Post on 31-Dec-2015
transcript
PAC IN SUBSAHARAN AFRICA 1
The New Developments
By
Dr. Solomon Orero MD
Consultant Obstetrician/ Gynaecologist
KMET/CSA
KENYA
February 2003
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!!
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Issues
Decision making in RH and Health in general Decision making linked to economic
empowerment Decision making linked to cultural norms and
practices
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“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”
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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.
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“Unsafe abortion is preventable yet remains a significant cause of Maternal Mortality in Sub Saharan Africa.”
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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
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
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
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”.
The Characteristics of the Woman who has Unsafe Abortion 11
Most likely, student, unemployed, Christian, given false identity
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 damagesChronic Morbidity Infertility and it’s Associated Problems in
the African Context
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
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!
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!
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
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
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
Lessons Learnt from KMET – Training 20
Dr. Orero during a training session. A participatory practical competency based training.
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
Comparisons and Replications 21
Sub-Saharan African Countries
Ghana – Ghana midwivesUganda – PRIME –DISHKenya – PRIME I, II, III, UNFPA,
Engender Health, AMKENI, MOH– Ipas/MYWO
Study Tours To KMET
Students for choice – USAEthiopia – IpasIpas – Chapel Hill NCZimbambwe, Uganda, Nigeria,
Mozambique, Sudan, Cameroun
COBAC 23
PIWH/CSA - COBAC 1996 – 2000
Research on community Based Abortion Care
Results – Peer Review JournalDramatized – “Koso and Naki”Film/ Video – “The Great Betrayal”
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
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
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.
The Policy Arena 27
Safe motherhoodThe ICPD platform of actionAdvocacy campaignsThe legal EnvironmentThe services provision, availability
and sustainability
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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”
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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