Make safe abortion accessible for displaced, migrant, and refugee women and girls: Part I

International Campaign for Women's Right to Safe Abortion

24 August 2015

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Make safe abortion accessible for
displaced, migrant, and refugee women and girls: Part I

“In any displaced population, approximately 4% of the total population will be pregnant at a given time. Of these pregnant women, approximately 15% will experience an obstetric complication such as obstructed or prolonged labor, pre-eclampsia/eclampsia, sepsis, ectopic pregnancy or complications of abortion.” (Women’s Refugee Commission)

“Girls who experience sexual violence are three times more likely to have an unintended pregnancy and girls under 15 who have experienced sexual violence are five times more likely to die in childbirth.” (Together for Girls)

Data from a case study in Kenya

Inter-Agency Reproductive Health Kits for Crisis Situations
Inter-Agency Working Group (IAWG) on Reproductive Health in Crises, 5th ed, 2011Having essential drugs, equipment and supplies available in a crisis is critical.The first reproductive health kits were developed by Marie Stopes International in 1992, specifically for use during the Bosnian crisis, when thousands of women were sexually abused and there was an urgent need for appropriate medical equipment. The Sexuality and Family Planning Unit of WHO’s Regional Office for Europe then reviewed and updated these kits for a second phase in Bosnia.In 1997, unrest in Albania led to the collapse of the health system, and maternity hospitals urgently requested basic surgical equipment to respond to the reproductive health needs of women. A referral/surgical obstetrics kit was then designed by the Representative of the United Nations Population Fund (UNFPA) in the country, which was intended to be adapted to local situations.A third version of the Kit was assembled by a number of agencies, including the International Federation of Red Cross and Red Crescent Societies, UNFPA, the United Nations High Commissioner for Refugees and the World Health Organization, to respond to the refugee crisis in the Great Lakes Region of Africa in 1997.These experiences led UNFPA to produce a consolidated set of reproductive health kits for use by humanitarian agencies. Further reviews in 2003, 2005 and 2010 led to modification of the contents of the Kits, based on suggestions of users and on newly identified needs. The Kits are now in their fifth version.The IAWG Reproductive Health Kits are complementary to the Interagency Emergency Health Kit, which is designed to meet the primary health care needs of displaced populations without medical facilities. For more information, see: Users are invited to make comments on the revised version of the RH Kit. All inputs will be considered for future revisions.The RH Kits are intended for use from the onset of a humanitarian response. The whole RH Kit actually consists of 12 kits covering different aspects of sexual and reproductive health needs. Kit 8, which deals with abortion, contains sufficient supplies for a three-month period for a population of 30,000.

Kit 8 = Management of miscarriage and complications of abortion
This kit is intended for use over a three-month period for an estimated overall population of 30,000 people. Along with antibiotics and a range of other items, it includes misoprostol in 200 mcg tablets, vacuum aspiration equipment, cannulae and informational materials on their use.
Use: To treat the complications arising from miscarriage (spontaneous abortion) and from unsafe induced abortion, including sepsis, incomplete evacuation and bleeding.
Instructions: Equipment should be used only by health personnel who have been trained to manage miscarriages and the complications of abortion, including performing uterine evacuation.
Target population: The contents of this Kit are based on epidemiological estimates of the number of pregnant women who may have a miscarriage (spontaneous abortion) or suffer complications of unsafe abortion in a three-month period. In the standard kit, enough misoprostol is included for an estimated 60 women, at three tablets each ( or 90 at two tablets each). (Misoprostol: for incomplete abortion treatment is a single dose of 600 mcg orally, OR a single dose of 400 mcg sublingually)

UNFPA is in charge of assembling and delivering the RH Kits. However, because logistics problems can occur in any setting, agencies should not be fully dependent on one source for these supplies. Relief agencies should be prepared by pre-positioning supplies wherever feasible and including RH supplies within their overall medical supply procurement.

