PAC IN SUBSAHARAN AFRICA 1

The New Developments

By

Dr. Solomon Orero MD

Consultant Obstetrician/ Gynaecologist

KMET/CSA

KENYA

February 2003

PAC IN SUBSAHARAN AFRICA 2

B.A 37 years old para 7 + 1 LD 5 years ago, last abortion a year ago. A known diabetic controlled on Lente Insulin and diet. As at 7.2.2003 she had been admitted for poorly controlled Diabetic. She was 8 weeks pregnant. Her last abortion was an elective abortion on an understanding that with 7 living children, 5 boys and 2 girls. Chronic Diabetic poorly controlled and a housewife. This time round she would have an elective abortion and BTL. Her husband was not in at the time. He arrived just when we were in theatre about to perform the two procedures!! We did neither of the procedures as we were unable to convince the man it was for the benefit of his wife nor could he accept vasectomy. He refused!!

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Issues

Decision making in RH and Health in general Decision making linked to economic

empowerment Decision making linked to cultural norms and

practices

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“A woman who has decided to procure an abortion will go ahead and have it irrespective of any other opinions to the contrary, the risks to her life not withstanding.”

“PROVIDERS”

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In spite of the high fertility rates in Sub Saharan Africa, contraceptive prevalence is very low. It has been found that 30% of women control their fertility by a combination of contraceptives and abortion and 3% use abortion only as a means of fertility control.

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“Unsafe abortion is preventable yet remains a significant cause of Maternal Mortality in Sub Saharan Africa.”

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GLOBALLY:

53 million abortions occur annually 20 million unsafe abortion occur annually 96% of unsafe abortions in Africa are unsafe 85% of abortions in Latin America unsafe

Reasons for Procuring Abortion 8

Education & career Peer pressure and feared parental reaction Partner pressure, refusing to recognize child Birth spacing or limiting all together Owner of pregnancy

– Parents, Age mate, Incest

Methods used for Procuring Abortion 9

Sharp objects– Knitting needles, bicycle wires– Plant stems

Concoctions– Strong juices, Liquid soap, overdose of drugs,

Herbals Vaginally inserted laundry detergents Ground glass gulped as powders

Decision Making for Abortion 10

“When a woman becomes pregnant in Sub-Saharan Africa whether or not that pregnancy is wanted and the subsequent events that follow may not entirely be her decision”.

The Characteristics of the Woman who has Unsafe Abortion 11

Most likely, student, unemployed, Christian, given false identity

In Private Sector 12

Single, educated, Employed,

Married, not known to partner

Impact & Consequences of Unsafe Abortion 13

30 – 54% of all Maternal Mortality due to Unsafe Abortion

50 – 62% Bed occupancy of all Gynecological Ward Admissions

Requires Expert Care to Correct damagesChronic Morbidity Infertility and it’s Associated Problems in

the African Context

Response and Management of Unsafe Abortion: 14

“In Sub Saharan Africa; the distance a woman has to walk to access safe abortion services in the public health sector is like the distance between heaven and earth you have to die to reach there.” Khama Rogo 1993

Response and Management of Unsafe Abortion: 15

On reflection at some of the answers we have given women who seek abortion services in the public health sector the statement unfortunately is very predictive!

Response and Management of Unsafe Abortion: 16

“Mum, young lady, in this hospital we only treat women who are already aborting, we don’t start it here, the law does not allow!” The message by that answer is clear! “Go and induce it by whatever means and then come back!” The case of the women who have suffered unsafe abortion for along time has been to say the least unfortunate. The waiting time averaged 12 hours quite often days to one week, the attitude of the staff appalling; the efficiency disgusting the interaction and communication just simply inhuman!

The Evolution of PAC Services in Sub-Saharan Africa 17

Defining and Embracing PAC Services

Emergency treatment of those who have suffered abortion complications or who potentially can suffer life threatening complications

Providing Post abortion Family Planning counseling and services Referral and linkages of the women who require other RH services to the

appropriate facilities or other practitioners. Community Involvement in RH service including Abortion Care services.The embracing of the PAC concept has had the effects of:-

Decentralizing abortion care from theatre to procedure rooms Embracing the use of simpler technologies in evacuating the uterus of its’

contents Decentralizing abortion care from the Doctor to other appropriate staff Providers shift in attitude Looking at effective ways of providing all the components of PAC

The KMET Experience 18

Abortion Care in the Private Sector The Collaboration between Various Cadres of

Health Providers The Decentralization of PAC from the Doctor to:-

– the MLPS– the CBHWKS

The Collaboration between the Private Sector and the Public Sector

The Evolution of KMET “Participating Practitioners Network” 19

Consultant Physicians(OB/GYNS)

General Practitioners

Mid Level Providers(Clinical Officers/Nurse Midwives)

Community Based Health Workers

(CBDS, TBAS, CHES, Herbalists)

Annual Meetings Linkages and cross referrals Respect and attitudinal change

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19 (2)

Congressman Jim Greenhood visiting KMET PPNW Programme. August, 2002

Lessons Learnt from KMET – Training 20

Dr. Orero during a training session. A participatory practical competency based training.

