A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014.

BACKGROUND: Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. METHODS: This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. RESULTS: There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. CONCLUSION: Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.

Improving health worker performance of abortion services: an assessment of post-training support to providers in India, Nepal and Nigeria.

BACKGROUND: Health worker performance has been the focus of numerous interventions and evaluation studies in low- and middle-income countries. Few have examined changes in individual provider performance with an intervention encompassing post-training support contacts to improve their clinical practice and resolve programmatic problems. This paper reports the results of an intervention with 3471 abortion providers in India, Nepal and Nigeria. METHODS: Following abortion care training, providers received in-person visits and virtual contacts by a clinical and programmatic support team for a 12-month period, designed to address their individual practice issues. The intervention also included technical assistance to and upgrades in facilities where the providers worked. Quantitative measures to assess provider performance were established, including: 1) Increase in service provision; 2) Consistent service provision; 3) Provision of high quality of care through use of World Health Organization-recommended uterine evacuation technologies, management of pain and provision of post-abortion contraception; and 4) Post-abortion contraception method mix. Descriptive univariate analysis was conducted, followed by examination of the bivariate relationships between all independent variables and the four dependent performance outcome variables by calculating unadjusted odds ratios, by country and overall. Finally, multivariate logistic regression was performed for each outcome. RESULTS: Providers received an average of 5.7 contacts. Sixty-two percent and 46% of providers met measures for consistent service provision and quality of care, respectively. Fewer providers achieved an increased number of services (24%). Forty-six percent provided an appropriate postabortion contraceptive mix to clients. Most providers met the quality components for use of WHO-recommended abortion methods and provision of pain management. Factors significantly associated with achievement of all measures were providers working in sites offering community outreach and those trained in intervention year two. The number of in-person contacts was significantly associated with achievement of three of four measures. CONCLUSION: Post-training support holds promise for strengthening health worker performance. Further research is needed to compare this intervention with other approaches and assess how post-training contacts could be incorporated into current health system supervision.

Costs of postabortion care in public sector health facilities in Malawi: a cross-sectional survey.

BACKGROUND: Health systems could obtain substantial cost savings by providing safe abortion care rather than providing expensive treatment for complications of unsafely performed abortions. This study estimates current health system costs of treating unsafe abortion complications and compares these findings with newly-projected costs for providing safe abortion in Malawi. METHODS: We conducted in-depth surveys of medications, supplies, and time spent by clinical personnel dedicated to postabortion care (PAC) for three treatment categories (simple, severe non-surgical, and severe surgical complications) and three uterine evacuation (UE) procedure types (manual vacuum aspiration (MVA), dilation and curettage (D&C) and misoprostol-alone) at 15 purposively-selected public health facilities. Per-case treatment costs were calculated and applied to national, annual PAC caseload data. RESULTS: The median cost per D&C case ($63) was 29% higher than MVA treatment ($49). Costs to treat severe non-surgical complications ($63) were almost five times higher than those of a simple PAC case ($13). Severe surgical complications were especially costly to treat at $128. PAC treatment in public facilities cost an estimated $314,000 annually. Transition to safe, legal abortion would yield an estimated cost reduction of 20%-30%. CONCLUSIONS: The method of UE and severity of complications have a large impact on overall costs. With a liberalized abortion law and implementation of induced abortion services with WHO-recommended UE methods, current PAC costs to the health system could markedly decrease.

Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh.

Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform.

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries.

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.

Unsafe abortion: the preventable pandemic.

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

Scaling-up a public health innovation: a comparative study of post-abortion care in Bolivia and Mexico.

