Within a postabortion care referral system, providers at all levels of the health care system are trained to:

• Recognize complications of abortion and gauge their severity;
• Treat complications promptly when they have the skills and equipment; and
• Refer women they are unable to treat to a facility where they know adequate treatment is available.

Health care workers at the community level. When trained to recognize the signs of abortion complications and to understand the importance of prompt referral to a medical provider, traditional healers or birth attendants can become the first, crucial link in the referral network. Particularly in remote areas, traditional or community health workers are often the first people that women turn to when suffering postabortion complications (255, 282). Community health workers who are trained to identify potential medical emergencies and arrange transport to another facility can make a critical difference in helping women to reach care in time (255, 293). Community healthworkers also can develop community awareness of the dangers of unsafe abortion and educate women about using family planning—important preventive strategies.

The effectiveness of a focus on recognizing complications and referring women for care, especially in rural areas, has been demonstrated in general obstetric referral systems that seek to reduce maternal deaths from all causes (28, 69). In a rural district in Pakistan, for example, a community-based program that trained traditional birth attendants to recognize obstetric complications and refer women promptly for care reduced maternal mortality from all causes by 80% over a 10-year period (28).

Health clinics and other primary care facilities. Primary care facilities include first-aid stations, nursing posts, dispensaries, family planning clinics, and health clinics. Primary care providers—the first level of the formal health care system—usually offer health education and basic medical treatments and perform basic laboratory tests. In an effective referral system, primary-level providers can recognize postabortion complications quickly and distinguish between the cases they can treat and those they must refer.

When primary-level providers are unable to provide necessary medical treatment for abortion complications—either because they lack the skills, equipment, or drugs or because the complication is severe—they quickly refer the woman to a facility where treatment is available (87, 99, 112). When they have the training and supplies, primary-level providers can stabilize the woman's condition and prepare her for transfer to another facility, beginning antibiotic therapy, fluid replacement, or basic pain control and sedation (251, 282, 289, 293). Also, if providers know which methods of unsafe abortion are commonly used in their area, they can be better prepared to recognize and treat the likely complications (232).

When the staff includes an appropriately trained provider, postabortion care at the primary level can include first-trimester (MVA) (186, 282). Often, no new medical facilities or staff are needed to provide emergency postabortion care at this level. Many clinics adding postabortion care, however, will need to acquire MVA equipment, and in most cases additional staff training will be required.

District hospitals—the first referral level. Women who need medical treatment that the primary health care center cannot provide are transferred to a first-referral hospital. These are district hospitals that provide inpatient services and have 20 or more beds. District hospitals should provide general emergency services and have staff, including at least one physician, available 24 hours a day. Staff at this level also are expected to be able to diagnose major complications, such as septicemia, peritonitis, and renal failure, and to refer women to another facility where treatment is available (see Table 3).

Most district hospitals should already have the facilities, equipment, and staff needed to provide life-saving surgical and medical procedures for all but the most serious abortion complications (293). The reality in many developing countries, however, is that most do not (175). To improve postabortion care, most will need to improve general emergency care practices, as well as to train personnel and acquire MVA equipment and supplies (282).

Regional, national, and university hospitals: secondary and tertiary levels. Regional hospitals that provide inpatient and outpatient services are considered secondary-level facilities, while university teaching hospitals and specialized national hospitals are tertiary-level hospitals. Because regional and national hospitals provide specialized surgical services in addition to all the services of the district hospitals, most should already have the facilities and equipment needed to provide good-quality postabortion care for all abortion complications, including the most severe (293). To improve postabortion care, however, they too may need to train personnel and to acquire MVA equipment (see Table 3).

Managing severe complications. Women with severe complications or whose pregnancy was second-trimester often need intravenous fluid replacement, large doses of antibiotics, and diagnostic services that are not available at lower levels of the health system (293). Some may need a blood transfusion, laparotomy, or hysterectomy (72, 154, 250, 282). While these procedures for treating severe complications should be available at national and university hospitals, as well as some regional and district hospitals, they often are unavailable. Planners of postabortion care strategies must ensure that specialized, higher-level care is available for women suffering severe complications. In some settings a postabortion care strategy may need to focus on improving care at the top health care institutions before expanding care to lower levels of the health care system.