Averting Repeat Abortions
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Providing immediate postabortion FP counseling and contraceptive methods,
as well as emergency treatment for complications of unsafe abortion when necessary, is
critical to reducing maternal deaths and averting repeat abortions. Women who have
undergone an abortion but do not have access to immediate FP services are at high risk of
repeat abortions, particularly given that a woman can become pregnant again within 2 weeks
of having an abortion.
Despite the relatively high total abortion rates in Kazakstan, only 41
percent of women report having had an abortion. Of this 41 percent, however, 70 percent
reported having had more than one abortion.
An evaluation at the Pathfinder-supported High Risk Clinic (HRC) at
Kenyatta National Hospital in Nairobi, Kenya showed that among patients admitted for the
treatment of abortion complications, 55 percent of those interviewed reported having had a
previous abortion (Mati 1997).
A study among abortion patients at three sites in Vietnam reveal an
average of 2.2 abortions per patient, suggesting a high incidence of repeat abortion
(Nguyen et al 1998).
Table 2. Prior Abortions Among Women Experiencing an Abortion
COUNTRY |
WOMEN WITH MULTIPLE ABORTIONS |
| Kazakstan |
70% > 1 (survey) |
| Kenya |
55% previous abortion |
| Vietnam |
2.2 average no. of abortions |
Source: Pathfinder International 1999.
Pathfinder-supported projects at hospitals in Kenya, Peru and Vietnam seek to ensure
that FP information and contraceptive methods are available to women who have had an
abortion or received treatment for an unsafe abortion. These projects have resulted
in significant increases in the number of women leaving facilities with a FP method.
The HRC in Nairobi was established in 1991 to provide FP/RH services for adolescent and
young adult women who had given birth or received treatment for an unsafe abortion at
Kenyatta National Hospital. An evaluation of the clinic’s services documented an
increase in the number of patients using a contraceptive method. Thirty-four percent of
the women surveyed reported using FP before coming to the clinic, while 54 percent
accepted a method after visiting the clinic (Mati 1997). |
| POSTABORTION AND POSTPARTUM CONTRACEPTION FOR YOUNG ADULTS AT
KENYATTA NATIONAL HOSPITAL, NAIROBI Family Planning Acceptance4Fifty-four percent
of clients, both postpartum and postabortion, accepted FP methods following counseling at
the HRC for young adults. This is an increase of 20 percent over the 34 percent of clients
who said they had ever used FP before coming to the HRC.
Among those who chose a
FP method, the most popular methods were the pill (58 percent), followed by injectables
(25 percent) and condoms (12 percent).
Postabortion patients were significantly more likely to accept a FP method than
postpartum patients. |
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Clinical assessments of health facilities in Peru showed that the number
of postabortion patients who left facilities with a contraceptive method was negligible
(Ferrando and Gutierrez 1998). After a Pathfinder-supported training course in FP
counseling and services for healthcare practitioners in 13 facilities, 43 percent of
postabortion patients reported receiving a contraceptive method after treatment (Ferrando
1998).
The Pathfinder-supported Reproductive Health Program in Vietnam has
resulted in dramatic increases in the number of abortion patients who receive
contraception, from an average of 12 percent across four program sites to an average of 49
percent, between 1995 and 1997 (Nguyen et al 1998).
Physicians trained by Pathfinder in Kazakstan and Azerbaijan report that
the percentage of abortion patients who receive contraception has increased from almost
zero at the start of the program to between 80 and 90 percent (Huber 1999).
Table 3. Increased Provision of Postabortion Contraception
PATHFINDER PROJECT |
BEFORE |
AFTER |
| Kenya |
negligible |
54% |
| Peru |
negligible |
43% |
| Vietnam |
12% |
49% |
| Kazakstan |
negligible |
80–90%* |
| Azerbaijan |
negligible |
80–90%* |
* Estimated by Ob/Gyn trainees.
Source: Pathfinder International 1999. |
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Considerations For PAC Introduction
And Sustainability5
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Postpartum FP can be a leading activity that providers find
highly acceptable, and presents a compelling rationale for extending FP services to
postabortion women in the same facilities, particularly in Latin America. In Africa,
postpartum FP was added to postabortion FP at Kenyatta National Hospital’s HRC. Most
providers find it natural to offer FP services to both groups, once they see the value of
the service to women and have managed to incorporate either postabortion FP or postpartum
FP into their work.
