Despite dramatic increases in contraceptive prevalence worldwide over the last 30 years, more than one-third of women who become pregnant each year have either an abortion or an unintended birth.1 Moreover, in many settings, women who have an abortion rarely leave the health facility "armed with the knowledge and the means to avoid repeating the process of unprotected intercourse [and] unwanted pregnancy."2 Thus, women who have had an abortion and who risk another unwanted pregnancy represent an important group whose family planning needs remain unmet.
In the 1990s, several international reproductive health organizations heeded the call to link abortion clients with family planning services to break the cycle of unintended pregnancy and abortion. Postabortion family planning programs were implemented in a number of countries. Where abortion is illegal, these programs are geared toward linking women who have undergone treatment for incomplete abortion with family planning services. Where the procedure is legal, these programs focus on providing contraceptive information and services to abortion clients to help them avoid further unintended pregnancies.
Turkey, which has a history of progressive policies and legislation designed to improve maternal and child health, legalized family planning education and the provision of temporary contraceptive methods in the mid-1960s; legalization of abortion and sterilization followed later, in 1983.3 Currently, Turkey's family planning program is relatively advanced and has helped the country achieve a total contraceptive prevalence rate of 64%. There is still a high degree of reliance on traditional methods, however; withdrawal, the most popular method, was used by 24% of currently married women in 1998.4
Turkish couples also strongly desire small families, and two-thirds want no more children. Yet the high failure rate of Turkey's most popular method—i.e., a pregnancy rate of 33% associated with withdrawal—combined with the widely held desire for smaller families has resulted in high levels of unintended pregnancy and of abortion.5
Turkey's abortion rate fell from 45 abortions per 1,000 women aged 15-49 in 1988 to 25 per 1,000 in 1998, and the proportion of pregnancies resolved by abortion decreased from 24 per 100 to 16 per 100 over the same period. Nevertheless, abortions in Turkey are still relatively common. Moreover, the country's 1998 total abortion rate—0.59 procedures per woman over her reproductive lifetime6—coupled with the fact that 73% of ever-married women have never had an abortion indicates a very high incidence of repeat abortions. In fact, nearly the same proportion of Turkish women have had two or more abortions as have had only one (13% vs. 14%, respectively).7
Two-thirds (67%) of abortions in Turkey are provided by private-sector obstetrician-gynecologists, with many of these physicians performing the procedure in their private offices.8 Although data on the specific techniques used in private-sector settings are unavailable, both dilation and curettage and manual vacuum aspiration (MVA) are believed to be used routinely. For the one-third of abortions that are obtained in the public sector, MVA is standard, and general practitioners are allowed to offer the procedure under the supervision of an obstetrician-gynecologist.9
A 1994 assessment of abortions provided in 26 public and university hospitals in Turkey indicated that 74% were performed using MVA instruments.10Thirty-two percent of the women having an abortion in those institutions received local anesthesia, 14% were treated with general anesthesia and 7% received either intravenous tranquilizers or intramuscular analgesics. In addition, nearly one-half (47%) were not given any medication for pain at all.
Although abortion legalization reduced the number of maternal deaths throughout Turkey, effective links between abortion and family planning services were not created.11 Service provision at many sites was disjointed, and several medical and administrative barriers restricted abortion clients' access to family planning services.
Many family planning providers, for example, would not offer immediate post-abortion insertion of the IUD, citing that it would alter the normal course of bleeding, which they needed to observe to verify the completeness of the abortion procedure. Many clients were only told to return for a follow-up visit, which was usually scheduled for when the woman had her first menses postabortion. In most cases, this return visit represented the earliest occasion for a discussion of family planning. Even though both types of services were frequently provided in the same facilities (although in different departments), the lack of integration12meant that abortion clients often left the premises without receiving any family planning information or services.13
This article compiles and analyzes a decade of experience in postabortion family planning services in Turkey, which were delivered through three related phases—first in a pilot program in a single public maternity hospital, then in an expansion of the program into 10 public facilities throughout the country (including three in Istanbul) and, finally, through further expansion into 12 private-sector and two public-sector hospitals in Istanbul.
