UNSAFE ABORTION AND CONTRACEPTION

IN GHANA

EMMANUEL SK MORHE

MB.ChB, FWACS, FGCS, MPH 8/9/2012

Unsafe abortion and contraception

Outline of presentation

8/9/2012

Definition

Unsafe abortion a public health problem

Value of contraception in the management

Outline the way forward

Capacity building for advocacy, training, service provision

and research in integrating contraception into maternity

and abortion care

Definitions

8/9/2012

Unsafe Abortion is a procedure for terminating an

unwanted pregnancy, carried out either by a person

lacking the necessary skills or in an environment lacking the

minimal medical standards, or both.

Contraception simply means prevention of pregnancy.

A contraceptive is a medication or device that is used to

prevent pregnancy.

Unsafe Abortion

8/9/2012

A major Public health problem in Ghana

Major cause of maternal and child morbidity and mortality

12% of maternal deaths in KBTH and KATH

Commonest cause of admissions to emergency Gynaecology wards (~40 %).

A lot of man-hours, hospital ward space and supplies go into managing abortion complications.

Huge economic cost to individuals, families and the nation.

.

8/9/2012

.

010

20

30

40

FR

EQ

UE

NC

Y

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

YEAR

Haemorrhage Hypertensive diseases

Abortions Genital tract infections

Obstructed labour/ Ruptured uterus Ectopic pregnancy

TRENDS IN DIRECT CAUSES OF MATERNAL DEATHS-KATH(1998-2007)

Kwawununu et al, 2011

Abortion Morbidity

In KBTH of 212 induced abortions

17.6% had blood transfusions,

56% spent 1-3 days

24.3% spent 7 days or more in hospital (Lassey, 1995)

In KATH of 252 cases

21.0% had blood transfusions,

26.2% had pelvic or generalized peritonitis,

5.6% impaired organ function,

1.2% perforated uterus ( Damalie, 2010 )

8/9/2012

Complications of unsafe abortion in Ghana

Incomplete abortion

Vaginal bleeding /Hypovolaemic shock

Visceral injuries:

lacerations, perforation of uterus, bladder, intestines

Sepsis

Septicaemia/septic shock

Peritonitis /Pelvic abscess

Acute poisoning (Pesticides)

Multiple organ failure

Death

Pelvic pain and dyspareunia

Tubal Infertility

Cervical weakness Recurrent spontaneous abortions

Preterm labour

Ectopic pregnancy

Vesicovaginal or rectovaginal fistula

Anxiety and Depression

Psychological trauma

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Acute clinical complications Chronic clinical complications

Methods employed in unsafe abortion

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Foreign bodies e.g. sticks and metal objects.

Drinking herbal concoctions and poisonous chemicals.

Vaginal insertion of herbal preparations or chemicals. which are often corrosive.

Taking high doses of over-the-counter medications.

Conventional methods

Misoprostol (Cytotec) (currently most common)

Surgical dilation and curettage/MVA by untrained personnel

Intra-amniotic injection of concentrated salt solution

NB: Methods vary across the country

Who are the providers of unsafe abortion?

chemical sellers/

pharmacist38%

Nurse/midwife

20%

Physicians12%

Self-induced

11%

'Quack' doctors

16%

Others)3%

Distribution of induced abortion by provider in Southern Ghana

0

10

20

30

40

50

60

70

80

%

8/9/2012 Ahiadeke, 2001

Source of data: Damalie 2010

Who are victims?

0

10

20

30

40

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Age Group

Distribution of abortion by age at last induced abortion

Women with less formal

education

Married< not married;

Parous<nulliparous;

Diverse religious

backgrounds

Christians/Moslems/Afric

an Traditionalist

Diverse cultural and

ethnic background

8/9/2012

Ahiadeke 2001, Konney et al, 2009; Srofenyo and Lassey, 2003; Turpin et al, 2002

perc

enta

ges

Factors contributing to unsafe abortion in Ghana (I)

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Social Stigma of abortion

practitioners, clients and civil society

Religion and cultural believes and norms

Lack of committed leadership/political will

Many years of restrictive laws.

