BACKGROUND: Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation. METHODS: An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country’s abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships. RESULTS: After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides. CONCLUSION: These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa. "
OBJECTIVE: Evaluate implementation of misoprostol for postabortion care (MPAC) in two African countries. DESIGN: Qualitative, program evaluation. SETTING: Twenty-five public and private health facilities in Rift Valley Province, Kenya, and Kampala Province, Uganda. SAMPLE: Forty-five MPAC providers, health facility managers, Ministry of Health officials, and non-governmental (NGO) staff involved in program implementation. METHODS AND MAIN OUTCOME MEASURES: In both countries, the Ministry of Health, local health centers and hospitals, and NGO staff developed evidence-based service delivery protocols to introduce MPAC in selected facilities; implementation extended from January 2009 to October 2010. Semi-structured, in-depth interviews evaluated the implementation process, identified supportive and inhibitive policies for implementation, elicited lessons learned during the process, and assessed provider satisfaction and providers' impressions of client satisfaction with MPAC. Project reports were also reviewed. RESULTS: In both countries, MPAC was easy to use, and freed up provider time and health facility resources traditionally necessary for provision of PAC with uterine aspiration. On-going support of providers following training ensured high quality of care. Providers perceived that many women preferred MPAC, as they avoided instrumentation of the uterus, hospital admission, cost, and stigma associated with abortion. Appropriate registration of misoprostol for use in the pilot, and maintaining supplies of misoprostol, were significant challenges to service provision. Support from the Ministry of Health was necessary for successful implementation; lack of country-based standards and guidelines for MPAC created challenges. CONCLUSIONS: MPAC is simple, cost-effective and can be readily implemented in settings with high rates of abortion-related mortality.
OBJECTIVE: To examine the impact of a national intervention to improve the post-abortion care (PAC) content of midwifery education in Nigeria. METHODS: A 3-part quantitative assessment was carried out during and post-intervention. The first baseline component developed and examined the intervention to improve teaching capacity and improve the PAC curriculum among 6 midwifery schools that were to become regional training centers. The second survey was a pre- and post-assessment conducted among midwifery instructors from all schools of midwifery in the country. In the third component, 149 midwives graduating from the 6 regional midwifery schools were interviewed once 3-9 months after graduation to evaluate whether the intervention had improved their knowledge of PAC and clinical practice, and the likelihood that they would provide PAC after graduation.
Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, post-abortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.
Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66,500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a post-abortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. post-abortion care focuses on treatment of incomplete abortion and provision of post-abortion contraceptive services. To enhance women's access to post-abortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.
Unsafe abortion in Sudan results in significant morbidity and mortality. This study of treatment for complications of unsafe abortion in five hospitals in Khartoum, Sudan, included a review of hospital records and a survey of 726 patients seeking abortion-related care from 27 October 2007 to 31 January 2008, an interview of a provider of post-abortion care and focus group discussions with community leaders. Findings demonstrate enormous unmet need for safe abortion services. Abortion is legally restricted in Sudan to circumstances where the woman's life is at risk or in cases of rape. Post-abortion care is Not easily accessible. In a country struggling with poverty, internal displacement, rural dwelling, and a dearth of trained doctors, mid-level providers are Not allowed to provide post-abortion care or prescribe contraception. The vast majority of the 726 abortion patients in the five hospitals were treated with dilatation and curettage (D&C), and only 12.3% were discharged with a contraceptive method. Some women waited long hours before treatment was provided; 14.5% of them had to wait for 5-8 hours and 7.3% for 9-12 hours. Mid-level providers should be trained in safe abortion care and post-abortion care to make these services accessible to a wider community in Sudan. Guidelines should be developed on quality of care and should mandate the use of manual vacuum aspiration or misoprostol for medical abortion instead of D&C.
