care (PAC) is the strategy to reduce death and suffering from the complications
of unsafe and spontaneous abortion. The elements of PAC are:
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.)
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.
refugee situation requires a protocol for managing post-abortion complications.
feasible, host-country health referral facilities should be used and
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:
to the woman about her condition
initial clinical assessment
surgery and uterine evacuation should be undertaken by qualified and
supervised staff in appropriate and safe conditions, preferably in a
host-country health facility.
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
addition, all staff providing PAC should know how to counsel and provide
family planning services.
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.
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:
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.
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.
Female Genital Mutilation
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.
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.
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.
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.
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.
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.
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.
"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.
who have undergone female genital mutilation, particularly Type III,
need special care, especially during pregnancy, delivery and the postpartum
an infibulated woman gives birth, staff should be aware of the following
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.
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
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.
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.
NGOs, host communities, and the government, which may already have active
campaigns in the country, could also be involved.
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.
"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.
Genital Mutilation Information Kit" (includes Joint UNICEF, UNFPA and
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.
Family Planning: A Practical Guide for Programmes Managers", WHO, Geneva,
Standard for the Provision of
Health Workers, Traditional Birth Attendants (TBAs)
above activities plus:
District Hospital (usually a host-country facility
Regional or National Hospital