Unsafe Abortion Situational Analysis

UNSAFE ABORTION SITUATIONAL ANALYSIS

in

SyriaArabRepublic

Dr Asmaa Abdulsalam1, Dr Salah Cheikha1, Dr Reem Dahman2, Dr. Aisha Jabre2

1 Syrian Society of Obstetrics and Gynecology

2 Syrian Ministry of Health

UNWANTED PREGNANCIES and unmet needs :-

• Incidence of unwanted pregnancies

According to a recent study sponsored by the Ministry of Health (MOH 2006), unwanted pregnancy was (159/ 886) =17.9% calculated from the women recently giving birth and not satisfied with having the last child.

• Vulnerable groups (refugees, internally displaced populations, youth, HIV positive women, etc)

There are not specific data for those groups

It is important to mention that all the studies and surveys done in Syria were conducted on married women , It is very critical topic to ask non married girls about their sexual relations and contraception use as sexual relationships are supposed to be restricted only to marriage either civil or religious.

Unmet needs are defined in all Syrian surveys and studies as the women who are capable of or think that they are capable of being pregnant (including the women who are currently pregnant and do not want the current pregnancy) and wish either to stop or postpone pregnancy,but at the same time these women do not use any method of contraception.

There are data from three different studies: The PAPFAM Survey carried out in 2002 (3) among married women in the 15-49 years age group; the Multi Indicators Cluster Survey done in 2006 (MICS 2006) also among married women 15-49 years old; and the study conducted by MOH 2006 on 10.000 women (1):

Table 1 summarizes the results from these three studies

Table 1. Evaluation of unmet needs for contraception in Syria
Unmet needs / STUDY
PAPFAM2002 / MOH2006 / MIC 2006
No more children / 14,1 / 14,5 / 6,2
Spacing / 16,5 / ? / 4,8
Risk Factors
Rural women / + / + / +
Illiterate women / + / + / +
Illiterate husband / ? / + / ?
Age 20-24 / ? / ? / +
Poor / ? / ? / +
Province Duran / ? / ? / +
Province El Rakka / ? / ? / +
High parity / + / ? / ?

While the PAPFAM 2002 and the MOH 2006 study show practically the same percentage of women who did not desire any more children (14.1 vs 14.5) a reduction in that unmet need is suggested by the data of the MIC 2006 study that shows a reduction in both, the percentage of women who do no want more children and who intend to space them,which may reflect the improvement in the contraception services beside other cultural and educational factors.

INTERVENTIONS TO PREVENT UNWANTED PREGNANCIES AND INDUCED ABORTIONS ( increase use of contraception through working more on quality of care and decreasing failure rate , adapting the WHO guidelines as regard Abortion and post abortion complications management in Syrian health centers.

Contraceptive information and services including EC

• Overall and method specific prevalence rate

The contraceptive prevalence among married women 15 to 49 years old was the subject of one study in 2002 and of two different studies in 2006. These studies showed marked increase of around 8 percentage points, in the use of modern contraceptive methods between the surveys conducted in 2002 and 2006. The difference in total use of any method was greater than for modern methods, but that may be influenced by the lack of registration of “withdrawal” in the 2002 survey.

In both years the intra uterine device was the most popular modern contraception method used in Syria, followed by Pills.Table 2 summarizes the results from these three studies

Table 2. Prevalence of contraceptive use per 100 married women aged 15-49, according to three different studies. Syria, 2002 and 2006
Methods / STUDY
PAPFAM2002 / MOH2006 / MIC 2006
IUD / 20.0 / 24.0 / 25.7
Pills / 12.3 / 11.8 / 12.9
Injections / -- / 1.3 / 0.9
Female sterilization / 1,2 / 2.4 / 1.2
Vasectomy / 0.03 / --
Condom / 1.6 / 2.7 / 1.6
Cervical cap / -- / 0.6 / 0.2
Total modern methods / 35.1 / 42.8 / 42.5
Periodic abstinence / 8.6 / 9.6 / 9.2
Withdrawal / -- / 6.6 / 1.7
Lactation Amenorrhea / 1.8 / 5.3 / 4.0
Current use of any method / 46.6 / 64.3 / 58.3

Use of contraception was highly associated with degree of education, provinces and women age, both in the PAPFAM 2002 and the MOH 2006 surveys

In the MOH 2006 survey, Suwyeda was the province with the highest prevalence of contraceptive use (74.9%) among the other Syrian provinces and also, where the unmet needs were the lowest, of only 6.4%.

