National Policy on the Prevention and Management of Abortion Complications (PMAC)

November 25, 2016

DOH ADMINISTRATIVE ORDER NO. 2016-0041

 

I. BACKGROUND/RATIONALE

Maternal mortality and morbidity due to complications from unsafe abortion is a public health, medical ethics and human rights issue. The latest data available on abortion reflects an estimated 610,000 unsafe abortions, over 100,000 hospitalizations, and 1000 deaths of women due to abortion-related complications each year (Alan Guttmacher Institute (AGI), Unintended Pregnancy and Induced Abortions in the Philippines: Causes and Consequences, page 3, 2013). Majority of these women are poor, married, Catholic and already have at least three children (Singh S et al., Unintended Pregnancy and Induced Abortion in the Philippines: Causes and Consequences, New York: Guttmacher Institute, 2006). This translates to about 70 women who induced abortion every hour, 11 women hospitalized every hour and three women who die every day from unsafe abortion complications (AGI, Meeting Women's Contraceptive Needs in the Philippines, 1 In Brief 2 (2009); citing 2008 projections from 2000 statistics on abortion incidence in the Philippines).

To address the harmful impact of unsafe abortions in the country and contribute to the reduction in maternal mortality to meet the Philippines commitment to the Sustainable Development Goals to decrease the maternal mortality ratio to two-thirds of 2010 levels, a policy on the Prevention and Management of Abortion and its Complications (PMAC) is needed to ensure safe and quality post abortion care enhanced with humane, respectful, non-judgmental, and compassionate approach to care. This new PMAC policy supersedes AO No. 45-B s. 2000.

II. OBJECTIVES

This Order is aimed to set overall policy directions and identify the roles and functions of Department of Health (DOH), its offices and partner agencies in the provision of quality post-abortion care in hospitals and all health facilities both public and private in the service delivery system. It shall also provide the guidelines for the integration of PMAC in the Reproductive Health (RH) programs.

III. SCOPE

This Order shall apply to all heads of public and private health facilities, healthcare providers (doctors, nurses and midwives) properly trained in any of the levels of post-abortion care, local government units (LGUs) and other relevant and concerned stakeholders.

IV. GENERAL GUIDELINES

1. PMAC includes comprehensive preventive and medical health care services on the following six key elements:

a. Prevention of threatened abortion;

b. Treatment of complications from spontaneous and induced abortion;

c. Counseling;

d. Family planning including contraceptive services;

e. Linking PMAC services to other Reproductive Health Services including STI evaluation and treatment, and HIV counseling and testing, and cancer screening; and

f. Integration of PMAC in the Service Delivery Network

2. Women and girls suffering abortion complications are entitled to humane, nonjudgmental, and compassionate post-abortion care, hence, no woman or girl shall be denied appropriate care and information on the ground that she is suspected to have induced an abortion. CAIHTE

3. PMAC shall be integrated into the DOH Safe Motherhood Program of the Women, Men and Children's Health Development Divisions (WMCHDDs) and MNCHN offices in the DOH Regional Offices (ROs) and LGUs. PMAC shall be included in existing emergency hotlines to provide information on PMAC services.

4. PMAC information shall be integrated into the Safe Motherhood indicators to be adapted from the form provided in Annex C which shall contain the type of abortion and services rendered following the existing quarterly reporting mechanism under the RPRH Law. The national repository of annual PMAC data shall be at the DOH WMCHDDs.

5. Training of PMAC providers must ensure that they have the competencies to provide quality, gender-responsive and culture sensitive healthcare services in accordance with national standards and guidelines. Ensuring quality PMAC care requires quality training, ongoing supervision, quality assurance, monitoring, and evaluation. The PMAC training may be a stand-alone training, or integrated into the BEmONC or CEmONC training.

6. To ensure continuity of the program, training of service providers and trainers on PMAC, provision of IEC materials, operational support (e.g., commodities, logistics) and regular supportive supervision of trained providers and monitoring and evaluation shall be regularly conducted.

V. SPECIFIC GUIDELINES

1. Prevention of threatened/spontaneous abortion

Prevention of abortion is a major component of the PMAC program. This involves early (1) prenatal care of at least 4 prenatal care visits, (2) facility based delivery, (3) patient education on the dangers, causes and proper management of vaginal bleeding during pregnancy and (4) referral of a high-risk pregnancy to the appropriate health care facility.

