Title Page
 The clinique d'Orthogenie at Hopital...
 Parivar Seva Sanstha, India
 Resumen en Espanol
 Resume Francais
 About the authors

Group Title: Quality/Calidad/Qualité
Title: From Patna to Paris
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088795/00001
 Material Information
Title: From Patna to Paris providing safe and humane abortion
Series Title: Quality =|Calidad =|Qualité
Physical Description: 30 p. : ill. ; 26 cm.
Language: English
Creator: Population Council
Publisher: Population Council
Place of Publication: New York
Publication Date: 2001
Subject: Women's Health Services   ( mesh )
Abortion, Induced   ( mesh )
Quality of Health Care   ( mesh )
Abortion   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Spatial Coverage: India
Bibliography: Includes bibliographical references.
Language: Text in English, with summaries in Spanish and French.
 Record Information
Bibliographic ID: UF00088795
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 48685990
lccn - 2008270254
issn - 1097-8194 ;

Table of Contents
        Cover 1
        Cover 2
    Title Page
        Title Page 1
        Title Page 2
        Page 1
        Page 2
        Page 3
    The clinique d'Orthogenie at Hopital Broussais, Paris
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
    Parivar Seva Sanstha, India
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
    Resumen en Espanol
        Page 28
    Resume Francais
        Page 29
    About the authors
        Page 30
Full Text





From Patna to Paris:
Providing Safe and
Humane Abortion

Q ,.,ii:\ I i-.!.. / Qualite, a publication of
the Population Council, highlights exam-
ples of clinical and educational programs
that bring a strong commitment, as well
as innovative and thoughtful approaches,
to the issue of high-quality care in sexual
and reproductive health. The series is
based on the philosophy that people have
a fundamental right to respectful treat-
ment, information, choice, and follow-up
from reproductive health care providers.
Q/C/Q documents projects that are
making important strides in one or more of
the following ways: broadening the choice
of methods and technologies available;
providing the information clients need to
make informed choices; enabling clients
to become more effective guardians of their
sexual and reproductive health; making
innovative efforts to increase the manage-
ment capacity and broaden the skills of
service providers at all levels; combining
health care, family planning, and related
services in innovative ways; and reaching
underserved and disadvantaged groups.

Projects are selected for documenta-
tion by an Advisory Group made up of
individuals who have a broad range of
experience with promoting quality of care
in sexual and reproductive health. None
of the projects documented is being
offered as a model for replication. Rather,
each is presented as an unusually creative
example of values, objectives, and imple-
mentation. These are "learning experi-
ences" that demonstrate the self-critical
attitude required to anticipate clients'
needs and find affordable means to meet
them. This reflective posture is exempli-
fied by a willingness to respond to
changes in clients' needs as well as to the
broader social and economic transforma-
tions affecting societies. Documenting the
critical choices these programs have
made should help to reinforce, in practi-
cal terms, the belief that an individual's
satisfaction with sexual and reproductive
health services is strongly related to the
achievement of broader health and popu-
lation goals.

d Population Council
The Population Council is an international, nonprofit, nongovernmental institution that seeks to im-
prove the well-being and reproductive health of current and future generations around the world and
to help achieve a humane, equitable, and sustainable balance between people and resources. The
Council conducts biomedical, social science, and public health research and helps build research
capacities in developing countries. Established in 1952, the Council is governed by an international
board of trustees. Its New York headquarters supports a global network of regional and country offices.
Population Council, One Dag Hammarskjold Plaza, New York, New York 10017 USA
tel: (212) 339-0500, fax: (212) 755-6052, e-mail:qcq@popcouncil.org, http://www.popcouncil.org.

Publication of this edition of Quality/Calidad/Qualite is made possible by support provided by the
Robert H. Ebert Program on Critical Issues in Reproductive Health of the Population Council, by the
Ford Foundation, and by the Gender, Family, and Development Program of the Population Council.
Statements made and views expressed in this publication are solely the responsibility of the authors
and not of any organization providing support for Q/C/Q. Any part of this document may be repro-
duced without permission of the authors so long as it is not sold for profit.
Cover photographs by (clockwise from top left): Debbie Rogow, Susan Wood, UNICEF, and Karen
Tweedy-Holmes. The photo on page 1 was selected from M/MC Photoshare at www.jhuccp.org/mmc.
Number Eleven 2001 ISSN: 1097-8194
Copyright 2001 The Population Council, Inc.

by Carmen Barroso

For millennia, women and girls have
found themselves facing unwanted preg-
nancies; across time and culture, they
have often turned to abortion. Today, an
estimated 46 million pregnancies each
year are terminated by abortion (AGI
1999). They are induced for a wide vari-
ety of reasons, including economic fac-
tors; personal circumstances such as an
absent partner or unfinished schooling;
health considerations; and social and
cultural factors.' The decision to termi-
nate a pregnancy may be simple and
straightforward or more complex and
difficult, depending on the client's so-
cial, legal, and personal context. But
abortion remains the last measure of
control women and girls have over their
fertility, providing "respite and tremen-
dous relief when performed under ap-
propriate conditions" (Londoiio 1989).
When performed by a trained pro-
vider with the appropriate equipment or
drugs, abortion is a safe, low-risk proce-

SFor example, in some settings where gender bias
heavily favors sons over daughters, couples have
sought i., .r... i. tests to determine the sex of
the fetus and subsequently abort female fetuses.
2 Recently, safe and effective medical abortifacients
have expanded women's options in some parts
of the world. Medical abortion refers to termina-
tion with a medication that promotes the body's
expulsion if ilr I .r.--,,, ,. / without surgical inter-
vention. This ranges from the clinically moni-
tored, safe, effective use of mifepristone and
misoprostol to the self-prescribed use of drugs
such as misoprostol (Cytotec) alone in countries
where safe, legal abortion is not available. Miso-
prostol users may well end up seeking hospital
care to complete the abortion, since the self-
treatment often triggers .I-- ;rn,,. i-,.. ui sepsis or
provider contact, thus allowing the user to avoid
serious legal or medical risks (Barbosa and
Arilha 1993).

dure.2 Because of legal and social restric-
tions, however, safe and humane abor-
tion is not always available; instead,
millions of women and girls seeking to
control their fertility resort to dangerous
procedures. The most common medical
complications of illegal or unsafe pro-
cedures include infection and hemor-
rhage. Data from Nigeria and Latin
America (where legal restrictions make

.i Now .


In the sixty minutes it takes to read this publication, nine women and girls
on average will die needlessly as a result of poorly performed abortions.

access to safe abortion extremely diffi-
cult) suggest that 4 out of every 10 pro-
cedures result in severe complications;
this risk is particularly grave for those in
rural areas (Makinwa-Adebusoye et al.
1997; Singh and Wulf 1994).
Not surprisingly, millions of women
and girls end up in hospital emergency
rooms for treatment of complications
after unsafe or incomplete abortion. For
example, emergency rooms in Egypt
alone treat 216,000 such women and

girls per year, while the figure is 142,200
for Nigeria, 288,700 for Brazil, and
106,500 for Mexico (Huntington 1998;
Henshaw 1998; Singh and Wulf 1994).
Some never make it to the hospital: the
fear of humiliating treatment and of legal
recriminations, along with poverty and
lack of access, undoubtedly deters many
critically ill women and girls from seek-
ing desperately needed emergency care.
In the end, unsafe abortion (and the
immense personal suffering that may
attend it) remains a serious global pub-
lic health problem. As a result of botched
procedures and the lack of accessible

Abortion remains the last
measure of control women and
girls haee over their Icrti! it.

and appropriate emergency care, 78,000
women and girls die each year unnec-
essarily; this avoidable loss accounts for
no less than 13 percent of all pregnan-
cy-related mortality (WHO 1998). In
addition to the human cost, treatment
of abortion complications constitutes a
serious drain on health-sector resources.
With access to safe, legal abortion
under severe constraint or debate in
many parts of the world, less attention
has been paid to the issue of quality of
abortion care. Yet at the same time that
millions of women and girls face abuse,
grave morbidity, and risk of death in their
quest to end an unwanted pregnancy,
millions more terminate their abortions
safely and with dignity. This issue of
Quality/Calidad/Qualite explores what
it means-and what it takes-to pro-
vide an adequate level of quality in
abortion care.
The following pages describe two
programs that operate in very different

settings but with a shared commitment
to providing high-quality abortion care
in a context of broader reproductive
health services: the Clinique d'Ortho-
g6nie of Broussais Hospital in France
and Parivar Seva Sanstha in India. Of
course, both programs operate in legal
climates that allow for safe services. But
both have also brought a pioneering
spirit to their work, introducing new
abortion technologies and a range of
reproductive health services that have
expanded options and reshaped the
design and delivery of care. In both
programs, each woman or girl who
arrives for abortion receives crucial
basic care, including:
Appropriate medical treatment to
ensure complete abortion and safe
If medically appropriate, choice
about issues such as anesthesia
and/or method of abortion;
Supportive counseling;
A range of related reproductive
health services, including a choice
of contraceptive methods to help her
avoid another unwanted pregnancy.
Counseling is an especially impor-
tant component of pregnancy termina-
tion care. With proper counseling, the
decision to terminate a pregnancy can
enable a woman to reflect upon her
sexual relationship, her fertility inten-
tions and behavior, and her own deci-
sionmaking process. Such reflection
"can facilitate or advance the process of
acquiring personal awareness and iden-
tity as few other experiences can..."
(Londofio 1989). An important part of
the success of both the Broussais
Hospital clinic and Parivar Seva Sanstha
rests on the selection and training of
staff who believe that having an abor-
tion is an opportunity to protect one's

