Draft Strategy Paper

Figure 2. Focus of PAC Strategy

Although we had expertise in training for FP and other selected RH interventions, we realized that preparing sites to offer PAC services required a shift in the management and training paradigm. Unlike FP, emergency services cannot be scheduled. There are different skills associated with emergency versus elective procedures. We needed to think about how to train for uncommon emergencies by using simulations, drills and algorithms, and to determine how various tools can guide the service provider through required procedures. Also, training is just one element that needs to be considered; there are many other issues internal and external to a service delivery point that need to be addressed.

How should the concept of PAC be introduced? Providers have a history of being interested in new technologies; however, use of MVA for appropriate cases is only one of many aspects of providing PAC services. We also needed to consider how to transfer skills related to critical thinking and total care of the patient. Finally, PAC services should be available wherever emergency treatment for complications of abortion is offered.

FP counseling for PAC is quite different from that for "regular" FP clients. Some women may need to be referred for other RH services, others may be preoccupied as they may have left home in a hurry and are worrying about their children or wondering how they are going to get home. Because providers need to be equipped to handle a range of situations from routine cases to life-threatening emergencies, the need for well trained and experienced preceptors and coaches is essential.

To better organize our thinking and to keep focused on our overall goal, we looked at the various programmatic considerations in terms of the following themes:

• Advocacy
• Access
• Institutionalization of Training
• Sustainability

These themes are defined in different ways in different contexts, and there are many issues that cut across these themes. Therefore, a review of these terms as they are used in the draft strategy paper will be helpful to frame our discussions over the next 2 days.

Advocacy

Government authorities, the press and society at large must recognize that unsafe abortion takes a heavy toll on women’s health and lives. Host-country counterparts must be committed to all aspects of PAC to ensure successful integration with existing maternal health services. In addition, in any country the government must be committed to supporting and expanding PAC services as an essential component of the healthcare system.

Government support for expansion of PAC services must include not only improvements in access to and quality of PAC services, it should also involve raising awareness of the urgency for treatment of complications due to incomplete abortion and the availability of other PAC services within the community.

Access

This theme includes a review and discussion of service delivery guidelines and practices existing prior to integration of PAC services. JHPIEGO believes in a cadre-neutral approach. In many developing countries, the question is not whether we should train doctors, nurses or midwives, but rather how do we improve access to services and who is available to do the job in both the public and private sectors? Recognizing that training is only one part of the multidimensional systems approach proposed, investment must be focused on training the cadre of health worker available at a given service delivery point. Frontline workers often feel helpless because they were not trained to meet the challenges of the services for which they are responsible, or are not allowed by laws and regulations to provide services in which they are competent.

Increasingly, nurses, midwives and medical assistants must assume the duties that were traditionally the domain of physicians. In Africa and most of Asia, this is typically the situation because physicians do not staff primary healthcare services sites. Given that physicians are often located far from these sites, uncomplicated bleeding problems can become more severe and life-threatening without immediate treatment. Thus, appropriate providers need to be trained to handle such situations. Also, provision of immediate postabortion FP counseling has proven to be most effective. Access to services includes provision of FP counseling as close to the point of service as possible.

JHPIEGO is committed to working with appropriate authorities and providing technical support to ensure that peripheral, and not just central, health services have the capacity to deal adequately with PAC concerns and emergency situations. This commitment involves exploring newer but simpler modalities of providing care where it is most needed—the community level. For example, the use of oral misoprostol, or prostaglandins, to control postpartum hemorrhage may have potential applications in postabortion cases by preventing uncomplicated bleeding problems from progressing to more severe problems. Prostaglandins also may be useful in life-threatening situations where immediate surgical treatment is unavailable.

All of these objectives require that trained healthcare providers have access to the drugs, medical supplies and basic equipment necessary for the provision of PAC services. Effort should be made to install appropriate logistics systems to make these basic supplies available at the service point levels.

