REPUBLIC OF GHANA Prevention & Management of Unsafe Abortion: Comprehensive Abortion Care Services Standards and Protocols I Third Edition April 2012 Foreword In addressing national and international goals of to in pregnancy termination and the increasing use of reducing unacceptably high maternal mortality medication abortion (Using “Cytotec” misoprostol) in and morbidity, it has become necessary to urban areas. improve all aspects of policies, standards and protocols. In Ghana, unmet need for Family Planning is In response to the objectives of the National RH Policy 35% (GDHS 2008), prevalence of induced abortion is and Standards, there is the need to extend services 7% (GMMS 2007) and complications of unsafe beyond postabortion care, to include the provision of abortion contribute 22 to 30 percent of all maternal quality comprehensive abortion care services to the deaths in our leading referral hospitals. extent permitted by law including strengthened contraceptive services. These standards and protocols Postabortion care is an integral part of Safe provide technical and managerial guidance for the Motherhood programmes and non-physicians, provision of quality services. It is an integral part of the specifically midwives' use of manual vacuum Reproductive Health Protocols. aspiration in the management of incomplete abortion has been demonstrated, widely disseminated and This document has been put together by a team of adopted internationally and in Ghana (more than a national experts with technical assistance from Ipas decade ago). However the problem of unsafe abortion and WHO, Geneva. The second edition has been continues to occur in alarming proportion and updated to among others take cognisance of the currently is the second leading cause of maternal advances made in medication abortion, strengthen death in Ghana. postabortion contraceptive services and make the document more reader friendly. Ghana Health Even though the law in Ghana permits abortion under Services is grateful to Ipas, WHO and all individuals and certain circumstances, and the National Reproductive organizations that have contributed to its Health Policy and Standards in the component of development Prevention and Management of Unsafe abortion and Post abortion Care has an additional objective “to It is my hope and desire that these will be put to use to provide abortion care services as permitted by law”, improve reproductive health services, improve access to safe legal abortion services are still maternal health outcomes and reduce maternal inadequate or lacking in many settings despite the mortality and morbidity in Ghana. advances made in the last 5 years. Findings of a strategic assessment of abortion and abortion care services in 2005 and subsequently the Ghana Maternal Mortality Study of 2007, confirmed the ”culture of silence" on abortion, the clandestine ..................................................... nature and high cost of services, the lack of knowledge DR. FRANK NYONATOR of the law by health workers and the general public, Ag. Director General, Ghana Health Service the many dangerous methods women and girls resort March 2012 Prevention & Management of Unsafe Abortion 03 Foreword In addressing national and international goals of to in pregnancy termination and the increasing use of reducing unacceptably high maternal mortality medication abortion (Using “Cytotec” misoprostol) in and morbidity, it has become necessary to urban areas. improve all aspects of policies, standards and protocols. In Ghana, unmet need for Family Planning is In response to the objectives of the National RH Policy 35% (GDHS 2008), prevalence of induced abortion is and Standards, there is the need to extend services 7% (GMMS 2007) and complications of unsafe beyond postabortion care, to include the provision of abortion contribute 22 to 30 percent of all maternal quality comprehensive abortion care services to the deaths in our leading referral hospitals. extent permitted by law including strengthened contraceptive services. These standards and protocols Postabortion care is an