Service Delivery

Copyright: Ipas

High quality PAC services should be accessible and available to all women who experience an incomplete abortion, whether it is spontaneous (miscarriage) or induced.  Research has shown that PAC services do not have to be limited to tertiary health facilities but can also be provided at lower-level, rural health facilities. Midlevel providers can safely provide PAC services, including treatment of complications using MVA or misoprostol. All levels of health systems should be equipped with the necessary equipment, drugs, and supplies to provide those services. PAC services should include counseling, treatment of incomplete and unsafe abortion and complications, contraceptive and family planning services, and other reproductive as needed. PAC services can be integrated with screening for STIs, HIV, and Gender-Based Violence which result from the same source of vulnerability as unintended pregnancy does – unprotected sex. The PAC Model page provides more information about the range of services that ideally should be provided to postabortion women.

PAC Consortium | General Resources | Training Resources | Studies & Assessments

PAC Consortium Materials

Essential Elements of Postabortion Care: Service Delivery Barriers and Resources
Postabortion Care Consortium, 2014
This compendium of resources provides strategies and tools to reduce barriers to service delivery. The list is not meant to be an exhaustive list of all resources related each barrier, but a compendium of tools that can be used by health workers and other professionals to overcome barriers to comprehensive PAC services. The barriers and resources are organized into the following categories based on the Essential Elements of PAC model.

General Resources

Midwives: Making a difference
Ipas, 2011
Midwives are the front line in keeping women healthy—through pre- and postnatal care and through comprehensive reproductive health care, including safe abortion. When skilled midwives make these important services available, accessible and affordable, they play a key role in reducing maternal mortality. This publication highlights three midwives from three different countries who provide abortion or postabortion care and how their work makes a difference.

Postabortion Care: Going to Scale
RamaRao, S, Townsend J, Diop N, Raifman, International Perspectives on Sexual and Reproductive Health, 2011
This commentary describes the current state of PAC: progress that has been made in research, policy change, and service delivery practices,and existing barriers to expanding PAC access.  The authors propose strategies for effectively scaling-up PAC programs and cite examples of successful PAC programs in African countries.  It is a call to action for the PAC field.

Packages of interventions: Family planning, safe abortion care, maternal, newborn and child health
UNICEF; UNFPA; WHO; World Bank, 2010
This document describes the key effective interventions organized in packages across the continuum of care through pre-pregnancy, pregnancy, childbirth, postpartum, newborn care and care of the child. The packages are defined for community and/or facility levels in developing countries and provide guidance on the essential components needed to assure adequacy and quality of care.

New Evidence and Strategies For Scaling Up Postabortion Care
UNFPA, Gynuity, 2010
All presentations from the “Regional Meeting of Key Stakeholders from Africa and the Arab States” are posted on this website. The presentations include programmatic updates and case studies, frameworks for integrating and scaling-up PAC services, and new information on MVA and misoprostol for PAC.

Rights of the Client
USAID: Extending Service Delivery (ESD), 2008
This is a list of ten rights for all community members, individuals, couples and clients, regardless of age, education, marital, ethnic, social, economic and political status.

Addressing unsafe abortion: A commitment to saving women’s lives, second edition
Ipas, 2008
Ten years after the International Conference on Population and Development (ICPD) in Cairo, unsafe abortion continues to be a major public-health and women’s rights issue. After summarizing the global problem of unsafe abortion, this two-page factsheet outlines the recommendations that have been made over the past 10 years to address this problem, the approaches used to implement these recommendations, and the regressive policies that have undermined them, including the far-reaching global gag rule that was reinstated by President George W. Bush in 2001.

A Guide for Fostering Change to Scale Up Effective Health Services
USAID and World Health Organization, 2007
As part of the Implementing Best Practice Initiative, this guide defines proven approaches to improve clinical and programmatic practices.  It details a step-by-step method for effectively scaling-up high impact reproductive health services.  Various stakeholders and change agents can benefit from the strategies in this document.

Putting quality first: An assessment of postabortion care services at Murtala Muhammad Specialist Hospital in Kano, Nigeria
T. Fetters; A. Akiode; E. Oji, 2004
Based on data from facility questionnaires, clinical observations and client exit interviews, this report assesses in detail the quality and accessibility of emergency postabortion-care services provided at Murtala Muhammad Specialist Hospital (MMSH), the largest public-sector hospital in Kano state, Nigeria.

Deciding women’s lives are worth saving: Expanding the role of midlevel providers in safe abortion care
Ipas; IHCAR, 2002
This publication in makes a compelling case for empowering, training and supporting midlevel providers, such as nurses, physician assistants and midwives, to deliver critically needed safe abortion and related services.

Training Resources

Postabortion Care Curriculum
USAID PAC Working Group, 2010
This curriculum includes a Reference Manual, Trainer’s Guide, and Participant’s Guide.  The Reference Manual outlines the core components of PAC, provides guidelines for treatment, and describes techniques for providing family planning and other reproductive health services to women who access PAC.  The Trainer’s Guide is a technical document that can be used for training skilled service providers, including physicians, nurses, and midwives, on providing PAC.

Providers as advocates for safe abortion care: A training manual
K. Turner; E. Weiss; G. Gulati-Partee, 2009
Organized in four parts, this training manual aims to foster an advocacy perspective in health-care providers who are involved in delivering abortion and/or postabortion care. The manual will help providers recognize their personal power as advocates and identify different circumstances and means to advocate for comprehensive abortion care to the full limits of the law.

