Postabortion Contraceptive Counseling Research Articles

Why do most young women not take up contraceptives after post-abortion care? An ethnographic study on the effectiveness and quality of contraceptive counselling after PAC in Kilifi County, Kenya

Post-abortion care (PAC) counselling and the provision of contraceptive methods are core components of PAC services. Nevertheless, this service is not uniformly provided to PAC patients. This paper explores the factors contributing to young women leaving health facilities without counselling and contraceptive methods. The paper draws from an ethnographic study conducted in Kilifi County, Kenya, in 2021. We conducted participant observation in health facilities and neighbouring communities, and held in-depth interviews with 21 young women aged 15–24 who received PAC. In addition, we interviewed 11 healthcare providers recruited from the public and private health facilities observed. Findings revealed that post-abortion contraceptive counselling and methods were not always offered to patients as part of PAC as prescribed in the PAC guidelines. When PAC contraceptive counselling was offered, certain barriers affected uptake of the methods, including inadequate information, coercion by providers and partners, and fears of side effects. Together, these factors contributed to repeat unintended pregnancies and repeat abortions. The absence of quality contraceptive counselling therefore infringes on the right to health of girls and young women. Findings underscore the need to strengthen the capacities of health providers on PAC contraceptive counselling and address their attitudes towards young female PAC patients.

Postabortion contraceptives uptake and its associated factors among clients visiting abortion care services in public hospitals in West Shewa Zone, Oromia regional state, Ethiopia, 2021.

Postabortion contraception is the initiation and use of postabortion contraceptive methods immediately after an abortion. It is a critical approach for preventing unwanted pregnancy, alleviating its complications, and avoiding repeated abortions by promoting immediate postabortion contraceptives provision. To assess the level of postabortion contraceptives uptake and its associated factors among clients visiting abortion care services in public hospitals in West Shewa Zone, Oromia regional state, Ethiopia. An institutional-based cross-sectional study was conducted in public hospitals in the West Shewa Zone from 1 March 2021 to 30 May 2021, among 227 proportionally allocated clients based on the proportion of the client served in the previous 3 months of the study period. Data were collected through face-to-face interviews using semi-structured and pretested questionnaire from women who received the abortion services. Bivariable and multivariable logistic regression were used to assess the association of independent variables with postabortion contraceptive uptake. Findings with p-value of 0.05 at 95% confidence interval were considered as statistically significant. The overall postabortion contraception uptake among abortion service clients in public hospitals was 164 (74%) while about 42% of them used long-term contraceptive methods. Postabortion contraceptive uptake was significantly associated with media exposure to postabortion family planning information (adjusted odds ratio: 3.4 (95% confidence interval: 1.03-11.27)) and counseling on postabortion family planning (adjusted odds ratio: 20.48 (95% confidence interval: 5.02-83.64)). Level of postabortion contraceptive method uptake in West Shewa was low as compared to the national target. Greater attention should be given on providing postabortion contraceptive counseling to increase the postabortion contraceptive uptake.

The association of quality contraceptive counseling measures with postabortion contraceptive method acceptance and choice: results from client exit interviews across eight countries

The availability of a variety of modern contraceptive methods is necessary but insufficient to provide a high-quality contraceptive service to postabortion clients. Women, especially young women, must be empowered to make informed choices about which methods they receive, including whether to use contraception following an abortion service. In this study, we conducted 2,488 client exit interviews with abortion clients after their induced abortion service or postabortion care visit in Ipas-supported health facilities in eight countries: Argentina, Bolivia, Ethiopia, Kenya, Mexico, Nepal, Nigeria, and Uganda. We evaluated the quality of postabortion contraceptive counseling across two domains of contraceptive counseling: information exchange and interpersonal communication. We measured the association between these quality elements and two outcomes: 1) client-perceived choice of contraceptive method and 2) whether or not the client received a modern contraceptive method. We examined these relationships while adjusting for sociodemographic and confounding variables, such as the client feeling pressure from the provider to accept a particular method. Finally, we determined whether associations identified differ by age group: under 25 and 25+. Information exchange and interpersonal communication both emerged as important counseling domains for ensuring that clients felt they had the ability to choose a contraceptive method. The domain of information exchange was associated with having received a contraceptive method for all abortion clients, including young abortion clients under 25. Nearly 14% of clients interviewed reported pressure from the provider to accept a particular contraceptive method; and pressure from the provider was significantly associated with a client’s perception of not having a choice in selecting and receiving a contraceptive method during her visit to the facility. Improving interpersonal communication, strengthening contraceptive information exchange, and ensuring clients are not pressured by a provider to accept a contraceptive method, must all be prioritized in postabortion contraceptive counseling in health facilities to ensure postabortion contraceptive services are woman-centered and rights-based for abortion clients.

