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Christian Hospitals in Nigeria Provide
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Post-Abortion Care and STD Management
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by Traci L. Baird, MPH (Ipas);
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Catherine Plewman, MA (International Family Health);
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Rakiya Booth, M.Sc., PHDC, FWACP (CHAN); and
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Ayo M. Tubi, M.Sc., FWACN (Ipas)
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What is CHAN?
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The Christian Health Association of Nigeria (CHAN), with over 300 health
institutions and 3,000 outreach facilities, is the largest nongovernmental
health care provider in Nigeria. CHAN facilities serve at least 40% of
the country's population, primarily those in rural areas or urban slums
and those with the fewest resources. In Nigeria's current climate of dwindling
resources, economic hardship, and a literally paralyzed public health system,
CHAN staff are a stable, committed group of health care providers who fill
a much-needed gap in services.
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Neglected Reproductive Health Issues
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Unsafe abortion is a serious cause of maternal death and injury in Nigeria.
Between 27% and 77% of all gynecological hospital admissions are attributable
to unsafe abortion; 1, 2 in most Nigerian
hospitals, incomplete abortion is the most common gynecological emergency.
Annually an estimated 20,000 Nigerian women die of complications from unsafely
performed abortion,3 representing about
half of all maternal deaths. Modern contraceptive use is increasing, but
remains low at about 4% among women of reproductive age.4
Few, if any, family planning programs have outreach efforts that include
abortion patients, making it difficult for many women to break the cycle
of unintended pregnancy and unsafe abortion.
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Another increasingly serious reproductive health issue in Nigeria is the
lack of detection and treatment of reproductive tract infections (RTIs)
and sexually transmitted diseases (STDs). While few widespread prevalence
studies have been conducted, a recent community survey of adolescents in
eastern Nigeria found that among sexually active girls, 19% had an STD
and 40% had an RTI.5 Despite a low initial
prevalence of HIV and AIDS-related illnesses, both are now rapidly increasing
in Nigeria, with HIV incidence doubling annually in some areas.6
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One way to address these reproductive health issues is to expand the quality
and range of services provided to women who seek care for abortion-related
complications. In addition to treating existing complications, comprehensive
post-abortion care (PAC) should include family planning counseling and
services and links to other reproductive health services, especially STD
diagnosis and treatment and HIV/AIDS awareness. Unfortunately, this integrated
approach is available only in a few health facilities in Nigeria.
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Finding Solutions
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In 1995, Ipas, International Family Health, and CHAN developed a project
to address some of these overwhelming and largely unmet reproductive health
needs. The project goals were to introduce PAC/STD services in a sample
of the CHAN hospitals, to ensure high quality services, and to establish
an ongoing training plan for additional CHAN health facilities. Other project
objectives include:
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training in manual vacuum aspiration (MVA) to manage incomplete abortion,
and in the skills necessary to diagnose, treat, and prevent STDs, including
HIV;
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developing workplans for integrating MVA/STD services into the existing
health care structure of CHAN institutions; and
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encouraging linkages and referrals between CHAN institutions and other
community and government-run health facilities.
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After conducting a simple needs assessment of 43 of the largest CHAN hospitals,
11 hospitals representing Catholic, Baptist, and other Christian denominations
were selected to participate. In August and September of 1996, 35 doctors
and nurses were trained in four six-day courses that covered the management
of incomplete abortion, post-abortion family planning, and STD diagnosis
and treatment. Two courses were held in the North of Nigeria and two in
the South to minimize travel costs and address regional differences. Each
hospital was provided with the items necessary to initiate the new services,
including MVA instruments and reference and training materials. Seed money
for a revolving drug fund for STD treatment is also being provided to each
hospital.
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Program Highlights
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Several interesting aspects of this project offer useful guidance to groups
working with religious health networks in other countries.
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Christian hospital staff recognize women's needs for post-abortion
care. In many parts of the world, women's access to high quality
post-abortion care is limited by negative attitudes of health care providers
and policymakers. Women may be denied services because of a perception
that they are immoral for having terminated a pregnancy, or they may not
be given family planning counseling if the doctor is busy or does not approve
of modern contraception. Christian hospitals are frequently assumed to
have these biases because some religious groups oppose information and
services related to sexuality and reproduction. When this project began,
the program planners expected to encounter resistance among CHAN hospital
staff to the need for safe post-abortion care and STD management.
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Instead, almost all of the church-affiliated hospitals approached about
this project were already very clear in their beliefs that women suffering
from incomplete abortion -- whether induced or spontaneous -- should receive
high quality treatment, and should have access to comprehensive reproductive
health services. Most of the hospitals already provided treatment for abortion
complications and many offered family planning, although rarely to post-abortion
patients.
