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Initiation of comprehensive PAC services is a
major step toward reducing maternal mortality and morbidity due to complications of
abortion. Further reduction calls for expanding PAC services to additional service
delivery sites and progressively into more remote areas. It is at this stage that the
private sector may begin to play a bigger role. For example, in Kenya more than 40 percent
of PAC services are provided by private practitioners. Compared to introduction of PAC services, there is less experience
with and therefore less available information about expansion of services. Therefore, the
following sections present a brief review of the factors that should be considered before
expanding PAC services. These factors are based largely on the lessons learned in
introducing services. It is anticipated, however, that most of them will need to be
addressed by country programs when considering expansion. |
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| National Strategy
Meetings |
Key stakeholders should review the national
policies, protocols and guidelines developed during the introduction phase and adapt them
as necessary in order to develop a country-level expansion strategy. The PAC Consortium
reference manual, Postabortion Care: A Reference Manual for Improving Quality of Care,
provides recommendations that can be adapted for each country. The review by key
stakeholders should focus on policies and protocols that will empower both healthcare
workers and traditional healthcare providers at the community level to become part of
expansion programs. This includes considering the level of care they will be allowed to
provide and the guidelines that will allow them greater access to higher referral levels.
The national strategy meetings should also include opportunities to discuss issues related
to community participation and social mobilization. In addition, orientation meetings
should be held with regional policymakers and program managers. The meetings should focus
on the importance of expanding PAC services throughout the country and what is needed to
accomplish the expansion. Once in place, the
national strategy will guide where, when and how PAC activities will be expanded. The
strategy will elaborate:
selection criteria for expansion sites,
which level of service providers will be
trained, and
the best way to transfer the knowledge and
clinical skills needed to provide quality services.
For most countries, the first level of expansion will most
likely be to district-level maternity hospitals or maternities in the capital which are
not yet providing PAC services. Subsequent expansion should include district hospitals and
polyclinics located further from the capital or large cities.
Questions regarding sustainability should be discussed at
these meetings as well. For example, in most countries, women pay for maternity services.
Therefore, the cost of providing PAC services should be determined, and a payment scale
developed so that women using the services can contribute to their sustainability. |
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| Developing Criteria
for Selection of Expansion Sites |
Assessment criteria for proposed expansion
sites should be drawn from the following factors:
current management of women presenting with
postabortion complications,
referral acceptance capability,
use of recommended IP practices,
FP counseling and services,
provision of other RH services,
stability of personnel, and
availability of equipment and supplies.
It is most important that proposed sites have projected
caseloads such that trained providers will be able to retain their competency. |
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| Needs Assessment |
A team composed of representatives of the MOH and providers involved in
the PAC introduction phase should assess proposed expansion sites to determine if they
meet the agreed-upon selection criteria. The most likely sites for the first level of
expansion services are district level maternity hospitals and large polyclinics. During
the needs assessment, staff will be told about the expansion strategy, and their interest
in integrating PAC into their existing RH services will be determined. Priority should be
given to clinics and hospitals willing to allocate some of their human and financial
resources and whose sites meet the selection criteria. |
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| Training |
Selected service providers and faculty
involved in the introduction phase will be identified as members of the expansion training
teams and trained as clinical trainers. The training will emphasize essentials of adult
learning principles, including participatory learning techniques and a focus on skill
building. Learning materials will be reviewed, and adapted if necessary, to ensure that
they meet the training needs for the expansion strategy. Developing teaching hospitals and their satellite clinics as model
training sites during the introduction phase lays the groundwork for improved preservice
training in PAC because medical, nursing and midwifery students use these facilities for
clinical training. Therefore, by the start of the expansion phase, preservice PAC training
should have been institutionalized. In Kenya and Nepal, preservice training has been
institutionalized and all medical graduates now receive PAC training. In Burkina Faso,
both medical and nurse midwifery students soon will be receiving this training as well.
Training in PAC should take advantage of other appropriate
training activities already in place. For example, in some teaching hospitals, general
practitioners come to the maternity for a 6-month rotation to learn new surgical
techniques. This is a perfect opportunity to introduce PAC and maximize the
physicians’ training time. Moreover, having improved knowledge and skills in IP, in
how to talk to patients and in counseling will improve the quality of care for any
surgical procedure, not just PAC.
Under the expansion phase of the project, only limited
inservice training should be needed. This should take place at model sites established
during introduction of services. Rollout of activities to the district level and beyond
will require the same level of knowledge and skills as was necessary to introduce PAC in
the teaching hospitals. As the expansion strategy evolves, a form of structured on-the-job
training may be the most effective and efficient way for service providers to attain
competency, especially in health facilities where the population base is smaller and fewer
women come for PAC services on a daily basis. |
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| Information,
Education and Communication (IEC) |
Informing people about the increased
availability of PAC services should be a key component of all community health education
activities. Because PAC is an integral part of maternal health, it should be discussed in
community meetings as one of the many services available. These meetings provide the
opportunity to highlight improvements in client management and IP. They also provide
healthcare staff an opportunity to solicit client perspectives—an essential element
in providing quality services—and give people the opportunity to ask questions,
present their views and get accurate information about PAC services. Information about the availability of other RH services, such as
fertility screening, STD management or cervical cancer testing, should be provided at
these meetings. Finally, visual or audio aids should be made available to augment the
limited time providers have for this purpose and to help women better understand the
services being offered. |
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| Management and
Logistics Systems |
With an increased number of service delivery
points, it is even more important that effective systems be in place to ensure adequate
supplies and accurate reporting of services. For example, clinic materials (e.g., gloves,
tenacula, specula, MVA equipment) should be available at sites with trained PAC providers.
(In some countries, hospital staff have established emergency kits that contain all the
essential supplies to treat a woman coming to the maternity with an emergency.) It may be
most efficient for PAC supplies to be integrated into the emergency obstetric care
supplies in a hospital’s central supply department. A number of MOHs have instituted logistics management systems at
both central and district levels, some of which are computer-assisted. These systems
should be modified to incorporate PAC logistics. For example, line items should be added
to the procurement form for easy resupply of MVA materials. Also, the MOH should have the
addresses of distributors of the MVA kits for resupply.
Data for monitoring PAC services will have to be collected
on a much larger scale. The systems developed during the introduction phase should be
reviewed and revisited. Again, the essential data needed to adequately monitor PAC
services should be reassessed. In addition, a system should be set up to track providers
trained and where they are assigned. Having this information will enable the MOH to better
decide where PAC can be offered and ensure that the necessary equipment and supplies are
at the new site. Ideally, monitoring of PAC services should be integrated into existing
efforts by the MOH. |
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