Introduction to Postabortion Care

International Agreement on PAC abortion” (Solo, 2000: 45). Moreover, quality

PAC is a relatively simple, effective, and cost-
Abortion complications are among the major efficient way to lower maternal death rates
reasons women seek emergency obstetric (AED, 2003: 21).
care. Postabortion care (PAC) consists of
emergency treatment for complications The Magnitude of the Problem
related to spontaneous or induced abortions,
family planning and birth spacing counseling, Worldwide, the World Health Organization
and provision of family planning methods (WHO) estimates that 67,000 women,
for the prevention of further mistimed or mostly in developing countries, die each year
unplanned pregnancies that may result in from untreated or poorly treated abortion
repeat induced abortions. PAC also includes complications. This number, which likely
services such as evaluation for sexually understates the true statistics, represents 13
transmitted infections, including HIV/ percent of all pregnancy-related deaths and is
AIDS. the tip of the iceberg, as many more women
live with resulting morbidities including
PAC has become more of a focus in chronic pain, chronic pelvic inflammatory
reproductive health programs during the disease, and infertility as a result of
past decade, particularly since the 1994 incomplete abortion. Serious social problems
International Conference on Population are also often caused or exacerbated by these
and Development (ICPD), when nearly 180 illnesses. Most deaths and disabilities resulting
countries agreed that no matter what an from abortion complications are preventable
individual country’s official position on the (AGI, 1999; WHO, 1998; WHO, 2003 cited
legality of abortion: in Corbett and Turner, 2003).

“In all cases, women should have access The Health System and PAC
to quality services for management of
complications arising from abortion. Many national health services dedicate a high
Postabortion counseling, education and percentage of beds in third and second level
family planning services should be offered facilities to accommodate the large number of
promptly, which will help to avoid repeat women who require postabortion emergency
abortions” (ICPD, 1994 paragraph 8.25). treatment. In sub-Saharan Africa, up to 50
percent of gynecological beds are occupied
“Improving PAC is an important way to help by patients with abortion complications
address the problem of unsafe abortion, (UNICEF, 1997 cited in Dabash, 2003).
reduce maternal morbidity and mortality, and Incomplete abortion is the most prevalent
improve women’s reproductive health. PAC abortion-related complication treated in
can be implemented in any country, no matter Bolivian hospitals. Health officials estimate
how prohibitive the law against abortion, that 47 to over 50 percent of hospital
as it deals with treating a woman after she beds on gynecology wards in secondary
had experienced an induced or spontaneous and tertiary level hospitals are occupied by

What Works: Postabortion Care 19

 women admitted for abortion complications Women in countries in which abortion is
(Billings et al., 2003b). In some countries, legal, such as India and Russia, also require
more than half of all obstetric/gynecologic access to PAC (Johnson et al., 2003). Even
expenditures in public hospitals are where abortion is legal and performed in safe
incurred on the treatment of women with facilities, some women will have complications.
abortion complications (Rance, 1994; A study in Perm, Russia, of women who had
World Bank, 1994). The complications facility-based abortions, found that 17 percent
bringing women to the attention of health of the women reported having to return to the
services include “sepsis, hemorrhage, facility for a postabortion complication and
genital and abdominal trauma, tetanus, 7 percent were hospitalized (Savelieva et al.,
perforated uterus, and poisoning from 2003). Women who suffer from spontaneous
abortifacient medicines” (Institute of abortion or miscarriage—an estimated 15
Medicine, 2003: 49). percent of pregnant women—may also have
complications that require medical follow up
One in four women who seek abortion lives (Laferla, 1986 and Hammerslogh, 1992 cited
in countries where abortion is forbidden or in Nielson, 1997).
allowed only to save a woman’s life (Rahman
et al., 1998 cited in Corbett and Turner, The PAC Consortium
2003). Where abortion is legally restricted or
not accessible, or even if legal, many women In 1993, the PAC Consortium was established
with unwanted pregnancies that result with representation of AVSC International
from lack of use of contraception or from (now EngenderHealth), Ipas, IPPF, the
contraceptive failure, resort to clandestine JHPIEGO Corporation, and Pathfinder
and often unsafe abortion, and in many cases International. The Consortium continues
suffer complications that require emergency to function as a 15-plus agency networking
medical care (Huntington et al., 1998). group.

