Dr. Solomon Orero Consultant Obstetrician/Gynecologist (Aga Khan and Nairobi Hospitals, Kenya) March 12, 2003

1. PAC IN SUBSAHARAN AFRICA
1
The New Developments
By
Dr. Solomon Orero MD
Consultant Obstetrician/ Gynaecologist
KMET/CSA
KENYA
February 2003

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

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

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

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”.

11. The Characteristics of the Woman who
has Unsafe Abortion 11
Most likely, student,
unemployed, Christian, given
false identity

12. In Private Sector 12
Single, educated, Employed,
Married, not known to partner

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

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

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!

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!

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

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

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

20. 19 (1)

21. 19 (2)
Congressman Jim Greenhood visiting KMET PPNW Programme. August, 2002

22. Lessons Learnt from KMET – Training
20
Dr. Orero during a training session. A participatory practical competency based training.

23. 20 (1)
Participants practical session during PAC training

24. 20 (2)
PD – Monica during a class PAC training session

25. 20 (3)
PAC room rearranged simply for use after training in a public facility Designed by KMET

26. 20 (4)
A cupboard for storage in a training facility Designed by KMET

27. 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

28. 20 (6)
A simplified procedure bed for MVA

29. 20 (7)
KMET Established a model Clinic in a Peri-urban Kisumu City

30. 20 (8)
KMET collaborate with many partners – PIWH, PPFA Bucks county
Pennsylvania

31. 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

32. Study Tours To KMET
Students for choice – USA
Ethiopia – Ipas
Ipas – Chapel Hill NC
Zimbambwe, Uganda, Nigeria,
Mozambique, Sudan,
Cameroun

33. 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”

34. 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

35. 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

36. 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.

37. The Policy Arena 27
Safe motherhood
The ICPD platform of action
Advocacy campaigns
The legal Environment
The services provision, availability
and sustainability

38. 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”

39. 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

40. 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