2 1 // d l ..

health and to move forward in one's
life-not a time to suffer.
Of course, even emergency room
providers who see women only for post-
abortion care can offer crucial nonjudg-
mental support and contraceptive coun-
seling. Particularly if securing an abor-
tion has been made into a frightening or
unsafe experience, clients may be vul-
nerable to making inappropriate or un-
realistic decisions about contraception.
For example, many girls say they will
"never have sex again," and therefore
resist the idea of contraception, leaving
themselves unprepared for their next sex-
ual encounter. Women hoping to avoid
a repeat experience may accept a long-
term or even permanent method that
they would otherwise not choose. Spe-
cial post-abortion counseling materials,
such as those developed by Ipas, are
enabling more programs to approach this
task with sensitivity and effectiveness.
The following articles provide con-
crete descriptions of the programmatic
elements that enable the Broussais
Hospital Clinic and Parivar Seva Sanstha
to provide the kind of care they believe
all women deserve-whether in the
North or South, whether arriving for
surgical abortion, medical abortion, or
treatment of complications: the best
available medical care, a range of serv-
ice options, and nonjudgmental emo-
tional support. The lessons from these
programs are particularly poignant when
contrasted with what we know about
the avoidable experience of their less
fortunate sisters.

lU 'C S i i, ri 4. *** v "

Alan Guttmacher Institute. 1999. Sharing
Responsibility: Women, Society and
Abortion Worldwide. New York: AGI.

Each year, 46 million women terminate unwanted pregnancies. In
proper settings, they can do so safely and with dignity.

Barbosa, Regina Maria and Margareth
Arilha. 1993. "The Brazilian experience
with Cytotec," Studies in Family Planning
24(4): 236-240.
Division of Reproductive Health, WHO.
1998. Unsafe Abortion: Global and
Regional Estimates of Incidence of and
Mortality due to Abortion, with a Listing
of Available Country Data, third ed.
Geneva: WHO.
Henshaw, S.K., et al. 1998. "The incidence
of induced abortion in Nigeria," Interna-
tional Family Planning Perspectives
24(4): 156-164.
Huntington, D., et al. 1998. "The post-
abortion caseload in Egyptian hospitals:
A descriptive study," International Family
Planning Perspectives 24(1): 25-31.
Londohio, M.L. 1989. "Abortion counseling:
Attention to the whole woman," Interna-
tionallournal of Gynecology and Obstet-
rics, supplement 3: 169-174.
Makinwa-Adebusoye, P., S. Singh, and S.
Audam. 1997. "Nigerian health profes-
sionals' perceptions about abortion,"
International Family Planning Perspec-
tives 23(4): 148-154.
Singh, S. and D. Wulf. 1994. "Estimated
level of induced abortion in six Latin
American countries," International Fam-
ily Planning Perspectives 20(1): 4-13.

The Clinique d'Orthogenie

at H6pital Broussais, Paris

by Martha Brady and Batya Elul

For much of the last century, access to
abortion in France was highly restricted,
permitted only if the woman's life was at
risk. Individuals aiding or abetting wom-
en in obtaining an abortion and indi-
viduals providing abortion could face a
large fine and a prison sentence of up to
five years. In the mid-1970s, the politi-
cal climate began to shift. In 1975, 343
women, including many prominent
writers and actresses, published a state-
ment declaring that they had had abor-
tions. A group of providers signed a let-
ter stating they had performed abortions
and women staged demonstrations call-
ing for legal reform. Support also came
from within government, as courts
declared that they could no longer
enforce the law. Further, Minister of
Health Simone Veil acknowledged that
it was impossible to prevent a woman
who was determined to end her preg-
nancy from having an abortion and,
consequently, that it was better to offer
her medical aid than to risk her life or
future fertility
Shortly thereafter, abortion-inter-
ruption volontaire de grossesse-was
legalized in France. Initially, the law
was fairly restrictive: the procedure was
allowed only through ten weeks of
pregnancy; public hospitals were not
required to provide the service; minors
had to secure parental consent; foreign-
ers had a three-month minimum resi-
dency requirement; and all clients had

to meet with a social worker and under-
go a one-week waiting ("reflection")
period before having the procedure. In
1982, in response to a shortage of
physicians willing to perform abortions,
the law was amended to require all
public health facilities to offer this serv-
ice; this new legal mandate led to the
establishment of the Clinique d'Ortho-
g6nie at H6pital Broussais. In 2001,
many of the remaining early restrictions
were lifted. Abortions may now be per-
formed through the twelfth week of
pregnancy; a minor may seek permis-
sion from an adult other than her par-
ent; and the residency requirement and
mandatory waiting period have been
removed. However, for most of its his-
tory, the Broussais Clinic operated
under the more restrictive conditions.

Tr:e Clinic Opens
Its hioors
The Clinique d'Orthog6nie at Broussais
Hospital, one of 50 public hospitals in
Paris, was opened in 1983 to conform to
French law requiring that all public-sec-
tor hospitals offer abortion services. No
other gynecological services were offered
at the facility, and the hospital director
opposed provision of abortion; to abide
by the new law, however, he created a
separate abortion clinic-the Clinique

4 i .. /- ,. i / .

Considering that the Broussais Hospi-
tal director's decision to provide abor-
tion was originally based on a legal
mandate rather than on a political com-
mitment to women's rights, the evolu-
tion of the clinic's philosophy is inspir-
ing. Indeed, the clinic has become a
shining example of care shaped specifi-
cally to respond to the needs of its
clients. Today, the clinic not only offers
a range of abortion services but has also
expanded its mandate to address a wide
range of reproductive issues.
Located in metropolitan Paris, the
Clinique d'Orthog6nie serves primarily
women residing in the city and its south-
ern suburbs, although women from else-
where in France may use the clinic's
services. In 1997, for example, while 60
percent of all abortion clients lived in
Paris, over 33 percent resided in the
suburbs, and 2 percent came from other
regions of France. The client population
is diverse both ethnically and in terms of
socioeconomic status, e.g., immigrants
living in France for at least three months
are eligible to use public services.
From its establishment in 1983 until
1996, the Broussais Clinic was under
the direction of Dr. Elisabeth Aub6ny.
Dr. Aubeny began practicing gynecology
in 1962 and had a distinguished record
based on more than 30 years in both
public- and private-sector reproductive
health programs. At the time of her ap-
pointment to the abortion service, she
had been working as a gynecologist in
another hospital within the same uni-
versity medical system as Broussais. Dr.
Aub6ny's dynamic leadership set the
tone for the clinic's work. She partici-
pated in the first clinical trial of mifepri-
stone (also known as RU 486), work
that led to the country's official autho-
rization of the drug in 1988 and for

which she is now well known, both in
France and internationally.
Dr. Aub6ny's vision of quality repro-
ductive health care is grounded in a
desire to help individuals achieve their
reproductive goals, and her approach is
based on the principle of respect for
women and their ability to make their
own decisions. She stresses that high
technical quality in itself is not suffi-
cient. Rather, it must be coupled with a
commitment to listen to clients and to
learn about their personal and emotion-
al experiences, as well as their immedi-
ate reproductive problems. Since Dr.
Aub6ny retired in 1996, the clinic has
been under the direction of Dr. Isabelle
Dagousset, who shares her predeces-
sor's commitment, energy, and vision.

Women hear about the Broussais clinic
and its services through a variety of
sources, including public service an-

The Broussais Hospital opened an abortion clinic in 1983, when the
French government required all public hospitals to provide this service.

nouncements, media coverage, and re-
ferral from other providers, as well as
from friends or family members. Some
women arrive for scheduled appoint-
ments; others come seeking information
and then make appointments. For most
clients, the first point of contact they
have with the clinic is by telephone,
and the staff believe that the telephone
encounter plays a critical role within the
delivery of services. To back up this view,
the clinic has developed a comprehen-
sive training program of no less than 160
hours for all staff members responsible
for answering the telephone and provid-
ing information. This intensive invest-
ment makes a difference. For example,
Anne, the receptionist, has both the
knowledge and the personal style that
put women at ease. When women speak
to Anne, they know they have reached
a place where they will receive care.
On entering the clinic, clients are
welcomed in a large and cheerful re-
ception area, furnished with comfort-
able chairs, magazines, and flowers.

