Postabortion Care (PAC) 101 Everything you wanted to know about PAC but didn’t know what to ask

1. Postabortion Care (PAC) 101Everything you wanted to know about PAC but didn’t know what to ask Carolyn Curtis, CNM, MSN, FACNM USAID PAC Team Leader Presentation at USAID Global Health Bureau Mini-university 10/27/06

2. Outline of Presentation • Global picture of Maternal Mortality • USAID’s Involvement in Postabortion Care • Findings of the 2001 USAID Global Evaluation • Overview of the USAID Postabortion Care Strategy • USAID PAC Model • Programmatic Strategy for scaling up PAC programs • The Global PAC Resource Package • What is it: • How will it be used

3. What is Postabortion Care? • Services to care for the complications that women may experience AFTERmiscarriage or induced abortion • Consists of three core components • Service delivery model that requires change in patient management to be effective (Johnson et al, 1993; Johnson et al, 1992)

4. Why should USAID support Postabortion Care Programs?

5. 13% • Each year, approximately 600,000 women die as a direct result of complications that arise during pregnancy, delivery, or the postpartum period

6. Incidence and complications related to miscarriage and induced abortion • Incidence • Worldwide, 37% of pregnancies end with: • Induced abortions • Miscarriages • Stillbirths • Source: AGI, 1999 • Complications • Hemorrhage • Uterine perforation • Sepsis • Infertility • Maternal death • Burden to families, health care systems & incur physical, emotional and financial costs

7. USAID and Postabortion Care

8. History of USAID and Postabortion Care Programs • Early 1970s – USAID funded research for development of MVA • 1990 – USAID began funding PAC programs • 2001 – Global Evaluation of Postabortion Care Programs • 2002-2004 – USAID PAC strategy developed • 2003 – Selected focus countries • 2003 –2006 Development of Global PAC Resource Package began • 2003-2008 – Implementation of Global PAC Strategy

9. 2001 USAID GLOBAL EVALUATION

10. PAC activities and programs in 42 countries in Africa, Asia, Latin America and Europe/Eurasia Clear need for PAC voiced by: Government Health professionals Women, men, and communities PAC Works!!! Strong in Emergency Treatment of Complications However MVA alone is not PAC Weak in FP Counseling and Services Linkages with other RH services Findings of the Global PAC Evaluation

11. USAID PAC STRATEGY

12. Review of documents, phone interviews, group discussions Analyzed and synthesized information into a report Meeting held with USAID to discuss alternatives Meetings with USAID PAC Working Group Documentation of the strategic plan Draft strategy vetted with CAs/PVOs/NGOs and USAID missions Continued meetings with USAID PAC Working Group to develop results framework and indicators Completion of the PAC Strategy paper Methodology for PAC Strategy

13. Reinforce that PAC can be done Have a strategy Commit more money for PAC PAC Strategy Response:  Strategy developed  Increased funding for FY ‘03 What could USAID do to improve their support for PAC programs?

14. Factors for selection High rates of: Unsafe abortion rates Maternal mortality Induced abortion Mission interest and willingness to fund for multiple years Commitment from the MOH for PAC and scale-up Work in an E&E country PAC Strategy Response  Focus on 5-6 countries in different regions  Mission buy-in  Ministry of Health support Countries selected: Bolivia, Cambodia, Haiti, Kenya, Nepal, Senegal, Tanzania How and where should USAID invest resources in PAC that result in most impact?

15. Strategy Paper • Revised Postabortion Care Model • Results Framework and Indicators • Selection of Focus Countries

16. USAID’s Postabortion Care ModelThree Core Components of Postabortion Care FP Counseling, Provision; Selected RH (STI,HIV) Emergency Treatment Immediately do... Community Empowerment through Community Awareness andMobilization

17. Country Program Results - Nepal • Activities Completed 1/04 to 9/05 • Established 2 PAC Training sites and 11 new PAC service sites at primary health center level • Nurses and midwives are primary providers • PAC services available 24 hrs/7 days week • FP acceptance rate – 91% • Services 60 to 150 km closer to women 4 1 6

