UNIT 10:
Safe Abortion and Post-Abortion Care for Adolescents
INTRODUCTION:   
Adolescents face many barriers to obtaining sexual and reproductive health services.  When it comes to safe abortion and post-abortion care, they must also deal with larger social taboos and concerns. Service providers may feel unclear about which services they can provide, when they can provide, and to whom they can provide services. Service providers may be caught between the clientÕs need for services and law(s) that determine how they can provide services. This is particularly true in the case of women and girls with disabilities, whose sexual and reproductive autonomy is often denied and their ability to decide if and when to have and raise children is questioned. Where abortion is illegal or access is restricted, women may seek unsafe abortions which jeopardizes their health and even their lives. Although many countries restrict or limit the provision of safe abortion services, women in nearly all countries can legally obtain comprehensive post-abortion care (cPAC). 
     	UNIT TRAINING OBJECTIVE:
To clarify values and attitudes related to safe abortion and post-abortion care for adolescent women.
To establish appropriate clinical and counseling approaches. 	
     	SPECIFIC LEARNING OBJECTIVES:
By the end of the unit, participants will be able to:
1. Identify their values related to adolescent sexuality, pregnancy, safe abortion, and cPAC. 
2. Explain the importance of safe abortion and cPAC for adolescents. 
3. Demonstrate appropriate medical and counseling approaches for adolescents who may seek safe abortion and cPAC services. 
     	TOTAL TIME: 5 HOURS 10 MINUTES





UNIT OVERVIEW: 
Session
Methods
Materials
Time
10.1

Values clarification
Flipcharts and markers
ÒA lot,Ó Òa little,Ó and Ònot at allÓ signs 
Tape
1 hour 45 minutes
10.2 
Trainer presentation
Case studies
Group discussion
Participant Handout 10a
Prepared flipchart
Slides 10.1-10.8
Flipcharts and markers
1 hour 20 minutes
10.3 
Trainer presentation
Role plays
Participant Handout 10b
Slides 10.9-10.12
Prepared flipcharts
1 hour 35 minutes
Unit Summary
Small group work
Participant Handout 10c
30 minutes

     	WORK FOR TRAINERS TO PREPARE IN ADVANCE:
* Review national or local laws and policies related to safe abortion, comprehensive post-abortion services, and parental consent and notification laws.  Find out if these or other laws and policies specifically refer to women and girls with disabilities and become familiar with their content. Revise content of activities as necessary. 
* Review The Nairobi Principles on Abortion, Prenatal Testing, and Disability to understand the position of selected womenÕs rights organizationsÑincluding those led by women with disabilitiesÑon abortion and disability and prepare for discussion with participants on the subject. 
* Review PathfinderÕs Abortion Policy Scan for Advocacy, available at:  https://www.pathfinder.org/publications/abortion-policy-scan-for-advocacy/
* Review slides 10.1-10.12
* Review and prepare Participant Handouts 10a-c.
* SO 10.1: Prepare three signs saying ÒA little,Ó ÒA lot,Ó and ÒNot at allÓ for the comfort continuum activity and sheets of paper with questions for reasons why activity. 
* SO 10.2: Prepare flipchart page with case study discussion questions. 
* SO 10.3: Prepare flipcharts on procedural considerations, strategies for pain management, and post-procedure considerations.
* Unit Summary: Review and prepare Participant Handout 10c Service Readiness Assessment Checklist. Work with adolescent and young women from your community in the review if possible. 
     	MAJOR REFERENCES AND TRAINING MATERIALS:

Ipas. 2011. Abortion Attitude Transformation: Values clarification activities adapted for young women. Chapel Hill, NC: Ipas. 

IPPF. 2014. Youth and Abortion: Key Strategies and Promising Practices for Increasing Young WomenÕs Access to Abortion Services. London: IPPF. 

Pathfinder International. 2008. Assessment of Youth-Friendly Postabortion Care Services: A Global Tool for Assessing Postabortion Care for Youth. Watertown, MA: Pathfinder International. 

Pathfinder International. 2014 Abortion Policy Scan for Advocacy. Watertown, MA: Pathfinder International.    

Postabortion Care Consortium (PAC). 2012. Youth-Friendly Postabortion Care Supplemental Training Module: TrainerÕs Manual. Washington, DC: PAC. 

Postabortion Care Consortium (PAC) Youth-Friendly Working Group. 2006. Technical Guidance on Youth-friendly PAC. Washington, DC: Pathfinder International. 

The Nairobi Principles on Abortion, Prenatal Testing and Disability. 2018. CREA. https://nairobiprinciples.creaworld.org/ 

Turner, K. L., E. Borjesson, A. Huber, and C. Mulligan. 2011. Abortion Care for Young Women: A Training Toolkit. Chapel Hill, NC: Ipas. 

USAID: Extending Service Delivery (ESD). 2008. Youth-Friendly Postabortion Care Cue Cards. Washington, DC: Pathfinder International. 

More resources available at http://pac-consortium.org/resources/youth/. 



SPECIFIC OBJECTIVE 10.1: REFLECT ON VALUES RELATED TO ADOLESCENT SEXUALITY, PREGNANCY, SAFE ABORTION AND PAC
     	TIME
       1 hour 45 minutes
     	METHODS
* Values clarification activities
* Group discussion
     	MATERIALS NEEDED 
* Signs: ÒA little,Ó ÒA lot,Ó and ÒNot at all.Ó
* Flipcharts and markers
     	STEPS

1. Set up the room by placing three signs in a row that establishes a continuum from ÒNot at allÓ to ÒA lot.Ó 

   Time: 1 hour 
2. Introduce the activity by telling participants that this activity is intended to help providers assess their comfort in providing safe abortion and comprehensive post-abortion care services to young women. Remind participants of the ground rules regarding confidentiality and respect for each otherÕs opinions and feelings. 