The clinic has .er cilopi-d a
compirehen she training program
of no less i liin 160 hours for I
staff ni,.-iijiir rIcjponiblel for
anI sI i:in the telephone. 1 i!
intensive investment makes a

Reflecting the clinic's commitment to
information as part of the client-pro-
vider exchange, there are bright yellow
pamphlets, clearly and concisely writ-
ten, with information about services
offered, operating hours, hotline num-
bers, and other practical details. In addi-

tion, information is available on a range
of topics related to reproductive health,
including surgical and medical abor-
tion; self-care after abortion; contracep-
tion; and sexually transmitted infec-
tions. Community notices and informa-
tion about social services (including
domestic violence and child care pro-
grams) are displayed on bulletin boards.
Clients are first greeted by one of the
clinic's administrative staff, usually a
receptionist. Depending on her particu-
lar needs, the woman may later meet
with a social worker, a nurse, or a gyne-
cologist-or all three. Moving from the
reception area to the clinic's interior,
one finds consultation rooms where
women can talk with social workers, as
well as fully equipped examination
rooms, a surgical suite (where surgical
abortions are performed), and designat-
ed waiting areas for women who are
having medical abortions. In the surgi-
cal suite, daybeds are available for wom-
en to rest following surgery.

Services ffere.
A small dedicated team of health care
providers combine talents and strengths
to provide an array of services. The clin-
ic is staffed by 11 medical gynecolo-
gists: nine female and two male. This
gender breakdown reflects a nationwide
trend in the field of medical gynecolo-
gy, where approximately 80 percent of
medical gynecologists are female.' The
clinic also employs a part-time phy-
sician assistant, two psychologists, and
various paramedical personnel. The
paramedical staff includes a supervisor,
two nurses, two secretaries, one nurse's
1 In France, medical gynecology is a distinct spe-
cialty from obstetric/surgical gynecology. Med-
ical gynecologists do not attend births or per-
form complex gynecological surgery.

aide, one full-time social worker, and
one marriage counselor.
Although the abortion service is in
many ways the raison d'etre for the clin-
ic, the staff actually provide a wide array
of reproductive health services. All con-
traceptive methods currently available in
France are offered, including oral con-
traceptives, IUDs, condoms, and dia-
phragms. Emergency contraception is
also available. Women may seek diag-
nosis and treatment of STIs, HIV testing,
Pap smears, primary screening and refer-
ral for infertility, and general gynecolog-
ical care. In some cases, these services
are provided on an as-needed basis to
clients who come in for abortion, but
women may also arrive at the clinic
specifically for these other services. This
comprehensive approach to care de-

H line is a client in her forties. She
came in for a follow-up visit for eval-
uation of a uterine fibroid; at the
same time she wants advice about
contraception. Further, she is con-
cerned about her overall health.
Helene has a complicated medical
history and although she tests nega-
tive for HIV, her husband recently
died of AIDS. The Broussais staff are
able to provide women like Helne
with medical attention, counseling,
education, and referrals.

Gilberte arrived at the clinic anxious
and upset; after a few months of try-
ing to conceive, she was still not preg-
nant. The provider with whom she
meets believes that offering reassur-
ance and information is the first step to
client satisfaction, and she teaches
Gilberte about fertility awareness. Gil-
berte learns how to recognize the days
during her cycle when she is most
likely to get pregnant and leaves the
clinic with greater peace of mind.

The Broussais Clinic serves a diverse population,
including long-time residents of Paris, low-income
immigrants from North Africa, and suburban

mands that the staff handle cases that
are not only unrelated to abortion, but
complex in nature.
Regardless of the nature of a woman's
visit, she will be treated with respect
and dignity. The staff try to make certain
each client leaves having gained some-
thing tangible, whether that is informa-
tion, support, or services.

Even with the range of reproductive
health care available, abortion remains
the cornerstone of the Broussais Clinic.
The clinic provides both surgical abor-
tion and medical abortion, the latter
using the mifepristone-misoprostol regi-
men. All abortion services are provided
on an ambulatory basis. Ultrasound is
used when there is doubt about the pre-
cise age or location of a pregnancy. Addi-
tionally, all women undergoing abor-
tions sign an informed consent form
before their procedure.

Surgical Abortion
Surgical abortions are provided through
12 weeks of gestation. Women electing
to have a surgical procedure with local
anesthesia arrive early in the morning,
usually before 8:00 a.m., and typically
are on their way home within three hours
or by lunchtime. For many years-as has
been the case in many countries where
clandestine abortion is a recent memo-
ry-general anesthesia was initially an
option for clients electing surgical abor-
tion. However, in recent years staff agreed
that local anesthesia was preferable, and
clients are no longer given the choice to
be put under general anesthesia.

medicala l portion:
The Protocol
Medical abortions are limited to gesta-
tions of seven weeks or less. Broussais
was a pioneer site for the use of mifepris-

Women can go to the Broussais Clinic for contraception, STI testing
and treatment, Pap smears, preliminary infertility care, and general
gynecology, as well as for abortion.

tone, also known as RU 486. The drug
was first introduced in the clinic in 1983
as part of the manufacturer's research
trials, and more than 20,000 Broussais
clients have now undergone medical
abortion. Currently, a majority of clients
opt for this method; for example, in
1997, 715 underwent surgical abortion
with local anesthesia while 1,081 had a
medical abortion using mifepristone and
The counselor explains the process
to each client step by step: how and
when to take the different drugs, when
she will begin to cramp and bleed, how
to know when she expels, and what to
do in the rare case she does not expel.
She also counsels clients (and their
partners, when possible) about contra-
ception. For clients who elect to have a
medical abortion, three clinic visits are
required over a two-week period:

Visit 1: fepristone
At her first visit, the woman swallows
three tablets (200 mg each) of mifepris-
tone; by law, she ingests these tablets
under the supervision of clinic person-
nel. At this time, she signs an addition-
al informed-consent form designed by
mifepristone's manufacturer. To accom-
modate women's schedules, a clinic
nurse is available on Saturdays to pro-
vide this drug and the hospital's emer-
gency room staff are available on
Sunday. The client leaves a few min-
utes after taking the mifepristone.
During the next few days, she may
begin to bleed or spot.

Visit 2: ,isoprostol
Clients return two days later to ingest
misoprostol. The second visit is quite a
bit longer than the first one. Unless the

8 # .,- 101idadl-

woman believes she has already ex-
pelled the products of conception and
this is confirmed by a provider, she takes
three tablets (200 pg each) of misopros-
tol orally. After taking the misoprostol,
the woman remains for up to three hours
in the clinic, where she may relax, walk
around, or lie down in one of two com-
fortable post-observation rooms. (One
of these rooms is for women and girls
only; the second is designated for cou-
ples.) During this time, she will proba-
bly experience cramping and start to
bleed and will probably undergo expul-
sion. Typically, women leave the Brous-
sais Clinic as soon as they expel, even if
far less than three hours have elapsed.
If a client wants to begin contracep-
tion, she can start the pill on the same
day as her second visit. (Clients who
want to use a different method are en-
couraged to use oral contraceptives for
the first month and then return to the
clinic or see their regular doctor to
switch methods. However, the client has
the final choice regarding her contra-
ceptive method.) During the next two
weeks or so, the woman will continue
to bleed and might have some more
cramping if she is still expelling prod-
ucts of conception.

About two weeks later, women return to
the clinic for a follow-up examination.
If a client did not undergo expulsion at
the clinic on the day she took miso-
prostol, ultrasound is used to confirm
the status of her abortion. For all other
women, a clinical examination is per-
formed and, if necessary, vacuum aspi-
ration is used to complete the abortion.
Success rates are extremely high, how-
ever; aspiration is needed in approxi-
mately 0.6 percent of the cases.

