Quality Of Post-abortion Care Research Articles

Assessing post-abortion care using the WHO quality of care framework for maternal and newborn health: a cross-sectional study in two African hospitals in humanitarian settings

BackgroundAbortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).MethodsWe mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals’ PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.ResultsAmong the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.ConclusionOur comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.

“They talked to me rudely”. Women perspectives on quality of post-abortion care in public health facilities in Kenya

BackgroundAccess to safe abortion is legally restricted in Kenya. Therefore, majority women seeking abortion services in such restrictive contexts resort to unsafe methods and procedures that result in complications that often require treatment in health facilities. Most women with abortion-related complications end up in public health facilities. Nevertheless, evidence is limited on the quality of care provided to patients with abortion complications in public health facilities in Kenya.MethodsData for this paper are drawn from a qualitative study that included interviews with 66 women who received post-abortion care in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on mechanisms of decision-making while seeking post-abortion care services, care pathways within facilities, and perceptions of patients on quality of care received including respect, privacy, confidentiality, communication and stigma.FindingsThe participants’ perceptions of the quality of care were characterized as either “bad care” or “good care”, with the good care focusing on interpersonal aspects such as friendliness, respect, empathy, short waiting time before receiving services, as well as the physical or functional aspects of care such as resolution of morbidity and absence of death. Majority of participants initially reported that they received “good care” because they left the facility with their medical problem resolved. However, when probed, about half of them reported delays in receiving care despite their condition being an emergency (i.e., severe bleeding and pain). Participants also reported instances of abuse (verbal and sexual) or absence of privacy during care and inadequate involvement in decisions around the nature and type of care they received. Our findings also suggest that healthcare providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older). For instance, women who experienced miscarriages reported supportive care whereas women suspected to have induced their abortions felt stigmatized.ConclusionThese findings have far reaching implications on efforts to improve uptake of post-abortion care, care seeking behaviors and on how to assess quality of abortion care. There should be emphasis on interventions meant to enhance processes and structural indicators of post-abortion care services meant to improve patients’ experiences throughout the care process. Moreover, more efforts are needed to advance the tools and approaches for assessing women experiences during post-abortion care beyond just the overriding clinical outcomes of care.

Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d'Ivoire.

Postabortion care (PAC) is an essential component of emergency obstetric care (EmOC) and is necessary to prevent unsafe abortion-related maternal mortality, but we know little regarding the preparedness of facilities to provide PAC services, the distribution of these services and disparities in their accessibility in low-resource settings. To address this knowledge gap, this study aims to describe PAC service availability, evaluate PAC readiness and measure inequities in access to PAC services in seven states of Nigeria and nationally in Côte d’Ivoire. We used survey data from reproductive-age women and the health facilities that serve the areas where they live. We linked facility readiness information, including PAC-specific signal functions, to female data using geospatial information. Findings revealed less than half of facilities provide basic PAC services in Nigeria (48.4%) but greater PAC availability in Côte d’Ivoire (70.5%). Only 33.5% and 36.9% of facilities with the capacity to provide basic PAC and only 23.9% and 37.5% of facilities with the capacity to provide comprehensive PAC had all the corresponding signal functions in Nigeria and Côte d’Ivoire, respectively. With regard to access, while ∼8 out of 10 women of reproductive age in Nigeria (81.3%) and Côte d’Ivoire (79.9%) lived within 10 km of a facility providing any PAC services, significantly lower levels of the population lived <10 km from a facility with all basic or comprehensive PAC signal functions, and we observed significant inequities in access for poor, rural and less educated women. Addressing facilities’ service readiness will improve the quality of PAC provided and ensure postabortion complications can be treated in a timely and effective manner, while expanding the availability of services to additional primary-level facilities would increase access—both of which could help to reduce avoidable abortion-related maternal morbidity and mortality and associated inequities.

Client Satisfaction in the Quality of Post Abortion Care Among Women Attending in Public Health Facility of Gambella, Ethiopia

Background: The quality of post-abortion care services is essential to improve the health of women who experience complications from abortion. Abortion and its complication is the most common cause of maternal death in Africa, particularly in Ethiopia. Despite this fact, little attention is given to the quality of post-abortion care. This study was aimed to assess client satisfaction in the quality of post-abortion care among women in the public health facility of Gambella, Ethiopia. Methods: A facility-based crossectional study was done among 194 participants. A consecutive sampling technique was used to select the study participants. A structured, pretested, and interviewer-administered questioner was used to collecting the data. Binary and multivariable logistic regression analysis was done to identify associated factors. An adjusted odds ratio with 95% CI was used to estimate the direction and strength of the association. Variable with a p-value <0.05 was considered as statistically significant. Results: About 169 (87.1%, 95% CI: (82, 91.8)) participants were satisfied in the quality of post abortion care (PAC) services. Unwanted pregnancy [AOR=1.8, 95% CI: (1.17, 10.9)], history of abortion [2.1, 95% CI: (1.6, 13.8)], assisted by physician [AOR=3.9 95% CI: (1.6, 8.6)], treated politely and respectfully [AOR=6.3, 95% CI: (1.82, 22.2)], the provider adress all questions raised by the client [AOR=5.1, 95% CI: (1.9, 14.5)] were significantly associated factors. Conclusion: The majority of the study participants were satisfied with the quality of post-abortion care services. Enhancing patient care in the facility, strengthening awareness of family planning services, and addressing the questions of the clients in a respected manner are important measures that increase client satisfaction.

Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis

BackgroundThe quality of obstetric care has been identified as a contributing factor in Indonesia’s persistently high level of maternal mortality, and the country’s restrictive abortion laws merit special attention to the quality of post-abortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals.MethodsUsing data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia’s most populous island, we applied a signal functions analysis to measure the health system’s capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures.ResultsForty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia’s current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C).ConclusionsOffering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/Gyns to perform this procedure would greatly improve the capacity of Java’s health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service.

From the shadows to light. Perceptions of women and healthcare providers of post-abortion care in Burkina Faso.

Despite political commitments to address maternal deaths due to abortion, women and girls in Burkina Faso still face impediments to accessing post-abortion care (PAC) services, including stigma, high costs, and negative patient-provider relationships. Based on a three-year ethnographic study in Ouagadougou, Burkina Faso (2011-2014), this paper provides an in-depth examination of the experiences and perceptions of patients and healthcare providers when seeking or delivering PAC. Extensive participant observation of PAC service delivery was carried out in five primary and three referral health facilities, as well as in-depth interviews with 13 healthcare providers and 39 patients. Data were analyzed using a thematic analysis approach and discussed using relevant literature. Patients and providers conceptualized PAC as literally "womb washing'', vividly reflecting on the realities around health risks of abortion, procreation and role of health providers. Moreover, women described PAC as a life-saving intervention capable of averting infections and other complications, but also bears significant risks of disclosure depending on the uterine evacuation technology used (manual vacuum aspiration versus medical abortion). In delivering PAC services, healthcare providers agonize over the dilemmas they face, mainly derived from their conceptualization of PAC services and how they cope with discomfort using PAC technology options. Our findings present the intersection between patients' and providers' conceptions of PAC, and how these perceptions drive the choice of technology for uterine evacuation to mitigate stigma. We argue that these perceptions drive patient and healthcare provider practices around decision making to seek or deliver care, and patient-provider interactions in health facilities. These findings offer important guidance for interventions seeking to improve access and quality of PAC.

Women's Satisfaction With and Perceptions of the Quality of Postabortion Care at Public-Sector Facilities in Mainland Tanzania and in Zanzibar.

In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative. We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients. Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received. Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.

Exploring Barriers: How to Overcome Roadblocks Impeding the Provision of Postabortion Care to Young People in Togo.

Family planning counseling and provision of a variety of contraceptive methods during postabortion care (PAC) can increase voluntary contraceptive use and prevent unintended pregnancies, helping to reduce maternal morbidity and mortality. Youth in Togo, however, face many barriers to accessing contraceptives during PAC including provider bias, parental consent policies, stigma, and pressure on young people to have children. This article describes the lessons learned from follow-up with providers who were trained on PAC to build their willingness and skills in offering youth-friendly PAC. With assistance from the Evidence to Action (E2A) Project, Togo's Division for Maternal and Infant Health and Family Planning (DSMI/PF) systematically applied IntraHealth International's Optimizing Performance and Quality (OPQ) approach to improve the quality of PAC at 5 health facilities from 2014 to 2016. OPQ identified gaps and helped establish solutions to shortcomings that hinder youth's access to contraceptive choice during PAC. To address these shortcomings, staff trained providers to improve their knowledge, attitudes, and skills with regard to (1) medical eligibility criteria for contraceptive use to remove age as justification for denying contraceptives; (2) AFPAC to increase the ability to consider gender-based violence and to encourage client-focused and age-sensitive counseling; and (3) monitoring through disaggregation of data by age, method, and parity for data-driven planning and delivery of AFPAC. Providers reported improved attitudes and empathy toward young PAC clients, efforts to screen for exposure to sexual and gender-based violence, and willingness to explore reproductive health needs and assist clients in choosing contraceptive methods. Previously, no youth PAC clients chose contraceptives during PAC or returned to the facility for routine follow-up. After providers received OPQ training, they treated 775 PAC clients in 5 health facilities between June and December 2016; 351 were ages 14-24, of whom 142 (40.5%) chose a modern contraceptive. The most common method selected by youth was oral contraceptive pills (44%), followed by implants (41%) and injectables (15%). Of the 142 youth PAC clients who chose a method, 86 (58.5%) returned for the 7-day follow-up. Training providers to offer AFPAC along with the application of OPQ to improve the quality of PAC increases voluntary contraceptive uptake, including implants, among youth who make up a substantial portion of all PAC clients. Incorporating AFPAC in family planning/reproductive health policies, norms, protocols, and PAC training, as Togo's DSMI/PF did, is an important element to ensuring institutionalization of the practice.

