Complications of unsafe abortion are a major contributor to maternal mortality and morbidity in developing countries and have been recognized by the international community as a key public health issue.  Approximately 22 million unsafe abortions take place annually (WHO, 2012), many of which require medical care for complications. These include retained products that lead to infection and hemorrhage, injury to internal organs, and psychological trauma. Many women also face long-term health problems, such as chronic pain, pelvic inflammatory disease, and infertility. Women who have suffered miscarriage (spontaneous abortion) and/or stillbirth may experience some of these complications, and thus also need emergency follow-up treatment (USAID, 2004). Postabortion care (PAC) is widely recognized an a critical practice to address complications related to miscarriage and incomplete abortion and reduce repeat abortions.  As such, PAC has been embraced as a important intervention to improve maternal health, the fifth Millenium Development Goal.  National Ministries of Health, NGOs, international reproductive health (RH) agencies, and donor organizations have increased their efforts to improve access to high quality PAC.

For most indicators in other sections of this database, the desired direction of the indicator is clear. For example, in HIV prevention, one seeks increased use of condoms and decreased incidence of HIV infections.  By contrast, increased use of PAC services is a more ambiguous indicator of the effectiveness of these services.  A good PAC program may treat an increasing number of cases in the short term; this increase may indicate that improved services are leading more women with complications to avail themselves of the services, or it may mean that the number of poorly performed abortions has increased in the community.  In light of these considerations, the best indicators for effective PAC are increases in the availability and quality of services rather than increases in the use of these services.

Methodological Challenges of Evaluating PAC

Data on trends and consequences of abortion and on the prevalence of unsafe abortion are generally difficult to collect. Some national-level RH surveys (e.g.,  DHS and RHS) have asked questions about abortion, but the data have proven unreliable in most cases.  Information on the risks of unsafe abortion for some vulnerable populations is particularly elusive.  Certain  women at high risk for unsafe abortion, such as adolescents and women who are refugees/internally displaced,  may not seek services in the public sector or may have limited access to such services.  Because of restrictive abortion policies in many countries, service providers may be reluctant to keep records of PAC clients, fearing recourse because of it’s association with abortion.  As such, the available  data do not cover these groups.  In particular, it would  be useful to know more about contraceptive use and the  magnitude and consequences of unsafe abortion among these groups.

Where existing systems for monitoring RH programs exist, they often exclude items related to PAC.  For example, in many countries, the commodities/logistics system or medical supplies list covers commodities related to all aspects of RH programs; yet, rarely do such systems track the procurement and use of manual vacuum aspiration (MVA) instruments used in treating abortion complications.

Even a simple count of the number of public and private facilities that provide PAC is often difficult to obtain. To avoid unwanted attention from higher authorities or  to guard the anonymity of the patients involved, many  facilities systematically avoid reporting the number of  cases treated for the complications of abortion under the mistaken belief that PAC is illegal.  To further complicate the problem, abortion-related cases are often classified as hemorrhage or infection, and are thus difficult to identify as abortion-related.

Information on the quality of abortion-related care is also difficult to collect.  Methodologies and data collection instruments exist for assessing quality of care (once one identifies facilities providing the services and has permission to conduct an evaluation of the services).  Yet even then, the techniques available for assessing quality for more routine RH services may be more difficult to apply in the case of PAC, given the desire for patient confidentiality and the psychological distress a woman may be experiencing.  In addition, assessment of services is made more difficult by the round-the-clock, emergency nature of the services and the relative low frequency of PAC patient arrivals compared to FP visits or deliveries in maternity settings. Furthermore, most developing country health systems lack guidelines and protocols for PAC, and the international guidance that exists currently is limited and poorly disseminated (WHO, 1995; Rogo, Lema, and Rae, 1999).

Determining the impact of unsafe abortion on maternal morbidity and mortality is rarely feasible.  RH programs seek to save the lives and protect the health of women who undergo unsafe abortion. Yet tracking the impact of unsafe abortion on maternal mortality and morbidity is fraught with a double set of challenges.  The first relates to trying to measure abortion accurately.  The second is measuring maternal mortality and morbidity with precision and assigning causes, including unsafe abortion. In short, it is difficult to measure maternal mortality and morbidity, much less the contribution of unsafe abortion to these two outcomes, or of interventions to reduce unsafe abortion.

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References:

WHO.  2012. Safe and unsafe induced abortion – Global and regional levels in 2008, and trends during 1995–2008

USAID. 2004.  Postabortion Care Strategy Paper.  Washington DC: PAC Working Group.

Postabortion Care Consortium Community Task Force. Essential Elements of Postabortion Care: An Expanded and Updated Model. Postabortion Care Consortium. July, 2002.

WHO. 1995. Complications of Abortion, Technical and Managerial Guidelines for Prevention and Treatment.  Geneva: WHO.

Rogo, KO, Lema VM, and Rae GO. 1999.  Postabortion Care: Policies and Standards for Delivering Services in Sub-Saharan Africa.  Chapel Hill, NC: Ipas.