2. Treatment of complications from spontaneous and induced abortion

Only doctors, nurses and midwives trained and certified to provide PMAC services are allowed to perform some level of post abortion care including vacuum aspiration (VA) and manual vacuum aspiration (MVA) for uncomplicated 1st trimester spontaneous abortion. To be able to increase availability of PMAC services throughout the country, improvement in the quality and range of care at every level of a health care facility is needed.

Protocols and standardized training are essential in the management of abortion per level of health care facility (Please see details in Annexes A and B) and shall include the following:

2.1 Initial quick assessment of the type of abortion (1>1 Trimester, 211d Trimester, Spontaneous, Incomplete, Septic, Induced etc.) and need of emergent care.

2.2 Stabilization of emergency conditions and treatment of any complications (prior, during or after treatment procedures)

2.3 Prompt referral and transfer of patients requiring higher level of care based on initial assessment/evaluation conducted.

2.4 Counselling of the patient on her medical condition and treatment plan.

2.5 Conduct of appropriate procedures by trained health care provider of the following:

2.5.1 Uterotonics

2.5.2 Vacuum aspiration (VA) I manual vacuum aspiration (MVA)

2.5.3 Sharp curettage if without access to VA/MVA cannula or if without available trained personnel to perform VA/MVA

2.6 Diagnosis and treatment of infection and severe complications.

2.7 Institutional safeguards and protocols that ensure patient confidentiality, privacy, protection of women's human rights.

2.8 Provision of PMAC Information, Education and Communication (IEC) materials;

2.9 Provision of family planning and the full range of reproductive health methods and commodities.

Comprehensive Emergency Obstetric and Newborn Care (CEmONC) and tertiary care facilities providing PMAC services shall endeavor to establish a team with a designated Post-Abortion Care (PAC) Officer of the day who will supervise the service providers assigned for PMAC services. The PAC Officer post will be rotated among the members of the team. DETACa

3. Counseling

3.1 All PMAC service providers shall be trained on counseling to enable them to use communication and counseling skills to perform these tasks with due consideration on the patient's rights to confidentiality and informed consent and the principle of informed choice and voluntarism.

3.2 Counseling in the context of post-abortion care shall be provided for the patient before and after the procedure and may include the following concerns as appropriate:

3.2.1 Condition, diagnosis, prognosis

3.2.2 Procedural benefits and risk/s

3.2.3 Reproductive Intention

3.2.4 Family Planning

3.2.5 Psychosocial concerns

3.3 Counseling should probe on other RH concerns that the patient may have that would require appropriate management or referral

4. Family planning including contraceptive services

A full range of family planning and contraceptive services shall be made available to everyone as stipulated in the RPRH Law. For the post-abortion cases, immediate initiation of family planning services shall be provided based on individual assessment. A period of six months is advised before the next pregnancy for optimal outcome. Proper referral and follow-up shall also be practiced.

5. Linking PMAC services to Other Reproductive Health Services including STI evaluation and treatment, and HIV counseling and testing, and cancer screening;

The provision of PMAC services shall be linked with other reproductive health services that involve STI evaluation and treatment, HIV testing and counselling and cancer screening.

6. Integration of PMAC in the Service Delivery Network

The Service Delivery Network (SDN) in communities shall integrate PMAC services in their health system and shall be on active surveillance for post abortion cases in the vicinity. Appropriate treatment, management, reinforcement and follow-up of post abortion cases shall be provided.

7. Conscientious objections and the requirement of third party authorization do not apply to PMAC cases since such cases fall under emergency cases under Republic Act 8344. Hence, it is unlawful for health service providers to refuse to provide PMAC services on the basis of conscientious objections or require third party authorization before providing such services. However in Family Planning provision, the conscientious objector may refer the patient to other accessible service providers.

8. All health care providers, health facility support staff, counselors, social workers, BHWs, CHTs and all other service providers dealing with women and girls with threatened abortion, spontaneous and induced abortion, and suffering from abortion complications are duty-bound to maintain the confidentiality and privacy of the women and girls and shall take into account that there is no law requiring service providers to report women and girls suffering abortion complications to the law enforcement authorities. PMAC providers who provide humane, nonjudgmental and compassionate post abortion care shall not be liable for criminal, civil and administrative complaints.

