Surgery for Family Planning, Abortion, and Postabortion Care

Excerpt

This chapter discusses two related but conceptually distinct health concerns in low- and middle-income countries (LMICs): (a) voluntary family planning, and (b) abortion, including postabortion care. In the first section, on family planning, the health condition of interest is unmet need: the percentage of women who would like to either stop or delay childbearing but who are not using any contraceptive method to prevent pregnancy. The unmet need for family planning (to either limit family size or determine the intervals between children) results in unintended and unwanted pregnancies, which in turn lead to a broad range of maternal and child conditions that increase morbidity and mortality. Surgical procedures for family planning can help reduce this unmet need, particularly the need to limit childbirth.

The second section concerns surgery for induced abortion (as opposed to spontaneous abortion, or miscarriage) and the surgical management of the complications of induced, mostly unsafe, abortion. Unsafe abortion is defined as abortion performed outside of health facilities (or any other place legally recognized for the procedure) or by an unskilled person (WHO 1992). The demand for abortion is high in many LMICs, and the illegality of the procedure in most of these countries increases the likelihood of postabortion complications from clandestine, unsafe procedures (Grimes and others 2006; Shah and Ahman 2009; Singh and others 2006; Singh 2010). Therefore, postabortion care is a significant health issue in LMICs. Timely, safe surgical interventions can reduce the morbidity and mortality associated with unsafe abortions.

The same surgical procedures used for abortion are also used to manage incomplete abortion, which is one of the most common postabortion complications and is often accompanied by other complications such as bleeding, sepsis, and genital injury. The surgical procedures used to manage such complications include laparotomy for sepsis and uterine injury and a wide range of minor procedures to repair injuries to the proximal birth canal.

Both sections discuss the burden of reproductive health conditions, including morbidity, mortality, and other effects. We discuss surgical procedures (their performance, inputs, and implementation) and the health workforce implications of scaling up those procedures in LMICs. We also explore evidence on the procedures’ effectiveness in reducing morbidity and mortality and improving quality of life as well as evidence on their cost-effectiveness. Finally, we outline future directions—including implementation challenges and considerations for increasing access to these surgical interventions—and conclude by summarizing the findings and recommendations.