FIGO WORKING GROUP ON UNSAFE ABORTION
LONG LIST OF ITEMS TO BE INCLUDED IN THE SITUATIONAL ANALYSIS
Dr. Eddie Mhlanga
UNWANTED PREGNANCIES

Incidence of unwanted pregnancies Unplanned and unwanted (unaccepted)
Information missing

Vulnerable groups (refugees, internally displaced populations, youth, HIV
positive women, etc)
Every woman is at risk
Under 13 weeks
Under 21 weeks – pregnancy risk to woman
Rape and incest
Social and economic condition
With increasing economic and social expectation the number of unwanted
pregnancies will increase
Rural and displaced communities

Determinants of unwanted pregnancies (including access to contraceptive
and contraceptive and user failure, violence against women, and lack of
social support of pregnant women).
Violence against women, unmarried, exploitation, failure of contraception,
exchange (poverty), lack of information or commodities
The status of women in society - in South Africa (virginity examination and
Gender Commission)

Consequences of unwanted pregnancies
Information missing

Barriers to certain methods (providers and health system barriers)
Weak health systems, insufficient human resources for reproductive health;
separation of HIV from other reproductive and sexual health conditions
INTERVENTIONS TO PREVENT UNWANTED PREGNANCIES AND INDUCED
ABORTIONS
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Support for Prevention
Contraception both modern and tradition
Information and access
Life skills programme - ? for adults
Economic empowerment
Male role in reproductive health
National and local provision of contraceptive technologies
Contraceptive information and services including EC
Insufficient promotion of contraception – contemporary and traditional
Overall and method specific prevalence rate
Specific methods (2003)
Female sterilization
Male sterilization
Pill
Injectables
IUD
Male condom

14.4
0.7
11.1
28.4
1.0
4.7
Which methods are approved and sold in the country?
Injectables (Depo Provera, NurIsterate)
Oral contraceptives (COC and POC) Condoms (male > female)
Female + male sterilisation,
IUCD (inert and copper containing)
IUCD hormone containing
Foams, creams and gels (spermaticides)

Which methods are distributed for free or at subsidized price through
public or private health networks in the country?
Injectables (Depo Provera, NurIsterate)
Oral contraceptives (COC and POC) Condoms (male > female)
Female + male sterilisation,
IUCD (inert and copper containing)
IUCD hormone containing
Foams, creams and gels (spermaticides)

Which is the real availability of methods in the public health services
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Information missing

What data are available on access to methods by young people,
unmarried women and other marginalized groups (rural people,
indigenous groups, refugees IDPs).
Information missing
Comprehensive Sexuality Education

What is the current situation of knowledge among women and men on
sexuality education?
Information missing

Are there governmental programs for comprehensive sex education?
YES

How comprehensive is the coverage of sexuality education programs? Out
of school youth?
In-school youth – secondary level, primary school. tertiary level
adults
National programme for sexuality education with NGO participation – PPASA,
loveLife, Ipas

How comprehensive and adequate is the training of teachers to provide
sexuality education?
May be need for strengthening of life skills

Which is the technical orientation (scope and content) of the existing
programs?
Information missing
Social protection of pregnant women and mothers of small children

Is employment of pregnant women protected by law during pregnancy and
after delivery and for how long?
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Maternity leave, UIF ???

Is the law enforced?
Information missing

How long is the legal parental leave? Is it paid? Is it the same for all
populations within the country?
Information missing

Is maternal breast feeding effectively protected for working women?

How is the compliance with the law on parental leave and maternal breast
feeding?
Information missing

Are there sufficient whole day nurseries, preschool and school for the
children of working women?
Information missing
Adoption

Is there support for women who wish to give baby to adoption?
Information missing

Is there an effective procedure for adoption in the country?
Information missing
ABORTION
Incidence
Number of legal or officially reported induced abortions
(1998) 439,334
(1999) 4 45,000
(2000) 4 51,132
(2003). 3 70,100

Reliability of data
 Underestimation, Not all provinces report of all TOPs performed
; illegal & unsafe abortion still common

Sources of data
Officially registered legal procedures
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UNSAFE ABORTION

Incidence
unknown

What data are available on the magnitude and severity of the problem of
unsafe abortion?
Number of admissions in 47 public hospitals in 9 provinces
2000 - 362 (282 to 441)/100.000 = 3,62 per 1000 women aged 12-49
1994 - 375 (299 to 451) 100,000 = 3.75 per 1000 women. aged 12-49

Source of data
Confidential Enquiry into Maternal Deaths

Characteristics of women who come for abortion (age, place of residence,
marital status, income)

Characteristic of providers of unsafe abortion and method used
Medicinals, chemicals, objects (needles, wires), enemas, chloroquine, castor oil,
dettol (antiseptics), physical, suicide

Availability of misoprostol, is it registered/approved, what indications?
Misoprostol available – misuse and use in obstetrics and gynaecology

Distribution channels, cost?
Quality of the care of women consulting for complications of abortion

