Postabortion Care

 

Welcome to the programmatic area on postabortion care within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. Postabortion care is one of the subareas found in the women’s health part of the sexual and reproductive health (RH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. Complications of unsafe abortion are a major contributor to maternal mortality and morbidity in developing countries and have been recognized by the international community as a key public health issue. Approximately 22 million unsafe abortions take place annually (World Health Organization, 2012), many of which require medical care for complications. These include retained products of conception that lead to infection and hemorrhage, injury to internal organs, and psychological trauma. Many women also face long-term health problems, such as chronic pain, pelvic inflammatory disease, and infertility. The indicators presented in this area can help inform program managers as the make programmatic decisions related to postabortion care and unsafe abortion. Key indicators to monitor and evaluate postabortion care can be found in the links at left.   Full Text Complications of unsafe abortion are a major contributor to maternal mortality and morbidity in developing countries and have been recognized by the international community as a key public health issue.  Approximately 22 million unsafe abortions take place annually (WHO, 2012), many of which require medical care for complications. These include retained products that lead to infection and hemorrhage, injury to internal organs, and psychological trauma. Many women also face long-term health problems, such as chronic pain, pelvic inflammatory disease, and infertility. Women who have suffered miscarriage (spontaneous abortion) and/or stillbirth may experience some of these complications, and thus also need emergency follow-up treatment (USAID, 2004). Postabortion care (PAC) is widely recognized an a critical practice to address complications related to miscarriage and incomplete abortion and reduce repeat abortions.  As such, PAC has been embraced as a important intervention to improve maternal health, the fifth Millenium Development Goal.  National Ministries of Health, NGOs, international reproductive health (RH) agencies, and donor organizations have increased their efforts to improve access to high quality PAC.   Essential Elements of PAC Community and service provider partnerships for preventing unwanted pregnancies and unsafe abortion, mobilizing resources to help women receive appropriate and timely care for complications from abortion, and ensuring that health services reflect and meet community expectations and needs;Counseling to identify and respond to women's emotional and physical health needs and other concerns;Treatment of incomplete and unsafe abortion and complications that are potentially life-threatening;Contraceptive and family planning (FP) services to help women prevent an unwanted pregnancy or practice birth spacing; andRH and other health services that are preferably provided on-site or via referrals to other accessible facilities in providers' networks. (PAC Consortium, 2002) For most indicators in other sections of this database, the desired direction of the indicator is clear. For example, in HIV prevention, one seeks increased use of condoms and decreased incidence of HIV infections.  By contrast, increased use of PAC services is a more ambiguous indicator of the effectiveness of these services.  A good PAC program may treat an increasing number of cases in the short term; this increase may indicate that improved services are leading more women with complications to avail themselves of the services, or it may mean that the number of poorly performed abortions has increased in the community.  In light of these considerations, the best indicators for effective PAC are increases in the availability and quality of services rather than increases in the use of these services. Methodological Challenges of Evaluating PAC  Data on trends and consequences of abortion and on the prevalence of unsafe abortion are generally difficult to collect. Some national-level RH surveys (e.g.,  DHS and RHS) have asked questions about abortion, but the data have proven unreliable in most cases.  Information on the risks of unsafe abortion for some vulnerable populations is particularly elusive.  Certain  women at high risk for unsafe abortion, such as adolescents and women who are refugees/internally displaced,  may not seek services in the public sector or may have limited access to such services.  Because of restrictive abortion policies in many countries, service providers may be reluctant to keep records of PAC clients, fearing recourse because of it's association with abortion.  As such, the available  data do not cover these groups.  In particular, it would  be useful to know more about contraceptive use and the  magnitude and consequences of unsafe abortion among these groups. Where existing systems for monitoring RH programs exist, they often exclude items related to PAC.  For example, in many countries, the commodities/logistics system or medical supplies list covers commodities related to all aspects of RH programs; yet, rarely do such systems track the procurement and use of manual vacuum aspiration (MVA) instruments used in treating abortion complications. Even a simple count of the number of public and private facilities that provide PAC is often difficult to obtain. To avoid unwanted attention from higher authorities or  to guard the anonymity of the patients involved, many  facilities systematically avoid reporting the number of  cases treated for the complications of abortion under the mistaken belief that PAC is illegal.  To further complicate the problem, abortion-related cases are often classified as hemorrhage or infection, and are thus difficult to identify as abortion-related. Information on the quality of abortion-related care is also difficult to collect.  Methodologies and data collection instruments exist for assessing quality of care (once one identifies facilities providing the services and has permission to conduct an evaluation of the services).  Yet even then, the techniques available for assessing quality for more routine RH services may be more difficult to apply in the case of PAC, given the desire for patient confidentiality and the psychological distress a woman may be experiencing.  In addition, assessment of services is made more difficult by the round-the-clock, emergency nature of the services and the relative low frequency of PAC patient arrivals compared to FP visits or deliveries in maternity settings. Furthermore, most developing country health systems lack guidelines and protocols for PAC, and the international guidance that exists currently is limited and poorly disseminated (WHO, 1995; Rogo, Lema, and Rae, 1999). Determining the impact of unsafe abortion on maternal morbidity and mortality is rarely feasible.  RH programs seek to save the lives and protect the health of women who undergo unsafe abortion. Yet tracking the impact of unsafe abortion on maternal mortality and morbidity is fraught with a double set of challenges.  The first relates to trying to measure abortion accurately.  The second is measuring maternal mortality and morbidity with precision and assigning causes, including unsafe abortion. In short, it is difficult to measure maternal mortality and morbidity, much less the contribution of unsafe abortion to these two outcomes, or of interventions to reduce unsafe abortion. __________ References: WHO.  2012. Safe and unsafe induced abortion - Global and regional levels in 2008, and trends during 1995–2008 USAID. 2004.  Postabortion Care Strategy Paper.  Washington DC: PAC Working Group. Postabortion Care Consortium Community Task Force. Essential Elements of Postabortion Care: An Expanded and Updated Model. Postabortion Care Consortium. July, 2002. WHO. 1995. Complications of Abortion, Technical and Managerial Guidelines for Prevention and Treatment.  Geneva: WHO. Rogo, KO, Lema VM, and Rae GO. 1999.  Postabortion Care: Policies and Standards for Delivering Services in Sub-Saharan Africa.  Chapel Hill, NC: Ipas.

