In 2007, an evaluation of postabortion care (PAC) services in Guinea found that despite reported routine provision of family planning counseling by providers after PAC, the proportion of women who left a health facility with a modern contraceptive method averaged only 45.63%. Soon thereafter, the U.S. Agency for International Development (USAID)/DC conducted an evaluation of PAC in Francophone Africa, which yielded similar results. At the Ratoma municipal clinic, which serves a population of 160,000 in Conakry, Guinea, the situation was found to be even worse—only 11% of women leaving our clinic following PAC services received a family planning method at the baseline assessment.
As ob/gyn specialists at the Ratoma clinic, we (Aminata Kaba and Sire Camara) understood that PAC is a critical time to help a woman identify and obtain a family planning method of her choice. However, we faced a lack of contraceptive options for clients at our clinic. To see an increase in the number of women leaving our clinic after PAC with a family planning method, we needed to ensure that they had options readily available to them on site.
Our in-country team attended a meeting sponsored by USAID in Senegal to share experiences, discuss assessment results, identify problems and possible solutions, and then each country developed an action plan for improving coverage for PAC clients. Our clinic was selected to be one of the program’s three pilot sites to increase to at least 60% the percentage of women who use a modern method of contraception after receiving PAC. As the head of the maternity ward (Kaba) and the manager of the clinic’s PAC services (Camara), we were chosen as “Champions” at our clinic to carry out the action plan.
We knew that our three main problems for low performance were: 1) lack of contraceptive options available at the emergency treatment site, 2) frequent stock-outs, and 3) the weak quality of counseling. To remedy these problems, we put in place a quality improvement and assurance approach developed by Jhpiego that required us to set performance standards, including those for infection prevention, counseling and pain management, for all aspects of PAC service delivery. These standards were measured through a baseline assessment and ongoing supportive supervision to monitor progress and identify gaps. We also advocated for the prevention of stock-outs and availability of contraceptives on site where emergency treatment was provided. From October 2009–September 2010, we instituted these two interventions to increase the number of women leaving the clinic with a family planning method of their choice. We used the performance standards to monitor and evaluate services, identify gaps and fill them—ultimately working toward improving services overall.
By October 2010, 197 women had received PAC services at our clinic and the percentage of women receiving a family planning method before leaving the Ratoma clinic increased from 11% to 59%. We found that the main reason for this improvement was an increase in and steady supply of contraceptive options, including long-acting methods, such as implants and IUDs, and short-acting methods, such as pills and injectables. Women at our clinic now had a variety of methods available to them. We achieved this steady supply by advocating with district health officials at the Ministry of Health through regular meetings to avoid stock-outs. In addition, we established weekly meetings with our staff to discuss any challenges and gaps identified during the initiative. Through our personnel’s consistent use of the performance standards, the quality of counseling improved significantly. We also kept detailed records to ensure accurate tracking of the numbers and types of contraceptives available at the clinic, which provided useful information for our meetings with district officials.
We have continued to improve our performance at Ratoma. As of the most recent assessment, conducted in September 2011, the percentage of women receiving a family planning method after PAC increased to 83% and the Ministry of Health congratulated our clinic for this achievement.
Sustained advocacy efforts with district health officials and relevant stakeholders to ensure availability of contraceptive options were essential to our clinic’s success in increasing the number of women able to choose a contraceptive option during PAC services. By giving us the opportunity to lead and develop our own plan of action at Ratoma, our clinic saw a significant increase in numbers. But if goes far beyond the two of us. We engaged our staff to join us in the effort-to be our eyes and ears at the clinic and, most importantly to work as a team to implement the performance standards and provide family planning options. Jhpiego’s Standards Based Management and Recognition (SBM-R®) approach values employee participation and buy-in. Even when the two of us are not at e clinic, we know that our team will carry on these critical efforts to ensure that women have options available to them.