integral part of Safe provide technical and managerial guidance for the Motherhood programmes and non-physicians, provision of quality services. It is an integral part of the specifically midwives' use of manual vacuum Reproductive Health Protocols. aspiration in the management of incomplete abortion has been demonstrated, widely disseminated and This document has been put together by a team of adopted internationally and in Ghana (more than a national experts with technical assistance from Ipas decade ago). However the problem of unsafe abortion and WHO, Geneva. The second edition has been continues to occur in alarming proportion and updated to among others take cognisance of the currently is the second leading cause of maternal advances made in medication abortion, strengthen death in Ghana. postabortion contraceptive services and make the document more reader friendly. Ghana Health Even though the law in Ghana permits abortion under Services is grateful to Ipas, WHO and all individuals and certain circumstances, and the National Reproductive organizations that have contributed to its Health Policy and Standards in the component of development Prevention and Management of Unsafe abortion and Post abortion Care has an additional objective “to It is my hope and desire that these will be put to use to provide abortion care services as permitted by law”, improve reproductive health services, improve access to safe legal abortion services are still maternal health outcomes and reduce maternal inadequate or lacking in many settings despite the mortality and morbidity in Ghana. advances made in the last 5 years. Findings of a strategic assessment of abortion and abortion care services in 2005 and subsequently the Ghana Maternal Mortality Study of 2007, confirmed the ”culture of silence" on abortion, the clandestine ..................................................... nature and high cost of services, the lack of knowledge DR. FRANK NYONATOR of the law by health workers and the general public, Ag. Director General, Ghana Health Service the many dangerous methods women and girls resort March 2012 Prevention & Management of Unsafe Abortion 03 References Ministry of Health, Republic of Ghana. 2006. Prevention and Management of Unsafe Abortion: Comprehensive Abortion Care Services: Standards and Protocols. Accra, Ghana. Mueller M et al. 2011. Antibiotic prophylaxis for medical and surgical first-trimester induced abortion. Cochrane Database of Systematic Reviews, in press. Neilson JP et al. 2010. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database of These evidence-based protocols were developed using the following as the main reference documents: Systematic Reviews. (1):CD007223. Baird, Traci L., Laura D Castleman, Robert E Gringle and Paul D Blumenthal. 2007. Clinicians guide to second-trimester Newmann SJ et al. 2010. Cervical preparation for second trimester dilation and evacuation. Cochrane Database of abortion, Second Edition. Chapel Hill, NC, Ipas. Systematic Reviews. (8):CD007310. Grossman D, Grindlay K. 2011. Alternatives to ultrasound for follow-up after medication abortion: a systematic Partnership for Maternal, Newborn & Child Health. 2011. A Global Review of the Key Interventions Related to review. Contraception. 83(6):504–510. Reproductive, Maternal, Newborn and Child Health (RMNCH). Geneva, Switzerland: PMNCH. Hyman, Alyson G. and Laura Castleman. 2005. Woman-centered abortion care: Reference manual. Chapel Hill, Promsonthi P, Preechapornprasert D, Chanrachakul B. Nitric oxide donors for cervical ripening in first-trimester NC, Ipas. surgical abortion. Cochrane Database of Systematic Reviews, 2009, (4):CD007444. Ipas. 2010. Safe abortion care (SAC) toolkit. Chapel Hill, NC: Ipas. Republic of Ghana.1992. Constitution of the Republic of Ghana. Accra, Ghana. Jackson E, Kapp N. 2011. Pain control in first-trimester and second-trimester Medical termination of pregnancy: a systematic review. termination of pregnancy: a systematic review. Contraception. 