Spatial and socio-economic correlates of effective contraception among women seeking post-abortion care in healthcare facilities in Kenya.

IntroductionInformation, counseling, availability of contraceptives, and their adoption by post-abortion care (PAC) patients are central to the quality of PAC in healthcare facilities. Effective contraceptive adoption by these patients reduces the risks of unintended pregnancy and repeat abortion.MethodsThis study uses data from the Incidence and Magnitude of Unsafe Abortion Study of 2012 to assess the level and determinants of highly effective contraception among patients treated with complications from an unsafe abortion in healthcare facilities in Kenya. Highly effective contraception was defined as any method adopted by a PAC patient that reduces pregnancy rate by over 99%.ResultsGenerally, contraceptive counseling was high among all PAC patients (90%). However, only 54% of them received a modern family planning method—45% a short-acting method and 9% a long-acting and permanent method. Adoption of highly effective contraception was determined by patient’s previous exposure to unintended pregnancies, induced abortion and modern family planning (FP). Facility level factors associated with the uptake of highly effective contraceptives included: facility ownership, availability of evacuation procedure room, whether the facility had a specialized obstetric-gynecologist, a facility that also had maternity services and the number of FP methods available for PAC patients.Discussion and conclusionFor better adoption of highly effective FP, counseling of PAC patients requires an understanding of the patient’s past experience with contraception and their future fertility intentions and desires in order to meet their reproductive needs more specifically. Family planning integration with PAC can increase contraceptive uptake and improve the reproductive health of post-abortion care patients.

Policy, law and post-abortion care services in Kenya.

BackgroundUnsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy.MethodsA cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality.ResultsThe provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge.DiscussionLegal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination.ConclusionGreater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.

Effects of an intervention initiated by a national society to improve postabortion care in rural facilities in Burkina Faso.

To evaluate the results of an intervention by the Societé de Gynécologues et Obstétriciens du Burkina (SOGOB) to improve postabortion care (PAC) in rural areas of Burkina Faso. From June 1, 2012, to May 31, 2013, SOGOB increased capacity for PAC by providing training in health care and equipment to 45 rural health facilities. Performance in PAC in the year before intervention (June 1, 2011, to May 31, 2012) was compared with that in the year following intervention (June 1, 2013, to May 31, 2014). The number of cases of incomplete abortion managed within a year increased from 1812 before the intervention to 2738 afterwards. Before capacity building, none of the health facilities was using misoprostol for management of incomplete abortion. After capacity building, misoprostol was used in 805 (29.4%) cases. The use of inappropriate methods to empty the uterus decreased (27.5% [498/1812] vs 1.4% [38/2738]; P<0.001). The frequencies of uterine perforation and pelvic infection also decreased (P≤0.01 for both). In the year after implementation, 2035 (78.3%) of 2600 women had taken up a family planning method before leaving the facility. SOGOB's intervention has improved the quality of PAC in rural health facilities in Burkina Faso.

Pain relief in postabortion care practiced by healthcare professionals in South Eastern Nigeria

Background: Postabortion care (PAC) is aimed at reducing maternal morbidity and mortality resulting from the incomplete abortion and abortion complications. The use of analgesia is an integral part of high quality PAC. Knowledge of the pattern of use of analgesia in PAC by healthcare professionals would help in planning group specific training programs for more effective PAC. Aim: This study is aimed at assessing the use of analgesia in PAC among healthcare professionals in South Eastern Nigeria. Subjects and Methods: This is a cross‑sectional questionnaire‑based survey carried out among healthcare professionals in Anambra State, Nigeria between June 1 and September 30, 2006. Participants were chosen using a multistage sampling technique. Pretested questionnaires assessing the practice of postabortion counseling were then administered. The data were analyzed using SPSS version 20.0 software. Frequencies were within 95% confidence limits. Results: A total of 437 health professionals were included in the study. The mean age was 38.2 (10.4) years. Formal PAC training influenced the use of analgesia positively (P < 0.001). The use of analgesia in PAC was also significantly higher among professionals working in tertiary healthcare center and private specialist hospitals when compared with other facilities (P = 0.02). In general complications were more when analgesia was not employed. Older professionals were more likely to employ pain relief in PAC (P = 0.01). Furthermore, doctors were significantly more likely to employ pain relief in PAC when compared to nurses (P = 0.001). Conclusion: This study revealed a low level of use of analgesia in PAC among the healthcare professionals. It also demonstrated a significant association between formal PAC training and use of analgesia in PAC. It is, therefore, recommended that increased PAC training and re‑training activities with emphasis on the need for analgesia should be conducted for healthcare professionals to improve the quality of PAC received by clients.

