Access to Contraception After an Abortion: Post-Abortion Care

For several years now, the prevailing consensus that abortion in risky conditions is a serious public health problem has led various international and national organizations to implement actions aimed at improving the quality of and access to post-abortion care (PAC). Commitments resulting from international conferences held in the 1990s, signed by every country in the world and followed up to guarantee that they are met, stress the need to “guarantee women’s access to post-abortion care (Naciones Unidas, 1995; 1996).

Approximately 3.7 million women die annually in the region from abortion-related complications. For each death, countless women suffer long-term injuries and disability (WHO, 2004). Due to the high rate and tragic consequences of unsafe abortion, there is an urgent need for timely, high quality post-abortion care (PAC) to be available for all women in Latin America and the Caribbean, where the incidence of abortion is still extremely high. Post-abortion care, a term coined in the early 1990s, refers to a set of reproductive health services, grouped into five main areas: timely treatment of abortion-related complications that threaten women’s lives; psychological and physical counseling for identifying and responding to women’s health needs and other concerns; contraception and family planning services; reproductive health and other types of services provided at the same health establishment or through referral to other complementary services; and alliances between the community and health service providers, in order to deal with the problems of unwanted pregnancy and unsafe abortion. As part of appropriate abortion care, the World Health Organization recommends the use of manual endouterine aspiration (MEA) instead of instrumental uterine curettage (IUC) since it is an effective, safer method. At several health establishments, services have been reorganized to offer PAC as an outpatient procedure, which has considerably reduced the costs and duration of women’s average hospital stay (Billings and Benson, 2005).

It is also felt that the implementation of post-abortion contraceptive services is crucial for preventing repeated interruptions of pregnancy, particularly in countries where abortion is illegal and there are very few counseling services for these cases, let alone ones in which family planning orientation is also offered. Chambers (1994) notes that family planning services should be linked to treatment for abortion complications as a means of breaking the cycle of repeated abortions. This is due to the fact that the users of these services are highly motivated to accept contraceptive methods after having undergone an abortion (p.85).

The aforementioned study undertaken in four Latin American countries by Lafaurie et al. (2005) observed an increase in contraceptive use after an abortion. In another study conducted in Colombia in 1993, the majority of women who were interviewed after aborting clearly expressed their intention to using a safe method such as an IUD, which they would be given on the day of their treatment for an incomplete abortion. Conversely, adolescents chose barrier methods (Mora Téllez et al., 1999).

Another study on PAC in Latin America, which analyzed the results of the 10 main operative research programs in hospitals in the public sector in the region between 1991 and 2002 reached a similar conclusion. It held that incorporating the use of appropriate technologies like MEA and using a woman-centered approach made it possible to save many of their lives and improve their reproductive health, as well as reducing costs for the health system in the region (http://www.ipas.org/spanish/womens%5Fhealth/postabortion%5Fcare).

A study conducted between late 1987 and mid-1990 in Nairobi (Kenya), Harare (Zimbabwe), Lusaka (Zambia), Mexico City, and Lagos and Jos (Nigeria) on women hospitalized for post-abortion treatment concluded that it was necessary both to improve abortion services and to disseminate the knowledge and services available in family planning programs. It warned, however, of the fact that counseling services might not have an effect on the acceptance of family planning in contexts where acceptance rates are already high. It also found that contraceptive use is associated with a major reduction in repeated pregnancies and that although counseling does not directly reduce the incidence of repeated abortion, it does so indirectly by reducing the repeated number of unwanted pregnancies. The author attributes this apparent paradox to the strong motivation to abort among women with unwanted pregnancies (Mati, 1993).

Several countries in the region have implemented post-abortion programs, with varying degrees of success. It is thought, however, that these services generally have a high level of acceptance and that they are becoming increasingly available (Rayas and Cattoti, 2004; Rayas et al., 2004). The report by these authors, based on a review of the relevant literature and a survey of key people involved in the issue from Bolivia, Brazil, Mexico, Nicaragua and Uruguay, identified both some of the significant progress made since 1994 in dealing with the problem of unsafe abortion through post-abortion services and some of the persisting limitations. They mention, for example, the fact that in Bolivia, the technical norm for treating hemorrhage during the first six months of pregnancy, published in 2001, covers dealing with emergencies, counseling services – including contraception and abortion – and referral to other services. These services are usually provided at specialized health establishments (secondary and tertiary level). Likewise, seven out of the eleven state university hospitals in Bolivia have included MEA as part of PAC.

Other studies undertaken in the region evaluate the quality of the care provided for women with abortion complications and post-abortion programs that show the limitations and challenges still to be faced.

Faúndes and Barzelatto (2005) analyze the experiences of Bolivia, which reveal the restrictions on obtaining post-abortion care, by showing that some hospitals, particularly those run by the Catholic Church, did not accept women suspected of having had an abortion (Camacho et al., 1996). In Argentina, women requesting treatment for post-abortion complications also suffered discrimination and mistreatment (Chiarotti et al., 2003). In another qualitative study on women hospitalized for abortion complications, also conducted in Bolivia, Ramos and Viladrich (1993) confirmed the insufficiency of the information given to hospitalized women. They also held that “neither material (contraceptive methods) nor cognitive resources (information on what to use or where to go) were substantially modified after the experience of medical services. These services made no effort to modify women’s contraceptive habits after abortion, as a result of which they remained exposed to (the risk of) unwanted pregnancies.”

