POSTABORTION CARE
FLIPCHART
A Tool For Client Counselling And Community Education on Unsafe Abortion
INTRODUCTION AND TIPS FOR USING
THE POSTABORTION CARE FLIPCHART
This flipchart is designed to enhance postabortion client counselling and community
education related to unsafe abortion. It is comprised of four separate sections focused
on the following topics:
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Pre-procedure counselling: This section focuses on the circumstances leading up to
a client’s presentation with abortion complications in order to understand her emotional and physical state and to begin identifying potential needs for related health
or social services. In addition, the section provides an overview of vacuum aspiration
and dilatation and curettage, and what clients should expect during the procedure.
Post-procedure counselling: Designed to guide counselling after treatment for
abortion complications, this section provides information on self-care, what to
expect during the recovery period, and danger signs that merit further medical
treatment. This section is also designed to help providers identify the clients’ needs
for other health or social services.
Postabortion family planning: Designed to support a discussion on the client’s
fertility plans and help her choose a contraceptive method to avoid future
unwanted pregnancy, this section explores the client’s knowledge and concerns
related to contraception and provides information on all methods that can be used
following abortion/treatment of abortion complications. Emergency contraception
is also covered.
Unsafe abortion in the community: Designed for use in heightening community
awareness and action on the problem of unsafe abortion, this section reviews the
dangers of unsafe abortion; signs/symptoms of abortion complications; the importance of prompt medical treatment; and health providers’ professional responsibility
to provide treatment to women with abortion complications. The information and
action messages in this section encourage women to seek treatment early, and are
aimed at mobilizing communities to ensure that women suffering incomplete
abortion receive the care they need in a timely manner. In addition, this section is
designed to heighten community awareness of family planning methods, including
emergency contraception, which can be used to prevent unwanted pregnancy. Lastly,
the section includes one page on legal termination of pregnancy to heighten awareness
of the circumstances under which pregnancy may legally be terminated, as well as the
safety of the procedure when conducted in hygienic conditions by qualified providers.
The four sections of the flipchart can be used together or separately, depending on a
client’s physical and emotional condition, which may affect the content and timing of
counselling. Client-centred counselling should, above all, be responsive to clients’
needs, and each postabortion counselling session is likely to be different,
depending on a client’s particular circumstances, preferences, questions, and
Introduction
needs. This flipchart is designed as a flexible counselling tool, and providers should
combine whatever sections or pages are most relevant to each client.
The User’s Guide accompanying this flipchart offers guidance on a wide range of issues
related to postabortion care. General tips for using this flipchart include:
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Make sure you understand the contents of the flipchart before using it.
Be sensitive to clients’ emotional and physical state, and ensure that counselling is
provided at moments when clients can fully participate in two-way counselling
(i.e. avoid moments when clients are affected by emotional distress, pain, or pain
control medication).
Place the flipchart so that clients can easily see the illustrations. When you show each
illustration, give the client a few moments to look at and understand what it shows.
Use the Questions outlined in the flipchart to encourage clients to talk about what
they know, their experiences, and their feelings about the subject. Pay close attention to what they tell you so that you can focus on the key issues of concern for
each client and provide information and counselling that is relevant for her particular circumstances. Use the Key Information sections as a reference in addressing
clients’ knowledge gaps, concerns, and questions. Use the Action Points provided in
the flipchart to remind you of key steps you can take during your interactions with
clients, communities, and other partners to help reduce abortion-related mortality
and morbidity and improve the quality of women’s lives.
Do not lecture too much or too long. People learn and remember more easily if they
have a chance to put things in their own words. Involve your clients in finding a
way to remember the important information you are giving them, such as steps they
should take to care for themselves during the recovery period or how they can use
a contraceptive method correctly.
Provide clear and accurate information. Use simple, non-technical, local terms and
language your clients understand.
Remember that your clients can provide you with valuable information that
will enable you to give the best and most appropriate care. Take the time to
understand how they are feeling and what their concerns are so that you can
provide high-quality care and give them practical information and advice that
will enable them to avoid future reproductive health problems.
Use supportive active listening and nonverbal communication skills, such as nodding
and smiling, to let clients know you are listening to them and to reduce their stress
and anxiety.
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ASSESSING A WOMAN’S
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MEDICAL CONDITION
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COUNSELLING QUESTIONS
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How are you feeling? What problems are you having?
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Can you tell me when the bleeding started? How?
What is the bleeding like?
Are you feeling any pain? Where? When did it start? How bad is it?
Do you feel warm? Have you had any chills?
Do you feel weak? Have you fainted?