Legal status of abortion

Definition:

 

The legal restrictions that establish the circumstances under which a woman can legally terminate a pregnancy.

Five possible degrees of restrictiveness of abortion laws can exist for a given country (CRLP, 1999):

  1. Abortion is permitted without restriction as to rea­son;
  2. Abortion is permitted on socioeconomic grounds (such laws allow consideration of a woman‘s eco­nomic resources, her age, her marital status, and the number of her living children);
  3. Abortion is permitted to protect a woman‘s mental health, as well as her life and physical health (interpretation of —mental health“ may vary across coun­tries, but it may encompass, for example, the psy­chological distress suffered by a woman who is raped or the severe strain caused by socioeconomic circumstances);
  4. Abortion is permitted to protect a woman‘s life and physical health (such laws may permit abortion on health grounds that may require the threatened in­jury to health be either serious or permanent); and
  5. Abortion is permitted only to save a woman‘s life, or the procedure is banned entirely.

Data Requirements:

 

Text of existing laws

Data Sources:

 

Penal codes, health codes, as well as reports of interna­tional law organizations that monitor the status of abor­tion

Purpose:

 

The purpose of this indicator is to measure the degree to which a woman has access to safe abortion care and postabortion care in a given country. 

Issue(s):

 

Abor­tion laws are just one factor, albeit an important one, which influence access to care. Various policies and the manner in which they are implemented, for example, may be more critical factors than the law(s). (See the following indicator, Policy status of abortion). Fur­thermore, although almost all countries have at least one legal indication (reason) for abortion, induced abor­tion services may be unavailable to the extent allowed by law.

Gender Implications:

 

An estimated 20 million unsafe abortions occur each year and claim the lives of approximately 47,000 women annually (Ipas, 2011). The great majority of deaths from abortion occur in coun­tries where abortion is either illegal, or where abortion is legal, but the status and access uncer­tain enough (such as in India) that women still resort to unsafe abortion. Maternal mortality has been identified as a compelling gender equity and human rights issue, and reduction of maternal mortality is called for in the action plans of nu­merous international conferences and conven­tions. It is difficult to reduce maternal mortality without attention to the toll that unsafe abortion takes. Where abortion is illegal, access to high-quality postabortion care, which includes providing family planning counseling and methods, is critical.

Policy status of abortion

Definition:

 

The policy environment concerning abortion

Policies are defined as including abortion laws but also regulations, guidelines, financial provisions, and cus­tomary practices affecting the delivery of abortion and postabortion care. These policies may be written or unwritten (e.g., informal guidelines) and may clarify how program services should be operationalized and provided at the health system level.

Evaluators can rate the policies on abortion care in terms of four levels of restrictiveness:

  1. Policies that encourage wide availability of abor­tion care, with few restrictions on access;
  2. Policies that allow abortion care to be provided, but with some restrictive provisions;
  3. Policies that significantly restrict access to abor­tion care; and
  4. Policies that prohibit provision of abortion care, except in relatively rare situations.

Similarly, evaluators can classify the level of support for postabortion care by four levels:

  1. Policies that are highly favorable towards the treat­ment of complications from abortion, including complications from illegal abortion;
  2. Policies that are moderately favorable towards postabortion care;
  3. Policies concerning postabortion care that are vir­tually non-existent, and care provided is ad hoc and highly variable; and
  4. Policies that limit women‘s access to postabortion care.

Data Requirements:

 

Information on current policies

Data Sources:

 

Penal codes; special statutes; court decisions; public health regulations and administrative codes; medical and nursing standards; and health care facility protocols

Note: While some policies are written and widely dis­seminated, others are informally developed and imple­mented by health facilities and providers as a matter of customary practice. For these informal policies, inter­views with health care providers and administrators may enable one to determine the prevailing policies in a given geographical setting.