Institutionalization
of Training

Inservice training has been the modus operandi for training service providers in most developing countries. International donors as well as Ministries of Health and Education personnel, however, increasingly are becoming aware that inservice training is not the most cost-effective or efficient way of providing basic education and training, especially for clinical procedures. Bringing providers to an inservice course incurs financial costs (training room rental, travel, food/lodging, etc.) and disrupts service provision (providers are required to take temporary leave from their posts to participate in training). Also, providers’ motivation to learn the skills being taught may be lacking; providers may not perceive the skill as an integral aspect of their job responsibilities because it was not a part of their preservice education. Finally, subjects taught during inservice training events may be perceived as "add-on services" that are not included in a basic package of services and therefore less important.

Although initially it may be necessary to introduce PAC services via inservice training, it is desirable that routine and regular training quickly be moved into the preservice setting. Preservice training provides a greater opportunity to influence provider attitudes and standardize skills. Targeting teaching hospitals for the introduction of PAC services lays the groundwork for medical, nursing and midwifery students to be trained in PAC. All health workers should understand the concept of PAC and the importance of being prepared for emergencies. Developing teaching hospitals and satellite clinics as model service, and then training, sites is important to ensuring that students have adequate opportunities for clinical practice.

Sustainability

Availability of and access to PAC are limited not only by material and human resources but equally by support from the host government. Commitment must be translated into actions that will encourage the host government to assume responsibility for ensuring continued availability and wider access to PAC. In addition, elements of PAC should be made available to the smallest health units of the healthcare system to serve as the entry point for women in need of PAC services. Implicating the smallest health units in PAC efforts, and linking them to clinics that could either provide PAC services or serve as the gateway for stabilization of critically ill women prior to referral, will further support the integration of PAC into the healthcare system.

Mobilizing community resources for PAC services is a critical factor for ensuring sustainability. In countries where patients are accustomed to paying for care, reasonable fees may be charged to those who can afford to pay for the services. Clients are generally willing to pay if the services provided are of good quality. The involvement of the private sector isexpected to increase availability of and access to PAC services since private sector providers supply a substantial portion of these services.

Collaboration

Discussion of these themes illustrates the number of programmatic issues that need to be considered in initiating and integrating improved PAC services. There is a lot of work to do and each individual and organization represented here brings valuable technical expertise. Collaboration at all levels is essential to ensure complementarity of efforts and coordination of resources. We look forward to hearing your comments and receiving your feedback over the next 2 days.

Summary

Programmatic approaches and models for introducing services exist, and there is great potential for expansion and decentralization of such services. The challenge is how to establish sustainable services that are fully integrated on a national scale. It is our hope that this workshop will help shape a strategy that can provide programmatic guidance to establishing PAC services in low-resource settings.

References

Fourth World Conference on Women. 1995. Platform, paragraph 106K. Beijing.

Ghosh A, ER Lu and N McIntosh. 1999. Establishing Postabortion Care Services in Low-Resource Settings. JHPIEGO Corporation: Baltimore, Maryland.

Huntington D (ed). 1998. Summary Report of a Global Meeting: Advances and Challenges in Postabortion Care Operations Research. Population Council: New York.

International Conference on Population and Development (ICPD). 1994. Programme of Action, paragraph 8.25. ICPD: Cairo.

Johns Hopkins University Center for Communication Programs (JHU/CCP). 1996. Put Yourself in Her Shoes. Video guide. JHU/CCP: Baltimore, Maryland.

Kinoti SN et al. 1995. Monograph of Complications of Unsafe Abortion in Africa. Reproductive Health Research Programme of Commonwealth Regional Health Community Secretariat (CRHCS) for East Central and Southern Africa, JHPIEGO Corporation and IPAS: Baltimore, Maryland.

United Nations Population Fund (UNFPA). 1999. Report of the International Forum for the Operational Review and Appraisal of the Implementation of the Programme of Action of the International Conference on Population and Development. http://www.unfpa.org/icpd/ round&meetings/hague_forum/reports/forumrept-ch8.htm. Viewed 15 April 1999.

Winkler J, E Oliveras and N McIntosh (eds). 1995. Postabortion Care: A Reference Manual for Improving Quality of Care. Postabortion Care Consortium: Baltimore, Maryland.