|
Post-abortion
care (PAC) is the strategy to reduce death and suffering from the complications
of unsafe and spontaneous abortion. The elements of PAC are:
-
emergency
management of incomplete abortion and potentially life-threatening
-
complications
post-abortion family planning counselling and services
-
making
links between post-abortion emergency services and other RH care
services.
Since
incomplete and/ or septic abortions may threaten a woman's life, health
providers must be able to deal promptly with their consequences. As
for obstetric emergencies, an appropriate referral system should be
established and available 24 hours a day. (See Chapter Three.)
When
planning for PAC, community needs and perceptions, including women's
preferences for type and gender of PAC provider and location of services,
must be solicited and considered.
Each
refugee situation requires a protocol for managing post-abortion complications.
Refer to Table 1 for broad guidelines on the type of facility,
the composition of staff and the types of emergency post-abortion care
that may be available. Factors to consider in developing the protocol
are:
-
staff
training, qualifications and supervision to achieve minimum standards,
-
supplies
and equipment, conditions (cleanliness, space, privacy, etc.) at
the health facilities,
-
emergency
transport system, and
-
capacity
of referral facility.
Where
feasible, host-country health referral facilities should be used and
supported.
Women
of reproductive age experiencing at least two out of three of the following
symptoms should be considered as potential patients with a threatened
or incomplete abortion:
The
following steps should be taken to manage post-abortion complications:
Talk
to the woman about her condition
Any woman who presents with complications of unsafe abortion or miscarriage
needs immediate high-quality care. Health care workers should be aware
that women seeking such care are under severe emotional stress in addition
to physical discomfort. Privacy, confidentiality and consent for treatment
should be ensured.
Conduct
initial clinical assessment
The initial assessment may reveal or suggest the presence of an immediate
life-threatening complication such as shock. Shock should be addressed
without delay in order to prevent death or keep the woman's condition
from worsening.
-
Managing
shock: All health personnel should know the universal measures to
treat shock: do not give fluids by mouth; keep airway open; turn
head and body to one side and keep warm. Health centres should be
equipped with IV fluids (saline, plasma substitutes or safe blood),
systemic antibiotics and oxygen.
Complete
clinical assessment
This consists of taking a thorough RH history, performing careful
physical and pelvic examinations and, when necessary, obtaining appropriate
laboratory tests. A complete assessment will identify other possible
complications (such as intra-abdominal injury, vaginal bleeding [light
to severe], infection/ sepsis and pain) leading to an appropriate treatment
plan.
Manage
complications
Complications should be treated immediately by qualified personnel.
Prompt referral and transfer may be needed if the woman requires treatment
beyond the capability of the facility where she is seen. Her condition
will need to be stabilised before she is transferred to a higher-level
referral service. The following treatments may be necessary:
Rest:
in case of light to moderate bleeding.
Replacement
of fluids:
in case of shock or severe vaginal bleeding, saline solution, plasma
substitutes or safe blood.
Laparotomy/
surgery:
in case of suspicion of an intra-abdominal injury. Intra-abdominal injury
is commonly due to uterine perforation, possibly as a result of an attempted
abortion.
Uterine
evacuation:
for removal of retained products of conception. First and early second-trimester
incomplete abortions can be treated by vacuum aspiration or dilatation
and curettage (D& C). Vacuum aspiration, manual or electric, has
been found to result in fewer complications than D&C and causes
less trauma to the patient. Health workers should refer incomplete abortions
in the middle-or late-second trimester to a facility with surgical and
full emergency backup for treatment.
Antibiotics:
for infection or septic shock. These are common complications of incomplete
abortion. Treatment with broad-spectrum antibiotics by IV or IM is indicated.
Management
of pain:
Appropriate pain management ensures that the woman experiences a minimum
of anxiety and discomfort. Women's needs for pain management will vary,
depending on their physical and emotional state.
Prevention
of tetanus:
A tetanus vaccination should be given, as a woman may have been exposed
to tetanus and her vaccination history is likely to be uncertain.
Laparotomy,
surgery and uterine evacuation should be undertaken by qualified and
supervised staff in appropriate and safe conditions, preferably in a
host-country health facility.