Assessment of Quality and Determinant Factors of Post-Abortion Care in Governmental Hospitals of Tigray, Ethiopia, 2013

Background: Unsafe abortion is one of the leading causes of maternal mortality and morbidity worldwide accounting for 13% of maternal deaths globally. Objective: To assess quality and determinant factors of post-abortion care in governmental Hospitals of Tigray, Ethiopia. Method: Institution based Cross-sectional study was conducted from January to May 2013. Four hundred twenty post apportion care clients were interviewed and 60 clients were observed to obtain qualitative data. Data was collected using pre prepared structured checklist and analyzed using SPSS version 16.00. The association between dependent and in dependent variables was assessed and presented using descriptive statistics, and logistic regression. Results: Majority (46.9%) of the study subjects fall in to the age category of 14-19 years. The study depicted that only 40.6% of the clients were satisfied. Client satisfaction was significantly associated with educational and occupational status, laboratory prescription and toilet access. Only 48 % of study subjects were informed about the available family planning methods and supplied with. The observational study revealed that 88.3% of the clients did not get the opportunity to pose questions or concerns. Only one of the health institutions has functional sink with adequate water supply in the abortion room. No more than 22.2 % of the care providers got refresher training on relevant areas. Conclusion: This study has identified main concerns that could have great input on the improvement of post abortion care. Hence, we can conclude that patient satisfaction is low and there is lack of refreshments trainings especially on counseling and supporting. Besides, there are shortage of materials and supplies. This all could have synergetic effect on compromising the quality of post abortion care. For this reason, it is recommended to skill up the providers with evidence based trainings to enhance quality of post abortion care.

Quality of post-abortion care in public health facilities in Ethiopia

Abstract Background: Comprehensive quality Post Abortion Care (PAC) is one of the important strategies to save lives where access to safe abortion is restricted by Law and services are inaccessible. Objective: The objective of the study was to assess the status of quality of PAC in health facilities of Amhara and Oromiya regional states. Methods: The study was cross-sectional by design and was conducted from November 2002 to March 2003. Patient interview, provider interview and direct service delivery observation were utilized to capture different aspects of care. Eleven health facilities (five in Oromiya and six in Amhara Regions), 103 post-abortion patients and 87 health service providers were included in the study. Results: although facilities were found to be prepared to manage abortion complications, some patients were delayed from receiving services because of requirement to pay before getting services, and to buy drugs and supplies from other sources. Patient-provider interaction was generally satisfactory as viewed by the respondents. Majority (88.3%) of patients felt that PAC services maintained confidentiality. Patients were not informed about the steps of each procedure. Nearly two-third of service providers informed the patients about the cause of their problem, but only 50.5% of them told the outcome of treatment. Information provision regarding important precautions and warning signs was uniformly very low in all study facilities. Only 53.4% of patients left the facilities counseled about family planning and 44.7% with contraceptives. But, 84.5% of women do not plan pregnancy within three months following the abortion. Great majority of the patients responded that they were satisfied with services they have obtained. Dissatisfaction included maltreatment by service providers, and inconvenient setup of service delivery. Patient assessment was principally based on last menstrual period and bimanual pelvic examination in most of the facilities. Service providers do not usually stick to infection prevention and universal precautions. Conclusion: the study has shown areas of improvement for better services to respond to various needs of the postabortion patients. [Ethiop.J.Health Dev. 2008;22 (1):26-33]

Integration of Post-Abortion Care: The Role of Township Medical Officers and Midwives in Myanmar

Complications of unsafe abortion are a significant cause of maternal morbidity and mortality in Myanmar, and are recognised by the Ministry of Health as a priority. The Department of Health developed a strategy to address the problem of abortion complications by integrating post-abortion care and contraceptive services into the existing township health system. The quality of post-abortion care was assessed by the Department of Health in 2000, using a baseline survey of health providers and post-abortion women in Bago Division. The integration of post-abortion care was led by the Township Medical Officers, who provided monthly in-service training and supervision of health care workers in each township. Hospital-based doctors and nurses, clinic midwives, village midwives and other volunteer health providers, including traditional birth attendants, were all trained. The role of the local clinic midwife was extended to make follow-up home visits to the women with post-abortion complications and provide them with contraception when requested. Preliminary results show positive outcomes. However, donor-funded projects may have a destabilising effect on township services by diverting attention and resources; donors need to work with government to support its priorities for health care. The future nationwide integration of post-abortion care services into township services should be planned in consultation with Township Medical Officers and midwives, the key providers of these services.