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Program achievements in several counties
indicate that where there is a favorable policy environment, PAC services can be
integrated into the existing primary healthcare system. Introduction of services
usually requires 1 to 2 years of major donor support for technical assistance, policy and
guidelines support, materials and model service site development, training and other
startup activities. Also, this is the time when the groundwork for creating sustainable
PAC services must be fostered. For example, before implementing PAC services it is
essential to gain endorsement by the government and commitment to support expansion of
services. Targeting teaching hospitals and their satellite clinics as clinical training
sites during the introduction phase helps ensure that medical, nursing and midwifery
graduates perceive PAC as a basic, rather than "add-on," service. Expansion of PAC services usually takes an additional 2 to 3
years and centers on strengthening preservice education and linking clinical training to
PAC service delivery sites. Establishing PAC training at model service sites where
different cadres can be trained together and work together is strongly recommended. The
integration of PAC into preservice education will help drive its expansion. For example,
as healthcare graduates are deployed not only to PAC clinical sites but also to other
healthcare posts in both the public and private sectors, they will establish services at
new sites throughout the country. As a consequence, governments will be leveraged to
assume greater responsibility for expanding services because trained healthcare workers
will need some support to continue to provide PAC services. In this scenario, donor
resource needs for long-term expansion efforts will be reduced significantly and should be
limited to technical assistance, with the host country assuming responsibility for the
equipment, supplies and management as well as staffing needs.
While the private sector may not play an active role in
the introduction of PAC services, it will definitely have an impact on the expansion of
these services. For example, private practitioners may directly offer PAC services or make
appropriate and timely referrals to the public sector. In any case, the way they practice
must conform to national standards and guidelines. Ensuring their support can be most
effectively accomplished by their inclusion from the early stages of advocacy onward.
Finally, to be successful, a strategy for introducing and
expanding PAC services should be country-driven and address issues of advocacy, access,
institutionalization of training and sustainability. The involvement of the community and
consideration of its members’ needs and perspectives are critical to establishing a
successful PAC program. (Specific introduction activities and recommended expansion
efforts are summarized in Table 1.) |
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| Table 1. Summary of PAC Introduction Activities
and Expansion Efforts |
|
INTRODUCTION ACTIVITIES |
EXPANSION EFFORTS |
| Policy/Advocacy |
Preliminary meetings to
raise the awareness of government officials and key stakeholders about the importance of
effective PAC services in improving maternal health; gain consensus and commitment to PAC
initiative
Needs assessment
Development of policies and
standards for PAC services
Orientation meetings
- Followup visits
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Review with key stakeholders
the progress made at the pilot sites
Reach a consensus on a
strategy for the appropriate approach to expand the delivery of quality PAC services
Assess potential expansion
sites according to agreed upon selection criteria
Assure that PAC policies,
norms and service delivery guidelines are appropriate for expanded services
Develop an appropriate
system for formative supervision of expanded PAC services and train supervisors
|
| Training |
Needs assessment
Sensitization to management
of PAC services and training using recommended IP practices
CTU Workshop/FP skills
standardization workshop
PAC training
Followup visits
|
Develop appropriate learning
materials which can be used for preservice training
Develop appropriate learning
materials which can be used for decentralized training
Strengthen clinical training
sites
Work with providers trained
during the introduction phase to train preservice trainers and additional providers from
expansion sites
|
| Service
Delivery |
Needs assessment
Development of policies and
standards for PAC services
Technical assistance visits
to set up PAC services (reinforce use of recommended management and IP practices, links to
other RH services, use of service delivery guidelines, availability of necessary equipment
and supplies)
Followup visits
|
Assess potential expansion
sites according to agreed upon selection criteria
Strengthen IP knowledge and
practices among hospital staff at PAC expansion sites and ensure good IP practice at the
sites
Set up a system to respond
to women’s expressed needs and desires for RH services, including FP counseling and
services or counseling and services for infertility
Provide technical assistance
to expansion sites to develop case management protocols
Develop an appropriate
system for formative supervision of expanded PAC services and train supervisors
Integrate necessary PAC
equipment and supplies into the current logistics and management systems to ensure the
institutionalization of quality PAC services
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| ATTACHMENT 1: PROVISION OF POSTABORTION CARE BY LEVEL
OF HEALTHCARE FACILITY AND STAFF |
LEVEL |
STAFF MAY INCLUDE |
EMERGENCY POSTABORTION CARE PROVIDED |
FAMILY PLANNING & OTHER REPRODUCTIVE HEALTH SERVICES |
| Community |
Community
residents with basic health training, Traditional birth attendants, Traditional healers |
Recognition
of signs and symptoms of abortion and serious postabortion complications
Referral to facilities where treatment is available |
Provision
of pills, condoms, diaphragms and spermicides
Referral and followup for FP as well as other RH services |
| Primary
(Primary health clinics, FP clinics or polyclinics) |
Health
workers, Nurses, Trained midwives |
All
primary care facilities. Above activities, plus:
Diagnosis based on brief medical assessment,
including pelvic examination
Resuscitation/stabilization (e.g., IVs) prior to transfer
Hematocrit/hemoglobin testing (optional) |
Provision of above methods plus IUDs, injectables and Norplant®
implants
Referral for voluntary sterilization
- Screening and treatment for STDs
- Infertility screening
- Antenatal counseling and services
- Cervical cancer testing
|
If
trained staff and appropriate equipment are available, above activities, plus:
- Initiation of emergency treatments
- antibiotic therapy
- IV fluid replacement
- oxytocics or misoprostol
MVA during first trimester for uncomplicated cases of
incomplete abortion
Pain management
- oral analgesics and sedation
- local anesthesia (paracervical block)
Referral for treatment of complications |
First Referral Level
(District hospital) |
Nurses,
Trained midwives,
General practitioners |
Above activities, plus:
Emergency uterine evacuation through second trimester
Treatment of most postabortion complications
Local and general anesthesia
Referral for treatment of severe complications (septicemia, peritonitis, renal failure)
Laparotomy and indicated surgery (including for ectopic pregnancy)
Blood cross match and transfusion |
Provision of above methods plus
voluntary sterilization
Followup
Simple testing (rapid plasma reagin, postcoital tests)
Simple infertility treatment (clomiphene)
Medical treatment |
Secondary and Tertiary Level
(Regional or referral hospital) |
Nurses,
Trained midwives,
General practitioners,
Ob/Gyn specialists |
Above activities, plus:
Uterine evacuation as indicated for all incomplete abortions
Treatment of severe complications (including bowel injury, severe sepsis, renal failure)
Treatment of bleeding/clotting disorders |
All above activities plus
advanced treatment |
Adapted from: WHO 1994.
Norplant® is the registered trademark of the Population Council for subdermal
levonorgestrel implants. |
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