A Systematic Review and Meta-Analysis on Post-Abortion Contraceptive Utilization and Associated Factors in Ethiopia.

BackgroundPost-abortion contraceptive utilization is the initiation and use of family planning methods at the time of management of abortion or before fertility returns. A significant discrepancy was reported regarding the prevalence and its associated factors of post-abortion contraceptive utilization in Ethiopia. So, this systematic review and meta-analysis aimed to estimate the pooled prevalence of post-abortion contraceptive utilization and its associated factors in Ethiopia.MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline was used. The databases such as PubMed, Google Scholar, Science Direct, Cochrane library, Scopus, CINAHL, Web of Science, and additional searches by using direct Google search, libraries, and preprint were searched. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal.ResultsA total of 17 studies with 13,075 individuals were included. Of these, 14 studies with 5,719 individuals were used to estimate the prevalence. The pooled prevalence of post-abortion contraceptive utilization in Ethiopia was 63.64% (95% CI: 57.75–69.53). The subgroup analysis reported the highest prevalence of post-abortion contraceptive utilization in a study conducted in Addis Ababa (77.40%), a study published in 2015–2021 (66.15%), and among studies with a sample size >400 (66.84%). The pooled odds ratio (OR) of post-abortion contraceptive utilization for the mothers who had post-abortion family planning counseling was 4.15 (95% CI = 1.30, 13.2), and history of family planning utilization was 4.28 (95% CI = 2.66, 6.89).ConclusionsThe pooled prevalence of utilization of post-abortion contraceptives in this meta-analysis remains low. Post-abortion family planning counseling and the history of the utilization of modern family planning methods were significantly associated with the practice of post-abortion contraceptives. The Ministry of Health should encourage post-abortion family planning utilization, making more efforts on post-abortion contraceptive counseling. Health facilities should work hard to strengthen the family planning counseling service, especially focusing on those who had no previous family planning utilization.

Women's Postabortion Contraceptive Preferences and Access to Family Planning Services in Mississippi.

Women's preferences for postabortion contraceptive care vary, and some may experience difficulties realizing their preferences owing to health systems-level barriers. We assessed Mississippi women's interest in postabortion contraceptive counseling and method use and the extent to which their method preferences were met. In 2016, women ages 18 to 45 completed a self-administered survey at their abortion consultation visit in Mississippi and a follow-up phone survey 4-8weeks later. Thirty-eight participants were selected for in-depth interviews. We computed the percentage of women who were interested in contraceptive counseling, initiating a method, and who obtained a method at the clinic. We also calculated the percentage who were using their preferred method after abortion and the main reasons they were not using this method. We analyzed transcripts using a theme-based approach. Of 323 women enrolled, 222 (69%) completed the follow-up survey. Of those completing follow-up, more than one-half (58%) reported that their consultation or abortion visit was the best time for contraceptive counseling, and 69% wanted to initiate contraception at the clinic. Only 10% obtained a method on site, and in-depth interview respondents reported they could not afford or did not like the options available. At the follow-up survey, 23% of respondents were using their preferred method. Women cited cost or lack of insurance coverage and difficulties scheduling appointments with community clinicians as reasons for not using their preferred method. Mississippi women have a large unmet demand for postabortion contraception. Policies that support on-site provision of contraception at abortion facilities would help women to realize their contraceptive preferences.

Availability, practices and acceptance of postabortion contraceptive services in health facilities: A study in six states of India

ObjectiveTo assess the availability of and practices around postabortion contraceptive services in health facilities, and document women’s acceptance of postabortion contraception in six Indian states. Study DesignWe conducted a survey of 4001 public and private health facilities that provide abortion-related care in six Indian states. In this analysis, we assess the availability and range of contraceptive methods offered, the protocols and practices around postabortion contraceptive counseling, the extent to which facilities require women to adopt contraception, and contraceptive uptake among women. ResultsAlthough some contraceptive methods and information were available at a majority of facilities (75–97%), the range of methods was lacking and the information provided to women varied considerably by state. 8–26% of facilities required women seeking induced abortions to accept a modern contraceptive method. Only half to two-thirds of postabortion patients adopted a modern method. ConclusionThe limited number of methods offered in facilities suggests that some women may not obtain the method they desire, or get information about the full range of methods that should be available. While contraceptive uptake should be voluntary, the requirement imposed by some facilities for women to adopt a modern contraceptive method in order to obtain an abortion must be addressed. ImplicationsSome 15.6 million Indian women had an induced abortion in 2015. Understanding the provision of postabortion contraceptive services in health facilities, including counseling, is necessary to inform policies and practices to better enable women and couples to make informed decisions to prevent future unintended pregnancies.

Postabortion contraceptive use in Bahir Dar, Ethiopia: a cross sectional study

BackgroundAlthough promoting postabortion family planning is very important and effective strategy to avert unwanted pregnancy, less attention was given to it in Ethiopia. Thus, this study aimed to assess contraceptive use and factors which are affecting it among women after abortion in Bahir Dar town.MethodsFacility based cross-sectional study was conducted in Bahir Dar town. The data was collected using structured interviewer administered questionnaire from women who obtain the abortion services. Bivariable and multivariable logistic regression was used to evaluate the association that demographic factor and reproductive characteristics have with postabortion contracetive use. Findings with p-value of < 0.05 at 95% CI were considered as statistically significant.ResultsA total of 400 women who received abortion service were participated in this study. The proportion of postabortion contraceptive use is 78.5%. Single women are 7.2 times more likely use contraceptive after abortion as compared to their counterpart. Contraceptive use is 2 times higher among women who have previous history of abortion as compared to their counterpart. Women who used contraceptive previously and who used contraception for index pregnancy are 4.73 and 2.64 times more likely to use contraceptive after abortion as compared to their counterpart respectively.ConclusionPostabortion contraceptive use is associated with age, marital status, having previous history of abortion, previous contraceptive use and using contraception for index pregnancy. Greater emphasis should be given on providing postabortion contraceptive counselling to increase utilization of postabortion contraceptive use.

Medical abortion in Nepal: a qualitative study on women\u2019s experiences at safe abortion services and pharmacies

BackgroundAlthough Nepal legalised abortion in 2002, a significant number of women continue to access unsafe abortions. An estimated 60% of all abortions performed in 2014 were unsafe, with unsafe abortion continuing to be a leading contributor to maternal mortality. Despite medical abortion access being solely permitted through government accredited safe abortion services, medical abortion pills are readily available for illegal purchase at pharmacies throughout the country.MethodsUtilising an Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology, underpinned by a health information pyramid conceptual framework, this qualitative exploratory study collected data from in-depth, open-ended interviews. The study explored the medical abortion and sexual and reproductive health experiences of ten women who accessed medical abortion through an accredited safe abortion service, and ten women who accessed unsafe medical abortion through pharmacies.ResultsThematic content analysis revealed emerging themes relating to decision-making processes in accessing safe or unsafe medical abortion; knowledge of safe abortion services; and SRH information access and post-abortion contraceptive counselling. Findings emphasised the interconnectivity of sexual and reproductive health and rights; reproductive coercion; education; poverty; spousal separation; and women’s personal, social and economic empowerment.ConclusionsWhile barriers to safe abortion services persist, so will the continued demand for medical abortion provision through pharmacies. Innovated and effective harm reduction implementations combined with access and information expansion strategies offer the potential to increase access to safe medical abortion while decreasing adverse health outcomes for women.

Correlates of contraceptive use 4 months postabortion: findings from a prospective study in Bangladesh

