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POPLINE records: Care for Postabortion Complications: Saving Women's Lives |
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Following are POPLINE records corresponding to selected citations in the bibliography of Care for Postabortion Complications: Saving Women's Lives (Population Reports L-10). Only the items that were particularly useful in the preparation of this issue of Population Reports are presented here. 33.DOCUMENT NUMBER: PIP/074528 ; IND/8021647 AUTHOR: Benson J ; Leonard AH ; Winkler J ; Wolf M ; McLaurin KE TITLE: Meeting women's needs for post-abortion family planning: framing the questions. GENERAL NOTES: Princeton University Library (SPR) ABSTRACT: Although women who undergo abortion are at risk of subsequent unwanted pregnancies, abortion services in developing countries are rarely linked to family planning services. This neglect of post-abortion contraceptive services reflects both the low priority allotted to women's reproductive health needs and national and international policies that restrict abortion-related programming. Even when abortion providers refer women to a family planning center, the clinic is often inaccessible or insufficiently supplied with modern contraceptives. preferable is a model involving on-site delivery of initial counseling and contraceptive provision after abortion coupled with referral to and contraceptive provision after abortion coupled with referral to community sources for continuity of care and resupply. Since women who are not adequately counseled are at high risk of method discontinuation, all family planning options must be clearly presented. In all cases, respectful treatment of abortion patients and understanding of the situation that led them to seek abortion will improve the acceptability of services. In the majority of cases, unwanted pregnancies occur because family planning services are unavailable, inaccessible, ineffective, or culturally unacceptable to women. The inclusion of women in the design of post-abortion services can help to identify the obstacles to family planning use. Fortunately, there is growing concern about the effects of unsafe, clandestine abortion (up to 200,000 maternal deaths each year) and the momentum for change exists. Ways must be found, however, to reach women who induce abortions clandestinely and never enter the health care system. SOURCE: Carrboro, North Carolina, IPAS, 1992. [8], 69 p. (RH Training Materials)
34. The Commonwealth Regional Health Community Secretariat conducted a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The literature review component of the study identified a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynecology admissions. Hemorrhage and sepsis were the most common complications of unsafe abortion seen at health facilities. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay and a reduced need for a repeat evacuation. Few articles focused exclusively upon the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behavior and abortion reported that almost all patients experiencing abortion complications had not used an effective, or any, method of contraception before becoming pregnant, especially among the adolescent population, while there were almost no studies on post-abortion contraception. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs are presented. SOURCE: HEALTH POLICY AND PLANNING. 1996 Jun;11(2):117-31.
40. Limited access to safe abortion is a leading cause of maternal mortality and morbidity in the developing world. Hospitals are often overwhelmed by the large number of women presenting for treatment of the complications of previous unsafe abortions. In many settings, the number of incomplete or septic abortions comprises more than half of all gynecological admissions. In the absence of measures to reduce the incidence of unsafe abortions, hospitals treat these female patients with complications in the most efficient and effective manner allowed by limited available resources. In most developing countries, Evacuation and Curettage (E&C) is the standard approach to treating cases of incomplete abortion. Requiring a physician, operating theater, and often general anesthesia, E&C is usually performed in the hospital setting. Patients may have to wait several days for treatment, a period during which complications such as hemorrhage and sepsis may develop. In the developed world, however, Manual Vacuum Aspiration (MVA) is the standard treatment for uterine evacuation. MVA usually requires neither anesthesia, anesthetist, operating theater, nor an overnight stay, and it may be performed by a wide range of trained medical personnel including physician's assistants, nurse practitioners, and nurse midwives who may work in rural health clinics with no operating room facilities. This paper documents the magnitude of differences in cost between MVA and E&C in the treatment of early incomplete abortions in the following four hospitals in Kenya: Kenyatta National Hospital in Nairobi, Kisii District Hospital, Eldoret District Hospital, and Machakos District Hospital. Data were collected over the period March-June 1991 and consider costs comprehensively in terms of staff time, in-patient or hotel costs, and drugs and equipment. Analysis found MVA to be the most appropriate and cost-effective way of managing incomplete abortion. Effort should therefore be made to extend the availability of MVA to all district hospitals and to effect changes in patient management which can maximize the benefits of MVA and the use of available resources. SOURCE: JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF EASTERN AND CENTRAL AFRICA. 1993;11:12-9.
75. To address the need for population-based studies on maternal morbidity--"the base of the iceberg"--the Ford Foundation sponsored surveys in Bangladesh, Egypt, India, and Indonesia. Prevalent morbidities across all sites were edema (10.3-22.9%), severe vomiting (19.2-23.3%), and urinary problems (12.3-29.4%). The percentage of respondents with at least 1 morbidity during the index pregnancy and puerperium ranged from 58.3% in India to 79.9% in Bangladesh. Long-term pregnancy-related morbidity was reported by 28.6% in Bangladesh, 25.5% in Egypt, 8.2% in India, and 19.7% in Indonesia. In each site, mothers who had experienced life-threatening or serious morbidities were more likely to want additional children, presumably because they were often primiparas. The ratios of women with morbidities to maternal mortality were 186:1 in Bangladesh, 374:1 in Egypt, and 251:1 in India. Even for very serious conditions, a significant proportion of women did not perceive the severity; in other cases, severity was perceived, but medical attention was not sought. A reduction in maternal mortality and disability requires a two-pronged strategy: 1) health education for women and their families about symptoms that require attention during pregnancy, labor, delivery, and the postpartum period (e.g., pelvic pain, foul discharge, fever, and bleeding), and 2) removal of geographic, financial, cultural, and psychological barriers to care-seeking. SOURCE: Research Triangle Park, North Carolina, Family Health International [FHI], Maternal and Neonatal Health Center, 1996 Dec. vii, 104 p.
86. This booklet details the impact of the technique of vacuum aspiration on the quality of treatment of incomplete abortion, the performance of first-trimester induced abortion, and endometrial biopsy. The benefits of using vacuum aspiration rather than sharp curettage for uterine evacuation are delineated, and the use of the manual vacuum aspiration (MVA) technology developed and distributed by International Projects Assistance Services is highlighted. The first chapter outlines the history of the use of vacuum aspiration for uterine evacuation and provides a chronology of the development of the MVA technique. Chapter 2 provides a clinical overview of the use of vacuum aspiration. Drawing on more than 25 years of clinical research, the effectiveness of vacuum aspiration is demonstrated, and its safety advantages over sharp curettage are demonstrated. The third chapter focuses on the programmatic implications of MVA for service delivery in a variety of settings. MVA use leads to improved quality of abortion care, increased access to abortion care, and a reduced use of resources. Specific experiences in Turkey, Bangladesh, and Zambia are cited, and implications for health care systems in general are discussed. It is concluded that introduction of MVA into diverse health care systems can improve the quality and availability of abortion care for women throughout the world. Addenda to the monograph detail the specifications and global availability of the MVA instruments and provide a description of gynecologic aspiration kits. SOURCE: Carrboro, North Carolina, IPAS, 1993. xiv, 67 p. (RH Training Materials)
