Introduction to PAC Module 1 - Session 1 Issues Surrounding Miscarriage, Induced Abortion and the Delivery of PAC Servi

1. Introduction to PACModule 1 - Session 1Issues Surrounding Miscarriage, Induced Abortion and the Delivery of PAC Services

2. Module 1 - Session 1Objectives At the end of this session, participants will be able to: • Define the term “abortion” • Discuss the magnitude of maternal mortality worldwide as well as in their country (if known) • Explain possible reasons for spontaneous abortion (miscarriage) • Explain possible reasons why women resort to induced abortion • Describe the abortion laws and regulations in their country and how they impact PAC services • Describe policies for postabortion care at their home facilities and how they impact PAC services

3. Defining Terms Throughout this course: • Abortion: the loss or termination of pregnancy, i.e., spontaneous abortion (miscarriage) or induced abortion. • The terms miscarriage and spontaneous abortion are used interchangeably. • Unsafe abortion: often used when induced abortion is performed by persons without the necessary skills and/or in an environment lacking medical standards.

4. Maternal Mortality Every minute around the world: • 380 women become pregnant • 190 women face unplanned pregnancies • 40 women have unsafe abortions • 1 woman dies Source: White Ribbon Alliance for Safe Motherhood.

5. Magnitude of Maternal Mortality • More than 536,000 maternal deaths annually • For every maternal death,10–15 maternal morbidities Maternal Mortality Ratio (MMR):Number of maternal deaths per 100,000 live births

6. Maternal Mortality and Unsafe Abortions In spite of local and international efforts: 20 million unsafe abortions every year: • 9,900,000 in Asia • 5,000,000 in Africa • 4,000,000 in Latin America and the Caribbean

7. Impact of Spontaneous and Induced Abortion • Of the estimated 20 million unsafe abortions yearly: • Between 10−50% will need medical care for complications • Abortion = 13% of all maternal deaths: • 68,000 deaths each year • About 15–20% of all pregnancies will end in spontaneous abortion or miscarriage

8. Incomplete Abortion: Other Potential Consequences • Increased risk of: • Ectopic pregnancy • Spontaneous abortions and premature delivery in subsequent pregnancies • Psychological trauma • When mothers die, children left behind are up to 10 times more likely to die

9. Postabortion Care • Postabortion care (PAC) is internationally recognized as an important intervention to address complications related to miscarriage and induced abortion. • PAC should be an integral part of all essential obstetric and newborn care programs. • PAC should not only include emergency care, but also family planning counseling and services.

10. Spontaneous Abortion WHO definition of spontaneous abortion (miscarriage): • Spontaneous loss of a clinical pregnancy before 20 completed weeks of gestation or, if gestational age unknown, a weight of500 g or less. • Worldwide, every year: • Up to 32 million pregnancies will end in spontaneous abortion.

11. Spontaneous Abortion (2) • Most miscarriages occur between the 6th and 12th week of pregnancy • Can result in complete or incomplete expulsion of the products of conception • PAC may require added counseling/support: • Grieving pregnancy loss • Anxiety concerning future fertility

12. Spontaneous Abortion (3) Known factors associated with miscarriage include: • Genetic factors: • Account for about 5% of spontaneous abortions • Hormonal causes • Infections: • Bacterial, viral, parasitic and fungal • Malaria in pregnancy • HIV, sexually transmitted infections (STIs)

13. Spontaneous Abortion (4) • Gender violence: • Women experiencing violence during pregnancy have higher rates of spontaneous abortion • Miscellaneous: • Other contributing factors: environment, smoking, drugs, placental abnormalities and medical illness

14. Spontaneous Abortion (5) • Exact cause may not be clear, even after a thorough history and physical exam. • Refer women with recurrent miscarriage for further evaluation.

15. Why Women Resort to Induced Abortion • Economical reasons: • Inadequate income; lack of employment • Socio-cultural problems: • A pregnancy out of wedlock • Cultural/religious stigma; social or family pressure; preference for a male child (if the fetus is a female) • Medical reasons: • History of obstetric or medical complications • HIV status • Knowledge of fetal abnormalities

16. Why Women Resort to Induced Abortion (2) • Unintended pregnancy due to: • Lack of access to FP services • Contraceptive method failure • Rape or incest • Other reasons such as: • Desire to space or limit pregnancies • Desire to delay pregnancy for personal reasons or circumstances • School enrollment status

17. Why Women Seek PAC Services • Women’s willingness and ability: • Dependence on decision-makers—may need permission or funds • Fear of stigma; may delay care to avoid rejection • Available sources of care: • Traditional vs. facility providers • Accessibility of health services • Need for confidentiality: • Fear of being recognized by providers or other clients in community

18. Why Women Seek PAC Services (2) • Importance of fertility: • Social norms for fertility and children • Perceptions of modern contraception • Provider attitude: • Provider attitudes/behavior toward PAC clients • Care must be gentle, supportive and encourage women to seek rather than hide from medical help • Care must be sympathetic to cultural factors

19. Factors That Hinder or Facilitate Delivery of PAC Services: The Delays Many pregnancy-related deaths are due to delays: • Recognizing that a problem exists: • Belief that problems are “normal” in pregnancy • Deciding to seek care: • Family decision-makers, fear of stigma, poor care in the past • Reaching care: • Lack of transport or funds • Receiving care: • Lack of comprehensive care, triage or staffing; negative attitudes toward PAC clients

20. Questions to Think About • What happens to a woman when she presents for PAC services in your facility? • Where does she present? Who sees her first? • Is she admitted or not? • Who provides the PAC services and where are they provided? • Who provides FP counseling and where is it done? • Are FP commodities available? • Are youth services available? • What is the cost?

21. Understanding Your Country’s Policies Regarding the Provision of PAC Services • Every country has laws, policies and/or regulations on induced abortion and PAC. • It is very important to practice within those regulations or guidelines.

22. Legal Status of Abortion vs. PAC • Sometimes the legal status of induced abortion and policies on postabortion care are confused. • Women in need of PAC services may be reluctant to seek care, even for spontaneous abortions. • If PAC clients are regarded as criminals, it may result in mistreatment. • Providers may also face stigma if their work is perceived as controversial.

23. Local Policies/Laws on PAC Services • Postabortion care is a lifesaving intervention that should be available to all women. • Every woman has the right to safe postabortion care, which should be of the highest quality possible, whether the abortion was spontaneous or induced.

24. Effect of Laws on PAC • Responsibility of clinical providers: • Provide PAC (including family planning) to all women in need, regardless of cause of abortion • Take necessary measures to save lives and preserve health of all • Provide emergency care • Offer counseling in prevention of unplanned pregnancy, FP and birth spacing

25. Effect of Laws on PAC (2) Responsibility of health care system: • Support provision of emergency PAC, regardless of cause of abortion • Prohibit punishment of properly trained PAC providers • Ensure access to FP counseling and services