Abortion Laws in Ethiopia

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 aswell 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 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 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 women’s status in society. The strategies for improving women’s status outlined in the policy include informing and educating the community on harmful traditional practices and ensuring women’s 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 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:

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 woman’s 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:

The pregnancy is a result of rape or incest; or The continuation of thepregnancy 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 The fetus has an incurable and serious deformity; or 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

TH 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

TH 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

TH 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

TH 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 woman’s 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

TH 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 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.

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:

• Options counseling: continuing or terminating the pregnancy
• Available methods of pregnancy termination and pain control medications (including the advantages and disadvantages of each)
• What will be done during and after the procedure
• Possible short- and long-term risks associated with the method of termination of pregnancy
• When to expect resumption of menses
• 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:
• Uterine size and position
• 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:

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 (µg) 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:

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

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

• Mifepristone PO
  200mg, followed 36 to 48 hours later by
• Misoprostol 800µg vaginally followed by 400µg of oral misoprostol every three hours, up to a maximum of four doses if abortion does not occur.
• 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.

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

• Suspected ectopic pregnancy or undiagnosed adnexal mass
• IUD in place (remove before administering medication)
• Chronic adrenal failure
• Concurrent long-term corticosteriod therapy
• History of allergy to mifepristone
• Hemorrhagic disorders or concurrent anticoagulant therapy
• Inherited porphyrias

Misoprostol

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.

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. Givepost-procedure counseling, as appropriate, on STDs, VCT, GBV,contraception, and other issues. Providethe 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.

 

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.

 

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)

• Flexible: 4,5,6,7,8,9,10,12mm
• Curved rigid: 7,8,9,10,12,14mm
• 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 200µg

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

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:

• Soak in a 0.5% chlorine solution for 20 minutes; or
• 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).