Phase IV: Going to Scale with Successful Change Efforts

This phase presents the closure of the two-phase pilot and the scale-up of activities by a range of actors to further expand access to postabortion care. The pilot program was implemented in two phases:
  1. The first phase, conducted at 44 facilities in 3 provinces (Nairobi, Central, and  Rift Valley), clearly demonstrated that private nurse-midwives are capable of delivering comprehensive PAC services, that women with abortion complications will access and use private-sector PAC services, and that this care can increase the accessibility and use of family planning and contraceptive services. 
  2. During the second phase, conducted in the same three provinces, 155 providers successfully treated more than 1,600 women with postabortion complications using MVA and counseled 81% of these women  in family planning. This resulted in 56% of clients leaving with or agreeing to return for a family planning method. The subsequent scale-up in Coast Province resulted in the training of 101 private nurse-midwives and clinical officers. More than 650 clients received treatment, with 98% being counseled in family planning after the procedure and 72% accepting a family planning method.
During scale-up activities, data was collected on reproductive health and other health services offered to women postabortion. Records show that three-quarters were counseled on STI/HIV prevention and/or treatment. Around half received counseling and screening for breast cancer, and nearly 40% received counseling about screening for cervical cancer. Half of the women also received nutrition counseling.
The peer support clusters established by the nurse-midwives proved to be a promising approach for enhancing supervision and support. For example, one large cluster developed during PRIME II later added two branches registered with the government under social services, raised funds for facility improvements and investments and established a continuing education program for its members.
To document the key determinants for further scale-up of PAC services in Kenya, PRIME II assisted in a 2004 study that used a provider survey and case studies to identify the factors contributing to the sustainability of PAC services:
  • Provider attitudes
  • Competition
  • Business acumen
  • Range of services offered
  • Quality of services
  • Participation in peer support networks. 
The study made the following recommendations to strengthen providers’ business and management capacities:
  • Identify an organization to represent providers' needs.
  • Redirect PAC advocacy to be more broad-based.
  • Support provider peer clusters.
  • Link providers to ready sources of capital.
  • Foster an appreciation for monitoring and evaluation among PAC providers.
The study concluded that PAC services can be sustainable if the provider’s facility is viable, but that private providers need technical assistance in improving general business practices and stronger initiatives to enhance understanding and acceptance of PAC services in the community. During a dissemination meeting of stakeholders, including public and private sector, local and international NGOs, donor organizations and health workforce regulatory bodies, recommendations were made to scale up PAC services beyond the private nurse-midwives’ facilities. An agreement was reached to increase access to PAC services by expanding the service provider group from doctors to nurse-midwives and clinical officers and decentralizing services to lower-level public, private and community-level facilities. In response, many agencies and organizations engaged in this critical service.
Capacity building: The Nursing Council of Kenya approved and incorporated PAC into its basic nurse and midwifery Bachelor of Science in Nursing program. The scope of practice of midwives and clinical officers was formally expanded to include provision of comprehensive postabortion care. These are the two cadres of health workers who staff most public-sector facilities; therefore, graduating nurse-midwives and clinical officers now have the skills capacity to provide PAC services. 
Clinical service delivery: Private nurse-midwives have continued to train within their clusters for expansion of services and supervision as they continue to offer services. Government facilities at lower levels that did not offer services before are now offering services.
Community PAC: The ACQUIRE project led by EngenderHealth in partnership with Society for Women and AIDS (SWAK) engaged communities in low-resource settings to increase access and quality use of PAC/FP services. Service providers in those communities (both government and private midwives) were trained in PAC--412 individuals in 16 community groups were trained to advocate for and support PAC efforts.   
Youth FP and PAC Services: To increase access to PAC services that are responsive to adolescents’ needs, a youth-friendly postabortion care (YFPAC) program was initiated by Pathfinder International. Building on existing programs, this program involved training three hospital-based health workers to offer PAC services that meet the special needs of youth. The AIDS, Population and Health Integrated Assistance (APHIA II) project supported peer educators. Theater groups were trained on prevention of unwanted pregnancies, unsafe abortion, STI/HIV and access to YFPAC services. The community leaders were also trained in advocacy for youth-focused needs. As a result, three facilities provided youth-friendly PAC/FP services, 16 providers were trained in adolescent friendly services, 422 adolescent PAC clients were served and 71 adolescents accepted modern family planning methods. 
MVA Equipment Supplies: The government was willing to purchase and distribute MVA equipment in bulk, but there were many obstacles in the face of this initiative. However, this equipment is available from donors and from pharmaceutical shops
In line with Constitutional provisions for high-quality reproductive health services, implementation of Kenya’s Vision 2030, and adherence to MDG 5, the Government of Kenya, via the MOH, has put in place mechanisms to reduce morbidity and mortality resulting from complications of spontaneous and induced abortion. To this end, the MOH continues to expand access to family planning and contraceptive services, including to adolescents and youth. Interventions include strengthening the supply of quality health services by taking advantage of FP commodities and equipping health care providers with appropriate skills, including those for long-acting and permanent contraception, while simultaneously increasing the demand for high-quality services through advocacy in partnership with other Government agencies such as the National Council for Population and Development (NCPD) and partners.
Furthermore, the MOH has focused on improving the quality of PAC services by emphasizing the ability of the health system to provide the core components of PAC (emergency treatment for complications of spontaneous or induced abortion; provision of family planning counseling and services, evaluation and treatment of STIs and HIV testing and counseling; and community empowerment through awareness and mobilization) in a manner that responds to the needs of clients and communities. This has resulted in the revision of the National PAC Training Curriculum and the development of the National PAC Reference Manual,both of which await a national launch. The curriculum uses a competency-based training approach and encompasses the use of misoprostol for PAC where appropriate. To further reduce the burden of complications resulting from spontaneous and induced abortion, the MOH has recently published Standards and Guidelines for Reducing Maternal Morbidity and Mortality from Unsafe Abortion in Kenya (MOMS, 2010), which provides standards and guidelines for primary and secondary prevention as well as PAC services.
These interventions are expected to significantly reduce maternal morbidity and mortality by reducing complications from spontaneous and induced abortion, thereby propelling the country towards its achievement of national and international reproductive health goals.