Hemorrhage. The leading cause of maternal death, hemorrhage can kill a woman within just a few minutes. During pregnancy or after delivery, hemorrhage can result from prolonged labor, uterine rupture, or early separation of the placenta from the uterine wall. Hemorrhage also can occur after miscarriage or unsafely induced abortion.

Sepsis. Infection can develop after delivery, miscarriage, or unsafe abortion, when tissue remains in the uterus, when unclean instruments or other objects are placed in the vagina, or when aseptic procedures are not followed. Septic abortion, when the endometrial cavity or its contents become infected, often follows incomplete abortion, spontaneous or induced.

Pregnancy-induced hypertension. This condition can be one of the most difficult of obstetric emergencies to prevent and to manage. The early stage of this disorder is characterized by high blood pressure, fluid retention (edema), and protein in the urine. Eclampsia can occur during pregnancy or after delivery and can result in convulsions, heart or kidney failure, cerebral hemorrhage, and death (52, 53).

Obstructed labor. This condition occurs when the infant's head cannot pass through the woman's pelvic opening. Obstructed labor can result from malpresentation of the infant or may be due to a woman's physical immaturity, stunted growth, pelvic distortion resulting from disease or malnutrition, or abnormalities of the cervix or vagina, sometimes resulting from female genital mutilation (260). Unless cesarean section can be performed, women struggling with obstructed labor can die from hemorrhage, uterine rupture, infection, or exhaustion. Obstructed labor and the resulting complications are the primary cause of maternal death in sub-Saharan Africa (147, 153, 233).

Complications of unsafe abortion. Common complications include incomplete abortion, infection, hemorrhage, and intra-abdominal injuries, including cervical laceration and uterine perforation (135, 154). All can be fatal if left untreated.

Maternal Morbidity

While little is known about the extent of maternal morbidity in developing countries, estimates have ranged from 16 to 100 episodes of illness or disability for each maternal death (148). Recent evidence suggests that these estimates may be too low. In Bangladesh, for example, for every maternal death, 73 other women experienced life-threatening illnesses related to pregnancy; in Egypt, 56 women. When every episode of pregnancy-related morbidity was counted separately (including minor morbidities and multiple morbidities for the same woman), totals reached 700 maternal illnesses in Bangladesh; over 1,000 in Egypt; and nearly 600 in India for every maternal death (75).

In addition to affecting a woman's physical health, these illnesses also may be detrimental to her social and economic well-being if they affect her ability to work or interact in her community (49, 55, 74, 245, 258, 292). Infertility can be a devastating condition for women emotionally, socially, and economically in countries where women derive their status from bearing children (289).

One of the most serious and most common pregnancy-related morbidities, obstetric fistula, results from obstructed labor. A fistula is an opening between the vagina and the rectum (recto-vaginal fistula) or the vagina and the urethra (vesico-vaginal fistula) that allows feces or urine to leak into the vagina. A women with a fistula suffers from incontinence, and the resulting odor and uncleanliness leave women uncomfortable and often ostracized by their communities. Obstetric fistula can be surgically repaired, although most women in developing countries lack access to such care.

Responding to the Need

International Statements Urge Humane Postabortion Care

Cairo. The United Nations International Conference on Population and Development (ICPD), held in Cairo in 1994, created the first globally recognized document to acknowledge that improving postabortion care is vital to women's health (187). In its much-debated paragraph 8.25, the conference's Program of Action states:

In no case should abortion be promoted as a method of family planning. All governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counseling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from abortion. Postabortion counseling, education and family planning services should be offered promptly which will also help to avoid repeat abortions. (264)

Mauritius. Also in 1994, representatives from 20 African countries met in Mauritius for the International Planned Parenthood Federation (IPPF) Conference on Unsafe Abortion and Postabortion Family Planning. The resulting Mauritius Declaration called upon participating countries to address the health and social problems that unsafe abortion causes for African women. The declaration called for countries to strengthen family planning information, education, and services; to emphasize male responsibility in family planning and in preventing unwanted pregnancies; to increase availability of high-quality, prompt, humane emergency treatment for women with complications of unsafe abortions, including adolescents; and to ensure the provision of postabortion counseling and family planning services (111).

