Article 545. - Principle.
(1)
The intentional termination of a pregnancy, at whatever stage or
however effected, is punishable according to the following
provisions, except as otherwise provided under Article 551.
(2) The nature and extent of the punishment given for
intentional
abortion shall be determined according to whether it is
procured
by the pregnant woman herself or by another, and in the
latter
case according to whether or not the pregnant woman gave
her
consent.
Article 546. - Abortion Procured by the Pregnant Woman.
(1) A pregnant woman who intentionally procures her own
abortion
is punishable with simple imprisonment.
(2) Any other person who procured for her the means of, or
aids her
in the abortion, shall be punishable as a principal
criminal or an
accomplice, with simple imprisonment.
(3) A pregnant woman who consents to an act of abortion
except as
is otherwise permitted by law, is punishable with simple
imprisonment.
Article 548. - Aggravated Cases.
Where abortion is performed apart from the circumstances
provided by law the punishment shall be aggravated as
follows:
(1) in cases where the criminal has acted for gain, or made
a
profession of abortion (Art. 92), he is punishable with
fine in
addition to the penalties prescribed in Article 547 above;
(2) in cases where the crime is committed by a person who
has no
proper medical profession, the punishment shall be simple
imprisonment for not less than one year, and fine;
(3) in cases where the crime is committed by a
professional, in
particular, by a doctor, pharmacist, midwife, or nurse
practising
his profession, the Court shall, in addition to simple
imprisonment and fine, order prohibition of practice,
either for a
limited period, or, where the crime is repeatedly
committed, for
life (Art. 123).
Article 549. - Attempt to Procure an Abortion on a
Non-Pregnant
Woman.
The general provisions relating to crimes impossible of
completion (Art. 29) shall apply in the case of attempt to
procure
an abortion on a woman wrongly supposed to be pregnant.
Article 550. - Extenuating Circumstances.
Subject to the provision of Article 551 below, the Court
shall
mitigate the punishment under Article 180, where the
pregnancy
has been terminated on account of an extreme poverty.
Article 551.-Cases where Terminating Pregnancy is Allowed
by
Law.
(1) Termination of pregnancy by a recognized medical
institution
within the period permitted by the profession is not
punishable
where:
a) the pregnancy is the result of rape or incest; or
b) the continuance of the pregnancy endangers the life of
the
mother or the child or the health of the mother or where
the birth of the child is a risk to the life or health of
the
mother; or
c) where the child has an incurable and serious deformity;
or
d) where the pregnant woman, owing to a physical or mental
deficiency she suffers from or her minority, is physically
as
well as mentally unfit to bring up the child.
(2) In the case of grave and imminent danger which can be
averted
only by an immediate intervention, an act of terminating
pregnancy in accordance with the provision of Article 75 of
this
Code is not punishable.
Article 552.- Procedure of Terminating Pregnancy and the
penalty of Violating the Procedure.
(1) The Ministry of Health shall shortly issue a directive
whereby
pregnancy may be terminated under the conditions specified
in
Article 551 above, in a manner which does not affect the
interest
of pregnant women.
(2) In the case of terminating pregnancy in accordance with
subarticle
(1) (a) of Article 551 the mere statement by the woman is
adequate to prove that her pregnancy is the result of rape
or
incest.
(3) Any person who violated the directive mentioned in sub-article
(1) above, is punishable with fine not exceeding one
thousand
Birr, or simple imprisonment not exceeding three months.
