Expanding Access to Postabortion Care Services in Angola with the Introduction of Misoprostol

Globally, 47,000 women die each year from complications due to unsafe abortion.1 Angola, a country with stark health disparities between its rural and urban populations, has a maternal mortality ratio of 610 maternal deaths per 100,000 live births.2 Complications resulting from unsafe abortion contribute significantly to maternal morbidity and mortality and abortion-related deaths are the leading cause of preventable maternal mortality in Angola. Postabortion care (PAC) is a globally endorsed intervention to treat complications due to incomplete abortion or miscarriage and provide family planning services. The World Health Organization (WHO) recommends misoprostol and manual vacuum aspiration (MVA) for the treatment of incomplete abortion and miscarriage.3 Misoprostol is a safe, effective, heat-stable and inexpensive treatment method,4,5 with efficacy rates similar to those of MVA.6,7 It can be administered by mid-level providers in facilities lacking MVA or other surgical capacity.8

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Final Report in Brief

n June 2012, the Angola National Directorate of Public Health and

the Ministry of Health, with support from Venture Strategies Innovations (VSI), initiated a pilot project in Luanda with the aim of increasing access to PAC and to ultimately help reduce maternal mortality and morbidity due to complications of unsafe abortion. Ten health centers in three municipalities in Luanda Province implemented the project: Samba and Kinanga in Samba

I

http://www.minsa.gov.ao/

municipality; Katambor, Kassequel, Alegria and Rocha Pinto in Maianga municipality; and Ana Paula, Viana II, KM12 and Bita Sapu in Viana municipality (Figure 1).

The primary goal of this project was to expand access to PAC by introducing misoprostol for treatment of incomplete abortion at all levels of the health care system. The project’s main objective was to evaluate the feasibility, safety and

effectiveness of misoprostol administration by nurses and midwives, including elementary midwives in health centers. The results of this project will serve as a basis for the revision of guidelines for the treatment of incomplete abortion in Angola.

PILOT PROGRAM COMPONENTSThe PAC pilot included three activities: 1) strengthening of facility-based PAC services, and expansion of services to health centers through integration of medical treatment with misoprostol; 2) an exit interview to assess women’s satisfaction with the misoprostol for PAC services; and 3) a provider survey to assess provider perspectives and acceptability of using misoprostol for PAC.

Facility-based PAC protocolPAC services included treatment of incomplete abortion and miscarriage,

contraceptive counseling and methods provision, and referral services to higher-level facilities. Misoprostol and MVA were used for the treatment of incomplete abortion and miscarriage at health facilities. Misoprostol for treatment of incomplete abortion was introduced as a first-line treatment option for women presenting with a uterine size equivalent to 12 weeks or less without signs of complications. MVA was reserved for more complicated cases, greater uterine size, or as a back-up method if treatment with misoprostol was unsuccessful. All women were to receive postabortion family planning counseling and their choice of a modern contraceptive. Women were referred from health centers to hospitals through existing referral linkages when cases were

complicated or treatment was beyond the capacity of the health center.

In total, 49 providers were trained at the ten participating health centers, ensuring that every health center had at least two trained providers.

RESULTSBetween June and September 2012, 402 women presented at health centers for treatment of incomplete abortion or miscarriage (Table 1). Of these women, over half (59%) completed an exit interview. In addition, thirty-three providers completed a provider survey.

Misoprostol was the primary treatment method used for incomplete abortion and

miscarriageThe introduction of misoprostol expanded access to PAC by building the capacity of nurses and midwives not previously trained in MVA to treat incomplete abortion. Of the 402 women treated for incomplete abortion and miscarriage, 375 (93%) were treated with misoprostol (Table 2). Safe and high-quality PAC services were provided at all levelsNo adverse events due to treatment and no maternal deaths were recorded during the pilot. Of the 231 women who returned for follow-up, 94% had a complete procedure with a single dose of misoprostol. Only nine women who returned for a follow-up visit required additional

interventions for completion, and only one woman was transferred to another facility due to treatment failure. In addition, all participating providers administered the correct dose of misoprostol (a single dose of 600 mcg) orally. Most women (78%) had no symptoms after taking misoprostol. Among those who reported symptoms, the most commonly reported were vaginal bleeding (20%), followed by abdominal pain (15%) and chills (8%). Contraceptive uptake varied by districtAn important component of PAC services is the counseling and provision of contraceptive methods after treatment. In total, the majority of women (71%) received a contraceptive method and of those, 64% received a method at their initial consultation (Table 3). Contraceptive

uptake varied by district, ranging from 68% in Maianga and Viana to 84% in Samba. The most common contraceptive methods given to women were injectable contraceptives (20%) and oral contraceptive pills (18%).

