Community-based surveillance of maternal deaths in rural Ghana

Joseph Adomako, Gloria Q Asare, Anthony Ofosu, Bradley E Iott, Tiffany Anthony, Andrea S Momoh, Elisa V Warner, Judy P Idrovo, Rachel Ward, Frank WJ Anderson

Bulletin of the World Health Organization 2016;94(2)

Objective: To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records. Methods: In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13-49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes/no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes/no question. A mortality review committee established the cause of death. Findings: Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes/no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records. 18 deaths no clear cause determined. Conclusion: The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.

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Tags: Ghana, maternal mortality, unsafe abortion, community-based study


FACT SHEET: Adolescents’ Need for and Use of Abortion Services in Developing Countries

The Guttmacher Institute has released this new fact sheet, which synthesizes available data into one easy-to-use resource. In 2008 (the most recent year for which estimates are available), about 3.2 million adolescent women aged 15-19 in developing countries had unsafe abortions, an annual rate of 16 per 1,000 adolescents. Guttmacher researchers expect to publish an updated estimate, along with additional data on adolescent abortion in the developing world, later in 2016.

The new fact sheet incorporates data from three recent studies of adolescent sexual and reproductive health needs and services in developing countries. It includes information about unsafe abortion incidence in specific countries and in the developing world in general, abortion service provision, access to postabortion care and barriers that adolescents face in accessing safe abortion services. The data show that adolescents are more likely than older women to self-induce abortion or go to an untrained provider, and they are more likely to have abortions later in pregnancy. Adolescents are also less likely than older women to start using contraceptives following postabortion care, which increases their likelihood of experiencing future unplanned pregnancies.

Cost and confidentiality are the biggest barriers adolescents in developing countries face in obtaining safe abortion services. To encourage adolescents to seek out safe and legal abortions and post-abortion care, it is critical to offer these services at an affordable cost or free of charge, and to involve other parties (including parents, guardians and spouses) only with the patient’s consent. Contraceptive counseling and method provision should also be included as part of comprehensive post-abortion services. Policymakers and health care providers in developing countries should make it a priority to provide adolescents with complete, medically accurate information about sex and pregnancy and access to confidential, youth-friendly services to minimize unplanned pregnancies and abortions.

Adolescents’ Need for and Use of Abortion Services in Developing Countries + Español + Français
Tags: Adolescents, access to services, cost, confidentiality

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Nicole Fineman/NY Times


When abortion providers are maligned as abortion promoters
by Dr. S. P. Choong

1 February 2016

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Dr SP Choong

As abortion rights activists, we are regularly having to explain to people the issues surrounding abortion, usually to people with quite negative opinions. Recently, an interesting conversation was started over a comment that ABORTION PROVIDERS are ABORTION PROMOTERS. This is a common allegation made against abortion rights activists and doctors, and it may be worth considering its merits, if any. This term implies that we are salesmen creating a demand for abortions as a business. It may seem obvious to us that this is clearly a fallacy, as we don’t need to create a demand but can see safe abortion as an unmet need.

But I think this idea needs to be taken more seriously as an anti-choice argument. This accusation implies that beyond services for unwanted pregnancies, we are also encouraging unplanned pregnancies. It would mean that we are actively discouraging the use of modern contraceptives to keep us in business. Since all responsible doctors actually use our contacts with clients as an opportunity to inform them on modern contraceptive methods, this argument is clearly untenable.

Of course, there are some unethical abortion providers who do abortions just for the profit. That happens when society creates the stigma and legal obstacles to safe abortions, whether perceived or real. It becomes easier to carry out ‘clandestine’ abortions at exorbitant fees as a special ‘favour’ to their clients. There are providers who are known to carry out these procedures only after office hours, often late at night, which further reinforces the impression of the legal risks involved.

However, abortion services should instead be seen in the context of other non-controversial medical services. Take, for example, an orthopedic surgeon, whose clients largely comprise victims of motor vehicle accidents. Can the surgeon be criticised for providing care needed by the accident victims? Can an excellent trauma department be blamed as the cause of so many motor vehicle accidents? Would it be better if the surgeon didn’t provide the service and would people then take more care in driving their vehicles, knowing that treatment for their injuries was not easily available?

