Expanding Access to Postabortion Care in through Integration of 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 -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 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 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 -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! ! 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! ! 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 . 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 size 䍸13 wks LMP! ! ! Administer misoprostol! or 736 women presented at a facility Uterine size 䍸13 wks LMP! Uterine size 䍸13 wks LMP! ! ! MVA*! ! Administer misoprostol! Administer misoprostol or ! ! with complications from unsafe ! MVA*! ! Uterine size !>13 wks LMP! ! ! abortion or miscarriage. Over one- Refer! if:! Uterine size !>13 wks LMP! D&E*! ! ! Uterine size >13! wks LMP, or! D&E*! ! ! fourth of these women (n=200) Other uterine evacuation Complicated case, or! ! ! ! methods, surgery! or other Woman prefers other method! Refer for severe complications! sought care at rural health centers ! ! procedures! to treat that did not provide treatment for ! ! complications! as needed! ! ! ! incomplete abortion at the time, and If medical If medical If medical management! fails management! fails ! as such these women were referred management fails! and woman! is and woman! is ! to other health facilities. clinically! stable! clinically! stable! ! ! ! ! Making Postabortion Care ! ! ! Repeat misoprostol treatment or Repeat treatment or ! ! ! Re-assess and treat! as necessary! Accessible to Rural Women Where Refer for further treatment! Refer for further treatment! ! ! ! They Seek Care ! Once the OR began, when a woman *Where MVA or D&E is not Refer if necessary! Refer if necessary! available, D&C can be used as a presented at any of the 68 second line treatment.! participating health facilities with Contraceptive counseling and method provision! signs of incomplete abortion, the Figure 3: Distribution of methods used for TIAM by facility level for costs for women needing PAC women enrolled in the OR (1 January - 15 July 2013) services, and lessens the burden

1%! on higher level facilities. 100%! 3%! 2%! 10%! 3%! 17%! 1%! Misoprostol Treatment Outcomes 80%! Among the 315 women enrolled in 47%! Referred Without the OR, 244 (78%) were treated with Treatment! misoprostol. Fifty one percent 60%! Other Methods! (n=124) of those treated with 95%! misoprostol returned for follow-up. 89%! 40%! 83%! MVA! Among the women who returned for whom data were recorded (n=120), 50%! D&C! 96% were successfully treated. Only 20%! five women required additional Misoprostol! treatment. These outcomes are consistent with the 91-98% efficacy 0%! rate of misoprostol for PAC observed Rural Health Rural/ District Provincial 6 Center Mission Hospital Hospital in randomized controlled studies. (n=128) ! Hopsital (n= (12)! (n=102)! (n=73)! Breaking this information down further, at rural health centers, 98% availability of misoprostol for PAC, hospitals, the percent referred for (n=84) of women were successfully the dangers of unsafe abortion and PAC treatment declined by nearly treated after a single 600mcg dose the importance of family planning, 95%, from 48% to 3%. of misoprostol. Of the two women during facility-based health Making postabortion care available who were not diagnosed as education sessions and community at rural health facilities through the successfully treated, one had to be meetings. Overall, 13,845 introduction of misoprostol referred for further treatment and community members were reached decreases the need for referrals, the other was sent home to wait an with messages about misoprostol for reduces the financial and time additional week. PAC during the course of the OR. Health providers led the Figure 4: The proportion of women presenting for PAC at rural health majority of the sessions (54%) and centers and rural and mission hospitals who were referred without village health workers led 14% of the receiving treatment, at baseline and during the operations research sessions. 98%! 100%! Reducing Referrals for Postabortion Care 80%! The introduction of misoprostol for 60%! 48%! PAC dramatically reduced the proportion of women at rural health 40%! centers and rural and mission 20%! 10%! hospitals that had to be referred for 3%! treatment (Figure 4). Only 10% of 0%! enrolled women who sought PAC Rural Health Center ! Rural/Mission Hospital ! services at RHCs were referred to a Baseline (September 2011-February 2012)! higher level facility, compared with Operations Research (1 January-15 July 2013)! 98% at baseline. At rural and mission At rural and mission hospitals, the Figure 5: Contraceptive methods provided at initial visit by facility level treatment success rate among those (1 January – 15 July 2013)* returning for follow-up was 93% (n=25). Only two women at these Condoms! Pills! Injectables! Implant! facilities received additional 120%! 4%! 17%! treatment. One was treated with 4%! 100%! 2%! 4%! misoprostol and the other with 22%! 10%! 9%! 15%! MVA. Finally, a third woman whose 80%! 33%! treatment with misoprostol at the 60%! provincial hospital was not 64%! 74%! 33%! 76%! 70%! successful was given a second dose 40%! of misoprostol at follow-up. 20%! 33%! 18%! 14%! 11%! 15%! Contraceptive Uptake 0%! The prevention of unwanted or Rural Health Rural/Mission District Provincial Total mistimed pregnancies through Center Hospital Hospital Hospital (n=244) ! (n=103)! (n=42)! (n=6)! (n=93)! effective family planning methods reduces the risks of maternal *Columns do not always sum to 100% because some women took more than one family planning method. mortality by reducing repeat 13 . The provision of family health centers (87%). The finding rural and mission hospitals (39%) planning counseling and services at that contraceptive uptake was high and the provincial hospitals (12%). the time and location women access (82%) among women who reported The follow-up visit is particularly services for spontaneous or induced not using a family planning method important as it not only allows for abortion is regarded as a proven prior to the last pregnancy indicates confirmation of the success of high-impact practice. When scaled effective counseling services. Over treatment, but also provides an up and institutionalized, this one-fourth of the contraceptive additional opportunity for provision maximizes investments in acceptors received injectables and counseling and family planning a comprehensive family planning implants at rural health centers, services. Ten percent of the women 14 strategy. As fertility can return as compared with 13% of acceptors at who returned for follow-up received soon as 10 days after an abortion or the provincial hospital (Figure 5). a contraceptive at follow-up and not miscarriage, provision of family at the initial visit. planning services is an essential Treatment Follow-up element of PAC. Over 80% of women Women treated with misoprostol Side Effects in the OR accepted a modern were advised to return after 7-14 Women treated with misoprostol contraceptive method as part of PAC days for follow-up. Women treated experienced minimal side effects. services. Rates of contraceptive at rural health centers were most Among the 124 women treated with uptake were highest at the likely to return for follow-up (75%), misoprostol who returned for provincial hospital (92%) and rural compared with those treated at follow-up, 29 women reported