83:116–126. Renner RM et al. 2009.Pain control in first trimester surgical abortion. Cochrane Database of Systematic Reviews. (2):CD006712. Lohr PA, Hayes JL, Gemzell-Danielsson K. 2008. Surgical versus medical methods for second trimester induced abortion. Cochrane Database of Systematic Reviews. (1):CD006714. Say L et al. 2010. Medical versus surgical methods for first trimester termination of pregnancy. Cochrane Database of Systematic Reviews. (1):CD003037. Kapp, N. et al. 2010. Cervical preparation for first trimester surgical abortion. Cochrane Database of Systematic Reviews. (2):CD007207. Tunçalp O, Gülmezoglu AM, Souza JP. 2010. Surgical procedures for evacuating Incomplete miscarriage. Cochrane Database of Systematic Reviews. (9):CD001993. Kulier R et al. 2001. Surgical methods for first trimester termination of pregnancy. Cochrane Database of Systematic Reviews. (4):CD002900. UNICEF, UNFPA, WHO, and World Bank. 2010. Packages of interventions: Family planning, safe abortion care, maternal, newborn and child health. Geneva, Switzerland. Kulier R et al. 2004. Medical methods for first trimester abortion. Cochrane Database of Systematic Reviews (1):CD002855, updated 2010. Wildschut H et al. 2011. Medical methods for mid-trimester termination of pregnancy. Cochrane Database of Systematic Reviews., (1):CD005216. Kulier R, Kapp N. 2011.Comprehensive analysis of the use of pre-procedure ultrasound for first- and second- trimester abortion. Contraception. 83:30–33. World Health Organization. 1992. The prevention and management of unsafe abortion. Report of a Technical Working Group. WHO/MSM/92.5. Geneva, World Health Organization. Ministry of Health, Republic of Ghana. 1999. National Reproductive Health Service Protocols. Accra, Ghana. World Health Organization. 2000. Managing complications in pregnancy and childbirth: A guide for midwives Ministry of Health, Republic of Ghana. 2003. National Reproductive Health Service Policy and Standards, 2nd Edition. and doctors. Geneva, Switzerland: WHO. Accra, Ghana. http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf Ministry of Health, Republic of Ghana. 2008. National Safe Motherhood Protocol. Accra, Ghana. World Health Organization. 2003. Safe abortion: Technical and policy guidance for health systems. Geneva, World Health Organization. 04 Ghana Health Service Prevention & Management of Unsafe Abortion 05 References Ministry of Health, Republic of Ghana. 2006. Prevention and Management of Unsafe Abortion: Comprehensive Abortion Care Services: Standards and Protocols. Accra, Ghana. Mueller M et al. 2011. Antibiotic prophylaxis for medical and surgical first-trimester induced abortion. Cochrane Database of Systematic Reviews, in press. Neilson JP et al. 2010. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database of These evidence-based protocols were developed using the following as the main reference documents: Systematic Reviews. (1):CD007223. Baird, Traci L., Laura D Castleman, Robert E Gringle and Paul D Blumenthal. 2007. Clinicians guide to second-trimester Newmann SJ et al. 2010. Cervical preparation for second trimester dilation and evacuation. Cochrane Database of abortion, Second Edition. Chapel Hill, NC, Ipas. Systematic Reviews. (8):CD007310. Grossman D, Grindlay K. 2011. Alternatives to ultrasound for follow-up after medication abortion: a systematic Partnership for Maternal, Newborn & Child Health. 2011. A Global Review of the Key Interventions Related to review. Contraception. 83(6):504–510. Reproductive, Maternal, Newborn and Child Health (RMNCH). Geneva, Switzerland: PMNCH. Hyman, Alyson G. and Laura Castleman. 2005. Woman-centered abortion care: Reference manual. Chapel Hill, Promsonthi P, Preechapornprasert D, Chanrachakul B. Nitric oxide donors for cervical ripening in first-trimester NC, Ipas. surgical abortion. Cochrane Database of Systematic Reviews, 2009, (4):CD007444. Ipas. 2010. Safe abortion care (SAC) toolkit. Chapel Hill, NC: Ipas. Republic of Ghana.1992. Constitution of the Republic of Ghana. Accra, Ghana. Jackson E, Kapp N. 2011. Pain control in first-trimester and second-trimester Medical termination of pregnancy: a systematic review. termination of pregnancy: a systematic review. Contraception. 