In the context of abortions, the term ‘accidents’ is rather appropriate because our clients usually refer to their unplanned pregnancies as ‘accidental’. Women in a sexual relationship without wishing to get pregnant use many methods to avoid pregnancy. Unfortunately, some methods are less effective than others and thus the pregnancy is an ‘accident’ as much as when you cross a road, your intention is not to be knocked down by a car!

Most people consider pregnancy a natural physiological process which a woman is consciously willing to undergo because she wants a child. However, the nine-month gestation period is not without risks for the woman as anyone working in an obstetric service knows. These risks of course vary depending on the quality of existing medical services. In third world countries, it is often considered a life threatening condition; there is a saying in Africa that ‘to be pregnant is to have one foot in the grave’.

In Malaysia, our official maternal mortality rate is 27 per 100,000 pregnancies. That is excluding other non-fatal and sometimes risky complications that occur during the pregnancy, at delivery and afterwards.

In contrast, the mortality rate for safe abortion in the first trimester is estimated at 0.6 per 100,000 pregnancies (Guttmacher Institute). Thus, a woman taking a pregnancy to term is exposed to 50 times the risk of death as compared to an early termination of pregnancy. Should a woman not be given a choice to discontinue an unwanted pregnancy, given these known medical risks, if she so wishes?

If, in addition, we take into account the psychological stress of realising her responsibility of care for the next 18 years of a child’s life and the disruption of any long-term plans made before the unplanned pregnancy, it is difficult to fathom how some conservative doctors and policy makers can glibly talk about the need for a psychiatric opinion before acknowledging that the medical risks and psychological stress cause by a denial of termination are real.

Ultimately, it is absurd for laws to dictate that the moment a woman’s uterus carries an embryo, that part of her body is suddenly the property of the state and anything the woman wants to have done is regulated by outside parties - she can’t even request treatment to save her life if the laws don’t permit it.

Tags: Malaysia, abortion providers, unplanned pregnancy

Statement by the International Federation of Gynecology & Obstetrics (FIGO)

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Unsafe abortion continues to be a major public health problem, causing thousands of death each year and resulting in many more women who suffer complications. Given the current critical shortage of specialized professionals in many countries, the involvement of a range of health worker cadres is essential to ensuring access to safe abortion and post-abortion care, including the provision of pos-abortion contraception.

FIGO has reviewed the WHO’s Guideline on “Health workers role in safe abortion care and post-abortion contraception” (WHO, 2015). The guideline addresses this critical issue and provides evidence-based recommendations on a regulated approach to expanding the role of health workers cadres in safe abortion and post-abortion contraception.

FIGO endorses and supports these recommendations and encourages its members to disseminate and advocate for the adoption of these recommendations within their national contexts.

Tags: FIGO, WHO, abortion guidelines, abortion providers


Understanding factors influencing adverse sex ratios at birth and exploring what works to achieve balance: the situation in selected districts of Nepal

Mahesh Puri, Anand Tamang

Centre for Research on Environment, Health and Population Activities (CREHPA), Nepal / Population Council, India

July 2015

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In South Asian countries, strong son preference has led to serious discriminatory practices towards girls and women, with negative effects on their status, health and development. These gender disparities have resulted in a skewing of population and child sex ratios. Nepal has begun showing signs of skewed or disturbed sex ratios at birth in some districts of the Terai and hill regions - a reflection of persistent gender discrimination, combined with a preference for small numbers of children and the increasing availability of prenatal diagnostic technologies including ultrasonography (USG) since the 1980s and consequently an increase in the practice of gender-biased sex selection.

While the Government of Nepal is committed to ensuring women’s legal right to abortion under certain conditions, disclosure of the sex of the foetus and subsequent termination of pregnancies carrying a female fetus are prohibited by law. In this scenario, district-level differences in sex ratios raise questions such as: what accounts for the worsening of the sex ratio at birth in some districts of Nepal, but not in neighboring districts? To what extent are USG and other prenatal diagnostic techniques misused in those districts? Our limited understanding of the answers to these questions poses a key challenge to our understanding of promising approaches that will halt or reverse trends in adverse sex ratios at birth in Nepal. The gap between policy and programme commitments and realities is the  limited evidence on effective programme strategies that reduce couples’ practice of sex selection in this country.

