Postabortion Family Planning Progress: The Role of Donors and Health Professional Associations

Leadership

USAID's global leadership has supported PAC programs in more than 40 countries worldwide by galvanizing support from the World Health Organization (WHO), FIGO, ICM, the International Council of Nurses (ICN), and donor organizations. USAID shared evidence with Senior Program Officers of the Gates Foundation and Family Planning 2020 (FP2020) that by providing voluntary postabortion family planning counseling and services at the same time and location as treatment, the average postabortion contraceptive uptake across 15 countries increased from 32% to 69%.⁶ USAID's advocacy led the Gates Foundation to adopt postabortion family planning as one of its initiatives for reaching FP2020 goals—specifically, enabling 120 million more women and girls to voluntarily use contraceptives. The recognition of the importance and role of postabortion family planning by the Gates Foundation and its inclusion in the foundation's programming will assist in institutionalizing PAC programming, leading to its sustainability in countries worldwide.

Terminology

Over the years, as new actors began implementing PAC programs, various terms have been used to describe these programs. Several countries use the term “comprehensive postabortion care” to define PAC programs that include voluntary family planning counseling and services. The Gates Foundation uses the terminology “post-pregnancy family planning” as the platform for implementing postabortion and postpartum family planning programs. ICM uses the terminology “abortion-related care” in its Essential Core Competencies for Basic Midwifery Education, which includes skills for postabortion family planning counseling and services.⁷

Statutes and Policy

USAID-supported PAC programs include emergency treatment for complications of induced or spontaneous abortion, counseling on and provision of family planning options, and community mobilization. These programs do not promote abortion as a method of family planning. USAID-funded PAC programs are guided by multiple statutory and policy requirements that include restrictions related to abortion. Additionally, the principles of voluntarism and informed choice articulated in legislative and policy requirements guide USAID's family planning program, including PAC. PAC is explicitly permitted in the standard provision that implements the Protecting Life in Global Health Assistance policy (formerly the Mexico City Policy).^8–10

PAC Working Group

In 1993, at a meeting of USAID cooperating agencies, USAID Administrator Brian Atwood highlighted the important role of family planning in preventing unsafe abortion and spoke of the need to work for “compassionate treatment of all women who are in such desperate circumstances that they are driven to seek an unsafe abortion” (written communication, Brian Atwood, 1993; Figure 1). In March 1993, the first reproductive health/family planning working group on PAC was convened by USAID. In 1994, USAID authorized the use of population funds for PAC and treatment for the first time, with family planning as the top priority.¹¹

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FIGURE 1

Key USAID Postabortion Care Activities, 1990 to 2018

Abbreviations: FIGO, International Federation of Gynecology and Obstetrics; FP, family planning; ICM, International Federation of Midwives; ICN, International Council of Nurses; PAC, postabortion care; RH, reproductive health; USAID, U.S. Agency for International Development.

PAC Program Evaluation

In 2001, USAID/Washington commissioned a global evaluation of its PAC program with the purpose of conducting “a comprehensive and thorough review and analysis of the outstanding programmatic and technical issues in the current PAC portfolio.”⁵ At the time of the evaluation, PAC was being provided by USAID and others in 40 countries. Findings revealed that the greatest success was in the first component, treatment of abortion complications. The second component, voluntary family planning counseling and services, was not implemented as well as emergency treatment, and needed to be strengthened. The case studies and literature highlighted several continuing challenges, including the need to change attitudes among both providers and clients, and management and organizational issues, such as the availability of family planning commodities. A recommendation for “comprehensive postabortion care” was made in an effort to ensure the delivery of voluntary family planning services for women. Another recommendation was that PAC programs should devote more attention to training, monitoring, and supervision of health care providers with regard to family planning knowledge, supportive attitudes, and technical skills to ensure high-quality family planning provision; organization of family planning services (physical location and space); counseling; information, education, and communication materials; contraceptive supply and method choice; privacy; and integration with providers of emergency care.⁵

Global PAC Strategy

In response to the 2001 global evaluation, the USAID PAC working group developed a multiyear strategy during 2003 and 2004 to advance and support the increased use of PAC with a particular focus on family planning counseling and services. Deliberative action was taken to address the challenges found in the global evaluation. Activities under the new strategy included (Figure 1 and Figure 2):

• Revision of the PAC model and results framework and indicators

• Selection of 6 focus countries for intensive support for PAC programming

• Establishment of the PAC Advisory Panel for the USAID PAC Working Group

• Development of a global PAC package, the “Global Resource Package”

• Establishment of the PAC Connection, a technical working group for USAID-funded implementing partners and USAID headquarters and field staff

• Publication of “Post Abortion Family Planning: A Key Component of Post Abortion Care” consensus statement¹²; a Family Planning High Impact Practice (HIP) Brief on Postabortion Family Planning⁶; and peer-reviewed articles in global journals

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FIGURE 2

Key Resources for Postabortion Family Planning

Abbreviations: FIGO, International Federation of Gynecology and Obstetrics; FP2020, Family Planning 2020; PAC, postabortion care.

These activities addressed key themes within the PAC strategy, including the following:

• Standardization of training materials, guidelines, and indicators

• Expansion and institutionalization of PAC at the country level

• Identification of successful models by working intensely in focus countries

• Leadership to identify further research needs

• Compilation of research findings regarding the impact of PAC programs

• Dissemination of this information to donors

• Monitoring and evaluation

Key relationships were developed during the strategy period with international professional associations, such as FIGO, ICM, and ICN, to standardize global PAC policies, expand the reach of the PAC model, and promote the best practices in implementing PAC programs. Three models that evolved from work in the focus countries included (1) the decentralization of PAC from hospitals to health centers, (2) increased community empowerment through use of the community action cycle, and (3) validation that the provision of family planning services immediately after treatment and before discharge from the facility increased uptake of voluntary postabortion family planning. These models were piloted and replicated in a number of countries. Other key activities accomplished during the strategy period are outlined in Figure 1.