Early Pilot Program
Evidence that women were relying on repeat abortion to control their fertility made it clear that the Turkish family planning program, despite its successes, was unable to meet the contraceptive needs of these women. Clients needed improved links between abortion and family planning services to have better access to quality family planning information and services. In response to this need, the Turkish Ministry of Health initiated a pilot postabortion family planning program in the early 1990s to link these services in a selected facility where large numbers of abortions were provided. It was hoped that the lessons learned from this pilot project could then be replicated in future sites.
Both the pilot and the subsequent phases of the postabortion family planning program were funded by the U.S. Agency for International Development (USAID), with technical assistance in the planning, implementation and evaluation phases provided by AVSC International (now EngenderHealth). The Turkish Ministry of Health, along with the national Social Insurance Organization (SKK) and private-sector partners, were key implementers and were actively involved at various stages of the program.
Zekai Tahir Burak (ZTB) Women's Health Education and Research Hospital in Ankara (hereafter referred to as ZTB Hospital) was selected as the first intervention site. The pilot postabortion family planning program was introduced in late 1991 and continued through September 1993. ZTB Hospital was chosen because the medical director was interested in providing postabortion family planning services, because the facility is one of the largest maternity hospitals in Turkey and because it performed more than 6,000 abortions annually in the early 1990s.14
Prior to the intervention, ZTB Hospital did not routinely offer postabortion family planning care. Even though the family planning clinic had been in existence at the hospital since 1966, abortion clients underutilized these services, as they were provided only at the client's request and staff made very little effort to counsel abortion clients about family planning. Additionally, method choice was limited by significant medical barriers.
Some providers felt that there was no need to start practicing contraception immediately after an abortion and that clients could wait until their next menstrual period to begin using a method. In addition, providers were biased against hormonal methods and felt that postabortion IUD insertions would raise infection and expulsion rates. Although in 1991 65% of abortion clients adopted a method at the ZTB family planning clinic, most of these women selected the condom, comparatively few chose the IUD and even fewer decided on a tubal ligation.15 To address this imbalance, the ZTB pilot program employed the four following strategies.
•Set up structural links between abortion and family planning services. The facility was renovated to improve client flow between the abortion and family planning outpatient clinics. The renovation created a large joint waiting room, a separate room for family planning counseling and an adjacent room for performing tubal ligations. This relatively minor renovation greatly improved access to services and patient flow.
•Overcome staff resistance to providing postabortion family planning services. Negative attitudes toward postabortion family planning held by many providers16 were based on several misconceptions. Two strategies were used to overcome this resistance. First, the hospital medical director conducted a study on the safety of postabortion IUD insertions. The results showed no increased infection risk or expulsion rate.17 Second, ZTB Hospital sponsored a series of conferences and seminars to reeducate staff on contraceptive technology. These updates on technology emphasized the importance of initiating use of a method to prevent pregnancy immediately after the abortion.
•Provide accurate information to abortion clients about family planning. Abortion clients lacked accurate information regarding the use of family planning methods during the postabortion period. To overcome this deficit, the integration of a strong counseling component was emphasized. The hospital began routinely training its staff to provide family planning counseling to abortion clients. A formal family planning counseling protocol for abortion clients was established in both group education settings and in couples counseling.
When women first came to the clinic to verify their pregnancy and to request an abortion, they attended a group session in which each contraceptive method was explained in detail. Clients were then given an appointment for their abortion. At that appointment, they met with a family planning counselor for a private counseling session; those who were accompanied by their husband met with a family planning counselor for couples counseling, which included a detailed discussion of the method chosen by the woman (or by the couple) to be used after the abortion. (Clients seemed quite happy with the quality of services, as 92% stated that they were satisfied enough to refer a friend to the facility.18)
•Improve method availability. The hospital expanded the range of methods available by offering the pill and the IUD; by training staff to do tubal ligations; and by setting up a system for vasectomy referrals. Contraceptive implants and injectables were later introduced into the method mix.
