2. Maternal mortality

3. Maternal mortality rates worldwide

4. Misoprostol pills

5. Registration Ulcers (old “traditional” registration) Postpartum Hemorrhage - PPH (heavy bleeding after birth) or post abortion care. Rarely other gynaecological indications ALTHOUGH used all the time in gynaecology

7. Mechanism of action Creates uterine cramps

8. Postpartum hemorrhage (PPH) PPH is the main cause of maternal mortality (25% of all MM). Every year 14 million women experience PPH. About 128,000 maternal death/ year because of PPH Even if the whole birth process seemed to have gone well, a woman might still get PPH. We cannot predict if PPH will happen MM due to PPH highest if: no emergency services, limited access to skilled birth attendants, poor transportation system

9. Postpartum hemorrhage (PPH) Postpartum hemorrhage is excessive vaginal bleeding within 24 hours after giving birth. This means more than 500 ml. of blood loss.

10. How much is 500 ml?

11. Picture: Pathfinder International, http://www.youtube.com/watch?v=N5s_sKAiQZ4

14. Postpartum hemorrhage (PPH) Why does it happen? Usually heavy bleeding happens because the uterus does not contract anymore after baby is out and the placenta is not delivered (~75% of PPH);

15. Placenta

16. Oxytocin is another medicine that can prevent PPH (injections that need to be in refrigerator) If a woman has no other choice than giving birth at home and there is no medical practitioner, using 3 tablets of misoprostol will cut her chance of getting heavy bleeding by more than 50%

17. How to use Misoprostol for PPH? Step 1 Step 2 Step 3 Step 4

18. How to use Misoprostol for PPH? STEP 1 Immediately after giving birth, dry the baby, put it on the belly of the mother. Cover the baby with warm cloth or blanket. Picture: Pathfinder International, http://www.youtube.com/watch?v=N5s_sKAiQZ4

19. How to use Misoprostol for PPH? STEP 2 Feel the belly to make sure there is not another baby in the womb, if there are no more children: Within 1 minute after the baby is born put 3 Misoprostol tablets of 200 mcg under the women’s tongue.

20. How to use Misoprostol for PPH? STEP 3 Clamp the cord.

21. How to use Misoprostol for PPH? STEP 4 Massage the womb (at the top end) until and after the placenta comes out until it is contracted (feels like hard ball). Do this every 15 minutes for the next 2 hours.

22. 1 2 3 4

23. 1 2 3 4

24. Go to the hospital: if heavy bleeding continues or the placenta does not come out within 30 minutes

25. Why do women have unwanted pregnancies? Rape Not using contraceptives No information Not available Too expensive cultural reasons While using contraceptives (the contraceptive pill is 98% effective)

26. 22% of all pregnant women choose to have an abortion 20% of all pregnant women have a spontaneous miscarriage http://www.guttmacher.org/pubs/fb_IAW.html

27. Every year 42 million women have an abortion. 21 million of these are illegal. About 48 000 women die from complications of unsafe abortion each year. http://www.guttmacher.org/pubs/fb_IAW.html

28. The world average statistic is that every woman will have 1 abortion during her lifetime

29. Abortion laws

30. Making abortion illegal does not reduce the number of abortions

31. WHO, Unsafe abortion, 2008 Legal status Vs unsafe abortion incidence

32. WHO, Unsafe abortion, 2003 http://who.int/reproductive-health/publications/unsafeabortion_2003/ua_estimates03.pdf Legal status vs Deaths due to unsafe abortions

33. WHO, Unsafe abortion, 2008

34. Source: http://whqlibdoc.who.int/publications/2007/9789241596121_eng.pdf

35. Mortality UNSAFE abortion is 1 : 440 Mortality of a SAFE abortion is < 1 : 500 000 Mortality of giving birth is 1 : 10 000

36. “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.” Dr Mahmoud F. Fathalla

37. Half of the women who have an abortion are mothers with children

38. an estimated 220.000 children worldwide lose their mothers every year from illegal abortion-related deaths.

41. We should trust our women, mothers, sisters with this kind of decision. We can not put ourselves in another woman’s shoes and make such a life-changing decision for her. We should respect the fact that they, and only they, can fully consider the implications of pregnancy, giving birth, childbearing, and adoption in their lives.

42. Abortion methods - Surgical methods 1.Vacuum Aspiration - Medical abortion

43. Medical abortion till 12 weeks of pregnancy at home Mifepristone (anti-progesterone) + Misoprostol (prostaglandin) (98% effective) (1 tablet Mifepristone 200 mg, after 24 hours 4 tablets Misoprostol 200 mcg sublingual or buccal Misoprostol alone (Cytotec) (90% effective) (4 tablets 200 mcg sublingual or buccal, repeated 3 times every 4 hours, total 12 tablets) Mifepristone and Misoprostol are on the WHO list of essential medicines. Misoprostol is also available in countries where abortion is legally restricted

47. Safe and Effective Misoprostol causes a miscarriage. Miscarriages are very common, compications are rare and women can handle the miscarriage themselves. This is the very reason why in many countries women take abortion pills at home, it is standard and accepted procedure.

