TABLE OF CONTENTS ACKNOWLEDGEMENTS........................................................................................................1 ORGANIZATION OF THIS DOCUMENT................................................................................2 Introduction............................................................................................................................3 1.1 Purpose of this document.................................................................................3 1.2 Background......................................................................................................4 1.3 Three key steps in the research process ........................................................7 Assessing the local context of unsafe abortion................................................9 Designing and testing service-delivery and community interventions using the local context as a foundation..............................................................10 Linking the research findings to policy and practice ......................................11 1.4 Commonly overlooked issues related to unsafe abortion...............................12 1.5 Ethical concerns.............................................................................................12 Privacy and confidentiality..............................................................................12 Informed consent............................................................................................13 Conducting Research..........................................................................................................16 2.1 Introduction.....................................................................................................16 2.2 Developing the research question..................................................................18 2.3 Study designs.................................................................................................20 Choosing a study population..........................................................................22 Time-frame.....................................................................................................23 Sampling techniques......................................................................................23 Interviewer training.........................................................................................25 2.4 Data collection................................................................................................25 Hospital record review....................................................................................25 Individual interviews.......................................................................................26 Group interviews............................................................................................28 Observation....................................................................................................29 Pretesting and modifying data collection instruments....................................29 2.5 Data management..........................................................................................30 2.6 Data analysis..................................................................................................31 2.7 Data dissemination.........................................................................................31 Summing up C linking research results to policy and practice.......................31 Hospital/Health Facility Studies on Unsafe Abortion.......................................................33 3.1 Introduction.....................................................................................................33 3.2 Hospital-based research................................................................................34 Clinical studies...............................................................................................34 Managing the treatment of abortion complications.............................34 Diagnostic studies..........................................................................................35 Documentation and assessment of services......................................35 Monitoring service statistics................................................................35 Patient and provider interviews...........................................................36 Cost assessment and comparison of treating abortion complications37 Hospital intervention studies..........................................................................41 3.3 Hospital studies on unsafe abortion:..............................................................42 Community Studies on Unsafe Abortion...........................................................................48 4.1 Introduction.....................................................................................................48 4.2 Indicators of performance...............................................................................50 4.3 Community research......................................................................................51 4.4 Examples of Community Research Studies...................................................53 GLOSSARY...........................................................................................................................59 Annex 1.................................................................................................................................64 Abortion Care: Actions by level of the health care system....................................................64 Annex 2.................................................................................................................................65 WHO Classification of Abortion..............................................................................................65 Annex 3.................................................................................................................................67 Developing indicators of performance within communities and for health services...............67 Annex 4.................................................................................................................................70 Examples of questions related to unsafe abortions...............................................................70 BIBLIOGRAPHY...................................................................................................................94 ACKNOWLEDGEMENTS This document was compiled and edited by IPAS in Carrboro North Carolina, USA under contract from the World Health Organization, with primary writing and editing by Brooke R. Johnson, Robert E. Gringle, and Traci L. Baird. Judith Winkler, Janie Benson, and Deborah Billings provided expert editorial review and subject matter suggestions. Additional