BACKGROUND: This study was conducted to compare the safety, effectiveness and acceptability of 400 mcg sublingual misoprostol and 600 mcg oral misoprostol for treatment of incomplete abortion. STUDY DESIGN: We used an open-label randomized controlled trial conducted from July 2005 to August 2006 in a large tertiary level maternity hospital in Antananarivo, Madagascar, and a large tertiary level hospital in Chisinau, Moldova. Three hundred consenting women seeking treatment for clinically diagnosed incomplete abortion with uterine size ≤12 weeks since last menstrual period were randomized to misoprostol either 600 mcg orally or 400 mcg sublingually. The primary outcome measure was the complete resolution of clinical signs and symptoms of incomplete abortion without need for surgical intervention. Women were seen for follow-up on Day 7 and, if necessary, on Day 14 to assess abortion status. The study was powered to detect a 7% difference in efficacy with a total of 142 women required in each arm. RESULTS: Efficacy rates were 94.6% and 94.5%, for the oral and sublingual routes, respectively (RR: 1.00, 95% CI=0.95–1.06, p=.98). At 1 week follow-up, more than 80% of women had completed abortions (77.8% oral and 84.8% sublingual, p=.12). Mean pain scores were 2.95 and 3.04, respectively, for the oral and sublingual groups. Side effects included abdominal pain, bleeding, headaches and dizziness/weakness with no differences reported between the two groups. Acceptability and satisfaction were high for both routes and women indicated a preference for medical versus surgical treatment if ever needed in the future. CONCLUSION: Both treatment regimens were very effective. Four hundred micrograms of sublingual misoprostol and 600 mcg oral misoprostol appear to have similar safety and effectiveness profiles when used for the treatment of incomplete abortion. A lower 400-mcg misoprostol dose may provide an alternative treatment option as well as have potential benefits in terms of cost.
OBJECTIVE: To assess the severity of abortion complications in Malawi and to determine associated risk factors. METHODS: Between July 20 and September 13, 2009, a cross-sectional survey was conducted at 166 facilities providing post-abortion care services. Data were collected for all women with an incomplete, inevitable, missed, complete, or septic abortion. Weighted percentages were calculated to obtain national estimates. RESULTS: In total, 2067 women met the inclusion criteria. Estimates suggest that 80.9% of women who presented for post-abortion care in Malawi in 2009 were married and 64.8% were from rural areas. One-quarter (27.4%) presented with severe or moderate morbidity. Sepsis (13.7%), retained products of conception (12.7%), and fever (12.3%) were the most common complications. The case fatality rate was 387 deaths per 100 000 post-abortion care procedures. Women with severe or moderate complications were significantly more likely to be from rural areas than from urban areas; to have reported interfering with their pregnancy; and to be separated, divorced, or widowed than to be single. CONCLUSION: In 2009, many women seeking post-abortion care in Malawi presented with complications. Advocacy is needed to influence policies that will allow expanded access to safe abortion services for women of all ages and in all areas.
This article presents estimates based on the research conducted in 2010 of the cost to the Ugandan health system of providing post-abortion care (PAC), filling a gap in knowledge of the cost of unsafe abortion. Thirty-nine public and private health facilities were sampled representing three levels of health care, and data were collected on drugs, supplies, material, personnel time and out-of-pocket expenses. In addition, direct Non-medical costs in the form of overhead and capital costs were also measured. Our results show that the average annual PAC cost per client, across five types of abortion complications, was $131. The total cost of PAC nationally, including direct Non-medical costs, was estimated to be $13.9 million per year. Satisfying all demand for PAC would raise the national cost to $20.8 million per year. This shows that PAC consumes a substantial portion of the total expenditure in reproductive health in Uganda. Investing more resources in family planning programmes to prevent unwanted and mistimed pregnancies would help reduce health systems costs.
Based on research conducted in 2012, we estimate the cost to the Rwandan health-care system of providing post-abortion care (PAC) due to unsafe abortions, a subject of policy importance not studied before at the national level. Thirty-nine public and private health facilities representing three levels of health care were randomly selected for data collection from key care providers and administrators for all five regions. Using an ingredients approach to costing, data were gathered on drugs, supplies, material, personnel time and hospitalization. Additionally, direct non-medical costs such as overhead and capital costs were also measured. We found that the average annual PAC cost per client, across five types of abortion complications, was $93. The total cost of PAC nationally was estimated to be $1.7 million per year, 49% of which was expended on direct non-medical costs. Satisfying all demands for PAC would raise the national cost to $2.5 million per year. PAC comprises a significant share of total expenditure in reproductive health in Rwanda. Investing more resources in provision of contraceptive services to prevent unwanted or mistimed pregnancies would likely reduce health systems costs.