87. Improving postabortion care can reduce the negative impact of unsafe abortion. Of the 53 million estimated induced abortions occurring annually about two out of five involve unsafe procedures. About one abortion occurs for every three births annually. 96% of abortions in Africa and 85% of abortions in Latin America are unsafe. About 100,000 to 200,000 women die every year from unsafe abortion, or 1 out of 400 women. Family planning is unavailable to over 120 million women in developing countries who desire contraception. Past moral and political controversies divert attention away from death and injury. The international community can take the opportunity to change affairs by adopting a women's health initiative globally. Improvements are needed in quality of care and accessibility of emergency treatment services. Emergency treatment services are usually only available at the tertiary level of care in urban areas. Poor transportation systems limit access. Access is also impaired by women's attitudes toward treatment centers. Availability of services needs to increased through decentralized centers. Clear protocols and comprehensive, systematic training must be accomplished in tandem with improvements in quality. Provision of technology such as manual vacuum aspiration is cost effective and an easy way to improve quality in primary care or outpatient settings. Unsafe abortion is a byproduct of the failure to provide adequate family planning for prevention of unwanted pregnancy. The obstacles, that interfere with provision of family planning to abortion users, should be removed. These obstacles include providers' lack of understanding of women's needs and motivations, separation between abortion and family planning services, misinformation about contraception following abortion, lack of acknowledgement about unsafe abortion, and women's low status. National and international policies also interfere with provision of contraception. Complete reproductive health care is a necessity for improvement in maternal health and mortality. SOURCE: ADVANCES IN ABORTION CARE. 1994;4(1):1-4. (RH Training Materials)
90. This report presents results of an operation research project to test the acceptability, effectiveness, and cost-effectiveness of postpartum/postabortion family planning services in the Peruvian Social Security Institute (IPSS). A study was conducted at the Rebagliati Hospital in Lima, Peru. Postpartum women were assigned to experimental and control groups. Women assigned to the experimental group received family planning education and the offer of free family planning services, including IUD insertion. Controls received only regular hospital services, not including family planning. The contraceptive prevalence of the groups was compared at 40 days and 6 months postpartum. Both postpartum and postabortion family planning were found to be highly acceptable to IPSS clients. Over 70% in each service accepted a contraceptive method prior to leaving the hospital. The group which received family planning education and services had higher contraceptive prevalence at both 40 days and 6 months postpartum than did the control group. It was estimated that adoption of both periods of family planning by the Rebagliati Hospital would add over 5700 IUD insertions to the IPSS, resulting in a 38% increase in the acceptance of this method for the entire system. Moreover, the very low cost of postpartum insertions would replace about 8000 more costly visits by women to IPSS and the Ministry of Health for interval insertions. Cost savings would be the equivalent of 20% of all family planning visits to IPSS. They have decided to adopt postpartum family planning as a regular activity in all of its hospitals. (author's modified) SOURCE: Lima, Peru, PROFAMILIA, 1990 May. [5], 18, [60] p. (USAID Contract No. DPE-3030-C-00-4070-00)
94. The worldwide trend toward liberalization of abortion laws has continued in the last 4 years with changes in Canada, Czechoslovakia, Greece, Hungary, Romania, the Soviet Union and Vietnam. 40% of the world's population now lives in countries where induced abortion is permitted on request, and 25% lives where it is allowed only if the woman's life is in danger. In 1987, an estimated 26 to 31 million legal abortions and 10-22 million clandestine abortions were performed worldwide. Legal abortion rates ranged from a high of at least 112 abortions/1,000 women of reproductive age in the Soviet Union to a low of 5/1,000 in the Netherlands. In recent years, abortion rates have been increasing in Czechoslovakia, England and Wales, New Zealand and Sweden and declining in CHina, France, Iceland, Italy, Japan and the Netherlands. In most Western European and English-speaking countries, about 1/2 of abortions are obtained by young, unmarried women seeking to delay a 1st birth, while in Eastern Europe and the developing countries, abortion is most common among married women with 2 or more children. Mortality from legal abortion averages 0.6 deaths/100.000 procedures in developed countries with data. Abortion services are increasingly being provided outside of hospitals, and for those performed in hospitals, overnight stays are becoming less common. National health insurance covers abortions needed to preserve the health of a pregnant woman in all developed countries except the United States, where Medicaid and federal insurance programs do not cover abortion unless the woman's life is in danger. (author's) SOURCE: FAMILY PLANNING PERSPECTIVES. 1990 Mar-Apr;22(2):76-89.
95. This is a continuation of a series of reports presenting data on induced abortion around the world. It contains a reprint of an article by Stanley K. Henshaw, together with selected tables updating the data presented in the sixth edition. The data are mainly by country and include time series. (ANNOTATION) SOURCE: New York, New York, Alan Guttmacher Institute, 1990. 120 p.
96. In developing countries (LDCs) maternal mortality (MM) is often the leading cause of death of women of childbearing age. 500,000 women worldwide die each year from pregnancy-related complications with 99% of these deaths occurring in LDCs. Women in these countries run 50-100 greater risk than women in modern industrialized countries. Risks vary per individual, but in general are greater for: very young women and women over age 35; woman in their 1st pregnancy or after their 4th; women with preexisting health conditions; women who are poor, malnourished, and uneducated; and women who are living in rural areas without access to health care. 75% of MM are direct obstetric deaths especially from hemorrhage, sepsis, toxemia, obstructed labor, and illegal and primitive abortion. Improving the income, education, health, and nutritional status could significantly improve MM rates. Access to family planning information and services could ultimately prevent 25-40% of MM. 3 major elements in any plan to address MM are prevention of complications, routine care, and backup measures for high risk and emergency cases. Current evidence suggests that screening techniques could identify the high risk population amongst pregnant women, thereby concentrating resources where they are most needed. Any strategy to provide the 3 necessary elements should use a 3-pronged approach: 1) stonger community-based care including screening and referral methods, provision of prenatal care, and access to family planning services; 2) stronger referral facilities including hospitals and health centers to provide care for complicated deliveries and obstetrical emergencies, and clinical and surgical methods of family planning; 3) an alarm and transport system to transfer women with high risk pregnancies from communities to referral facilities. 2 cost models to implement such an approach were developed. The 1st model represents a US$2/capita/annum expenditure. A 2nd model would involve a US$1/capita/annum expenditure. The 2nd model, while not preventing as many maternal deaths, is more cost-effective. Any initiative to improve maternal health depends upon political commitment, allocation of necessary resources to maternal health and family planning services, and support from media and other non-governmental sectors in terms of health education. SOURCE: Washington, D.C., The World Bank, 1987. iv, 52 p.
103. This report analyzes the results of an operations research project carried out at two sites in Egypt to improve the medical care and counseling of postabortion patients. Preintervention and postintervention surveys and observations were conducted. After the introduction of vacuum aspiration under local anesthesia, the number of cases treated with dilatation and curettage under general anesthesia dropped from an average of 169 per month to 16. The majority of the remaining cases (an average of 119 per month) were treated with vacuum aspiration. Both providers' and women's knowledge about postabortion complications improved. Family planning information provided to postabortion patients increased as a result of the project's training program. The proportion of patients intending to use a contraceptive method increased by 30 percentage points due to the improved counseling. Future programs linking family planning and postabortion medical services should be prepared to improve the medical care of existing emergency health services and to add counseling services. (author's) SOURCE: STUDIES IN FAMILY PLANNING. 1995 Nov-Dec;26(6):350-62.
126. In much of the developing world, sharp curettage (SC) is the most commonly used technique for treating incomplete abortion. The procedure is usually performed in a hospital setting where physicians and operating theaters are available; it often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. This study examined the hypothesis that use of manual vacuum aspiration (MVA)--a variation of vacuum aspiration--would be less costly than SC and thus be advantageous to healthcare systems with limited resources. The purpose of this study was to identify and, where possible, to explain the factors that contributed to cost differences between MVA and SC for treatment of incomplete abortion. To achieve this objective, researchers observed patient management and documented resource use at hospital sites in Kenya and Mexico. The results of the study support the researchers' hypothesis that, in most cases, treatment with MVA required a shorter patient stay and fewer hospital resources than SC, as the 2 techniques were practiced at the various study sites. The policy decision to adopt MVA, supported by procurement of instruments and incorporation of training in its use, is the basic prerequisite to achieving reduced levels of resource use. The study results also suggest that the full advantages of MVA can be realized only if it is introduced in conjunction with certain changes in patient management, such as offering outpatient treatment for incomplete abortion. (author's) SOURCE: SOCIAL SCIENCE AND MEDICINE. 1993 Jun;36(11):1443-53.
