Overview of Pathfinder
International’s Postabortion Care Activities
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Pathfinder International supports PAC activities in 13 countries:
Azerbaijan, Bolivia, Brazil, Ecuador, Ethiopia, Indonesia, Kazakstan, Kenya, Mexico, Peru,
Tanzania, Uganda and Vietnam. Pathfinder’s PAC activities include three components:
Treatment of incomplete abortion complications
Provision of postabortion FP
Linkage with ongoing RH services, particularly with ongoing
contraceptive services
In some settings, Pathfinder supports all three components; in others, one or two
components. Where only one component is supported, it is most often postabortion
contraceptive services. Subsequently, inclusion of all PAC components may be feasible,
particularly in Latin America.
The Challenge for PAC Services
- A woman comes for treatment of an unsafe abortion because we failed to provide
effective FP services.
- If she leaves without FP, we have failed her twice.
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Adapted from: Pathfinder International 1999; Postabortion Care Consortium
1994.
PAC is a means to improve women’s RH, and make FP an integral component of
maternity care. Postpartum FP services are a natural complementary component when
providers and health policymakers agree that women need access to both good postpartum and
postabortion contraceptive services in all settings of maternity care.
In several countries, the effective introduction of PAC services has followed a
progression that first introduces postpartum FP. The next step is the provision of
postabortion FP services in the context of good counseling and informed choice. Training
in MVA with local anesthesia and other elements of care to improve treatment of incomplete
abortion is then added. In one setting, an intermediate step included improved treatment
of incomplete abortion through outpatient management using local anesthesia with classic
D&C, before MVA was introduced.
In some settings, it is possible to introduce all elements of PAC simultaneously,
including the use of MVA equipment; however, we have found a flexible and incremental
approach is often necessary and more productive. PAC combined with postpartum FP achieves
a synergy that makes FP part of comprehensive maternity care. The result is a major
increase in access to FP in public sector programs with the capacity for sustainability
and institutionalization within maternity services.
Several of Pathfinder’s evaluation and research reports document the substantial
increase in the percentage of women receiving a method of FP in the immediate postabortion
period after PAC services are initiated. Baseline levels of postabortion contraception are
usually close to zero before training and implementation, rising to 30–60 percent of
women receiving a postabortion FP method soon after services are initiated. This is
especially significant for the many women who do not know how rapidly they can again
become pregnant after an abortion.
A study by Guzman, Ferrando and Tuesta (1995) documents that major cost savings can be
achieved by treating women with incomplete abortions in an outpatient setting using local
anesthesia with D&C or MVA. When the Lima, Peru maternity hospital replaced D&C
with MVA, there was a relatively small change in cost. The cost savings from MVA were
minimal when considering the major savings of providing treatment for incomplete abortion
on an outpatient basis instead of in the operating room with general anesthesia.
Furthermore, the use of MVA is a further refinement that adds to the quality of care by
making the procedure simpler and less painful. |
| PAC IN MATERNAL PERINATAL INSTITUTE, LIMA, PERU Time
and Cost Analysis for Inpatient D&C Versus Outpatient D&C or MVA2
The Maternal Perinatal Institute could save US$50,000 a year if
uncomplicated, incomplete abortions were treated on an outpatient basis by D&C or MVA.
MVA reduces the hospital stay by 90 percent compared to inpatient
D&C.
MVA requires 40 hours less than inpatient D&C and only 19
minutes less than outpatient D&C, the primary time difference between inpatient and
outpatient care being in the postoperative phase.
Total mean patient cost for inpatient D&C was US$68.93, compared to US$16.30
for outpatient MVA and US$16.70 for outpatient D&C. |
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Another important aspect of PAC, changing the uncaring or punitive
attitude of providers, is a major challenge. Therefore, training activities need to
consider all staff at the institution—doctors, nurses and social workers. It is
important to address values and attitudes as well as the elements of good counseling and
clinical care. In the early stages of PAC introduction, the changing of values often
occurs institution by institution, followed later with wide acceptance and broad policy
changes. Pathfinder’s Comprehensive RH & FP Training Curriculum incorporates
the elements needed for attitude change as well as the acquisition of PAC skills. Our
approach to offer a full range of FP services, cost-effectiveness and quality improvement
facilitates a change in values related to PAC. PAC services could expand with additional
resources in all the countries represented here, and in most other countries where
Pathfinder works. Training needs are great and support for counseling, service delivery
and implementation of new systems is necessary in the initial phase. Within a period of
2–3 years, cost savings may be experienced by maternity care facilities through
reductions in the number of women being treated for repeat unsafe abortions and fewer
deliveries.
Pathfinder uses a number of materials to plan and implement PAC services. A needs
assessment tool evaluates hospitals contemplating the introduction of PAC activities.