Perspectives from providers:

Speaking about women receiving misoprostol for PAC, a midwife at Gutaurare Rural Health Center in Mutare District noted, “They really felt good because in the past we used to refer to the hospital for PAC, but with the use of misoprostol we are treating without complications, no costs, and it is very effective.”

A Midwife at Charter Clinic in Chimanimani District reported: “They come expecting to be transferred and go for invasive procedures like D&C, but after discussing with them, they end up accepting the misoprostol. In our community, a few success stories have made them believe in PAC.” Figure 6: Misoprostol regimens pocket reference for clinicians

CERVICAL RIPENING Dose Route Instructions Vaginal or 400 mcg Give 3 hours before the procedure. sublingual

INTRAUTERINE FETAL DEATH Reduce doses in women with not use with previous cesarean section. Dose Route Instructions 13-17 weeks 200 mcg Vaginal Every 6 hours, maximum 4 doses. 18-26 weeks 100 mcg Vaginal Every 6 hours, maximum 4 doses. >26 weeks 25 mcg Vaginal Every 6 hours. OR 25 mcg Oral Every 2 hours.

MEDICATION ABORTION Use as permitted within the country’s legal framework. Regimen MEDICATION ABORTION WITH AND MISOPROSTOL Up to 9 weeks gestation Mifepristone 200 mg oral followed 24 to 48 hours later by misoprostol 800 mcg vaginal, sublingual or buccal. For oral route, 400 mcg misoprostol can be used up to 7 weeks of gestation. 9-12 weeks gestation Mifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vagi- nal. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses. 12-24 weeks gestation Mifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vaginal or 400 mcg oral. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses. Dose Route Instructions MEDICATION ABORTION WITH MISOPROSTOL ONLY Up to 12 weeks gestation Vaginal or 800 mcg Every 3 hours, maximum 3 doses. sublingual 12-24 weeks gestation 400 mcg Vaginal or sublingual Every 3 hours, maximum 5 doses.

