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Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care" South Africa 2 - 6 December 2001. The paper in pdf-format Mozambique Abortion Situation Country Report Aida Libombo Momade Bay Ustá 1. Country Profile on Abortion Services 1.1 Country overview Mozambique has a population of 17,242,240 inhabitants, according to projections of 1997 Census. Almost 73% of that population live in rural areas; 70% of Mozambican population below poverty line; 23% are women in the reproductive age group and 46% of the total population below 15 years of age. The Crude Birth rate is 45.2 per 1000 population; the Death rate 18.6 per 1000; Life Expectancy is 46 (44.5 for men and 47.5 for women) and the population growth rate is 2.7% for the period 1996-2000. According to the 1997 Demographic and Health Survey (DHS), Neonatal Mortality is estimated to be 54 per 1000 live births, Infant Mortality 135/1000 and Child Mortality (<5) 201/1000. 1.2 Reproductive Health Situation The Total Fertility rate is 5.6 births and Maternal Mortality is estimated between 500 and 1500 per 100,000 live births. Additional findings from the 1997 DHS, showed that: 40% of girls between 15 to 19 years old had already experienced motherhood; only 5% of the adolescents were using contraceptives; although 50% of the female and 76% of the male populations knew the existence of the condom, only 2% of female and 10% of male reported to have used the condom on the last intercourse. These findings, and many others before shows the degree of risk to unwanted and unplanned pregnancies, and also exposure to sexually transmitted infections including HIV/AIDS among our adolescents. Regarding the utilisation of health services, the access to the general population is around 40%. Forty four percent of deliveries take place in health facilities (81% in urban areas and 33% in rural areas). The Caesarean-section rate is 2.7%, with a range of 7.3% in urban areas to 1.4% in rural areas. About 72% of women report prenatal care. Contraceptive prevalence (modern methods) is quite low (5%) and varies widely, from 28% in the southern capital of Maputo to 0.7% in the northern Province of Cabo Delgado. In urban areas 17% of women use modern contraceptive methods while only 2% of rural women do so. The main studies undertaken in the field of Safe motherhood identified the following causes of Maternal Deaths: Puerperal Sepsis, Haemorrhage, Eclampsia and Abortion complications.

Table 1. Abortion seekers by age Age Frequency Percent <15 1 .3 15-20 104 34.7 20-25 92 30.7 26-30 42 14.0 31-35 32 10.7 >35 29 9.7 Total 300 100 Table 2. Abortion by marital status Marital Status Total Percent Single 192 64.0 Married/living with a partner 103 34.4 Divorced/Widow 5 1.6 Total 300 100

Tables 1 and 2 show some preliminary results from a study being conducted at the Central Hospital in Maputo, to find out what are the reasons for seeking abortion 1.3 HIV/AIDS Mozambique is one of the most seriously affected African countries by HIV/AIDS, in the continent. AIDS is a serious problem which is on the increase. It is affecting mainly the economically active population, and 63% of the estimated 700 daily new infections occur among people below 30 years old. The current prevalence of HIV infection among people aged 15 to 49, is 12% countrywide ranging from 5.7% in the northern part of the country to 16.6% in the central region, on the Beira corridor. The prevalence in the southern part of the country on the Maputo corridor is 13.2%. In response to this alarming prevalence of HIV/AIDS in the country, a national Strategic Plan was developed and a Multisectoral National Council for AIDS was created. At the same time activities are being intensified to revert the situation. 1.4 Reproductive Health and the Mozambican Government Mozambican Health Sector Policies and Strategies The above-described demographic, economic and social profile of Mozambique and the results obtained from surveys, MDR in 1998/99 and SMNA in 1999, demonstrated the great challenges that existed within the health sector. To face that situation it was necessary to introduce new approaches, in terms of health policies, to maximise the use of scarce resources and to prepare enabling environment for sustainable health programs. The main health reforms introduced were: Decentralisation; Deconcentration of functions; Integration of related health programs; Sector wide approach; Development of a National Strategic Plan and provincial strategic plans; Reinforcement of partnerships; Implementation of new strategies, such as Adolescent/Youth Sexual and Reproductive Health and Rights and Maternal and Perinatal Mortality reduction strategy; and Creation of a multissectoral national committee for Adolescent and Youth. Interventions already in place: The above policies and health reforms are already been translated into concrete interventions, such as: Needs assessment of the availability and quality of basic and comprehensive EmOC services offered by the National Health System in eight provinces. Training of health personnel in the provision of basic and comprehensive EmOC (general practitioners, surgical technicians, medical technicians, MCH nurses and basic midwives) in the diagnosis, treatment and monitoring of women with major obstetric complications. This training has also contents of interpersonal communication skills. Training of Health care providers (nurses, general practitioners) on abortion treatment, its complications, counselling and post abortion family planning. Acquisition and distribution of equipment, supplies and essential drugs for provision of basic and comprehensive EmOC (according to the Mother and Baby package guidelines) Adoption of a basic information system to obtain data, which can be used to assess the results and impact of this intervention through selected process indicators. Implementation of Maternal and Perinatal deaths Audit and Obstetric Complications, through the Provincial MM Committees. Creation of District Maternal Mortality Committees. Improvement of referral and communication system through the network of primary health care sites (health centres and posts) and a referral hospital that provides comprehensive EmOC. Provision of Sexual and Reproductive Health services for Adolescent and Youth (training of health personnel, development of curriculum) 1.5 Laws and Policies The Law concerning abortion in Mozambique is still a penalising one. By the recognition of the seriousness of the complications related to unsafe abortion, and their implications on the high Maternal Mortality rates, an agreement was reached between the Ministry of health and the Department of Obstetrics & Gynaecology of the Central Hospital of Maputo, to provide Safe Abortion services for selected cases as decided by the responsible authority. This has been extended to other Central hospitals as well to Provincial Hospitals and General Hospitals in the country. Currently, clients seeking safe abortion are offered the services in those hospitals for pregnancies up to 12 weeks gestational age, on request, unless there is no consent from parents, guardians or partners. 1.6 Provider Profile Training on the treatment of abortion, its complications, counselling and post abortion family planning has now been included in the formal training curriculum for doctors, assistant medical officers and MCH nurses. After graduation, there are programmes for continuous in-service training for safe abortion, abortion complications, counselling and post-abortion care and family planning.

