A walk in the Park

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This blog is dedicated to everyone who has struggled with Community Medicine. Through my posts I hope to simplify and demystify community medicine. The emphasis will be on clarifying concepts rather than providing ready-made answers to exam questions.

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I hope that my exertions will make your experience with community medicine seem like a “Walk in the Park”

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WHO updates fact sheet on Preventing Unsafe Abortion (22 June 2017)

The World Health Organization (WHO) has updated its fact sheet on preventing unsafe abortion.

Background Information:

Unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

The persons, skills and medical standards considered safe in the provision of abortion are different for medical and surgical abortion and also depend on the duration of the pregnancy. What is considered ‘safe’ should be interpreted in line with current WHO technical and policy guidance.

The immediate determinants of the risks of an induced abortion, such as the termination method used and gestational age, are influenced, in turn, by underlying social determinants: i.e.

  • the legal context,
  • the availability of safe abortion services,
  • the level of stigma surrounding abortion,
  • the degree of women’s access to information on abortion, and
  • a woman’s age and socioeconomic status.

The legal context and the level of safety are closely intertwined, but the association is context-specific. For example, where restrictive laws are liberally interpreted, women can receive safe care in certain contexts; conversely, where liberal laws are poorly implemented, women sometimes abort with delay and under unsafe conditions. Thus, illegal abortion is not synonymous with unsafe abortion.

Women, including adolescents, with unwanted pregnancies often resort to unsafe abortion when they cannot access safe abortion. Barriers to accessing safe abortion include:

  • restrictive laws;
  • poor availability of services;
  • high cost;
  • stigma;
  • conscientious objection of health-care providers; and
  • unnecessary requirements such as:
    • mandatory waiting periods.
    • mandatory counselling.
    • provision of misleading information
    • third-party authorization
    • medically unnecessary tests.

Key Messages:

Based on data from 2008, there are approximately 22 million unsafe abortions annually. Unsafe abortions lead to an estimated 7 million complications such as:

  • incomplete abortion (failure to remove or expel all of the pregnancy tissue from the uterus)
  • haemorrhage (heavy bleeding)
  • infection
  • uterine perforation (caused when the uterus is pierced by a sharp object)
  • damage to the genital tract and internal organs by inserting dangerous objects such as sticks, knitting needles, or broken glass into the vagina or anus.

Between 2010–2014:

  • On average, 56 million induced (safe and unsafe) abortions occurred worldwide each year.
  • There were 35 induced abortions per 1000 women aged between 15–44 years.
  • 25% of all pregnancies ended in an induced abortion.

Each year between 4.7% – 13.2% of maternal deaths can be attributed to unsafe abortion

Around 7 million women are admitted to hospital as a result of unsafe abortion every year in developing countries.

The annual cost of treating major complications from unsafe abortion is estimated at $680 million.

Mortality from unsafe abortion disproportionately affects women in Africa. While the continent accounts for 29% of all unsafe abortions, it sees 62% of unsafe abortion-related deaths.

Unsafe abortion related mortality:

  • Developed regions: 30 deaths/ 100 000 unsafe abortions
  • Developing regions: 220 deaths/ 100 000 unsafe abortions  and
  • Sub-Saharan Africa: 520 deaths/ 100 000 unsafe abortions.

Risk factors:

Any woman with an unwanted pregnancy who cannot access safe abortion is at risk of unsafe abortion.

Poor women are more likely to have an unsafe abortion than more affluent women.

Deaths and injuries are higher when unsafe abortion is performed later in pregnancy.

The rate of unsafe abortions is higher where access to effective contraception and safe abortion is limited or unavailable.

Complications:

The major life-threatening complications resulting from unsafe abortion are

  • haemorrhage,
  • infection, and
  • injury to the genital tract and internal organs.

Signs and symptoms

The critical signs and symptoms of complications that require immediate attention include:

  • abnormal vaginal bleeding
  • abdominal pain
  • infection
  • shock (collapse of the circulatory system).

Access to treatment for abortion complications:

Health-care providers are obligated to provide life-saving medical care to any woman who suffers abortion-related complications, including treatment of complications from unsafe abortion, regardless of the legal grounds for abortion. However, in some cases, treatment of abortion complications is administered only on the condition that the woman provides information about the person(s) who performed the illegal abortion.

The practice of extracting confessions from women seeking emergency medical care as a result of illegal abortion puts women’s lives at risk. The legal requirement for doctors and other health-care personnel to report cases of women who have undergone abortion, delays care and increases the risks to women’s health and lives. UN human rights standards call on countries to provide immediate and unconditional treatment to anyone seeking emergency medical care.

Prevention and control:

Unsafe abortion can be prevented through:

  • good sexual education;
  • prevention of unintended pregnancy through use of effective contraception, including emergency contraception; and
  • provision of safe, legal abortion.

In addition, deaths and disability from unsafe abortion can be reduced through the timely provision of emergency treatment of complications.

Useful Links:

Link to the updated fact sheet:

http://who.int/mediacentre/factsheets/fs388/en/

Link to WHO Clinical practice handbook for safe abortion (English, Chinese, Spanish) (2014):

http://who.int/reproductivehealth/publications/unsafe_abortion/clinical-practice-safe-abortion/en/

Link to WHO publication Health worker roles in providing safe abortion care and post-abortion contraception (English, French, Spanish) (2015):

http://who.int/reproductivehealth/publications/unsafe_abortion/abortion-task-shifting/en/

Link to editorial in WHO Bulletin describing the correct interpretation and operationalization of unsafe abortion:

http://who.int/bulletin/volumes/92/3/14-136333.pdf?ua=1