Postabortion women should know that fertility returns quickly and consider contraceptive options. Hospital Staff Trained to Provide Family Planning discusses innovative steps taken in a Colombian hospital that treats more than 250 women a month for complications of incomplete abortion.
For women who have undergone abortion, fertility returns quickly -- as early as 14 days. Therefore, it is important that health providers offer postabortion clients timely family planning services so that they may prevent a subsequent unplanned pregnancy.
Family planning is one of the key elements of quality postabortion care, according to a report from international health care experts meeting in Bellagio, Italy.1 Other components of care include emergency treatment for unsafe abortion and related complications, which can reduce maternal mortality and morbidity, and links between emergency care and comprehensive reproductive health services, which can improve women's overall health.
"Beyond medical treatment for the immediate emergency, providers should tell the woman how she can avoid this problem again," says Dr. Khama Rogo, chairman of the Kenya Medical Association and an expert on postabortion care, who attended the Bellagio meeting. "That is the single most important thing. They should tell her there is a way of preventing unwanted pregnancy."
At minimum, providers should inform women that their fertility returns quickly, says Meena Cabral, program officer for the World Health Organization (WHO). "They should be told there are a variety of contraceptive methods that suit their different circumstances and needs," she says. "If the health service cannot provide these methods on site, health workers should provide information on where women can go to obtain them."
Family planning services for post-abortion patients can help avoid future unwanted pregnancies and unsafe abortions, which can reduce maternal deaths. WHO estimates that 20 million women undergo unsafe abortions each year, resulting in 70,000 deaths and thousands of serious health problems due to complications, including infections and infertility.2 Approximately 13 percent of all maternal deaths worldwide are due to unsafe abortion, although the figure is as high as 60 percent in some countries. Unsafe abortion rates are highest in Latin America, Russia and Africa.
Yet, in spite of recommendations that family planning be offered to postabortion patients, counseling and services are often lacking. In Vietnam, nearly half of 500 women treated for abortion complications said they did not receive any information on family planning at the place where they received their abortion.3 In Ghana, a survey of 29 women admitted to district hospitals found that 25 of them were not told before discharge that they could become pregnant as soon as they resumed sexual relations, and only one said she had been told how to obtain contraception when she returned to her community.4 In Oaxaca, Mexico, a survey of 132 postabortion patients found that 58 percent of the women did not receive family planning information. Of the 42 percent who did receive information, 70 percent selected a method -- but nearly half did not receive the method they wanted.5
When family planning services are offered during the postabortion period, women often take advantage of them. In Zimbabwe, one program offers family planning to postabortion women at Harare Central and Parirenyatwa hospitals. Researchers interviewed more than 1,300 women and found that contraceptive acceptance rates increased from 46 percent before the program to 97 percent after it began.6 In Egypt, when family planning was added to one hospital's postabortion services, by referring women to a family planning clinic in the hospital, the percentage of women who said they intended to use contraception increased from 37 percent to 62 percent.7
Emergency services
Better ways to integrate family planning with emergency treatment are needed, experts say. Emergency treatment centers have different goals and deliver health care in different ways than do family planning programs.
"Women with abortion complications come to hospital emergency rooms, not family planning clinics," says Charlotte Hord of Ipas, a U.S.-based organization that provides training in postabortion care. "In emergencies, the focus is on curative services. Family planning is considered preventive care. Most emergency room staff have not had training in family planning, and they do not have methods on site."
An informal assessment in Turkey by AVSC International (AVSC) found that there were no formal links between abortion and family planning services. Typically, postabortion care, reversible family planning methods and sterilization were offered in three separate units of the hospital.8 In Peru, an initial assessment of Ministry of Health hospitals found that postabortion family planning services were rare -- family planning was offered in an outpatient facility and only on weekdays for a few hours per day.
Many other factors can adversely affect access to family planning. They include lack of staff time and training, misinformation among providers about which contraceptive methods can be safely used by postabortion women, provider training that focuses on clinical skills but not on family planning counseling, punitive provider attitudes toward abortion patients, lack of understanding of women's perspectives and needs, failure to acknowledge prevalence of unsafe abortion and the need for family planning, and concern among abortion providers that family planning could ultimately limit their earnings.
