|
|
| placeholdplacehold |
Introducing PAC services is different from
introducing an elective service or a new contraceptive. Providers and trainers must be
prepared to provide a range of treatments—from performing an uncomplicated MVA to
treating life-threatening emergencies. While elective procedures can be scheduled,
patients presenting with incomplete abortion are often quite sick and may require
stabilization prior to MVA. Also, training is only one aspect that needs to be considered
in establishing high quality, comprehensive PAC services in a particular country. Advocacy
and consensus building efforts, overall management of services (including IP and patient
flow) and service delivery issues need to be considered at the start of the project to
ensure its success. A sound introduction strategy can lay the groundwork for future
expansion efforts. Soliciting support and commitment
from key stakeholders is crucial. Much advocacy work has to be done prior to the start of
project activities. Stakeholders may have questions or concerns about potential misuse of
equipment or management of the overall PAC services, for example. These questions need to
be reviewed in detail in order to gain their support. These stakeholders can then serve as
spokespersons for the project and become advocates for raising awareness of the need to
provide quality care to women suffering from complications of incomplete abortion.
Finally, once this support has been obtained, it is recommended that the activities
described below be reviewed and adapted as appropriate in order to introduce services in a
particular country. |
|
 |
| Needs Assessment |
The community—including its key
stakeholders and leaders—should be involved, and findings from the needs assessment
should be incorporated into the PAC service delivery strategy. Visits should be made to
potential sites to observe service delivery practices and determine client and provider
needs for PAC services. The communities served by these sites also should be assessed to
learn about community needs and perspectives. The assessment of service provision should
address the capacity to deal with emergencies and treat complications; IP practices; FP
service provision; linkages between PAC services and other hospital and community
services; and suitability of a clinic’s location as a future training site (i.e.,
connection to a medical, nursing or midwifery school). Data collection should include:
observation of service delivery practices
in the clinic or hospital;
interviews with providers, government
officials and administrators to determine management issues; and
review of logbooks to examine recorded
caseloads and case fatality rates as well as what information is currently collected on a
regular basis.
These data will contribute to defining the needed training
activities as well as the efforts necessary to strengthen the sites in preparation for
provision of quality PAC services. Moreover, sharing the results of the needs assessment
is an important part of the advocacy work because it sensitizes key stakeholders to
relevant issues and proposed solutions and provides an opportunity to solicit their
feedback. |
|
|
| Policies and Service
Delivery Guidelines |
One of the most important activities relevant
to program planning and soliciting interest and support will be the process of developing
national policies and service delivery standards for PAC. Guidelines are essential to
ensure high quality service delivery, training, supervision and management practices. The
guidelines development process facilitates discussions while providing an official record
of consensus among appropriate stakeholders. If
current policies and guidelines do not include appropriate information relative to PAC,
these documents must be updated. Policies should highlight all aspects of PAC services
(treatment of emergencies, counseling and provision of FP, and linkages to other RH
services) and should include information on case management, relationship with other RH
services, management of PAC instruments and a list of necessary equipment and supplies.
The guidelines provide the details of how and by whom the services are to be managed and
delivered. As mentioned earlier, a cadre-neutral approach as well as a commitment to
maximize access to PAC services in the country is needed. If nurses and other nonphysician
healthcare workers will be providing PAC services at remote sites, national policy must
reflect this, and protocols detailing their role and responsibility should be clearly
articulated.
Key stakeholders from both the private and public sectors
must be involved in this process. Development of relevant PAC guidelines not only
encourages close study of reference materials, but also results in a better understanding
of the subject matter and prompts discussions regarding how best to integrate PAC services
into the healthcare system. In addition, this process provides an opportunity to discuss
logistics and management issues before the start of services.
Implicitly included in this process is an analysis of the availability and cost
implications of essential drugs, medical supplies and basic equipment for PAC services. To
facilitate this process, a majority of the individuals working to develop or update
policies, protocols and guidelines for PAC should have attended the Infection Prevention
and Management of PAC Services Workshop (see below). The greatest challenge, however,
remains dissemination of guidelines and monitoring their use once they have been approved.
|
|
|
| Infection Prevention
and Management of PAC Services Workshop |
Sensitization activities should not be
limited to service providers but should include (to the extent possible) all clinic or
hospital clinical, administrative and management staff. Strengthening IP practices at
sites where PAC will be integrated is an important first step. In fact, the introduction
of PAC services provides a good opportunity to assess and strengthen the quality of
recommended IP practices throughout the facility. Typically this involves training staff
from the teaching hospital (maternity service) and nearby ambulatory sites. Given that IP
practices are fundamental to all services offered by the sites, introducing simple and
practical IP concepts and recommended practices early in the project can encourage
providers to think about how to strengthen overall management of clinical services at a
particular site. Training should include not only those staff responsible for provision
and management of services but also the individuals responsible for processing supplies
and equipment (instruments, gloves, drapes, etc.) as well as those administrators and
managers responsible for ordering and managing supplies needed for IP. Training content
should cover management issues related to emergency preparedness as well as skills related
to implementation of recommended IP practices, and provide adequate opportunity to
practice the newly acquired knowledge and skills. Finally, overall management of the site
must be considered to ensure appropriate integration of PAC. It is recommended that PAC experts with appropriate experience in
IP visit the sites selected for introduction of PAC prior to the workshop to determine
present practices. They should also visit the sites 2–3 days following the workshop
to assist participants with implementing the recommended practices and with solving
problems. Participants in the workshop will be considered the core team for improving
practices and will spearhead improved practices at service sites. Regular followup to
monitor progress in introducing recommended practices by local or regional PAC experts
should be built into the introduction activities.