support within IPAS was provided by Forrest Greenslade, Ann Leonard, Ann Gerhardt, Colleen Bridger, and Joan Healy. Graphic design of text figures are the work of Beth L. Rimmer, and Veronica Williams assisted with bibliographic research. The following select group of international health professionals provided invaluable review, revision, and content input: Francine Coeytaux, Henry David, Tomas Frejka, Mihai Horga, Michael Mbizvo, and Kajsa Sunström. The ground-breaking work of Irene Figà-Talamanca on conducting studies on unsafe abortion served as an inspiration and model for this work. 1 ORGANIZATION OF THIS DOCUMENT Chapter 1 of this document provides the reader with an introduction to the steps needed to conduct research on unsafe abortion. Chapter 2 provides information about data collection, management, and analysis, including a description of the basic research tools necessary to conduct research. Chapters 3 and 4 provide literature sources, examples, and various suggestions for conducting local-level, hospital, and community studies on the problem of unsafe abortion. A glossary provides detailed definitions of all words and terms highlighted in bold print in the text. In the annexes readers will find: a list of essential interventions to prevent and manage abortion at different levels of the health care system(Annex 1); the WHO criteria for categorizing induced abortion (Annex 2); issues to consider when developing indicators of performance for health services (Annex 3); and a list of questions that might be asked of patients (Annex 4). Each chapter is referenced with suggested readings that can provide researchers with more detailed information about past studies and more technical aspects of data collection, management and analysis. A complete bibliography concludes the document. 2 Chapter 1 Introduction 1.1 Purpose of this document As part of an effort to provide responsive and comprehensive reproductive health services, an important question must be asked: Is there a problem of unsafe abortion1? If there is, policy-makers, programme managers, and health-care professionals have an obligation to follow up with the question: What can be done to address this problem? Providing answers can lead to initiatives that reduce the incidence of unsafe abortion, while improving women's overall health, and promoting safe motherhood. In many countries, whether or not to provide legal, induced abortion on request or for specified indications is a contentious issue. Countries with legal restrictions or limited access to safe reproductive health services must look beyond the cultural and/or religious debate associated with induced abortion to the public health issues associated with unsafe abortion. Wherever safe abortion is severely restricted, policy-makers and public health officials and providers should assume that there will be high levels of maternal morbidity and mortality. Even where legal abortion or menstrual regulation is allowed, unsafe abortion may be a problem. A quick check of the casualty and female wards in major public hospitals can confirm whether unsafe abortion is a public health problem. However, in most cases, the number of women who report to a hospital or clinic with abortion complications represent only a fraction of the uncounted total number of those who seek to terminate their pregnancy, or experience spontaneous abortion. The purpose of this document is to guide those who have an interest in research studies that will provide a more complete understanding of the problems of unsafe abortion, and in developing practical, humane responses to these problems. This may seem to be an impossibly large undertaking, even for the most dedicated health professional with an interest in women's reproductive health. The design and implementation of large-scale, population-based studies, together with the analysis and dissemination of results is usually considered a complex, time-consuming, expensive and specialized field. The problem of unsafe abortion, however, is often better studied through relatively simple, small-scale research studies. Modest interventions can be implemented, and those with successful outcomes can be expanded into community or even national programmes. This document provides examples of research initiatives and explanations of the tools necessary to implement hospital and community service interventions. 1 Independent of prevailing legislation, an unsafe abortion is defined by the WHO as "... a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both" (WHO, 1993) which therefore exposes the women to an increased risk of morbidity and mortality. 3 Those with little or no research training will find this document useful, as will social scientists who may not have conducted research on the question of unsafe abortion. Throughout the document, the term "researcher" refers to whomever is conducting the research activity under discussion. While acknowledging the benefits of social-science training and experience in data collection to the quality of research results, the researcher referred to in this document may be a medical scientist, an obstetrician/gynaecologist, a nurse/midwife, programme manager, or some other appropriate person with the ability to complete satisfactorily the work and apply the results to reproductive health policies and programmes C regardless of previous research training. This document does not attempt to provide all of the information that is required to carry out large-scale epidemiologic or demographic research. Such information is available through other resources. Nevertheless, the style of research explained in this document can be conducted together with epidemiologic or demographic research to arrive at an understanding of unsafe abortion in the broadest context. This document guides the researcher to conduct practical, small-scale, local-level studies, since the problem of unsafe abortion can be most effectively addressed at this level. This usually means focusing on the district or provincial hospital where most abortion care is provided but study sites may also include sites such as a school, church, or local factory or business. Well planned and well conducted local-level research efforts often lead to an immediate positive impact on the health of women at risk for the damaging consequences of unsafe abortion C a result that is not often tied directly to national studies. The cumulative effects of lessons learned from local-level research can be used to construct effective large-scale regional or national interventions. 