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His Excellency Dr PascoaI Mocumbi
Prime Minister of Republic of Mozambique
At the IHCAR-Ipas Conference in South Africa
Ladies and Gentlemen
My very special thanks for inviting me to participate in this Conference. The meeting gives me the opportunity to share insights and experiences on policies related to the provision of menstrual regulation and elective abortion care by Midlevel Providers (MLPs) that will help us to use available technologies and resources as effectively as possible for the benefit of those who need them most. It is a good occasion to appreciate and evaluate the role of the MLPs in providing safe abortion care services: the progress and challenges on this matter should be discussed openly.
First of all I would like to say that I see the roles of midlevel providers in Menstrual Regulation and Elective Abortion Care as part of the efforts underway worldwide to implement the ICPD commitments to reduce the maternal morbidity and mortality rates.
We all know that 500,000 women die from pregnancy related causes, other 300 million women, representing more than a quarter of the adult population living in the developing countries, currently suffer from short or long term illness relating to pregnancy and childbirth.
Although strategies have been adopted under the Safe motherhood Initiative since 1987 their effectiveness varies country to country and over 90% of reported maternal deaths occur in developing countries which account for 88% of the world's births, and where the complications of pregnancy and childbirth are leading causes of death among women of reproductive age (AbouZahr and Royston, 1991).
Secondly, we also know the reason why developing countries account for such high toll of maternal deaths: the reason is lack of skilled attendants and of the respective enabling environment.
Motivated skilled attendants adequately equipped, and with supportive policies and regulations should be able to fill the following functions:
Many of us, policy makers and implementers are caught in political, social, financial and ethical dilemmas as we struggle to set priorities and make hard choices amongst competing demands and tasks.
The Conference offers a unique opportunity to reflect on an share experiences about how to expand health access advancing the roles of specific health care providers- Midlevel Providers in Menstrual Regulation and Elective Abortion Care.
It is a matter of policy choice that requires a thorough reflection about delegation of responsibility and necessarily about enabling legislation. Though I shall use examples from my own country I know that our problems and dilemmas in seeking and finding solutions are not unique.
Mozambique has a population of around 17,600,000 people, 52% of whom are women. Projections for 2001 suggest that 44.5% of the population is under 15, and that around 90% are in a state of dependence. This means that Mozambicans are young, and are more prone to consume than to produce, which has implications for such socio-economic development sectors as health, education, water, housing and employment.
The rate of dependence may be women by the advance of the HIV/AIDS epidemic, which has a disproportional impact on the economically active population. The current rate of infection is in the order of 12.2%, while the natural population growth rate is 2.4%. About 75% of our people live in the rural areas, though the war that ravaged the country from 1976 to 1992 led to a signfficant rate of urban migration over the past 10-15 years. The settlements that grew up around the cities and towns during this period are still there, creating difficulties for urban planning, sanitation and the adequate treatment of waste.
In 2000 Mozambique's gross domestic product (GDP) was estimated at 230 lJSD per capita. From 1996- 1999 GDP growth was estimated at a little over 10% per year. However, notwithstanding this substantial growth, poverty levels are very high (around 70% of the total population). It is worth noting here that poverty in Mozambique has an essentially female face.
Mozambique benefited from the HIPC (Highly Indebted Poor Countries) initiative, resulting in the re-direction of resources that had previously been used to service the external debt towards the social sectors. A considerable proportion of those resources was allocated to the health sector and employed in programs with a direct impact on poverty levels, including implementation of the national strategic plan to combat and prevent HIV/AIDS. However, we should not forget that, even since qualifying for debt relief, expenditure on debt service has been higher than the whole health budget. In point of fact debt service over the next five years will be 55 million lJSD per year, while current expenditure in the health sector is approximately 30 million lJSD.
The health status and epidemiological profile of Mozambicans is to a great extent a consequence of current levels of socio-economic development and the burden of the foreign debt. To give just one example, our maternal mortality rates, at around 600-1100/100,000 live births, are considered to be among the highest in the world.
The recently presented Health Sector Strategic Plan that comprises a plan of action to reduce maternal and perinatal mortality (2002-2005) had a clear focus on consolidating the gains obtained from the intensive post-war reconstruction program in the health sector. The focus is now on improving equity and quality, through sustainable institutional development within the context of civil service and public finance reforms.