3. Tell participants that when you read a statement, they should move to the sign that best reflects their feelings. Encourage participants to be honest about their own feelings and to try to not pay attention to other participants. 

4. Read the first statement from Content: Comfort Continuum Statements below. Have participants move to a place on the continuum. Ask for a few volunteers to explain their position. If, based on someone elseÕs explanation, participants want to move to a different place on the continuum, encourage them to do so. 

5. Continue through the rest of the statements, discussing participantÕs placement after each one. 

       Content: Comfort Continuum Statements 
* How comfortable are you with the idea of providing safe and legal induced abortion services in your country?
* How comfortable are you in discussing abortion with colleagues at work?
* How comfortable are you in discussing abortion outside of a work setting?
* How comfortable are you in discussing comprehensive post-abortion care for unsafe or illegal abortions with your colleagues?
* How knowledgeable are you about your countryÕs laws and policies on abortion services?
* What do you know about the legality of access to comprehensive post-abortion care in your country, regardless of the legal status of abortion?
* How comfortable are you working in a place where women are treated for complications from unsafe abortions?
* How comfortable are you or would you be in working in a facility where abortions are performed?
* How much disapproval would you expect from your family and/or friends if you provided (or assisted with) comprehensive post-abortion care or abortion services?
* How comfortable would you be treating a woman who was suffering from complications from an unsafe abortion?
* How comfortable are you or would you be in performing (or assisting with) an abortion in the first trimester?
* How comfortable are you or would you be in performing (or assisting with) an abortion in the second trimester?
* How comfortable are you with the idea of every woman having the right to access safe abortion and comprehensive post-abortion care services? 
* How comfortable are you with the idea of every adolescent women having the right to access safe abortion and comprehensive post-abortion care services?
* How comfortable are you or would you be in providing (or assisting with) abortion for every woman that obtains one, regardless of her reasons?

6. Once you have read through and discussed each of the statements, have participants return to their seats. Have two participants share their feelings about the activity. 

7. Facilitate a conversation with the whole group about the different responses and levels of comfort in the room using the discussion prompts below. Refer to the reasons participants gave when taking their place on the continuum. 
* What do you observe about your responses to the statements? Other peopleÕs responses?
* Were there times when you wanted to be with the majority of the group? Did you move? Why or why not? How did that feel?
* Did any of your responses surprise you? How about other peopleÕs responses?
* What did you learn about your own and othersÕ comfort levels with abortion?
* What observations do you have about the groupÕs overall comfort level with abortion? 

8. Ask the participants to reflect on the experiences that have influenced their comfort and discomfort around abortion or comprehensive post-abortion care. Invite them to imagine how a different set of life circumstances might have led to a different perception of abortion. Is disability an element that brings additional comfort or discomfort? If yes, is this related to the disability of the mother or of the child? Ask a few participants to share their reflections. 

9. Discuss how these different levels of comfort with abortion affect social attitudes and norms on abortion, how women may feel about themselves if they have an abortion, and how providers might feel about providing abortions or comprehensive post abortion care. 

10. Ask participants to reflect on how their comfort or discomfort with abortion and/or adolescents affects their ability to provide quality abortion care.  How does provider comfort or discomfort with abortion affect the services that are provided, such as counseling or clinical care?  What about a providerÕs level of comfort with treating an adolescent client who is unmarried and sexually active?  How does a providerÕs level of comfort affect their ability to provide care to an adolescent who has sought a second trimester abortion? What if the adolescent client has a disability? Would the level of comfort or discomfort vary according to the type of disability? What does non-judgmental care look like?  Emphasize that provider attitudes have a big effect on their ability to provide quality, non-judgmental services, and that provider attitudes also affect womenÕs experiences and satisfaction with those services. 

> TrainerÕs Note: If questions arise during the discussion on abortion laws and policies in the country, be prepared to gently correct misinformation or provide correct information once participants have finished the discussion. When it comes to abortion and disability, remember to refer participants to the Nairobi Principles on Abortion, Prenatal Testing, and Disability included in the references list of this unit and use them to guide the discussion. 
 
11. Leave time for any outstanding questions, concerns, or comments. Thank the group for their participation. 

Time: 60 minutes

12.  Divide participants into groups of three to five. Give each group a flip chart and markers. Assign each group one or more of the questions from Content: ReasonÕs Why Statements below. 

       Content: Reasons Why Statements
1. What are all the reasons women have sex?
2. What are all the reasons adolescent women have unprotected sex?
3. What are all the reasons women become pregnant?
4. What are all the reasons women have an unintended pregnancy?
5. What are all the reasons women terminate a pregnancy?
6. What are all the reasons women continue an unintended pregnancy?
7. What are all the reasons women may make decisions about their unintended pregnancy that they really donÕt want to make?
8. What are all the reasons adolescent women feel like they canÕt make their own decisions about sexual activity, contraceptive use, pregnancy, and abortion?
9. What are all the reasons governments regulate womenÕs sexual activity, contraceptive use, pregnancies, and abortion?

13. Give each group 10 minutes to brainstorm all of the possible responses to the questions they have been given. Encourage them to think as deeply and broadly as possible about the range of women they see in their clinics including women with disabilities and the difference in their lives and circumstances. Have each group record their responses on flip chart paper highlighting all the relevant points related to women with disabilities that emerged from their answers.

14. Have each group present their responses to the larger group. Once all the groups have presented, ask the group as a whole to add any extra responses to the presentations. Invite participants to take some time to walk around the flip charts and review the responses.