* * *
Technical and Procedural Guideline
for Safe Abortion Services in
I. Introduction
II. Types Of Abortion Services
III. Legal Provisions for Safe Abortion Services
IV. Implementation Guide for Safe Abortion Services
VI. Procedures During Termination
VII. Post-Procedure Care
VIII. Referral Arrangemnts
IX. Providers’ Skills and Performance.
X. Abortion Services by Level of Care.
XI. Essential Equipment And Supplies
XII. Monitoring and Evaluation
Appendices
CBRHA: Community-Based
Reproductive Health Agent
CHA: Community Health Agent
DACA: Drug Administration and
Control Authority
FDRE: Federal Democratic
FMOH: Federal Ministry of
Health
FP: Family Planning
GBV: Gender-Based
Violence
GMP: General Medical Practitioner
ICPD:
International
Conference on Population and Development
IPPF: International
Planned Parenthood Federation
IUCD: Intrauterine
Contraceptive Device
LNMP: Last
MVA: Manual
Vacuum Aspiration
PHCU: Primary Health-Care
Unit
RH: Reproductive Health
SMC: Sharp
Metallic Curettage
STDs: Sexually Transmitted
Diseases
TBA: Traditional Birth
Attendant
VCT: Voluntary Counseling
and Testing
VIA: Visual
Inspection of Cervix Using Aceto-Acetic Acid
Abortion is more than a medical issue, or an
ethical issue, or a legal issue. It is, above all, a human issue, involving
women and men as individuals, as couples, and as members of societies (Tietze,
1978).
Statistical returns from health facilities across the country and from hospital-based studies show that unsafe abortion is among the top 10 reasons for hospital admissions for women. Unsafe abortion accounts for nearly 60% of all gynecologic admissions and almost 30% of all obstetric and gynecologic admissions. Due to the clandestine nature of unsafe abortion services, however, these figures represent only the tip of iceberg, not the full magnitude of the problem.
It
is estimated that there are 3.27
million pregnancies in
Institution-based studies have shown that the cost of care to the health system for abortion complications is enormous. In addition, the loss of productivity due to absence from work by the patient and her attending family members can affect the overall economy.
In reference to abortion, the international community has pledged commitment to reducing the need for abortion through expanding and improving family planning (FP) services and, where the laws of the land allow, providing women with high-quality abortion care. Furthermore, at the five-year review of the ICPD, there were calls for governments to consider reviewing laws that contain punitive measures against women who undergo illegal abortions. Governments have also agreed that, in circumstances where abortion is not against the law, health systems should train and equip providers and take measures to ensure that abortion services are safe and accessible. Additional measures to safeguard women’s health are also required.
At
the UN summit in 2000, governments of the world ratified the Millennium
Development Goals (MDGs) as an international tool for reducing poverty and
improving the standard of living in the developing world. One of the eight MDGs
is to reduce the maternal mortality rate by 75% (from 1990 levels) by the year
2015. Preventing unsafe abortion is one of the five strategies for reducing
maternal mortality that was endorsed by the World Health Organization (WHO) in
2004.
In response to these developments at the global level and changes in social and gender relations within the country, the government of the Federal Democratic Republic of Ethiopia (FDRE) has reviewed its laws and policies within the last decade.
Articles 14, 15, and 16 under Section I (Human Rights) of the Constitution refer to the rights to life, liberty, and security of the person. Article 35 refers to women’s equality with men and their rights to information and the capacity to be protected from the dangers of pregnancy and childbirth.
The
Women’s Policy recognizes the low status accorded to women in
·
The Health Policy of the Transitional Government of Ethiopia (1993) states that the health needs of women and children require particular attention. The policy recommends decentralizing services and “enriching the concept and intensifying the practice of family planning for optimal family health and planned population dynamics.” The policy also discusses the need for “adequate maternal health care including care for high-risk pregnancies” and, in reference to health-related laws, recommends “developing new rules and regulations to help in the implementation of the current policy and addressing new health issues.”
Cognizant
of the extent of the problem of unsafe abortion, and with due recognition of
the need for an integrated approach to reducing maternal morbidity and
mortality, the FMOH has issued this guideline for health workers across the
country. The guideline was developed by the FMOH on the basis of the authority
vested in it by the House of Representatives of the FDRE per Article 552 sub-article
1 of the Penal Code of Ethiopia (promulgated in May 2005).
Aim of the guideline
This
guideline is a working document on the techniques and procedures that must be
observed in providing safe termination of pregnancy services as permitted by
the recently revised law (
In
the process of developing this guideline, due consideration has been given to
the knowledge and skills acquired in basic education by all cadres of health
providers. This guideline is for health managers, program coordinators, and all
categories of health-care providers practicing in
This
guideline will be implemented in all health institutions recognized by the FMOH
as specified under Section X: Abortion Services by Level of Care. The guideline
is meant to ensure that all women obtain standard, consistent, and safe
termination of pregnancy services as permitted by law.
