05_XXX_MM1 Implementing Safe Abortion: technical and policy guidance for health systems Ronnie Johnson, PhD UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction Department of Reproductive Health and Research Geneva, Switzerland

05_XXX_MM2 Outline 1. Goals 2. WHO safe abortion guidance: underlying principles 3.The concept of comprehensive abortion care 4. Applying the WHO Strategic Approach (including scaling up)

05_XXX_MM3 Our Goals To reduce maternal morbidity and mortality related to unwanted pregnancy and abortion (MDG 5, target A) To provide universal access to good- quality sexual and reproductive health care, including contraception and safe abortion (MDG 5, target B)

05_XXX_MM4 Maternal mortality in Europe Russia – 28 per 100,000 women of reproductive age Romania – 24 Moldova – 22 Ukraine – 18 Hungary – 6 Switzerland – 5 Source: World Health Organization 2007

05_XXX_MM5 Safe abortion: underlying principles

05_XXX_MM6 Focus on prevention

05_XXX_MM7 Prevention of… 1. Unintended pregnancy through early comprehensive sex education and readily accessible, high-quality contraceptive services 2. Unsafe abortion by providing comprehensive abortion care to all women and adolescents who want to terminate a pregnancy 3. Abortion-related mortality and morbidity by focusing on 1 and 2 above plus providing emergency treatment for all abortion-related complications

05_XXX_MM8 Focus on health and human rights for all women

05_XXX_MM9 Laws, norms, standards, and guidelines on abortion should aim to Protect the health and human rights of all adolescents and women of reproductive potential Facilitate prevention of unintended pregnancy Ensure that everyone legally eligible has ready access to high-quality services Eliminate barriers to access and high-quality services Ensure appropriate referrals when required

05_XXX_MM10 Recognize that High-quality sex education and good access to (and use of) high-quality contraceptive counselling and methods is the only way to reduce the number of unintended pregnancies and the subsequent need for abortion Even with "perfect" contraceptive use, there will always be a need for safe abortion When performed by skilled health providers in appropriate settings, abortion is one of the safest of all medical procedures Restrictive laws/policies do not reduce the overall rate of abortion but do increase the proportion of procedures that are unsafe

05_XXX_MM11 Be mindful of potential barriers to safe abortion

05_XXX_MM12 Remove barriers to facilitate access and quality of care  Many barriers are not actually specified or required in the law itself  It is the responsibility of the Ministry of Health and/or professional associations to review and remove such barriers in order to ensure access to the extent allowed by law

05_XXX_MM13 Barriers to safe abortion Potentially, anything that restricts a woman's ready access to services Legal, policy, administrative barriers Provider, facility barriers Sociocultural, religious barriers

05_XXX_MM14 Comprehensive Abortion Care Access Quality Choice Sustainability Courtesy of Ipas, 2005

05_XXX_MM15 "The Strategic Approach" A process that countries can use to: Identify and prioritize needs for reproductive health policy, programmes and research Test appropriate interventions to address priority needs Scale up successful demonstration projects

05_XXX_MM16 Strategic Assessment Policy & Programme Strengthening Developing and Testing Programme Innovations Scaling-Up Successful Interventions STAGE I Reproductive Health Challenges Improved Reproductive Health Status and Programmes STAGE IISTAGE III The Strategic Approach implementation process

05_XXX_MM17 Begin the process with the end in mind… Develop a package of interventions to provide abortion care appropriate for the Moldova context Generate evidence of the feasibility and effectiveness of the interventions on a small scale Scale up the model services – Horizontal scaling up - Expansion – Vertical scaling up - Institutionalization

05_XXX_MM18 Scaling up Success depends on developing a systematic strategy for both expansion and institutionalization, including: Assessing needs and priorities for strengthening access and quality of care Assessing demand for services and how to enhance the scalability of the interventions Building capacity of the institutions implementing the interventions Ensuring a supportive social, political, and resource environment Developing the capacity of a resource team to support the process

05_XXX_MM19 Successful scaling up also requires … Strategies for: Mobilizing resources Advocacy Procurement and distribution of equipment, supplies, drugs Training Coordination, management, supportive supervision Monitoring, evaluation, and quality improvement

05_XXX_MM20 Models for scaling up safe abortion care Build regional service-delivery and training capacity in government institutions and then extend services to more remote areas – For every 500,000 population there should be 5 safe abortion care facilities, at least one of which provides comprehensive care Contract out government services to NGOs, such as Marie Stopes, IPPF, or other local organizations Combine public and private models

05_XXX_MM21 Scaling up services in Moldova Implement CAC in 13 perinatal centres and then assess gaps in full population coverage Pilot services have been implemented in two perinatal centres Two more are planned in the initial horizontal scale up; these should be chosen strategically Must also consider vertical scaling up – i.e., institutionalizing CAC within national reproductive health strategy and national Ministry of Health budget

05_XXX_MM22 In short… Scaling up is a complex political, organizational and managerial challenge rather than a focused technical task… But, tools are available to support the process.

05_XXX_MM23 WHO/ExpandNet draft

05_XXX_MM24 WHO guidance on safe abortion Available for downloading at

05_XXX_MM25 WHO guidance on medical abortion Available at: