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Atención postaborto: servicios vitales y PF
- 7. ¿Cuál es la situación mundial? Fuente: OMS World Health Day on Safe Motherhood, 1998.
- 15. La buena interacción entre clienta y proveedor promueve la aceptación de la PF en la APA Antes de la intervención Después de la intervención Fuente : Langer y col., Huntington. Population Council 1998. Estudio de México: Porcentaje de clientas que aceptaron un método de PF 58 29 0 20 40 60 80 100
- 19. Establecimiento de servicios de APA Promoción y establecimiento de consenso Participación de la comunidad Evaluación de las necesidades Gerencia de los servicios de APA Prevención de infecciones Estandarización de la planificación familiar Actualización de la tecnología anticonceptiva Políticas Normas de la prestación de servicios Gerencia de la capacitación en APA Seguimiento
- 34. Estudio de admisiones al departamento de obstetricia y ginecología en Egipto Fuente : Huntington y col., en Huntington. Population Council 1998. N = 22.656
- 36. Aceptabilidad de la PF en el postaborto por parte de las clientas 75% 54% 63% 62% 82% 92% 0 20 40 60 80 100 Recibieron método de PF Recibieron asesoramiento de PF Modelo 1 Modelo 2 Modelo 3 Porcentaje de mujeres que recibieron servicios de PF en el postaborto: Fuente: Solo y col., Huntington/Population Council 1998. Kenia
- 40. Método Cuándo empezar a usarlo Comentarios Condón Cuando se vuelven a tener relaciones sexuales Se usa con otros métodos para obtener doble protección Anticoncepción hormonal Inmediatamente Eficaz inmediatamente Puede usarse incluso si hay infección DIU Primer trimestre Segundo trimestre Inmediatamente o se pospone De 4 a 6 semanas postaborto Cuando no hay infección Como en el caso del postparto AQV: Oclusión tubárica* Inmediatamente Se pospone Procedimiento a séptico/cuando no hay infección Esperar hasta que desaparezca la infección o lesión Vasectomía sin bisturí* En cualquier momento Si se dispone de servicios adecuados Planificación familiar en el postaborto (PFPA) *Se requiere el consentimiento informado de la clienta
Notas del editor
- Postabortion Care OVERVIEW Cover Slide : Use the paragraphs (below) to open the presentation. Postabortion care (PAC) is a widely accepted public health strategy that aims to reduce maternal mortality and morbidity from unsafe abortion, and to prevent repeat abortion. PAC is a critical reproductive health service that focuses on women who suffer from complications of abortion. Recent medical technologies and tested service delivery strategies now make it possible to provide this essential service in lower-resource settings. The health community and donor agencies have access to a wealth of resources that, if coordinated, could have an immediate and significant impact on reducing levels of maternal mortality and morbidity resulting from the complications of unsafe and spontaneous abortion. Deaths and injuries related to abortion are almost wholly preventable. The following reference materials are recommended to supplement this module: Postabortion Care Consortium. Postabortion Care: A Reference Manual for Improving Quality of Care . 1995. Postabortion Care Consortium. Postabortion Care: A Global Health Issue (Video: 12 minutes). 1994. New approaches to early abortion. Outlook; 1998; 16(2): 1-6, 8. Care for Postabortion Complications: Saving Women’s Lives. Population Reports L(10). 1997. POLICY Project, USAID/REDSO/ESA, and USAID/AFR/SD. What Can You Do? Postabortion Care in East and Southern Africa . 1997. Brazzier E, Rizzuto R and Wolf M. Prevention and Management of Unsafe Abortion: A Guide for Action . New York: Family Care International, Inc, 1998.
- Slide 2 : This presentation module reviews the essential principles of PAC, its link to the results framework of the Global Bureau/Office of Population, Health and Nutrition (G/PHN) and the basic steps towards establishing PAC services. The presenter should remind the participants that abortion remains a sensitive issue. The term postabortion care services does not imply support for induced abortion, and it does not promote the use of induced abortion in programs funded by USAID. ( Optional Slides 29 and 30 [Slides 31 and 32 in Spanish] include additional information about USAID support for PAC and USAID abortion regulations.)
- Slide 3 : This presentation module provides an overview of the elements of PAC and why PAC services are important. It also presents some of the key issues and emerging strategies for increasing access to and quality of PAC services. The presenter should briefly outline the objectives of the module and explain specific objectives on an as-needed basis. Specifically, this module’s objectives include the following: (objectives appear on Slide 3 ). (The presenter should make sure the audience is familiar with the abbreviation G/PHN and spell it out if necessary.)
- Slide 4 : Before showing Slide 4 , the presenter should ask participants the following question: “Why PAC?” Pause… “Let’s look at the key elements of PAC services.” Take time to explain briefly each of the elements. Emergency treatment of incomplete abortion and potentially life-threatening complications : Complications of bleeding and infection are the two immediate causes of mortality and morbidity in incomplete abortions. Prompt medical evaluation and treatment by uterine evacuation of the products of conception (POC) and antibiotics when infection is present usually prevents terminal progression of complications. (See also Optional Slide 37 [Slide 39 in Spanish .]) Postabortion FP counseling and services : Traditionally, the link between emergency services for incomplete abortion and postabortion reproductive healthcare is either weak or non-existent in most instances. Women are discharged without the benefit of counseling in family planning or in other reproductive health needs. The lack of linkage places women at risk for another pregnancy that may be unwanted. Links between postabortion emergency services and the reproductive healthcare system : The emergency treatment may be the very first contact by a woman with the healthcare system. This contact is an opportunity for the healthcare system to improve the woman’s overall reproductive health status through appropriate referral to other reproductive health services she requires. Use the following paragraph to summarize this section. PAC services take a threefold approach to improving women’s reproductive health services: 1) providing accessible emergency medical services for abortion complications, 2) preventing unwanted pregnancies and repeat abortions and 3) referring to the healthcare system for other reproductive health needs.
- Slide 5 Before showing this slide, the presenter should ask the participants the following questions: “ When we hear or read or say the term unsafe abortion, what does it mean?” “ How about incomplete abortion?” “ Then another term, spontaneous abortion?” In discussing abortion, it is important to define what we mean by some of the adjectives that describe it. The World Health Organization (WHO) has defined unsafe abortion as a termination of pregnancy not provided through approved facilities and/or persons. This definition is affected by legal standards of each country. (For specific information about abortion law in specific countries see Rahman, Katzive and Henshaw 1998.) Medical textbooks define spontaneous abortion as a natural phenomenon that occurs in as much as 15% of known pregnancies. Most of the attributable causes are genetic and lead to a nonviable pregnancy. Incomplete abortion describes the incomplete expulsion of the products of conception (POC). It can follow either spontaneous or unsafe abortion. The retention of these products leads to complications of bleeding and infection. Regardless of the initiating event, spontaneous or unsafe abortion, prompt and safe uterine evacuation of retained POC has to be performed to prevent death and injury. PAC services target the provision of emergency services specifically towards resolving the cause of complications. As such, PAC is a life-saving medical intervention.
- Slide 6 : Why postabortion care? Let’s begin by looking at the magnitude of the situation. Worldwide, 22% of all pregnancies are terminated through induced abortion. An additional 15% of all pregnancies result in spontaneous abortion (miscarriage) or stillbirth. (See also Optional Slide 31 [Slide 33 in Spanish] .) Of particular concern, many of the women who experience induced or spontaneous abortion are at risk of serious illness and death. Spontaneous abortion can be risky if quality medical services for treating complications are not accessible to women in need of those services. Induced abortions can be risky if they are performed by unskilled persons and/or in environments lacking minimal medical standards.
- Slide 7 : The vast majority of maternal deaths from unsafe abortion occur in developing countries. This table shows the risk of death from unsafe abortion, the number and percentage of maternal deaths due to unsafe abortion, by region and in Europe. As shown in Slide 5 , WHO defines unsafe abortion as the termination of a pregnancy that has not been provided through approved facilities and/or persons. Estimates show that about 20 million unsafe abortions occur worldwide each year, resulting in 80,000 maternal deaths and hundreds of thousands of disabilities. (See Optional Slide 31 [Slide 33 in Spanish] .) Worldwide, Latin America has the highest rate of unsafe abortion. Asia has the highest absolute number of unsafe abortions. And Africa has the highest death rate from unsafe abortion.
- Slide 8 : As mentioned before, spontaneous abortion (or miscarriage) also can be dangerous. Poor reproductive health contributes to miscarriage; poor access to emergency care means that spontaneous abortion also becomes life-threatening. Complications can arise from both unsafely induced abortion and spontaneous abortion. The most common complications of abortion are incomplete abortion, sepsis, hemorrhage, and intra-abdominal injury . Except for intra-abdominal injury, all complications can result from either induced or spontaneous abortion. When a patient presents at a hospital or clinic with these other complications, it is often difficult for a provider to distinguish whether the complications are arising from an induced abortion or from a spontaneous abortion. The number one complication is incomplete abortion. It refers to the situation where tissue remains in the uterus following an abortion. Typical symptoms include pelvic pain, cramps or backache, persistent bleeding and an enlarged uterus. Retention of this tissue can lead to severe bleeding and infection, and, subsequently, serious illness and death if the abortion is not “completed.”
- Slides 9 and 10 shift the focus of the magnitude of the problem to the country level. The facilitator will need to tailor this portion of the presentation depending upon whether or not abortion is legal in the country. Depending on a particular country, the facilitator should use either Slide 9 or Slide 10 to prompt participants to consider their own local situation. If abortion is not legal in the country, the presenter should use Slide 9; if abortion is legal in the country, the presenter should use Slide 10. At this point in the presentation, the presenter can ask the participants for their comments about the magnitude of the problem locally. The facilitator should use the appropriate slide ( 9 or 10 ) to guide participants to discuss their own local situation. Note the difficulty in obtaining reliable, valid statistics in places where abortion is legally restricted due to the sensitivity of the topic and methodological difficulties in obtaining accurate information. Discuss the priority of the issue--is it a priority? Why, or why not? (Optional Slides 32 and 33 [Slides 34 and 35 in Spanish] provide an explanation of the magnitude of the situation at the country level.)
- The postabortion care concepts attempt to address the high national mortality and morbidity ratio in countries where induced abortion is not legal. In countries where abortion is legal, the issue is provision of postabortion family planning services to prevent future unwanted pregnancies and repeat use of abortion as an alternative to contraception. Thus, in countries where abortion is legal, use Slide 10 in place of Slide 9. Note for bullet 4 above : Besides considering the burden that abortion imposes on the healthcare system, the facilitator may also ask participants to consider the burden that repeat abortion places on the individual and on the community. (Optional Slides 32 and 33 [Slides 34 and 35 in Spanish] provide an explanation of the magnitude of the situation at the country level.)
- Slide 11: Barriers in access to adequate family planning services are a major contributor to the problem of unsafe abortion. Conversely, unsafe abortion is a prime indicator of the unmet need for safe and effective contraceptive methods . Most women who seek treatment for abortion complications are not using family planning. In most healthcare systems, women treated for abortion complications rarely receive any counseling or services to prevent subsequent unwanted pregnancies. Because a woman seeking treatment for abortion complications may have already experienced an unwanted pregnancy—either as a result of not using contraception or method failure—she may be in need of effective contraception. The time of emergency treatment provides an important opportunity to counsel a woman about family planning and provide her with a method of her choice. Factors contributing to risk of repeat abortion Separation of emergency services from FP services Lack of FP services for some groups of women (e.g., adolescents, single women) Lack of recognition of the need for immediate contraception (provider and patient) Lack of recognition of problem of unsafe abortion and patient FP needs (provider)
- Slides 12 and 13 : Why is PAC an important intervention? The facilitator can provide an example for each of the bulleted points. The following are suggested examples: Slide 12 : If complications of abortion are treated promptly, the lives of many women at risk can be saved . Provision of family planning services at the time of emergency treatment can help break the cycle of abortion and prevent future unwanted pregnancy. PAC is not abortion; it is a component of essential obstetric care. Therefore, it is an acceptable strategy for reducing morbidity and mortality due to abortion in countries where induced abortion is legally restricted. In fact, it is a critical strategy for preventing abortion. It provides family planning services to those with greatest unmet need. PAC is not a stand-alone service. Establishing PAC services does not mean setting up a new independent program. PAC services are completely integrated with other existing reproductive health services. As such, PAC should be viewed as an essential component of a quality reproductive healthcare program. PAC can help to conserve scarce healthcare resources . Unsafe abortion puts a tremendous burden on the healthcare system because complications of abortion consume enormous resources. For example, among the major hospitals in sub-Saharan Africa, women with abortion complications make up the majority of patients in the gynecology wards. It is not unusual to see women lying in the halls, or 2-3 to a bed, awaiting treatment. These patients often require significant attention from healthcare providers and need antibiotics, blood and other scarce supplies. Improved PAC services can speed up treatment and recovery and reduce the number of patients.
- Slide 13 High quality services can be provided using a low-tech approach : Manual vacuum aspiration (MVA) (rather than curettage) is a low-technology but effective procedure that can be done in low-resource settings. The integration of counseling, infection prevention practices and referral services into the program are necessary elements that can contribute to high quality. (See Optional Slide 37 [Slide 39 in Spanish] .) PAC can be integrated into existing healthcare services : Using MVA allows for flexibility in where services can be provided and who can provide the services. WHO has identified the prompt treatment of incomplete abortion as an essential element of obstetric care that should be available at every district-level hospital. Treatment of uncomplicated incomplete abortion can be provided at the primary care level or in family planning clinics through the use of MVA.
- Slide 14: There is a biologic rationale for starting contraception immediately after an abortion has occurred. What are some examples of FP methods that a woman or the couple can use immediately postabortion? (See chart in Optional Slide 38 [Slide 40 in Spanish] .) All modern methods of contraception are appropriate for use after incomplete abortion as long as the service provider: Screens the woman for the standard precautions for use of a particular method and Gives adequate counseling Natural family planning (NFP) and fertility awareness are also options that a woman can choose. Recommendations for contraceptive use following first trimester abortion (up to 14 weeks from last menstrual period [LMP]) are similar to those for interval use (i.e., women who have not been pregnant within the last 4 to 6 weeks and are not breastfeeding). Recommendations for contraceptive use following second trimester spontaneous or incomplete abortion are more similar to those for the postpartum period. Notes : Immediate postabortion FP should be made available if the woman wants it . Adequate counseling and fully informed consent are required before voluntary surgical contraception (VSC) procedures are performed. Often it is not possible to obtain informed consent at the time of emergency care.
- Slide 15 : An intervention at a hospital in Oaxaca, Mexico, aimed to improve postabortion services in a variety of ways including improvement of interpersonal relationships between the provider and the postabortion care patient . Oaxaca is the capital city of an impoverished, rural state in Mexico. The hospital in this study treats 1 or 2 postabortion patients daily, many of whom speak one of 20 local languages or dialects but do not understand Spanish (the language of the physicians). All providers in the hospital’s Ob/Gyn department participated in a 14-hour workshop on interpersonal relations. The workshop had the following objectives: To improve the quality of care for the postabortion patient To promote a change of attitude among healthcare personnel toward more humane service delivery To value quality and human warmth as important tools in an integral care package To recognize the woman behind every patient and accompany her during the recuperation process To reflect on the service vocation of healthcare professionals One result of improved interpersonal communication between provider and postabortion patient was a significant increase in the percentage of women who accepted a postabortion contraceptive method (from 29% previously to 58% following the study; refer to graph in Slide 15 ). In addition, improved interpersonal communication between provider and postabortion patient resulted in a significant increase in the percentage of women who received the method at the hospital before discharge (from 29 to 57%--not shown here in graph).
- Slide 16 PAC services are linked from the bottom up to G/PHN strategic objectives. PAC services do in fact support existing strategic objectives.
- Slide 17 : Particularly for young adults, emergency treatment for abortion complications is often a woman’s first entree to the healthcare system. A healthcare visit for abortion complications presents an important opportunity to evaluate a woman's overall health, educate her on the importance of healthy reproductive behavior, and introduce other services, such as STI/HIV diagnosis and treatment, prenatal care and social services. Postabortion care should be regarded as an integral component of reproductive healthcare, with clearly established links between curative treatment and preventive services.
