September 2013

 

   

Expanding Access to Postabortion Care in Zimbabwe through the Integration of Misoprostol

FINAL REPORT  

 

 

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Zimbabwe  Ministry  of  Health  and  Child  Care  Through  the  combined  efforts  of  the  government,  organizations,  communities  and  individuals,  the  Government  of  Zimbabwe  aims  to  provide  the  highest  possible  level  of  health  and  quality  of  life  for  all  its  citizens,  and  to  support  their  full  participation  in  the  socio-­‐economic  development  of  the  country.  This  vision  requires  that  every  Zimbabwean  have  access  to  comprehensive  and  effective  health  services.  The  mission  of  the  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  is  to  provide,  administer,  coordinate,  promote  and  advocate  for  the  provision  of  quality  health  services  and  care  to  Zimbabweans  while  maximizing  the  use  of  available  resources.  

Venture  Strategies  Innovations  (VSI)    VSI  is  a  US-­‐based  nonprofit  organization  committed  to  improving  women  and  girls'  health  in  developing  countries  by  creating  access  to  effective  and  affordable  technologies  on  a  large  scale.  VSI  connects  women  with  life-­‐saving  medicines  and  services  by  engaging  governments  and  partners  to  achieve  regulatory  approval  of  quality  products  and  integrating  them  into  national  policies  and  practices.  

 

Zimbabwe  Ministry  of  Health  and  Child  Care  The  Permanent  Secretary  Kaguvi  Building,  4th  Floor  Central  Avenue  (Between  4th  and  5th  Street)  Harare,  Zimbabwe  Telephone:  +263-­‐4-­‐798537-­‐60  Website:  http://www.mohcw.gov.zw    Venture  Strategies  Innovations  19200  Von  Karman  Avenue,  Suite  400  Irvine,  California  92612    USA  Telephone:  +1  949-­‐622-­‐5515  Website:  www.vsinnovations.org        

 

 

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Acknowledgements

Zimbabwe  Ministry  of  Health  and  Child  Care:  Dr.  Bernard  Madzima,  Director,  Maternal  and  Child  Health  Ms.  Margaret  Nyandoro,  Deputy  Director,  Director  of  Reproductive  Health    Principal  Investigators  :  Dr.  Tsungai  Chipato,  University  of  Zimbabwe  Dr.  Partson  Zvandasara,  University  of  Zimbabwe  Dr.  Velda  Mushangwe,  University  of  Zimbabwe    VSI  program  team:  Ndola  Prata,  Medical  Director  Nuriye  Nalan  Sahin  Hodoglugil,  Associate  Medical  Director  Katharine  Rivett,  Program  Manager  Engeline  Mawere,  Program  Officer  Molly  Moran,  Monitoring  and  Evaluation  Specialist  Alice  Mpete,  Nurse  Administrator  Allison  Boiles,  Communications  Specialist    This  project  could  not  have  been  completed  without  the  contributions  of  the  expert  staff  and  colleagues  at  the  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  and  Venture  Strategies  Innovations  (VSI),  whose  dedication  to  this  operations  research  and  invaluable  contributions  to  its  development  led  to  its  successful  implementation.  The  operations  research  program  benefited  from  the  participation  of  the  district  officials,  who  contributed  to  supportive  supervision  and  monitoring  of  operations  research  activities.  The  operations  research  also  benefitted  from  the  participation  of  community  leaders  and  other  community  members  who  led  and  participated  in  community  awareness  activities.  Tarra  McNally,  former  VSI  Country  Representative,  initiated  the  preliminary  work  on  this  operations  research,  and  oversaw  the  activities  until  August  2013  and  Melody  Liu  provided  data  management  support  until  August  2013.  Debbie  Koh  provided  programmatic  support  until  January  2013.  Most  importantly,  VSI  would  like  to  thank  all  of  the  women  who  consented  to  participate  in  this  operations  research.              

 

 

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Executive Summary

The  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  is  committed  to  preventing  maternal  mortality  and  morbidity  due  to  unsafe  abortion  and  miscarriage  by  ensuring  access  to  high  quality  postabortion  care  (PAC).  The  estimated  maternal  mortality  ratio  (MMR)  of  960  maternal  deaths  per  100,000  live  births  ranks  Zimbabwe  among  the  40  countries  globally  with  the  highest  MMR.  Abortion-­‐related  complications  are  among  the  primary  obstetric  causes  of  maternal  death  in  Zimbabwe.      Misoprostol  and  manual  vacuum  aspiration  (MVA)  are  two  treatment  methods  recommended  by  the  World  Health  Organization  (WHO)  for  the  treatment  of  incomplete  abortion  and  miscarriage  (TIAM).  Misoprostol  is  a  safe,  effective,  heat-­‐stable  and  inexpensive  treatment  method  for  incomplete  abortion  and  miscarriage.  Misoprostol  has  been  shown  to  be  as  effective  as  MVA  for  TIAM  and  can  be  administered  by  primary  care  providers  in  facilities  that  lack  capacity  to  provide  MVA  or  other  surgical  methods.    In  2011,  after  successful  advocacy  by  the  ZMoHCC,  misoprostol  was  added  to  the  Essential  Drugs  List  of  Zimbabwe  (EDLIZ).  To  advance  the  government  objective  of  ensuring  timely  access  to  quality  PAC  services,  the  ZMoHCC  and  Venture  Strategies  Innovations  (VSI),  a  US-­‐based  non-­‐profit  organization,  conducted  operations  research  (OR)  to  provide  evidence  on  the  feasibility  and  acceptability  of  introducing  misoprostol  in  the  PAC  service  package  to  be  delivered  at  all  levels  of  the  health  system,  from  hospitals  to  rural  health  centers.    

The  ZMoHCC’s  and  VSI’s  joint  OR  was  conducted  in  68  health  facilities  in  four  districts  of  Zimbabwe.  The  OR  sites  included  a)  provincial  hospitals  b)  district  hospitals  c)  rural  and  mission  hospitals  and  d)  rural  health  centers.  A  training  of  trainers  was  conducted  for  40  senior  doctors  and  nurses,  followed  by  cascade  trainings  for  135  primary  care  nurses  (PCNs),  nurses  and  midwives  from  all  sites.  Facility  services  from  September  2011  to  February  2012  were  reviewed  to  provide  a  baseline  facility  assessment.  Operations  research  (OR)  was  conducted  from  January  2013  to  June  2013,  during  which  misoprostol  was  available  for  women  at  these  facilities.  Also  during  this  time,  health  providers  and  Village  Health  Workers  (VHWs)  disseminated  key  messages  on  the  dangers  of  unsafe  abortion,  the  availability  of  misoprostol  for  TIAM  and  family  planning  services  at  OR  sites,  and  the  importance  of  preventing  unwanted  pregnancies.    

According  to  the  facility  assessment,  prior  to  the  OR,  there  was  limited  availability  of  PAC  services  at  the  OR  sites.  In  addition  to  the  provincial  hospital,  only  one  of  three  district  hospitals  and  six  of  thirteen  rural  and  mission  hospitals  reported  offering  TIAM.  Dilatation  and  curettage  (D&C)  was  the  TIAM  treatment  method  available  at  the  largest  number  of  facilities  (n=5)  with  only  two  facilities  offering  MVA.    

Rural  health  centers  (RHCs)  and  rural  and  mission  hospitals  readily  introduced  PAC  services  that  included  TIAM  with  misoprostol.  At  RHC’s,  89%  of  women  who  enrolled  in  the  OR  were  treated  with  misoprostol.    At  rural  and  mission  hospitals,  95%  of  those  enrolled  were  treated  with  misoprostol.  Primary  care  nurses,  the  highest  level  of  trained  staff  at  most  RHCs,  treated  over  40%  of  the  women  who  were  administered  misoprostol  for  TIAM.  The  number  receiving  misoprostol  for  PAC  at  RHCs  increased  fourfold  in  just  four  months.    

 

 

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The  introduction  of  misoprostol  for  PAC  dramatically  reduced  the  proportion  of  women  at  RHCs  and  rural  and  mission  hospitals  that  had  to  be  referred  for  treatment.  Only  10%  of  enrolled  women  who  sought  PAC  services  at  RHCs  were  referred  to  a  higher  level  facility,  compared  with  98%  at  baseline.  At  rural  and  mission  hospitals,  the  percentage  of  women  referred  for  PAC  treatment  declined  by  nearly  95%,  from  48%  to  3%.    

Health  providers  at  the  OR  facilities  and  VHWs  in  the  catchment  areas  increased  community  awareness  of  the  availability  of  misoprostol  for  PAC,  the  dangers  of  unsafe  abortion,  and  the  importance  of  family  planning  during  facility-­‐based  health  education  sessions  and  community  meetings.  Overall,  13,845  community  members  were  reached  with  messages  about  misoprostol  for  PAC  during  the  course  of  the  OR.      

Among  the  women  who  returned  for  follow-­‐up  for  whom  data  were  recorded  (n=120),  96%  were  successfully  treated.    Only  one  woman  at  an  RHC  had  to  be  referred  for  further  treatment;  at  rural  and  mission  hospitals  only  two  women  received  additional  treatment.  These  outcomes  are  consistent  with  the  91-­‐98%  efficacy  rate  of  misoprostol  for  PAC  observed  in  randomized  controlled  studies.    

The  provision  of  family  planning  counseling  and  services  at  the  time  and  location  that  women  access  services  for  spontaneous  or  induced  abortion  is  regarded  as  a  proven  high-­‐impact  practice  to  maximize  investments  in  a  comprehensive  family  planning  strategy,  especially  when  scaled  up  and  institutionalized,.  Over  80%  of  women  in  the  OR  accepted  a  modern  contraceptive  method  as  part  of  PAC  services.  Rates  of  contraceptive  uptake  were  highest  at  the  provincial  hospital  (92%)  and  RHCs  (87%).    

Women  treated  with  misoprostol  were  advised  to  return  after  7-­‐14  days  for  follow-­‐up.  Women  treated  at  RHCs  were  most  likely  to  return  for  follow-­‐up  (75%),  compared  with  those  treated  at  rural  and  mission  hospitals  (39%)  and  the  provincial  hospitals  (12%).  Ten  percent  of  the  women  who  returned  for  follow-­‐up  received  a  contraceptive  at  follow-­‐up  and  not  at  the  initial  visit.    

Women  treated  with  misoprostol  experienced  minimal  side  effects.  Among  the  124  women  treated  with  misoprostol  who  returned  for  follow-­‐up,  29  women  reported  having  some  side  effect  after  taking  the  tablets.  The  most  commonly  reported  side  effect  was  abdominal  pain  reported  by  16  women,  followed  by  chills  and/or  fever  (n=8),  nausea  and  vomiting  (n=5)  and  diarrhea  (n=5).      The  following  recommendations  on  opportunities  to  strengthen  PAC  services  in  Zimbabwe  are  based  on  the  results  of  the  OR  and  lessons  learned  by  the  ZMoHCC  and  providers  during  project  implementation.  Consequently,  a  number  of  the  recommendations  encompass  issues  related  to  scaling  up  PAC  services  in  Zimbabwe  that  are  not  specifically  tied  to  data  from  the  OR.  

1. Introduce  TIAM  with  misoprostol  within  a  referral  system  at  RHCs,  where  PAC  services  are  not  currently  available.  

2. Integrate  misoprostol  for  TIAM  at  those  health  facilities  currently  providing  PAC  services.  3. Provide  on-­‐the-­‐job  training  on  the  use  of  misoprostol  for  PAC  following  the  treatment  and  

referral  protocols  for  PAC  services,  to  all  PAC  service  providers:  physicians,  midwives,  and  nurses,  including  PCNs.    

4. Continue  to  strengthen  postabortion  family  planning  provisions.  

 

 

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5. Develop  and  distribute  practical,  durable  job  aids  to  support  providers  in  correctly  identifying  women  eligible  for  treatment  with  different  methods  and  those  who  should  be  referred.    

6. Build  community  awareness  on  the  availability  of  PAC  services,  the  dangers  of  unsafe  abortion,  the  importance  of  preventing  unwanted  pregnancies,  and  raise  awareness  of  the  availability  of  family  planning  services  at  health  facilities,  by  training  health  providers  at  facilities  and  VHWs  on  how  to  incorporate  these  messages  in  their  educational  activities.    

7. Complete  the  revision  of  the  Comprehensive  Abortion  Care  guidelines  and  protocols  ensuring  the  inclusion  of  updated  information  on  PAC  services.  Disseminate  and  implement  the  revised  guidelines.    

8. Incorporate  training  on  misoprostol  for  TIAM  in  the  pre-­‐service  curricula  of  the  medical,  nursing,  and  midwifery  schools  

9. Register  misoprostol  for  TIAM,  which  is  an  important  first  step  in  ensuring  the  supply  of  a  high-­‐quality  product.  

10. Strengthen  provider  capacity  and  utilization  of  MVA  for  PAC  to  address  cases  that  are  not  eligible  for  misoprostol;  phase  out  D&C.    

   

 

 

 

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Acronyms and Local Terms

D&C   Dilatation  and  curettage    

D&E   Dilatation  and  evacuation  

IEC   Information,  education  and  communication    

M&E     Monitoring  and  Evaluation  

MCAZ   Medicines  Control  Authority  of  Zimbabwe  

MVA   Manual  vacuum  aspiration  

OR   Operations  research  

ZMOHCC   Zimbabwe  Ministry  of  Health  and  Child  Care  

MRCZ   Medical  Research  Council  of  Zimbabwe  

MVA     Manual  vacuum  aspiration  

PAC     Postabortion  care  

RHC   Rural  Health  Centre  

TIAM   Treatment  of  incomplete  abortion  and  miscarriage  

TOT   Training  of  trainers  

VHW   Village  Health  Worker  

VSI   Venture  Strategies  Innovations  

WHO   World  Health  Organization  

ZICOM   Zimbabwe  Confederation  of  Midwives  

ZSOG   Zimbabwe  Society  of  Obstetricians  and  Gynecologists  

 

 

 

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Table of Contents

Acknowledgements  ...............................................................................................................................  iii  

Executive  Summary  ...............................................................................................................................  iv  

Acronyms  and  Local  Terms  ...................................................................................................................  vii  

Table  of  Contents  ................................................................................................................................  viii  

List  of  Tables  and  Figures  ......................................................................................................................  ix  

1.  Introduction  ......................................................................................................................................  10  

2.  Goal  and  Objectives  ..........................................................................................................................  11  

3.  Background  .......................................................................................................................................  11  3.1  Maternal  health  and  unsafe  abortion  in  Zimbabwe  ..................................................................  11  3.2  Misoprostol  for  the  treatment  of  incomplete  abortion  and  miscarriage  ..................................  14  3.3  Policies  and  regulations  enabling  the  use  of  misoprostol  in  Zimbabwe  ....................................  14  3.4  Rationale  for  the  introduction  of  misoprostol  for  PAC  ..............................................................  15  

4.    Operations  Research  Components  ..................................................................................................  15  

5.    Methods  ..........................................................................................................................................  15  5.1  Participating  districts  .................................................................................................................  15  5.2  Participating  facilities  .................................................................................................................  17  5.3  Postabortion  care  service  delivery  .............................................................................................  19  5.4  Community  awareness  campaign  ..............................................................................................  22  5.5  Monitoring  and  evaluation  of  the  operations  research  .............................................................  23  5.6  Data  collection  tools,  data  management  and  data  analysis  ......................................................  23  

6.    Operations  Research  Implementation  Timeline  ..............................................................................  25  

7.  Results  ..............................................................................................................................................  26  7.1  Postabortion  care  service  delivery  .............................................................................................  26  7.2  Follow-­‐up  and  referrals  due  to  treatment  failure  ......................................................................  31  7.3  Side  effects  .................................................................................................................................  32  7.4  Contraceptive  method  provision  ...............................................................................................  32  7.5  Access  to  postabortion  care  services  .........................................................................................  35  7.6  Community  awareness  ...............................................................................................................  36  7.7  Provider  perspectives  on  the  introduction  of  misoprostol  for  treatement  of  incomplete  abortion  and  miscarriage  .................................................................................................................  37  

8.  Discussion  and  Conclusions  ..............................................................................................................  41  

9.  Programmatic  Recommendations  ....................................................................................................  44  

10.  References  ......................................................................................................................................  48  Appendix  A:  Misoprostol  Regimens,  Pocket  Reference  for  Clinicians  .............................................  51  Appendix  B:  Contraceptive  Guide,  Pocket  Reference  for  Clinicians  ................................................  52  Appendix  C:  Community  Brochure  for  Women  ...............................................................................  53  

       

 

 

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List of Tables and Figures

Table  1:  Selected  characteristics  of  participating  districts  ...................................................................  16  Table  2:  Levels  of  health  facilities  in  Zimbabwe,  services  provided  and  staffing  .................................  18  Table  3:  Health  facility  participation,  by  district  ..................................................................................  18  Table  4:  Providers  at  cascade  trainings,  by  cadre  and  district  .............................................................  22  Table  5:  Distribution  of  enrolled  women,  by  treatment  method  and  district  ......................................  27  Table  6:  Distribution  of  operations  research  providers  and  treatment  method  employed  .................  28  Table  7:  Obstetric  history  and  socio-­‐demographic  traits  of  enrolled  women,  by  facility  ....................  29  Table  8:  Number  of  enrolled  women  treated  with  misoprostol  who  returned  for  follow-­‐up  visit,  by  

facility  level  ..................................................................................................................................  32  Table  9:  Contraceptive  method  used  prior  to  pregnancy  for  enrolled  women  ...................................  33  Table  10:  Family  planning  uptake  at  initial  visit  for  enrolled  women  ..................................................  33  Table  11:  Enrolled  women  who  received  family  planning  counseling  and  method  at  initial  or  follow-­‐

up  visits,  by  facility  level  ..............................................................................................................  34  Table  12:  Availability  of  clients'  preferred  contraceptive  method,  by  facility  level  .............................  34  Table  13:  Client  travel  time  and  means  of  transport,  by  facility  level  ..................................................  36  Table  14:  Characteristics  of  providers  who  responded  to  survey  ........................................................  38    Figure  1:  Trends  in  maternal  mortality  in  Zimbabwe,  1994  -­‐  2011  ......................................................  12  Figure  2:  Expanding  access  to  postabortion  care  operations  research  implementation  sites  in  

