By Dr Munyaradzi Murwira
Background
According to the World Health Organisation (WHO), family planning (FP) and comprehensive abortion care are part of primary health care (PHC), and the availability of these services is essential for achieving universal health coverage (UHC). However, lack of access to these services remains a big challenge across the world. Health care providers in many African countries lack the relevant skills and knowledge to provide evidence-based, person-centred and respectful services in these critical areas.
Post-abortion family planning (PAFP) is the use of family planning methods immediately after an abortion or treatment of abortion complications. The provision of FP is important for women in the post-abortion period because fertility can return surprisingly quickly after an abortion. Post abortion FP is a recognised key strategy to reduce unintended pregnancy, repeat-induced abortions and lower morbidity and mortality among women. WHO recommends that women can safely use the full range of contraceptive methods, including condoms, spermicides, oral contraceptives, emergency contraceptive pills, injectable, implants, intrauterine devices (IUDs), and female sterilisation? However, the accessibility and quality of PAFP services remain a challenge in Africa where a higher number of unintended pregnancies occur each year after abortion or miscarriage.
Repeated abortions will more likely be clandestine and unsafe leading to complications. Unsafe abortion contributes up to 13% of maternal deaths globally (and up to 25% in some developing countries).
Importance of Post Abortion Family Planning
A report by the Guttmacher Institute in 2010 titled “Post Abortion Family Planning: Addressing the Cycle of Repeat Unintended Pregnancy and Abortion”, explores the linkages between FP and abortion. The report notes that, if contraception were accessible and used consistently and correctly, by women wanting to avoid pregnancy, maternal deaths would decline by an estimated 25–35%. Fifty-five million unintended pregnancies in developing countries occur every year to women not using a contraceptive method. Another 25 million occur because of incorrect use of a contraceptive method and method failure. These statistics provide firm evidence that family planning reduces abortion, thus decreasing the risk of maternal deaths.
In 1994, the international health community identified post abortion care (PAC) as an important strategy to reduce maternal mortality by treating complications related to unsafe abortion and providing post abortion FP counseling and services to prevent repeat unplanned pregnancies and abortions. However, PAC services have historically sought to reduce maternal mortality by treating the symptoms of hemorrhage and sepsis rather than by treating women’s unmet need for FP, thus overlooking the potential of post abortion FP to interrupt the cycle of repeat unplanned pregnancy, abortion and complications leading to maternal death.
The lack of FP counseling and services after an abortion quickly leads to another unwanted pregnancy and induced abortion, because fertility returns within two to three weeks after miscarriage or induced abortion. This makes it essential to ensure that post abortion FP counseling and service delivery are offered to all women who present for emergency post abortion care before discharge from hospital. Providing post abortion FP benefits communities and countries in many ways including decreased unsafe abortions; reduced maternal mortality, reduced social and health costs.
A global evaluation of abortion care programs in 2001 found that in the delivery of post abortion care, the component of FP counseling and services did not receive as much attention as the emergency treatment component. The World Bank recommends that post abortion care be strengthened by ensuring contraceptive counseling and that FP services are provided in the same facility where post abortion care is provided to decrease opportunity costs. At the national level, barriers to providing post abortion family planning include lack of sufficient financing for family planning, lack of adequate training, and lack of availability of PAC services at the primary care level.
A study in Zimbabwe on post abortion FP showed that, when on-site counseling and access to free contraceptives are provided at the same location and at the same time as emergency treatment, women were significantly more likely to adopt highly effective methods of contraception, had fewer unplanned pregnancies, and were less likely to have a repeat abortion during follow-up. In Senegal community mobilization and the decentralization of services from tertiary hospitals to health center levels has been successful in increasing the uptake of post abortion FP.
Program Implications
Evidence suggested that offering FP counseling, training providers, using dedicated providers improves post abortion FP counseling and services uptake. Even if a woman wants to have a child immediately after an abortion or miscarriage, the World Health Organization (WHO) and Federation of International Gynaecology and Obstetrics (FIGO) guidelines recommend she should wait at least 6 months before getting pregnant again. Facilities and providers should help women by offering highly effective family planning methods.
Reorganisation of services using simple models, job aids, effective counseling, and written instructions will be required for health systems to provide contraceptives for all clients post abortion. Policies and funding decisions need to emphasize post abortion family planning needs and resources. These resources include not only the training for post abortion care services, but family planning commodities and other equipment needed to provide the package of post abortion care services. Training for in-service and pre-service providers should prioritise FP within post abortion care.
Conclusion
Post abortion family planning is a key element of post abortion care. It is essential to strengthen the FP component in PAC services, not only to prevent repeat unintended pregnancy and abortion, but also because it is integral to achieving the sustainable development goals (SDGs). Women and communities should demand quality PAC services that are accessible, with cost-effective post abortion FP services to improve women’s’ health and ultimately better quality of life in the community. Almost every abortion-related death and disability could be prevented through universal access to sexual reproductive health (SRH) including family planning and post abortion care.
Dr M Murwira is a Public Health Expert with special interest in Sexual Reproductive Health, and Population & Development.
