Safe abortion: WHO technical and policy guidance.

In 2003, the World Health Organization published its well referenced handbook Safe Abortion: Technical and Policy Guidance for Health Systems to address the estimated almost 20 million induced abortions each year that are unsafe, imposing a burden of approximately 67 thousand deaths annually. It is a global injustice that 95% of unsafe abortions occur in developing countries. The focus of guidance is on abortion procedures that are lawful within the countries in which they occur, noting that in almost all countries, the law permits abortion to save a woman's life. The guidance treats unsafe abortion as a public health challenge, and responds to the problem through strategies concerning improved clinical care for women undergoing procedures, and the appropriate placement of necessary services. Legal and policy considerations are explored, and annexes present guidance to further reading, international consensus documents on safe abortion, and on manual vacuum aspiration and post-abortion contraception.     

Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care

Objective

To assess the contribution of nonphysician clinicians (NPCs) to comprehensive emergency obstetric care (CEmOC) in Tigray, Ethiopia.

Methods

We conducted a retrospective review of the obstetric records of all women treated from January 1, 2006, to December 31, 2008, at the 11 hospitals and 2 health centers with CEmOC status in Tigray. Data were collected using 2 questionnaires, one concerning the facility and the other concerning the patient.

Results

During the studied period 25,629 deliveries and 11,059 obstetric procedures (3369 of which were major surgical interventions) were performed at these 13 institutions. Overall, NPCs performed 63.3% of these procedures, which included 1574 (55.5%) of a total of 2835 cesarean deliveries. Whereas the cesarean deliveries performed by physicians were more often elective, those performed by NPCs were more often indicated by an emergency. Maternal deaths, fetal deaths, and length of hospital stay did not statistically differ by type of attending staff.

Conclusion

Not only do NPCs perform a significant proportion of emergency obstetric procedures in Tigray, but the postoperative outcomes achieved under their care are similar to those attained by physicians. Strengthening NPC training programs in emergency obstetric surgery should further reduce maternal and fetal mortality and morbidity in Ethiopia.     

Reconceptualizing safe abortion and abortion services in the age of abortion pills: A discussion paper

At the conference “Developing an Advocacy Agenda for Abortion in the 21st Century and Making Change Happen” held on 5–7 September 2018, Lisbon, Portugal, organized by the International Campaign for Women's Right to Safe Abortion, it was argued that abortion services not only need to be treated as a bona fide form of health care but also completely reconceptualized, particularly because of the influence of medical abortion pills. It emerged, however, that there is no consensus on how this reconceptualization should be configured. Indeed, substantial differences arose, or so it appeared, complicated not only by different exigencies in national settings but also reflecting differing perspectives, specifically, those held primarily by health professionals compared to those held by advocates who felt they spoke for women needing abortions. In the course of these discussions, questions emerged on how much women should be able to do on their own, whether and why services were necessary in every case, where services should be located, what they should offer, who should provide them, and who should be in charge of the process.The biggest discussion was over the extent to which women can safely self-manage use of medical abortion pills for abortion in both the first and second trimester, and to what extent health professional control should be relinquished. Regardless of these arguments, however, since 1988 with the discovery in Brazil that misoprostol is an abortifacient, over-the-counter access to medical abortion (MA) pills began to put self-management of abortion on the map. Today, self-management is happening in almost every country, and we have no idea how many abortions are taking place anymore. Moreover, because of the work of safe abortion information hotlines, there is a growing body of evidence that self-management of abortion by women is safe – or at least far less unsafe than what prevailed in the past.Looking beyond the abortion rights movement, the crux of the issue is whether the state should continue to control abortion, with power over individual decisions delegated to the medical profession – or whether, as has been happening at a snail's pace for the last half century, and as with contraception and emergency contraception too – control can and should be more and more in women's hands.This paper examines these perspectives and attempts to describe what a consensus might look like. It concludes that convincing governments and conservative health professionals to accept a large dose of self-management will not be easy.     

Attitudes of doctors toward establishing safe abortion units in Ghana.

OBJECTIVES: To assess physician knowledge of the current legal status of abortion in Ghana and determine the proportion physicians in favor of establishing units where safe abortion would be provided, and the proportion of those willing to offer such services. METHODS: A survey conducted at Komfo Anokye Teaching Hospital, Ghana, in August 2003. Using a self-administered questionnaire, 74 randomly selected physicians expressed their views on whether abortion units should be established within national health facilities in Ghana, and what role they would play in them. RESULTS: Of the 59 physicians (80%) who favored the establishment of safe abortion units within national health facilities, 27 (36%) indicated a willingness to take part in counseling only, 33 (45%) were prepared to carry out abortions, and 14 (19%) said they would play no role in these units. CONCLUSION: Most physicians participating in this study conducted in Ghana were willing to play some role in the provision of safe abortion services.     