Postabortion FP is the most important health component among the
three elements that define PAC (the other two being linkage to ongoing FP and other RH
services, and treatment of incomplete abortion using MVA). PAC can save lives primarily by
preventing the need for future unsafe abortion through the immediate and ongoing provision
of FP services.
Linkages with ongoing FP and other RH services are needed to
provide postabortion clients with effective, accessible and acceptable FP services. This
is a major challenge, and requires different mechanisms than for most FP clients. Women do
not generally return for ongoing FP to the facility providing treatment for incomplete
abortion. Other RH services are also included, but in practice are not easy to link for
this particular group.
Treatment of incomplete abortion using MVA can be a sensitive and
difficult clinical component to introduce in many hospitals that use classical D&C.
MVA does not itself have a major effect on mortality of postabortion patients. The real
benefits are in promoting the overall better treatment of women suffering from incomplete
abortions by reducing pain, permitting the use of local anesthesia (instead of general),
taking the procedure out of the operating room, and permitting verbal interaction and
empathy between women and their caregivers. This creates a better climate during this
stressful time in which a woman can make a clear, informed, unpressured choice about the
contraceptive options that will be best for her.
Providers can improve many of these elements during the use of D&C, with a logical
progression to MVA in the future if MVA is not acceptable at first. In some settings in
Africa the use of MVA itself is attractive to providers and carries no special
sensitivity. Ideally, all three elements of good PAC would be introduced at the same time,
but in practice, the first two above can be a good place to start.
Current Elements of PAC by Health Impact and Related Services
Postabortion contraception provided before discharge
Related postpartum contraception before discharge that may
precede or follow postabortion contraception
Linkages to ongoing FP services with or without other RH services
Replacement of D&C by MVA, facilitating use of outpatient
setting, with emphasis on supporting postabortion contraception and cost savings for
procedure and future abortions averted
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Evaluation of PAC Services
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Based on the above considerations, some of the most important indicators
of successful PAC services are the following:
The proportion (percentage) of PAC patients leaving the facility with
a method of contraception is readily accessible with routine data collection sources.
This immediate postabortion contraception acceptance rate can increase dramatically over a
short period.
Ongoing use of FP at 6 months or 1 year is needed to measure
continued use and the successful implementation of linkages with ongoing FP services.
The contraceptive method mix is very important in order to assess
quality and voluntarism. The method mix should be compared with the postpartum FP method
mix, since we expect the two to be quite different.
The use of MVA for treating PAC patients facilitates cost savings
by taking the procedure to the outpatient department and using local anesthesia.
Client satisfaction with all elements of the PAC services should
be documented periodically through exit interviews, followup interviews or both.
These evaluation components are key to assessing postabortion FP and the client
perspective of PAC services. Other evaluation elements can enhance the clinical quality of
care assessment for PAC services. |
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Conclusions
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The lack of effective, accessible and acceptable FP services is the most
obvious failure leading to unsafe abortions. Given the rapid return of fertility following
abortion, it is necessary to ensure that effective and client-sensitive postabortion FP
services are provided. Change of attitude by providers, sometimes including a change from
punitive practices, is just as necessary as improving clinical management of postabortion
complications. Special training, support and evaluation for the postabortion FP component
is required in complete PAC services. The complementary roles of postpartum and
postabortion FP combine with the other elements of PAC services to amplify the total
effect on maternal health. |
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Notes
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4. Adapted from: Mati JKG. 1999. High Risk
Young Adults Clinic, Kenyatta National Hospital, Nairobi, Kenya. (Evaluation Notes).
Pathfinder International: Boston, Massachusetts. (January). 5.
Adapted from: Huber D. 1998. Key Strategic Elements for PAC Introduction and
Sustainability. Pathfinder International: Boston, Massachusetts. Internal Report. |
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References
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Bowles E and K Bourne. 1999. Family Planning and the Prevention of
Abortion. Pathfinder International: Boston, Massachusetts. Draft. (April). Ferrando
D. 1999. Improving Postabortion Care Services in Peru. (Evaluation Notes).
Pathfinder International: Boston, Massachusetts. (January).