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KEY INFORMATION TO SHARE WITH CLIENTS
Bleeding and pain during early pregnancy can be caused by either miscarriage or an
unsafely induced abortion. A miscarriage happens when the pregnancy ends before the
foetus has any chance of survival. Miscarriage usually happens in the first 12 weeks of
pregnancy and is a sign that something was wrong with the fertilised egg. An unsafe
abortion is when someone does something to end a pregnancy, in a way that is dangerous
to the woman. Unsafe abortion can cause heavy bleeding, pain, and various internal
injuries. For example, putting sharp objects into the vagina and uterus (womb) can
harm the woman’s reproductive organs and cause internal bleeding. Purposely falling
or hitting the stomach can also cause serious injury or bleeding inside the body. Placing
chemicals, herbs, or other mixtures in the vagina can cause burns, irritation, or infection.
Drinking or swallowing chemicals or herbs to cause abortion can also cause complications.
Both miscarriage and unsafe abortion can result in serious health problems that require
medical attention. If parts of the foetus or placenta remain in the uterus, the woman
may develop an infection, leading to fever and pain in her reproductive organs. If the
infection goes untreated, the woman’s reproductive organs may be damaged, making it
difficult for her to become pregnant or bear children again. A woman could also die
from infection or the internal injuries caused by unsafe abortion methods.
To assess a woman’s medical condition and to determine the best course of treatment,
it is usually necessary for the nurse/doctor to perform a pelvic examination. This will
involve feeling the size of the uterus and examining for signs of infection and injuries
to the vagina, cervix, and uterus. The examination can be uncomfortable—especially for
someone who is already in pain, so pain medication may be given to reduce discomfort.
Other medications may be given to prevent infection, and some laboratory tests may
be needed as well.
ACTION MESSAGES FOR THE PROVIDER
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Pre-procedure counselling
Do you remember when your last menstrual period was?
What do you think is wrong with you? Have you ever had this problem before?
Do you know how problems such as these are treated?
Have you ever had a pelvic examination before?
Do you have any questions or concerns that I can answer?
Protect the client’s privacy and assure her of the confidentiality of any information
she shares with you.
Listen to the client to understand what problems she is experiencing, the severity of
her pain, and the circumstances leading up to the problem.
Inform the client about her overall physical condition, giving her as much information as possible about what is happening inside her body.
Explain what will be done to help her, what she can expect during the procedure,
and what pain control medication will be given. Encourage her to try to relax as this
will help ease the discomfort and at the same time make it easier to assess the size
of the uterus.
Encourage the client to share her concerns. Answer the client’s questions, and
reassure her the way you would reassure a friend.
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Section 1
TREATMENT PROCEDURE:
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MANUAL VACUUM ASPIRATION
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QUESTIONS FOR DISCUSSION
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What do you see in this picture?
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complications before?
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KEY INFORMATION TO SHARE WITH CLIENTS
ACTION MESSAGES FOR THE PROVIDER
The most common complication of miscarriage and unsafely induced abortion is when
parts of the pregnancy are left in the uterus. If these are not removed or cleaned,
serious infection may result. Vacuum aspiration is one of the best procedures for
removing the retained products from the uterus. Manual vacuum aspiration (also
known as MVA) uses a simple tube attached to a hand-held syringe to clean out the
uterus. The tube can also be connected to an electric pump, which is known as electric
vacuum aspiration (EVA). During the procedure, the woman lies back on an examining
table with her knees bent up. To start with, the skin around and inside the vagina will
be cleaned, and then a metal instrument (called a speculum) will be used to open the
vagina so that the nurse/doctor can see the cervix (the opening of the uterus). The
speculum may cause the woman to feel some pressure. The provider may clean away
any blood clots or tissue from the cervix. If the cervix is not open, another instrument
will be used to slowly open it. Once the cervix is open, the small tube attached to the
syringe or pump will be inserted into the uterus to gently clean out any parts of the
pregnancy from the uterus. This procedure takes about 10 minutes.
Women may experience different levels of pain, depending on their medical condition,
as well as their fear and anxiety. Most women say that the pain or discomfort they feel
during the procedure is like strong menstrual cramps. Relaxing and taking slow, deep
breaths can help lessen the pain. Medications, such as paracetamol, can also help
reduce the pain. Thirdly, there are some medicines that can be given by injection to
lessen pain during the procedure and/or to reduce anxiety. Therefore, it is very important for women to tell the nurse or doctor how they are feeling and to ask for pain
medication if the pain becomes too strong. Every client has the right to choose her
preferred pain control option or options (from among all options that are available
and safe for her condition).
Pre-procedure counselling
Have you heard anything about this procedure?
Do you have any questions about the procedure?
Do you have any concerns about what you see in this picture?
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Inform the client about her overall physical condition and the treatment option(s)
available. Explain the risks and benefits associated with the procedure, and tell her
about any medicines that should be taken before treatment, as well as any laboratory tests that may be needed.
Ask the client if there is anyone whom she wants to involve in the discussion about
her condition or treatment option(s).
Assess the client’s level of pain and anxiety, and provide appropriate pain control
medication, including analgesia, anxiolytics, or local anaesthetics (i.e. paracervical
block), as needed.
Explain what to expect during the procedure. Tell the client to ask for pain
medication if the pain becomes too strong during the procedure.
