UNSAFE ABORTION SITUATIONAL ANALYSIS
in
Syria Arab Republic
Dr Asmaa Abdulsalam1, Dr Salah Cheikha1, Dr Reem Dahman2, Dr. Aisha
Jabre2
1
Syrian Society of Obstetrics and Gynecology
2
Syrian Ministry of Health
UNWANTED PREGNANCIES and unmet needs :
Incidence of unwanted pregnancies
According to a recent study sponsored by the Ministry of Health (MOH 2006),
unwanted pregnancy was (159/ 886) =17.9% calculated from the women recently
giving birth and not satisfied with having the last child.

Vulnerable groups (refugees, internally displaced populations, youth,
HIV positive women, etc)
There are not specific data for those groups
It is important to mention that all the studies and surveys done in Syria were
conducted on married women , It is very critical topic to ask non married girls
about their sexual relations and contraception use as sexual relationships are
supposed to be restricted only to marriage either civil or religious.
Unmet needs are defined in all Syrian surveys and studies as the women who
are capable of or think that they are capable of being pregnant (including the
women who are currently pregnant and do not want the current pregnancy) and
wish either to stop or postpone pregnancy, but at the same time these women
do not use any method of contraception.
There are data from three different studies: The PAPFAM Survey carried out in
2002 (3) among married women in the 15-49 years age group; the Multi
Indicators Cluster Survey done in 2006 (MICS 2006) also among married
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women 15-49 years old; and the study conducted by MOH 2006 on 10.000
women (1):
Table 1 summarizes the results from these three studies
Table 1. Evaluation of unmet needs for contraception in Syria
STUDY
PAPFAM2002
MOH2006
MIC 2006
Unmet needs
No more children
14,1
14,5
6,2
Spacing
16,5
?
4,8
Risk Factors
Rural women
Illiterate women
Illiterate husband
Age 20-24
Poor
Province Duran
Province El
Rakka
High parity
+
+
?
?
?
?
?
+
+
+
?
?
?
?
+
+
?
+
+
+
+
+
?
?
While the PAPFAM 2002 and the MOH 2006 study show practically the same
percentage of women who did not desire any more children (14.1 vs 14.5) a
reduction in that unmet need is suggested by the data of the MIC 2006 study that
shows a reduction in both, the percentage of women who do no want more
children and who intend to space them, which may reflect the improvement in the
contraception services beside other cultural and educational factors.
INTERVENTIONS TO PREVENT UNWANTED PREGNANCIES AND INDUCED
ABORTIONS ( increase use of contraception through working more on
quality of care and decreasing failure rate , adapting the WHO guidelines as
regard Abortion and post abortion complications management in Syrian
health centers.
2
Contraceptive information and services including EC

Overall and method specific prevalence rate
The contraceptive prevalence among married women 15 to 49 years old was the
subject of one study in 2002 and of two different studies in 2006. These studies
showed marked increase of around 8 percentage points, in the use of modern
contraceptive methods between the surveys conducted in 2002 and 2006. The
difference in total use of any method was greater than for modern methods, but
that may be influenced by the lack of registration of “withdrawal” in the 2002
survey.
In both years the intra uterine device was the most popular modern contraception
method used in Syria, followed by Pills. Table 2 summarizes the results from
these three studies
Table 2. Prevalence of contraceptive use per 100 married women aged
15-49, according to three different studies. Syria, 2002 and 2006
STUDY
PAPFAM2002
MOH2006
MIC 2006
Methods
IUD
20.0
Pills
Injections
Female sterilization
Vasectomy
Condom
Cervical cap
Total modern methods
Periodic abstinence
12.3
-1,2
Withdrawal
Lactation Amenorrhea
3
24.0
25.7
8.6
11.8
1.3
2.4
0.03
2.7
0.6
42.8
9.6
--
6.6
1.7
1.8
5.3
4.0
1.6
-35.1
12.9
0.9
1.2
-1.6
0.2
42.5
9.2
Current use of any method
46.6
64.3
58.3
Use of contraception was highly associated with degree of education, provinces
and women age, both in the PAPFAM 2002 and the MOH 2006 surveys
In the MOH 2006 survey, Suwyeda was the province with the highest prevalence
of contraceptive use (74.9%) among the other Syrian provinces and also, where
the unmet needs were the lowest, of only 6.4%.
The prevalence of contraception use among illiterate women was the only 45%
compared to 71% among highly educated women, in the same survey

Which methods are approved and sold in the country?
It is of importance to mention that till now all contraceptive methods are not
allowed by Syrian law. In spite of that, all methods are “de facto” approved but
the MOH, however, it is to be noted that Emergency contraceptive pills forms are
not available in Syria and not prescribed. Consequently, there is a need to
regulate this law

Which methods are distributed for free or at subsidized price
through public or private health networks in the country?
The Syrian government is ensuring that all contraceptive methods are available,
free of charge of to every village all over Syria. However, there are not specific
studies to evaluate if the methods are always available at the clinic level or there
are occasional discontinuation of supplies.

