Abortion

Not all pregnancies last the normal nine months (40 weeks) and result in the birth of a baby. In some cases pregnancy ends by itself; this is called a miscarriage or spontaneous abortion. Miscarriages usually occur before the 26th week. In some cases an operation is carried out to end the pregnancy; this is called induced abortion.

Miscarriage or spontaneous abortion

Out of every one hundred pregnancies, ten to twenty end in miscarriage. Miscarriage occurs when the pregnancy ends before the baby has chance of survival. Most miscarriages occur in the first 12 weeks of pregnancy.

What causes a miscarriage? By far the most common reason is that something is wrong with the fertilized egg.  If the egg had continued to grow and develop, it would have resulted in a baby with severe abnormalities such as deformed or missing organs. Miscarriage, therefore, can sometimes be nature’s way of stopping such abnormal births.

A miscarriage may also result if a woman has a serious illness such as malaria or syphilis, a severe fall, or a problem with her reproductive organs. Some miscarriages occur because the fertilized egg was implanted someplace other than the womb, usually in the fallopian tube. Such pregnancies almost always miscarry and can be very dangerous.

The signs of miscarriage

There are two main signs of miscarriage - bleeding from the vagina and pain in the lower abdomen. The bleeding is usually slight to begin with, but goes heavier and soon big clots appear. Both the bleeding and the pain can be quite similar to those accompanying a heavy menstrual period, especially for an early miscarriage. It may therefore be difficult to tell when a miscarriage happens, especially if pregnancy was never suspected.

“Complete” miscarriages

A miscarriage is described as “complete” when all the tissues of the developing embryo or foetus and the placenta have passed out through the vagina. With a complete miscarriage, the bleeding will stop after a few days. In this case a woman should rest and avoid any heavy lifting or exercise for 2-3 weeks. The woman should keep herself clean and avoid sexual contacts.

Incomplete miscarriage: A miscarriage is incomplete when part of the foetus or placenta remains inside the womb. A miscarriage is more likely to be incomplete if it happens between the tenth and twentieth week of pregnancy. Bleeding continues and there is a good chance that the dead tissues inside the womb will become infected, which usually causes fever and pain in the abdomen. When a miscarriage is incomplete, the womb must be completely emptied as soon as possible by a trained health worker in a hospital or clinic. If an incomplete miscarriage becomes infected, it can lead to fever and pain in the reproductive organs that does not go away. If the infection is not treated it can cause scarring in the fallopian tubes, which can make a woman infertile. If a woman has any signs of infection after a miscarriage, she should go immediately for a checkup.

After a miscarriage, especially an incomplete one, a woman should wait several months before trying to get pregnant again. During this time a family planning method should be used to avoid pregnancy.

Repeated miscarriages: Some women have miscarriages again and again. After one or two miscarriages early in pregnancy, a woman should be reassured not to worry.  But after the third or fourth miscarriage occurs late in pregnancy, a woman should be encouraged to have a medical examination to see if any explanation can be found.

Induced abortion: Miscarriages are also called “Spontaneous abortions “, which means they start on their own. There are, however, times when a woman ends the pregnancy by an “induced abortion”.  The procedure is usually performed early in the pregnancy, during the first three months. The woman is given an injection to reduce the pain, and then a doctor cleans out the womb using instruments that are inserted through the vagina. The operation usually takes about 15 minutes. If it is done by a trained person, with proper equipment and in a clean environment, the operation is not dangerous.

If an unsafe method is used to induce an abortion, the woman is likely to have a major infection in her reproductive organs.

If for some reason a woman has had an induced abortion and she develops any of the signs-fever or chills, pain in the abdomen, cramping or backache or bleeding from the vagina that does not stop or is very heavy or bad smelling discharge from the vagina or delay (6 weeks or more) in resuming normal periods, she should go to a hospital for treatment immediately. Delay can mean death.

Legislation

It is very important to have suitable and comprehensive legislation to pressure fearlessly and effectively the agenda for population stabilization contained in the National population policy 2000. However, there are two specific Acts, which are meant for specific purposes, and these are as under:

The prenatal Diagnostic Techniques (Regulation and prevention Act.) 1994:

The Act and the rules framed there upon came into force on 1st January 1996. The Act prescribes the conditions under which the prenatal diagnostic techniques can be used to diagnose foetal abnormalities. DISCLOSURE OF SEX OF THE FOETUS IS PROHIBITED. Punishments are prescribed for violations of the law.