Encourage the client to share her concerns and to ask questions about the
procedure. Reassure the client about any concerns she may have about her physical
condition or the treatment procedure. Ask what can be done to make her feel more
comfortable and less anxious.
Obtain the client’s informed consent before beginning any treatment.
Talk to the client throughout the procedure and explain what you are doing
at each step.
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Section 1
TREATMENT PROCEDURE:
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DILATATION AND CURETTAGE
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QUESTIONS FOR DISCUSSION
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What do you see in this picture?
i Do you know how this medical equipment is used?
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complications before?
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KEY INFORMATION TO SHARE WITH CLIENTS
Have you heard anything about this procedure?
Do you have any questions about the procedure?
Do you have any concerns about what you see in this picture?
ACTION MESSAGES FOR THE PROVIDER
The most common complication of miscarriage and unsafely induced abortion is when
parts of the pregnancy are left in the uterus. If these are not removed or cleaned,
serious infection may result. Dilatation and curettage (D&C), also known as sharp
curettage, is one procedure for removing the retained products from the uterus.
A small metal instrument called a curette is used to remove any remaining parts of
the pregnancy from the uterus.
During the procedure, the woman lies back on an examining table with her knees bent
up. To start with, the skin around and inside the vagina will be cleaned, and then a
metal instrument (called a speculum) will be used to open the vagina so that the
nurse/doctor can see the cervix (the opening of the uterus). The speculum may cause
the woman to feel some pressure. The provider may clean away any blood clots or
tissue from the cervix. Some pain medicine may be used to numb the cervix, and if the
cervix is not already open, another instrument will be used to gently open it. Once
the cervix is open, the curette is inserted into the uterus to remove any parts of the
pregnancy. This procedure normally takes about 30 minutes.
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Inform the client about her overall physical condition and the treatment option(s)
available. Explain the risks and benefits associated with the procedure, and tell her
about any medicines that should be taken before treatment, as well as any laboratory tests that may be needed.
Ask the client if there is anyone whom she wants to involve in the discussion about
her condition or treatment option(s).
Explain what to expect during the procedure and what pain control options
are available.
Encourage the client to share her concerns, and to ask questions about the
procedure. Reassure the client about any concerns she may have about her physical
condition or the treatment procedure. Ask what can be done to make her feel
comfortable and less anxious. Provide sedatives, as needed.
Obtain the client’s informed consent before beginning any treatment.
As appropriate (if the woman is conscious or semi-conscious), talk to her throughout
the procedure and explain what is being done during each step.
D&C is usually done under general or regional anaesthesia, or heavy sedation to ensure
that the woman does not feel any pain during the procedure.
Pre-procedure counselling
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Section 1
SELF-CARE
AFTER TREATMENT
FOR ABORTION COMPLICATIONS
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DON’T
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QUESTIONS FOR DISCUSSION
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How are you feeling?
h Has anyone told you how to take care of yourself as you recover and what
danger signs to look out for? Do you feel ready to talk about this? Is there
anyone whom you would like to involve in this discussion?
h Is there anyone at home who will be able to help you as you recover?
KEY INFORMATION TO SHARE WITH CLIENTS
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Do you know how soon after treatment you could become pregnant again?
h Do you have any questions or concerns about your health or your
ability to care for yourself during the next few days that would you
like to talk about?
ACTION MESSAGES FOR THE PROVIDER
After treatment, it is normal to have bleeding and cramping (similar to a menstrual
period) for up to one week. Sometimes rubbing the lower stomach helps to ease pain
and stop the bleeding, and some women also say that holding bottle of warm water
against the stomach helps to reduce the pains. Medicines, such as paracetamol, can
also help reduce the pain. Self-care after treatment for incomplete abortion or miscarriage includes:
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Using clean cloths, pads, or cotton wool, and changing them every 2-4 hours.
Drinking plenty of water, and eating nourishing foods.
Getting plenty of rest, and avoiding heavy lifting and chores (such as collecting
water or firewood) for 2 to 3 days.
Returning to normal activities only when you feel better.
Taking all medications as directed, even if you feel better, and returning for
follow-up visit as instructed by the nurse or doctor.
Avoiding sexual relations or putting anything inside the vagina (no douching,
no tampons, etc.) until at least three days after the bleeding has stopped.
Using a contraceptive method right away if another pregnancy is not wanted soon
because fertility usually returns within two weeks after treatment.
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Assess the client s overall level of pain, and provide pain control medication,
if necessary.
Inform the client about her overall physical condition and how to care for herself
at home.
Inform the client about what to expect during the recovery period and where to go
for care or advice if she has any concerns or problems.
Ask the client about any concerns or questions that she may have, and reassure her.
Emphasise that pregnancy can happen again soon—before the return of menses
and ask her if she wants to discuss using family planning.
It is normal to have feelings of sadness or depression. Some women find it helpful to
talk with a counsellor or trusted friend.