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Which is the real availability of methods in the public health services
The PAPFAM STUDY in 2002 and the study conducted by MOH in 2006
evaluated the participation of the different health sectors is in the provision of
contraceptive methods. In both studies the main contraceptive provider were the
primary health care centers followed by the private clinics. The public sector,
including public health care centers and hospital provided between 47 and 46%
of the contraceptive methods in both studies, although in 2006 the primary health
care centers increased their participation while the hospitals decreased. At the
same time the private clinic decreased their participation while the pharmacies
increased their percentage (Table 3)
Table 3. Participation of the various health sectors on the provison of
contraceptive methods.
CONTRACEPTIVE PROVIDER
Primary health care centers
PAPFAM2002
MOH 2006
38.9
43.4
8.2
3.2.
Private clinic
31.3
25.8.
Pharmacy
10.6
14.6.
Private hospitals
2.8
4.7.
Family Planning Clinics
4.9
3.0
Public hospitals

What data are available on access to methods by young people,
unmarried women and other marginalized groups (rural people,
indigenous groups, refugees IDPs).
No data available about unmarried women, however every person can get the
contraception methods without being asked if he/she is married or not.
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ll methods are available all over SYRIA through widespread of medical services (
either private or public including pharmacies) even in most rural areas
The data available as regard of why women do not use contraception in spite of
lack of desire to get pregnant :-Lack of knowledge forms only 3% of the reasons,
“The methods are not available or costly” is the reason given for not using
contraceptives by less than 1%, which reflects the availability of all methods free
of charge all over Syria
Comprehensive Sexuality Education

What is the current situation of knowledge among women and men
on sexuality education?
This is a very critical issue in the community

Are there governmental programs for comprehensive sex education?

How comprehensive is the coverage of sexuality education
programs? Out of school youth?
Still there is no governmental effort in the field of sexuality education except for
HIV AIDS program and the availability of voluntary counseling in the main 4
centers in the country

How comprehensive and adequate is the training of teachers to
provide sexuality education?
There is no program for training and the qualified persons in this field are very
few in the whole country
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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The employment of pregnant women is protected by law during pregnancy and
after delivery for the following period Syrian labor law (4) :- Women could not be
fired from their jobs once they get pregnant.

How long is the legal parental leave? Is it paid? Is it the same for all
populations within the country?
Mothers are allowed 4 months maternal leave for the first child, 3 months for the
second and 2.5 month for third child, completely paid. After that they can get one
month 80% paid
After the fourth child they do no longer have the right to get maternal leave. They
can get leave, but will not be paid at all.

Is maternal breast feeding effectively protected for working women?
Every lactating woman can benefit from one hour lactation /day. In order to fulfill
with the law, they are allowed either to arrive to work one hour later or to leave
one hour earlier.
In addition, any employee has the right to have 5 years off of his work not paid
without loosing her/his position.
In addition working women are protected by other legal rules: By law each
woman has the right to be employed regardless of being married or pregnant. By
law women should not be employed in hard heavy dangerous work and, women
under 18 years old should not work beyond 8 o'clock in the night except under
exceptional conditions

How is the compliance with the law on parental leave and maternal
breast feeding?
There is no data on the level of compliance of the law

Are there sufficient whole day nurseries, preschool and school for
the children of working women?
No hard data on this issue was found
Adoption
7

Is there support for women who wish to give baby to adoption?

Is there an effective procedure for adoption in the country?
(Information on this point is missing)
ABORTION:
Incidence
The incidence of induced abortion was estimated in 3.9% according to the MOH
2006 study 18.8% of women reported one spontaneous abortion, 14.3%
reported two or more spontaneous abortions while 67% had no history of
abortion. The incidence of induced abortion may be underestimated because
unmarried women were not included. Induced abortion was defined in the study
as the termination of pregnancy according to the wish of the woman or her
husband.
Although the world experience shows that the abortion rate obtained through
face to face interview are invariable underestimated, particularly in countries
where abortion is legally and morally condemned, the responsible for the
study defend their results sustaining that from the feedback they got from the
data collectors in the field during the study there was no difficulty in getting
the answers about induced abortion although it is sensitive and socially
undesirable It was planned to start asking about non sensitive socially
desirable questions then came to the abortion questions, it was also planned
that the data collectors teams are composed of one female and one male
and the female was the person responsible for asking the questions and filling
the questionnaires. The data collectors were well trained on the questionnaire
used in addition they themselves have good experience in household surveys
, understanding the community and even the dialect used in each region in
Syria. Even when the pregnancy is not planned and unwanted, in many
cases the women continue their pregnancies for many reasons: for example,
doctors can convince the women to continue because induced abortion is not
allowed on religious reasons, many of the families accept the pregnancy at
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the end, because abortion is considered (HARAM) not allowed and they will
be punished by GOD, and sometimes the costs are beyond their capacities.
Or even they start using some drugs but then they fail in terminating the
pregnancy and they continue to the end
Based on all of the above, the figure maybe higher than the 3.9% found in the
study, but never as high as the 20% estimated by others.