15. Use the following discussion questions to facilitate a group discussion about their comfort levels. 
* What are some reasons for having sex that make you feel uncomfortable? 
* Is there anything about persons with disabilities having sex that makes you feel uncomfortable? If yes, what? 
* What are some reasons for unintended pregnancy that make you feel uncomfortable?
* What reasons for abortion make you feel uncomfortable?  Why do these reasons make you uncomfortable?  
* How do your personal values influence your level of discomfort with certain reasons for having sex, using contraception, experiencing unintended pregnancy, and obtaining an abortion?
* How does your own discomfort with abortion affect your ability to provide non-judgmental services to women who have had an abortion?  
* In what way might your discomfort with adolescents who are unmarried and sexually active and who have obtained an abortion affect your ability to provide quality care? 
* Does disability play a role in deepening your discomfort? 
* How do you feel about women having to make a decision about their unintended pregnancy that they really donÕt want to make?
* How do you feel about parents/guardians who want to make decisions about the reproductive lives of adolescent clients for them? What if the client has a disability? An intellectual and developmental disability?  
* What are the reasons that governments may regulate womenÕs pregnancies and abortion? Are these more regulated than other medical conditions and procedures? 
* How does our discomfort on the following affect our ability to provide sexual and reproductive health care to young people, especially quality abortion or post abortion care?
o Having non-marital sex
o Using contraception, especially hormonal methods
o Experiencing unintended pregnancy
o Seeking abortion 

* How does our discomfort with the following affect our ability to provide sexual and reproductive health care to young persons with disabilities, especially quality abortion or post-abortion care?
o Having non-marital sex, 
o Using contraception, especially hormonal methods
o Experiencing unintended pregnancy
o Seeking abortion 

* Might clients sense this discomfort? What effect could this have on the quality of health care we provide?

16. Close the activity by discussing how individualsÕ discomfort with some womenÕs reasons (for having sex, using contraception, getting pregnant or seeking an abortion) can result in services and systems that deny women access to safe, high-quality abortion and comprehensive post-abortion care services. This can lead some women to have to risk their health and lives to obtain an unsafe abortion. 

17. Allow time for any final questions, comments, or concerns. 




SPECIFIC OBJECTIVE 10.2: EXPLAIN THE IMPORTANCE OF ACCESS TO SAFE ABORTION AND PAC FOR ADOLESCENTS
     	TIME
       1 hour 20 minutes
     	METHODS
* Trainer presentation
* Case studies 
* Group discussion
     	MATERIALS NEEDED
* Slides 10.1-10.8
* Flipcharts and markers
* Prepared flipchart with Case Study Discussion Questions
* Participant Handout 10a: Safe Abortion Access Case Studies 
     	STEPS 

1. Introduce the topic. Remind participants of the discussions about barriers to seeking abortion in Units 3 and 7, and the previous discussion about the values component of safe abortion and comprehensive post-abortion care in this unit. 
2. Say: In this session we are going to discuss the specific challenges that adolescent clients face in seeking safe abortion and post-abortion care services. 

Time: 20 minutes

3. Ask participants to brainstorm some reasons that young people seek unsafe and late abortions. Remind participants to think about reasons specific to vulnerable and marginalized groups of young people, including young persons with disabilities. After some ideas have been shared, begin the presentation with Content: Adolescent and Youth-Specific Barriers (Slides 10.1-10.8) below. 

       Content: Adolescent and Youth-Specific Barriers (Slides 10.1-10.8)

Slides 10.1-10.2: Reasons that Adolescents Seek Unsafe or Late Abortion 
* They deny the pregnancy. 
* They are unaware they are pregnant. 
* They fear the reactions of their parents, in-laws, partners, peers, and/or communities. 
* They are unaware of where to seek safe abortion services.
* There are no legal, safe abortion options. 
* Their access to abortion services is restricted due to age, marital status, disability or dependent on a parentÕs or partnerÕs consent.  
* They lack financial resources.
* They lack transportation (or cannot afford it) /services are far away. 
* They lack accessible transportation (for young persons with disabilities) and services are far away.
* Services are inaccessible or unwelcoming due to physical, attitudinal, or communication barriers (for young persons with disabilities) and accommodation is not provided. 
* They are misinformed about safe abortion and seek out ÒhomeÓ or traditional approaches. 
* They do not know whom or how to ask for help. 
       Source:  PAC Consortium YFPAC Training Module


Slide 10.3: Summary of Barriers
* Adolescents often seek late and unsafe abortion services. As a result, adolescents may end up with more serious complications (including death) than adults. 
* Many adolescents also present late at health facilities when they are pregnant or because of complications of either a spontaneous or unsafe abortion. 
Source:  PAC Consortium YFPAC Training Module

4. Pause and ask participants to brainstorm some ways to reduce barriers and encourage adolescent clients to seek early care for pregnancy, abortion, and/or comprehensive post abortion care. Remind participants to consider barriers that may be specific to distinct groups of adolescents, including young persons with disabilities. Once participants have responded, return to the presentation with Slide 10.4: Addressing Barriers below. Remind participants that these suggestions are not comprehensive, merely some ideas for them to start from. 

Slide 10.4: Addressing Social Barriers
* Provide information to community leaders.
* Engage religious leaders.
* Provide education to parents/guardians/caregivers.
* Set up informal or formal social support networks.
* Organize values clarification workshops for health-care providers and staff.
       Source:  PAC Consortium/IPAS  

Slide 10.5 Addressing Economic and Logistical Barriers
* Lower the cost of abortion care or establish sliding cost scales for adolescents.
* Request accessible and affordable public transport routes or establish facility transport service (e.g. with local taxi services).
* Create a community-run transportation network.
* Use a community fund to assist in covering costs for services or transportation.

Slide 10.6 Addressing Legal and Policy Barriers
* Ensure that facilities provide abortion services to the fullest extent of the law to all clients, including women and girls with disabilities. 
* Create and/or adopt good clinical standards and guidelines if they do not exist, and remove language barriers in those that do exist. Ensure that those standards and guidelines are disability-inclusive.
* Understand the parameters of the law and the legal indications of what is permissible for any client who seeks abortion care.
* See Pathfinder InternationalÕs Abortion Policy Scan for Advocacy. 