having some side effect after taking knowledge of providers (Figure 6). Lessons Learned for Scaling Up the tablets. The most commonly the Integration of Misoprostol Increasing the number of providers reported side effect was abdominal in PAC Services who are comfortable using pain (n=16), followed by chills The OR offers implementation misoprostol for TIAM and providing and/or fever (n=8), nausea and lessons for scaling up the integration all other components of PAC vomiting (n=5), and diarrhea (n=5). of misoprostol in postabortion care. services will help maintain quality of As many providers deliver services during expansion. Ensuring the quality of postabortion care at the Additionally, because it is often postabortion care services is government referral hospitals, it is doctors who determine the critical to assessing the important to ensure that all of the treatment choices in hospitals, their effectiveness of introducing providers providing PAC services are inclusion in the training and misoprostol. Results from the OR, formally trained with standardized orientation to the program is including treatment outcomes, knowledge and skill assessment essential - even if midwives and follow-up visit rates, experience of tools on the appropriate use of nurses are the ones to administer side effects with misoprostol and misoprostol for TIAM, as well as misoprostol. Involvement of doctors contraceptive uptake, provide overall assessment, management in misoprostol trainings will further strong evidence that quality and follow-up of PAC cases. During familiarize them with different services were delivered as the OR, pocket references detailing treatment options, which may misoprostol was integrated into misoprostol regimens and decrease reliance on D&C as a PAC services. contraceptive provision options primary treatment method at contributed to the standardized higher-level hospitals. Finally, recognizing the challenge in services, to all PAC service eligible for misoprostol, and accurately estimating gestational providers: doctors, midwives, phase out D&C. age, strengthening the ability of and nurses, including primary providers, including primary care care nurses. Conclusions nurses, to do this through on-the-job 4. Continue to strengthen The operations research provides clinical training is important to postabortion family planning strong evidence for the feasibility ensure that medical protocols are provision. and effectiveness of integrating observed for determining eligibility 5. Develop and distribute practical, misoprostol for TIAM into the of women for misoprostol durable job aids that support postabortion care service package at treatment. providers to better comply with all levels of health facilities in the PAC protocol in correctly Zimbabwe. The integration of “I honestly met it [misoprostol] identifying women eligible for misoprostol made safe, high quality with skepticism but have since treatment and those who should and acceptable PAC services taken it in and it’s a worthy be referred. available to women at rural health alternative to other more invasive 6. Build community awareness on centers in Zimbabwe. Bringing PAC procedures.” the availability of PAC services, services to rural health centers Doctor, Chimanimani District the dangers of unsafe abortion, allowed women to receive and the importance of treatment quickly, preventing Programmatic preventing unwanted further risks, and reduced the need Recommendations pregnancies, along with the for them to spend time and money The following recommendations are availability of family planning travelling to referral hospitals. Task- based both on the results of the OR services at health facilities; train shifting of TIAM to primary care as well as the learning that was health providers at facilities and nurses capitalizes on the investment gained by the ZMoHCW and village health workers to that the government of Zimbabwe providers during the OR pertaining incorporate these messages in has made in developing this cadre of to what is needed to strengthen their educational activities. staff. In the longer term, the burden postabortion care services in 7. Complete the revision of the of treating uncomplicated cases at Zimbabwe. As such, a number of the Comprehensive Abortion Care referral hospitals may be reduced as following recommendations guidelines ensuring the inclusion a larger proportion of cases are encompass larger issues relating to of updated information on PAC treated at primary or secondary scaling up postabortion care services services. Disseminate and levels. At the referral hospital level, in Zimbabwe that are not specifically implement the revised using misoprostol to replace D&C for tied to data from the OR. guidelines. medically eligible cases, as well as 8. Incorporate training on strengthening MVA provision will 1. Introduce misoprostol for TIAM misoprostol for TIAM in the pre- reduce the added risks and costs within a referral system, at rural service curricula of the medical, associated with D&C for both health centers where PAC nursing, and midwifery schools. patients and the health system. services are not currently 9. Register misoprostol for TIAM, Ultimately, the incorporation of available. which is an important first step misoprostol into postabortion care 2. Integrate misoprostol for TIAM in ensuring the supply of a high- services at all levels of health at those health facilities quality product. facilities supports the government’s currently providing PAC services. 10. Strengthen provider capacity commitment to health equity for the 3. Provide on-the-job training on and utilization of MVA for rural and urban populations of the use of misoprostol for PAC in postabortion care, to address Zimbabwe. accordance with the treatment cases where women are not and referral protocols for PAC

References

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This brief was produced by VSI ©2013. For a copy of the full technical report contact: [email protected].