The changes made at ZTB Hospital appear to have had an immediate impact. In one year, the use of a modern contraceptive among abortion clients increased dramatically as a result of the pilot program. For example, the proportion of clients who left the hospital after their abortion with a contraceptive method rose from 65% in 1991 to 97% in 1992 (Table 1). In addition, through the 1990s the annual numbers of abortions provided at the hospital fell from 4,100 in 1991 to 1,709 in 1998.
Because hospital policies and the abortion client population remained stable over the period, this reduction may be attributable at least in part to the prevention of repeat abortions through the provision of postabortion family planning services. According to client records and reports from clinic staff, the couples counseling at ZTB appears to have resulted in more effective contraceptive use, which contributed further to the reduction in repeat abortions.19
The pilot program also seems to have influenced a change in the method mix. In the six months preceding the intervention, the method that abortion clients were most likely to accept was the condom (44%), followed by no method (35%), the IUD (20%) and tubal ligation (1%, Table 2). In the six months following initiation of the intervention, the proportion of abortion clients choosing the IUD increased more than twofold, to 49%, and the percentage deciding on a tubal ligation rose dramatically, to 15%. Given that the majority of Turkish couples want no more children, a postintervention method mix weighted toward highly effective methods is more in line with actual fertility preferences than the preintervention mix.
Replication at 10 Sites
The strategy to replicate the ZTB experience involved expanding the availability of postabortion family planning services to 10 more large public hospitals throughout Turkey from 1992 to 1998. These hospitals received varying levels and types of technical assistance based on their individual needs and interest. Some initiatives were as simple as conducting a contraceptive technology update for staff, while other sites required more extensive training, renovation and assistance in arranging for additional contraceptive supplies to expand the method mix.
For example, in Konak Maternity Hospital in Izmir, the primary program activity was training providers to expand the method mix they offered. One pro-vider was trained in no-scalpel vasectomy technique and another in the insertion of contraceptive implants; this professional training helped make the Konak clinic one of the leading family planning facilities in Turkey. As a result of this particular hospital's efforts to recruit vasectomy clients from among the husbands of abortion clients, it won a unique reputation for offering "postabortion vasectomy."20
The intervention carried out in the Maternity Hospital (Etlik) of the Turkish Social Insurance Organization in Ankara provides a different example, as it was conducted more formally and required the assistance of an international consultant to facilitate postabortion family planning counseling and services. The intervention later involved renovations, including the purchase of equipment for an operating theater for tubal ligations. Finally, to improve method choice, several providers were trained in no-scalpel vasectomy technique and in the provision of injectable contraceptives.
One of the later interventions, conducted in Eskisehir Maternity Hospital in 1997, was more comprehensive. It began with on-site training in both postabortion and postpartum family planning that lasted five days; staff were trained in communication skills, family planning counseling, infection prevention and contraceptive technology.
The interventions at the original ZTB pilot site and at the 10 expansion sites served as prototypes in the curriculum drafted by Turkey's General Directorate of Maternal-Child Health and Family Planning (the "Postabortion Family Planning Curriculum").21 This curriculum includes modules from several others developed by EngenderHealth (i.e., "Family Planning Counseling: A Curriculum Prototype," and "COPE—Client-Oriented Provider-Efficient Services"), as well as modules that were written in-country. The counseling piece of the curriculum adapts the GATHER* approach to postabortion family planning. The curriculum was field-tested in Eskisehir and was later used in the expansion of the intervention into Istanbul.
Unfortunately, standard data were not routinely collected when these postabortion services were being established in the expansion sites. Thus, service statistics to adequately track the progress of the postabortion program from 1991 through 1998 are incomplete. To assess program progress, we sent a questionnaire to the 10 expansion sites in 1999, requesting data from the previous year. We then compared these data with other data collected in 1994 as part of a situation analysis of Turkey's reproductive health care services;22 that situation analysis had included all but two (the Adana clinic and the Zubeyde Hanim Maternity Hospital) of the original 10 postabortion program expansion sites.
