Anita Ghosh, M.A. Program
Development Officer, JHPIEGO Corporation · Prof. Bibiane Kone, M.D. President, Cellule de
Recherche en Santé de la Reproduction (CRESAR) · Jean Lankoande, M.D. CRESAR · Placide
Tapsoba, M.D. Research Associate, The Population Council
This paper reviews the training strategy implemented at
two sites in Burkina Faso to establish postabortion care (PAC) services to improve the
clinical care and followup of postabortion patients. An initial needs assessment was
conducted to determine the extent to which current management of postabortion patients
included recommended clinical management protocols, postabortion family planning
counseling and services and links to other reproductive health services. Using the
findings, the training strategy focused on strengthening infection prevention (IP)
practices and management of services at the sites in addition to training providers in the
skills required to offer PAC services. Because this program is the first of its kind in
francophone West Africa, much work had to be done prior to and during the interventions to
sensitize the appropriate officials and service providers to the need to strengthen
services for postabortion patients. Facilitating the exchange of information between the
two pilot sites and raising the awareness of the need for family planning services in
general-not just after treatment for abortion-were also important aspects of the training
strategy. PAC services were established 4 months ago (October 1997) at both sites and
additional staff are already being trained in PAC service provision at both sites. Future
directions of the program include decentralization of services and strengthening of
supervision and monitoring systems.
The abortion law in Burkina Faso is restrictive. Abortion
is permitted only to save the life of the mother and must be approved by three physicians.
Induced abortion for any other reason and without proper approval is subject to legal
sanctions. Such restrictions have many unintended negative results, including a dearth of
reliable abortion-related data. Given the sensitive nature of the topic, standard
demographic survey questions normally result in significant under-reporting in this area.
Likewise, the number of women who present with complications from induced abortion in
Burkinabè hospitals and health centers is often not clear. Statistics on the number of
women who have had complications from an induced abortion are combined with those cases
that receive treatment for spontaneous miscarriage. Although the numbers are not precise,
the Division of Family Health in Bobo-Dioulasso estimates that at least 28% of maternal
deaths are due to abortion-related causes (Traoré 1997).
Currently, in Burkina Faso, as in most hospitals
throughout sub-Saharan Africa, the standard technique for treatment of incomplete abortion
is sharp curettage (SC). Patients are admitted to the hospital and often wait for many
hours before they undergo a uterine evacuation procedure in the main operating theater.
The procedure is often performed under heavy sedation or general anesthesia - increasing
the risk of surgical complications, generally causing the patient to stay for at least one
overnight in the hospital and increasing the cost of care.
Comprehensive postabortion care (PAC)a has been proven to be a more effective approach to
managing clients with postabortion complications (Huntington 1995; Malla et al 1996; Solo
et al 1996). This approach had not yet been introduced into francophone West African
countries, although it is being used in other countries worldwide such as Egypt, Ghana,
Kenya and Nepal (Huntington 1995; Malla et al 1996; Otsea et al 1997; Solo et al 1996).
Furthermore, experiences in several of these countries demonstrate that the use of manual
vacuum aspiration (MVA) for treatment of bleeding complications is safer and less costly
than dilatation and curettage (D&C). MVA provides better quality care while using far
fewer hospital resources and reducing the length of hospital stay up to 50% or more (Malla
et al 1996).
This paper describes a collaborative project developed by
the Burkina Faso Chapter of the Reproductive Health Research Network (CRESAR) in
partnership with the JHPIEGO Corporation and The Population Council. The goal of the
project is to contribute to a decrease in maternal mortality and morbidity associated with
incomplete abortions in Burkina Faso through the training of staff in improved treatment
procedures and postabortion family planning.
The immediate objectives of the project include:
- increasing the clinical knowledge of Obstetric/Gynecologic
specialists in the care and treatment of spontaneous or induced abortions, including the
use of MVA with both appropriate pain management and recommended infection prevention (IP)
practices;
- improving the family planning (FP) counseling knowledge and
skills of physicians and healthcare staff providing treatment for postabortion
complications;
- increasing the knowledge and use of FP services among women
receiving treatment for an induced abortion or miscarriage;
- establishing two MVA service sites in Burkina Faso which
potentially could serve as training sites;
- describing and comparing the cost, feasibility and
acceptability of MVA services for the treatment of postabortion complications with D&C
services.
