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DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY TEACHING HOSPITAL, LUSAKA, ZAMBIA Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care"
South Africa 2 - 6 December 2001.
The paper in pdf-format
Midwives’ role in management of elective abortion and post-abortion care Zambian Country Report Velepi Mtonga Table of contents Abbreviations TABLES ABBREVIATIONS 1. Country profile on health services Zambia is a landlocked country with an area of 752,612 square km (2.5% area of Africa). The preliminary estimate for the 2000 population of Zambia is 10,285,631; of the total 5,070,891 are males while 5,214,740 are females. The growth rate for Zambia between1990 - 2000 was 2.9% as compared to 3.1% in 1980 - 1990. This shows that Zambia’s average annual population growth rate declined by 6.4%. Copperbelt province has the highest population followed by Lusaka, Northern, and Southern and Eastern provinces. Northwestern has the lowest population followed by Western (1). Zambia is one of the poorest countries in the world with very high inflation rates and is implementing the Structural Adjustment Program (SAP) now called the Poverty Alleviation Program. The economic recovery program was introduced to turn around the protracted decline of the economy into a sustainable position and consequent improvement in living standards and quality of life for the people (2). For example almost 85% of Zambians earn less than US$1 per day and the incidence of poverty has risen from 69% to 73% between 1996 and 1998 with majority of the poor living in the rural areas. Zambia also recorded an increase in deprivation for its households from 35.1% in 1996 to 38.4% in 1997 (UNDP 1998). Inequities exist along geographical and gender lines. For example women are more constrained in their access to health care than men for financial, educational and social reasons.
In 1991 the Zambian government embarked on a process of Health sector reforms with the aim of not only improving the accessibility of health services and reducing mortality and morbidity, but also improving quality of life for all Zambians. The reform process involved the establishment of Central Board of Health ( CBoH) in 1996 which acts as a technical unit responsible for the delivery and implementation of health reforms and the development of the primary health care (PHC) program, which constitutes an important component of the health care delivery system. This has entrusted decentralization of the health services with responsibility of planning, implementing, monitoring and managing PHC program to district Health Boards.
The government through the ministry of health (MOH) is the main source of funding for the health sector contributing 57% with cooperating partners contributing 43% in the year 2000 and the community contributing through user fees and being actively involved in the decision making process through Neighborhood Health committees. One of the major achievements of the 1990’s reform has been the pooling of GRZ and donor funds to support the running costs of the district and their Hospital Management Boards (the district basket).
The reforms, however, have gone "off the rails" and need to be placed "back on track" as there seemed that more emphasis was placed on systems development rather than effecting early and much needed improvement in service delivery. (Sector wide approach to health a proposed Health sector supplied investment programme (2001-2005) Joint identification and formulation mission for Zambia. (Vol. 2 analysis of the health sector March 2000) The paradigm shift from systems development to services delivery was subsequently recognized in the 1998 - 2000 National Strategic Plan but has proved difficult to deliver due to limited resources and rising demands for services provision with the impact of the HIV/AIDS pandemic.
1.1 The Impact of HIV/AIDS.
Zambia's burden of disease has significantly changed due to HIV/AIDS. The number of house holds experiencing chronic illness and death is increasing with a corresponding increase in the number of orphans estimated at 950,000 (CSO - 1998). HIV/AIDS has also brought disruption and changes in social networks and support systems due to vastly increased burden of care on the health sector, communities nd households. For example, women carry a much greater burden of care created by HIV/AIDS, as well as being more vulnerable for both physiological and social reasons.
1.2 Reproductive Health statistics
Women and children are still the most commonly affected by diseases. While milestones have been achieved with interventions for childhood diseases in effectively reducing deaths and disability, the same cannot be said about women’s health problems. Pregnancy and childbirth disorders are the second main reason for hospital admission amongst females over 15 years.
Safe motherhood strategies and Interventions put in place by Government to improve women’s health, have not yet borne fruit especially in the rural areas as manifested by the high maternal mortality rates, at 649/100,000 live births with some rural area rates being as high as 889/1,000,000. The five major causes of maternal mortality are Hemorrhage (34%), Sepsis (12%), Eclampsia (5%), Obstructed labor (8%) and unsafe Abortion (4%) (Nsemukila et al 1998). Other causes include Malaria (11%) and HIV/AIDS (10%).
