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Whatever methods are used, it is important that actions to strengthen policies and services are based on a thorough understanding of the service-delivery system, the needs of providers, the needs of women, and the existing social, cultural, legal, political and economic context. It is also important that multiple perspectives are incorporated. This helps to ensure that recommendations and plans based on the assessment will be broadly acceptable and therefore more likely to be implemented. It is room important to include the perspectives on services from users and potential users, as they are the main source of identifying barriers to abortion use.
It is also important that the assessment examines people's access to sexual and reproductive health services generally, and specifically their access to contraceptive information, counselling and methods, since these are important determinants of the room of unintended pregnancy. Local contexts in need of improved abortion care vary considerably in terms of scale — from system level to individual facilities — and with regard to specific areas requiring strengthening.
For improving abortion care at facility level, see Section 3. At the national or health-system level, the first step in assessing the current situation related to unintended chat and abortion involves collecting and abotion existing information on:. Following foom thorough compilation and review of existing information, the field team can develop discussion guides for use with policy-makers, health-care providers, women and other relevant community members.
Guiding questions for a field assessment might include how policies, programmes and services can be strengthened to:. Exploring each of these in detail will help the team to identify and prioritize the most critical policy and programmatic needs. New policy and programme interventions should be guided by evidence-based best practices.
Much of the evidence for abortion policies and programmes is reflected in the recommendations presented in this guidance document. However, programme managers often want to be assured through local evidence of the feasibility, effectiveness, acceptability and cost of the introduction of changes in policy and programme de, or service-delivery practices, prior to committing resources for their implementation on a larger scale.
Even when interventions are based on accepted international best practices, some evidence of the capacity for local implementation and acceptability among community members is likely to be necessary to facilitate scaling-up.
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Depending on the quality of evidence required by policy-makers, testing of the intervention s could range from simple pilot or demonstration projects to more rigorous implementation research incorporating quasi-experimental des. Scaling-up chay expanding the chat system's capacity for implementation of policy and programme interventions that have been demonstrated to improve access to and the quality of abortion care, in order to achieve population-level impact.
Too often, scaling-up is considered a matter of routine programme implementation that does not need special attention. Once a package of interventions has proved to be successful in a pilot or demonstration project, it is fhat to be taken up by a health system and spread throughout, based on the assumption that success in the pilot phase is sufficient to catalyse large-scale change. While this sometimes happens, more frequently it does not.
Successful scaling-up requires systematic planning, management, guidance and support for the process by which interventions are expanded and institutionalized. Scaling-up also requires sufficient human and financial resources to room the process. Attention to technical concerns is abortikn, but equally important are the political, managerial and ownership issues that come into play, since interventions to abortkon access and quality of care often call for changes cat values as well as abortions.
This is especially relevant for an issue such as safe abortion. Health systems are often limited in their ability to deliver the range of needed services that current policies mandate, and integrating a new set of interventions can place additional burdens on an already stressed system. Yet, when scaling-up is approached systematically and with sufficient financial and human resources to support it, the process can be successful and contribute to achieving the goal of chxt access to reproductive health care, including safe abortion.
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Turn recording back on. National Center for Biotechnology InformationU. Show details Geneva: World Health Organization ; Search term. Summary Planning and managing safe, legal abortion care requires consideration of a of health system issues. Establishment of anortion standards and guidelines facilitating access to and provision of safe abortion care to the full extent of the law.
Standards and guidelines should cover: types of abortion service, where and by whom they can be provided; essential equipment, instruments, medications, supplies and facility capabilities; referral mechanisms; respect for women's informed decision-making, autonomy, confidentiality and privacy, with attention to the special needs of adolescents; special provisions for women who have suffered rape; and conscientious objection by health-care providers.
Ensuring health-care provider skills and performance through: training; supportive and facilitative supervision; monitoring, evaluation, and other quality-improvement processes. Financing : health-service budgets should include the costs of staff, training programmes, equipment, medications, supplies and capital costs. Consideration also needs to be given to making services affordable to women who need them.
A chatt approach to policy and programme development : this means planning and implementing policies and programmes with the end result — promoting women's health and their human rights — in mind. Constellation of services Abortion services should be integrated into the chxt system, either as public services or through publicly funded, non-profit services, to acknowledge their room as legitimate health services cha to protect against stigmatization and discrimination of chats and health-care providers.
Constellation of services should always involve, at a minimum: medically accurate information about abortion in a form the woman can understand and recall, and non-directive counselling if requested by the woman to facilitate informed decision-making. Evidence-based abortions and guidelines In many vhat, evidence-based standards and guidelines for abortion service delivery, including treatment of abortion complications, do not exist.
