Introduction to PAC Module 1 - Session 1 Issues Surrounding Miscarriage, Induced Abortion and the Delivery of PAC Services

Module 1 - Session 1 Objectives At the end of this session, participants will be able to: Define the term “abortion” Discuss the magnitude of maternal mortality worldwide as well as in their country (if known) Explain possible reasons for spontaneous abortion (miscarriage) Explain possible reasons why women resort to induced abortion Describe the abortion laws and regulations in their country and how they impact PAC services Describe policies for postabortion care at their home facilities and how they impact PAC services

Defining Terms Throughout this course: Abortion: the loss or termination of pregnancy, i.e., spontaneous abortion (miscarriage) or induced abortion. The terms miscarriage and spontaneous abortion are used interchangeably. Unsafe abortion: often used when induced abortion is performed by persons without the necessary skills and/or in an environment lacking medical standards.

Maternal Mortality Every minute around the world: 380 women become pregnant 190 women face unplanned pregnancies 40 women have unsafe abortions 1 woman dies Source: White Ribbon Alliance for Safe Motherhood.

Magnitude of Maternal Mortality More than 536,000 maternal deaths annually For every maternal death,10–15 maternal morbidities Maternal Mortality Ratio (MMR): Number of maternal deaths per 100,000 live births

Maternal Mortality and Unsafe Abortions In spite of local and international efforts: 20 million unsafe abortions every year: 9,900,000 in Asia 5,000,000 in Africa 4,000,000 in Latin America and the Caribbean

Impact of Spontaneous and Induced Abortion Of the estimated 20 million unsafe abortions yearly: Between 10−50% will need medical care for complications Abortion = 13% of all maternal deaths: 68,000 deaths each year About 15–20% of all pregnancies will end in spontaneous abortion or miscarriage

Incomplete Abortion: Other Potential Consequences Increased risk of: Ectopic pregnancy Spontaneous abortions and premature delivery in subsequent pregnancies Psychological trauma When mothers die, children left behind are up to 10 times more likely to die

Postabortion Care Postabortion care (PAC) is internationally recognized as an important intervention to address complications related to miscarriage and induced abortion. PAC should be an integral part of all essential obstetric and newborn care programs. PAC should not only include emergency care, but also family planning counseling and services.

Spontaneous Abortion WHO definition of spontaneous abortion (miscarriage): Spontaneous loss of a clinical pregnancy before 20 completed weeks of gestation or, if gestational age unknown, a weight of 500 g or less. Worldwide, every year: Up to 32 million pregnancies will end in spontaneous abortion.

Spontaneous Abortion (2) Most miscarriages occur between the 6th and 12th week of pregnancy Can result in complete or incomplete expulsion of the products of conception PAC may require added counseling/support: Grieving pregnancy loss Anxiety concerning future fertility

Spontaneous Abortion (3) Known factors associated with miscarriage include: Genetic factors: Account for about 5% of spontaneous abortions Hormonal causes Infections: Bacterial, viral, parasitic and fungal Malaria in pregnancy HIV, sexually transmitted infections (STIs)

Spontaneous Abortion (4) Gender violence: Women experiencing violence during pregnancy have higher rates of spontaneous abortion Miscellaneous: Other contributing factors: environment, smoking, drugs, placental abnormalities and medical illness

Spontaneous Abortion (5) Exact cause may not be clear, even after a thorough history and physical exam. Refer women with recurrent miscarriage for further evaluation.

Why Women Resort to Induced Abortion Economical reasons: Inadequate income; lack of employment Socio-cultural problems: A pregnancy out of wedlock Cultural/religious stigma; social or family pressure; preference for a male child (if the fetus is a female) Medical reasons: History of obstetric or medical complications HIV status Knowledge of fetal abnormalities

Why Women Resort to Induced Abortion (2) Unintended pregnancy due to: Lack of access to FP services Contraceptive method failure Rape or incest Other reasons such as: Desire to space or limit pregnancies Desire to delay pregnancy for personal reasons or circumstances School enrollment status

Why Women Seek PAC Services Women’s willingness and ability: Dependence on decision-makers—may need permission or funds Fear of stigma; may delay care to avoid rejection Available sources of care: Traditional vs. facility providers Accessibility of health services Need for confidentiality: Fear of being recognized by providers or other clients in community

Why Women Seek PAC Services (2) Importance of fertility: Social norms for fertility and children Perceptions of modern contraception Provider attitude: Provider attitudes/behavior toward PAC clients Care must be gentle, supportive and encourage women to seek rather than hide from medical help Care must be sympathetic to cultural factors

Factors That Hinder or Facilitate Delivery of PAC Services: The Delays Many pregnancy-related deaths are due to delays: Recognizing that a problem exists: Belief that problems are “normal” in pregnancy Deciding to seek care: Family decision-makers, fear of stigma, poor care in the past Reaching care: Lack of transport or funds Receiving care: Lack of comprehensive care, triage or staffing; negative attitudes toward PAC clients

Questions to Think About What happens to a woman when she presents for PAC services in your facility? Where does she present? Who sees her first? Is she admitted or not? Who provides the PAC services and where are they provided? Who provides FP counseling and where is it done? Are FP commodities available? Are youth services available? What is the cost?

Understanding Your Country’s Policies Regarding the Provision of PAC Services Every country has laws, policies and/or regulations on induced abortion and PAC. It is very important to practice within those regulations or guidelines.

Legal Status of Abortion vs. PAC Sometimes the legal status of induced abortion and policies on postabortion care are confused. Women in need of PAC services may be reluctant to seek care, even for spontaneous abortions. If PAC clients are regarded as criminals, it may result in mistreatment. Providers may also face stigma if their work is perceived as controversial.

Local Policies/Laws on PAC Services Postabortion care is a lifesaving intervention that should be available to all women. Every woman has the right to safe postabortion care, which should be of the highest quality possible, whether the abortion was spontaneous or induced.

Effect of Laws on PAC Responsibility of clinical providers: Provide PAC (including family planning) to all women in need, regardless of cause of abortion Take necessary measures to save lives and preserve health of all Provide emergency care Offer counseling in prevention of unplanned pregnancy, FP and birth spacing

Effect of Laws on PAC (2) Responsibility of health care system: Support provision of emergency PAC, regardless of cause of abortion Prohibit punishment of properly trained PAC providers Ensure access to FP counseling and services