The prevalence of contraception use among illiterate women was the only 45% compared to 71% among highly educated women, in the same survey

• Which methods are approved and sold in the country?

It is of importance to mention that till now all contraceptive methods are not allowed by Syrian law. In spite of that, all methods are “de facto” approved but the MOH, however, it is to be noted that Emergency contraceptive pills forms are not available in Syria and not prescribed. Consequently, there is a need to regulate this law

• Which methods are distributed for free or at subsidized price through public or private health networks in the country?

The Syrian government is ensuring that all contraceptive methods are available, free of charge of to every village all over Syria. However, there are not specific studies to evaluate if the methods are always available at the clinic level or there are occasional discontinuation of supplies.

• Which is the real availability of methods in the public health services

The PAPFAM STUDY in 2002 and the study conducted by MOH in 2006 evaluated the participation of the different health sectors is in the provision of contraceptive methods. In both studies the main contraceptive provider were the primary health care centers followed by the private clinics. The public sector, including public health care centers and hospital provided between 47 and 46% of the contraceptive methods in both studies, although in 2006 the primary health care centers increased their participation while the hospitals decreased. At the same time the private clinic decreased their participation while the pharmacies increased their percentage (Table 3)

Table 3. Participation of the various health sectors on the provison of contraceptive methods.

CONTRACEPTIVE PROVIDER / PAPFAM2002 / MOH 2006
Primary health care centers / 38.9 / 43.4
Public hospitals / 8.2 / 3.2.
Private clinic / 31.3 / 25.8.
Pharmacy / 10.6 / 14.6.
Private hospitals / 2.8 / 4.7.
Family Planning Clinics / 4.9 / 3.0

• What data are available on access to methods by young people, unmarried women and othermarginalized groups (rural people, indigenous groups, refugees IDPs).

No data available about unmarried women, however every person can get the contraception methods without being asked if he/she is married or not.

ll methods are available all over SYRIAthrough widespread of medical services ( either private or public including pharmacies) even in most rural areas

The data available as regard of why women do not use contraception in spite of lack of desire to get pregnant :-Lack of knowledge forms only 3% of the reasons, “The methods are not available or costly”is the reason given for not using contraceptives by less than 1%, which reflects the availability of all methods free of charge all over Syria

Comprehensive Sexuality Education

• What is the current situation of knowledge among women and men on sexuality education?

This is a very critical issue in the community

• Are there governmental programs for comprehensive sex education?
• How comprehensive is the coverage of sexuality education programs? Out of school youth?

Still there is no governmental effort in the field of sexuality education except for HIV AIDS program and the availability of voluntary counseling in the main 4 centers in the country

• How comprehensive and adequate is the training of teachers to provide sexuality education?

There is no program for training and the qualified persons in this field are very few in the whole country

Social protection of pregnant women and mothers of small children

• Is employment of pregnant women protected by law during pregnancy and after delivery and for how long?

The employment of pregnant women is protected by law during pregnancy and after delivery for the following period Syrian labor law (4) :-Women could not be fired from their jobs once they get pregnant.

• How long is the legal parental leave? Is it paid? Is it the same for all populations within the country?

Mothers are allowed 4 months maternal leave for the first child, 3 months for the second and 2.5 month for third child, completely paid.After that they can get one month 80% paid

After the fourth child they do no longer have the right to get maternal leave. They can get leave, but will not be paid at all.

• Is maternal breast feeding effectively protected for working women?