Purpose:

 

Laws specifically addressing when a pregnant woman can have an abortion based on the circumstances of her pregnancy provide an initial indication of the policy environment. Currently, about 62 percent of the world‘s population live in the 64 countries that legally permit abortion either without restriction as to reason or on broad socioeconomic grounds. The remaining 38 per­cent live in countries that have varying degrees of re­striction (CRLP, 1999).

Yet abortion and postabortion care-related laws can be highly misleading with regard to what authorities actu­ally tolerate or encourage, which may be either more or less restrictive than the laws alone would indicate. In some countries, "menstrual regulation," or early abor­tion when pregnancy has not been confirmed, is offi­cially sanctioned and widely available, even though laws on the books are highly restrictive with respect to "abor­tion." In other countries, abortion is legal for a wide range of circumstances, but policies significantly restrict access. For this reason, one must often go beyond the official regulations and determine the actual policy to­ward abortion.

A range of institutions and individuals (e.g., clinical providers, administrative health care personnel, profes­sional associations, judicial authorities) may create and implement policies, which may vary by geographic area or from one health care system/facility to another.  Fur­thermore, policies with a major impact on postabortion care and abortion care may not be formally spelled out, but rather may be developed and carried out on an ad hoc basis.

Examples of the content included in abortion-related policies include:

 

Abortions per 1,000 women of reproductive age

Definition:

This is the abortion rate, representing the number of induced abortions occurring in a specified reference period (e.g., one year) per 1,000 women of reproductive age (15-44 or 15-49).

The abortion rate (AR) is calculated as:

# of abortions                                           x 1000
_______________________________________
Total mid-year population of women 15-44 (or 49)

 

The total abortion (TAR) rate is the total number of abortions a woman will have in her lifetime if current levels persist. This lifetime risk is a cohort measure and can be calculated with period measures (age-spe­cific abortion rates) or approximated by multiplying the abortion rate by the length of the reproductive period (30-35 years), (Bertrand and Tsui, 1995).  Thus, the to­tal abortion rate is calculated as:

TAR= 35 x abortion rate

Where: 35 = # of years of reproductive life span.

Data Requirements:

Total number of induced abortions occurring in a given year or reference period; the enumerated or estimated mid-period population for the same period

Data Sources:

Data on abortions: where abortion laws are liberal, of­ficial statistics are likely to provide the most accurate numbers; where abortion is restricted, data will be less accurate but one may derive estimates from surveys of providers, population-based surveys, hospital-based studies, or a combination of sources.

Census data or projections based on census data usu­ally provide information on the population of women 15-49.

Purpose:

Rates and ratios are two of the most widely used abor­tion measures. They are indispensable statistics for documenting levels of abortion across time and space. The abortion rate is a useful tool in the evaluation of contraceptive services, either for the purpose of setting a baseline or for measuring progress. The abortion rate reflects contraceptive method and user effectiveness, as well as access to services. The rate is less useful than facility-based or other data for the evaluation of demonstration projects or the effects of separate pro­gram components.

Several factors affect the rate: 1) the proportion of women who become pregnant in a year; 2) the likeli­hood a pregnancy is unwanted; and 3) the likelihood an unwanted pregnancy will be terminated. Consequently, increasing effective contraceptive use and thus decreas­ing the number of unwanted pregnancies can lower the abortion rate, while potentially lowering fertility.  On the other hand, if the number of pregnancies is constant but more unwanted pregnancies are carried to term, the abortion rate will also decrease, with the effect of po­tentially increasing fertility.

Like the total fertility rate, the TAR is eas­ily understood and serves as an effective statistic for comparative purposes. The advantage of the TAR is that is takes into account the probability of becoming preg­nant and the probability of terminating each pregnancy throughout the reproductive life cycle. Like the abor­tion rate, a high TAR may indicate several factors, in­cluding the availability and quality (or lack thereof) of contraceptive services. A high TAR may also reflect a high prevalence of traditional contraceptive method use in a given country.

Development of the abortion rate by specific age ranges (such as 15-19 or 24) can also be a useful tool for docu­mentation of those groups at particular risk for abor­tion.

Issue(s):

Rates and ratios are often seriously compro­mised in terms of accuracy.  As stated above, where abortion is restricted, data are likely to be inaccurate. In these circumstances, data may require adjusting for underreporting, misclassification or socioeconomic con­ditions that reflect the safety of clandestine abortion and the likelihood that a woman with complications from an induced abortion seeks and receives treatment. Even in less restricted settings, research has shown that women underreport their abortion experiences. Where judicial reprisal or severe physical or psychological damage is a possibility, accurate reporting is even less likely.  For years, researchers have attempted different methods for collecting sensitive and personal informa­tion at little or no threat to the research subjects. The National Survey of Family Growth in the United States includes computer-assisted inter­views, which maximize a respondent‘s privacy.

Percent of obstetric and gynecological admissions owing to abortion

Definition:

The percent of admissions to an obstetric or gynecological ward at a health care facility due to abortion-related complications for a reference pe­riod (e.g., one-year)

This indicator includes both complications resulting from spontaneous abortion (miscarriage) and those oc­curring as a result of induced abortions.