深圳地区未婚流动妇女人工流产现状及流产后干预措施研究

目的了解深圳地区未婚流动妇女人工流产的现状,探讨给予人工流产术后服务的有效性和安全。方法2012年6月至2013年6月深圳市龙华新区观澜人民医院计划生育门诊因早孕行无痛人工流产妇女700例。将术后接受屈螺酮炔雌醇片避孕妇女纳入研究组（350例）,未服用药物者为对照组（350例）。两组均采取面对面咨询的方式进行生殖健康、避孕知识及流产后注意事项的宣教。观察两组妇女的阴道出血量、出血时间、术后月经恢复时间及12个月内再次流产的情况。结果在700例妇女中,未婚人工流产者占19．14％（134／700）,外来流动人口占70．29％（492／700）,重复流产者占68．57％（480／700）。研究组妇女术后阴道出血时间[（7．23±2．65）d]与对照组[（12．12±3．41）d]比较,差异有统计学意义（P〈0．05）。研究组妇女术后月经恢复时间[（30．56±5．53）d]与对照组[（34．51±5．54）d]比较,差异有统计学意义（P〈0．05）。研究组妇女术后12个月内再次流产率（18．13％,60／331）与对照组（34．46％,112／325）比较,差异有统计学意义（P〈0．05）。结论未婚流动妇女人工流产后给予短效口服避孕药及生殖健康知识宣教等干预措施,可有效降低未婚妇女的重复流产率。     

Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil

Objective

To evaluate the reported occurrence of spontaneous and induced abortion, and abortion-associated severe maternal morbidity in Brazil.

Methods

A secondary analysis of the 2006 Brazilian Demographic Health Survey was conducted. Interview data on women's experience of spontaneous/induced abortion and associated factors were analyzed overall and by geographic region. Multinomial logistic regression was performed to identify factors independently associated with abortion. The risk of associated severe maternal morbidity was estimated.

Results

The reported lifetime rates of spontaneous and induced abortion were 13.3% and 2.3%, respectively, and were highest in the north (4.3%) and northeast (3.5%). The rate of spontaneous abortion was higher among women aged 40-49 years (odds ratio [OR] 1.15; 95% confidence interval [CI], 1.03-1.30) and among those with 0 or 1 children or delivery (OR 1.97; 95% CI, 1.36-2.85 vs OR 1.98; 95% CI, 1.37-2.86). Induced abortion was not associated with sociodemographic factors. Abortion significantly increased the risk of complications (hemorrhage and infection).

Conclusion

Spontaneous abortion was significantly associated with parity and maternal age. Abortion in general carried a higher risk of severe maternal complications.     

药物流产患者的临床观察及护理

目的:探讨药物流产对不同孕周稽留流产的疗效。方法:对160例稽留流产的临床资料进行回顾性分析。结果:药物流产与稽留流产的孕周密切相关:孕周越小,完全流产率越高,排胎时间越短,阴道流血量越少;孕周越大,不全流产及流产失败率越高,排胎时间越长,出血量多的机会明显增加。结论:一旦确诊为稽留流产,如果无药物流产的禁忌症,应尽早行药流术,以提高流产的成功率,减少并发症的发生。     

The relationship between spontaneous and induced abortion and the occurrence of second-trimester abortion in subsequent pregnancies