Every lactating woman can benefit from one hour lactation /day. In order to fulfill with the law, they are allowed either to arrive to work one hour later or to leave one hour earlier.

In addition, any employee has the right to have 5 years off of his work not paid without loosing her/his position.

In addition working women are protected by other legal rules: By law each woman has the right to be employed regardless of being married or pregnant.By law women should not be employed in hard heavy dangerous work and, women under 18 years old should not work beyond 8 o'clock in the night except under exceptional conditions

• How is the compliance with the law on parental leave and maternal breast feeding?

There is no data on the level of compliance of the law

• Are there sufficient whole day nurseries, preschool and school for the children of working women?

No hard data on this issue was found

Adoption

• Is there support for women who wish to give baby to adoption?
• Is there an effective procedure for adoption in the country?

(Information on this point is missing)

ABORTION:-

• Incidence

The incidence of induced abortion was estimated in 3.9% according to the MOH 2006 study 18.8% of women reported one spontaneous abortion, 14.3% reported two or more spontaneous abortions while 67% had no history of abortion. The incidence of induced abortion may be underestimated because unmarried women were not included. Induced abortion was defined in the studyas the termination of pregnancy according to the wish of the woman or her husband.

Although the world experience shows that the abortion rate obtained through face to face interview are invariable underestimated, particularly in countries where abortion is legally and morally condemned, the responsible for the study defend their results sustaining that from the feedback they got from the data collectors in the field during the study there was no difficulty in getting the answers about induced abortion although it is sensitive and socially undesirable It was planned to start asking about non sensitive socially desirable questions then came to the abortion questions, it was also planned that the data collectors teams are composed of one female and one male and the female was the person responsible for asking the questions and filling the questionnaires. The data collectors were well trained on the questionnaire used in addition they themselves have good experience in household surveys , understanding the community and even the dialect used in each region in Syria. Even when the pregnancy is not planned and unwanted, in many cases the women continue their pregnancies for many reasons: for example, doctors can convince the women to continue because induced abortion is not allowed on religious reasons, many of the families accept the pregnancy at the end,because abortion is considered (HARAM) not allowed and they will be punished by GOD,and sometimes the costs are beyond their capacities. Or even they start using some drugs but then they fail in terminating the pregnancy and they continue to the end

Based on all of the above, the figure maybe higher than the 3.9% found in the study, but never as high as the 20% estimated by others.

• Sources of data

National study conducted in 2006 among 10000 women, executed by MOH, under the supervision of Professors from DamascusUniversity. It is the only community based survey performed through face to face interviews.

• Reliability of data :

The study was done by the Central bureau of statistics in Syria, on a representative sample from the six health regions in Syria ( east 13.9% ,north 30.6%, middle 14.5%, coast 9.7%, Damascus 24.5%, and south regions 6.8%) according and proportional to the distribution of the population in whole Syria. By clustering, the families inside each cluster was chosen by systematic randomization even inside the family one woman was selected randomly, the questionnaires were tested before implementation of the study , ethical consideration , informed consent, confidentiality were all considered.95 data collectors working in MOH primary health care centers distributed in whole Syria worked in this study

UNSAFE ABORTION

• Incidence

There is no data available on the Incidence of unsafe abortion :-

From a hospital based study conducted in Syria about the information system it was found that the registration system is not computerized and deficient and the national classification of diseases system is not used which make it impossible at the moment to have accurate information about the problem of unsafe abortion unless prospective multi center study is conducted

• What data are available on the magnitude and severity of the problem of unsafe abortion?
• Source of data
• Characteristics of women who come for abortion (age, place of residence, marital status, income)

It is of importance to mention that there is no hospital based studies about abortion or its complications in Syria , no information about the attitude , believes and behaviors of care givers of induced abortion

• Characteristic of providers of unsafe abortion and method used

The care provider was a gynecologist in 92% of the cases. Dilatation and curettage was used in 86% of cases of induced abortion, 9% using drugs and in 85% of these cases the drug was prescribed by a gynecologist.

