Complications from spontaneous and unsafely induced abortions are a major cause of maternal mortality and poor health in most developing countries. The World Health Organization estimates that nearly 70,000 women worldwide die every year from such problems, the most common of which are infection, hemorrhage and injuries to the cervix and uterus. These complications also increase the stress on already-strained health systems: In some countries, treatment of abortion complications accounts for more than half of hospital obstetrics and gynecology budgets.
Social stigma and lack of access to high-quality emergency medical services or to the financial resources to pay for them are major barriers to adequate care. Most health systems rely on resource-intensive methods of uterine evacuation, such as sharp curettage, that prevent their use at every level of care, making access particularly difficult for women who do not live near hospitals. Even when emergency medical treatment is available, it often is not linked to additional services that would help women prevent repeated unintended pregnancies and other reproductive health problems.
As countries around the world confront the need to prevent abortion-related mortality and morbidity, they find themselves facing not only medical and technical issues, but also social and political sensitivities and the need to reorient and retrain health care providers. The four articles that make up our third Issues in Perspective examine these issues and look at ways of dealing with them.
In their overview, Maureen Corbett and Katherine Turner describe how the loss of life and health caused by abortion complications and barriers to their treatment led to the development of a new concept called postabortion care [see article]. In tracing the evolution of this concept--which includes not only emergency medical care, but also family planning counseling and services and links to sources of other reproductive health care--they highlight the need to move from a purely medical model of care to a broader public health model that encompasses both curative and preventive services.
Deborah Billings and colleagues address issues of both medical technique and comprehensiveness in comparing three models of care used to treat patients with abortion complications in public hospitals in Mexico City [see article]. In their study, the provision of the full package of postabortion care services appeared to matter more than the type of procedure used for uterine evacuation: Women who received counseling and family planning services tailored to their specific needs, as well as treatment by sharp curettage or manual vacuum aspiration, rated their quality of care higher than did those who were treated with sharp curettage but received only general information about their health status and treatment and about contraception.
Dale Huntington and Laila Nawar's description of efforts to develop a postabortion care program in Egypt focuses on the barriers posed by political and social sensitivities about abortion [see article]. The authors note that in countries such as Egypt, where abortion is legally restricted and socially sanctioned, postabortion care must be positioned as a health care issue rather than a religious, legal or social issue. Indeed, despite the program's success in providing documentation of the poor standard of care and means of improving treatment, it has yet to win approval for importation of essential manual vacuum aspiration instruments because of their association with abortion itself.
In addressing the need for and components of postabortion counseling, Jill Tabbutt-Henry and Kristina Graff note that this essential element of care should be integrated into all interactions between provider and patient [see article]. Many providers, they point out, need training and support to prepare them to counsel women who have complications from the loss of a wanted pregnancy or termination of an unwanted one. In addition, they say, policymakers, program planners and supervisors must take the lead in establishing policies and structuring services to support providers' efforts.
Also in This Issue
• Family planning policymakers and program planners have long debated the question of whether contraceptive use is driven primarily by the service environment or by the socioeconomic and demographic characteristics of the population. Charles Ketende and colleagues study the situation in Uganda, where modern contraceptive use has recently increased in areas served by a program designed to improve the availability and quality of reproductive health services [see article]. Their analysis finds that although certain program interventions may have helped create a demand for family planning services, the subsequent use of those services was not closely tied to facility-based efforts.
• With the reestablishment of Bangladesh's doorstep delivery program earlier this year, concerns raised in the mid-1990s about the effect of the program on the status of women have resurfaced. Using longitudinal and cross-sectional data from women served by the program, James Phillips and Mian Bazle Hossain find that household outreach is associated with increases in women's status [see article]. They note, however, that this relationship is largely attributable to the program's positive impact on women's control over their fertility rather than to the home visits themselves.