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Expanding Access to Postabortion Care in Zimbabwe Through Integration of Misoprostol Final Report in Brief

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Expanding Access to Postabortion Care in Zimbabwe Through Integration of Misoprostol Final Report in Brief Expanding Access to Postabortion Care in Zimbabwe through Integration of Misoprostol Final Report in Brief Introduction Recent signs of economic improvement and the slowing of the HIV epidemic in Zimbabwe provide opportunities to reverse the decline of maternal health.1 The estimated maternal mortality ratio (MMR) of 960 maternal deaths per 100,000 live births2 ranks Zimbabwe among the 40 countries globally with the highest MMR.3 Abortion-related complications are one of the primary obstetric causes of maternal death in Zimbabwe.4 The Zimbabwe Ministry of Health and Child Welfare (ZMoHCW) is committed to preventing maternal mortality and morbidity resulting from unsafe abortion and miscarriage by ensuring access to high quality postabortion care (PAC). To support this commitment, the ZMoHCW and Venture Strategies Innovations (VSI), a US-based non-profit organization, conducted operations research (OR) to provide evidence on the feasibility and effectiveness of introducing misoprostol for the treatment of incomplete abortion and miscarriage (TIAM) in the first trimester, into the PAC service package and protocol of Zimbabwe’s health system. This brief presents the evidence from the operations research demonstrating the effectiveness and feasibility of integrating misoprostol for TIAM at all levels of the health system, from provincial hospitals to rural health centers. An estimated 3,000 Zimbabwean postabortion care can reduce the health facilities in Zimbabwe will women died during childbirth in human and financial burden of support the ZMoHCW’s commitment 2010. For every woman who dies, unsafe abortion and miscarriage. To to expanding access to PAC services another 20 suffer serious injury or address the abortion-related causes for all women. disability. An estimated 174,739 of maternal mortality and morbidity, DALYs (disability adjusted life the ZMoHCW has undertaken Postabortion Care Services: years) will be lost each year if several initiatives to improve access An Evidence-based, nothing more is done to improve to quality postabortion care. In Effective Response maternal health in Zimbabwe.3 2008, the Department of Postabortion care (PAC) is defined as a package of services to address Reproductive Health launched a Background training program for doctors, complications related to incomplete The primary obstetric causes of midwives and clinical officers on the abortion and miscarriage. The maternal death in Zimbabwe use of manual vacuum aspiration components of PAC include reported in the 2007 Maternal and (MVA) for the treatment of community and service provider Perinatal Mortality Study were: incomplete abortion and miscarriage partnerships, counseling, treatment postpartum hemorrhage, (TIAM). Misoprostol, a safe, effective of incomplete abortion and pregnancy-induced and low-cost uterotonic for TIAM, miscarriage, contraceptive services hypertension/eclampsia, sepsis and was added to the Essential Drugs List and reproductive and other health 5 abortion-related causes.4 There is of Zimbabwe (EDLIZ) in 2011. services. PAC links curative services international consensus that the Integration of misoprostol for TIAM (TIAM) with preventive services 6 timely provision of appropriate into the PAC services delivered at all (family planning). The World Health Organization (WHO) defines Figure 1: Districts and health facilities that participated in the operations research misoprostol into the PAC service package at all levels of the health UMGUZA DISTRICT ! MUTARE DISTRICT! system, from hospitals to rural Pop. = 81,781! Pop. = 434,379! Rural Health Center = 8! HARARE! Rural Health Center = 20! health centers (RHCs). Expanding the Rural/Mission Hospital = 1! Rural/Mission Hospital = 3! delivery of PAC services to RHCs District Hospital = 1 District Hospital = 1! Provincial Hospital = 0! Provincial Hospital = 1! supports the government of Zimbabwe’s commitment to increasing health equity as presented in the 2007-2015 Roadmap to Health, as does the training of a new corps of primary care nurses to provide preventive and basic curative services at RHCs.12 MATOBO DISTRICT! CHIMANIMANI DISTRICT! Pop. = 110,266! Pop. = 136,055! Rural Health Center = 8! Rural Health Center = 15! Operations Research: Rural/Mission Hospital = 4! Rural/Mission Hospital = 5! Background District Hospital = 1! District Hospital = 0! Provincial Hospital = 0! Provincial Hospital = 0! The ZMoHCW’s and VSI’s collaborative OR was conducted in 68 health facilities in four districts of incomplete abortion as the retention was added to the WHO list of Zimbabwe (Figure 1). The OR sites of products of conception after an Priority