Postabortion Care Overview

Maternal & Neonatal Health

Postabortion Care

Background

The international health community contains a wealth of resources that, if coordinated, could have an immediate and significant impact in reducing global levels of maternal mortality and morbidity stemming from the complications of unsafe abortion. Deaths and injuries from incomplete abortion are almost wholly preventable through existing means.

In order to reduce the risk of long-term illness or disability, and death, to women presenting with the complications of incomplete abortion, healthcare systems must provide easily accessible, quality postabortion care at all service levels. Currently, emergency postabortion care is provided mainly in higher level district hospitals. Not only does this lead to the high cost of providing these services, but it makes them inaccessible to many women. The prevention of abortion-related illness and mortality is dependent on the availability of emergency postabortion care throughout the healthcare system. "Whether it is health information and education, stabilization and referral, uterine evacuation, or specialized care for the most severe complications, at least some components of emergency care must be available at every service delivery site in the healthcare system."¹

The concept of postabortion care presented in this manual provides the basis for reducing mortality and morbidity from incomplete abortion, whether spontaneous or induced.

Scope of the Problem

Recent estimates are that at least 15% of all pregnancies end in spontaneous abortion, and though death is less likely than in cases of unsafe abortion, women who present with suspected spontaneous abortion also need immediate care.² In some countries abortion is the cause of as many as 50% of pregnancy-related deaths.³ And, according to recent World Health Organization (WHO) estimates, up to 15% of pregnancy-related mortality worldwide is due to abortion.¹

Although accurate data on the impact of unsafe abortion on maternal health is lacking, WHO estimates⁴ that:

Worldwide, 20 million unsafe abortions occur each year.

70,000 women die each year as a result of complications following unsafe abortion.

1 in 8 pregnancy-related deaths are due to unsafe abortion.

Currently available regional data on the impact of unsafe abortion on maternal health is summarized in Table 1.

Table 1. Impact of Unsafe Abortion by Region

Region Number of unsafe abortions (1000s)^†† Unsafe abortions per 1000 women 15-49 Number of deaths from unsafe abortion^†† Mortality from unsafe abortion per 100,000 live births Case fatality per 100 unsafe abortions Risk of death

More developed countries
2340

8

600

4

0.03

1 in 3700

Less developed countries^†
17620

17

69000

55

0.4

1 in 250

Africa
3740

26

23000

83

0.6

1 in 150

Asia^†
9240

12

40000

47

0.4

1 in 250

Europe
260

2

100

2

0.04

1 in 2600

Latin America
4620

41

6000

48

0.1

1 in 800

USSR (former)
2080

30

500

10

0.03

1 in 3900

^{† Japan has been excluded from the regional estimates, but is
included in the total for developed countries.

^†† Based on 1990 UN projection of births.}
Adapted from: WHO, 1994b.

Elements of Postabortion Care

Comprehensive postabortion care services should include both medical and preventive healthcare. The key elements of postabortion care are:

Emergency treatment of incomplete abortion and potentially life-threatening complications

Postabortion family planning counseling and services

Links between postabortion emergency services and the reproductive healthcare system

Emergency Treatment

Every health system provides some level of emergency postabortion care services⁵ because at least 15% of all recognized pregnancies end in spontaneous abortion (miscarriage).² Although emergency postabortion care services are needed virtually everywhere, their quality and accessibility vary widely. Emergency treatment of postabortion complications often is offered only at secondary and tertiary care centers in urban areas. Unfortunately, poor transportation systems in many developing countries place centralized services out of reach of most poor, rural women. This gap in services makes even spontaneous abortion life-threatening in many instances.

Increasing the availability of emergency postabortion care services throughout the health system requires decentralizing treatment services and improving the quality and range of care at every level. These steps must be backed up by establishing clear protocols for service delivery and comprehensive, systematic training.

Emergency treatment for postabortion complications includes:

An initial assessment to confirm the presence of abortion complications

Talking to the woman regarding her medical condition and the treatment plan

Medical evaluation (brief history, limited physical and pelvic examinations)

Prompt referral and transfer if the woman requires treatment beyond the capability of the facility where she is seen

Stabilization of emergency conditions and treatment of any complications (both complications present before treatment and complications occurring during or after the treatment procedure)

Uterine evacuation to remove retained products of conception (POC)

WHO has identified the prompt treatment of incomplete abortion as an essential element of obstetric care that should be available at every district-level hospital.⁶ Fortunately, treatment of uncomplicated incomplete abortions also can be provided at the primary care level or in family planning clinics through the use of manual vacuum aspiration (MVA). Table 2 provides information on the postabortion care services appropriate to each level of healthcare facility.