- Slide 18 : The facilitator should use these questions to promote discussion of the status of PAC services in participants’ settings.
- Slide 19 : Although PAC is not an add-on or vertical program, new programs need to be introduced in a systemic and planned manner. This graphic illustrates the spheres of activities that are needed to introduce PAC services at a site, or within a broader reproductive health program. Depending on the political and healthcare situation in a country, initiating services will take from 1 to 2 years and will usually require major donor resource input (technical assistance, policy and guidelines support, materials and site development, training and followup) to prepare the groundwork for a sustainable PAC program in a country. Support for a number of key activities such as those shown in the graphic above need to be programmed and implemented to establish PAC services. Slide 19 lists key PAC activities and their link to each other. The concentric circle attempts to illustrate how these components are related. Establishing PAC services involves working in clinical sites with healthcare providers and their administrators to establish guidelines, update knowledge on infection prevention and contraception, and develop appropriate essential skills. The results of a needs assessment form the basis for developing the level of effort required to establish PAC. Advocacy and consensus building are key factors not only in gathering support for introducing PAC services but also in expanding its reach nationally. (See also Optional Slides 39 and 40. [Slides 41,42 and 43 in Spanish] )
- Slide 20 [ Slides 20 and 21 in Spanish] lists activities that must occur if PAC services are to become established and expanded within a country. These may also be discussed in more detail, as needed. For example, linking emergency treatment and active provision of postabortion reproductive healthcare will improve women’s health by breaking the cycle of unwanted or mistimed pregnancies . Each country program must work to determine how to maximize access to PAC services in the country setting (i.e., if nurses and other nonphysician healthcare workers are needed to provide PAC services at remote sites, national policy must reflect this and protocols detailing their role and responsibility must be clearly articulated). A one-day orientation for maternity/hospital/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 to: Elicit staff interest and involvement in the PAC activities Discuss how staff can incorporate the PAC services into their work For hospital sites, orientation meetings should include staff on all levels from admitting, labor and delivery and the hospital administration. Nurse-midwives referring women to the hospital from the community maternities for postabortion care should be invited so that they are aware of the PAC project and can make timely referrals. Faculty from various preservice institutions should be invited as well. These orientation meetings can serve as an important advocacy tool. PAC clinical trainers, representatives from the MOH and guest speakers can make presentations to demonstrate their commitment to the program and prepare themselves to address questions and dispel rumors during and after the meetings. PAC Training : 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 learn how to counsel patients and manage uncomplicated cases as well as life-threatening emergencies. This training activity should provide an overview of PAC and focus on training providers in how to talk to the patient during the MVA procedure and provide counseling before (as appropriate) and after the procedure. Appropriate providers should be trained to conduct MVA, and all providers should review recommended infection prevention practices. For teaching hospitals, it is recommended that teams of physicians and nurse-midwives be trained.
- Slide 21 (Slide 22 in Spanish) : The bullets may be discussed in detail. For example: Advocacy Recognize PAC as a concept. Identify stakeholders at all levels. Improve access and quality of services. Raise awareness in the community. Government authorities, the press and society at large must recognize that unsafe abortion takes a heavy toll on women’s health and lives. Host-country counterparts must be committed to all aspects of PAC to ensure successful integration with existing maternal health services. In addition, in any country the government must be committed to supporting and expanding PAC services as an essential component of the healthcare system. Government support for expansion of PAC services must include not only improvements in access to and quality of PAC services, it should also involve raising awareness of the urgency for treatment of complications due to incomplete abortion and the availability of other PAC services within the community.
- Slide 22 ( Slides 23 and 24 in Spanish) : The bullets may be discussed in detail. For example: Management and Logistics Systems Effective systems need to 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. In countries where the MOH has instituted computer-assisted logistics management systems, 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. The essential data needed to monitor PAC services adequately should be assessed. 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 decide more efficiently 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.
