LATIN AMERICAN OPERATIONS RESEARCH SUMMARIES

Postabortion Summary #4:

Postabortion Quality of Care in Guatemala

Mario Lobos Orellana, M.D., Gustavo Gutierrez, M.D.,
Carlo Bonatto, M.D., Instituto Guatemalteco de Seguridad Social;
Emma Ottolenghi, M.D., The Population Council

INTRODUCTION
Integration of family planning into postabortion treatment is an important step in improving reproductive health services in Latin America. Presently, only a handful of health care systems in the region offer integrated care. One place where integration has taken place is a large Social Security Institute (IGSS) hospital in Guatemala City which treats 150 postabortion women monthly. Treatment consists of D&C followed by hospitalization. Contraceptives available in-hospital were limited before the study to the IUD and minilaparotomy. Women desiring other methods could receive them if they returned for a checkup, routinely scheduled for three to six weeks after hospital discharge.

With Population Council assistance, IGSS conducted a study of the postabortion service between November 1995 and July 1996. The objective was to examine the quality of care provided, including (1) client-provider interaction, (2) information given to the client, (3) contraceptive availability, and (4) provider ability to diagnose infection status at time of admission. This ability is important if an institution wants to insert IUDs immediately postabortion, because infection is a contraindication for insertion.

METHODOLOGY
A sample of 304 postabortion women, diagnosed at admission as not infected, was asked at discharge to return for a checkup and interview within three to five days. To maximize return, they were offered 50 quetzales (about $8.00) to defray visit costs. Returning women who participated in the study were interviewed about their experience in-hospital. Upon completing the interview, the women were examined to determine if there was evidence of infection. Nonusers of family planning were offered contraception.

RESULTS
Overall, 200 (66%) of the 304 women returned. As intended, payment produced a much higher return rate than usually encountered among postabortion women. Under normal circumstances only about 25% of postabortion women return for checkup.

About 68% of those returning were ages 20 to 35, 20% were over 35, and 12% less than 20. Approximately 91% of women reported being “well-treated” during the postabortion experience. About 8% said treatment was “so-so,” and 1% rated it “bad.” The most common reason for dissatisfaction was length of waiting time in the emergency room before admission. Most women experiencing long waits were being kept under observation by providers, a fact that may not have been adequately explained to them.

About 88% of women received in-hospital family planning information, and 25% received an IUD. No women were sterilized. The remaining 149 did not receive a contraceptive, although 124 stated they would have preferred to receive a method predischarge. About 82% of nonusers accepted a method at the follow-up visit, mainly DMPA. Only a few women knew symptoms of postabortion complications or how soon fertility returned. At checkup, 15% had a pelvic infection, including 5 of 51 IUD users (10%) and 25 of 149 non-family planning users (17%). The small difference in infections encountered suggests that infection status usually cannot be detected or predicted at the time of admission.

DISCUSSION
One-third of the sample was lost to follow-up. Despite this limitation, results suggest that clients are satisfied with postabortion treatment, and that a large demand for predischarge contraception exists. A need for improved counseling about fertility return and postoperative complications was detected. The difficulty of diagnosing infection immediately postabortion was confirmed. As a result of the study, IGSS increased in-hospital contraceptive availability to include hormonal and barrier methods, and published patient information materials. IGSS may also wish to consider delaying insertion for or providing antibiotics to women receiving IUDs. Since few women return for postabortion visits, strategies for increasing return should also become an institutional priority.

ACKNOWLEDGMENTS: Technical and financial assistance was provided to IGSS by the Council Program Development Fund.

USAID funded Latin American Operations Research Summaries as part of The Population Council's INOPAL III project (1995-1998), Contract CCP-95-C-00-00007-00 (formerly CCP-3030-C-00-5007-00), Project No. 936-3030, USAID Office of Population.

Summary issued 10/28/96.