Post-abortion care (PAC), an innovation for treating women with complications of unsafe abortion, has been introduced in public health systems around the world since the 1994 International Conference on Population and Development (ICPD). This article analyzes the process of scaling-up two of the three key elements of the original PAC model: providing prompt clinical treatment to women with abortion complications and offering post-abortion contraceptive counseling and methods in Bolivia and Mexico. The conceptual framework developed from this comparative analysis includes the environmental context for PAC scale-up; the major influences on start-up, expansion, and institutionalization of PAC; and the health, financial, and social impacts of institutionalization. Start-up in both Bolivia and Mexico was facilitated by innovative leaders or catalyzers who were committed to introducing PAC services into public health care settings, collaboration between international organizations and public health institutions, and financial resources. Important processes for successful PAC expansion included strengthening political commitment to PAC services through research, advocacy, and partnerships; improving health system capacity through training, supervision, and development of service guidelines; and facilitating health system access to essential technologies. Institutionalization of PAC has been more successful in Bolivia than Mexico, as measured by a series of proposed indicators. The positive health and financial impacts of PAC institutionalization have been partially measured in Bolivia and Mexico. Other hypotheses--that scaling-up PAC will significantly reduce maternal mortality and morbidity, decrease abortion-related stigma, and prepare the way for efforts to reform restrictive abortion laws and policies--have yet to be tested.

Reducing the costs to health systems of unsafe abortion: a comparison of four strategies.

BACKGROUND AND METHODOLOGY: Strategies to reduce health systems costs of providing abortion and post-abortion care while simultaneously improving quality of care are well documented but infrequently applied. We created 'Savings', a spreadsheet-based tool that allows policymakers and other stakeholders to estimate and compare the feasibility and sustainability of different strategies of providing abortion and post-abortion care. By applying cost data primarily from Uganda, we showed the per-case costs under four policy and service delivery scenarios. RESULTS: The mean per-case cost of abortion care (in US dollars) was $45 within the setting that placed heavy restrictions on elective abortion and used a conventional approach to service delivery; $25 within the restrictive legal setting that used recommended interventions for treating complications; $34 within the legal setting that allowed elective abortion and relied on a conventional approach to service delivery; and $6 within the liberal legal setting that used recommended interventions. DISCUSSION AND CONCLUSIONS: Using recommended technical interventions substantially reduced costs regardless of the legal setting. The greatest reduction in costs (86%) occurred from using recommended interventions within a liberal legal setting rather than using conventional interventions within a restricted setting. These findings should support policy and practice efforts to reform abortion laws and to offer accessible, safe abortion services.

What Factors Contribute to Postabortion Contraceptive Uptake By Young Women? A Program Evaluation in 10 Countries in Asia and sub-Saharan Africa.

BACKGROUND: Unintended pregnancy disproportionately affects young women and adolescents in developing countries. The abortion care setting offers a unique opportunity for adolescents and young women to access a full range of contraceptive services. This evaluation assesses the factors that influence contraceptive uptake among adolescents and young women seeking abortion care in health facilities. METHODS: Following provider training, we analyzed client log book data from 921,918 abortion care cases in 4,881 health facilities in 10 countries from July 2011 through June 2015. Log book data included client characteristics such as age, pregnancy gestation, type of service provided, and contraceptive method provision. Health facility characteristics were obtained through administration of a site baseline form prior to initiation of programmatic support by Ipas, an international NGO. Programmatic support included integration of postabortion contraceptive services with abortion care, improvements in commodities logistics, health worker training, upgraded recordkeeping, and post-training follow-up with providers and sites to solve problems and improve performance. We analyzed abortion cases by 3 age categories, ≤19 years, 20-24 years, and ≥25 years, and conducted unadjusted and adjusted analyses for the primary outcomes of interest: receipt of a contraceptive method at the time of care; type of contraceptive method selected; and the client, clinical care, and facility characteristics associated with contraceptive uptake. RESULTS: Overall, 77% of women left the facility with a contraceptive method. The majority (84%) of contraceptive acceptors selected a short-acting method, especially oral contraceptives. In the adjusted model, women ≤19 were less likely to choose a method than women 25 years or older (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.79 to 0.96). Adolescents and young women were also significantly less likely to choose a long-acting, reversible contraceptive than those ages 25 or older (≤19 years: OR, 0.59; 95% CI, 0.52 to 0.67; 20-24 years: OR, 0.68; 95% CI, 0.63 to 0.73). Women treated by an Ipas-trained provider were significantly more likely to select postabortion contraception than women treated by non-Ipas-trained providers (OR, 1.37; 95% CI, 1.20 to 1.57). CONCLUSIONS: Programmatic support to health systems, including provider training in contraceptive counseling and provision, was associated with women's higher acceptance of postabortion contraception. However, gaps remained for young women, especially adolescents, who were significantly less likely than older women to accept postabortion contraception. Health systems and facilities should pay increased attention to meeting the contraceptive needs of young women and adolescents.