A normal menstrual period usually returns within 4 to 8 weeks, however, fertility
can return as soon as two weeks after treatment and before the return of normal
menstrual periods. If another pregnancy is not wanted soon, a method of family
planning should be used.
Post-procedure counselling
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Section 2
DO
DON’T
COMPLICATIONS FOLLOWING
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TREATMENT FOR INCOMPLETE
ABORTION/MISCARRIAGE
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QUESTIONS FOR DISCUSSION
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What do you think is happening in this picture?
h Do you know what danger signs you should look out for over the next few
days as you recover?
KEY INFORMATION TO SHARE WITH CLIENTS
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What would you do if you noticed any of these problems?
h Where is the nearest health facility to your home?
How would you get there?
ACTION MESSAGES FOR THE PROVIDER
Sometimes, a woman may continue to have problems after treatment for incomplete
abortion or early pregnancy bleeding. This is rare, but if a woman has any of the
following symptoms after treatment, she should go immediately to the clinic for help:
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Heavy bleeding from the vagina (bleeding that is more than a normal
menstrual period)
Prolonged bleeding (more than two weeks)
Prolonged cramps (more than a few days)
Fever or chills
Smelly liquid coming from the vagina
Severe or increased pain
Vomiting or feeling nauseous
Confusion, fainting
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Inform the client about signs of complications following her treatment. Use simple
terms that are easy to understand.
Ensure that the woman knows where to seek care if she experiences any
further problems.
Ask the client about any concerns or questions that she may have, and reassure her.
A day or so after the uterus has been cleaned, all signs of pregnancy like nausea and
tender breasts should go away. If these signs do not go away, there is a chance that
the woman is still pregnant, possibly with an ectopic pregnancy. This is an emergency,
and medical care should be sought immediately.
Post-procedure counselling
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Section 2
ASSESSING NEEDS
FOR OTHER
SERVICES AND COUNSELLING
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QUESTIONS FOR DISCUSSION
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What do you see in these pictures? Are these situations common
in your community?
h Do you feel comfortable talking confidentially about the circumstances
leading up to your treatment here today?
h Do you have any children? How many? How did you feel when you
found out that you were pregnant this most recent time? Was this a wanted
pregnancy or an unplanned pregnancy? Do you want to get pregnant again?
h Can you tell your partner if you do not want to have sex? Have you ever
been pressured to have sex against your will?
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Have you ever used a family planning method? If no, what are your
reasons? If yes, how did you and your partner feel about family planning?
h Have you and your partner ever used a condom? If no, why not?
If yes, how did you feel about using it? How did your partner feel?
h Do you think that either you or your partner may be at risk for STIs?
Do you know where to go for testing and treatment?
h Have you ever been counselled about HIV? Would you be interested in
confidential HIV counselling and testing? Do you know where to go for
these services?
h Do you have any questions or concerns that you would like to discuss?
doctor who can help her make decisions about how to take care of herself and
maybe carry a pregnancy to term. She may also need referral to a facility where
confidential STI screening is available, since some STIs can cause miscarriage.
KEY INFORMATION TO SHARE WITH CLIENTS
Talking about personal issues, such as sexual relationships, can be very difficult, but
discussing these topics can help ensure that health risks and problems are identified
and addressed. Women who experience unintended pregnancy or miscarriage are
sometimes at increased risk of:
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HIV and other STIs: If a woman is unable to protect herself against unwanted pregnancy, she may be unable to protect herself against sexually transmitted infections
(STIs), including HIV/AIDS, especially if she has trouble getting her partner to use a
condom. Therefore, some women also need referral to a facility where confidential
testing for STIs, including HIV/AIDS, and cervical cancer screening services are available.
Rape, incest, domestic violence: A woman who became pregnant from someone
forcing her to have sex may need special counselling and legal assistance so that she
can protect herself in the future. Women’s rights groups, legal aid societies, rape crisis
centres, and organisations working on domestic violence may be a source of support
and advice. Trained counsellors can assist women in these difficult circumstances to
cope with their feelings of anger, shame, humiliation, and fear. They can also help
women decide whether they want to report the incident, prosecute the aggressor, or
take other steps to protect themselves.
Infertility treatment: A woman who has had several miscarriages and who
has been unable to bear any children may need to speak with an infertility
Post-procedure counselling
Adolescents—married and unmarried—may also have special needs for counselling or
support to cope with abusive or exploitative relationships or other social or economic
circumstances that put them at risk of sexual and reproductive health problems.
ACTION MESSAGES FOR THE PROVIDER
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Assure the client of the confidentiality of any information she shares, and protect
her privacy. Ensure that other staff or clients do not interrupt the counselling session.
Explain to the client that you discuss these issues with all women because you are
concerned for their safety and health, and you want to tell them what other
services are available if they are ever in need.