Nearly two-thirds (65%) of women reported not using contraceptives before requiring PAC services (Figure 2). Of the 35% of women who reported using contraceptives, 18% did not use the method regularly, and the remaining 18% used the method regularly, but cited method failure as the reason for pregnancy. This further emphasizes the importance of strengthening access to family planning services.

Providers felt confident in using misoprostol for postabortion careA total of 33 health providers

participated in provider surveys, representing all participating health facilities. All agreed or strongly agreed that it was easy to learn how to use misoprostol to treat incomplete abortion; that they felt comfortable using misoprostol to treat incomplete abortion; and that the training they had received made them confident in using misoprostol for treatment of incomplete abortion.

CONCLUSIONSEnabling health centers to provide PAC through the integration of misoprostol as a treatment method increases the availability of PAC services and brings them closer to women. The introduction of misoprostol increased access to PAC by training nurses, midwives and elementary midwives on using misoprostol for the treatment of incomplete abortion and miscarriage. The project demonstrated that misoprostol is a safe, effective and feasible treatment method for incomplete abortion at all levels of the health system, including those facilities that do not have the capacity for MVA. RecommendationsExpand PAC services to all health centers and hospitals by training all providers on the use of misoprostol for the treatment of incomplete

abortion and miscarriage. Update technical guidelines to include misoprostol for the treatment of incomplete abortion and miscarriage and disseminate the revised guidelines to all major stakeholders and PAC health providers.

Engage providers and other municipality health staff in community sensitization activities to raise awareness of unwanted pregnancy, the consequences of unsafe abortion, availability of PAC services, and the importance of follow-up. Acknowledgements We would like to express our gratitude to all contributors and participants, including the providers and enrolled women, without whom

this project would not have been possible. In particular, we would like to acknowledge the contributions of the Head of the Reproductive Health Department of the National Directorate of Public Health, Dr. Maria Ines Neves; the Provincial

Director of Health Luanda, Dr. Maria Isabel Neves Massocolo; and the Provincial Coordinator for the Reproductive Health program, Dr. Joana Fernandes. In addition, all of the providers who participated, including Elisa Pinto John, Samba Health Center (HC); Vanda Peres Cruz, Kassequel HC; S. Gennaro Samba, Katambor HC; Matondo Jossai, CS Joy, Beatriz Passos Gonga, Rocha Pinto HC; Maria de Fátima Favors, Km 12 HC; Filomena M. Kangupe, I Viana HC; Maria Domingos, Viana II HC; and Rita Meliana Mbiyeye, Bita Sapu HC.

Figure 1: Project sites in Luanda Province

Viana

Maianga

Samba

n June 2012, the Angola National Directorate of Public Health and

the Ministry of Health, with support from Venture Strategies Innovations (VSI), initiated a pilot project in Luanda with the aim of increasing access to PAC and to ultimately help reduce maternal mortality and morbidity due to complications of unsafe abortion. Ten health centers in three municipalities in Luanda Province implemented the project: Samba and Kinanga in Samba

municipality; Katambor, Kassequel, Alegria and Rocha Pinto in Maianga municipality; and Ana Paula, Viana II, KM12 and Bita Sapu in Viana municipality (Figure 1).

The primary goal of this project was to expand access to PAC by introducing misoprostol for treatment of incomplete abortion at all levels of the health care system. The project’s main objective was to evaluate the feasibility, safety and

effectiveness of misoprostol administration by nurses and midwives, including elementary midwives in health centers. The results of this project will serve as a basis for the revision of guidelines for the treatment of incomplete abortion in Angola.

PILOT PROGRAM COMPONENTSThe PAC pilot included three activities: 1) strengthening of facility-based PAC services, and expansion of services to health centers through integration of medical treatment with misoprostol; 2) an exit interview to assess women’s satisfaction with the misoprostol for PAC services; and 3) a provider survey to assess provider perspectives and acceptability of using misoprostol for PAC.

