Post-Abortion Family Planning:
A cost-effective best practice
for reducing maternal morbidity
and mortality
Carolyn Curtis, CNM, MSN, FACNM
USAID 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
Who Seeks Abortion and Why?
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
Who Gets Unsafe Abortions
and Who Dies from Them?
Percentage distribution of unsafe abortion
and associated mortality, by age
percentage
30
25
26
28
20
23
18
15
10
25
18 17
14
11 10
5
5
4
0
<20
20-24
25-29
30-34
35-39
>39
age
Incidence of unsafe abortion
Mortality from unsafe abortion
(WHO,2007)
USAID’s Postabortion Care Model
Three Core Components of
Postabortion Care
Emergency
Treatment
Immediately
do...
FP Counseling,
Provision;
Selected RH
(STI,HIV)
Community Empowerment through
Community Awareness and Mobilization
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
How We Fail Women Who Want PAC FP
(Situation Analyses in Dominican Republic, Haiti, Nicaragua,
Population Council, 2008)
100
80
77
60
60
40
20
32
20
0
Using FP before pregnancy (method failure)
Desire to space or limit next pregnancy
Desired a FP method before leaving facility
Left facility with FP method
(Population Council, 2008)
Barriers to FP Provision
in PAC Services
National Norms/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 budget
Health System Barriers
• Lack of policies/guidelines
• Lack of organized services
to provide FP
• Limited method mix
• Lack of IEC materials
• Stockouts of contraceptives
Provider
• 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)
Client
• Lack of
counseling on
FP methods
and availability
• Additional
charges for FP
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
Decentralization and
Community Mobilization Works!
Family Planning
Acceptance Rates
100
90
80
70
60
50
40
30
20
10
0
• Sites increased
from 81 to 433
• 33% increase in
number of PAC
clients in Nepal
and Senegal
60
53
40
36
Nepal (PAC only) Senegal (PAC
(2003-2005)
only) 2003-2005)
• FP acceptance
among PAC and
other clients
almost doubled
Family Planning Visits - Nakuru District,
Kenya - All Clients
13,807
14000
12000
10000
No. of facilities
No. New FP visits
No. Returning FP visits
8,565
8000
6000
4,362
4000
2,034
2000
0
3
Kenya 2005
22
Kenya 2006
• Average cost
per facility
to decentralize
PAC = $2432 USD
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 costeffective than abortion services in terms of
births averted
Evidence Based Recommendations
• 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
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)
Postabortion care services
ARE NOT COMPLETE
until you have done
family planning counseling
and service delivery!
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Postabortion Family Planning Why be Involved