Post Abortion Care is Health Care – Dr. Kakaire

Dr. Kakaire 

The Executive Director of the Association of Obstetricians and Gynecologists of Uganda (AOGU) as well as lecturer at Makerere University School of Medicine Dr. Othman Kakaire has urged health service providers in both public and private facilities to provide Post Abortion Care (PAC) without fear because it is fully provided for in the Ministry of Health standards and guidelines.

Dr. Kakaire was speaking yesterday at a closeout meeting for the Advocacy for Prevention of Maternal Mortality and Morbidity (APMM) project which has been running for the past five years with funding from the federation of International Gynecologists and Obstetricians (FIGO).

In an interview with our reporter, Dr. Kakaire stressed that PAC is a key component of health care in Uganda and in the course of the APMM project, AOGU trained medical personnel all over the country how to manage PAC cases.

“We are a professional health association and therefore we articulate the ministry’s position” Dr. Kakaire said in justification of AOGU’s decision to advocate for PAC and other SRHR services promoted by the Ministry of health.

Read the full interview below:

QN: Why did you put emphasis on PAC in the APMM project?

This was a stigmatized service, there was too much stigma and this stigma cut across all sectors including health service providers.

We therefore needed something to engage the different people in order to address this problem.

Girls and women were suffering with pain but when they come to us health workers, we stigmatized them. They were not a priority. If there was an emergency caesarean and someone breeding due to a miscarriage here, a doctor would rush to go and do a caesarean yet this evacuation would take less than five minutes. Prioritization was affected by that kind of stigma.

QN: What did you do to end the Stigma related to PAC? 

We engaged all stakeholders with a lot of emphasis on health providers and here we looked at the issue of attitude change through what we called values clarification and attitude transformation (VCAT).

How do you come to terms with assisting somebody who had a miscarriage when you are so much opposed to it as a health service provider? So we had to help them come out of that prejudice.

We told them; set your personal beliefs aside and manage the patient as they come with different problems.

The other thing which we did was skilling, because some health workers did not know the procedure. If you came to me and I do not know how to manage the problem, I just abuse you and discourage you and tell you it is illegal, go away; but the problem is lack of skill.

A girl who came with an unintended pregnancy would receive the most hostile reception from the doctors and even the midwives.

They would bring the law very fast saying that our laws do not allow this and they chase away the person instead doing harm reduction.

QN: What is harm reduction and was it a component of the project?

Harm reduction is reducing death and injury due to unsafe abortion by giving people the right information and it was part and parcel of our engagements with the medical personnel wherever we went.

It is about sitting and showing this person and telling her the dangers of inducing an abortion from an unskilled person and incase she went ahead and did it, what should she do when complications happen. If you do it and you bleed you will feel pain, you will feel fever, don’t stay home, come back to us, we are always willing to help.

Because people would think that since I have gone to induce, the whole process is criminal, if I go to the hospital may be I will end up in prison.

QN: Why is harm reduction important in preventing Insafe abortions?

When you come with a pregnancy, you are entitled to get the information from us. We can tell you when you induce an abortion from a lay person or even or even a doctor in his clinic, you are going to get complications and some of these complications include bleeding, infection, perforation and you may never get pregnant again.

The person gets to understand that. When you have understood these, do you still want to go ahead and terminate your pregnancy or you say let me leave it. About 70% of the women don’t go ahead to induce.

We remain with the 30% who are determined. These 30%, we tell them that much as we don’t offer abortion in this country, if you feel that you must; these are the medicines available on the market in Uganda but we don’t supply them. You can go and source them at pharmacies but we don’t offer the service.

If we know of professional providers that offer that service safely, we refer you there instead of pushing someone into unsafe methods and they die.

People have a right to information. That is information and the client has a right to that information. When you give the information, that is where you stop, unless if that person has a legal indication for terminating the pregnancy.

QN: What are the legal indications for terminating a pregnancy legally?

A woman can come to me and I terminate her pregnancy in the hospital because she has a legal indication. If she has a condition which makes it risky for her to get pregnant and for some reason she conceives, we have to terminate it because if we don’t, she will die.

If this person presents in the hospital even when everybody is watching, you are duty bound to terminate the pregnancy. It is protected by the law.

If someone comes with a pregnancy that is not in the uterus, do you leave it there? No, because it is very dangerous to the life of the woman.

If one comes with a pregnancy which will become a cancer tomorrow, a molar pregnancy for example, do you leave it there?  It has to be terminated. We terminate these all the time.

If you come with a pregnancy which has formed a sac without an embryo, there is no fetus inside but only water, do you leave it there? No, you have to terminate it.

There are people who have had pregnancy grow in the ovary or on liver. This is very dangerous pregnancy which must be terminated.

If the embryo died, you do a scan the embryo is not alive, you can’t leave it there. Leaving it there puts the life of the woman at a risk of dying also.

QN: What are some of the project successes that you can share with our readers?

We have skilled many health service providers in offering PAC and we have also skilled them in harm reduction, counselling.

I am told girls and women who go to health facilities now, they find at least people with a positive attitude who are willing to help.

When we started the project five years ago, the contribution on abortion complications to maternal health was 26% but now it has come down to less than 8%.

Among medical colleagues, the level of stigma has gone down.

We can now freely talk about abortion which was a taboo prior to the project.

We came out as AOGU and wrote a position paper about abortion which can be found on our website.

QN: How did you engage the Ministry of Health in the course of the project?

We worked with the ministry from the inception of the project. We are a professional health association and therefore we articulate the ministry’s position. We guide them but we also have to conform to the policies from the ministry. We collaborated with the reproductive health division, Maternal and Child Health Commissioner etc.

Even when the project has ended, our working relations with the ministry and many of our local and international partners will continue because we still have a lot to do together.

QN: What next, now that the APMM project has closed?

First we are grateful to FIGO and or sister associations in different countries for walking this journey with us.

What next is to look for more funding because as you can see we have more work to do.

The issue of skilling for example cannot be a one off. We have to keep skilling health service providers and making their skills improve because it is a dynamic group. People are coming in and others are going out. You train people today, tomorrow they will not be there.

There other thing is advocacy. It is a continues process, you cannot stop until you achieve total acceptance and that cannot be a one off project.

So we have to keep advocating. Our advocacy is that abortion should not be made a punishable offence.  It is not about legalization but decriminalization of abortion and let those who are doing it underground do it in the open and safely instead of going underground and harming people.

We still want to engage religious leaders and let them understand these issues and I still believe that we should engage politicians because they are the legislators, they make the laws. We cannot run away from them. We need members of parliament for example if we are going to have abortion decriminalized.