Ferrando D. 1998. Improving Postabortion Care in Peru. Pathfinder International:
Boston, Massachusetts.
Ferrando D and M Gutierrez. 1998. The Current State of Postabortion Care in Public
Hospitals in Peru. Pathfinder International: Lima, Peru.
Guzman A, D Ferrando and L Tuesta. 1999. Treatment of Incomplete Abortion: An
Evaluation of Manual Vacuum Aspiration Versus Curettage in the Maternal Perinatal
Institute in Lima, Peru. (Evaluation Notes). Pathfinder International : Boston,
Massachusetts. (January).
Huber D. 1999. Personal communication. (March).
Huber D. 1998. Key Strategic Elements for PAC Introduction and Sustainability.
Pathfinder International: Boston Massachusetts. Internal Report.
Mati JKG. 1999. High Risk Young Adults Clinic, Kenyatta National Hospital, Nairobi,
Kenya. (Evaluation Notes). Pathfinder International: Boston, Massachusetts. (January).
Mati JKG. 1997. Evaluation of Reproductive Health Services, High Risk Young Adults
Clinic, Kenyatta National Hospital, Nairobi, Kenya. Pathfinder International: Nairobi,
Kenya.
Nguyen MT et al. 1998. Client Perspectives on Quality of Contraceptive and Abortion
Services at Three Sites in Vietnam. Hanoi, Vietnam.
Novaes da Mota C and S Webb. 1998. The Practice of Induced Abortion Among Low-Income
Populations in Rio de Janeiro: Perspectives of Clients and Health-Care Providers.
Pathfinder International: Boston, Massachusetts.
Pathfinder International. 1999. (April).
Pile JM et al. 1998. The Quality of Abortion in Turkey. Paper prepared for
Global Meeting on Postabortion Care: Advances and Challenges in Operations Research.
Population Council: New York.
Postabortion Care Consortium. 1994. Postabortion Care: A Global Health Issue.
(Video). Postabortion Care Consortium.
Sharing Responsibility: Women, Society and Abortion Worldwide. 1998. Alan
Guttmacher Institute: New York.
Yoseph S. 1993. A Survey of Illegal Abortion in Addis Ababa. Addis Ababa,
Ethiopia. |
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Additional Pathfinder Studies and
Reports of PAC
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Colton T. August 1998. Abortion Policy and Practice in Latin America
and the Caribbean: A Review with Annotated Bibliography. Pathfinder International:
Boston, Massachusetts. Crosbie C. 1997. Presentation to USAID: Peru Postabortion
Program. (November).
der Korkanian D. 1998. A Project Review of Pathfinder International’s PP/PA
Family Planning Services. Pathfinder International: Boston, Massachusetts. (August).
Ferrando D. 1997. Clinical Training Evaluation Postpartum and Postabortion
Contraception: Summary. Pathfinder International: Lima, Peru. (March).
Guzman A, D Ferrando and L Tuesta. 1995. Treatment of Incomplete Abortion: Manual
Vacuum Aspiration Versus Curettage in the Maternal Perinatal Institute in Lima, Peru.
Pathfinder International: Latin America South Office. (October).
Kabira D. 1998. NCIH Paper Presentation: Interventions to Improve Access in
Postpartum and Postabortion Family Planning Services: Three Case Studies,
Kenya-Peru-Vietnam. Pathfinder International: Boston, Massachusetts.
Novaes da Mota C. and S Webb. 1996. The Practice of Induced Abortion Among
Low-Income Populations in Rio de Janeiro: Perspectives of Clients and Health Care
Providers. Pathfinder International: Boston, Massachusetts. (November).
Pathfinder International. 1998. Hospital Assessment Guide for PAC Services.
Pathfinder International: Boston, Massachusetts. (July).
Pathfinder International. 1993. Addressing the Consequences of Unsafe Induced
Abortion: A Program Strategy for Improving the Health of Women. Pathfinder
International: Boston, Massachusetts. (January).
Shumba P. 1997. The High Risk Clinic, the Kenyatta National Hospital. Women’s
Voice 20. Nairobi, Kenya. (August). |
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