Using a PAC training intervention and a complementary
operations research (OR) study, the project is designed to examine treatment of
complications of spontaneous or induced abortion and postabortion FP counseling and
services in emergency treatment services. More specifically, the project is designed to
determine the most effective and efficient way to operationalize and implement services
that link emergency treatment and postabortion FP counseling and services, how such an
integrated package of PAC services is best offered and by whom.
This project represents the first efforts to introduce PAC
services in francophone West Africab. It will
examine the feasibility of providing PAC services in a maternity setting. It is
anticipated that this approach can be adapted for similar settings (hospitals) in the West
Africa region.
Two government teaching hospitals that serve as major
referral centers in two urban areas of Burkina Faso were chosen by CRESAR for inclusion in
the projectc. Review of hospital records reflect
that abortion-related admissions account for 4.36% and 5% of all patients admitted to the
national hospitals in Ouagadougou and Bobo-Dioulasso respectively (Bazié 1996).
The training intervention was comprised of a variety of
activities leading to the launch of PAC service provision:
- Advocacy and Consensus-Building:
- Needs Assessment
- Preliminary Meetings to Gain Consensus
- Development of Policies and Standards for PAC Services
- Orientation Meetings
- Training for PAC Service Delivery
- Needs Assessment
- Training in Use of Recommended IP Practices
- Contraceptive Technology Update (CTU) Workshop
- PAC Training
- Followup visits
The overall training strategy focused on strengthening the
IP practices and overall clinic management at the service delivery sites in addition to
training providers in the skills required to provide PAC services. The successful
implementation of this strategy required a comprehensiveplanning process which was highly
dependent upon active coordination and communication among all stakeholders. Stakeholders
included the staff at both maternities, key MOH officials and CRESAR as well as the two
technical assistance agencies, The Population Council and JHPIEGO Corporation. In
addition, assistance from UNFPA was solicited and provided at all stages as they play a
key role in providing support to the MOH for FP activities.
The following section describes, in chronological order,
the activities conducted under the training intervention.
Preliminary Meetings to Gain Consensus: A
number of meetings and conversations were held prior to the start of the project to ensure
that all of the key stakeholders were supportive of the proposed program.
Needs Assessment: Training interventions
were designed based on data collected from the needs assessment conducted at the start of
the project. The methodology focused on site visits to observe the service delivery
settings and to determine the client and provider needs for implementing PAC services
including: service provision capacity for treating complications, IP practices, FP service
provision, linkages between PAC services and other hospital and community services, and
suitability of clinic's location as a future training site. Data collection included
observation of service delivery in the clinic, interviews with providers and MOH officials
to determine clinic management issues and perceived caseload, review of logbooks to
examine recorded caseload and the type of information collected on a regular basis, and
review of national service delivery guidelines to examine the standards established for
PAC service provision.
Based on the results of the needs assessment and
discussions among the partners, it was determined that the training strategy would focus
on building the capacity of the sites to offer PAC services. The needs assessment findings
highlighted the following:
- IP practices were poor and needed to be strengthened at
both maternities before the introduction of PAC services.
- Staff needed updated contraceptive technology information.
- Service delivery guidelines for PAC did not exist.
Each of these areas was addressed in the design of the
training strategy to improve the quality of services. Also, it was agreed that management
of PAC patients would be integrated into the overall services of the maternities. This
integration required the development of a plan outlining how women who present with
postabortion complications would be received and handled by the maternity. The need for
sharing information with maternity and other hospital staff not directly involved with the
project was highlighted.
Training in Use of Recommended IP Practices:
IP training was a necessary first step in preparing the maternities to offer PAC services
because use of the recommended IP practices is fundamental to all services offered by the
maternities. Introducing IP concepts early in the project encouraged providers to think
about how to strengthen overall management of clinical services. Training included not
only those staff responsible for provision and management of services but also the
individuals responsible for processing supplies and equipment (instruments, gloves,
drapes, etc.). Training content covered recommended IP practices and introduced the
concept of PAC-related IP needs.
CTU Workshop: Data collected during the
needs assessment revealed that many providers were working with outdated FP information.