Facility-based PAC protocolPAC services included treatment of incomplete abortion and miscarriage,

contraceptive counseling and methods provision, and referral services to higher-level facilities. Misoprostol and MVA were used for the treatment of incomplete abortion and miscarriage at health facilities. Misoprostol for treatment of incomplete abortion was introduced as a first-line treatment option for women presenting with a uterine size equivalent to 12 weeks or less without signs of complications. MVA was reserved for more complicated cases, greater uterine size, or as a back-up method if treatment with misoprostol was unsuccessful. All women were to receive postabortion family planning counseling and their choice of a modern contraceptive. Women were referred from health centers to hospitals through existing referral linkages when cases were

complicated or treatment was beyond the capacity of the health center.

In total, 49 providers were trained at the ten participating health centers, ensuring that every health center had at least two trained providers.

RESULTSBetween June and September 2012, 402 women presented at health centers for treatment of incomplete abortion or miscarriage (Table 1). Of these women, over half (59%) completed an exit interview. In addition, thirty-three providers completed a provider survey.

Misoprostol was the primary treatment method used for incomplete abortion and

miscarriageThe introduction of misoprostol expanded access to PAC by building the capacity of nurses and midwives not previously trained in MVA to treat incomplete abortion. Of the 402 women treated for incomplete abortion and miscarriage, 375 (93%) were treated with misoprostol (Table 2). Safe and high-quality PAC services were provided at all levelsNo adverse events due to treatment and no maternal deaths were recorded during the pilot. Of the 231 women who returned for follow-up, 94% had a complete procedure with a single dose of misoprostol. Only nine women who returned for a follow-up visit required additional

interventions for completion, and only one woman was transferred to another facility due to treatment failure. In addition, all participating providers administered the correct dose of misoprostol (a single dose of 600 mcg) orally. Most women (78%) had no symptoms after taking misoprostol. Among those who reported symptoms, the most commonly reported were vaginal bleeding (20%), followed by abdominal pain (15%) and chills (8%). Contraceptive uptake varied by districtAn important component of PAC services is the counseling and provision of contraceptive methods after treatment. In total, the majority of women (71%) received a contraceptive method and of those, 64% received a method at their initial consultation (Table 3). Contraceptive

uptake varied by district, ranging from 68% in Maianga and Viana to 84% in Samba. The most common contraceptive methods given to women were injectable contraceptives (20%) and oral contraceptive pills (18%).

Nearly two-thirds (65%) of women reported not using contraceptives before requiring PAC services (Figure 2). Of the 35% of women who reported using contraceptives, 18% did not use the method regularly, and the remaining 18% used the method regularly, but cited method failure as the reason for pregnancy. This further emphasizes the importance of strengthening access to family planning services.

Providers felt confident in using misoprostol for postabortion careA total of 33 health providers

participated in provider surveys, representing all participating health facilities. All agreed or strongly agreed that it was easy to learn how to use misoprostol to treat incomplete abortion; that they felt comfortable using misoprostol to treat incomplete abortion; and that the training they had received made them confident in using misoprostol for treatment of incomplete abortion.

CONCLUSIONSEnabling health centers to provide PAC through the integration of misoprostol as a treatment method increases the availability of PAC services and brings them closer to women. The introduction of misoprostol increased access to PAC by training nurses, midwives and elementary midwives on using misoprostol for the treatment of incomplete abortion and miscarriage. The project demonstrated that misoprostol is a safe, effective and feasible treatment method for incomplete abortion at all levels of the health system, including those facilities that do not have the capacity for MVA. RecommendationsExpand PAC services to all health centers and hospitals by training all providers on the use of misoprostol for the treatment of incomplete

abortion and miscarriage. Update technical guidelines to include misoprostol for the treatment of incomplete abortion and miscarriage and disseminate the revised guidelines to all major stakeholders and PAC health providers.

Engage providers and other municipality health staff in community sensitization activities to raise awareness of unwanted pregnancy, the consequences of unsafe abortion, availability of PAC services, and the importance of follow-up. Acknowledgements We would like to express our gratitude to all contributors and participants, including the providers and enrolled women, without whom

this project would not have been possible. In particular, we would like to acknowledge the contributions of the Head of the Reproductive Health Department of the National Directorate of Public Health, Dr. Maria Ines Neves; the Provincial

Director of Health Luanda, Dr. Maria Isabel Neves Massocolo; and the Provincial Coordinator for the Reproductive Health program, Dr. Joana Fernandes. In addition, all of the providers who participated, including Elisa Pinto John, Samba Health Center (HC); Vanda Peres Cruz, Kassequel HC; S. Gennaro Samba, Katambor HC; Matondo Jossai, CS Joy, Beatriz Passos Gonga, Rocha Pinto HC; Maria de Fátima Favors, Km 12 HC; Filomena M. Kangupe, I Viana HC; Maria Domingos, Viana II HC; and Rita Meliana Mbiyeye, Bita Sapu HC.

Table 2: Incomplete abortion and miscarriage cases presenting by municipality (June-September 2012) (n=402)

Table 1: Data for analysis, by municipality (June – September 2012) Maianga Samba Viana Total

Women presenting for treatment of incomplete abortion and miscarriage

160 (39.8%) 69 (17.2%) 173 (43.0%) 402

Exit Interviews with women 124 (77.5%) 33 (47.8%) 79 (45.7%) 236 (58.7%) Provider Surveys 16 (48.5%) 7 (21.2%) 10 (30.3%) 33 (67.3%)

Maianga (n=160)

Samba (n=69)

Viana (n=173)

Total (n=402)

Treatment at initial visit Treatment of incomplete abortion 148 (92.5%) 69 (100.0%) 171 (98.8%) 388 (96.5%) Other/unspecified 12 (7.5%) 0 2 (1.2%) 14 (3.5%) Method at baseline MVA 7 (4.4%) 1 (1.5%) 18 (10.4%) 26 (6.5%) Misoprostol 152 (95.0%) 68 (98.6%) 155 (89.6%) 375 (93.3%) Other 1 (0.6%) 0 0 1 (0.3%) Result of initial treatment at follow-up visit Successful treatment (out of all women treated) 113 (70.6%) 29 (42.0%) 76 (43.9%) 218 (54.2%) Received additional treatment 4 (2.5%) 1 (1.5%) 4 (2.3%) 9 (2.2%) Transferred to another facility 1 (0.6%) 0 0 1 (0.3%) Did not return for a follow-up 42 (26.3%) 38 (55.1%) 91 (52.6%) 171 (42.5%) Other/unspecified 0 1 (1.5%) 2 (1.2%) 3 (0.7%) Successful treatment (out of women who returned for follow up) 113 (95.8%) 29 (93.5%) 76 (92.7%) 218 (94.4%)

n June 2012, the Angola National Directorate of Public Health and

the Ministry of Health, with support from Venture Strategies Innovations (VSI), initiated a pilot project in Luanda with the aim of increasing access to PAC and to ultimately help reduce maternal mortality and morbidity due to complications of unsafe abortion. Ten health centers in three municipalities in Luanda Province implemented the project: Samba and Kinanga in Samba

municipality; Katambor, Kassequel, Alegria and Rocha Pinto in Maianga municipality; and Ana Paula, Viana II, KM12 and Bita Sapu in Viana municipality (Figure 1).

The primary goal of this project was to expand access to PAC by introducing misoprostol for treatment of incomplete abortion at all levels of the health care system. The project’s main objective was to evaluate the feasibility, safety and

effectiveness of misoprostol administration by nurses and midwives, including elementary midwives in health centers. The results of this project will serve as a basis for the revision of guidelines for the treatment of incomplete abortion in Angola.

PILOT PROGRAM COMPONENTSThe PAC pilot included three activities: 1) strengthening of facility-based PAC services, and expansion of services to health centers through integration of medical treatment with misoprostol; 2) an exit interview to assess women’s satisfaction with the misoprostol for PAC services; and 3) a provider survey to assess provider perspectives and acceptability of using misoprostol for PAC.

Facility-based PAC protocolPAC services included treatment of incomplete abortion and miscarriage,

contraceptive counseling and methods provision, and referral services to higher-level facilities. Misoprostol and MVA were used for the treatment of incomplete abortion and miscarriage at health facilities. Misoprostol for treatment of incomplete abortion was introduced as a first-line treatment option for women presenting with a uterine size equivalent to 12 weeks or less without signs of complications. MVA was reserved for more complicated cases, greater uterine size, or as a back-up method if treatment with misoprostol was unsuccessful. All women were to receive postabortion family planning counseling and their choice of a modern contraceptive. Women were referred from health centers to hospitals through existing referral linkages when cases were

complicated or treatment was beyond the capacity of the health center.

