PAC IN SUBSAHARAN AFRICA 1

1. PAC IN SUBSAHARAN AFRICA 1 The New Developments By Dr. Solomon Orero MD Consultant Obstetrician/ Gynaecologist KMET/CSA KENYA February 2003

2. PAC IN SUBSAHARAN AFRICA 2 B.A 37 years old para 7 + 1 LD 5 years ago, last abortion a year ago. A known diabetic controlled on Lente Insulin and diet. As at 7.2.2003 she had been admitted for poorly controlled Diabetic. She was 8 weeks pregnant. Her last abortion was an elective abortion on an understanding that with 7 living children, 5 boys and 2 girls. Chronic Diabetic poorly controlled and a housewife. This time round she would have an elective abortion and BTL. Her husband was not in at the time. He arrived just when we were in theatre about to perform the two procedures!! We did neither of the procedures as we were unable to convince the man it was for the benefit of his wife nor could he accept vasectomy. He refused!!

3. 3 Issues • Decision making in RH and Health in general • Decision making linked to economic empowerment • Decision making linked to cultural norms and practices

4. 4 “A woman who has decided to procure an abortion will go ahead and have it irrespective of any other opinions to the contrary, the risks to her life not withstanding.” “PROVIDERS”

5. 5 In spite of the high fertility rates in Sub Saharan Africa, contraceptive prevalence is very low. It has been found that 30% of women control their fertility by a combination of contraceptives and abortion and 3% use abortion only as a means of fertility control.

6. 6 “Unsafe abortion is preventable yet remains a significant cause of Maternal Mortality in Sub Saharan Africa.”

7. 7 GLOBALLY: • 53 million abortions occur annually • 20 million unsafe abortion occur annually • 96% of unsafe abortions in Africa are unsafe • 85% of abortions in Latin America unsafe

8. Reasons for Procuring Abortion 8 • Education & career • Peer pressure and feared parental reaction • Partner pressure, refusing to recognize child • Birth spacing or limiting all together • Owner of pregnancy • Parents, Age mate, Incest

9. Methods used for Procuring Abortion 9 • Sharp objects • Knitting needles, bicycle wires • Plant stems • Concoctions • Strong juices, Liquid soap, overdose of drugs, Herbals • Vaginally inserted laundry detergents • Ground glass gulped as powders

10. Decision Making for Abortion 10 “When a woman becomes pregnant in Sub-Saharan Africa whether or not that pregnancy is wanted and the subsequent events that follow may not entirely be her decision”.

11. The Characteristics of the Woman who has Unsafe Abortion 11 Most likely, student, unemployed, Christian, given false identity

12. In Private Sector 12 • Single, educated, Employed, • Married, not known to partner

13. Impact & Consequences of Unsafe Abortion 13 • 30 – 54% of all Maternal Mortality due to Unsafe Abortion • 50 – 62% Bed occupancy of all Gynecological Ward Admissions • Requires Expert Care to Correct damages • Chronic Morbidity • Infertility and it’s Associated Problems in the African Context

14. Response and Management of Unsafe Abortion: 14 “In Sub Saharan Africa; the distance a woman has to walk to access safe abortion services in the public health sector is like the distance between heaven and earth you have to die to reach there.” Khama Rogo 1993

15. Response and Management of Unsafe Abortion: 15 On reflection at some of the answers we have given women who seek abortion services in the public health sector the statement unfortunately is very predictive!

16. Response and Management of Unsafe Abortion: 16 “Mum, young lady, in this hospital we only treat women who are already aborting, we don’t start it here, the law does not allow!” The message by that answer is clear! “Go and induce it by whatever means and then come back!” The case of the women who have suffered unsafe abortion for along time has been to say the least unfortunate. The waiting time averaged 12 hours quite often days to one week, the attitude of the staff appalling; the efficiency disgusting the interaction and communication just simply inhuman!

17. The Evolution of PAC Services in Sub-Saharan Africa 17 Defining and Embracing PAC Services • Emergency treatment of those who have suffered abortion complications or who potentially can suffer life threatening complications • Providing Post abortion Family Planning counseling and services • Referral and linkages of the women who require other RH services to the appropriate facilities or other practitioners. • Community Involvement in RH service including Abortion Care services. The embracing of the PAC concept has had the effects of:- • Decentralizing abortion care from theatre to procedure rooms • Embracing the use of simpler technologies in evacuating the uterus of its’ contents • Decentralizing abortion care from the Doctor to other appropriate staff • Providers shift in attitude • Looking at effective ways of providing all the components of PAC

18. The KMET Experience 18 • Abortion Care in the Private Sector • The Collaboration between Various Cadres of Health Providers • The Decentralization of PAC from the Doctor to:- • the MLPS • the CBHWKS • The Collaboration between the Private Sector and the Public Sector

19. The Evolution of KMET “Participating Practitioners Network” 19 Consultant Physicians (OB/GYNS) General Practitioners Mid Level Providers (Clinical Officers/Nurse Midwives) Community Based Health Workers (CBDS, TBAS, CHES, Herbalists) • Annual Meetings • Linkages and cross referrals • Respect and attitudinal change

20. 19 (1)

21. 19 (2) Congressman Jim Greenhood visiting KMET PPNW Programme. August, 2002

22. Lessons Learnt from KMET – Training 20 Dr. Orero during a training session. A participatory practical competency based training.