83:116–126. Renner RM et al. 2009.Pain control in first trimester surgical abortion. Cochrane Database of Systematic Reviews. (2):CD006712. Lohr PA, Hayes JL, Gemzell-Danielsson K. 2008. Surgical versus medical methods for second trimester induced abortion. Cochrane Database of Systematic Reviews. (1):CD006714. Say L et al. 2010. Medical versus surgical methods for first trimester termination of pregnancy. Cochrane Database of Systematic Reviews. (1):CD003037. Kapp, N. et al. 2010. Cervical preparation for first trimester surgical abortion. Cochrane Database of Systematic Reviews. (2):CD007207. Tunçalp O, Gülmezoglu AM, Souza JP. 2010. Surgical procedures for evacuating Incomplete miscarriage. Cochrane Database of Systematic Reviews. (9):CD001993. Kulier R et al. 2001. Surgical methods for first trimester termination of pregnancy. Cochrane Database of Systematic Reviews. (4):CD002900. UNICEF, UNFPA, WHO, and World Bank. 2010. Packages of interventions: Family planning, safe abortion care, maternal, newborn and child health. Geneva, Switzerland. Kulier R et al. 2004. Medical methods for first trimester abortion. Cochrane Database of Systematic Reviews (1):CD002855, updated 2010. Wildschut H et al. 2011. Medical methods for mid-trimester termination of pregnancy. Cochrane Database of Systematic Reviews., (1):CD005216. Kulier R, Kapp N. 2011.Comprehensive analysis of the use of pre-procedure ultrasound for first- and second- trimester abortion. Contraception. 83:30–33. World Health Organization. 1992. The prevention and management of unsafe abortion. Report of a Technical Working Group. WHO/MSM/92.5. Geneva, World Health Organization. Ministry of Health, Republic of Ghana. 1999. National Reproductive Health Service Protocols. Accra, Ghana. World Health Organization. 2000. Managing complications in pregnancy and childbirth: A guide for midwives Ministry of Health, Republic of Ghana. 2003. National Reproductive Health Service Policy and Standards, 2nd Edition. and doctors. Geneva, Switzerland: WHO. Accra, Ghana. http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf Ministry of Health, Republic of Ghana. 2008. National Safe Motherhood Protocol. Accra, Ghana. World Health Organization. 2003. Safe abortion: Technical and policy guidance for health systems. Geneva, World Health Organization. 04 Ghana Health Service Prevention & Management of Unsafe Abortion 05 World Health Organization. 2003. Maternal and Neonatal Health: A Guide for Doctors and Midwives. Geneva, World Acknowledgements Health Organization. World Health Organization. 2011. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 3rd ed. Geneva, World Health Organization. This standards and protocols document has been The Ghana Health Service would like to acknowledge prepared jointly, and in different stages, by the Ghana the participation and valuable contributions of Health Service/Ministry of Health and several institu- participants and resource persons at the consensus tions and individuals with an interest and building workshop on the standards. commitment in reducing maternal mortality. 1. Prof. Fred T. Sai Presidential Advisor on Population and HIV/AIDS 2. Dr Robert Sagoe Ghana Medical Association 3. Mrs. Cynthia Bruce-Smith Komfo Anokye Teaching Hospital 4. Ms. Kathlyn P.P Ababio Ghana Registered Midwives Association/Nurses & Midwives Council 5. Ms. Edna Kuma African Women Lawyers Association 6. Ms. Perfect Pearl Bleboo Retired Midwifery Tutor /Consultant 7. Mrs. Mary Dampson Head, Public Health Nursing School 8. Dr. T.N. Awua Siaw Director, Institutional Care Division, Ghana Health Service 9. Dr. Kofi Ahmed Chief Medical Officer, Ministry of Health 10. Dr. Caroline Jehu-Appiah Deputy Director Policy Planning Monitoring and Evaluation Division, GHS 11. Dr. Joseph. E. Taylor Obs/ Gynaecologist, Regional Health Administration, Eastern Region 12. Dr. Ali Samba Obs/ Gynaecologist, UGMS, Korle- Bu Teaching Hospital 13. Prof P.K. Nyame Rector,Ghana College of Physicians & Surgeons/Ghana Medical & Dental Council 14. Mrs. Gladys