PAC IN SUBSAHARAN AFRICA 1 : 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 : 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!!
3 : 3 Issues
Decision making in RH and Health in general
Decision making linked to economic empowerment
Decision making linked to cultural norms and practices
4 : 4
“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”
5 : 5
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.
6 : 6
“Unsafe abortion is preventable yet remains a significant cause of Maternal Mortality in Sub Saharan Africa.”
7 : 7
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 : 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 : 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 : 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 : The Characteristics of the Woman who has Unsafe Abortion 11
Most likely, student, unemployed, Christian, given false identity
In Private Sector 12 : In Private Sector 12
Single, educated, Employed,
Married, not known to partner
Impact & Consequences of Unsafe Abortion 13 : 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 damages
Chronic Morbidity
Infertility and it’s Associated Problems in the African Context
Response and Management of Unsafe Abortion: 14 : 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 : 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 : 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 : 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 : 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 : 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
19 (1) : 19 (1)
19 (2) : 19 (2)
Congressman Jim Greenhood visiting KMET PPNW Programme. August, 2002
Lessons Learnt from KMET – Training 20 : Lessons Learnt from KMET – Training 20
Dr. Orero during a training session. A participatory practical competency based training.
20 (1) : 20 (1)
Participants practical session during PAC training
20 (2) : 20 (2)
PD – Monica during a class PAC training session
20 (3) : 20 (3)
PAC room rearranged simply for use after training in a public facility Designed by KMET
20 (4) : 20 (4)
A cupboard for storage in a training facility Designed by KMET
Lessons Learnt from KMET 20 (5) : 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) : 20 (6)
A simplified procedure bed for MVA
20 (7) : 20 (7)
KMET Established a model Clinic in a Peri-urban Kisumu City
20 (8) : 20 (8)
KMET collaborate with many partners – PIWH, PPFA Bucks county Pennsylvania
Comparisons and Replications 21 : Comparisons and Replications 21 Sub-Saharan African Countries
Ghana – Ghana midwives
Uganda – PRIME –DISH
Kenya – PRIME I, II, III, UNFPA, Engender Health, AMKENI, MOH
Ipas/MYWO
Study Tours To KMET : Study Tours To KMET Students for choice – USA
Ethiopia – Ipas
Ipas – Chapel Hill NC
Zimbambwe, Uganda, Nigeria, Mozambique, Sudan, Cameroun
COBAC 23 : COBAC 23 PIWH/CSA - COBAC 1996 – 2000
Research on community Based Abortion Care
Results – Peer Review Journal
Dramatized – “Koso and Naki”
Film/ Video – “The Great Betrayal”
Themes for Discussion after the Video 24 : 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 : 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 : 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 : The Policy Arena 27 Safe motherhood
The ICPD platform of action
Advocacy campaigns
The legal Environment
The services provision, availability and sustainability
28 : 28 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”
29 : 29 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 : 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