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Participants practical session during PAC training

20 (2)

PD – Monica during a class PAC training session

20 (3)

PAC room rearranged simply for use after training in a public facility Designed by KMET

20 (4)

A cupboard for storage in a training facility Designed by KMET

Lessons Learnt from KMET 20 (5)

PAC in the private sector is “doable”. Quality training in all elements of PAC is mandatory It is possible to MLPS and Doctors together under the

same programme “KEY” to success – supportive facilitative supervision, monitoring and evaluation

CBHWKs can be good advocates for PAC and FP especially ECP

All cadres of health providers in RH can come together and discuss RH issues

20 (6)

A simplified procedure bed for MVA

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KMET Established a model Clinic in a Peri-urban Kisumu City

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KMET collaborate with many partners – PIWH, PPFA Bucks county Pennsylvania

Comparisons and Replications 21

Sub-Saharan African Countries

Ghana – Ghana midwivesUganda – PRIME –DISHKenya – PRIME I, II, III, UNFPA,

Engender Health, AMKENI, MOH– Ipas/MYWO

Study Tours To KMET

Students for choice – USAEthiopia – IpasIpas – Chapel Hill NCZimbambwe, Uganda, Nigeria,

Mozambique, Sudan, Cameroun

COBAC 23

PIWH/CSA - COBAC 1996 – 2000

Research on community Based Abortion Care

Results – Peer Review JournalDramatized – “Koso and Naki”Film/ Video – “The Great Betrayal”

Themes for Discussion after the Video 24

Decision making on abortion the dilemma of the victim The cost of accessing safe and unsafe abortion The role of men in abortion care as culprits, financiers, support in its

various forms The role of clinical service providers either as perpetrators of the

high incidence of unsafe abortion or as potential promoters of safe abortion care services

The roles of informal providers in abortion care “The herbalists, the CBDS, the CBHES, the CBHWKS, the TBAs.

The role of Gate Keepers in the community in abortion care The role of the community itself in abortion care The role the legal system and policies in Abortion care

The Post Research Intervention Opportunities 25

Putting PAC services in place through physical facilities improvement in both the public and private sector

Training of Clinical Service Providers in comprehensive Post Abortion Care Services

Community sensitization, education and mobilization by using the established structures of: CBDS, Herbalists, TBAs, Government Administrative Structures, CBOs and organized groups especially women groups

Advocacy at the community level for timely utilization of health services for RH services

Development of IEC materials Continuous follow up monitoring and evaluation

The Evolving COBAC Intervention Model:- 26

This model aims at community level initiatives with the sole focus on:-

Complimenting and strengthening existing PAC efforts Collaborate with the MOH, Community Social and Health care

networks

The whole intervention is geared towards addressing Abortion issues and their contribution to Maternal Mortality. At the community level initiative we are addressing the community norms, values and attitudes, discussing laws and policies regarding abortion, their interpretation, Health service provision.

The Policy Arena 27

Safe motherhoodThe ICPD platform of actionAdvocacy campaignsThe legal EnvironmentThe services provision, availability

and sustainability

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M.A. 18 yrs old, a house girl works 450 Kms from home. Got pregnant. Had an unsafe abortion. Who did it could not differentiate the anus from the vagina. Destroyed anus, rectum, bladder, uterus, intestines. The woman lost her uterus, fertility, and to add insult to injury she ended up with a permanent COLOSTOMY! She survived but at what cost? Another preventable statistics. “My heart bled for her as we repaired what was left of her womanhood”

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YES – movement forward 2 decades later Progress to a large extent in pilot & programmes ACCESS/special populations Support/ NGOS/ Religious Based Organizations Sustainability Legal environment Integration Adoption of technological change EOC Guidelines include PAC

Way Forward 30

Overcome culture of silence Condemnation from sex The issues of war & health Scaling up

– Process– Resource mobilization– Attitude

Challenge– Legal environment– Existing social groupings– Training, supervision, M &E– Introduction of PAC in Basic MLPS training Institutions