Postabortion Care Workshop Proceedings: Workshop Presentations

Maternal & Neonatal Health

Issues in Establishing Postabortion Care Services in Low-Resource Settings: Workshop Presentations

Decentralizing PAC Services: Insights from a Decade in Africa (continued)

Khama Rogo, MD, PhD

The Road Ahead
	The constraints to PAC decentralization in Africa are formidable and invariably similar in all countries. But it is only through decentralization that outreach, accessibility and availability can be obtained. We should all aim at reducing to the very minimum the bleeding time a woman with complications of abortion must endure before reaching a caring provider. That provider should in turn possess the necessary technical skills, backed by essential functional equipment and commodities, for stopping the bleeding, evacuating the uterus and providing postabortion FP. This should be our target for both urban and rural Africa. The road to this realization, however, has many bumps and potholes. We must learn to drive through them. I would like to suggest a few issues for consideration in this most challenging process.
Figure 3. The Road Ahead

Adopting a Wider Choice of Entry Points for PAC	The Ipas entry model described above has much compelling strength. It however has proved to be slow and at times inflexible. Alternatives need to be sought. Could PAC be introduced, through the private sector, local authorities or professional organizations? Would these approaches find favor with MOHs?

Working with Professional Groups	Resistance to PAC from professional associations can be detrimental and even lethal to the process of decentralization. Embracing professional associations in the process is one way of insuring against their opposition. Should this not be made an integral activity in the decentralization process?

Working Around Legal and Policy Barriers	Decentralization of PAC has been bogged down by perceived legal and policy barriers even when they do not exist. Does the law in reality restrict nonphysicians from providing PAC? Do Nursing Council policies/ regulations allow their participation? These questions have been raised and dealt with in, Ghana, Kenya, South Africa and Uganda. While the answers must be sought locally, could international and regional nursing bodies not provide comprehensive guidelines to be used by national associations? The International Federation of Gynaecology and Obstetrics, International Nurses Association and other organizations and societies should be brought together to provide clear interpretations and guidelines to national professional organizations on these issues.

Monitoring and Quality Assurance	As is the case with new programs, monitoring and evaluation of decentralized PAC services is essential. Evaluation and quality assurance require allocation of resources and trained personnel. The challenge is much greater when all the aspects of decentralization are taken into account. Most African countries lack the framework within which the diverse interests of the public sector, private sector and local authority can be adequately responded to. Without proper monitoring and evaluation, quality can easily suffer, giving opponents of PAC a reason to challenge decentralization. Who should take this responsibility? Would it work with PAC where it has failed in FP or SMI?

Sustainability	Today’s level of resources invested in PAC is only a small proportion of the real need. Currently, African governments spend large amounts of money in taking care of abortion complications, transporting patients long distances to district hospitals for sharp curettage and managing long-term complications of pelvic sepsis. There is an urgent need to rationalize this expenditure and turn it over to the more cost-effective PAC approach. Donor funding alone cannot be expected to satisfy this great need. Catalytic spending of what is available from donors is therefore critical. Donor funding could cover more mileage when used to assist in re-directing government spending, reviewing existing policies and legislation, and plugging the gaps in commodity supplies. Collaboration and not competition between international NGOs is needed to minimize overlap. As was shown in recent baseline surveys, peripheral facilities require considerable upgrading to ensure quality of PAC services. Uninterrupted supply of MVA equipment is another issue that has threatened continuity of PAC. Happily, Ipas is currently addressing this issue and should have proper distribution points in every country African in due course. The private sector has proved to be more sustainable as far as PAC is concerned. This has been shown by the Marie Stopes clinics and more recently has been substantiated in the KMET project in Western Kenya. Since most PAC clients are willing to pay a small fee, cost sharing in the public sector should be encouraged, as long as the funds raised are recycled back to the very service.

Community Participation in PAC	Community support or hostility toward women with unwanted pregnancies or women seeking PAC is a major determinant of prevention of unsafe abortion practices and associated complications. Programs to improve PAC have focused almost exclusively on secondary prevention at the hospital level. We now have reason to doubt if secondary prevention alone can seriously impact on maternal morbidity and mortality at the community level. Innovative ways of enhancing community participation are called for. One such effort is taking place in Western Kenya today. With support from the Rockefeller Foundation, The Centre for the Study of Adolescence, in collaboration with the Pacific Institute for Women’s Health, has completed the first phase of a pilot project entitled COBAC: Developing Strategies to Reduce Unsafe Abortion and Maternal Mortality at Community Level. This project has: Acquired in-depth understanding of community perceptions and attitudes toward unwanted pregnancy and abortion Identified high risk groups Identified both formal and informal providers Assessed the attitudes and skills of these providers Established barriers to collaboration between formal and informal providers In the second phase, the communities are now designing their own interventions including IEC, advocacy and safe services. Community involvement is the ultimate level of decentralization. Efforts to work at this level should therefore be given the highest priority.