ObjectivesUsing the social determinants framework as a guide, this study sought to understand correlates of postabortion contraceptive use at the individual, family and abortion service delivery levels. Study designThis prospective study assessed correlates of contraceptive use 4 months postabortion and timing of initiation using a facility-based sample of 398 abortion clients who selected pills, condoms, injectables or no method immediately following the procedure. We measured potential correlates immediately following abortion, inclusive of spontaneous or induced abortion, and assessed contraceptive use outcomes 4 months postabortion. Multivariable logistic regression models identified correlates at each level. Potential individual level correlates included contraceptive and abortion history and fertility intentions; family correlates included intimate partner violence (IPV), discordance in fertility intentions and household decision-making; and service delivery correlates included procedure type and postabortion contraceptive counseling. ResultsReported contraceptive use 4 months postabortion was high (85.4%). Contraceptive use at the index pregnancy (resulting in abortion) was the primary correlate of contraceptive use 4 months postabortion (adjusted odds ratio=2.9; 95% confidence interval: 1.5–5.9). Delayed contraceptive initiation was more common among women who reported past year IPV (36.8% vs. 19.5%; p=.03) particularly with spousal accompaniment for abortion, those in relationships with discordant fertility intentions (44.4% vs. 21.9%; p=.04) and those receiving medication abortion (56.7%) or dilation and curettage (57.1%), compared to manual vacuum aspiration (12.6%; p<.01). ConclusionsContraceptive use at the index pregnancy was the primary correlate of contraceptive use 4 months postabortion. Abortion procedure type and relationship dynamics were correlated with delayed postabortion contraceptive initiation. Women who reported IPV delayed initiation when accompanied by their spouse for abortion. ImplicationsPostabortion contraceptive counseling should assess previous use patterns and provide information on using contraception effectively. Delayed initiation among women reporting IPV could be addressed through comprehensive, confidential counseling that includes violence screening, support for contraceptive initiation and offer of woman-controlled methods.

Postpartum and Post‐Abortion Contraception: From Research to Programs

Contraception following delivery or an induced abortion reduces the risk of an early unintended pregnancy and its associated adverse health consequences. Unmet need for contraception during the postpartum period and contraceptive counseling and services following abortion have been the focus of efforts for the last several decades. This article provides an introduction to the more focused contributions that follow in this special issue. We discuss the validity and measurement of the concept of unmet need for family planning during the postpartum period. We then present key findings on postpartum contraceptive protection, use dynamics, and method mix, followed by an assessment of interventions to improve postpartum family planning. The evidence on postabortion contraceptive uptake and continuation of use remains thin, although encouraging results are noted for implementation of comprehensive abortion care and for the impact of post-abortion contraceptive counseling and services. Drawing on these studies, we outline policy and program implications for improving postpartum and post-abortion contraceptive use.

Assessment of Post Abortion Contraceptive Intention and Associated Factors among Abortion Clients in Gondar Town, North West Ethiopia, 2013

Unintended pregnancies continue to be a major global tragedy for millions of women and abortion is an issue which affects every country in the world. The World Health Organization estimates that 20 million unsafe abortions take place each year, in which 80,000 maternal deaths occur due to complications. Cross- sectional study was employed to assess post abortion contraceptive intention and associated factors among abortion clients in Gondar town, Northwest Ethiopia 2013. Six hundred thirty study subjects were included in the study by using a simple random sampling technique. The collected data entered and analyzed by using SPSS version 20.0 software packages. The degree of association between independent and dependent variables were assessed using odds ratio with 95% confidence interval and p-value ≤0.05. The data analyzed using bivariate and multivariate logistic regression. A total of 630 study participants with abortion were assessed. The extent of the post abortion contraceptive intention among 630 clients was (73.5%). Divorced/widowed women (AOR: 0.277, 95% CI :( 0.151, 0.508).) was a factor negatively associated with the post abortion contraceptive intention whereas married women (AOR: 1.747, 95% CI :( 1.046, 2.916)), abortion from unintended pregnancy (AOR: 3.430, 95% CI (1.597, 7.366) and post abortion contraceptive counseling (AOR: 2.627, 95% CI: (1.366, 5.049)) were factors positively associated with post abortion contraceptive intention. Generally, the post abortion contraceptive intention found in this study was low as compared with others study. Variables like married women, divorced/widowed, abortion from unintended pregnancy and post abortion contraceptive counseling were significant predictors of the post abortion contraceptive intention.

Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam

ObjectiveTo determine predictors of repeat abortion in 3 provinces in Vietnam. MethodsIn a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥2) abortions. ResultsOverall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P<0.05). ConclusionRepeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion.

Contraceptive counseling in Turkey after induced abortion

ObjectiveTo determine the effectiveness of post-abortion contraceptive counseling to women with unwanted pregnancy and to investigate use of modern contraceptive methods among Turkish women. MethodsA prospective case–control study was conducted at 3 Turkish centers between March 23, 2008, and January 10, 2011. A total of 333 women enrolled in the study were divided into 2 groups. Women in group 1 (n=140) presented with unwanted pregnancy requiring induced abortion whereas women in group 2 (n=193) had requested contraception counseling. ResultsThe use of coitus interruptus or condoms was significantly more frequent in group 1 than in group 2 (P<0.001). No statistically significant differences were detected between the 2 groups in their use of oral contraceptives, intrauterine devices, injection methods, calendar methods, and other methods. The education level attained by women in group 1 was lower than that of women in group 2 (P=0.041). ConclusionIncreased effort is required to ensure that sufficient education about family planning is provided to Turkish women for the prevention of unwanted pregnancies and induced abortions.