Sources of data
National study conducted in 2006 among 10000 women, executed by MOH,
under the supervision of Professors from Damascus University. It is the only
community based survey performed through face to face interviews.

Reliability of data :
The study was done by the Central bureau of statistics in Syria, on a
representative sample from the six health regions in Syria ( east 13.9% ,north
30.6%, middle 14.5%, coast 9.7%, Damascus 24.5%, and south regions
6.8%) according and proportional to the distribution of the population in
whole Syria. By clustering, the families inside each cluster was chosen by
systematic randomization even inside the family one woman was selected
randomly, the questionnaires were tested before implementation of the study ,
ethical consideration , informed consent, confidentiality were all
considered.95 data collectors working in MOH primary health care centers
distributed in whole Syria worked in this study
UNSAFE ABORTION

Incidence
There is no data available on the Incidence of unsafe abortion :From a hospital based study conducted in Syria about the information system it
was found that the registration system is not computerized and deficient and the
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national classification of diseases system is not used which make it impossible
at the moment to have accurate information about the problem of unsafe abortion
unless prospective multi center study is conducted

What data are available on the magnitude and severity of the
problem of unsafe abortion?

Source of data

Characteristics of women who come for abortion (age, place of
residence, marital status, income)
It is of importance to mention that there is no hospital based studies about
abortion or its complications in Syria , no information about the attitude , believes
and behaviors of care givers of induced abortion

Characteristic of providers of unsafe abortion and method used
The care provider was a gynecologist in 92% of the cases. Dilatation and
curettage was used in 86% of cases of induced abortion, 9% using drugs and in
85% of these cases the drug was prescribed by a gynecologist.
The place of abortion was in 45% of the cases in private clinic, and in 40% in
private hospitals, 3.4% induced abortion was at home and only 8.8% in public
hospitals, as induced abortion is legally permitted in Syria only for medical or
fetal causes

Availability of misoprostol, is it registered/approved, what
indications? Distribution channels, cost?
Misoprostol is available in the a tablet form (Cytotec), it is neither registered nor
approved by the Syrian MOH. It is illegally entered to the country from
neighboring countries and used informally in the clinic, hospitals and at home.
The indications for using Misoprostol are: termination of pregnancy, induction of
labor, and for post abortion bleeding and postpartum hemorrhage
It is distributed through pharmacies, costing one dollar for each tablet. In the
study it was used in 6 out of 326 cases
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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?
According to the MOH 2006 study, in 61.9% of the complicated cases the same
care provider managed these complications. Anesthesia was used in 89.3% of
cases and mainly general anesthesia 70.9%. Medical counseling was done in
58.2% of the cases , social counseling in 69.3%
Almost all women (95.5%) expressed their satisfaction about the care they
received, place and care providers.

Are physicians and other health professionals trained following WHO
recommended methods for treatment of incomplete abortion?
Physicians and other health professionals training are not following WHO
recommended methods for treatment of incomplete abortion , According to
national study on practices during childbirth and deliveries it was clear that there
is no written guidelines to be followed in the Syrian hospitals in 98% of the cases
(7) ( The study was executed by MOH together with Damascus University and
funded by UNFPA)

Is the country implementing WHO guidance?
The country is not implementing WHO guidance till now, but MOH funded by
UNFPA is in the phase of preparing national guidelines
Consequences of Unsafe Abortion

The abortion related maternal mortality
From a national community based study using sisterhood methods about the
causes of maternal mortality (5) no single case was reported or analyzed as
being unsafe abortion.
It is of importance to mention that when the team was planning to conduct the
maternal mortality study in Syria the main obstacle was the that the death
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registration is poor so only the causes of 129 maternal mortality were intensively
studied and analyzed .and it was impossible to estimate the rate

Magnitude and severity of complications of unsafe abortion
A near miss study (6) was conducted in Damascus University maternity hospital
in 2007. There was only one case out of 89 cases of near misses diagnosed as
threatening abortion 14 weeks gestation ( not induced abortion ) that bled
vigorously giving rise to hypovolemic shock and required massive blood
transfusion (near miss) which was managed properly
The data which are available ( from community based survey) on the magnitude
and severity of the problem of unsafe abortions are as follows: 13.7% medical
problems in the form of bleeding, 54.8% of other medical complications and fever
23.8% , Infertility (as reported by the women that they could not get pregnant
again after induced abortion and as they were told by their care providers) 4.8%,
but no near miss case was reported.
Psychological problems 36.3%.( being sad , feeling guilty ,afraid from GOD)
Social problems 12.3%.( in the form of Physical violence and blaming from the
husband , parents and mother in law)

