In Hospitals Across Africa, A Lack Of Post-Abortion Care
Some of Onikepe Owolabi's most vivid memories of medical school in her native Nigeria are of the teenage girls she saw in the emergency room of a rural hospital with complications from an unsafe abortion — painful infections that, if left untreated, can lead to permanent disability or even death.
Each time, Owolabi, now a senior research scientist with the Guttmacher Institute, a nonprofit reproductive rights organization in the U.S. that supports abortion rights, assisted doctors in promptly providing the girls with a group of essential obstetric services known collectively as "post-abortion care," or PAC.
Abortion is illegal in Nigeria except to save a woman's life and carries a heavy jail sentence for both the provider and the patient. But post-abortion care is a form of emergency medicine that all countries have pledged to provide to women with complications of a miscarriage or an induced abortion, irrespective of the legal status of the latter. And many do so with the technical and financial support of the United States.
Indeed, amid the political back-and-forth between Democrats and Republicans over U.S. aid for abortion overseas, post-abortion care represents a rare piece of common ground. The term was first introduced in the early 1990s to describe a public health solution to the problem of unsafe abortion, and U.S. funding for PAC has been permitted under anti-abortion restrictions on U.S. aid. Funding for PAC was even allowed under the Trump administration's expanded Mexico City Policy, which barred federal global health funding to nongovernmental groups that provide or refer patients for abortions. (That ban was rescinded in January by President Biden.)
Still, as Owolabi and her colleagues at Guttmacher have found in recent years, post-abortion care is often unavailable where abortion is prohibited, and most abortions are unsafe — the very places post-abortion care is needed most.
In a 2018 assessment of health centers' capacity to provide post-abortion care in 10 low-income countries, they found what they described in The Lancet Global Health as "an alarming state of health care" for women with complications from an abortion or miscarriage. In 7 of the 10 countries (Bangladesh, Kenya, Namibia, Nepal, Rwanda, Tanzania and Uganda), fewer than 10% of primary care facilities could provide basic post-abortion care services, such as removal of retained tissue and antibiotics administered by injection.
Last year, the Guttmacher team conducted a similar study in Zimbabwe, finding that just over 20% of 227 health facilities could provide basic post-abortion care, with more than half the country's population lacking access to the services.
"When you look at country-level data on emergency obstetric care around the world, you see improvement in access to commodities [such as drugs and medical supplies] for a variety of pregnancy complications," says Owolabi. "But even as everything else in maternal health moves forward, PAC gets left behind."
She and other researchers say the problem is partly due to the stigma surrounding abortion, particularly in countries where the procedure is prohibited. "It's [society's] way of punishing women" for getting an abortion in the first place, says Owolabi. "No one is saying that explicitly, but that's what the data and the funding show."
But there's also the fact that the skills and supplies needed to provide post-abortion care are the same as those needed to safely perform abortions. And researchers say that's forced the U.S. Agency for International Development to walk a fine line between the two. While USAID funds post-abortion care programs in more than 40 countries, that funding may not be used to equip health workers with the best tool for the job: a portable plastic device known as the manual vacuum aspiration (MVA) kit.
Why quality post-abortion care is hard to access
For decades, health authorities have encouraged the use of the MVA kit as the preferred technology for post-abortion care. A small hand-held syringe attached to a flexible polyethylene tube, the device uses suction to remove the contents of the uterus, such as a fetus or embryo or a piece of the placenta. Safe, effective and easy to operate, it requires no electricity or clinical infrastructure (such as a sterile operating theater or IV lines), causes minimal discomfort and can be used by health workers like nurses and midwives.
For those same reasons, the MVA kit is also the world's most widely used tool for safe surgical abortion, making it subject to federal restrictions under the 1973 Helms Amendment to the Foreign Assistance Act as it's been interpreted by USAID. Unlike the Mexico City Policy, which bars groups that provide abortions from receiving U.S. funding when it is in effect, the Helms Amendment bars the use of any U.S. foreign aid to pay for abortions.
Passed in 1973, the Helms Amendment went into effect just as USAID was ramping up global distribution of the MVA kit — part of a vast new family planning program aimed at curbing population growth in poor countries.
While the Helms Amendment refers only to abortion "as a method of family planning," USAID construed it as eliminating assistance for all abortions — even to save a woman's life or in cases of rape in war zones. The agency also interpreted the law as a ban on the purchase and distribution of the MVA kit "for any purpose," requiring ministries of health to procure the device independently of other medical supplies.