Beijing. In 1995 the Fourth World Conference on Women, held in Beijing, reaffirmed the importance of providing emergency medical care to women suffering postabortion complications. Paragraph 106(j) of the Beijing Statement urges that governments:

Recognize and deal with the health impact of unsafe abortion as a major public health concern, as agreed in paragraph 8.25 of the Programme of Action of the International Conference on Population and Development. (263)

Unsafe Abortion Increasing Among Young Women

Women under age 20 often account for more than their share of abortion complication cases reported by developing-country hospitals (34, 97, 145, 216, 222, 256). In Kenya, for example, 53% of septic abortion patients were under age 20 (10). In two Nigerian studies adolescent girls represented 61% and 74% of septic abortion patients (6, 7). Similarly, young and unmarried women often account for more than their share of abortion-related deaths. For example, in a Ugandan study almost 60% of deaths due to unsafe abortion occurred among women under age 20 (266). A Nigerian study found that abortion complications were the most common cause of death among unmarried women ages 15 to 24, particularly those in school (203).

Low contraceptive use. As young women in many developing countries marry later, more are experiencing sex before marriage. While some adolescents become sexually active by choice, others are coerced or forced—either physically or because of economic need—into sex. Few young people, especially the unmarried, use contraception the first time they have sex (182, 194). Studies in a number of countries have found that women delay about one year on average between starting sexual activity and first using modern contraceptives (12, 50, 137). Many pregnancies occur within a year after first sexual intercourse (50, 298), and most are unintended (194). For example, among 200 16-year-olds delivering at Harare Maternity Hospital, Zimbabwe, over one-half had become pregnant within just three months of starting sexual activity (173). In Mexico City nearly two-thirds of women ages 18 to 19 with premarital sexual experience reported that they had been pregnant at least once (193).

Faced with unintended pregnancy, many young women turn to abortion rather than getting married or bearing the child as a single mother (37). For example, a Nigerian study found that 90% of unmarried and working women with unintended pregnancies had abortions (203). Another Nigerian study, involving 1,800 never-married women ages 14 to 25, found that, of those who had experienced sexual relations, nearly half of students and two-thirds of nonstudents had been pregnant, and nearly all had ended their pregnancies with abortion (201). In some areas of Nigeria and Kenya young people know more about—and have more favorable attitudes toward—abortion than modern contraception (25).

Many young women risk unsafe abortion to avoid leaving school (208). In one Zambian study, for example, 81% of women hospitalized for complications of unsafe abortions were students who did not want mistimed pregnancy to disrupt their education (237). Young women who have given birth rarely return to school, whether they are married or not (84). Some countries routinely expel students who become pregnant; in Kenya alone nearly 10,000 are forced to leave school each year because they are pregnant (70).

Young, unmarried women are more likely than older women to seek abortions from untrained providers and to attempt dangerous, late, and often self-induced abortions, often because of fear, shame, lack of access, or lack of money (37, 66, 97, 108, 216, 284). Furthermore, for the same reasons, young women are more likely to delay seeking medical care for abortion complications (241, 299). For example, Nigerian adolescents said that, if they suffered abortion complications, they would be more likely to run away from home than to tell their parents or go to a health facility (66).

PUT YOURSELF IN HER SHOES

Filmed in Zambia, the video illustrates the key points of postabortion family planning counseling through the stories of four women hospitalized after unsafe abortion. The photos on pages 6 and 9 come from the video.

The video is intended for emergency care providers, such as gynecologists, obstetricians, other physicians, nurse-midwives, nurses, and medical officers, as well as family planning counselors. The video shows how to make a clear, useful referral for family planning services and emphasizes the three essential messages that providers need to convey clearly to women to help prevent future unintended pregnancies and repeat abortions.

The video training package includes a user's guide, a checklist on postabortion family planning counseling, and a prototype brochure for clients. The video was developed and produced by Johns Hopkins Population Communication Services (JHU/PCS) in collaboration with the Program for Appropriate Technology in Health (PATH).