This indicator is calculated as:

(# of admissions to an obstetric or gynecological ward at a health care facility due to abortion-related complications for a reference pe­riod / Total # of obstetric or gynecological ward admissions) x 100 

Postabortion complications include hemorrhage, local and systemic infection, injury to the genital tract and internal organs, and toxic or chemical reactions from attempts at self-induced or unsafe abortion. This indi­cator omits long-term sequelae (physical impairment, pain, pelvic inflammatory disease, secondary infertil­ity, increased rate of ectopic pregnancy).

Data Requirements:

Counts of women admitted to an obstetric or gynecological ward  health care facility for treatment of abortion-related complications during a ref­erence period

Data Sources:

Special studies or services statistics from health facili­ties providing treatment of abortion complications

Note: In hospitals in developing countries, treatment of abortion complications may be performed in many dif­ferent locations within the facility, such as the gyneco­logical ward, emergency room or operating room; data collection should therefore include admissions from all locations.

Purpose:

This indicator monitors changes in caseloads and has important administrative implications. Evaluators and managers can also use it to track resource use and needs for treatment of abortion-related complications. It also has policy implications in that it is useful for assessing the cost of unsafe, induced abortions to individual hos­pitals or to a national health system. Numbers of ad­missions for abortion complications can also provide denominators for other useful indicators, such as the percentage of PAC patients under the age of 20 or the percentage of PAC patients presenting at 12 or fewer weeks of pregnancy.  In some individual facilities, such as health centers, however, the number of admissions for abortion complications may be small so that calcu­lation of percentages may be inappropriate.

Peru provides an example of current efforts to improve the quality of information about PAC caseloads at pub­lic sector health centers and hospitals in one state. The process involves completion of a standardized clinical history form for each postabortion patient receiving treatment in the facility.  The form requests informa­tion about a limited number of key indicators, such as diagnosis, patient age, evacuation technique used, and duration of pregnancy.  Providers in these facilities are accustomed to completing a similar form for obstetric deliveries, so they have easily adopted the form. Staff are responsible for entering the information into a data­base at each facility, and the Ministry of Health makes the information available for use at the facility, state, and national levels.

This indicator can estimate the extent of induced abor­tion in countries where abortion is restricted. Research­ers have utilized data on abortion-related hospital ad­missions to construct such estimates. Evaluators can extrapolate the number of abortion-related hospital ad­missions to estimate the number of abortions in the population by using a variety of multipliers. These multipliers will be region and country specific. They will vary by the degree of restrictiveness of the legal and social climate, the availability of induced abortion performed by trained providers, the procedures used by clandestine providers, the availability of antibiotics, and the socioeconomic status of the women who undergo abortions. To address the uncertainty related to these multipliers, researchers have suggested using a range of estimates with several different multipliers (Singh and Wulf, 1994).

The best way to collect data for this indicator may be to conduct special studies at specific facilities (e.g., hos­pitals in urban areas). A hospital-based study in Nige­ria indicated that over 75 percent of gynecological ad­missions to hospitals were due to abortion-related causes (Rogo, Lema, and Rae, 1999).

A possible alternative indicator is Percent of women treated for PAC at service facilities who die.

Issue(s):

This indicator includes both complications due to in­duced and to spontaneous abortions. While it is often of interest to distinguish between the two types in order to estimate the number of induced abortions, this infor­mation is often difficult to obtain.  Moreover, many would question the ethics of asking young women if they have had an abortion in restrictive legal settings. Clinical evidence is often inconclusive, and reports may also be heavily biased in restrictive environments. Even where service providers are fairly certain that an abor­tion-related complication results from an induced abor­tion, they may choose not to report this in the records due to a legally and/or socially restrictive environment. This omission results in service data that are potentially misleading in terms of the number of spontaneous ver­sus induced abortions.

Evaluators have used several approaches in attempting to distinguish between spontaneous and induced abor­tions. These approaches range from a series of ques­tions asked of the patient to multipliers based on the biological occurrence of spontaneous abortion to mul­tipliers based on expert opinion of the proportion of hospitalizations due to complications of induced abor­tion.

Number/percent of service delivery points providing postabortion care services by type and geographic distribution

Definition:

The total number and percent of service delivery points (SDPs) providing postabortion care (PAC) services by type of facility (e.g., health center, district hospital, private physician) and geographic location.

Service delivery points should include those in both the public and private health care sectors.

This indicator is calculated as:

# of SDPs of a particular type that deliver PAC services in a given area x 100
_____________________________________________________
Total # of SDPs of that type in the area

 

Postabortion care consists of:

A third component, which does not need to be included in order to be counted for this indicator, is: 

Data Requirements:

Total number, type, and geographic location of facili­ties providing postabortion care services; total number of service delivery facilities by type and location

Data Sources:

National program records; private and NGO records; provider interviews; and observation of services

Purpose:

The purpose of this indicator is to measure the degree to which PAC services are available within a given country. 

Ideally, information collected for this indicator can serve to monitor other key indicators, such as the percentage of facilities offering PAC services in a given region or at a given level of care (e.g., health center, district hos­pitals, and tertiary hospitals). Another alternative in­dicator is the number, type, and geographic distribution of SDPs that have commodities, equipment, and trans­port for postabortion care.