127. A demonstration project was implemented at hospitals in Kenya, Mexico, and Ecuador between January and August 1991 to identify and explain the factors that contribute to cost differences between the use of dilation and curettage (D&C) and manual vacuum aspiration (MVA) to treat incomplete first-trimester abortion. After an introduction and a brief discussion of methodology, the results are presented for duration of hospital stay associated with each procedure, for the cost of treating patients for incomplete abortion, and for trends in duration of stay and resource utilization. It was found that MVA offers significant potential benefits for women, service providers, and health care systems and that it requires fewer resources for most of the cost elements studied (staff, drugs, and hospitalization). The results indicate that realization of the full benefits of MVA depends upon the adoption of changes in patient-management protocols. The discussion continues with a consideration of the policy and protocol decisions required for a change from D&C to MVA, including the purchase of MVA instruments, training and procedural adaptations (including the adoption of new sterilization procedures and the implementation of appropriate pain control practices), patient-management issues (location of the evacuation procedure in a treatment room rather than an operating room, level of priority given to incomplete abortion patients, and modifying hospital discharge protocols to eliminate needless waiting time), and decentralization of abortion care to lower levels of the health care system (which is not required, but which enhances resource savings and women's health). The outcomes of policy changes related to the treatment of incomplete abortion will be reduced waiting times, resource reallocation, and improved accessibility of services. These findings have already contributed to policy changes in Kenya, Mexico, and Ecuador and to discussions with Ministry of Health representatives from Zambia and Zimbabwe. Appendices provide additional information about the study sites, explain variations in data collection, and describe cost determinants. SOURCE: Washington, D.C., World Bank, Population and Human Resources Department, 1993 Jan. v, 31 p. (Policy Research Working Papers WPS 1072)
145. In 1994, the Commonwealth Regional Health Community Secretariat for east, central and southern Africa conducted a study to substantiate the extent of abortion complications in the region during 1980-1994. In some countries, as many as 76% of hospital gynecology admissions are incomplete abortion patients. Thus, unsafe abortion is a significant public health problem. Hemorrhage and sepsis are the leading complications of abortion. There is limited information on the cost of treating abortion complications. Manual vacuum aspiration, an effective and safe method of emptying the uterus, reduces the cost for treating incomplete abortion cases by 66% when compared to sharp curettage. According to the limited information that exists in the literature on men's role, men do play a minor role in a woman's decision to end a pregnancy. They may provide financial support, however. Most women suffering from unsafe abortion complications either do not use effective contraception or use no contraception. There are many documents on the legal aspects of abortion. There are no documents on postabortion family planning services. Unsafe methods of induced abortion (e.g., traditional methods) cause serious injuries and death. Treatment of abortion complications are costly for health care systems. Concerns about side effects and lack of access to and information about family planning services are the major obstacles to contraceptive use. Abortion laws tend to be restrictive, which encourages illegal, unsafe abortions. The administrative requirements for legal abortion diminishes access to safe, legal abortion. SOURCE: [Baltimore, Maryland, JHPIEGO, 1995]. [2], xv, 103, [200] p.
146. In a study to assess the efficacy of and safety of vacuum aspiration syringe in the management of incomplete abortion, 300 patients with nonseptic abortion were evacuated by their method in the ward. A control group of 285 patients was evacuated in the theatre by sharp curettage. All patients were followed up for 21 days; 54.7% of the study patients were evacuated without any need for analgesia while all the control patients were given intravenous pethidine and valium. 2.3% of vacuum aspiration and 3.5% of control patients needed reevacuation (p.0.05). 70.3% of vacuum aspiration cases were dry by day 7 compared to 64.6% of the control group (p>0.05). Immediate complications of nausea and vomiting were seen in 5.3% of the study patients (p<0.001). There was 1 uterine perforation in the control group. 5.4% of the study and 6.0 of the control patients developed mild to severe sepsis (p>0.05). Vacuum aspiration is a safe, simple, and quick method of treating incomplete abortion. Its wider use in developing countries is highly recommended. (author's) SOURCE: EAST AFRICAN MEDICAL JOURNAL. 1990 Nov;67(11):812-22.
154. In societies with restrictive abortion laws, clandestine induced abortion by unskilled personnel results in needless and very high mortality and morbidity. To aid women with abortion complications, and to reduce the incidence of complications, clinicians must have access to and acquire skills to use safe, cost-effective technologies that have been developed. Women often have incorrect information on reproduction, It is necessary to provide accurate information on sexuality and contraception. Access to contraceptive services should be provided, as should legalized abortion. Physicians and nonphysicians should be trained. Septic abortion is a common complication of induced abortion. It leads to endotoxic shock. The management of septic abortion requires: 1) extensive laboratory and x-ray investigation; 2) large doses of antibiotics; 3) treatment of fluid and blood loss; and 4) surgical evacuation of the uterus. This places tremendous strain on the health resources of developing countries. The strain could be prevented by training health workers to perform vacuum aspiration. Incomplete abortion without sepsis may occur following induced abortion. This is best managed by vacuum aspiration followed by ergometrine. Dilatation and curettage may also be used. Bleeding is a major complication of incomplete abortion. It requires a blood transfusion unless the bleeding is mild and protracted. Injuries to the genital organs can occur, as can life-threatening toxic reactions. (author's modified) SOURCE: INTERNATIONAL JOURNAL OF GYNAECOLOGY AND OBSTETRICS. 1989;(Suppl 3):21-8.
157. A 10-year review of maternal mortality was conducted at the Municipal hospital Miguel Couto in Rio de Janeiro. 32 deaths occurred between January 1978-December 1987. In the same period, there were 18,071 livebirths, giving an overall maternal mortality ratio of 177/100,000 livebirths. Maternal mortality increased from 128/100,000 livebirths in 1978 to 462/100,000 in 1987. Abortion-related deaths accounted for 47% of the total mortality, followed by toxemia (19%), and hemorrhage (13%). The contribution of abortion-related mortality to maternal mortality increased 172% over the 10-year period studied. These results indicate that maternal mortality has been increasing in a population of urban poor and that the leading cause of death is induced abortion. In a setting where access to abortion is highly restricted and desire to regulate fertility is high, death due to illegal abortion is a major contributor to maternal mortality. The rise in abortion-related mortality over the past 10 years is attributed to a lack of family planning services in conjunction with urban socioeconomic conditions conducive to smaller families. (author's) SOURCE: OBSTETRICS AND GYNECOLOGY. 1990 Jan;75(1):27-32.
161. A variety of recommendations are made for improving postabortion counseling about ovulation, safe methods for preventing pregnancy, and accessibility of family planning (FP) services. This article includes an 18 by 24 inch chart of postabortion FP information (clinical conditions, precautions, and recommendations), which is appropriate for providers. "If the woman" situations are given specific solutions. For instance, if the postabortion woman is under stress, in pain, or not prepared to make a decision, then informed, voluntary decisions are not possible. Long-acting, permanent, or provider-dependent methods are, thus, not recommended. Temporary methods and a referral for longer-acting methods are suggested in this "if the woman" situation. Natural FP is not recommended until a regular menstrual period returns. At the Bellagio Conference in 1993 about 25 international experts recommended that contraceptive protocols should be based on the assessment of each woman as an individual (personal characteristics, clinical conditions, and service delivery capabilities in the patient's treatment and residential area). Postabortion FP should use a problem-solving approach tailored to the individual as a means of increasing the likelihood of acceptable and effective care. Clinical conditions are of equal or lesser importance to personal preferences, constraints, and social contexts. Clinicians must be aware of the factors that led to the unwanted pregnancy, as a means of helping the client select an appropriate method. A working group recommends that all modern contraceptives may be used immediately following postabortion care. Women should abstain from intercourse until bleeding stops. SOURCE: ADVANCES IN ABORTION CARE. 1994;4(2):1-4. (RH Training Materials)
163. This counseling guide gives detailed guidelines on how the family planning provider should counsel clients. 2 essential ingrediants are showing clients that the counselor cares and giving the client clear information. Charts and diagrams are provided for use with the client as well as sources for obtaining audiovisual teaching materials. The guide has many examples of good and bad dialogues between client and counselor. Topics include essentials of counseling; dealing with clients' feelings; listening and questioning; greeting clients; countering false rumors and information; helping choose a method of birth control; how to help on the return visit; AIDS information for family planning clients; holding group discussions; and family planning for the breastfeeding woman. Contraceptive methods described include the IUD; condoms; injectable contraceptives; tubal ligation; oral contraceptives, vasectomy; and foaming spermicidal tablets. A question/answer test is provided for the reader. Illustrations are drawn from a variety of cultures and languages. SOURCE: POPULATION REPORTS. SERIES J: FAMILY PLANNING PROGRAMS. 1987 Dec;(36):2-28. (RH Training Materials)
