Behavior Profile: USAID MCGL - Women Seek Postabortion Care| Health Goal: Reduce repeated unintended pregnancy | ||
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Women and adolescents seek care for bleeding in (early) pregnancy and associated complications or following an incomplete abortion
Percent of women who have lost a pregnancy, either induced or spontaneously, who report having consulted a provider in the 48 hours afterwards
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Behavior Analysis |
Strategy | ||
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BEHAVIOR AND STEPSWhat steps are needed to practice this behavior?Women and adolescents seek care for bleeding in (early) pregnancy or any complications from a miscarriage, incomplete abortion or induced abortion
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FACTORSWhat factors may prevent or support practice of this behavior?StructuralAccessibility: Care is not always available, especially in rural areas, and at times providers, even when trained, refuse to provide care relating to abortion for any reason, including spontaneous abortion or miscarriage Accessibility: Legal framework for PAC services is often confusing for providers and clients alike Accessibility: Cost, distance and service hours make accessing care particularly hard for some groups of women, such as adolescents and youth Accessibility: Minors are not always allowed to seek care without family permission, often in writing Service Provider Competencies: Providers are not always trained on how to offer compassionate, emotional support and counseling for women and adolescents on the emotional complexity of having had a spontaneous or induced abortion Service Provider Competencies: Providers are often unable to provide care impartially, without judgement on what the woman should or should not have done, resulting in some cases, even, in explicit abuse of the woman. This is even more pronounced for adolescents and youth Service Experience: Construct of "safe" and necessary care from a clinical perspective often differs than that of PAC clients, who often cite their top priority as supportive counseling, compassion, and privacy Service Experience: Women are unable to find privacy because facilities are not designed to provide it or because staff do not respect it SocialFamily and Community Support: Advice from a trusted support person is often the most critical factor in where, when and what kind of care is sought for complications from abortion (either induced or spontaneous) Family and Community Support: Concerns of public disclosure and privacy, along with fear of repercussions should the community find out, are often paramount for women, especially adolescents and youth, in considering care-seeking Family and Community Support: Intense community stigma, including lack of broad support for anything related to abortion, including PAC, and active discrimination, shaming and marginalization and even violence often exist Family and Community Support: Adolescents seldom feel comfortable discussing pregnancy with family members and therefore often lack options for support for an unintended pregnancy Gender: Fear of disclosure to partner (due to risk for IPV or just not wanting partner to know) discourages early care-seeking Gender: Complex notions of femininity and motherhood inhibit prompt care-seeking, including ideas of who controls a woman's body at different age-stages prevent women from seeking care for fear of public judgement in addition to private shame, including ideals that define a woman as a body that should produce children or an adolescent as a body that is pure and should not have sexual relations. Norms: Public community and religious norms often marginalize women who have experienced abortion or pregnancy loss as immoral or having failed in their role as a woman or as an adolescent Norms: Public norms provoke feelings of guilt, shame, embarrassment for women Norms: In some cases, private opinions differ from public norms, with many community members supportive of women who experience spontaneous abortion or abort in cases of rape or incest InternalAttitudes and Beliefs: For many women, abortion (both spontaneous and induced) carries with it psychological trauma, interlaced with feelings of guilt, shame, denial, grief and other internal cognitive and non-cognitive experiences that often result in ‘emotional paralysis’ which can inhibit or delay medical care following the experience and interest in contraception Knowledge: Women do not always know they should seek follow-up care, especially in cases of early spontaneous abortion or medical abortion using misoprostol or other method Knowledge: Women do not always know they are entitled to PAC, nor where to seek it, especially in cases where the legality of abortion is unclear or uncertain Knowledge: Women, especially young women and adolescents, do not always know that fertility can return quickly after pregnancy and/or abortion, making a decision to prevent future unintended pregnancy urgent |
SUPPORTING ACTORS AND ACTIONSWho must support the practice of this behavior, and what actions must they take?InstitutionalPolicymakers: Institutionalize provider behavior change content for postabortion providers at all stages of training and professional development Policymakers: Include easy to understand language on the right and need for PAC, including clarity on what the law allows providers to offer, in health-related policies and community governing documents Managers: Include competencies related to psychological and emotional support in supportive supervision and mentorship Managers: Ensure privacy for client consultations to facilitate confidentiality Providers: Practice client-centered care, remove from service delivery all personal bias and judgement on reasons for care-seeking and follow-up recommendations Providers: Maintain and reassure clients of strict confidentiality
