Purpose
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The purpose of this paper is to summarize lessons learned from
establishing PAC services in seven countries: Colombia, the Dominican Republic, Indonesia,
Kenya, Tanzania, Turkey and Uzbekistan. |
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Background
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Over the past decade, national ministries of health, providers and
policymakers have begun to acknowledge complications of abortion as a major public health
issue—one that takes its toll on scarce human and financial resources and, more
important, on women’s lives. To address this issue, a number of agencies have worked
toward furthering the Postabortion Care Initiative. PAC consists of the following three
elements:
emergency treatment for complications of spontaneous or induced
abortion,
postabortion FP counseling and services, and
linkages between emergency abortion treatment services and comprehensive
reproductive healthcare services.
AVSC International has been one of those agencies working in PAC. We are a service
delivery organization with more than 25 years of experience working in over 50 countries.
Our approach to service delivery—which we call a systems approach—involves
working with all levels of systems, from individual sites to government health ministries
and nongovernmental organization networks to other CAs. We focus on practical solutions
for program improvement, especially where resources are scarce. We transfer knowledge and
skills for establishing and improving sustainable health services to policymakers,
providers and managers of health systems in the countries where we work. The end goal of
this approach is to develop services and management systems that are of good quality,
comprehensive and sustainable.
AVSC has been involved in PAC activities since 1991. Besides being a founding member of
the Postabortion Care Consortium1 (with Ipas, JHPIEGO,
Pathfinder International and International Planned Parenthood
Federation), AVSC has worked in a number of countries, including the Central Asian
Republics, Colombia, the Dominican Republic, Indonesia, Kenya, Tanzania and Turkey, to
increase access to and improve the quality of PAC services. As with its other RH
activities, AVSC has employed a systems approach in its PAC work. Strategies that AVSC has
used for PAC within this approach include:
Training providers in programmatic and clinical aspects of PAC
(including MVA, postabortion counseling, management and organization of services, and IP)
Training in and instituting facilitative styles of supervision and
forging links between supervision and training
Linking PAC with other RH services
Finding ongoing funding sources for equipment and identifying ways to
make MVA equipment available locally at reasonable cost
Developing cost-sharing/cost-recovery plans
- Advocating for nationally based policy and healthcare standards and guidelines
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Lessons Learned
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AVSC’s work in PAC has so far met with both successes and challenges.
Our activities have yielded lessons that are proving valuable as we expand to other sites
within a given country, or launch programs in new countries. |
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Lesson 1: There
Is No One Recipe for PAC |
Social norms, religion, politics and donor policies play a strong part in
establishing PAC services. These qualities vary from country to country and affect where
and what components of PAC are carried out. We have conducted PAC work in countries where
abortion is strictly illegal, legally restricted but culturally accepted and practiced,
and unrestricted. Each of these situations presents different programming needs. It is
therefore important to have a good understanding of national and local law and abortion
practice, and postabortion-related circumstances at proposed PAC sites, and to tailor PAC
services and activities to the specific environment.
Examples
In Colombia, abortion is strictly illegal under all
circumstances, but good quality, private abortion services can be found. Additionally, PAC
and all other health services are covered under a new law that guarantees universal
healthcare despite ability to pay. This gives hospitals more flexibility to provide PAC
services and ensure that they are reimbursed for them. Colombia’s environment has
thus been conducive to PAC work.
Abortion is legal in Turkey, so for AVSC, training in MVA is not
an option. Instead we are focusing on postabortion FP—the second component of
PAC—as a major part of improving the quality of postabortion services.
In Tanzania, where abortion is highly restricted, PAC work began
with a low profile, small-scale pilot project in just three sites. Although this proved a
slow approach, it enabled the program to gradually gain acceptance from local
policymakers. Now PAC is increasingly recognized as an important component of basic RH,
and the MOH is moving forward with plans for national expansion of PAC services.
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Lesson 2: PAC ?
MVA |
Each of the three elements of PAC is critically important for women.