VI. IMPLEMENTING MECHANISM

A. ROLES AND RESPONSIBILITIES

1. DOH CENTRAL OFFICE

1.1. Women, Men and Children's Health Development Divisions (WMCHDDs) — Formerly Family Health Office (FHO), shall perform the following:

- Lead and oversee the implementation of this policy.

- Mobilize national, local and international community support for capacity development on PMAC.

- Conduct regular assessment, monitoring and evaluation. aDSIHc

- Develop guidelines for the Regional Office arrangements with the Local Government Units and the Private Sector.

1.2. Health Facilities Development Bureau (HFDB) — shall ensure data availability and information system in PMAC facilities

1.3. Health Facilities and Services Regulatory Bureau (HFSRB) — regulate facilities' based on PMAC protocols and standards.

1.4. Health Human Resource Development Bureau (HHRDB) — shall collaborate relevant trainings for specific categories of health workers and technical assistance and expert services.

1.5. Health Promotion and Communication Service (HPCS) — shall develop complete and accurate IEC materials on the risks of unsafe abortion and importance of post-abortion care. These shall be addressed to policymakers, government and non-government agencies, and private sectors including media, the general public and other stakeholders to eliminate the stigma commonly faced by abortion patients.

1.6. Bureau of Local Health Systems Development (BLHSD) — shall provide technical assistance in the enhancement /strengthening of the existing referral system between health facilities. They shall assist LGUs through the DOH ROs in the mobilization of support for the implementation of this policy.

1.7. Knowledge Management Information Technology Services (KMITS) — shall provide technical assistance in the development and maintenance of a hotline and media platform for reporting and monitoring of PMAC services.

2. PHILIPPINE HEALTH INSURANCE CORPORATION (PhilHealth)

• Shall ensure the congruence of this policy with existing and upcoming PhilHealth policies

• Create/utilize/improve appropriate benefit package that will support the strict implementation of these standards

• Provide support for advocacy on the protocol and the PhilHealth benefit package

3. DOH REGIONAL OFFICES

• The DOH Regional Offices shall be tasked to monitor the implementation of PMAC services in the DOH retained hospitals, the LGUs and coordinate with private hospitals and facilities in the area. The DOH Regional Offices shall submit to regional PMAC data to the WMCHDDs on a quarterly basis and shall explore partnership agreements with the private sector to provide technical assistance and provide PMAC services.

4. DOH HOSPITALS

• Ensure training, supportive supervision and mentoring of all personnel at all levels of facilities

• Monitor and evaluate the implementation of PMAC and submit PMAC data to the DOH ROs on a quarterly basis.

5. LOCAL GOVERNMENT UNITS

Provide support for advocacy

• Ensure budgetary appropriation towards PMAC and related activities in line with the National Objectives for Health

• Ensure complete and timely reporting of data

6. NON-GOVERNMENT ORGANIZATIONS, PROFESSIONAL GROUPS, OTHER NATIONAL GOVERNMENT AGENCIES/ORGANIZATIONS AND PRIVATE SECTORS

1.8. Shall participate in the National Technical Working Group on PMAC ETHIDa

1.9. Partners in the resources provision, training, dissemination, monitoring and evaluation of the implementation of the PMAC guidelines

B. MONITORING AND EVALUATION

The national repository of annual PMAC data shall be at the DOH WMCHDDs. The following data shall be integrated in the regular monitoring of the Safe Motherhood Program:

1. Delivery of rights-based, gender-responsive, culture-sensitive and non-judgmental PMAC services in DOH hospitals, LGU hospitals and, where available, primary health care facilities

2. Allocations for PMAC where it can be disaggregated from Safe Motherhood program

3. Number of PMAC providers trained per year

PMAC shall be included in the Annual RPRH Law Accomplishment Report.

C. FUNDING MECHANISM

Funding of this program shall be from the regular budget of the WMCHDDs with support from partner offices or agencies as mentioned in Section VI.1.

