National Policy on the Prevention of Illegal and Unsafe Abortion and Management of Post-Abortion Complications

February 6, 2018

DOH ADMINISTRATIVE ORDER NO. 2018-0003

 

I. BACKGROUND AND RATIONALE

An estimated 25% of all pregnancies ended in an induced abortion between 2010-2014 worldwide and each year, between 4.7% to 13.2% of maternal deaths can be attributed to unsafe abortion. (Preventing Unsafe Abortion Fact Sheet, WHO, June 2017).In the absence of data on abortion, this estimation translates to a range of 84 to 236 maternal deaths that can be attributed to illegal and unsafe abortion of the total 1,786 confirmed maternal deaths in the country in 2016. (National Safe Motherhood Program Report, 2016).A maternal death review conducted on the same year found 6 cases of women who died of hemorrhage as a result of abortion. The women were poor, married (except for 1 case),in their 40s, and were on their 4th pregnancy. (Maternal Death Review Report, National Safe Motherhood Program, 2016).

Women seek abortion because of unintended pregnancies. But for the growing number of disadvantaged women and men of reproductive age who wish to regulate their fertility and have fewer children, correct and consistent use of effective contraceptive methods is hard to access. Among others, societal norms, economic conditions, legal obstacles and other systemic factors have a profound impact on a woman's decision to seek abortion and for a Filipino woman, this means illegal and unsafe abortion. aDSIHc

In the light of the absolute prohibition of abortion in the country (Revised Penal Code, Act No. 3815 declares: "Abortion is a Crime in the Philippines") the health sector headed by the Department of Health upholds the right to health of every Filipino while respecting the law. This policy shall therefore strengthen the country's commitment to women's health to deal with the health impact of illegal and unsafe abortion as a major public health concern and to prevent the preference for illegal and unsafe abortion through an improved family planning program implementation and service provision.

II. OBJECTIVE

This Order seeks to provide technical guidance to public health program implementers and service providers in the prevention of illegal and unsafe abortion and the provision of quality post-abortion care in all public and private health facilities in the country.

III. SCOPE OF APPLICATION

This Order shall apply to all providers of family planning and maternal care services in the public and private sector and at all levels of the health care delivery system.

IV. DEFINITION OF TERMS

1. Abortion is the termination of pregnancy before the fetus is capable of extra-uterine life. (Preventing Unsafe Abortion Fact Sheet, WHO June 2017).

2. Unsafe abortion is a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking minimal medical standards or both. (Preventing Unsafe Abortion Fact Sheet, WHO June 2017).

3. Unintended pregnancy is a pregnancy that is either unwanted (that is, the pregnancy occurred when no children, or no more children, were desired) or mistimed (that is, the pregnancy occurred earlier than desired).It mainly results from not using contraception, or inconsistent or incorrect use of effective contraceptive methods. (Preventing Unsafe Abortion Fact Sheet, WHO June 2017).

4. Family Planning Program refers to a program which enables couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so, and to have access to a full range of safe, affordable, effective, non-abortifacient modern natural and artificial methods of planning pregnancy. (Republic Act 10354).

5. Post-abortion Care is an approach for reducing deaths and injuries from incomplete and unsafe abortions and their related complications. It is an integral component of comprehensive abortion care and includes 5 essential elements: 1) treatment, 2) counseling, 3) family planning services, 4) other reproductive health and health services, and 5) community and service provider partnerships. (Ipas. Org)

6. Supportive Counseling is the provision of psychosocial support to women who have had an abortion to enable them to handle the emotional and psychological response to the experience.

7. Audio-Visual Privacy is a health service provision whereby every step is taken to ensure that the client is not seen while undergoing health assessment and physical examination; likewise, the client-health provider conversation is not heard specially during supportive counseling session. This measure protects the client from public scrutiny.

V. GUIDING PRINCIPLES

All health workers implementing family planning and safe motherhood program in communities as well as those providing services in health facilities shall be guided by the following principles: (ICPD 1994,Quoted from: Warriner IK and Shah IH, eds.,Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006).

1. Prevention of unsafe abortion is a safe motherhood intervention. Thus, prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion.

2. Women who have unwanted pregnancies shall have ready access to reliable information and compassionate counseling from health service providers.

