As in many West African countries, accessing quality reproductive health services in Togo remains difficult, particularly outside of urban centers. Currently, a woman in Togo has a 1 in 67 chance of dying due to maternity-related causes, and unsatisfied need for family planning (FP) stands at 40.5% (PRB 2012). Given these statistics, there is much need for improved access to quality care to FP and other reproductive health services within the country.
E2A assessed the implementation and scale-up of Postabortion care (PAC) programs in four Francophone West African countries, including Togo. The assessment focused on the FP component of PAC. Each of the four countries applied a Virtual Fostering Change methodology for the scale-up of PAC programs, beginning in 2008.
The provision of FP within PAC services – a key component of the widely accepted PAC model – has been identified as a high-impact practice which contributes to the use of FP by women who need FP services. While the impact of this practice is known, more evidence is needed about successful approaches to its implementation and sustainable scale-up. The purpose of the assessment conducted by E2A was to identify the core activities undertaken by the four countries to strengthen PAC-FP services at the point of treatment and factors that contributed to – or hindered – success. In addition, the assessment looked at the role the Virtual Fostering Change methodology played in introducing and sustaining FP within PAC services. Virtual Fostering Change was introduced following a regional meeting in 2008 that focused on strengthening the quality and scale-up of PAC services in West Africa. The meeting was sponsored by the US Agency for International Development (USAID) and the World Health Organization, with support and participation from the Implementing Best Practices Initiative, governments, national and international organizations.
Between September 2012 and March 2013, E2A, working with guidance from key government partners in the region, USAID, and participants of the 2008 PAC meeting, collected data from health facilities, including conducting interviews with service providers, reviewing service delivery statistics, and leading focus group discussions. Key government counterparts were interviewed, as were projects that provided technical assistance to the initiative, and E2A conducted a desk review of PAC programs as a complementary feature of the work.
E2A's assessment report of the PAC program in Togo is referenced below.
Results of the assessments were presented at a regional workshop, held last October in Saly, Senegal. Based on the assessment results, representatives from the four countries, along with others in Francophone West Africa, have made plans to strengthen certain aspects of PAC service delivery over the next year. The assessment provides a useful contribution to understanding what works and does not work in PAC program implementation. E2A is committed to strengthening FP within PAC services and will seek opportunities to apply these programmatic lessons widely.
Improving the Quality of PAC in Togo
Based on the assessment findings and a corresponding action plan for strnegthening PAC developed by Togo's Division of Family Health, E2A worked with five health facilities in Togo to increase access to PAC-FP services, expand the method mix offered during PAC to include long-acting reversible contraceptives, and generally improve quality, with a focus on youth-friendly PAC services.
E2A appointed a three-person quality-improvement team at each of the facilities: one who was in charge of FP at the facility, the other who oversaw the maternity ward, and the district supervisor for FP and reproductive health. E2A also appointed a quality-improvement team at the Division of Family Health that was responsible for monitoring at each facility.
E2A supported trainings with the Division of Family Health and target facilities on quality improvement, including national and district supervisors. E2A used IntraHealth International’s Optimizing Performance and Quality tools to strengthen PAC service delivery, and shared key messages with service providers on: the need for FP (regardless of whether the abortion was provoked induced or spontaneous); return to fertility after abortion; and the importance of pregnancy spacing and method eligibility criteria for PAC. Additionally, all target facilities now report using standardized PAC registers, after E2A had adapted and translated the PAC register from the PAC Global Resource Center for use in Togo.
Results from the quality improvement interventions show promise on positively influencing the uptake of contraception during PAC. In one year, family planning counseling with postabortion clients increased from 31% to 91%. Of those counseled, provision of a contraceptive methods before discharge increased from 37% to 60%. Oral contraceptives remained the most popular method, but use of injectables and implants increased. The country-driven approach, which tended to use existing resources and minimal external support, has potential for sustainability and scale-up in Togo and application elsewhere.
You can read a peer-review journal article on this activity, which appeared in Global Health: Science and Practice, here.