The package is available in English, and a French version is expected in late 1997. Send inquiries to: Manager, Media/Materials Clearinghouse, Johns Hopkins Population Information Program, 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA; fax 410-659-6266; or e-mail mmc@jhuccp.org.

Additional Publications on Postabortion Care and Family Planning

Family Planning Counseling:
A Curriculum Prototype.
(Trainer's manual and
participant's handbook).
AVSC International, 1995.

Talking with Clients about
Family Planning: A Guide
for Health Care Providers.
AVSC International, 1995.

Contact:
AVSC International
Material Resource Department
79 Madison Ave.
New York, NY  10016, USA.
———————————————————————————
Postabortion Care Course
Handbook: Guide for
Participants. JHPIEGO, 1995.

Postabortion Care Trainer's
Notebook. JHPIEGO, 1995.

Contact:
JHPIEGO
Materials Division
1615 Thames St.,
Suite 200
Baltimore, MD 21231, USA
Fax: 410-614-0586.

Family Planning Following Postabortion
Treatment (wall chart). Ipas, 1997.

Manual Vacuum Aspiration Guide for
Clinicians. L. Yordy, A.H. Leonard, and
J. Winkler. Ipas, 1993.

Meeting Women's Needs for Postabortion
Family Planning: Framing the Questions.
J. Benson, A.H. Leonard, J. Winkler, M.
Wolf, and K.E. McLaurin. Ipas, 1992.
(Issues in Abortion Care 2).

Pain Control for Treatment of Incomplete
Abortion with MVA.
A. Margolis, A.H. Leonard, and L. Yordy.
Advances in Abortion Care 3(1): 1-8.
Ipas, 1993.

Postabortion Care: A Reference Manual for
Improving Quality of Care. J. Winkler, E.
Oliveras, and N. McIntosh, editors.
Postabortion Care Consortium, 1995.

Postabortion Family Planning: A Curricu-
lum Guide for Improving Counseling and
Services. J. Winkler and R. Gringle,
editors. Ipas, 1996.

Protocol for Reusing Ipas Manual Vacuum
Aspiration Instruments. A.H. Leonard and
L.Yordy. Advances in Abortion Care
2(1):1-12. Ipas, 1992.
Contact:
Ipas
P.O. Box 999
Carrboro, NC  27510, USA.
Fax: 919-929-0258.
Single copies of Advances in
Abortion Care issues are available
free of charge.

Clinical Management of
Abortion Complications:
A Practical Guide.
World Health Organization
Maternal Health and Safe
Motherhood Programme, 1994.

Complications of Abortion:
Technical and Managerial
Guidelines for Prevention
and Treatment.
World Health Organization,
1995.

Postabortion Family Planning:
Guidelines for Programme
Managers.
World Health Organization,
[forthcoming].

Contact:
World Health Organization
Publications Center
1211 Geneva 27,
Switzerland
Fax: 41-22-791-0746.

1 Use accurate language that works for the local setting. The most important first step in a postabortion care program is being able to describe the issue of unsafe abortion accurately. Most people need help understanding the need for treatment of complications of unsafe abortion. Many people are uncomfortable discussing the topic of abortion, especially when legal restrictions on abortion exist. Using words that clearly describe postabortion complications as a public health problem can lessen public sensitivities by focusing attention on how to improve people's health.

Rarely is abortion totally forbidden or totally permitted in any country. Thus health care providers have found it useful to avoid terms such as "illegal abortion" to describe the condition of a bleeding woman and to use, instead, a more accurate medical description, such as "incomplete abortion." Such terminology allows health professionals to respond to a medical condition rather than react to a social or legal dilemma.

In Bolivia, for example, where maternal mortality is extremely high and few people use effective contraception, reproductive health—including family planning and postabortion care services—has been a taboo subject. Until recently, health workers have been unable to describe reproductive health problems in language that was acceptable to government officials and the public. Then postabortion care programs began referring to " complications of unsafe abortion" to draw attention to the serious health consequences of unsafe abortion. In this way they began to gain the necessary support from policy-makers and the public for solving reproductive health problems.