In part I of the present paper an analytic review is presented of the literature on the possible harmful influence of a spontaneous or induced abortion on the course of a subsequent pregnancy.Lack of unanimity proved the most striking result of the analysis. One part of the authors concluded to a relationship between second-trimester abortion and a preceding spontaneous or induced abortion, whereas the others reached a negative result.Since it was thought that the design of all the investigations reviewed showed minor or major deficiencies it was decided to formulate the conditions that must be fulfilled in order to be able to draw valid conclusions on the possible relationship between a second-trimester abortion and a preceding spontaneous or induced first-trimester abortion and to carry out a study that fulfilled the necessary criteria. (The authors should like to stress that the conditions formulated can serve as a model for all investigations that aim at studying the possible relationship between a gestational derangement and a specific disturbance occurring during a preceding pregnancy.) The conditions are that a distinct definition of the disturbances and derangements should be given and strictly adhered to; that the index cases and their controls should be consecutively collected from a clearly defined population; that the induced or spontaneous abortion should immediately precede the second-trimester abortion and that the index cases and their controls should be matched as far as possible (pregnancy order, age at parturition, period of parturition) with exclusion of possible other causes of immature delivery (severe congenital malformations, multiple births, intrauterine infection, uterine anomalies) from the index cases and the controls.After completion of the study a posteriori matching should be carried out to establish whether the frequency of other possible relevant factors differed between index pregnancies and controls.The second part of the present study consists of the investigation of all 87 cases of second-trimester abortion (deliveries at a duration of 112–197 days and/or a birth-weight of less than 1000g) that occurred during a 5-yr period (1973–1977) in the Amsterdam department. Of these 87 deliveries 59 belonged to the category in which the outcome of the delivery under investigation was considered to be related to disturbances observed in the pregnancy itself and not to the preceding pregnancy. In 6 cases the second-trimester abortion was preceded by an induced abortion and in 13 cases by a spontaneous abortion. In 19 cases out of the remaining 28 cases an anomaly in the preceding pregnancy was detected.A control group of 56 pregnancies was composed. Each index case was matched with 2 patients with a similar rank of gestation and with the same maternal age. One of these controls had delivered as near as possible prior to the date of immature delivery of the index case and the other as near as possible after that date. In the control group 3 patients had an induced abortion and 8 a spontaneous abortion in the preceding pregnancy. The difference between the index group and the control group is significant (P < 0.001).Since the possibility had to be taken into account that the relationship between a spontaneous abortion and an induced abortion and the outcome of a subsequent pregnancy are not similar, both groups were separately investigated with the exclusion of the other index cases and their controls. Of 15 second-trimester abortions not preceded by a spontaneous abortion 6 underwent an induced abortion prior to the pregnancy as compared to 3 in the 30 controls (P 0.04). Of the 22 pregnancies not preceded by an induced abortion, 13 had had a spontaneous abortion prior to the present pregnancy as compared to 8 in the 44 controls (P 0.003).It is concluded that a relationship, presumably of a cause-effect nature, exists between an induced abortion and a second-trimester abortion in a subsequent pregnancy. The relationship between a spontaneous abortion and a second-trimester abortion in a subsequent pregnancy is far more significant. In the latter cases an inherent fetal, idiopathic wastage syndrome is thought to be present causing both the first- and the second-trimester abortion.     

The need for family planning and safe abortion services among women sex workers seeking STI care in Cambodia

In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method--5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n = 1744) and 21.9% (n = 588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general.     

The role of advocacy in implementing the South African abortion law

In order to translate the abortion law in South Africa into services that ensure equity of access and women's right to control their bodies, interventions are needed to change judgemental views on abortion. This paper describes formative research conducted in the Northern Cape Province among 436 community members, 29 women seeking an abortion and 80 health service providers, to develop appropriate interventions to these ends. Based on the findings, two interventions were developed. These interventions appeared to substantially influence personal views by getting people to make a connection between the need for abortion services and the circumstances in which unwanted pregnancies occur. There was a shift towards greater support for women's right to choose in relation to abortion among women community members, though not among men, who resisted this right for married women. Amongst providers (almost all women) there was an increase in willingness to support service provision and to support staff working in abortion services. These tools could be used in sexuality education in schools and in nurse-midwifery/medical training, to complement current advocacy initiatives taking place at policy and programme levels in South Africa, to help to reduce the public health problem of unsafe abortion.     

Providing safe abortion services: Experiences and perspectives of providers in South Africa

Despite abortion being legally available on request up to and including the gestational age of 12 weeks in South Africa, barriers to access remain. Barriers include provider opposition to abortion and a shortage of trained and willing providers, which has implications for access to safe abortion services. Exploring the factors that determine providers’ levels of involvement in abortion services can facilitate improvements in service provision.Providers' conceptualizations of abortion are influenced by numerous factors, including moral and religious views, in which abortion is perceived by some as a sin, whereas others view access to safe abortions as an important component of a woman's right to reproductive autonomy and choice.Barriers to service provision include limited abortion and values clarification training and misinterpretation of conscientious objection. Providers have difficulties with the emotional and visual impact of second trimester abortions.There is an urgent need to address provider shortage, and abortion education and training need to be included in medical and nursing curricula to ensure sustaining abortion services.     

Meeting health care needs of women experiencing complications of miscarriage and unsafe abortion: USAID's postabortion care program

Each year, an estimated 210 million women become pregnant. Worldwide, more than one fourth of these pregnancies will end in abortion or an unplanned birth. While many abortions may result from the desire to delay or avoid pregnancy, 15% to 20% of pregnancies will end in miscarriage or stillbirth with some causative agents being malaria, HIV/AIDS, and physical violence. Postabortion care (PAC) is needed to provide treatment for complications caused by incomplete or spontaneous abortion and critical family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions. In 2003, the United States Agency for International Development (USAID) initiated a 5-year strategy wherein seven countries were provided financial funding and technical assistance. Since 2003, more than 3000 women have been seen in health centers and health posts for PAC services; more than 14,000 community members have received messages on unsafe abortion; family planning, and complications of unsafe abortion and miscarriage; and more than 600 documents were reviewed for inclusion in a global PAC resource package. This package has been used for developing Cambodia's national PAC policy and for developing patient education materials and provider job aids in Cambodia and Tanzania. These promising methodologies will be replicated in other countries.     