Slides 10.7-10.8: Addressing Health System Barriers
* Provide abortion care for young women in easily accessible locations.
* Support clinics to keep an extensive schedule/remain open as late as possible.
* Ensure that misoprostol medical abortions are available locally and provide them.
* Ensure the entire facility (including the waiting room, the counselling rooms, the examination and procedure rooms, the recovery rooms and the bathrooms) is accessible to persons with disabilities and provides both visual and auditory privacy. Where possible, provide private rooms and separate toilets for abortion clients.
* Ensure effective communication between the client and the provider by providing accommodations as needed by young persons with different types of disabilities.
* Ensure confidentiality for all clients, including young people and clients with disabilities. 
* Use data collection forms that are neutral and non-judgmental, disability-sensitive, and do not require clients to complete excessive or unnecessary paperwork.  If possible, make data collection forms available in an accessible format (i.e., braille, large print, easy to read etc.). Ensure the reception staff is trained and available to support persons with disabilities to complete data collection forms if necessary. 
* Do not require unnecessary return visits as recommended by international protocols.  
* Frame counseling about sexual and reproductive health using positive, respectful, and disability inclusive language and terms. 
* Interpret legal indications broadly.
* Avoid any actions that might traumatize the client and ensure that providers assess and address the needs of all clients.

5. Conclude the presentation by asking for questions or clarifications from participants. If there is time, ask participants to share positive experiences of providing safe abortion and comprehensive post-abortion care services to young women, including women with disabilities.

Time: 1 hour 
6. Explain to participants that you will be dividing them into small groups to discuss case studies on reducing barriers to safe abortion and comprehensive post-abortion care.

7. Divide participants into six small groups. Provide each group with a flipchart. 

8. Distribute Participant Handout 10a: Safe Abortion Access Case Studies. Assign each group a different case study. Post the flipchart with the case study discussion questions (below) at the front of the room and review with participants. Ask groups to read their assigned case study, then take 20 minutes to brainstorm and record answers to the discussion questions. 

       Content: Case Study Discussion Questions
a. What are the challenges identified in the case study?
b. What possible strategies exist to address the challenge?
c. How could you determine which is the best strategy to implement? How would you involve young people in determining the strategy?
d. Which do you think is the best strategy?
e. What would be the first steps you would take to implement the strategy? 
f. How would you involve young people in implementing the strategy?
g. How do you think health officers and/or facility administrators would react to the proposed strategy?

9. When the groups have completed their discussion, have them report back to the plenary by having a representative first read their case study, and then present the strategy the group created to address the challenge. 

10. In plenary, compare how different groups addressed similar issues. Ask participants to identify any common elements that appear in the strategies, and brainstorm any elements that may be lacking, such as strong partnerships with young people, or focus on young persons with disabilities.

11. Facilitate a group discussion using the following questions: 
a. How did it feel to create a strategy that addresses some of the challenges that young women face in obtaining abortion care?
b. What, if any, were the challenges your group faced in creating that strategy?
c. Do you think you face any of these challenges in your community? How would these strategies help you there?
d. What steps might you take when you get to your facility to address these challenges?

12. Close the activity by leaving time for any additional questions or comments. Remind participants that each facility is different, both in their challenges and their approaches to addressing those challenges. Remind them of the resources available to them, both those listed at the start of this unit and those in the community, including young women themselves. 





PARTICIPANT HANDOUT 10A: SAFE ABORTION ACCESS CASE STUDIES
Adapted from IPAS/PAC Consortium
Case Study 1: Community Resistance
Parents and religious leaders in the community are not happy that their local community health facility provides abortion services, especially to young women. They feel like the clinic is promoting promiscuity, teaching the girls to hide things from their family, and going against the teachings of the church.  In fact, young women are more likely to be admitted to the clinic with complications from unsafe abortion.  Very few actually come for safe abortion services. 
Case Study 2: Cost and Transportation
A district hospital serves a large rural area and provides safe abortion services.  Not many young women come to the hospital for safe abortion services.  If they do, they often only have barely enough money to cover the cost of the service.  They have very little money for transportation and certainly no money for food or a hotel. They usually come alone and need to return home on the same day they come for the abortion.  The trip can take several hours, over bad roads.  
Case Study 3: Consent Law
A private clinic provides safe abortions.  Recently they began enforcing a new law that requires young women below the age of 17 to seek a parentÕs consent to the abortion.  If the parent is not available, they will need to obtain a judgeÕs consent.  In just a few months, the number of young women who request an abortion has reduced by half, but the number of post-abortion care cases has dramatically increased. 
Case Study 4: Privacy , Confidentiality, and Informed Consent.
Many young women with disabilities say they prefer not to come to the facility for abortion services, because they are afraid that they will see someone that they know.  There is also a persistent rumor that people working in the facility share stories with their families and neighbors about women who come for abortions and that women with disabilities are forcibly sterilized thereafter.  
Case Study 5: Provider Attitudes
When a young woman comes to a public health facility in her community, the receptionist loudly asks if the young woman is here for an abortion, asks her age twice, then sucks her teeth and shakes her head. She loudly announces to the doctor that the young woman is there to have an abortion and has come alone.  When the young woman meets the doctor, he asks her age and then asks about her husband and wants to know if her husband knows she is getting an abortion. The provider tells her he cannot provide the abortion to her.  He does not tell her why. 
Case Study 6: Low Service Use Among Young Women
A referral hospital discovers that its abortion patient load is mostly women over the age of 30.  Yet other data shows that many young women present with complications of unsafe abortion and there have even been several deaths.  


