Moving from research to program: the Egyptian Postabortion Care Initiative

The paper describes assesses a project that sought to improve the standard of care for women with abortion complications in Egypt, from pilot program to work with the Ministry of Health and Population.

Successes and failures:

• the initiative used a highly flexible, innovative management style that was consistent with contemporary theories of how to diffuse innovation and scale up pilot activities
• during the pilot study and initial expansion, the program maintained a strictly defined sense of identity as a postabortion research activity, achieving rapid success and demonstrating promise that drew the attention of innovative managers and policymakers
• the program’s replication was limited to carefully controlled circumstances, and the program failed to create circumstances for its scaling-up: It did not create broad enough partnerships or integrate the new services into an existing program
• the strategy modelled on family planning programs’ strategy for introducing new contraceptives was not functional for postabortion care, because of sensitivities regarding abortion

As an active communication program brought together larger and larger groups of clinicians, and Ministry of Health and Population managers spurred dialogue about the clinical experience and knowledge gained, strategies for how to proceed were identified. Ownership of the postabortion program passed to the national Safe Motherhood Program, which incorporated most elements of the service delivery package and did away with the term “postabortion care.”

Policy implications:

• postabortion initiatives will never be able to entirely avoid the politically charged atmosphere unique to abortion, particularly in settings where access to induced abortion services is legally restricted
• decisions related to abortion are made very slowly, and service delivery innovations must become usual and customary practices before a policy will change
• the lag in critically important operational policy decisions (e.g., approval of the commercial importation of manual vacuum aspiration instruments) requires the long-term commitment of the program’s international supporters
• this approach to influencing policymaking is qualitatively different from the approach taken for other health care topics, and reflects a profound understanding of the politics of abortion, rather than an avoidance of the political process
• a program will make many trade-offs and compromises as it moves from research to small-scale expansion and then to a national program. The scaling-up of postabortion care services is no different from the scaling-up of other programs. Family planning programs cannot provide postabortion initiatives with the support that is required for going to scale with improvements in emergency medical services, and Safe Motherhood programs have a limited ability to provide contraceptive-related services. Postabortion care straddles these programs and ultimately will be realised only as holistic programming is achieved for women’s reproductive health services