Zimbabwe  ....................................................................................................................................  17  Figure  3:  Postabortion  care  clinical  protocol  used  for  the  operations  research  ..................................  20  Figure  4:  Service  delivery  and  referral  protocols  for  postabortion  care  based  on  facility  level  ...........  21  Figure  5:  Data  flow  and  management  ..................................................................................................  24  Figure  6:  Distribution  of  TIAM  methods  for  enrolled  women,  by  facility  level  ....................................  27  Figure  7:  Method  of  initial  treatment  for  enrolled  and  treated  women,  by  month  ............................  30  Figure  8:  Proportion  of  enrolled  women  referred  without  treatment,  at  baseline  and  operations  

research  .......................................................................................................................................  30  Figure  9:  Enrolled  women  who  received  misoprostol,  by  month  ........................................................  31  Figure  10:  Proportion  of  enrolled  women  who  returned  for  follow-­‐up,  by  facility  level  .....................  31  Figure  11:  Contraceptive  methods  provided  at  initial  visit,  by  facility  level  .........................................  35  Figure  12:  Cumulative  number  of  community  members  reached  with  awareness  messaging  ...........  37  Figure  13:  Perspectives  on  using  misoprostol  for  postabortion  care  ...................................................  39  Figure  14:  Provider  perspectives  on  family  planning  services  ..............................................................  39            

 

 

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1. Introduction

The  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  is  deeply  committed  to  improving  maternal  health  in  Zimbabwe  and  to  increasing  access  to  essential  drugs  and  services.  With  a  population  of  12.4  million,  Zimbabwe  has  been  facing  severe  economic  challenges,  which  has  adversely  affected  maternal  health  outcomes  (United  Nations  Development  Program  and  the  Government  of  Zimbabwe,  2010).  From  2000  to  2008,  Zimbabwe’s  GDP  shrunk  by  an  estimated  40%  (United  Nations  and  Government  of  Zimbabwe,  2010).  The  proportion  of  the  population  living  below  the  Total  Consumption  Poverty  Line  (TCPL),  which  is  the  minimum  expenditure  needed  to  buy  a  basic  basket  of  items  for  subsistence,  was  72%  in  2003;  this  percentage  is  estimated  to  have  increased  as  a  result  of  the  economic  crisis  of  2008  (United  Nations  Development  Program  and  the  Government  of  Zimbabwe,  2010).  As  the  economy  has  worsened,  so  has  access  to  and  delivery  of  maternal  health  services,  resulting  in  a  high  maternal  mortality  ratio  (MMR).    Most  recent  estimates  report  the  MMR  at  960  maternal  deaths  per  100,000  live  births  (Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International,  2012).    Based  on  the  1994  MMR  estimate  of  283  per  100,000  live  births,  there  was  a  300%  increase  over  fifteen  years  (Central  Statistical  Office  [Zimbabwe]  and  Macro  International  Inc.,  1995).        Globally,  47,000  women  each  year  are  estimated  to  die  from  complications  due  to  unsafe  abortion  (WHO,  2011b)  and  one  in  four  women  having  an  unsafe  abortion  is  likely  to  face  severe  complications  (WHO,  2007).    Hundreds  of  thousands  of  disabilities  are  caused  by  unsafe  abortion  annually  (WHO,  2007)  and  almost  all  of  these  occur  in  developing  countries  (Grimes  et  al.,  2006).  Deaths  due  to  complications  of  abortion  are  one  of  the  major  causes  of  maternal  mortality.    According  to  one  community-­‐based  study  in  Zimbabwe,  complications  from  unsafe  abortion  was  a  primary  cause  of  maternal  deaths  in  urban  and  rural  settings  (Mbizvo  et  al.,  1994).    Postabortion  care  (PAC)  is  defined  as  a  package  of  services  to  address  complications  related  to  incomplete  abortion  and  miscarriage.  The  components  of  PAC  are  community  and  service  provider  partnerships,  counseling,  treatment,  contraceptive  services  and  reproductive  and  other  health  services  (Corbett  and  Turner,  2003).      As  such,  PAC  links  curative  services,  such  as  treatment  of  incomplete  abortion  and  miscarriage  (TIAM),  with  preventive  services,  like  family  planning  (Ipas  and  VSI,  2011)  (Figure  X).  As  part  of  a  comprehensive  reproductive  health  strategy,  PAC  services  can  also  be  vital  in  preventing  unintended  pregnancies,  thereby  contributing  to  the  reduction  of  maternal  morbidity  and  mortality.  The  1994  International  Conference  on  Population  and  Development  (ICPD)  Program  of  Action  urged  all  governments  and  organizations  to  “strengthen  their  commitment  to  women’s  health”  and  “deal  with  the  health  impact  of  unsafe  abortion  as  a  major  public  health  concern  (United  Nations,  1995).”  Since  then,  PAC  has  been  widely  embraced  as  an  important  intervention  to  reduce  maternal  mortality.      The  Zimbabwe  Ministry  of  Health  and  Child  Care  collaborated  with  Venture  Strategies  Innovations  (VSI),  a  US-­‐based  nonprofit  organization,  to  expand  access  to  high  quality  PAC  services  through  the  integration  of  misoprostol  for  the  treatment  of  incomplete  abortion  and  miscarriage  (TIAM)  at  all  levels  of  public  sector  health  facilities  in  four  districts  in  Zimbabwe.  Operations  research  (OR)  was  conducted  to  demonstrate  the  feasibility  and  acceptability  to  patients  and  providers  of  integrating  misoprostol  into  existing  reproductive  health  services.  With  the  integration  of  misoprostol,  this  joint  OR  made  PAC  newly  available  at  rural  health  centers  (RHCs),  the  lowest  level  health  facilities  in  Zimbabwe.    The  expansion  of  PAC  services  to  the  periphery  was  intended  to  afford  women,  

 

 

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especially  those  living  in  rural  areas,  greater  access  to  TIAM  and  postabortion  family  planning  services.      The  expansion  of  high  quality  PAC  services  is  critical  to  reaching  Zimbabwe’s  long-­‐term  goal  of  reducing  maternal  mortality  and  morbidities  due  to  complications  of  unsafe  abortion.      

2. Goal and Objectives

The  main  goal  of  this  operations  research  (OR)  was  to  assess  the  feasibility  of  integrating  misoprostol  for  treatment  of  incomplete  abortion  and  miscarriage  (TIAM)  into  postabortion  care  (PAC)  services  in  Zimbabwe.    The  specific  objectives  of  this  OR  were:  

• To  demonstrate  that  the  provision  of  misoprostol  for  the  treatment  of  incomplete  abortion  is  feasible  to  implement  in  all  health  facilities  in  Zimbabwe’s  health  system;  

• To  understand  the  logistics  and  other  management  implications  when  introducing  the  use  of  misoprostol  for  treatment  of  incomplete  abortion  in  all  public  and  private  sector  settings;  

• To  provide  evidence  for  integrating  misoprostol  into  the  existing  PAC  strategy  for  Zimbabwe;  • To  understand  postabortion  contraceptive  uptake,  method  choice,  and  client  characteristics  

after  treatment  of  incomplete  abortion  with  medication;  • To  provide  empirical  evidence  for  the  establishment  of  a  revised  protocol  for  the  treatment  

of  incomplete  abortion  in  Zimbabwe,  according  to  provider  and  level  of  access;  • To  document  provider  perspectives  on  the  inclusion  of  misoprostol  in  PAC  services.  

3. Background

3.1 MATERNAL HEALTH AND UNSAFE ABORTION IN ZIMBABWE The  impact  of  political  and  economic  factors  on  maternal  health  in  Zimbabwe  has  been  particularly  significant.  As  noted  earlier,  Zimbabwe’s  maternal  and  mortality  rate  (MMR)  has  increased  significantly  since  1994  (Figure  1).            

 

 

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Figure  1:  Trends  in  maternal  mortality  in  Zimbabwe,  1994  -­‐  2011  (maternal  deaths  per  100,000  live  births)  

 ¹Central  Statistical  Office  [Zimbabwe]  and  Macro  International  Inc.  1995.  Zimbabwe  Demographic  and  Health  Survey,  1994.  Calverton,  Maryland:  Central  Statistical  Office  and  Macro  International  Inc. ²Central  Statistical  Office  [Zimbabwe]  and  Macro  International  Inc.  2000.  Zimbabwe  Demographic  and  Health  Survey  1999.  Calverton,  Maryland:  Central  Statistical  Office  and  Macro  International  Inc. ³WHO/UNICEF/UNFPA  and  The  World  Bank.  Maternal  mortality  in  2005.  Estimates  developed  by  WHO,  UNICEF,  UNFPA  and  the  World  Bank.  Geneva:  World  Health  Organisation;  2007. ⁴Central  Statistical  Office  (CSO)  [Zimbabwe]  and  Macro  International  Inc.  2007.  Zimbabwe  Demographic  and  Health  Survey  2005-­‐06.  Calverton,  Maryland:  CSO  and  Macro  International  Inc. ⁵Zimbabwe  Ministry  of  Health  and  Child  Welfare.  Maternal  and  Perinatal  Mortality  Study.  Ministry  of  Health  and  Child  Welfare  [Zimbabwe],  2007. ⁶Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International.  2012.  Zimbabwe  Demographic  and  Health  Survey  2010-­‐11.  Calverton,  Maryland:  ZIMSTAT  and  ICF  International  Inc.  Based  on  MDG  5,  which  aims  to  reduce  the  maternal  mortality  ratio  by  75%  by  2015,  Zimbabwe’s  target  is  to  reach  a  MMR  of  174  (United  Nations  Development  Program  and  Government  of  Zimbabwe,  2010).  This  is  considered  to  be  unattainable  based  on  recent  trends  and  the  current  MMR  of  960.  A  number  of  health  system  constraints  make  achieving  this  goal  extremely  difficult.    For  example,  as  of  2010,  80%  of  public  sector  midwifery  posts  were  vacant  (United  Nations  Development  Program  and  Government  of  Zimbabwe,  2010).  Additionally,  the  National  Pharmaceutical  Company  (NatPharm)  of  Zimbabwe,  which  is  the  national  drug  procurement  and  distribution  body  for  all  government  hospitals  and  clinics,  has  experienced  a  sharp  decrease  in  funding  over  the  past  two  decades,  leading  to  a  lack  of  procurement  of  essential  pharmaceuticals  (United  Nations  Industrial  Development  Organization,  2011).      The  main  obstetric  causes  of  maternal  death  in  Zimbabwe,  as  reported  in  the  2007  Maternal  and  Perinatal  Mortality  Study,  were  postpartum  hemorrhage  (PPH)  (18.6%),  pregnancy-­‐induced  hypertension/eclampsia  (15.7%),  sepsis  (12.3%),  and  abortion-­‐related  causes  (2.6%)  (ZMoHCW,  2007).  An  earlier  study  of  maternal  mortality  from  1996  found  23%  and  15%  of  maternal  deaths  in  Harare  city  and  Masvingo  district,  respectively,  to  be  attributable  to  unsafe  abortion  (Fawcus  et  al.,  1996).  It  is  important  to  note  that  abortion-­‐related  mortality  and  morbidity  are  typically  under-­‐reported  (Grimes  et  al.,  2006).Given  the  weakening  of  the  health  system  since  then,  a  decline  in  unsafe  abortion  deaths  from  1996  to  2007  would  have  been  unlikely.    Unsafe  abortion  is  defined  by  the  World  Health  Organization  (WHO)  as  a  procedure  for  terminating  an  unintended  pregnancy  that  is  carried  out  by  individuals  without  the  necessary  skills  and/or  in  an  

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�2010-­‐11⁶  

 

 

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environment  that  does  not  conform  to  minimum  medical  standards  (WHO,  2011b).    Globally,  an  estimated  21.6  million  unsafe  abortions  occur  each  year  (Shah  and  Ahman,  2010).  An  estimated  6.2  million  unsafe  abortions  occur  each  year  in  Africa  alone.  The  number  of  unsafe  abortions  worldwide  has  increased  in  recent  years,  and  will  likely  continue  to  increase  with  population  growth  unless  women’s  access  to  contraception  and  safe  abortion  is  expanded  and  strengthened  (WHO,  2011b).      When  women  do  not  receive  timely  and  appropriate  treatment  for  complications  from  unsafe  abortion,  the  consequences  can  be  severe.  Common  complications  related  to  unsafe  abortion  are  hemorrhage,  sepsis,  peritonitis,  and  trauma  to  the  cervix,  uterus,  vagina  and  abdominal  organs  (WHO,  2012).  About  one  in  four  women  undergoing  an  unsafe  abortion  is  likely  to  develop  temporary  or  lifelong  disabilities  requiring  medical  care  (WHO,  2012).  Complications  from  unsafe  abortions  also  lead  to  a  loss  of  productivity,  an  economic  burden  on  public  health  systems,  and  stigma  (Benson  et  al.,  2012;  Grimes  et  al.,  2006).      According  to  Zimbabwe’s  Termination  of  Pregnancy  Act  No.  29  of  1977,  abortions  may  be  performed  where  the  life  of  the  mother  is  endangered,  where  there  is  a  serious  risk  that  the  child  will  be  born  with  a  physical  or  mental  defect,  and  where  there  is  a  reasonable  possibility  that  the  fetus  was  conceived  as  a  result  of  unlawful  intercourse.  A  magistrate  is  required  to  confirm  unlawful  intercourse,  and  two  physicians  must  certify  the  medical  indications  required  for  an  abortion  (ZMoHCW,  2001).    Additionally,  a  directive  from  the  ZMoHCC  states  that  an  abortion  may  be  performed  where  the  woman  is  HIV  positive  and  chooses  to  terminate  the  pregnancy.  If  a  woman  has  an  illegal  induced  abortion  she  can  be  jailed  as  a  criminal  offender.    As  a  result  of  this  abortion  policy,  health  providers  are  sometimes  hesitant  to  perform  abortions,  even  in  situations  where  the  woman  meets  the  legal  requirements  (Johnson  et  al.,  2002).  Consequently,  many  women  seeking  abortions  turn  to  unskilled  providers,  whose  methods  may  include  traditional  medicine,  overdoses  of  malaria  tablets  or  contraceptive  pills,  or  the  insertion  of  needles  or  roots  into  the  vagina  (Pierce  and  Settergreen,  2000).      The  ZMoHCC  is  committed  to  scaling  up  high-­‐quality  postabortion  care  (PAC)  services,  and  the  Department  of  Reproductive  Health  launched  a  drive  in  2008  to  train  doctors,  midwives  and  clinical  officers  to  use  MVA.  A  total  of  100  providers  (selected  from  across  all  eight  provinces  in  Zimbabwe)  were  trained  to  use  MVA.  It  is  important  to  note  that  no  primary  care  nurses  from  rural  health  centers  (RHCs)  were  trained.  Despite  this  initiative,  MVA  is  still  only  available  in  a  small  number  of  district,  provincial  and  central  level  hospitals,  leaving  limited  treatment  options  for  women  at  the  lower-­‐level  RHCs.  While  some  nurse  midwives  and  physicians  at  the  district,  provincial  and  central  hospitals  have  been  trained  on  MVA  by  UNFPA  and  the  ZMoHCC,  MVA  is  not  used  widely  in  practice.  The  moving  of  trained  providers  outside  of  the  country  and  high  staff  turnover  at  all  levels  of  the  health  system  may  also  limit  the  consistent  provision  of  MVA  at  facilities.  Dilatation  and  curettage  (D&C)  continues  to  be  the  primary  treatment  method  for  incomplete  abortion  at  district  and  provincial  hospitals,  despite  the  fact  that  the  World  Health  Organization  no  longer  recommends  its  use  (WHO,  2012).  The  use  of  D&C  as  a  primary  treatment  method  is  problematic  because  it  has  higher  complication  rates  (WHO,  2012)  and  it  restricts  PAC  access  to  facilities  with  physicians,  the  only  providers  allowed  to  undertake  this  procedure  in  Zimbabwe.  Consequently,  increasing  women’s  access  to  PAC,  particularly  in  rural  areas,  is  challenging  when  D&C  is  the  primary  treatment  method.      

 

 

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3.2 MISOPROSTOL FOR THE TREATMENT OF INCOMPLETE ABORTION AND MISCARRIAGE The  WHO  defines  incomplete  abortion  as  the  retention  of  products  of  conception  after  an  induced  abortion  or  a  spontaneous  abortion  and  considers  its  treatment  an  essential  element  of  obstetric  care  (WHO,  1991).  Misoprostol,  a  prostaglandin  E1  analogue  in  tablet  form,  and  vacuum  aspiration,  are  two  of  the  treatment  methods  recommended  by  the  WHO  for  the  treatment  of  incomplete  abortion  and  miscarriage  (TIAM)  (WHO,  2012).  In  2009,  the  WHO  included  misoprostol  for  the  treatment  of  incomplete  abortion  in  its  Model  List  of  Essential  Medicines  (WHO,  2009)  and  in  2011,  in  its  list  of  Priority  Life-­‐saving  Medicines  for  Women  and  Children  (WHO,  2011a).  Further,  misoprostol  has  been  recommended  for  use  in  postabortion  care  (PAC)  by  the  International  Federation  of  Gynecology  and  Obstetrics  (Shaw,  2007),  along  with  many  other  international  professional  organizations  and  associations  (ACOG,  2009).    

In  recent  years,  misoprostol  has  increasingly  been  used  for  TIAM  and  other  obstetric  conditions  (Karanja  et  al.,  2013;  Fawole  et  al.,  2012;  Osur  et  al.,  2013;  Shochet  et  al.,  2012).  For  evacuation  of  the  uterus,  it  has  efficacy  rates  of  91%  to  99%,  a  range  that  is  comparable  to  the  efficacy  rates  of  surgical  evacuation  procedures  (Raghavan  and  Bynum,  2009).    Reported  satisfaction  with  misoprostol  for  PAC  is  high  among  both  women  and  health  providers.  Over  90%  of  women  report  being  satisfied  or  very  satisfied  with  treatment  of  incomplete  abortion  using  misoprostol  (Bique  et  al.,  2007;  Dao  et  al.,  2007;  Diop  et  al.,  2009),  and  providers  also  report  high  levels  of  satisfaction  with  the  treatment  (Ipas  Nigeria  and  SOGON,  2011).  