Phase I, Step 1: Country Activities

1. FIGO member societies in countries with an induced abortion rate of 30 per 1,000 among women ages 15–44 or an unsafe abortion rate of 10 per 1,000 were invited to participate in the initiative.

2. Participating countries in the project identified a focal point and conducted a situational analysis of unsafe abortion in their country.

3. After completion of the analysis, each country held a national workshop with the participation of the government and interested parties. The results were discussed and a country action plan was developed to respond to the deficiencies. The action plan was adopted as a country commitment by the government and civil society.

Phase I, Step 2: Regional Activities

FIGO's headquarters organized regional workshops for countries in their respective regions. Each participating country presented the various problems encountered in their country related to unsafe abortion and the actions taken to solve them. Country action plans were refined at the regional workshop, and government representatives attending the regional workshops were asked to commit themselves to implementing the action plans during the ensuing 2 years.

Phase II

Country action plans developed at the regional workshops were implemented. Phase II began with the launching of the action plan and at a minimum will end when the goal of reducing unsafe abortion is reached.

Implementation

When the global project began in 2008, 40 countries accepted the invitation to participate. Initially, only 26 of 40 member societies included voluntary postabortion contraception in their action plans. From 2008 to 2016, regional workshops were held annually in which the progress against the country action plans was reviewed with representatives of the member societies and the respective Ministries of Health.

The regional workshops showed 2 ways in which postabortion contraception activities could be more effective: (1) offering a choice of contraceptive methods before the patient's discharge, and (2) including the option of voluntary long-acting reversible contraceptives (LARCs). One presentation entitled “The role of post abortion contraception to reduce unsafe abortion” was prepared to emphasize the importance of voluntary postabortion contraception to reduce unsafe abortion.¹⁴ By 2013, all 40 countries included voluntary postabortion contraception in their action plans.

Although advocacy for postabortion contraception was important, the member societies also learned that more could be achieved by introducing postabortion contraception as a new clinical service in hospitals and by introducing postabortion contraceptive services into teaching hospitals and in the training curriculum of residents. The ability of the national member societies to initiate or improve the provision of postabortion contraceptive services was reflected in the radical changes seen in their new action plans. The action plans included what each society or its prominent members could do through teaching hospitals to act directly on the provision of family planning services. In addition, several societies were active in providing family planning training for public health providers.

As of 2017, immediate postabortion contraceptive services are provided in teaching hospitals in 46 participating countries. In 8 Caribbean and Central American countries, updated guidelines are now in use, and emphasis is being placed on postabortion contraception counseling and the provision of voluntary contraceptive methods. Honduras and Nicaragua have included training on the provision of intrauterine devices and implants to increase their voluntary use by postabortion patients.¹⁵

Uniting Postabortion and Postpartum Family Planning Initiatives

In most low-resource settings, treatment for postabortion complications often occurs in the same location where deliveries are performed by skilled birth attendants. As countries strengthen their national programs to offer family planning to postpartum women, they should ensure that postabortion clients are counseled and offered voluntary family planning services. Including postabortion family planning when introducing postpartum family planning in health facilities makes sense both programmatically and technically. Thus, the Gates Foundation has committed to addressing postabortion and postpartum family planning through a common framework of post-pregnancy family planning.

As part of its priority programming for 2018–2020, the Gates Foundation continues to invest in postabortion family planning programs in its 9 priority countries. The Gates Foundation supports service delivery efforts at national and subnational levels, as well as innovative operations research on best practices for ensuring that women who seek medical abortion, both within and outside health facilities, have immediate access to a broad range of postabortion contraceptive counseling and voluntary services. Special interest exists for developing innovative solutions for women who access pharmacies or drug shops where immediate access to postabortion family planning could be expanded. Examples of current investments are noted in Box 3.

The global postpartum family planning steering committee, which was established in 2014 to support the organization of the 2015 Chiang Mai global postpartum family planning meeting, continues to be supported through the Gates Foundation. As part of the FP2020 secretariat's mandate, the postpartum family planning component has been expanded to also address postabortion family planning, with FP2020 now including the following functions as part of its work:

• Regular coordination calls for postpartum/postabortion family planning global steering committee (comprising all donors active in this space, as well as other critical stakeholders, such as WHO)

• Webinars and/or other knowledge platforms for countries to share best practices/experiences/issues/requests for assistance including the dissemination of the postabortion family planning HIP brief⁶

• The inclusion of postpartum/postabortion family planning in regional focal point workshops and linking relevant technical partners when family planning needs are identified

• Working with countries to ensure postpartum/postabortion family planning efforts are incorporated into and tracked against national family planning costed implementation plans, Global Financing Facility investment cases, and FP2020 action plans

• Coordination with postabortion family planning around data/program information use for postabortion family planning and postpartum family planning advocacy purposes

In addition, the Gates Foundation has provided funding to FP2020's Rapid Response Mechanism for dedicated support of country-level catalytic postpartum/postabortion family planning activities. The Foundation looks forward to its continued work with the global family planning community to ensure that there are no missed opportunities to give women increased access to their preferred contraceptive methods where and when they want them.