If population figures are available, information collected for this indicator may help determine if the number and type of facilities providing services are sufficient for the population served. Indicators developed by UNICEF, WHO, and UNFPA for monitoring access to emergency obstetric care can provide guidance.

Issue(s):

All countries should be able to moni­tor the availability of PAC services for treatment of abor­tion complications. In countries where abortion is se­verely restricted, evaluators may have difficulty obtain­ing accurate information on all the facilities providing PAC services. Even in countries where abortion laws may be less restrictive, providers (espe­cially private providers) may be less open to admitting that they provide such services because of the stigma attached to abortion and a desire to protect the privacy of their patients.

References:

USAID Core Components of the Postabortion Care Model. USAID, 2011. Accessed in June, 2011.  Available at: http://pdf.usaid.gov/pdf_docs/PNADU081.pdf

Number/percent of practitioners trained in postabortion care by type and geographic distribution

Definition:

The total number and percent of practitioners trained in postabortion care (PAC) by type of specialty and geographic location

As a percent, this indicator is calculated as:

# of practitioners of a particular specialty and practicing in a given area trained in PAC x 100
_________________________________________________________________
Total #  of providers of that specialty practicing in the area (e.g., district)

 

PAC training consists of:

Data Requirements:

Number of practitioners trained in PAC by specialty and geographic location; the number of all providers by spe­cialty and location of practice.

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Data Sources:

National program records; private and NGO program records; and training institution records (e.g., medical and midwifery school records)

Purpose:

The purpose of this indicator is to measure the extent to which practitioners are trained in PAC, which in turn influences the availability of such services.

If denominators by type of practitioner are available, data collected for this indicator may be used to deter­mine the percentage of provider types trained in a given country, for example, the percentage of ob-gyn or gen­eral practitioners or nurse-midwives trained in PAC.

Issue(s):

A limitation of this indicator relates to the follow-up monitoring of practitioners applying their skills to their jobs. Training of providers often takes place in settings such as teaching hospitals. Once providers are assigned to their posts, they may find it challenging to apply the skills they learned. Once providers are spread out geo­graphically in a given country, evaluators may have dif­ficulty routinely monitoring how and whether they are using the skills they learned in training.

Alternative indicators may include:

References:

Postabortion Care Training Course for Primary Health Care Facilities: Trainer's Guide. Arab Republic of Egypt Ministry of Health and Population. 2005.

Percent of service delivery points providing postabortion care services that meet a defined standard of quality

Definition:

Indicators for the Essential Elements of Postabortion CareThe essential elements of postabortion care (PAC) consist of:

While providing these essential elements of PAC at a service delivery point (SDP), the following components of quality should be present:

This indicator is calculated as:

# of SDPs providing PAC services that meet a defined quality standard x  100 __________________________________________________________

Total # of SDPs offering PAC services

 

Data Requirements:

Scores for each facility on data collection instruments developed to assess the quality of services at a network of facilities; for the denominator, counts of SDPs offer­ing PAC services

Data Sources:

Checklists; observation of services; informal patient and provider interviews; and review of facility records such as surgical logbooks for routine monitoring or supervi­sion of the quality of PAC services

Facility audits, patient interviews, and/or observation of patient-provider interaction for more in-depth spe­cial studies

Purpose:

Although measurement of service quality is challeng­ing, managers and providers can use the indicators out­lined in this database and other existing resources to routinely assess their own programs. For instance, there are several specific indicators for quality in Indicators for the Essential Elements of Postabortion Care, developed by the EngenderHealth ACQUIRE project and the PAC Consortium, Essential Elements Task Force (2006.) The type of services available will depend on the level of the facil­ity within the broader health care system. Health care systems should strive to decentralize PAC services so that women have access to emergency care within a rea­sonable time and distance from their homes.

Researchers have conducted a number of PAC opera­tions research projects in Latin America and Africa, tak­ing care to ensure informed consent and protection of patient confidentiality in studies on abortion-related services. This research has documented changes in quality after the introduction of PAC interventions in a variety of health care settings.

Issue(s):

The complexity of clinical service provision requires the monitoring of many aspects of care. Appropriate infection prevention practices, for example, require that providers carry out a number of different steps in the process of clinical care. 

References:

Indicators for the Essential Elements of Postabortion Care. EngenderHealth ACQUIRE project and the PAC Consortium, Essential Elements Task Force. 2006.

Percent of women receiving postabortion care services who receive pain medication prior to the uterine evacuation procedure

Definition:

Of those women receiving either triage, stabilization, or emergency treatment services for complications related to miscarriage or unsafe abortion during the past year, the percentage of women who received pain medication (local anesthetics, analgesics, sedatives, or some combination of these three) prior to the uterine evacuation procedure. If possible, evaluators should disaggregate clients by the following age ranges: 10-14, 15-19, and 20-24.