 Misoprostol  presents  a  number  of  advantages  as  a  treatment  in  resource-­‐constrained  settings.  Firstly,  it  can  be  administered  orally  or  sublingually  for  the  treatment  of  incomplete  abortion.  Further,  it  is  inexpensive  (Blum  et  al.,  2007),  easy  to  store,  stable  in  field  conditions,  and  has  an  excellent  safety  profile  (el-­‐Refaey  et  al.,  2006).  The  effectiveness  of  misoprostol  means  that  it  can  be  used  as  a  safe  alternative  to  surgical  methods.      The  use  of  misoprostol  as  part  of  PAC  presents  minimal  service  delivery  requirements  in  terms  of  staff  and  facilities.  Neither  physicians  nor  operating  theatres  are  required  for  safe  and  effective  use;  thus,  it  creates  an  opportunity  to  extend  PAC  services  to  health  facilities  where  surgical  capacity  may  not  be  available  (Ipas  and  VSI,  2011).  In  areas  where  vacuum  aspiration  or  other  surgical  methods  are  available,  it  provides  clients  and  providers  with  an  additional,  non-­‐surgical  treatment  option.  This  adds  value  for  a  number  of  reasons,  including  reduced  staff  time,  allowing  women  to  choose  between  undergoing  surgical  or  medical  treatment,  and  task-­‐shifting  treatment  to  primary  care  providers.  Misoprostol  as  part  of  PAC  also  provides  potential  cost  savings  to  both  the  health  care  system  (Hodoglugil  et  al.,  2011)  and  to  women,  as  medical  methods  are  typically  available  at  a  lower-­‐cost  than  surgical  methods  (Ipas  and  VSI,  2011).  Most  significantly,  by  enabling  PAC  at  primary  levels  of  the  health  system,  misoprostol  can  bring  these  services  closer  to  women  and  significantly  expand  access  to  timely,  safe  and  effective  care.    

3.3 POLICIES AND REGULATIONS ENABLING THE USE OF MISOPROSTOL IN ZIMBABWE As  a  result  of  the  strong  evidence  on  the  safety  and  efficacy  of  misoprostol  for  TIAM  in  numerous  countries  and  the  effectiveness  of  misoprostol  in  resource-­‐constrained  settings,  the  ZMoHCC  strongly  supports  expanding  access  to  misoprostol.  A  Misoprostol  Technical  Working  Group  (TWG)  was  formed  by  VSI  in  January  2011  and  was  composed  of  stakeholders  from  the  ZMoHCC,  NGOs,  and  professional  groups  including  the  Zimbabwe  Confederation  of  Midwives  (ZICOM)  and  the  Zimbabwe  

 

 

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Society  of  Obstetricians  and  Gynaecologists  (ZSOG).    The  primary  purpose  of  the  TWG  was  to  provide  input  on  the  operations  research  (OR)  protocols.  As  leaders  of  the  Misoprostol  TWG,  the  ZMoHCC  successfully  advocated  for  the  inclusion  of  misoprostol  on  the  Essential  Drugs  List  of  Zimbabwe  (EDLIZ)  for  obstetric  and  gynaecological  indications  in  2011.    Additionally,  the  ZMoHCC  will  include  misoprostol  for  TIAM  in  the  Comprehensive  Abortion  Care  (CAC)  Guidelines  that  are  currently  being  updated.      

3.4 RATIONALE FOR THE INTRODUCTION OF MISOPROSTOL FOR PAC Training  all  providers  who  are  authorized  to  provide  PAC  services  in  the  use  of  misoprostol  for  TIAM  will  help  increase  access  to  essential  PAC  services  for  women  in  Zimbabwe.      Dilatation  and  curettage  (D&C),  a  method  no  longer  recommended  by  the  WHO,  is  the  current  primary  treatment  method  used  in  Zimbabwe’s  hospitals.  While  MVA  is  approved  for  use,  it  is  not  widely  utilized.  Given  this  reality,  integrating  misoprostol  for  PAC  at  all  levels  of  the  health  care  system,  including  RHCs,  will  serve  to:  1)  leverage  the  current  staffing  levels  available  in  Zimbabwe  to  expand  women’s  access  to  PAC  services,  particularly  in  the  rural  areas  and  2)  provide  an  additional  method  of  uterine  evacuation  that  offers  an  effective  and  safe  non-­‐surgical  option  to  women  seeking  TIAM.    

4. Operations Research Components

In  January  2013,  the  ZMoHCC,  with  the  support  of  VSI,  launched  operations  research  (OR)  to  assess  the  feasibility  of  introducing  misoprostol  for  the  treatment  of  incomplete  abortion  and  miscarriage  (TIAM)  into  postabortion  care  (PAC)  services  in  four  districts  in  Zimbabwe.  As  part  of  standard  PAC  protocol,  the  OR  was  designed  to  ensure  that  women  presenting  for  PAC  were  offered  misoprostol  (or  a  choice  of  methods  where  available),  provided  with  postabortion  contraceptive  counseling  and  offered  a  modern  method  choice,  and  that  women  experiencing  complications  were  referred  to  higher-­‐level  facilities  per  the  existing  referral  system.      The  OR  included  three  components:  

1) PAC  Service  delivery:  Service  delivery  included  1)  integrating  misoprostol  into  existing  facility-­‐based  clinical  PAC  services  by  training  providers  at  higher-­‐level  facilities  to  use  misoprostol  as  an  additional  treatment  option  and  2)  expanding  PAC  services  to  rural  health  centers  (RHCs)  and  rural  hospitals  through  introducing  non-­‐surgical  treatment  with  misoprostol.  

2) Community  awareness:  A  community  awareness  campaign  was  conducted  to  provide  information  on  the  availability  of  PAC  at  RHCs  and  hospitals  and  to  establish  links  between  the  community  and  medical  system  to  improve  PAC  care,  including  postabortion  contraception  and  prevention  of  unwanted  pregnancies.  

3) Monitoring  and  evaluation:  Data  was  collected  on  service  delivery  provision,  community  awareness  activities,  and  provider  perspectives  on  the  introduction  of  misoprostol.  In  addition,  supportive  supervision  was  undertaken  to  monitor  OR  activities.  

5. Methods

5.1 PARTICIPATING DISTRICTS The  Technical  Working  Group  (TWG)  selected  four  of  Zimbabwe’s  59  districts,  located  in  three  of  the  country’s  eight  provinces,  for  participation  in  the  operations  research  (OR).  These  districts  were:  Mutare,  Chimanimani,  Matobo  and  Umguza.  Mutare  and  Chimanimani  are  located  in  Manicaland  Province  in  eastern  Zimbabwe.  Umguza  and  Matobo  districts,  both  of  which  are  in  southern  

 

 

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Zimbabwe,  are  located  in  Matebeleland  North  and  Matebeleland  South  Provinces,  respectively  (Figure  2).  The  districts  were  selected  by  the  Misoprostol  TWG  with  the  aim  of  representing  the  country’s  diversity  in  terms  of  geography,  resources,  and  political  affiliation.  The  districts  were  chosen  specifically  because  they  have  high  mortality  and  morbidity  rates  (MMRs)  and  relatively  poor  obstetric  services.  Capturing  this  diversity  was  intended  to  help  ensure  that  the  challenges  of  introducing  misoprostol  across  a  variety  of  settings  would  be  documented  in  the  OR,  and  that  the  lessons  learned  would  provide  more  complete  insight  into  how  the  ZMoHCC  could  scale  up  the  introduction  of  misoprostol  and  postabortion  care  (PAC)  nationally.      Table  1:  Selected  characteristics  of  participating  districts  

 

(a)Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International,  2012  

 

  Mutare   Chimanimani   Umguza   Matobo  Population   434,379   136,055   81,781   110,266  Total  fertility  rate(a)   4.8   4.8   4.1   4.2  Percentage  Delivered  in  Health  Facility  (a)   60.9%   60.9%   63.5%   69.3%  

Median  Years  of  Education  Completed  (Women)  (a)   8.7   8.7   7.2   8.3  

Median  Years  of  Education  Completed  (Men)  (a)   9.8   9.8   7.1   7.9  

Literacy  (Women)  (a)   94.4%   94.4%   87.9%   92.9%  Literacy  (Men)  (a)   96.0%   96.0%   83.5%   91.5%  Health  Insurance  Coverage  (Women)  (a)   4.7%   4.7%   3.0%   4.7%  

Health  Insurance  Coverage          (Men)  (a)   9.6%   9.6%   4.2%   7.4%  

Wealth  quintile(a)  Lowest   17.5%   17.5%   61.0%   26.8%  Second   21.5%   21.5%   13.5%   23.2%  Middle   29.2%   29.2%   8.6%   26.7%  Fourth   20.4%   20.4%   8.5%   17.3%  Highest   11.3%   11.3%   8.3%   6.1%  

 

 

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Figure  2:  Expanding  access  to  postabortion  care  operations  research  implementation  sites  in  Zimbabwe  

 

5.2 PARTICIPATING FACILITIES The  healthcare  system  in  Zimbabwe  operates  on  four  levels  from  the  primary  to  the  specialist/referral  level:  rural  health  center  (RHC),  rural  hospital,  district-­‐level  hospital,  provincial  hospital,  and  central  hospital  with  some  variations  (clinics,  maternity  hospitals,  mission  hospitals,  and  rural  hospitals)  depending  on  the  district.  The  referral  system  is  hierarchical  with  increasingly  complex  cases  referred  to  higher-­‐level  facilities.  In  urban  catchment  areas  such  as  Harare  and  Bulawayo,  RHCs  can  refer  patients  directly  to  the  central  hospitals.        

MUTARE DISTRICT!Pop. = 434,379!

Rural Health Center = 20!Rural/Mission Hospital = 3!

District Hospital = 1!Provincial Hospital = 1!

CHIMANIMANI DISTRICT!Pop. = 136,055!

Rural Health Center = 15!Rural/Mission Hospital = 5!

District Hospital = 0!Provincial Hospital = 0!

MATOBO DISTRICT!Pop. = 110,266!

Rural Health Center = 8!Rural/Mission Hospital = 4!

District Hospital = 1!Provincial Hospital = 0!

UMGUZA DISTRICT !Pop. = 81,781!

Rural Health Center = 8!Rural/Mission Hospital = 1!

District Hospital = 1 Provincial Hospital = 0!

HARARE!

 

 

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Table  2:  Levels  of  health  facilities  in  Zimbabwe,  services  provided  and  staffing*  

Level  of  facility     Services  Provided   Staffing  

Central  Hospital    

• Specialty  services    • Management  of  complicated  cases    

• Obstetricians,  gynecologists,  neonatologists,  pediatricians,  pediatric  surgeons  

• Midwives,  Registered  General  Nurses  (RGNs)  and  State  Certified  Maternity  Nurses  (SCMNs)  

Provincial  hospitals    

• Management  of  complicated  cases   • Obstetricians,  gynecologists,  neonatologists,  pediatricians,  anesthetists  

• Midwives,  RGNs  and  SCMNs  

District  /mission/rural  hospitals      

• Basic  Emergency  Obstetric  and  Neonatal  Care  (BEmONC)  and  Comprehensive  Emergency  Obstetric  and  Neonatal  Care  (CEmONC)    

• Long-­‐acting  and  permanent  contraceptive  methods    

• Supervision  of  lower  levels:  RHCs  and  Village  Health  Workers  

• District  medical  officer,  MDs  • Clinical  officers  • Midwives,  RGNs,  nurse  anesthetists  • Pharmacists  

Clinics/Rural  Health  Centers  (RHCs)  

• Antenatal  Care  (ANC)  • Basic  delivery  care  including  ENC;  

Basic  Emergency  Obstetric  and  Neonatal  Care  (BEmONC)  

• Family  planning  

• Sometimes  a  midwife  or  RGN  • SCMN  • Primary  care  nurses  • Nurse  aides  

Village  Health  Workers  (VHW)    

• Immunization;  health  promotion  • Family  planning:  counseling,  

resupplies  and  referrals    

•  1  VHW  per  100  families  

*Adapted  from:  Taylor,  P.,  P.  Gomez,  et  al.  (2010).  Maternal  and  Child  Health  Integrated  Program:  Zimbabwe  Situation.    A  total  of  68  health  facilities  participated  in  the  OR  (Table  3).  All  facilities  in  three  of  the  four  districts  that  conducted  deliveries  were  selected  to  participate  in  the  OR.  The  exception  was  Mutare  District  where  25  of  the  50  eligible  facilities  were  selected  to  participate  because  the  project  scope  could  not  allow  for  monitoring  and  supervision  of  more  than  25  facilities  per  district.  In  Mutare,  the  VSI  Program  Officer  worked  with  the  Mutare  District  Nursing  Officer  to  select  25  facilities  that  included  a  diversity  of  facility  levels  in  rural  and  urban  settings.  Three  urban  health  centers  from  Mutare  were  selected  to  participate;  for  the  purposes  of  this  OR,  they  are  grouped  with  the  RHCs  as  they  are  all  health  centers.    

Table  3:  Health  facility  participation,  by  district  

Facility  Level    District  

Mutare   Chimanimani   Umguza   Matobo   Total  Rural  Health  Center*   20   15   8   8   51  Rural  and  Mission  Hospital   3   5   1   4   13  

District  Hospital   1   0   1   1   3  Provincial  Hospital   1   0   0   0   1  TOTAL   25   20   10   13   68  *Three  facilities  in  Mutare  District  that  are  included  in  the  category  of  “rural  health  center”  are  actually  classified  as  “urban  health  centers;”  for  the  purpose  of  this  analysis  they  are  included  in  this  category  as  they  are  both  health  centers.    

 

 

19  

5.3 POSTABORTION CARE SERVICE DELIVERY Postabortion  care  services  included:  

• Treatment  of  incomplete  abortion  and  miscarriage  (TIAM):    Providers  treated  with  misoprostol,  manual  vacuum  aspiration  (MVA),  dilatation  &  curettage  (D&C)  and  dilatation  and  evacuation  (D&E).    Treatment  method  was  dependent  upon  the  level  of  facility,  and  what  facility  staff  were  authorized  and  equipped  to  do.  

• Family  planning  counseling  and  distribution  of  contraceptives:    All  women  were  to  be  provided  with  postabortion  family  planning  counseling  and  their  choice  of  a  modern  contraceptive  method.      

• Referral:    To  ensure  comprehensive  services  appropriate  to  the  needs  of  the  individual  patient,  all  heath  facilities  followed  established  ZMoHCC  referral  protocols  linking  lower  level  facilities  to  district  or  provincial  hospitals.    

 The  introduction  of  TIAM  with  misoprostol  at  RHCs  was  seen  as  having  the  greatest  potential  to  expand  PAC  access  to  rural  women.  In  the  OR,  these  facilities  provided  PAC  services  to  women  presenting  with  incomplete  abortion  and  miscarriage  with  a  uterine  size  equivalent  to  13  weeks  and  without  signs  of  complications.  Women  in  need  of  PAC  outside  of  the  OR  districts  generally  had  to  travel  to  mission  or  district  hospitals  for  PAC  services.      5.3.1 Clinical Protocols When  a  woman  presented  at  any  of  the  68  participating  health  facilities  with  signs  of  incomplete  abortion,  the  provider  conducted  a  clinical  assessment,  described  the  OR,  and  enrolled  her  after  obtaining  informed  consent.  All  women  who  agreed  to  participate  were  included,  regardless  of  the  method  of  PAC  treatment  they  received,  whether  they  were  eligible  for  misoprostol,  or  whether  they  had  to  be  referred  to  a  higher-­‐level  facility  without  receiving  treatment.  The  clinical  assessment  established  whether  any  emergency  treatment  was  needed;  the  woman’s  eligibility  to  receive  misoprostol;  whether  a  referral  was  needed;  and  the  consequent  treatment  plan.    The  course  of  treatment  for  the  woman  depended  on  the  woman’s  condition,  treatment  methods  available,  and  the  woman’s  preference  (if  more  than  one  option  was  available  and  deemed  appropriate  by  the  provider),  per  the  established  clinical  protocols  presented  below  (Figure  3).    The  World  Health  Organization  (WHO)-­‐recommended  regimen  of  600mcg  oral  misoprostol  for  the  treatment  of  incomplete  abortion  was  used  in  the  OR  (WHO,  2012).    

 

 

20  

Figure  3:  Postabortion  care  clinical  protocol  used  for  the  operations  research*  

 *Dilatation  &  curettage  (D&C)  was  included  in  the  operations  research  clinical  protocol  because  it  is  widely  used  in  Zimbabwe  despite  the  fact  that  it  is  not  a  method  recommended  by  the  WHO.     5.3.2 Patient Eligibil ity A  woman  was  eligible  to  receive  misoprostol  if  she  had  an  open  cervical  os,  vaginal  bleeding,  and  was  at  or  under  13  weeks  since  her  last  menstrual  period  (LMP).  A  woman  was  ineligible  to  receive  misoprostol  if  she  had  a  known  allergy  to  misoprostol  or  other  prostaglandins;  confirmed  or  suspected  ectopic  pregnancy,  signs  of  sepsis  or  active  pelvic  inflammatory  disease;  and/or  hemodynamic  instability  or  shock.    For  women  presenting  with  signs  of  incomplete  abortion  and  miscarriage  with  thirteen  weeks  or  fewer  after  the  last  menstrual  period  (LMP),  providers  offered  women  the  choice  of  treatment  method  (MVA  or  misoprostol)  if  she  was  medically  eligible  for  both  methods.    Women’s  gestational  age  was  identified  through  medical  history  (the  first  day  of  her  last  menstrual  period)  and  pelvic  exam.    All  women  were  asked  to  return  for  a  follow-­‐up  visit  between  seven  and  fourteen  days  after  the  initial  visit  to  confirm  that  the  treatment  was  complete.  Women  were  advised  to  return  to  the  health  facility  prior  to  their  appointment  if  they  experienced  any  excessive  pain,  bleeding,  or  showed  signs  of  infection.  They  were  given  a  Misoprostol  for  PAC  brochure  (in  English,  Shona  or  Ndebele),  which  used  pictorials  to  illustrate  when  the  woman  needed  to  return  to  the  facility  prior  to  her  follow-­‐up  appointment  (Appendix  C).  All  women  received  contraceptive  counseling  during  their  first  and  follow-­‐up  visit,  and  were  either  offered  the  method  of  their  choice  or  referred  to  another  facility  if  their  preferred  method  was  not  available.    Figure  4  presents  the  service  delivery  and  referral  protocols,  based  on  the  facility  level  where  the  woman  presents  for  treatment.  The  figure  includes  the  procedures  to  follow  if  initial  treatment  fails.    

