PAC%20IN%20SUBSAHARAN%20AFRICA%20%20%201

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PAC IN SUBSAHARAN AFRICA 1

• The New Developments
• By
• Dr. Solomon Orero MD
• Consultant Obstetrician/ Gynaecologist
• KMET/CSA
• KENYA
• February 2003

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PAC IN SUBSAHARAN AFRICA 2

• B.A 37 years old para 7 1 LD 5 years ago, last
  abortion a year ago. A known diabetic controlled
  on Lente Insulin and diet. As at 7.2.2003 she had
  been admitted for poorly controlled Diabetic. She
  was 8 weeks pregnant. Her last abortion was an
  elective abortion on an understanding that with 7
  living children, 5 boys and 2 girls. Chronic
  Diabetic poorly controlled and a housewife. This
  time round she would have an elective abortion
  and BTL. Her husband was not in at the time. He
  arrived just when we were in theatre about to
  perform the two procedures!! We did neither of
  the procedures as we were unable to convince the
  man it was for the benefit of his wife nor could
  he accept vasectomy. He refused!!

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• Issues
• Decision making in RH and Health in general
• Decision making linked to economic empowerment
• Decision making linked to cultural norms and
  practices

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• A woman who has decided to procure an abortion
  will go ahead and have it irrespective of any
  other opinions to the contrary, the risks to her
  life not withstanding.
• PROVIDERS

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• In spite of the high fertility rates in Sub
  Saharan Africa, contraceptive prevalence is very
  low. It has been found that 30 of women control
  their fertility by a combination of
  contraceptives and abortion and 3 use abortion
  only as a means of fertility control.

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• Unsafe abortion is preventable yet remains a
  significant cause of Maternal Mortality in Sub
  Saharan Africa.

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• GLOBALLY
• 53 million abortions occur annually
• 20 million unsafe abortion occur annually
• 96 of unsafe abortions in Africa are unsafe
• 85 of abortions in Latin America unsafe

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Reasons for Procuring Abortion 8

• Education career
• Peer pressure and feared parental reaction
• Partner pressure, refusing to recognize child
• Birth spacing or limiting all together
• Owner of pregnancy
• Parents, Age mate, Incest

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Methods used for Procuring Abortion 9

• Sharp objects
• Knitting needles, bicycle wires
• Plant stems
• Concoctions
• Strong juices, Liquid soap, overdose of drugs,
  Herbals
• Vaginally inserted laundry detergents
• Ground glass gulped as powders

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Decision Making for Abortion 10

• When a woman becomes pregnant in Sub-Saharan
  Africa whether or not that pregnancy is wanted
  and the subsequent events that follow may not
  entirely be her decision.

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The Characteristics of the Woman who has Unsafe
Abortion 11

• Most likely, student, unemployed, Christian,
  given false identity

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In Private Sector 12

• Single, educated, Employed,
• Married, not known to partner

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Impact Consequences of Unsafe Abortion
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• 30 54 of all Maternal Mortality due to Unsafe
  Abortion
• 50 62 Bed occupancy of all Gynecological Ward
  Admissions
• Requires Expert Care to Correct damages
• Chronic Morbidity
• Infertility and its Associated Problems in the
  African Context

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Response and Management of Unsafe Abortion
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• In Sub Saharan Africa the distance a woman has
  to walk to access safe abortion services in the
  public health sector is like the distance between
  heaven and earth you have to die to reach there.
  Khama Rogo 1993

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Response and Management of Unsafe Abortion
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• On reflection at some of the answers we have
  given women who seek abortion services in the
  public health sector the statement unfortunately
  is very predictive!

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Response and Management of Unsafe Abortion
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• Mum, young lady, in this hospital we only treat
  women who are already aborting, we dont start it
  here, the law does not allow! The message by
  that answer is clear! Go and induce it by
  whatever means and then come back! The case of
  the women who have suffered unsafe abortion for
  along time has been to say the least unfortunate.
  The waiting time averaged 12 hours quite often
  days to one week, the attitude of the staff
  appalling the efficiency disgusting the
  interaction and communication just simply inhuman!

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The Evolution of PAC Services in Sub-Saharan
Africa 17

• Defining and Embracing PAC Services
• Emergency treatment of those who have suffered
  abortion complications or who potentially can
  suffer life threatening complications
• Providing Post abortion Family Planning
  counseling and services
• Referral and linkages of the women who require
  other RH services to the appropriate facilities
  or other practitioners.
• Community Involvement in RH service including
  Abortion Care services.
• The embracing of the PAC concept has had the
  effects of-
• Decentralizing abortion care from theatre to
  procedure rooms
• Embracing the use of simpler technologies in
  evacuating the uterus of its contents
• Decentralizing abortion care from the Doctor to
  other appropriate staff
• Providers shift in attitude
• Looking at effective ways of providing all the
  components of PAC

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The KMET Experience 18

• Abortion Care in the Private Sector
• The Collaboration between Various Cadres of
  Health Providers
• The Decentralization of PAC from the Doctor to-
• the MLPS
• the CBHWKS
• The Collaboration between the Private Sector and
  the Public Sector

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The Evolution of KMET Participating
Practitioners Network
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• Consultant Physicians
• (OB/GYNS)
• General Practitioners
• Mid Level Providers
• (Clinical Officers/Nurse Midwives)
• Community Based Health Workers
• (CBDS, TBAS, CHES, Herbalists)
• Annual Meetings
• Linkages and cross referrals
• Respect and attitudinal change

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19 (1)
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19 (2)

• Congressman Jim Greenhood visiting KMET PPNW
  Programme. August, 2002

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Lessons Learnt from KMET Training 20

• Dr. Orero during a training session. A
  participatory practical competency based training.