Abortion is the termination of pregnancy before fetal viability, which is conventionally taken to be less than 28 weeks from the last normal menstrual period (LNMP). If the LNMP is not known, a birth weight of less than 1000gm is considered as abortion.
There are two types of care related to termination of pregnancy: woman-centered abortion care and postabortion care.
Woman-centered abortion care is a comprehensive approach to providing abortion services that takes into account the various factors that influence a woman’s individual mental and physical health needs, her personal circumstances, and her ability to access services. This care includes a range of medical and related health services that support women in exercising their sexual and reproductive rights.
Woman-centered abortion services have three key elements. These are:
Postabortion care is a comprehensive service for treating women that present to health-care facilities after abortion has occurred spontaneously or after an attempted termination. Postabortion care has five essential elements, which are:
Several methods of termination of pregnancy are available. The best method for a woman depends on the duration of pregnancy, the general health status of the woman, the availability of each method, the distance from a referral center, the knowledge and skill of the provider, and the level of care.
Health workers involved in the care of women should be well aware of the provisions of this guideline, which is an official interpretation of the law on safe abortion services as outlined below. Knowledge of the law is essential so that providers not only know what is expected of them but can also inform and educate women and the community at large.
Article 551 of the Penal Code of the FDRE allows termination of pregnancy under the following conditions:
1. Termination of pregnancy by a recognized medical institution within the period permitted by the profession is not punishable where:
2. In the case of grave and imminent danger which can be averted only by an immediate intervention, an act of terminating pregnancy in accordance with the provisions of Article 75 of this Code is not punishable.
Timing and place for terminating pregnancy
1. Termination of pregnancy as permitted by the law can be conducted in a public or private facility that fulfills the pre-set criteria.
2. A woman who is eligible for pregnancy termination should obtain the service within three working days. This time is used for counseling and diagnostic measures necessary for the procedure.
3. All health facilities at the level of a health center and above can perform termination of pregnancy as permitted by Article 551 for pregnancies less than 12 weeks of gestation from the first day of the LNMP.
4. Termination of pregnancy between 13 and 28 weeks of gestation should be done in a secondary or tertiary level of care.
5. Women who are eligible for pregnancy termination should have the necessary information to seek abortion care as early in pregnancy as possible.
Þ Where the continuation of the pregnancy endangers the life of the
mother or the child or the health of the mother or where the birth of the child
is a risk to the life or health of the mother
· The provider should, in all good faith, follow the knowledge of standard medical indications that necessitate termination of pregnancy to save the life or health of the mother.
· The woman should not necessarily be in a state of ill health at the time of requesting safe abortion services. It is therefore the responsibility of the health provider in charge to assess the woman’s conditions and determine in good faith that the continuation of the pregnancy or the birth of the fetus poses a threat to her health or life.
3. Implementation guide for
Article 551 sub-article 1C
Þ Where the fetus has an incurable and serious deformity
Þ Where the pregnant woman, owing to a physical or mental deficiency
she suffers from or her minority, is physically as well as mentally unfit to
bring up the child
· The provider will use the stated age on the medical record for age determination to determine whether the person is under 18 or not. No additional proof of age is required.
· A disabled person is one who has a condition called disability that interferes with his or her ability to perform one or more activities of everyday living. Disability can be broadly categorized as mental or physical.
5. Implementation guide for Article 551 sub-article 2
Þ
In the case of grave and imminent danger, which can be averted only by
an immediate intervention, an act of terminating pregnancy in accordance with
the provisions of Article 75 of this Code is not punishable
· Health providers responsible for the provision of comprehensive abortion care services are authorized to perform abortion procedures on women whose medical conditions warrant the immediate termination of pregnancy.
Applicable for all sub-articles:
The first steps in providing abortion care are to establish that the woman is pregnant and, if she is, to estimate the duration of the pregnancy. Taking the woman’s history, performing a bimanual pelvic examination, conducting the required laboratory investigations, counseling the client to help her decide between alternative options, and obtaining her consent are all part of the pre-procedure care.
a. Counseling
· Provide sufficient and accurate information on the comparative risks of continuing the pregnancy to term or terminating the pregnancy and on the risks associated with the method of pregnancy termination.