One client described her experience
with medical abortion:

I just finished the RU 486 process
and surprisingly enough, I feel very
well; a few minor cramps, but a clear
conscience. The RU 486 process of
abortion was simple, easy, and com-
fortable. The only discomfort I experi-
enced was slight nausea after ingest-
ing the prostaglandin tablets, and no
more than 45 minutes of cramps. The
cramps, however, were very strong
and uncomfortable, but passed even-
tually. Afterward, I expelled the con-
tents of my abortion rapidly, without
any discomfort or pain. It was very
I am grateful that I had the option
of the RU 486 procedure. Taking pills
orally in order to induce a natural
abortion gave me peace of mind. I
could not have comfortably experi-
enced a surgical abortion, which
would have given me great stress emo-

Although counseling is a key element of
all services offered at the clinic, this
aspect of care is particularly important
in the abortion service. According to Dr.
Aub6ny, the term "counseling" as used
at Broussais goes beyond the exchange
of information regarding the abortion
method selected. It refers to providing
the opportunity for women to discuss
their concerns, experiences, and plans
for future conception and contraception.
Providing nonjudgmental support is key,
e.g., not categorizing a woman as "good"
or "bad" based on whether she used

Medical Abortion in De. elopinm: Countric-,

One may ask whether the experience
at the Broussais Clinic has any rele-
vance to the delivery of services in
developing countries. The answer is
clearly yes. Over the past few years,
several studies of mifepristone-miso-
prostol medical abortion have been
conducted in developing countries. In
one study, the French regimen was
used by 799 women eight weeks preg-
nant or less in Cuba, China, and India
[see the following section of this edi-
tion for a brief description of the Indian
experience]. While success rates var-
ied by site (China 91 percent, Cuba 84
percent, India 95 percent), nearly all
women (84-95 percent) were highly
satisfied or satisfied with their experi-
ence and, similarly, the vast majority
(84-96 percent) reported that they
would choose medical abortion again.
Women consistently rated the avoid-
ance of surgery, avoidance of general
anesthesia, less pain, safety, ease, and
compatibility with everyday responsi-

contraception, or on whether she has
had previous abortions. As Dr. Aub6ny
cautions, "We must remember that the
women who have abortions are the
same women who have babies, too!"
Dr. Aubeny personally selected staff
who share a common vision and com-
mitment to women's health care. For
example, Therese, who counsels med-
ical abortion clients, spent many years
of her professional life working in coun-
seling services. She believes that her ten
years of experience as a family coun-
selor in Brazil helped broaden her
understanding of the complexity of
interpersonal relationships.
Christine, a nurse for over 30 years,
worked for many years in emergency

abilities among the method's best fea-
tures. Some women, however, did not
like the bleeding they experienced
with the method and felt that the abor-
tion dragged on too long. Another
study, employing a reduced dose of
mifepristone and allowing women the
option of taking their misoprostol at
home (and consequently eliminating
the most lengthy clinic visit), is con-
cluding in Tunisia and Vietnam.
Another potentially promising
method of medical abortion in devel-
oping countries entails the use of miso-
prostol alone. Misoprostol, marketed
under the name of Cytotec, is inexpen-
sive, does not require refrigeration,
and is already available in over 60
countries for the prevention of ulcers.
Several studies from Cuba show that
this method may induce abortion in
approximately 90 percent of cases.
Studies are ongoing to determine the
best regime for use of misoprostol

room surgery, where she witnessed first-
hand the mortality and morbidity caused
by illegal and unsafe abortion. Her pro-
fessional experience, her concern for
women, and her philosophy about this
work, including an ideological belief in
women's right to have safe abortions,
psychological support, and counseling,
led her to Broussais Clinic in 1988.
Francine is a social worker with ex-
pertise about a range of social services
in Paris. She has seen that women's abil-
ity to solve their health problems is
often tied to larger social or economic
problems. Conversely, she has also seen
that women who suffer these larger
problems may be particularly vulnera-
ble to an unwanted pregnancy.

Autonomy, control in decisionmaking,
and choice are the hallmarks of the
client-provider transaction at Broussais.
This posture begins with the first con-
tact. It is the clinic's policy that women
must take the initiative to seek abortion
themselves, and the decision to have an
abortion must be their own. Hence, the
clinic does not accept initial phone in-
quiries made on behalf of a woman by
her partner. The phone receptionists
also pay attention to choice: to accom-
modate women's schedules, the clinic
offers counseling sessions in both morn-
ings and afternoons, five days a week.
Once the woman or girl arrives at the
clinic, she meets with one of the three
full-time counselors. The counseling ses-
sions are intended to help women with
decisionmaking on a variety of issues,



including contraceptive or abortion
method selection. A psychologist holds
a weekly session in which women who
are having particular difficulties decid-
ing whether to terminate their pregnan-
cy or who have had multiple termina-
tions can explore issues of sexuality and
decisionmaking in more depth.
Christine reports that medical abor-
tion clients experience autonomy in the
sense that they are "in charge of the
process." (Christine initially had some
misgivings about medical abortion that,
in hindsight, she believes she may have
communicated to her clients; with time
and experience, however, she became
more comfortable with the method and
believes it is an important option to pro-
vide.) Ultimately, all clinic staff mem-
bers are committed to respecting
individual choice, even when it some-

Partners are welcome at the Broussais Clinic, but women must make the initial phone contact themselves. Counselors also find that
some women view the experience of abortion as an opportunity to reflect upon their personal and sexual relationships.


times contradicts their own opinions.
Virtually every staff member echoes this

Our purpose is to enable each woman
to make the best choice for herself.
-Virginie, staff nurse

Our main purpose as clinicians is to
organize ourselves so that women who
decide to have an abortion can have
one quickly and safely.
-- I ;, physician

In our clinic, the woman is in charge
of the process of abortion. It is her
abortion, and her choice is what is
most important.
Clinic counselor

We are here to adapt to each woman.
SEach woman is a special case for us.
Clinic administrator

Or, as Dr. Aubeny comments succinctly:
The best abortion for a woman is one
that she has chosen for herself.

The staff understand that many wom-
en can assume greater autonomy when
they feel they are in a supportive envi-
ronment. Often, part of that support may

Fngaging a girl or woman in a
conscious de isionmal ing process
about her abortion procedure is
sometimes an overture or
opening to conlmideriln her
options more broadly.

come from a partner, friend, or family
member. In keeping with the philoso-
phy of empowering the woman to make
decisions, it is the client who decides

The guiding principle at the Broussais Clinic is that a
woman be in charge of her own abortion decision.
The counselor's job is to help her integrate the event
into her life.

whether she wants her partner to be
involved. For this reason, in 1994, a
special room was built so that the part-
ners, friends, or family of clients having
medical abortions could join them dur-
ing the waiting period; there are now
separate waiting rooms for those
women with partners and those who
are unaccompanied. Staff members
report that more and more women are
bringing their partners, for both med-
ical and surgical abortion procedures.
Of course, the staff understand that
each woman or girl has different needs
for information and for discussion, and
that each woman must feel in control of
her decision to engage in such discus-
sion. Th6rese explains, "Counseling is a
complex matter. One has to start where
and when the woman is ready. I am
always available for women, but can
only go so far with every woman. Each
woman has a right not to speak as well
as to speak."

12 / ,.

The staff see that effective counseling
can have unexpected benefits for the
girls and women who come through the
doors at Broussais. Abortion counseling
at Broussais is clearly aimed at helping
clients reflect upon and find meaning in
the experience. As Christine explains,
engaging a girl or woman in a con-
scious decisionmaking process about
her abortion procedure is sometimes an
ouverture or opening to considering her
options more broadly. Jacqueline, a
clinic nurse, adds, "We provide a link
between the abortion experience and
the future-the woman's future and
future contraception. We help a woman
integrate this event into her life."
Similarly, Th6rese has learned that
the experience of facing an unwanted
pregnancy can in some ways be a posi-
tive one for many women and girls.
"Women must gain something by hav-
ing this [abortion] experience," explains
Th6rese. She offers an example: "For
some women or couples, even though
they have chosen not to proceed with
the pregnancy, they are at least com-
forted in knowing that they are fertile."
Among those clients who select med-
ical abortion, many consciously choose
to view the products of conception, and
this process seems to complement the
counseling. According to Therese, this
experience often provides a sense of
relief that the abortion is complete, as
well as an emotional sense of closure.

One of the most striking aspects of the
medical abortion service at Broussais is
the very high effectiveness rate, which
has increased to 99 percent in the past

few years. The staff members are con-
vinced that the strides they have made
in providing emotional and psychologi-
cal guidance have contributed to this
increase. Jacqueline, a staff nurse, ex-
plains that when women receive better
care, they actually experience less ten-
sion, thus making the expulsion of the
products of conception easier. Therese
agrees that there are psychological as-
pects to the expulsion during medical
abortion, agreeing, "Counseling helps
improve the success rate of medical abor-

!save Rx o this

tion because women who are more re-
laxed have an easier time." Further, she
has observed that the group setting helps
to provide encouragement for women
to the expel products of conception.

Selecting counselors and staff members
who share the clinic's vision of repro-
ductive health care is important, but is
not enough by itself to result in the kind
of quality counseling that clients at
Broussais receive. Complementing the
160 hours of training the telephone
receptionists receive, each counselor
receives 400 hours of specialized train-
ing. The cost for such counselor training

is 28,000 FF (or US $5,000), a signifi-
cant sum even for the Broussais Hospi-
tal. The staff feel that the benefits reaped
from such counseling clearly make it a
wise investment in the long term.