3. Women shall have access to quality services for the management of complications arising from illegal and unsafe abortion, free from judgmental, discriminating and degrading treatment. ETHIDa

4. Post-abortion counseling, education and family planning services shall be offered promptly, to help avoid repeat abortions.

VI. SPECIFIC GUIDELINES

Health staff in public and private facilities providing family planning and maternal health services shall be guided by the following in the provision of direct services to clients:

A. The Role of Family Planning in the Prevention of Unintended Pregnancy and Illegal and Unsafe Abortion

1. Efficiently use pregnancy tracking, birth planning, antenatal and postnatal check-ups and other health center-based activities to counsel women and couples on family planning and its benefits.

2. Inform women, especially those in their third pregnancy, about family planning options and provide acceptable contraceptives and counseling services according to individual needs and personal choice.

3. Provide correct information and make available family planning services to adolescents in accordance with the law (Responsible Parenthood and Reproductive Health Law of 2012). At all times, provide non-judgmental, non-threatening counseling to adolescents and their parents.

4. Educate the public including adolescents about the legal status of abortion in the country, the complications of unsafe abortion as well as the benefits of family planning in the prevention of unintended pregnancies, saving women's lives and the promotion quality family life through such activities as: community health education, usapan series on health issues, youth camps and other similar fora.

5. All primary health care facilities shall have a designated room for counseling services and a staff appropriately trained to counsel clients on all health concerns including those with unwanted pregnancies. The counseling room shall be compliant with audio-visual privacy standards to ensure confidentiality.

B. Managing Post-Abortion Complications

 Post-abortion care shall be an integral part of basic and comprehensive emergency obstetric and newborn care (B/CEmONC) and shall include the following elements:

1. Treatment of incomplete and unsafe abortion complications

Complications of unsafe abortion requires emergency care. The major life-threatening complications resulting from unsafe abortion are hemorrhage, infection, and injury to the genital tract and internal organs. Thus —

1) At public birthing centers, the health team headed by the MHO/CHO shall do the following, guided by the BEmONC and referral protocols:

a. Perform an initial assessment and take note of the following signs and symptoms of complications:

a) Vaginal bleeding

b) Abdominal pain

c) Infection

d) Hypovolemic shock

b. Administer loading dose of appropriate life-saving drugs as necessary: oxytocin, antibiotics, anti-convulsants, among others.

c. Make prompt referral and arrange for transport to the nearest facility with CEmONC (comprehensive emergency obstetric and newborn care) capability such as: District Hospitals with Obstetrics and Gynecology Department, Provincial Hospitals, Regional Hospitals and Medical Centers or tertiary private hospitals within the service delivery network where a definitive diagnosis can be made and appropriate care can be delivered quickly.

d. During transport, assign a staff (doctor, nurse or midwife) to accompany the patient and make the necessary endorsements to the health team in the referral facility.

e. While the patient is in transit, the MHO/CHO or an assigned staff shall make an urgent call to the referral hospital to alert the admitting officer or medical officer of the referral.

f. The health staff who accompanied the patient shall make a follow-up of the referred case by making a call to the referral hospital after 24 hours from admission to get an update of the patient's status. The time of call as well as any update on the referred patient's status shall be appropriately recorded in the Family Record or any similar record in the health facility. cSEDTC

g. Upon discharge from hospital confinement, a home visit may be done by the health center nurse or midwife, if desired by the patient. This action is meant to provide continuity of care. The patient's permission for home visit by the Rural Health Unit or health Center Staff shall be sought at the time of hospital discharge. A hospital staff shall notify the RHU or health Center Staff of the discharge and the patient's desire for a home visit and follow-up care.

h. The health center nurse or midwife shall update the Municipal Health Officer (MHO) or City Health Officer (CHO) accordingly.

i. In situations where a doctor or referral facility is not available, nurses and midwives may administer life-saving drugs guided by AO 2015-0020: Guidelines in the Administration of Life-Saving Drugs during Maternal Care Emergencies by Nurses and Midwives in Birthing Centers.

2) In private birthing centers operated by midwives,the following protocol shall be implemented:

a. Perform an initial assessment and take note of the following signs and symptoms of complications:

i. Vaginal bleeding

ii. Abdominal pain

iii. Fever

b. Refer to a tertiary hospital without delay.

i. Arrange for an ambulance or emergency transport to convey the patient to the referral hospital.

ii. Accompany the patient to the referral hospital and properly endorse the patient to the attending physician or nursing staff.

c. Notify the nearest RHU-based birthing center of the referred patient and make the necessary endorsements. This will facilitate after discharge follow ups at home if desired by the patient.