In total, 49 providers were trained at the ten participating health centers, ensuring that every health center had at least two trained providers.

RESULTSBetween June and September 2012, 402 women presented at health centers for treatment of incomplete abortion or miscarriage (Table 1). Of these women, over half (59%) completed an exit interview. In addition, thirty-three providers completed a provider survey.

Misoprostol was the primary treatment method used for incomplete abortion and

miscarriageThe introduction of misoprostol expanded access to PAC by building the capacity of nurses and midwives not previously trained in MVA to treat incomplete abortion. Of the 402 women treated for incomplete abortion and miscarriage, 375 (93%) were treated with misoprostol (Table 2). Safe and high-quality PAC services were provided at all levelsNo adverse events due to treatment and no maternal deaths were recorded during the pilot. Of the 231 women who returned for follow-up, 94% had a complete procedure with a single dose of misoprostol. Only nine women who returned for a follow-up visit required additional

interventions for completion, and only one woman was transferred to another facility due to treatment failure. In addition, all participating providers administered the correct dose of misoprostol (a single dose of 600 mcg) orally. Most women (78%) had no symptoms after taking misoprostol. Among those who reported symptoms, the most commonly reported were vaginal bleeding (20%), followed by abdominal pain (15%) and chills (8%). Contraceptive uptake varied by districtAn important component of PAC services is the counseling and provision of contraceptive methods after treatment. In total, the majority of women (71%) received a contraceptive method and of those, 64% received a method at their initial consultation (Table 3). Contraceptive

uptake varied by district, ranging from 68% in Maianga and Viana to 84% in Samba. The most common contraceptive methods given to women were injectable contraceptives (20%) and oral contraceptive pills (18%).

Nearly two-thirds (65%) of women reported not using contraceptives before requiring PAC services (Figure 2). Of the 35% of women who reported using contraceptives, 18% did not use the method regularly, and the remaining 18% used the method regularly, but cited method failure as the reason for pregnancy. This further emphasizes the importance of strengthening access to family planning services.

Providers felt confident in using misoprostol for postabortion careA total of 33 health providers

participated in provider surveys, representing all participating health facilities. All agreed or strongly agreed that it was easy to learn how to use misoprostol to treat incomplete abortion; that they felt comfortable using misoprostol to treat incomplete abortion; and that the training they had received made them confident in using misoprostol for treatment of incomplete abortion.

CONCLUSIONSEnabling health centers to provide PAC through the integration of misoprostol as a treatment method increases the availability of PAC services and brings them closer to women. The introduction of misoprostol increased access to PAC by training nurses, midwives and elementary midwives on using misoprostol for the treatment of incomplete abortion and miscarriage. The project demonstrated that misoprostol is a safe, effective and feasible treatment method for incomplete abortion at all levels of the health system, including those facilities that do not have the capacity for MVA. RecommendationsExpand PAC services to all health centers and hospitals by training all providers on the use of misoprostol for the treatment of incomplete

abortion and miscarriage. Update technical guidelines to include misoprostol for the treatment of incomplete abortion and miscarriage and disseminate the revised guidelines to all major stakeholders and PAC health providers.

Engage providers and other municipality health staff in community sensitization activities to raise awareness of unwanted pregnancy, the consequences of unsafe abortion, availability of PAC services, and the importance of follow-up. Acknowledgements We would like to express our gratitude to all contributors and participants, including the providers and enrolled women, without whom

this project would not have been possible. In particular, we would like to acknowledge the contributions of the Head of the Reproductive Health Department of the National Directorate of Public Health, Dr. Maria Ines Neves; the Provincial

Director of Health Luanda, Dr. Maria Isabel Neves Massocolo; and the Provincial Coordinator for the Reproductive Health program, Dr. Joana Fernandes. In addition, all of the providers who participated, including Elisa Pinto John, Samba Health Center (HC); Vanda Peres Cruz, Kassequel HC; S. Gennaro Samba, Katambor HC; Matondo Jossai, CS Joy, Beatriz Passos Gonga, Rocha Pinto HC; Maria de Fátima Favors, Km 12 HC; Filomena M. Kangupe, I Viana HC; Maria Domingos, Viana II HC; and Rita Meliana Mbiyeye, Bita Sapu HC.

