Meeting Health Care Needs of Women Experiencing Complications of Miscarriage and Unsafe Abortion: USAID's Postabortion Care Program

Carolyn Curtis, CNM, MSN

J Midwifery Womens Health. 2007;52(4):368-375.

Abstract and Introduction

Each year, an estimated 210 million women become pregnant. Worldwide, more than one fourth of these pregnancies will end in abortion or an unplanned birth. While many abortions may result from the desire to delay or avoid pregnancy, 15% to 20% of pregnancies will end in miscarriage or stillbirth with some causative agents being malaria, HIV/AIDS, and physical violence. Postabortion care (PAC) is needed to provide treatment for complications caused by incomplete or spontaneous abortion and critical family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions. In 2003, the United States Agency for International Development (USAID) initiated a 5-year strategy wherein seven countries were provided financial funding and technical assistance. Since 2003, more than 3000 women have been seen in health centers and health posts for PAC services; more than 14,000 community members have received messages on unsafe abortion; family planning, and complications of unsafe abortion and miscarriage; and more than 600 documents were reviewed for inclusion in a global PAC resource package. This package has been used for developing Cambodia's national PAC policy and for developing patient education materials and provider job aids in Cambodia and Tanzania. These promising methodologies will be replicated in other countries.

... In no case should abortion be promoted as a method of family planning. All governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health aspect of unsafe abortion as a major public health concern, and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority, and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counseling ... Post-abortion counseling, education, and family-planning services should be offered promptly, which will also help to avoid repeat abortions.^[1]

Each year, an estimated 210 million women become pregnant.^[2] Worldwide, more than one fourth of these pregnancies will end in either abortion or an unplanned birth. Women often have an abortion because of a desire to delay or avoid pregnancy.^[3,4] Fifteen to twenty percent of pregnancies will end in miscarriage or stillbirth.^[5] Some causes for spontaneous abortion include malaria, HIV/AIDS, and physical violence.^[6,7,8,9] Postabortion care (PAC) is needed to provide treatment to women experiencing complications caused by incomplete or spontaneous abortion and to provide critical family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions.

The term PAC was developed in 1993. Three critical elements of PAC included: 1) emergency treatment for complications of spontaneous or induced abortions; 2) postabortion family planning counseling and services; and 3) linkages to other reproductive health services, such as management of sexually transmitted infections. Women presenting for PAC come due to complications related to spontaneous or induced abortion. This article highlights the need for PAC programs in developing countries, describes the United States Agency for International Development (USAID) PAC program and its related policies, and reviews the results of selected activities of the USAID PAC working group.

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Cite this: Meeting Health Care Needs of Women Experiencing Complications of Miscarriage and Unsafe Abortion: USAID's Postabortion Care Program - Medscape - Jul 01, 2007.

Comparison of WHO Global and Regional Estimates of Unsafe Abortion and Related Deaths, 2000
Region	Annual Number of Unsafe Abortions (In Millions)	Annual Number of Deaths from Unsafe Abortion	Risk of Death from Unsafe Abortion
World total	19. 0	70,000	1in300
Developed countries	.5	300	1in3700
Developing countries	18. 5	69,000	1in250
Africa	4. 2	29,800	1in150
Asia	10. 5	34,000	1in250
Latin America and Caribbean	3. 7	3700	1in800

Source: WHO, 2000

US Policy Governing USAID Family Planning Funds
Helms Amendment "None of the funds made available under this Act may be used to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortions." Source: HR. 2673 Omnibus Appropriations Bill, Division D. FY 2004
Kemp-Kasten Amendment "None of the funds made available in this Act nor any unobligated balances from prior appropriations may be available to any organization or program which, as determined by the President of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization." Source: HR. 2673 Omnibus Appropriations Bill, Division D. FY 2004
Method Mix (DeConcini) Amendment "That in order to reduce reliance on abortion in developing nations, funds shall be available only to voluntary family planning projects which offer, either directly or through referral to, or information about access to, a broad range of family planning methods and services." "... In awarding grants for natural family planning under section 104 of the Foreign Assistance Act of 1961 no applicant shall be discriminated against because of such applicant's religious or conscientious commitment to offer only natural family planning; and additionally all such applicants shall comply with the requirements of the previous provision." Source: HR. 2673 Omnibus Appropriations Bill, Division D. FY 2004
Siljander Amendment "Provided further that none of the funds made available under this Act may be used to lobby for or against abortion." Source: HR. 2673 Omnibus Appropriations Bill, Division D. FY 2004
Mexico City Policy This regulation prohibits non-US, nongovernmental organizations to which USAID provides family planning assistance funding either directly or through subawards from using their own or other, non-USAID donor funds to provide or promote abortion as a method of family planning.