Assess the woman’s need for additional services, counselling and/or referral—e.g.
voluntary testing and counselling for HIV/AIDS (VCT); screening and treatment for
STIs/RTIs, cervical cancer screening, or other medical problems; counselling from a
psychologist, counsellor, or religious institution; legal advice/assistance for rape, incest,
violence; or specialist for repeated miscarriages.
h Encourage the client to share her questions and concerns, and assist her in
identifying additional sources of help as needed.
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Section 2
HOW
PREGNANCY OCCURS
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QUESTIONS FOR DISCUSSION
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How are you feeling? Is this a good time to talk?
Do you have any concerns or questions?
Do you know how pregnancy occurs?
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KEY INFORMATION TO SHARE WITH CLIENTS
If a woman does not want to be pregnant, what can she do?
Do you want to get pregnant again? If so, when?
ACTION MESSAGES FOR THE PROVIDER:
Once a woman reaches puberty, her ovaries begin to release a mature egg each month.
This is called ovulation. The egg travels down the fallopian tube towards the uterus.
If a woman has sexual intercourse during ovulation and the egg comes in contact with
a man’s sperm in the fallopian tube or in the uterus, the egg may become fertilised.
If the egg is fertilised, it may attach itself to the lining of the uterus. This is the
beginning of pregnancy. However, if the egg is not fertilised by a man’s sperm, it
simply passes out of the woman’s body, and about two weeks later, the lining of
the uterus comes out as menstrual bleeding.
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Be sure that it is a good time for your client to talk about pregnancy and family
planning options—i.e. ensure that she is not in pain or still recovering from the
treatment procedure.
Explore your client’s knowledge about pregnancy and contraception so that you
can provide more relevant information and counselling.
Identify any myths or misperceptions that your client holds about contraception so
that you can address these effectively.
Pregnancy can be prevented by using a modern method of contraception or family
planning. Most of these methods work by preventing sperm from fertilising an egg,
or by preventing the fertilised egg from attaching itself to the wall of the uterus.
When used correctly, modern contraceptives have proven very safe and effective
for most women. Although there are many myths about the side effects and dangers
of contraception, using family planning is safer than going through pregnancy
and childbirth.
Postabortion family planning
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Section 3
PREVENTING
UNWANTED
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PREGNANCY
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QUESTIONS FOR DISCUSSION
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Is this a good time to talk about family planning? Is there anyone you
would like to involve in this discussion?
How do you feel about using a family planning method to avoid getting
pregnant again soon? How does your partner feel about family planning?
Have you ever used a family planning method in the past? Have you ever
had any problems with family planning? What were they?
KEY INFORMATION TO SHARE WITH CLIENTS
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What other family planning methods have
you heard of? What have you heard about these methods?
Do you have any questions or concerns about using family planning?
For women in your community, where is the closest clinic that offers
family planning? What do you think about the quality and cost of the
services there? Do you have any difficulties getting services there?
ACTION MESSAGES FOR THE PROVIDER
Family planning methods can help women prevent or space pregnancies. A woman can
become pregnant within two weeks after miscarriage or abortion treatment—even
before the return of a normal menstrual period. Therefore, it is important to think
about whether another pregnancy is wanted; if not, an appropriate method of contraception should be used.
Any woman can safely use modern family planning methods immediately after an
abortion or miscarriage. All modern family planning methods—other than sterilisation—
are temporary. Some short-term family planning methods, such as condoms and oral
contraceptive pills, can be started right away, and they can also be easily discontinued.
In other words, if a woman is using these methods and then decides that she wants to
become pregnant, she can stop using the method and may be able to get pregnant
again soon. Other long-term family planning methods, such as injections and
implants, can also be started right away, but they cannot be discontinued immediately
if the woman decides she wants to become pregnant again. For example, injectable
contraceptives last up to three months. Implants can last up to five to seven years,
but they can be removed at any time.
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Ensure that the client knows that fertility can return within two weeks after
abortion or miscarriage, and before the return of her menstrual period.
Explore the client’s future childbearing intentions, as well as her preferences, past
experiences, and concerns related to contraception. Help her select a method that
best protects her against unwanted pregnancy and other reproductive health risks,
such as STIs/HIV/AIDS.
If possible, show real samples of various contraceptive methods instead of relying
solely on the flipchart illustrations.
Discuss the advantages and possible issues of concern for the method(s) she is considering. Explain any known side effects and how these side effects can be managed.
Encourage the client to ask questions and share her concerns. Offer to provide
counselling to the woman’s partner.
Never pressure a client to accept a contraceptive method. If she is not ready to
accept a method, inform her of her contraceptive options and be sure that she
knows where to go in her community to obtain these methods.
Other methods of family planning can also be used once a woman has fully recovered
from her treatment. For example, an inter-uterine contraceptive device (IUD/IUCD) can
be inserted in the uterus to prevent pregnancy for up to ten years. Male and female
sterilisation are surgical procedures to permanently prevent pregnancy. Natural family
planning methods like periodic abstinence are not recommended until a normal
menstrual pattern returns. If there are any concerns about STIs, including
HIV/AIDS, couples should use condoms since it is the only method that will
help prevent infection, as well as pregnancy.