In addition, policies that restrict family planning use to certain groups may pose a barrier. For example, adolescents constitute a large number of abortion patients in some public hospitals, yet policies or cultural taboos may prohibit adolescents or unmarried women from obtaining family planning services.
Also, women who have undergone an abortion may not be receptive to counseling, but may be more focused on recovery, their return home, or on preventing family members or legal authorities from knowing about the cause of their hospitalization. In an AVSC study of postabortion patients at three clinics in Colombia, researchers found that women were often too distressed to receive family planning messages. "Even if you have provider interest and family planning methods available, many women are too nervous, upset, distracted before the surgical procedure," said Andrea Eschen of AVSC.
Although all postabortion women should understand that fertility returns quickly, they should not be asked to make a decision about long-acting, permanent or provider-dependent methods if they are in pain, under stress, or simply not ready. Ipas recommends offering temporary methods to these women, such as condoms, and making arrangements for them to consider other options later. Health workers should inform all women about where to obtain contraceptives in their communities. Experts also emphasize that a woman's acceptance of family planning should never be a prerequisite for treatment of abortion complications.
Remember counseling
At the Ahmadu Bello University Teaching Hospital in northern Nigeria, a sign on the wall says: "Doctors: Remember to counsel your patients about family planning." The hospital offers on-site family planning information and services to postabortion clients. In the past three years, approximately 40 percent of postabortion patients leaving the hospital have accepted a family planning method, compared with Nigeria's national contraceptive prevalence rate of 6 percent.9
In providing family planning services to postabortion clients, information and counseling are critical. However, providers should begin the process of counseling by asking a woman about her needs and goals, not by providing her with a list of contraceptive choices.
"Providers should ask themselves, 'How will the information I solicit assist the woman in meeting her goals?' " says Dr. Karen Stein of the Population Council, who has studied postabortion counseling extensively. "They should ask if she was using family planning at the time of her unintended pregnancy. For a woman who was using a method, they should ask if she wishes to continue. What in her circumstances could be changed to help her use the method more successfully? If she does not wish to continue the same method, what information does she need about a new method, about the practicalities of how it will work in her life, how this method will impact on her life?"
For example, a diaphragm requires cleaning and storage, which may not be available to some women. Injectables and the subdermal implant Norplant can alter bleeding patterns, which may be a concern to some women whose religious beliefs require that they be isolated when bleeding occurs.
Providers can use "decision trees," flow charts that contain a series of questions for clients, with directions for actions the provider can take based on client responses. In one decision tree chart, clients are first asked if they were using a contraceptive method at the time they became pregnant. Those who were and want to continue the same method are asked to repeat the directions for correct use and are given a chance to ask questions. Those who want a new method, or those who were not using contraception, are given condoms and are scheduled for further counseling or services.10
In addition to training in counseling techniques, providers must also have accurate, up-to-date knowledge of contraceptive methods. In general, women should be encouraged to abstain from sexual relations until vaginal bleeding stops. Afterward, any modern method can be used.11
Counseling about correct and consistent use of contraceptives is critical since several studies among postabortion women found they were using a family planning method at the time they became pregnant. In Vietnam, 60 percent of 500 women surveyed said they were using contraception -- predominantly condoms or withdrawal -- at the time they became pregnant.12 A study of 455 women admitted to hospitals in Tanzania for abortion complications found problems among those using contraceptives at the time they became pregnant. Some, for example, borrowed oral contraceptive pills from friends and used them only before sexual intercourse.13
Hospital Staff Trained to Provide Family Planning
In Cali, Colombia, staff at the Hospital Universitario del Valle treat more than 250 women a month for complications of incomplete abortion. Many of the women they see are repeat clients.
"We have many, many patients we have attended three or four years ago and we are attending them again," says Dr. Angela Torres, an obstetrician-gynecologist. "Some patients are not using any method of contraception. Some are using a method but using it incorrectly. ... We see women who think they will not become pregnant if they drink seven glasses of water after intercourse."
The Hospital Universitario, a large tertiary-care center located in the southern part of the country, is a referral point for many women from Colombia's rural areas. The ages of postabortion patients range from as young as 12 to older than 49. Fourteen percent of these patients are under the age of 20.