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21  

Figure  4:  Service  delivery  and  referral  protocols  for  postabortion  care  based  on  facility  level    

   5.3.3 Health Provider Training The  OR  training  included  the  following  topics:  diagnosing  and  assessing  women  who  present  with  symptoms  of  incomplete  abortion;  the  different  treatment  methods  used  for  incomplete  abortion;  identifying  the  eligibility  of  women  for  misoprostol  treatment  (600  mcg  orally);  the  adherence  to  the  clinical  protocols  for  the  treatment  of  incomplete  abortion  including  misoprostol;  informing  women  about  treatment  methods  (i.e.,  what  to  expect,  warning  signs  and  follow-­‐up  schedule);  and  comprehensive  counseling  on  family  planning  and  contraceptives.  The  training  was  conducted  through  interactive  methods,  including  case  discussions,  role  plays  and  demonstrations.  Providers  also  participated  in  values  clarification  activities  related  to  providing  PAC  services.  Additionally,  providers  were  trained  in  OR  monitoring  and  evaluation,  including  how  to  complete  data  collection  tools.  Providers  were  given  pocket  guides  (one  set  for  each  facility),  with  information  on  misoprostol  dosages  and  postabortion  contraception  (Appendix  A,  B).      A  training  of  trainers  (TOT)  was  conducted  in  Harare  in  February  2012  for  40  doctors,  senior  nurses,  midwives,  district  pharmacists  and  Reproductive  Health  Officers  (RHOs)  from  the  four  OR  districts.  Cascade  trainings  organized  by  the  ZMoHCC  and  VSI  were  held  in  December  2012  in  Bulawayo  and  Mutare.  Two  providers  from  each  of  the  OR  facilities  participated  in  the  cascade  trainings.  The  District  Nursing  Officers  and  community  sisters  from  each  OR  district  selected  the  providers  who  would  participate  in  the  cascade  trainings.  Most  RHCs  are  manned  by  2  nurses  (typically  primary  

Repeat misoprostol treatment or Refer for further treatment! Re-assess and treat as necessary!

Repeat treatment or !Refer for further treatment!

!If medical

management fails and woman is clinically stable!

!If medical

management fails and woman is clinically stable!

If medical management fails!

Health Center!!!!!!!!!!!!!!!!!!!!!

District Hospital! Provincial Hospital!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!

Uterine size 13 wks LMP!Administer misoprostol or

MVA*!!

Uterine size >13 wks LMP!D&E*!!

Other uterine evacuation methods, surgery or other

procedures to treat complications as needed!

Uterine size 13 wks LMP!Administer misoprostol or

MVA*!!

Uterine size >13 wks LMP!D&E*!!

Refer for severe complications!

Contraceptive counseling and method provision!

Refer if necessary!

Uterine size 13 wks LMP!Administer misoprostol!

!

!Refer if:!

Uterine size >13 wks LMP, or!Complicated case, or!

Woman prefers other method!

Refer if necessary!

*Where MVA or D&E is not available, D&C can be used as a second line treatment.!

 

 

22  

care  nurses)  so  because  two  providers  were  trained  per  facility,  all  the  nurses  at  RHCs  were  trained.  At  district  and  provincial  hospitals  nurses  were  chosen  from  the  relevant  departments  and  wards  (for  example,  FCH  and  the  female  ward).    In  total,  135  providers  were  trained,  50  from  Mutare  District,  40  from  Chimanimani  District,  25  from  Matobo  District,  and  20  from  Umguza  District  (Table  4).  In  addition,  refresher  trainings  were  held  in  December  2012  for  the  40  providers  who  had  attended  the  initial  TOT.  The  refresher  trainings  were  held  to  review  the  materials  that  had  initially  been  presented  in  February  and  the  final  OR  protocols  and  data  collection  tools.    Table  4:  Providers  at  cascade  trainings,  by  cadre  and  district  

  Mutare   Chimanimani   Matobo   Umguza  Provincial  and  

central  hospital  health  officers  

Total  

Training  of  trainers  (TOT)   5   5   5   5   20   40  Cascade  trainings   50   40   25   20   -­‐-­‐-­‐   135  

Primary  Care  Nurse   20   22   12   12   -­‐-­‐   66  Nurse   25   12   3   4   -­‐-­‐   44  Midwife   4   6   8   4   -­‐-­‐   22  Sister  in  Charge   1     2     -­‐-­‐   3  

TOTAL   50   40   25   20   20   175    Providers  who  attended  the  cascade  trainings  gave  feedback  to  all  providers  involved  in  conducting  deliveries  at  their  respective  facilities,  so  that  all  of  these  providers  had  correct  information  on  how  to  use  misoprostol  for  PAC.    “Feedback  training”  is  used  as  a  term  in  Zimbabwe  to  describe  sharing  of  information  received  at  a  training  with  other  providers  at  their  facility.  Additionally,  on-­‐the-­‐job  refresher  trainings  and  supportive  supervision  were  conducted  throughout  the  OR  by  project  monitoring  staff,  to  ensure  that  all  providers  involved  in  PAC  services  at  each  participating  facility  had  received  training  on  misoprostol  and  were  following  the  OR  protocol.  

5.4 COMMUNITY AWARENESS CAMPAIGN The  expansion  of  PAC  services  can  only  have  impact  if  women  who  need  them  know  that  they  are  available  and  have  confidence  in  the  facilities  that  offer  them.  Accordingly,  the  program  included  a  community  awareness  campaign  to  ensure  that  communities  were  aware  of  where  misoprostol  was  available  to  treat  incomplete  abortion  and  miscarriage.    

Key  messages  of  the  community  awareness  campaign  were  based  on  the  following  themes:  • The  dangers  of  unsafe  abortion  • The  availability  of  PAC  services  with  misoprostol  at  participating  OR  health  facilities  • The  importance  of  preventing  unwanted  pregnancies    • The  availability  of  family  planning  methods  at  health  facilities    

 Providers  and  Village  Health  Workers  (VHWs)  were  trained  on  the  key  messages  and  asked  to  educate  women  and  other  community  members  during  village-­‐level  meetings  about  these  messages.  Providers  were  asked  to  incorporate  education  sessions  on  misoprostol  into  existing  weekly  group  education  sessions  held  at  their  facilities.  Village  Health  Workers  were  tasked  to  include  messages  on  misoprostol  for  PAC  in  the  community  sensitization  sessions  and  home  visits  that  they  held  in  their  locales.  

 

 

 

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5.5 MONITORING AND EVALUATION OF THE OPERATIONS RESEARCH The  ZMoHCC,  in  collaboration  with  VSI,  developed  data  collection  tools  for  the  OR.    Tools  were  developed  to  collect:    baseline  data  on  PAC  service  provision  prior  to  the  OR,  PAC  service  delivery  data  during  the  OR,  community  awareness  activities  conducted  during  the  OR,  and  provider  perspectives  and  acceptability  with  using  misoprostol  for  TIAM.    The  data  collection  tools  used  for  the  OR  are  described  below  in  Section  5.6  of  the  Methods:  Data  Collection  Tools.  VSI  and  ZMoHCC  monitoring  staff  were  responsible  for  collecting  completed  data  collection  tools  on  a  monthly  basis.        Monitoring  and  evaluation  (M&E)  activities  were  undertaken  by  monitoring  staff  hired  for  the  OR  as  well  as  district  nursing  officers  and  community  sisters  who  were  trained  in  monitoring  and  supportive  supervision.  Additionally,  VSI’s  Zimbabwe  Program  Officer  provided  oversight  to  all  M&E  activities.  In  coordination  with  high-­‐level  officials  from  the  ZMoHCC,  the  Program  Officer  conducted  targeted  supportive  supervision  to  facilities  that  were  encountering  challenges  during  the  OR.    Supportive Supervision Regular  monthly  visits  by  OR  monitoring  staff  took  place  in  order  to  assess  the  status  of  the  project  and  to  provide  supportive  supervision  to  health  providers  and  other  facility  staff.  OR  monitoring  staff  ensured  that  providers  were  following  the  correct  clinical  protocols  that  had  been  laid  out  for  the  OR;  if  there  were  protocol  violations,  they  worked  with  providers  to  ensure  that  they  understood  how  to  correct  them.  They  also  reviewed  all  data  collection  tools,  confirming  that  forms  were  being  filled  out  correctly,  that  there  were  no  additional  issues  to  be  addressed  or  need  to  retrain  providers.  In  addition  to  quantitative  data  collected  with  the  M&E  tools,  OR  monitoring  staff  also  collected  qualitative  information  from  providers  and  district  supervisors  about  the  OR  to  monitor  the  integrity  of  implementation  and  to  ensure  timely  identification  of  challenges.  

5.6 DATA COLLECTION TOOLS, DATA MANAGEMENT AND DATA ANALYSIS The  ZMoHCC,  VSI  and  the  Misoprostol  TWG  collaboratively  developed  data  collection  tools  for  the  OR.  The  tools  included  the  Facility  Assessment  Tool;  Monthly  Facility  Form;  PAC  Service  Delivery  Form;  PAC  Logbook;  Community  Education  Logbook;  and  Provider  Survey.  The  data  flow  for  each  tool  is  represented  in  Figure  5.      

 

 

24  

Figure  5:  Data  flow  and  management  

   Facility Assessment Tool Baseline  data  from  the  68  facilities  participating  in  the  OR  was  collected  by  VSI  monitoring  staff  in  August  2012  prior  to  the  initiation  of  any  OR  program  components.  The  baseline  gathered  information  on  current  PAC  service  provision,  costs  and  available  equipment.  The  data  were  gathered  using  the  Facility  Assessment  Tool  developed  for  the  OR.  VSI’s  monitoring  staff  completed  a  Facility  Assessment  Tool  at  each  of  the  68  OR  facilities.  These  tools  were  then  mailed  to  VSI’s  M&E  team  in  Irvine,  CA,  where  they  were  entered  into  Microsoft  Excel  and  then  exported  into  Stata/SE  12  (StataCorp  2011)  for  analysis.    Monthly Facil ity Form Operations  research  monitoring  staff  used  a  Monthly  Facility  Form  to  record  key  service  delivery  indicators,  misoprostol  stock,  and  record  challenges  or  questions  that  providers  brought  up  during  monitoring  visits.  Monthly  Facility  Forms  were  completed  during  the  OR  by  monitors  during  their  monthly  supervisory  visits.  The  OR  monitoring  staff  then  entered  the  forms  into  an  Excel  spreadsheet  and  emailed  them  to  the  VSI  Zimbabwe  Program  Officer  in  Harare,  as  well  as  to  VSI’s  M&E  team  in  Irvine,  CA.   Postabortion Care Service Delivery Form and Postabortion Care Logbook A  PAC  Service  Delivery  Form  was  completed  by  health  providers  for  each  woman  enrolled  in  the  OR  after  she  granted  consent.    The  form  documented  PAC  services  provided  at  the  facility,  including  assessment  of  clinical  condition,  method  of  treatment,  and  contraceptive  method  provided.    The  form  also  included  a  referral  section.    One  part  of  the  section  stayed  at  the  health  facility  where  the  referral  was  made,  and  the  other  was  given  to  the  woman  to  bring  to  the  facility  to  which  she  was  referred.  The  PAC  Service  Delivery  Forms  were  collected  on  a  monthly  basis  by  OR  monitoring  staff  and  sent  to  the  VSI  Program  Officer  in  Harare.  VSI’s  Data  Manager  in  Harare  then  entered  the  data  from  the  PAC  Service  Delivery  Forms  into  a  central  database  in  Epi  Info  3.5.4,  which  was  emailed  to  

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25  

VSI’s  M&E  team  in  Irvine,  CA  on  a  monthly  basis.  VSI’s  M&E  team  then  exported  the  data  into  Stata/SE  12  (StataCorp  2011).  Data  analysis  was  conducted  by  VSI’s  M&E  team  in  Stata  in  August  2013.        Data  on  all  women  enrolled  in  the  OR  presenting  with  incomplete  abortion  were  also  entered  into  a  PAC  Logbook,  which  summarized  key  information  (age,  gestational  age,  diagnosis,  method  of  treatment,  etc.)  for  each  woman.      Community Education Logbook Providers,  VHWs,  and  OR  monitoring  staff  completed  entries  in  a  Community  Education  Logbook  to  capture  the  number  of  community  educations  sessions  they  led,  the  date  of  the  education  sessions,  and  how  many  community  members  were  involved.  Health  providers  at  OR  sites  and  VHWs  completed  entries  in  the  Community  Education  Logbook  when  they  held  education  sessions  about  misoprostol.  Village  Health  Worker  logbooks  were  deposited  at  the  OR  sites.  OR  monitoring  staff  collected  the  logbooks  and  mailed  them  to  the  VSI  Zimbabwe  Program  Officer  in  Harare,  who  mailed  them  to  VSI’s  M&E  team  in  Irvine,  CA.  Data  from  the  Community  Education  Logbooks  were  entered  into  Microsoft  Excel  and  then  exported  into  Stata/SE  12  (StataCorp  2011).The  data  were  analyzed  by  VSI’s  M&E  team  using  Stata/SE  12  (StataCorp  2011).   Provider Survey All  providers  who  participated  in  the  OR  and  were  trained  on  the  appropriate  use  of  misoprostol  for  TIAM  were  asked  to  complete  a  short  self-­‐administered  survey  to  share  their  perspectives  on  the  program,  their  level  of  acceptability  with  misoprostol  for  TIAM,  their  level  of  satisfaction  and  challenges  they  experienced,  and  any  other  relevant  experiences  with  using  misoprostol  for  TIAM.    In  May  and  June  2013,  OR  monitoring  staff  distributed  and  collected  the  surveys  as  part  of  their  routine  supervisory  visits.    Providers  completed  the  surveys  in  private  and  returned  them  to  the  monitor  in  a  sealed  envelope;  they  took  an  average  of  less  than  15  minutes  to  complete.  The  OR  monitoring  staff  left  a  copy  of  the  survey  and  an  envelope  if  one  of  the  providers  was  not  present  during  the  visit;  the  provider  then  completed  the  survey  and  returned  it  to  the  monitoring  staff  member  at  the  next  visit.    The  completed  Provider  Surveys  were  collected  by  monitoring  staff  and  mailed  to  the  VSI  Data  Manager  in  Harare.  The  VSI  Data  Manager  in  Harare  then  entered  the  data  using  Epi  Info  3.5.4  and  emailed  the  data  to  VSI’s  M&E  team,  who  exported  the  data  into  Stata/SE  12  (StataCorp  2011).  This  database  was  analyzed  by  the  VSI  M&E  team  in  Irvine,  CA  using  Stata/SE  12  (StataCorp  2011).    The  final  data  analysis  for  this  report  was  conducted  by  VSI’s  M&E  team  in  August  2013.  The  final  technical  report  was  written  by  VSI’s  M&E  team  in  September  2013  in  Irvine,  CA.      

6. Operations Research Implementation Timeline

All  of  the  operations  research  (OR)  activities,  including  the  preparatory  phase,  implementation,  data  collection  and  analysis,  took  place  between  2010  and  2013  (Figure  X).  The  ZMoHCC  and  VSI  were  responsible  for  the  ongoing  management  and  oversight  of  the  OR  activities.  A  formal,  full  assessment  of  the  capacity  of  stakeholders  to  introduce  misoprostol  was  conducted  in  November  2010.    During  this  assessment,  VSI  staff  met  with  the  Ministry  of  Health,  the  National  Pharmaceutical  Company  of  Zimbabwe  (Natpharm),  and  various  maternal  health  stakeholders.        

 

 

26  

In  February  2012,  VSI  conducted  a  training  of  trainers  (TOT),  which  was  followed  by  the  cascade  training  of  providers  in  December  2012.  In  July  and  August  2012,  the  ZMoHCC  and  VSI  staff  conducted  facility  assessments  at  all  facilities  in  the  four  OR  districts  to  gather  baseline  information  about  resources,  staffing  and  current  postabortion  care  (PAC)  services.  The  protocol  for  the  operations  research  was  approved  by  the  Medical  Research  Council  of  Zimbabwe  (MRCZ),  the  Medicines  Control  Authority  of  Zimbabwe  (MCAZ)  and  the  Joint  Research  Ethics  Committee  (JRECH)  in  November  2012.    Cascade  trainings  were  held  in  December  2012.    Provision  of  services  with  misoprostol  was  initiated  only  after  ensuring  that  facilities  had  the  required  supplies.  For  this  reason,  implementation  started  at  different  times  in  the  different  districts.  Implementation  began  between  January  and  February  2013.      At  the  end  of  March  2013,  the  Medicines  Control  Authority  of  Zimbabwe  (MCAZ)  and  Medical  Research  Council  of  Zimbabwe  (MRCZ)  conducted  facility  site  visits  to  check  for  protocol  compliance  and  regulation  of  misoprostol  by  pharmacists  and  providers.  US-­‐based  VSI  staff  conducted  a  monitoring  and  evaluation  visit  in  April  2013,  during  which  time  they  visited  33  facilities  across  all  four  districts  (eight  in  Mutare,  eight  in  Chimanimani,  eight  in  Matobo  and  nine  in  Umguza).      At  the  beginning  of  June  2013  VSI  replaced  all  current  misoprostol  stock  in  the  OR  facilities  with  new  stock  to  enable  the  facilities  to  continue  to  offer  PAC  services  until  the  ZMoHCC  restocks  them  through  Natpharm.    At  the  end  of  June  2013,  OR  implementation  ended.  During  the  two  months  that  followed,  VSI  staff  cleaned  and  analyzed  OR  data.  The  final  report  was  completed  in  September  2013.    

7. Results

Data  collection  began  at  the  68  operations  research  facilities  in  January  2013.  While  some  facilities  did  not  receive  their  misoprostol  until  February,  providers  could  still  enroll  women  in  the  operations  research  (OR)  and  provide  treatment,  or  refer,  as  specified  in  the  clinical  protocol.  The  time  period  for  data  collection  was  intended  to  be  six  months  (January  –  June  2013);  however,  data  continued  to  be  collected  through  mid-­‐July,  in  order  to  ensure  that  follow-­‐up  data  could  be  gathered  for  women  who  enrolled  in  June.  