Using sensitization to management issues and IP training
as a first step in improving the quality of services (e.g., maternity care) provides a
noncontroversial introduction to the sensitive subject of PAC and can gather momentum for
the project. In addition, by doing this, PAC is presented not as an "add-on"
service but rather as an essential element to be integrated into existing services, all of
which require attention to quality. |
|
|
| Contraceptive
Technology Update (CTU) |
Data from the needs assessment will provide
information regarding the FP knowledge and skills of providers. In most cases, it will be
necessary to update service providers’ knowledge about contraceptive methods,
especially as they relate to the needs of postabortion women. Also, this update provides
an opportunity to stress the benefits of immediate on-site provision of FP counseling and
services as part of the comprehensive package of PAC services. In some cases, a FP skills standardization workshop may be required
to strengthen providers’ clinical skills as well as their knowledge. In most
countries, national FP training efforts are traditionally focused on PHC or Maternal and
Child Health (MCH)/FP centers, resulting in the exclusion of teaching hospitals from these
efforts. As a consequence, faculty and clinical preceptors working in teaching hospitals
often have little or no training in FP and may require considerable technical assistance
in this area. |
|
|
| Staff Orientation
Meetings |
One-day orientation meetings for hospital and
clinic staff who have not been an integral part of the preparations for the introduction
of PAC, as well as for staff from neighboring clinic sites, should be held. The purpose of
these meetings is to elicit staff interest and involvement in the PAC activities and
discuss how staff can incorporate them into their work (e.g., more timely referrals from
surrounding sites, prompt evaluation of PAC patients, better referral of PAC patients for
FP, etc.). The meeting will provide staff with an opportunity to review important
information regarding the problem of incomplete abortion, the elements of PAC, and
information about MVA and how PAC services will function at the facility. A presentation
of the proposed PAC service delivery plan should also be reviewed to gain consensus and
help in finalizing the plan. For hospital sites,
orientation meetings should include staff at all levels from admitting to labor and
delivery, as well as those from hospital administration. Key health workers who may refer
women from surrounding areas should be invited so that they are aware of the availability
of PAC services and make timely referrals. Faculty from various preservice institutions
also should be invited.
These orientation meetings can serve as an important
advocacy tool. Not only do the meetings provide an opportunity to disseminate information,
but those who give presentations can articulate their views and become more vocal
advocates for the issue of managing complications of abortion. PAC clinical trainers,
representatives from the Ministry of Health (MOH) and other stakeholders should be
encouraged to make presentations in order to demonstrate their commitment to PAC, address
questions and dispel rumors. |
|
|
| Technical Assistance
to Set Up Clinic Sites |
Development of PAC services requires careful
planning and coordination. A number of policy decisions (e.g., management of equipment and
materials, rotation schedules and responsibilities) and program planning steps have to be
completed before the initiation of training and delivery of services at a particular site.
A PAC expert should be available to work with project staff to assist with preparing the
sites to offer services. Patient flow, organization of emergency services, case
management, IP, record keeping, FP counseling and FP referrals should all be reviewed. A
team approach to service delivery, in which different cadres work together to provide PAC
services, should be fostered. Also, a system for collecting the information needed for
routine monitoring of PAC services should be established. Consideration should be given to
the data needed to adequately evaluate the introduction and later the expansion of PAC
services as well. |
|
|
| Training |
Once the above activities have been
successfully accomplished, PAC training can be carried out. Caring for the total needs of
the patient—not just the medical emergency—should be stressed as an important
element of the training strategy. Participants should learn to:
- accurately diagnose incomplete abortion and other causes of
vaginal bleeding;
- talk with patients before MVA and counsel them after the
procedure about FP and other RH care, as appropriate; and
- manage uncomplicated cases as well as life-threatening
emergencies.
This training activity should provide an overview of PAC,
focus on training providers in how to talk to the patient during the MVA procedure and use
recommended IP practices. Team training involving both physicians and nurses or midwives
is recommended. |
|
|
| Monitoring
Activities |
When possible, the PAC expert who helped
develop the program and conduct the training, together with local representatives, should
conduct the initial followup visits to the PAC service delivery sites to ensure the
provision of comprehensive services. In the absence of patients, "clinical
drills" on how the provider might manage hemorrhage or sepsis should be conducted, or
clinical demonstrations using models can be done. During these visits, the post-training
knowledge and skills of the new providers and other members of the PAC team should be
assessed, and management issues that may hinder provision of PAC services should be
addressed. Meetings with representatives from the hospital administration or supervisory
staff from the clinic should be held to ensure their continued support of the project and
to discuss how to maintain services. |
|
|
| Summary of Steps
Needed to Introduce PAC |
The goal of PAC services is improved
women’s healthcare at all levels of the healthcare system. To accomplish this
requires a multidimensional approach that must be conducted within a favorable policy
environment. The key steps needed to successfully introduce PAC services are
summarized in Figure 1. Figure 1. Introduction of PAC Services
|
|
|
|