Quality and efficiency of care for complications of unsafe abortion: A case study from Bangladesh

Treating complications of unsafe abortion can be financially draining for health systems. This analysis assessed incremental health system costs of service delivery for abortion-related complications in the Bangladesh public health system and confirmed that providing postabortion care with vacuum aspiration is less expensive than using dilation and curettage (D&C). Implementing several evidence-based best practices, such as replacing D&C with vacuum aspiration, reducing use of high-level sedation, authorizing midlevel providers to offer postabortion care, and providing postabortion contraceptive counseling and services to women while still at the health facility, could increase the quality and cost efficiency of postabortion care in Bangladesh.

Strategies for improving the acceptability and acceptance of the copper intrauterine device

Intrauterine devices (IUDs) are highly effective and are the most widely used reversible contraceptive method in the world. However, in developed countries IUDs are among the least common methods of contraception used. We evaluated the effect of interventions to increase uptake of the copper IUD, a long-acting, reversible contraceptive method. To determine effectiveness of interventions to improve uptake and continuation of the copper IUD. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, PsycINFO, PubMed, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP) and OpenSIGLE. We also handsearched references of relevant reviews and included studies. We included randomised controlled trials (RCTs) and controlled before and after studies of interventions which measured use and uptake of contraception including copper IUD as an outcome. Two authors independently screened the search results for relevant studies and extracted data from included studies. We used RevMan 5.1 to calculate Peto odd ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes. We conducted meta-analysis by pooling data for similar types of intervention where possible. We used the GRADE system to evaluate the quality of evidence. Nine studies representing 7960 women met our inclusion criteria, including seven randomised controlled trials and two controlled before and after studies that reported IUD uptake postintervention. We evaluated the qualityof evidence as moderate to low. Three studies on contraceptive counselling and referrals by community workers showed an increase in uptake of the IUD among intervention groups (Peto OR 2.00; 95% CI 1.40 to 2.85). Two studies on antenatal contraceptive counselling also favoured the intervention groups (Peto OR 2.33; 95% CI 1.39 to 3.91). One study on postnatal couple contraceptive counselling also showed an increase in IUD uptake compared to control (Peto OR 5.73; 95% CI 3.59 to 9.15). The results of one study evaluating postnatal home visits and two studies on enhanced postabortion contraceptive counselling did not reach statistical significance. Community-based interventions and antenatal contraceptive counselling improved uptake of copper IUD contraception. Since the copper IUD is one of the most effective reversible contraceptive methods, primary care and family planning and practitioners could consider adopting these interventions. Although our review suggests these interventions are clinically effective, a cost-benefit analysis may be required to evaluate applicability.

Predictive factors for uptake of post-abortion care in western Kenya

The objective of this study was to establish factors associated with the receipt of post-abortion contraceptive counselling and uptake at private health facilities in western Kenya. A crosssectional study was conducted at 25 private health facilities from July 2004–October 2004. A total of 403 women were interviewed following post-abortion care (PAC) via manual vacuum aspiration (MVA). Nurse-midwives provided the majority of PAC (55%). Only 44% of women received contraceptive counselling and 31% adopted a method. The strongest predictor for receipt of counselling was obtaining PAC at a low MVA volume facility (odds ratio 5.63). Women who received contraceptive counselling, and those who had an unplanned pregnancy, were three times more likely to adopt a method. Uptake of a method was also influenced by counselling time. Busy facilities in western Kenya should consider training staff specifically for post-abortion contraceptive counselling to increase uptake following PAC.