VII. PENALTY CLAUSE

Criminal, civil, and administrative complaints for violation of the PMAC AO may be filed with the Reproductive Health Officer (RHO) of the hospital, hospital director or head of the health facility, local government administrator, DOH WMCHDDs, the Civil Service Commission, Philippine Medical Association, and Professional Regulations Commission. Anonymous complaints naming the institution, medical provider, date and time of the incident are allowed.

Relevant government offices shall provide free legal assistance to the complainant and provide protection against retaliatory actions and suits.

VIII. REPEALING CLAUSE

The provision of previous Orders and other related issuances inconsistent or contrary with the provisions of this Administrative Order, including AO 45-B s 2000, are hereby repealed. All other provisions of existing issuances which are not affected by this Order shall remain valid and in effect.

IX. EFFECTIVITY

This order takes effect fifteen (15) days upon publication in an official gazette.

(SGD.) PAULYN JEAN B. ROSELL-UBIAL, MD, MPH, CESO II

Secretary of Health

ANNEX A

PMAC services are divided into three (3) based on the level of health care facility. Below tables summarize the PMAC services appropriate at each level of health care facility:

Table 1: Community Level Provider (e.g. BHS)
Service Provider	1. Trained Barangay Health Workers (BHWs)
available	2. Community Health Teams (CHTs)
PMAC services	1. Recognition of signs and symptoms of abortion and abortion available complications;
	2. Rights-based, gender-responsive, culture-sensitive, non-
	judgmental and humane handling of client; and
	3. Prompt referral to facilities where treatment is available
Competencies	IEC Skills
Equipment/Supplies	1. IEC materials
	2. Recording logbook
Follow-up care	1. Referral for further counseling and possible use of FP methods
	2. Provision of IEC materials
	3. Referral to appropriate facility for other RH concerns
Table 2: RHU, Private Clinics (MCP accredited), Lying-in Facilities (Basic Emergency
Obstetric and Newborn Care (BEmONC) and non-BEmONC)
Service Provider	1. Trained and Certified Nurses
available	2. Trained and Certified Midwives
	3. Trained and Certified General Practitioners
PMAC services	Above activities, plus:
available	1. History and PE to establish the diagnosis and recognize
	emergencies
	2. Institute appropriate clinical management, including IV hydration,
	provision of uterotonics or antibiotics when indicated
	3. Prompt referral to facilities where treatment is available in cases
	requiring higher level of care
	4. Anti-tetanus serum injection
	5. Counseling on return to fertility, birth spacing and provision of
	IEC materials
	6. Evacuation by VA/MVA in cases of uncomplicated 1st trimester
	incomplete abortion, non-septic, non-induced
	7. 1st trimester induced abortion, complicated spontaneous abortion,
	and 2nd trimester abortion whether induced or spontaneous are
	referred to a higher level facility
Competencies	Clinically diagnose the type of abortion and recognizing complications
	as well as counselling and IEC skills
Equipment/Supplies	1. VA/MVA kits and uterotonics and other drugs used for post-
	abortion care
	2. IV needs
Follow-up care	1. Counseling
	2. Provision of appropriate Family Planning method
Table 3: Level 1 Hospitals
Service Provider	1. Trained and Certified Nurses
available	2. Trained and Certified Midwives
	3. Trained and Certified General Practitioners
	4. OB-Gynecologists
PMAC services	Above activities, plus:
available	1. History and PE to establish the diagnosis and recognize
	emergencies
	2. Institute appropriate clinical management, including IV hydration,
	provision of uterotonics or antibiotics when indicated
	3. Prompt referral to facilities where treatment is available in cases
	requiring higher level of care
	4. Anti-tetanus serum injection
	5. Counseling on return to fertility, birth spacing and provision of
	IEC materials
	6. Evacuation by VA/MVA in cases of uncomplicated 1st trimester
	incomplete abortion, non-septic, septic, non-induced
	7. 1st trimester induced abortion, complicated spontaneous abortion,
	and 2nd trimester abortion whether induced or spontaneous are
	referred to a higher level facility
Competencies	Clinically diagnose the type of abortion and recognizing complications
	as well as counseling and IEC skills
Equipment/Supplies	1. VA/MVA kits and uterotonics and other drugs used for post-
	abortion care
	2. IV needs
Follow-up care	1. Counseling
	2. Provision of appropriate Family Planning method
Table 4: Level 2 and 3 Hospitals
Service Provider	1. Trained and Certified Nurses
available	2. Trained and Certified Midwives
	3. Trained and Certified General Practitioners
	4. OB-Gynecologists
PMAC services	In addition to the above activities which may be done by trained and
available	certified midwives and nurses, the following should be done by
	trained and certified doctors:
	1. Uterine evacuation of retained products of conception whether
	by MVA or sharp or suction curettage or uterotonic depending
	on the age of gestation (AOG)
	2. Treatment of severe complications including bowel injury,
	sepsis, renal failure
	3. Treatment of clotting disorders
	4. Diagnosis and treatment of infection, and severe complications
	such as septicemia, peritonitis, renal failure, bowel injury, which
	would require laparotomy, diagnosis and treatment of clotting
	disorders, renal failure correction of anemia; blood crossmatching
	and transfusion, anti-tetanus serum injection, among others;
	5. Provision of IEC return to fertility and birth spacing counseling
	and Provision of IEC materials
Competencies	1. Familiarity with different types of abortion, complications and
	appropriate management or able to refer to proper provider
	2. Familiarity with different methods of family planning including
	post abortal IUD; able to counsel patient on method best for her
Equipment/Supplies	1. MVA, sharp curettage sets uterotonics and other drugs used for
	post-abortion care
	2. laparotomy sets (hysterectomy sets)
	3. anesthesia machine and needs
	4. appropriate IV antibiotics and IV needs
	5. blood transfusion capability
	6. laboratory capability
	7. anti-tetanus serum
	8. Educational materials on different FP methods
Follow-up care	1. Counseling
	2. Provision of appropriate Family Planning method