Table 2. Provision of Postabortion Care by Level of Healthcare Facility and Staff

Level Staff May Include Emergency Postabortion Care Provided Postabortion Family Planning

Community Community residents with basic health training
Traditional birth attendants

Traditional healers

Recognition of signs and symptoms of abortion and serious postabortion complications

Referral to facilities where treatment is available

Provision of pills, condoms, diaphragms and spermicides
Referral and followup for these and other methods

Primary
(Primary health clinics, Family planning clinics or Polyclinics)
Health workers
Nurses

Trained midwives

General practitioners
All primary care facilities. Above activities, plus:

Diagnosis based on medical history and physical and pelvic examination

Resuscitation/preparation for treatment or transfer

Hematocrit/hemoglobin testing

Referral, if needed

Provision of above methods plus IUDs, injectables and Norplant^{^�} implants
Referral for voluntary sterilization

If trained staff and appropriate equipment are available. Above activities, plus:

Initiation of emergency treatments

antibiotic therapy

intravenous fluid replacement

oxytocics

Uterine evacuation during first trimester for uncomplicated cases of incomplete abortion

Pain control

simple analgesia and sedation

local anesthesia (paracervical block)

First Referral Level
(District hospital)
Nurses
Trained midwives

General practitioners

Ob/Gyn specialists
Above activities, plus:

Emergency uterine evacuation through second trimester

Treatment of most postabortion complications

Local and general anesthesia

Diagnosis and referral for severe complications (septicemia, peritonitis, renal failure)

Laparotomy and indicated surgery (including for ectopic pregnancy)

Blood crossmatch and transfusion

Provision of above methods plus voluntary sterilization
Followup

Secondary and Tertiary Level
(Regional or Referral hospital)
Nurses
Trained midwives

General practitioners

Ob/Gyn specialists
Above activities, plus:

Uterine evacuation as indicated for all incomplete abortions

Treatment of severe complications (including bowel injury, severe sepsis, renal failure)

Treatment of bleeding/clotting disorders

All above activities

Adapted from: WHO, 1994a.¹
Norplant^{^�} is the registered trademark of The Population Council for subdermal levonorgestrel implants.

Postabortion Family Planning

Lack of access to adequate family planning services is a major contributor to the global problem of unsafe abortion; conversely, unsafe abortion is a prime indicator of the unmet need for safe and effective contraceptive methods. In most health systems, women treated for abortion complications rarely receive any counseling or services to prevent subsequent unwanted pregnancies. Because a woman seeking treatment for incomplete abortion already may have experienced an unwanted pregnancy either as the result of not using contraception or method failure, she may be in need of effective contraception.

A number of factors limit provision of family planning services to women who have experienced an abortion. These factors, which increase a woman's risk of repeated unwanted pregnancies, include:

Lack of understanding of and attention to women's reproductive health needs on the part of providers

Lack of services for some groups of women (e.g., adolescents, single women)

Separation of emergency postabortion care services and family planning services

Misinformation among providers about appropriate postabortion contraceptive methods

Lack of acknowledgment of the problem of unsafe abortion and the resulting need for contraceptive services

In recognition of the above, in 1993, a technical working group on postabortion family planning, sponsored by several international agencies, developed recommendations for establishing postabortion family planning services. The key recommendation stated that a range of contraceptive methods, accurate information, sensitive counseling and referral for ongoing care should be available and accessible to all women who have experienced abortion.⁷

Steps necessary to realize this goal include:

Establishing strong functional links between emergency postabortion care services and family planning services

Developing protocols for postabortion contraception

Using research to support improvements in the quality of postabortion care

Because ovulation returns rapidly following an abortion, with the subsequent risk of repeat pregnancy, postabortion family planning services need to be initiated immediately. For example, following pregnancy loss during the first trimester, ovulation may occur as early as day 11 and usually occurs before the first menstrual bleeding.^8,9 In contrast to the postpartum period, women who have experienced spontaneous or unsafe abortion face an almost immediate risk of pregnancy.

All modern methods of contraception are appropriate for use after abortion as long as the provider screens the woman for the standard precautions for a method and gives adequate counseling. Recommendations for contraceptive use after first-trimester abortion are similar to those for interval use (i.e., women who have not been pregnant within the last 28 days). Recommendations for contraceptive use after second-trimester abortion are more similar to those for postpartum women (with the notable exception of concerns about estrogen-related precautions which do not apply after abortion). In either case, thorough counseling is essential so that the client chooses a method that meets her needs and that she can use safely and effectively.

Links to Other Reproductive Health Services

Linking emergency postabortion care services with other reproductive health services is essential and logical, yet these services remain distinctly separate in much of the world. This separation leaves women without access to reproductive healthcare and contributes significantly to women's poor overall health status.