- Slide 23 (Slide 25 in Spanish) : The bullets may be discussed in detail. For example: Training : Providing PAC services requires a shift in the typical training approach that has been used for family planning. Unlike family planning services, PAC services cannot be scheduled; they are not elective. Often, PAC services are required in response to an emergency. Providers need to be trained to use a full range of essential skills (e.g., critical thinking, verbal anesthesia and total patient care) to ensure that patients receive high quality PAC services. Training for uncommon emergencies must also be included in the strategy. Learning materials will need to be reviewed, and adapted if necessary, to ensure that they meet PAC training needs. 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. By the start of the expansion phase, preservice PAC training should have been institutionalized. Training in PAC should take advantage of other appropriate training activities already in place. For example, by introducing general practitioners to PAC when they come to the maternity for a 6-month rotation at teaching hospitals to learn new surgical techniques, physicians’ training time can be maximized. 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, only limited inservice training should be needed, which should take place at model sites established during introduction of services. 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.
- Slide 24 (Slide 26 in Spanish) : The bullets may be discussed in detail. For example: 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).
- Slides 25 and 26 (Slides 27 and 28 in Spanish) : We can apply a number of lessons that we have learned from introducing PAC services. For example ( bullet 3 above ), the role of advocacy and gaining consensus and support from key stakeholders is crucial both to initiating and continuing PAC services in a country. Local providers ( bullet 5 above ) need to be trained as technical experts (e.g., experts in performing MVA).
- Slide 26 (Slide 28 in Spanish) : South-to-South collaboration ( bullet 1 above ) has been very effective in Africa (e.g., providers from Burkina Faso received PAC training in Ghana and, in turn, these providers from Burkina were able to train Senegalese providers. Operations research ( bullet 2 above ) is available about PAC and this research can be used to find the best way to provide PAC services.
- Slide 27 (Slide 29 in Spanish) : This quote from Brian Atwood, former USAID Administrator, demonstrates USAID’s commitment to strengthen PAC services. ( Optional Slides 29 and 30 [Slides 31 and 32 in Spanish] include additional information about USAID support for PAC and USAID abortion regulations.)
- Optional Slide 30 (Slide 32 in Spanish) : Optional slide--if participants would be interested in exactly what USAID can and can’t support.
- Optional Slide 31 (Slide 33 in Spanish) : This slide presents the magnitude of the problem of unsafe abortion. It is related to Slides 6 and 7 .
- Optional Slide 32 (Slide 34 in Spanish) uses a study conducted in Egypt to illustrate the magnitude of the problem at the country level. A nationally representative study conducted in approximately 15% of public-sector hospitals in Egypt revealed that among 22,656 admissions to the Ob/Gyn departments during a continuous 30-day study, 19% of patients were admitted for treatment of an induced or spontaneous abortion. The graph illustrates the percentages. (Consider adding data from other regions.)
- Optional Slide 33 (Slide 35 in Spanish) projects an estimate of the induced abortion rate in Egypt. (Consider using examples from the REDSO PAC overhead set.)
- PAC can achieve high family planning acceptance. Studies in Kenya ( Optional Slide 34 [ Slide 36 in Spanish] ) and Mexico ( Slide 15 ) have documented the effectiveness of providing counseling and FP methods postabortion. As shown in Slides 15 and Optional Slide 34 (36 in Spanish) , clients are receptive to postabortion family planning services, Optional Slide 34 ( Slide 36 in Spanish) : A study in Kenya (Solo et al) examined three models for delivering family planning services to postabortion patients in hospital settings (at 6 hospitals in Kenya). In Model 1 Ob/Gyn staff provided family planning services on the ward. In Model 2 MCH/FP outpatient staff came to the hospital’s Ob/Gyn ward to provide FP services. In Model 3 postabortion patients were referred from the Ob/Gyn department to the hospital’s MCH/FP clinic for family planning services (patients who indicated a desire for contraceptives were escorted to the family planning clinic prior to discharge). The study showed substantial changes in the quality of postabortion services under all models. However, provision of family planning in the Ob/Gyn department by the same staff who provided emergency treatment was the most effective in terms of reaching more women with counseling (92% of clients) and increasing acceptance of a family planning method (82% of clients). (Refer to graph in Optional Slide 34 [Slide 36 in Spanish] .)
- Optional Slide 35 (Slide 37 in Spanish) PAC is not its own separate, vertical program. PAC is an integral element of FP and RH services.