· The information and counseling provided to women requesting safe termination of pregnancy must include a minimum of the following:
o Options counseling: continuing or
terminating the pregnancy
o Available methods of pregnancy
termination and pain control medications (including the advantages and
disadvantages of each)
o What will be done during and
after the procedure
o Possible short- and long-term
risks associated with the method of termination of pregnancy
o When to expect resumption of
menses
o Follow-up care
· The information should be clear, objective, and non-coercive, and should be provided in a language understandable to the woman. The information should be supplemented with written materials whenever possible.
b.
Informed decisionmaking
· All women undergoing pregnancy termination should, after receiving objective counseling, consent to the procedure of termination in writing.
· The health-care institution and the health worker who provides the service has an ethical obligation not to disclose the information provided by the woman unless permitted by the woman or ordered by a court of law.
Before any procedure to terminate a pregnancy, a detailed medical history and confirmation of the pregnancy and gestational duration must be documented.
a. The medical history. Ask
and document the following:
·
Age
·
Reproductive history (number of pregnancies, deliveries, abortions)
·
First day of LNMP
·
Gestational age based on LNMP (note that lactating women may not report a
missed period)
·
History of drug allergy
·
Any medical or surgical illness (Note: assessment of life-threatening
illnesses as indication for termination and known medical and surgical
illnesses that may need special care shall be given due emphasis)
b. Physical examination. Undertake the following:
·
General physical examination to establish the general health of the woman
·
Bimanual pelvic examination to establish:
o Uterine size and position
o The presence of other uterine pathology, such as fibroids
c. Laboratory investigation. Do the following laboratory tests if
available (the absence of such tests should not be reason to prevent safe
abortion services):
·
Blood group and RH factors
·
Urine analysis
·
Pregnancy test
·
VDRL
·
Smear and Gram’s stain of vaginal discharge as appropriate
·
Cervical cancer screening
·
Ultrasound and genetic tests as appropriate
3. Exclude extra-uterine pregnancy
Suspect ectopic pregnancy if:
If ectopic pregnancy is suspected, make sure the woman is evaluated by the most senior health provider around or refer her to the next level of care.
Assess gestational duration based on:
· The first day of the LNMP
· Physical findings (abdominal and pelvic examination)
· Ultrasound (optional)
5. Cervical preparation
The following groups of women need cervical preparation regimens:
Depending on their availability, administer either of the following drugs in the recommended dosages:
· Misoprostol 400 micrograms (µg) vaginally or orally three to four hours before the procedure; or
· Mifepristone 200 milligrams (mg) orally 36 hours before the procedure.
All health institutions that are given the authority should provide termination of pregnancy by one of the recommended methods, depending on the gestational duration.
Administer the following combination of drugs in the specified dosage:
o Mifepristone 200mg orally, followed 36 to 48 hours later by
o Misoprostol 800µg vaginally (insert misoprostol deep into the vagina or instruct the woman to do so herself). For gestations up to seven completed weeks, you may administer misoprostol 400µg orally.
o Mifepristone PO
200mg, followed 36 to 48 hours later by
o Misoprostol 800µg
vaginally followed by 400µg of oral misoprostol every three hours, up to a
maximum of four doses if abortion does not occur.
o Alternatively,
mifepristone 200mg followed after 36 to 48 hours by misoprostol 400µg orally
every three hours up to five doses if abortion does not occur.
Contraindications:
o Suspected ectopic pregnancy or undiagnosed adnexal mass
o IUD in place (remove before administering medication)
o Chronic adrenal failure
o Concurrent long-term corticosteriod therapy
o History of allergy to mifepristone
o Hemorrhagic disorders or concurrent anticoagulant therapy
o Inherited porphyrias
o History of allergy to prostaglandins, including misoprostol
Rule out the above clinical conditions before administering either of the two drugs.
After administering mifepristone, advise women to come back 36 to 48 hours later to take misoprostol. Also, inform women to expect bleeding and possible expulsion of the products of conception, and tell them who to contact in case complications arise.