164. The 2 greatest health risks for women in their reproductive years are pregnancy and childbirth. This is especially true in developing countries, where more than half a million women die each year in pregnancy or childbirth. A concerted effort by families, communities, and health care professionals, especially maternal health care providers, can make childbearing safer. Maternal health care providers, as well as referral centers, have a responsibility to promote improvements in women's health. Referral centers can offer emergency treatment when labor or delivery complications occur at home, provide a safer place to deliver for those women likely to develop complications, and offer treatment for problems that develop during pregnancy. The role of the community in the provision of maternal health care is important. Prenatal screening, trained health care workers who could attend deliveries at home, available transportation to referral centers, family planning and education and adequate food supplies are some of the ways communities can take an active role in maternal health care. Because many women prefer traditional birth attendants (TBAs) or relatives even when trained providers are available, maternal health programs need to cooperate and integrate TBAs into the maternal health care system. Training for TBAs, as well as training for health care providers and doctors and nurse, is important for the establishment of a responsive health care system. Controversy exists about where the emphasis should lie in maternal health care. While preventive care and safer delivery is important, referral centers and transportation needs also require resource consideration. Although community-level maternal health care is not yet widespread, appropriate training, communication, and cooperation can help to achieve this goal and give priority care to maternal health. SOURCE: POPULATION REPORTS. SERIES L: ISSUES IN WORLD HEALTH. 1988 Sep;(7):1-31. (RH Training Materials)
178. Trained providers can perform manual vacuum aspiration (MVA) on an outpatient basis outside of an operating room. They need to support patients and provide proper pain control medication, especially since women are conscious during MVA. They must respond to the specific needs of each patient. Medications are anesthesia, anxiolytics (anti-anxiety drugs), and analgesia. The ideal MVA pain control strategy is clear communication, sensitive support and handling by providers, analgesia that allays the feeling of pain in the receptors of the central nervous system, anxiolytics, and paracervical block, which numbs all local sensation. Constant attention and reassurance (verbal anesthesia) minimize fear levels. An advantage of local anesthesia is that the patient is able to react and report any changes in discomfort or pain. The analgesic drugs include narcotics, narcotic combinations, nonsteroidal anti-inflammatory drugs, nonnarcotic drugs, and dissociative drugs/analgesic. The generic names for the anxiolytics are diazepam and midazolam. Two frequently used anesthetics for paracervical block are lidocaine and chloroprocaine. Narcotics, anxiolytics, and anesthetics can depress or stop respiration, thus a ventilating bag and oxygen must always be present. Local anesthetics can induce allergic reactions, such as itching, rash, and hives, as well as toxic reactions, ranging from ringing in ears to tonic-clonic convulsions. SOURCE: IPAS ADVANCES IN ABORTION CARE. 1993;3(1):1-8. (RH Training Materials)
184. Outlined are 7 strategies for combatting unsafe abortion, even in countries with limited resources and serious legal obstacles. One of the most basic tasks is to educate the public, political leaders, and health authorities about the harm and costs associated with unsafe abortion. To cultivate strong leadership for the campaign to improve access to safe abortion, coalitions of community and religious leaders and representatives from legal, medical, media, and social welfare sectors should be formed. Also important is the dissemination of research findings to government decision makers and donor agencies. Topics for study include: societal costs of unsafe abortion, measurement of abortion morbidity, contraceptive use following abortion, subpopulations of women (e.g., adolescents), and resource needs for improved services. The provision of vacuum aspiration instruments, infection prevention equipment, contraceptives, and printed technical materials can be important in countries with limited technology. Training programs for abortion care providers--midwives, private sector physicians, public sector hospital staff, and post-abortion family planning personnel-can be used to introduce improved technology. Where possible, high quality, comprehensive abortion services can be provided directly to women. Finally, international collaboration and experience sharing among those working to combat unsafe abortion is urged. SOURCE: PLANNED PARENTHOOD CHALLENGES. 1993;(1):43-6.
186. Abortion is illegal in many countries, yet health systems in every country do provide emergency treatment for abortion complications. Nearly every country allows abortion in cases of rape, incest, and/or risk to the mother's life. Health systems in a country where abortion is illegal neither admit the magnitude of the need for abortion related care not plan legally indicated services effectively. Thus nearly 200,000 women die annually from complications of unsafe abortion and many more face serious injuries. 99% of the deaths and injuries happen in developing countries. A proactive approach by the health systems, even within their present legal framework, would improve the quality and effectiveness of current abortion care. 1st they must acknowledge the problem of unsafe abortion. They then need to integrate abortion care into the comprehensive reproductive health care system. Most importantly, they must decentralize both preventive and curative services. Nigeria, Nicaragua and Bangladesh have been able to provide needed abortion care, despite the restricted legal environment. Nigeria now trains medical students in manual vacuum aspiration (MVA) to treat incomplete and septic abortions which has fewer complications than does dilation and curettage (D&C). Nigeria also added family planning counseling and services to women undergoing MVA. Nicaragua changed its penal code to allow therapeutic abortion to not only save the mother's life, but also in cases of rape or incest and if the fetus is severely abnormal. Like Nigeria, Nicaragua also replaced D&C with MVA. Bangladesh promotes menstrual regulation, despite restrictions on abortion. Romania, Turkey, and Zambia are examples of countries that liberalized their abortion laws resulting in reduced maternal deaths. SOURCE: Carrboro, North Carolina, International Projects Assistance Services [IPAS], 1991. [5], 34 p. (RH Training Materials)
187. Unsafe abortion is responsible for at least 70,000 maternal deaths each year. The 1994 International Conference on Population and Development set the goal of reducing this statistic by 50% by the year 2000. To facilitate the work of health professionals, policymakers, and international aid agencies in this area, the Initiatives in Reproductive Health Policy group has outlined 10 measures: 1) educate staff at all levels about the impact of unsafe abortion and local prevention; 2) take initiative in publicizing the issue; 3) describe the problem accurately and in language that emphasizes the public health rather than political aspects of unsafe abortion; 4) incorporate abortion care into country programs and assessments; 5) make use of existing technical and training materials; 6) use appropriate technology (e.g., manual vacuum aspiration) in clinical programs; 7) increase country capacity to undertake training, service delivery, and health systems research; 8) expand abortion care to include other reproductive health care issues such as sexually transmitted diseases; 9) broaden measures of program success to include accessibility, quality of care, and changes in the socioeconomic costs of unsafe abortion; and 10) encourage funding sources and policymakers to provide adequate resources and a supportive political environment. SOURCE: INITIATIVES IN REPRODUCTIVE HEALTH POLICY. 1996 Jan;1(1):4-5.
190. Uganda has a total fertility rate of 7.3 children per woman and a population growing at the annual rate of 2.8%. The government is actively promoting family planning on primarily a health basis. In Uganda, abortion is illegal except to save a mother's life. Despite such legislation, however, both induced and spontaneous abortion occurs in Uganda even when a mother's life is not in jeopardy. The rate of induced abortion is increasing, as evidenced by the growing rates of maternal mortality related to abortions registered in Ugandan hospitals. Research indicates that the majority of all induced abortions were among young, single, low parity women, most often in secondary school or university. A 1992 study by Bazira found the following reasons among women for terminating pregnancy: 50% did so out of a desire to continue their education, 25.7% feared their parents, 8.3% could not afford to care for a child, 3.0% had a spouse who did not want a child at that time, and 5.3% had completed their families. There is a low prevalence of contraceptive use among women who seek induced abortion, with lack of knowledge about contraception and the unavailability of contraceptives being the two main reasons for nonuse of contraception. Sepsis and hemorrhage comprised 60% of complications resulting from induced abortion. SOURCE: AFRICAN JOURNAL OF FERTILITY, SEXUALITY AND REPRODUCTIVE HEALTH. 1996 Mar;1(1):79-80.