It is important to identify the reproductive health services that each woman may need and offer her as wide a range of services as possible. For example, providers need to be alert to symptoms of sexually transmitted diseases (e.g., trichomoniasis or mucopurulent cervicitis) and provide the appropriate treatment for them. Also, for women over age 30-35, it may be possible to offer cervical cancer screening at the time of treatment or to provide referral to a facility where screening is available. Finally, women treated for spontaneous abortion may have special reproductive healthcare needs, such as special followup for management of recurrent spontaneous abortion (infertility) or advice before attempting to become pregnant again or about prenatal care.

Rationale for the Use of MVA

The treatment of incomplete abortion almost always requires removal of retained products of conception (POC) from the uterus. Dilatation and curettage (D&C), the traditional method of removing tissue from the uterus, is accomplished by scraping the uterine walls with a metal curette. Vacuum aspiration uses suction to remove uterine tissue through a cannula with minimal scraping of the uterine walls. Vacuum aspiration, which has been used for more than two decades in industrialized countries, may be performed using suction provided by an electric or foot pump or a specially designed manual vacuum aspiration (MVA) syringe. Although uterine evacuation can be achieved either with suction or by D&C, suction has been found to be the safer method. As illustrated in Figure 1, vacuum aspiration has lower rates for the complications most commonly associated with uterine evacuation.

Figure 1. Comparison of Complication Rates (Vacuum Aspiration versus D&C), 1982-1984

Source: Hart and Macharper, 1986.¹⁰

Moreover, as shown in Table 3, which summarizes findings from 13 comparative studies, vacuum aspiration has fewer complications in nearly all situations. Thus, while complications can occur with vacuum aspiration, as they can for any medical procedure, it is a safer means of uterine evacuation.

Table 3. Summary of 13 Studies Comparing Vacuum Aspiration and D&C

Major Complications Reviewed Complications with vacuum aspiration per 100 procedures
Range of averages
(N=95,136)
Complications with D&C per 100 procedures
Range of averages
(N=17,166)
Studies with lower complication rates for vacuum aspiration than D&C (%)

Excessive blood loss
0 - 15.7

0.5 - 28

10 of 13 (78%)

Pelvic infection
0.2 - 5.4

0.7 - 6

7 of 9 (78%)

Cervical injury
0 - 3.1

0.3 - 6.4

6 of 7 (86%)

Uterine perforation
0 -0.5

0 - 3.3

10 of 12 (83%)

Source: Greenslade et al, 1993.¹¹

Using MVA as the method of uterine evacuation also reduces the cost of providing quality postabortion care. In one district hospital in Kenya, where the treatment protocol was changed from sharp curettage (D&C) under general anesthesia to MVA using local anesthesia, the average cost of treating a patient fell by 66%.¹² Similarly, in one Mexican hospital D&C was at least 50% more expensive than MVA.¹² One reason for the lower cost of MVA is that while D&C usually is performed in operating rooms using general anesthesia, MVA can be done in family planning clinics or polyclinics with local anesthesia. Additionally, the simplicity of MVA allows it to be performed by a trained, nonphysician health worker. By contrast, D&C generally is performed only by a physician who often is a specialist.

MVA not only increases cost-effectiveness, but it also increases the potential for earlier access to services by allowing postabortion services to be provided in primary healthcare facilities. This is an important factor in reducing risk to women. Additionally, in many cases, the use of MVA at the local level reduces the need for referrals to higher levels within the healthcare system. For example, if women can be treated at primary healthcare facilities, they do not need to be transported to district or tertiary care facilities, and therefore are less likely to suffer injury or death as a result of abortion complications. With fewer cases referred to these facilities, staff are able to focus on providing care for serious complications and limited healthcare resources can be better utilized. Even when services are provided in tertiary care facilities, if postabortion care is provided outside the operating room, the waiting time before and recovery time after the procedure are shortened (see Figure 2). Reduction in the use of operating theater facilities and hospital beds also helps alleviate crowding and reduce delays in treatment.

Figure 2. Average Length of Stay for MVA versus D&C at Two Mexican Hospitals

figure2.gif (7582 bytes)

Source: Greenslade et al, 1993.¹¹

In summary, using MVA as the method of uterine evacuation to treat incomplete abortion is preferred because:

the risk of complications is reduced,

access to services is increased,

the cost of postabortion services is reduced,

and the resources used are reduced.

In addition, use of MVA offers the potential for earlier access to care, when management is easier and serious complications less likely.

References

¹World Health Organization: Complications of Abortion: Technical and Managerial Guidelines for Prevention and Treatment. Geneva, WHO, 1994a.