Once misoprostol has been administered during the second visit, observe women for four hours, during which time up to 90% of them will expel the products of conception. If abortion does not occur during the observation period, women should be advised to come back to the health facility about two weeks later to confirm that the abortion has been completed. In cases of severe bleeding or other complications, women should be advised to report to the health facility immediately. If by the end of the two-week follow-up period the abortion has failed, use surgical methods to complete the process.
For pregnancies 12 weeks of gestation or less from the first day of the LNMP, the preferred surgical method of termination is manual or electric vacuum aspiration. Dilatation and curettage should be used only where vacuum aspiration or medical methods are not available. All efforts should be made to replace dilatation and curettage and sharp metallic curettage (SMC) with vacuum aspiration at all levels of care.
a. Vacuum aspiration. Vacuum aspiration is an alternative, safe method of terminating an otherwise uncomplicated pregnancy up to 12 completed weeks’ gestation from the first day of the LNMP. Considerations include:
· Follow steps for cervical preparation as in Section V.5 above.
· Make sure the vacuum aspiration instrument is functioning properly. Inspect the instrument for optimal use.
· Observe steps to ensure that the products of conception are evacuated completely.
· Inspect the evacuated tissue for floating villi to confirm that it is the products of conception.
· Staff should protect themselves and clients by applying universal precautions routinely (see Appendix II).
· Staff should follow recommended steps for instrument processing (per Appendix III).
· Safely handle and dispose blood, blood-soaked materials, sharps, and products of conception as per the guideline for infection prevention.
· SMC procedure should be done in a procedure room equipped for providing general anesthesia.
· Local or general anesthesia should be administered irrespective of the gestational period.
· Dilate cervix using dilators of gradually increasing size. Exercise caution while using metallic dilators and curettes in order to minimize the risk of cervical injury and uterine perforation.
· Following the procedure, observe the woman until her vital signs are stable and she is able to walk unassisted.
Post-procedure care is as essential as care during the procedure in ensuring the best outcome in abortion services.
Special considerations: Anti-D Ig G 250 iu should be given IM for all non-sensitized RhD negative women after termination of pregnancy by any method.
A well-functioning referral system is vital to providing safe and high-quality abortion services. All health personnel involved in the care of the woman have an ethical responsibility to direct her to appropriate services at any time. Referral arrangements enable women to access routine care and prompt treatment for complications.
In order to effectively discharge their responsibilities, providers should acquire basic knowledge and skills during their pre-service training and get periodic updates through on-the-job training. Training content should address both technical and clinical skills as well as the attitudes and beliefs of service providers. Values clarification exercises that help providers distinguish between their own values and their clients’ right to safe reproductive health services are an essential component of all training programs. The selection of training sites should take into consideration the volume of patients, so that providers will get the opportunity to acquire adequate skills in managing abortion and its complications.
In order to make safe abortion services as permitted by law accessible to all eligible women, the role of midlevel providers such as nurses and midwives should be expanded to include providing comprehensive abortion services, including uterine evacuation using MVA and medical abortion. Pre-service and in-service training for midlevel providers should reflect this expanded role.
The following table illustrates the tasks that are required to provide comprehensive abortion care and the role of certain categories of reproductive health providers, namely general medical practitioners (GMPs), health officers, midwives, clinical nurses, and public health nurses.