Abortions and legality
When confronted with growing numbers of cases of abortion complications we took policy measures that reduced gradually the restrictions of the existing legislation. These measures allowed public hospitals to offer abortion care and opened space for comparative studies on illegal and legal abortion to be carried out.
The studies and documentation offer persuasive evidence in favor of introducing policy and programmatic changes.
The serious consequences of illegally induced abortions are reflected in the extremely high costs of hospital care for illegal abortion patients. In Maputo hospital expenditures associated with complications have been analyzed, and were found to be significantly higher for illegal abortions than for legal abortions. However, for the individual patient illegal abortion was still cheaper than legal abortion, as the hospitals charged up to 350.000,00 Meticais (about USD 15).
The medical and economic implications of illegally induced abortions are also a reflection of the professional ability of the provider of the intervention, the abortionist.
The Ministry of Health is devoting great attention to the role of health workers in the provision of illegal abortions, with a view to creating conditions for improving their performance. The advent of affordable, easily available, medically safe and appropriate pharmaceutical methods for pregnancy interruption may contribute to reducing the discrepancy between the large demand and the limited resources often found in the public hospital services,
Determining factors and changes related to menstrual regulation and elective abortions
However, the question of induced abortions and maternal morbidity and mortality continues to be one of the problems that Mozambique, like other countries in the region, will have to face and to resolve in the coming years.
There is no doubt that the best way of preventing unsafe abortions is to prevent unwanted pregnancies. Studies carried out in Mozambique show that we have had a partial success in this area, with increased knowledge about and use of modem and effective contraceptive methods (though only in some parts of the country). The studies also show that access to hospital services is beyond the women's socio-economic level.
We are engaged in providing training for the different reproductive health providers (MCH nurses, Midwives, Medical Assistants and MD) ranging from family planning to antenatal, peri-natal and gynaecological care.
The policy of offering abortion care in Mozambique's public hospitals has had a number of results. On the one hand, there has been a fall in the number of cases of severe complications in comparison with women who did not have their abortions in hospital; but on the other hand a relatively large number of women continue to risk their lives by submitting themselves to abortions in extremely precarious and dangerous conditions, for lack of access to the safe services.
It should nonetheless be stressed that the number of women arriving in hospitals with complications from abortions is falling year by year, due to the increased accessibility and safety of the services offered in areas where we have already managed to implement them.
With Peace and Stability, it will gradually be possible to offer MR and elective abortion throughout the country, and improved access will mean less unwanted pregnancies and clandestine abortion will become the exception.
What can be proposed to improve this situation further? First there is space to improve information and services so that contraception is more readily available, particularly to younger, unmarried women and those living in the new peripheral shanty towns built by migrants to big cities like capitals.
It is well known that people with very poor education/information and living conditions are capable of learning about contraception and that many of them will try to prevent unwanted pregnancies. It is also possible for hospitals to offer unwanted pregnancy terminations in spite of the scarcity of their resources. For example where doctors have trained midwife/nurses and delegated to them the use of Misoprostol for pregnancy termination.
The efforts to prevent unwanted pregnancy need to be improved and strengthened, and methods more widely disseminated. In our region family planning programs that could prevent unwanted pregnancy and abortion are addressed essentially to married couples, whilst programs specific to adolescents, single men and women and women who are post-abortion are almost non-existent.
Unwanted pregnancies will continue to occur - due to contraceptive failure, unplanned sexual intercourse or a partner's unwillingness to support or to undertake contraceptive use. In these cases safe abortions will still be needed, to protect women and society from severe complications and maternal deaths.
Ladies and Gentlemen
During the meeting to review implementation of the International Conference on Population and Development (ICPD+5), the governments agreed that "the health systems should train and equip health service providers to offer accessible abortion services in suitable conditions".
In Mozambique investment in human capital development is considered to be one of the priorities for poverty reduction, and at the same time a necessary condition for sustainable economic growth. In this context the health sector is expected to play a fundamental role in improving both the welfare of the poor and the quality of human capital. Concretely it must set priorities on a cost-benefit basis, seeking to reduce the high rates of mortality, morbidity and disability - in other words the burden of disease - at minimal cost.