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.     

Expectant management of incomplete abortion in the first trimester

Objective

To evaluate the effectiveness and acceptability of expectant management of induced and spontaneous first trimester incomplete abortion.

Methods

A prospective observational trial, conducted between June 2006 and November 2007, of 2 groups of patients diagnosed with an incomplete abortion: 66 patients who had received misoprostol for an induced abortion (group 1) and 30 patients who had had a spontaneous abortion (group 2). Transvaginal ultrasound was performed weekly. The success rate (complete abortion without surgery), time to resolution, duration of bleeding and pelvic pain, rate of infection, number of unscheduled hospital visits, and level of satisfaction with expectant management were recorded.

Results

The incidence of complete abortion was 86.4% and 82.1% in groups 1 and 2 respectively at day 14 after diagnosis, and 100% in both groups at day 30 (two group 2 patients underwent curettage and were excluded from the analysis). Both groups reported 100% satisfaction with expectant management, although over 90% of the women reported feeling anxious.

Conclusion

Expectant management for incomplete abortion in the first trimester after use of misoprostol or after spontaneous abortion may be practical and feasible, although it may increase anxiety associated with the impending abortion.     

药物流产与人工流产在终止早期妊娠的对比分析

目的:观察药物流产与人工流产在终止早期妊娠的临床比较。方法:选择450例育龄妇女妊娠8周内要求终止妊娠的孕妇,随机分成甲、乙两组。甲组用药物流产,乙组用负压吸宫流产。结果:甲组完全流产207例,完全流产率92%,乙组安全流产219例,完全流产97.3%,两组完全流产率经统计学处理无显著性差异。甲组阴道流血天数12.73±4.46天,乙组11.62±5.93天,经统计学处理无显著性差异,阴道流血量;甲组78±15.14ml,乙组72.67±9.98ml,流血量经统计学处理,有显著性差异。结论:两组完全流产效果及流血天数均无显著性差异。药物流产简单易行,局部无创伤,能避免子宫穿孔,宫腔内感染,宫腔黏连等危险因素,是一种较为简便,安全有效的理想方法。     

Complications of unsafe abortion: a case study and the need for abortion law reform in Nigeria

Complications of unsafe abortion account for 30-40% of maternal deaths in Nigeria. This paper reports a case of unsafe abortion by dilatation and curettage, carried out by a medical practitioner in a private clinic on a 20-year-old single girl in Lagos, Nigeria. The girl was 16 weeks pregnant. She suffered complications consisting of perforation of the vaginal wall through the utero-vesical space into the abdominal cavity with gangrenous loops of small intestine herniating through it. Information was obtained from her case notes and the operating theatre register. She had a resection and anastomosis of the small intestine and had to remain in hospital, where she made a full recovery, for two weeks. Unsafe abortion is fraught with many complications, including pelvic sepsis, septicaemia, haemorrhage, renal failure, uterine perforation and other genital tract injuries, and gastro-intestinal tract injuries. Where expert, emergency treatment for these is not available, women die. Unsafe abortion procedures, untrained abortion service providers, restrictive laws and high morbidity and mortality from abortion tend to occur together. We advocate for a review of the existing restrictive laws in Nigeria in order to reduce the high morbidity and mortality from unsafe abortion.     

The role of prophylactic use of low dose aspirin and calheparin in patients with unexplained recurrent abortion

Objective: To study the effect of prophylactic use of low dose aspirin and heparin on patients with recurrent unexplained pregnancy loss.

Methods: Prospective case control study conducted on 180 pregnant women randomized into two equal groups. Group 1 received low-dose aspirin 75?mg and heparin 5000?IU subcutaneous every 12?h. Group 2 received no treatment.

Results: There was a statistically significant difference between the two study groups regarding number of patients who completed their first trimester (66 versus 39) (p values 0.018). The outcome regarding completion of first trimester was not related to age, BMI or number of previous abortions in both the study groups. Complications of the use of aspirin calheparin occurred in 60% of the patients. The most common complication was bruising at injection site occurring in 60% of the patients followed by bleeding gums (14.4%), gastrointestinal troubles (12.2%), epistaxis (10%) and transient thrombocytopenia in only 2.22% of the patients (Table 4).

Conclusion: The use of prophylactic dose of calheparin and aspirin is associated with increased chance of passing 1st trimester safely regardless the age, body mass index or number of abortion in women with unexplained recurrent spontaneous abortion.