The pre-natal Diagnostics Techniques (Regulation and prevention of Misuse ) Act is a progressive piece of legislation aimed at eliminating the social evil of female foeticide, which often follows pre-natal sex determination.

Medical termination of pregnancy Act (MTP):

In order to prevent and control morbidity and mortality related to abortion, the Medical termination of pregnancy Act (MTP) was passed by the parliament in 1971, which was implemented form 1st April 1972 all over India except Jammu and Kashmir where it was implemented in November 1976.

The MTP Act, 1971 has stipulated the conditions under which abortions can be done, the persons who can perform the abortions and places where abortions can be done.

The following conditions are specified by the Act

Medical condition of mother

When the mother is suffering from any physical or mental health problems or she is at risk to develop any problem and continuation of pregnancy may endanger mother’s life or may be injurious to her physical and mental health.

Eugenic: when there is a risk of child being born with serious physical or mental handicap because of viral infection, intake of drugs, exposure to x-rays and radiations during pregnancy: incompatibility of blood, insanity etc.

Humanitarian: when pregnancy occurs after rape

Pregnancy: pregnancy due to failure of family planning device being used. This clause allows abortion on request by the women.

Socio-economic conditions such condition which may injure the health of mother. This is another clause, which provides lot of scope for abortion on request.

According to the Act, only authorized Registered Medical practitioner having prescribed experience in OBG can perform the MTP. If the period of pregnancy is below 12 weeks a doctor does the abortion without consulting any other doctor. But if it is above 12 weeks then two doctors together must decide on the need for termination. The termination can be done by any one of the doctors. During emergency situation if the pregnancy is at 20 weeks or above, a single doctor can do the MTP without consulting the second doctor even in an unrecognized clinic or hospital.

It is very important to take written consent of the women. If the women is the minor or in a state of shock or insane then written consent of guardian must be taken. Abortion under the MTP Act 1971 is considered as a personal matter and therefore strict confidentiality is to be maintained by the service providers, identify of the women is to be kept confidential.

The doctor is protected from any legal action for any kind of problem cause or any problem, which is likely to occur because of termination, provided the doctor, and has taken all the precautions and proper care. But if any of the rules are violated, then the doctor is liable for punishment, which may include a fine up to Rs.1000.

Termination of pregnancy on medical and Eugenic basis is good for both mother and child but no consider/use it as method for prevention of unwanted child especially the female child is unethical and antisocial and should be discouraged. Repeated abortions are harmful to mother’s health and lead to high mortality and morbidity. Women should be explained about these and motivated for other methods of contraception.

The MTP Act was amended in 1975. The following amendments were done.

• The Chief District Medical Officer was empowered to certify the necessary qualification for doctor to perform abortions. Earlier it was done by certification Board.
• Qualification required for performance of abortion; a) if RMP has assisted in the performance of 25 MTPs, b) if the doctor has six months of houseman ship in OBG. c) if he has postgraduate qualification in OBG d) if a doctor who graduated before the 1971 Act was enacted, has 3 year experience in OBG e) and those who graduated after the Act were enacted, have 1 year of experience in OBG.
• The Non-Governmental organization (NGO) could also under take the abortion services after taking license from the Chief District Medical Officer.

Despite the MTP Act 1971 (amendment 1975) and the service provision made under it by remote hilly and tribal areas even in urban areas, by persons who are neither skilled nor authorized under the Act.

• The major factors responsible for it are identified as:
• Lack of access to safe abortion clinics due to non-availability of such clinics in rural and remote hilly and tribal areas and lack of financial sources to reach the clinics in urban areas,
• Lack of information about availability of safe abortion services,
• Lack of privacy and impersonal atmosphere in government run clinics or hospitals for MTP services,
• Reluctance of unmarried and widowed women to go to clinics/hospitals.