Even today the law criminalizes abortion.

Ignorance of the existing laws.

practitioners and general population

Factors contributing to unsafe abortion (II)

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Late policy development on CAC.

CAC standards and protocols came in 2006

Poor implementation of health policies.

Poor health services infrastructure

Lack of trained personnel

Inadequate contraceptive services

Lack of empowerment of women.

Poverty, deprivation and socio-cultural norms

How do we address the problem of unsafe abortion?

8/9/2012

Prevent unwanted pregnancy

Contraception/HTSP

Manage unwanted pregnancy

CAC model

Manage complications of unsafe abortion

PAC model

Contraception is of central value

(1)PAC model: Treat unsafe abortion complications

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Promote PAC as an effective public health strategy

Emergency treatment: EOU/Antibiotics/Transfusion

Counselling psychosocial or emotional support

Postabortion family planning.

provide family planning on the gynecologic w ard

Link to other reproductive health services

Screening and treatment of STIs, cervical cancer.

Community and Service Provider Partnerships

In treatment, prevention and advocacy efforts including

mobilization of resources

Address emotional and physical health needs of women PAC in Action, 2002, No. 2

(2) CAC model: Manage unsafe abortion

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Includes all components of PAC model.

Plus elective abortion care by trained personnel (to

the extent allowed by law).

The law:

I. To protect life of the woman

II. To protect physical and mental health of the woman

III. Rape, defilement or incest

IV. For fetal malformation incompatible with life

CAC is based on evidence

Evidence in support of CAC: Abortion Mortality: Abortion is safer the earlier in pregnancy it is performed

0.6

1.7

3.4

8.9

0.40.1 0.2

7.1

0

2

4

6

8

10

<9 9–10 11–12 13–15 16–20 21+ All

abs.

Births

Sources: All births and abortions: Grimes DA, 2006;

Abortion by gestation: Bartlett et al., 2004 (1988–1997 data)

Deaths per 100,000

Abortions by gestation

Some CAC implementation principles in Ghana

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I. CAC is an integral part of RH care

II. Right to access service.

III. Thorough clinical evaluation and procedural

documentation required.

IV. Right to privacy and confidentiality.

V. Partner or spousal consent may be encouraged

but not mandatory.

VI. A method of contraception should be accepted or

acceptable to the client.

CAC: Specific Policies

8/9/2012

I. Abortion is not and shall not be used as family

planning method in Ghana

II. For Rape, defilement or incest legal evidence not

required for abortion care.

III. Pregnancy in a minor <16 years is considered as a

result of statutory rape.

IV. A parent or an adult acting in loco parentis can give

consent on behalf of the minor <18 years.

V. No psychiatric assessment required to establish

mental or emotional distress.

Policies: Conscientious Objection

8/9/2012

Refusal to carry out procedure based on moral, religious or ethical grounds.

Only those directly involved in performing abortion procedure can claim conscientious objection.

A service provider claiming conscientious objection has the duty of care to refer the client to an accessible provider.

No provider has the right to conscientious objection in an

emergency situation.

No individual may claim conscientious objection if the client

is below 18 years ( Children’s Act 1998, Act 560).

Elective abortion care:

Surgical method

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MVA: Recommended up to 12 weeks

EVA: Recommended < 12 weeks

D&E for second trimester terminations

Need osmotic dilators e.g. laminaria/dilapan (not

available in Ghana)

D&C no longer recommended, reserved for well

trained providers.