In the case of Brazil, Rayas and Cattoti (2004) note that although PAC services are supposed to be provided at all health establishments, in practice these are only available at the main urban centers. They also observe that instrumental uterine curettage continues to be the prevailing technique, although since 1999, there has been an increase in the number of outpatient procedures using MEA.

In Nicaragua, a study conducted in 2003 revealed several problems related to post-abortion services: quality is occasionally deficient, equipment is in poor condition, the personnel lack continuing education, there is no referral system, cases are under-reported and medical histories are poorly documented, which prevents proper follow-up. The study also found that half the establishments lack proper equipment and that women seeking PAC services receive inhumane treatment. It also noted that some of them were denied PAC, when health providers assumed that their incomplete abortions had been induced and were therefore probably illegal (Rayas and Cattoti, 2004; Rayas et al., 2004).

Benson et al. (1998) note how at a certain hospital in Lima, post-abortion services have been developed for which the medical personnel were trained in MEA and family planning, as well as inter-personal relations. The virtually complete replacement of instrumental uterine curettage by this technique led to the reduction of the average hospital stay (from 33.3 to 6.4 hours) and of the cost of care per patient (from $119 to $49). Other important advantages for users included the reduction of their perception of pain and the fact that they felt more satisfied with the services they received. Moreover, the use of contraceptives among the women attended for abortions rose from 31% to 64%.

In Guatemala, post-abortion care services were developed in hospitals after 1996, while health providers received training in this kind of care (Ministerio de la Salud Pública y Asistencia Social, 2005). A survey conducted from July 2003 to December 2004 at 22 national hospitals showed an increase in the number of procedures with MEA (from 38% to 68%) and a reduction in those performed with the IUC in the women attended. It also recorded an increase in counseling regarding effective contraceptive methods (from 31% to 78%) as well as in the percentage of women discharged from hospital using some contraceptive method (from 20% to 49%). The vast majority (86%) of women interviewed at the hospitals declared that the health providers had explained the use of various methods to them: 80% mentioned the Pill, while 59% mentioned both condoms and injectable contraceptives. Another survey undertaken at 178 health institutions in this Central American country showed that the contraceptive methods offered were mainly female sterilization and vasectomy (71% and 74% of the women treated), the IUD (67%), condoms (62%), implants (61%) and the rhythm method (60%). As for hormonal methods, injectable methods were offered to 58% of the women while 55% were offered the pill. Depending on the case, these women could choose between spermicides, emergency contraception and female condoms (Prada et al., 2005).

In Uruguay, accessibility to and coverage of post-abortion treatment were mainly limited to urban areas and were not specifically included as part of reproductive health programs. PAC only recently began to be regulated, while MEA was used to an extremely limited extent. Instrumental uterine curettage was used in emergencies with anesthesia and hospitalization. When a woman suffered complications, she was usually given treatment but only rarely offered contraceptive methods or referred to other services. No syllabus at universities where medicine, nursing or obstetrics are taught includes sexual or reproductive health. Nevertheless, extracurricular programs have been created and in 2003, medical residents began to take courses on contraception and PAC, although very few health professionals have received MEA training (Rayas and Cattoti, 2004; Rayas et al., 2004).

In Mexico, the introduction of MEA also reduced costs, the duration of hospitalization and the possible negative consequences of abortion on women’s health (Johnson et al., 1993). Also, midwives, not just doctors, can perform MEA. Another study undertaken in this country indicates that PAC services form part of the Health Secretariat’s programs. In theory, all women have access to public services when they suffer complications from abortion or have incomplete abortions. Most cases, however, are resolved through curettage rather than MEA. Another study also cites the poor level of treatment given to Mexican women who suffer abortion complications (Langer et al., 1999). In Chile and El Salvador, it has been shown that women were denounced by personnel of the hospital where they received PAC, and many of them ended up in jail (Casas et al., 1996; McNaughton et al., 2004).

One study describes the training of family planning service providers in post-abortion counseling for the University Hospital of Cali, Colombia. It also describes the introduction of a new program for PAC, which includes family planning counseling and supplying contraceptives before women leave hospital. It also points out that the women were given information on where to obtain contraceptives in their communities. Likewise, an obligatory regulation was established whereby women seeking sterilization were to be referred to secondary level health services. At this hospital, attempts were also made to improve the relationship between users and providers and to cover the specific needs of women from the indigenous population, who were not familiar with clinical settings or with information on family planning (Barnett, 1997).

The results of a survey of users that received post-abortion services at a clinic in Bogotá, conducted to assess new care strategies, showed an increase in the percentage of women that chose a contraceptive method once they had received medical supervision after treatment. This proves the need, as part of this service, of resolving doubts about contraceptive practice in relation to aspects such as the proper use of the method recommended and its possible side effects (Mora Téllez et al, 1999).

Likewise, in Panama, a counseling technique that included aspects on reproductive risk and post-abortion family planning proved to be more effective than an information technique that provided more superficial, briefer information. It was found that with the first technique, users were more likely to accept contraceptive use (Farfán et al., 1997).

On the basis of these results, several authors recommend undertaking research to standardize complementary services that can be provided as part of PAC and family planning. They also recommend documenting the effect of both more complete counseling and the provision of follow-up services for women identified as having high-risk pregnancies and/or repeated abortions (Mati, 1993).

^ Top of page