Lack
of access to adequate family planning services is a major contributor
to the problem of unsafe abortion. Conversely, unwanted pregnancy and,
in many cases, unsafe abortion are prime indicators of the unmet need
for safe and effective family planning services. In most health systems,
women treated for the complications of unsafe abortions rarely receive
any counselling services to prevent subsequent unwanted pregnancies.
Clearly, when a woman receives care for post-abortion complications
she should also receive comprehensive family planning counselling and
services, if she so desires. At a minimum, all women receiving PAC should
understand:
-
that
the prompt return of ovulation can result in pregnancy even before
menses returns; and
-
that
there are safe contraceptive methods that can prevent pregnancy,
and where those methods can be obtained.
In
addition, all staff providing PAC should know how to counsel and provide
family planning services.
(Refer
to Chapter Six for further details on family planning services.)
Linking
emergency PAC services with other RH services is essential and logical,
yet in much of the world these services remain distinctly separate.
As a result, many women have no access to RH care and suffer poor overall
health.
It
is important to identify the RH services that each woman may need and
offer her as wide a range of services as possible, such as:
-
Treatment
for reproductive tract infections
-
Cervical
and breast cancer screening and treatment (if applicable)
-
Advice
on proper nutrition
-
Advice
on family planning methods
-
Advice
about antenatal care
-
Links
to under-five clinics for existing children (if applicable)
-
Referral
for services following sexual violence
-
Referral
for counselling services following diagnosis as HIV-positive.
PAC
services should be continuously reviewed. Managers of these services
should assess the level of use of these services, review all clients'
records, the availability and proper use of equipment and supplies,
regularly assess specific indicators of the quality of care, identify
changes or problems that occur, provide feedback to staff, and intervene
to correct any problems identified.
Monitoring
may include: direct observation of staff at work; use of checklists
(for example, to evaluate critical skills); examination of clinic records;
and discussions with patients, staff and the community.
Indicators to monitor effectiveness
of PAC services
-
Incidence
of unsafe and spontaneous abortions: The incidence will indicate
the magnitude of the problem and point to possible underlying causes.
For instance, the incidence of unsafe abortion might indicate inadequate
family planning coverage for women who want to avoid or delay pregnancy.
-
Quality
of PAC services: The ability of staff to undertake all aspects of
PAC should be reviewed periodically through direct observation of
staff and/ or review of medical records.
-
Protocol
for management of complications of unsafe and spontaneous abortions
is developed and used
-
Staff
are trained to manage complications of unsafe and spontaneous abortions
-
Health
facilities are equipped with appropriate materials
-
Protocol
for post-abortion family planning and links with other RH services
are developed and used
-
Reporting
and monitoring system to ensure quality of care are in place
-
Type
I: Excision of the prepuce with or without excision of part or all
of the clitoris.
-
Type
II: Excision of the clitoris together with partial or total excision
of the labia minora.
-
Type
III: Excision of part or all of the external genitalia and stitching/
narrowing of the vaginal opening (infibulation).
-
Type
IV: Unclassified
-
pricking,
piercing or incision of the clitoris and/ or labia
-
stretching
of the clitoris and/ or labia
-
introcision
-
scraping
(angurya cuts) or cutting (gishiri cuts) of the vagina or surrounding
tissue
-
introduction
of corrosive substances or herbs into the vagina
-
any
other procedure that falls under the definition of female genital
mutilation
Female
Genital Mutilation
Female
genital mutilation comprises all procedures that involve partial or
total removal of the female external genitalia and/ or injury to the
female genital organs for cultural or any other non-therapeutic reasons.
It is estimated that female genital mutilation has been performed on
approximately 130 million women and girls. About two million girls risk
being subjected to female genital mutilation each year. Most of the
girls and women who have undergone female genital mutilation live in
28 African countries, although some live in Asia, and in other regions.
Approximately
15 per cent of women and girls subjected to female genital mutilation
undergo infibulation. Most others undergo a clitoridectomy or excision.
There is a high incidence of infibulation in Djibouti, Somalia and northern
Sudan, and a high rate of complications.
Infibulation
is also reported in southern Egypt, Eritrea, Ethiopia, northern Kenya,
Mali and Nigeria.