SPECIFIC OBJECTIVE 10.3: DEMONSTRATE APPROPRIATE MEDICAL AND COUNSELING TECHNIQUES FOR ADOLESCENT SAFE ABORTION AND PAC SERVICES
     	TIME
     	METHODS
* Trainer presentation
* Role plays
     	MATERIALS NEEDED
* Participant Handout 10b: YFPAC Cue Cards
* Flipchart: Procedural Considerations
* Flipchart: Strategies for Pain Management
* Flipchart: Post-Procedure Considerations
     	STEPS

Time: 10 minutes 

1. Introduce the content. Tell participants that the group has had a chance to explore some of their values related to safe abortion and post-abortion care and brainstorm strategies for making safe abortion and post-abortion care more accessible to all young women, including young women with disabilities .The next session will review some of the specific counseling and clinical needs of young women seeking these services. 

2. Present Content: Considerations for Counseling Adolescent Clients (Slides 10.9-10.12) below. Remind participants that the group has previously discussed adolescent-friendly counseling in Units 3, 7, and 8. 

3. Say: Our behavior reflects our attitudes, beliefs, and emotions, even when weÕre not aware of it. All of the non-judgmental language and counseling techniques weÕve discussed for general SRH services also need to  be applied to young women seeking safe abortion and post-abortion care. 

       Content: Considerations for Counseling Adolescent Clients (Slides 10.9-10.12)

Slide 10.9: Before the Facility
When a young woman comes to a facility for treatment of an incomplete abortion, she has already had contact with, and will have contact with, more than just the health provider. These may include:
* Parents/guardians/caregivers
* Traditional Healers
* ÒQuacksÓ
* Friends/Peers
* Partners
* Community
* Faith Leaders 
* Other clinic staff

She may have gotten conflicting information and had a range of experiences Ð likely negative -- with any of these people.   She may be feeling defensive, frightened, anxious, and/or frustrated. 

Slide 10.10: Provider Attitude 
It is essential that the provider demonstrate supportive attitudes.  This is essential not just for the quality of the clinical care provided, but to allow the young woman to relax, communicate effectively, and relay her fears. Adolescent clients who are afraid or have experienced judgmental attitudes from service providers, service facility staff, or others, will be reluctant to share information, and in particular, may be afraid to talk about what kinds of unsafe abortion strategies theyÕve attempted. This can be particularly true for adolescent clients with disabilities who often face additional attitudinal barriers in accessing care. 
Counseling during safe abortion and post-abortion care is essential: it is key to positive physical and emotional health outcomes. Ensuring that counseling is available and accessible to all adolescent clients, including young persons with disabilities, is therefore a priority. 

Source: Adapted from PAC Consortium YF PAC Training

Slides 10.11-10.12: Safe Abortion and PAC Counseling
Safe abortion and post-abortion care counseling can: 
* Provide adequate, clear and accessible information to help the adolescent make an informed decision.
* Help the adolescent evaluate her feelings and opinions.
* Act as an emotional support for the adolescent.
* Help the adolescent anticipate consequences.
* Support the adolescent in making informed and conscious health decisions, including the adoption of contraception to avoid future unintended pregnancy. 

Safe abortion and post-abortion care counseling does not: 
* Enforce a pre-determined solution to the adolescentÕs problems.
* Make decisions for the adolescent. 
* Promote a life plan that has been successful in the past or with other clients.
* Express the counselorÕs judgment about the adolescentÕs behavior.

It is important to keep in mind that all the above mentioned Òdo and donÕtsÓ apply for all clients accessing safe abortion and post-abortion care counseling without any restriction on the basis of education level, disability, or financial status.

Source:  PAC Consortium YF PAC Training

4. Take time for participant questions at the end of this presentation. While participants are discussing, set up 3 Flip Charts in separate parts of the room. Divide participants into three groups and assign each group to one flip chart. 

Time: 45 Minutes 
       Content: Activity Introduction
	Source:  PAC Consortium YFPAC Training
Introduce the activity by telling participants that clinical procedures for safe abortion and post-abortion care are the same for both adult and adolescent clients. Methods can include using manual vacuum aspiration, misoprostol and electric vacuum aspiration. Where various methods for safe abortion or post abortion care are available, and when providers are equally skilled in the use of different methods, the least invasive method should be used.  Dilation and curettage (D&C) should not be used unless the other methods are not available or it is the only appropriate method for that particular case.  
5. Dilation and curettage is also used when other safe methods are not available or as indicated. There are some additional aspects of care that should be considered when treating adolescents, which the group will review in this activity. 

6. Tell participants that they will start at the flip chart to which they have been assigned.  They should read the content on the flip chart, discuss, and mark what their group thinks are the two most important points. This should take 10 minutes. 

7. After 10 minutes, the groups should rotate to a new flip chart station and read the content on that flip chart. They should again discuss the content and mark the two most important points which have not been marked by the previous group. 

8. After another 10 minutes, groups should rotate to the last flip chart station and again discuss the content and mark an additional two points. 

9. When groups have completed all three flip charts, allow participants 5 minutes to walk individually around the room and look again at each flip chart to see what other groups have marked as important. 

10. In plenary, review the key points each group chose and answer any remaining questions. 

Time: 40 minutes

11.  Distribute Participant Handout 10c: YFPAC Cue Cards. Give participants 5 minutes to review the cue cards, explaining that they may want to use them during the next activity. 

12. Ask participants to form pairs: each pair should take turns playing a provider and client. Explain that you will read a case study out loud, and that the pairs will then have 10 minutes to practice role playing appropriate counseling and clinical techniques. 

