Post-Abortion Family Planning: Post-Abortion Family Planning: A cost-effective best practice A cost-effective best practice for reducing maternal morbidity for reducing maternal morbidity

and mortalityand mortality

Carolyn Curtis, CNM, MSN, FACNMUSAID Postabortion Care Team Leader

Reconvening Bangkok Bangkok, Thailand

March 2010

The Magnitude of the Problem

Each year (worldwide):

• 205 million pregnancies

• 40% of them unplanned

• 137 million women have unmet need for FP

• 20 million unsafe abortions

• 67,000 women die from unsafe abortion: 13% of all pregnancy-related deaths

• Half of all deaths from unsafe abortion are in Asia

Women who seek abortion are:• Married, cohabitating or living in union

(65%)

• Interested in using a contraceptive (50%)

• Repeat aborters (20%) —Kidder, Sonneveldt, Hardee, 2004

Women who seek abortion are:• Married, cohabitating or living in union

(65%)

• Interested in using a contraceptive (50%)

• Repeat aborters (20%) —Kidder, Sonneveldt, Hardee, 2004

Women seek abortion to: postpone pregnancy

or stop childbearing

altogether — Alan Guttmacher, 2007

Women seek abortion to: postpone pregnancy

or stop childbearing

altogether — Alan Guttmacher, 2007

Who Seeks Abortion and Why?

Who Gets Unsafe Abortions and Who Dies from Them?

(WHO,2007)

Percentage distribution of unsafe abortion and associated mortality, by age

14

26 25

18

11

5

18

28

23

17

104

0

5

10

15

20

25

30

<20 20-24 25-29 30-34 35-39 >39

age

pe

rce

nta

ge

Incidence of unsafe abortion Mortality from unsafe abortion

Percentage distribution of unsafe abortion and associated mortality, by age

14

26 25

18

11

5

18

28

23

17

104

0

5

10

15

20

25

30

<20 20-24 25-29 30-34 35-39 >39

age

pe

rce

nta

ge

Incidence of unsafe abortion Mortality from unsafe abortion

USAID’s Postabortion Care ModelThree Core Components of

Postabortion Care

Immediatelydo...

Community Empowerment through Community Awareness and Mobilization

Emergency Treatment

FP Counseling, Provision;

Selected RH (STI,HIV)

What occurs with Postabortion Care ?

Treatment for hemorrhage, sepsis or other complications experienced AFTER miscarriage or induced abortion

Treatment of unmet need for family planning by providing FP counseling and services to PREVENT the next unplanned pregnancy that may result in a repeat abortion

Service delivery model that requires reorganizing services to be effective

32

77

60

20

0

20

40

60

80

100

Using FP before pregnancy (method failure)Desire to space or limit next pregnancyDesired a FP method before leaving facilityLeft facility with FP method

32

77

60

20

0

20

40

60

80

100

Using FP before pregnancy (method failure)Desire to space or limit next pregnancyDesired a FP method before leaving facilityLeft facility with FP method

(Population Council, 2008)

How We Fail Women Who Want PAC FP (Situation Analyses in Dominican Republic, Haiti, Nicaragua,

Population Council, 2008)

• Lack of policies/guidelines

• Lack of organized services to provide FP

• Limited method mix• Lack of IEC materials• Stockouts of

contraceptives

• Lack of counseling on FP methods and availability• Additional charges for FP

Barriers to FP Provision in PAC Services

National National Norms/PoliciesNorms/Policies

• Some cadres not allowed to provide PAC services

• Limitations on who can receive FP (age, # of pregnancies)

• “Poor” location of PAC services

• No FP commodities in budgetHealth System BarriersHealth System Barriers

ProviderProvider

• Negative provider attitude

• Lack of knowledge about rapid return to fertility

• Little to no FP counseling

• Lack of referral for FP methods (if cannot be provided on-site)

ClientClient

Joint Statement on Post abortion FP endorsed by:

- FIGO

- ICM

- ICN

Purpose:

To highlight the

importance of

Family Planning in

Post abortion Care Programs

Key consensus points

• Unmet need for FP is the primary cause of induced abortion

• All postabortion women should receive voluntary postabortion family planning counseling

• A wide range of contraceptive methods, including long acting should be offered

• Postabortion family planning uptake is high when quality services are offered before discharge

• Provision of universal access to postabortion family planning should be a standard of practice for doctors, nurses, and midwives.

• FIGO, ICM and ICN health professionals have a special advocacy role with policymakers and governments

Family Planning Acceptance Rates

40 36

6053

0102030405060708090

100

Nepal (PAC only)(2003-2005)

Senegal (PAConly) 2003-2005)

Family Planning Acceptance Rates

40 36

6053

0102030405060708090

100

Nepal (PAC only)(2003-2005)

Senegal (PAConly) 2003-2005)

• Sites increased from 81 to 433

• 33% increase in number of PAC clients in Nepal and Senegal

• FP acceptance among PAC and other clients almost doubled

• Average cost per facility to decentralize PAC = $2432 USD

Decentralization and Community Mobilization Works!

3

2,034

8,565

22

4,362

13,807

0

2000

4000

6000

8000

10000

12000

14000

Kenya 2005 Kenya 2006

Family Planning Visits - Nakuru District, Kenya - All Clients

No. of facilitiesNo. New FP visitsNo. Returning FP visits

Cost of FP Services Compared to PAC and Abortion Services

FP can be less costly than PAC or abortion services!

Nigeria• PAC consumes 3.4% of total health

expenditures

• Annually, PAC services cost 4 times the cost of contraceptives

Kazakhstan• Abortion services accounted for almost

1% of total public health spending in 2004

• Contraceptives are 3.2 times more cost-effective than abortion services in terms of births averted

• Recognize that PAC is a golden opportunity to address unmet FP and maternal mortality

• Ensure that national guidelines/policies include:– Nurses and midwives as providers of PAC and FP services– Support for decentralization of services to health centers /

dispensaries that have maternities– FP supplies and commodities are in national budgets

• Reorganize services:– to allow PAC services and FP counseling and service

delivery 24 hours/day– To encourage referral for long acting and/or permanent

methods

• Increase access to postabortion FP - move services closer to the community

Evidence Based Recommendations

What’s at Stake?

If contraception were provided to the 137 million

women who lack access:maternal mortality would decline by 25% to 35%.

(Lule, Singh and Chowdhury, 2007)

If contraception were provided to the 137 million

women who lack access:maternal mortality would decline by 25% to 35%.

(Lule, Singh and Chowdhury, 2007)

Postabortion care services

ARE NOT COMPLETE

until you have done family planning counseling

and service delivery!