Based on the above-mentioned premise of "training and equipping health service providers to offer accessible abortion services in suitable conditions", we are placing greater emphasis on the training of technical staff to offer better and more wide-ranging health services including family planning and essential obstetric care (basic and comprehensive).
Evaluation of the experience of training middlewlevel technicians: midwives and medical assistants
In Mozambique the scarcity of trained obstetricians/gynecologists and other professionals with sufficient surgical training led the Ministry of Health to start in the early 80's a three-year training course for assistant medical officers. The individual record, with an emphasis on professional dedication, behavior and motivation for surgery is considered particularly important. Those applicants regarded as most suitable for the training are submitted to an entry examination and an interview. The interviewers are demanded to assess not only the ability to learn technical skills of the applicant but whether she or he is conscious of the limits of their competence.
Ten years of experience in the outcome of surgery delegated to assistant medical officers who have been specifically prepared during three-year training courses (to manage obstetric emergencies and other most common general surgical emergencies) indicates that the rate of complications after major obstetric surgery is similar for the medical officers and specialists in obstetrics and gynecology. Experiences from other countries, such as Bangladesh, Thailand and Zaire, show similar results.
However, it is important to ensure that safe abdominal delivery can be technically achieved in settings that are devoid of medical doctors, but have an appropriately organized referral level for situations that are beyond the competence of the delegated providers.
When doctors are unavailable, non-conventional pragmatic solutions must be sought to avoid unnecessary maternal deaths and severe pregnancy complications, such as intrapartum fetal deaths and fistulas. The decision to perform life saving major surgical interventions is often more difficult than the intervention itself. Even so, preliminary experience from activities carried out in rural areas, where these assistant medical officers are frequently working in isolation, indicates that their surgical work is quite successful.
We believe that the Mozambican experience can be considered h other settings with similar staff shortages.
There is little doubt that insufficient scientific attention has been paid to the fact that, in several low-income countries, a de facto delegation of advanced surgical responsibilities has taken place over the last decade.
Whereas this is a well-known fact in the field there is still controversy in many countries regarding the quality of services provided and the sustainability of the achievements. In the absence of alternatives, however, the delegation of responsibility in medicine, pediatrics, obstetrics and surgery will remain a reality for most low-income countries for the foreseeable future.
The cost of training doctors is ten times or more that of training medium-level health workers such as medical assistants or fully trained MCH nurses and nurse-midwives. The fact that medical doctors often tend to move away from rural to urban areas is further reinforcement of the need to find other solutions to staffing in remote areas.
Cost-effectiveness analyses and follow-up results of mortality levels in remote areas should provide a reasonable argument in favor of sustained training and permanent supervision of medium-level health workers.
Laws and policies have direct Impact on the availability of skilled care by defining what types of care can be provided by what categories of providers, and on the utilization of care by facilitating (or obstructing) women's access to information and services. Laws and policies are necessary but hey are not sufficient conditions. We may find situations where there are good laws but no access, and other situations where with (restrictive) law there are good practices.
What is needed is courage to take decisions and make hard choices that can save lives and improve people's health. Being a physician I recognize that we doctors are part of the problem when we resist to allow delegation of responsibilities. It is time for us to help our governments to consider the importance, the feasibility and the appropriateness of training midlevel providers.
Thank you very much for your attention.
Johannesburg, 3 December 2001
Machungo, F. et al, Re2roductive Characteristics and Post-Abortion Health Consequences in Women Underdoing Illegal and Legal Abortion in Maputo. Soc. Sci. Med. Vol. 45, N.l 1 (1997).
Vaz, F et al Training Medical Assistant for Surgery, Bulletin oft he World Health Organization, 77 (8), 1999.
Pereira, C. Et al, Caesarean Deliveries bv Assistant Medical Officers in Mozambigue, News on Health Care in Developing Countries 3/95, Vol. 9, 1995.
Agadjanian, V. Ouasi Legal Abortion Services in Sub-Saharian Setting: Users' Profile and Motivations, InternationaI Family Planning Perspectives, Vol. 24, Number 3, 1998.