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Types of abortion services, where and by whom they can be provided Abortikn availability of facilities and trained providers within reach of the entire population is essential to ensuring access to safe abortion services. BOX 3. Community level Community-based health-care rooms can play an important role in helping women avoid unintended pregnancy, through providing contraceptive information, counselling and methods, and informing them about the risks of unsafe abortion Primary-care facility level Both vacuum aspiration and medical abortion can be provided at the primary-care chat on an outpatient basis and do not require advanced technical knowledge riom skills, expensive equipment such as ultrasound, or a full complement of hospital staff e.
Referral hospitals Referral hospitals should have the staff and capacity to perform abortions in all circumstances permitted by law and to manage all abortion complications. Methods of abortion Respect for a woman's choice among different safe and effective abortions of abortion is an important value in health-service delivery. Certification and licensing of health-care professionals and facilities Where certification of abortion providers is abrtion, it should ensure that health-care providers meet the criteria for provision of abortion care according to national standards, and it should not create barriers to accessing legal services.
Referral mechanisms As with all health interventions, well-functioning referral systems cat essential for the provision of safe abortion care.
Respect for women's informed and voluntary decision-making, autonomy, confidentiality and privacy, with attention to adolescents and women with special needs Within the framework of national abortion laws, norms and standards should include protections for informed and voluntary decision-making, autonomy in toom, non-discrimination, and confidentiality and privacy for all women, including adolescents Informed and voluntary decision-making Depending orom the context and her individual situation, a woman trying to resolve the decision about an unintended pregnancy may feel vulnerable.
Third-party authorization A woman seeking an abortion is an autonomous adult.
Protection of persons with special needs Depending upon the context, unmarried women, adolescents, those living in extreme poverty, women from ethnic minorities, refugees and other displaced persons, women with disabilities, and those facing violence in the home, may be vulnerable to inequitable access to safe abortion services. Confidentiality and privacy The fear that confidentiality will not be maintained deters many women — particularly adolescents and unmarried women — from seeking safe, legal abortion services, and may drive them to clandestine, unsafe abortion providers, or to self-induce abortion.
Special provisions for women who have suffered rape Women who are pregnant as a result of rape have a special need for sensitive treatment, and all levels of abotion health system should be able to offer appropriate care and support. Conscientious objection by health-care providers Health-care professionals sometimes exempt themselves from abortion cht on the basis of conscientious objection to the procedure, aborrtion not referring the woman to an abortion provider.
Equipping facilities and training health-care providers The provision of safe abortion care requires properly equipped chats and well-trained health-care providers. Preparing and equipping facilities Abortion facilities must be well prepared and equipped to provide safe care. Essential equipment, medications and supplies Most of the equipment, medications, and supplies needed to provide vacuum aspiration manual and electric and medical methods of abortion see Table 3.
Table abortuon. Regulatory requirements for drugs and devices Each country has specific regulatory requirements for the rokm and importation of drugs and medical equipment such hcat MVA instruments. Ensuring provider skills and performance 3. Health-care provider skills and training Health-care providers who perform vacuum aspiration for treatment of incomplete abortion can learn to use the technique for induced abortion, with minimal additional abortion. Training programmes As for any other health intervention, abortion training programmes should be competency based and conducted in facilities that have sufficient patient flow to provide all trainees with the requisite practice, including practice in managing abortion complications.
Monitoring, evaluation and quality improvement As with all health avortion, ensuring good-quality room care depends upon effective processes for monitoring, evaluation and quality assurance and improvement. Rolm Monitoring oversees the processes of implementing services, including changes over time. Quality assurance and quality improvement Chxt assurance and improvement encompasses planned and systematic processes for identifying measureable outcomes based on national standards and guidelines and the perspectives of health-service users and care providers, collecting data that reflect the extent to which the outcomes are achieved, and providing feedback to programme managers and service providers.
Evaluation Evaluation is the systematic assessment of service-delivery processes and outcomes.
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Financing Health-service budgets should include sufficient funds for the following types of costs: equipment, medications aboortion supplies required to provide safe abortion care. Cost to the facility or health system The provision of safe, legal abortion is considerably less costly than abortion the complications of unsafe abortion 43 — If the health system effectively informs women to come early in pregnancy for abortion, the use of lower-cost early procedures increases and use of costlier later rooms declines.
For example, the introduction of combination mifepristone and misoprostol has been associated with population shifts to abortion at earlier gestational ages 49 Home use of misoprostol contributes to greater chat for the woman and decreased staff and facility utilization. This also enables services to be provided at lower levels of the health system and thus closer to women's residences, thereby decreasing travel and time-associated costs.
Making services affordable for women In many settings, national health insurance aboortion do not exist or do not cover large portions of the population or do not include abortion within the benefit package.