2 Work within an existing system or program. Before creating a new administrative structure for postabortion care training or service delivery, explore whether existing systems or programs could be adapted. Incorporating postabortion care into an existing infrastructure often helps providers integrate it with their other work and helps sustain delivery of training and services.

In Nigeria, for example, postabortion care has been integrated into the routine ob-gyn internship and residency programs in 12 teaching hospitals. Integrating instruction in postabortion care into the framework of the hospital training system has made it easier for participants to learn and to train others. New physicians viewed postabortion skills as a normal and mandatory part of their medical training. A 1990 evaluation showed that most people who had trained others, after learning about postabortion care themselves, were working in teaching hospitals where they were authorized and expected to share their knowledge (205).

3 Establish services where women will seek them. When deciding whether to integrate postabortion care with other services offered at a particular hospital or health center, first determine whether women would logically look for these services at that facility. Facilities that do not currently treat complications of unsafe abortion, such as most family planning clinics, would need to plan outreach to hospital staff, patients—and even the community at large—to inform them that postabortion services are now available at the facility. Because secondary and tertiary hospitals usually offer some level of postabortion treatment, they are reasonable places to seek integration. In contrast, primary-level health centers and stand-alone NGO clinics are more likely to need an education component when adding a postabortion care program.

When integrating postabortion services into a hospital-based family planning clinic, internal referral protocols should be adapted to allow women who need emergency postabortion care to be automatically referred to the family planning clinic and to insure that treatment is available elsewhere in the hospital during hours when the clinic is closed.

4 Be prepared for a new approach to family planning. One of the biggest challenges of postabortion care for family planners is learning to recognize the differences between postabortion family planning and family planning provided postpartum or on a regular basis. While the typical family planning client is healthy, a woman who has just experienced an abortion may be physically ill, in great pain, and under emotional and physical stress. Service providers should adapt their counseling accordingly.

For example, when trainers from the Zimbabwe National Family Planning Council (ZNFPC), Zimbabwe's largest family planning service delivery organization, attended a special course in postabortion family planning, they were surprised to learn that, despite their expertise in family planning counseling, they needed new skills for talking with women who had experienced postabortion complications. While women seeking family planning usually are considered "clients," women treated for complications of unsafe abortion, instead, are "patients" with medical concerns that seldom arise in a typical family planning counseling situation. When counseling these patients, service providers should help the women identify the reasons for their unintended pregnancy in order to help them to avoid another one (161).

5 Be inclusive in preparing for a postabortion care program. From the beginning, inform everyone who might have a stake in supporting the program or in opposing it. Listen to their suggestions and concerns and coordinate activities with them. If necessary, expand the planning process to include officials from the Ministry of Health (MOH) or other national or local officials, colleagues from other hospital or health center departments, and other people who have a particular interest in the issue. When organizing a local program within a hospital department or clinic, inform the entire staff of the planned changes, and explain their expected involvement in the new activity.

In Malawi, for example, a local physician initiated post-abortion care programming by convening a national group representing health professionals, donor agencies, and the MOH to review the problems of unsafe abortion and to propose an approach to resolving them. He presented data that met the concerns of policy-makers and also addressed the training and service delivery issues that were important to health care providers. As a result, the planning team was able to agree on a postabortion care strategy that addressed people's concerns.

6 Take a comprehensive approach to service delivery changes. As an alternative to sharp curettage for treating women with incomplete abortion, introducing manual vacuum aspiration (MVA) technology is a significant step toward improving postabortion care. Do not expect a change in technique to bring about other improvements automatically, however, unless changes also are made in patient management and service delivery. Program planners should consider whether such other aspects of patient care as the location of postabortion care services, the amount of time women wait before or after treatment, and any special training needed for staff working with postabortion women need to be adapted.

For example, in a South American hospital patients being treated for incomplete abortion originally received sharp curettage in an inpatient procedure room and were made to wait through a post-surgical observation period of approximately 10 hours. To improve the quality of services, the hospital began training staff to use MVA but did not adapt the hospital's protocols to make MVA an outpatient procedure, with quick discharge. Rather than travel home when discharged late at night, most women chose to stay overnight, thus increasing the cost of their treatment and crowding the hospital wards unnecessarily (128).