Table 1: Abortion care tasks by provider category
Task |
Provider category |
||||
|
GMPs |
Health officers |
Midwives |
Clinical nurses |
Public health nurses |
|
|
Patient assessment |
|
|
|
|
|
|
· History taking |
ü |
ü |
ü |
ü |
ü |
|
· Physical examination |
ü |
ü |
ü |
ü |
ü |
|
· Bimanual pelvic exam |
ü |
ü |
ü |
ü |
ü |
|
· Dating gestation |
ü |
ü |
ü |
ü |
ü |
|
Counseling |
+ |
+ |
ü |
ü |
ü |
|
Uterine evacuation |
|
|
|
|
|
|
· MVA |
ü |
ü |
ü |
ü |
ü |
|
· SMC |
ü |
ü |
X |
X |
X |
|
· Medical abortion |
ü |
ü |
ü |
ü |
ü |
|
Pain medications |
|
|
|
|
|
|
· Analgesics |
ü |
ü |
ü |
ü |
ü |
|
· Narcotics/sedatives |
ü |
ü |
ü |
X |
X |
|
·
Paracervical block |
|
|
|
|
|
|
Treatment of complications |
|
|
|
|
|
|
· Identification |
ü |
ü |
ü |
ü |
ü |
|
· Antibiotics |
ü |
ü |
ü |
ü |
ü |
|
· IV fluids |
ü |
ü |
ü |
ü |
ü |
|
· Blood transfusions[1] |
ü |
ü |
X |
X |
X |
|
· Maintain airways |
ü |
ü |
ü |
ü |
ü |
|
· Repair of minor injuries |
ü |
ü |
ü |
X |
X |
|
· Abdominal surgery |
ü |
ü |
|
|
|
|
Post-procedure care |
ü |
ü |
ü |
ü |
ü |
|
Follow-up care |
ü |
ü |
ü |
ü |
ü |
|
Universal precautions |
ü |
ü |
ü |
ü |
ü |
|
Postabortion contraception |
ü |
ü |
ü |
ü |
ü |
|
· Information |
ü |
ü |
ü |
ü |
ü |
|
· Counseling |
+ |
+ |
ü |
ü |
ü |
|
· Method choice |
ü |
ü |
ü |
ü |
ü |
|
· Informed choice/referral |
ü |
ü |
ü |
ü |
ü |
|
Linkages with other RH services |
|
|
|
|
|
|
· Counseling |
ü |
ü |
ü |
ü |
ü |
|
· Screening |
ü |
ü |
+ |
+ |
+ |
|
· Treatment |
ü |
ü |
ü |
ü |
ü |
|
· Referral |
ü |
ü |
ü |
ü |
ü |
|
Instrument processing |
ü |
ü |
ü |
ü |
ü |
|
Education on: |
|
|
|
|
|
|
· The dangers of unsafe abortion |
ü |
ü |
ü |
ü |
ü |
|
· Prevention of unwanted pregnancy |
ü |
ü |
ü |
ü |
ü |
|
· Legal provisions for abortion |
ü |
ü |
ü |
ü |
ü |
|
Training junior health professionals and community health workers |
ü |
ü |
ü |
ü |
ü |
|
Maintain records and submit reports |
ü |
ü |
ü |
ü |
ü |
Key:
ü = Roles expected from that category of professionals
X = Roles not expected of that category of professionals
+ = Members of that category may initiate and/or partly perform the task
Training curricula on abortion care should enable health providers to competently perform the tasks described in the above table. The following health workers are authorized to perform abortion procedures for first-trimester pregnancy using medical abortion and/or MVA:
· Clinical nurses
·
Public health nurses
· Midwives
· Health officers
· GMPs and above
GMPs and health officers with additional training on the specific skills needed for second-trimester abortion and specialists in obstetrics and gynecology are authorized to perform second-trimester abortion procedures.
In organizing abortion care services, program planners and facility managers should take into consideration:
· Emergency abortion services that provide life-saving procedures on a 24-hour basis.
· Elective abortion services that are performed at the request of the woman or on the recommendation of the health-care provider.
The following table summarizes the elements of abortion services and staffing patterns at different levels of care.