7.1 POSTABORTION CARE SERVICE DELIVERY Health  providers  enrolled  a  total  of  315  women  presenting  for  treatment  of  incomplete  abortion  and  miscarriage  (TIAM)  in  the  OR  between  1  January  2013  and  15  July  2013.  Misoprostol  was  used  to  treat  the  majority  of  enrolled  women  (76%),  and  dilatation  and  curettage  (D&C)  was  the  second  most  commonly  used  treatment  (16%).    In  Mutare  district,  D&C  was  used  to  treat  almost  one-­‐third  of  enrolled  women.  Manual  vacuum  aspiration  (MVA)  was  only  used  to  treat  two  enrolled  women,  both  in  Mutare  district.  It  is  noteworthy  that  data  collected  during  the  baseline  assessment  revealed  that  only  two  facilities  reported  having  functioning  MVA  equipment  (data  not  shown).    Four  women  were  treated  with  other  methods  (two  with  oxytocin,  one  with  dilatation  and  evacuation  (D&E),  and  one  with  expectant  management).  A  total  of  15  women  (5%)  were  referred  at  their  initial  visit  without  receiving  treatment.      

 

 

27  

Table  5:  Distribution  of  enrolled  women,  by  treatment  method  and  district  

Treatment  method  

District  Chimanimani  

(n=86)  Matobo  (n=28)  

Mutare  (n=177)  

Umguza  (n=24)  

TOTAL  (n=315)  

Misoprostol*   81  (94.2%)  

26  (92.9%)  

117    (66.1%)  

20    (83.3%)  

244  (77.5%)  

Dilatation  and  Curettage  (D&C)  

0   2  (7.1%)  

48  (27.1%)   0   50  

(15.9%)  

Manual  vacuum  aspiration  (MVA)  

0   0   2    (1.1%)   0   2    

(0.6%)  

Other  methods**   2  (2.3%)   0   1  

(0.6%)  1  

(4.2%)  4  

(1.2%)  Referred  without  treatment  

3    (3.5%)   0   9    

(5.1%)  3  

 (12.5%)  15    

(4.8%)  *Four  women  (two  from  Chimanimani  and  two  from  Umguza)  were  referred  after  initial  treatment  with  misoprostol.  **Other  methods  include  oxytocin  (n=2),  dilatation  and  evacuation  (n=1)  and  expectant  management  (n=1).    

According  to  the  facility  assessment,  prior  to  the  OR,  there  was  limited  availability  of  postabortion  care  (PAC)  services  at  the  OR  facilities.  In  addition  to  the  provincial  hospital,  only  one  of  three  district  hospitals  and  six  of  thirteen  rural  and  mission  hospitals  reported  offering  TIAM.  Dilatation  and  curettage  (D&C)  was  the  TIAM  treatment  method  available  at  the  largest  number  of  facilities  (n=5),  with  only  two  facilities  offering  MVA.  Only  one  rural  health  center  reported  offering  TIAM  at  the  time  of  the  assessment;  they  administered  oxytocin  (data  not  shown).      During  the  OR,  all  levels  of  health  facilities  in  participating  districts  were  able  to  provide  TIAM.  Treatment  methods  used  for  women  enrolled  in  the  OR  varied  by  facility  level  (Figure  6).  Rural  and  mission  hospitals  used  misoprostol  to  treat  the  highest  proportion  of  enrolled  women  (95%).    The  proportion  of  enrolled  women  treated  with  misoprostol  was  similar  at  RHCs  and  district  hospitals  (89%  and  83%,  respectively).  The  proportion  of  cases  treated  with  misoprostol  was  lowest  at  the  provincial  hospital,  where  only  half  of  enrolled  women  received  misoprostol.  Almost  half  of  the  enrolled  women  at  the  provincial  hospital  were  treated  with  D&C.      

Figure  6:  Distribution  of  TIAM  methods  for  enrolled  women,  by  facility  level    

 *Four  women  (two  from  Chimanimani  and  two  from  Umguza)  were  referred  after  initial  treatment  with  misoprostol.  **Other  methods  include  oxytocin  (n=2),  dilatation  and  evacuation  (n=1)  and  expectant  management  (n=1).  

89%   95%  83%  

50%  

17%  

47%  

2%  1%  

3%  1%  

10%  3%  

0%  

20%  

40%  

60%  

80%  

100%  

Rural  Health  Center  (n=128)    

Rural/Mission  Hopsital                          (n=73)  

District  Hospital                (n=  (12)  

Provincial  Hospital  (n=102)  

Referred  Without  Treatment  

Other  Methods  

MVA  

D&C  

Misoprostol  

 

 

28  

Treatment  methods  for  enrolled  women  varied  by  the  level  of  provider.  Close  to  three-­‐fourths  of  enrolled  women  given  misoprostol  were  treated  by  a  primary  care  nurse  (PCN)  or  nurse:  about  half  received  treatment  from  a  PCN  (43%),  and  almost  one-­‐third  received  treatment  from  a  nurse  (30%).  Midwives  provided  misoprostol  to  15%  of  the  enrolled  women  who  received  the  drug  for  treatment,  and  doctors  provided  the  medicine  to  9%.  Of  the  50  enrolled  women  treated  with  D&C,  the  vast  majority  (92%)  received  treatment  from  a  nurse,  while  6%  received  treatment  from  a  doctor.  It  is  important  to  note  here  that  all  D&C  cases  were  treated  by  a  doctor,  in  collaboration  with  a  team  of  nurses;  so  while  nurses  documented  46  cases  of  D&C,  and  listed  their  provider  level  on  the  documentation,  a  doctor  conducted  the  surgical  procedure.    

Table  6:  Distribution  of  operations  research  providers  and  treatment  method  employed  

  Misoprostol*  (n=244)  

D&C  (n=50)  

MVA  (n=2)  

Other  methods**  

(n=4)  

Referred  without  

treatment  (n=15)  

Total  (n=315)  

Primary  Care  Nurse  (PCN)  

105  (43.0%)   0   0   2  

(50.0%)  5  

(33.3%)  112  

(35.6%)  

Nurse   74  (30.3%)  

46  (92.0%)  

1  (50.0%)  

1  (25.0%)  

7  (46.7%)  

129  (41.0%)  

Midwife   37  (15.2%)   0   0   0   2  

(13.3%)  39  

(12.4%)  Clinical  Officer  

3  (1.2%)   0   0   0   0   3  

(1.0%)  

Doctor   21  (8.6%)  

3  (6.0%)  

1  (50.0%)   0   0   25  

(7.9%)  

Other   4  (1.6%)  

1  (2.0%)   0   1  

(25.0%)  1  

(6.7%)  7  

(2.2%)  *Of  the  women  treated  with  misoprostol,  four  were  also  referred,  two  by  midwives  (for  “proc  fever”  and  excess  bleeding/severe  anemia),  one  by  a  nurse  (for  D&C)  and  one  by  a  PCN  (patient  was  pale).    **  Other  methods  include  oxytocin,  dilatation  and  evacuation  (D&E)  and  expectant  management.    For  the  remainder  of  the  report,  the  majority  of  analyses  are  presented  by  facility  level,  as  this  is  where  there  was  the  most  variation  in  the  data.      Obstetric  history  and  socio-­‐demographics  for  women  enrolled  in  the  OR  are  presented  in  Table  7.  Women  enrolled  at  RHCs  had  the  highest  number  of  pregnancies  and  children  (mean  gravida  3.1  and  mean  parity  1.9).    One-­‐fifth  of  enrolled  women  were  less  than  or  equal  to  19  years  of  age.  A  higher  proportion  of  women  aged  36  and  above  (18%)  presented  at  RHCs,  compared  to  other  facility  levels.  Women  enrolled  at  the  provincial  hospital  reported  the  highest  levels  of  education,  with  81%  reporting  completing  secondary  education  and  14%  reporting  completing  post-­‐secondary  education.  Approximately  one-­‐quarter  of  the  enrolled  women  at  RHCs,  rural  and  mission  hospitals  and  district  hospitals  reported  completing  primary  education.  The  majority  of  enrolled  women  (87%)  reported  being  married.  A  total  of  53  enrolled  women  (17%)  reported  having  a  previous  abortion,  and  5%  reported  having  more  than  one  previous  abortion  (data  not  shown).      

 

 

29  

Table  7:  Obstetric  history  and  socio-­‐demographic  traits  of  enrolled  women,  by  facility  level  

   

Facility  level  Rural  

Health  Center  

Rural  and  Mission  Hospital  

District  Hospital  

Provincial  Hospital   Total  

Obstetric  history    (n=315)  

Mean  gravida  (min;  max)   3.1    (1;  12)  

2.5    (1;  8)  

3.0    (1;  5)  

2.3    (0;  6)  

2.7    (0;  12)  

Mean  parity  (min;  max)   1.9    (0;  11)  

1.3    (0;  11)  

1.8    (0;  4)  

1.2    (0;  5)  

1.5    (0;  11)  

Socio-­‐demographic  characteristics  Mean  age    (min;  max)  (n=312)*  

27.2    (15;  43)  

25.2  (14;  40)  

28.3  (16;  47)  

25.1  (15;  39)  

26.1  (14;  47)  

<19   26  (20.3%)  

17  (23.3%)  

3  (25.0%)  

16  (16.2%)  

62  (19.9%)  

20-­‐24   21  (16.4%)  

18  (24.7%)  

1  (8.3%)  

22  (22.2%)  

62  (19.9%)  

25-­‐35   58    (45.3%)  

33  (45.2%)  

6  (50.0%)  

58  (58.6%)  

155  (49.7%)  

36  and  above   23  (18.0%)  

5  (6.9%)  

2  (16.7%)  

3  (3.0%)  

33  (10.6%)  

Education  (n=291)**  

None   1    (0.8%)  

1  (1.4%)   0   1  

(1.1%)  3  

(1.0%)  

Primary   30  (24.6%)  

18  (26.1%)  

3  (27.3%)  

4  (4.5%)  

55  (18.9%)  

Secondary   85  (69.7%)  

43  (62.3%)  

8  (72.7%)  

72  (80.9%)  

208  (71.5%)  

Post-­‐secondary   6    (4.9%)  

7  (10.1%)   0   12  

(13.5%)  25  

(8.6%)  Marital  status  (n=293)***  

Single   10  (8.1%)  

13  (18.3%)  

5  (45.5%)  

9  (10.3%)  

37  (12.6%)  

Married/in  union/cohabitating  

114  (91.9%)  

57  (80.3%)  

6  (54.5%)  

78  (89.7%)  

255  (87.0%)  

Widowed/divorced   0   1    (1.4%)   0   0   1    

(0.3%)  *Where  the  total  is  less  than  315,  *  indicates  missing  values  for  that  variable.  Three  providers  at  the  Provincial  Hospital  are  missing  data  on  age.  **A  total  of  24  women  were  missing  data  on  education,  six  from  RHCs,  four  from  rural  and  mission  hospitals,  one  from  a  district  hospital  and  13  from  the  provincial  hospital.  ***A  total  of  22  women  were  missing  data  on  marital  status,  four  from  RHCs,  two  from  rural  and  mission  hospitals,  one  from  a  district  hospital  and  15  from  the  provincial  hospital.      The  total  number  of  women  enrolled  in  the  OR  who  were  treated  with  misoprostol  increased  from  January  to  May  (Figure  7).  The  number  of  women  treated  with  misoprostol  in  May  (n=57)  and  June  (n=55)  remained  steady,  and  the  number  of  reported  cases  in  July,  where  data  was  only  collected  through  the  15th  of  the  month,  was  38.  The  number  of  enrolled  women  treated  with  D&C  increased  during  the  first  four  months  of  the  OR  (from  zero  cases  in  January  to  15  cases  in  April),  and  decreased  during  the  remaining  months.  MVA  was  used  to  treat  only  two  enrolled  women,  one  in  April  and  one  in  June.    

 

 

30  

Figure  7:  Method  of  initial  treatment  for  enrolled  women,  by  month  

 *Data  was  only  collected  for  the  first  two  weeks  of  the  month  in  July.  

 The  baseline  data  revealed  that  of  all  PAC  cases  presenting  at  RHCs  between  September  2011  and  February  2012,  98%  had  to  be  referred  to  a  higher-­‐level  facility  for  treatment  (Figure  8).  At  rural  and  mission  hospitals,  almost  half  of  presenting  PAC  cases  had  to  be  referred  for  treatment  at  baseline.  During  the  OR,  referrals  at  these  lower-­‐level  health  facilities  decreased,  with  only  10%  of  enrolled  women  at  RHCs  and  3%  at  rural  and  mission  hospitals  being  referred  without  receiving  treatment.    Figure  8:  Proportion  of  PAC  cases  referred  without  treatment,  at  baseline  and  during  the  operations  research  

   A  total  of  115  enrolled  TIAM  cases  were  treated  at  RHCs  during  the  OR,  compared  to  only  three  cases  that  were  treated  at  baseline  (data  not  shown).  The  number  of  women  receiving  misoprostol  for  PAC  at  RHCs  increased  fourfold  in  just  four  months,  while  the  number  of  women  presenting  at  RHCs  who  had  to  be  referred  remained  low  throughout  the  OR  (Figure  9).    

0  

10  

20  

30  

40  

50  

60  

January            (n=13)  

February  (n=17)  

March            (n=38)  

April  (n=60)   May                  (n=72)  

June              (n=66)  

July                      (n=49)  

Misoprostol   D&C   MVA  

98%  

48%  

10%  3%  

0%  

20%  

40%  

60%  

80%  

100%  

Rural  Health  Center     Rural/Mission  Hospital    

Baseline  (September  2011-­‐February  2012)  

Operahons  Research  (1  January-­‐15  July  2013)  

 

 

31  

Figure  9:  Enrolled  women  at  Rural  Health  Centers  who  received  misoprostol  or  were  referred,  by  month  

 

7.2 FOLLOW-UP AND REFERRALS DUE TO TREATMENT FAILURE All  women  who  were  treated  for  incomplete  abortion  or  miscarriage  were  asked  to  return  for  follow-­‐up  any  time  between  seven  and  fourteen  days  after  their  initial  treatment  with  misoprostol.    However,  data  on  follow-­‐up  visits  were  only  reported  by  providers  for  women  who  received  misoprostol  as  their  initial  treatment  method;  follow-­‐up  data  is  not  available  for  enrolled  women  who  received  other  treatment  methods.      Of  the  244  women  initially  treated  with  misoprostol,  almost  half  returned  for  follow-­‐up.  Follow-­‐up  was  highest  at  the  RHCs  (75%),  and  lowest  at  the  provincial  hospital  (12%)  and  district  hospital  (10%)  (Figure  X).      Figure  10:  Proportion  of  enrolled  women  who  were  initially  treated  with  misoprostol  who  returned  for  follow-­‐up,  by  facility  level  

   Of  the  women  who  returned  for  follow-­‐up  and  for  whom  data  was  available  on  treatment  diagnosis,  96%  were  diagnosed  as  successfully  treated  (Table  8).    Only  five  enrolled  women  were  diagnosed  as  not  having  been  successfully  treated  and  only  one  of  these  women  had  to  be  referred  for  completion  of  uterine  evacuation.  Of  the  remaining  four  women,  one  was  sent  home  to  wait  

0  

5  

10  

15  

20  

25  

30  

January           February     March               April                   May                         June                        July                                  

Treated  with  misoprostol   Referred  

75%  

39%  

10%   12%  

49%  

0%  

20%  

40%  

60%  

80%  

100%  

Rural  Health  Center                                        (n=128)  

Rural/Mission  Hospital                                          (n=73)  

District  Hospital                                                            (n=12)  

Provincial  Hospital                                                                                        (n=102)  

Total                                  (n=315)  

 

 

32  

another  week  (she  had  come  back  one  week  after  initial  treatment),  one  was  treated  with  MVA,  and  two  were  given  an  additional  dose  of  misoprostol.    Table  8:  Number  of  enrolled  women  treated  with  misoprostol  who  returned  for  follow-­‐up  visit,  by  facility  level  

     

Rural  Health  Center  (n=128)  

Rural  and  Mission  Hospital  (n=73)  

District  Hospital  (n=12)  

Provincial  Hospital  (n=102)  

Total  (n=315)  

Initially  treated  with  misoprostol  

114    (89.1%)  

69    (94.5%)  

10    (83.3%)  

51    (50.0%)  

244    (77.5%)  

Returned  for  follow-­‐up  and  available  data  on  the  treatment  diagnosis*  

86  (75.4%)    

27  (39.1%)  

1  (10.0%)    

6    (11.8%)  

120  (49.2%)    

Patient  successfully  treated   84  (97.7%)  

25  (92.6%)  

1  (100.0%)  

5  (83.3%)  

115  (95.8%)  

Patient  not  successfully  treated  

2  (2.3%)  

2  (7.4%)   0   1  

(16.7%)  5  

(4.1%)  Received  additional  intervention  or  referral  at  follow-­‐up    

Misoprostol   0   1    (50.0%)   0   1    

(100.0%)  2    

(40.0%)  

MVA   0   1    (50.0%)   0   0   1    

(20.0%)  

Referred   1  (50.0%)     0   0   0   1    

(20.0%)  Sent  home  to  wait  another  week  

1  (50.0%)     0   0   0   1    

(20.0%)  *A  total  of  124  women  returned  for  follow-­‐up,  but  data  on  treatment  diagnosis  was  missing  for  four  women  (two  from  RHCs,  one  from  a  rural  and  mission  hospital,  and  one  from  a  district  hospital).Only  data  on  the  120  women  who  returned  for  follow-­‐up  and  had  data  on  their  treatment  diagnosis  are  presented  here.    There  were  no  abortion-­‐related  deaths  reported  in  the  four  districts  during  the  OR.  

7.3 SIDE EFFECTS  Providers  asked  women  who  were  initially  treated  with  misoprostol  and  who  returned  for  follow-­‐up  whether  they  had  experienced  any  side  effects  from  the  drug.  The  majority  of  women  (77%)  did  not  report  experiencing  any  side  effects.  Twenty-­‐nine  (23%)  women  out  of  the  124  who  returned  for  follow-­‐up  reported  experiencing  at  least  one  side  effect.  The  most  prominent  side  effects  reported  was  pain/cramping  (13%),  followed  by  chills/fever  (7%).    

7.4 CONTRACEPTIVE METHOD PROVISION  Women  enrolled  in  the  OR  were  asked  which  contraceptive  method  they  were  using  prior  to  this  current  pregnancy.  As  the  question  did  not  specify  a  time  period  prior  to  the  pregnancy,  it  is  important  to  note  that  some  of  these  women  may  have  reported  a  method  that  they  were  using  prior  to  the  time  period  when  they  got  pregnant.  Almost  half  of  the  enrolled  women  for  whom  data  was  available  on  contraceptive  use  prior  to  this  pregnancy  reported  not  using  a  contraceptive  method  prior  to  this  pregnancy.  Of  the  55%  of  enrolled  women  who  did  report  using  a  method,  the  majority  (39%)  was  taking  the  pill,  while  8%  was  using  injectables  and  1%  was  using  implants.    

