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Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care" The paper in pdf-format
Mozambique Abortion Situation Country Report Aida Libombo
The Crude Birth rate is 45.2 per 1000 population; the Death rate 18.6 per 1000; Life Expectancy is 46 (44.5 for men and 47.5 for women) and the population growth rate is 2.7% for the period 1996-2000. According to the 1997 Demographic and Health Survey (DHS), Neonatal Mortality is estimated to be 54 per 1000 live births, Infant Mortality 135/1000 and Child Mortality (<5) 201/1000. 1.2 Reproductive Health SituationThe Total Fertility rate is 5.6 births and Maternal Mortality is estimated between 500 and 1500 per 100,000 live births. Additional findings from the 1997 DHS, showed that: 40% of girls between 15 to 19 years old had already experienced motherhood; only 5% of the adolescents were using contraceptives; although 50% of the female and 76% of the male populations knew the existence of the condom, only 2% of female and 10% of male reported to have used the condom on the last intercourse. These findings, and many others before shows the degree of risk to unwanted and unplanned pregnancies, and also exposure to sexually transmitted infections including HIV/AIDS among our adolescents. Regarding the utilisation of health services, the access to the general population is around 40%. Forty four percent of deliveries take place in health facilities (81% in urban areas and 33% in rural areas). The Caesarean-section rate is 2.7%, with a range of 7.3% in urban areas to 1.4% in rural areas. About 72% of women report prenatal care. Contraceptive prevalence (modern methods) is quite low (5%) and varies widely, from 28% in the southern capital of Maputo to 0.7% in the northern Province of Cabo Delgado. In urban areas 17% of women use modern contraceptive methods while only 2% of rural women do so. The main studies undertaken in the field of Safe motherhood identified the following causes of Maternal Deaths: Puerperal Sepsis, Haemorrhage, Eclampsia and Abortion complications. |
Table 1. Abortion seekers by age
Table 2. Abortion by marital status
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Tables 1 and 2 show some preliminary results from a study being conducted at the Central Hospital in Maputo, to find out what are the reasons for seeking abortion
1.3 HIV/AIDS
Mozambique is one of the most seriously affected African countries by HIV/AIDS, in the continent. AIDS is a serious problem which is on the increase. It is affecting mainly the economically active population, and 63% of the estimated 700 daily new infections occur among people below 30 years old. The current prevalence of HIV infection among people aged 15 to 49, is 12% countrywide ranging from 5.7% in the northern part of the country to 16.6% in the central region, on the Beira corridor. The prevalence in the southern part of the country on the Maputo corridor is 13.2%.
In response to this alarming prevalence of HIV/AIDS in the country, a national Strategic Plan was developed and a Multisectoral National Council for AIDS was created. At the same time activities are being intensified to revert the situation. 1.4 Reproductive Health and the Mozambican Government To face that situation it was necessary to introduce new approaches, in terms of health policies, to maximise the use of scarce resources and to prepare enabling environment for sustainable health programs. The main health reforms introduced were:
Interventions already in place:
1.5 Laws and Policies By the recognition of the seriousness of the complications related to unsafe abortion, and their implications on the high Maternal Mortality rates, an agreement was reached between the Ministry of health and the Department of Obstetrics & Gynaecology of the Central Hospital of Maputo, to provide Safe Abortion services for selected cases as decided by the responsible authority. This has been extended to other Central hospitals as well to Provincial Hospitals and General Hospitals in the country. Currently, clients seeking safe abortion are offered the services in those hospitals for pregnancies up to 12 weeks gestational age, on request, unless there is no consent from parents, guardians or partners. 1.6 Provider Profile After graduation, there are programmes for continuous in-service training for safe abortion, abortion complications, counselling and post-abortion care and family planning. |
Table 3. Training of Providers in Post abortion Care
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Table 3 information applies to newly trained providers since those trained before the inclusion in the curriculum are having in services training for the procedures. 1.7 Organization of Abortion ServicesIn almost all hospitals in Mozambique women are offered free services for the treatment of spontaneous abortion, its complications and counselling. At the Central Hospitals of Maputo, Beira and Nampula, and General Hospitals in Maputo, safe abortion services are offered, on request, and has to be authorised by someone responsible locally appointed at hospital level. In most cases this person is resident Obstetrician & Gynaecologist or hospital Director. All procedures as from the diagnosis by ultrasound scanning, insertion of misoprostol (abortion is by medical induction), manual vacuum aspiration, follow up, post abortion counselling, post abortion care and family planning are done by a midlevel provider and in the case of Mozambique, mainly by an MCH nurse. The cost of all this (ultrasound scanning, insertion of tablets and MVA) for voluntary interruption of pregnancy is around USD 15. Although abortion is still restricted, it is widely known that safe abortion is available in most public and private hospitals and clinics were the services are offered using the above procedure. |
Table 4. Availability of Post abortion Care service delivery records
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We do not have a standard record keeping system nation wide. It is only at hospital level. 1.8 Knowledge and perceptions about abortionWomen, who seek for safe abortion services, get the information from friends or other satisfied clients and at a lower scale from the health care providers. |
Table 5. Knowledge of family planning among abortion seekers
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2. Midlevel Providers and Abortion Services
2.1 Duties and Responsibilities In Mozambique, the scarcity of trained obstetricians and other professionals with sufficient surgical training, to cover the country, motivated the Ministry of Health to start a 3 years training course for Medical Assistants or Nurses to become Assistant Medical Officers, and the first course was started in 1984. After their training, the newly graduated Assistant Medical Officers are posted in rural hospitals were they take care most of the emergency and some elective surgery in the field of obstetrics and gynaecology, general surgery, as well traumatology. The above-mentioned Midlevel Providers do also get frequent in-service training on treatment of abortion and its complications, post-abortion care, including counselling and family planning. 2.2 History of Post abortion Services in MozambiqueIn 2000 a group of Obstetricians/Gynaecologists attended a course on Post-abortion Care (PAC) in Uganda, and back in Mozambique they organised a training course of trainers for PAC. Also clinical guidelines were adapted to the country needs. Participants included 3 doctors, 2 Assistant Medical Officers and 12 MCH nurses. The idea was to send them back to locally train other MCH nurses on PAC. Currently MCH nurses are trained during their formal training on Abortion care. At the CHM and 2 General Hospital in Maputo MCH nurses were already trained to do USS diagnoses of pregnancy by Ultrasound, vaginal insertion of misoprostol tables and to do MVA. Currently PAC services are being provided in some health units in the country. 2.3 Scope of Post abortion Care Practise of Midlevel Providers |
Table 6. Midlevel Providers (Assistant Medical Officers and MCH nurses/Midwives) Scope of Practice
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Yes* done by Assistant Medical Officers 3. Professional Organisations of Midlevel ProvidersCurrently is being established a national midwives association.
4. Lessons Learned related to access to Safe Abortion Services
5. Conclusion |
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Updated 19 June 2002 |