Kankam Retired Midwifery Tutor /Consultant 15. Dr Sylvia Deganus Obs/ Gynaecologist, Tema General Hospital, GHS 16. Dr. Sophia Winful District Director, GHS/Eastern Region 17. Dr. Richard B. Turkson Legal Consultant, Ipas 18. Lawrence Aduonum-Darko Consultant 19. Ms. Marian Amissah Health Promotion Unit, GHS 20. Mrs. Mary Arday-Kotei Deputy Director, Health Promotion Unit, GHS 21. Mrs. Mercy Offei Deputy Director of Nursing Services, Obs/Gyn Dept. KBTH 22. Mrs. Ernestina Djokotoe President, Ghana Registered Midwives Association 23. Dr. A. Arkutu Country Director, Pathfinder International 24. Mrs. Nana Oye Lithur CHRIAG/AWLA 25. Ms. Ruby Akua Aglagoh AWLA 26. Mrs. Elizabeth Obeng-Yeboah Dept. of Women (MOWAC) 27. Mr. Fred Yao Gbagbo National Population Council Secretariat 28. Dr. Charles Fleischer-Djoleto WHO, Ghana 06 Ghana Health Service Prevention & Management of Unsafe Abortion 07 World Health Organization. 2003. Maternal and Neonatal Health: A Guide for Doctors and Midwives. Geneva, World Acknowledgements Health Organization. World Health Organization. 2011. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 3rd ed. Geneva, World Health Organization. This standards and protocols document has been The Ghana Health Service would like to acknowledge prepared jointly, and in different stages, by the Ghana the participation and valuable contributions of Health Service/Ministry of Health and several institu- participants and resource persons at the consensus tions and individuals with an interest and building workshop on the standards. commitment in reducing maternal mortality. 1. Prof. Fred T. Sai Presidential Advisor on Population and HIV/AIDS 2. Dr Robert Sagoe Ghana Medical Association 3. Mrs. Cynthia Bruce-Smith Komfo Anokye Teaching Hospital 4. Ms. Kathlyn P.P Ababio Ghana Registered Midwives Association/Nurses & Midwives Council 5. Ms. Edna Kuma African Women Lawyers Association 6. Ms. Perfect Pearl Bleboo Retired Midwifery Tutor /Consultant 7. Mrs. Mary Dampson Head, Public Health Nursing School 8. Dr. T.N. Awua Siaw Director, Institutional Care Division, Ghana Health Service 9. Dr. Kofi Ahmed Chief Medical Officer, Ministry of Health 10. Dr. Caroline Jehu-Appiah Deputy Director Policy Planning Monitoring and Evaluation Division, GHS 11. Dr. Joseph. E. Taylor Obs/ Gynaecologist, Regional Health Administration, Eastern Region 12. Dr. Ali Samba Obs/ Gynaecologist, UGMS, Korle- Bu Teaching Hospital 13. Prof P.K. Nyame Rector,Ghana College of Physicians & Surgeons/Ghana Medical & Dental Council 14. Mrs. Gladys Kankam Retired Midwifery Tutor /Consultant 15. Dr Sylvia Deganus Obs/ Gynaecologist, Tema General Hospital, GHS 16. Dr. Sophia Winful District Director, GHS/Eastern Region 17. Dr. Richard B. Turkson Legal Consultant, Ipas 18. Lawrence Aduonum-Darko Consultant 19. Ms. Marian Amissah Health Promotion Unit, GHS 20. Mrs. Mary Arday-Kotei Deputy Director, Health Promotion Unit, GHS 21. Mrs. Mercy Offei Deputy Director of Nursing Services, Obs/Gyn Dept. KBTH 22. Mrs. Ernestina Djokotoe President, Ghana Registered Midwives Association 23. Dr. A. Arkutu Country Director, Pathfinder International 24. Mrs. Nana Oye Lithur CHRIAG/AWLA 25. Ms. Ruby Akua Aglagoh AWLA 26. Mrs. Elizabeth Obeng-Yeboah Dept. of Women (MOWAC) 27. Mr. Fred Yao Gbagbo National Population Council Secretariat 28. Dr. Charles Fleischer-Djoleto WHO, Ghana 06 Ghana Health Service Prevention & Management of Unsafe Abortion 07 29. Mrs. Mildred Ampadu-Mensah Regional Health Directorate /Greater Accra Regions We also wish to acknowledge Dr. Gloria Quansah- 30. Ms. Mary Amoateng Nurses & Midwives Council Asare and Mr. Stephen Ntsua of the Reproductive and 31. Dr. Gloria Quansah Asare Reproductive & Child Health Unit, GHS Child Health Unit of the Ghana Health Service and Mrs. 32. Mr. Stephen Ntsua Reproductive & Child Health Unit, GHS Josephine Addy of Ipas Ghana Office for coordinating 33. Mrs. Josephine Addy Ipas, Ghana the activities. 