13. Read Content: Role Play 1 below. 

(Role plays adapted from PAC Consortium YFPAC Training)

       Content: Role Play 1
Lucy is a 16-year-old young woman from a rural village who now works as a house girl in a wealthy familyÕs home in the capital. She doesnÕt have much free time, but she does see a young man from down the street occasionally. Sometimes he stops and talks to Lucy when she is working outside. Lucy enjoys his company and they have begun spending some time together, going for walks or to the movies. Recently they had sex for the first time. Lucy left school when she was very young and being far from home, she doesnÕt have anyone to talk to about sex or pregnancy or contraception.  She didnÕt know that you could get pregnant the first time you have sex and was unaware of the signs and symptoms of pregnancy.  She began feeling nauseous and tired, and when she had missed her third period she asked her employer if she could go the doctor.  Her employer, a woman, was furious with her for Òbeing so stupidÓ and threatened to kick her out of the house. She talked to her male friend, and he told her how she could end the pregnancy using a cassava stick.  Later that night, her employer found Lucy bleeding and brought her in for treatment. 
14. After pairs have finished the role play, ask the participant who played Lucy to provide some feedback to the participant who played the provider on how they felt. 

15. Tell participants to swap roles for the next role play. Read Content: Role Play 2 (below) and allow an additional 10 minutes for the second role play. 

       Content: Role Play 2
Nisha is a 19-year-old woman with a visual disability who works in a small shop in the provincial capital. She lives with her uncle, who she rarely sees.  She sends most of her wages back to her family in a rural village which is a few hours from the city. Nisha started seeing Mathew about six months ago. He has been kind and generous to her, buying her meals and presents and they have started having sex occasionally.  They do not use condoms or contraception.  When she missed her period, she asked a friend for help, and her friend gave her some pills to take to Òbring down her period.Ó When Nisha fell ill, her friend took her to the hospital where she was admitted for treatment. 

16. After the role play, ask the participant who played Nisha to give their partner feedback on how they felt during the counseling and Òtreatment.Ó 

17. In the plenary, ask the group to discuss the following questions: 
a. When you were in the client role, what behaviors did you notice that were not comforting? What behaviors were comforting? 
b. When you were in the provider role, what behaviors felt natural? Which did you have to think more about or use the cue cards for?
c. What counseling techniques were most helpful? What types of questions did you ask?
d. Was it difficult to separate the client from her circumstances? 
e. How did you make a transition from post-abortion care to talking about contraception or dual protection? Was the transition easy?

18. Allow time for any closing questions or comments. Thank participants for their participation and their willingness to explore this topic. 


PARTICIPANT HANDOUT 10B: YFPAC CUE CARDS 

Source:  Adapted from the Extending Service Delivery Project YFPAC Cue Cards.  See:  https://www.k4health.org/toolkits/htsp/youth-friendly-postabortion-care-yfpac-job-aids-english

Card 1: Before Procedure
* Welcome the client and make her comfortable.
* Ensure privacy and confidentiality.
* Take history and include a risk assessment for STI/HIV and SGBV, using the HEEADSS approach.
* Assess client to ensure:
? Vital signs do not indicate shock
? Vaginal bleeding is not excessive
? No abdominal injury is present
? No visible signs of STI
* If needed, make arrangements with available trained health provider for the procedure, or refer to a higher-level facility.
* If client desires, involve a support person (e.g., friend, partner, or parent) in all counseling but ensure the adolescent client remains your main focus. 
* Discuss her reproductive desires and intentions post procedure.
* Discuss contraceptive options and provide counseling as appropriate. 
* Remember: Ask/ Observe/ Examine client as appropriate.
* Ensure that all equipment is sterilized and ready.
* Explain the procedure to the client and answer any questions she may have.
* Obtain informed consent for the procedure and for pain management.
* Ensure the client gets adequate pain medication:
o IV/IM: 15-30 minutes before procedure
o By mouth: 30 to 60 minutes before procedure

Card 2: During MVA Procedure
* Ensure privacy, including bodily privacy. Ask the client to undress and lie on the examination table only when you are ready to begin the procedure.
* Monitor vital signs and provide verbal support. A support person or an assistant can help if available.
* Monitor the client closely for pain.  Give pain management counseling and use additional pain medication that is safe for the client, if needed.
* Reassure the client during the procedure.
* Follow all infection prevention procedures.
* Inspect tissue to ensure the procedure is complete.




Card 3: After MVA Procedure 
* Observe the client for 1 to 2 hours; check vital signs and vaginal bleeding every 30 minutes.
* Provide pain medication for cramping.
* Continue to ensure privacy and confidentiality.
* If the client agrees, include a support person (e.g. friend, partner or parent) when giving instructions/counseling but ensure the adolescent client remains your main focus.
* Inform the client to take the following actions:
? Rest.
? Insert nothing in vagina. 
? No sexual intercourse until there has been no vaginal bleeding for 2 days, then she can resume sexual intercourse when she feels comfortable to do so.  
? She can resume sexual intercourse when she feels comfortable to do so.
? Take medicines given by provider.
? Watch for warning signs and come back to the health facility if there is:
* Severe abdominal pain
* Fever
* Bleeding that is much heavier than a normal period
* Foul odor from vagina
* Bleeding that lasts more than two weeks
* Vomiting or nausea
* Inform her she can get pregnant within 10 days after an abortion or miscarriage and before she has her next period.  If she does not want to become pregnant she should abstain from sexual activity or adopt the use of a contraceptive method of her choice.  At a minimum provide condoms.  
* Provide contraceptive counseling and support her in choosing a method before she is discharged. Remember: post-abortion care has not been completed until contraceptive counseling and an opportunity to choose a contraceptive method has been provided.
* If the client states that she intends to become pregnant again, counsel her to avoid becoming pregnant for at least six months (depending on the type of abortion, gestational age and possible complications) by using an effective contraceptive method. This will contribute to a healthier next pregnancy.
* For all adolescents, and particularly for very young adolescents and adolescents with disabilities, screen for potential sexual abuse, gender-based violence or sexual coercion, counsel and refer as needed.  
* To avoid defaulters, make sure to offer a family planning method before the patient is discharged. If possible schedule a return visit within one week for client ensure no problems from the procedure, to provide HIV counselling and testing as needed, and to further discuss her contraceptive needs.
* Discharge the client after 1 to 2 hours if she is comfortable, stable, and able to walk without assistance. 
* Record all findings in the client record.




