ETHIOPIA. Criminal Code, Proclamation No. 414/2004.

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 Ethiopia, May 2006.

 

 

Table of Contents

 

 

Foreword. 2

Acknowledgments. 3

List Of Abbreviations. 5

I. Introduction. 6

II. Types Of Abortion Services. 9

III. Legal Provisions for Safe Abortion Services. 10

IV. Implementation Guide for Safe Abortion Services 11

V. Pre-Procedure Care. 13

VI. Procedures During Termination. 15

VII. Post-Procedure Care. 18

VIII. Referral Arrangemnts. 18

IX. Providers Skills and Performance. 19

X. Abortion Services by Level of Care. 21

XI. Essential Equipment And Supplies. 23

XII. Monitoring and Evaluation. 24

Appendices


 

 

List of Abbreviations

 

CBRHA: Community-Based Reproductive Health Agent

 

CHA: Community Health Agent

 

DACA: Drug Administration and Control Authority

 

FDRE: Federal Democratic Republic of Ethiopia

 

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 Normal Menstrual Period

 

MVA: Manual Vacuum Aspiration

 

PHCU: Primary Health-Care Unit

 

PO: Per Os

 

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

 


 

 

I. Introduction

 

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 Ethiopia every year, of which approximately 500,000 end in either spontaneous or unsafely induced abortion. The maternal mortality rate in Ethiopia is 1.68 per 1,000 women aged 15 to 49 years. According to the REDUCE model, unsafe abortion is the most common cause of maternal mortality, accounting for up to 32% of all maternal deaths in the country. For each woman that dies from complications of unsafe abortion, many more sustain short- and long-term morbidities, including infertility.

 

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.

 

Ethiopia has ratified international human rights conventions and treaties that are legally binding and that form international law. The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), which provides the foundation for reproductive rights, is one such notable convention. The Tehran Proclamation, the International Conference on Population and Development (ICPD), the Fourth World Congress on Women, and the 2000 United Nations (UN) Summit are some of the major forums at which national governments have expressed their commitment to improving the status of women in society. These and other international initiatives have yielded wider recognition of individuals rights to lead safe and responsible reproductive lives and have underscored the responsibility of governments to not only respect those rights but also to create the legal and policy environment for their realization.

 

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 womens 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 womens equality with men and their rights to information and the capacity to be protected from the dangers of pregnancy and childbirth.

 

The Womens Policy recognizes the low status accorded to women in Ethiopia and elaborates on the unacceptably high level of maternal mortality, high fertility rates, low use of contraceptives, harmful traditional practices such as female genital cutting and early marriage, and disproportionately high illiteracy rates. It also describes how the laws of the land negatively affect womens status in society. The strategies for improving womens status outlined in the policy include informing and educating the community on harmful traditional practices and ensuring womens access to basic health care and information on FP methods. The policy also states that conditions whereby women can have effective legal protection of their rights shall be facilitated.

         

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 (May 9, 2005). In developing the guideline, members of the Task Force reviewed and analyzed relevant knowledge, evidence, and experience. New, locally applicable, and appropriate procedures will be included based on national, regional, and international studies. Clinical guidelines are defined as systematically developed statements that assist clinicians in making decisions about appropriate treatment for specific conditions.

 

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 Ethiopia. Instructors from teaching institutions and reproductive health care trainers may also find the guideline useful.

 

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.

 


 

II. TYPES OF ABORTION SERVICES

 

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 womans 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:

 

  • Choice: which includes the right to determine if and when to become pregnant, to continue or terminate a pregnancy, to select between options, and to have complete and accurate information.
  • Access: which includes having access to termination of pregnancy services that are provided by trained and competent providers with up-to-date clinical technologies and that are easy-to-reach, affordable, and non-discriminatory.
  • Quality: which refers to respectful, confidential services that are tailored to each womans needs using accepted standards and appropriate referral procedures.

 

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:

 

  • Community-service provider partnerships involving the local community and informal health workers (CHAs, CBRHAs, TBAs) in addition to formal health personnel. These partnerships are designed to increase recognition of the signs and symptoms of pregnancy complications, to mobilize resources, and to address social and economic issues at the community level.
  • Counseling, whereby women are provided with accurate and complete information on reproductive health issues including FP, voluntary counseling and testing (VCT), and gender-based violence (GBV).
  • Emergency treatment of incomplete abortion and its complications.
  • FP services based on free and informed choice and the availability of methods.
  • Linkage of the above services with other reproductive health services including the diagnosis and treatment of sexually transmitted diseases (STDs); information on breast feeding, child nutrition, and immunization; screening of reproductive tract cancers; and so on.

 

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.

 

 

III. LEGAL PROVISIONS FOR SAFE ABORTION SERVICES

 

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:

 

  1. The pregnancy is a result of rape or incest; or
  2. 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; or
  3. The fetus has an incurable and serious deformity; or
  4. 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 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.

 

 

IV. IMPLEMENTATION GUIDE FOR SAFE ABORTION SERVICES

 

1. Implementation guide for Article 551 sub-article 1A

 

    Where the pregnancy is a result of rape or incest

 

  • Termination of pregnancy shall be carried out based on the request and the disclosure of the woman that the pregnancy is the result of rape or incest. This fact will be noted in the medical record of the woman.