This indicator is calculated as:

(Number of women who received pain medication prior to the uterine evacuation procedure/ Total number of women receiving postabortion care (PAC) services)x 100

Data Requirements:

Counts of women presenting to a health facility (private office, health center, or hospital) for emergency treatment of abortion-related complications during a one-year period and who received pain medication

Data Sources:

Special studies or service statistics from health facilities providing triage, stabilization, treatment, and/or referral.  If possible, evaluators should disaggregate clients by those 25 years and older and youth (≤ 24).

Note: In hospitals in developing countries, treatment of abortion complications may be performed in many different locations within the facility, such as the gynecological ward, emergency room, or operating room; data collection should therefore include encounters from all locations.

Purpose:

The goal of pain management during PAC is to help women remain as comfortable as possible while minimizing medication-induced risks and side effects. A combination of patient education, verbal support, oral medications, paracervical block and gentle operative techniques provides effective pain relief for most women (Ipas, 2009; WHO 2003). A prospective longitudinal study from 1990–1991 conducted in Harare, Zimbabwe, found that 38 percent of the 834 women treated with manual vacuum aspiration (MVA) for incomplete abortion reported experiencing severe pain during the procedure, but virtually all MVA patients (93.6 percent) received no pain medication (Mahomed et al., 1994). Therefore, the administration of pain medication prior to a PAC procedure to alleviate the woman’s anxiety and discomfort is a critical element of quality of care. 

Pain has both physiological and psychological aspects. Adequate pain management requires medication for physiological pain and counseling for the psychological aspects of pain. This indicator assesses the administration of medication for physiological pain. “Physiologically, there are two types of pain for MVA patients: the deep, intense pain which accompanies the cervical dilation and stimulation of the internal cervical os and a diffuse lower abdominal pain with cramping from the movement of the uterus” (Solo, 2000: 45, 46, 48). Three types of drugs, either singly or in combination, are used to manage pain during abortion: analgesics, which alleviate the sensation of pain; tranquillizers, which reduce anxiety; and anesthetics, which numb physical sensation. In most cases, analgesics, local anesthesia and/or mild sedation supplemented by verbal support and reassurance, are sufficient (WHO, 2012). However, counseling should not be seen as a replacement for alleviation of pain. 

Issue(s):

As mentioned above, pain management also requires counseling, which this indicator does not address.  There may be instances where the provider understood that pain medication should be administered and intended to use it but was unable to due to lack of available drugs.  There may be other instances where a provider administers pain medication, but under- or over-doses due to rationing, inadequate training and/or skills, or the personal belief that women who have induced an abortion should feel pain as a form of punishment for their actions.  In these cases, the PAC client may have received pain medication, but not in compliance with quality of care guidelines.

References:

USAID Postabortion Care Working Group.  “What Works: A Policy and Program Guide to the Evidence on Postabortion Care”.  February 2007.

Castleman L, Mann C.  “Manual Vacuum Aspiration (MVA) for Uterine Evacuation: Pain Management”. Ipas, 2009.

Mahomed et al. A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion, International Journal of Gynecology & Obstetrics, Volume 46, Issue 1, July 1994.

Solo J. Easing the pain: Pain management in the treatment of incomplete abortion, Reproductive Health Matters, Volume 8, Issue 15, May 2000.

"Safe abortion:  technical and policy guidance for health systems (2nd ed.)", WHO, Geneva, 2012.

Number/percent of service delivery points that offer contraception to postabortion care clients

Definition:

The total number and percent of service delivery points (SDPs) offering family planning counseling and methods to postabortion care (PAC) patients.

The numerator includes all SDPs offering family plan­ning after a woman receives treatment of abortion com­plications. The denominator includes the total number of SDPs offering PAC in a given country.

This indicator is calculated as:

# of SDPs offering family planning counseling and methods to postabortion care patients x 100 _________________________________________________________________

Total # of SDPs offering PAC

Data Requirements:

Count of the total number of health facilities offering PAC and total number of health facilities routinely offering family planning to women who have received PAC services

Data Sources:

Service statistics; provider and patient interviews; and observation of services; interviews with patients or ac­tual observation of services (preferred); provider inter­views (useful); logbooks and patient records (potentially useful but often incomplete or inaccurate)

Purpose:

The recovery period after PAC services is an opportu­nity for health providers to offer comprehensive repro­ductive care.

Providers should offer counseling on family planning following any PAC service, because women can regain their fertility as soon as 14 days af­ter an abortion and before the next menses. As an essential element of PAC, before leaving the health facility every woman treated for complications from an abortion should be aware that pregnancy can occur immediately and use of a contraceptive method can prevent an unwanted pregnancy, if the woman wishes a method. For those women who select a method at the time of treatment, counseling should include: assessment of the woman‘s personal situation, contraceptive options (almost all methods can be started immediately following PAC procedures), method use, side effects of the method selected, and resupply options. In countries where STI/HIV/AIDS is prevalent, providers should encourage dual protection (Rogo, Lema, and Rae, 1999).

Possible alternative indicators may include:

Issue(s):

PAC clients should not be referred for family planning.  Contraceptives should be available on site and in the same location (i.e. room or ward) where the PAC services are offered.  If an SDP offers contraceptives as part of PAC, but the client must obtain her chosen method at a  different part of the hospital (which may require more waiting time, more paperwork, and have different hours of operation), this should be a red flag for evaluators to address.   