Pre-abortion care

The first steps in providing care to establish that the women is needed pregnant and, if so, to estimate the duration of the pregnancy and confirm that the pregnancy is intrauterine. The risks associated with induced abortion, through small when abortion is properly performed, increase with the duration of pregnancy (Grimes and castes 1979). Thus determination of the length of pregnancy is a critical factor in selecting the most appropriate abortion method.

Every health service delivery points should have staff trained and competent to take the woman’s history and perform and competent to take the woman’s history and perform a bimanual pelvic examination (internal examination). Health centers not staffed and equipped to provide induced abortion must be able to refer women promptly to the nearest services. Staff should be competent to offer counseling to help the women consider her options.

During physical examination, the health worker should also assess the position of uterus (whether it  is anteverted, retroverted  or otherwise positioned) and rule out sexually transmitted infections (STIs)  and reproductive tract infections (RTIs)  as well as other conditions such as anemia or malaria that may require additional services and procedures or referral for medical attention. In cases where serious cervical pathology is observed, the women should be referred to appropriate facilities for further examination.

Ultrasound scanning

Ultrasound scanning is not necessary for the provision of early abortion (RCOG 2000). Where it is available, ultrasound can aid the detection of ectopic pregnancies beyond about 6 weeks of pregnancy. Some providers find the technology helpful before or during abortion procedures at later stages of pregnancy. Where ultrasound is used, services delivery sites should, if possible, provide separate areas where women seeking abortion can be scanned, away from those receiving prenatal care.

Pre-existing conditions

In addition to confirming and estimating the duration of pregnancy, health workers should obtain  a full medical history and assess other factors that may affect the provision of abortion, and information about any drugs the women is taking that could interact with those to be used during the procedure.

From a clinical point of view, presence of HIV infection in a women-undergoing abortion requires the same precautions as for other medical /surgical interventions. If the women are known to be HIV-positive, she may need special counseling.

Reproductive tract infection (RTIs)

The presence of infection in the lower reproductive tract at the time of abortion is a risk factor for post-procedural RTIs. The routine use of antibiotics at the time of abortion has been reported to reduce the post-procedural risk of infection by half. However, where antibodies are not available for prophylactic use, abortion can be performed. In any case, strict observation of cleaning and disinfections procedures plays an essential role in preventing post-procedural infection:

If clinical signs indicate infection, the women should be treated immediately with antibodies and abortions can then be carried out, where laboratory testing for RTIs is routinely performed and if there are no visible signs of infections, abortion should not be delayed to wait for the test results.

Ecotopic pregnancy

When a fertilized egg settles in a place outside the uterine cavity foetus starts developing in an abnormal position. It is called ectopic pregnancy. Most common places of ectopic pregnancy are fallopian tube, ovary, Douglas pouch( area behind the uterus).

Ecotopic pregnancy can be life-threatening. Signs that might indicate extra uterine pregnancy include uterine size smaller than expected for the estimated length of pregnancy and lower abdominal pain, especially if accompanied by vaginal bleeding and spotting, dizziness or fainting, pallor and, in some women, an adnexal mass, if ectopic pregnancy is suspected, it is essential to confirm diagnosis immediately and initiate treatment or transfer the women as soon as possible to a facility that has the capacity to confirm diagnosis and initiate treatment.

Cervical cytology

An abortion request may be an opportunity for assessing cervical cytology of women, especially when there is a high prevalence of cervical cancer and STIs. However, accepting such services must never be a condition for a woman to obtain an abortion and these services are not required in order to perform abortion safely.

Information and counseling

The provision of information is an essential part of good-quality abortion services, information must be complete, accurate and easy to understand, and be given in a way that respects the woman’s privacy and confidentiality.

Decision –making counseling

Counseling can be very important in helping the women considered her options and ensure that she can make a decision free from pressure. Counseling is voluntary, congenital and provided by a trained person.

If the women opt for abortion, the health workers should explain any legal requirements for obtaining it. The women should be given as much time as she needs to make a decision, even if it means returning to the clinic later. However, the greater safety and effectiveness of early abortion should be explained. The health workers should also provide information for women who decide to carry the pregnancy to term and/or consider adoption, including referral as appropriate.

