Health systems in Bolivia and Mexico are successfully integrating post-abortion care into their national health strategies.

Photo courtesy of Richard Lord

Every year, more than 68,000 women worldwide die from complications caused by unsafe abortions — those performed under unhygienic conditions or by untrained providers. Millions suffer injuries that have adverse effects on their health and lives.

Women need and have a right to high-quality care when experiencing complications from unsafe abortion. After the 1994 International Conference on Population and Development (ICPD) in Cairo, stakeholders throughout the world have been working to incorporate postabortion care (PAC) — including clinical care and contraceptive services — into public-sector health services so that women can have access to timely, often life-saving care.  

Ipas researcher Dr. Deborah Billings and her colleagues Dr. Barbara B. Crane, Dr. Janie Benson, Julie Solo and Tamara Fetters have published a groundbreaking study that examines the ways in which PAC services were “scaled-up” — initiated, expanded and incorporated (“institutionalized”) — into national health systems in Bolivia and Mexico. Their findings were published in the June 2007 issue of Social Science & Medicine, in an article entitled “Scaling-up a public health innovation: A comparative study of post-abortion care in Bolivia and Mexico.”

The authors created case studies based on interviews with 49 key stakeholders in both countries and a review of health-care policies, service statistics, and reports from international organizations working with the health sector. From the findings, they developed an evidence-based model for PAC scale-up, which highlights the three stages and the necessary inputs and conditions to make each a success. These include financial resources, visionary leadership, public sector-civil society partnerships, training, policies, research and appropriate technologies.     

Both Bolivia and Mexico have been successful at institutionalizing PAC to different degrees. Success in Bolivia has been particularly strong, due to coordinated efforts among stakeholders in government and civil society, the development of comprehensive PAC norms for health services, and a commitment to training health-care providers in how to put the norms into practice.  The cost of PAC services is covered through Bolivia’s national maternal and child health insurance, which significantly reduces the amount of money that women and their families need to spend to obtain care. 

Today, PAC services are available at primary, secondary, and tertiary health care facilities in Bolivia. Six medical and nursing schools require that students receive training in PAC, including using manual vacuum aspiration (MVA) in place of dilatation and curettage (D&C).

PAC services are offered in all of Mexico’s major health systems, but decentralization, size and the diversity of services present challenges to fully institutionalizing PAC. In Mexico, few services are available to women at the primary level of care, although efforts to create and strengthen such services are under way.  National norms define MVA as the recommended technology for PAC, which is used to treat most women seeking care in one of Mexico’s rural-based health-care systems. However, its use is limited in systems that cover state workers, employees in the private sector and marginalized urban populations.

Ultimately, the success of PAC scale-up needs to be measured by its impact on the lives of women, health-care systems and society at large.  The authors present a set of health, financial and social indicators that can be used to evaluate whether investing in PAC is strategic.  Indicators include decreasing repeat unwanted pregnancy and unsafe abortion, as well as unsafe abortion-related death and illness; reducing the cost of services; and diminishing abortion-related stigma. 

Introducing, expanding and working toward institutionalizing PAC in both Bolivia and Mexico created new openings for discussing abortion and the consequences of unsafe abortion. Whether this has led to a greater commitment to legislative reform of restrictive abortion laws is a question that has yet to be examined in contexts such as Mexico City, where since April 2007, abortion is decriminalized during the first 12 weeks of pregnancy.

Dr. Billings and her colleagues hope that the model for institutionalizing PAC and the indicators of success they propose will help to guide efforts to expand PAC initiatives internationally.  At the same time, they urge stakeholders to weigh the costs and benefits of scaling-up PAC services in lieu of working toward increasing access to safe, legal abortion.

“If options are available,” says Billings, “it makes more sense to invest in safe abortion services so that women won’t experience complications in the first place. It’s good preventive health care; it makes economic sense for health-care systems, and most of all, it makes sense for women’s health and lives.”

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