 

  • Women who request termination of pregnancy after rape and incest are not required to submit evidence of rape and incest and/or identify the offender in order to obtain an abortion services.

 

2. Implementation guide for Article 551 sub-article 1B

 

    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 womans 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

 

    Where the fetus has an incurable and serious deformity

 

  • If the physician after conducting the necessary tests makes the diagnosis of a physical or genetic abnormality that is incurable and/or serious, termination of pregnancy can be conducted.

 

 

4. Implementation guide for Article 551 sub-article 1D

 

    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.

 

  • It is therefore the responsibility of the health provider in charge to assess the womans conditions and determine in good faith that the woman is disabled either mentally or physically.

 

  • Termination of pregnancy under Article 551 sub-article 1D will be done after proper counseling and informed consent.

 

 

5. Implementation guide for Article 551 sub-article 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

 

        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 provider has to secure an informed consent for the procedure using a standard consent form, which is annexed to this guideline (Appendix I).

 

  • The provider shall not be prosecuted if the information provided by the woman is subsequently found to be incorrect.

 

  • Minors and mentally disabled women should not be required to sign a consent form to obtain an abortion procedure.

 

 

V. PRE-PROCEDURE CARE

 

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 womans 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.

 

1.      Counseling and informed decisionmaking

 

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.

 

2.      Diagnosis of pregnancy

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 Grams stain of vaginal discharge as appropriate

        Cervical cancer screening

        Ultrasound and genetic tests as appropriate

 

3.      Exclude extra-uterine pregnancy

 

Suspect ectopic pregnancy if:

 

  • A woman presents with amenorrhea, severe lower abdominal pain and tenderness, and vaginal bleeding; and/or
  • Uterus is smaller than expected for gestational duration, and there is an adnexal mass discovered upon bimanual pelvic examination; and/or
  • A woman with a positive pregnancy test above six weeks of gestational duration has no intrauterine gestational sac or is found to have an extra-uterine gestational sac on trans-abdominal ultrasonography.

 

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.

 

4.      Assessment of gestational age

 

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:

 

  • Nulliparous women and those aged 18 or below with gestational duration of more than nine weeks
  • All pregnant women at gestations more than 12 weeks

 

Depending on their availability, administer either of the following drugs in the recommended dosages:

 

        Misoprostol 400 micrograms (g) vaginally or orally three to four hours before the procedure; or

        Mifepristone 200 milligrams (mg) orally 36 hours before the procedure.

 

 

VI. PROCEDURES DURING TERMINATION

 

All health institutions that are given the authority should provide termination of pregnancy by one of the recommended methods, depending on the gestational duration.

 

1. Medical abortion

 

Administer the following combination of drugs in the specified dosage:

 

  • Up to nine completed weeks since the LNMP:

o       Mifepristone 200mg orally, followed 36 to 48 hours later by

o       Misoprostol 800g 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 400g orally.

 

  • After 12 completed weeks since the first day of the LNMP:

o       Mifepristone PO 200mg, followed 36 to 48 hours later by

o       Misoprostol 800g vaginally followed by 400g 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 400g orally every three hours up to five doses if abortion does not occur.

 

  • Misoprostol or gemeprost alone can be alternative methods for gestation above 12 weeks.
  • Unless clinical evidence of incomplete abortion is present, routine surgical evacuation is not necessary.
  • Depending on the need for pain control, non-narcotic analgesics should be prescribed during and after medical abortion.

 

Contraindications:

 

  • Mifepristone

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

 

  • Misoprostol

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.

 

2. Surgical methods

 

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.

 

  1. Sharp metallic curettage. Where vacuum aspiration is available, dilatation and curettage and SMC are not recommended. If SMC is to be used for termination of pregnancy, it should be done by a trained health officer, medical doctor, or gynecologist. While all general recommendations for vacuum aspiration should be practiced, these specific procedures should also be followed:

 

        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.

 

 

 

 

VII. POST-PROCEDURE CARE

 

Post-procedure care is as essential as care during the procedure in ensuring the best outcome in abortion services.

  • Monitor vital signs; look for pallor; do an abdominal examination for tenderness and fluid accumulation; perform a pelvic examination if there is excessive vaginal bleeding.
  • Identify, manage, and refer for complications as appropriate.
  • Give discharge instructions (using simple language that is sequential and appropriate for the level of understanding of the woman) on symptoms and signs that indicate complications and the availability of 24-hour care for any condition.
  • Give post-procedure counseling, as appropriate, on STDs, VCT, GBV, contraception, and other issues.
  • Provide the chosen method of contraception immediately after abortion, following the WHO eligibility criteria.
  • Administer TT for all eligible women before discharging.
  • Do Papanicolau smear or VIA for all women, whenever available.
  • Provide STD screening, partner tracing, and sexual health counseling.
  • In the absence of complications, the woman can be discharged as soon as she feel able and her vital signs are stable.
  • Give a follow-up appointment seven to 10 days after the procedure.