Beyond Counseling: The
Job of the -. ial Worker
Many women who come to the Brous-
sais Clinic are young and single with
children; often they are in precarious
social and financial situations. Sixty per-
cent of clients have problems negotiat-
ing financial payments and getting the
proper paperwork filled out so that they
can receive the benefits to which they
are entitled. Francine, the social worker
at Broussais Clinic, assists clients expe-
riencing socioeconomic problems. She
helps the women maneuver through the
complex French health care bureaucra-
cy so that all who need care can receive
it. At times, this involves finding creative
solutions to clients' problems. Although
providing this type of social assistance
to women is not obligatory in French
public-sector clinics, the staff believe
that this service is important for other-
wise many women would-for logisti-
cal, bureaucratic, or financial reasons-
be denied the services they need.

antainng Staff
. mn itme n t an f
, orale

Working at the Broussais Clinic is not
easy. First, it is emotionally demanding
to support women and girls as they con-
front not only an unwanted pregnancy,
but also a range of related personal
concerns. Further, because staff are per-
sonally invested in the well-being of

their clients, it is sometimes difficult to
stay neutral in the face of a woman's
own choices. Dr. Aubeny's comment
reflects the moral framework that
guides the staff in this regard:

One must always keep in mind that it
is never easy for women to have an
abortion. Our job is to offer the best
choice for women by offering the
best choice of services.... It requires a
basic respect for each woman and a
commitment to women's autonomy
and their rights in decisionmaking.

It is also taxing to work in an abor-
tion clinic in a setting where anti-choice
activists seek to intimidate providers.
Indeed, on three occasions from 1990
to 1995, demonstrators chained them-
selves together outside the clinic walls
to protest the services Broussais pro-
vides to women and girls. These attacks
forced the staff to reflect on and discuss
why they had initially chosen to work in
an abortion clinic: largely, a personal
commitment to abortion rights and/or to
quality reproductive health care for
women. In the end, the anti-choice
attacks on the clinic actually solidified
the bonds between staff members and
increased their dedication to preserving
women's right to choose abortion.
In addition to sharing a sense of
commitment to the goals of the clinic,
the clinic brings staff together on a reg-
ular basis. Monthly meetings provide the
opportunity for education, training, and
social interaction, and all staff, both med-
ical and paramedical, are welcome to at-
tend. Before the meetings get started,
there is animated conversation, as the
discussion touches on social matters
(such as members' babies, husbands, and
personal lives), or on larger social prob-

ss~z!ki r


According to staff, quality rests in the details, and
they are gratified when a client leaves saying, "Thank
you for the day I spent at the Broussais Clinic."

lems (such as domestic violence, poli-
tics, and attacks on abortion clinics).
Gni.-all.,. the monthly meetings focus
on a particular substantive theme. This
may be a clinical issue, such as pain
management, or when to allow women
to leave the clinic after taking misopros-
tol. Another focus might be a counsel-
ing concern, such as how to cope with
dissatisfied or hostile clients. The meet-
ings also provide a venue to review the
educational materials, in which the staff
members collectively consider how
well the existing materials, which are
prepared by the government, are meet-
ing the evolving needs of their clients.
Once there is consensus about what
new material to produce and what the
content should be, a subset of staff
members will design the materials.'
Such consensus is part of the man-
agement style at the clinic. Typically,
decisions are initially generated at the
management level. However, they are
subsequently discussed with all staff

members at the monthly staff meetings
or at a special meeting to achieve group
Clearly, working at the clinic signi-
fies shared commitments, staff unity,
and opportunity for professional devel-
opment. The staff members get a great
deal of support from each other, and a
strong sense of collaboration is evident
throughout the clinic. As one counselor
said, "Here we are a real team. We have
a sense of being a team and women
sense the unity of our provider group."
All of this helps explain why most staff
members say that they do not experi-
ence burnout.
The most satisfying reward, however,
comes from the women and girls for
whom the staff provide care. As one
staff physician put it, "People always
want numbers," but it is important to
understand how the success has come
about, one woman at a time. "It is in the
details that you arrive at the essentials."
At the Broussais Hospital Clinique
d'Orthog6nie, the staff achieve the final
measure of success when clients say,
"Thank you for the day I spent here."
Toward that end, they undertake an
enormous effort day after day to give
meaning to the guiding words of Dr.
Women have a right not only to
abortion. They also have a right not to

' As part of a broad information and education
campaign, the French health authorities have
provided much of the general information about
clinical procedures and contraceptive methods.
-.. ... ; *;, the need for supplementary mate-
rials, the clinic staff has started to develop some
of its own documents. While funding for pro-
duction and printing is covered by the hospital,
the clinic staff maintains control of the content,
layout, and design.

It is not surprising to find high-quality,
woman-centered reproductive health
services in France today. Nor is it surpris-
ing to learn that women in France have
access to a range of fertility-regulating
technologies. What is particularly note-
worthy about the Broussais Clinic is the
way in which these services are offered.
The goal is not simply to perform a pro-
cedure correctly, but to empower wom-
en to make decisions about what serv-
ices they need, about the technology
they want to use, and about the quality
of their overall health and lives. While
many of the service elements found at
Broussais are unique to that clinic,
there are universal themes that have a
much broader application.
1. Particularly with sensitive services such
as abortion, hiring staff who share the
mission and purpose of a program
is key to ensuring stability and qual-
ity of care. In the case of the Brous-
sais Clinic, providers draw strength
from their shared commitment not
only to abortion rights and quality of
care, but also to the autonomy of
the client with respect to the inter-
ests of the provider.
2. High-quality care requires invest-
ments in training far beyond that

which is typical of many programs.
At the Broussais Clinic, this compre-
hensive training extends to staff who
answer the telephone (and who can
influence a client's decision about
service use) and those who work in
the reception area. What appears at
first to be a startling up-front invest-
ment in training has paid off in satis-
faction among both staff and clients.
3. With proper counseling, women are
comfortable with being more direct-
ly involved in the abortion experi-
ence, whether deciding about the
method of abortion or, for the major-
ity who opt for medical abortion,
expelling and viewing the products
of conception. Engaging clients in
an active process of reflection and
autonomous decisionmaking can
actually lead to personal growth for
many women and girls experienc-
ing unwanted pregnancy.
4. As a simple and safe procedure, and
as the final measure of control a
woman has over her fertility, surgi-
cal and medical abortions have a crit-
ical role in women's overall repro-
ductive health services. Ensuring its
proper place in comprehensive care
is a challenge for providers, health
service delivery systems, policymak-
ers, and women's health advocates.

by Shelley Clark
Sneh Vishwanath
Sunanda Rabindranathan

Most reproductive health programs hope
to provide and maintain high-quality,
affordable, and accessible care. How-
ever, precisely in the settings where the
unmet needs are greatest, resources for
facilities, supplies, and personnel are
often most limited; when the service
being offered is as personally or politi-
cally sensitive as abortion, programs
face an added challenge in protecting
the dignity of both clients and pro-
viders. Indeed, many organizations fac-
ing such financial and social dilemmas
have resigned themselves to lower stan-
dards or have simply dissolved. In this
context, the story of Parivar Seva Sanstha
in India is a particularly inspiring and
useful example of how innovation can
overcome adversity.

India was the first country in the world
to adopt a national family planning pro-
gram, in the hopes of reducing popula-
tion growth rates. The government of In-
dia presented its first five-year plan to
limit family size and control population
growth in 1952. However, because the
only method widely provided was ster-
ilization, the proportion of couples using
contraception began to stagnate. In fact,
by 1970 about 70 percent of those with
an unmet need for family planning were
younger couples who wanted spacing

methods. With little access to temporary
methods, a large number of these wom-
en had unwanted pregnancies. Many re-
sorted to backstreet and illegal abortions.
In 1972, Parliament passed the Medi-
cal Termination of Pregnancy Act, which
granted women the legal right to termi-
nate an unwanted pregnancy on liberal
social and socio-medical grounds. Un-
fortunately, although women have re-
tained their legal right to abortion, al-
most 30 years later many still lack access
to safe, affordable, and licensed abor-
tion providers. There are several reasons
why women do not use legal abortion
services in India. First, many women
and girls are unaware that abortion is in
fact legal. Second, there are too few
trained abortion providers and basic facil-
ities. As a result, despite its legal status,
as many as 80 percent of the abortions
provided in India are performed in the
backstreett" offices of unlicensed pro-
viders (Chhabra and Nuna 1993). Some
of these unlicensed providers offer rela-
tively safe procedures in their private of-

We dedicate this article to our co-author, Dr. Sneh
Vishwanath, Medical Advisor to Parivar Seva Sanstha,
who died on 4 June 2001 after a brief illness. Sneh was
an exceptional person. Through her research and serv-
ice delivery activities, she helped ensure that high-
quality, affordable, and accessible services were provid-
ed to women. Her contribution to PSS and to Indian
women is acknowledged with deep gratitude.

fices but charge exorbitant rates. How-
ever, for most women in India, particu-
larly those living in rural areas, safe,
affordable, and high-quality abortion is
still unattainable.

