Evaluation of a multi-pronged intervention to improve access to safe abortion care in two districts in Jharkhand.

BACKGROUND: Despite the adoption of the Medical Termination of Pregnancy Act in 1972, access to safe abortion services remains limited in India. Awareness of the legality of abortion also remains low, leading many women to seek services outside the health system. Medical abortion (MA) is an option that has the potential to expand access to safe abortion services. A multi-pronged intervention covering a population of 161,000 in 253 villages in the Silli and Khunti blocks of Jharkhand was conducted between 2007 and 2009, seeking to improve medical abortion services and create awareness at the community level by providing information through community intermediaries and creating an enabling environment through a behavior change communication campaign. The study evaluates the changes in knowledge about abortion-related issues, changes in abortion care-seeking, and service utilization as a result of this intervention. METHODS: A baseline cross-sectional survey was conducted pre-intervention (n = 1,253) followed by an endline survey (n = 1,290) one year after the completion of the intervention phase. In addition, monitoring data from intervention facilities was collected monthly over the study period. RESULTS: Nearly 85% of respondents reported being exposed to safe abortion messaging as a result of the intervention. Awareness of the legality of abortion increased significantly from 19.7% to 57.6% for women, as did awareness of the specific conditions for which abortion is allowed. Results were similar for men. There was also a significant increase in the proportion of men and women who knew of a legal and safe provider and place from where abortion services could be obtained. Multivariate analysis showed positive associations between exposure to any component of the intervention and increased knowledge about legality and gestational age limits, however only interpersonal communication was associated with a significant increase in knowledge of where to obtain safe services (OR 4.8, SE 0.67). Utilization of safe abortion services, and in particular MA, increased at all intervention sites over the duration of the intervention with a shift towards women seeking care earlier in pregnancy. CONCLUSION: The evaluation demonstrates the success of the intervention and its potential for replication in similar contexts within India.

Establishing second trimester abortion services: experiences in Nepal, Viet Nam and South Africa.

This paper describes experiences and lessons learned about how to establish safe second trimester abortion services in low-resource settings in the public health sector in three countries: Nepal, Viet Nam and South Africa. The key steps involved include securing the necessary approvals, selecting abortion methods, organising facilities, obtaining necessary equipment and supplies, training staff, setting up and managing services, and ensuring quality. It may take a number of months to gain the necessary approvals to introduce or expand second trimester services. Advocacy efforts are often required to raise awareness among key governmental and health system stakeholders. Providers and their teams require thorough training, including values clarification; monitoring and support following training prevents burn-out and ensures quality of care. This paper shows that good quality second trimester abortion services are achievable in even the most low-resource settings. Ultimately, improvements in second trimester abortion services will help to reduce abortion-related morbidity and mortality.

Implementation of misoprostol for postabortion care in Kenya and Uganda: a qualitative evaluation.

OBJECTIVE: Evaluate implementation of misoprostol for postabortion care (MPAC) in two African countries. DESIGN: Qualitative, program evaluation. SETTING: Twenty-five public and private health facilities in Rift Valley Province, Kenya, and Kampala Province, Uganda. SAMPLE: Forty-five MPAC providers, health facility managers, Ministry of Health officials, and non-governmental (NGO) staff involved in program implementation. METHODS AND MAIN OUTCOME MEASURES: In both countries, the Ministry of Health, local health centers and hospitals, and NGO staff developed evidence-based service delivery protocols to introduce MPAC in selected facilities; implementation extended from January 2009 to October 2010. Semi-structured, in-depth interviews evaluated the implementation process, identified supportive and inhibitive policies for implementation, elicited lessons learned during the process, and assessed provider satisfaction and providers' impressions of client satisfaction with MPAC. Project reports were also reviewed. RESULTS: In both countries, MPAC was easy to use, and freed up provider time and health facility resources traditionally necessary for provision of PAC with uterine aspiration. On-going support of providers following training ensured high quality of care. Providers perceived that many women preferred MPAC, as they avoided instrumentation of the uterus, hospital admission, cost, and stigma associated with abortion. Appropriate registration of misoprostol for use in the pilot, and maintaining supplies of misoprostol, were significant challenges to service provision. Support from the Ministry of Health was necessary for successful implementation; lack of country-based standards and guidelines for MPAC created challenges. CONCLUSIONS: MPAC is simple, cost-effective and can be readily implemented in settings with high rates of abortion-related mortality.

Roles of pharmacists in expanding access to safe and effective medical abortion in developing countries: a review of the literature.

Unsafe abortion continues to be a major contributor to maternal mortality and morbidity around the world. This article examines the role of pharmacists in expanding women's access to safe medical abortion in Latin America, Africa, and Asia. Available research shows that although pharmacists and pharmacy workers often sell abortion medications to women, accurate information about how to use the medications safely and effectively is rarely offered. No publication covered effective interventions by pharmacists to expand access to medical abortion, but lessons can be learned from successful interventions with other reproductive health services. To better serve women, increasing awareness and improving training for pharmacists and pharmacy workers about unsafe abortion - and medications that can safely induce abortion - are needed.