From concept to measurement: operationalizing WHO’s definition of unsafe abortion

1. From concept to measurement: operationalizing WHO’s definition ofunsafe abortion Bull World Health Organ 2014;92:155

2. Unsafe abortion • a procedure for terminating a pregnancy • Performed by persons lacking the necessary skills • or in an environment not in conformity with minimal medical standards, • or both.

3. “safe” abortion • Nothing in the definition predetermines who should be considered a “safe” abortion should be • provider or what the appropriate skills or standards for performing abortions • are not static; they evolve in line with evidence-based WHO recommendations.

4. WHO guidelines: now recommend Mifepristone and misoprostol – or misoprostol alone if mifepristone is not available – and vacuum aspiration in lieu of the sharp curettage used formerly. • induced abortions provided at the primary care level or by non-physician health-care providers as safe.

5. Risk • Lowest if an evidence-basedmethod is used to terminate an early pregnancy in a health facility; • Highest if a dangerous method, such as • the use of caustic substances orally or • vaginally or the insertion of sticks into the uterus, • is employed clandestinely to terminate an advanced pregnancy Bartlett LA, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S et al. Risk factors for legal induced abortion-related mortality in the United States. ObstetGynecol 2004;103:729–37.

6. Illegal abortion is notsynonymous with unsafe abortion • The legal context and the level of safety are closely intertwined • Where restrictive laws are liberally interpreted, women can receive safe care. • Conversely, where liberal laws are poorly implemented, women sometimes abort with delay and under unsafe conditions.

7. Preventing unsafe abortion Between 2010-–2014: • On average, 56 million induced (safe and unsafe) abortions occurred worldwide each year. • There were 35 induced abortions per 1000 women aged between 15–44 years. • 25% of all pregnancies ended in an induced abortion. • The rate of abortions was higher in developing regions than in developed regions. Fact sheet Updated May 2016 http://www.who.int/mediacentre/factsheets/fs388/en/

8. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, sixth edition; 2011. Department of Reproductive Health and Research, WHO • Around 22 million unsafe abortions are estimated to take place worldwide each year, • almost all in developing countries. • In 2008, there were an estimated 47 000 deaths due to unsafe abortion. • Africa is disproportionately affected, with nearly two-thirds of all abortion-related deaths.

9. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, sixth edition; 2011. Department of Reproductive Health and Research, WHO • Around 5 million women are admitted to hospital as a result of unsafe abortion every year in developing countries. • While more than 3 million women who have complications following unsafe abortion do not receive care.

10. The annual cost of treating major complications from unsafe abortion is estimated at $680 million • When induced abortion is performed by appropriately trained persons using correct techniques it is a safe procedure. • Almost every abortion death and disability could be prevented through sexuality education, use of effective contraception, provision of safe, legal induced abortion, and timely care for complications. Vlassoff et al. Economic impact of unsafe abortion-related morbidity and mortality: evidence and estimation challenges. Brighton, Institute of Development Studies, 2008 (IDS Research Reports 59).

11. Barriers to accessing safe abortion • restrictive laws; • poor availability of services; • high cost; • stigma; • conscientious objection of health-care providers • unnecessary requirements such as: • mandatory waiting periods. • mandatory counseling. • provision of misleading information • third-party authorization • medically unnecessary tests.

12. Unsafe abortion can be prevented Though: • good sexual education; • prevention of unintended pregnancy through use of effective contraception, including emergency contraception; and • provision of safe, legal abortion.

13. Abortion incidence between 1990 and 2014: global, regional, and sub-regional levels and trends

14. 35 abortions occurred annually per 1000 women aged 15–44 years worldwide in 2010–14, (90% uncertainty interval [UI] 33 to 44) • which was 5 points less than 40 (39–48) in 1990–94 (90% UI for decline −11 to 0). • Because of population growth, the annual number of abortions worldwide increased by 5·9 million (90% UI −1·3 to 15·4), • from 50·4 million in 1990–94 (48·6 to 59·9) to 56·3 million (52·4 to 70·0) in 2010–14.

15. In the developed world, the abortion rate declined 19 points (−26 to −14), from 46 to 27. In the developing world, we found a non-significant 2 point decline (90% UI −9 to 4) in the rate from 39 to 37. Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010–14.

16. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010–14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010–14 and the grounds under which abortion is legally allowed.

17. Interpretation • Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. • Ensuring access to sexual and reproductive healthcare could help millions of women avoid unintended pregnancies and ensure access to safe abortion.