Anyone planning to order RH Kits is asked to prepare a plan for in-country distribution of the kits, including how many of which kits go to which partners in which geographical areas. It should also include detailed plans for in-country transport and storage, which cadres of health personnel will use the kits, and provisions for items that need to be kept cool (cold-chain). To order the kits or to send comments/suggestions about their contents:

Shattered Lives: MSF Video, 7 March 2009
Young girls from Burundi, Colombia and other countries tell the story of the sexual violence that happened to them. (6:42 min)MSF Policy on providing safe abortion in humanitarian settings
Question & answer: from MSF website MSF provide birth control and abortions as part of your programs? What are your criteria?
MSF policy includes the provision of contraceptives and safe abortion care as part of the response to women’s and girls’ health needs. Unwanted pregnancy and unsafe abortion contribute significantly to ill health and mortality among girls and women. Unsafe abortion is one of the main causes of maternal mortality worldwide. Contraceptives are offered in all relevant projects and whenever local considerations allow it.The treatment of abortion-related complications and the termination of pregnancy to save a woman from a life-threatening complication are part of all MSF obstetric care.The decision on whether to provide termination of pregnancy on request at a specific project is taken very carefully – the safety of patients and staff is our first concern. The relevant laws, customs and perceptions have to be considered on a case by case basis.What is your position on abortions?
MSF does not have a political position on abortions. We see the consequences of unsafe abortion as a medical issue: unsafe abortions cause suffering and death and contribute to the overall burden of ill health.

Do you provide abortions in all of your programs? What about in countries where abortion is illegal?
Our aim is to reduce suffering and death in places that are affected by conflict and crisis. If the life of the mother is threatened, the physician must come to a decision with the patient or her family.
If the life of the mother is not immediately in danger, but she wants to terminate her pregnancy for whatever reason, MSF weighs all the relevant factors and decides whether or not we can offer safe abortion care. This can be a difficult decision because we have seen time and time again that in the absence of safe abortion care women will seek to terminate an unwanted pregnancy by other means, and unsafe abortions very often lead to more suffering and even death. However, providing this service in some places can present a risk to patients and staff. We assess the risks to our patients and staff in order to make this decision. The relevant laws, customs and perceptions have to be considered on a case by case basis.

Do you have a policy on when you can perform an abortion (weeks into pregnancy)?
Termination of pregnancy on request in MSF projects is supported until the end of the first trimester. Termination of pregnancy at a later gestational age may be considered in exceptional cases.

Does MSF provide the morning after pill?
Yes. When a girl or woman approaches MSF with the fear of being pregnant, as result of forced sex, sexual violence, failure of a contraceptives or any other reason, MSF will assess if emergency contraception is an option and provide it if it is the choice of the patient.

Does MSF encourage abortion for any other reason that for the health of the woman?
MSF does not encourage abortion at all. The termination of pregnancy is solely the choice of the woman or girl. MSF does not have abortion as an objective; MSFs objective is to prevent the consequences of unsafe abortion. Given all evidence, women who decide that they cannot keep a pregnancy will find a way to terminate this pregnancy, even if this will put their life at risk. MSF aims to reduce the consequences of unsafe abortion.

To work with MSF do doctors in the field have to be willing to perform abortions?
MSF staff members have to understand and agree with the MSF policy for reproductive health, including the policy on abortion. It is, however, the personal choice of each medical professional to perform or not to perform an abortion. Medical staff who personally do not want to perform an abortion are not excluded from MSF – they are assigned to positions where it is not required for them to perform an abortion.

MSF Staff Blogs
“[In Central African Republic,] the abortion rate has risen drastically, many unwanted pregnancies being a result of the war crime of gang rape.” Alison Criado-Perez, 14 May 2014.

To escape the war people fled their homes in the Central African Republic capital Bangui. Women wait to receive relief supplies, 7 January 2014

… Much more challenging than [delivering] babies [in Central African Republic] is the situation with unwanted pregnancies. A subject often considered as taboo, but responsible for a high proportion of maternal deaths. On my very first day in the capital, Bangui, a woman presented to the hospital with an abortion. Already in septic shock, she died.

The reality for women here, where contraception is either hard to access or not accepted (for example by a husband or mother-in-law) is that abortion is the other form of birth control, but one that comes with high risks. Often performed in the community by “traditional” methods the women come to us with signs of poisoning, trauma, or overdoses of conventional medicines. The illegality of all this means that getting any reliable history from the patient is like blood from a stone, leaving us to make presumptions and guesses. And at the end of it all, often the pregnancy remains.

Together with my midwife counterpart we are training the staff here to recognise and react to the women presenting with abortion complications. Having workshops for our national colleagues on the signs of sepsis and emergency treatment, running regular drills in the department and increasingly giving the responsibility of management to them.

Together we are making sure that, whatever the reason, these women get quick access to life-saving treatment and procedures. And just like getting those babies out, this is met with a genuine enthusiasm, so much so that we have now accomplished a major milestone; national staff providing training to the other staff. Skills not just learnt, but being transferred too.

Benjamin Black, 29 July 2015


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