200. An informal study was conducted in order to reveal 1) whether family planning (FP) information and services are offered to women who receive abortions, 2) how provider attitudes and program design affect postabortion services, and 3) whether women are being pressured to accept specific methods in exchange for receiving a safe abortion. Profiles of the provision of FP and abortion services were developed for India, Turkey, and a country in South America (anonymous because abortion is illegal) through observation of client-provider interactions, discussions with providers and other knowledgeable sources, and reviews of records and written protocols. The factors which were found to specifically affect postabortion provision of FP services included service delivery and administrative structures; service standards and training in contraceptive technology; service delivery factors such as comfort at the site, continuity of care, timing of services, and integration of services; provider attitudes toward their clients, their own responsibility, timing, and financial considerations; and client factors such as orientation to services, misinformation, and attitudes towards sex and abortion. It is concluded that whereas the high incidence of abortion in the world signals a failure of health care systems to respond to women's reproductive health needs, the inadequacy of postabortion contraception services represents a double failure. It is recommended that providers, policy-makers, and funding agencies 1) learn what abortion clients need, want, and experience; 2) improve provider attitudes and knowledge; 3) overcome institutional barriers by integrating FP services with abortion services or, if this is not possible, by strengthening referral systems; and 4) improve service quality. SOURCE: New York, New York, AVSC International, 1995 Sep. 11 p. (AVSC Working Paper No. 9)
209. This paper presents steps that safe motherhood programs can take to address the problem of unsafe abortion. The author discusses studies and training programs throughout the 1980s and 1990s in all regions of the world, with a focus on sub-Saharan Africa, particularly Kenya. Previous studies have shown abortion-related mortality in Africa to be extremely high, ranging from 20 to 80% of all maternal deaths. The author identifies 2 strategies for decreasing maternal mortality due to unsafe abortion: 1) improving abortion services by improving the treatment of abortion complications; decentralizing safe abortion services; and providing postabortion family planning services and 2) liberalizing the abortion law and removing or revising policies that restrict access to services, such as the uneven distribution of authorized providers in the urban, tertiary facilities; the restrictions on the types of providers who can perform the services; and the administrative requirements that must be met before the procedure can be performed (e.g., committee approval and multiple signatures from certified physicians). Based upon the high levels of maternal mortality because of unsafe abortion, the author concludes that safe motherhood programs have a responsibility to address this issue and to incorporate some of the suggested changes into their programs. SOURCE: JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF EASTERN AND CENTRAL AFRICA. 1993;11(1):3-7.
210. In Latin America, induced abortion is the 4th most commonly used method of fertility regulation. Estimates of the number of induced abortions performed each year in Latin America range from 2.7 to 7.4 million, or from 10 to 27% of all abortions performed in the developing world. Because of restrictive laws, nearly all of these abortions, except for those performed in Barbados, Belize, and Cuba, are clandestine and unsafe, and their sequelae are the principal cause of death among women of reproductive age. 1 of every 3-5 unsafe abortions leads to hospitalization, resulting in inordinate consumption of scarce and costly health-system resources. Increased contraceptive prevalence and restrictive abortion laws have not decreased clandestine practices. This article addresses how the epidemic of unsafe abortion might be challenged. Recommendations include providing safer outpatient treatment and strengthening family planning programs to improve women's contraceptive use and their access to information and to safe pregnancy termination procedures. In addition, existing laws and policies governing legal abortion can be applied to their fullest extent, indications for legal abortions can be more broadly interpreted, and legal constraints on abortion practices can be officially relaxed. (author's) SOURCE: STUDIES IN FAMILY PLANNING. 1993 Jul-Aug;24(4):205-26.
214. The impact of an intervention that upgraded physicians' clinical and interpersonal communication skills on postabortion outcome was assessed in a pilot project carried out in the obstetrics-gynecology wards of two Egyptian hospitals. The five-day training program for senior staff included demonstrations of manual vacuum aspiration instruments, guidelines for the management of incomplete abortion, treatment of abortion-related complications, pain management, and family planning counseling. The emphasis of the training was on holistic patient care. The evaluation was based on 552 observations of abortions, 550 patient interviews, 154 physician interviews, and 66 nurse interviews as well as review of the records of 1141 postabortion patients. 47% of abortions were classified as induced prior to hospital admission and 48% were spontaneous abortions. In the pre-intervention period, dilatation and curettage under general anesthesia was standard procedure; after the training, manual vacuum aspiration was used in over 90% of procedures and only 52% of patients received general anesthesia, resulting in a shorter hospital stay. Other changes noted in the post-intervention period included improved infection control, fewer reports of pain, dramatic increases in the provision of counseling on postoperative problems and family planning issues, and a rise from 37% in the pre-intervention period to 62% in the percentage of abortion patients who intended to initiate contraceptive use. Based on the effectiveness of this project, a larger scale program is planned to introduce manual vacuum aspiration and minimal pain control medication to other areas of Egypt and to provide medical staff with family planning counseling skills. SOURCE: Cairo, Egypt, Egyptian Fertility Care Society, 1995 May. xi, 37 p. (USAID Contract No. DPE-3030-C-00-0022-00, Strategies for Improving Family Planning Service Delivery)
219. Third World women with complications from an illegally induced abortion tend to postpone seeking medical treatment, because of both a lack of knowledge about the signs of infection or hemorrhage and a fear of moral and legal sanctions. At admission, hospital policies require that women be questioned repeatedly until they acknowledge whether their symptoms are a result of induced or spontaneous abortion. In Bolivia, women hospitalized for abortion-related complications also face financial sanctions. They are charged 450 Bs (US$105) for dilatation and curettage); social security coverage is denied as is eligibility for sliding scale fees based on ability to pay. Interviews with 12 patients and 14 staff members at 4 Bolivian hospitals revealed substantial variation in the postabortion care women receive. Care seemed to be more dependent on the personal ethics of staff members than definite policies. In general, however, these women did not receive the moral support needed to help them overcome their feelings of ambivalence, guilt, and depression. Rather, a double standard prevails, where women alone bear responsibility for the pregnancy and then are blamed for seeking termination under illegal conditions. SOURCE: WOMEN'S GLOBAL NETWORK FOR REPRODUCTIVE RIGHTS NEWSLETTER. 1994 Jan-Mar;(45):19-20.
233. This volume is the product of molding chapters written by ten professionals into a coherent work on maternal mortality. After a brief introduction about the nature of the problem in developing countries, chapters pertain to measurement problems, maternal mortality trends, the links between women's status and maternal mortality, maternal causes of death, abortion related mortality, maternal morbidity, and prevention through the delivery of health care and family planning. Future needs are identified as productive use of resources (buildings and personnel), creative strategies, sensitivity to women's obstacles to use of the health system, and improved infrastructure (community-based care, referral, and transportation). Political will, broad public support, and sufficient funding are key factors in reducing maternal mortality. One cited study found that, in 202 widely different societies, most women worked full time work up to delivery and resumed work shortly thereafter. Reproductive age women have demanding schedules and require three times as much iron per day as men. About 50% of nonpregnant women of the developing world are anemic; 66% of pregnant women suffer from anemia. Anemia increases risks from hemorrhage and other complications from childbirth. Women continue to place their health at risk by bearing many children, because in patriarchal societies it is the only path to social status and personal achievement. A woman, who bears many children, brings a higher status to her husband, who is able to prove his virility. Many children are a source of labor power and social security in old age. Teenage marriage favors high fertility. Education of females has a strong impact on fertility and is described as the "medication against fatalism." Maternal morbidity affects 16 women for every maternal death. Morbidity after pregnancy can result in puerperal hypertension, cardiac failure, acute prolapse of the cervix, psychiatric illness, and adverse conditions related to obstructed labor, obstetric hemorrhage, puerperal infection, and injuries from obstructed labor. The average life-time risk of pregnancy-related death is estimated to be 1/25 in Africa, 1/38 in South Asia, 1/870 in East Asia, and 1/1750 in the developed world. SOURCE: Geneva, Switzerland, World Health Organization [WHO], 1989. 233 p.
239. National and regional estimates of the incidence of induced abortion in Brazil, Colombia, and Mexico from the late 1970s to the early 1990s indicate a clear rise in the abortion rate in Brazil and increases in the abortion ratio in all three countries. Cross-sectional analysis showed no significant correlation between the abortion rate and contraceptive use, except in Mexico in the early 1990s, where a strong positive association was observed. Longitudinally, the abortion rate increased as contraceptive use increased in most regions of Brazil and Mexico throughout the study period, and in parts of Colombia until the mid-1980s. In Colombia and the most urban region of Mexico, the abortion rate declined as contraceptive use stabilized or increased. The abortion ratio was positively associated with contraceptive use over time in nearly every region of each country. The role of abortion in fertility decline was greatest in Brazil, where the general fertility rate would have been nearly 13% higher in the early 1990s if the abortion ratio had not increased from its level in the late 1970s. Abortion tended to have a greater impact on fertility in regions where contraceptive use was low. Overall, contraceptive use appears to have been a more important determinant of fertility than abortion, but abortion has played an important subsidiary role in determining fertility levels and trends in these countries. (author's) SOURCE: INTERNATIONAL FAMILY PLANNING PERSPECTIVES. 1997 Mar;23(1):4-14.