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One potential difficulty is that some women in the communities served by
these hospitals may avoid seeking abortion-related care at CHAN hospitals
for fear of moral or religious reprimand. The participating hospitals and
religious leaders recognize the need to raise community awareness about
the negative health consequences of incomplete abortion and the availability
of trained staff and nonjudgmental treatment services. Public outreach
will be a stronger component of future project activities.
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Coordination with public sector health facilities can facilitate
post-abortion family planning services. The range of family planning
services offered at CHAN hospitals varies widely due to religious beliefs,
inadequate staff training, and a frequent lack of contraceptive commodities.
To standardize the availability of post-abortion family planning, all project
participants received training in counseling and service delivery. The
training stressed that, regardless of the contraceptive methods offered
by the hospital, every woman treated for incomplete abortion needs to leave
the hospital knowing four things: she can get pregnant almost immediately,
contraceptive methods exist that can prevent pregnancy, condoms can also
prevent STD/HIV infection, and where in the community she can receive family
planning.
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Since the training, staff at participating hospitals have been creative
in ensuring access to family planning services. Several hospitals that
do not provide modern methods themselves have established links with Local
Government Authority (LGA) health centers (public sector, primary level
health facilities), which do provide contraceptives. Patients treated for
incomplete abortion or STDs at CHAN hospitals now have access to family
planning counseling and services, and clients of the LGA health centers
can be referred to the CHAN hospitals if they need abortion treatment services.
In some areas, records of referrals are kept by both the LGA center and
the referring doctor to facilitate appropriate feedback and follow-up.
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STD management is a logical component of the PAC model. As
the prevalence of STD infection and HIV/AIDS mounts, health professionals
are increasingly aware of the need for prevention and management services.
Although CHAN staff in many hospitals were conducting STD training prior
to this project, very few hospitals had integrated these services into
a post-abortion setting. For many women, seeking care for abortion complications
may be their only contact with the formal health system. By integrating
STD management into the overall PAC training course, CHAN staff were able
to build their skills in general STD/HIV prevention and management and
to better address women's related reproductive health needs. One difficulty
identified in this integrated approach is that a six-day training course
may not allow enough time to cover the full range of clinical and management
issues involved in PAC and STD services.
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Nongovernmental health associations can conduct their own training
and monitoring. Because of CHAN's decentralized structure, its
central Secretariat plays a coordinating role but does not mandate specific
policies or practices for individual hospitals. Bringing together the Secretariat,
the CHAN Zonal Managers from each of Nigeria's four health zones, and other
staff at the zonal level was key to making the PAC/STD services sustainable
at the hospital level. Although public sector medical consultants conducted
the initial clinical course, participating CHAN hospital staff now have
the necessary skills and materials to conduct subsequent training in CHAN
hospitals. CHAN zonal staff are taking part in the monitoring and support
visits conducted regularly throughout the project to ensure that the CHAN
network has the internal capacity to provide technical assistance in PAC/STD
services to its member institutions.
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Discussion
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Religious hospitals provide a significant portion of reproductive health
services around the world, especially in rural areas. It is clear that
the health professionals in the Christian hospitals in Nigeria are committed
to improving women's health, and they see incomplete abortion and STDs
primarily as health problems, and not just as moral or religious issues.
This project represents an exciting and successful approach to improving
women's health through a private-public partnership and referral network.
It is among the first efforts to build the capacity of religious health
institutions to address these neglected aspects of reproductive health.
Based on the Nigeria experience, religious organizations in many countries
may be appropriate partners for expanding post-abortion care -- in a context
of comprehensive reproductive health -- to the facilities and communities
where it is most needed to save lives.
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References
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1. Unuigbe, J.A., Oronsaye, A.U., Orhue, A.A.E. Abortion-related morbidity
and mortality in Benin City, Nigeria: 1973-85. Int J Gyn Ob, 26, 1988.
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2. Konje, J.C., Obisesan, K.A., Ladipo, O.A. Health and economic consequences
of septic induced abortion. Int J Gyn Ob, 37, 1992.
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3. Population Council Report. Prevention of Morbidity and Mortality for
Unsafe Abortion in Nigeria. NY: Population Council, 1991.
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4. Federal Office of Statistics [Nigeria] and IRD/Macro International Inc.
Nigeria Demographic and Health Survey 1990. Columbia, MD: IRD/Macro International,
1992.
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5. Brabin et al. Reproductive tract infections and abortion among adolescent
girls in rural Nigeria. The Lancet, 345, 1995.
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6. Obisesan K.A., Olaleye O.D., Adeyemo A.A. The increasing prevalence
of HIV-1 and HIV-2 infections in a low risk antenatal population in south
west Nigeria. Int J Gyn Ob 56, 1997.
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This article was reprinted with permission from Ipas (www.ipas.org)
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from "Dialogue," Volume 1, Number 2, Sep 1997.
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