18. Introduction • In countries where mifepristone is approved, women have improved access to medical abortion; however, abortion rates do not increase. (Level II-3) • Women who can choose their method of abortion have higher satisfaction rates. (Level II-1)

19. Pre-procedure care • In the absence of readily accessible ultrasound, gestational age can be estimated using last menstrual period (LMP), clinical history, and physical examination, in women who are certain of the date of their LMP. Ultrasound is needed when uncertainty remains. (Level II-2) • The probability of ectopic pregnancy among women requesting abortion is consistently lower than in the general population. (Level II-3)

20. Medical abortion regimens • There is limited evidence regarding teratogenicity of mifepristone, but overall the risk appears to be low. (Level III) • Misoprostol is a known teratogen when used in the first trimester of a pregnancy. (Level II-2) • The risk of teratogenicity is high with the use of methotrexate. (Level II-3)

21. Medical abortion regimens • Oral mifepristone 200 mg and buccal misoprostol 800 μg is 95% to 98% effective up to 49 days after last menstrual period. The risk of ongoing pregnancy is less than 1%. (Level I) • Oral mifepristone 200 mg and buccal, vaginal, or sublingual misoprostol 800 μg is 87% to 98% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is less than 3.5%. (Level I) • Intramuscular/oral methotrexate and vaginal/buccal misoprostol is 84% to 97% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is 0.4% to 4.3%. (Level I)

22. Providing medical abortion 11.There is no evidence to support or refute the routine administration of Rh immunoglobulin to Rh negative women who undergo medical abortion before 49 days last menstrual period. (Level III) 12.There is no strong evidence supporting routine antibiotic prophylaxis for medical abortion. (Level II-2)

23. Providing medical abortion 13.Medical abortion is associated with bleeding, which is often heavier than a menstrual period, and with potentially severe cramping. (Level III) 14.Prophylactic ibuprofen administration does not provide superior pain control compared with as-needed dosing in women undergoing medical abortion. (Level I)

24. Post-abortion care 15.Follow-up rates are similar for both remote and in-clinic visits. (Level II-2) 16.When both women and their clinician believe successful expulsion has taken place, based on history alone, complete abortion is likely. (Level II-2) 17.Either ultrasound and/or serial bhCG measurements provide definitive evidence of pregnancy termination. (Level I)

25. Post-abortion care 18.A fall of beta human chorionic gonadotropin levels of 80% or more from pre-treatment to first follow-up at 7 to 14 days is indicative of a completed medical abortion. (Level II-2) 19.If ultrasound is used to assess completion of a medical abortion, endometrial thickness alone is not predictive of the need for subsequent surgical intervention. (Level II-2) 20.Retained products of conception requiring aspiration are more common in medical compared with surgical abortion. (Level II-2)

26. Post-abortion care 21.A second dose of misoprostol may lead to completion of a medical abortion when there is a retained gestational sac or an ongoing pregnancy. (Level III) 22.Severe complications following medical abortion are rare. (Level II-2) 23.Ovulation may occur as soon as 8 days after starting the medical abortion procedure. (Level III) 24.Insertion of intrauterine device at the follow-up visit after medical abortion is associated with higher insertion rates and equivalent expulsion rates compared with delayed insertion. (Level I)

27. Phase 2 (2565-2569) Phase 4 (2575-2579) สร้างความเข้มแข็ง เป็น 1 ใน 3 ของเอเชีย ปฏิรูประบบ แผน 20 ปีกสธ. ประเทศไทย 4.0 สู่ความยั่งยืน ประชารัฐ ยุทธศาสตร์ชาติระยะ 20 ปี และปฏิรูปประเทศไทยด้านสาธารณสุข แผนปฏิรูป แผนพัฒนาเศรษฐกิจและสังคมแห่งชาติ ฉบับที่ 12 (พ.ศ.2560 – 2564) Phase 1 (2560-2564) นโยบายรัฐบาล Phase3 (2570-2574) กรอบแนวคิด ทิศทางการวางแผน 20 ปี (4 Phase) 5

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29. บริบทสุขภาพคนไทย บริบทสุขภาพคนไทย โลกเชื่อมต่อการค้าการลงทุน ความก้าวหน้า Technology การเปลี่ยนแปลงสภาพภูมิอากาศ สังคมผู้สูงอายุ ความเป็นสังคมเมือง 3

30. People centered approach Mastery Retreat MOPH ทิศทางกระทรวงสาธารณสุข Originality Humility เป็นองค์กรหลักด้านสุขภาพ ที่รวมพลังสังคม เพื่อประชาชนสุขภาพดี พัฒนาและอภิบาลระบบสุขภาพ อย่างมีส่วนร่วมและยั่งยืน MOPH เป้าหมาย ประชาชนสุขภาพดี เจ้าหน้าที่มีความสุข ระบบสุขภาพยั่งยืน 4