240. In countries where abortion is illegal, a range of approximate levels of induced abortion can be calculated from data on the number of women hospitalized for treatment of abortion complications, after correcting for underreporting and misreporting and adjusting to eliminate spontaneous abortions. An estimated 550,000 women are hospitalized each year as a result of complications from induced abortion in Brazil, Chile, Colombia, the Dominican Republic, Mexico, and Peru. About 2.8 million abortions are estimated to occur in these countries annually when women not hospitalized as a result of induced abortion are taken into account. If the situation in the six countries is assumed to be typical of the entire region, then about 800,000 women are probably hospitalized because of complications of induced abortion in Latin America in a given year, and an estimated 4 million abortions take place. The abortion rate most likely ranges from 23/1000 women aged 15-49 in Mexico to 52/1000 in Peru, and the absolute number ranges from 82,000 in the Dominican Republic to 1.4 million in Brazil. From 17% of pregnancies in Mexico to 35% in Chile are estimated to end in induced abortion. (author's) SOURCE: INTERNATIONAL FAMILY PLANNING PERSPECTIVES. 1994 Mar;20(1):4-13.
243 This study tested three different ways to improve postabortion care (PAC) at six hospitals in Kenya. The focus was on improving emergency treatment through the introduction or upgrading of manual vacuum aspiration (MVA) techniques. In Model 1, family planning (FP) services were provided on the gynecology ward by gynecology ward staff. In Model 2, FP services were provided on the gynecology ward by maternal-child health services and FP (MCH-FP) staff. In Model 3, services were provided in MCH-FP clinics by MCH-FP staff. Data were obtained from 319 incomplete abortion patients, 106 provider staff, and 92 male partners of patients during February-March and June-July of 1996. Other data were obtained from logbook reviews, questionnaires from medical superintendents and hospital matrons, cost study worksheets, and daily logs of researchers. The intervention included training in MVA and postabortion FP, provision of equipment and supplies, and reorganization of services. The evaluation was conducted during March-May 1997. Findings indicate that, on average, 35% of gynecological ward admissions were for incomplete abortions. The demographic and reproductive profile of patients was the same as pre- and post-intervention. Most provider interviews were with nurses. MVA treatment increased pre- and post-intervention. Duration of stay was reduced. Providers had more positive attitudes post-intervention. Pain control remained a problem. Model 1 was the most effective in provision of FP counseling. Model 3 had the highest quality of care. SOURCE: Nairobi, Kenya, Population Council, Africa Operations Research and Technical Assistance Project, 1998 Jan. [3], vi, 45 p. (USAID Contract No. CCC-3030-C-00-3008-00)
246. 60 health care professionals met in Istanbul in April, 1992, to discuss experiences in family planning (FP) counseling. The participants came from 25 countries and included physicians, nurses, midwives, managers, psychologists, social workers, and other health educators. Participants agreed that counseling involves two-way communication; assists clients in making informed, voluntary decisions about fertility and the use of contraceptives; helps clients practice contraception correctly; and is responsive to clients' individual needs and values. To promote client satisfaction and effective method use, FP providers can use counseling to build relationships with their clients. The need to permeate the FP program with a counseling philosophy was frequently articulated. The participants suggested that community health workers need basic training in communications and assessment of client needs as well as education about contraceptive methods. Participants discussed whether sexuality and prevention of AIDS and other sexually transmitted diseases should be incorporated into FP counseling. Many participants stressed that sexuality is intrinsically linked to choices about and satisfied use of contraceptives. Participants reported that policymakers who lack knowledge of FP counseling may mistakenly believe that it is a form of psychological therapy and doubt the ability of clients to make their own decisions. The participants said that other FP staff often misunderstand counseling. The participants suggested group information sessions, followed by private counseling, screening clients, and then tailoring counseling to individual needs. Counseling members felt that to cut costs programs often fail to provide funding for follow-up and evaluation. Participants identified several important areas for research. There is a major need to assess the impact of counseling on acceptance of contraceptives, continuation of use, and satisfaction with methods among clients. SOURCE: INTERNATIONAL FAMILY PLANNING PERSPECTIVES. 1993 Jun;19(2):67-71.
247 The Association for Voluntary Surgical Contraception (AVSC) investigated the linkages between induced abortion and family planning services in a qualitative research project conducted in Colombia, India, and Turkey. Study methodologies included interviews with abortion and family planning service providers, record review, observation, and discussions with policy-makers. In general, abortion and family planning services were entirely separate. Although postabortion clients clearly wanted to avoid another unwanted pregnancy, they generally failed to receive family planning information and services. Abortion providers tended not to view contraceptive provision as their responsibility and, in many cases, had negative attitudes toward abortion patients. Services for abortion and family planning often were not available on the same day or in the same location. In some areas in India, where abortion patients were provided with contraception (IUD and sterilization), its provision was coerced as a condition for abortion. AVSC is working to raise awareness of the need to integrate service links between abortion and family planning programs. SOURCE: AVSC NEWS. 1993 Dec;31(4):4.
249. To reduce the anxiety and pain experienced by women who are having abortions, pre-abortion psychological counseling should be given. Since general anesthesia increases the risk of death, it should be avoided. If a paracervical block is to be used, attention should be paid to methods for safe, effective administration. Narcotic analgesics are effective, especially when given intravenously. Meperidine (Demerol) is almost always available at low cost. Small doses given intravenously produce good analgesia, are reasonably short-acting, and can be readily reversed with the narcotic antagonist naloxone (Narcan). Occasionally, respiratory depression may occur with small doses. Fentanyl may be preferable to meperidine where available. A safer approach to analgesia is non-narcotic analgesics. These include naproxen, nonsteroidal antiinflammatory drugs and a variety of major and minor tranquilizers. In the US, oxygen is always administered during barbiturate anesthesia. Ketamine is widely used nonbarbiturate that produces general anesthesia. It depresses respiration only high doses. Precautions are necessary when using ketamine. Nitrous oxide produces analgesia without loss of consciousness. Vacuum curettage abortion can be remarkably safe. (author's modified) SOURCE: INTERNATIONAL JOURNAL OF GYNAECOLOGY AND OBSTETRICS. 1989;(Suppl 3):131-40.
255. This report presents the major findings of a study of induced abortion in Nepal, based on 165 cases out of the 1576 female patients identified as having abortion-related complications who were admitted to 5 major hospitals in urban Nepal during a 1-year study period. Traditional birth attendants had been the service providers for two-fifths of the women. A longer delay in hospital referrals and lengthier hospital stays occurred for cases of induced abortion than for those of spontaneous abortion. 12 of the 165 women in the study died in the hospital, most of them from tetanus. Deaths resulting from abortion-related complications represented more than half of all maternity-related deaths in the hospitals studied. The authors suggest that health risks could be reduced considerably by strengthening the hospital-referral system and by taking some preventive steps, such as educating the traditional birth attendants and other paramedical providers about the consequences of unsafe abortion practices; increasing the availability of contraceptive methods; and promoting the use of menstrual regulation, which has recently become available in Nepal on a limited scale, mostly in private clinics. (author's) SOURCE: STUDIES IN FAMILY PLANNING. 1992 Sep-Oct;23(5):311-8.
258. Women in developing countries face up to a 200 times higher risk of death from pregnancy, childbirth, and unsafe abortions than women in developed countries. The failure to take clear, scientifically informed action in the 1990s will likely result in more pregnant women dying than in any other decade. About 7 million newborns die each year due to maternal health problems. Maternal death also adversely affects the health and socioeconomic prospects for surviving children, families, and communities. In 1987, the World Bank, WHO, UNFPA, and many other organizations began the Safe Motherhood Initiative to reduce maternal mortality and morbidity (cost of a substantial reduction = about US $2/capita/year). Its short-term goals include improving the quality of, increasing access to, and educating the public about family planning services and maternal health care. Longterm goals encompass improving women's socioeconomic status. The Initiative helps countries develop safe motherhood programs, including a workable health infrastructure and targeting behavior. Research in Bangladesh, Ethiopia, and Guatemala shows that community-based approaches, such as family planning and training and use of midwives, reduce maternal mortality in high mortality areas. Appropriate referral and treatment of emergency obstetric complications are needed for considerable and sustained reduction of maternal death. Safe motherhood depends on interlinked steps: adolescent's nutritional status, woman's knowledge about contraception, danger signs during pregnancy, sexually transmitted diseases, access to trained health providers, and access to health care facilities or emergency transport to these facilities. National and political support of a safe motherhood program is needed. This report provides various approaches to tailoring a program to its setting, ranging from one with a limited health infrastructure to one with extensive services. SOURCE: Washington, D.C., World Bank, 1993. xv, 143 p. (World Bank Discussion Papers No. 202)
259. Presented in this appendix are decision trees to guide the post-abortion family planning counseling of women undergoing their first, second, or third or more pregnancy termination. Clients are asked whether they were using a contraceptive method at the time of the unwanted pregnancy. Those who indicate they were, and want to continue with this method, are asked to repeat the directions for use and given the opportunity to ask questions. Those who indicate they do not want to try a new method and are non-users are provided with condoms and given a return appointment for further discussion. Women with a history of repeat abortions who do not intend to practice birth control are referred for specialized counseling or, if desired, sterilization services. SOURCE: INTERNATIONAL JOURNAL OF GYNECOLOGY AND OBSTETRICS. 1994;45 Suppl:S25-7.