23. 20 (1) Participants practical session during PAC training

24. 20 (2) PD – Monica during a class PAC training session

25. 20 (3) PAC room rearranged simply for use after training in a public facility Designed by KMET

26. 20 (4) A cupboard for storage in a training facility Designed by KMET

27. Lessons Learnt from KMET 20 (5) • PAC in the private sector is “doable”. • Quality training in all elements of PAC is mandatory • It is possible to MLPS and Doctors together under the same programme “KEY” to success – supportive facilitative supervision, monitoring and evaluation • CBHWKs can be good advocates for PAC and FP especially ECP • All cadres of health providers in RH can come together and discuss RH issues

28. 20 (6) A simplified procedure bed for MVA

29. 20 (7) KMET Established a model Clinic in a Peri-urban Kisumu City

30. 20 (8) KMET collaborate with many partners – PIWH, PPFA Bucks county Pennsylvania

31. Comparisons and Replications 21 Sub-Saharan African Countries • Ghana – Ghana midwives • Uganda – PRIME –DISH • Kenya – PRIME I, II, III, UNFPA, Engender Health, AMKENI, MOH • Ipas/MYWO

32. Study Tours To KMET • Students for choice – USA • Ethiopia – Ipas • Ipas – Chapel Hill NC • Zimbambwe, Uganda, Nigeria, Mozambique, Sudan, Cameroun

33. COBAC 23 PIWH/CSA - COBAC 1996 – 2000 • Research on community Based Abortion Care • Results – Peer Review Journal • Dramatized – “Koso and Naki” • Film/ Video – “The Great Betrayal”

34. Themes for Discussion after the Video 24 • Decision making on abortion the dilemma of the victim • The cost of accessing safe and unsafe abortion • The role of men in abortion care as culprits, financiers, support in its various forms • The role of clinical service providers either as perpetrators of the high incidence of unsafe abortion or as potential promoters of safe abortion care services • The roles of informal providers in abortion care “The herbalists, the CBDS, the CBHES, the CBHWKS, the TBAs. • The role of Gate Keepers in the community in abortion care • The role of the community itself in abortion care • The role the legal system and policies in Abortion care

35. The Post Research Intervention Opportunities 25 • Putting PAC services in place through physical facilities improvement in both the public and private sector • Training of Clinical Service Providers in comprehensive Post Abortion Care Services • Community sensitization, education and mobilization by using the established structures of: CBDS, Herbalists, TBAs, Government Administrative Structures, CBOs and organized groups especially women groups • Advocacy at the community level for timely utilization of health services for RH services • Development of IEC materials • Continuous follow up monitoring and evaluation

36. The Evolving COBAC Intervention Model:- 26 This model aims at community level initiatives with the sole focus on:- • Complimenting and strengthening existing PAC efforts • Collaborate with the MOH, Community Social and Health care networks The whole intervention is geared towards addressing Abortion issues and their contribution to Maternal Mortality. At the community level initiative we are addressing the community norms, values and attitudes, discussing laws and policies regarding abortion, their interpretation, Health service provision.

37. The Policy Arena 27 • Safe motherhood • The ICPD platform of action • Advocacy campaigns • The legal Environment • The services provision, availability and sustainability

38. 28 M.A. 18 yrs old, a house girl works 450 Kms from home. Got pregnant. Had an unsafe abortion. Who did it could not differentiate the anus from the vagina. Destroyed anus, rectum, bladder, uterus, intestines. The woman lost her uterus, fertility, and to add insult to injury she ended up with a permanent COLOSTOMY! She survived but at what cost? Another preventable statistics. “My heart bled for her as we repaired what was left of her womanhood”

39. 29 YES – movement forward 2 decades later • Progress to a large extent in pilot & programmes • ACCESS/special populations • Support/ NGOS/ Religious Based Organizations • Sustainability • Legal environment • Integration • Adoption of technological change • EOC Guidelines include PAC

40. Way Forward 30 • Overcome culture of silence • Condemnation from sex • The issues of war & health • Scaling up • Process • Resource mobilization • Attitude • Challenge • Legal environment • Existing social groupings • Training, supervision, M &E • Introduction of PAC in Basic MLPS training Institutions