Quality of care is important for all family planning clients, especially postpartum women, who may want to space pregnancies, and postabortion women, who may want to prevent other unplanned pregnancies.
Health workers who provide care for these two groups of women often view them as similar. However, the experiences, health needs and reproductive goals of postpartum and postabortion women can be very different. Health workers who want to provide high-quality care must take this into account.
"The postpartum woman has two people to look after now -- herself and her child," says Dr. Emma Ottolenghi, a consultant with the Population Council in Latin America who has done extensive research in postpartum and postabortion service delivery. "She is not in a crisis situation. She may have questions about how to take care of the baby, how to breastfeed. The postabortion woman is in crisis, and she may not be able to be a good advocate for herself. She may want to know whether she can conceive again or if there has been any damage to her fertility, but she may be afraid to ask questions."
While health providers may see their primary role as promoting acceptance of contraception among postabortion and postpartum women, quality of care is a broader undertaking. Quality of care means helping women to identify their individual reproductive health needs and helping them make choices that will meet those needs.
Providing family planning and other reproductive health services for postpartum and postabortion women "should be about the client's choice, not the health worker's," says Dr. Monir Islam, chief of the family planning and population unit at the World Health Organization (WHO). "The focus should be on the client's needs, not on promoting a particular method."
Providers may define quality in family planning services as preventing unplanned pregnancy, but clients may view quality as the ability to gain control over their bodies, to maintain their reproductive health and to improve satisfaction with their sexual relationship, says Dr. Aníbal Faúndes of Brazil, an obstetrician and an expert on women's health.1 "Quality cannot be judged only by effectiveness and avoidance of complications," he says. "It also includes other attributes, such as ... personal preferences and lack of interference with women's everyday life and sexual satisfaction."
In providing care for postpartum and postabortion women, health workers must consider the clients' needs for accurate information, empathetic counseling, and accessible services. Workers also must consider how service delivery systems, provider attitudes and client perspectives can affect postpartum and postabortion women's access to contraception and other reproductive health services.
And providers must consider women's needs for related reproductive health services. For example, postpartum women also need information about breastfeeding, infant care and nutrition. Women undergoing treatment for incomplete abortions, whether spontaneous (miscarriage) or induced, need emergency treatment for complications, plus information about symptoms that may indicate an infection and need to return to the health-care provider.
Clients' needs first
While both postpartum and postabortion women need information about family planning, the need is immediate for postabortion women. Fertility often returns within two weeks following an abortion.
Ovulation generally does not occur during the first six weeks for postpartum women. If the woman breastfeeds, she may be able to rely on the lactational amenorrhea method (LAM) of family planning and may not need to consider another contraceptive for up to six months.2 Consequently, while she may be counseled and given supplies before leaving the hospital, the need is not immediate.
Counseling is an important element of quality services. For postabortion and postpartum women, counseling should begin by helping the woman discuss her past contraceptive experiences and identify her future reproductive health needs.
When counseling both postabortion and postpartum women, providers should ask the client if she wants future pregnancies and offer information on contraceptive methods if she chooses to delay or space births. In addition, providers should help women understand the effects an individual contraceptive method will have on her life and help her assess the practicality of using a particular method. For example, condoms will require a male partner's knowledge and consent and must be used during every act of intercourse. Progestin-only methods may cause bleeding between menstrual periods, and women need to consider how or if that will affect their work and family life. Oral contraceptives are highly effective at preventing pregnancy, but offer no protection for women at risk of sexually transmitted diseases.
In addition to information about family planning methods, both postpartum and postabortion women need to know what they should expect during their recovery and how to care for themselves, says Dr. Karen Stein, who works with the Population Council on quality of care issues. In addition, providers should also offer information about: the signs and symptoms of health problems indicating that the client needs to return for additional care; how the woman can take care of her health to prevent future problems; when can she return to her usual work and household activities; and when can she resume sexual intercourse.
Providers should not offer women information about family planning while they are under stress. It is considered unethical to discuss contraception while women are in the physical and emotional stress of labor. Counseling during this time of anxiety may also be ineffective. Interviews with postabortion patients at El Galaa and El Menia University hospitals in Egypt found that the women were not immediately interested in contraception. Most were preoccupied with recovery from a painful experience and seeking recuperation and rest.3
Privacy is considered another important element of quality of care services. For providers who work with postabortion patients, this can be especially difficult due to overcrowding in emergency wards. However, experts say something as simple as hanging a curtain at a window or painting the glass, or turning an examining table so it does not face the hallway, can help enhance privacy.
When planning postabortion or postpartum care, program managers should consider who will be responsible for providing information, counseling and services. Often, when busy staff are not assigned specific responsibilities, family planning may be ignored as other duties take precedence. Therefore, it is important that hospitals develop protocols, outlining who will perform which tasks.