Table 2: Abortion
services by level of care
|
Level of care |
Type of health personnel
available |
Abortion
services |
|
Community |
· Traditional birth attendants (TBAs), community health workers (CHAs), community-based reproductive health agents (CBRHAs) |
· Recognize signs and symptoms of pregnancy · Recognize signs and symptoms of abortion and its complications · Provide RH education, including FP and the risks of unsafe abortion · Distribute appropriate contraceptives, including emergency contraceptives · Inform communities and women on the legal provisions for safe abortion · Refer women to postabortion and safe abortion services |
|
Health posts/stations |
· Frontline health workers (health extension workers) |
The above activities plus: · Check vital signs · Provide pain medication |
|
Health centers |
· Health officers, midwives, clinical nurses, public health nurses, laboratory technicians |
The above activities plus: · Counseling · General physical and pelvic examination · Vacuum aspiration up to 12 completed weeks of pregnancy · Medical abortion up to nine completed weeks of pregnancy · Administer antibiotics and IV fluids · Train community-level workers and junior health professionals in abortion service provision |
|
District/zonal hospitals |
· Same as above, plus GMPs, with or without an obstetrician-gynecologist |
The above activities plus: · Uterine evacuation for second-trimester abortion · Treatment of most complications · Blood cross-matching and transfusion · Local and general anesthesia · Laparotomy and indicated surgery · Diagnosis and referral for serious complications such as peritonitis and renal failure · Train all cadres of health professionals (pre- and in-service) |
|
Referral hospitals |
· Same as above plus obstetrician-gynecologists |
The above activities plus: · Treatment of severe complications (including bowel injury, tetanus, renal failure, gas gangrene, severe sepsis) · Treatment of coagulopathy |
|
Private facilities: |
|
|
|
Lower clinics |
· Staffed by nurses and assistants |
· Perform functions described under health posts/stations |
|
Medium clinics |
· Staffed by a health officer or GMP and a team of other health workers |
· Perform functions described under health centers |
|
Higher clinics |
· Staffed by a specialist or a GMP and a team of other health workers |
· Perform functions described under health centers |
|
MCH centers and hospitals |
· Staffed by specialists (obstetricians/gynecologists), a GMP, and a team of other health workers |
· Perform functions described under district and referral hospitals |
Health facilities providing safe abortion services should be equipped with basic equipment, instruments, and consumables that have to be replenished regularly, such as pain medications, antibiotics, IV fluids, disinfectants, and so on. Following is a list of these basic supplies that should always be available in sufficient amounts in all health facilities rendering services. Program managers, facility directors, and other responsible persons should include these items in the routine budgeting, procurement, and distribution systems.
1. Basic supplies:
· Equipment and supplies for instrument processing
2. Instruments and equipment for first-trimester uterine evacuation:
a. Basic uterine evacuation
· Sponge forceps or uterine packing forceps
· Malleable metal sound
· Pratt or Denniston dilators: sizes 13-27 French
· Medium self-retaining speculum
· 50ml container for local anesthesia
· 500ml container for antiseptics
· Plastic strainer
· Clear glass dish for tissue inspection
· Long sponge forceps
· Container for cleansing solution
· Single tooth tenaculum forceps
b. Vacuum aspiration with electric pump
· Basic uterine evacuation supplies
· Vacuum pump with extra glass bottles
· Connecting tubing
· Cannulae (any of the following)
o Flexible: 4,5,6,7,8,9,10,12mm
o Curved rigid: 7,8,9,10,12,14mm
o Straight rigid: 7,8,9,10,12mm
c. Manual vacuum aspiration
· Basic uterine evacuation supplies
· Vacuum aspirators
· Adapters
· Flexible or semi-rigid cannulae, sizes 4-12mm
d. Twelve-weeks plus
· Basic uterine evacuation supplies
· Pratt or Denniston dilators: sizes 29-43
· Curette: size 1 or 2
3. Drugs for medical abortion:
Health facilities and clinical providers should maintain data on abortion services through regular recording systems such as logbooks, clinical records, and daily activity records. The logbook for registering clients receiving abortion services that is shown in Appendix IV should be used by all health facilities providing abortion services. Data from the logbook should be regularly reported through the health management and information system, following the reporting format attached as Appendix V.
Program managers should monitor services to assess whether they are being provided up to standard, so that they can take corrective measures as appropriate. Among others, monitoring abortion services should include:
Evaluation of abortion services should provide data on the extent to which those services have contributed to reducing maternal mortality from unsafe abortion. However, the gathering of such data, which requires a vital events registration system or the study of a very large population, may not be feasible in the Ethiopian setting. Instead, as many maternal mortality reduction programs do, it is imperative to focus on process or output indicators. The following indicators can be used when evaluating abortion services:
Type of services to be monitored
Indicators for
measuring activities
Sources of information
Types of
questions to ask
Infection prevention
· Percentage of cases in which infection prevention practices were adhered to fully
· Observe services using checklist
· Was no-touch technique used?