In some circumstances the women may be under pressure from her partner or other family members to have an abortion. Unmarried adolescents and women who are HIV-infected may be particularly vulnerable to such pressure. All women who are known to be HIV-infected need to know the risk of pregnancy to their own health and the risk of transmission of the virus to their infants. They also need to know about treatments available for themselves and for preventing transmission to infants in order to make an informed decision about whether to continue with the pregnancy or have it terminated, where permitted by law. They may also request additional counseling. If staff know or suspect that the woman has been subjected to sexual violence or abuse they should refer her for other counseling and treatment services as appropriate. Managers should ensure that all staff knows about the availability of such resources in the health system and the community.

Information on abortion procedures

At a minimum, a woman must be given information on:

1. What will be done during and after the procedure
2. What she is likely to experience ( e.g. menstrual-like cramps, pain and bleeding )
3. How long the procedure will take
4. What pain management can be made available to her
5. Risks and complications associated with the method
6. When she will be able to resume her normal activities, including sexual intercourse; and
7. Follow-up care.

If a choice of abortion methods is available, providers should be trained to give women clear information about which methods are appropriate, based on the length of pregnancy and the women’s medical condition and potential risk factors.

Contraceptive information and services

Provision of contraceptive information and services is an essential part of abortion care as it helps the woman avoid unintended pregnancies in the future.

Every woman should be informed that ovulation can return as early as about two weeks after abortion, putting her risk of pregnancy unless an effective contraceptive method is used. She should be given accurate information to assist her in choosing the most appropriate contraceptive method to meet her needs. If the woman is seeking an abortion following what she considers to be a contraceptive failure, the provider should discuss whether the method may have been used incorrectly and how to correct its use, or whether it may be appropriate for her to change to a different method. The final selection of a method however must be women’s alone.

A women’s acceptance of a contraceptive method must never be precondition for providing her an abortion.

Managing abortion complications

When appropriately trained personnel perform abortion, complications are rare. Nevertheless, every service delivery site at every level of the health system should be equipped and have personnel trained to recognize abortion complications and to provide or refer women for prompt care, 24 hours a day (world health organization 1994) facilities and skills required to manage abortion complications are similar to those needed to care for women have had a miscarriages.

Incomplete abortion

Incomplete abortion is uncommon with vacuum aspiration when a skilled provider performs the abortion. It is more common with medical methods of abortion. Signs and symptoms include vaginal bleeding, abdominal pain and signs of infection.

It should also be suspected if, upon visual examination, the tissue aspirated during surgical abortion does not confirm to estimate duration of pregnancy. Staff at every health care facility should be trained and equipped to treat incomplete abortion by re-evacuating the uterus with vacuum aspiration, paying attention to the possibility of hemorrhage or infection.

Failed abortion

Failed abortion can occur in women who have undergone either surgical or medical methods of abortion. If, at the follow-up visit after either type of procedure, the pregnancy is continuing, termination of the pregnancy requires vaccum aspiration or D&E for second-trimester pregnancies.

Hemorrhage

Hemorrhage can result from retained products of conception, trauma or damage to the cervix or, rarely, uterine perforation. Depending on the cause, appropriate treatment may include re-evacuation of the uterus and administration of uterotonic drugs to stop the bleeding, intravenous fluid replacement and in severe cases, blood transfusion laparoscopy or exploratory laparotomy.To reduce of the incidence of hemorrhage it is advised to use oxytocins routinely.If hemorrhage is heavy it constitutes an emergency. However, every service delivery site must be able to stabilize and treat or refer women with hemorrhage as quickly as possible.

Infection

Infection rarely occurs following properly performed abortion. Common symptoms include fever or chills, foul-smelling vaginal or cervical discharge, abdominal or pelvic pain, prolonged vaginal bleeding or spotting, uterine tenderness, and/or an elevated white blood cell count. When infection is diagnosed, health care staff should administer antibiotics and, if retained products of conception are a likely cause of infections, re-evacuate the uterus,. Women with severe infections may require hospitalization. As discussed in section other sections, prophylactic prescription of antibiotics has been found to reduce the risk of post-abortion infection and should provide where possible.