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.

 

VIII. REFERRAL ARRANGEMENTS

 

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.

  • Refer a woman if the type of care that she needs is beyond the capacity of your institution.
  • Clearly state her condition at the time of referral, what was done, and the reason for referral on the referral paper.
  • Alert the receiving health facility, particularly if the woman is suffering from complications and needs immediate care; transportation; care during transport, including accompanying health personnel; and/or free services, as appropriate.
  • A referral should only be made by the most senior health professional on duty.
  • The referral center should provide feedback to the referring center on the type of complication ascertained, the care provided, the outcome of the treatment, and the plan for subsequent care.
  • If VCT services are not provided in your health facility, refer the woman to the nearest center.
  • Inform victims of rape about legal and psychological support and refer as needed.
  • All women referred to the next level are entitled to care without any precondition.
  • Referral arrangements for social support and care are an integral part of overall abortion care.

 

 

IX. PROVIDERS SKILLS AND PERFORMANCE

 

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

        Physical examination

        Bimanual pelvic exam

        Dating gestation

Counseling

+

+

Uterine evacuation

 

 

 

 

 

        MVA

        SMC

X

X

X

        Medical abortion

Pain medications

 

 

 

 

 

        Analgesics

        Narcotics/sedatives

X

X

        Paracervical block

 

 

 

 

 

Treatment of complications

 

 

 

 

 

        Identification

        Antibiotics

        IV fluids

        Blood transfusions[1]

X

X

X

        Maintain airways

        Repair of minor injuries

X

X

        Abdominal surgery

 

 

 

Post-procedure care

Follow-up care

Universal precautions

Postabortion contraception

        Information

        Counseling

+

+

        Method choice

        Informed choice/referral

Linkages with other RH services

 

 

 

 

 

        Counseling

        Screening

+

+

+

        Treatment

        Referral

Instrument processing

Education on:

 

 

 

 

 

        The dangers of unsafe abortion

        Prevention of unwanted pregnancy

        Legal provisions for abortion

Training junior health professionals and community health workers

Maintain records and submit reports

 

Key:

= 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.

 

 

X. ABORTION SERVICES BY LEVEL OF CARE

 

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

 

 

XI. ESSENTIAL EQUIPMENT AND SUPPLIES

 

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:

 

  • IV fluids with give sets
  • Syringes and needles
  • Sterile gloves of different sizes
  • Cotton balls or gauze sponges
  • Antiseptic solutions
  • Antibiotics
  • Pain medications
  • Long needle holders

        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:

 

  • Mifepristone 200mg
  • Misoprostol 200g

 

 

XII. MONITORING AND EVALUATION

 

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:

 

  • Analyzing patterns or problems using service statistics
  • Documenting the proportion of women seeking repeat abortions
  • Observing counseling and clinical services
  • Ensuring regular and continuous supply of equipment and supplies
  • Aggregating data from the health facility upwards
  • Reviewing measures to improve services

 

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:

 

  • The number, type, and percentage of facilities providing abortion services by geographic area (by woreda, zone, or region, or countrywide)
  • The increase in the use of legal abortion services (access)
  • Changes in patterns and rates of hospital admissions for abortion complications
  • The number and categories of providers trained in abortion care
  • An assessment of the quality of training
  • The number and percentage of eligible provider-alt:solid windowtext .5pt;mso-yfti-tbllook:480;mso-padding-alt: 0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid windowtext;mso-border-insidev: .5pt solid windowtext'>

    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:

     

    • Wash hands thoroughly with soap and water immediately before and after contact with each patient.
    • Use high-level disinfected or sterile gloves, replacing them between patients and procedures.
    • Never use gloved hands to open and close doors or to process instruments.
    • Wear clean gowns, aprons, goggle, and masks.
    • Clean floors, beds, toilets, walls, and rubber draw sheets with detergents and hot water. If they are soaked with blood or body fluids, use a 0.5% chlorine solution.
    • Wear heavy-duty gloves when cleaning surfaces and washing bed sheets spilled with blood and body fluids and when processing equipment for reuse.
    • Dispose of waste contaminated with blood, body fluids, laboratory specimens, or body tissues safely, following facility protocols.
    • Avoid recapping needles whenever possible. If necessary, use the scoop method.
    • Dispose of sharps in puncture-resistant containers and bury or incinerate them.
    • All reusable instruments should be soaked in a 0.5% chlorine solution and cleaned with soap and water immediately after use and sterilized or high-level disinfected.

     


    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:

     

    • Decontamination: Soak instruments in a 0.5% chlorine solution for 10 minutes.
    • Cleaning: Clean instruments with warm water and detergent; do not use soap. Wear masks and heavy-duty gloves during cleaning. Disassemble the instrument and make sure all the parts are cleaned thoroughly.
    • High-level disinfection:

    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 autoclave being used).

     

     


    Appendix IV: Logbook for Abortion Procedures

     

     


Appendix V: Quarterly/Monthly Reporting Format for Abortion Services

 

Region: Name of Health Facility:

Zone: Year (Eth. Cal):

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.