprostol for abortion prior to 12-14 weeks gestation. Use dilatation and evacuation and medical methods for abortion are recommended after 12-14 weeks gestation. Guidance on abortion methods (pp. 41, 3-4). 9 Filename Filename

Pain management All women should be routinely offered pain medication during both medical and surgical abortions. In most cases, analgesics, local anaesthesia and/or conscious sedation supplemented by verbal reassurance are sufficient, although the need for pain management increases with gestational age General anaesthesia is not recommended routinely for vacuum aspiration or dilatation and evacuation. Remarks: Medication for pain management for both medical and surgical abortions should always be offered, and provided without delay to women who desire it. In most cases, analgesics, local anaesthesia and/or conscious sedation supplemented by verbal reassurance are sufficient, although the need for pain management increases with gestational age (p. 6). 10 Filename Filename

Infection prevention All clinical and support staff in all facilities that provide abortion services should understand and apply standard precautions for infection prevention and control for both their own protection and that of their patients. Antibiotics should be provided routinely following surgical abortion. Guidance on infection prevention (pp. 49 and 6). Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. 11 Filename Filename

Post-abortion contraception All modern methods of contraception, including IUDs and hormonal contraceptives, can be initiated immediately following surgical or medical abortion, as long as attention is paid to each woman’s health profile and the limitations associated with certain methods. Guidance on postabortion contraception (p. 52). Filename Filename

Planning and managing safe abortion care Safe abortion: technical and policy guidance for health systems Planning and managing safe abortion care

Comprehensive abortion care services Comprehensive care includes: Medically accurate information and non-directive counselling to facilitate informed decision-making; Abortion services delivered without delay; Timely treatment of abortion complications; Contraceptive information and offers of counselling and methods. 14 Filename

Where services should be provided Abortion care provided at the primary-care level and through outpatient services in higher-level settings is safe, and minimizes costs while maximizing the convenience and timeliness of care for the woman. Allowing home use of misoprostol following provision of mifepristone at the health-care facility can further improve the privacy, convenience and acceptability of services, without compromising on safety. Inpatient abortion care should be reserved for the management of medical abortion for pregnancies of gestational age over 9 weeks (63 days) and management of severe abortion complications (p. 65) Filename

At primary-care level Health-care workers trained to provide counselling on contraception, unwanted pregnancy and abortion A broad range of contraceptive methods, including IUDs, implants, and injectables Vacuum aspiration (manual or electric) for pregnancies of gestational age up to 12-14 weeks Medical methods of abortion for pregnancies of gestational age up to 9 weeks, or up to 12 weeks if the woman can stay in the facility until the abortion is complete Prompt referral for women needing services that cannot be provided on-site Filename

Good-quality services respect human rights Good quality means respecting, protecting, and fulfilling: Women’s informed and voluntary decision-making; Women’s autonomy; Women’s confidentiality and privacy. Within the framework of national abortion laws, norms and standards should include protections for informed and voluntary decision-making, autonomy in decision-making, non-discrimination, and confidentiality and privacy for all women, including adolescents. These human rights are enshrined in international and regional human rights treaties, as well as in national constitutions and laws. 17 Filename

Confidentiality Health-care providers have a duty to protect medical information against unauthorised disclosures, and to ensure that women who do authorise release of their confidential information to others do so freely and on the basis of clear information. Adolescents deemed mature enough to receive counselling without the presence of a parent or other person are entitled to privacy, and may request confidential services and treatment. Guidance on confidentiality and privacy (pp. 68-69). Filename

Privacy Health-service managers should ensure that facilities provide privacy for conversations between women and providers, as well as for actual services. Procedure rooms should be partitioned for visual and auditory privacy, and only facility staff required for the abortion should be present. There should be a private place for undressing, curtained windows, and cloth or paper drapes to cover the woman during the procedure. Filename

Legal and policy considerations Safe abortion: technical and policy guidance for health systems Legal and policy considerations Filename

Laws and policies on abortion Should protect women’s health and their human rights… 21 Filename

An enabling regulatory and policy environment is needed to ensure that every woman who is legally eligible has ready access to safe abortion care Policies should be geared to: Respecting, protecting and fulfilling the human rights of women; Achieving positive health outcomes for women; Providing good-quality contraceptive information and services; Meeting the particular needs of poor women, adolescents, rape survivors and women living with HIV. 22 Filename

Summary Elimination of unsafe abortion requires Good sexuality education Ready access to and availability of contraception Ready access to and availability of safe, legal abortion Safe abortion care requires Skilled, knowledgeable providers Use of WHO-recommended methods Hygienic conditions Safe, legal abortion protects women’s health and their human rights 23

Questions and discussion http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/index.html 24