Programming should focus on elements 2 and 3 as much as on element 1, and should ensure
strong linkages between these elements and other services. The novelty of MVA technology
often overshadows the other two elements of PAC. To address this, AVSC is experimenting
with changing the order in which PAC training is conducted and services are
established, such as by introducing the non-technology elements of PAC first.
Examples
In Tanzania, MVA procedures have been linked with counseling, FP
and improved IP practices, but D&C procedures have not benefited from the same
linkages. This has occurred because such great attention and funding was channeled towards
MVA rather than improving the quality of all PAC services. We are working to tackle this
challenge in Tanzania.
In Colombia, providers have been attracted to MVA technology
because it saves resources and is safer for the patients. Other aspects of PAC services,
such as counseling and FP, have received less attention because they are not new
innovations or technologies, and because hospital staff already have some experience with
FP. To promote a better integrated, more client-focused PAC program (versus one that is
MVA-focused), we are now carrying out training in PAC counseling before training providers
in MVA.
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Lesson 3: Old
Habits Die Hard |
We cannot expect a 5-day training course alone to result in the complete
change of practice. Programming for PAC, including MVA training, must routinely include
planned followup and technical assistance. Including these elements will help facilitate
such change as the transition from D&C to MVA and from general to local anesthesia.
PAC program trainings are most effective if they include followup and ongoing technical
assistance plans (which involve appropriate supervisors) that are implemented in a timely
way.
Examples
In Colombia, many doctors prefer general to local anesthesia for
MVA because the client is asleep throughout the procedure. Interacting with an awake
client during a stressful and sometimes painful procedure requires provider skill that
must be developed. PAC training will now include particular emphasis on provider
communication skills to be used before, during and after the treatment procedure. The
training also helps providers better understand the needs of PAC clients.
In Kenya, some doctors have returned to using D&C because
they are faster at this familiar procedure. Their MVA training included too few hands-on
supervised cases. Supplemental practice and ongoing supervision to complement the initial
PAC training is key to developing a new clinical competence.
In the Dominican Republic, incountry AVSC staff originally
planned quarterly monitoring visits to new trainees. Monthly monitoring visits are now
conducted because of the slow pace of effecting change in service delivery within the
public health system. Followup is carried out 3 to 4 weeks after the initial training
session.
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Lesson 4: PAC
Counseling — More Than Just Family Planning Information |
Counseling for PAC clients needs to be flexible and should not be pegged
to a particular aspect of service provision. Each woman’s situation differs from
another’s. What is unique to counseling a woman with a spontaneous abortion? Is the
emergency room an appropriate place to talk to clients about FP? When it is medically
feasible, women appreciate being given a range of information before, during and after the
treatment procedure. The challenge is to ensure that each patient receives pertinent
counseling under appropriate circumstances. AVSC is field-testing a new PAC counseling
module designed to build communication skills and develop awareness of the range of needs
postabortion patients may have. The module is for doctors and nurses who are the ones to
work with these patients, rather than specifically for specialized counselors, who are
rarely on the scene.
Example
- In Indonesia, the quality of counseling services has been lacking for PAC
clients. Many sites cannot find time to provide patients with even minimal information
about the MVA procedure, even though interviews indicate women want the information. If
they do find the time, providers often are unsure about what they should tell the woman.
Also, doctors frequently report that women do not want FP until a month or more after
their treatment procedure, but a midwife who talks with PAC clients about the rapid return
to fertility provides a vast majority with immediate postabortion FP. Clearly skill in
communication and an interest in making sure women have all pertinent information are
essential parts of high quality PAC services.
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Lesson 5:
Whole-Site Is Better |
Information on PAC should be provided not only to those providers
receiving clinical or programmatic training, but also across other departments, staff
levels and site levels of the health sector in order to bolster knowledge and
institutionalization of the new program. One strategy for accomplishing this is to provide
an all-staff orientation to the PAC program when improved services begin.
Example
- In the Dominican Republic, we have learned that representatives of the different
departments at a site should always be a part of PAC orientation and training sessions,
even if they just sit in on the introduction. In one hospital, staff from the FP
department participated in the introductory sessions of the initial PAC orientation and
clinical training. They became familiar with the PAC program objectives and the
contributions their department could make to this program.
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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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