Card 4: Warning Signs
* Signs of Shock
o Skin cool and clammy
o Systolic BP < 90/60
o Pulse ³ 110 and weak
o Respiratory rate > 30

> If in shock, consider ruptured ectopic pregnancy
o No fluids by mouth
o Begin IV fluids
o Infuse IV fluids Ð 1 liter over 20 minutes and a total of 1500 ml over 1 hour

* Signs of Infection
o Temp ³ 38¡
o Foul smelling vaginal discharge
o Lower abdominal pain (tender uterus)
o Rebound tenderness
o Prolonged bleeding
o Purulent cervical/vaginal discharge
o Cervical motion tenderness

> If septic, begin antibiotics as soon as possible before uterine evacuation. 

* Signs of Abdominal Injury
o Nausea, vomiting, fever
o Abdominal or shoulder pain
o Prolonged bleeding
o Distended abdomen, absent bowel sounds
o Rebound tenderness

> If abdominal injury suspected, stabilize and transfer to higher level of care. 










Card 5: Contraceptive Referral
* Methods to be started immediately, even with confirmed injury or possible infection: 
o Oral contraceptives (preferably combined)
o Injectables
o Implants
o Condoms (male and female)
* Methods to be started once infection is ruled out or resolved: 
o IUD
* Methods which can be started once injury to genital tract has healed (as available): 
o IUD
o Combined vaginal ring
o Diaphragm 
* Methods which can be used in cases of uncomplicated uterine perforation (as available): 
o Combined vaginal ring
o Diaphragm




Flipchart 1: Procedural Considerations
* Treatment options are the same for adolescents and adult clients.  However, adolescents often wait longer to seek services, which may result in more severe complications. 
* Only ask the client to undress once you have completed the history, answered her questions, and are ready for the procedure. There is no need for the client to undress completely (only from the waist down).  Provide client with a cover sheet. 
* A smaller speculum should be used during the exam and procedure. 
* Perform exam gently and slowly and explain what to expect before any action. 
* Make sure that adolescents with disabilities have a full understanding of the exam and procedure, and that accommodation is provided according to needs throughout the procedure. Provide complete and direct information on treatment options: 
o MVA and misoprostol are highly effective, have fewer complications and are preferred to D&C.  D&C is recommended when no other safe options are available. 
o Adolescents may prefer misoprostol because it is simple, avoids surgery, and has a shorter recovery time. Adolescents should be informed that misoprostol use may result in a longer period of bleeding and spotting, which may compromise their concerns over privacy and confidentiality.  Further, the necessary follow-up visit after the administration of misoprostol may be difficult for some adolescents. 

Flipchart 2: Strategies for Pain Management 
* Understand all options to prevent and treat, including different medication options  and dosing limits.
* Ensure the client receives adequate treatment for pain. 
* Talk with the adolescent client throughout the procedure. 
* Explain each step of the procedure before it is performed. 
* Ensure that adolescents with disabilities have access to this information. Provide any accommodations as needed and ensure information is available in accessible formats. 
* During the procedure, move slowly, without jerky or quick motions. 
* Show the client how to minimize pain by taking slow deep breaths breathing in through the nose and out through the mouth.  This type of breathing will help her relax. 
* Tell the adolescent client she can and should ask for additional pain medication if the pain becomes too strong.  
* Reassure her that she can ask you to pause briefly at any point in the procedure. 
* Avoid giving wrong impressions (for example, saying Òthis wonÕt hurtÓ when it will hurt, or ÒIÕm almost doneÓ when you are not). 
* Allow the client to have a supportive friend, partner, or relative at her side if she wishes. 

Flipchart 3: Post-Procedure Considerations
* An adolescent may not be able to remain at the clinic as long as an adult woman can. She may not have permission from her family or husband to leave her home or community and she may be missed after a certain period of time. 
* Provide counseling about contraceptive options and provide the method post procedure if possible. 
* Make sure that the information provided is accessible and understandable for adolescents with disabilities, and always ensure that clients select their preferred contraceptive option out of free will.
* If she is unwilling to accept a method immediately post procedure, remind her that pregnancy can occur again within 10-14 days.   Encourage her to return to the clinic any time to obtain a method.  At a minimum provide condoms.  
* Screen for potential sexual abuse, violence, or coercion and refer to appropriate psycho-social services. 
* Consider that the safe abortion or post-abortion care visit may be the first visit to a health facility and provide an opportunity to assess, address, and/or refer for other sexual and reproductive health needs, such as: 
o HIV counseling and testing. 
o STI assessment and treatment. 
o Dual protection strategies. 
o HPV vaccination (where available). 
o Other issues, such as nutrition, anemia, etc.  



UNIT 10 SUMMARY
     	TIME
       30 minutes
     	METHODS
       Small group work 
     	MATERIALS NEEDED
       Participant Handout 10d: Service Readiness Assessment Checklist
     	STEPS

1. Ask participants to reflect on everything theyÕve discussed as part of this unit. Distribute Participant Handout 10c: Service Readiness Assessment Checklist to participants. Give them 5 minutes to quickly review the checklist individually. 

2. Ask participants to spend some time, either individually, or grouped according to their clinics, assessing their own clinics. Ask them to bring back their results for Unit 15: Providing Adolescent Services. 




