Postabortion Care Shows Unmet Family Planning Needs
As part of the 2011 International Conference on Family Planning in Dakar, Senegal, I participated in a USAID-sponsored meeting on postabortion care. I learned several things that seemed unfathomable, including:
- Of the 205 million pregnancies each year in Africa, 40% are unplanned and 20% result in unsafe abortions.
- Of the women seeking abortion— which, let's face it, happens whether or not it is legal—65 % are married, 50% are interested in contraception, and 20% are repeat aborters.
- Of the women in Africa who die each year from unsafe abortion, a staggering 46% are under the age of 25.
What this tells us about the magnitude of unmet need for family planning is clear. In Africa alone, 137 million women have an unmet need for family planning. Look at that number: 137 million women.
The purpose of family planning is to give all people—women and men— the right to choose their family size. We know that women seek abortion to postpone pregnancy or to stop childbearing all together. Family planning reduces unintended pregnancies, which reduces the incidence of abortion. Family planning costs far less than postabortion care (75% less, according to one World Bank study in Nigeria). Family planning saves lives. So what's the problem? Barriers to family planning include social norms, lack of knowledge of family planning among providers, lack of commodities (e.g., pills, condoms, IUDs, injectables), and the cost factor.
The total fertility rate in Africa—the average number of pregnancies a woman can expect over her lifetime—is 5.5. The average number of children women in Africa say they want is 4.7. The difference—what is called "unwanted fertility"—is an indicator that women are exposed to unintended pregnancy and unsafe abortion. Across 23 African countries, one study found that 1 of 4 married women aged 15-49 (reproductive age) have a need for family planning. In the 15-19 age group, the number is 1 in 3. The reality is that if you are a woman in Africa, you face a 1 in 4 chance of being pregnant or having a child by age 19.
This meeting addressed what’s working in postabortion family planning in Africa. I learned about strengthening community demand for family planning services, increasing access to long-acting methods such as contraceptive implants and injectables, and revising policy service guidelines that allow for task-shifting—that is, enabling nurses or midwives to offer services previously provided only by doctors only. With doctors in short supply, and demand for family planning so great, task-shifting makes total sense. Why didn't we think of that earlier? National policies and norms are the answer to that question. But these are being revised in some countries.
Some success stories:
- In postabortion care clinics in Guinea, staff maintains a stock of contraceptives, including long-term methods. This is crucial when you remember why women are there and that fertility can return in as few as 2 weeks. Yet amazingly, providing family planning methods at the site of services is rarely done, though it is a best practice. Guinea also trains service providers to offer counseling; this increased the percentage of clients being counseled on family planning as part of postabortion care from 11% to 80%.
- Rwanda just completed a national study on the quality of care of postabortion services. The study found that 40% of pregnancies were unwanted, even though the contraceptive prevalence rate (or CPR—the percentage of women of reproductive age who are practicing, or whose sexual partners are practicing, any form of contraception) is 45%—extremely high for Africa, where the overall CPR is 28%. The study also found that myths and misconceptions about postabortion care and its legality are widespread, even among healthcare providers. These misperceptions are perpetuated because abortion—and postabortion care—can be a taboo subject.
- In Tanzania, services are being decentralized, and offered at the community heath center level. Previously, postabortion care was available only at district hospitals, which effectively meant it was only accessible to the 25% of women who live in urban areas or have the means to get there. By training providers in rural health centers and sensitizing village leaders to the importance of postabortion care, Tanzania has greatly extended the availability of services.
The take home messages: Sex happens. Children are born, but abortion—both induced and spontaneous—also happens. Postabortion care is legal, and can be provided with USAID funding (remember, this meeting was sponsored by USAID). For the greatest benefit, postabortion care must include three major components: emergency obstetric care, counseling, and family planning.
Access to family planning methods and the right to contraception are the hallmarks of this international conference. One hopes that such a gathering of world leaders, policy makers, program managers, subject matter experts, and reproductive health service providers will have an impact on the availability of family planning services worldwide, and sooner rather than later. Lives are at stake.
Laura Raney from FHI 360 is a regular guest contributor to the K4Health Blog.