Global evaluation of USAID"s postabortion care [PAC] program [: executive summary]

The report includes case studies of PAC in Bolivia, Kenya, Ghana, and Nepal. Despite relatively limited funding, the program has enjoyed remarkable success. There are now PAC programs in Africa, Latin America and the Caribbean, Europe and Eurasia, and Asia and the Near East. USAID cooperating agencies (CAs) have effectively used USAID"s funding and leadership to leverage funding from foundations as well as from bilateral and multilateral donors. Together, the international community has initiated PAC activities in more than 40 countries. Over a quarter of all countries with populations over 2 million have some USAID funded PAC activities. Striking progress has been made in starting PAC activities in most regions with a high burden of mortality from unsafe abortion. Success to date has been greatest in the treatment of abortion complications. In those countries with PAC programs -- in hospitals, clinics, and small maternity facilities at the community level -- women are receiving treatment through manual vacuum aspiration (MVA), which is safer and less costly than traditional dilation and curettage (D&C). One important innovation has been the demonstration in a number of countries that trained nurse-midwives can provide high-quality treatment, thus expanding access to the community level. Kenya, for example, has shown evidence of declines in hospital admissions for abortion complications and in hospital maternal mortality, and appears to have helped redirect resources to the prevention of obstetric deaths from other causes. In other countries, PAC contributions have helped reduce maternal mortality in hospitals, the frequency of hospitalizations for severe complications from abortion, and the demand for PAC. In Kenya, Ghana, and Bolivia, abortion appears to be a declining contributor to the total morbidity of women. While many of the programs were begun as pilot studies, most countries are in the process of scaling up. Despite varying country contexts, PAC managers and providers and the CAs working with them have sought to expand access to services. There are notable successes: Bolivia has incorporated PAC into its national health insurance program, thus removing financial barriers. Mexico and Egypt have sponsored operations research on the social and cultural barriers that lead women to delay seeking help and treatment. Many countries, using operations research data, have trained providers to be more compassionate than they had been, using materials produced by USAID"s CAs. PAC"s second component -- family planning (FP) counseling and services -- is not as strong as the first component and depends on the maturity of the national FP program. In countries with strong programs, this PAC component is facilitated by the presence of trained providers; extensive information, education and communication (IEC); good contraceptive logistics; and high demand. Few countries have such a program, however. The third component - linkages with other reproductive health (RH) services -- is very weak. In general, this component has received insufficient attention in protocols, training, implementation, and monitoring. Like the second component, the third depends on the national RH health program. In circumstances where other RH services, such as diagnosis and treatment of sexually transmitted infections (STIs), are very poor or unavailable, linkages are difficult, if not futile. The Ghana case study (appended to the full report) demonstrates the challenge involved in establishing effective linkages. The Kenyan case study illustrates the importance of doing so in a country with a high prevalence of HIV. USAID should define what this component realistically should comprise in differing country contexts. Challenges facing PAC programs include: the critical need for data demonstrating PAC"s unique contribution to reducing maternal morbidity and mortality; the absence of PAC activities in many countries with a high burden of mortality; the inability of PAC programs to reach the majority of the population in any country; and the need to generate the community-level demand for PAC that will provide a basis for PAC sustainability.