3) At the referral hospital,the ER or admitting staff shall endorse the patient immediately to the Obstetrics and Gynecology Department for the needed examination and management by a specialist.

a. Timely treatment of heavy blood loss is critical for hemorrhaging patients, as delays can be fatal.

b. Patients manifesting signs of infection need to be treated with antibiotics along with evacuation of any remaining pregnancy tissue from the uterus as soon as possible.

c. Patients suspected of having injury to the genital tract and/or internal organs shall be referred to an appropriate department(s) for possible co-management.

2. Supportive Counseling to identify and respond to women's emotional and physical health needs.

1) Primary health care facilities such as RHUs, Birthing Centers, District Hospitals and other community-based hospitals as well as referral hospitals shall provide supportive counseling services to post-abortion clients among others.

2) Supportive counselors shall listen and help post-abortion clients talk about their concerns. The counselor-client relationship shall be respectful, caring and accepting for the healing process to take place and for better appreciation of possible options to address the problem. SDAaTC

3) Supportive counselors can be general practitioners such as MHOs and CHOs, nurses, midwives, social workers, clinical psychologists, general psychologists and psychiatrists.

4) Based on prudent mental health assessment and at the discretion of the facility doctor a patient may be referred to a more specialized provider such as centers for mental health for specialized care.

5) At the referral hospital, supportive counseling shall be done in conjunction with post-abortion care. At the community level, this shall be started after hospital discharge.

3. Contraceptive and family planning services to help women prevent future unintended pregnancies and abortions.

Women who have undergone abortion are at risk of another unintended pregnancy and represent an important group with unmet family planning needs. The following shall therefore be provided in all health facilities:

1) A range of contraceptive methods, accurate information, supportive counseling, and referral for permanent methods shall be made available and accessible to all women who have undergone abortion as desired. (Please refer to Specific Guidelines Item A, and B on Supportive Counseling).

2) Contraceptive protection shall be recommended in the face of the immediate possibility of unintended pregnancy. For a woman who does not want to become pregnant, she or her partner shall be advised to use a contraceptive that will be effective.

3) A supportive counselor shall ensure that the decision to use a contraceptive method, particularly long-term or permanent method, is made at a time when the woman is neither under stress nor in pain and made solely by the woman and if desired, by the couple.

4. Other reproductive and health services that can be provided on-site or referrals to other health facilities within the service delivery network.

1) Post-abortion clients having other reproductive health concerns such as violence against women, gynecologic conditions, cancers, HIV and sexually transmitted infections shall be appropriately managed including referrals to appropriate facility or specialist.

5. To efficiently mobilize resources towards preventing unintended pregnancies and unsafe abortions and to make sure health services meet community expectations, Community and service-provider partnerships shall be configured as follows:

1) The local health system represented by the city/municipal health officer in coordination with local chief executives such as the municipal/city kagawad for health shall build alliance with community leaders, civil society and non-government organizations, religious groups, and other community-based groups to establish support groups including support group for women who had abortion.

2) The support groups shall be appropriately acknowledged by the LGUs through an ordinance or resolution.

6. Services provided at the referral hospital as well as pre-referral services provided at the RHU, Health Center or Birthing Center shall be covered by PhilHealth Benefit Package.

7. The following indicators shall be the indicators for quality post-abortion care and shall be reported as part of the National Safe Motherhood Program Results Matrix starting 2018:

1) Number of women who were referred to and managed at hospitals for post-abortion care disaggregated according to age:

• 10-14 years old

• 15-19 years old

• 20-35 years old

• 36-49 years old

2) Number of women who died as a result of post-abortion complications disaggregated according to the same age groupings in item 1).

VII. REPEALING CLAUSE

This Administrative Order rescinds AO 2016-0041 dated November 25, 2016 and other related issuances which are inconsistent or contrary with the provisions of this Administrative Order. All other provisions of existing issuances which are not affected by this Order shall remain valid and in effect. acEHCD

VIII. EFFECTIVITY

This order shall take effect fifteen (15) days upon publication in the Official Gazette or any newspaper of general circulation.

 

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health