265. Worldwide experience has revealed that family planning programs play an essential role in reducing the number of abortions by providing the means to avoid unintended pregnancies. The high abortion rates seen in developing countries and in Central and Eastern Europe and the former Soviet Union are linked to unmet need for contraception, which need affects at least 120 million couples in developing countries alone. In some countries, desire to curtail fertility may outpace the availability of FP services. This may result in a short-term simultaneous increase in the use of contraception and abortion. As contraceptive use becomes the norm, abortion rates fall substantially. In South Korea, for example, contraceptive usage increased from 24% in 1971 to 77% in 1988, while lifetime abortion rates increased to 2.9 in 1978 and then decreased to 1.9 by 1991. Abortion rates are lower when modern methods of contraception are used. Thus, in Russia, use of effective contraception increased from 19% to 24% during 1990-94, and the abortion rate per 1000 women dropped from 109 to 76. In Colombia and Mexico, where abortion causes 1/3 maternal deaths, expanding availability of effective contraception has led to a decline in the abortion rate. When women who have had abortions are provided with life-saving care and access to contraceptive counseling and services, maternal deaths and repeat abortions are reduced. The US Agency for International Development believes that increasing access to effective contraception is an effective way to reduce reliance on abortion. SOURCE: [Unpublished] 1996 Aug. 9 p.
268. A controlled trial of 357 patients in Zimbabwe compared suction curettage with conventional curettage. Patients with an incomplete abortion were randomly assigned to the suction group (179 patients) or to the conventional group (178 patients). Those with septicemia, peritonitis, or severe hypovolemia and those with a gestational age greater than 18 weeks were excluded. All patients had a preoperative hemoglobin level greater than 10 g/dl. Intravenous pethidine (50-100 mg) and diazepam (5-10 mg), as well as ergometrine, were administered. Mean blood loss was significantly less in the suction group (19.2 ml vs. 36.3 ml, p < .0001). significantly fewer patients in the suction group lost more than 100 ml of blood (p = .009). although blood loss increased with gestational age in both groups, the suction method was associated with a significantly reduced blood loss at 12 wks or less at 4-8 wks, p < .0001 at 9-12 wks, p = .004). 22 conventional patients experienced severe pain, while 9 suction patients did (p = .02). upon follow-up (77% of the suction group and 74% of the conventional group), the mean hemoglobin level in the suction group was significantly higher (p < .04). 14% (20) of the suction patients had a hemoglobin level less than or equal to 10g/dl, while 26% (35) of the conventional patients did (p = .02). 2 suction patients (1%) required reevacuation; no conventional patients did. 2 suction patients (1%) and 7 conventional patients (4%) developed postabortal sepsis. although no suction patients experienced uterine trauma, 1 conventional patients had a broad ligament hematoma consistent with uterine perforation. there was no significant difference in mean duration of vaginal bleeding after evacuation (4.9 days for suction vs. 5.2 days for conventional patients). in view of these results, suction curettage is preferable to conventional curettage because of its speed, low postabortal sepsis rate, low reevacuation rate, and the amount of blood loss and pain associated with it. SOURCE: SOUTH AFRICAN MEDICAL JOURNAL. 1993 Jan;83(1):13-5.
277. The Postabortion Care Consortium has prepared this manual to provide clinicians important information on furnishing comprehensive postabortion care services. It aims to help clinicians treat incomplete abortion and its life threatening complications. The manuals covers all activities needed to provide appropriate, high quality postabortion care: counseling, patient assessment, infection prevention, pain management, treatment of incomplete abortion, management of problems and complications during manual vacuum aspiration (MVA) (e.g., shock, severe vaginal bleeding, infection/sepsis, and intra-abdominal injury), and postabortion family planning. The last chapter of the manual describes the quality of care process which objectively and systematically monitors and evaluates client care based on pre-determined standards. The process helps service providers and managers eliminate or correct identified problems and to assure that client care is the best it could be, given the resources available. Safe and efficient services, staff treating women with respect in a non-judgmental manner, readily available postabortion family planning services, and well-established links to other health care services are characteristics of quality postabortion care programs. Appendices include assessment and treatment of complications, general principles of emergency postabortion care, a sample referral form (postabortion complications), processing MVA instruments, processing surgical gloves, use of pain medications, equipment and supplies needed for MVA, essential drugs for emergency abortion care, precautions for performing MVA, and preparation of instruments for MVA. This manual is available from: JHPIEGO Corporation, Materials Management, 1615 Thames Street, Baltimore, MD 21231-3447. Tel: (410) 614-3206, e-mail: info@wpo.jhpiego.org. Cost: $6.00 plus shipping. SOURCE: [New York, New York], Postabortion Care Consortium, 1995. [187] p. (RH Training Materials)
279.
DOCUMENT NUMBER: PIP/097455 A Bellagio Technical Working Group meeting sought to develop guidelines for post-abortion family planning services in order to break the cycle of repeated abortions. In the areas of service delivery, it was recommended that abortion providers establish links with family planning programs as well as offer some type of contraceptive service, whether supplies, counseling, or referral. To enhance the integration of family planning and abortion services, nongovernmental programs are urged to provide menstrual regulation and induced abortion to the fullest limits of local law. In addition, there are untapped opportunities for nongovernmental organizations to assist public sector family planning programs through the provision of supplies and training. Community-based distribution workers and pharmacists represent another means of directing women who have received an abortion to contraceptive services. Post-abortion family planning services that are individualized to personal risk factors and needs are more likely to be effective than those based solely on protocols defined by contraceptive method. Similarly, program success requires that women's perspectives are incorporated into the design of services. Family planning counselors should develop simple assessment mechanisms to determine the amount, level, and type of information a woman needs, based on her life-style, contraceptive history, and physical and psychological state. Wherever possible, post-abortion family planning care should be delivered in the context of decentralized but comprehensive reproductive health care. SOURCE: INTERNATIONAL JOURNAL OF GYNECOLOGY AND OBSTETRICS. 1994;45 Suppl:S3-S23. (RH Training Materials)
282. The World Health Organization (WHO) Maternal Health and Safe Motherhood Programme has primarily targeted these flexible guidelines on the prevention and treatment of abortion complications to program managers responsible for planning, implementing, supervising, and evaluating women's health care. Decision-makers responsible for a national health system, managers responsible for a group of service delivery points, and the staff of individual health facilities also will likely benefit from these guidelines. Following the introduction and an overview of abortion care, the WHO manual discusses legal and social factors influencing abortion care, planning for abortion care, and the initial assessment in emergency abortion care. Chapter 6 addresses methods of uterine evacuation, including those based on trimester of pregnancy and cervical dilatation. Other clinical components of abortion care (e.g., postabortion family planning and infection control), information, and counseling for the patient comprise chapters 7 and 8. Facilities and equipment are examined in chapter 9. Tasks, training, and supervision of personnel are discussed in chapter 10. Chapter 11 is dedicated to overcoming obstacles to access to abortion care through decentralization, referral, transport, and coordination. Chapter 12 addresses quality of care, monitoring, evaluation, record-keeping, ensuring the medical quality of abortion care, and operations research. Budgeting for abortion care, sources of funding for abortion care, and financial management and audit are examined under the broad topic of cost-effective management of abortion care services. The last chapter addresses how to prevent unsafe abortion through a safe motherhood intervention which includes educating the public; family planning; and expanding access to safe, high-quality emergency abortion care. It also examines the role of elective abortion and alliances to improve maternal health. The annexes include infection control procedures, equipment and drugs needed for abortion care, training materials, and model records for use in abortion care services. SOURCE: Geneva, Switzerland, WHO, 1995. 147 p.
