israel_complications of unsafe abortion
TRANSCRIPT
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Postabortion Care:
The Missing Ingredient in ReducingMaternal Mortality
Ellen Israel, CNM, MPH
Pathfinder International
MCHIP Asia Regional Meeting,
Dhaka, May 3-6, 2012
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What is the problem?
Unsafe abortion is one of the
3 leading causes of maternalmortality.. (WHO, 2011).
In 2008, half of all abortions
in the world were unsafe; 98%
occurred in developing
countries.
Severe
bleeding
24%
Infections
15%
Eclampsia
12%Obstructed
labor
8%
Unsafe
abortion
13%
Other direct
causes8%
Indirect causes
20%
Though death from unsafe abortion
fell to 47,000 in 2008 (from 69,000 in 2003),
the proportion of women dying remains stagnant at 13% of maternal
deaths.
Death from unsafe abortion is highest in countries with the most
restrictive abortion policies.
Morbidity and disability caused by unsafe abortion affects women at,
at least, 10 times the mortality rate.
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The problem in Asia
Abortion rates did not decrease between 2003and 2008:
26/1,000 in South Central (e.g., India) and
Western Asia
36/1,000 in Southeastern Asia(compared to 29/1,000 in Africa)
Even in countries where abortion is not restricted,
there are high percentages of substandardprocedures in both public and private facilities
e.g., Nepal, Cambodia, and India; only 2/5 of services
are considered safe in India.
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Why is postabortion care (PAC) neglected
to address maternal mortality?
PAC is usually excluded from maternal health programs and
services largely because of the pervasive stigma attached to
abortion and women who seek them.
PAC being sidelined leads to few or no services, or poor andlimited services, which dont address the root causes of
unsafe abortion.
To ensure universal access to comprehensive PAC, abortion-
related stigma must be addressed.
The root causes of unsafe abortion include barriers to
obtaining and using contraception, and a broad array of
gender and other barriers.
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Political will is fundamental to ensuring
universal access to PAC
Governments signed on to multiple international
agreements over the years that reiterated the public
health imperative and right of women to receive PAC
services without discrimination.
Governments need support and even pressure to live
up to their commitments to ensure PAC as an
integrated maternal health service for all women
who need it.
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What are general solutions?
Mobilize and support governments to address unsafe
abortion and comprehensive PAC services integrated with
maternal and reproductive health.
Decentralize and scale-up services on all facility levels as part
of integrated, one-stop shop services.
Develop networks of stakeholders with interest in womens
health and rights to engage in national assessments of need,
develop standard training and protocols for comprehensive
PAC services, ensure commodity supply lines, and include in
HMIS.
Ensure availability ofmisoprostol for PAC, bringing services
closer to the community (e.g., in health posts). Misoprostol
use makes PAC provision more acceptable for some providers.
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Global Misoprostol Registration by Indication
NEPAL
INDIA
TANZANIA & ZANZIBAR
NIGERIABANGLADESH
ZAMBIA
UGANDA
SUDAN
GHANAKENYA
Last updated: September 2011
*Misoprostol may or may not be registered for gastriculcers
SOMALILAND
MOZAMBIQUE
PAKISTAN
SIERRA LEONE
MALAWI
ETHIOPIA
MALI
BOLIVIA
Registered for postpartum hemorrhage (PPH) & treatment of incomplete abortion*
Registered for PPH and other ob/gyn indication*
Registered for PPH*
Registered for another ob/gyn indication, not PPH*
Registered for gastric ulcers only
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What are general solutions? contd
Within PAC programs, recognize and address thegender constraints/barriers to womens:
Desire to limit or space;
Desire to exercise reproductive control; and
Ability to effectively exercise reproductive control.
Work to address PAC needs ofyoung women and girls.
Emphasize attitude change for providers around thedangerous withholding of reproductive health services
(e.g., contraception and PAC) from young people and
unmarried youth.
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What IS being done that is effective?
National attention to PAC and scale-up. Examples include
Rwanda and Peru.
Advocacy. Holding countries to the task of signed
agreements; involvement from parliament, stakeholder
networks, government ministries, and civil society groups.
Integration. Integrating PAC with, as an equal component
of, maternal health programs and services.
Contraception/family planning (FP). Strengthening
contraception/FP as an essential reproductive health servicein and of itself to reduce unintended pregnancy, unsafe
abortion, and need for PAC services.
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The Postabortion Care
Consortium (PACC)
Pathfinder is the current Chair of the PACC
Initially formed in 1993 by JHPIEGO, IPPF, Pathfinder, Ipas,
and EngenderHealth, in recognition of the unsafe abortion
toll on women and the need to promote PAC as a publichealth imperative.