Table 1 Reproductive health and abortion statistics
Birth rate
Maternal mortality
CPR 26% Age at first birth 18-19 years Birth interval 32 months
Life expectancy at birth (in 2000) is 35 years for women and 37 years for men. Fertility rate declined to 6.1% in 1990 from 6.5 % in the 1980s. Fertility is lower in urban (5.1) population than in rural (6.9) population. 30% of women will have given birth at 18 years of age and 66% by 20 years. More than 31% teenage girls begin child bearing at 15-19 years of age. Reproductive health services include: ante-natal care, contraceptive services, STD/HIV (preventive), adolescent health being provided at public health centers at primary level, cervical cancer screening and abortion services. Legal surgical and medical management of abortion being offered only at tertiary centers i.e. UTH in the gynae emergency ward and gynae in-patient wards and Ndola Central Hospital offers TOP on medical grounds only.
1-3. Magnitude of the problem of unsafe abortion There is certainly underreporting of contributions of abortion related maternal mortality and morbidity due the fact that not all Termination of Pregnancy (TOP) are performed in the hospital. Hospitals may be used only if complications arise. Also the stigma of abortion traditionally dictates the secrecy of the procedure. Hospital based studies of maternal mortality in 1983 by Mhango et al (4) indicated that abortion contributed 15%. In a multi-center hospital based study by Mati et al unsafe abortion contributed 30% (6) and in a nation wide retrospective case control study by Nsemukila et al (1998) (7), abortion contributed 4%. Perhaps the design was not appropriate for abortion, given the clandestine nature but unsafe abortion was still among the 5 major causes of maternal mortality.
i. Adolescents Many more health facilities and hospitals have realised that there is need to have youth friendly corners where information can be given to youths on reproductive health and sexuality. A number of NGOs are working in collaboration with the CBoH to educate youths on their reproductive health and have assisted in the setting up of youth friendly corners in health centers.
ii.Demand for TOP The women often obtain TOP services form unskilled providers, often untrained community members known to provide such services. Such abortion lead to high rates of infection, serious injuries, infertility and often death. This places a great burden on the hospital budgets, as they have to treat such cases with expensive antibiotics and increases the hospital stay of the patient. However elective legal TOP is offered at the UTH and Table 2 shows the number done between 1996 and 2000. TABLE 2. Elective TOP at UTH, 1996 – 2000
1996 saw a marked increase in elective abortion due to the fact that the hospital had introduced private practice and elective abortion was provided at a low cost of ZK10, 000 ($3) and the surgeon was paid a fee. With the withdrawal of private practice there was a sharp decline in elective TOP as seen in the above table. Other hospitals performed few TOPs but records were poorly kept. For example, in Ndola, 7 cases were recorded, in Livingstone District Hospital, 22 cases were recorded over 13 months and in Mongu, only 1 case was recorded for the previous year. In all these hospitals TOPs were performed under GA using sharp curettage (SC). However 10 - 20 TOPs were probably performed but not documented. (Kinoti et al -Monograph.Unpublished? ). The demand for services is there and we have a challenge to prevent unwanted pregnancy and also to capture all women requiring TOPs so that they may be offered safe legal abortion. 1.4 Demand for PAC services
They noted that other elements of PAC service delivery that needed improvement were:
The three institutions that have been made into training centers are now training staff using on the job training (OJT) approach. Key staff who were identified (nurse/midwives and doctors) have been equipped with necessary knowledge and skills. These are now training other health providers within their hospitals and districts. The main aim of the CBoH is to scale up the services to at least 100 service sites. The Churches Medical Association of Zambia (CMAZ) has also been training staff in church mission hospitals in the provision of PAC services. 2 Abortion laws and policies Zambia has had one of the most ‘ liberal ‘ laws on abortion in Sub - Sahara Africa. The Termination of Pregnancy Act of 1972 permits abortion if continuation of pregnancy involves the risk to the life or injury to the physical or mental health of the mother, or if there is substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be severely handicapped. A legal abortion can also be obtained if continuation of pregnancy involves a risk of injury to the physical or mental health of any of her existing children (8). Below is the summary of the abortion legislation:
The law is both oblique and explicit. Oblique in that it is subject to administrative professional discretion and explicit in that it confers users to seek the services when the need arises. Although the Act is said to be liberal compared to others in the Sub-Saharan region, it is restrictive in that the conditions in the law render hospital abortion services inaccessible to the majority of women who live far from the hospital and one can hardly find even a single physician present in the remote areas of Zambia.