Guidelines for postabortion FP counseling and services were essentially nonexistent; two
sentences in the maternal and child health section of the Policy and Standards for MCH/FP
Services in Burkina Fasod. (These guidelines
stipulate that curettage be used to treat complicated cases.) A CTU workshop was held for
providers representing both maternities to update providers and prepare them to develop
draft policies and guidelines for PAC.
Development of Policies and Standards for PAC
Services: Perhaps the most important activity relevant to program planning and
soliciting interest and support for the project was the process of developing national
policies and standards for PAC services. Providers, representatives from CRESAR and the
MOH were all involved in drafting these two documents. The development of these documents
encouraged close study of reference materials, which resulted in a better understanding of
the subject matter and prompted discussions regarding the integration of services into the
overall maternity service. The importance of talking to the patient and counseling before,
during and after the MVA procedure was recognized as essential to the provision of quality
services and highlighted in the protocols document as a separate section.
PAC Training: JHPIEGO's long-standing
experience worldwide has demonstrated the importance of competency-based training (CBT)
programs that focus on learning by doinge. With this
approach, trainers use anatomic models to guide participants as they learn the basic steps
and sequence required to perform a clinical procedure. Participants practice their
clinical skills on models before practicing with actual clients. This technique reduces
the number of actual cases required for clinical competency (Ajello 1994). JHPIEGO
supports site-based training for gaining clinical expertise. The perceived caseload of
postabortion patients at the two selected maternities, however, was not adequate to
support a group-based training activity. Discussions with senior Burkinabè officials
determined that four Ob/Gyn specialists from Burkina would be trained at the Korle Bu
Teaching Hospital in Accra, Ghana since the PAC program at Korle Bu, established in 1993,
manages 5-6 cases/day on average thus providing a viable model site for PAC service
delivery (Ghosh 1997).
Caring for the total needs of the patient-not just the
medical emergency-was stressed as an important element of the training strategy.
Participants learned how to counsel patients and manage uncomplicated cases as well as
life-threatening emergencies. A group-based training activity for both physicians and
nurse-midwives was organized in Ouagadougou.
This training activity provided an overview of PAC and MVA
and focused on talking to the patient and PAC FP counseling. All of the specialists
identified for the training in Ghana were invited to this training.
Orientation Meetings: Half-day meetings were
held at each PAC service site for approximately 60 to 80 medical and administrative staff
(30 to 40 at each site). The purpose of the meetings was to elicit staff interest and
involvement with the project and to discuss how staff could incorporate the PAC services
into their daily routine. The meetings also provided staff with an opportunity to review
important information regarding the problem of incomplete abortion, the elements of PAC
services, information regarding MVA, and how PAC services would function at their hospital
site. The orientation meetings included staff on all levels from admitting, labor and
delivery and the hospital administration. Nurse-midwives referring women to the hospitals
from the community maternities for PAC were invited so that they would be aware of the PAC
Projectand make timely referrals. Faculty from various preservice institutions attended
the meetings as well.
Followup visits: The trainer involved in the
development of the project and in the clinical training of the providers is conducting
followup visits to the two maternity sites to ensure the provision of quality and
comprehensive PAC services. During these visits, the trainer assesses the knowledge and
skills of those trained and works with staff to address management issues that may hinder
provision of quality PAC services.
OR Results: Baseline data were
collected from April - September 1997. Preliminary analyses of the client interview (239
cases) showed that more than half of the women attending for PAC services were in the
20-29 year-old age group, the majority presented with vaginal bleeding, and the mean
pregnancy duration was 9.6 weeks (CRESAR 1997).
Training followup will be conducted in January 1998 and
the followup data collection will take place through April-May 1998 with the results
available soon after.
PAC services have been launched at both sites and PAC
service delivery has been ongoing since October 1997. A core group of PAC Clinical
Trainers at each hospital have been training their colleagues in recommended IP practices
and in provision of PAC services.
Review of the training intervention activities highlighted
the following as integral to the progress of the program and the discussion is organized
around these three areas:
- advocacy and and sensitization of appropriate stakeholders
- sequencing and location of training activities
- perceived need of FP services among providers
Advocacy: Because this program is the first
of its kind in the region, much advocacy work had to be done before the project started.
Concerns about the program included potential misuse of equipment and questions about
managing the overall PAC service. Sharing the results of the needs assessment was an
important part of the advocacy work because it sensitized key stakeholders to relevant
issues and proposed solutions. The development of policies and standards documents
specifically for PAC services was also useful in soliciting support from the appropriate
stakeholders. The document development process facilitated discussions while providing an
official record of consensus among this group.
