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Implementing Implementing Safe Abortion: Safe Abortion: technical and policy guidance for technical and policy guidance for

health systemshealth systems

Ronnie Johnson, PhD

UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction

Department of Reproductive Health and Research

Geneva, Switzerland

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OutlineOutline

1. Goals

2. WHO safe abortion guidance: underlying principles

3.The concept of comprehensive abortion care

4. Applying the WHO Strategic Approach (including scaling up)

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Our GoalsOur Goals

To reduce maternal morbidity and mortality related to unwanted pregnancy and abortion (MDG 5, target A)

To provide universal access to good-quality sexual and reproductive health care, including contraception and safe abortion (MDG 5, target B)

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Maternal mortality in EuropeMaternal mortality in EuropeRussia– 28 per 100,000 women of reproductive age

Romania– 24

Moldova – 22

Ukraine– 18

Hungary– 6

Switzerland– 5 Source: World Health Organization 2007

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Safe abortion: Safe abortion: underlying principlesunderlying principles

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Focus on prevention

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Prevention of…Prevention of…

1. Unintended pregnancy through early comprehensive sex education and readily accessible, high-quality contraceptive services

2. Unsafe abortion by providing comprehensive abortion care to all women and adolescents who want to terminate a pregnancy

3. Abortion-related mortality and morbidity by focusing on 1 and 2 above plus providing emergency treatment for all abortion-related complications

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Focus on health and human Focus on health and human rights for all womenrights for all women

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Laws, norms, standards, and guidelines Laws, norms, standards, and guidelines on abortion should aim toon abortion should aim to

Protect the health and human rights of all adolescents and women of reproductive potential

Facilitate prevention of unintended pregnancy

Ensure that everyone legally eligible has ready access to high-quality services

Eliminate barriers to access and high-quality services

Ensure appropriate referrals when required

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Recognize thatRecognize thatHigh-quality sex education and good access to (and use of) high-quality contraceptive counselling and methods is the only way to reduce the number of unintended pregnancies and the subsequent need for abortionEven with "perfect" contraceptive use, there will always be a need for safe abortionWhen performed by skilled health providers in appropriate settings, abortion is one of the safest of all medical proceduresRestrictive laws/policies do not reduce the overall rate of abortion but do increase the proportion of procedures that are unsafe

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1

Be mindful of potential barriers to Be mindful of potential barriers to safe abortionsafe abortion

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2

Remove barriers to facilitate access Remove barriers to facilitate access and quality of careand quality of care

Many barriers are not actually specified or required in the law itself

It is the responsibility of the Ministry of Health and/or professional associations to review and remove such barriers in order to ensure access to the extent allowed by law

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3

Barriers to safe abortionBarriers to safe abortion

Potentially, anything that restricts a woman's ready access to services

Legal, policy, administrative barriers

Provider, facility barriers

Sociocultural, religious barriers

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Comprehensive Abortion Care Comprehensive Abortion Care

Access

Quality

Choice

Sustainability

Courtesy of Ipas, 2005

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"The Strategic Approach""The Strategic Approach"

A process that countries can use to:

Identify and prioritize needs for reproductive health policy, programmes and research

Test appropriate interventions to address priority needs

Scale up successful demonstration projects

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Strateg

ic Ass

essmen

t Policy & Programme Strengthening

Developing

and Testing

Programme

Innovations

Scaling-Up

Successful

Interventions

STAGE I

ReproductiveHealth

Challenges

Improved ReproductiveHealth Status

and Programmes

STAGE II STAGE III

The Strategic Approach The Strategic Approach implementation processimplementation process

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Begin the process with the end in mind…Begin the process with the end in mind…

Develop a package of interventions to provide abortion care appropriate for the Moldova contextGenerate evidence of the feasibility and effectiveness of the interventions on a small scale Scale up the model services– Horizontal scaling up - Expansion– Vertical scaling up - Institutionalization

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Scaling upScaling upSuccess depends on developing a systematic strategy for both expansion and institutionalization, including:

Assessing needs and priorities for strengthening access and quality of care

Assessing demand for services and how to enhance the scalability of the interventions

Building capacity of the institutions implementing the interventions

Ensuring a supportive social, political, and resource environment

Developing the capacity of a resource team to support the process

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Successful scaling up also requiresSuccessful scaling up also requires……

Strategies for:Mobilizing resourcesAdvocacyProcurement and distribution of equipment, supplies, drugsTrainingCoordination, management, supportive supervisionMonitoring, evaluation, and quality improvement

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Models for scaling up safe abortion careModels for scaling up safe abortion care

Build regional service-delivery and training capacity in government institutions and then extend services to more remote areas– For every 500,000 population there should be 5 safe

abortion care facilities, at least one of which provides comprehensive care

Contract out government services to NGOs, such as Marie Stopes, IPPF, or other local organizations

Combine public and private models

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Scaling up services in MoldovaScaling up services in Moldova

Implement CAC in 13 perinatal centres and then assess gaps in full population coverage

Pilot services have been implemented in two perinatal centres

Two more are planned in the initial horizontal scale up; these should be chosen strategically

Must also consider vertical scaling up– i.e., institutionalizing CAC within national reproductive

health strategy and national Ministry of Health budget

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2

In short…In short…

Scaling up is a complex political, organizational and managerial challenge rather than a focused technical task…

But, tools are available to support the process.

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3

WHO/ExpandNetWHO/ExpandNet

www.expandnet.netwww.expandnet.net

draft

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WHO guidance on safe abortionWHO guidance on safe abortion

Available for downloading at

http://www.who.int/reproductive-health/publications/safe_abortion/index.html

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5

WHO guidance on medical abortionWHO guidance on medical abortion

Available at: http://whqlibdoc.who.int/publications/2006/9241594845_eng.pdf