The Foun i-ng of
arivar Sva Sanst' a
To tackle the growing problems of its
floundering family planning program
and inadequate safe abortion services,
in 1976 the government of India called
for greater involvement of voluntary or-
ganizations. Dr. Sudesh Bahl Dhal, an
obstetrician-gynecologist from Delhi,
responded to this call, founding an orga-
nization dedicated to providing safe and
affordable abortion services. This new
organization became affiliated with
Marie Stopes International, a worldwide
organization based in London that now
works in more than 32 countries around
the world.
Dr. Dhal opened the doors of the first
clinic in Delhi in 1979, under the Marie

Stopes name. In the hopes of lessening
the stigma associated with abortion, she
boldly heralded the event with overt
media campaigns advertising safe abor-
tion services offered with warmth and
care. The clinic, like many abortion serv-
ices around the world, quickly found it
was meeting a very real need. As more
and more patients sought out their serv-
ices, additional Marie Stopes clinics
were opened throughout India and the
service offerings widened beyond abor-
tion. As the organization grew to have a
national reach, it changed its institution-
al name to Parivar Seva Sanstha (PSS),
meaning Family Helping Organization;
the clinics, however, continued to oper-
ate under the name of Marie Stopes.

orti n are at : SS
Despite limited resources, Parivar Seva
Sanstha's commitment to offering care
that is friendly, safe, affordable, and effi-
cient remains paramount. For the client,
this begins when she enters the clinic,


The first aim is to put the client at ease and encourage her to ask questions. This is particularly important because many clients
are reluctant to speak frankly in front of a doctor, especially if there are large gaps in social status.

typically located to allow easy access,
by passing through the now-famous
arches signifying the entry to a PSS
facility. She is welcomed by a coun-
selor, who confirms and records the
reason for her visit, and asks her to take
a seat. Because the personalized care
delivered at PSS frequently results in
moderate delays, clients usually spend
15 minutes in the waiting area before
being called in for an individual coun-
seling session.
Staff take particular pride in the phys-
ical appearance, comfort, and cleanli-
ness of the clinics. In a typical clinic, the
orderly reception area is furnished with
chairs, a television, magazines, and toys
for children, along with informational
brochures in the local language (or with
pictures only), posters describing meth-
ods of contraception, and a jar of free
condoms. As one client straightforward-
ly explained, "What I like about PSS is
the sitting space. I had an abortion be-
fore at [another] clinic; but here it is big
and spacious."

Counseling is considered one of the
most important components in service
delivery, and confidentiality is a hallmark
of that process. Although the clinic is
often crowded, counseling takes place in
a private room or semi-private curtained-
off enclosure. All information exchanged
during this session is strictly confiden-
tial. The case histories of the clients are
kept under lock and key, and neither the
client's name nor the procedure for
which she is admitted to the clinic is di-
vulged to any outsider. Indeed, women
often remark that they chose PSS be-
cause they were confident that their visit
would not become the talk of the town.

The quality of the counseling is also of
paramount importance. Individual pre-
abortion counseling typically lasts about
ten minutes. The first aim is to put the
client at ease and encourage her to ask
questions. The counselors take pains to
establish rapport and to alleviate ner-
vousness. If the woman wishes, her hus-

band or other relatives may join the
counseling session. Information is pre-
sented using nontechnical terms, and
every effort is made to have staff who
can speak to clients in their local lan-
guages, which is critical as many wom-
en are not fully conversant in or com-
fortable with English or Hindi. Coun-
selors probe the client's knowledge of
reproductive health and family plan-
ning before explaining the various
choices available to her. One counselor
explained that some clients are reluc-
tant to speak frankly in front of a doctor,
especially if there are large gaps in
social status.
The counselor then takes a personal
and medical history. According to the
counselors, nearly all of the women
have made up their minds about want-
ing an abortion before arriving at the
clinic; most wish to terminate pregnan-
cy for one of two reasons: either they
already have their desired number of
children and do not want any more, or

they became pregnant while lactating,
and their current child is too young. In
rare cases of uncertainty, the counselor
encourages the woman to discuss her
situation and examine her options. The
counselor explains the abortion proce-
dure and the use of any pain medica-
tions, as well as any potential compli-
cations. The woman then signs an in-
formed-consent form.
Available contraceptive options are
also explained during this counseling
session and emphasis is given to the
importance of using contraceptive meth-
ods to avoid another unwanted preg-

nancy. If, as is often the case, the hus-
band is present and supports the abor-
tion decision, the counselor consults the
client about inviting her husband in for
contraceptive counseling. The husband's
presence can be important, as it is often
he who ultimately makes decisions
about contraceptive use.

The Abortion ocedurc
To date, only surgical abortion is avail-
able at PSS clinics. Equipment and sup-
plies vary according to local conditions,
but a typical clinic has two operating

Medical Abortion at PSS and in India

Given the leadership of PSS in the intro-
duction of manual vacuum aspiration in
India, it is not surprising that the organi-
zation is eager to become the first non-
governmental organization in the coun-
try to offer medical abortion services. Al-
though mifepristone (RU 486) has not
yet been approved in India as an aborti-
facient, India was one of the first coun-
tries in the developing world to offer
medical abortion through clinical trials.
In 1991-93, the Population Council con-
ducted a trial at K.E.M. Hospital in Pune,
in the state of Maharashtra, using the
French regimen (described in the first
part of this report); the trial demonstrat-
ed that this option was safe and highly
acceptable to Indian women. This study
was followed by a similar trial using the
French regimen that offered access
through a variety of providers, including
the research hospital in Pune, a family
planning clinic in Mumbai, and a rural
health station located outside Pune. The
most recent study, conducted by the All
India Institute of Medical Sciences, gave
women a lower dose of mifepristone (200
mg) rather than the standard French
dose of 600 mg and found the reduced

dose to be equally effective in producing
complete abortion.
PSS is about to embark on several
mifepristone trials, which aim to make
this method more affordable, practical,
and acceptable to their clients. The gov-
ernment's Ministry of Health and Family
Welfare has approved a study of women
seeking termination of pregnancy up to
56 days using (a) mifepristone, followed
by misoprostol; and (b) misoprostol alone.
PSS plans to conduct trials in four clinics
(two in Delhi, one in Agra, and one in
Jaipur), demonstrating that NGOs can
safely and effectively provide this new
option.' As in the French regimen, wom-
en who request a termination of preg-
nancy will receive a general checkup and
be screened for eligibility. If the woman
is in good health, has no contraindica-
tions, and is within the predefined gesta-
tional age limit, she will be given full in-
formation about both surgical and med-
ical options and asked to choose between
the two. Unlike the French regimen, how-

SAlthough PSS has completed the development
phase of the project, implementation awaits
approval for PSS to import the drug.

theaters: one for early, simple abortions
(which constitute the vast majority of
procedures), and the other for early pro-
cedures performed with concurrent
sterilization and for all second-trimester
procedures. On average, about ten pro-
cedures overall are carried out during a
clinic session.
Eighty-five percent of all procedures
are carried out in the first trimester
(before 12 weeks of gestation) and al-
most all are performed by manual vac-
uum aspiration (MVA)." PSS was among
the first to bring MVA to India 23 years
ago, and over the last five years this

ever, which restricts access to women with
gestation up to 49 days LMP (i.e., the first
day of her last menstrual period occurred
no more than 49 days ago), the protocol
to be used by PSS will offer mifepristone
to women up to 56 days LMP.
Women who are eligible and who
choose to participate in the study will
take the first drug, mifepristone, in the
clinic at the reduced dose (200 mg).
Since mifepristone tablets are relatively
expensive to produce and the previous
study found the lower dose did not result
in diminished efficacy, this regimen will
make the method more affordable and
therefore accessible to women with lim-
ited financial resources.
Finally, in contrast to all previous mife-
pristone trials in India, women will be
given the option of either returning to the
clinic two days later to take 400 pg oral
misoprostol or taking misoprostol at
home. Previous trials in Vietnam and
Tunisia demonstrated that over 85 per-
cent of women preferred to take the
misoprostol in the comfort and privacy of
their own home. All women will also be
provided with instructions on how to
reach a health care provider promptly
with any concerns or questions. Approxi-
mately two weeks after taking the first
drug, women will return to the clinic to

method has become increasingly popu-
lar for early abortion. To meet the grow-
ing demand, PSS has helped organize
and conduct MVA training of medical
practitioners in their clinics. By in-
troducing MVA, PSS has been able to
increase significantly the number of