The results were encouraging: By 1999, six of the nine expansion sites for which 1998-1999 data were available—a 10th site (Zubeyde Hanim Maternity Hospital) had dropped out of the initiative by then—had reached postabortion family planning acceptance rates of more than 90% (Table 3). The three hospitals that had achieved more modest acceptance rates nevertheless represent noteworthy increases from their 1994 levels. Of the six high-performing sites in 1999, two had had relatively high acceptance rates in 1994, which reflect interventions begun prior to that year.
The importance of commitment from the hospital leadership emerged as the key lesson learned from the expansion phase of the intervention. Some of the participating public-sector hospitals—and the original ZTB pilot program hospital—achieved high contraceptive acceptance rates because hospital directors were committed to providing postabortion family planning services. In sites where leadership and support did not exist, however, progress was either slow or nonexistent.
Perhaps this initiative's most striking aspect is its ongoing self-sustainability. External assistance to all initiative hospitals ended several years before 1998 and in most cases involved technical assistance for a few months only. Yet, the provision of postabortion family planning services has continued unabated for years.
Another lesson learned is the importance of conducting follow-up visits in intervention facilities. These visits, conducted a few times in the early months following the intervention, depended on the individual needs of each facility and helped reinforce the impact of the intervention. Facilities that did not receive this type of support were slow to progress.
The initiative is also noteworthy for its relatively low cost. The costs of integrating family planning services into abortion services are minimal, as many of the costly ingredients for a successful postabortion family planning program, such as staff and infrastructure, already exist. The other intervention inputs, such as contraceptive supplies and patient education materials, are relatively inexpensive, and the clinic-based nature of the approach further keeps costs low.
Moreover, since clients have already come to the hospital seeking services, the need to design additional outreach and mass media communication efforts is eliminated. While a formal cost-effectiveness analysis of this postabortion family planning initiative has not yet been conducted, an analysis undertaken by the Turkish Social Insurance Organization demonstrated that offering IUD insertions and tubal ligations as postabortion rather than as interval procedures reduced their cost by 57% and 49%, respectively.23
Program Expansion in Istanbul
A Change in Focus
In 1998, USAID revised its program strategy in Turkey. Rather than work on a nationwide basis, it chose to focus on fewer but high-priority interventions in selected provinces. The program also adopted a more integrated approach among its cooperating agencies and partner organizations in planning, implementing and monitoring activities. As part of the new strategy, USAID and its partner organizations decided to build on their previous experiences in initiating postabortion services and to launch a larger initiative, to maximize the impact of the interventions.
The model used in the earlier phases of the intervention was replicated in hospitals in the greater-metropolitan areas of selected provinces. The focus was shifted from individual facilities scattered throughout the country to facilities where large numbers of clients sought abortion services. The intervention targeted all major facilities in those areas, beginning with Istanbul, which was chosen because this city of more than 10 million people is the fastest growing metropolitan area in Turkey.
An estimated one-quarter to one-third of Turkey's abortions are performed in Istanbul.24 This fact, coupled with the current growth of the private health sector, made Istanbul an excellent site to scale up the postabortion family planning initiative. Moreover, because two-thirds of abortions in Turkey are provided by the private sector, we focused on private hospitals in this phase of the initiative (although two public-sector hospitals in Istanbul were included in this third phase as well).
Although initial assessments indicated that barriers to quality postabortion family planning were similar in both the public and private sectors, the different dynamics of the private sector created additional barriers and made interventions more difficult. For example, although the number of private hospitals in Istanbul is growing, they are physically much smaller than public hospitals, and they serve fewer clients. Thus, this phase had to cover comparatively more private facilities to reach a significant number of abortion clients. Also, since the private sector is not overseen by any one managing entity (as is the public sector), private hospitals had to be approached on an individual basis, which slowed progress.
The foremost difficulty in providing family planning through the private sector is that many physicians see no financial incentive in it. (Providing abortions, however, has significant financial benefits for some physicians.) Additionally, some providers see the time required to attend training activities as an impediment.