"Program managers must look at the whole system of service delivery to make sure procedures are in place for postpartum and postabortion clients to receive family planning services," says Dr. Karen Hardee, an FHI research scientist who specializes in quality of care issues. "The linkages need to be in place to ensure the delivery of quality care to these clients. Can someone in the postpartum ward send the woman's name to the family planning clinic? Can someone give the postabortion woman condoms and information about where to obtain other family planning services? Program managers must make sure a process is in place to ensure service delivery."
"You have to look at your own individual resources and see what makes sense," says Joan Healy of Ipas, a U.S.-based nonprofit organization that provides training on postabortion care services. "In a ward, could gynecology nurses provide counseling? Could they escort women to the hospital's family planning clinic?"
Because many women deliver their babies at home and not in a health-care facility, and because many women who seek abortion do not have complications that necessitate a trip to a hospital emergency room, health-care providers must find ways to deliver family planning services outside the postpartum or postabortion wards. Some programs have trained traditional birth attendants or midwives to provide counseling about family planning for postpartum women.
Respect for all
Counseling and information about family planning should be delivered in ways that are respectful and empathetic. Yet, while motherhood often brings elevated status for women, postabortion patients may be scorned or ignored. One postabortion patient at a Kenya hospital said she was offered little information about return to fertility or about what contraceptive options might be available to her in the future. "I was just told to go away since I'd been a bother," she said.4 Another woman at a hospital in Brazil said, "I saw the doctor ... and he was angry with me and said: 'Look, mother, you are pregnant, and we are here to take care of mothers who want children, not those who don't.' "5
"If you have a baby in your arms, you are a beautiful mother," says Dr. Angela Torres, an obstetrician-gynecologist from Cali, Colombia. "With an abortion, a woman may feel guilty and feel she is punished by her family and by society. You have to focus on her feelings and needs. You have to give her information to help her make a choice that will work with her lifestyle."
While counseling postpartum and postabortion women about reproductive health needs, providers should consider both the physical and emotional well-being of the client. Providers should recognize that the state of physical and emotional health can be very different for a woman who has just given birth and a woman who has undergone an unsafe abortion.
"The postabortion woman may be overwhelmed with emotions -- pain, guilt, relief, sadness," says Janet Jackson, a program officer with the International Planned Parenthood Federation (IPPF) European Network and an expert in quality of care issues. "The postpartum woman is assumed to be mostly pleased and delighted with her baby, but she also could be 'burdened' at the thought of another mouth to feed, or she could be disappointed with the baby's sex. Counseling must be tailored to meet the individual specific needs of postpartum and postabortion women. Counseling should focus on ... listening to and hearing the client's needs, enabling that person to explore options, and to come to a decision that is right for that particular time. "
Finding the appropriate time to introduce the subject of family planning to postpartum and postabortion clients is important. For postpartum women, there may be several opportunities to raise the issue of family planning. Ipas notes that postpartum women may have several contacts with providers -- during prenatal visits, postnatal care, and child care visits.6 Family planning information and counseling also may be available on the maternity ward. However, providers may have limited opportunities to counsel postabortion patients about family planning since the women may be in the hospital briefly, and during that time may be in pain or under stress. Family planning services may not be routinely offered on the emergency or gynecology ward, where providers may be too busy with curative or life-saving services.
"Often, there isn't time to include the family planning element, and there is no back-up way to provide information," says Jackson of IPPF. "That sort of follow-up hasn't been thought out, and needs to be developed. Family planning and counseling skills should not be extra options in training. There should be a requirement that health-care workers get in-service training on these issues when they work with postpartum and postabortion patients."
However, because hospitalization for birth or abortion complications may be a woman's only contact with the health-care system, providers must find ways to educate postpartum and postabortion clients about health services that are available -- either at the health facility itself or through referral to another health center.
"Seeking treatment for abortion complications may be the only time a woman ever comes for health care," says Charlotte Hord of Ipas. "This is a busy time, but this may be an opportunity for the provider to explore other issues that may affect women's health or use of family planning, such as sexually transmitted diseases or domestic violence."
Integrated services, costs
In attempts to make information and counseling more accessible to clients, some hospitals have integrated family planning and other reproductive health services into postpartum and postabortion care. In these cases, the provision of information and counseling, plus the availability of contraceptive methods, increased family planning acceptance rates.
In Mexico, the Instituto Mexicano del Seguro Social (IMSS) pioneered an effort to train physicians and paramedical staff to educate women at high risk for pregnancy complications about family planning use, which was later adapted in Honduras by the Instituto Hondureño de Seguridad Social.7 In both Mexico and Honduras, when physicians intensified their efforts to inform women about contraception, women's awareness of reproductive risks and family planning increased. Before the training program in Honduras, about 18 percent of women said they were offered a contraceptive method. Afterward, 46 percent said they were offered family planning.