2 MVA involves using a hand-held syringe attached
to a cannula to suction the contents of the uterus
and is used to induce abortion in women up to
12 weeks of gestation. MVA completely evacu-
ates the uterus in more than 98 percent of clients
and can be performed on an outpatient basis
using local anesthesia. Although electrical vac-
uum aspiration is equally effective, it requires a
constant source of electricity.

have the completion of the abortion
assessed by manual exam or ultrasound,
depending on current clinical practices.
Special efforts will be made to contact
women who do not return for their fol-
low-up visit.
PSS providers are enthusiastic about
the prospect of providing this method.
The head doctor at one of the clinics, Dr.
Sandeep Suri, lamented that medical
abortion is not yet available at their clin-
ic, as she feels that many women fear
surgery and the risk of infection and,
therefore, would eagerly choose mifepri-
stone. In addition, she notes that many
Indian women come to the clinic asking,
"Is there no medicine for abortion?" They
have already heard about abortifacient
drugs through informal channels. For
example, local newspapers have recently
run stories about medical abortion and
several staff members have heard that
mifepristone (probably smuggled in from
China) is available on the black market in
India. Dr. Indu Kulshreshtha concurs
with Dr. Suri's eagerness to offer medical
abortion, noting, "Satisfaction is always
higher with choice; this is as true for
abortion procedures as it is for contracep-
tive methods." Providers generally agree,
however, that counseling is essential to
find the best method for each woman.


Women who undergo a simple MVA generally recover after 10-15
minutes. Those who have a simultaneous tubectomy have a longer
resting period.

women they serve and the quality of the
services they offer. According to Dr.
Indu Kulshreshtha, a clinic physician,
most clients find MVA preferable to
other surgical methods.
The use of anesthesia in first-trimester
procedures often depends on the wom-
an's history. Nulliparous women are giv-
en local anesthesia, but most parous
women receive no pain medication. In-
stead, providers talk with the client and
hold her hand during the procedure;
this method, which the staff fondly call
"PSS anesthesia," appears to work well
for most women.
The procedures for second-trimester
abortion (13-20 weeks) vary according
to the duration of gestation and the ex-
perience of the doctor. Most are early-
second-trimester procedures and can
be carried out with local anesthesia and
sedation. Even for later abortions, i.e.,
those performed at 15-20 weeks of ges-
tation, 90 percent of the procedures are
carried out with local anesthesia and a

sedative. However, depending on the
physician and the emotional state of the
woman, a few procedures are carried
out under general anesthesia; an anes-
thesiologist is generally available to
work at the clinic on an as-needed basis
for this purpose.
A woman who requests a tubectomy
may have the sterilization performed
concurrently with first-trimester abor-
tion; the double procedure is normally
carried out under local anesthesia or

Posta' rLion Care
After the abortion procedure, women
move to the recovery room and rest on
recliners or beds. The resting period is
generally 15-20 minutes after an MVA,
or longer for those women who have
received general anesthesia. While the
clients rest, staff again review both post-
abortion care and (if appropriate) con-
traception. Staff members report that
about 60 percent of women accept
some form of contraception concurrent
with or immediately subsequent to the
abortion. A further 10 percent accept it
when they return for a follow-up visit.
The most popular long-term method is
an IUD, while the most common spac-
ing methods are oral contraceptive pills
and injectables.

lentt Satisfaction

Most women hear about PSS from a
trusted friend or family member, or are
referred by other health care facilities.
Some are even referred by public-sector
clinics that provide abortion but advise
clients that "PSS has better services."
Many select PSS because of its relative-
ly affordable fees. But almost universal-
ly, clients also arrive with the expecta-

tion that PSS will provide friendly, safe,
and efficient abortion services. In gener-
al, comments from clients are a testimo-
ny to their satisfaction with the experi-

I was a little nervous about the oper-
ation, but the staff were so cordial that
I felt at ease. I feel very happy with the
I have been married only recently
and don't want to have a child yet. I
want to plan my family. My neighbor
had used the Marie Stopes service
and recommended it to me. The best
thing was the attitude of the staff.
They were warm and friendly and
boosted my confidence when I was
apprehensive about the procedure.
Two years ago I had undergone an
abortion by the local dai [midwife]. I
was not satisfied with the experience
I had with the dai. PSS was different
because the atmosphere was very
warm and the staff were very polite to
me. Also, the dai had carried out the
operation at her house. lAti PSS, the
staff were very professional.

Asked what they liked least about the
clinic or what ideas they had for im-
proving the services, clients have sug-
gested a cafe or tea stall, a swing for the
children, displaying the rate card at the
reception desk, and more seating. PSS
providers are clearly pleased that their
clinics have a reputation for excellence
and that former clients, medical provi-
ders, chemists,3 and government health
care workers all recommend their serv-
ices. One provider proudly noted that
"the only women who don't come here
are women who don't know about us."

3 The English term in India for pharmacists.

The commitment to providing safe, effi-
cient, and humane abortion services has
been a hallmark of the success of PSS.
Much thought and effort go into im-
proving quality of care. Some aspects of
quality have been institutionalized even-
ly across the organization. For example,
service protocols are standardized, and
compliance is assessed through the use
of strict procedural guidelines and check-
lists. At the time of employment, every
clinic employee is trained in clinic pro-
cedures. Refresher programs are con-
ducted to meet the changing needs of
the clientele. A trained outside observer
periodically monitors activities at the clin-
ics and in community projects. The pur-
pose of these evaluations is not to cri-
tique the staff, but rather to assist them
to articulate problems in service delivery,
correct shortfalls, and plug loopholes.
For some aspects of quality, however,
maintaining uniform standards across
such a culturally and economically di-
verse country is a herculean task. For ex-
ample, while all clinics have two toilets,
standby electric generators, and a reli-
able 24-hour water supply, there is tre-
mendous diversity in the size and con-
dition of each facility. A modern clinic
in an upper-income subdivision of Delhi
may be cramped but maintained in pris-
tine condition, while a large clinic in a
poor periurban neighborhood remains
in need of substantial repairs and renova-
tion. Optimizing the available resources,
therefore, requires a great deal of coop-
eration and patience as steady (but
often frustratingly slow) improvements
are made. PSS's ability to upgrade facil-
ities is greater if it owns the building,
but many of its clinics are in rented
sites. Investing in physical improve-

ments in a rented space is particularly
risky because PSS has been forced to
vacate sites either because of rent hikes
or because landlords have demanded
exorbitant payments from the organiza-

Since PSS provides a wide range
of repr'od uLct ive health services
that includes abortion, there is
no ,soril stignmii attached to
being an abortion provider.

tion after the clinics have started func-
tioning. To avoid such disruptive moves
and allow more investment in site
improvements, PSS is trying to purchase
clinic premises wherever possible.
Another hallmark of the PSS ap-
proach has been its responsiveness to
the community's demand for a broader
range of related reproductive health
services. Although abortion is PSS's flag-
ship service in the clinics and remains

PSS has expanded from a singular focus on abortion to provide
testing for STIs (including HIV), infertility checkups, and gyneco-
logical care.

central to its mission, staff learned early
on that their abortion clients generally
had inadequate knowledge of and
access to contraceptive methods, suf-
fered from infection, or needed counsel-
ing. Hence, PSS expanded from a sin-
gular focus on abortion provision to a
more comprehensive reproductive
health agenda. As one staff member at
PSS explained, "In order to provide
abortion services, we found it was nec-
essary to fix some problems as well."
PSS began providing family planning
counseling, as well as IUDs, pills, con-
doms, Depo-Provera, and sterilization.
The clinics also began to offer gyneco-
logical consultations, infertility check-
ups, and diagnosis and treatment for
reproductive tract infections and STIs,
including HIV. Some of the clinics also
have laboratory facilities; where no lab
facilities exist, the flow chart of syn-
dromic management based on national
AIDS control guidelines is followed.
PSS also opened two clinics for men, as
pilots, again offering a broad range of
reproductive health services, including
vasectomy and condoms, STI and HIV
testing, and infertility testing.
Over the years, communities have ex-
pressed a demand for an even wider array
of reproductive health services. In
response to these concerns, PSS devel-
oped an integrated program comprised of
immunization, pediatric services, and
antenatal and postnatal care. These pro-
grams were specifically designed to make
pregnancies healthier and deliveries safer
as well as to decrease infant mortality. PSS
also increased its immunization program
and strengthened links with the govern-
ment maternal and child health services.
To promote education, engage the
community in its projects, foster public
trust in the institution, and generate new
clients, PSS developed projects involv-
ing volunteers. Opinion leaders helped

. 0 / I '-. I.