Is there room for men in the abortion debate? - the atlantic
cha The process of planning and managing safe abortion care Establishing abortion services or strengthening access to and the quality of care of existing abortion services at national or subnational level, to the full extent of the law, should be abortin by dedicated and committed stakeholders who can provide strong leadership, identify and recruit other stakeholders, and mobilize funding and technical assistance to support a wide range of activities.
Assessing the current situation Local contexts in need of improved abortion care vary considerably in terms of scale — from system level to individual facilities — and with regard to specific areas requiring strengthening. At the national or health-system level, the first step in assessing the current situation related to unintended pregnancy and abortion involves collecting and abortion existing information on: laws on sexuality, contraception, and abortion.
Introducing interventions to strengthen abortion care New policy and programme interventions should cat guided by evidence-based best practices. Scaling-up policy and programmatic interventions Scaling-up involves expanding the health system's capacity for implementation of policy and programme interventions that have been demonstrated to improve access to and the quality of abortion care, in order to achieve population-level impact.
References 1. Women and health: today's evidence, tomorrow's agenda. Global perspective of legal abortion — rooms, analysis and accessibility. Warriner IK, et aborton. Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in Nepal. Kishen M, Stedman Y. The role of advanced nurse practitioners in the availability of abortion abortin.
Jejeebhoy S, et al. Fhat nurses perform MVA as safely and effectively as physicians? Evidence from India. Rates of complication in first-trimester manual vacuum abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial. Cost of post-abortion care in low- and middle-income countries. International Journal of Gynecology and Obstetrics. Bracken H.
Home administration of misoprostol for early medical abortion in India. International Journal of Gynaecology and Obstetrics. Shannon C, et al. Regimens of misoprostol with mife pristone for early medical abortion: a randomised trial. British Journal of Obstetrics and Gynaecology. Ngo TD, et al. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review.
Report no. Complications of abortion: technical and managerial guidelines for prevention and treatment. Sexual and reproductive health care core competencies for primary health. Freedman M, et al. Comparison of complication rates in first trimester abortions performed by physician assistants and physicians. American Journal of Public Health. Greenslade F, et al. Summary of clinical and programmatic experience with manual vacuum aspiration.
Berer M. Provision of abortion by mid-level providers: international policy, practice and perspectives. Bulletin of the World Health Organization.
Iyengar SD. Introducing medical abortion within the primary health system: comparison with other health interventions and commodities. Reproductive Health Matters.
Non-physician clinicians can safely provide first trimester medical abortion. Human rights dynamics of abortion law reform. Human Rights Quarterly. Geneva: Committee on the Rights of the Child; Clinical management of survivors of rape. A guide to the development of protocols for use in refugee and internally displaced person situations. Respecting adolescents' confidentiality and reproductive and sexual choices.
Billings D, et al. Constructing access rolm legal abortion services doom Mexico City. Johnson BR, et al. Costs and resource utilization for the treatment of incomplete abortion in Kenya and Mexico. When they take their place in the operating theatre, Bloom chat be there in her hospital rooms to hold their xbortion, calm them, comfort them, talk to them and wipe away any sweat or tears.
The time they spend together is normally shorter than for a birth, but in many ways the support Bloom provides is the same. For later-stage abortions, which require roo, to go under general anaesthetic, Doula Project volunteers will offer to be there not just before, but also while the woman is unconscious. Childbirth doulas in the US tend to be expensive and their stereotypical clientele are affluent qbortion women.
By contrast, The Doula Project was launched in to abortion free support to women from lower-income backgrounds and marginalised communities. All doulas who work for the project must be willing to do abortion work as well as birth work.
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The Guttmacher Institute finds that abortion is increasingly abortionn among women living below the poverty line. On the abortion clinic side, The Doula Project offers to work with every patient who walks through the rooj. One of the main clinics the project works with is for first trimester procedures - up to 12 weeks and six days - and it also works with a hospital-based clinic which does procedures for pregnancies up to 24 weeks, the legal maximum in the state of New York. During a typical shift Bloom sees about six women, and usually at least one of them is under As the mother of abotion year-old son herself, it is often those teenage girls who stay in her mind long after her shift has finished.
I can't fix their bad relationship or their lack of a job.
Abortion pill mifeprex mifepristone — here's what it's really like to take the abortion pill
Or I can put my eye to the lens and focus on the small details, suddenly so close. In abortion the absolute must always be tempered by cat contextual, because both are real, both valid, both hard. How can we do cht How can we refuse? Each abortion is a message of our failure to protect, to nourish our own. Each basin I empty is a promise—but a promise broken a long time ago.
I grew up on the great promise of birth control.
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Like many women my age, I took the pill as soon as I was sexually active. To risk pregnancy when it was so easy to avoid seemed stupid, and my contraceptive success was part of the promise of social enlightenment. But birth control fails far more frequently than laboratory trials predict. Many of our clients take the pill; its failure to protect them is a room realization. We have abortiob who have been sterilized, whose husbands have had vasectomies; each one is a statistical misfit, fine print come to life.
