Introduction

To reduce the risk of long-term disability or death from the complications of abortion, governments must commit to working with communities and providing easily accessible, high quality emergency services at all levels of the healthcare system. Although needed virtually everywhere, in many countries emergency treatment for incomplete abortion is:

• available only in secondary or tertiary hospitals located in major urban cities;

• performed in operating rooms by a team of specialists; and

• abusually provided by sharp curettage (dilatation and curettage [D&C]), usually done under heavy sedation or general anesthesia.

Lack of transportation and prohibitive costs place these centralized services out of reach of most poor, rural women. Furthermore, the continuum of care usually ceases once the emergency situation has passed, leaving women trapped in the dangerous cycle of unwanted pregnancy and unsafe, often illegal abortion.

Although the importance of linking emergency care and family planning (FP) is obvious, until recently these two types of care rarely were offered together. Indeed, it was not until 1993 that Ipas coined the phrase “postabortion care” (PAC) to include:

• emergency treatment of incomplete abortion and potentially life-threatening complications;

• provision of family planning counseling and services; and

• links between emergency care and other reproductive health (RH) services (e.g., infertility screening, sexually transmitted disease [STD] management, cervical cancer detection or antenatal care).

Since then, much has happened. For example, as a result of the efforts of many individuals and organizations, postabortion activities supported by the United States Agency for International Development (USAID) have been launched in more than 30 countries.¹ Also, manual vacuum aspiration (MVA), an effective method of treating bleeding complications that promises increased access to emergency care, is being promoted globally. Compared to D&C, MVA offers a number of advantages. It does not require use of heavy sedation or general anesthesia, and can be provided in an outpatient setting by nurses and midwives using inexpensive reusable instruments and equipment. Furthermore, it is easier to teach and to attain competency in MVA compared to D&C. Finally, much has been learned through operations research regarding how best to link emergency care with FP and other RH services, mobilize community support and make better use of the private sector to provide PAC services.

Significant gaps, however, still exist in implementing the overall PAC strategy. For example, at the USAID-supported PAC Cooperative Agencies meeting in January 1999, it was reported that the existing demand for services has not yet been met in any one country, nor has the full array of PAC services been provided. Moreover, key issues such as advocacy, expansion of services, institutionalization and sustainability of PAC services were yet to be addressed. As a consequence, a number of recommendations were made to address these gaps. One of these, “...the need to develop a comprehensive approach to PAC services, including the design, implementation and scale-up,” provided the impetus for this paper.

In the first section, the key elements in a PAC strategic framework are briefly described. In subsequent sections, these elements are integrated into the major steps needed to introduce and expand PAC services in countries with limited resources. These recommendations are based primarily on JHPIEGO’s and our partners’ programmatic experience of the last 5 years, as well as other lessons learned in the field.

Key Elements

• forming a network of community members;
• conducting a needs assessment;
• convening dissemination events;
• developing, implementing and evaluating an action plan; and
• using evaluation results to plan new initiatives and gain additional support.

While use of MVA rather than D&C should be encouraged, if it is not yet available, FP and other RH services should be linked to existing emergency services. Moreover, to gain government support for PAC services, advocacy efforts should be directed toward:

• raising awareness of the urgency needed in treating complications due to abortion;
• linking FP and other RH services to emergency services, and increasing access to and improving the quality of these services; and
• encouraging the acceptance of PAC services within the community.

Women and Communities. Working with women and their communities is crucial to improving access to PAC. Women’s networks, traditional leaders and traditional healthcare workers should all be involved in the introduction and expansion of PAC services. Community members should be asked their opinions about the problem and potential solutions. Women who are leaders in the community will be instrumental in informing others about PAC. Determining where women go for emergency care, as well as what their views are on PAC services, can help provide the framework for introducing or expanding PAC services and integrating them into the existing healthcare system. As the community becomes involved in the introduction or subsequent expansion of these needed health services, it can be mobilized to provide transport for PAC as well as essential obstetric care (EOC).

