September 2004, Vol. 10, No. 3

Field Report
Lessons from Introducing Postabortion Care in Egypt

Complications from unsafe or incomplete abortion include hemorrhage, severe infection, and shock. These conditions can arise with either induced or spontaneous abortion, also known as miscarriage, and can kill a woman if not treated promptly. Population Council research has shown that women who experience complications from miscarriage or unsafe abortion are among the most neglected of all reproductive health care patients.

In the early 1990s, Population Council staff in Egypt began discussions with government representatives about a program of work to improve postabortion care in that country. This initiative eventually developed from research investigations to program implementation. “Lessons learned in this endeavor offer insights into working with sensitive topics like abortion and female genital cutting,” says Nahla Abdel-Tawab, Population Council public health researcher in Cairo.

Egypt’s postabortion care initiative
Egypt’s abortion policy allows the practice only when a woman’s life is in danger. This policy can have an unfortunate impact on how caregivers treat postabortion complications. Population Council researchers made clear from the start that the rationale for studying this topic was to improve health care, not to make induced abortion more accessible. “We always spoke of postabortion care as a neglected dimension of medicine and emphasized the need for protecting those women against unplanned pregnancy,” explains Laila Nawar, former Population Council regional advisor based in Cairo, currently a Council consultant and research advisor at the Cairo Demographic Center. “The trust we were able to build with program managers and policymakers was instrumental to the success of our initiative.”

The body of research conducted on postabortion complications over the past decade has raised awareness of the problem among public health officials in Egypt. For example, the initial pilot study showed that changes in the clinical management of postabortion patients and a brief, intensive training program for health-care providers could lead to significant improvements in patient care. An assessment of the postabortion caseload showed that one in five obstetric hospital admissions in Egypt is for emergency treatment of incomplete abortion. And a study of psychosocial stress related to postabortion care showed that women who suffer spontaneous abortion are largely ignorant of the reasons for the miscarriage.

Council researchers used targeted briefings to reach appropriate government officials and donor agencies with the results of their investigations, and government officials supported continued work on postabortion services.

The Council worked with Ipas, a nonprofit women’s health organization, to develop a strategy statement to guide the growth of Egypt’s postabortion care program. The pilot study was scaled up in ten hospitals and in the process provided training for some of Egypt’s leading obstetrician/gynecologists in the proper care of women who suffer complications from miscarriage or unsafe abortion.

During this phase, the program was largely affiliated with Egypt’s family planning program. Eventually, however, the postabortion care initiative was folded into Egypt’s Essential Obstetric Care Program. Significantly, the term “postabortion care” was dropped as the protocols appear largely within guidelines for managing bleeding in pregnancy, which is a primary complication of incomplete abortion. Moreover, the protocols do not emphasize the inclusion of family planning counseling. By integrating these protocols within the national safe motherhood program, the initiative graduated from a research activity to a large-scale program, supported by the government and provided as a routine emergency medical service to women in Egypt’s hospitals.

The current situation
Recently, the USAID-funded Tahseen/Catalyst project initiated a training program on improved postabortion care, including family planning counseling, for providers in several public hospitals and in curative care settings.

One stumbling block to the program continues to be a shortage of equipment, known as manual vacuum aspiration (MVA) instruments, for treating incomplete abortion. During MVA a health-care provider inserts a thin, syringe-like instrument into the uterus through the cervix and uses gentle suction to empty it. The Egyptian Ministry of Health and Population has rejected three applications for the importation of MVA instruments. “This response can be attributed to the review board’s reluctance to approve any technology that is even indirectly associated with induced abortion,” elaborates Abdel-Tawab.

Because MVA instruments are difficult to obtain in the private sector, many physicians continue to use dilation and curettage rather than the less complicated and less painful MVA procedure to treat incomplete abortion.

“We are hopeful that the expansion efforts and the continuous training activities for the Ministry of Health and Population will build a constituency of providers who are competent in managing complications of incomplete abortion, who are conversant with the technique of MVA, and who will inform regulatory bodies of the importance of approving MVA instruments to save the lives of thousands of Egyptian women,” says Abdel-Tawab.

Sources
Huntington, Dale and Laila Nawar. 2003. “Moving from research to program—The Egyptian postabortion care initiative,” International Family Planning Perspectives 29(3): 121–125. (offsite full text) (offsite PDF)

Huntington, Dale, Laila Nawar, Ezzeldin Osman Hassan, Hala Youssef, and Nahla Abdel-Tawab. 1998. “The postabortion caseload in Egyptian hospitals: A descriptive study,” International Family Planning Perspectives 24(1): 25–31.

Huntington, Dale, Laila Nawar, and Dalia Abdel-Hady. 1997. “Women’s perceptions of abortion in Egypt,” Reproductive Health Matters 5(9): 101–107.

Huntington, Dale, Ezzeldin Osman Hassan, Nabil Attallah, Nahid Toubia, Mohamed Naguib, and Laila Nawar. 1995. “Improving the medical care and counseling of postabortion patients in Egypt,” Studies in Family Planning 26(6): 350–362.

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See Also

• "Reproductive health/Postabortion care," overview (full text)