Postabortion family planning
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Section 3
EMERGENCY
CONTRACEPTION
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QUESTIONS FOR DISCUSSION
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Have you heard about emergency contraceptive pills? What do you
know about them?
Have you, or anyone you know, used emergency contraceptive pills?
What happened?
KEY INFORMATION TO SHARE WITH CLIENTS
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Where can a woman get emergency contraception?
Do you have any concerns or questions about emergency contraception?
ACTION MESSAGES FOR THE PROVIDER
Emergency contraception is an important method of family planning that many
women do not know about. Emergency contraception can be used after unprotected
sex (i.e. after having sex with no contraception or after having a condom break or slip
during sexual intercourse).
Emergency contraceptive pills (ECPs) are the most common form of emergency contraception. They are simply higher-than-normal doses of ordinary contraceptive pills.
If taken within two or three days (72 hours) of unprotected sex, these pills prevent a
fertilised egg from attaching itself to the lining of the uterus, which stops the pregnancy from beginning. The pills do not cause abortion because they are not effective
once pregnancy has begun. Emergency contraceptive pills are highly effective when
they are used correctly. Only two out of 100 women who use them become pregnant.
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Ensure that clients know about emergency contraception, how to get ECPs, and
the importance of using this method immediately after unprotected sex.
Liaise with rape crisis centres, VCT centres, women’s shelters, youth centres, etc.
that provide services to victims of sexual abuse and violence to ensure that they
can provide appropriate services and prompt referrals to women who are at risk of
unwanted pregnancy.
All providers should know about ECPs and provide information on this option
alongside other family planning methods.
Insertion of an IUD/IUCD can also serve as a method of emergency contraception.
Emergency contraception should not replace using other methods of contraception,
especially condoms, since condoms prevent STIs, including HIV/AIDS. However, they
provide an important option for victims of sexual violence, for women who have
infrequent or unpredictable sexual intercourse, or for couples whose contraceptive
method failed.
Postabortion family planning
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Section 3
UNPLANNED
PREGNANCY
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QUESTIONS FOR DISCUSSION
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What do you see in this picture? Are these women at risk of unwanted or
unplanned pregnancy? What other reproductive health problems are they
at risk of?
b What are some of the reasons a woman or girl may not want to
be pregnant?
KEY INFORMATION TO SHARE WITH COMMUNITY MEMBERS
Although many people assume that unwanted pregnancy is primarily a problem among
adolescent girls, in most countries, the majority of women facing unplanned, unwanted
pregnancies are married and already have several children. There are many reasons why
a pregnancy may be unwanted. A woman may feel that she wants to space her
children better or already has too many children to support. A woman may not want to
have a child because she wants to continue her schooling or her employment. A
woman may also have health problems that would be worsened by a pregnancy. She
may be in an unstable relationship, or she may have been raped. She may be unmarried
and face rejection by her family or community if she has a child outside of marriage.
Although proper use of family planning could prevent most unplanned and unwanted
pregnancies, it is estimated that 350 million couples around the world lack information
about family planning or lack access to a wide range of methods. Even where family
planning services exist, women may not be able to use them because they do not know
about them, they do not have the necessary funds, or their husband/partner is opposed
to using family planning. In addition, many women simply do not have control over
sexual intercourse, and unplanned and unwanted pregnancy can be the result of forced
sex or rape. Adolescent girls face special obstacles in using contraception because they
often do not understand how pregnancy occurs; they have limited information about
safe, effective methods of preventing pregnancy; and they may be afraid to admit that
they are sexually active to parents, health workers, and others. In addition, health staff
sometimes refuse to provide contraceptive services to young people.
Unsafe abortion in the community
b
What types of women are most likely to have an unwanted
pregnancy? Why? What puts them at risk?
b If a woman does not want to be pregnant, what can she do?
Unwanted pregnancy can also occur because a contraceptive fails. It is estimated that
there are 8 to 30 million pregnancies each year that are either caused by contraceptive
failure—i.e. either contraceptives not working properly or by couples using contraceptives
inconsistently or incorrectly. For example, if a woman is taking contraceptive pills but
forgets to take them every day, she could become pregnant. Although it is rare,
condoms can sometimes break or slip off when they are not used correctly.
Women who are at risk of unplanned or unwanted pregnancy are also at risk for a
number of other reproductive health problems because they are having unprotected
sex. They may be at risk for STIs, including HIV/AIDS.
ACTION MESSAGES FOR THE COMMUNITY:
b
b
Unplanned pregnancy can be avoided if information and family planning services
are available to women—married and unmarried—and their partners.
Men can also play an important role in preventing unwanted and unplanned
pregnancy. They should be informed about family planning so they understand
how these methods work and how safe and effective they are.
b
Section 4
UNSAFE
b
ABORTION
b
QUESTIONS FOR DISCUSSION
b
What do you see in this picture? Does this happen in your community?
b What other methods do women use to try to end an unwanted pregnancy?