48. 1.The assistance of a doctor is NOT necessary; a woman can do it herself! 2. If abortion is illegal in her country, a woman can say she had a miscarriage Abortion with pills

49. Pharmacy In the pharmacy a woman can say she needs misoprostol because her sister is going to give birth soon at home She can also say she has rheumatoid arthritis.

50. medical abortion = abortion with pills = induced miscarriage

51. When it’s better NOT to take the medicines at home? When a woman is alone When the first day of your last menstrual period was more than 12 weeks ago (officially supported till 9 weeks) A woman cannot get to a hospital or first aid centre within 2 hours There is no absolute contraindication to medical abortion

52. When it’s better NOT to take the medicines at home? 123123

53. How to use misoprostol for abortion? 1.A woman can put 4 pills of 200 micrograms Misoprostol under the tongue. Do not swallow for at least 30 minutes! 2.After 3 hours put another 4 pills of Misoprostol under the tongue. Do not swallow! 3.After 3 hours put another 4 pills of Misoprostol under the tongue. Do not swallow!

54. So remember… Total 12 pills 4 pills – wait 3 hours – 4 pills – wait 3 hours – 4 pills under the tongue The success rate is about 90%. The earlier in pregnancy taken, the less complication risk.

55. Practice…

56. What to expect? Bleeding and cramps Sometimes side effects after misoprostol (normal) vomiting, diarrhea, fever, headaches

57. How much bleeding and pain after misoprostol? The next day you a woman should feel fine (no heavy pain) Bleeding can last up to 3 weeks Ipas, Medical Abortion Study Guide, 2009

58. What to expect? Normal effects: …… Side effects: …….

59. Complication symptoms If there is heavy bleeding that lasts for more than 2-3 hours and soaks more than 2 maxi sanitary pads/ kangas per hour If there is strong pain that does not go away few days after taking the medicines. If a woman has vaginal discharge that smells bad. If the woman has a continuous high fever or ever fever above 39 Celsius

60. 1. 2. 3. 4. !

61. 1. 2. 3. 4. !

62. What to say to the doctor or nurse? In countries where abortion is legally restricted she can say, she had a spontaneous miscarriage. The doctor CANNOT see the difference.

63. How to know it worked? There was bleeding (more than menstruation) She feels well and NOT pregnant No pain or fever few days later Check with home pregnancy test after 2-3 weeks (not earlier!) Check with ultrasound after around 10 days

64. Remember! Bleeding ≠ Abortion Sometimes a woman has bleeding but the pregnancy continues No Bleeding = No Abortion

65. And what if it did not work? Repeat abortion after few days or have a surgical abortion

66. Extra info Use of painkillers (NSAID’s like Ibuprofen or Paracetamol) IUD and ectopic pregnancy Post-abortion care – use of contraceptives ( a woman can get pregnant immediately after the miscarriage!!!!)

68. Anatomy of Female Reproductive System

69. Anatomy of Male Reproductive System

70. Menstrual Cycle

71. Fertility Period of highest fertility is immediately before and after ovulation Women can get pregnant at any time in their cycles, even during menstruation Women can get pregnant immediately after an abortion, and soon after birth, even during breastfeeding

72. Journey of the Ovum

74. Contraceptives No method is 100% effective 85% of sexually active women NOT using contraceptives will get pregnant within one year

75. Emergency Contraception (ECP) Contraception used after intercourse and before implantation. Does not disrupt an ongoing pregnancy For pills see http://ec.princeton.edu/ http://ec.princeton.edu/ IUD within 7 days

76. Emergency Contraception pills Progestin-only pills or ulipristal acetate pills (ella one) Some daily birth control pills can be used as emergency contraception. – Pills containing combined progestin and estrogen pills (look for pills containing levonorgestrel) – To use the pills, within 72 hours of unprotected sex, the woman should take one dose of 100 µg ethinylestradiol + 500 µg levonorgestrel (2-4 birth control pills). 12 hours later she should take a second dose of the same pills (2-4 birth control pills). – May cause nausea, and menstruation may come slightly early or slightly late, but should come within a month

77. Sexually Transmitted Infections (STI’s) May have no symptoms, or symptoms may take a long time to appear Can be prevented by condom use Can have such symptoms as: genital itching, irritation, burning or sores; abnormal discharge from penis or vagina, pain or discomfort during intercourse, internal or external genital warts, fever Some STI’s are easily treated with antibiotics HIV needs extensive treatment

79. PEP?

80. PEP Post Exposure Prophylaxis A combination of drugs given after high risk sex or rape Can reduce risk of HIV/AIDS Should be taken in less than 72 hours after exposure Can be taken with antibiotics to prevent other STI’S Not 100% effective Usually available in hospitals or clinics

81. Pregnancy Signs: – Missed menstrual period – Nausea, vomiting – Tiredness, fatigue – Frequent urination Measured from first day of last menstruation Birth is expected 37 – 42 weeks after last menstruation

82. Giving Birth If pregnancy is normal women can safely give birth at home with the help of a skilled birth attendant If there have been problems with the pregnancy, it is better to give birth in the hospital Pre-natal exams by midwives or skilled birth attendants throughout the pregnancy can help identify possible problems