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20 (1)

• Participants practical session during PAC
  training

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20 (2)

• PD Monica during a class PAC training session

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20 (3)

• PAC room rearranged simply for use after
  training in a public facility Designed by KMET

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20 (4)

• A cupboard for storage in a training facility
  Designed by KMET

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Lessons Learnt from KMET 20 (5)

• PAC in the private sector is doable.
• Quality training in all elements of PAC is
  mandatory
• It is possible to MLPS and Doctors together under
  the same programme KEY to success supportive
  facilitative supervision, monitoring and
  evaluation
• CBHWKs can be good advocates for PAC and FP
  especially ECP
• All cadres of health providers in RH can come
  together and discuss RH issues

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20 (6)

• A simplified procedure bed for MVA

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20 (7)

• KMET Established a model Clinic in a Peri-urban
  Kisumu City

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20 (8)

• KMET collaborate with many partners PIWH, PPFA
  Bucks county Pennsylvania

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Comparisons and Replications 21

• Sub-Saharan African Countries
• Ghana Ghana midwives
• Uganda PRIME DISH
• Kenya PRIME I, II, III, UNFPA, Engender
  Health, AMKENI, MOH
• Ipas/MYWO

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Study Tours To KMET

• Students for choice USA
• Ethiopia Ipas
• Ipas Chapel Hill NC
• Zimbambwe, Uganda, Nigeria, Mozambique, Sudan,
  Cameroun

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COBAC 23

• PIWH/CSA - COBAC 1996 2000
• Research on community Based Abortion Care
• Results Peer Review Journal
• Dramatized Koso and Naki
• Film/ Video The Great Betrayal

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Themes for Discussion after the Video 24

• Decision making on abortion the dilemma of the
  victim
• The cost of accessing safe and unsafe abortion
• The role of men in abortion care as culprits,
  financiers, support in its various forms
• The role of clinical service providers either as
  perpetrators of the high incidence of unsafe
  abortion or as potential promoters of safe
  abortion care services
• The roles of informal providers in abortion care
  The herbalists, the CBDS, the CBHES, the CBHWKS,
  the TBAs.
• The role of Gate Keepers in the community in
  abortion care
• The role of the community itself in abortion care
• The role the legal system and policies in
  Abortion care

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The Post Research Intervention Opportunities
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• Putting PAC services in place through physical
  facilities improvement in both the public and
  private sector
• Training of Clinical Service Providers in
  comprehensive Post Abortion Care Services
• Community sensitization, education and
  mobilization by using the established structures
  of CBDS, Herbalists, TBAs, Government
  Administrative Structures, CBOs and organized
  groups especially women groups
• Advocacy at the community level for timely
  utilization of health services for RH services
• Development of IEC materials
• Continuous follow up monitoring and evaluation

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The Evolving COBAC Intervention Model- 26

• This model aims at community level initiatives
  with the sole focus on-
• Complimenting and strengthening existing PAC
  efforts
• Collaborate with the MOH, Community Social and
  Health care networks
• The whole intervention is geared towards
  addressing Abortion issues and their contribution
  to Maternal Mortality. At the community level
  initiative we are addressing the community norms,
  values and attitudes, discussing laws and
  policies regarding abortion, their
  interpretation, Health service provision.

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The Policy Arena 27

• Safe motherhood
• The ICPD platform of action
• Advocacy campaigns
• The legal Environment
• The services provision, availability and
  sustainability

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• M.A. 18 yrs old, a house girl works 450 Kms from
  home. Got pregnant. Had an unsafe abortion. Who
  did it could not differentiate the anus from the
  vagina. Destroyed anus, rectum, bladder, uterus,
  intestines. The woman lost her uterus, fertility,
  and to add insult to injury she ended up with a
  permanent COLOSTOMY! She survived but at what
  cost? Another preventable statistics. My heart
  bled for her as we repaired what was left of her
  womanhood

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• YES movement forward 2 decades later
• Progress to a large extent in pilot programmes
• ACCESS/special populations
• Support/ NGOS/ Religious Based Organizations
• Sustainability
• Legal environment
• Integration
• Adoption of technological change
• EOC Guidelines include PAC

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Way Forward 30

• Overcome culture of silence
• Condemnation from sex
• The issues of war health
• Scaling up
• Process
• Resource mobilization
• Attitude
• Challenge
• Legal environment
• Existing social groupings
• Training, supervision, M E
• Introduction of PAC in Basic MLPS training
  Institutions