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CTG and ultrasound assessment of amniotic fluid should not be used, as the only form of surveillance in SGA fetuses and BPP should not be done in preterm SGA fetuses. The optimal gestation to deliver the SGA fetus will depend upon the gestational age of the fetus and Doppler study of the umbilical artery (Fig. 3). In the SGA fetus with umbilical artery, AREDF delivery by caesarean section is recommended. Early admission is recommended in women in spontaneous labor with an SGA fetus in order to instigate continuous fetal heart rate monitoring.29
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The situation of induced abortion has changed markedly over the past few decades. This report provides updated information on the incidence of abortion worldwide, the laws that regulate abortion and the safety of its provision. It also looks at unintended pregnancy, its relationship to abortion, and the impact that both have on women and couples who increasingly want smaller families and more control over the timing of their births.
Information on trends in abortion methods used in legally restrictive settings is available for just three countries: Colombia and Mexico (between 1992 and 2008), and Pakistan (between 2002 and 2012). Data on misoprostol use were not collected for the earlier years in Colombia and Mexico because its use was considered to be very limited at that time. According to surveys of health professionals, an estimated one-half of all abortions in Colombia in 2008 and nearly one-third in Mexico in 2007 were done using misoprostol alone. At the same time, the proportions of procedures performed by physicians and untrained providers have declined, which suggests that reliance on surgical methods and unsafe traditional methods have both dropped.112 In Pakistan, the proportion of health professionals who responded that misoprostol was commonly used was much higher in 2012 than in 2002, and this change was more evident in urban areas than in rural areas.113
The abortion-provision picture is mixed for the countries that liberalized their laws within roughly the past two decades (Figure 3.3). One of the first challenges to instituting safe services is communicating that abortion is now legal and where it is available. Informing health professionals and women of a newly granted right is an enormous challenge, especially where rates of illiteracy and poverty are high, and where abortion continues to be strongly stigmatized. The fact that many countries have unclear laws and service provision guidelines that sometimes conflict with the law makes this challenge even more difficult to overcome.
Access to legal abortion can be impeded if large numbers of providers claim conscientious objection, which in the absence of efficient referral systems can translate to delays, in turn leading to riskier procedures at later gestations, or even the denial of legal care.121 Greater acceptability of medication abortion could help address this barrier to timely care, especially right after legal reform when health professionals are expected to transition to provision of a new service.122 In fact, evidence from several countries shows that health professionals may be more willing to provide medication abortion than surgical abortion, because they are more removed from the process of the abortion itself.123
Sometimes, safe services can coexist with clandestine and unsafe ones years after liberalization. In Ethiopia,o for example, only a little over half (53%) of abortions in 2014 were legal procedures about nine years after law reform; nevertheless, that constituted significant progress as the level in 2008 was about half that (27%).125 In Nepal, which enacted more sweeping legal change than any other country since 2000, 63% of health facilities provided legal abortions as of 2014, and 42% of all abortions that year were legal.95 Barriers to safe abortion care that persist in Nepal include women's inadequate knowledge of its legality and of where to obtain services; poor availability, especially in rural areas; long distances to health facilities; and high costs, despite legislation ensuring the contrary.
The specific methods of abortion used in broadly legal countries have undergone a sea change since mifepristone was approved, starting with China and France in 1988.110 By about the mid-2000s, combination medication abortions outnumbered surgical procedures in several countries, including Finland, France and Sweden (Figure 4.2). However, use of the surgical D&C procedure, which is no longer recommended by WHO, was still common in some former Soviet Bloc and satellite countries: In Armenia, nearly six out of 10 abortions in 2010 were by D&C, as were three out of 10 that year in Georgia129 and four out of 10 in Belarus in 2013.130
Small-scale studies in Nepal, South Africa and Tunisia found that women are sometimes denied care even when they legally qualify for an abortion.33 Some of these women were turned away because they could not pay for their abortions; others because the clinics lacked the staff or equipment to perform the abortion, or required the woman to first undergo unnecessary laboratory tests. Women denied services might obtain referrals and receive legal abortions elsewhere, but they may also turn to unsafe abortions from untrained providers or continue with an unwanted pregnancy.
The likelihood of needing medical treatment after using misoprostol probably ranges widely. The rate of experiencing an incomplete abortion and needing care is likely low among women who get and follow accurate instructions from a knowledgeable medical professional or another reliable source. But the need for care can rise among women who are given no or minimal instructions about how to correctly use the drug and what to expect. The vast majority of misoprostol use in legally restrictive settings likely occurs outside the formal medical sector; in these countries, misoprostol is likely purchased from pharmacies, street vendors and to some extent, over the Internet.
Women may choose misoprostol because its use mimics the culturally acceptable "bringing on (or down) of menses," a perception that is shared across a broad range of countries, from Argentina20 to Bangladesh21 to Cambodia.22 Its use also allows women to exert control over a highly personal and private process. All women who use misoprostol need accurate information about how to use it correctly and how it works, because without a full understanding, they can unnecessarily experience problems or seek unneeded care. Just as important, women also need to know how to recognize symptoms of an incomplete abortion, which can occur even with correct use.
Women who experience complications from unsafe abortion need immediate postabortion care. In countries that severely restrict abortion, however, many women put off seeking care until their symptoms become life-threatening.144,145 The longer they remain untreated, the worse the outcome; thus, much of the mortality associated with induced abortion can be attributed to treatment delays.146 Recommended standards of postabortion care incorporate the following key elements: immediate treatment of complications, including pain management; provision of contraceptive counseling and services, and STI/HIV care; and mobilization of community partnerships to improve services and spread information about their availability.147
The heterogeneity in the design of studies assessing the severity of complications, and in the definitions of "mild," "moderate" and "high" severity, is too large to enable comparisons and conclusions from this body of studies.s,181 An alternative approach uses a uniformly defined, acute-severity measure known as "near miss," for which clinically defined life-threatening symptoms signal that the woman would have died if she had not received emergency care in time. A pooled analysis of data from 11 countries in Africa, Asia and Latin America estimates that 240 near-miss events from complicated abortions and miscarriages occur each year per 100,000 live births.29
But abortions do not automatically become safe with legalization. We now have a body of evidence on lessons learned once legal change has been accomplished. Nepal provides a good example of steps that contribute to efficient implementation: establish a simple process for certifying facilities, ensure that abortions are affordable, incorporate training into curricula of medical and nursing schools, permit trained midlevel staff to provide abortions, strengthen referrals between all reproductive health care services, and conduct information campaigns to educate the public about legal reform and to decrease stigma.232 2b1af7f3a8