Background: Unsafe abortion is an important cause of maternal mortality worldwide, and an estimated 47,000 women lose their lives every year due to complications of unsafe abortion, almost all of which could have been prevented, In addition, 5 million women are estimated to suffer disability as a result of complications due to unsafe abortion (WHO 2011b).
Afghanistan, one of the 16 countries with the highest maternal mortality ratios in the world and the highest in south Asia, there is little data on the incidence of complications of spontaneous, incomplete, or unsafe abortion, In southeast Asia, the estimated abortion rate in 2008 was 36 per 1,000 women aged 15–44 years.
Interventions: In 2017, Ministry of Public Health (MoP) of Afghanistan, undertook the revision of the PAC guidelines, by creating a technical working group meeting with technical assistance from AFGA RH department and other stakeholders. The Afghan Family Guidance Association (AFGA) was one of the lead technical partner, to share the filed based evidence and inclusion of right based approach. One of the key interventions to support expansion of PAC services included in the revised guidelines was the use of medical treatment for incomplete abortion with misoprostol, which is one of the two recommended treatment options, along with manual vacuum aspiration (MVA) (WHO, 2012a). In order to contribute to maternal death reduction, PAC services are included and reflected in the Ministry of Public Health’s Reproductive Health Strategy of 2017–2021 and is included in Afghanistan BPHS and EPHS health systems. Recently PAC is also included as an indicator in the HMIS system of MoPH.
Despite all the efforts from the govt. including infrastructure, inclusion of PAC services in Reproductive Health Strategy, availability of the guidelines and comprehensive training material; the availability and access to PAC services were remain low. The major reasons behind low uptake and access, was lack of trained service providers and lack of awareness at community level.
Post revision of the PAC guidelines in 2017, The Afghan Family Guidance Association (AFGA) had initiated the provision of PAC services from two of the AFGA static clinics based out of the government hospitals in Kabul and Mazar Provinces. These static clinics are based in two of the well-known and busiest government hospitals. A three-pronged strategy were adopted by AFGA – Capacity building of the service providers, ensure the availability of the commodities (Misoprostol) and create demand though outreach by empowering communities through community awareness and mobilization sessions by trained midwifes.
AFGA have 71 trained community outreach midwives working in remote areas of 6 provinces of Afghanistan. The community outreach midwives are hired by AFGA. They are providing short term FP contraceptive and consultation and SRH services counselling and referrals. 13 Community Outreach Midwives are referring clients to one of clinic based in Kabul province for PAC services and 18 community outreach midwives are referring clients for PAC services to our static clinic based in Mazar province. They are the major referral links between community and service providers for PAC & FP services.
Increase in case from 2018 to 2019 (around26%) is majorly contributed by awareness and demand generation by these trained midwifes.
AFGA procured the required infrastructure from IPPF funds and trained its 8 services providers on PAC, based on the guidelines and training material developed by MoPH. In continuation, two lead trainers of AFGA were trained on PAC, Value clarification and Harm reduction by IPPF SARO.
Misoprostol is included in essential drug list of Ministry of Public Health (MoPH) under specialized drugs, which is not accessible to clients in the local market. However, MoPH is supplying misoprostol to AFGA clinics for providing PAC services. Clients are referred to the AFGA clinics from the public and private health facilities and through outreach midwives. AFGA has an overarching MoU with the MoPH. This model is found to be one of the best Public private partnership (PPP) model) where govt. is not only providing commodities but also referring the clients from its public health facilities to AFGA clinics.
In 2019, AFGA provided 11,097 post‑abortion counselling services and 4,077 post‑abortion treatment services, an increase of 35 per cent from 2018. Of these, 3,016 were to manage post‑abortion complications and 1,061 to treat incomplete abortion. In 2019, 45 per cent of these services were provided to young people and the uptake of modern contraception by post‑abortion clients was 90 per cent. Based on the success of this pilot, AFGA is planning to scale up to two more sites of Kabul and Herat provinces this year from the APB 2020 Budget of IPPF. Currently, AFGA is providing PAC services though eight clinics.
Table 1: Total PAC services by AFGA in 2018 & 2019
Table 2: Age segregated data for PAC services
Story of Hamida, from Kunduz province, Afghanistan
One of AFGA clients Ms. Hamida living in Kunduz province has been referred to AFGA clinic, covering three hours distance from Kun duz province with severe septicemia and missed abortion. She received services for incomplete Abortion (MVA) and treatment of septicemia and received post abortion counselling and contraceptive.
She quoted “In my previous miscarriage I never received proper treatment and post abortion family planning and contraceptive services which led me to have repetitive miscarriage. I am really happy from your services and will refer to you clients from my neighbourhood” Since then AFGA have been receiving many clients from Kunduz province.
Package of PAC services by AFGA:
- Use of medical treatment for incomplete abortion with misoprostol
- Manual Vacuum Aspiration (MVA)
- Provision of family planning counselling and methods
- Diagnosis and treatment of sexually transmitted infections (STIs)
- Voluntary counselling and testing for HIV/AIDS
- Emotional support and counselling to women who are victims of gender-based violence
- Education about the risks and consequences of unsafe abortion
- Education to increase family planning and contraceptive use (preventing unwanted pregnancies and unsafe abortion)
The following services are provided during follow up visits.
- Confirm successful treatment with history and physical exam
- If uterine evacuation is not complete and the woman does not have complications or a medical condition requiring MVA at the hospital level, a second dose of misoprostol is given for the treatment.
- Provide contraceptive counselling and other services as needed.
- Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012;379(9816):625–32.
- WHO (2019) Trends in Maternal Mortality: 2000 to 2017. Geneva: World Health Organization. Available from: https://data.worldbank.org/indicator/ SH.STA.MMRT?most_recent_value_desc=true [Accessed 13 March 2020] 28
- WHO (2009) Afghanistan Health Sector Assessment Needs. Available from: https://www.who.int/hac/donorinfo/cap/cap_afghanistan_2009.pdf [Accessed 11 May 2020] 29
WHO (2012) Information sheet. Unsafe abortion incidence and mortality. Available from: https://apps.who.int/iris/bitstream/handle/10665/75173/ WHO_RHR_12.01_eng.pdf?sequence=1 [Accessed 17 March2020]
Written by: Deepesh Gupta, Sr. Project Advisor, SRHR, IPPFSARO
Technical Support: Dr. Ataur Rahman, Director Programme, IPPF SARO, Mr. Naikmal Naikmal Shah, CEO AFGA