Procedures for linking various services may also need changes. For example, when contraceptive counseling after postabortion care is offered only in a family planning clinic, family planning clinic staff or an outreach worker should make daily rounds to the treatment area to ensure that each woman has the opportunity to talk with a family planning counselor. Ideally, family planning services and counseling can be offered in the same area where MVA is performed.

7 Establish a local, sustainable supply of MVA instruments and other important commodities. Just as family planning programs cannot offer a full range of options if certain contraceptive methods are unavailable, postabortion care programs will be incomplete without a consistent and accessible supply of needed instruments and related commodities. New programs should look ahead to when a donor agency will no longer provide support. Having MVA and postabortion care recognized officially as part of the public health system will make it easier for government hospitals and health centers to request MVA instruments and commodities as part of their regular supply needs. For their part, government administrators can plan for a long-term supply by including MVA instruments and commodities in the national equipment registry or a similar listing of officially approved medical supplies.

8 Plan for decentralization. Postabortion care should be as widely available as possible. In many cases women will not survive the journey to a referral hospital because it is too far away. In Nicaragua the MOH, having identified postabortion care as a service needed at the community level, has adopted a decentralized approach and organized 16 local comprehensive health care systems that are responsible for health care training, provision, and management at the community level. All 16 have organized service delivery programs for hospitals, and some also offer training. About half offer decentralized postabortion care at the health-center level (117).

9 Work for policy support for postabortion care. For postabortion care to become widely accessible and to respond to women's needs, supportive policies must be adopted and promulgated. Grassroots activists and health care professionals who understand the needs of women and their families can be vital sources of information for policy-makers. Information can be conveyed by:

• Disseminating printed information, studies, and results from other postabortion care experiences that show how postabortion care can save women's lives.
• Organizing regional or national conferences to discuss the need for postabortion care and to review the local capacity for implementing postabortion care, and
• Conducting pilot demonstration projects that illustrate the approaches likely to succeed in a particular context.

For example, in 1994 the Commonwealth Regional Health Community Secretariat (CRHCS), the coordinating body for health issues in 13 countries in Central and Southern Africa, undertook a study, with technical assistance from Ipas and the Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO), to collect evidence of the magnitude of the problem of unsafe abortion and to encourage policy-makers to identify specific program strategies to address the problem. Information was collected in two ways: (1) a 3-country, 13-hospital study of provider and patient perspectives and the costs of treating abortion complications; (2) a review of the literature on abortion in the region. A monograph summarizing the results and making recommendations was prepared and presented to the Conference of Ministers at its annual meeting in November 1994 (145). As a result, the Ministers agreed to raise the issue of unsafe abortion in their own countries and to develop appropriate local action plans to address this issue.

Charlotte E. Hord is on the staff of Ipas (International Projects Assistance Service), an international not-for-profit, nongovernmental organization dedicated to improving women's health through a focus on reproductive health care.

The GATHER Approach to Postabortion Family Planning Counseling

G GREET the woman politely by name. Introduce yourself by name. Ask the woman how she is feeling and if she feels well enough to talk with you about family planning.

If she does not feel well enough to talk: Make arrangements to return to speak with her later. Give her a brochure or card with your name on it, and invite her to ask for you before she leaves. If possible, find out when she will be discharged and make arrangements to return before she leaves.

If she feels well enough to talk: Go with her to a place where you can talk privately. Ask the woman if she would like to include her partner or anyone else in the discussion or if she prefers to speak with you privately. Explain to her that you will not tell others what the two of you discuss, and honor this commitment. Women treated for postabortion complications often need extra reassurance about confidentiality.

A ASK the woman how she is and when she will go home. Express concern and empathy for her situation. Some women will want to talk about their treatment, and others may not. The woman has just experienced a medical emergency and may still be frightened and in pain. She may be worried about how she will get home or who is taking care of her children. Be prepared to talk with her about her immediate concerns first. If she has questions about her treatment or her health, be prepared to be her advocate and help her obtain information from doctors or nurses. Make sure she has been told about symptoms that would require her to return for further medical care.