PARTICIPANT HANDOUT 10D: SERVICE READINESS ASSESSMENT CHECKLIST
Source:  Adapted from Turner et al, Abortion care for young women: A training toolkit, 2011
This tool outlines sample questions to assess service facility readiness to provide abortion and post-abortion care services to adolescent and young women. Trainers should review this tool and select or adapt questions as appropriate for their local legal and policy context. If possible, trainers should engage adolescent and young women with and without disabilities in the review of this tool prior to use to ensure that their actual needs and desires for high-quality abortion and post-abortion care services are met. 
This tool should not be adapted to avoid difficult conversations about cultural values on abortion and post-abortion services. 
A. Does the facility offer rights-based care for adolescents and young people, including young persons with disabilities? 
* Does the facility have written policies or protocols that affirm young peopleÕs rights to sexual and reproductive health information and services, privacy, and confidentiality? 
* Has facility staff been trained on assessing adolescentsÕ evolving capacity and supporting independent decision-making? Does the facility have guidelines that support independent decision-making by adolescent clients?  Do facility staff adhere to these guidelines?
* Does the facility have a visible and clear statement on the rights of clients, including adolescents? 
* Are the above-mentioned policies, protocols, guidelines and statements inclusive of persons with disabilities and consistently applied with them? 

B. Does the facility offer opportunities for adolescents and young people to participate in ensuring youth friendly quality of care?
* Are young people, and specifically young women, involved in service delivery in any way other than as clients? How?
* Did young people, and specifically young women, participate or partner in the design of abortion and post-abortion care services? How? 
* Do young women participate or partner in the evaluation of service delivery for abortion or post-abortion care services? How? 
* Does a partnership with young people or youth groups exist?
* Are adolescents with disabilities an active stakeholder in shaping more inclusive and accessible services that meet their needs? If yes, how? Do they participate in the processes of improving service quality and/or accountability?

C. Is the facility making safe abortion and post-abortion care services available to young women?
Note: Not all questions may be applicable to your facility. Work with young women in your community to choose questions based on their needs. 
* Is the facility open at hours outside of typical school and work hours? 
* Is there a separate entrance for young women?
* Is the facility accessible for persons with different types of disabilities?
* Do key areas of the facility provide both visual and auditory privacy for young women?
o Reception and waiting room? Are these accessible to persons with disabilities? 
o Counseling room? Is this accessible to persons with disabilities? 
o Examination and procedure room? Are these accessible to persons with disabilities? 
o Recovery room and bathrooms/toilet facilities? Are these accessible to persons with disabilities? 
* Can young women be seen without an appointment? 
* Does scheduling/provider workload allow for longer than usual counseling times when needed?
* Are medical records secure and never left easily visible to other clients or staff not directly involved in the clientÕs care?

D. Clinic policies and guidelines

* Do clinical standards and protocols for safe abortion care for young women exist? If so, have they been distributed to, known by and adhered to by providers?
* Do clinical standards and protocols for post-abortion care for young women exist? If so, are they widely disseminated? 
* Do facility policies or protocols require additional reporting on, or apply restrictions to, safe abortion or post-abortion care for young women not present in the law?  How?
* Are facility policies or protocols disability inclusive?

E. Community outreach and education

* Does the facility conduct, support, or coordinate community outreach and education on young womenÕs sexual and reproductive health and rights and the need to reduce unsafe abortion, including access to safe abortion services and post-abortion care? Are these accessible to young women with disabilities?
* Does the facility have any client handouts or materials about safe abortion and post-abortion care that are accessible to all young women including those with disabilities? Were young women involved in designing or producing these materials? 

F. Payment and financial support

* Do payment options (sliding scale, free, other) exist for young women without means to pay full costs?
* Is the clinic connected to any support mechanisms (local womenÕs groups, abortion funds, women with disabilities lead organizations, other) to help young women get financial support for abortion and post-abortion care services or other financial needs such as transportation or housing?

G. Staff preparedness
* Have all staff received training on or orientation to the legal and policy status of safe abortion and post-abortion care services in the country?
* Have all staff members attended a workshop that includes values clarification activities on providing safe abortion and post-abortion care to all young women including young women with disabilities?
* Can young women be seen by a service provider of their preferred or requested sex? Can young women request a change in service provider for any reason?
* Are there peer educators/counselors present who can help young women or accompany them through the services if needed?

H. Referrals and other health services
* Are referrals made for any services not provided at the facility? Are those referrals made as part of institutional referral agreements? Are there any established mechanisms to ensure client follow-up?
* Are the referral mechanisms and options accessible for adolescent with disabilities?
* Are other health care services provided as part of the same visit if needed?
* How easy is it to navigate among the different health services during the same visit?
* Are safe abortion and post-abortion care services fully integrated with screening and response for sexual and gender-based violence? 
* Are clients seen for safe abortion and post-abortion care services routinely offered access to contraceptive counseling and services?

I.Is the facility offering safe abortion and post-abortion care services that are clinically appropriate to young women?
* Are providers trained to counsel young women on sexuality, sexual and reproductive health, and safe abortion and post-abortion care?
* Are providers trained in the clinical specifics of youth friendly safe abortion and post-abortion care?
* Are providers trained to address stigma and self-stigma associated with seeking safe abortion and post-abortion care? 
* Are providers prepared to alleviate young womenÕs pain, and to identify higher levels of anxiety and lower tolerance for pain among young women?
* Are providers trained to offer the same quality standard of safe abortion and post-abortion services to adolescents with disabilities?

J. Is the facility recording age and disability-disaggregated safe abortion and post-abortion care statistics? 
Note: In places with legal or customary restrictions on access to abortion, facilities may decide not to do this if not required by law. 
* Does a logbook/register exist for safe abortion and post-abortion care services, which includes client age and disability?
* Is the facility recording, and disaggregating by age and disability, data for: 
o Number of clients asking for safe abortion in the past year. 
o Number of clients receiving safe abortion care in the past year. 
o Number of clients seeking post-abortion care in the past year. 
o Number of clients receiving post-abortion care in the past year. 
o Number of clients seen for complications from unsafe abortion in the past year. 
o Types of complications seen. 
o Unsafe abortion-related morbidity and mortality. 
o Percentage of clients asking for post-abortion contraception in the past year (by method if possible). 
o Percentage of clients receiving post-abortion contraception in the past year (by method if possible). 
o Percentage of clients receiving other services (by service). 


Module 16/Unit 7