Uterine perforation

Usually, uterine perforation goes undetected and resolves without the need for intervention. A study of more than 700 women undergoing concurrent first-trimester abortion and laparoscopic sterilization found that 12 out of the 14 uterine perforations were so small that they would not have been recognized had laparoscopy not been performed. Where available, laparoscopy is the investigative method of choice. If the laparoscopy examination and/or the status of the patient give rise to any suspicion of damage to bowel, blood vessel or other structures, a laparotomy to repair damaged tissues may not be needed.

Anesthesia –related complications

Local anesthesia is safer than general anesthesia, both for vacuum aspiration in the first trimester and for dilatation and evacuation in the second trimester. Where general anesthesia is used, staff must be skilled in stabilization management of convulsion and impairment of cardio respiratory function. Narcotic reversal agents should always be readily available.

Long-term sequelae

The vast majority of women who have a properly performed induced abortion will not suffer any long-term effects on their general or reproductive health. The exceptions are a proportion of the small number of women who have severe complications of abortion.

Research shows no association between safely induced first-trimester abortion and adverse out comes of subsequent pregnancies. Sound epidemiological data show no increased risk of breast cancer for women and appear to be the continuation of pre-exciting conditions.

Instruction for care after abortion

Women undergoing abortion should receive clear, simple, oral and written instructions about how to care for themselves after leaving the health care facility, including how to recognize complications that require medical attention. While they for a medically induced abortion to be completed, women should be able to contact a physician or other health worker who can answer questions and provide support.

Assessing the current situation

For instance, the assessment may reveal that some providers or potential providers, feel negative about abortion, even where it is legal on request. In this case, programme planners will need to consider ways to ensure that eligible women can access services.

Establishing national norms and standards

Norms and standards should be framed to ensure that good-quality abortion services are available to the extent permitted by law. They should set critical indicators for providing the essential elements of good-quality abortion care delivered by public, private and non-governmental agencies, including

• Types of abortion services and where they can be provided
• Essential equipment, supplies, medications and facility capabilities
• Referral mechanism
• 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

Types of abortion services and where they can be provided

Establishing early abortion services at the primary level can greatly improve access for eligible women. Training and equipping health professional at the primary level to provide early abortion services and to make appropriate referrals may thus be one of the most important investments to consider. Where capacity to provide quality reproductive health services at the primary level dies not an exists, a minimum step is to create effective referral mechanism from primary to higher levels.

Community level

Community-based health workers play an important role in helping women avoid unwanted pregnancy providing information and contraceptives, and informing them about the consequences of unsafe abortion. They also need to be able to inform women how to obtain safe, legal abortion care without undue delay, and refer women with complications of unsafe abortion for appropriate care.

Primary-care facility level

Primary health-care centers generally have basic medical capacity and some trained health care workers. Both vacuum aspiration and medical methods of abortion can be considered at this level, since they do not require overnight stay.

Establishing national norms and standards

Staff likely to include nurses, midwives, health assistants, and in some contexts, physicians. Health personal who have already been trained and have demonstrated ability to perform a bimanual pelvic examination to diagnose signs of pregnancy and to perform a trans cervical procedure such as IUD insertion can be trained to perform vacuum aspiration. Where medical methods of abortion are registered and available, such staff can also administer and supervise the treatment.

As with management of normal birth and spontaneous abortion, referral arrangements must be in place to ensure prompt, higher level of care. If required, for this reason, trained staff should be available on call during and after health center hours, in case of need.

District hospital (first referral) level:

District level facilities should offer all primary-care level abortion services as outlined, even where such services are also available at lower levels of care, specialized elements of care are rarely required for abortion and should  not be a routine part o abortion services delivery, especially where resource are limited. For example, routine use of specialized equipment such as ultrasound for early abortion increase costs to the health system and is not necessary for the provision o early abortion. General anesthesia should not normally be used for early abortion since it increases the risk and costs of the procedure. Hospital should therefore offer abortion care on an outpatient’s basis which is safe minimize costs and enhance convenience to the women.

Secondary and tertiary referral hospitals

Secondary and tertiary hospital should have staff and facility capacity to perform abortions in all circumferences permitted by law and to manage all complications of unsafe abortion. The provision of abortion care at teaching hospitals is particularly important to ensure that relevant cadres of health professionals develop competence in abortion service delivery during clinical training rotations.