The PACC strives to ensure universal access to
comprehensive PAC services everywhere in the world.
The PACC is committed to assisting any and all governments,
groups, and individuals in the development and
implementation of PAC programs and services, including
community engagement, that address unsafe abortion.
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The PACC, contd
Specific priorities of the PACC for the next two years:
Ensuring Youth-friendly PAC services everywhere
Ensuring misoprostol for PAC to increase access and to
bring services closer to the community
Addressing the lack of MVA equipment, misoprostol and
other necessary supplies for PAC services
Working within countries, with government and civilsociety, to ensure PAC programs that address holistically
women with incomplete abortion, including capacity
building and scale-up of PAC nationally
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The 5 Essential Elements of PAC
In 2002, after much discussion and refining, the PACC
endorsed the 5 essential elements of PAC.
1. Community and service provider partnerships
2. Counseling
3. Treatment of incomplete abortion and complications
4. Contraception and family planning services
5. Reproductive and other health services (e.g., referrals)
The 5 elements reflect critical areas that all PAC programs
should address to be fully effective. Each element requires
specific attention.
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The PACC Contd
The PACC has and is forming Task Forces to develop resourcesto fill gaps: Youth, Misoprostol, Essential Supplies, Quality
Service Delivery (including contraception and infection
prevention), and Community engagement and partnerships.
The PACC sees itself as closely allied with and complementary
to USAIDs PAC Connection. For example, the PACC is able to
address sustainability of MVA equipment and promotemisoprostol to complement the PAC Connections excellent
work on improving universal post-PAC contraception within
communities and facilities.
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Lack of policies/guidelines
Lack of organized services to
provide FP Limited method mix
Lack of IEC materials
Stock-outs of contraceptives
Lack of counseling on FP
methods and availability
Additional charges for FP
Barriers to FP Provision in PAC Services
National Norms/Policies
Some cadres not allowed to
provide PAC services
Limitations on who can receive
FP (age, # of pregnancies)
Poor location of PAC services
No FP commodities in budget
Health System Barriers
Negative provider attitude
Lack of knowledge about rapid
return to fertility
Little to no FP counseling
Lack of referral for FP methods (if
cannot be provided on-site)
Religious concerns
EMONC/BMONC training only
focuses on emergency treatment
Provider
Client
Other
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WHO Recommendations
Follow WHOs recommendations to prevent ill-effects of
unsafe abortion:
Making safe abortion services available and accessible
where abortion is not restricted by law or policy
Ensuring that permitted reasons for abortion are
supported by the national legislative process and health
systems;
Granting access to services for the management of
complications from unsafe abortion, or PAC
Providing post abortion counseling and provision of
contraceptives which help avoid repeat abortion.
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Recommendations on how to ensure
integration of PAC with maternal health
Ensure integration by including PAC in language, protocols,programming, budgets, and data collection for maternal
health. Dont allow it to be separated or diminished.
Include PAC in adolescent and youth sexual and reproductive
health and youth-friendly maternal health programs.
Conduct values clarification and attitude change exercises
starting at the top with policymakers, health care managers,
providers, community opinion makers and members, etc
Ensure post-PAC contraceptive services are of high quality, and
provided immediately, on-the-spot.
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Recommendations, contd
Work with the rights and health networks in your country
along with government to ensure maximum access to
comprehensive PAC services.
Ensure access to misoprostol to increase access to PAC
Ensure access to young and unmarried women to PAC
services without discrimination
Work with the PAC Consortium to gain strength throughexperience and tool sharing for problem solving.
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Resources and references Facts on Induced Abortion Worldwide, Guttmacher Inst. Jan. 2012
Unsafe abortion: Global and regional estimates of the incidence of unsafe
abortion and associated mortality in 2008, WHO
Induced Abortion: Incidence and Trends Worldwide from 1995-2008, Gilda
Dedgh et al., in the Lancet, Jan. 2012
Unsafe Abortion: The Missing Link in Global Efforts to Improve MaternalHealth, Guttmacher Policy Review, Spring 2011
Essential Elements of Post-abortion Care: Origins, Evolution and Future
Directions, Corbett, M. and Turner, K, Intl Family Planning Perspectives,
Sept. 2003
Womens Demand for Reproductive Control: Understanding and
Addressing Gender Barriers, McCleary-Sills, J., et al.Intl Center for
Research on Women, Feb. 2012
Facts on Induced Abortion in Pakistan, Guttmacher In Brief, May 2009
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Thank youEllen Israel: [email protected]
PAC Consortium: www.pac-consortium.org
mailto:[email protected]://www.pac-consortium.org/http://www.pac-consortium.org/http://www.pac-consortium.org/http://www.pac-consortium.org/mailto:[email protected]