Working with Refugees	The promise of Cairo to treat reproductive rights as a human right seems to be lost in refugee camps. There, victims of rape are left to suffer silently, on their own. Women with incomplete abortion, whose incidence is expected to be higher under the deplorable circumstances of refugee survival, cannot access PAC. This is not a resource or technical problem but a cruel manifestation of inhumanity. Decentralization of PAC to all refugee camps is the only way of reaching this traumatized and marginalized population.

Conclusion
	It has become increasingly clear that PAC cannot be the domain of district, university teaching or national hospitals alone. Every level of healthcare has a useful role to play. Decentralization of PAC not only brings services closer to the people. It also reduces morbidity and mortality due to delays and the cost of treatment, and improves the overall performance of health services by relieving time and resources for highly trained professionals to do more specialized services. Most PAC activities can be undertaken at lower levels than the district hospital. The clamor to decentralize must however be approached with a broad and open mind. We must understand the players and listen to their concerns. We must study the service delivery infrastructure and its weaknesses. We must be ready to commit resources to support these efforts. Ipas has been the road for over a decade in Africa. Still, much more needs to be done to make PAC services a reality to the poor communities in both urban and rural Africa.

References
	Billings D et al. 1999. Training Midwives to Improve Postabortion Care in Ghana. Ipas: Carrboro, North Carolina. Delivery of Improved Services for Health (DISH) Project. 1999. Decentralizing Integrated Post Abortion Care in Uganda: A Pilot Training and Support Initiative for Improving the Quality and Availability of PH Services. A Baseline Report. DISH Project: Kampala, Uganda. French B, N Waithaka and A Omide. 1998. A Pilot Study of Clinical Officers in Provision of PAC Services in Kenya. Ipas: Carrboro, North Carolina. Guttmacher S et al. 1998. Abortion reform in South Africa: A case study of the 1996 Choice on Termination of Pregnancy Act. International Family Planning Perspectives 24(4): 191–194. Henshaw S et al. 1998. The incidence of induced abortion in Nigeria. International Family Planning Perspectives 24(4): 156–164. 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. Kisumu Medical & Educational Trust (KMET) and Family Planning International Assistance. 1998. Expanding Opportunities for Preventing Unsafe Abortion in Western Kenya, Annual Report 1998. KMET and Family Planning International Assistance: Nairobi, Kenya. Kisumu Medical & Educational Trust (KMET) and Family Planning International Assistance. 1997. Expanding Opportunities for Preventing Unsafe Abortion in Western Kenya, Annual Report 1997. KMET and Family Planning International Assistance: Nairobi, Kenya. Orero S. 1999. PAC Service Provision as Part of Reproductive Health Services in Kakuma and Dadaab Refugee Camps of North Eastern Kenya. Ipas: Carrboro, North Carolina. PRIME Project. 1999. Expanding Opportunities for PAC for Communities Through Private Nurse/Midwives in Kenya: A Needs Assessment. Draft Report. PRIME Project: Nairobi, Kenya. Rogo K. 1999. Preventing Maternal Mortality Network (PMMN) Project in Western Kenya: Report of a Needs Assessment Study. Kisumu Medical and Educational Trust: Nairobi, Kenya. Rogo K. 1993. Induced Abortion in Kenya. Paper prepared for International Planned Parenthood Federation. Centre for the Study of Adolescence: Nairobi, Kenya. (October). Rogo K and L Bohmer. 1999. Developing Strategies to Reduce Morbidity and Mortality Due to Unsafe Abortion at the Community Level. Report of Pre-intervention Research. Centre for the Study of Adolescence and Pacific Institute for Women’s Health: Los Angeles, California. Rogo K, V Lema and G Rae. 1999. Post Abortion Care: A Service Delivery Policy, Standards and Procedures Manual. Ipas: Carrboro, North Carolina.

Decentralizing PAC Services: Insights from a Decade in Africa (continued)

The Road Ahead

Conclusion

References