Medical Abortion:< 9 weeks

Misoprostol and

Mifepristone

Misoprostol alone

800ug Misoprostol

Vaginally

Repeat after 3-6 hours

Up to 3 doses

8/9/2012

200 mg Mifepristone

800ug Misoprostol

vaginally

400ug Misoprostol

orally

36-48 hrs. later plus

Efficacy 96-98% Efficacy 88%

or

(3) Prevent unwanted pregnancy:

Family planning & contraception in Ghana

8/9/2012

First introduced in Ghana in early 1960s by the

Christian council of Ghana

Modern contraception by PPAG/IFPP in 1966

Funded by USAID

National population policy in 1969

Focus on population growth and GDP for development

Research e.g. UG, Danfa and later Navrongo

Amended in 1994 to reflect actions plans on RH at ICPD

Cairo 1994

Evidence based message for HTSP:

Return to fertility after pregnancy

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A woman can become pregnant before her menses

returns after pregnancy

If not on contraception,

as early as 4 weeks postpartum when not breastfeeding;

as early as 6 weeks postpartum if she regularly

breastfeeds and also gives her baby other food on

regular basis;

From 6 months after delivery if she practices LAM

As early as 2 weeks after first trimester abortion or

miscarriage

Target Audience for HTSP

contraceptive message ?

8/9/2012

Adolescents Avoid pregnancy before 18 years of age

Newly married couples Should plan when to become pregnant

Pregnant women Should plan birth control while pregnant

Postpartum Women Choose a method

Postabortion women Go home with a method

Source : Contraceptive Technology Update Series

8/9/2012

Source : Contraceptive Technology Update Series

8/9/2012

Challenges of contraception and abortion care

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• Lack of capacity

Sustainability of procurement and resupply of

MVA instruments and Contraceptives

• Ensuring high-quality and accessible services

Social, religious, policy and legal restrictions.

Provider bias in offering contraception after pregnancy

Inadequate state investment in contraception

Way forward

We need leaders with vision and passion

Public-private partnerships in building capacity

Services by public and private

Contraception and PAC/CAC

Training

Middle level staff

Physicians/Specialists/Fellows (IFPFP/GCPS)

Research

Intervention projects (IFPFP)

Good record keeping

Advocacy

Key partners: MOH, GHS, Teaching Hospitals, GCPS,

IFPFP, ACNM, R3M partners:

Use health services research evidence to improve family

planning services

Inadequate RH services

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Pong Tamale Health Center • 10 deliveries/month • Staffed by 2

midwives • Refer 100% of

PAC/CAC • LARC provision

Tamale Teaching Hospital • 2006-2007: sepsis leading

cause of death • 1 death/month from abortion

related complications • Received 20 referrals for

PAC/month

Savelugu Hospital • Labor/delivery unit • Recently added c-sections • Staffed by 7 midwives, 1 MD • Referral of almost all PAC • Referral of 100% CAC • No LARC provision

IFPFP baseline needs assessment, 2010

Integration of GCPS Family Planning Fellowship/IFPFP

with other reproductive health projects in Ghana

ACNM in Kumasi, 2010 FP fellows teach midwifery students

Private midwives as preceptors for FP

and CAC Queen mothers association

Summary: Positive national RH policies and initiatives

8/9/2012

• National contraception protocols

• Wide range of contraceptives are available

• Abortion law liberalized since 1985

• Abortion care to be provided to full extent as

permitted by law in 2003

• CAC abortion standards and protocols

developed in 2006

• Midwives included in abortion care to

increase capacity

Summary

8/9/2012

Total population is 24 million

Modern Contraceptive prevalence rate, 17%

Unmet need for contraception 35%

Pregnancies unwanted or mistimed 40%

MMR 350/100,000 live births

59% of births assisted by skilled attendants

Maternal deaths from unsafe abortion 12%

GDHS 2008, GMHS 2007

http://www.justmaps.org/maps/africa/ghana/

Conclusions

8/9/2012

We cannot continue to ignore the fact that

women die everyday from unsafe abortion and many more

severe ill-health

The options for unwanted pregnancy are difficult choices that

may be painful and may hurt the woman physically,

emotionally and spiritually.

Unwanted pregnancy is often a consequence of bad choice of

not using effective contraception.

We need dispassionate deliberations, careful planning

and resolute implementation of evidence based

interventions to address the problem.