In spite of these differences between the public and private sectors, the interventions undertaken in Istanbul were similar to those in the pilot and public-sector expansion phases. Assessments of "candidate facilities" to determine which intervention was needed to improve the quality of postabortion family planning services resulted in the following intervention strategies.
•Train staff. Staff training sessions were designed on-site and were tailored to meet the site's individual needs. The postabortion family planning curriculum, developed during the previous phase, was used to guide the training, which focused on providing contraceptive technology updates and on improving counseling, infection prevention and recordkeeping skills. The training placed special emphasis on better understanding the client perspective and on meeting client needs, and ended with an action plan to be implemented by the facility's staff.
•Introduce specific approaches and techniques to improve services. Specific service-quality improvement technique, such as the Inreach25 approach and the self-assessment technique known as COPE,26 were applied in all sites and became integral parts of the Istanbul intervention. We used Inreach to better inform hospital clients about family planning services available in the same facility and to link abortion clients with existing family planning services that were within their reach. We introduced the COPE self-assessment tool, which uses simple problem-solving techniques, into on-site training to help the hospital staff identify and address the problems preventing them from providing quality postabortion family planning services.
•Develop client information and education materials. The site assessments revealed that information, education and communication materials specific to postabortion family planning were inadequate. Although many public-sector sites in the earlier phase lacked such materials, or used them inefficiently, the private hospitals had none at all. Thus, the private-sector intervention involved reviewing, reprinting and distributing to all program sites the materials that were developed earlier in the intervention. These included a client brochure and a wallchart on postabortion family planning that provided brief information on methods and conveyed key messages regarding their delivery during the postabortion period. Both the training sessions and the curriculum stressed the use of these materials.
•Set up a management information system and collect data. The lack of a working data collection system in the early phases of the intervention indicated the need for such a system for collecting standard and timely data. A simple, user-friendly form was developed and the information collected was kept to a minimum. Repeated follow-up visits to educate nurses responsible for recordkeeping resolved any problems with data collection that came up.
In addition, a series of surveys, the Istanbul Family Planning Quality Surveys, were designed to monitor the progress of the USAID program. These incorporated items on postabortion family planning and were carried out in all of the facilities participating in the postabortion family planning program in Istanbul. (These surveys covered a total of 128 private- and public-sector health facilities, 26 of which provided abortion services.27) The first of these surveys, conducted in 1998, was used as a baseline for the program and the surveys were to be repeated every 18 months.
The Istanbul expansion phase of the postabortion family planning intervention began in September 1998 and is ongoing. Since 1998, 14 additional hospitals have been included in the program, all but two of which are private, bringing the total number providing organized postabortion family planning services in Istanbul to 17.
Figure 1 illustrates the progress that the 14 Istanbul hospitals made from 1998 to 2000. Prior to the intervention, on average, 37% of clients at these facilities accepted a method of family planning after their abortion.28 At the end of the first month of the intervention, during which on-site training workshops were conducted, that average had increased to 44%.29 Since interventions were started at individual hospitals at different times, the cut-off times for follow-up data collection were also different, although all sites were followed up for at least nine months; by that time, hospitals reported an acceptance rate of 72%.
Preliminary results from this third phase of the intervention highlight the similarities and differences in the public and private sectors. In both types of facilities, family planning acceptance rates increased in the early period of the intervention. Acceptance rates then stabilized and remained constant, an indication of sustainability in both sectors. However, acceptance rates in the private hospitals plateaued at a lower level. For example, the three public hospitals in Istanbul involved in the second phase—Zeynep Kamil and two government Social Insurance facilities SSK Bakiroy and SSK Goztepe—achieved acceptance rates of more than 90% (see Table 3), while the level was around 70% in the 14 hospitals in Istanbul (see Figure 1). This somewhat lower prevalence of postabortion method acceptance primarily results from private physicians' preference to delay giving their abortion clients a method until a return visit after the procedure. These physicians claim that it would be inappropriate to ask the client to pay for two services—an abortion and a family planning visit—at the same time.
USAID's plans to expand the postabortion family planning initiative have been achieved by the inclusion of seven additional private hospitals in Istanbul as of March 2001. The completion of this last phase means that all major public and private facilities providing abortion in Istanbul have now established family planning services for abortion clients.