Discuss with her in broad terms the events that led up to her emergency treatment. The woman's condition may have resulted from the miscarriage of a wanted pregnancy. Do not assume that all women treated for abortion complications want to avoid another pregnancy. Ask whether or not she wants to become pregnant again soon. Tailor your discussion to the woman's responses.

If she desires pregnancy again soon: Express compassion for her loss and help her to obtain the reproductive health services she needs.

If she does not want to become pregnant again soon: Help her to reduce the chances of another unintended pregnancy by offering her family planning.

The woman may lack access to family planning or may worry about side effects of using modern methods. She may be under pressure from her partner (or family) to use (or not to use) a particular method. She may be exposed to sexual coercion or violence. Do not assume anything about the woman, the circumstances of her unintended pregnancy, or her reasons for abortion. Instead, listen to her and express empathy. Help the woman to assess whether the events that caused her unintended pregnancy could lead to another pregnancy. Help the woman to assess her need for contraception, including a realistic view of whether or when she will have sexual intercourse again. For example, an adolescent may say that she is not going to have sex again, but she may either change her mind or be pressured into sex later. Some women who do not want to resume sexual relations immediately may nevertheless be pressured or coerced by partners.

In counseling the woman, emphasize three points:

(1) She could become pregnant again right away.
(2) She can delay or avoid another pregnancy by using family planning.
(3) You can help her obtain and use family planning services.

Ask the woman if she is interested in learning more about family planning. Ask if she has ever used family planning.

If she has never used family planning: Ask her what she has heard about family planning. Ask if she prefers a particular method and for what reasons. Encourage her to ask questions, and answer them clearly and directly.

If she has used family planning in the past or was using a method when she became pregnant: Help her to assess what went wrong so that she can avoid another unintended pregnancy. She may distrust her contraceptive method or even all methods. She may need help correcting her method use, finding reliable resupply, talking with her partner, or switching to another method.

T TELL the woman briefly about various family planning methods as appropriate, relating them to her particular situation and needs. For example, if she says she does not want another child for several years and wants a method that she does not have to worry about every day, tell her especially about the long-term effectiveness of injectables, Norplant implants, and the IUD, if these methods are available. Use any visual aids you have, such as flip charts, posters, and brochures, to better describe the methods. Have samples of various methods available so that the woman can see them and handle them if she wishes. Encourage her to ask questions.

H HELP the woman consider her own situation and her contraceptive needs as well as any other issues that affect her ability to use contraception (including the situation that led to unintended pregnancy). Help her to decide which method or methods best fit her needs. If the woman wants a particular method and has no medical reason not to use that method, focus on that method to help her decide whether it will meet her needs. For example, you can ask, "Do you think you can remember to take a pill every day?" or "Can you tell your partner that you are using family planning?"

Do not choose a method for the woman; instead, help her to assess her needs, to match them with the various methods, and to choose the method that best meets her needs and fits her preferences.

Make sure that the woman's physical condition or recent treatment does not rule out the method she wants. (See enclosed wall chart, "Family Planning Following Postabortion Treatment.") Provide the method she has chosen, if medically appropriate.

E EXPLAIN:

• How to use the method, giving a step-by-step description;
• How to discuss use with her sexual partner, if possible;
• How to become comfortable and accustomed to using the method;
• How to continue use, including how and where to get supplies and follow-up care when needed;
• How to deal with common side effects, if any, including which symptoms are not serious, and which, if any, could be warning signs of a more serious condition that requires seeing a doctor or nurse.

R REFER the woman for a return visit and follow-up care, as needed. If the woman traveled a long distance for emergency treatment, refer her to a family planning clinic or another source of family planning close to her home, whenever possible. (You will need to learn what services are available in other areas, including pharmacies that sell contraceptives). Encourage her to see a family planning provider any time that she needs more supplies or has questions or concerns. Develop a referral and follow-up protocol for women who do not want to decide about family planning immediately after their postabortion treatment.