1.2 Background In 1967 the World Health Assembly recognized unsafe abortion as a serious health problem.2 However, at that time only limited information was available on the extent of the problem.3 A number of research initiatives were undertaken after 1967 (see David [ed.] 1974), but most ended or were discontinued during the 1980s C a decade marked by the cutting of abortion research funds, censorship of abortion topics, and other efforts to stop or slow down research and action on the issue of abortion (Coeytaux 1988). 2The World Health Assembly Resolution WHA 20.41 stated: "Recognizing that abortion constituted a serious public health problem in many countries, urged WHO to assist member states, upon their request, in the development of family-planning services within the basic health services". 3Figà-Talamanca I. A guidebook for conducting studies on unsafe induced abortion. Unpublished manuscript. 4 International awareness of abortion increased following the 1987 Safe Motherhood Conference in Nairobi that drew attention to the need to reduce maternal mortality and morbidity. As a result, a number of researchers began to collect and make available data on the causes of maternal mortality. The known dimensions of the problem of unsafe abortion are documented in the 1994 second edition of Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion. Worldwide, an estimated 20 million unsafe abortions take place each year, a ratio of one unsafe abortion to every seven births. Many women suffer chronic and often irreversible health problems as a result of complications from unsafe abortion. Globally, an estimated 13% of pregnancy-related deaths C or one in eight C are due to unsafe abortion.4 Nearly 90% of unsafe abortions take place in the developing world.5 In many developing countries as many as one in every four maternal deaths is caused by unsafe abortion. In the words of the WHO Maternal and Newborn Health/Safe Motherhood unit, "The tragedy is all the greater because abortion-related deaths are entirely preventable". In recent times, many countries have liberalized their abortion laws. By 1990, it was estimated that 75% of the world's population lived in countries where induced abortion is permitted on medical or on broader social and economic grounds; however, many women still resort to abortions performed by unskilled providers or in unsafe conditions6 as a result of barriers that impede access to safe abortion. Such barriers include lack of information, distance, economic constraints, and lack of confidentiality. In a number of countries, access to safe, legal induced abortion is either completely prohibited, allowed only to save the woman's life, or permitted only when the pregnancy is the result of rape or incest. Globally, 25% of the world's population live in countries with very restrictive abortion laws where women lack access to safe abortion services.7 Most of these women live in Asia, Africa, and Latin America. In many developing countries, confronting the problem of unsafe abortion has been a low priority for country health planners. Little is known about the short-term and long-term health consequences. Controversies have often led authorities to deny the existence of the problem and to adopt a policy of neglect. Poor abortion-related care is easy to perpetuate where abortion is a forbidden, secretive, or controversial topic. Breaking the cycle of abortion neglect, silence and denial is never easy, and attempting to provide useful research results with little or no funding in hostile settings is especially difficult. Because unsafe abortion is a medical, health-system and social problem, it requires the combined approaches of bio-medical, health-system and social-science research methodologies. The approach used in each setting must be designed specifically to fit particular social, cultural, economic, political and epidemiological conditions. For example, attempts to collect quantifiable data from women seeking care for complications of unsafe abortion may fail because women are reluctant to discuss their experiences 4 World Health Organization. Abortion: a tabulation of available data on the frequency and mortality of unsafe abortion, 2nd. edition. WHO/FHE/MSM/93.13. Geneva, 1994. 5World Health Organization. Complications of abortion: technical and managerial guidelines for prevention and treatment. Geneva, 1995. 6Henshaw SK, Morrow E. Induced Abortion: A world review , The Alan Guttmacher Institute, New York, 1990. 7 Henshaw SK. Induced abortion: a world review. Family Planning Perspectives 1990; 22(2). 5 for fear of negative personal, social, legal, and even medical consequences. In some areas with liberal abortion laws, women, providers and the community may discuss abortion openly, which facilitates research and affects the questions asked. However, even when abortions are legally available for broad indications, there will be instances where secrecy and reluctance to discuss abortion will be encountered. Despite these and other complexities, today more than ever before there is a strong mandate from the international community to address the public health issue of unsafe abortion. Early in 1994, the Advances in Abortion Care8 series published an issue focused on diminishing the negative impact of unsafe abortion by improving postabortion care. In that same year, several organizations joined the Postabortion Care Consortium9 to encourage work in this area. Three key elements of postabortion care were proposed: # emergency treatment services for complications of spontaneous abortion or unsafely induced abortion; # postabortion family-planning services (including counselling and contraceptive method delivery); # links between emergency abortion treatment services and comprehensive reproductive health care.10 Delegates to the United Nations International Conference on Population and Development in Cairo (1994) and the Fourth World Conference on Women in Beijing (1995) adopted resolutions such as paragraph 8.25 of the 1994 International Conference on Population and Development Programme of Action which states: All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Both conferences confirmed the importance of improving care for women who suffer complications of unsafe abortion as an element of reproductive health. The Beijing platform of action further affirmed that: Since unsafe abortion is a major threat to the health and life of women, research to understand and better address the determinants and consequences of induced abortion, including its effects on subsequent fertility, reproductive and mental health and contraceptive practice, should be promoted, as well as research on treatment of complications of abortions and postabortion care. 8Advances in abortion care. Publication available from IPAS, 303 E. Main St., PO Box 100, Carrboro, NC 27510, USA 9 Founding agencies: AVSC International, IPAS, IPPF, JHPIEGO and Pathfinder International 10Greenslade FC, et al. Postabortion care: a women's health initiative to combat unsafe abortion. Advances in Abortion Care, 1994; 4(1). 6