In providing information, counseling and services, providers should consider the elements of quality outlined in the framework developed by researcher Judith Bruce of the Population Council.8 These include: a choice from among a variety of methods; accurate information on how to use a method and possible side effects; technical competence of providers; a relationship between provider and client that is respectful and allows time for dialogue and questions; mechanisms to encourage continued effective contraceptive use, such as reminder cards or home visits for method resupply; and an appropriate range of services, which includes integrating family planning with other reproductive health services. An expanded framework, developed by the Pan American Health Organization and FHI, includes these elements, plus availability of essential supplies; accessibility and availability of services, and coordination of reproductive health services, including STD treatment and maternal and child health.9
A major concern for providers is that improving quality is too costly or time-consuming. However, quality does not have to be expensive.
"Quality of care interventions may be frightening," says Meena Cabral, a WHO program officer. "Program managers can be put off looking at the list of things to do. But counseling about family planning doesn't always have to take hours and hours. There are simple tools for health workers -- check lists, decision trees, flow charts -- that can help them. After some practice, it becomes easier to help the client."
"Certain elements of quality of care require little expense," says Dr. Stein of the Population Council. "Asking providers to wash their hands will not cost anything. Having staff greet a woman courteously, tell her diagnoses, tell her what procedures will be performed, tell her results of tests -- those do not cost anything."
At the Instituto Chileno de Medicina Reproductiva in Santiago, Chile, clients seeking family planning or maternal-child health services were asked what they saw as quality care. The women mentioned cleanliness of the facility, short waiting times, and opportunities to learn about their bodies. However, provider respect for clients was frequently mentioned as a key component of quality. "You are treated totally different here, you are treated as an equal," says one client.10
"Respect for patients can make a tremendous difference," says Jennifer Potts of Ipas. "Being kind is very low cost."
When health-care workers consider the expense of adding elements of quality of care, they also should consider the expense of not providing quality, says Dr. Islam of WHO. "If you do not provide quality, this will certainly increase your work load later on," he says. "Providing information on family planning may take 10 minutes but may prevent a client from coming back for a repeat abortion."
Dr. Hardee of FHI agrees. "Providers should not ask, 'Is there an additional cost?' but instead ask, 'Is the benefit worth the additional cost?' The cost of provider training or of condom distribution may be far less than the cost of providing health care for a mother and child when births are spaced too closely or for a woman who has repeat abortions. The provider should not think, 'Today I gave 10 women contraceptives.' Instead he or she should say, 'Today I talked with 10 women, and they were satisfied with the information they got and the method they chose.'"
-- Barbara Barnett
References
- Faúndes A. Quality of care in postpartum contraception. Presentation at Family Health International Postpartum Conference, Mexico City, September 1991.
- Balogh SA, Cole LP. Contraceptive services for the postpartum and postabortion woman. In Gynecology and Obstetrics. Eds: Droegemueller W, Sciarra JJ. (Philadelphia: J.B. Lippincott, 1994)6:1-11.
- Huntington D, Nawar L, Abdel Hady D. An Exploratory Study of the Psycho-social Stress Associated with Abortions in Egypt. Final Report. Cairo: Population Council, 1995.
- Ominde A, Makumi M, Billings D, et al. Postabortion Care Services in Kenya: Baseline Findings from an Operations Research Study. New York: Population Council, 1997.
- Arilha M, Barbosa RM. Cytotec in Brazil: 'At least it doesn't kill.' Reprod Health Matters 1993;2:41-52.
- Benson J, Leonard AH, Winkler J, et al. Meeting Women's Needs for Post-Abortion Family Planning: Framing the Questions, Issues in Abortion Care 2. (Carrboro, NC: International Projects Assistance Services , 1992) 7.
- Martínez-Manautou J, Mojarro O, Velasco V, et al. Final Technical Report: Family Planning Based on Reproductive Risk. Mexico City: Instituto Mexicano del Seguro Social, 1989. Providing Family Planning Services on the Basis of Reproductive Risk. Operations Research Family Planning Database Summaries. New York: Population Council, 1993.
- Bruce J. Fundamental elements of high-quality care: a simple framework. Stud Fam Plann 1990; 21(2):61-91.
- Hardee K, Gould BJ. A process for quality improvement in family planning services. Int Fam Plann Perspect 1993;19(4):147-52.
- Vera H. The client's view of high-quality care in Santiago, Chile. Stud Fam Plann 1993; 24(1):40-49.
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