At any follow-up visit:

• Assess whether the woman is in good health and satisfied with the method she is using;
• Address any side effects;
• Support and encourage the woman to continue effectively using contraception, if that is her intention;
• Help the woman stop or switch methods when she wishes or when it is appropriate for medical reasons.

Always ask the woman if she has any questions, and provide the answers. Always ask if the woman needs other reproductive health care, and provide appropriate care or referral.

Family Planning Can Prevent Abortion

Trends. Over the long-term, increasing contraceptive use can and does reduce abortion (56, 77, 94, 265). This trend has been consistently demonstrated at different times in many countries and different cultures. Chile is the most often cited example: In the 1960s, after the government started an intensive family planning program that increased contraceptive use sevenfold, the number of women treated at hospitals for abortion complications decreased markedly (51, 167).

Other historical examples come from Japan and Hungary. In Japan abortion was a significant factor in the country's initial fertility reduction (94), but as contraceptive use rose between the 1950s and the 1970s, the abortion rate dropped (77). In Hungary, between 1966 and 1977, as OCs and IUDs replaced traditional methods as the preferred family planning methods among most contraceptive users, the abortion rate, which had been rising during the 1950s and early 1960s, dropped sharply (42, 77, 265, 301, 305) (see Figure 1).

More recently, a similar trend has been seen in elsewhere around the world. In Bogota, Colombia, for example, while use of contraception increased by 33% between 1976 and 1986, the abortion rate dropped by 45%, from 49 abortions per 1,000 women to 27. In Mexico City and the surrounding region, a 24% increase in contraceptive use between 1987 and 1992 was accompanied by a 39% drop in the abortion rate, from 41 abortions per 1,000 women to 25 (239). In Russia, after family planning programs began in 1991, contraceptive use increased and the abortion rate dropped. In 1995 the abortion rate was one-third lower than it had been in the 1980s (136). In Kazakstan between 1988-89 and 1993-95, Pill and IUD use rose by 32%, while the abortion rate dropped by 15%—"clear and convincing evidence that contra ception has been substituted for abortion" (304).

Behind the trends. What explains these trends? In countries where the desire to have fewer children has become the norm but where contraceptive use remains low, usually because contraception is not yet widely available and accessible, abortion rates often rise, even as contraceptive prevalence rises. Eventually, however, as awareness and availability of contraception catches up with people's desires to have fewer children, contraceptive use becomes widespread and abortion rates fall (56, 77, 94, 237, 265). Thus any rise in abortion rates represents a short-term phenomenon that often occurs during the initial stages of a country's fertility transition.

This has been the pattern in Japan, Mexico, Russia, South Korea, and Thailand (77, 94). The case of South Korea is typical. While contraceptive use increased from 24% in 1971 to 77% in 1988, the abortion rate peaked in 1978, and by 1991 it had dropped by one-third (94, 210, 265).

Increasingly, women in developing countries want to have fewer children. For example, comparing data for 15 countries surveyed by the World Fertility Survey in the 1970s and again by the Demographic and Health Surveys since 1985, Charles Westoff found that the desired number of children has declined in all 15 countries, in most by 20% to 25% (271). Few developing countries, however, have reached the point where contraceptive use is widespread enough to meet the needs of almost all women who want to avoid pregnancy (226).

Many women treated for complications of unsafe abortion have not used family planning but say that they would be interested in it (see Chapter 2.2, Avoiding Repeat Abortion). Improving family planning programs by providing more contraceptive methods, making them more convenient to obtain, and offering more information and better counseling would help many women and men use contraception and would help reduce abortion rates.

What Can Be Done?

• Make a commitment to address unsafe abortion and act on that commitment;
• Describe the problem of unsafe abortion in their area accurately and consistently, tailoring their approach to the audience addressed;
• Work with women's groups;
• Support their advocacy with international statements that call for improved postabortion care, such as the Cairo Program of Action (see International Statements Urge Humane Postabortion Care).

• Educate the public, political leaders, health authorities, and community leaders about unsafe abortion and its consequences;
• Form coalitions among themselves and with health officials;
• Establish relationships with the news media to publicize the problem;
• Urge understanding for women who have undergone unsafe abortions.