The orientation meetings also proved to be an important
advocacy tool. Not only did the meetings provide an opportunity to disseminate
information, but those who gave presentations articulated their views and became more
vocal advocates for the issue of managing complications of abortion. The PAC clinical
trainers, representatives from CRESAR and guest speakers who made presentations during the
meetings demonstrated their commitment to the program and prepared themselves to address
questions and dispel rumors during and after the meetings.
Training: Using IP training as a first step
provided a noncontroversial introduction to the sensitive subject of PAC and gathered
momentum for the project. The IP training involved individuals from various levels and
departments in the hospital thus improving general awareness and quality of IP practices.
In addition, PAC was presented not as an "add-on" servicebut rather as an
element to be integrated into existing services, all of which require attention to IP.
The distance between the two project sites is 300
kilometers (5 to 6 hours by road); therefore the opportunities for regular exchange are
limited. Participants involved in the training activities have reported that they
benefitted from attending training with their colleagues from the other maternity and that
it has been helpful to have the maternities alternate hosting of training activities.
Using both maternities for training encouraged sharing of problem-solving efforts and
experiences. The same principle applied to those who traveled to Ghana for training:
participants felt that it was important to observe a functioning service to determine what
works as well as what challenges have been encountered and resolved.
FP services: Prior to the start of
this program, little or no FP counseling was provided to women presenting with incomplete
abortion. The existing FP clinic at both maternities was located in a small room in the
maternity wing and services were not provided regularly. Based on the advocacy efforts
described earlier, CRESAR secured a grant from UNFPA to build and equip a FP clinic at the
hospital in Ouagadougou. This new clinic highlights the commitment of the hospital to FP
services and benefits not only PAC clients but other women coming to the hospital for
services. The head of the maternity service in Bobo-Dioulasso indicated that this project
helped him to realize the importance of FP, and he has taken steps to strengthen the
existing service in the hospital.
Both maternities are part of teaching hospitals. As such,
many medical, nursing and midwifery students rotate through these clinics for FP training.
Therefore, strengthening FP service provision in these maternities can have a major impact
on FP training.
- Successful development and initiation of PAC services was
dependent on the leadership and commitment of the Heads of the Maternities and the
Division of Family Health. The head of the maternity in Ouagadougou served the critical
role of spokesperson for the project.
- Implementation of recommended IP practices takes time
because this requires not only access to certain materials but also behavior change on the
part of providers and cleaning staff. Regular followup visits were useful in providing
support and technical assistance was required to ensure behavior changes.
- Development of a PAC program requires careful planning and
coordination. At the hospitals, a number of policy decisions (e.g., management of
equipment/materials, rotation schedules, staff responsibilities) and program planning
steps had to be completed prior to the initiation of training and delivery of services.
- Those responsible for FP service delivery must receive the
requisite FP training. The national FP program had not trained providers at the teaching
hospitals to provide FP services. Although discussions with the Division of Family Health
(DFH) and CRESAR indicated that FP training was to be provided by the DFH, this did not
take place. As a result, the project made the appropriate arrangements and some providers
received training through other programs sponsored by a local NGO.
- Introduction of PAC services is different from introduction
of an elective service or a new contraceptive. PAC providers and trainers must be prepared
to provide a range of treatments from performing an uncomplicated MVA to treating
life-threatening emergencies. While elective procedures can be scheduled, patients
presenting with incomplete abortion are often quite sick and may require stabilization
prior to MVA.
- Preservice training in PAC will ensure a continuous supply
of providers who can offer PAC services in the country.
Targeting teaching hospitals for the introduction of PAC
services lays the groundwork for medical, nursing and midwifery students to be trained in
PAC. Interviews with hospital staff reveal that management of incomplete abortion using
D&C is often delegated to interns because they are the ones expected to manage the
"bloody work" (DeGanus-Amorin 1997; Kone, Thieba and Lankoande 1996). On-site
training by trained providers must take place to ensure that additional providers at the
two maternities are trained.
Existing training curricula should be reviewed and revised
as necessary to include PAC training so that systematic training of students in PAC is
institutionalized. Particular attention should be paid to providing students the
opportunity for clinical practice.