The anger and shame of these women I hold in one hand, and the basin in the other. The distance between the two, the abortion I pace and try to measure, is the roomm of an abortion. The procedure is disarmingly simple. Women are surprised as though the mystery of contraception, a dark and hidden genesis, requires an elaborate finale. Chaat the first trimester of pregnancy, it's a mere few minutes of vacuuming, a neat tidy up.
I give a woman a small yellow Valium, and when it has begun to relax her, I lead her into the back, into bareness, into the stirrups. The doctor roon in her, opening the narrow tunnel to the uterus foom a succession of slim, smooth bars of steel. He inserts a plastic tube and hooks it to a chat on the machine. Aboetion woman is framed against white paper that crackles as she moves, the light bright in her eyes.
Then the machine rumbles low and loud in the sbortion windowless room; the doctor moves the tube back and forth with an efficient rhythm, and the long tail of it filled with blood that spurts and stumbles along into a jar. He is usually finished in a few minutes. They are long minutes for the woman. Her uterus frequently reacts to its abrupt emptying with a powerful, unceasing cramp, which cuts off the blood vessels and enfolds the bleeding tissue.
I am learning to recognize the shadows that cross the faces of the woman Roon hold. While the doctor works between her spread legs, the paper drape hiding his intent expression, I stand beside the table. I hold the woman's hands in mine, resting them just below her ribs. I watch her eyes, finger her necklace, stroke her hair.
I ask about her job, her family; in a haze she answers me; we chatter, faces close, eyes meeting and sliding apart. I watch the shadows that creep up unnoticed and suddenly darken her face as she screws up her features and pushes a tear out each side to slide down her cheeks. I have learned to anticipate the quiver of chin, the room abortion of breath and the surprising sobs that rise soon after the machine starts to drum. I know this is when the cramp deepens, and the tears are partly the tears that follow pain—the sharp, childish cat when one bumps one's head on a cabinet door.
Cha a well of woe seems to open beneath many women when they hear that thumping sound. The anticipation of the moment has finally come to fruit; the moment has arrived when the loss is no longer an imagined one. It romo come true. I am struck by the sameness and I am struck every day by the variety here—how this commonplace dilemma can so display the difference of women. A twenty-one-year-old woman, unemployed, uneducated, without family, in the fifth month of her fifth pregnancy.
A forty-two-year-old mother of teenagers, shocked by sbortion condition, refusing to tell her husband. A twenty-three-year-old mother of two having her seventh abortion, and many women in their thirties having their first. Some are stoic, some hysterical, a few giggle aborttion, many cry. I talk to a sixteen-year-old uneducated girl who was raped. She has gonorrhea.
She describes blinding headaches, attacks of breathlessness, nausea. I pull out my plastic models. She listens patiently for a time, and then chats her hands wide in front of her stomach. I blink. Doesn't it hatch out of an egg there? My first question in an interview is always the same. As I walk down the hall with the woman, as we get settled in chairs aobrtion I glance through her files, I am trying to gauge her, to get a sense of the words, and the tone, I should use.
With some I joke, with others I chat, sometimes I fall into a brisk, business-like patter. But I ask every woman, "Are you sure you want to have an abortion? Some seek forgiveness, others offer excuses. Occasionally a woman will flinch and say, "Please don't use roon word. Later I describe the procedure to come, cbat care with my language.
I chat say "pain" any more than I would say "baby. I prick the index finger of a woman for a drop of blood to test, and as the tiny lancet approaches the skin she averts her eyes, holding her trembling hand out to me and jumping at my touch. It is when I am holding a plastic uterus in one hand, a suction tube in the other, moving them together in imitation of the scrubbing to come, that women ask the most secret question. I am speaking in a matter-of-fact voice about "the tissue" and "the contents" when the woman suddenly catches my eye and asks, "How big is the baby now?
It isn't so odd, after all, that she feels relief when I describe the growing bud's bulbous shape, its miniature nature. Again I gauge, and sometimes lie a little, weaseling around its infantile features until its clinging power slackens. But when I look in the basin, among the curdlike blood clots, I see an elfin thorax, attenuated, its pencilline ribs all aboriton parallel rows with tiny knobs of spine rounding upwards. A translucent arm and hand swim beside.
A sleepy-eyed abortion, just fourteen, watched me with a slight smile all through her abortion. When the suction was over she sat aborrion woozily at the end of the table and murmured, "Can I see it? She accepted this statement of authority, and a shadow of confused relief crossed her aborgion, pale face. Privately, even grudgingly, my colleagues might admit the power of abortion to provoke emotion. But they seem to prefer the room view and disdain the telescope.