2.1 Provider profile The training of midwives in Zambia started way back in February 1971 for Enrolled Midwives and July 1971 for Registered Midwives and takes one year. Since then Zambia has trained 4811 enrolled midwives and 4497 registered midwives. After completion of general nurse training, the nurses are deployed in non-delivery areas, which includes gynaecological wards where abortion patients are cared. These are expected to offer both pre and post abortion counseling and emergency resuscitation for patients presenting with complications of abortion. They do not offer MVA. Midwives largely provide uncomplicated antenatal, delivery and post-natal care including contraceptive services. Midwives work independently but refer at risk patients to medical doctors. Clinical officers receive a 2-year training but their curriculum does not allow them to cover sufficient experience in gynaecology and obstetrics and are not allowed to provide abortion services. The medical school in Zambia was opened in 1967 and the first medical students graduated in 1974. About 841 Zambian doctors have so far graduated from the University of Zambia (UNZA) school of medicine. The under graduate program is seven years. Thereafter they rise through the ranks of junior resident medical officers, senior house officers and after another year of postgraduate they become registrars. The four year Master of Medicine programme (Mmed) started in 1986 and twelve (12) candidates have so far graduated in the department of Obstetrics and Gynaecology. This confers specialist status. All the levels of medical doctors provide various degrees of reproductive health care including management of patients with complications of abortion with the specialist (if available) dealing with the more complicated cases. The specialists are concentrated at the only teaching hospital, The University Teaching Hospital (UTH). The other hospitals are largely run by SHOs / GMOs who can provide complicated and surgical treatment for obs and gynae patients. During the 7year training for their first degree, the 7th year students have to perform five (5) MVAs for abortion complications and also have didactic lectures on the TOP Act. As interns they perform all evacuations after a brief induction. After internship those that remain at UTH, Ndola and Kitwe Central hospitals continue to provide evacuations using MVA and those posted to the district hospitals use sharp curettage under General Anesthesia, as they lack the MVA kits. For postgraduate students in obs and gynae i.e. interested Registrars undergo unstructured training in provision of elective TOP. Acquiring this skill is optional, but acquiring MVA skills for care of abortion complications is mandatory. 2.2 Knowledge, Attitudes and perception of abortion In the community mostly Non-Governmental Organizations (NGO) are working hand in hand with the government to educate and discuss sexual issues including contraception, abortions, STIs including HIV/AIDS. There is still a lot of IEC to be given to the community on the importance of seeking counsel on the issue of abortion, and the importance of preventing unwanted pregnancy. The church and other church organizations have also stepped up the education on reproductive goals. One such organization is the Youth for Christ which has introduced an Options Crisis Pregnancy Center in Ndola (1999), where they seek to assist the youths who have preferred to keep their pregnancies and those that are going through an emotional crisis after going though an abortion. They also teach chastity and abstinence to youths in schools and counseling in various areas that affect the youths. i. Policy makers They have also addressed the issue of prevention and management of abortion in the ‘Family Planning in Reproductive Health: Policy Framework, Strategies and Guidelines which stipulates that all health workers will address the problem of contraceptive failure or induced abortion in a sensitive and humane manner and will counsel women and inform them about the possibilities of legal abortion and its requirements according to the Termination of Pregnancy Act of 1972. But there exists a gap between policy and implementation. ii. Patients' perceptions Because of low availability of medical care services and the high costs, many women resort to self-induced abortions. The judgmental attitudes of both the community and the health providers has contributed to high rate of self-induced abortions. Most women and youths when faced with the issue of unwanted pregnancy would rather secretly find a way of terminating it before anyone notices it. But unfortunately most of them have ended up with complications. Below is the summary of how the clients induce abortions outside the hospitals. |
Table 3 Ways used to induce abortions