Enhancing Postabortion Care Counseling Skills—An Interactive Learning Tool
IntraHealth, 2008
IntraHealth developed the DVD Enhancing Postabortion Care Counseling Skills—An Interactive Learning Tool to enhance or refresh the counseling skills of experienced providers of postabortion care (PAC) services.  Through skills and behaviors modeled in this DVD, counselors can learn to build client trust and work with the client to find a safe, effective family planning method. As learners, providers explore two stories that realistically portray the challenges counselors face when offering family planning counseling to PAC clients. The program demonstrates different counseling behaviors, and providers are challenged to choose the most appropriate behaviors based on PAC standards of practice. As part of the learning program, learners receive immediate feedback on their choices from a “mentor.” The setting is Kenya, but many of the counseling skills will be applicable in other locations. For more information, or to order the DVD, contact Nola Bower-Smith.

Abortion attitude transformation: A values clarification toolkit for global audiences
K. Turner and K. Chapman Page, 2008
This toolkit is a resource for trainers, program managers and technical advisors who organize or facilitate training events and advocacy workshops in the field of sexual and reproductive health. It provides experienced trainers with the background information, materials, instructions, and tips necessary to effectively facilitate abortion values clarification and attitude transformation interventions.

Postabortion Care Flip Chart
E. Brazier; A. Babcheck; R.C. Faul-Doyle; L. Barbosa; S. Keralis; Family Care International, 2005
This flip chart is designed to enhance postabortion client counselling and community education related to unsafe abortion. It is comprised of four separate sections focused on the following topics: pre-procedure counselling, post-procedure counselling, postabortion family planning, and unsafe abortion in the community.

Related resources: PAC Instructions for Clients (English), PAC Provider Instruction Booklet – Part 1 (French)PAC Provider Instruction Booklet – Part 2 (French)

Woman-centered postabortion care: Trainer’s manual
K.Turner; T. McInerney; J. Herrick, 2004
This trainer’s manual is intended for use by trainers who lead trainings in woman-centered PAC for a broad audience, including health-care workers, administrators, program managers, health educators and social workers. Designed to accompany Woman-centered postabortion care: Reference manual, this manual presents learner-centered, participatory training methods. It comes with a CD-ROM that includes PowerPoint® presentations, additional training resources and adaptable training exercises.

Counseling the Postabortion Care Client: A Training Curriculum
EngenderHealth, 2003
EngenderHealth’s training curriculum for health care providers is designed to make counseling an integral part of comprehensive postabortion care (PAC) services. With an emphasis on improving provider-client communication, Counseling the Postabortion Client: A Training Curriculum can help providers to integrate high-quality counseling into routine interactions with postabortion clients.  The curriculum is available in English, French, and Spanish.

Studies & Assessments

Quality and efficiency of care for complications of unsafe abortion: A case study from Bangladesh
Johnston HB, Akhter S, Oliveras E, 2012
Service delivery of postabortion care and costs associated with treatment of complications from unsafe abortion were assessed at all levels of care in Bangladesh.  While PAC services were increasingly available at lower level health facilities, proven best practices like vacuum aspiration, misoprostol for PAC, and postabortion family planning are not widely used.  Integrating these evidence-based practices with continued decentralization of care can improve the quality and cost-effectiveness of PAC services in Bangladesh.

Pathways and consequences of unsafe abortion: A comparison among women with complications after induced and spontaneous abortions in Madhya Pradesh, India
Banerjee S., Andersen K., Warvadekar, J, 2012
This study included women who sought treatment for postabortion complications at a district hospital in India following either spontaneous or induced abortion.  Women experiencing complications after an induced abortion generally consulted family members and relatives, and visited other health care providers or traditional medics before going to a tertiary care center.  Conversely, most women who had complications related to spontaneous abortions quickly visited a qualified medical doctor or nurse.  These findings have implications for service delivery and highlight the need to reduce stigma around abortion and PAC and increase availability of services.

A randomized controlled trial of 400-micrograms sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian Hospitals
Dabash R, Ramdan MC, Darwish E, Hassanein N, Blum J, Winikoff B, 2010
This randomized control trial of 697 women compared outcomes associated with treatment of incomplete abortion using misoprostol or MVA in Egyptian Hospitals.  Both strategies were effective in treating incomplete abortion and few complications occurred.  Women treated with misoprostol were significantly more likely to be satisfied with the treatment method and willing to recommend it to a friend.

Postabortion care counseling practiced by health professionals in southeastern Nigeria
Adinma, J.I. et al
International Journal of Gynecology and Obstetrics, 111, pages 53-56, 2010
A cross-sectional questionnaire-based survey was conducted among healthcare professionals in 2006 in Anambra State, southeastern Nigeria to determine the practice of postabortion care (PAC) counseling among healthcare professionals in southeastern Nigeria. Conclusion: A high proportion of health professionals reported practicing PAC counseling. However, less than half had received formal training in PAC counseling. An increased PAC training activity program, with an emphasis on counseling, is recommended for health professionals to improve the overall quality of PAC service delivery.

Scaling Up Post-Abortion Care in Guatemala: Initial Successes at National Level
Kestler E., Valencia L., Del Valle V., Silva A, 2006
This article describes the service delivery strategies employed to scale-up PAC in Guatemala between July 2003 and December 2004 and the impact of the program after 18 months.  Use of MVA for treatment of incomplete abortion increased, as did provision of family planning services and uptake of modern contraceptive methods. The intervention improved health systems infrastructure and management and enhanced M&E capacity through initiating an abortion surveillance system. Despite these advances, the prevalence of severe postabortion complications remained the same, which suggests that there is more to be done.