Expanding access to postabortion care in Rwanda: A pilot project integrating misoprostol into the national comprehensive postabortion care program

Background: Unsafe abortion contributes to almost a fifth of maternal deaths in East Africa. In Rwanda, more than 16,700 women received care for abortion complications in 2009, just two-thirds of those needing treatment. In 2011, the Rwanda Ministry of Health (MOH) launched a comprehensive postabortion care (PAC) pilot integrating misoprostol for treatment of incomplete abortion and miscarriage (IAM) and strengthening all components of PAC, to inform national scale-up. Methods: 146 providers were trained in PAC and data collection from all 55 public hospitals and health centers in four pilot districts (Bugesera, Kicukiro, Nyabihu and Gisagara). The MOH developed a PAC protocol to standardize service delivery. Data were collected between February and October 2012 from the pilot's PAC registers. Results: 921 women were treated for IAM during the pilot, 408 (44.3%) at hospitals and 513 (55.7%) at health centers. Nurses (66.9%) and doctors (33.1%) provided most services. Misoprostol was used to treat 83.4% of all women in health centers and hospitals, compared to oxytocin (13.1%), manual vacuum aspiration (0.4%), and dilatation and curettage (3.0%). At pilot's end, the 50 health centers were treating 91.1% of women presenting with IAM; whereas at baseline, only two health centers provided PAC. Thus, referrals from health centers to hospitals reduced to 8.9%. Postabortion contraception uptake varied between districts from 34.6% to 84.1%. Conclusion: Rwanda's PAC pilot enabled nurses to provide PAC, including treatment with misoprostol, which was not previously possible. Expansion of PAC services is expected to increase women's access and reduce health system costs.