A postabortion care strategy is a public health approach that focuses on identifying and correcting critical deficits in emergency medical service delivery and management. In a postabortion care approach, health systems treat abortion complications quickly and efficiently and ensure that medical care, family planning, and other reproductive health care are available and accessible to as many women as possible. Postabortion care includes family planning counseling and services offered to all women treated for abortion complications (and their partners, when appropriate) to reduce their risk of future unwanted pregnancies and repeat abortions and refers women to other reproductive health services as needed (87, 277).

Working in stages. The key to an effective postabortion care strategy is starting with whatever improvements in care are most feasible and most appropriate for each particular setting—and starting immediately. The level of medical care available and factors that affect women's access to care vary widely throughout developing countries. In many situations a postabortion care strategy will need to be developed and introduced in stages. For example, in some Latin American countries the stigma attached to manual vacuum aspiration (MVA) equipment was so great that many practitioners were not eager to adopt the new technique for postabortion care. In such settings working first to offer family planning services to all postabortion women met with more success (100). In other settings a full-scale program training physicians in MVA, creating an MVA treatment area, and introducing family planning services has been successful (177).

In most developing countries improving postabortion care is an enormous challenge. Improving care requires leadership within the health system, strategic planning, programmatic change, and cooperation among various sectors of the health system. Often, advocates of improved postabortion care will find that they are at only the beginning stage of an overall postabortion care plan. Ultimately, all postabortion care strategies should make available care that is complete, appropriate, and prompt. The word "CAP" can be used as an acronym to help remember the three components of effective postabortion care:

Complete care: Ensuring that all women treated for complications of unsafe abortion are offered family planning counseling and services as well as other reproductive health care (see Chapter 3).
Appropriate care: Adopting manual vacuum aspiration (MVA) and switching to local anesthesia to provide women with better care and to consume fewer resources (see Chapter 4). Training providers, including nonphysicians where appropriate, to provide postabortion care under local anesthesia.
Prompt care: Avoiding delays by decentralizing postabortion care and setting up a referral system so that women receive care earlier (see Chapter 5).

A postabortion care strategy is a combined approach that emphasizes both treatment and prevention—treatment of the current emergency and prevention of future unintended pregnancies, especially among women highly likely to resort to unsafe abortion. Effectively treating abortion complications, providing family planning to prevent future unintended pregnancies and unsafe abortions, and linking women to other reproductive health services can substantially reduce the number of abortion-related deaths—taking a significant step toward the global goal of reducing maternal mortality.

Communicating for change. Information, education, and communication (IEC) programs to identify and publicize the scope of the problem and alert the public and health care providers to potential solutions are a critical part of a postabortion care strategy (282). Health system administrators and policy-makers first need to learn about and acknowledge the magnitude of the problem of unsafe abortion in their countries before they can plan ahead to provide the care women need (186). Thus, advocacy for better postabortion care is often the necessary first step. Public health advocates can speak out about the need to provide postabortion care, citing local statistics on women's deaths and the costs to local hospitals and clinics (184, 187, 282) (see sidebar What Can Be Done?). Community health workers and primary-level providers can develop campaigns informing the public about the dangers of unsafe abortion and the need to seek care immediately when complications develop (87, 184, 187, 282).

Also, mass-media campaigns can alert the public to the problem of unsafe abortion. In Bolivia, for example, the 1994 and 1996 national reproductive health campaigns included radio and television spots about maternal deaths caused by unsafe abortion. According to evaluation findings, people were more likely to recall the spots about unsafe abortion than any of the others in the campaign (234, 267).

When health officials, political and community leaders, and women's organizations speak out about maternal mortality and the dangers of unsafe abortion, they can encourage public discussion and sometimes generate public will to address the problem. For example, Bolivia's vice president and his wife called attention to the need to reduce maternal mortality by appearing together in a television spot for the 1996 national reproductive health campaign (234). Later, when the Bolivian secretary of health sparked controversy by publicly discussing unsafe abortion, the resulting media coverage reached all corners of the country. While no formal programmatic action has yet resulted from this public debate, many people throughout the country became convinced of the need to provide care for women suffering from abortion complications (31).

Within the health system, providers at all levels often need to be educated about the seriousness of abortion complications. Baseline research for an Egyptian project, for example, found that few physicians knew the common long-term health effects of unsafe abortion (214). In many countries providers are unaware of the magnitude of the problem in their area or the large role that abortion complications play in causing maternal deaths. Also, educating providers about the dangers of folk abortion methods is important in some areas. In Nepal, for example, a 5-hospital study found that vaginal preparations and ointments, the most common abortion methods used by traditional birth attendants, were associated with half of the deaths reported (255).

Providers and others in the community invariably have questions about the legality of treating postabortion complications. In Kenya, for example, during a postabortion care workshop, providers asked that training include a session explaining their country's abortion restrictions so that providers would understand clearly the legality of providing postabortion care (243). Advocates can provide clear information, citing international mandates such as the Cairo Program of Action as well as national and local statements that postabortion care is legal and important (145) (see sidebar, International Statements Urge Humane Postabortion Care).

Addressing negative attitudes. An important component of every strategy to improve postabortion care is addressing negative attitudes—among the public, among policy-makers, and among health care providers. Effective postabortion care training programs for health care providers encourage them to examine their attitudes about unsafe abortion and the women who suffer its consequences. Providers learn to examine the social problem of unsafe abortion, including its role in maternal deaths. Role-playing exercises can help providers look at individual women's experiences and to empathize with the circumstances that lead them to have unsafe abortions. Empathy means putting oneself in another person's situation and trying to understand that person's feelings and point of view (see sidebar Put Yourself In Her Shoes). When providers and others learn to empathize, they learn not to assume that they know the woman's circumstances but instead to see each woman as an individual who needs medical care (276).

Saving lives, resources, and money. Planning and implementing an effective postabortion care strategy, however, does not mean that developing-country health systems must devote a majority of their health resources to postabortion care. Many improvements in postabortion care require only minimal additional expenditures for equipment, facilities, or staff (89, 126, 282). In fact, providing improved postabortion care that is strategically planned for and effectively delivered is likely to consume fewer health resources than the "crisis management" approach currently found in most countries. For example, cost comparisons at four Kenyan sites found that treatment with manual vacuum aspiration on an outpatient basis was 23% to 66% less costly than the standard treatment using sharp curettage and requiring an overnight stay (126). Comparisons among five Mexican hospitals found that costs were 17% to 72% lower with planned postabortion care that included MVA on an outpatient basis. Savings came from changes in patient management, including treatment on an outpatient basis and use of local anesthesia (126).

Furthermore, the health care improvements needed for an effective postabortion care strategy are the same improvements needed to improve medical care for all pregnancy-related emergencies and even many general emergencies. Thus a plan to improve postabortion care can contribute to improvements in other key aspects of medical care and be part of a larger initiative to improve all emergency care.