Is there an established national level mechanism for monitoring and
evaluation of maternal mortality and morbidity resulting from unsafe
abortion?
NO, there is not a established national level mechanism for monitoring and
evaluation of maternal mortality and morbidity resulting from unsafe abortion.
The death certificates are defective in Syria, MOH is working now on improving
the death registry and establishing national committee for editing maternal
deaths but not in duty yet.

Cost of unsafe abortion to the health system, women and families
As there are no good records of unsafe abortions there is no way to estimate its
cost.
LEGAL SITUATION OF ABORTION AND REGULATORY FRAMEWORK
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
National Laws
Syrian punishment law from 22nd June 1949 established punishment for the
physicians , woman and the husband, Abortion is Only allowed when there is a
severe medical problem that threatens the life of the mother, at the same time
abortion is not allowed when there is abnormalities of the fetus even if the
abnormality is incompatible with life. If the woman died the care provider can be
prosecuted and jailed from 4 to 7 years , and if the method used was dangerous
the punishment will be increased to be from 5 to 10years.
If abortion was against the will of the woman the care provider will be prosecuted
for at least 10 years in the prison
Provision of Legal Abortion Services

Is the law being complied with for each legal indication?
YES the law is being complied with for each legal indication which are the
medical problems that will severely threaten the life of the mother if pregnancy
continues provided that there is a medical report signed by two Professors.
stating that clearly in their report.

Which methods are used in the country for legal abortion?

Which is the real availability of those methods for legal abortion services in
the public health services, and how much they cost?

How is the access to legal abortion services by young people,
unmarried women and other marginalized groups (rural people,
indigenous groups, refugees).
No data available about how is the access to legal abortion services by young
people, unmarried women and other marginalized groups (rural people,
indigenous groups, refugees).

Is the physician and mid level provider training following the WHO
recommended methods for legal abortion?
The physician and mid level provider depend on their own experience and the
training they get in the faculty and post graduate training
13
They do not follow training of the WHO recommended methods for legal abortion

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?
The country is not implementing the WHO and UNFPA recommended list of
essential medicines and essential commodities that includes MVA. The classical
method is still used i.e. evacuation and curettage, some times suction, recently
Misopristol is becoming increasingly used, but the figure is not available

Are FIGO Ethics Committee Recommendations recognized and
followed by the OBGYN society?.
FIGO Ethics Committee Recommendations are neither recognized nor followed
by the OBGYN society because it is not available to the members of the society
but they follow the Syrian syndicate ethics.
In situations of restrictive laws:

Are women being prosecuted and jailed after induced abortion?
Women can be prosecuted and jailed after induced abortion from 6 months to 3
years

Are health providers/facilities following the ethical principle of
confidentiality of health records in the care of women with induced
abortion?
As induced abortions are either very rare or unrecognized at the health services,
there are no cases of denouncing a woman for inducing an abortion

What are the consequences for physicians and other health
professionals?
Professionals can be prosecuted and jailed for providing or facilitating or selling
or prescribing abortificient drugs or methods for induced abortion by one to
three years
14
The consequences for physicians and other health professionals are preventing
them from working and by closing the clinic or the hospital..
Dr.Asmaa Abdulsaalm
18th April 2008
References:1. H Bashour , A Abdulsalam , Jaber A , M Tabaa , S Cheikha,
Dahman R, Khadra M., Laham M.Contracetives unmet needs
national report in Syrian Arab Republic .Minisrty of health and
UNFPA.2006
2. THE MICS 2006 ( Multi Indicators Cluster Survey) 2006
unbublished data
3. PAPFAM Survey FROM 2002
4. Syrian labor law (4)
5. Abdulsalam A, Dahman R, Cheikha S, Jaber A, Khadra M, Tabbaa
M, Laham M, Bashour H. REPORTING CAUSES OF MATERNAL
MORTALITY IN SYRIA,Ministry of health, Damascus Uni. And
UNFPA, 2006.
6. Shtayan A ,Abdulsalam A. Near Misses : Astudy in Dar- Eltawlid
University Hospital. The Second annual congress of. Damascus
university – faculty of medicine May2007
7. AbdulSalam A., Bashour H., Cheikha S. et al. Routine Care of
Normal Deliveries as Applied in Syrian Maternity Ward . JAMBS
2004; vol.6,NO.2, :134-140.
8. Syrian punishment law from 22nd June 1949.
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