285. The Maternal Health and Safe Motherhood Programme under WHO's Division of Family Health has compiled maternal mortality data in its 3rd edition of Maternal Mortality Ratios and Rates. The report contains data up to 1991. These data come from almost all WHO member countries. 1988 estimates reveal that 509,000 women die each year from causes related to pregnancy and childbirth. Most die from preventable causes such as aseptic abortions and lack of adequate health care. 4000 of these maternal deaths occur in developed countries. Thus developing countries, where 87% of the world's births occur, experience 99% of maternal deaths. In fact, the lifetime risk of death from causes related to pregnancy and childbirth in developing countries is 1:57 compared to 1:1825 in developed countries. Women in countries of western Africa have the greatest risk (1:18) and those in North America the smallest risk (1:4006). Even though the maternal mortality ratio for developing countries fell from 450-520 per 100,000 live births between 1983-1988, it increased in western African countries (700-760). This report consists mainly of tables of maternal mortality estimates for each country and in some cases certain areas of each country, for the world and various regions and subregions, and changes in maternal mortality since 1983 for the world and various regions and subregions. The world comparison table includes live births, maternal deaths, maternal mortality ratios and rates, lifetime risk, and total fertility. Country tables list year, data sources, maternal mortality ratio, indication if abortion deaths were included or not, and reference. SOURCE: [Unpublished] [1991]. 100 p. (WHO/MCH/MSM/91.6)
287 This manual, prepared by the World Health Organization (WHO) for managers of abortion care and family planning programs, seeks to provide direction in 6 areas: 1) the need for postabortion family planning and the service delivery obstacles to providing such care; 2) ways design, management, and delivery of services affect the quality and acceptability of family planning services offered to women who have had an abortion; 3) how the woman's clinical condition after abortion can affect the appropriateness of methods of contraception and counseling; 4) the impact of the psychological and sociological aspects of abortion on family planning counseling, method choice, and continuity of method use; 5) ways to modify and coordinate existing services to improve the quality of care and ensure informed decision making; and 6) strategies for stimulating cooperation among groups involved in providing family planning services after abortion. The first five chapters provide general information on these issues useful for all program managers, while the final four chapters are dedicated to the needs of particular service delivery settings (e.g., emergency and elective abortion treatment services) and policy issues. SOURCE: Geneva, Switzerland, [WHO], Family and Reproductive Health, Division of Reproductive Health (Technical Support), 1997. ix, 84 p. (Practical Guide)
289. WHO's Technical Working Group on Unsafe Abortion met in April 1992 to establish guidelines on the prevention and management of unsafe abortion to provide more effective support to countries. More specifically, the group has identified clinical guidelines for emergency treatment of abortion complications at the first contact and first referral levels. The report begins with a preface, introduction, and background information on unsafe abortion (definitions and overview of the contribution of unsafe abortion to maternal mortality). The next section discusses draft guidelines for the clinical management of complications of unsafe abortion. The discussion encompassed expanding access to care, services at the primary care level, services at the first referral level, and use of the clinical guidelines. A discussion of the need for more research in management and complications of unsafe abortion follows. Specific discussion topics included referral and communication, antibiotics, training and staff roles, women's perspectives, management issues, attitudes toward abortion, and specific areas of focus for WHO's Maternal Health and Safe Motherhood Programme. The next section addresses indicators of progress in the management of unsafe abortion. The section on provision of immediate postabortion contraception examined sociomedical characteristics to be considered regarding postabortion contraception and development of guidelines on contraception after an unsafe abortion. Need for additional clinical and operations research in immediate postabortion contraception is discussed in the next section. The next-to-last section examines indicators of progress in the provision of postabortion contraception and prevention of repeat unsafe abortion. The report ends with a conclusion and follow-up actions. SOURCE: Geneva, Switzerland, WHO, Division of Family Health, 1993. [3], 23 p. (WHO/MSM/92.5)
292. Unsafe abortion as a public health issue represents a serious concern to the World Health Organization (WHO). Treatment of complications of such abortions uses a disproportionate share of hospital resources in developing countries, and poorly performed procedures lead to reproductive tract infections and infertility. Data on unsafe abortion, defined as "an abortion not provided through approved facilities and/or persons," are scarce and unreliable given legal constraints. This document presents a complication of available data on the frequency of unsafe abortion and associated mortality extracted from WHO's Maternal Health and Safe Motherhood Program database. The estimates, which must necessarily be viewed as "best guesses," were obtained from hospital studies and adjusted to take into account the country's abortion law. The annual incidence on unsafe abortions worldwide is set at 20 million, for a ratio of one unsafe abortion to seven births. 90% of these procedures occur in developing countries. About 70,000 women die each year from complications of unsafe abortion, and 13% of pregnancy-related deaths are attributable to this procedure. The rate of unsafe abortions/1000 women aged 15-49 years is 26 in Africa, 12 in Asia, 2 in Europe, 41 in Latin America, 17 in Oceania, and 30 in Russia. The rate of mortality from unsafe abortions/1000 live births is 83 in Africa, 47 in Asia, 4 in Europe, 48 in Latin America, 29 in Oceania, and 10 in Russia. Governments are urged to examine the health impact of unsafe abortion, reduce the need for abortion through expanded family planning programs, and frame abortion legislation on the basis of women's health and well-being. SOURCE: Geneva, Switzerland, WHO, Division of Family Health, 1993. [3], 114 p. (WHO/FHE/MSM/93.13)
293. The World Health Organization's Maternal Health and Safe Motherhood Programme arranged for the publication of this manual to help health workers prevent death and serious injury from abortion complications. The manual lays out steps to address these complications. Health workers should adapt the guidelines based on local conditions, national standards and regulations, training, and availability of drugs and instruments. The information is presented according to the sequence of decisions to be made when women have symptoms of abortion. The manual uses decision trees to guide health workers in managing abortion complication cases. Its 1st chapter provides guidelines on the triage approach to identify and treat abortion complications that need immediate attention. It also helps health workers conduct a clinical assessment to determine what condition to treat first in women suffering from multiple conditions. Steps in the treatment of shock, moderate to light vaginal bleeding, severe vaginal bleeding, intra-abdominal injury (e.g., perforations), and sepsis are covered in chapters 2-6. General principles of abortion care are highlighted in chapter 7 as they apply to stabilization and referral, intravenous fluid replacement, blood transfusion, administration of medicines, antibiotics, pain control, tetanus, and diuretics. The annexes address equipment and facilities for abortion care; a sample referral form; emergency resuscitation materials; essential drugs for emergency abortion care; supplies for surgical uterine evacuation procedures; instruments and equipment for 1st and 2nd trimester uterine evacuation; instruments and supplies for laparotomy; laboratory and blood materials; manufacturers, suppliers, and sources of procurement of emergency gynecologic equipment; manual vacuum aspiration; and dilation and curettage. SOURCE: Geneva, Switzerland, WHO, Division of Family Health, Maternal Health and Safe Motherhood Programme, 1994. iv, 77 p. (Safe Motherhood Practical Guide)
295. This paper gives revised estimates of maternal mortality in 1990 by country and region, WHO regions, and UNICEF regions. The new estimates use available data, adjust for underreporting and misclassification of maternal deaths, and develop a simple model for predicting values for countries without reliable national data. Reliability is expected to be better than that in previously published reports. These estimates are considered baseline estimates that will be compared with estimates in the year 2000. Findings indicate that in 1990 there were 585,000 female deaths due to pregnancy-related causes. This new estimate is 80,000 women higher than previously estimated. Maternal mortality was particularly high in sub-Saharan Africa at 870 maternal deaths/100,000 live births. Maternal mortality was 190/100,000 in Latin America, 560/100,000 in South Central Asia, 440/100,000 in Southeastern Asia, 320/100,000 in Western Asia, and 95/100,000 in Eastern Asia. The maternal mortality ratio was 480/100,000 compared with a previous estimate of 420/100,000 in developing countries and 27/100,000 vs. 26/100,000 in developed countries. The method of estimation relies on the use of general fertility rates and the proportion of births that are assisted. SOURCE: [Unpublished] 1996 Apr. iv, 16 p. (WHO/FRH/MSM/96.11) |
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