The place of abortion was in 45% of the cases in private clinic, and in 40% in private hospitals, 3.4% induced abortion was at home and only 8.8% in public hospitals, as induced abortion is legally permitted in Syria only for medical or fetal causes

• Availability of misoprostol, is it registered/approved, what indications? Distribution channels, cost?

Misoprostol is available in the a tablet form (Cytotec), it is neither registered nor approved by the Syrian MOH. It is illegally entered to the country from neighboring countries and used informally in the clinic, hospitals and at home.

The indications for using Misoprostol are: termination of pregnancy, induction of labor, and for post abortion bleeding and postpartum hemorrhage

It is distributed through pharmacies, costing one dollar for each tablet. In the study it was used in 6 out of 326 cases

Quality of the care of women consulting for complications of abortion

• Which methods are used in the country for incomplete abortion? Who can provide these methods?

According to the MOH 2006 study, in 61.9% of the complicated cases the same care provider managed these complications. Anesthesia was used in 89.3% of cases and mainly general anesthesia 70.9%. Medical counseling was done in 58.2% of the cases , social counseling in 69.3%

Almost all women (95.5%) expressed their satisfaction about the care they received, place and care providers.

• Are physicians and other health professionals trained following WHO recommended methods for treatment of incomplete abortion?

Physicians and other health professionals training are not following WHO recommended methods for treatment of incomplete abortion , According to national study on practices during childbirth and deliveries it was clear that there is no written guidelines to be followed in the Syrian hospitals in 98% of the cases (7) ( The study was executed by MOH together with Damascus University and funded by UNFPA)

• Is the country implementing WHO guidance?

The country is not implementing WHO guidance till now, but MOH funded by UNFPA is in the phase of preparing national guidelines

Consequences of Unsafe Abortion

• The abortion related maternal mortality

From a national community based study using sisterhood methods about the causes of maternal mortality (5) no single case was reported or analyzed as being unsafe abortion.

It is of importance to mention that when the team was planning to conduct the maternal mortality study in Syria the main obstacle was the that the death registration is poor so only the causes of 129 maternal mortality were intensively studied and analyzed .and it was impossible to estimate the rate

• Magnitude and severity of complications of unsafe abortion

A near miss study (6) was conducted in DamascusUniversity maternity hospital in 2007. There was only one case out of 89 cases of near misses diagnosed as threatening abortion 14 weeks gestation ( not induced abortion ) that bled vigorously giving rise to hypovolemic shock and required massive blood transfusion (near miss) which was managed properly

The data which are available ( from community based survey) on the magnitude and severity of the problem of unsafe abortions are as follows: 13.7% medical problems in the form of bleeding, 54.8% of other medical complications and fever 23.8% , Infertility(as reported by the women that they could not get pregnant again after induced abortion and as they were told by their care providers) 4.8%, but no near miss case was reported.

Psychological problems 36.3%.( being sad , feeling guilty ,afraid from GOD)

Social problems 12.3%.( in the form of Physical violence and blaming from the husband , parents and mother in law)

• Is there an established national level mechanism for monitoring and evaluation of maternal mortality and morbidity resulting from unsafe abortion?

NO, there is not a established national level mechanism for monitoring and evaluation of maternal mortality and morbidity resulting from unsafe abortion.

The death certificates are defective in Syria, MOH is working now on improving the death registry and establishing national committee for editing maternal deaths but not in duty yet.

• Cost of unsafe abortion to the health system, women and families

As there are no good records of unsafe abortions there is no way to estimate its cost.

LEGAL SITUATION OF ABORTION AND REGULATORY FRAMEWORK

• National Laws

Syrian punishment law from 22nd June 1949 established punishment for the physicians , woman and the husband, Abortion is Only allowed when there is a severe medical problem that threatens the life of the mother, at the same time abortion is not allowed when there is abnormalities of the fetus even if the abnormality is incompatible with life. If the woman died the care provider can be prosecuted and jailed from 4 to 7 years , and if the method used was dangerous the punishment will be increased to be from 5 to 10years.