Percent of postabortion care clients counseled on contraception

Definition:

Of those women receiving either triage, stabilization, referral for emergency treatment, or emergency treatment services for complications related to miscarriage or unsafe abortion during the past year – regardless of location of services – the percentage of women who received  contraceptive  counseling prior to leaving the facility.

This indicator is calculated as:

(Number of women receiving contraceptive counseling/ Total number of women receiving postabortion care services) x 100

Data Requirements:

Counts of women presenting to a health facility (private office, health center, or hospital) for emergency treatment of abortion-related complications during a one-year period.  If possible, evaluators should disaggregate clients by those 25 years and older and youth (≤ 24).

If targeting and/or linking to inequity, classify outlets where counseling is taking place by location (poor/not poor) and disaggregate by area served.  Exit interviews can be conducted with clients to determine client's poverty status.

If possible, evaluators should disaggregate clients by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Special studies or service statistics from health facilities providing triage, stabilization, treatment, and/or referral. 

Note: In hospitals in developing countries, treatment of abortion complications may be performed in many different locations within the facility, such as the gynecological ward, emergency room, or operating room; data collection should therefore include encounters from all locations.

Purpose:

Contraceptive counseling – and provision – are critical elements of postabortion care (PAC).  This is a useful indicator for monitoring if this element of PAC is being provided and where gaps in quality of care may be.  Numbers of encounters for abortion complications can also provide denominators for other useful indicators, such as the percentage of PAC patients under the age of 20 or the percentage of PAC patients presenting at 12 or fewer weeks of pregnancy. In some individual facilities, such as private offices, health huts, health posts, and health centers, however, the number of encounters for abortion complications may be small so the calculation of percentages may be inappropriate.

Issue(s):

This indicator includes both complications due to spontaneous abortion and induced abortions. Service providers often times assume a woman’s future reproductive intentions and her desire for family planning based on whether the abortion was spontaneous or induced abortion.  However, at the time of PAC treatment, counseling should be offered to each woman to help her clarify her reproductive intentions.  Even a woman who has had a spontaneous abortion and wants to become pregnant again immediately, may benefit from delaying a subsequent pregnancy.  

While it is often of interest to distinguish between the two types in order to estimate the number of induced abortions, this information may be difficult to obtain, particularly in a legally and/or socially restrictive environment, or inconsistently recorded.  Moreover, many would question the ethics of asking young women if they have had an abortion in restrictive legal settings. Clinical evidence is often inconclusive, and reports may also be heavily biased in restrictive environments. Even where service providers are fairly certain that an abortion-related complication resulted from an induced abortion, they may not record this. This omission results in service data that are potentially misleading in terms of the number of spontaneous versus induced abortions.  

Percent of deaths related to unsafe abortion

Definition:

The proportion of maternal mortality that can be attributed to unsafe abortion.  Unsafe abortion is defined by WHO as a procedure meant to terminate an unintended pregnancy that is performed by individuals without the necessary skills, or in an environment that does not conform to the minimum medical standards, or both.

This indicator is calculated as:

(Total number of deaths related to unsafe abortion/ Total number of maternal deaths) x 100

Because of the social and political sensitivity surrounding induced abortion, it is very difficult to conduct high-quality research to measure its incidence.  Consequently, there are large evidence gaps in the documentation of abortion incidence and abortion-related morbidity.  The 2010 document, “Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review” by the Guttmacher Institute is a useful resource for calculating this indicator.

Data Requirements:

Country-specific maternal mortality data, best-guess incidence of unsafe abortion

Data Sources:

The number of maternal deaths due to unsafe abortions is usually estimated from community reports or hospital data of abortion deaths as a percentage of all maternal deaths. For some countries national reproductive age mortality surveys and/or official reporting provide data.

National community studies or reporting are assumed to provide the best estimate available and are used without adjustments. For a small number of countries for which no information is available, an assumption is made that they have the same percentage of abortion-related maternal mortality as other countries in the region, or as other countries having similar abortion laws, total fertility rate, contraceptive use, and percentage hospital deliveries, and data can be extrapolated from national or sub-national abortion data using the regional and global estimation process.

Evaluations of available data for a country consider a wide range of abortion research to make appropriate assumptions and adjust as needed to approximate the most probable magnitude of unsafe abortions for a given country.

Purpose:

This indicator measures to what extent unsafe abortion contributes to national estimates of maternal mortality. Unsafe abortion is one of the five major causes of maternal mortality and accounts for 13% of maternal deaths globally but up to 50% in sub-Saharan Africa (Rogo 2004).  It accounts for 70,000 maternal deaths each year and causes a further 5 million women to suffer temporary or permanent disability. (Shah I and Ahman E 2009). Yet unsafe abortion is the most easily preventable and treatable cause of maternal death and disability (Rogo 2004).  The determinants of unsafe abortion include restrictive abortion legislation, poor social support, lack of female empowerment, inadequate contraceptive services and poor health-service infrastructure. 

