Improving Postabortion Care in Egypt: A Case Study

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Improving Postabortion Care in Egypt A Case
Study

• Nahla Abdel-Tawab,
• Regional Advisor
• FRONTIERS Program

International Conference on Best Practices
November 20-21,2006 Islamabad
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Abortion a global problem

• According to WHO estimates, up to 15 of
  pregnancy-related mortality worldwide is due to
  abortion.
• 70,000 women die as a result of complications
  following unsafe abortion.

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Why postabortion care

• Providing comprehensive treatment and counseling
  to PA patients is the first step in saving
  womens lives, reducing repeat unsafe abortions,
  helping women to cope with miscarriages and
  improving womens overall health.

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Abortion in Egypt

• The National Maternal Mortality Survey (NMMS,
  2000) showed that abortion (spontaneous or
  induced) accounts for 4 of maternal deaths.
• 11 of pregnancies in 2000 ended in spontaneous
  abortion

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Legal status of abortion in Egypt

• Egyptian law forbids abortion unless the mothers
  life is in imminent danger
• A physician who performs an abortion faces up to
  three years in prison.

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Program for improving postabortion care in Egypt

• In Egypt the Population Council conducted a
  series of OR studies beginning with a small pilot
  study in 1993 followed by other policy-related
  research and interventions to influence policies.

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Elements of Postabortion Care addressed in PC work

• Emergency treatment of incomplete abortion and
  potentially life-threatening complications
• Family planning counseling
• Links between postabortion emergency services and
  the RH health care system

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Emergency Treatment of Incomplete Abortion

• Manual vacuum aspiration under local anesthesia
  e.g. para-cervical block
• Treatment of complications
• Counseling about medical condition as well as
  family planning

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Caseload study

• A 1998 study conducted in 88 public hospitals
  showed that one in every five obstetric
  admissions was for postabortion treatment.
• (Huntington et al., 1998)

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OB/GYN Department Admissions During 30 Day Period
in Egyptian Public Sector Hospitals
Certainly Induced 5
Probably Induced 2
Possibly Induced 58
Spontaneous 35
Type of OB/GYN Admission (n22,656)
WHO Classification Scheme (n4,153 postabortion
patients)
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1994 Pilot Study

• Two sites (El Galaa El Menia hospitals).
• Changes introduced through intensive clinical
  training to use MVA under local anesthesia with
  minimal pain control medications and to provide
  high quality counseling to postabortion patients.

• The study revealed substandard quality of PAC
  services and revealed feasibility of rapidly
  improving outcomes related to both providers and
  patients.

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1995-1998

• A series of OR studies which contributed to the
  growing body of international evidence and
  created an environment for scientific study of
  abortion done in collaboration with EFCF.
• Small scale expansion program
• Caseload study
• Womens perceptions of abortion
• Cost analysis of postabortion services
• Effects of counseling the husbands of
  postabortion patients

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Expansion program

• The pilot study was followed by a small scale
  expansion of services from two hospitals to 10
  hospitals (university, teaching and MOHP).
• The goal of the expansion was to influence
  national policy by engaging high-level policy
  advisors.
• The program also created a pool of experienced
  postabortion care clinicians.

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1998 - 2000

• Follow-up of participating hospitals to ensure
  adherence to improved PAC.
• Institutionalization of improved PAC in selected
  university and teaching hospitals (EFCF)
• Elements of the PAC service delivery package were
  implemented within the MOHPs essential obstetric
  care program.
• MVA is specified as the procedure of choice for
  treatment of incomplete abortion at than 20 weeks
  gestation.

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However,

• The protocol does not use the term postabortion
  but uses bleeding in pregnancy
• The protocol does not emphasize integration of FP
  counseling.

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FRONTIERS work on PAC (2004-2006)

• Creating linkages between safe motherhood and FP
  programs testing two models of providing FP
  services to postabortion patients

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Linking FP with Postabortion Care

• Model I
• Improved PAC FP counseling referral to a FP
  clinic
• Model II
• Improved PAC FP counseling offering FP methods

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Linking FP with Postabortion Care

• Results
• Both models are feasible to implement
• Model II associated with improved quality of
  counseling
• Equal levels of contraceptive use at 3 months
  post discharge (25 - 30)
• Very low acceptance of FP methods on the ward

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Accomplishments

• Accumulating a body of evidence on improving
  postabortion care within the Egyptian context
• Desensitization of policy makers and health
  professionals to the topic of postabortion care
• Paving the way for more interventions for
  improving postabortion care
• Institutionalization of improved PAC in three
  leading university and teaching hospitals
  Following work initiated by the Population

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Accomplishments

• Three hospitals have become training centers on
  improved PAC.
• Improved PAC is now part of the graduate program
  for OB/Gyn in two universities.
• Elements of the PAC service delivery package were
  implemented within the MOHPs essential obstetric
  care program.
• TAKAMOL and FRONTIERS programs currently working
  on integrating family planning counseling into
  service delivery protocols for Emergency
  Obstetric Care.

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Lessons learned

• Positioning the problem within the health care
  domain as opposed to religious, legal or social
  arenas
• Building trust with the government
• Little emphasis on distinguishing between induced
  or spontaneous abortion
• Work with partners e.g. reputable research
  organizations, service delivery CAs, safe
  motherhood and postpartum FP programs

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Remaining challenges

• Ensuring continuity of supplies of MVA
  instruments
• Integration of FP and curative care services
• Integration of PAC within medical and nursing
  school curricula
• Womens empowerment to negotiate number of
  children and timing of pregnancies