Essential Elements of Postabortion Care: An Expanded and Updated Model PAC Consortium Community Task Force
The Postabortion Care (PAC) Consortium1 is pleased to introduce the Essential Elements of Postabortion Care: An Expanded and Updated Model. Based on a continuum of care approach, this expanded and updated PAC model builds on more than ten years of cooperating agency (CAs), NGO and donor experience with the original PAC model, first articulated by Ipas2 in 1991, and published as a model by Ipas in 19943 and by the PAC Consortium in 19954. PAC program achievements and lessons learned with the original PAC model, combined with commitments to the 1994 ICPD Programme of Action5 and the experience of various organizations and countries which included additional elements in their PAC programs over the years6,7,8 inspired the PAC/Community Task Force to expand and update the original PAC model to reflect progress and an expanded vision of high-quality and sustainable PAC services. Morbidity and mortality due to unsafe abortion continue to pose a serious global threat to women's health and lives. It is estimated that worldwide, every year, almost 20 million unsafe abortions take place and 80,000 women die from complications following unsafe abortion. Access to contraceptive methods to prevent unwanted pregnancy and a continuum of postabortion care that includes comprehensive counseling, access to contraception and family planning to prevent future unwanted pregnancies or to practice birth spacing, and access to reproductive and other health services, are all essential means of preventing unsafe abortion and improving the lives of women and their families. The PAC Consortium's Expanded and Updated Postabortion Care Model Postabortion care is an approach for reducing morbidity and mortality from incomplete and unsafe abortion and resulting complications and for improving women's sexual and reproductive health and lives. The PAC Consortium's five essential elements of PAC are:
The original PAC model had three components: 1) emergency treatment services for complications of spontaneous or unsafely induced abortion, 2) postabortion family planning counseling and services, and 3) links between emergency abortion treatment services and comprehensive reproductive health care, and focused primarily on clinical and related facility-based services from a health care provider perspective. In the years since the first model was published, most PAC activities and programs concentrated efforts on training and equipping physicians and mid-level clinicians to perform uterine evacuation with MVA, expanding services to the primary level of care, and linking treatment with family planning and other reproductive health services. These efforts continue to be extremely important for ensuring women's access to high quality postabortion care services. The expanded and updated model adds the community as an essential element and acknowledges that a strong and effective partnership among community members and health care providers can strengthen efforts to reduce maternal mortality and morbidity due to complications from unsafe and incomplete abortion. Projects and research have demonstrated important linkages between and among community health workers, community members and formally trained service providers in the care and management of women with complications from abortion and other obstetric emergencies, and in overcoming obstacles to use of contraceptive and family planning services. These linkages need to be strengthened and expanded to improve and ensure the accessibility, acceptability and use of quality PAC services. The new model also highlights counseling as an essential element, on its own, in recognition that counseling a woman who is experiencing complications from an unsafe or incomplete abortion should include but not be limited to, family planning and contraceptive education and services. Counseling should cover the full range of reproductive and other health and emotional needs and concerns that arise for women in these circumstances. Counseling can help ensure that a woman's needs and concerns are identified and assessed and that appropriate services available at the treatment facility are offered at the time of treatment or via referral to another accessible facility. Rationale for Each Essential Element of the Updated and Expanded PAC Model Community and Service Provider Partnerships Highlighting community and service provider partnerships as the first essential element of PAC acknowledges the vital role community members have in contributing to the reduction of maternal morbidity and mortality and improving women's sexual and reproductive health and lives. To achieve universal local access to sustainable, high-quality PAC and other health services, community members, lay health workers and traditional healers and formally trained service providers must work in partnership. This partnership includes:
In the original PAC model counseling was part of the second element, "postabortion family planning counseling and services". In the Essential Elements of PAC Model, counseling stands on its own as an essential element because effective counseling for women who are experiencing incomplete abortion and possible complications should permeate every component of services, from first contact between the woman and provider to the last contact, and cover more than family planning and contraception. In this expanded and updated vision of PAC, women and their service providers identify and address broader emotional and physical health and other needs and concerns. Providers may be able to respond to women's needs directly or provide referrals within their service network. The aims of counseling as an essential element are to:
Treatment Emergency treatment for complications of spontaneous or unsafely induced abortion was the first element of the original PAC model and has been the focus of many PAC activities. It remains an essential and critical element of PAC because in many cases, an incomplete abortion will need to be treated by uterine evacuation. The rewording of this element recognizes that incomplete and unsafe abortions do not always involve complications, are not always life threatening and treatment is therefore not always an emergency. Nonetheless, complications are potentially life threatening without swift and appropriate medical attention. The Essential Elements of PAC Model recognizes that high-quality treatment uses manual vacuum aspiration (MVA) wherever possible and depending on local conditions, and includes standard infection prevention precautions, informed consent, appropriate pain management, sensitive physical and verbal patient contact and follow-up care. Contraceptive and Family Planning Services Despite increases in modern contraceptive use in the last decade, significant numbers of women of childbearing age want to delay or avoid pregnancy, or practice birth spacing, but are not using contraception. Access to a wide range of contraceptive methods, including emergency contraception, to prevent unwanted pregnancy and help women to practice birth spacing, including emergency contraception where authorized, are effective strategies for preventing future unwanted pregnancies and unsafe abortion and helping women achieve their reproductive goals. For women who do not desire pregnancy or are clinically advised against an immediate pregnancy, if they are not offered contraceptive methods in the same facility following treatment for abortion complications, they may not return or follow up on a referral for provision of a contraceptive method. For women who desire pregnancy, family planning services may still be essential for ensuring adequate spacing for healthy pregnancies and healthy children. Reproductive and Other Health Services The original PAC model included linkages between emergency treatment services and comprehensive reproductive health care. This element has been modified in the Essential Elements of PAC Model to include reproductive and other health services that are provided on-site at the facility where treatment has taken place, or via referrals to other accessible facilities. In many cases, PAC services are offered in facilities that also provide other health services. It is important to reinforce the connections among these services and establish mechanisms for ensuring that women who need other health services are provided with those services. The second essential element in the updated and expanded model, counseling, is one of these mechanisms to help ensure that appropriate reproductive and other health needs and concerns are assessed and the services available at the treatment facility are offered at the time of treatment, or that these services are offered via referral to another facility. An important link between the new counseling element and this element is that effective counseling should contribute to increase recognition, access and use of the reproductive and other health services women need. The expanded and update model encourages providing appropriate reproductive and other health services at the time women receive treatment for abortion complications, preferably at the same facility. When it is not possible for a facility to provide needed additional services, functional referral and counter-referral systems and follow-up mechanisms, including record keeping, should be established or improved and monitored to ensure that women's needs are being met. Reproductive and other health services might include, for example:
Illustrative examples of indicators include: In communities
At health care facilities
Conclusion Eight years after the original PAC model was first published, PAC Consortium member organizations support an updated and expanded model that expresses an updated and expanded vision of high-quality PAC. By expanding from facility-based, clinical services to a more comprehensive public health model, the Essential Elements of Postabortion Care Model includes prevention, treatment, counseling and services to respond to women's sexual and reproductive health needs and concerns. As PAC programs based on the Essential Elements of Postabortion Care Model are designed, implemented and evaluated and our understanding of high-quality, sustainable PAC services is further informed by experience and lessons learned, future revisions of this model are likely and will be welcomed. References
Suggested Citation: Postabortion Care Consortium Community Task Force. Essential Elements of Postabortion Care: An Expanded and Updated Model. Postabortion Care Consortium. July, 2002.
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