Are these methods effective? Are they safe?
KEY INFORMATION TO SHARE WITH COMMUNITY MEMBERS
Many women try to end pregnancies that are unplanned and unwanted. It is estimated
that there are 46 million abortions around the world each year—in Africa, approximately 11,500 each day. Ending a pregnancy is very safe under certain circumstances—
when a trained health worker or doctor uses proper methods in a clean environment,
using clean instruments—and when less than 12 weeks have passed since the woman’s
last period. Nevertheless, almost half of the abortions that take place each year
(20 million around the world) are unsafe—performed by unskilled providers, using
unsafe methods in unclean conditions.
Both married women and adolescent girls experience unwanted pregnancy and have
abortions. However, adolescent girls are more likely to have an unsafe abortion. Even in
those countries where safe abortion services may be available, adolescents may not
have information about where services are available, or they may not have the funds
to pay for such services. In addition, having a child can be much more of a problem
for unmarried adolescent girls than for older married women. It can make it impossible
for a young girl to finish school or to find work, and it may make it difficult for her to
get married.
b
What types of women are most likely to resort to unsafe methods of
ending an unwanted pregnancy?
b How can the community address the problem of unsafe abortion?
Unsafe abortion can result in serious health problems that require urgent medical
attention. If parts of the foetus or placenta remain in the uterus, the woman may
develop an infection, leading to fever and pain in her reproductive organs. If the
infection goes untreated, the woman’s reproductive organs may be damaged, making
it difficult for her to become pregnant or bear children again. A woman could also die
from infection or the internal injuries caused by unsafe abortion methods.
ACTION MESSAGES FOR THE COMMUNITY
b
b
If a woman is faced with an unwanted pregnancy, she should find out what safe
options are available, given her particular circumstances. The woman should be
discouraged from seeking help from an unskilled provider or resorting to unsafe
methods of terminating pregnancy.
If unsafe abortion is a problem in your community, work with community leaders,
health providers, and others to raise awareness of the dangers of unsafe methods of
terminating pregnancy, and to ensure that women and men of reproductive age
know how contraception can be used to prevent unwanted pregnancy.
Dangerous methods used to end an unwanted pregnancy include drinking poisonous
herbs or other drugs or substances, inserting foreign and sharp objects into the uterus,
placing herbs or chemicals into the vagina, or undergoing physical injury or abuse.
These methods generally do not work, and they are very unsafe. For example, inserting
sharp objects into the vagina or uterus can damage the reproductive organs and cause
internal bleeding. Purposely falling or hitting the abdomen can also cause serious
injury or bleeding inside the body. Similarly, placing chemicals, herbs, or other mixtures
in the vagina can cause burns, irritation, or infection.
Unsafe abortion in the community
b
Section 4
COMPLICATIONS OF MISCARRIAGE
b
AND UNSAFE ABORTION
b
QUESTIONS FOR DISCUSSION
b
What do you see in this picture? Why is this woman sick?
b What are the danger signs of complications of abortion or miscarriage?
b What should be done if a woman has any of these problems? Where can
she go for help?
b How are women with these complications treated at the hospital/clinic?
Are women from this community afraid to seek treatment for abortion
complications? Why or why not?
KEY INFORMATION TO SHARE WITH COMMUNITY MEMBERS
Heavy bleeding during pregnancy can happen because of miscarriage or because of an
unsafely induced abortion. Miscarriage occurs when pregnancy ends before the developing foetus has any chance of survival. Miscarriage usually occurs in the first 12 weeks
of pregnancy and indicates that something was wrong with the fertilised egg. During
miscarriage, a woman may experience considerable bleeding and pain. An unsafe
abortion can also result in heavy bleeding, pain, and internal injuries. Any of the
following symptoms may indicate that a woman needs immediate medical treatment
for complications of miscarriage or abortion:
b
b
b
b
Bleeding from the vagina that does not stop or is very heavy
Fever or chills
Pain in the abdomen, cramping or backache
Bad-smelling discharge from the vagina
If a woman has an illegal abortion and then develops complications, what
rights does she have? Will she be punished if she goes for medical help?
b What can be done in this community to ensure that women get help
promptly when they experience abortion complications? How can family
members and other people in the community help?
Medical services for abortion complications usually include an assessment of the
woman’s health; a discussion with the woman about her medical condition and
treatment plan; and treatment of any complications. If a woman’s condition permits,
counselling about her condition and procedure options should be provided before
treatment of complications. Counselling and reassurance should be offered before and
during treatment. Afterwards, counselling on self-care and options to prevent unwanted
pregnancy in the future should also be given.
ACTION MESSAGES FOR THE COMMUNITY
b
b
In settings where abortion is legally restricted, women with complications of abortion
or miscarriage often fear that seeking medical treatment will result in punishment
or prosecution. However, regardless of whether the abortion itself was spontaneous
(i.e. miscarriage) or induced legally or illegally, health providers have a professional
responsibility to provide high-quality care for women with abortion complications,
not punish them.