ANNEX B

Key steps for the management of abortion and its complications

Type of	Presentation	History	Assessment of Patient	Treatment
Abortion
Threatened	Woman or girl of	• Dates of LMP and	• Stable vital signs	Conservative
Abortion	reproductive age who:	previous normal	• Examination of heart,	management
	• Has history of delayed	menstrual period	lungs, abdomen and	• Complete bed rest
	menses	• Duration and amount of	extremities	with sexual
	• Has vaginal bleeding	bleeding	• Vaginal bleeding	abstinence
	• May or may not have	• Severity of cramping and	• Uterine enlargement	• Tocolytics
	abdominal cramping	location of abdominal	• Closed cervix
	or lower abdominal	pain		Expectant management
	pain	• History of contraceptive
		use
		• Bleeding or clotting
		disorder
Incomplete	Above presentation plus:	Above history plus:	• Cervix is open	• Stabilize the patient
Abortion, non-	• Passage of meaty	• History of passage of	• Meaty tissue in the	(IV hydration,
septic, non-	tissue/fetal parts per	meaty material	vaginal canal	uterotonics, and
induced	vagina	• History of continued	• Light to moderate	antibiotics if
	• Continued bleeding	cramping	vaginal bleeding	indicated
			• Profuse vaginal	• Uterine evacuation
			bleeding leading to	by appropriate
			severe anemia or	method
			hypotension	• Refer to a facility
				with blood
				transfusion (BT)
				capability after
				stabilizing the
				patient (IV fluids,
				uterotonics)
Incomplete	Above presentation plus:	Above history plus:	• Open cervix	• Stabilize the patient
abortion, septic,			• Uterine or adnexal	(IV fluids
induced	History of manipulation or	History of manipulation or	tenderness	uterotonics, IV
	instrumentation	instrumentation	• Foul discharge	antibiotics
			• Fever	• Refer to a facility
	fever and chills	History of intake of	• In severe cases such	capable of
		abortifacient	as in sepsis, or	managing sepsis,
	foul vaginal discharge		uterine perforation or	DIC, and able to
			bowel perforation	perform
	severe abdominal pain		patient may have	laparotomy, blood
			unstable vital signs,	transfusion and
			renal failure,	dialysis
			sensorial changes,
			acute abdomen, or
			clotting disorder

 

ANNEX C

PREVENTION AND MANAGEMENT OF ABORTION COMPLICATIONS REPORT FORM

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________________________________

(Reporting Date)

No.	Name	Age	Address	Final Diagnosis	Management
1
2
3
4
5
6
7
8
9
10

 

Prepared by:

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Approved by:

__________________________________________

Noted by:

__________________________________________ cSEDTC