Staff struggle to provide care for all the women who need it. Women who come to the hospital with nonseptic, spontaneous abortion (miscarriage) may wait hours to been seen. Depending on the availability of an anesthesiologist, the waiting time for dilation and curettage can be up to three days. A woman treated for septic abortion may be hospitalized 24 to 84 hours for mild to moderate complications, but longer if the problems are more severe.
In the past, family planning information was offered sporadically to postabortion clients. Discussions about family planning often depended on the individual provider's interest and knowledge of contraception. Patients are reluctant to initiate discussions. Some do not approve of family planning, while others may lack money to pay for family planning services or do not know how to obtain them once they return to their communities.
A routine part of care
With the help of the secretary of health, the hospital has recently introduced a new program designed to make family planning a routine part of postabortion care, as well as postpartum services. The hospital staff offers counseling and provides contraceptive methods before women return home. They also tell women where in their own communities that can obtain additional contraceptive supplies. Because the hospital's operating room is always busy, female sterilization is scheduled at a secondary level hospital. And the hospital provides information on correct use of modern and traditional methods as well.
A variety of staff members -- physicians, nurses, volunteers -- have been trained to provide family planning information. "Many people interact with the patient," says Dr. Torres. "We don't want them to have to say, 'I don't know. You'll have to wait.'"
In addition, the hospital is working to improve the interaction between providers and clients. "Providers may have punitive attitudes toward postabortion patients," says Dr. Torres. "Patients' fear of punishment by providers may make them reluctant to come to the hospital in the first place."
For postabortion patients, the hospital emergency department may be their only encounter with the health-care system. Therefore, staff must use this opportunity to educate women about family planning options, Dr. Torres says.
The hospital is paying special attention to the needs of rural women. "We want to make sure these women get information about family planning that suits their lifestyle and their attitudes," Dr. Torres says. "In dealing with indigenous groups, the hospital is new, all the information is new."
To help women who may want contraception, the staff gives each woman a card. On the card is a calendar, marked with the date of the woman's next anticipated menses. Staff explain that in order to prevent pregnancy, the woman must begin using a family planning method before menses begins. Many rural women prefer traditional family planning methods. "We explain how to used these methods correctly, but we tell them if they change their minds, they can use a modern contraceptive method, too."
-- Barbara Barnett
Other concerns
Counseling for postabortion women should include information about complications that necessitate a return visit to a health-care provider -- fever, chills, abdominal pain or cramping, backache, prolonged or heavy bleeding, a foul-smelling vaginal discharge, or a delay (six weeks or more) in the return of menses. Providers should also help the client assess her risks of sexually transmitted disease and the risks of her partner.
"In Guatemala, when women returned three to five days after abortion, we asked them how they were feeling, and they said fine," says Dr. Emma Ottolenghi, a consultant with the Population Council. "Then we asked, 'Are you having any unusual vaginal discharge?' and they said, 'Oh, yes, but that's normal.' We asked, 'Are you having any pain?' and they said, 'Oh, yes, but that's normal, too.' It is not normal, and that is what we need to focus [counseling] on."
An important factor to examine when incorporating family planning into postabortion care is service delivery. Several options under study include decentralized services, formal referral procedures between hospitals and family planning programs, and use of traditional birth attendants or midwives to provide contraceptives.
"At many hospitals, the family planning clinic is far away from the acute obstetric/gynecology ward, so referrals are not always effective or appropriate," says Michelle Folsom, who works with the U.S. Agency for International Development (USAID) in east and southern Africa. "Staff in the obstetric/gynecology ward need to be trained in family planning counseling and service delivery, and encouraged to integrate family planning into their routine care."
One recommendation from the Bellagio conference is to provide abortion care in the context of other reproductive health services, whether services are provided on-site or clients are referred to other facilities or agencies. For example, providers could offer screening for sexually transmitted diseases or could refer women who are victims of domestic violence to other programs.
