Russian Academy of Medical Sciences (RAMS) (Savelieva) & EngenderHealth (Pile, Sacci, & Loganathan)

The research communicated in this 71-page document was motivated by the fact that abortion remains a primary means of fertility control in Russia (3 out of 5 pregnancies end in abortion), a country that also has high rates of repeat abortions (around 40%). Abortion continues to be an important cause of preventable morbidity and mortality among women of reproductive age: As the authors note, in 2001, abortions accounted for 27.7% of maternal deaths in Russia, as compared with an estimated 13% of all maternal deaths globally (MOH unpublished, 2002; WHO, 1997).

In response, EngenderHealth, the Population Council's FRONTIERS Program, and the Research Center of Obstetrics, Gynecology, and Perinatology of the Russian Academy of Medical Sciences (RAMS), with support from the Perm Health Departments, undertook an operations research study to test models for increasing contraceptive use and reducing the repeat abortion rate among abortion clients in Perm, Russia. The intervention was designed to explore the significance of using interpersonal communication as a strategy - training providers to counsel women - as well as the provision of printed informational materials for providers and clients.

Specifically, researchers sought to investigate the relative effectiveness of two models of postabortion care (PAC) in reducing repeat abortions and increasing contraceptive use. Researchers interviewed 1,516 women who had an elective abortion procedure at 5 facilities in Perm, Russia before and after 2 models of interventions were carried out through the John Snow, Incorporated, Women and Infant Project (JSI/WIN). Model I consisted of training providers in family planning counselling and interpersonal communication skills and developing and supplying provider job aids (e.g., flipcharts) and client education materials on postabortion family planning. The strategy here involved institutionalising pre-discharge family planning counselling and information for all postabortion clients and ensuring that this counselling would be carried out in a respectful, non-judgmental, and non-coercive manner. Model II had the same intervention components, but in addition offered a free initial 3-month supply of condoms, birth control pills, DMPA (depot medroxyprogesterone acetate, or Depo Provera - a long-acting form of injectable birth control), or an intra-uterine device (IUD) to all postabortion clients requesting a modern contraceptive method.

Selected Findings:

• Knowledge about postabortion family planning and the rapid return of fertility increased among both providers and clients in the intervention groups. Prior to the intervention, only half of providers correctly responded that fertility returns within 2 weeks after an abortion, in contrast to 83% of providers after the intervention. The majority of women in the intervention groups (74-90%) also responded correctly, whereas less than half of women in the control group were able to answer correctly.
• The provision of birth control ("commodities") in Model II increased the likelihood that providers would discuss family planning with postabortion clients, but did not result in a significant increase in use of family planning at one year postabortion. Health care workers appeared more motivated and more likely to provide family planning counselling to abortion clients if family planning methods are available and if management buy-in and support is present.
• Receiving family planning counselling at the follow-up visit was an important factor in reducing repeat abortion. Non-repeat abortion clients were significantly more likely to have received counselling during their follow-up visit as compared to repeat abortion clients, who had received no counselling at their follow-up visit (50% versus 39%).
• After the intervention, use of a modern contraceptive method was significantly greater among clients in the intervention groups (62% in Model I and 67% in Model II) than among control group clients (53%).
• At the 13-month follow-up interview, repeat abortion rates had declined in all the groups (18% in the control group, and around 13% for both the Model I and II groups). This suggests factors other than the intervention influenced repeat abortion rates, such as client and service-use characteristics.

The authors of the study stress that women in the Model II group received better counselling and more information than those in the control and Model I groups, which translated into improved knowledge of postabortion pregnancy prevention. Based on the observation that improved counselling provided in the Model II group led to those women being more likely to leave the facility certain of their choice of family planning method, with the intention to start using their method immediately, the authors recommend that all health care workers providing services to abortion clients be trained in family planning counselling and interpersonal communication skills. In addition, they urge that family planning counselling be institutionalised at all levels of service delivery where services are provided to abortion clients. When considering how to institute training for this type of counselling, programme planners may wish to keep in mind the fact that the study showed that "women-friendly" contraceptive family planning counselling, in particular, was found to be key. Further, "providers' high satisfaction with the new model is also a facilitating factor."

In conclusion, "Results of the study indicate that institutionalizing family planning counseling for all abortion clients is a low-cost quality-enhancing intervention for the existing healthcare system that does not require increased personnel, purchase of expensive equipment, or remodeling of health care facilities. Because of this, the counseling interventions included in the study can be easily replicated in any Russian oblast or city health care facility." The design and preliminary findings from this operations research study were the impetus for developing the first National PAC Services Delivery Guidelines for Russia. The guidelines were published in Moscow in April 2003 and are being widely disseminated.

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