34. Mr. Kofi Asare Ipas, Ghana 35. Mrs Patience Boni Municipal Health Directorate, Tema The development of these standards and protocols have been made possible under the leadership and FOREIGN PARTICIPANTS support of Professor Agyeman-Badu Akosa, Director General of the Ghana Health Service, Professor F. T. Sai 35. Mr. Fermando Diez deleon Ipas Mexico and Dr. Eunice Brookman-Amissah. Their commitment 36. Ms. Christine Kaseba University Teaching Hospital, Zambia to the cause of reducing maternal morbidity and 37. Ms. Hawa Shekararu Ipas Nigeria mortality due to complications of unsafe abortion is 38. Dr. Ronnie Jonhson World Health Organization –Headquarters Geneva commendable. RESOURCE PERSONS/FACILITATORS 39. Ms. Mary Luke Ipas NC 40. Dr Eunice Brookman Amissah Ipas Africa Alliance 41. Ms. Patty Skuster Ipas Chapel Hill 42. Ms. KatherineTurner Ipas NC 43. Ms.Charlotte Hord Smith Ipas NC 44. Ms. Tamara Braam Ipas Africa Alliance 45. Nuniye Ortali World Health Organization –Headquarters Geneva 46. Helena von Hertzen World Health Organization –Headquarters Geneva Second Edition Reviewed By: Dr. Gloria Quansah Asare - Director FHD The Ghana Health Service wishes to acknowledge the We are grateful for the technical support provided by Dr. Patrick K Aboagye - Deputy Director, FHD, in charge of RCH invaluable efforts and commitment of the technical the resource persons from Ipas and WHO Geneva. Dr. Baffour Opoku - Dept. Obst & Gynae (KATH) team of Ghanaian experts who drafted the initial Special thanks go to Dr. Richard B. Turkson for the legal Dr. Emmanuel Srofenyo - Dept. Obst & Gynae, Ridge Hostpital standards and protocols document. expertise provided throughout. Special Thanks also go Dr Devine Banyubala - Medico legal Dept, GHS to Ms. Karen Otsea for assisting with the finalization of Dr. Koma Jehu-Appiah – Ipas Ghana They are: the document. Dr. Joseph C. Mills - Ipas Ghana Mrs. Cynthia Bruce-Smith, Ms. Perfect Blebo, Mrs. Mrs. Josephine Addy - Ipas Ghana Gladys Kankam, Dr. Patrick K. Aboagye, Dr. Sylvia The Ghana Health Service is sincerely grateful to Ipas Dr. Ali Samba - Dept. of Obst and Gynae, KBTH Deganus and Dr. Joe Taylor. for funding for the development and printing of this Dr. Joseph E. Taylor - Obstetrician Gynaecologist document. Dr. Dalia Brahmi, Ipas NC Further reviews and finalization were conducted by Dr. Laura Castleman, Ipas NC this team and others - Professor F.T. Sai, Dr. Robert Ms. Mary Fjerstad, Ipas NC Sagoe, Mrs. Mary Dampson, Mrs. Mercy Offei, Ms. Dr. William Powell, Ipas NC Kathlyn Ababio, Dr. Ali Samba, Mrs. Josephine Addy Ms. Patty Skuster, Ipas NC and Dr. Gloria Quansah Asare. Ms. Katherine L. Turner, Ipas NC 08 Ghana Health Service Prevention & Management of Unsafe Abortion 09 29. Mrs. Mildred Ampadu-Mensah Regional Health Directorate /Greater Accra Regions We also wish to acknowledge Dr. Gloria Quansah- 30. Ms. Mary Amoateng Nurses & Midwives Council Asare and Mr. Stephen Ntsua of the Reproductive and 31. Dr. Gloria Quansah Asare Reproductive & Child Health Unit, GHS Child Health Unit of the Ghana Health Service and Mrs. 32. Mr. Stephen Ntsua Reproductive & Child Health Unit, GHS Josephine Addy of Ipas Ghana Office for coordinating 33. Mrs. Josephine Addy Ipas, Ghana the activities. 34. Mr. Kofi Asare Ipas, Ghana 35. Mrs Patience Boni Municipal Health Directorate, Tema The development of these standards and protocols have been made possible under the leadership and FOREIGN PARTICIPANTS support of Professor Agyeman-Badu Akosa, Director General of the Ghana Health Service, Professor F. T. Sai 35. Mr. Fermando Diez deleon Ipas Mexico and Dr. Eunice Brookman-Amissah. Their commitment 36. Ms. Christine Kaseba University Teaching Hospital, Zambia to the cause of reducing maternal morbidity and 37. Ms. Hawa Shekararu Ipas Nigeria mortality due to complications of unsafe abortion is 38. Dr. Ronnie Jonhson World Health Organization –Headquarters Geneva commendable. RESOURCE PERSONS/FACILITATORS 39. Ms. Mary Luke Ipas NC 40. Dr Eunice Brookman Amissah Ipas Africa Alliance 41. Ms. Patty Skuster Ipas Chapel Hill 42. Ms. KatherineTurner Ipas NC 43. Ms.Charlotte Hord Smith Ipas NC 44. Ms. Tamara Braam Ipas Africa Alliance 45. Nuniye Ortali World Health Organization –Headquarters Geneva 46. Helena von Hertzen World Health Organization –Headquarters Geneva Second Edition Reviewed By: Dr. Gloria Quansah Asare - Director FHD The Ghana Health Service wishes to acknowledge the We are grateful for the technical support provided by Dr. Patrick K Aboagye - Deputy Director, FHD, in charge of RCH invaluable efforts and commitment of the technical the resource persons from Ipas and WHO Geneva. Dr. Baffour Opoku - Dept. Obst & Gynae (KATH) team of Ghanaian experts who drafted the initial Special thanks go to Dr. Richard B. Turkson for the legal Dr. Emmanuel Srofenyo - Dept. Obst & Gynae, Ridge Hostpital standards and protocols document. expertise provided throughout. Special Thanks also go Dr Devine Banyubala - Medico legal Dept, GHS to Ms. Karen Otsea for assisting with the finalization of Dr. Koma Jehu-Appiah – Ipas Ghana They are: the document. Dr. Joseph C. Mills - Ipas Ghana Mrs. Cynthia Bruce-Smith, Ms. Perfect Blebo, Mrs. Mrs. Josephine Addy - Ipas Ghana Gladys Kankam, Dr. Patrick K. Aboagye, Dr. Sylvia The Ghana Health Service is sincerely grateful to Ipas Dr. Ali Samba - Dept. of Obst and Gynae, KBTH Deganus and Dr. Joe Taylor. for funding for the development and printing of this Dr. Joseph E. Taylor - Obstetrician Gynaecologist document. Dr. Dalia Brahmi, Ipas NC Further reviews and finalization were conducted by Dr. Laura Castleman, Ipas NC this team and others - Professor F.T. Sai, Dr. Robert Ms. Mary Fjerstad, Ipas NC Sagoe, Mrs. Mary Dampson, Mrs. Mercy Offei, Ms. Dr. William Powell, Ipas NC Kathlyn Ababio, Dr. Ali Samba, Mrs. Josephine Addy Ms. Patty Skuster, Ipas NC and Dr. Gloria Quansah Asare. Ms. Katherine L. Turner, Ipas NC 08 Ghana Health Service Prevention & Management of Unsafe Abortion 09 Contents Purpose Of The Document These Standards and Protocols have been written to address the knowledge and PART I: STANDARDS 14 service gaps in Ghana. The goal of publishing this document is to facilitate the provision of a package of services called Comprehensive Abortion Care (CAC) that SECTION ONE: INTRODUCTION 15 will reduce unwanted pregnancy and abortion-related maternal morbidity and Overview 15 mortality. This document is directed to health providers and service managers. It Objectives of Comprehensive Abortion Care (CAC) 15 contains guidance on how, by whom and in which facilities CAC services should Guiding Principles for the implementation of CAC services 16 be provided, all of which is based on sound, current evidence of safe medical practice and the laws of Ghana. SECTION TWO: TYPES OF SERVICES AND WHERE THEY CAN BE PROVIDED 19 Uterine evacuation methods 19 Table 2.1: Methods of abortion 20 Providers and services suitable to different levels of the health care system 21 PART II: CLINICAL PROTOCOLS 22 SECTION ONE: INITIAL ASSESSMENT AND REFERRAL TO SERVICES 23 Provided at all facility levels SECTION TWO: SAFE INDUCED ABORTION: PRE-PROCEDURE CARE 24 Provided at all Registered Health Care Facilities equipped with trained health providers and necessary infrastructure, per Standards for Comprehensive Abortion Care (Appendix 2) Step 1: Establish rapport with the client, determine her needs and reasons for her visit 24 Step 2: Take client history 24 Step 3: Conduct Pre-Abortion Counselling on pregnancy options 25 Step 4: Perform assessment 26 Step 5: Counselling on abortion methods/techniques 26 Table 2.1: Characteristics of abortion methods during the first 12 weeks of pregnancy 27 Step 6: Provide counselling on post-abortion contraception and method provision 28 Step 7A: Provide counselling on pain management options 29 Table 2.2: Sources of pain and pain management 30 Step 7B: Create a Personalised Pain Management Plan with client 31 Step 8: Confirm that the decision to have abortion still stands 31 Step 9: Obtain informed consent 31 Step 10: Perform laboratory and other investigations, if available and necessary 31 Step 11: Administer pre-procedure medications 31 Step 12: Prepare to perform safe abortion using recommended method 31 10 Ghana Health Service Prevention & Management of Unsafe Abortion 11