Unsafe abortion in the community
b
b
Women and their families should not delay seeking medical care because of fear of
being punished. Delaying seeking care can cost women their lives.
Women who need treatment for complications of miscarriage or abortion have a
right to high-quality care. They have a right to be treated with respect, and a right
to be informed of their medical condition and treatment options. Regardless of their
age and marital status, women also have a right to information on contraceptives
and to contraceptive services if they want to space or prevent pregnancies.
If health providers in your community are rude or unkind to women with complications of miscarriage or abortion, work with community leaders, district health
officials, and facility managers to try to address the problem so that women with
these problems will feel more comfortable seeking treatment immediately.
b
Section 4
SAFE, LEGAL TERMINATION
b
OF PREGNANCY
b
QUESTIONS FOR DISCUSSION
b
What do you see in this picture? What do you think has happened to the
woman in this picture?
b Do you know of any special circumstances under which abortion is legally
permitted? What circumstances are these?
KEY INFORMATION TO SHARE WITH COMMUNITY MEMBERS
b
Do you know where a woman can go for confidential counselling
about her options?
ACTION MESSAGES FOR THE COMMUNITY
Even where abortion laws are restrictive, in most countries, there are special
circumstances under which abortion is legally permitted. For example, in seven
countries in sub-Saharan Africa, abortion is legal when pregnancy results from rape.
In 23 sub-Saharan African countries, abortion is legal in cases when the pregnancy
puts a woman’s life at risk, and in 16 other countries, pregnancy termination is legal
if the woman’s physical health is endangered.
Women often do not know the circumstances under which abortion is legal. In
addition, health providers are frequently unaware of the circumstances under which
pregnancy may be legally terminated, and they often lack the knowledge and the skills
to provide quality care to women facing a pregnancy that is the result of rape or incest
or a pregnancy that endangers their life and well-being. As a result, for many women,
safe, legal pregnancy termination services are not available or accessible.
b
b
If a woman is pregnant because of rape or incest, or if pregnancy endangers her
health or life, it is important for her to know the legal status of abortion. Ask for
help and advice from a health facility, rape crisis centre, women’s rights organisation,
legal aid society, or human rights organisation.
If unsafe abortion is a serious problem in your community, work with community
leaders, women’s groups and health providers to ensure that safe, high-quality
services for legal pregnancy termination are available to women who need them.
Even in countries where the law does allow women to have abortions under certain
circumstances, health policies, providers’ attitudes, and poor quality services can
prevent women from getting safe services. As a result, many women still use unskilled
abortion providers and unsafe methods of terminating an unwanted pregnancy, even
though the health system could legally provide these services.
Unsafe abortion in the community
b
Section 4
ACKNOWLEDGEMENTS
The development of this flipchart was funded by the generous support of The Compton
Foundation and an anonymous donor. FCI would like to express our sincere thanks to
the following individuals and institutions for their invaluable contributions to the
content of the flipchart and for their assistance during pre-testing:
Dr. Godfrey Alia, Mulago Hospital, Mulago, Uganda
Ms. Mercy Abbey, Ministry of Health, Accra, Ghana
Mr. Vic Davis, Korle Bu Teaching Hospital, Accra, Ghana
Ms. Comfort Louisa Antwi, Mamprobi Polyclinic, Accra, Ghana
Ms. Charlotte Dada, T’s Maternity Home, Accra, Ghana
Ms. Susan Wright-Hansen, Rehoboth Maternity Home, Accra, Ghana
Mrs. Henrietta Duah, Henrietta’s Clinic/Maternity Home, Accra, Ghana
Major Beatrice Laryea, Military Hospital, Accra, Ghana
Ms. Peace Ananga, Midwifery Training School, Sekondi, Ghana
Our special thanks to the following reviewers for their suggestions and advice
regarding the flipchart:
Dr. Solomon Orero, Obstetrician/Gynaecologist, Kenya
Ms. Betty Farrell, EngenderHealth/ACQUIRE Project
Ms. Maureen Corbett, Intrahealth International
Ms. Kristina Graff, Independent Consultant
Acknowledgements
The content and text of this flipchart were developed by Ellen Brazier and
Amy Babcheck, Family Care International. The illustrations were developed by
Regina C. Faul-Doyle.
Production Management: Luz Barbosa with assistance from Spencer Keralis.
Design and Layout: Green Communication Design, Canada
© Family Care International Inc., 2005
Not-for-profit organisations may use any of the material in this publication freely as
long as it is not used for commercial purposes. FCI would appreciate acknowledgments
and copies of any adaptations when possible.
For copies and information on prices, contact:
Family Care International
588 Broadway, Suite 503
New York, NY 10012, USA
Tel: (++1 212) 941.5300
Fax: (++1 212) 941.5563
E-mail: [email protected]
Website: www.familycareintl.org
a