Life-saving Medicines for 11 included the following facility induced or spontaneous abortion, Women and Children. categories: a) provincial hospitals, b) and considers the treatment of district hospitals, c) rural and incomplete abortion and miscarriage Misoprostol, a non-surgical method, mission hospitals, and d) rural health an essential element of obstetric requires minimal staff and centers. A baseline facility care. Misoprostol and vacuum infrastructure; it requires neither assessment was conducted at the 68 aspiration are the methods physicians nor operating theaters. facilities prior to the introduction of recommended by the WHO for the The medicine allows for task-shifting misoprostol to provide information treatment of incomplete abortion to mid-level providers, which can 7 on existing PAC services. Facility and miscarriage. Dilatation and reduce the burden on the few assessments included a review of curettage (D&C) is not doctors available at health facilities services provided from September recommended as a treatment and potentially lower health service 2011 to February 2012. OR data method for first trimester uterine costs for the system and for 7 refers to the period from January evacuation by the WHO. patients. 2013 to June 2013. Health providers and village health workers The Case for Integrating Bringing Postabortion Care Misoprostol into Closer to the Women in Need disseminated key messages on the Postabortion Care The potential impact of timely, dangers of unsafe abortion, the A growing body of evidence has quality postabortion care services on availability of misoprostol for TIAM demonstrated that medical the health of women in Zimbabwe and family planning services at OR treatment of incomplete abortion will only be achieved if these sites, and the importance of with misoprostol is an effective services reach the women in need. preventing unwanted pregnancies. 8,9 alternative to MVA. In 2009, the In view of advancing this goal, the Misoprostol was donated by VSI for WHO included misoprostol for the ZMoHCW and VSI conducted the OR and the supervisory team treatment of incomplete abortion operations research to provide ensured its availability at facilities and miscarriage in its Model List of evidence on the feasibility and throughout the OR period. A training 10 Essential Medicines, and in 2011, it effectiveness of introducing of trainers was conducted for 40 senior doctors and nurses, followed provider conducted a clinical Eighty-nine percent of women by cascade trainings for 135 assessment to establish whether any enrolled in the OR at RHCs and 95% providers (primary care nurses, emergency treatment was needed. of those enrolled at rural and nurses and midwives) from all sites. After obtaining informed consent to mission hospitals were treated with participate in the OR, the clinical misoprostol (Figure 3). Primary care Operations Research: protocol presented in Figure 2 was nurses, the highest level of trained Key Findings followed. The course of treatment staff at most rural health centers, Availability of Postabortion Care depended on the woman’s were highly utilized and treated over Services at Baseline condition, gestational age, 40% of the women who were According to the facility assessment, treatment methods available at the administered misoprostol for TIAM. prior to the OR, there was limited site, and the woman’s preference (if Slightly more than half of the availability of postabortion care more than one option was available women enrolled at the provincial services at the OR sites. In addition and deemed appropriate by the and district hospitals received to the provincial hospital, only one provider). The WHO recommended misoprostol. At the provincial of three district hospitals and six of regimen of 600mcg oral misoprostol hospital, only two women were thirteen rural and mission hospitals for TIAM was used in the operations treated with MVA, and the rest of reported offering TIAM. Dilatation research.7 the incomplete abortion cases and curettage was the TIAM (n=48) were treated with D&C. treatment method available at the Rural health centers and rural and largest number of facilities (n=5), mission hospitals readily introduced Health providers at the OR facilities with only two facilities offering PAC services that included the and village health workers in the MVA. Only one rural health center treatment of incomplete abortion catchment areas promoted reported offering TIAM at the time and miscarriage with misoprostol. community awareness of the of the assessment, through the administration of oxytocin. Figure 2: Service Delivery and Referral Protocols for PAC, based on facility level According to the facility assessment, ! ! ! women sought postabortion care at Health !Center! District !Hospital! Provincial! Hospital! all levels of health facilities. From ! ! ! ! ! ! September 2011 to February 2012, Uterine
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