Unsafe abortions occur primarily in the developing world. In many less developed countries, access to appropriate services at the primary level, a functioning referral system, and the inclusion of quality postabortion care with essential counseling and contraception remains poor or nonexistent (Fawcus SR 2008). Even when such care is available, distance, cost and the stigma often associated with abortion can discourage women from seeking treatment.  Because of these barriers, poor women are the most likely to experience complications from unsafe abortion. The Millennium Development Goal to improve maternal health is unlikely to be achieved without addressing unsafe abortion and associated mortality and morbidity.    

Issue(s):

In countries where induced abortion is restricted and inaccessible, or even where abortion is legal but difficult to obtain, little information is available on abortion incidence and practices. Whether legal or illegal, induced abortion is generally stigmatized and frequently censured by religious teaching. Because of the difficulty of quantifying and classifying abortion in such circumstances, its occurrence tends to be unreported or under-reported. Surveys show that under-reporting occurs even where abortion is legal and, when taking place in clandestine circumstances, it may not be reported at all or declared a spontaneous abortion (miscarriage).  

Abortion statistics are therefore notoriously incomplete, and it is recognized that in countries where induced abortion is restricted or illegal, its magnitude can only be estimated indirectly and with great difficulty. Estimates will have to be adjusted for mis- and under-reporting, as data available from community studies and hospital data will only show the “tip of the iceberg”. The adjustments will largely depend on the methods used for abortion, and on assumptions of its relative incidence in rural and urban areas. Estimates of the incidence of unsafe abortion and resulting maternal mortality have a degree of uncertainty. They should be considered only as best estimates relying on the information currently available.

References:

Singh S, Remez L and Tartaglione A,eds., Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review, New York: Guttmacher Institute; and Paris: International Union for the Scientific Study of Population, 2010.

Shah I. and Ahman E.  “Unsafe abortion: global and regional incidence, trends, consequences, and challenges,” Journal of Obstetrics and Gynaecology Canada (12) 2009: 1149-58.

Fawcus S.R. “Maternal mortality and unsafe abortion,” Best Practice and Research. Clinical Obstetrics and Gynaecology (3) 2008: 533-48.

Guttmacher Institute.  Abortion Worldwide: A Decade of Uneven Progress, 2009.

Rogo K.O. “Unsafe abortion and maternal mortality: is Africa prepared to face the reality?” East African Medical Journal February 2004: 61-62.

Percent of postabortion care clients who left the facility with a contraceptive method

Definition:

Of those women receiving either triage, stabilization, referral for emergency treatment, or emergency treatment services for complications related to miscarriage or unsafe abortion during the past year – regardless of location - the percentage of women who received a modern contraceptive  method prior to leaving the facility.

This indicator is calculated as:

(Number of women who received postabortion care services and a contraceptive method/ Total number of women receiving postabortion care services) x 100

Data Requirements:

Counts of women presenting to a health facility (private office, health center, or hospital) for emergency treatment of abortion-related complications during a one-year period and who left the facility with a contraceptive method. If possible, evaluators should disaggregate clients by those 25 years and older and youth (≤ 24).

If possible, evaluators should disaggregate clients by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Special studies or service statistics from health facilities providing triage, stabilization, treatment, and/or referral. 

Note: In hospitals in developing countries, treatment of abortion complications may be performed in many different locations within the facility, such as the gynecological ward, emergency room, or operating room; data collection should therefore include encounters from all locations.

Purpose:

The provision of contraception is a critical part of postabortion care (PAC).  This is a useful indicator for monitoring if this element of PAC is being provided and where gaps in quality of care may be – either from the provider’s end or in contraceptive commodity security.  Numbers of encounters for abortion complications can also provide denominators for other useful indicators, such as the percentage of PAC patients under the age of 20 or the percentage of PAC patients presenting at 12 or fewer weeks of pregnancy. In some individual facilities, such as private offices, health huts, health posts, and health centers, however, the number of encounters for abortion complications may be small so the calculation of percentages may be inappropriate.

Issue(s):

This indicator includes both complications due to spontaneous abortion and induced abortions. Service providers often times assume a woman’s future reproductive intentions and her desire for family planning based on whether the abortion was spontaneous or induced abortion.  However, at the time of PAC treatment, counseling should be offered to each woman to help her clarify her reproductive intentions.  Even a woman who has had a spontaneous abortion and wants to become pregnant again immediately, may benefit from delaying a subsequent pregnancy.  

While it is often of interest to distinguish between the two types in order to estimate the number of induced abortions, this information may be difficult to obtain, particularly in a legally and/or socially restrictive environment, or inconsistently recorded.  Moreover, many would question the ethics of asking young women if they have had an abortion in restrictive legal settings. Clinical evidence is often inconclusive, and reports may also be heavily biased in restrictive environments. Even where service providers are fairly certain that an abortion-related complication resulted from an induced abortion, they may not record this. This omission results in service data that are potentially misleading in terms of the number of spontaneous versus induced abortions. 

Also an additional issue with increased used of misoprostol for PAC treatment, is that women may not be completing the procedure in the facility.  In these cases, certain methods of contraception, such as IUD insertion, will not be provided before the woman leaves the facility.