Service Providers. A cadre-neutral approach should be supported. For many developing countries, the question is not whether doctors, nurses or midwives should be trained, but rather who is available to do the job in both the public and private sectors? Because training is only one part of the multidimensional systems approach proposed, investment must be focused on training the cadre of healthcare worker available at a given service delivery point (see Attachment 1, Provision of Postabortion Care by Level of Healthcare Facility and Staff). 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. Often they are the first point of contact for patients suffering from complications of abortion; however, in many countries they have not been trained to manage these cases. Increasingly, nurses, midwives and medical assistants must assume the duties that were traditionally in the domain of physicians. In Africa and most of Asia, this is typically the situation because physicians do not staff primary healthcare (PHC) 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, nurses, midwives or other healthcare workers need to be trained to handle such situations.

Healthcare Facilities. PAC services should be integrated into existing maternal health, safe motherhood or EOC services, and should be offered at the lowest level facility possible. Where possible, emergency services (MVA for bleeding, antibiotics for sepsis and IVs for stabilization or referral) need to be available 24 hours a day. Appropriate logistics systems must be in place to ensure that the drugs, medical supplies and basic equipment necessary for the provision of these services are continually available. Also, because providing immediate postabortion FP has proven to be most effective, efforts should be made to provide counseling and services as close to the point of emergency care as possible.

Government and Regulatory Bodies. Existing service delivery guidelines and practices must be reviewed and issues of access to services must be discussed before starting the project. A commitment 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 is needed. This commitment involves exploring newer but simpler ways of providing care where it is most needed—the community level. For example, the use of oral misoprostol, a prostaglandin, to control postpartum hemorrhage may have potential applications in preventing postabortion bleeding from progressing to more severe problems. Use of misoprostol may be especially important in rural or remote areas where medical services are limited. Before misoprostol is incorporated into PAC, however, guidelines for its use in managing postabortion bleeding need to be established.

Although initially it may be necessary to introduce PAC services via inservice training, it is desirable that training quickly be incorporated into the preservice setting. Training in PAC should be considered an essential part of the basic skills package being taught in medical, nursing and midwifery schools. Each time the RH component of the preservice curriculum is revised, PAC training should be added or, if necessary, improved. Preservice training provides a greater opportunity to influence provider attitudes and standardize skills. As with other clinical skills, preservice PAC training will be most effective when it occurs toward the end of the educational program, close to the time when the student will be working independently in the clinical setting (e.g., internship or clinical preceptorship).

Targeting teaching hospitals for the introduction of PAC services lays the groundwork for medical, nursing and midwifery students to be trained in PAC. All students 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 ensure that students have adequate opportunities for clinical practice. It is equally important for students to have the opportunity to observe and work with a well functioning team of providers offering PAC services.

Preservice education and training efforts should address provider attitudes and sensitize those being trained to the complex issues surrounding PAC. Furthermore, it is essential that the service delivery system be able to support what students learn in the preservice setting. Model clinical sites used for PAC training, where different cadres can be trained together as a team, play an important role in the institutionalization of training and the expansion of PAC services.

With either inservice or preservice training, competency-based learning packages are required. With each country, a decision needs to be made about whether existing training materials can be adapted or new ones developed specifically for the program. Experience has demonstrated that these packages should include learning guides, algorithms, protocols and use of anatomic models for initial practice.

Another issue to be addressed is how service providers will maintain their skills after training. A critical mass of healthcare providers needs to receive initial training, and then have the opportunity to maintain their skills, so that there are enough competent professionals available to provide 24-hour service at health facilities. If caseloads are small, these individuals should be trained in small groups (three to five individuals) in order to get sufficient clinical experience with patients.

The community also plays an important role in ensuring sustainability of any PAC program. Mobilizing community resources and support for PAC services is a key factor. For example, 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. In coming years, involvement of the private sector is expected to increase availability of and access to PAC services because private sector providers already supply a substantial portion of these services in many countries.

¹The seven USAID-supported agencies are AVSC International, INTRAH/PRIME, JHPIEGO Corporation, Johns Hopkins University Center for Communications Programs, Pathfinder International, The POLICY Project and the Population Council.