Female
genital mutilation causes grave damage to girls and women and frequently
results in serious health consequences which may include an increased
individual risk of bloodborne infections such as HIV. Some of the effects
are immediate; others become apparent only years later. Girls and women
undergoing the more severe forms of mutilation are particularly likely
to suffer serious and long-lasting complications. Documentation and
studies are available on the nature of the physical short-term and long-term
complications described below, but there has been little study of the
sexual or psychological effects of the procedure or of the frequency
with which complications occur. The mortality rate of girls and women
undergoing genital mutilation is unknown as few records are kept and
deaths due to the practice are rarely reported.
Usually
the operation is performed on girls between four and ten years of age
or younger, or, in some areas, adolescent girls. Village women, TBAs
or male barbers generally perform the operation, usually without anaesthetics
or antiseptics. The effects on health depend on the extent of the cutting,
the skill of the operator, the cleanliness of the tools and environment,
and the physical condition of the girl.
The
effects of the procedure last a lifetime and may threaten not only the
woman's reproductive health and well being, but also the health of her
children. Health workers in refugee situations are seldom knowledgeable
about the physical, psychological and social consequences of female
genital mutilation, nor are they always sensitive to the cultural beliefs
that support the practice.
Therefore,
it is vital that field staff determine whether female genital mutilation
is practised within a refugee population and identify who is responsible
for undertaking the procedure.
RH
programmes should include strategies to discourage female genital mutilation,
emphasising the link between the practice and poor reproductive, sexual
and general health in women and girls. It is vital to understand the
reasons for the practice before embarking on information campaigns.
Efforts to eliminate female genital mutilation can greatly be enhanced
by enlisting the support of responsible community members.
The
"medicalisation" of female genital mutilation (i. e., supporting health
care professionals to perform female genital mutilation in health facilities
under more hygienic conditions) is not acceptable in the attempt to
make this procedure "safer". Medicalisation does not eliminate the harm
caused by female genital mutilation and it legitimises the procedure.
Health workers employed in refugee situations must be informed that
their involvement in "medicalising" female genital mutilation will not
be tolerated under any circumstances. Severe disciplinary measures,
including possible termination of workers' contracts, should be taken
if they are found to be performing female genital mutilation.
Women
who have undergone female genital mutilation, particularly Type III,
need special care, especially during pregnancy, delivery and the postpartum
period.
When
an infibulated woman gives birth, staff should be aware of the following
points:
-
the
formation of rigid scar tissue around the vaginal opening as a result
of the mutilation is likely to lead to delay in the second stage
of labour, which may endanger both the woman and the baby; and
-
extensive
episiotomies may be needed to allow for safe delivery.
Women
who have undergone infibulation need special care when using some forms
of contraceptive methods, such as the IUD, and in managing the complications
of unsafe and spontaneous abortion. Sexually transmitted diseases (STDs)
are also more difficult to diagnose and women may be at a greater individual
risk for bloodborne infections, including HIV.
The
issue of harmful traditional practices, including female genital mutilation,
should be approached with great sensitivity. While there are no hard
and fast rules when working to prevent and eliminate these practices,
the following strategies and examples may provide some guidance to field
workers:
Experience
has shown that the initial step in addressing harmful traditional practices
is providing education and information on such practices, focusing on
their negative consequences. However, action-oriented activities must
follow initial awareness building.
-
Campaigns
to eliminate these practices are more likely to succeed and be accepted
by the target population when they initially emphasise the harmful
health consequences rather than the legal or human rights aspects.
Laws should be seen to be protective rather than punitive and designed
to prevent harm to children. This aspect should be emphasised at
the community level so that the law comes to be seen as providing
protection and support to the individual.
-
It
is necessary to have a thorough understanding of the nature and
extent of the particular practice, including its roots and social
consequences. Health workers can acquire this knowledge through
discussions with the refugees, themselves.
-
Educate
target populations (both men and women), such as religious leaders,
traditional leaders (chiefs, tribal elders and political leaders),
teachers, TBAs and other health workers, as well as the general
refugee population (including women, men and children) about the
harmful health consequences of these practices. It is particularly
important to educate young girls about these issues.
-
Promote,
provide technical support to, and mobilise resources for national
and local groups that will initiate community-based activities aimed
at eliminating harmful traditional practices. National committees
to eliminate harmful traditional practices exist in many countries
and their expertise should be tapped.
-
In
Kenya, local NGOs running campaigns aimed at eliminating female
genital mutilation discovered that refugees were more open to discussing
the topic if it was included in workshops that covered other RH
issues, such as STDs, HIV/ AIDS and safe motherhood, rather than
if it was presented on its own. However, the campaign in refugee
situations in Ethiopia began as a stand-alone model and was very
successful. Only later was it incorporated into a larger RH programme.