Table 3: Women who received a contraceptive method at the initial visit or at follow up, by municipality (n = 402)

Maianga (n=160)

Samba

(n=69) Viana

(n=173) Total

(n=402)

Total number of women accepted a contraceptive method

109 (68.1%) 58 (84.1%) 117 (67.6%) 284 (70.6%)

Accepted at the initial visit 99 (61.9%) 58 (84.1%) 99 (57.2%) 256 (63.7%) Accepted at follow-up visit 10 (17.5%) 0 18 (24.3%) 28 (7.0%)

Figure 2: Contraceptive use before pregnancy (n = 402)

17.5% 17.5%

65.0%

0%10%20%30%40%50%60%70%80%90%

100%

Used regularly, the method failed

Not used regularly Not used

This brief was produced by VSI ©2013.

n June 2012, the Angola National Directorate of Public Health and

the Ministry of Health, with support from Venture Strategies Innovations (VSI), initiated a pilot project in Luanda with the aim of increasing access to PAC and to ultimately help reduce maternal mortality and morbidity due to complications of unsafe abortion. Ten health centers in three municipalities in Luanda Province implemented the project: Samba and Kinanga in Samba

2 WHO. Trends in Maternal Mortality: 1990 to 2008: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: WHO, 2010.

municipality; Katambor, Kassequel, Alegria and Rocha Pinto in Maianga municipality; and Ana Paula, Viana II, KM12 and Bita Sapu in Viana municipality (Figure 1).

The primary goal of this project was to expand access to PAC by introducing misoprostol for treatment of incomplete abortion at all levels of the health care system. The project’s main objective was to evaluate the feasibility, safety and

effectiveness of misoprostol administration by nurses and midwives, including elementary midwives in health centers. The results of this project will serve as a basis for the revision of guidelines for the treatment of incomplete abortion in Angola.

PILOT PROGRAM COMPONENTSThe PAC pilot included three activities: 1) strengthening of facility-based PAC services, and expansion of services to health centers through integration of medical treatment with misoprostol; 2) an exit interview to assess women’s satisfaction with the misoprostol for PAC services; and 3) a provider survey to assess provider perspectives and acceptability of using misoprostol for PAC.

Facility-based PAC protocolPAC services included treatment of incomplete abortion and miscarriage,

contraceptive counseling and methods provision, and referral services to higher-level facilities. Misoprostol and MVA were used for the treatment of incomplete abortion and miscarriage at health facilities. Misoprostol for treatment of incomplete abortion was introduced as a first-line treatment option for women presenting with a uterine size equivalent to 12 weeks or less without signs of complications. MVA was reserved for more complicated cases, greater uterine size, or as a back-up method if treatment with misoprostol was unsuccessful. All women were to receive postabortion family planning counseling and their choice of a modern contraceptive. Women were referred from health centers to hospitals through existing referral linkages when cases were

complicated or treatment was beyond the capacity of the health center.

In total, 49 providers were trained at the ten participating health centers, ensuring that every health center had at least two trained providers.

RESULTSBetween June and September 2012, 402 women presented at health centers for treatment of incomplete abortion or miscarriage (Table 1). Of these women, over half (59%) completed an exit interview. In addition, thirty-three providers completed a provider survey.

Misoprostol was the primary treatment method used for incomplete abortion and

miscarriageThe introduction of misoprostol expanded access to PAC by building the capacity of nurses and midwives not previously trained in MVA to treat incomplete abortion. Of the 402 women treated for incomplete abortion and miscarriage, 375 (93%) were treated with misoprostol (Table 2). Safe and high-quality PAC services were provided at all levelsNo adverse events due to treatment and no maternal deaths were recorded during the pilot. Of the 231 women who returned for follow-up, 94% had a complete procedure with a single dose of misoprostol. Only nine women who returned for a follow-up visit required additional

interventions for completion, and only one woman was transferred to another facility due to treatment failure. In addition, all participating providers administered the correct dose of misoprostol (a single dose of 600 mcg) orally. Most women (78%) had no symptoms after taking misoprostol. Among those who reported symptoms, the most commonly reported were vaginal bleeding (20%), followed by abdominal pain (15%) and chills (8%). Contraceptive uptake varied by districtAn important component of PAC services is the counseling and provision of contraceptive methods after treatment. In total, the majority of women (71%) received a contraceptive method and of those, 64% received a method at their initial consultation (Table 3). Contraceptive

uptake varied by district, ranging from 68% in Maianga and Viana to 84% in Samba. The most common contraceptive methods given to women were injectable contraceptives (20%) and oral contraceptive pills (18%).