Insights from an expert group meeting on the definition and measurement of unsafe abortion.

Until recently, WHO operationally defined unsafe abortion as illegal abortion. In the past decade, however, the incidence of abortion by misoprostol administration has increased in countries with restrictive abortion laws. Access to safe surgical abortions has also increased in many such countries. An important effect of these trends has been that, even in an illegal environment, abortion is becoming safer, and an updated system for classifying abortion in accordance with safety is needed. Numerous factors aside from abortion method or legality should be taken into consideration in developing such a classification system. An Expert Meeting on the Definition and Measurement of Unsafe Abortion was convened in London, UK, on January 9-10, 2014, to move toward developing a classification system that both reflects current conditions and acknowledges the gradient of risk associated with abortion. The experts also discussed the types of research needed to monitor the incidence of abortion at each level of safety. These efforts are urgently needed if we are to ensure that preventing unsafe abortion is appropriately represented on the global public health agenda. Such a classification system would also motivate investment in research to accurately measure and monitor abortion incidence across categories of safety.

Early abortion services in the United States: a provider survey.

The objective of this study was to describe the availability of early surgical and medical abortion among members of the National Abortion Federation (NAF) and to identify factors affecting the integration of early abortion services into current services. Telephone interviews were conducted with staff at 113 Planned Parenthood affiliates and independent abortion providers between February and April 2000, prior to FDA approval of mifepristone. Early abortion services were available at 59% of sites, and establishing services was less difficult than or about what was anticipated. Sites generally found it easier to begin offering early surgical abortion than early medical abortion. Physician participation was found to be critical to implementing early services. At sites where some but not all providers offered early abortion, variations in service availability resulted. Given the option of reconsidering early services, virtually all sites would make the same decision again. These data suggest that developing mentoring relationships between experienced early abortion providers/sites and those not offering early services, and training physicians and other staff, are likely to be effective approaches to expanding service availability.

Meeting the need for safe abortion care in Ethiopia: results of a national assessment in 2008.

Complications of an unsafe abortion are a major contributor to maternal deaths and morbidity in Africa. When abortions are performed in safe environments, such complications are almost all preventable. This paper reports results from a nationally representative health facility study conducted in Ethiopia in 2008. The safe abortion care (SAC) model, a monitoring approach to assess the amount, distribution, use and quality of abortion services, provided a framework. Data collection included key informant interviews with 335 health care providers, prospective data on 8911 women seeking treatment for abortion complications or induced abortion and review of facility logbooks. Although the existing hospitals perform most basic abortion care functions, the number of facilities providing basic and comprehensive abortion care for the population size fell far short of the recommended levels. Almost one-half (48%) of women treated for obstetric complications in the facilities had abortion complications. The use of appropriate abortion technologies in the first trimester and the provision of post-abortion contraception overall were reasonably strong, especially in private sector facilities. Following abortion law reform in 2005 and subsequent service expansion and improvements, Ethiopia remains committed to reducing complications from an unsafe abortion. This study provides the first national snapshot to measure changes in a dynamic abortion care environment.

Public hospital costs of treatment of abortion complications in Nigeria.

