Medication Abortion In Humanitarian Aid Settings

This online course is designed to train humanitarian aid workers in how to safely provide medication abortion, or abortion with pills.

1.1) Abortion in the Global Context

Abortions can occur spontaneously, commonly referred to as a miscarriage, or as the result of a deliberate intervention, also known as an induced abortion.

Induced abortion is quite common. Studies show that around one in four pregnancies end in induced abortion.

Women and girls all around the world – of all ages, religions, nationalities, and social classes – have abortions.

An estimated 56 million induced abortions occur worldwide every year.

About half of these abortions (31 million) are safe abortions and about half (25 million) are unsafe.

According to the World Health Organization (WHO), an unsafe abortion is the termination of a pregnancy either:

• by persons lacking the necessary skills, or
• In an environment that does not conform to minimal medical standards,
• or both.

Examples of unsafe abortion include:

• Using traditional herbs
• Drinking harmful toxic substances such as soap or chlorine
• Incorrectly taking different medications
• Inserting dangerous objects such as sticks, roots, needles, or broken glass into the vagina or anus.

Unsafe abortion is one of the main causes of maternal death worldwide, and the only cause that is almost entirely preventable.

In some contexts, up to 30% of maternal deaths are due to unsafe abortion.

According to the Guttmacher Institute, unsafe abortion leads to at least 22 800 deaths every year;

• another 7 million women are hospitalized due to complications from unsafe abortion, such as heavy bleeding, infection, and injury to the genital tract and internal organs.

These complications can also lead to life-long consequences such as infertility and chronic pain.

Women with unwanted pregnancies often resort to unsafe abortion when they cannot access safe abortion care.

Barriers to safe abortion care include restrictive laws, poor availability of services, high cost, stigma, and unnecessary requirements such as mandatory waiting periods, mandatory counseling, and medically unnecessary tests that delay care.

Women living in low-income countries, poor women, and women in humanitarian settings are more likely to have an unsafe abortion.

97% of unsafe abortions happen in developing countries.

In Africa and Latin America, 3 out of 4 abortions are unsafe.

The risk of dying from unsafe abortion is the highest in Africa.

According to the WHO, abortions are considered safe if:

• the person providing or supporting the abortion is trained; and
• the abortion is provided via a WHO-recommended method that is appropriate to the pregnancy duration.

WHO-recommended methods for safe abortion include:

Medication abortion , or an abortion with pills, which is the focus of this course; and

Manual vacuum aspiration , or MVA, which is a simple outpatient procedure that involves inserting a narrow plastic tube into the uterus and safely removing the pregnancy using suction.

MVA can be provided by many different kinds of health care workers and in basic health care facilities, but will not be described in detail in this course.

1.2) Medication Abortion

In medication abortion, pills are taken to cause the uterus to contract and push out the pregnancy in a process that is similar to a miscarriage.

Medication abortion has been a significant advancement in abortion care and has many advantages:

• It is non-invasive and often seen as a more natural process.
• It can be provided outside of, or with reduced visits to, a health care facility.
• It can often occur in the woman’s home, allowing for more privacy and confidentiality.
• It is highly effective and very safe.

The risk of severe, life-threatening complication is extremely low (less than 1%).

• It does not cause infertility or affect future pregnancies.
• It does not need surgically-trained health care professionals, sterile instruments, or hygiene requirements.
• The pills are low-cost and do not require refrigeration or a cold chain.

For all these reasons, medication abortion has expanded access to safe abortion care for women across the world

• especially in low-resource and humanitarian settings – and has allowed women to play a greater role in their own care.

The two drugs involved in medication abortion are mifepristone and misoprostol.

Mifepristone: Mifepristone blocks progesterone, the main hormone of pregnancy.

Mifepristone causes:

• The pregnancy to separate from the inside of the uterus;
• The cervix to soften and open; and
• The uterus to be more sensitive to misoprostol.

Misoprostol: Misoprostol is a prostaglandin that stimulates the uterus to contract and push out the pregnancy.

Misoprostol is available in most places and can also be used for other purposes, such as inducing labor, managing bleeding after delivery, and treating stomach ulcers.

Misoprostol is stable at room temperature but can rapidly deteriorate when exposed to high humidity or high temperature.

Therefore misoprostol should be kept in double aluminum blister packaging and stored in a cool, dry place.

1.3) Woman-Centered Abortion Care

Woman-centered abortion care approaches the person undergoing the abortion not only as a patient but as a whole person, taking into account their physical, emotional, and social well-being and adapting care to their needs and circumstances.

Women undergo abortion for many different reasons.

Most women have already thought about their options and made the decision to have an abortion before seeking care.

Each woman’s reason for ending a pregnancy is different and providers should be empathetic and non-judgmental towards a woman’s situation and decision.

Abortion providers’ values and attitudes can have an important influence on the way they interact with women having abortions.

Studies show that positive encounters with empathetic, respectful providers increase women’s satisfaction with their care, improve the likelihood that information is understood, and make women more likely to seek health care in the future.

Abortion providers should continuously reflect upon and identify their own subconscious biases in order to try to minimize their influence on the care they provide.

To ensure positive interactions, abortion providers should:

• Ensure privacy and confidentiality
• Speak neutrally and respectfully
• Listen attentively
• Ask thoughtful, open-ended questions
• Use simple, non-technical language
• Show empathy and kindness to all women in their care