²Wolf M: Consequences and Prevention of Unsafe Abortion: Report of Two Panels at the XIII World Congress of Gynaecology and Obstetrics (KE McLaurin and LG Lamp�, eds). Issues in Abortion Care 3. Carrboro, North Carolina, IPAS, 1994.

³Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion. Report of a Technical Working Group, April 12-15, 1992, Geneva, WHO, 1993.

⁴World Health Organization: Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, 2nd ed. Geneva: WHO, 1994b.

⁵McLaurin KE: Health Systems' Role in Abortion Care: The Need for a Pro-Active Approach. Issues in Abortion Care 1. Carrboro, North Carolina, IPAS, 1991.

⁶World Health Organization: Essential Elements of Obstetric Care at First Referral Level. Geneva, WHO, 1991.

⁷Wolf M and Benson J: Meeting Women's Family Planning Needs for Post-Abortion Family Planning: Report of a Bellagio Technical Working Group. International Journal of Gynecology and Obstetrics 45(Suppl) S3-S23, 1994.

⁸L�hteenm�ki P et al: Return of Ovulation After Abortion and After Discontinuation of Oral Contraceptives. Fertility and Sterility 34(3): 246-249, 1990.

⁹L�hteenm�ki P: Postabortal Contraception. Annals of Medicine 25(2): 185-9, 1993.

¹⁰Hart G and Macharper T: Clinical Aspects of Induced Abortion in South Australia from 1970-1984. Australian and New Zealand Journal of Obstetrics and Gynaecology 26: 219-224, 1986.

¹¹Greenslade F et al: Summary of Clinical and Programmatic Experience with Manual Vacuum Aspiration. Advances in Abortion Care 3(2), 1993.

¹²Johnson BR, Benson J and Hawkins BL: Reducing Resource Use and Improving Quality of Care with MVA. Advances in Abortion Care 2(2), 1992.

General References

El Kabarity H et al: Suction Abortion Versus Traditional Evacuation in the Management of Incomplete Inevitable Abortions. Presented at the International College of Surgeons, Fifth African Federation Congress, Cairo, Egypt, November 1985.

Filshie GM, Ahluwalai J, Beard RW: Portable Karman Curette Equipment in Management of Incomplete Abortions. The Lancet 1114-1116, November 1973.

Filshie GM et al: Evacuation of Retained Products of Conception in a Treatment Room and Without General Anesthesia. British Journal of Obstetrics and Gynecology 84:514-5169, 1977.

Greenslade F et al: Manual Vacuum Aspiration: A Summary of Clinical & Programmatic Experience Worldwide. Carrboro, North Carolina, IPAS, 1993.

Greenslade et al: Post-Abortion Care: A Women's Health Initiative to Combat Unsafe Abortion. Advances in Abortion Care 4(1), 1994.

IPAS: Gynecologic Aspiration Kits with Karman Cannulae and Syringes for Treatment of Incomplete Abortion. Carrboro, North Carolina, IPAS, 1994.

Kizza APM and Rogo KO: Assessment of the Manual Vacuum Aspiration (MVA) Equipment in the Management of Incomplete Abortion. East African Medical Journal 67(11): 812-822, 1990.

Leonard AH and Ladipo OA: Post-Abortion Family Planning: Factors in Individual Choice of Contraceptive Methods. Advances in Abortion Care 4(2), 1994.

Mahomed K et al: Improved Treatment of Abortion Complications and Post-Abortion Family Planning in Zimbabwe. Presented at the 1992 Annual Meeting of the American Public Health Association, Washington, D.C., November 1992.

Manual Vacuum Aspiration for Treatment of Incomplete Abortion. Outlook 12:1, 1994.

McLaurin KE et al: Post-Abortion Family Planning: Reversing a Legacy of Neglect. The Lancet 342:1099-1100, 1993.

Gadea P and Romero C: Legrado Uterino por Aspiraci�n Manual. Revista de la Federaci�n Centroamericana de Sociedades de Obstetricia y Ginecolog�a 4(2):42-45, 1992.

Pernoll ML (ed): Current Obstetric & Gynecologic Diagnosis & Treatment. 7th ed. Norwalk, Appleton & Lange, 1991.

Verkuyl DAA and Crowther CA: Suction vs Conventional Curettage in Incomplete Abortion—A Randomized Controlled Trial. South African Medical Journal 83:13-15, 1993.

Wolf M and Benson J: Meeting Women's Needs for Post-Abortion Family Planning: Report of a Bellagio Technical Working Group. International Journal of Gynecology and Obstetrics 45(Suppl): S3-23, 1994.

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