Unsafe abortion is a significant contributor to maternal mortality in Nigeria, and treatment of postabortion complications drains public healthcare resources. Provider estimates of medications, supplies, and staff time spent in 17 public hospitals were used to estimate the per-case and annual costs of postabortion care (PAC) provision in Ogun and Lagos states and the Federal Capital Territory. PAC with treatment of moderate complications (US $112) cost 60% more per case than simple PAC (US $70). In cases needing simple PAC, treatment with dilation and curettage (D&C, US $80) cost 18% more per case than manual vacuum aspiration (US $68). Annually, all public hospitals in these 3 states spend US $807 442 on PAC. This cost could be reduced by shifting service provision to an outpatient basis, allowing service provision by midwives, and abandoning the use of D&C. Availability of safe, legal abortion would further decrease cost and reduce preventable deaths from unsafe abortion.

Testing the Safe Abortion Care model in Ethiopia to monitor service availability, use, and quality.

OBJECTIVE: To implement the Safe Abortion Care (SAC) model in public health facilities in the Tigray region of Ethiopia and document the availability, utilization, and quality of SAC services over time. METHODS: The project oriented providers in 50 public health facilities in Tigray to the SAC model. Changes in SAC indicators between baseline and endline were assessed using a retrospective review of procedure logbooks at baseline and prospective monitoring of procedure logbooks for facility performance after introduction of the SAC model. RESULTS: Availability of SAC services increased from 39% to 86% of the recommended number of 5 facilities per 500000 population, primarily as a result of functional improvements at health centers. Decentralization was accompanied by a 94% increase in the annualized number of women who received services. The proportion of uterine evacuation procedures for induced abortion rose from 7% to 60% (P<0.01), and the proportion performed with recommended technology increased from 30% to 85% (P<0.01). The proportion of abortion patients who received modern contraception also increased from 31% to 78% (P<0.01). DISCUSSION: While widespread service delivery improvements were recorded using the SAC monitoring approach, the project design was built around existing programmatic activities of the local health authority and reflects some related research limitations. For example, there was no comparison group of facilities, timing did not allow for prospective collection of the baseline data before the intervention, and facilities received different levels of monitoring support. CONCLUSION: Using the SAC model, public health facilities tracked progress and made needed adjustments, which improved service delivery. Continued focus on critical safe abortion care elements should increase the availability, quality, and use of life-saving care to reduce preventable abortion mortality in the region.

Evaluating abortion-care programs: old challenges, new directions.

The evaluation of abortion-care programs and policies has been largely neglected by both national governments and international organizations. This article provides a conceptual framework for evaluating the intermediate outcomes of a safe abortion program, including laws and policies, women's care-seeking behavior, and the quality of, access to, and use of services. The methodological challenges in evaluating these outcomes are described. For each outcome, key indicators for measuring progress in program implementation are offered, along with country examples of successful evaluation approaches. The article concludes with recommendations for improvements in infrastructure, resource availability, and political commitment to support evaluation of safe abortion programs.

Postabortion care in Latin America: policy and service recommendations from a decade of operations research.

Unsafe abortion contributes significantly to maternal mortality and morbidity in Latin America. Postabortion care (PAC) using preferred technologies and a woman-centred approach to treat the complications of unsafe abortion can save women's lives and improve their reproductive health, as well as reduce costs to health systems. This article reviews results from 10 major PAC operations research projects conducted in public sector hospitals in seven Latin American countries, completed and published between 1991 and 2002. The studies show that following relatively modest interventions, the majority of eligible patients were being treated with manual vacuum aspiration (MVA), a method preferred for safety and other reasons over the method conventionally used in the region, sharp curettage (SC). A number of studies showed improvements in contraceptive counselling and services when these were integrated with clinical treatment of abortion complications, resulting in substantial increases in contraceptive acceptance. Finally, data from several studies showed that, in most settings, reorganizing services by moving treatment out of the operating theatre and reclassifying treatment as an ambulatory care procedure substantially reduced the resources used for PAC, as well as the cost and average length of women's stay in the hospital. These studies suggest that comprehensive PAC can and should be available to all women in Latin America. Such efforts should be coupled with work to improve primary prevention, including better contraceptive services to prevent unwanted pregnancy and safe, legal abortion services to reduce the number of clandestine and unsafe abortions.