• Learn to recognize abortion complications, know how and where to refer women for emergency care, make referrals quickly;
• Obtain training in postabortion care, including manual vacuum aspiration (MVA), where available;
• Ensure that equipment, drugs, and supplies are on hand to treat complications;
• Maintain communication and transportation systems with district-level hospitals to ensure prompt referral and transport for women with serious complications.

• Establish a protocol for quickly and effectively treating postabortion complications;
• Switch from general to local anesthesia, adopt MVA for early uterine evacuation;
• Designate or create a treatment room exclusively for postabortion care;
• Make clear to staff that providing family planning is an essential part of postabortion care and is a regular staff responsibility, not an extra or optional activity;
• Demonstrate respectful interactions with women treated for abortion complications and make clear that all staff are expected to behave respectfully;
• Monitor quality of services through on-going supervision;
• Train providers in postabortion care—both clinical aspects, including MVA, and psychosocial aspects;
• Make sure that family planning training is part of all training in postabortion care;
• See that all staff are appropriately trained and new staff members are trained as they arrive;
• Provide trainees with printed educational materials;
• Supervise and monitor the care and counseling that trainees provide;
• Organize seminars where staff can discuss their feelings about postabortion care;
• Hold update sessions to address special concerns such as adolescent patients or HIV infection;
• Use training and references manuals available from the World Health Organization and others (see Additional Publications on Postabortion Care and Family Planning);
• Emphasize the need to provide supportive counseling during treatment;
• Ensure that trained counselors are available for all women and that backup personnel are available when needed;
• Provide family planning counseling and services to all women treated for abortion complications, and offer reproductive health care that responds to women's needs;
• Ensure that counselors are capable of establishing rapport and helping women to discuss their family planning goals and needs.

• Send family planning staff to emergency wards provide postabortion family planning counseling and services;
• Inform staff about how unsafe abortion causes substantial maternal mortality and how postabortion family planning can save women's lives;
• Show respect for women receiving care for abortion complications and avoid passing judgment on them;
• Provide opportunities for staff to discuss postabortion care and their feelings about abortion.

• Decentralize postabortion care to district hospitals by providing training and equipment for postabortion care;
• Conduct educational events for local advocates, publicly support and encourage local efforts, and maintain contact with local advocates;
• Organize conferences to share data about the extent of unsafe abortion, its role in maternal mortality, and costs to area hospitals and clinics;
• Conduct seminars and workshops to improve the efficiency of referral and transport between levels of care.

• Establish a postabortion care strategy and a referral system, train local staff to recognize postabortion complications, and assure transport for women needing care;
• Provide training in postabortion care, including MVA, to physicians, nurses, midwives in both the public and private sectors where appropriate; arrange for supervision and ongoing training so that they maintain their skills, and assure high-quality training in sharp curettage where MVA is not available;
• Decentralize postabortion care to district hospitals and primary health care centers and train providers at those levels;
• Include postabortion care kits and necessary supplies on national medical supply purchase lists and ensure that supplies are distributed throughout all levels of the health care system;
• Make sure training in postabortion care is required in preservice training curricula for doctors and other health professionals;
• Encourage and conduct research and disseminate findings, include questions on abortion in health surveys and other research. When postabortion programs are started, conduct needs assessments and operations research to learn the most effective ways to introduce postabortion care and family planning;
• Educate government officials and donor agencies about the problem.

• Encourage and fund research on unsafe abortion, including operations research on effective ways to introduce and improve postabortion care and family planning;
• Provide equipment and supplies for postabortion care;
• Fund technical assistance and training for postabortion care projects;
• Provide contraceptive supplies and necessary equipment for postabortion family planning programs;
• Increase in-country capacity to undertake training, service delivery, and health systems research;
• Encourage international collaboration by providing a forum in which advocates working to improve postabortion care can share experiences.
• Adapted from Benson et al. 1996 (32), McLaurin et al. 1996 (187), McKay & Hartley 1993 (184), and WHO 1995 (282).