CommunityCommunity Leaders: Normalize postabortion care-seeking and publicly praise the standard of supporting women and families to seek necessary medical care for any and all reasons Community Leaders: Guide communities to adapt attitudes around the role and value of women in society Religious Leaders: Discuss the importance of seeking health care for any reason without judgement or shame Religious Leaders: Reinforce women’s value and dignity as human beings and the importance of compassion over judgement. Teachers: Provide young people with complete and correct information about PAC School Staff: Let students know that they are available to listen and provide emotional support without judgement HouseholdFamily Members: Reinforce, without judgement, the importance of skilled care for all maternal health concerns including abnormal bleeding, cramping, or other conditions
Family Members: Be open and supportive of the decisions of other women, including adolescents and youth, ensure they receive appropriate care when they are asked for support Family Members: Tangibly and emotionally, without judgement, support women who have gone through an abortion of any kind (taking tasks, allowing for extra rest, providing space for discussion) Male Partners: Support wife/partner to receive appropriate medical care as needed for any reason without question or judgement Male Partners: Actively participate with wives/partners in reproductive decision-making |
POSSIBLE PROGRAM STRATEGIESWhat strategies will best focus our efforts based on this analysis?Strategy requires Communication Support Enabling EnvironmentPartnerships and Networks: Support engagement with private sector, pharmacies, CHWs to expand availability, including use of telehealth to “prescribe” medical methods for women far from a health facility Policies and Governance: Update, clarify, and effectively disseminate policies and legal framework ensuring explicit access to PAC for all women Policies and Governance: Ensure that policies and protocols for PAC standards of care include privacy, mental health care and counseling, and follow-up Systems, Products and ServicesInfrastructure: Prioritize budget line for facility renovations to ensure audio and visual privacy and establish minimum standards of privacy for facilities Products and Technology: Support expansion of PAC as part of primary health care, including the use of medical methods for emergency treatment of incomplete abortion and availability of PAFP methods Products and Technology: Explore establishing or expanding telehealth options to provide initial level of care or screening for those women and adolescents unable or uninterested in care in a brick-and-mortar facility Quality Improvement: Incorporate technical training and values clarification activities for providers into pre-service, in-service, and continuing professional training Quality Improvement: Adapt and roll out values clarification and attitudes transformation activities for health managers (district and national levels), health providers, community leaders, even school educators Quality Improvement: Integrate role playing for emotional support and adolescent-responsive care into trainings and mentorship Quality Improvement: Collect and use data on delivery of comprehensive PAC (emphasizing PAFP and counseling) to hold facilities accountable for adhering to established policies and protocols Demand and UseCommunication: Expand outreach and public communication around bleeding in pregnancy, available services, where to access, etc., so women experiencing a miscarriage know the danger signs and are able to access care in a timely manner Communication: Train providers in how to help couples/families develop emergency plans for medical care (including finances, transport, shifting of household tasks) Communication: Create communications to reduce stigma around common pregnancy complications, including bleeding, and the importance of the client's mental health during and after adverse events Communication: Create or enhance crisis hotline, textline, or internet platform for women and adolescents to receive automated information on crises during pregnancy, including screening and referral to in-person care and/or counseling as necessary or desired Communication: Integrate messages on fertility awareness, including after pregnancy loss, into adolescent sexuality curricula and broader maternal health discussions and communications Collective Engagement: Support CHWs to encourage women to access care for any reason, including postabortion or bleeding in pregnancy, and to provide emotional and mental health support to women who have experienced pregnancy loss for whatever reason Collective Engagement: Integrate messaging on maternal care, including the importance of seeking prompt care for bleeding during or after pregnancy, into speeches, sermons, and community events Collective Engagement: Use the Social Norms Exploration Tool (SNET) to engage communities around untangling and changing harmful norms around pregnancy loss Skills Building: Develop job aids and other tools for providers to guide the provision of client-centered care with a focus on the particular trauma associated with pregnancy loss or abortion. |
