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safe_abSafe abortion: Technical and policy guidance for health systems
2003 – 106 pages

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At the Special Session of the United Nations General Assembly in June 1999, Governments agreed that “in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health.” This document provides technical guidance for health systems to turn this agreement into reality.

Contents
Introduction
Chapter 1: Safe abortion services: the public health challenge
Summary
1 Background
2 Induced abortion
3 Unsafe abortion
4 Safe abortion
5 Legal, policy and contextual considerations
6 The challenge – making safe services available
References 1

Chapter 2: Clinical care for women undergoing abortion
Summary
1 Pre-abortion care

1.1 Patient history
1.2 Physical examination
1.3 Laboratory testing
1.4 Ultrasound scanning
1.5 Pre-existing conditions
1.6 Reproductive tract infections (RTIs)
1.7 Ectopic pregnancy
1.8 Rh-isoimmunisation
1.9 Cervical cytology
1.10 Information and counselling

1.10.1 Decision-making counselling
1.10.2 Information on abortion procedures
1.10.3 Contraceptive information and services

2 Methods of abortion

2.1 Cervical preparation
2.2 Pain management

2.2.1 Medication for pain
2.2.2 Anaesthesia

2.3 Surgical abortion

2.3.1 Vacuum aspiration
2.3.2 Dilatation and curettage
2.3.3 Dilatation and evacuation
2.3.4 Other surgical methods of abortion
for use in later pregnancy
2.3.5 Tissue examination following surgical abortion

2.4 Medical methods of abortion

2.4.1 Mifepristone and prostaglandin

2.4.1.1 Up to 9 completed weeks since
last menstrual period
2.4.1.2 From 9 to 12 completed weeks since
last menstrual period
2.4.1.3 After 12 completed weeks since last
menstrual period

2.4.2 Misoprostol or gemeprost alone

2.4.2.1 Up to 12 completed weeks since
last menstrual period
2.4.2.2 After 12 completed weeks since
last menstrual period

2.4.3 Other medical abortion agents

2.5 Other issues related to abortion procedures
2.5.1 Infection prevention and control

2.5.1.1 Handwashing and use of protective barriers
2.5.1.2 Cleaning
2.5.1.3 Safe disposal of waste contaminated
with body fluids
2.5.1.4 Safe handling and disposal of “sharps”
2.5.1.5 Safe cleaning of equipment after use

2.5.2 Managing abortion complications

2.5.2.1 Incomplete abortion
2.5.2.2 Failed abortion
2.5.2.3 Haemorrhage
2.5.2.4 Infection
2.5.2.5 Uterine perforation
2.5.2.6 Anaesthesia-related complications
2.5.2.7 Long-term sequelae

3 Follow-up

3.1 Recovery period

3.1.1 Surgical methods of abortion
3.1.2 Medical methods of abortion

3.2 Contraceptive method provision and STI counselling
3.3 Instructions for care after abortion

References

Chapter 3: Putting services in place
Summary
1 Assessing the current situation
2 Establishing national norms and standards

2.1 Types of abortion services and where they
can be provided

2.1.1 Community level
2.1.2 Primary-care facility level
2.1.3 District hospital (first referral) level
2.1.4 Secondary and tertiary referral hospitals

2.2 Essential equipment, supplies, medications
and facility capabilities

2.2.1 Regulatory requirements for drugs and devices

2.3 Referral mechanisms
2.4 Respect for women’s informed decision-making,
autonomy, confidentiality and privacy, with attention
to the special needs of adolescents

2.4.1 Informed and free decision-making
2.4.2 Autonomy in decision-making
(third party authorization)
2.4.3 Confidentiality
2.4.4 Privacy

2.5 Special provisions for women who have suffered rape

3 Ensuring provider skills and performance

3.1 Provider skills and training

3.1.1 Training programmes

3.2 Supervision
3.3 Certification and licensing of health professionals
and facilities

4 Monitoring and evaluation of services

4.1 Monitoring
4.2 Evaluation

5 Financing

5.1 Cost to the facility or health system
5.2 Making services affordable for women

References

Chapter 4: Legal and policy considerations
Summary
1 Women’s health and international agreements
2 Laws and their implementation
3 Understanding legal grounds for abortion

3.1 When there is a threat to the woman’ s life
3.2 When there is a threat to the woman’s physical
or mental health
3.3 When pregnancy is the result of rape or incest
3.4 When there is fetal impairment
3.5 For economic and social reasons
3.6 On request
3.7 Limits on length of pregnancy
3.8 Other limits

4 Creating an enabling policy environment

4.1 Goals
4.2 Constellation of services
4.3 Methods of abortion
4.4 Range of providers
4.5 Service fees
4.6 Health system requirements/quality of care
4.7 Public information

5 Removing administrative and regulatory barriers
References

Annex 1: Further reading and resources
Annex 2: International consensus documents in relation
to safe abortion
Annex 3: Instruments and supplies for manual vacuum
aspiration (MVA)
Annex 4: Contraception following abortion