Data taken from the United States Agency for International Development.^[9]

Appendix: USAID Postabortion Care Strategy: Provision of Care by Level of Health Care Facility and Staff

Level/Staffing	Component One Emergency Treatment	Component Two Postabortion Family Planning
*Community Level* Staffing may include community residents with basic health training, traditional birth attendants, traditional healers	1. Recognition of signs and symptoms of abortion and postabortion complications 2. Referral to facilities where treatment is available	1. Provision of pills, condoms, diaphragms, and spermicides 2. Referral and follow up for these and other methods
*Primary Level* - Primary health clinics, family planning clinics, or polyclinics Staffing may include health workers, nurses, trained midwives, general practitioners	*All Activities above AND:* 3. Diagnosis based on medical history; physical examination and pelvic examination 4. Resuscitation/preparation for treatment or transfer 5. Tetanus vaccination 6. Referral, if needed	*All Activities above AND:* 3. IUDs, injectable contraceptives, Norplant implants, and standard days method 4. Referral for voluntary sterilization
	*If Trained Staff and Appropriate Equipment Available: all activities above AND:* 7. Counseling regarding treatments/emotional support 8. Hematocrit/hemoglobin testing 9. STI evaluation and treatment 10. Initiation of emergency treatments: antibiotic therapy, intravenous fluid replacement, oxytocics 11. Uterine evacuation during first trimester for uncomplicated cases 12. Appropriate pain control: simple analgesia and sedation and/or local anesthesia (paracervical block)	5. Family planning follow up and referral to primary and community level for long-term FP follow up 6. HIV counseling 7. F/U appt or referral for HIV counseling and testing (as program dictates) 8. Referral to primary/secondary/tertiary sites as appropriate for gender-based violence, psychological/emotional needs; HIV counseling and testing
*First Referral Level* - District Hospitals Staffing may include nurses, trained midwives, general practitioners, obstetrician/gynecologists, specialists	*Activities above AND:* 13. Emergency evacuation for fetal death through second trimester 14. Treatment of most postabortion complications 15. Local and general anesthesia 16. Diagnosis and referral for severe complications (septicemia, peritonitis, renal failure) 17. Laparotomy and indicated surgery (including for ectopic pregnancy) 18. Blood crossmatch and transfusion	*All Activities above AND:* 9. Voluntary sterilization
*Secondary and Tertiary Level* - Regional or Referral Hospitals Staffing may include nurses, trained midwives, general practitioners, obstetrician/gynecologists, specialists	*Activities above AND:* 19. Uterine evacuation as indicated for all cases 20. Treatment of severe complications (including bowel injury, severe sepsis, renal failure) 21. Treatment of bleeding/clotting disorders	All Activities above

IUD = intrauterine device; STI = sexually transmitted infection.
Adapted from: World Health Organization. Clinical management of abortion complications: A practical guide. Available from: www.who.int/reproductive-health/publications/clinical_mngt_abortion_complications/index.html [Accessed March 22, 2007].

Appendix: USAID Postabortion Care Strategy: Core Components 2 and 3

Core Component 2: Family Planning Counseling and Provision, STI Evaluation and Treatment, and HIV Counseling and/or Referral for HIV Testing (See Component One for Level of Health Facility and Staff)

1. Counseling regarding the return of ovulation within 2 weeks after emergency treatment

2. Counseling regarding self-care at home, including any emotional sequelae

3. Counseling regarding the ability to carry a future pregnancy as desired and the need to wait 6 months before attempting another pregnancy

4. Counseling regarding behaviors that put one at risk for HIV/STI transmission

5. Counseling regarding contraceptive methods that can be used (oral contraceptives, diaphragm, condom, Norplant, Depo-Provera, standard days method, spermicides, IUDs, and voluntary sterilization)

6. Provision of oral contraceptives, condoms, diaphragms, spermicides, IUD, Norplant, Depo-Provera, voluntary sterilization, and/or instruction regarding the standard days method

7. Listing and evidence of linkages to community/primary/secondary/tertiary referral sites for contraceptive methods not available at treating facility

8. Evidence of linkages and referral mechanisms to/from community, primary, secondary, and tertiary facilities for the provision of the following services:

Pre-pregnancy family planning counseling and provision
Initial emergency treatment
Postabortion family planning (initiation of method and appointment and/or referral for long-term family planning follow-up, incorporating all methods, including standard days method, enabling women to continue family planning services in their communities)
STI evaluation and treatment (based on prevalence and availability of resources)
HIV counseling and VCT (based on prevalence and availability of resources)
Counseling for emotional sequelae or gender-based violence

9. Referrals to community/primary/secondary/tertiary sites for family planning follow up, HIV/STI counseling/screening/treatment follow-up

Core Component 3: Community Empowerment Through Community Awareness and Mobilization

1. Educate community about causes of unsafe abortion, miscarriage, and postabortion complications

2. Educate community regarding three delays and their effect on maternal mortality

3. Each community with evidence of listings and/or linkages between community and community/primary/secondary/tertiary resources that can provide:

Family planning counseling and services
Counseling regarding three delays and their effect on maternal mortality/morbidity
Emergency treatment
VCT and HIV treatment
STI counseling, testing, and treatment

4. Have communities make decisions about type and number of PAC facilities for their community

5. Have communities make decisions regarding transporting of women for emergency treatment

6. Have community generate resources for PAC services (facility, funds for payment of services, transportation, and equipment)

Note: "Community" includes local, district, and national governments; ministries of health and education; NGOs; PVOs; women's groups; professional organizations; FBOs; traditional birth attendants; traditional healers; male leadership; community-based distributors; and other stakeholders appropriate to each specific community.
IUD = Intrauterine device; STI = sexually transmitted infection; VCT = voluntary counseling and testing for HIV.
Depo-Provera is manufactured by Pfizer Pharmaceuticals, New York, NY; Norplant is manufactured by Wyeth-Ayerst Laboratories, Collegeville, PA.

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Meeting Health Care Needs of Women Experiencing Complications of Miscarriage and Unsafe Abortion: USAID's Postabortion Care Program

Abstract and Introduction

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Appendix

Appendix: USAID Postabortion Care Strategy: Provision of Care by Level of Health Care Facility and Staff

Appendix

Appendix: USAID Postabortion Care Strategy: Core Components 2 and 3

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