18. Country Programs in Bolivia and Kenya Community Empowerment

19. Results of Community Empowerment - Bolivia • Health fairs in high school and in community reach • 1500 adolescents and • 1500 community members • Health centers now provide minimum of 8 hours of service daily • Pharmacies expand hours of service to 24 hours on rotational basis • Municipality Operational Plan of Action includes free courses on prenatal care and danger signs proposed by community groups

20. Community Mobilization - Kenya

21. Identified by community Lack of information and misconceptions about pregnancy bleeding during pregnancy family planning Poor couple and inter-familial communication and relationships Lack of knowledge and use of local health facilities and FP/RH services offered Lack of male involvement in RH and FP matters Pre and Post Test Findings (n-412) Vaginal bleeding as danger sign (66% to 90%) Causes of maternal death in their community Vaginal bleeding (41% to 64%) Violence against women (24%) Condoms have dual protection (77% to 84%) Community Mobilization - Kenya

22. PAC Decentralization – Nepal, Senegal, Tanzania • Decentralized PAC programs from hospitals to 124 health centers, health posts, and dispensaries • 3275 women seen in health centers and in 2005 • Decreased Geita district hospital caseload by 64% in Tanzania • Average of 73% accepted FP method.

24. Rationale for Package Provide evidence for practice in one location Scale-up PAC programs from evidence base Assist countries to begin or scale-up PAC programs Standardize Training curriculum Messages Features Developed in collaboration with WHO, FIGO, ICM Each section peer-reviewed by international panel of experts Field testing in Tanzania, Senegal and Bolivia Launch in Spring/Summer 2007 Global PAC Resource Package

25. Global PAC Resource Package - Contents • Research Compendium • Synthesis and recommendations for • national policies • tools • curricula • service delivery guidelines • Individual Education and Behavior Change Communication (IEC/BCC) Materials • Other items may include • “Allocate Model” for forecasting costing for PAC services • Standardized training curriculum • Facilitators Manual for PAC Community Mobilization

26. Global PAC Resource Package • Resources from 12 organizations and 15 countries • Research Compendium • > 400 articles reviewed for inclusion • Policies, Tools, Curricula, Service Delivery Guidelines • >96 documents were reviewed for inclusion • IEC/BCC materials • > 100 documents reviewed for inclusion • Each section independently reviewed by: • International review panelists with expertise in specific area

27. Global PAC Resource Package – Will it be Useful? • Cambodia • IEC/BCC materials in Global PAC Resource Package: • Adapted 4 tools • User’s guide: • Identified weakness in Service Delivery Guidelines, training materials; curriculum • Reviewer saw resources helpful in assisting local staff to identify the gaps.

28. Coming in Spring/Summer 2007! www.postabortioncare.org

29. Global PAC Resource Package – Preliminary Research Findings

30. Global PAC Resource Package – Preliminary Research Findings • It’s the postabortion care model not the clinicalmethod that determines the information and counseling women receive • Sharp curettage and MVA are equally effective • Sharp curettage can be done safely in an outpatient setting using systemic analgesia • Pain management is needed for MVA • Misoprostil is not for home use alone, access to emergency treatment still needed • MVA is not always less costly than D&C

31. Global PAC Resource Package – Preliminary Research Findings • PAC reduces repeat abortion • Pills, IUD, and Norplant are safe to use postabortion • Women should be told to wait 6 months before getting pregnant again • The educational packet should include information on f/u home care; complications; contraceptive methods; return to fertility; wait time for next pregnancy; when to return for f/u • Provider empathy and support is critical

32. Global PAC Resource Package - Research Findings • HIV+ women are 1.4 times more likely to miscarry; women with spontaneous abortion may need to be evaluated, counseled, and referred for HIV testing • STIs increase the incidence of spontaneous abortion • PAC patients need to be treated for malaria/counseled about preventing malaria • There are other counseling needs that need referral to community agencies – gender based violence; psychological sequelae • Men and women desire for men to have more integral part in counseling for PAC; f/u care; complications; contraceptive methods, etc.

33. Questions and Answers