“The pool of women seeking postabortion In 1994, Ipas developed the original
care is diverse, but all have urgent postabortion care model, Essential Elements
psychological and physiological needs. All of PAC, which was subsequently adopted
are bleeding. Those who have induced the by USAID and the PAC Consortium. This
abortion may be fearful of the consequences innovative model emphasized the need not
of being discovered and eager to ensure only to provide for women’s emergency
that their unwanted pregnancy has been needs, but also to help women avoid further
terminated. Those who have miscarried— mistimed or unplanned pregnancies and
especially those who desired the pregnancy— other reproductive health problems. The
are experiencing the grief of pregnancy PAC model, as it became known, listed three
loss” (Abdel-Tawab et al., 2002: 191-192). essential elements:
Interviews with postabortion patients during
a project conducted in Egypt revealed that • Emergency treatment for complications
the most salient issue confronting them of spontaneous or induced abortion;
was “physical survival” (Abdel-Tawab et al., • Postabortion family planning counseling
2002). and services; and

20 What Works: Postabortion Care

• Linkages between emergency care and all USAID population, health, and nutrition
other reproductive health services, for officers dated September 10, 2001. The memo
example, management of STIs. stated “The U.S. Agency for International
Development’s (USAID) Population, Health
To transform the largely medical PAC model and Nutrition Center places high priority
to a public health model, the PAC Consortium on preventing abortions through the use of
added two elements in 2002, (Postabortion family planning, saving the lives of women
Care Consortium Community Task Force, who suffer complications arising from unsafe
2002): abortion, and linking those women to voluntary
family planning and other reproductive health
• Counseling tailored to each woman’s services that will help prevent subsequent
emotional and physical needs; and abortions. Postabortion care should be a key
• Community and service provider component of both our Safe Motherhood
partnerships. and family planning programs”
(USAID. 2003. Guidance on the Definition
U.S. Government and USAID Position on and Use of the Child Survival and Health
PAC Program Funds, FY 2003 Update—Final,
May 23).
Currently, “over half of the developing
world’s population lives in countries in which In 2003, building on an evaluation of its global
at least some PAC activity has been initiated” PAC program in 2001 (Cobb et al., 2001),
(Cobb et al., 2001: 13). USAID, which has USAID revised its model for postabortion
supported PAC activities in over 30 countries care and developed a five-year strategic plan
since the early 1990s, specifically identifies results framework and indicators for PAC.
postabortion care as a priority in reproductive These documents serve as the framework
health (EngenderHealth and Ipas, 2001). for USAID’s efforts to reduce maternal
Support of postabortion care programs by mortality, morbidity, and repeat abortions by
the U.S. government was evidenced in January supporting improved access to and quality
2001 by a statement made by the White of PAC services over the next few years.
House Press Secretary on the restoration of USAID adopted the principles proposed by
the Mexico City Policy: “…the President’s the PAC Consortium in Essential Elements of
clear intention is that any restrictions do not Postabortion Care and maintained a streamlined
limit organizations from treating illnesses model via integrating the community and
caused by legal or illegal, abortions, for service delivery partnerships component into
example, postabortion care” (see http://www. its three core components while maintaining
whitehouse.gov/news/releases/20010123. counseling tailored to each woman’s emotional
html). This position is allowed under previous and physical needs as an integral part of all
policies that have had wide congressional its quality postabortion care services. The
support. three core components of the USAID PAC
Strategy (USAID, 2003) are:
Support of the administration was further
emphasized by the Assistant Administrator of • Emergency treatment for complications
USAID in an email that was sent globally to of spontaneous or induced abortion;

What Works: Postabortion Care 21

 • Family planning counseling and service interventions that have provided evidence on
provision, STI evaluation and treatment, PAC services are subdivided into the three
and HIV counseling and/or referral for components of the USAID PAC Strategy.
HIV testing; and
• Community empowerment through The module also identifies knowledge gaps
community awareness and mobilization. for which there is a need for further PAC
research, including care needs of HIV
International Donors and PAC positive women, refugee women and women
who are subject to trafficking and such issues
A number of other donors, including the as demand generation and the community
Department for International Development level contributions for PAC services. For the
of the UK and UNFPA, support PAC. evidence related to each intervention, the
Numerous countries have come to recognize Gray Type strength of evidence (I to V) is
the contribution that PAC can make to listed and for each intervention, a summary
saving women’s lives. For example, the of the strength of the evidence is included.
government of Kenya’s 1997 reproductive
health guidelines and standards for service Since 1994, PAC programs have been initiated
providers states, “the prompt treatment of in at least 40 countries around the world, 30
postabortion complications is an important of which receive USAID funds (Cobb et
part of health care that should be available at al., 2001). This module will assist program
every district-level hospital” (cited in Cobb managers and policymakers in using evidence
et al., 2001: 7). to expand and improve quality of and access
to their programs. In addition, it may become
Addressing the needs of women who are an important resource in countries which
experiencing abortion complications is a have not yet introduced PAC programs.
clear public health mandate; women should
have all needed emergency care to prevent
death and disability, and the information and
services they need in order to make healthy
decisions for themselves and their families.

The “What Works-PAC” Module

This document describes what is known about

PAC interventions and addresses lessons
learned by multiple studies largely conducted
since 1990. It includes peer reviewed
publications, and gray literature where
appropriate, and is organized in sections
describing which interventions have given
positive results, which have not been shown
to be effective, as well as common practices
that are unnecessary or can be harmful. The

22 What Works: Postabortion Care