Abstract
Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30-70 percentage points within 1-3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria.
Highlights
Worldwide, 210 million women become pregnant annually; 135 million will have a live birth, and 75 million, or one-third, will have a spontaneous or induced abortion and need postabortion care (PAC).Postabortion Care: 20 Years of Evidence www.ghspjournal.orgUSAID’s PAC model contains 3 components: emergency treatment, family planning, and community empowerment.Of the 75 million abortions, 31 million are spontaneous and 44 million are induced; half of the induced abortions are unsafe, performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards.[1]Since 1994, the United States Agency for International Development (USAID) has supported implementation of PAC programs in more than 40 countries to address complications related to miscarriage and incomplete abortion.[2]
In 2007, USAID published the first global PAC research compendium, ‘‘What Works, A Policy and Program Guide to the Evidence on Postabortion Care,’’ which reviewed the PAC literature from 1994 through 2003.4 This article summarizes the major findings on PAC interventions with strong evidence, described in the forthcoming second edition of USAID’s global PAC research compendium
The second edition builds on the first edition by including more detailed findings that address the cycle of repeated unintended pregnancy and abortion.[4,5,6]
Summary
210 million women become pregnant annually; 135 million will have a live birth, and 75 million, or one-third, will have a spontaneous or induced abortion and need postabortion care (PAC). USAID’s PAC model contains 3 components: emergency treatment, family planning, and community empowerment. Since 1994, the United States Agency for International Development (USAID) has supported implementation of PAC programs in more than 40 countries to address complications related to miscarriage and incomplete abortion.[2] PAC may be a unique service delivery model that is both curative and preventative—curative in treating incomplete abortion and the symptoms of hemorrhage and sepsis; preventative in providing family planning services to address unmet need for contraception and reduce unintended pregnancies and repeat abortions. The 3 components of USAID’s PAC model are[2]:
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