 

 

33  

Table  9:  Contraceptive  method  used  prior  to  pregnancy  for  enrolled  women  

 *Data  on  contraceptive  method  using  prior  to  pregnancy  is  missing  for  23  enrolled  women.    Of  the  131  women  who  reported  using  no  contraceptive  method  prior  to  this  pregnancy,  82%  took  a  contraceptive  method  home  with  them  at  their  initial  visit  (Table  10).  Of  the  women  who  reported  using  a  contraceptive  method  prior  to  this  pregnancy,  it  is  noteworthy  that  15%  did  not  take  home  a  method  at  their  initial  visit.  Only  26%  of  enrolled  women  aged  19  or  less  took  home  a  contraceptive  method  at  initial  visit  (data  not  shown).    Table  10:  Family  planning  uptake  at  initial  visit  for  enrolled  women  

 Reported  using  a  family  planning  method  prior  to  this  pregnancy  

(n=161)  

Reported  not  using  a  family  planning  method  prior  to  this  

pregnancy  (n=131)  

Received  contraceptive  method  at  initial  visit    

137  (85.1%)  

107  (81.7%)  

Did  not  receive  contraceptive  method  at  initial  visit  

24  (14.9%)  

27  (20.6%)  

 Overall,  providers  reported  that  96%  of  women  enrolled  in  the  OR  received  family  planning  counseling  at  their  initial  visit  (Table  11).  The  majority  (91%)  of  enrolled  women  who  returned  for  follow-­‐up  also  received  family  planning  counseling.  Higher  proportions  of  women  at  the  provincial  hospital  and  RHCs  (91%  and  81%,  respectively)  received  a  contraceptive  method  at  their  initial  visit,  compared  to  rural  and  mission  hospitals  (58%)  and  district  hospitals  (50%).  In  total,  82%  of  enrolled  women  received  family  planning  at  either  the  initial  or  follow-­‐up  visit.  Ten  percent  of  women  received  a  contraceptive  method  at  follow-­‐up  and  not  at  the  initial  visit.        

39%  

8%   6%  1%   2%  

45%  

0%  

10%  

20%  

30%  

40%  

50%  

Pills   Injectables   Condoms   Implant   Natural  Family  Planning  

None  

 

 

34  

Table  11:  Enrolled  women  who  received  family  planning  counseling  and  method  at  initial  or  follow-­‐up  visits,  by  facility  level  

   

Rural  Health  Center  (n=128)  

Rural  and  Mission  Hospital  (n=73)  

District  Hospital  (n=12)  

Provincial  Hospital  (n=102)  

Total  (n=315)  

Initial  visit  Family  planning  counseling  provided  at  initial  visit   119  (93.0%)   71  

(97.3%)  11  

(91.7%)  101  

(99.0%)  302  

(95.9%)  Received  contraceptive  method  at  initial  visit  

103  (80.5%)  

42  (57.5%)  

6  (50.0%)  

93  (91.2%)  

244  (77.5%)  

Women  returned  for  follow-­‐up  visit    

97  (75.8%)  

31  (42.5%)  

2  (16.7%)  

7  (6.9%)  

137  (43.5%)  

Family  planning  counseling  provided  at  follow-­‐up  visit  

88  (90.7%)  

28  (90.3%)  

1  (50.0%)  

7  (100.0%)   124  (90.5%)  

Received  contraceptive  method  at  follow-­‐up  visit  

72  (74.2%)  

19  (61.3%)   0   7  

(100.0%)  98  

(71.5%)  Received  contraceptive  method  at  follow-­‐up  and  NOT  at  initial  visit  

8  (8.2%)  

4  (12.9%)   0   1  

(14.3%)  13  

(9.5%)  

Received  contraceptive  method  at  either  initial  or  follow-­‐up  visit  

111  (86.7%)  

46  (63.0%)  

6  (50.0%)  

94  (92.2%)  

257  (81.6%)  

 The  majority  of  enrolled  women  (94%)  reported  that  their  preferred  method  of  contraception  was  available  at  initial  visit  (Table  12).  For  the  fifteen  women  whose  preferred  method  was  not  available,  ten  took  home  a  method  and  five  did  not  (data  not  shown).    Table  12:  Availability  of  clients'  preferred  contraceptive  method,  by  facility  level  

Preferred  contraceptive  available?  

Rural  Health  Center  (n=101)  

Rural  and  Mission  Hospital  (n=59)  

District  Hospital  

(n=9)  

Provincial  Hospital  (n=92)  

Total  (n=261)*  

Yes   91  (90.1%)  

58  (98.3%)  

7  (77.8%)    

90  (97.8%)  

246  (94.3%)  

No   10  (9.9%)  

1  (1.7%)  

2  (22.2%)  

2  (2.2%)  

15  (5.7%)  

*Data  on  availability  of  client’s  preferred  contraceptive  method  was  missing  from  a  total  of  54  women:  27  from  RHCs,  14  from  rural  and  mission  hospitals,  3  from  district  hospitals  and  10  from  the  provincial  hospital.    Of  the  women  who  took  home  a  contraceptive  method  at  initial  visit,  70%  took  pills,  15%  took  condoms  and  15%  took  injectables.  Ten  women  (4%)  received  implants.      

 

 

35  

Figure  11:  Contraceptive  methods  provided  at  initial  visit,  by  facility  level  

 *Columns  will  not  always  sum  to  100%  because  some  women  took  more  than  one  family  planning  method.    

7.5 ACCESS TO POSTABORTION CARE SERVICES  Women  enrolled  in  the  OR  were  asked  by  a  provider  how  long  it  took  them  to  get  to  the  health  facility.  On  average,  it  took  women  65  minutes  to  travel  to  the  facility.  These  times  ranged  from  43  minutes  (provincial  hospital)  to  66  minutes  (RHCs)  to  93  minutes  (rural  and  mission  hospitals)  (Table  13).        Over  one-­‐third  of  enrolled  women  walked  to  the  facility  where  they  received  treatment.  The  highest  proportion  of  women  who  walked  was  reported  at  the  RHCs  (54%).  One-­‐fourth  of  women  took  a  bus  (24%)  and  almost  one-­‐third  (29%)  took  a  car.  Women  were  asked  about  the  cost  of  their  transport  to  the  health  facility  (data  not  shown).    Amongst  the  112  women  who  reported  paying  for  transport,  98  had  data  on  the  amount  of  money  they  paid  for  transport.  The  highest  average  transport  amounts  were  to  the  rural  and  mission  hospitals  (6.0  USD)  and  district  hospitals  (8.6  USD).  Women  at  RHCs  and  provincial  hospitals  reported  the  lowest  amounts  (2.9  USD  and  2.1  USD,  respectively).          

18%   14%  33%  

11%   15%  

64%   74%   33%   76%   70%  

22%   10%  33%  

9%   15%  

4%  2%  

17%  4%   4%  

0%  

20%  

40%  

60%  

80%  

100%  

120%  

Rural  Health  Center                              (n=103)  

Rural/Mission  Hospital                            (n=42)  

District  Hospital                                        (n=6)  

Provincial  Hospital                            (n=93)  

Total                                          (n=244)  

Implant  

Injectables  

Pills  

Condoms  

 

 

36  

Table  13:  Client  travel  time  and  means  of  transport,  by  facility  level  

Time  and  mode  of  transport    

Rural  Health  Center  

Rural  and  Mission  Hospital  

District  Hospital  

Provincial  Hospital   Total  

Time  to  facility  (n=315)  Mean  time  to  facility  in  minutes  (min;  max)  

65.8  (0;  480)  

92.7  (0;  780)  

64.7  (15;  180)    

43.4  (0;  900)    

64.7  (0;  900)  

Median  time  to  facility  in  minutes  (min;  max)  

40  (0;  480)  

60  (0;  780)  

52.5  (15;  180)  

30.0  (0;  900)      

30.0  (0;  900)  

Means  of  transport  (n=281)*  

Walk   65    (53.7%)  

23    (33.3%)  

3  (25.0%)  

9    (11.4%)  

100    (35.6%)  

Wheelbarrow   14    (11.6%)  

2    (2.9%)   0     0     16    

(5.7%)  

Bike     2    (1.7%)  

1    (1.4%)  

1  (8.3%)   0   4    

(1.4%)  

Bus   11    (9.1%)  

23    (33.3%)  

3  (25.0%)  

31    (39.2%)  

68    (24.2%)  

Car   27    (22.3%)  

18    (26.1%)  

4  (33.3%)  

32    (40.5%)  

81    (28.8%)  

Ambulance   0   1    (1.4%)  

1  (8.3%)  

4    (5.1%)  

6  (2.1%)  

More  than  one  method**  

2    (1.7%)  

1    (1.4%)   0   3  

 (3.8%)  6  

 (2.1%)  *Data  on  means  of  transport  is  missing  for  34  women  (seven  from  RHCs,  four  from  rural  and  mission  hospitals,  and  23  from  the  provincial  hospital.  **At  RHCs,  two  women  walked  and  took  a  car.  At  a  rural  hospital,  one  woman  walked  and  took  the  bus.  At  the  provincial  hospital,  two  women  walked  and  took  the  bus  and  one  woman  walked  and  took  a  car.  

7.6 COMMUNITY AWARENESS Health  providers,  VHWs,  OR  monitoring  staff,  and  Health  Promotion  Officers  were  trained  on  the  key  messages  of  the  OR  (dangers  of  unsafe  abortion,  the  availability  of  PAC  services  with  misoprostol  at  participating  OR  health  facilities,  the  importance  of  preventing  unwanted  pregnancies,  and  the  availability  of  family  planning  methods  at  health  facilities).    They  were  asked  to  disseminate  these  messages  to  community  members.  Health  providers  primarily  did  this  via  education  sessions  at  their  health  facilities,  while  VHWs  focused  on  spreading  messages  at  community  meetings.  A  total  of  565  education  sessions  were  held  over  the  course  of  the  OR;  health  providers  led  the  majority  of  the  sessions  (54%)  and  VHWs  led  14%  of  the  sessions  (data  not  shown).  The  number  of  community  members  reached  by  health  providers,  VHWs  and  OR  monitoring  staff  steadily  increased  throughout  the  OR  (Figure  12).    Overall,  13,845  community  members  were  reached  with  messages  about  misoprostol  for  PAC  during  the  course  of  the  OR.        

 

 

37  

Figure  12:  Cumulative  number  of  community  members  reached  with  awareness  messaging  

 

7.7 PROVIDER PERSPECTIVES ON THE INTRODUCTION OF MISOPROSTOL FOR TREATEMENT OF INCOMPLETE ABORTION AND MISCARRIAGE  Providers  who  had  either  been  trained  at  the  cascade  trainings  or  received  feedback  from  their  colleagues  about  their  trainings  were  invited  to  complete  a  Provider  Survey.  During  the  last  two  months  of  the  OR,  monitoring  staff  visited  each  facility  and  explained  to  providers  the  purpose  of  the  Provider  Survey,  which  was  to  gather  provider  perspectives  on  using  misoprostol  for  TIAM.  Monitoring  staff  left  Provider  Surveys  at  the  facility  and  asked  that  staff  member(s)  who  had  received  training  on  using  misoprostol  for  TIAM  complete  the  survey,  which  they  would  then  collect  at  their  supportive  supervision  visit  the  following  month.    In  total,  94  surveys  were  completed  (Table  14)  and  at  least  one  provider  from  each  OR  facility  completed  a  survey.    The  majority  of  providers  who  completed  a  survey  worked  at  RHCs  (69%),  and  over  half  were  primary  care  nurses  (53%).  Almost  all  of  respondents  (92%)  reported  working  in  a  rural  area  and  two-­‐thirds  had  between  one  and  ten  years  of  work  experience.  Only  12  respondents  (13%)  reported  having  ever  been  trained  on  MVA.    

   

0  

1000  

2000  

3000  

4000  

5000  

6000  

7000  

8000  

9000  

December   January   February   March   April   May     June  

Health  Promohon  Officer   Monitoring  Staff   Village  Health  Worker  

Other   Provider  

n=7,790  

n=3,062  

n=2,527  

n=529  n=529  

 

 

38  

Table  14:  Characteristics  of  providers  who  responded  to  survey  

Level  of  facility  where  provider  works  

Rural  Health  Center   65  (69.2%)  

Mission/Rural  Hospital  

23  (24.5%)  

District  Hospital   1  (1.1%)  

Provincial  Hospital   5  (5.3%)  

Provider  level  

Primary  Care  Nurse   50  (53.2%)  

Nurse   18  (19.2%)  

Midwife   23  (24.5%)  

Physician   3  (3.2%)  

Location  of  primary  work  site  

Rural   86  (91.5%)  

Urban   8  (8.5%)  

Years  providing  PAC  services    

1  –  5  years     35  (37.2%)  

6  –  10  years     33  (35.1%)  

11-­‐20  years     11  (11.7%)  

21  –  30  years   10  (10.6%)  

31  –  40  years   5  (5.3%)  

Ever  trained  in  MVA*  

Yes   12  (13.0%)  

No   80  (87.0%)  

*Missing  data  on  two  providers  (one  at  a  rural  health  center  and  one  at  a  rural  and  mission  hospital)  on  whether  they  have  ever  received  training  on  MVA.  Percents  are  calculated  out  of  the  92  providers  for  whom  we  have  data  for  this  question.    Providers  were  asked  their  level  of  agreement  with  a  number  of  statements  relating  to  misoprostol  for  PAC  and  family  planning  provision  (Figure  13).    The  vast  majority  of  providers  agreed  or  strongly  agreed  that  it  was  easy  to  learn  how  to  use  misoprostol  to  treat  incomplete  abortion  (95%)  and  that  they  were  able  to  manage  their  clients’  pain/symptoms  after  they  took  misoprostol  (89%).  However,  over  half  of  providers  felt  that  they  needed  more  training  on  using  misoprostol  for  TIAM.        

 

 

39  

Figure  13:  Perspectives  on  using  misoprostol  for  postabortion  care*  

 *N’s  in  this  figure  reflect  the  number  of  providers  who  responded  to  each  specific  question.    The  majority  of  providers  stated  that  they  were  able  to  provide  postabortion  family  planning  (93%)  and  89%  stated  that  they  had  an  adequate  supply  of  family  planning  methods  (Figure  14).    Figure  14:  Provider  perspectives  on  family  planning  services*  

 *N’s  in  this  figure  reflect  the  number  of  providers  who  responded  to  each  specific  question.    Providers  were  asked  a  number  of  open-­‐ended  questions  relating  to  the  provision  of  misoprostol  for  PAC,  as  well  as  questions  around  PAC  service  delivery  and  community  perceptions  of  PAC  services.  Four  key  themes  emerged:  1)  positive  perceptions  of  misoprostol  for  PAC,  2)  stigma  associated  with  seeking  PAC  and  the  importance  of  raising  community  awareness  of  PAC  services,  3)  effective  counseling  and  privacy  are  essential  to  providing  high-­‐quality  PAC  services,  and  4)  the  need  for  additional  training  and  scaling  up  misoprostol  for  PAC.    Perceptions of Misoprostol for Postabortion Care Providers  noted  that  people  in  their  communities  felt  very  positive  about  the  availability  of  misoprostol  for  PAC.  One  midwife  noted  that  initially  women  needed  a  lot  of  health  education  to  inform  them  about  misoprostol,  but  now  that  women  have  been  successfully  treated  with  misoprostol,  “they  are  beginning  to  believe.”  Numerous  providers  noted  that  women  appreciated  misoprostol  because  it  is  “easy  to  swallow  and  efficient,”  as  well  as  being  safe,  highly  effective,  and  convenient.      

95%  

55%  

89%  

0%   20%   40%   60%   80%   100%  

"It  was  easy  to  learn  how  to  use  misoprostol  to  treat  incomplete  aborhon."  (n=92)  

"I  feel  that  I  need  more  training  to  be  confident  in  using  misoprostol  to  treat  incomplete  

aborhon."  (n=91)  

"I  am  able  to  manage  the  pain  and  symptoms  of  my  clients  ater  they  take  misoprostol."  (n=91)  

93%  

89%  

0%   20%   40%   60%   80%   100%  

"I  am  able  to  regularly  counsel  my  clients  on  postaborhon  contracephon."  (n=90)  

"I  have  an  adequate  supply  of  family  planning  methods."  (n=90)  

 

 

40  

The  majority  of  respondents  noted  that  misoprostol  was  cheap,  both  in  terms  of  the  price  of  the  drug  (which  was  free  during  the  OR)  and  in  terms  of  transport.  The  fact  that  women  did  not  have  to  take  transport  to  a  hospital  to  access  PAC  services  was  cited  as  one  of  the  key  benefits  of  misoprostol.  One  midwife,  54  years  old,  working  at  a  RHC  noted:  “They  [people  in  the  community]  really  felt  good  because  in  the  past  we  used  to  refer  to  the  hospital  for  PAC,  but  with  the  use  of  misoprostol  we  are  treating  without  complications,  no  costs,  and  it  is  very  effective.”  A  PCN  working  at  a  RHC  stated,  “The  community  is  appreciating  postabortion  care  services  because  it  prevents  death  or  other  complications  that  may  arise.”  Some  providers  said  men  and  women  appreciated  that  PAC  services  could  now  be  accessed  “while  they  are  near  their  families,”  as  they  no  longer  had  to  travel  to  a  hospital  to  get  the  services.   Stigma and Community Awareness of Postabortion Care Services Providers  felt  that  the  stigma  attached  to  seeking  PAC  can  prevent  women  from  accessing  services,  particularly  if  the  woman  is  unmarried.  Lack  of  knowledge  about  the  availability  of  PAC  services  was  cited  as  a  key  constraint,  particularly  in  communities  served  by  RHCs  where  misoprostol  was  being  introduced  as  the  sole  PAC  treatment  available.  Distance  and  the  need  for  referral  to  hospitals  was  cited  as  a  key  barrier  preventing  women  from  accessing  PAC.    Health  education  and  improved  awareness  of  the  availability  of  PAC  services  were  cited  as  extremely  important  in  influencing  women  to  access  PAC,  and  as  priority  areas  for  improving  services.    A  number  of  respondents  noted  the  importance  of  involving  VHWs  in  awareness  activities,  as  well  as  traditional  leaders,  kraal  heads,  and  village  headmen.  Respondents  felt  it  was  important  to  train  VHWs  to  disseminate  messages  about  the  availability  of  misoprostol  for  PAC.  They  also  identified  “broadcasting  though  the  media”  as  a  means  for  disseminating  messages,  and  one  respondent  said  that  the  government  should  try  to  reach  men  with  messages  about  PAC  via  radio  announcements.  The  continued  provision  of  pamphlets  to  women  was  cited  as  essential,  in  order  to  continually  raise  awareness  about  misoprostol  for  PAC  services.  Posters  were  also  mentioned  as  an  important  means  of  communicating  messages  about  PAC  services.      Effective Counseling and Privacy for High-Quality PAC Services

Respondents  stated  that  some  women  feel  fear  and  anxiety  when  coming  to  a  facility  for  PAC  services;  they  may  be  scared  of  needing  to  be  transferred  and  getting  an  invasive  procedure,  fear  losing  fertility,  or  be  scared  of  being  accused  of  having  a  “criminal  abortion.”  They  may  also  be  scared  of  stigmatization  from  their  

community  and  their  husband.  However,  providers  noted  that  after  talking  to  women,  they  were  able  to  alleviate  many  of  these  fears,  and  after  receiving  counseling,  most  women  “become  relaxed.”      Providers  universally  agreed  that  privacy  is  extremely  important  to  women  when  they  come  to  a  health  facility  for  PAC:  “That  is  where  their  dignity  lies.”  It  is  important  as  “no  one  wants  to  be  seen  while  examination  or  treatment  is  being  done”  and  additionally,  they  may  be  “grieving  over  the  lost  pregnancy.”  One  provider  noted  that  privacy  was  particularly  important  to  women  belonging  to  the  Apostolic  Church,  as  these  women  may  face  serious  repercussions  from  elders  within  their  church  if  it  is  discovered  that  they  visited  a  health  facility.  The  need  for  women  to  talk  openly  with  their  

“They  come  expecting  to  be  transferred  and  go  for  invasive  procedures,  i.e.  D&C,  but  after  discussing  with  them  they  end  up  accepting  the  misoprostol.  In  our  community  a  few  success  stories  have  made  them  believe  in  PAC.”  

