PREVENTION AND MANAGEMENT OF ABORTION AND ITS COMPLICATIONS (PMAC) POLICY

I. BACKGROUND/RATIONALE

The Philippine Reproductive Health (RH) Program, created through
Adm. Order 1-A, s. 1998 has ten elements, one of which is the Prevention
and Management of Abortion and its Complications (PMAC). This element,
aims to address the health and medical care needs of the many Filipino
women who have had abortion, regardless of cause. Statistical reports
show that among DOH-retained hospitals, abortion and its complications
has been consistently the number 3 leading cause of hospital discharge
during the five-year period of 1994-1998. A University of the
Philippines Population Institute (UPPI) study conducted in 1994 shows
that some 300,000 to 500,000 induced abortions are done clandestinely a
year given that abortion is illegal in the country. This roughly
translates to some 46 induced abortions done every hour in the country.
Of the women who have induced abortions, one in every five women ends up
being hospitalized due to complications. Women who have spontaneous
abortion can also develop complications and end up being hospitalized.
The problem of abortion and its complications thus exacts a heavy toll
on the already limited health system resources and also on the general
health and well being of the woman, her family and the society as a
whole.

The existing health services available for women who have had
abortion are limited to the medical treatment of the abortion
complications. These services do not include counseling and referral to
other available RH services, both of which are components of quality
PMAC. A study conducted by the DOH-UNFPA in 1999 showed that there are
no policies and guidelines on PMAC and that women who had induced
abortion are discriminated against when they are hospitalized.

The PMAC element of the RH Theme is hereby established with the
end view that women who have abortion are given quality and humane
post-abortion care services by competent, compassionate, objective and
non-judgmental service providers in a well-equipped institution,
complemented by a supportive environment. In addition, women with
threatened abortion are also given care to prevent them from progressing
into a complete abortion. Likewise, preventive measures established
will ensure that future pregnancies are properly timed, thereby
excluding abortion.

II. GOAL

To improve the quality of health care services for the prevention
and management of abortion and its complications in the Philippines.

III. OBJECTIVES

To strengthen the capability of the country’s health care system
in the prevention and management of abortion and its complications.

To improve the accessibility of quality post-abortion care services to all women of reproductive age in the country.

IV. COVERAGE/SCOPE

For the first year of implementation, PMAC shall initially be
implemented in four (4) pilot hospital sites, including two DOH-retained
hospitals, one LGU hospital and one private hospital. By the end of the
fifth year of implementation (end of 2004), 50 DOH-retained hospitals
shall be providing quality PMAC services.

The activities to be implemented include the following:

a.      Training of Service Providers on the prevention and management of abortion and its complications, including counseling

b.      Upgrading of health facilities in terms of minor renovations and provision of needed equipment and instruments

c.       Strengthening of linkages of appropriate services
within the hospital facility with the aim of providing a holistic
approach to quality care for PMAC

d.      Establishment of an effective referral system to link
the community with the appropriate health care facilities for PMAC
service

e.      Ensuring the availability of necessary supplies and drugs

f.        Provision of PMAC services in the health facilities.

V. GUIDELINES AND PROCEDURES

PMAC should provide comprehensive preventive and medical health
care services. This should include the following three key elements:

1.    Prevention and treatment of abortion and its complications;
2.    Counseling
3.    Linkages between PMAC and other RH services

1.         Prevention and Treatment of abortion and its complications

Each level of the health care delivery system should provide
services for the prevention and treatment of abortion and its
complications.

The prevention of abortion is a major component of this element of
the PMAC program. Abortions may be prevented if high-risk pregnancies
are recognized early and this shall be done through early prenatal care.
Patient education during prenatal care shall include information on the
dangers of vaginal bleeding during pregnancy, its possible causes, and
what patient should do if she has vaginal bleeding while pregnant. If a
woman is identified in the prenatal visit to be a high-risk gravida, she
should identify possible blood donors and their contact
numbers/addresses. This is to ensure that blood is readily available
should the need for blood transfusion arises. For all sites where PMAC
will be implemented, coordination with the voluntary blood donation
program will be done.

Proper infection prevention measures shall be adhered to strictly
by the service providers and instituted in the facilities where
treatment of abortion patients takes place. This will preclude the
occurrence of iatrogenic infections among abortion patients.

While treatment of abortion complications often is offered at
secondary and tertiary care centers in urban areas, poor transportation
system in many areas place centralized services out of reach of most
poor, rural women. These gaps in services make even spontaneous abortion
life-threatening in many instances. Increasing the availability of PMAC
services throughout the health system requires decentralizing treatment
services and improving the quality and range of care at every level.
These steps shall be backed up by establishing standardized protocols
for service delivery and comprehensive, systematic training.

Management for abortion complications shall include:

•      An initial assessment to confirm the presence of complications
•      Medical evaluation (brief history, limited physical and pelvic examinations)
•      Talking with the patient regarding her medical condition and the treatment plan
•      Prompt referral and transfer if the patient requires treatment
beyond the capability of the facility where initial
assessment/evaluation was conducted
•      Stabilization of emergency conditions and treatment of any
complications (both complications present before treatment and
complications that occur during or after the treatment procedure)
•      Conduct of appropriate procedures, specifically uterine evacuation to remove products of conception (POC)
•      Health education

The efficient prevention and management of abortion complications
is dependent on care being integrated throughout the health care system,
from the first point of contact to the most sophisticated tertiary
level hospital. Whether it is health information, medical assessment,
stabilized care for the referral, uterine evacuation or specialized care
for the most serious complications, at least some components of PMAC
should be available at every service delivery site in the health care
system (Table 1). Table 2 summarizes the key steps for the management of
abortion and its complications.