- PAC training and service provision need to be
decentralized.
Targeting tertiary-level hospitals addresses the needs of
only the small number of women who are successful in seeking treatment at these
facilities. The CRESAR is currently working with the MOH to identify additional sites that
should be targeted for establishment of services. The policies and standards documents
serve as the basis for these discussions. Also, the policies and standards documents have
been developed and disseminated among senior officials and the two maternities but further
dissemination and decentralization to regional and district levels must take place.
- Ensuring quality of service provision
Now that service delivery mechanisms have been introduced,
they need to be supported by appropriate supervision and monitoring systems. In addition,
a system through which continued equipment needs and resupply of expendable supplies and
MVA kits can be provided needs to be formalized. Issues of partner involvement and
referral of women with severe complications need more attention and it is anticipated
these issues will be addressed through supervisory and monitoring systems.
CRESAR has made a bold first step in bringing PAC services
to Burkina Faso. Services have been established at two tertiary hospitals and policies and
guidelines for PAC service provision have been developed. Decentralization of service
provision and continued supervision and monitoring need to be on the agenda of future
program efforts.
| 1 |
Traoré G, Division of Family Health. Opening
remarks: Contraceptive Technology Update Workshop, April 1997, Bobo-Dioulasso, Burkina
Faso. |
| 2 |
Huntington D et al., Improving the Medical
Care and Counseling of Postabortion Patients in Egypt, Studies in Family Planning,
1995, 26(6):350-362. Malla K et al., Establishing
Postabortion Care Services in Nepal, JHPIEGO Technical Report FCA-25, 1996.
Solo J et al., Testing Alternative Approaches to Providing
Integrated Treatment of Abortion Complications and Family Planning in Kenya: Findings from
Phase I, The Robert H. Ebert Program on Critical Issues in Reproductive Health and
Population, 1995. |
| 3 |
Ibid. Otsea
K et al., Midwives Deliver Postabortion Care Services in Ghana, IPAS Dialogue Paper,
1997, 1 (1). |
| 4 |
Malla K et al., Establishing Postabortion
Care Services in Nepal, JHPIEGO Technical Report FCA-25, 1996. |
| 5 |
Bazié A, State of Unsafe Abortion in Burkina
Faso, African Journal of Fertility, Sexuality and Reproductive Health, 1996, 1 (1):
66-67. |
| 6 |
Ajello C et al., A Humanistic Approach to IUD
Clinical Training: Results of Comparative Study in Thailand, JHPIEGO Technical Report
FCA-04, 1994. |
| 7 |
Ghosh A, JHPIEGO Trip Report for Ghana,
January1997. |
| 8 |
C.R.E.S.A.R., Analyse Préliminaire
Population Council Recherches Opérationnelles, September 1997. |
| 9 |
Personal Communication: Sylvia
DeGanus-Amorin, January 1997. Personal
Communication: Drs. Kone, Thieba, Lankoande, September 1996. |
a "Comprehensive PAC services should
include both medical and preventive health care. The key elements of PAC are: emergency
treatment of incomplete abortion and potentially life-threatening complications,
postabortion FP counseling and services, and links between postabortion emergency services
and the reproductive health care system." (Winkler J et al., Postabortion Care: A
Reference Manual for Improving Quality of Care, Postabortion Care Consortium, 1995, 1-2)
b A similar study is scheduled to be carried out
by the Reproductive Health Training and Research Center (Centre de Formation et de
Recherche en Santé de la Reproduction [CEFOREP] in Dakar, Senegal in 1998.
c Centre Hospitalier National Yalgado
Ouédraogo in Ouagadougou; Centre Hospitalier National Sanou Souro in Bobo-Dioulasso.
d The language included in the document is as
follows: "Care will be provided at all maternities to all postabortal women
presenting without complications. Complicated cases requiring interventions (curettage)
will be referred to centers equipped to handle these cases." (Politique et Standards
des Services SMI/PF au Burkina Faso, Ministère de la Santé de l'Action Sociale et de la
Famille, Section 5.6)
e The CBT training approach employs: A clinical
coaching process that ensures continual feedback to the training participant until mastery
of the procedure has been achieved Use of participant learning guides and competency-based
performance checklists to assist the participant to progress from skills acquisition to
skills competency.
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