Nearly two-thirds (65%) of women reported not using contraceptives before requiring PAC services (Figure 2). Of the 35% of women who reported using contraceptives, 18% did not use the method regularly, and the remaining 18% used the method regularly, but cited method failure as the reason for pregnancy. This further emphasizes the importance of strengthening access to family planning services.

Providers felt confident in using misoprostol for postabortion careA total of 33 health providers

participated in provider surveys, representing all participating health facilities. All agreed or strongly agreed that it was easy to learn how to use misoprostol to treat incomplete abortion; that they felt comfortable using misoprostol to treat incomplete abortion; and that the training they had received made them confident in using misoprostol for treatment of incomplete abortion.

CONCLUSIONSEnabling health centers to provide PAC through the integration of misoprostol as a treatment method increases the availability of PAC services and brings them closer to women. The introduction of misoprostol increased access to PAC by training nurses, midwives and elementary midwives on using misoprostol for the treatment of incomplete abortion and miscarriage. The project demonstrated that misoprostol is a safe, effective and feasible treatment method for incomplete abortion at all levels of the health system, including those facilities that do not have the capacity for MVA. RecommendationsExpand PAC services to all health centers and hospitals by training all providers on the use of misoprostol for the treatment of incomplete

abortion and miscarriage. Update technical guidelines to include misoprostol for the treatment of incomplete abortion and miscarriage and disseminate the revised guidelines to all major stakeholders and PAC health providers.

Engage providers and other municipality health staff in community sensitization activities to raise awareness of unwanted pregnancy, the consequences of unsafe abortion, availability of PAC services, and the importance of follow-up. Acknowledgements We would like to express our gratitude to all contributors and participants, including the providers and enrolled women, without whom

this project would not have been possible. In particular, we would like to acknowledge the contributions of the Head of the Reproductive Health Department of the National Directorate of Public Health, Dr. Maria Ines Neves; the Provincial

Director of Health Luanda, Dr. Maria Isabel Neves Massocolo; and the Provincial Coordinator for the Reproductive Health program, Dr. Joana Fernandes. In addition, all of the providers who participated, including Elisa Pinto John, Samba Health Center (HC); Vanda Peres Cruz, Kassequel HC; S. Gennaro Samba, Katambor HC; Matondo Jossai, CS Joy, Beatriz Passos Gonga, Rocha Pinto HC; Maria de Fátima Favors, Km 12 HC; Filomena M. Kangupe, I Viana HC; Maria Domingos, Viana II HC; and Rita Meliana Mbiyeye, Bita Sapu HC.

3 WHO. Technical and Policy Guidance on Safe Abortion. Second Edition. Geneva: WHO, 2012.

1 World Health Organization (WHO). Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Third Edition. Geneva: WHO, 2011.

Provider perspectives

6 Dao B, Blum J, Thieba B, et al. Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa. BJOG: An International Journal of Obstetrics & Gynaecology, 2007;114 (11):1368-75.

4 el-Refaey H, O'Brien P, Morafa W, et al. Use of oral misoprostol in the prevention of postpartum hemorrhage. British Journal of Obstetrics and Gynaecology 1997;104:336-39.5 Blum J, Winikoff B, Gemzell-Danielsson K, et al. Treatment of incomplete abortion and miscarriage with misoprostol. International Journal of Gynecology & Obstetrics 2007;99:S186-89.

7 Bique C, Ustá M, Debora B, et al. Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion. International Journal of Gynecology & Obstetrics 2007;98 (3):222-6.

“Let the PAC services be integrated permanently in all health centers, because the patients are already accustomed. There have been

fewer cases of transfers to hospitals. Let the supply of misoprostol continue.”

“I like the approach of PAC services. Misoprostol is easy and effective administration.”

Participating health center, Viana Municipality