And according to Siri Suh, an assistant professor of sociology at Brandeis University and an expert on post-abortion care where there isn't access to MVA, countries continue to rely on outdated methods.
Suh says the most prevalent of these is a surgical procedure known as "dilation and curettage," or D&C, which involves the use of a sharp metal instrument, a "curette," to scrape out tissue retained in the uterus.
Research has shown that D&C is less safe, less effective and more painful than MVA, and because it can only be performed by a doctor with access to an operating room, it's also significantly more expensive. Studies in Uganda and Malawi found that by switching from D&C to MVA, hospitals could reduce the average cost per case of post-abortion care by as much as 43%, from $45 per patient using D&C to $25 using MVA. And yet in Uganda, Malawi and many other poor countries, D&C persists. Suh and others describe it as a form of "obstetric violence."
In her new book, Dying to Count: Post-Abortion Care and Global Reproductive Health Politics in Senegal, Suh explores how anxieties about the MVA kit's capacity to induce abortion, which is illegal in Senegal, have constrained its integration into routine care.
Dubbed the "PAC pioneer of West Africa," Senegal is celebrated for having been among the first countries to decentralize post-abortion care from large urban hospitals to smaller facilities in rural areas. But as Suh found, health officials took pains to prevent the MVA kit from being used to perform abortions, often by keeping it behind lock and key. Suh says this greatly impeded access to the tool for post-abortion care, leaving many women to undergo substandard treatment.
That includes what's known as digital curettage, whereby a provider uses two fingers to remove the contents of the uterus, a method WHO has long considered unsafe.
"It's incredibly painful," says Suh. "It's used extensively across sub-Saharan Africa when there's no one trained on MVA, or the [MVA's] syringe is broken, or it's locked up because the head doctor isn't around. And it's often performed without medication for pain." Indeed, as a 2018 study by researchers at Guttmacher found, of more than 900 patients who received post-abortion care at facilities in Kinshasa, the capital of the Democratic Republic of Congo, close to a quarter of them were treated with digital curettage and just over a tenth received medication for pain.
Asked about its decision not to procure the MVA kit for the post-abortion care programs USAID supports, an agency spokesperson did not respond to the question but offered this comment:
"USAID has long championed the reproductive health and reproductive rights of women and girls, including access to voluntary family planning and providing support for post-abortion care."
A disputed device
Anu Kumar was just starting her career as a medical anthropologist when she went to Cairo to attend the United Nations international conference on population and development. It was September 1994, and Kumar still recalls the weight of that moment when, as she puts it, "179 governments made the reproductive health and rights of women a global development priority."
It was also the moment that post-abortion care was first formally recognized as an apolitical solution to the public health problem of unsafe abortion.
"We managed to get PAC accepted as a concept, and that was important," says Kumar. "But at the end of the day, post-abortion care is still only dealing with the aftermath."
Suh echoes that critique, arguing that post-abortion care represents "a system of global reproductive governance that withholds affordable obstetric care from low-income women until after they've resorted to unsafe procedures." Of course, she adds, "PAC is infinitely more beneficial to women than no treatment at all."
Twenty-five years later, Kumar is the president and chief executive of the reproductive rights group Ipas, which advocates expanding access to safe abortion care. Ipas developed and refined the MVA kit now in use in more than 100 countries. "The U.S. government paid for this technology and then turned its back on it," she says, noting that Ipas was founded in 1973 to carry out manufacturing and distribution of the device after passage of the Helms Amendment earlier that year.
"The Helms Amendment is really our genesis story," says Kumar. "It's why we exist." And so it's fitting, she says, that Ipas could help shape the Abortion is Health Care Everywhere Act, the first bill to repeal the Helms Amendment. Introduced last year by Rep. Jan Schakowsky, (D-Ill.), the bill was re-introduced this week and is co-sponsored by more than 140 members of Congress.
Meanwhile, Ipas and partners continue to supply the MVA kit to clinics around the world, including many in conflict-affected countries where researchers say strengthening post-abortion care remains an urgent priority.
"A big part of [this work] is just explaining to health workers what PAC is," says Sara Casey, director of the Reproductive Health Access, Information and Services in Emergencies Initiative (RAISE) at Columbia University. "That it's not controversial. That it's something you can do, something your ministry of health wants you to do."
Where health systems are on the brink of collapse, and distrust in health services often runs high, providing post-abortion care is already hard enough, says Casey, who with colleagues at RAISE has worked to improve access to the intervention in conflict settings around the world. And it's made all the more difficult, she says, when health workers can't use the best tool for the job.
"Why tie a hand behind their back?" she asks. "Why not help them instead?"
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