- Optional Slide 36 ( Slide 38 in Spanish) : To ensure good client-provider interaction (CPI), the following six actions should occur when the client and provider meet: 1) The provider should treat the client well. 2) The client and provider should interact. 3) The provider should tailor information to the client. 4) The provider avoid giving too much information to the client. 5) The provider should provide the method the client wants. 6) The provider should help the client understand and remember. (Please refer to Theme II “Client-Centered Communication” for the six basic principles of good CPI). Established program planning models are available : PAC programs have been established in more than 30 countries. The accumulated data have documented the successes and lessons learned in establishing PAC programs.
- Optional Slide 37[Slide 39 in Spanish] ( supports Slides 4 and 13 ): Let’s take a closer look at each of the elements of PAC, starting with emergency treatment for abortion complication. Although emergency postabortion care services are needed virtually everywhere in a country’s healthcare system, their quality and accessibility vary widely. Emergency services often are offered only at secondary and tertiary care centers in urban areas. Poor transportation, lack of facilities and trained healthcare providers in developing countries place emergency services out of reach of most poor, rural women. This gap in services makes complications of abortions, even in spontaneous abortion, life threatening in many instances. Regardless of the initiating event, spontaneous or induced abortion, prompt and safe uterine evacuation of retained tissue has to be performed to prevent death and illness. A preferred procedure for treating incomplete abortion is Manual Vacuum Aspiration , or MVA. Vacuum aspiration, either manually or through an electrical pump, uses suction to remove products of conception (POC) through a cannula or tube. In MVA, a specially designed syringe that creates 1 atmosphere of pressure is preferred because of its simplicity, safety and efficacy in uterine evacuation. Compared to sharp curettage (accomplished by scraping the uterine surface with a metal curette) or D&C (the more traditional procedure), MVA is lower risk to the patient, less painful, and less costly to the healthcare system in terms of providers’ time and patient stays. Unlike sharp curettage, MVA does not require an operating theatre or general anesthesia, so it can be performed on an outpatient basis at decentralized locations. In Ghana and in other parts of the world, nurses and midwives have been trained to provide MVA services. Removal of retained products of conception (POC) in incomplete abortions almost always controls bleeding and infection. Providing MVA services at lower-level facilities can go a long way to reduce morbidity and mortality, but improving referral systems also is critical. Accurate diagnosis of the severity of complications must be made, systems for responding to various needs must be established across facility levels, and transportation must be improved.
- Optional Slide 38 [ Slide 40 in Spanish] ( supports Slide 14 )
- Optional Slide 39 [Slide 41 in Spanish] ( supports Slide 19 ) lists basic activities that need to be conducted (not necessarily in the order listed above) when PAC services are introduced in a country. Each of these can be discussed in more detail, as needed. For example: Technical assistance for clinic site setup : A PAC expert should be available to work with project staff to assist in preparing the sites to offer services. Patient flow, organization of emergency services, case management, infection prevention, record keeping, family planning counseling and family planning referrals as well as data collection systems should all be reviewed. (Also see Optional Slide 40 (Slides 42 and 43 in Spanish) , Needs Assessment .)
- Optional Slide 40 (Slides 42 and 43 in Spanish) : Needs assessment ( supports Slide 19 ) visits should be made to several potential sites that will be included in a PAC introduction project to observe service delivery practices and to determine the client and provider needs for implementing PAC services, including: Service provision capacity for treating complications Infection prevention (IP) practices FP service provision Linkages between PAC services and other hospital and community services 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 in the clinic Interviews with providers and Ministry of Health (MOH) officials to determine clinic management issues and perceived caseload Review of logbooks to examine recorded caseload and types of information currently collected on a regular basis Review of national service delivery guidelines to examine the standards established for management of incomplete abortion. Results of the needs assessment should be shared with key stakeholders to sensitize them to relevant issues and proposed solutions and solicit their feedback.
- Optional Slides 41 and 42 (Slides 44 and 45 in Spanish) : A number of resources are available that can help countries introduce PAC services. These two optional slides list a few examples of PAC training materials that are currently available. (Facilitators may want to suggest additions to this list or provide additional handouts.)