Recognizing these gaps in understanding,… we have undertaken a project that aims to shed light on the issue of gender-biased sex selection in India, Bangladesh, Pakistan and Nepal, and make evidence-based recommendations for actions that hold promise for responding to adverse sex ratios at birth in these settings. In Nepal, two adjoining hill districts located in the western development region, namely, Kaski (where sex ratios are adverse) and Tanahun (where sex ratios are normal) were selected for study. This study adopted a mixed method design that included a population-based survey of 1,000 married women with at least two children, one of whom was aged 0–5 years; and 29 key informant interviews with stakeholders such as district-based public and private sector health care providers and programme implementers/managers.

Results show that several background characteristics of sampled women in the two districts were similar: their age distribution and religious affiliation, for example. Differences were however observed in terms of ethnicity/caste composition, level of education, household wealth, paid work, status of women and women’s agency. Women in Kaski were better educated, were better off in terms of household wealth, and had greater freedom of movement and self-efficacy than women in Tanahun.

…Nearly all stakeholders from both the study districts mentioned that Kaski was a more developed district than was Tanahun, had better access to sex selection technology and people living in this district were better informed about sex selection procedures and the location of USG services than were those in Tanahun. Several stakeholders suggested that factors underlying normal or “balanced” sex ratios in Tanahun may therefore be its dominant rural population, its relative poverty and more limited purchasing power of its residents, the more limited number of diagnostic facilities and trained providers, and women’s more limited access to available facilities….

In the long term, what is required are programmes which aim to empower girls, promote gender equality and improve girls’ overall situations. Programmes must focus on keeping girls in school and ensure that they complete a secondary education, providing girl-friendly education to encourage school retention, and expand the reach of the universal scholarship scheme for girls. Other efforts adopted in neighboring countries, including conditional cash transfer schemes that provide benefits to parents when their daughter achieves immunization, education and other milestones, and remains unmarried until age 18 may also hold promise.

Tags: Nepal, son preference, empowering girls


Forum: Why do we need to talk about unsafe abortions in the Philippines?

20 January 2016

Criminalized under all circumstances, abortion remains a taboo subject in the Philippines, underlining the pressing need for open spaces and discussion on the topic, as demonstrated at a public forum in Manila on 20 January, organized by members of the Philippine Safe Abortion Advocacy Network (PINSAN) and the Women’s Global Network for Reproductive Rights.

This was one of the first open public events in recent years to discuss issues and challenges surrounding abortion in the country. It was attended by over 50 participants from local civil society organizations and media outlets, politicians and academics, government employees and officials, including representatives from the Philippines Commission on Women, the Population Commission, the Former Dept of Health Secretary/Chair of the National Implementation Team for the RPRH Law and provincial DOH officers from Quezon City, Davao and Tacloban. There was a unanimous agreement to support the aims of PINSAN, to demystify and de-stigmatize abortion, and encourage public discussion on the realities of unsafe abortion. A number of speakers also supported the demand to decriminalize abortion to prevent women from being arrested and imprisoned.

At the end, participants held a minute’s silence and lit candles as a memorial to the thousands of women who have needlessly died from unsafe abortion and the denial of post-abortion care in the Philippines.

From the PINSAN Call for Action:
…Each day, approximately 1,671 women in the Philippines undergo medically unsafe abortion procedures. 274 of them are hospitalized. 13% of women who have had an abortion in the Philippines cite pregnancy as a result of rape as their reason for getting an abortion…

Despite the rights guaranteed in the Philippine Constitution, the Responsible Parenthood and Reproductive Health Law, Magna Carta for Women, and Prevention and Management of Abortion and its Complications Policy of the Department of Health, women all over the country are still denied services and are subjected to cruel and inhumane treatment when seeking care at health facilities.

Tags: Philippines, unsafe abortions, decriminalization of abortion
Copyright © 2016 International Campaign for Women's Right to Safe Abortion, All rights reserved.

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