Midwife  

 

 

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provider  was  expressed  by  many;  women  receiving  PAC  may  need  to  “open  up  [about]  all  her  problems,”  “express  views  and  feelings”  and  tell  “all  of  her  burning  issues”  without  having  fear  of  being  overheard.  Ensuring  privacy  has  “encouraged  [women]  to  visit  the  clinic  whenever  they  have  an  abortion.”  It  was  noted  that  hanging  curtains  in  the  wards  would  allow  for  more  privacy.    Additional Training and Scaling up of Misoprostol for Postabortion Care Providers  made  the  recommendation  that  misoprostol  should  always  be  available  at  health  facilities  and  one  provider  suggested  it  be  made  available  over  the  counter.  The  vast  majority  of  respondents  stated  that  more  staff  should  be  trained  on  using  misoprostol  for  PAC.  Most  said  that  all  nurses  should  be  trained,  while  some  stated  that  nurse  aides  should  be  trained  as  well,  in  case  a  PAC  case  presented  while  a  nurse  was  away  from  the  facility.  One  provider  felt  that  “all  health  workers”  should  be  trained  in  using  misoprostol  for  PAC.  Refresher  trainings  were  identified  as  important,  as  well  as  conducting  regular  “review  meetings”  so  that  nurses  can  share  their  experiences  using  misoprostol  and  “discuss  challenges  and  the  way  forward.”  It  was  also  noted  that  receiving  “feedback”  after  training  was  not  sufficient,  and  that  all  providers  offering  PAC  services  should  be  trained  to  use  misoprostol.  Providers  highlighted  the  importance  of  providing  pamphlets  to  women  so  that  they  can  continue  to  read  and  learn  about  PAC.  One  provider  also  noted  the  need  for  a  big  chart  to  put  on  the  wall,  outlining  how  to  use  misoprostol  for  PAC.  In  addition  to  needing  further  training  on  misoprostol  for  PAC,  providers  also  highlighted  the  need  to  be  trained  on  MVA,  Jadelle  insertions,  and  conducting  pap  smears.  

8. Discussion and Conclusions

POSTABORTION CARE SUCCESSFULLY PROVIDED AT RURAL HEALTH CENTERS Introducing  misoprostol  into  postabortion  care  (PAC)  services  enabled  providers  at  rural  health  centers  (RHCs)  in  operations  research  (OR)  districts  to  offer  PAC  services.  Prior  to  the  OR,  RHCs  referred  almost  all  PAC  cases  for  treatment  to  a  hospital.  The  number  of  RHCs  providing  PAC  services  increased  from  one  to  51  during  the  OR,  and  the  program  brought  services  closer  to  women  in  their  communities.  The  proportion  of  women  presenting  for  PAC  who  were  referred  without  being  treated  dropped  from  98%  at  baseline  to  10%  during  the  OR.    During  the  OR,  114  women  were  treated  at  RHCs,  an  increase  from  the  three  cases  that  RHCs  reported  treating  during  the  baseline  assessment.  Only  one  woman  treated  at  an  RHC  with  misoprostol  during  the  OR  had  to  be  referred  for  additional  treatment.    Bringing  services  closer  to  women  and  providing  treatment  in  a  timelier  manner  is  expected  to  decrease  the  likelihood  of  further  complications  and  morbidity  due  to  incomplete  abortion  and  miscarriage.    

POSTABORTION CARE SERVICES TASK-SHIFTED TO PRIMARY CARE NURSES Globally,  there  has  been  a  general  move  to  decentralize  PAC  services  (Brookman-­‐Amissa  et  al.,  1999)  and  to  provide  services  at  lower-­‐level  facilities  (Wanjiru  et  al.,  2007).  Further,  research  has  shown  that  shifting  the  treatment  of  PAC  cases  to  mid-­‐level  health  providers  can  be  cost  effective  (Johnston  et  al.,  2007;  King  et  al.,  1997).  Thirty-­‐six  percent  of  PAC  cases  in  the  OR  were  treated  by  primary  care  nurses  (PCNs),  demonstrating  that  training  this  cadre  of  providers  in  misoprostol  for  PAC  can  provide  increased  treatment  options  for  women  at  RHCs  where  the  PCNs  are  often  the  highest-­‐level  clinician  available.  By  introducing  PAC  at  RHCs,  the  OR  provided  increased  opportunities  for  task-­‐sharing  

“I  honestly  met  it  with  skepticism  but  have  since  then  taken  it  in  and  it’s  a  worthy  alternative  to  other  more  invasive  procedures.”  

Doctor  

 

 

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among  different  levels  of  providers.  Additionally,  the  introduction  of  misoprostol  increased  the  treatment  options  available  at  hospitals  and  provided  a  method  that  could  be  carried  out  by  nurses  at  hospitals  instead  of  only  by  physicians.    

FAMILY PLANNING ESSENTIAL FOR HIGH-QUALITY POSTABORTION CARE Provision  of  family  planning  services  including  contraception  is  an  essential  element  of  PAC.  The  prevention  of  unwanted  or  mistimed  pregnancies  by  the  adoption  of  effective  family  planning  methods  will  reduce  the  risks  of  maternal  mortality  by  reducing  repeat  abortions  and  the  health  consequences  of  poor  spacing  or  unwanted  pregnancies.  Ensuring  that  every  woman  who  receives  PAC  services  also  receives  family  planning  counseling  and  the  provision  of  a  modern  contraceptive  method,  if  she  desires,  has  been  cited  as  the  most  significant  challenge  to  the  provision  of  high-­‐quality  PAC  (RamaRao  et  al.,  2011).    A  cross-­‐sectional  study  undertaken  in  Zimbabwe  at  two  central  hospitals  showed  that  significantly  more  women  who  receive  PAC  services  that  include  a  family  planning  component  were  found  at  follow-­‐up  to  have  higher  use  of  contraception,  significantly  fewer  unplanned  pregnancies,  and  fewer  repeat  abortions  than  women  who  had  not  received  postabortion  family  planning  counseling  (Johnson  et  al.,  2002).      The  majority  of  women  in  the  OR  (82%)  accepted  a  modern  contraceptive  method  as  part  of  PAC  services.  Rates  of  contraceptive  uptake  were  highest  at  the  RHCs  (87%)  and  the  provincial  hospitals  (92%).  Long-­‐lasting  contraceptives,  injectables  and  implants,  which  offer  more  reliable  protection,  were  more  likely  to  be  the  methods  of  choice  at  the  RHCs  (26%  of  accepters)  than  at  the  provincial  hospital  (13%).  Contraceptive  uptake  was  also  high  (82%)  among  women  who  reported  not  using  a  family  planning  method  prior  to  the  last  pregnancy.  While  the  most  recent  Demographic  and  Health  Survey  (DHS)  data  reports  that  58%  of  reproductive  age  women  are  not  currently  using  a  modern  contraceptive  method  (Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International,  2012),  the  OR  data  showed  that  only  45%  of  enrolled  women  reported  not  using  a  family  planning  method  prior  to  this  pregnancy.  As  the  question  asked  in  the  OR  was  not  clear  about  the  time  period  for  when  the  contraceptive  was  used,  this  might  point  to  the  fact  that  there  were  more  women  in  the  OR  who  were  not  using  a  contraceptive  method  when  they  got  pregnant,  and  that  they  were  reporting  family  planning  use  for  a  time  in  the  past,  prior  to  this  pregnancy.    For  the  women  who  had  not  been  using  contraception  prior  to  this  current  pregnancy,  PAC  presents  what  may  be  their  only  opportunity  to  access  family  planning.      Encouraging  contraceptive  uptake  by  youth  has  been  shown  in  the  literature  to  be  challenging  (Evans  et  al.,  2013).  The  fact  that  only  26%  of  enrolled  women  aged  19  or  less  took  home  a  contraceptive  method  at  initial  visit  highlights  the  need  for  providers  to  be  trained  on  specific  counseling  strategies  for  adolescents.  

FOLLOW-UP HIGHEST AT RURAL HEALTH CENTERS Increasing  follow-­‐up  rates  improves  overall  service  quality  by  ensuring  that  PAC  services  are  comprehensive.  In  this  OR,  follow-­‐up  data  was  only  available  on  women  initially  treated  with  misoprostol.    Overall,  49%  of  enrolled  women  who  were  initially  treated  with  misoprostol  returned  for  follow-­‐up.  The  highest  follow-­‐up  rates  were  seen  at  the  RHCs,  where  75%  of  women  returned  for  follow-­‐up.  Over  half  (54%)  of  women  enrolled  at  RHCs  reported  that  they  walked  to  the  facility,  illustrating  that  these  lower  level  facilities  may  be  more  accessible  than  higher-­‐level  facilities.  When  PAC  services  are  closer  to  women’s  homes,  it  is  easier  for  them  to  return  for  follow-­‐up.  Women  often  have  to  travel  further  to  reach  a  hospital  than  a  health  center,  making  it  more  challenging  for  them  to  return  for  follow-­‐up.    

 

 

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TREATMENT METHOD MIX HIGHLIGHTS CONTINUED RELIANCE ON DILATATION AND CURETTAGE AT HOSPITALS Misoprostol,  a  World  Health  Organization  (WHO)-­‐recommended  method  for  the  PAC,  was  used  in  78%  of  cases  throughout  the  OR.  The  highest  rates  of  misoprostol  use  were  seen  at  the  lower-­‐level  facilities  (89%  at  RHCs  and  95%  at  rural  and  mission  hospitals).    Dilatation  and  Curettage  (D&C)  is  not  a  method  recommended  by  the  WHO  (WHO,  2012).  However,  during  the  OR,  D&C  was  used  to  treat  16%  of  enrolled  women;  almost  half  (47%)  of  all  enrolled  women  at  the  provincial  hospital  were  treated  with  D&C.  All  cases  treated  with  D&C  were  at  the  district  or  provincial  hospitals,  illustrating  a  continued  reliance  on  surgical  methods  at  these  higher-­‐level  facilities.  As  the  ZMoHCC  works  to  decrease  the  reliance  on  D&C  as  a  primary  treatment  method  for  PAC,  misoprostol  provides  an  alternative  that  is  cheaper  than  surgical  procedures,  easy  to  learn  to  use,  with  significantly  lower  complication  rates  than  D&C.  

NEED FOR MORE EXTENSIVE PROVIDER TRAINING ON MISOPROSTOL FOR POSTABORTION CARE Respondents  to  the  Provider  Survey  highlighted  the  need  to  train  additional  providers  in  PAC.  It  is  important  to  note  that  while  the  administration  of  misoprostol  itself  is  not  difficult  to  learn,  the  more  challenging  areas  are  in  diagnosing  women  presenting  with  symptoms  of  incomplete  abortion  and  miscarriage,  managing  side  effects,  and  caring  for  clients  after  the  procedure.  As  many  providers  deliver  PAC  at  the  government  referral  hospitals,  it  is  important  to  ensure  that  all  of  the  providers  offering  PAC  services  are  formally  trained  with  standardized  knowledge  and  skill  assessment  tools  on  the  appropriate  use  of  misoprostol  for  treatment  of  incomplete  abortion  and  miscarriage  (TIAM),  overall  assessment  protocols,  and  management  and  follow-­‐up  of  PAC  cases.  Increasing  the  number  of  providers  who  are  comfortable  with  using  misoprostol  for  TIAM  and  providing  all  other  components  of  PAC  services  will  help  maintain  quality  of  services  during  expansion.  Additionally,  because  it  is  often  doctors  who  determine  the  treatment  choices  in  hospitals,  their  inclusion  in  the  training  and  orientation  to  the  program  is  essential  -­‐  even  if  midwives  and  nurses  are  the  ones  to  administer  misoprostol.  It  can  be  also  expected  that  involvement  of  doctors  in  misoprostol  trainings  will  further  familiarize  them  with  different  treatment  options,  which  could  decrease  reliance  on  D&C  as  a  primary  treatment  method  at  higher-­‐level  hospitals.  

COMMUNITY AWARENESS OF UNSAFE ABORTION AND PAC SERVICES Community  sensitization  activities  were  an  important  component  of  the  OR,  where  18,962  community  members  were  reached  with  messages  about  misoprostol,  PAC  and  the  dangers  of  unsafe  abortion.  However,  it  is  important  to  note  that  the  population  of  the  four  OR  districts  was  762,481,  meaning  that  only  2.5%  of  the  population  was  reached  with  these  messages.  Health  providers  led  the  majority  of  education  sessions  (54%),  indicating  that  providers  are  able  to  incorporate  messages  about  misoprostol  and  PAC  into  already-­‐existing  education  sessions.  Village  Health  Workers  provided  only  13%  of  the  education  sessions,  and  Provider  Survey  respondents  highlighted  that  more  VHWs  should  be  sensitized  to  be  able  to  incorporate  key  messages  into  their  work.    

IMPLEMENTATION CHALLENGES  Providers  at  some  district  and  provincial  hospitals  did  not  follow  the  protocol  of  offering  all  women  presenting  for  TIAM  the  opportunity  to  enroll  in  the  OR.  Enrollment  numbers  at  these  facility  levels  (n=12  at  district  hospitals  and  n=102  at  the  provincial  hospital)  were  much  lower  than  expected.    Despite  repeated  efforts  to  improve  adherence  to  the  protocol  (including  visits  by  high-­‐level  ZMoHCC  officials  to  these  sites),  providers  continued  to  exclude  some  of  the  PAC  patients.  The  exact  

 

 

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reasons  for  exclusion  were  not  completely  understood.  One  explanation  is  that  it  is  clear  that  not  enough  providers  at  the  provincial  and  district  hospitals  were  trained.  Other  factors  identified  during  the  site  visits  included  low  provider  motivation,  as  enrolling  women  necessitated  completing  additional  paperwork.  This  protocol  violation  was  not  observed  at  the  RHCs  or  rural  and  mission  hospitals.    Despite  efforts  by  monitoring  staff  to  increase  enrollment  at  the  district  and  provincial  hospitals,  overall  numbers  remained  relatively  low.  

Accurately  estimating  the  gestational  age,  both  through  the  date  of  the  last  menstrual  period  (LMP),  and  by  bimanual  exam  during  the  OR  was  also  identified  as  a  challenge  (data  not  presented).  One  reason  was  that  women  could  not  remember  the  first  day  of  their  LMP,  and  specific  training  for  gestational  age  assessment  through  bimanual  exam  was  not  included  in  the  provider  training.    Ensuring  provider  competency  in  estimating  gestational  age  is  essential  for  the  delivery  of  the  appropriate  treatment  to  women  seeking  PAC.  Estimation  can  be  particularly  challenging  in  rural  areas  where  women  often  do  not  recall  the  date  of  LMP.  Both  misoprostol  and  manual  vacuum  aspiration  (MVA)  are  recommended  for  treatment  of  first  trimester  uncomplicated  cases  of  incomplete  abortion  and  miscarriage.    Strengthening  the  ability  of  providers,  including  primary  care  nurses,  to  accurately  estimate  gestational  age  is  needed  to  better  ensure  that  misoprostol  for  TIAM  is  administered  for  women  in  the  first  trimester.  Midwives,  who  often  demonstrate  skill  in  this  area,  may  be  a  valuable  resource  for  this  training.

Another  implementation  challenge  involved  the  collection  of  follow-­‐up  data.  In  the  OR,  49%  of  all  women  who  were  treated  with  misoprostol  returned  for  follow-­‐up.  It  is  plausible  that  if  a  woman  was  feeling  well  after  the  procedure,  she  may  not  have  felt  it  necessary  to  return  to  the  health  facility  for  a  follow-­‐up  visit,  and  that  the  distance  to  the  health  facility  could  also  have  been  a  contributing  factor.  However,  data  on  why  or  why  not  women  returned  for  follow  up  was  not  collected.  This  gap  may  introduce  bias  into  the  results,  as  it  is  unknown  if  there  were  other  factors  involved  in  the  decision  to  return  (or  not  return)  for  follow-­‐up.    Additionally,  while  providers  and  VHWs  were  able  to  effectively  gather  data  on  the  number  of  community  education  sessions  they  led  and  on  how  many  people  attended,  data  were  not  collected  on  any  socio-­‐demographic  variables  on  the  attendees.  Consequently,  the  age/sex/religious  affiliation  of  the  attendees  are  not  known,  all  of  which  would  have  been  useful  in  informing  who  the  audience  was  for  the  messages.  Data  were  also  not  collected  on  how  well  attendees  understood  or  retained  messages.      