Which methods are used in the country for incomplete abortion? Who can
provide these methods?
Curettage still done in a significant proportion of cases

Which is the real availability of those methods in the public health
services, and how much they cost?
Information missing
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
How is the access to treatment of incomplete abortion services by young
people, unmarried women and other marginalized groups (rural people,
indigenous groups, refugees, IDPs)?
Information missing

Is physicians and other health professionals training following WHO
recommended methods for treatment of incomplete abortion?
Lack of expertise in diagnosing and managing the seriously ill women – Saving
Mothers Report

Is the country implementing WHO guidance?
Guidelines for management of causes of maternal mortality – early pregnancy
losses
Consequences of Unsafe Abortion

The abortion related maternal mortality
Maternal Mortality Ratio, reported 2001 575
(deaths per 100,000 livebirths).8
Maternal Mortality Ratio, adjusted 2005 400
(deaths per 100,000 livebirths).8
MMR ranges between 270
and 530
FAILURE TO MONITOR MATERNAL
DEATHS LEADS TO NOT BEING ABLE
TO NOTE IMPROVEMENT AND
DETERIORATION

Magnitude and severity of complications of unsafe abortion
Sterility and chronic pelvic pain, depression
Reduced productivity, schooling
Death aggravated by HIV epidemic – deaths increased by 20% from 1998 to 2000
– 2004 (Saving Mothers)
Social impact of maternal deaths – social deprivation, economic downsizing
Cost to the health system – immediate care with intensive care and chronic
medications for rehabilitation
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
Is there an established national level mechanism for monitoring and
evaluation of maternal mortality and morbidity resulting from unsafe
abortion?
Information missing

Cost of unsafe abortion to the health system, women and families
LEGAL SITUATION OF ABORTION AND REGULATORY FRAMEWORK
International standards
ICPD
Millennium Development Goals
National Laws
Abortion and Sterilisation Act, 1975
Choice on Termination of Pregnancy Act, 1996
Sterilisation Act, 2000
CTOP Amendment Act, 2004
Notification of and Confidential Enquiry into Maternal Deaths

To save the women’s life
YES

To preserve women’s physical health
YES

To preserve women’s mental health
YES

To preserve women’s health (no specification)
YES

Pregnancy resulting from rape
YES

Severe fetal malformation
YES

Socioeconomic reasons
YES

Women’s choice
YES
Regulatory framework-key elements
TENENTS OF CHOICE ON TERMINATION OF PREGNANCY ACT, 1996
< 13 weeks
Upon request
Information on alternatives and dangers – nurse or doctor
13 – 20 weeks
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Upon request AND social & economic condition, rape or incest, detrimental to
life of the woman, severe congenital abnormalities – doctor/midwife to consult
another doctor/midwife, doctor implement
> 20 weeks according to the LNMP
Detrimental to woman’s health
Detrimental to foetus’ health
Severe congenital abnormalities
- Doctor/midwife to consult another doctor/midwife, doctor/midwife implement
Only the consent of the woman is required
A woman is a female of any age
Those under 18 years are advised to consult their parent(s), guardian, family
friend, etc. on condition that should the minor choose not to consult, TOP will not
be denied TOP service
Those unwilling to provide TOP on basis of conscious, must inform the woman on
her right to TOP, and to refer such a woman to someone who will provide the
service
Registered nurses and midwives trained for termination of pregnancy services
Provision of Legal Abortion Services

Is the law being complied with for each legal indication?
Information missing

Which methods are used in the country for legal abortion?
D&C
Misoprostol
MVA
Prostaglandins – E2, F2 alpha, gels and tablets
Hysterotomy
Oxytocin

Which is the real availability of those methods for legal abortion services in
the public health services, and how much they cost?
Limited number of facilities providing TOP services
Stigmatisation of health care providers
In spite of the obstacles the Maternal Death (Saving Mothers) report shows
reduction of deaths
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
How is the access to legal abortion services by young people, unmarried
women and other marginalized groups (rural people, indigenous groups,
refugees).
Information missing

Is the physician and mid level provider training following the WHO
recommended methods for legal abortion?
WHO guidelines modified to varying degrees for implementation

Is the country implementing the WHO recommended list of essential
medicines that includes mife/miso and essential commodities list of WHO
and UNFPA that includes MVA? Are these being used?
YES

Are FIGO Ethics Committee Recommendations recognized and followed
by the OBGYN society? Extend this point.
FIGO recommendations are in line with the national guidelines as well as the
Ethics with regard to termination of pregnancy
Most controversial has been the age of consent for the woman younger than 18
years of age
In situations of restrictive laws: (NOT APPLICABLE)

Are women being prosecuted and jailed after induced abortion?

Are health providers/facilities following the ethical principle of
confidentiality of health records in the care of women with induced
abortion?

What are the consequences for physicians and other health
professionals?
Are professionals being prosecuted and jailed for providing induced abortion?
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