Around the world, women with few economic resources undergo unsafe abortion procedures in countries where the procedure is illegal or very costly. Unsafe abortions can be dangerous; approximately 78,000 women die from abortion-related complications each year, accounting for about 13% of the estimated global maternal mortality rate. Countless others suffer long-term health consequences, including infertility.
Postabortion Care (PAC) is a critical health care service that can save the lives of women who suffer from medical complications due to unsafe or incomplete abortions. It is estimated that 20 million women undergo unsafe abortions each year; nineteen million of those women live in developing countries, and the remainder live primarily in Eastern Europe. One third of these women will suffer serious complications, but less than half of them will receive the hospital treatment that they need. Comprehensive, accessible and empathetic PAC services are crucial in order to meet the physical and emotional needs of these women. Ultimately, the goal of comprehensive PAC services is to prevent both unwanted pregnancies and unsafe abortion.
The Five Elements of Comprehensive Postabortion Care
The PAC Consortium a group comprised of reproductive health agencies, including CATALYST Consortium partners and donors, raised awareness of the importance of addressing the consequences of unsafe abortion in the early 1990s. At that time the PAC Consortium identified three key elements of PAC services: emergency treatment of complications, the provision of contraception and family planning services and the establishment of a link between the postabortion visit and reproductive and other health services. In 2002, the PAC Consortium revised this model to include two more elements: general patient counseling and community and service provider partnerships.
The inclusion of community-service partnerships as a key element of postabortion care demonstrates the Consortium's acknowledgment that the accessibility and quality of PAC services is dependent upon community awareness of postabortion care and the willingness of community members to rely upon or to access care at local health care facilities. For communities, partnerships encourage community mobilization, in order to prevent unwanted pregnancies and unsafe abortion and to help women and communities recognize when women have complications that require medical attention. For providers, partnerships can be useful in developing PAC programs that meet the community's expectations and needs.
CATALYST's PAC Programming
Postabortion care is one of CATALYST's primary programmatic areas, and the Consortium's programming reflects an emphasis on increasing the accessibility and quality of PAC services. In working to achieve these goals, CATALYST provides country-level technical assistance and works in collaboration with the PAC Consortium to increase awareness about PAC within the international public health community and to increase the scope of PAC activities worldwide.
The CATALYST Programmatic Model: Applications in Peru and Bolivia
CATALYST's PAC approach is based on the PAC Consortium's "Five Elements of PAC" model and on the "Integral Postabortion Care Services Model," a holistic PAC program developed by Pathfinder International, a CATALYST partner organization. Pathfinder has successfully implemented and scaled up this model in Peru. The integral model incorporates all of the traditional elements of postabortion care and also addresses the need for institutionalization of PAC programming, which is critical for assuring that a program can be scaled up and sustainable.
In both Peru and Bolivia, Pathfinder/CATALYST collaborates with the local Ministries of Health in order to integrate comprehensive, systematized PAC services into the national reproductive health agendas.
Another important component of the Peru and Bolivia programs has been the adoption of Manual Vacuum Aspiration (MVA) as the preferred method for first-trimester uterine evacuation in the event of an incomplete abortion. MVA is safe, effective and poses fewer health risks to the patient--including a reduced risk of uterine perforation--than the traditional means of uterine evacuation, dilation and curettage (D & C). MVA is usually performed as an outpatient procedure. In accordance with U.S. government policy, CATALYST does not use USAID funding to purchase MVA equipment, although this funding can be used to train providers in MVA techniques.
Because of the need for working within the socio-cultural, political and economic context of each country, the general programmatic model takes different forms in different geographic settings. For example, the process of MVA approval in Bolivia took over two years, so Pathfinder/CATALYST staff began implementing other elements of PAC programming, such as family planning and the provision of contraception, prior to MVA approval.
The scope of the programs in Bolivia and Peru also differ. In collaboration with the Peruvian Ministry of Health, Pathfinder-Peru began a pilot PAC program in thirteen hospitals in 1997; since that time, the program has been scaled up to incorporate both hospitals and health centers and also reaching a much broader geographic area.
In Bolivia, PAC services have been included in the national medical insurance package, which necessitates countrywide implementation of PAC programs, in order to assure that services are accessible for all Bolivian citizens. Pathfinder/CATALYST has received USAID funding to implement PAC programs in four of the nine Departments in Bolivia as well as the capital city of La Paz; IPAS has received funding to implement PAC programs in the remaining five departments. PAC providers in 29 hospitals have been trained under the Pathfinder/CATALYST program, with plans to expand to 10 more hospitals in the future.