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The Egyptian Postabortion Care Inititative Moving from Research to Program— The Egyptian Postabortion Care Initiative In settings where abortion is legally restricted and social- stricted, it is extremely difficult to gain approval to purchase By Dale ly sanctioned, the medical treatment of women who have or manufacture the instruments, because of their associa- Huntington had unsafe or incomplete abortions is often a willfully ne- tion with abortion. Procurement decisions are frequently and Laila Nawar glected service. Research conducted in the 1990s brought made by officials who are not clinicians or who are unfa- attention to the low quality of care and inhumane treatment miliar with the need for improved postabortion services.4 Dale Huntington is that many patients receive as a result of this neglect.1 The As a result, operational policies that govern the availabili- senior health special- concept of postabortion care was central to this research, ty of manual vacuum aspiration instruments have changed ist, World Bank, which highlighted three essential services for providers to more slowly than medical guidelines for providing postabor- Washington, DC; at offer women who seek care for an incomplete abortion: tion care. Both are important for the expansion of pilot the time this article emergency medical treatment of complications, family plan- programs. was written, he was with the Population ning counseling and services, and referral for other repro- Three bodies of theoretical literature are relevant to un- Council, Cairo and ductive health care needs. By clearly positioning the prob- derstanding program expansion: those on the diffusion of New Delhi. Laila lem within the health care domain—as opposed to religious, innovation theory,5 public policy formation6 and knowl- Nawar is program legal or social arenas—advocates of postabortion care have edge management.7 Recent work has begun organizing these associate, Population created a less-volatile atmosphere for research and program three streams into a single discussion. For example, Sim- Council, Cairo. development. mons and colleagues have identified seven elements of suc- Yet, tension continues to surround activities concerned cessful expansion programs, including allowing for adap- with abortion. As postabortion care programs expand out tation and incremental change, working through the of the pilot phase and scale up their activities as elements political process by adopting a highly pragmatic manage- of larger, ongoing health care programs, they test the lim- ment style and engaging the support of one or more poli- its of public officials’ support. The literature offers little ev- cymakers who are open to change.8 The Egyptian postabor- idence of how successfully these programs have managed tion care experience is an example of how these elements resistance associated with the politics of abortion and grown contributed to the successful expansion of a small-scale ac- from pilot studies to national programs. tivity into a national program, and the lessons learned are An additional difficulty confronting postabortion pro- applicable to other settings. grams concerns the supply of manual vacuum aspiration instruments. The overwhelming body of evidence favors THE EGYPTIAN PROGRAM: INITIAL PHASES the use of manual vacuum aspiration for the treatment of The few studies on Egyptian abortion practices reported incomplete abortion at an early gestational age;2 as a result, during the 1970s9 did not initiate a strong research tradi- it has become the standard for postabortion care.3 Pilot tion, and the growing importance of conservative socio- postabortion projects and small-scale expansion programs religious forces during the 1980s squelched interest in im- generally operate with donated instruments, because they proving routine medical care for incomplete abortion.* This are conducted before the commercial importation or local trend ran counter to changes in population programs in manufacturing of instruments receives regulatory approval. This partly reflects the sociopolitical tensions surround- *On a worldwide scale, Egypt’s abortion policy is somewhat restrictive. The 1937 penal law (still in effect) explicitly prohibits acts that cause an abor- ing abortion-related health care, which create extraordinary tion and stipulates stiff penalties for practitioners; it also contains provi- pressure to demonstrate medical benefits and acceptabil- sions permitting any medical treatment necessary to save the life of a woman, which have been interpreted to justify abortion in life-threaten- ity of new clinical practices. Attention to ensuring sustained ing circumstances (source: Azer A, Law as an instrument for social change: provision of manual vacuum aspiration is generally put off an illustration from population policy, Cairo Papers in Social Science, 1979, Vol. 2, No. 4). In any case, the legal definition of abortion is strongly mod- until after the program has achieved a degree of success erated by religious considerations. Egyptian Islamic theologians general- and recognition. ly view abortion to save a woman’s life as acceptable, although what con- Foundations’ and donor agencies’ generous donations stitutes a life-threatening condition is not clearly defined (sources: International Planned Parenthood Federation, Unsafe abortion and sexu- of manual vacuum aspiration instruments have greatly eased al health in the Arab world, paper presented at the conference Unsafe Abor- the implementation of demonstration projects and research tion and Sexual Health in the Arab World, Damascus, Syria, Dec. 1992; and Omran A, Family Planning in the Legacy of Islam, New York: Routledge Press, studies. However, the long-term viability of a program that 1972). As a result of conflicting legal provisions and differing theological relies on donated instruments is uncertain (at best), and a opinions, abortion in Egypt remains a complex issue and a not uncommon practice (source: Huntington D, Abortion in Egypt: official constraints and sustainable supply of instruments is crucial for a national popular practices, in: Makhlouf Obermeyer C, ed., Cross-Cultural Perspec- program. In settings where access to abortion is legally re- tives on Reproductive Health, New York: Oxford University Press, 2001). Volume 29, Number 3, September 2003 121 The Egyptian Postabortion Care Initiative the years leading up to the 1994 International Conference a management approach geared toward introducing ser- on Population and Development, as operations researchers vice delivery improvements over a relatively short period were being drawn into investigations of what constitutes of time. A mix of international and local experts provided (and how to deliver) an appropriate constellation of re- intensive training for senior clinicians in each of the 10 hos- productive health care services. pitals, followed by extensive supervision of on-the-job clin- As international dialogue opened in the early 1990s, Pop- ical training of junior staff and nurses. The United Nations ulation Council researchers in Cairo began discussions with Population Fund provided a sufficient quantity of manual the minister of state for population and family planning vacuum aspiration sets to last in the 10 sites for several years about developing a program to study the routine care pro- of services.* The program had a positive impact on pro- vided to women who have had an incomplete abortion and viders’ postabortion care knowledge and skills, and on pa- to improve service delivery by instituting changes that could tients’ intentions to use family planning methods.12 be implemented fairly quickly. (This early contact with an As part of a generalized shifting of responsibilities with- …trust among influential government official known for having an inter- in the Egyptian government that was under way during this est in innovative policy was key to garnering support for period, oversight for the postabortion program moved to researchers, the program.) Implicit in this discussion was an under- the Ministry of Health and Population after the pilot study. program standing that the rationale for studying postabortion ser- During this first phase of the program’s expansion, it was vices was to improve existing health care services, not to still closely linked to the national family planning program managers and generate data for advocating greater access to induced abor- in a number of ways: It was organized along the lines of a tion. This trust among researchers, program managers and contraceptive introduction program, it emphasized pro- policymakers policymakers has guided the program to the present. viding contraceptives or referral for family planning ser- A 1994–1995 operations research study10 was one of the vices, and its funding came from the population sectors of has guided the first to reveal the substandard quality of care that is pro- the U.S. Agency for International Development and the vided to postabortion patients and the feasibility of rapid- Egyptian government. The goal of the expansion was to in- program to ly improving outcomes related to both providers (e.g., tech- fluence national policy by engaging high-level policy advi- nical knowledge, surgical techniques and interpersonal sors. Population Council staff worked with the Ministry of the present. communication skills) and patients (e.g., pain management Health to convene a technical advisory committee to re- and use of local anesthesia, knowledge about the timing of view and approve training materials and norms of care for return to fertility
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