In Kenya, researchers are examining different ways of providing family planning to postabortion clients in six hospitals. The Population Council, in collaboration with Ipas, Kenya Ministry of Health and the Family Planning Association of Kenya, is trying to determine which model of family planning delivery is most effective: family planning services provided in the hospital ward by gynecology staff; services offered in the hospital but provided by staff from the hospital's family planning clinic; or services offered at the family planning clinic. At Nyeri Provincial Hospital, for example, staff escort patients from the gynecology ward to a family planning clinic, where they receive counseling and may choose a family planning method. A survey of patients and staff found both groups were satisfied.14
In the Araucanía region of southern Chile, Temuco Regional Hospital discontinued family planning services for postabortion women, believing it would be more cost-effective to provide services in another setting, such as a local health-care center. An assessment conducted by Ipas, however, found that some postabortion patients do not go to a health center for a follow-up visit and, consequently, do not obtain family planning services. The hospital has since reintroduced family planning services.15
Because many women who have complications from abortions do not come to hospitals for treatment, programs in several African countries are examining alternative ways to deliver family planning information, including the use of midwives and traditional birth attendants. In Uganda, midwives at the Mulago Hospital have been trained to provide postabortion family planning counseling.16 In Tanzania, nurses participated in a pilot training program to enable them to provide family planning counseling to postabortion clients.17 In Ghana, where unsafe abortion is considered the greatest cause of maternal death, midwives are being trained to provide postabortion services, including family planning. "Midwives live in the community and can best relate with them [female patients], thus making women patronize the services more than before," said one hospital midwife supervisor.18
-- Barbara Barnett
References
Wolf M, Benson J. Meeting women's needs for postabortion family planning. Report of a Bellagio Technical Working Group. Int J Gynecol Obstet 1994;45 (Suppl):S3-33.
World Health Organization, Division of Family Health, Maternal Health and Safe Motherhood Programme. A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion. 2nd edition. Geneva: World Health Organization, 1993.
Katz K, Waszak C, Hieu DT, et al. Assessment of postabortion family planning services in Vietnam. Presentation at the American Public Health Association meeting, San Diego, Oct. 30-Nov. 2, 1995.
Ghanaian Ministry of Health, Ghana Registered Midwives Association, International Projects Assistance Services. Training Non-physician Providers to Improve Postabortion Care: Baseline Assessment of Postabortion Care Services in Four Districts of Eastern Region, Ghana. Carrboro, NC: International Projects Assistance Services, 1997.
Barahona V, Casas B, Ramírez F, et al. Improvement of Postabortion Services in the Mexican Health System. Postabortion Summary #2. Latin American Operations Research Summaries. New York: Population Council, 1996.
Mahomed K, Healy J, Tandon S, et al. Improved treatment of abortion complications and postabortion family planning in Zimbabwe. Presentation at the American Public Health Association meeting, Washington, November 8-12, 1992.
Improving the Counseling and Medical Care of Postabortion Patients in Egypt. Final Report. Cairo: Egyptian Fertility Care Society and Population Council, 1995.
Neamatalla GS, Verme CS. Postabortion Women: Factors Influencing their Family Planning Options. AVSC Working Paper No. 9. New York: AVSC International, 1995.
Benson J, Leonard AH, Winkler J, et al. Meeting Women's Needs for Postabortion Family Planning: Framing the Questions. Issues in Abortion Care 2. Carrboro, NC: International Projects Assistance Services, 1992.
Toubia N. Decision trees to guide post-abortion family planning counseling -- alternative approaches determined by women's abortion history. Int J Gynecol Obstet 1994;45(Suppl):S25-27.
Greenslade FC, McLaurin KE, Leonard AH. Reproductive health approach to family planning. Presentation at USAID Cooperating Agencies Meeting, Washington, February 25, 1994.
Katz.
Mpangile GS, Leshabari MT, Kihwele DJ. Factors associated with induced abortion in public hospitals in Dar es Salaam, Tanzania. Reprod Health Matters 1993;2:21-31.
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.
IPAS. Southern Chile. Latin America Reports. Carrboro NC: International Projects Assistance Services, 1996.
IPAS. Uganda. Africa Reports. Carrboro NC: International Projects Assistance Services, 1995.
IPAS. Tanzania. Africa Reports. Carrboro NC: International Projects Assistance Services, 1995.
Ghanaian Ministry of Health.
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