The abortion patient’s family and the community have an important
role in providing support to the abortion patient. IEC shall be
undertaken to make community members aware of the health risks and
complications of abortion, and what to do to help women who have an
abortion or abortion complications access the health services they need.
They shall also be made aware that patients who induced their abortion
should be assisted in obtaining family planning counseling and services
that allow them to avoid unintended pregnancy and consequently,
abortion.

Table 1: Summarizes the recommended PMAC services appropriate at each level of health care facility.

Table 1: Provision of PMAC services by Level of Health Care Facility

Table 2: Key steps for the management of abortion and its complication

2.         Counseling

Abortion patients have varied needs and concerns that can be
addressed through counseling. Health service providers shall thus be
trained on counseling to enable them to use communications and
counseling skills to perform tasks such as the following:

1.      Assess and acknowledge the abortion patient’s needs and concerns;

2.      Answer the patient’s questions and give her information
about her condition, treatment procedures to be done, what to expect
during her stay in the health facility, post-procedure care and warning
signs she has to look out for; and

3.      Help the patient make decisions about family planning,
sexually transmitted diseases (STD) prevention, and other reproductive
health services.

Counseling in the context of post-abortion care shall be provided
for the patient before, during and after the procedure for definitive
treatment, which is uterine evacuation by the appropriate method. For
the woman who has a threatened abortion, counseling shall focus on
answering the informational needs of the patient such as questions
regarding progression of her condition to a completed abortion and
future fertility, and addressing emotional concerns.

Counseling includes addressing the emotional concerns such as
grief, fear, anger, guilt, depression and other emotional issues that a
woman who had an abortion, or is having a threatened abortion, may
experience. At times, the emotional issues may also involve the woman’s
partner/husband. In these instances, counseling shall also be provided
to the partner/husband. Joint counseling for the woman and her partner
may be done, if the woman indicates that she wants him to be involved in
the counseling process.

In the country’s current health setting, women treated for
abortion complications are not routinely provided with appropriate
counseling services to prevent subsequent unwanted pregnancies. The
providers of post-abortion care typically do not view the provision of
contraceptive services as part of their tasks. In addition,
post-abortion care services and family planning services are not always
coordinated because of some administrative divisions within the
facility/hospital.

Since ovulation returns rapidly following an abortion, with the
subsequent risk of repeat pregnancy, post-abortion family planning
services shall be initiated immediately. Post-abortion family planning
shall include all the essential components of good family planning care,
and shall be based on an individual assessment of every woman’s
situation. All modern methods of contraception are appropriate for use
after abortion as long as the provider screens the woman for the
standard precautions for a method and gives adequate counseling.

Some post-abortion patients who want to postpone another pregnancy
may be unable to make a decision at the time of post-abortion care. The
program shall undertake measures to ensure that they can return for
follow-up or that they are referred appropriately to a nearby facility.
They shall likewise be counseled before they are referred to another
facility for appropriate care.

3.         Linking PMAC services to Other Reproductive Health Services

Linking PMAC services with other reproductive health services is
essential and logical, yet these services have remained separate in most
of the country’s health delivery outlets. This separation has resulted
to abortion patients having no access to other reproductive health
services.

It is important to identify the reproductive health services that
each of the abortion patient may need and offer her as wide a range of
services as possible. For example, providers need to be alert to
symptoms of reproductive tract infections (RTIs) to include sexually
transmitted diseases (e.g., trichomoniasis or prucopurulent cervicitis)
and provide the appropriate treatment for them. Also, for women over age
30, it may be possible to offer cervical cancer screening at the time
of treatment or to provide referral to a facility where screening is
available. Finally, women treated for spontaneous abortion (infertility)
or advice before attempting to become pregnant again or about prenatal
care. The staff at the different levels of health care facilities must
be able to identify high-risk patients/clients and provide instructions
for reproductive health care.

VI. IMPLEMENTING MECHANISM

A.        National Level

The overall responsibility for policy development, standard
setting and coordination & integration of PMAC activities shall rest
with the Center for Family Health (CFH). The CFH is likewise tasked to
ensure that PMAC services are given funding and technical support.

B.        PMAC Technical Working Group

The CFH shall convene a Technical Working Group (TWG) on PMAC to be composed of the following:

The TWG is mainly tasked to prepare the policies and guidelines
for the PMAC. It shall also be responsible for preparing the action plan
to bring PMAC to scale in the country.

C.        Regional Level

The Center for Health Development (CHD) shall be tasked to monitor
the implementation of PMAC services in the DOH retained hospitals, the
Local Government Units (LGU) and coordinate with private hospitals in
the area.

D.        Quality Assurance Program

The PMAC element, in all aspects of implementation, shall apply
the standards and concepts set by the Sentrong Sigla to ensure quality
health services. The PMAC TWG, shall therefore coordinate closely with
the Sentrong Sigla Steering Committee and its 4 pillars to ensure that
quality standards are developed and updated to conform with program
structures and directions.

E.        Linkages

All health facilities shall establish PMAC services as part of a
network with other RH services. These RH services are, but not limited
to, Maternal Care, Family Planning, Infertility services, RTIs, Violence
Against Women, Adolescent RH, Men’s RH Involvement, etc.

VII. EFFECTIVITY

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

Adopted: 02 May 2000

(SGD.) ALBERTO G. ROMUALDEZ, JR., MD
Secretary of Health