9. Programmatic Recommendations

The  following  recommendations  are  based  both  on  the  results  of  the  operations  research  (OR)  as  well  as  lessons  learned  from  the  ZMoHCC  and  providers  regarding  ways  to  strengthen  postabortion  care  (PAC)  services  in  Zimbabwe.  As  such,  the  following  recommendations  go  beyond  the  results  presented  in  this  report,  and  encompass  larger  programmatic  issues  in  the  country.  

 

 

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INTRODUCE TREATMENT OF INCOMPLETE ABORTION AND MISCARRIAGE WITH MISOPROSTOL WITHIN A REFERRAL SYSTEM AT RURAL HEALTH CENTERS, WHERE POSTABORTION CARE SERVICES ARE NOT AVAILABLE It  is  a  critical  priority  to  expand  PAC  services  with  misoprostol  to  facilities  that  are  not  currently  offering  PAC.  When  PAC  services  are  introduced  at  the  lowest  level  of  the  health  care  system  (at  RHCs  or  rural  hospitals),  it  brings  essential  reproductive  health  services  closer  to  women.  Women  presenting  with  uncomplicated  cases  of  incomplete  abortion  or  miscarriage  can  be  safely  and  effectively  treated  at  RHCs.    They  also  have  access  to  a  referral  system  in  the  event  that  they  have  complications  or  need  to  be  referred  to  a  higher-­‐level  health  facility  for  surgical  treatment.  As  PAC  services  are  expanded,  it  will  also  be  important  to  ensure  that  data  is  continuously  collected  on  the  treatment  of  PAC  patients.  Integrating  the  PAC  Logbook,  which  was  created  for  this  OR,  into  the  ZMoHCC  routine  health  information  system,  will  provide  a  means  for  accurately  tracking  treatment  methods  for  incomplete  abortion  and  miscarriage  (TIAM),  as  well  as  key  indicators  such  as  contraceptive  uptake  and  return  for  follow-­‐up.

INTEGRATE MISOPROSTOL FOR TREATMENT OF INCOMPLETE ABORTION AND MISCARRIAGE AT THOSE HEALTH FACILITIES CURRENTLY PROVIDING PAC SERVICES Integrating  misoprostol  into  existing  PAC  services  at  higher-­‐level  facilities  that  are  currently  providing  TIAM  with  other  methods  will  allow  women  to  have  a  non-­‐surgical,  less  expensive  treatment  option  which  will  save  time  for  both  women  and  providers.  Misoprostol  can  be  administered  by  nurses,  thus  freeing  up  the  time  of  physicians  for  more  complicated  cases.

PROVIDE ON-THE-JOB TRAINING ON THE USE OF MISOPROSTOL TO ALL POSTABORTION CARE SERVICE PROVIDERS: PHYSICIANS, MIDWIVES, AND NURSES, INCLUDING PRIMARY CARE NURSES  Training  providers  at  all  levels  of  the  health  system  in  Zimbabwe  will  expand  access  to  PAC  services,  particularly  for  women  living  in  rural  areas.  It  is  particularly  important  to  train  primary  care  nurses  (PCNs),  who  are  often  the  highest-­‐level  clinicians  at  RHCs.  All  providers  of  PAC  services  at  higher-­‐level  facilities  should  be  trained  as  well,  and  it  is  not  sufficient  to  rely  on  trained  providers  to  give  “feedback”  to  untrained  providers  at  facilities  with  large  staff.  On-­‐the-­‐job  trainings  using  standardized  knowledge  and  skills  assessment  tools  should  be  held  to  ensure  that  the  maximum  number  of  providers  is  trained  to  administer  misoprostol  for  PAC.  

CONTINUE TO STRENGTHEN POSTABORTION FAMILY PLANNING PROVISIONS While  family  planning  uptake  was  high  for  women  enrolled  in  the  OR  (82%  took  home  a  contraceptive  method  at  either  the  initial  or  follow-­‐up  visit),  there  were  still  58  enrolled  women  who  did  not  receive  a  method.  Women  may  experience  pressure  from  family  members  to  get  pregnant  again  quickly,  so  it  is  important  that  clinicians  provide  culturally  appropriate  counseling  to  ensure  that  women  have  a  clear  understanding  of  when  they  can  get  pregnant  again  and  what  contraceptive  methods  are  available  to  them.  In  addition,  providers  should  ensure  that  women  know  how  to  properly  use  their  chosen  methods;  with  55%  of  women  enrolled  in  the  OR  reporting  that  they  were  using  contraception  prior  to  this  pregnancy,  it  is  possible  that  women  experienced  method  failure,  which  proper  counseling  can  work  to  address.  Providers  should  continue  to  receive  supportive  supervision  so  that  they  understand  how  to  properly  counsel  women  on  family  planning  methods  in  ways  that  are  acceptable  and  easily  understood.    

 

 

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DEVELOP AND DISTRIBUTE PRACTICAL, DURABLE JOB AIDS TO SUPPORT PROVIDERS IN CORRECTLY IDENTIFYING WOMEN ELIGIBLE FOR TREATMENT WITH DIFFERENT METHODS AND THOSE WHO SHOULD BE REFERRED It  is  important  to  keep  service  providers’  skills  and  knowledge  up-­‐to-­‐date  and  certain  components  of  providers’  training  need  to  be  reinforced  to  assure  that  the  protocol  and  reporting  system  are  followed  correctly.  The  misoprostol  pocket  guides  and  PAC  brochures  developed  by  VSI  and  the  ZMoHCC  should  continue  to  be  distributed  to  providers.  In  addition,  larger  job  aids  should  be  made,  outlining  PAC  protocols  for  women,  distinguishing  between  recommended  protocols  for  women  at  less  than  or  equal  to  13  weeks  gestation  and  over  13  weeks  gestation.  

BUILD COMMUNITY AWARENESS ON THE AVAILABILITY OF POSTABORTION CARE SERVICES, THE DANGERS OF UNSAFE ABORTION, THE IMPORTANCE OF PREVENTING UNWANTED PREGNANCIES, AND RAISE AWARENESS OF THE AVAILABILITY OF FAMILY PLANNING SERVICES, BY TRAINING HEALTH PROVIDERS AT FACILITIES AND VILLAGE HEALTH WORKERS ON HOW TO INCORPORATE THESE MESSAGES INTO THEIR EDUCATIONAL ACTIVITIES Engage  providers,  Village  Health  Workers  (VHWs),  district  health  staff,  and  local  administrators  in  additional  community  awareness  activities  to  raise  awareness  of  unwanted  pregnancy,  the  consequences  of  unsafe  abortion,  and  availability  of  PAC  services.  In  addition  to  the  general  activities  for  the  wider  community,  activities  and  materials  should  be  created  specifically  to  target  adolescents.  Young  women  aged  less  than  or  equal  to  19  years  comprised  20%  of  the  women  enrolled  in  the  OR,  indicating  that  there  is  a  need  for  this  group  to  be  educated  both  on  the  dangers  of  unsafe  abortion  and  on  how  to  prevent  unwanted  pregnancies,  as  well  as  about  the  availability  of  high-­‐quality  PAC  services  at  all  levels  of  the  health  system.    

COMPLETE THE REVISION OF THE COMPREHENSIVE ABORTION CARE GUIDELINES AND PROTOCOLS ENSURING THE INCLUSION OF UPDATED INFORMATION ON POSTABORTION CARE SERVICES; DISSEMINATE AND IMPLEMENT THE REVISED GUIDELINES After  the  Comprehensive  Abortion  Care  (CAC)  Guidelines  are  finalized,  it  will  be  critical  to  ensure  that  the  guidelines  and  protocols  are  disseminated  to  all  health  facilities  providing  PAC  services.  Supportive  supervision  should  also  be  provided  to  ensure  that  providers  are  correctly  implementing  the  protocols.

INCORPORATE TRAINING ON MISOPROSTOL FOR TREATMENT OF INCOMPLETE ABORTION AND MISCARRIAGE IN THE PRE-SERVICE CURRICULA OF THE MEDICAL, NURSING, AND MIDWIFERY SCHOOLS In  order  to  ensure  the  sustainable  dissemination  of  correct  and  updated  clinical  protocols  and  guidelines,  training  on  misoprostol  for  TIAM  should  be  incorporated  into  the  pre-­‐service  curricula  of  all  medical,  nursing  and  midwifery  schools  in  Zimbabwe.

REGISTER MISOPROSTOL FOR TREATMENT OF INCOMPLETE ABORTION AND MISCARRIAGE, WHICH IS AN IMPORTANT FIRST STEP IN ENSURING THE SUPPLY OF A HIGH QUALITY PRODUCT Registration,  the  process  by  which  a  drug  is  approved  by  a  regulatory  agency  for  importation,  

 

 

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distribution  and  marketing  for  a  specific  medical  indication,  is  also  a  key  strategy  for  improving  access  to  misoprostol.    Registration  is  important  because  it  allows  for  the  drug  to  be  marketed  for  approved  indications  and  to  ensure  that  an  insert  with  proper  dosages  and  instructions  for  providers  and  pharmacists  is  included  with  the  product.  It  safeguards  product  quality  through  oversight  provided  by  a  drug  regulatory  board.  In  order  to  ensure  the  availability  of  misoprostol  for  PAC  at  all  levels  of  the  health  care  system,  it  will  be  important  both  to  ensure  that  a  misoprostol  product  is  registered  for  TIAM  and  that  policies  are  in  place  for  procurement.

STRENGTHEN PROVIDER CAPACITY AND UTILIZATION OF MANUAL VACUUM ASPIRATION FOR POSTABORTION CARE TO ADDRESS CASES THAT ARE NOT ELIGIBLE FOR MISOPROSTOL; PHASE OUT DILATATION AND CURETTAGE Providers  should  be  trained  to  provide  MVA  and  equipped  with  MVA  supplies.  Only  two  facilities  reported  having  functioning  MVA  equipment  at  baseline,  and  only  two  of  the  women  enrolled  in  the  OR  were  treated  with  MVA.  To  be  truly  comprehensive,  a  PAC  program  should  include  all  methods  of  uterine  evacuation  recommended  by  the  WHO.  D&C,  a  method  of  uterine  evacuation  not  recommended  by  the  WHO,  should  be  phased  out.    

 

 

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World  Health  Organization  (WHO),  Unsafe  Abortion:  Global  and  Regional  Estimates  of  the  Incidence  of  Unsafe  Abortion  and  Associated  Mortality  in  2008,  sixth  ed.,  Geneva:  WHO,  2011.  

World  Health  Organization  (WHO).  Technical  and  Policy  Guidance  on  Safe  Abortion.  Second  Edition.  Geneva:  World  Health  Organization,  2012.    

World  Health  Organization.  Essential  Elements  of  Obstetric  Care  at  First  Referral  Level.  Geneva:  WHO,  1991.  

World  Health  Organization.  Priority  Medicines  for  Mothers  and  Children.  Geneva:  WHO,  2011a.  

World  Health  Organization.  Unsafe  abortion:  global  and  regional  estimates  of  incidence  of  unsafe  abortion  and  associated  mortality  in  2008.  (6th  ed.)  Geneva:  WHO,  2011b.  Accessed  online  2  January  2013  at:  http://whqlibdoc.who.int/publications/2011/9789241501118_eng.pdf  

World  Health  Organization.  WHO  Model  List  of  Essential  Medicines.  16th  list  (updated)  March  2009.  Accessed  online  23  April  2011  at:  http://www.who.int/selection_medicines/committees/expert/17/sixteenth_adult_list_en.pdf  

Zimbabwe  Ministry  of  Health  and  Child  Welfare  (ZMoHCC).    Maternal  and  Perinatal  Mortality  Study.  Ministry  of  Health  and  Child  Welfare  [Zimbabwe],  2007.  

Zimbabwe  Ministry  of  Health  and  Child  Welfare,  National  guidelines  for  post  abortion  care  in  Zimbabwe,  Harare,  Zimbabwe:  Ministry  of  Health  and  Child  Welfare,  2001.  

Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International.  2012.  Zimbabwe  Demographic  and  Health  Survey  2010-­‐11.  Calverton,  Maryland:  ZIMSTAT  and  ICF  International  Inc.  

 

 

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APPENDIX A: MISOPROSTOL REGIMENS, POCKET REFERENCE FOR CLINICIANS

 

                       

CERVICAL RIPENINGDose Route Instructions

400 mcg Vaginal or sublingual Give 3 hours before the procedure.

INTRAUTERINE FETAL DEATHReduce doses in women with not use with previous cesarean section.

Dose Route Instructions13-17 weeks200 mcg Vaginal Every 6 hours, maximum 4 doses.18-26 weeks100 mcg Vaginal Every 6 hours, maximum 4 doses.>26 weeks25 mcg Vaginal Every 6 hours.OR25 mcg Oral Every 2 hours.

MEDICATION ABORTIONUse as permitted within the country’s legal framework.

RegimenMEDICATION ABORTION WITH MIFEPRISTONE AND MISOPROSTOLUp to 9 weeks gestationMifepristone 200 mg oral followed 24 to 48 hours later by misoprostol 800 mcg vaginal, sublingual or buccal. For oral route, 400 mcg misoprostol can be used up to 7 weeks of gestation.9-12 weeks gestationMifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vagi-nal. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses.12-24 weeks gestationMifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vaginal or 400 mcg oral. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses.Dose Route InstructionsMEDICATION ABORTION WITH MISOPROSTOL ONLYUp to 12 weeks gestation

800 mcg Vaginal or sublingual Every 3 hours, maximum 3 doses.

12-24 weeks gestation

400 mcg Vaginal or sublingual Every 3 hours, maximum 5 doses.

 

 

52  

APPENDIX B: CONTRACEPTIVE GUIDE, POCKET REFERENCE FOR CLINICIANS

 Adapted from: MAQ Exchange: Contraceptive Technology Update

Contraceptive Guide for POSTPARTUM SERVICESPocket Reference for Clinicians

DELIVERY

Condoms/SpermicidesIntrauterine Device (IUD)a

Tubal Ligation

Lactational Amenorrhea Methodb

ALL WOMEN

BREAST-FEEDING WOMEN

NON-BREAST-FEEDING WOMEN

Combined Oral or Injectable Contraceptives (COCs/CICs)c

48 HOURS

3 WEEKS

4 WEEKS

6 WEEKS

6 MONTHS

9 MONTHS

Diaphragm/Cervical Cap

Male Sterilization

Progestin-only Pills or InjectablesCombined Oral or Injectable Contraceptivesc

Progestin-only Pills or Injectables

Emergency Contraception

aIf delivery is in a health care facility, IUD can be inserted immediately postpartum (within 48 hrs).

cDuring the first 6 months postpartum, COCs/CICs may affect the quantity of breastmilk and the healthy growth of the infant. However, if no other methods are available or acceptable, a woman may use COCs/CICs starting 6 weeks postpartum.

bNatural family planning (NFP) may be harder for breastfeeding women as reduced ovarian function makes fertility signs more difficult to interpret. As a result, NFP can require prolonged periods of abstinence during breastfeeding.

 

 

53  

APPENDIX C: COMMUNITY BROCHURE FOR WOMEN

TREATMENT OF INCOMPLETE ABORTION ANDMISCARRIAGE WITH MISOPROSTOL TABLETS

Using misoprostol tablets to treat incomplete abortion

WHAT WILL HAPPEN WHEN YOU TAKE THE TABLETS HOW CAN YOU MANAGE THE SIDE EFFECTS?

CRAMPING

BLEEDING

DIARRHOEA

FEVER / CHILLS

VOMITING / NAUSEA

HEAVY BLEEDING FEVER

CONSTANT CRAMPING

HOW TO TAKE MISOPROSTOL TABLETS

MANY WOMEN DO NOT HAVE SIDE EFFECTS

If you are having an incomplete abortion, you

can be treated safely and effectively with

misoprostol pills

Misoprostol causes the uterus to contract. You

will have some vaginal bleeding and cramping

and you may see blood clots.

But some women may experience fever, chills,

nausea or diarrhoea. These should go away on

their own in a few hours.

You can take pain medicines for cramps. Fever

medicines are rarely needed. Drinking lots of

water and getting rest will also help. Most side

effects will disappear on their own in a short

time.

You should seek immediate help if you have:

Heavy bleeding

Fever which lasts more than a day or starts

any day after the day you take misoprostol

Constant cramping and pain that does not

get better with medication, rest, or heating

pad

The feeling of being very sick

••••Swallow 3 tablets (600 mcg ) with water

WHEN SHOULD YOU SEEK HELP FROM AHEALTH CARE PROVIDER?

 

 

54  

   

WHAT IS THE BEST CONTRACEPTIVE METHOD FOR ME?

WHEN SHOULD I COME BACK FOR FOLLOW - UP?

DATE OF YOUR FOLLOW-UP VISIT:

............................../............................./.........................

LOCATION:

.......................................................................................

.......................................................................................

.......................................................................................

.......................................................................................

PHONE

.......................................................................................

......................................................................................

You are able to get pregnant again within a couple of weeks. If you would like contraception, it should be started immediately. You can start most methods at the same time you take your misoprostol tablets

Please come back for a follow-up visit in 1 - 2 weeks to ensure that your treatment was successful.

Using misoprostol tablets to treat incomplete abortion

If you are having an incomplete

abortion, you can be treated safely

and effectively with

misoprostol tablets

HEALTH CLINIC

WHAT IS THE BEST CONTRACEPTIVE METHOD FOR ME?

WHEN SHOULD I COME BACK FOR FOLLOW - UP?

DATE OF YOUR FOLLOW-UP VISIT:

............................../............................./.........................

LOCATION:

.......................................................................................

.......................................................................................

.......................................................................................

.......................................................................................

PHONE

.......................................................................................

......................................................................................

You are able to get pregnant again within a couple of weeks. If you would like contraception, it should be started immediately. You can start most methods at the same time you take your misoprostol tablets

Please come back for a follow-up visit in 1 - 2 weeks to ensure that your treatment was successful.

Using misoprostol tablets to treat incomplete abortion

If you are having an incomplete

abortion, you can be treated safely

and effectively with

misoprostol tablets

HEALTH CLINIC