· Were MVA instruments properly processed?
Management and organization of services
· Average amount of time abortion care clients spend in the facility
· Average amount of time from arrival to procedure
· Hours during which service are available
· Observe and evaluate patient flow
· Review client records and conduct interviews with staff
· During which time(s) of the day does the client waiting time increase?
Counseling
· Number and percentage of clients receiving counseling
· Observe counseling sessions using performance checklist
· Review cases from logbook
· Were women with special needs given referrals?
Contraceptive counseling and services
· Number and type of contraceptives dispensed on site
· Number and percentage of women who received contraceptive counseling
· Number and percentage of women desiring contraception who received a method
· Observe counseling
· Conduct exit interviews
· Review logbooks
· How well were women counseled about available contraceptive methods?
· Did women leave with a desired method or information?
· Did women have to go to another facility to receive a contraceptive method?
Client satisfaction
· Percentage of women who indicate that they received respectful care
· Percentage of women who agree that services fees are reasonable
· Conduct exit interview
· Review service fee charges
· Did women feel that they were treated respectfully?
· Did women think the amount that they had to pay for services was reasonable?
The table above could serve as a useful tool for monitoring quality of care at the facility level. Facility directors and program managers are encouraged to develop and apply such tools as part of their monitoring plans.
Appendix I: Consent Form
Consent Form
for Uterine Evacuation
Draft
After having consulted with my health service provider about my health condition, I, (name of client) , hereby consent to a procedure for safe termination of pregnancy. I have been counseled and informed about the alternative methods and about the possible side effects and outcomes of the procedure.
In the event of complications arising during the procedure, I request and authorize the responsible health service provider to do whatever is necessary to protect my health and wellbeing.
I confirm that the information that I provided to my health service provider is accurate.
Signature Date
Appendix II: Universal Precautions
Health-care workers involved in providing abortion services should follow these universal precaution measures in order to prevent the transmission of infection from providers to patients, from patients to providers, and to the community:
Appendix III: Instrument Processing
Follow specific instructions for processing medical instruments, as appropriate. For instruments and equipment that can be reprocessed through high-level disinfection, follow the steps described below:
o Soak in a 0.5% chlorine solution for 20 minutes; or
o Boil for 20 minutes.
Note: Rinse with sterile water after processing with chemicals and dry with a sterile towel.
· Store or use immediately: After instruments are processed, they should be kept in a dry, sterile or high-level disinfected container, protected from dust and other contaminants. Instruments processed with boiling or solutions should be reprocessed every two days until used.
Metallic instruments such as tenaculum, speculum, and curettes should be sterilized using steam autoclave at a temperature of 121oC at a pressure of 106 KPa for 20 minutes (following the instructions of the a utoclave being used).
Appendix IV: Logbook for
Abortion Procedures
Appendix V:
Quarterly/Monthly Reporting Format for Abortion Services
Region: Name of Health Facility: Zone: Year ( Woreda: Quarter/Month:
|
|
Total |
Safe Abortion |
Postabortion |
|
1. Number of women who received abortion care |
|
|
|
|
2. Completed gestation (weeks) |
|
|
|
|
· Less than 8 weeks |
|
|
|
|
· 8 to 12 weeks |
|
|
|
|
· Greater than 12 weeks |
|
|
|
|
3. Type of procedure/method |
|
|
|
|
· MVA |
|
|
|
|
· SMC |
|
|
|
|
· Medical abortion |
|
|
|
|
· Other (specify___________) |
|
|
|
|
4. Women who expressed desire to delay further pregnancy |
|
|
|
|
5. Women who received a contraceptive method |
|
|
|
|
6. Women referred for a contraceptive method |
|
|
|
|
7. Women referred to another facility for abortion care (by reason) |
|
|
|
|
8. Women with major complications |
|
|
|
|
9. Women who died from complications of abortion |
|
|
|
Prepared by:
Approved by:
[1] While the decision to transfuse blood shall be made by a senior clinician, all categories of nurses can administer and monitor blood transfusions.