Peru: Leadership Facilitates Sustainability of Postabortion Care Services
OR Summary no. 42

 

Background

In 1996 the Peruvian Ministry of Health (MOH), Ipas, and the Population Council tested an improved postabortion care (PAC) model at the Hospital Carrión in Lima. The two-year intervention included training to improve clinical care, a switch from sharp curettage to manual vacuum aspiration (MVA) for treatment of incomplete abortion, provision of family planning information and methods, and service reorganization to provide PAC as an outpatient service and to concentrate services in the obstetrics-gynecology (OB-GYN) emergency room. Significant service improvements and cost savings resulted from the intervention, and the MOH and Ipas began replication of the service in hospitals in other states.

In 2000 with support from FRONTIERS, Ipas conducted an evaluation study to assess the sustainability of the improvements made during the original intervention. Services were considered sustainable if they had been incorporated as routine hospital practices and continued without external support. The study examined four major aspects of the changes: (1) clinical care, including the use of MVA; (2) provision of family planning information and methods following PAC services; (3) provision of medical care information to clients; and (4) costs to the hospital and clients. Data were collected through review of clinical records, exit interviews with 119 PAC clients, a patient flow analysis, a supplies and equipment audit (or inventory), and in-depth interviews with providers and policymakers. Data from 2000 were compared to pre- and post-intervention data obtained during the 1996 study.

Findings

• Overall, the changes in PAC services have been maintained or improved since the 1996 intervention, with resulting benefits to both the hospital and postabortion clients. MVA has replaced sharp curettage for treatment of virtually all medically appropriate cases of incomplete abortion. In 2000, hospital records showed that MVA use was maintained for an average of 99 percent of patients.
   
• Provision of family planning information and methods increased steadily as PAC services became routine. Nearly three quarters of clients interviewed during the follow-up reported that they had received information about the risk of an immediate pregnancy, and nearly 90 percent received family planning information and obtained a method (see Table).
  
  Percentage (%) of postabortion clients who received family planning information and methods

• Close to two-thirds of postabortion clients (62%) at follow-up reported that they had been informed about the treatment they needed—a significant improvement over pre-intervention proportions (10%). However, less than one-third of clients at follow-up received information on major warning signs such as severe pain and bleeding.
   
• Pain management was inadequate during the intervention and remained inadequate at follow-up. About two-thirds of postabortion clients received light sedation during treatment, and one-third received a combination of medications such as sedation and a paracervical block. However, few patients received pain medication before or after treatment.
   
• The time PAC clients spent in the hospital diminished markedly over time. The concentration of services in the OB-GYN emergency room, combined with the shift to outpatient PAC services, reduced the length of stay from 33.3 hours to 6.4 hours post-intervention, and to 6.7 hours at follow-up. Time spent waiting for services dropped from 5.3 hours before the intervention to 2.9 hours after, and averaged 2.6 hours at follow-up. 
   
• Following the introduction of MVA and outpatient treatment for postabortion cases, per patient costs to the hospital dropped from $118.73 to $45.13, and declined further to $33.45 at follow-up. Out-of-pocket expenses for patients (including admission, treatment fees, medications and some supplies) declined from $52.98 before to $37.40 after the intervention. At the time of the 2000 follow-up, clients’ costs averaged $32.75. The hospital is recovering over 80 percent of the full cost of providing PAC services as compared to less than half (45%) prior to the intervention.

Policy Implications

• Strong support and commitment from both hospital leadership and the MOH helped establish the improved PAC services as an element of routine care. Motivation for change also came from the reduced length of patient stay and related hospital costs. Within the hospital’s staff, replication of the original training on MVA use and counseling sustained the skills to perform the procedure and maintain high-quality care.
   
• Dissemination of the findings on the benefits of the new model convinced reluctant staff members of the value of the new PAC services. Broader dissemination of the findings in Peru and in other Latin American countries resulted in recognition of the “Hospital Carrión model.” This external recognition and a feeling of “ownership” on the part of hospital staff further reinforced the improvements.

January 2004

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Source: Benson, Janie and Victor Huapaya. 2002. "Sustainability of postabortion care in Peru," FRONTIERS Final Report. Washington, DC: Population Council. (PDF, 685 KB)

This project was conducted with support from the U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT under Cooperative Agreement Number HRN-A-00-98-00012-00