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iii. Health care providers (Knowledge, Attitudes &Perceptions) DOCTORS Even in countries where abortion is legal, some providers who disapprove of abortion have difficulty separating their personal feelings about abortion from their professional commitment to provide medical care. Many doctors are not even aware that TOP is legal even for social reasons. NURSES The study, which was done in Zambia and South Africa, confirmed that the participant’s perception of abortion greatly influenced their attitudes towards the client. Nurses confessed that they were more sympathetic towards the woman with a spontaneous abortion than the one who had induced abortion. The study confirmed that the complexity of the abortion experience in nurses varied in the amount and type of stress it generates for them. The manner in which the nurses responded to the procedure was found to be a joint function of their psychological state and the reason for which abortion was done (p115). Most medical staff still feel that they are not obliged to give information as far as abortion is concerned (14). Price (1983:154) described one of the psychodynamic sources associated with emotional reactions of nurses as follows: "over-identification with the fetus and lack of identification with the aborting woman on a conscious/unconscious level". The study concluded that the participants’ perception of abortion greatly influenced their attitudes towards the client. Since the provision of quality PAC services started in January 2001, there has been a marked improvement of the attitudes towards both the patients seeking TOP and those patients presenting with complications of abortion. The providers are being taught to provide humanistic counseling and care for these patients. Most patients have appreciated these services. This has been demonstrated by the manner in which patients come back to the hospital for further inquiry or help. 3 The Nurses Act Before the revision of the nurses Act, nurses and midwives were not allowed to operate on their own. They could not run nursing homes, due to legal barriers. The revised Nurses and Midwives Act of 1997 has expanded the scope of practice of the Nurse and Midwife. The nurse/midwife is now allowed to provide therapeutic, palliative and rehabilitative care and treatment of illnesses normally carried out in nursing and midwifery practice and in a nursing home (11). Some of the responsibilities a nurse is now able to carry out include:
3.1 Midwives role in abortion service Now counseling in reproductive health issues is being offered at every health center and hospitals mainly by trained midwives. Testing of blood is offered and treatment of various STIs provided. Also activities on prevention of mother to child transmission of HIV, including support of those mothers who are found to be HIV positive. Following the approval and the signing of the new Act, legal barriers have been removed to an expanded role for nurses in provision of certain primary medical care services. Nurses have now been given a greater role in the provision abortion services. They can now be trained to perform MVA for patients with incomplete abortion but not for elective abortion.
3.2 Midwifery curriculum
The current intakes of midwifery students at UTH are being used to try the implementation of the new curriculum. They have an opportunity to provide quality PAC services but not MVA. 4 Organization of abortion services 4.1 Elective TOP services Many health centres have been equipped to provide all maternal and neonatal services but not TOPs. Few centres in Zambia perform elective abortion on social grounds. This is because specialists are not obliged to perform or allow TOP in their centers if it impinges on their religious or moral beliefs. Therefore the health centres have to refer clients seeking TOP to the tertiary centres which allow TOPs. Many clients bypass the health centre and have to pay bypass fee of ZK 25,000.00 after which they are referred to see a medical doctor who is pro - abortion for clerking and counseling to determine the indication for termination and contraceptive choice. A TOP form has to be signed according to the TOP Act and client’s consent obtained. The client can have TOP services the same day or at the latest the next day. Termination of pregnancy below 12 weeks is performed surgically using MVA and those between 12 - 20 weeks medically using misoprostol. The surgical termination cost ZK 6000.00 and the medical ones depends on the number of misoprostol tablets used and each costs ZK 3500.00 in the department of Ob/Gyn UTH. The surgical terminations are ambulant day procedures and clients are discharged after 2hrs if all is well with a contraceptive method. A follow - up visit is scheduled at seven days thereafter visits are only if clients experience problems either with FP method or complication from TOP. 4.2 Record keeping and health statistics 5 Post - abortion care services Recently in June 2001, three Central Hospitals (UTH, Kitwe and Ndola) have been set up as training centers for post abortion care (PAC) and use a structured PAC on the job training (OJT) module. Trainees include both Nurses and Doctors who undergo the same course except that the nurses have not yet been taught how to perform MVA. A pilot programme has been initiated in Lusaka by CMAZ/ FHI in which nurse/midwife have been taught how to perform MVA. The nurses and midwives had started performing MVA but under the supervision of medical doctors