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!