Clearly then, each programme must be tailored to the community it
serves.
-
In
some countries, alternative income-generating activities should
be devised for those who earn money through harmful practices. Traditional
practitioners must also be able to find other ways to secure the
respect of their community.
-
Videos
provide an excellent means of demonstrating the harmful effects
of some traditional practices. Videos depicting a female genital
mutilation operation or a woman who has not undergone female genital
mutilation giving birth have proved to be very effective.
-
The
use of drama and other cultural activities, such as plays or songs,
can also be an effective method of disseminating information on
the negative effects of harmful traditional practices. Radio, local
papers, and mosques may also be used to help disseminate this information.
-
In
the Sudan, some health workers focus mostly on men in their campaign
to save girls from female genital mutilation. Men are often the
primary decision-makers in the family, though they are also generally
unaware of the exact nature and severity of the procedure.
-
Health
workers in Uganda support a "rite of passage" ceremony while trying
to eliminate the harmful practices of female genital mutilation.
Programmes encourage the ceremonial aspects of the "coming of age"
for young women, but eliminate the "cutting" part of the process.
In Sierra Leone, female genital mutilation is part of an initiation
rite for women's secret societies. These societies can be very important
for women's self-empowerment, not only because they provide a support
network, but because they also provide contacts for income- generating
activities. While it is important to encourage groups that empower
women, it is equally important to encourage initiation ceremonies
that do not require female genital mutilation.
-
The
importance of educating girls and women cannot be overstated. The
incidence of harmful traditional practices, such as female genital
mutilation and early childhood marriage, decreases as female literacy
increases. Therefore, promoting and supporting female education,
both the enrolment of girls in schools and adult literacy, should
be a priority.
-
Growing
immigrant populations in industrialised countries have brought female
genital mutilation with them to countries where it had not been
practised. UNHCR discourages informing refugees, before resettlement,
of the criminalisation of the practice in resettlement countries.
Experience has shown that if told prior to departure, mass female
genital mutilation operations may be conducted in the country of
asylum before resettlement occurs. When refugees are resettled to
countries that have laws against female genital mutilation, the
authorities of the resettlement country should be encouraged to
inform refugees of these laws upon their arrival.
Field
staff are advised to plan carefully their strategy for eliminating harmful
traditional practices in conjunction with the refugee community, implementing
partners and any other relevant UN organisations. It is important to
work with the refugee community to ensure measures taken are as effective
as possible.
Local
NGOs, host communities, and the government, which may already have active
campaigns in the country, could also be involved.
Monitoring
the change in female genital mutilation practices in a community is
very difficult. Programmes should monitor complications experienced
by women during birth and investigate any deaths that may be related
to female genital mutilation. Health care providers, both in health
facilities and in the community, should be supervised and monitored
routinely to ensure that they are not practising female genital mutilation.
Further
Readings
"Clinical
Management of Abortion Complications: A Practical Guide", WHO, Geneva,
1994.
"Complications
of Abortion: Technical and Managerial Guidelines for Prevention and
Treatment", WHO, Geneva, 1995.
"Female
Genital Mutilation: Findings from the Demographic and Health Surveys
Program", Macro International Inc., Washington, DC, 1997.
"Female
Genital Mutilation Information Kit" (includes Joint UNICEF, UNFPA and
WHO
Statement
on female genital mutilation), WHO, Geneva, 1994.
"How
To Guide: From Awareness to Action – Eradicating Female Genital Mutilation
in Refugee Camps in Eastern Ethiopia", UNHCR, Geneva, 1997.
"Management
of Pregnancy, Childbirth and the Postpartum Period in the Presence of
Female Genital Mutilation: A Report of a WHO Technical Consultation",
WHO, Geneva, 1998.
"Policy
Paper on Eradication of Harmful Traditional Practices", UNHCR, Geneva
1997.
"Post-abortion
Care: A Reference Manual for Improving Quality of Care", Post-abortion
Care Consortium, JHPIEGO Corporation: Baltimore, MD, 1997.
"Post-abortion
Family Planning: A Practical Guide for Programmes Managers", WHO, Geneva,
1997.
|