USAID's final plan for the postabortion program in Turkey was to expand the initiative to the heavily populated Cukurova region in southern Turkey. In 2000, postabortion family planning was established in one public maternity hospital in Cukurova, and the program will be added to two more public hospitals there in 2001. Follow-up surveys on quality will provide additional data on the program's progress.
The inadequacy of family planning services for abortion clients, which leads many women to go on to have repeat abortions, constitutes a major public health issue in Turkey. The postabortion family planning program was designed to address this important need by establishing linkages between abortion and family planning services. In countries where abortion is common, many observers believe that women prefer abortion to family planning. Our experience in Turkey shows that women turn to abortion simply because contraceptive options are not readily available. Once quality family planning services are made available to abortion clients, they accept family planning methods at high rates.
A recent analysis of abortion trends in Turkey shows that the rate of abortion has declined significantly over the last decade, with the shift away from less-effective traditional family planning methods toward modern methods being an important factor in that decline.30 These results imply that the postabortion family planning program efforts implemented throughout the 1990s contributed to the decline in abortion, both by increasing the use of contraceptives among women who had had an abortion and by tilting the method mix toward more effective methods.
The most encouraging aspect of the postabortion family planning approach is that it is highly replicable and sustainable. The program's model was replicated successfully in Turkey in almost all of the selected sites. Of the 11 large public hospitals that initiated postabortion family planning services as part of the overall intervention, 10 continue to provide postabortion services several years afterward, with no external assistance. Postabortion family planning services were successfully replicated in the private sector as well. The services delivered in the private sector faced additional challenges in terms of sustainability, however. Of the 12 original private-sector hospitals that initiated postabortion family planning services, all of them continue to provide these services.
The delivery of postabortion family planning in Turkey also has proven cost-effective, since any additional costs of integrating family planning services into existing abortion services are minimal. Facilities providing abortion services have an existing infrastructure and staff, which can be built upon with little cost, to provide family planning services. Thus, postabortion family planning creates a synergy by bringing together the existing resources of two types of services without the need for many additional ones.
The postabortion family planning model requires a systematic and integrated approach, however. Many elements are necessary for success, including the commitment and motivation of decision-makers, clinical and counseling training for staff, relevant educational materials for clients, and adequate space and family planning commodities. Each of these elements must be present in order to make the model work.
Providers' misconceptions about post-abortion family planning and medical barriers to these services can be overcome with scientifically valid information collected through local clinical studies, such as the one conducted in the assessment of the pilot experience in the ZTB Hospital. Also, each intervention must be tailored to the needs of the individual hospital. The level and nature of the assistance required by individual hospitals varies considerably, depending on its individual needs.
The commitment of decision-makers was a particularly important criterion in the success of postabortion interventions. At the national level, the program required support from management at the Ministry of Health and at the Social Insurance Organization. Similarly, the success of individual hospital-based interventions required commitment from those hospitals' directors. The delivery of postabortion services was successful only in sites where such leadership and support were present.
The most important challenge for the postabortion family planning program in Turkey was reaching the private sector. While the elements required to establish a successful program are similar in both sectors, implementation in the private sector faces even more barriers. First, the lack of a single management entity means that interventions must be directed to individual hospitals. Second, abortion services are also provided by thousands of private physicians working in individual private practices. An attempt to reach significant numbers of these physicians in Turkey would require more extensive efforts and resources. Finally, some private practitioners choose not to participate in postabortion family planning initiatives because they do not see any financial incentive in the family planning part of it. However, despite these challenges, increasing numbers of physicians are beginning to provide postabortion family planning services to attract clients who demand better access to family planning.
Turkey is similar to several other countries where legal abortion has been widely used to control fertility. While abortion rates have been declining in Turkey, several neighboring Eastern European countries continue to have exceptionally high rates of abortion.31 The postabortion program experience in Turkey can provide valuable lessons for such countries: Postabortion family planning is a low-cost, high-impact intervention that can be adapted to other country settings.