Lesson 6:
Training Alone Is Not Enough; Supervisors’ Support Is Vital |
Training providers in FP counseling and MVA is not enough to create a PAC
program. PAC programming must also involve supervisors and administrators, whose buy-in is
encouraged by fostering their participation in ongoing program development and problem
solving. Training providers without institutional support does not produce change that is
fully incorporated into the actual delivery of services.
Examples
In Tanzania, we initially included only ob/gyns and a few other
providers in clinical training. During our midterm evaluation of the program, we found
that administrators also wanted to be included in PAC and other trainings so they could
better supervise and support their staff.
In Uzbekistan, we conducted contraceptive technology updates as
part of our PAC work. Some providers, however, were unable to practice what they had
learned because of supervisor resistance. This experience highlighted the need to garner
supervisors’ support and keep them involved with the activities of the programs.
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Lesson 7: Pain
Management — the Forgotten Need |
Currently, recommendations for the management of pain for PAC clients is
culled from literature and experience with pain management for induced abortion.
Postabortion and abortion clients often have different physical conditions (e.g., women
with incomplete abortion usually have dilated cervices). Issues related to pain control
for PAC need to be further explored and disseminated. AVSC is pursuing research on pain
management specific to PAC.
Examples
In Tanzania the lack of national standards for treatment of
incomplete abortion results in a situation in which insufficient or no pain medication is
provided.
In Indonesia most MVA procedures are performed with no pain
medication, while general anesthesia and heavy sedation are used for others.
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Lesson 8:
Don’t Forget About Adolescents and Men |
Programming for PAC should include adolescents. Even in countries where
abortion is legal, adolescents often resort to unsafe and illegal abortions. PAC
strategies need to reach out to adolescents, not just recognizing their presence within
program design, but also seeking their perspectives. In this way, PAC programming will
ensure that adolescent PAC clients receive the treatment and FP they need. PAC
programming should also incorporate men whenever possible. Men play an important and often
influential role in PAC. FP, education, referrals to other services, even information
about postprocedure care and warning signs—all provide possible avenues for promoting
male involvement in PAC.
Examples
In Uzbekistan, despite the legal status of abortion, adolescents
face many of the same barriers to access that their contemporaries face in those countries
with legally restrictive abortion policies. They have no place to go for FP and, if they
become pregnant, there are few places for them to go for abortions. As a result, they may
resort to unsafe abortions outside of the mainstream healthcare system, where
confidentiality is pledged.
In Turkey, men play an important postabortion role. We have
learned that postabortion FP doesn’t have to focus on IUDs and pills: vasectomy has
emerged as an effective and frequently utilized postabortion FP method.
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Lesson 9:
Misoprostol Is Here, and It’s Changing the Face of Abortion Complications |
In some of the countries where AVSC works, the use of drugs such as
misoprostol to induce abortion has led to a decrease in the severity of abortion
complications. Most women present with incomplete abortions rather than with more severe
complications such as perforation or infection. Additional information on misoprostol
usage will provide further insight into implications for PAC service delivery.
Examples
In Colombia and the Dominican Republic, the use of misoprostol by
women to induce abortions has increased sharply in the past few years. One large referral
hospital in Colombia reports that the numbers of patients admitted for abortion
complications has remained steady over recent years, but the vast majority of current
cases are incomplete abortion, and most of these are thought to be the result of
misoprostol use.
In Indonesia, abortion is highly restricted and a prescription is
required for misoprostol. It is possible that some doctors are privately providing the
drug to women to stimulate abortions in the interest of reducing the incidence of unsafe,
traditional abortion techniques performed by untrained providers.
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Lesson 10: Think
Sustainability |
Long-term planning for PAC services must address such issues as the future
supply of equipment, human resources, training, program ownership and
sustainability. Because many programs are still in the nascent stage, the planning process
for sustainability must begin now so that effective mechanisms are built in from the
onset. Incountry committees, advisory groups or consortiums are one way to maintain an
active dialogue with ministries of health and private providers, and promote inclusion of
PAC services within country health systems. A focus on building capacity and the existence
of PAC "champions" also enhance the future of PAC work.
Examples
In many countries, issues of equipment sustainability have yet to
be addressed. Programs currently receive donated MVA equipment free of charge. Part of the
challenge rests in raising awareness that equipment will not always be donated, and at the
same time encouraging interest in taking PAC on as a new or broadening program initiative.
In the Dominican Republic, an exchange of training was set up
such that providers at one site trained those at another in MVA use while, in exchange,
those at the other site trained the first site in minilaparotomy. Such exchanges
contribute to incountry program sustainability.
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Conclusions
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Many of the lessons learned from AVSC’s work in PAC are not new.
Concepts such as the need for whole-site training, facilitative supervision and long-term
sustainability planning are as pertinent in PAC as they are in AVSC’s past experience
providing clinic-based FP and introducing new technologies such as minilaparotomy and
no-scalpel vasectomy. Others, however, are specific to PAC. Our work in FP has exposed us
only indirectly to working with PAC clients in emergency rooms, where religious and
cultural norms, legal policies and the individual emotions of providers and clients often
collide. Undoubtedly, as we expand our body of work in PAC, we will continue to encounter
both old and new successes and challenges in PAC, and add to the list of lessons learned. |
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Notes
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1. The Postabortion Care Consortium is a group of agencies established in
1993 to encourage USAID, UNFPA and other international agencies to address unsafe abortion
in their policies and programs. |
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