Humanizing access to modern contraceptive methods in national hospitals in Guatemala, Central America

Background The overall situation in Guatemala, Central America, regarding programs caring for women's reproductive health has been lagging behind for some decades. Since the year 2000, 56% of Guatemalan families have lived below the poverty line. Guatemala has one of the highest fertility rates (lifetime births per woman) in Latin America and the Caribbean countries, comparable to those observed in less developed countries in Africa. Considering the lack of sex education, poor access to effective contraceptive methods and issues of unwanted pregnancy, Guatemalan women engage in illegal and unsafe abortions, which often causes harm and sometimes death. A key strategy designed to improve women's health is through free and informed access to contraceptive methods that are effective and accepted by Guatemalan women. Study Design From July 1, 2003, to December 31, 2006, specially hired trained facilitators visited 22 public hospitals for 1 week to train corresponding physician staff in postabortion counseling, enabling them to assist patients to select and use an effective contraceptive method. To monitor the progress achieved, the trained facilitators returned 4 weeks later. The main purpose of the training was to focus in strengthening the understanding and technical capacity of the hospital staff to implement postabortion contraceptive counseling and to enable women to obtain an effective contraceptive method prior to hospital discharge. Results Out of 22 hospitals, 21 managed to improve their record for counseling patients admitted for postabortion complications, from 31% to 96%. Furthermore, the percentage of women being discharged from the hospital with an effective contraceptive method rose from 20% to 64% from 2003 to 2006. Conclusion The successful results obtained during this study to meet postabortion demands by Guatemalan women point out to the urgent need for the government to expand this initiative within the national health system, including health centers nationwide. This is one of the worldwide recommendations previously made by the World Health Organization.

Anticoncepción y aborto en Argentina: perspectivas de obstetras y ginecólogos

To explore the role of obstetricians and gynaecologists in reproductive public health policies in Argentina. Combination of quantitative methods (survey, n=467) and qualitative methods (semistructured interview, n=35; focus groups, n=6). The great majority of respondents believe that abortion and contraception are serious public health issues. Seven out of 10 considered the implementation of family planning services and post-abortion contraceptive counseling to be priorities. One-half favored promoting social debate on abortion. The great majority thought that de-criminalization of abortion would help to diminish maternal mortality and that abortion should not be penalized when the womans life or health is at risk, or in cases of rape or fetal malformations. Abortion and contraception are important issues for physicians. Advocacy efforts within this community need to focus on an integral vision of health, emphasizing their social responsibility.

Scaling-up a public health innovation: A comparative study of post-abortion care in Bolivia and Mexico

Post-abortion care (PAC), an innovation for treating women with complications of unsafe abortion, has been introduced in public health systems around the world since the 1994 International Conference on Population and Development (ICPD). This article analyzes the process of scaling-up two of the three key elements of the original PAC model: providing prompt clinical treatment to women with abortion complications and offering post-abortion contraceptive counseling and methods in Bolivia and Mexico. The conceptual framework developed from this comparative analysis includes the environmental context for PAC scale-up; the major influences on start-up, expansion, and institutionalization of PAC; and the health, financial, and social impacts of institutionalization. Start-up in both Bolivia and Mexico was facilitated by innovative leaders or catalyzers who were committed to introducing PAC services into public health care settings, collaboration between international organizations and public health institutions, and financial resources. Important processes for successful PAC expansion included strengthening political commitment to PAC services through research, advocacy, and partnerships; improving health system capacity through training, supervision, and development of service guidelines; and facilitating health system access to essential technologies. Institutionalization of PAC has been more successful in Bolivia than Mexico, as measured by a series of proposed indicators. The positive health and financial impacts of PAC institutionalization have been partially measured in Bolivia and Mexico. Other hypotheses—that scaling-up PAC will significantly reduce maternal mortality and morbidity, decrease abortion-related stigma, and prepare the way for efforts to reform restrictive abortion laws and policies—have yet to be tested.

Women's reproductive health needs in Russia: what can we learn from an intervention to improve post-abortion care?

It has been well documented that abortion is a common means of controlling fertility in Russia. Women undergo repeat abortions throughout their reproductive lives, but recent studies of abortion trends in the Russian Federation suggest that abortion rates are on the decline, use of modern contraceptives is increasing, and women dislike abortion as a method of fertility control. Using data collected during 1999-2003 in women's health facilities in three Russian cities, this paper reports the results of an evaluation of interventions to improve post-abortion care, which show an impressive increase in post-abortion contraceptive counselling but no reduction in the rate at which women present at clinics for repeat abortions. The findings indicate a discrepancy between women's stated preferences for modern medical contraceptive methods and their abortion-seeking behaviour. Further exploration of these data suggests that certain women resort to abortion with greater frequency than others, and points to the need for a more focused investigation of these women. These results indicate the complexities associated with changing what has been a relatively common and long-standing practice, and have implications for improving reproductive health services. Meeting the reproductive health needs of Russian women requires not only improved provider and client knowledge but may also demand a more focused delivery of client-centred care than may be the case in other settings.