Pathfinder has collaborated with the Postabortion Care Consortium in the development of Postabortion
Care: A Reference Manual for Improving Quality of Care, 1995. Pathfinder recently
produced a training module, Postpartum and Postabortion Contraception,
February 1998, in the series A Comprehensive Reproductive Health and Family Planning
Training Curriculum. A forthcoming module will be Module 11: MVA for the Treatment
of Incomplete Abortion. |
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Special Need for Postabortion Family
Planning
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Lowering the rate of abortion, particularly unsafe abortion, is a critical
public health concern in many developing countries. About 20 million unsafe abortions take
place in developing countries every year, resulting in approximately 78,000 preventable
maternal deaths. Abortion-related mortality is hundreds of times higher in developing
countries than in developed countries (for example, 680 deaths per 100,000 procedures in
African countries versus 0.2 to 1.2 deaths per 100,000 procedures in developed countries)
(Sharing Responsibility 1998). In addition to the human cost of unsafe abortion,
the financial cost to national healthcare systems in personnel, equipment and supplies for
abortion-related care is enormous. For example, in Brazil the treatment for unsafe
abortion accounts for almost half of the national obstetrics budget (Novaes da Mota and
Webb 1998). Increasing the availability of effective contraceptive methods is essential
to reducing the rate of abortion and preventing maternal deaths caused by unsafe abortion.
A review of recent studies on the incidence of abortion, as well as data from Pathfinder
projects, confirms the following:
High abortion rates coincide with high unmet FP needs.
Over the long term, abortion rates fall as contraceptive prevalence
rates rise.
In countries in Central and Eastern Europe and Central Asia that were
formerly part of the Soviet Union, access to modern contraceptive methods has led to a
rapid drop in abortion rates.
Numerous studies and program evaluations have documented the relationship between unmet
FP needs and abortion. In developing countries, high percentages of women who have had
abortions report not using FP, or using less effective methods, at the time of pregnancy.
A study of abortion patients in Turkey found that while 77 percent of
clients said they had used at least one FP method in the past, the method most commonly
used was withdrawal (50 percent) (Pile et al 1998).
An evaluation of a program supported by Pathfinder in Vietnam showed
that between 34 and 67 percent of abortion patients were using FP at the time of their
pregnancy, but that most of these were using traditional methods (Nguyen et al 1998).
In Peru, an evaluation of a Pathfinder PAC project found that only 24
percent of the patients surveyed had been using FP at the time of their pregnancy. Among
these, 73 percent reported using the rhythm method (Ferrando 1998) (see below).
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| PAC IN 13 PERUVIAN MINISTRY OF HEALTH HOSPITALS Family
Planning Acceptance3
Twenty-four percent of women were using a FP method at the time of their
pregnancy, 73 percent of whom reported using the rhythm method.
Forty-three percent accepted a contraceptive method after receiving treatment.
Most common methods accepted were the pill (45 percent), injectable (20 percent), and IUD
(20 percent).
Reasons for not accepting a FP method included:
Thirty-five percent wanted to make sure they had
"recovered" (i.e., had a menstrual period) before accepting contraception.
Thirty-five percent were not offered contraception, reflecting in
part high turnover in medical staff at some facilities after the Pathfinder training.
Fifteen percent were told that the method they chose was not in
stock.
Fifteen percent received no information on FP.
Client Satisfaction
- Eighty-five
percent of patients said that they were treated with respect, while 15 percent said they
were treated with indifference.
Seventy percent were conscious during the MVA procedure and
received information about what was happening.
Twenty-six percent of clients felt no pain during the MVA
procedure, 45 percent felt minor pain, and 29 percent moderate to severe pain.
- About half (52 percent) felt comfortable asking questions and expressing fear or
pain. Among those who asked questions, 62 percent reported that they received clear,
easily understood responses.
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- A WHO-supported study in hospitals in Addis Ababa, Ethiopia showed that only 15 percent
of women admitted to hospitals for treatment of incomplete or septic abortion had been
using a modern contraceptive method when they became pregnant (Yoseph 1993).
Table 1. Proportion of Women Using Family Planning Immediately Before
Abortion
COUNTRY |
PERCENTAGE |
| Peru |
24% |
| Ethiopia |
15% |
| Kenya |
34% |
Source: Pathfinder International 1999.
Postabortion Contraception as a Premier Component of PAC
- All PAC elements support effective postabortion contraception.
- Future abortions are prevented best by complete contraceptive services.
- Replacement of abortion by contraception is a global trend.
- Abortion mortality will drop more by preventing abortion than by changing
evacuation technique.
- MVA facilitates improved postabortion contraception.
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Notes
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1. Parts of this paper are adapted from: Bowles E
and K Bourne. 1999. Family Planning and the Prevention of Abortion. Pathfinder
International: Boston, Massachusetts. Draft. 2. Adapted from:
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).
3. Adapted from: Ferrando D. 1999. Improving Postabortion
Care Services in Peru. (Evaluation Notes). Pathfinder International: Boston,
Massachusetts. (January). |
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