Table 3. Training of Providers in Post abortion Care Type of provider Total years of pre- professional education Duration of professio-nal medical training Duration of pre service training in abortion service delivery Duration of in service training in abortion Duration of apprenticeship on the job training Training in clinical abortion procedures Training in abortion counselling Doctors 12 6 years + Ob/gy training Integrated Nil     Assistant Medical Officers 10 3 + 3 years Integrated Nil     General Nurses 10 3 years Nil Nil     MCH nurses 10 3 years Integrated Integrated

Table 3 information applies to newly trained providers since those trained before the inclusion in the curriculum are having in services training for the procedures. 1.7 Organization of Abortion Services In almost all hospitals in Mozambique women are offered free services for the treatment of spontaneous abortion, its complications and counselling. At the Central Hospitals of Maputo, Beira and Nampula, and General Hospitals in Maputo, safe abortion services are offered, on request, and has to be authorised by someone responsible locally appointed at hospital level. In most cases this person is resident Obstetrician & Gynaecologist or hospital Director. All procedures as from the diagnosis by ultrasound scanning, insertion of misoprostol (abortion is by medical induction), manual vacuum aspiration, follow up, post abortion counselling, post abortion care and family planning are done by a midlevel provider and in the case of Mozambique, mainly by an MCH nurse. The cost of all this (ultrasound scanning, insertion of tablets and MVA) for voluntary interruption of pregnancy is around USD 15. Although abortion is still restricted, it is widely known that safe abortion is available in most public and private hospitals and clinics were the services are offered using the above procedure.

Table 4. Availability of Post abortion Care service delivery records Level of Health Care System Are records kept? Number of Abortions Provided Number of complications Monetary costs of specific services provided Community No Total By type of provider By Method By Gestation   To individual To health care system Primary No               District/First Referral Some               Secondary and Tertiary Yes

We do not have a standard record keeping system nation wide. It is only at hospital level. 1.8 Knowledge and perceptions about abortion Women, who seek for safe abortion services, get the information from friends or other satisfied clients and at a lower scale from the health care providers.

Table 5. Knowledge of family planning among abortion seekers Know about modern FP Total Percent Yes 281 93.6 No 19 6.4 Total 300 100

2. Midlevel Providers and Abortion Services 2.1 Duties and Responsibilities In Mozambique those referred to, as midlevel providers are the Assistant Medical Officers, MCH nurses and Nurse Midwives. In Mozambique, the scarcity of trained obstetricians and other professionals with sufficient surgical training, to cover the country, motivated the Ministry of Health to start a 3 years training course for Medical Assistants or Nurses to become Assistant Medical Officers, and the first course was started in 1984. After their training, the newly graduated Assistant Medical Officers are posted in rural hospitals were they take care most of the emergency and some elective surgery in the field of obstetrics and gynaecology, general surgery, as well traumatology. The above-mentioned Midlevel Providers do also get frequent in-service training on treatment of abortion and its complications, post-abortion care, including counselling and family planning. 2.2 History of Post abortion Services in Mozambique In 2000 a group of Obstetricians/Gynaecologists attended a course on Post-abortion Care (PAC) in Uganda, and back in Mozambique they organised a training course of trainers for PAC. Also clinical guidelines were adapted to the country needs. Participants included 3 doctors, 2 Assistant Medical Officers and 12 MCH nurses. The idea was to send them back to locally train other MCH nurses on PAC. Currently MCH nurses are trained during their formal training on Abortion care. At the CHM and 2 General Hospital in Maputo MCH nurses were already trained to do USS diagnoses of pregnancy by Ultrasound, vaginal insertion of misoprostol tables and to do MVA. Currently PAC services are being provided in some health units in the country. 2.3 Scope of Post abortion Care Practise of Midlevel Providers

Table 6. Midlevel Providers (Assistant Medical Officers and MCH nurses/Midwives) Scope of Practice Type of procedure Offered this level of Provider (Y/N)? If Yes specify method Method of Pain Management Used Type of Supervision Required when Performing the Procedure On site Remote Medical Abortion (use of vaginal misoprostol) Yes Analgesics     First Trimester Surgical No       Second Trimester Surgical         Emergency treatment of Abortion complications Stabilization Yes       Uterine Evacuation Yes*       Management of Spontaneous abortion Stabilization Yes       Uterine Evacuation Yes*       Post abortion Contraception Counselling Yes       Services Yes

Yes* done by Assistant Medical Officers 3. Professional Organisations of Midlevel Providers Currently is being established a national midwives association. 4. Lessons Learned related to access to Safe Abortion Services The availability of safe abortion service in several health units in the country has proved that: The number of complications due to abortion has decreased significantly; Although having the knowledge of contraceptives, the number of abortion seekers is still high even among the married and/or living with a permanent partner; A midlevel provider can offer abortion services safely; 5. Conclusion The success of midlevel providers offering PAC services may provide an opportunity to expand low cost service provision to safe abortion services when legal limitations are removed. The impact of safe abortion services on maternal mortality and morbidity could be significant.

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Updated 19 June 2002