trained in PAC. Since all the trained doctors left the nurses have stopped performing MVA. This is really a pity because this might have been a stepping stone to menstrual regulation. The PAC services are offered within the emergency Gynae wards at the three centres using MVA for evacuation of uterus. For those using sharp curettage, counseling is done in the gynae ward and evacuation in theatre under GA. Patients are referred from health centres and after registering they present themselves to the gynae emergency wards. If patients by pass the health centre the pay ZK 25,000.00 thereafter the services are free. The nurse/ midwife receives the patient, enters vital statistics in the admission book, does initial assessment and pre MVA counseling with the doctor, assists in the MVA procedure by providing verbacaine and continues with post MVA couneling. Efforts to improve PAC in Zambia were started on a pilot basis by Ipas in 1989. MVA equipment was provided and doctors were trained in a number of sites. After the pilot project ended, equipment was not replaced and services were discontinued at every site except UTH and Ndola (14). With the introduction of the provision of quality PAC services the nurse/midwives are being trained in the provision of the services. Below is the summary of PAC services currently being provided since the year 2000: |
Table 4 Summary of PAC services
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5.1 ROLE OF NURSES/MIDWIVES IN PAC In the quest for safe motherhood, the health providers face the challenge of providing emergency care for the complications of unwanted pregnancy. Reduction in the need for induced abortion and prevention of unsafe abortion can be achieved through the provision of FP services and making these services accessible to the women in need. Accordingly, the health professionals are being trained in management, evacuation of removal of products of conception using MVA and post abortion counseling for FP. The implementation of the PAC package, which includes emergency care of abortion complications and post abortion contraception, counseling and initiating a contraceptive method of choice is one way of dealing with this challenge. |
Table 5 PAC statistics Jan to December 2000
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Table 6 January – September 2001
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6 Complications and outcome The complication rate has not been investigated, but since the introduction of PAC no women have reported back with bleeding or infection. The women who have had elective abortion have complained of moderate to severe pain during the procedure. Some are given analgesics such as Brufen, while the majority have had the procedure done under verbacaine. Due to the attitude of some providers towards TOP, very few providers take interest in the TOP clients. There is need to conduct studies about complication rate in relation to provider especially when nurses begin to perform MVA although studies in Ghana have shown no difference in complication rates. Other studies include the effect of elective abortion on the adolescents. The administrators in the hospitals where PAC has been initiated have testified that it has brought a lot of benefits to their institutions i.e.
7 Incentives and Barriers Laws and regulations The resistance might come from the midwives, as performing MVA will add to their workload. A lot of teamwork will be required in this area. The nurses and midwives in Zambia owe a lot to the GNC and the Zambia Nurses Association (ZNA) for fighting tirelessly for the law to be changed in their favor. 8 Lessons learned Zambia still has a lot of lessons to learn as far as the works around abortion is concerned. The most important is the change of attitude towards the women who request TOP. We believe this will come about when counseling skills will be instilled or taught to health providers. Some women have after all decided not to terminate their pregnancies after a good counseling session. Others have taken steps to ensure the prevention of the next unwanted pregnancy. The presence of a nurse/midwife during TOP or MVA has brought a lot of comfort and confidence in a lot of clients. One woman testified that there was a great difference between her first MVA and the second. She felt supported during the second MVA Efforts are being made through PAC to ensure that every hospital and health center provides quality services. Youth friendly corners need to be strengthened to help the youths meet their reproductive goals. We believe prevention is better than cure. Sex education need to be strengthened in schools and for youths in the community. 9 Challenges
10 Conclusion Zambian midwives can participate in the provision of quality abortion services in many different ways even if the law is restrictive. They can offer counselling and family planning services. Now that the 1997 Nurses Act has been passed they can save lives of women who come in with complication of abortions by providing the full PAC package which includes performing MVA. REFERENCES
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Updated 19 June 2002 |