PSS now operates a vast program relying on community-based volunteers, who educate other women about reproductive health.

select local women to act as PSS edu-
cation and community-based distribu-
tion (CBD) volunteers. These women are
then trained in various aspects of repro-
ductive health and disseminate this
information to other women. Over time,
these programs have grown into huge
endeavors of their own.4
Like many other NGOs, PSS faces
difficulties in recruiting and retaining
staff, particularly in rural or remote
areas. All of the clinics strive to employ
a minimum of one counselor, two doc-
tors, two nursing staff, one clinic atten-
dant, one clinic aide, and two field
staff. Most doctors and other staff mem-
bers stated that they choose to work at
PSS because of its professional environ-
ment. As one clinic counselor said:

SIn Sitapur, in the state of Uttar Pradesh, the com-
munity-based distribution system reached the
doorsteps of 300,000 people before the project
came to an end. In another program in the towns
of Bhubaneswar and Balasor in Orissa state, CBD
workers are currently reaching 200,000 urban
slum dwellers.

I have been with Marie Stopes for 16
years. It has been a learning experi-
ence for me: helping people make
contraceptive choices, and handling
clinic accounts and promotional acti-
vities. All this has helped me grow
personally as well as professionally.

Since PSS provides a wide range of
reproductive health services that in-
cludes abortion, there is no social stig-
ma attached to being an abortion pro-
vider. However, turnover is exacerbated
by other factors. Because PSS is a non-
profit social service enterprise, salary
levels are not comparable to what staff
could earn in other sectors. Further, most
of the clinic staff, especially doctors, are
women. Some leave when their hus-
bands are transferred to new places.
Others, who work at the clinics for a few
years when their children are young, la-
ter want to hone their professional skills
and venture into other areas. As is com-
mon for many programs, there is also
relatively high turnover of field staff.

Many clinics cope with the resulting
shortages by training staff members to
work as a team and perform multiple
functions. This multi-tasking offers many
advantages by helping individuals grow
professionally and building team spirit.
It also increases productivity and teach-
es staff to work under pressure. More-
over, maintaining a staff that performs
interchangeable jobs allows the serv-
ices to operate smoothly and efficiently.
To keep up staff morale and improve
communication, each clinic convenes
monthly meetings that provide continu-
ing education on medical topics, in-
cluding new contraceptive methods.

Shitruh:l1 its 33 (linis. PSS cares
for more than 1.5 million women
and men every year. Since its
inception in 1979, approximately
;Ji 2,0 ii ,ihortionrs have been
;ber fornw I C' .

PSS had decided to offer temporary
methods in a country where such meth-
ods were often in short supply. To ensure
consistent access to and affordability of
these methods, the organization devel-
oped a plan to reach the large number of
women who lived in areas with no PSS
clinics. In 1987, PSS launched a social
marketing division to distribute pills and
condoms. PSS's brand of oral contracep-
tives, iron/folic acid tablets, and its three
condom brands (each aimed at particu-
lar groups) are also sold in pharmacies.
While the social marketing program
has helped PSS to keep its clinics and out-
reach programs adequately stocked and
to reach out to various sectors through

retail marketing, maintaining quality
while keeping prices affordable is still a
challenge. The abortion service general-
ly helps PSS sustain itself financially, as
do the social marketing, STD/RTI treat-
ment, and Medicheck (complete repro-
ductive checkups for women) programs
available at some clinics. However, re-
sources vary from one community to
another and it takes a couple of years
for a new clinic to become self-suffi-
cient. Sites in low-income areas and
new sites are subsidized by PSS. To fos-
ter realistic goals for achieving quality,
each PSS clinic devises its own plan for
incremental improvements in care.

:'arivar Seva
Sanstha Today
Over the past 20 years, PSS has grown
steadily. Today PSS boasts a network of
33 clinics, two mobile units, and
numerous projects and programs locat-
ed in 18 of India's 28 states, including
the impoverished states of Rajasthan,
Uttar Pradesh, Madhya Pradesh, Bihar,
and Orissa. Through these clinics, PSS
cares for more than 1.5 million women
and men every year. Since its inception
in 1979, approximately 802,000 abor-
tions have been performed in the Marie
Stopes clinics, of which 72,000 were
performed in the year 2000. PSS owes
this growth in part to concerted efforts
to expand access, especially to margin-
alized groups. For example, PSS delib-
erately attempts to locate its clinics in
the heart of communities with high
population densities and low economic
resources. When this strategy is imprac-
tical or not feasible, PSS brings services
directly to clients' doorsteps through
mobile clinics, which offer a broad

The primary mission of PSS-to enhance people's quality of life through improving their reproductive health-has not
changed. The right to terminate pregnancy with safety, dignity, and personal support is part of that mission.

range of reproductive health services
(excluding abortion) and through a net-
work of field workers who spread the
word about the services. PSS has also
made impressive strides to reach young
people and men. In 1987, it launched
an ambitious Family Life Education
Project, which worked through commu-
nity institutions to provide young peo-
ple information about health, reproduc-
tion, sexuality, contraception, parent-
ing, and interpersonal relationships.
This project has now extended its audi-
ence through a distance-learning pro-
gram, a correspondence course that
awards candidates a certificate on satis-
factory completion of the course. To
reach men, PSS started male-only clin-
ics in the states of Tamil Nadu and
Orissa that offer an integrated package

of services to men with a special
emphasis on family planning and men's
reproductive health.
Along with its clinical and program-
matic innovations, the cornerstone of
PSS's success remains its commitment
to quality and to a client orientation.
The primary mission-to improve the
quality of life of people through improv-
ing their reproductive health-has not
changed. Nor has the belief that women
seeking to terminate pregnancy have
the right to do so with safety, dignity,
and personal support.

Chhabra, Rami and S.C. Nuna. 1993.
Abortion in India: An Overview. New
Delhi, India: Veerendra Printers.

:.esumen en Espafiol

Dado que el acceso al aborto legal y seguro
se encuentra severamente limitado en mu-
chas parties del mundo, se le ha prestado
muy poca atenci6n al tema de la calidad
de la atenci6n relacionada al aborto. Esta
edici6n de Quality/Calidad/Qualit6 exa-
mina dos programs que operan en contex-
tos legales que permiten servicios seguros,
pero que tambidn han hecho un gran
esfuerzo por analizar y practicar la cali-
dad en la atenci6n relacionada al aborto.
En el Hospital Broussais Clinique d'Ortho-
g6nie en Francia, un pequeiio y dedicado
equipo atiende a una diverse poblaci6n
urbana. Adems de practicar procedimien-
tos seguros, el equipo busca potenciar a
sus clients, para que ellas puedan decidir
qu6 servicios necesitan, qu6 tecnologia
quieren utilizar, y que calidad de salud y
de vida desean tener. Por lo dicho el per-
sonal pone en manos de las mujeres clien-
tes todo el poder de elecci6n y la respon-
sabilidad posibles. Segin la etapa gesta-
cional en la que se encuentran, las mujeres
que acuden a la clinica pueden elegir un
aborto quirDrgico o medico, consistiendo
el Oltimo en el uso combinado de mife-
pristona (RU 486) y misoprostol. La clinica
Broussais desempefi6 un papel de pionero
al introducir el aborto medico en 1983, y
aunque este protocolo generalmente re-
quiere tres visits a lo largo de dos sem-
anas, en la actualidad es el que mis solic-
itan sus clients.
Con el prop6sito de fomentar la capaci-
dad de reflexi6n y decision informada de
sus clients, el program Broussais le da
muchfsima importancia al process de ori-
entaci6n, el cual suele estar enfocado en
las inquietudes, experiencias, y futuras in-
tenciones reproductivas de la mujer.
Muchos de los miembros del personal
creen que la buena orientaci6n propor-
ciona oportunidades para el crecimiento
personal e incluso "ayuda a mejorar las
tasas de exito de los abortos medicos (que
hoy rondan por el 99 por ciento) dado que
a las mujeres que estin mis tranquilas les
result mis ficil (expulsar los products
de la concepci6n)". Nuevos miembros del
personal de orientaci6n reciben unas 400
horas de capacitaci6n especializada, una

inversi6n notable, incluso en un entorno
donde se dispone de recursos suficientes
para garantizar la salud pbblica.
Resulta muy distinta la situaci6n de
Parivar Seva Sanstha (PSS), una entidad afi-
liada a Marie Stopes International que opera
33 clfnicas a lo largo de la India. Aunque
el aborto es legal en la India, el acceso a
servicios seguros y de bajo precio es suma-
mente limitado. La PSS se destaca por pro-
veer servicios que reinen esos dos re-
quisitos, y que ademAs tratan de una ma-
nera sensible y respetuosa a las mujeres.
Se le da much importancia a la utiliza-
ci6n de espacios que protegen la intimidad
de la mujer durante las sesiones de orienta-
ci6n, y al mantenimiento de una confi-
dencialidad absolute. Tambien se trata de
brindar una mejor calidad de apoyo durante
el aborto en si, al cual la mayoria de las
mujeres se someten sin anestesia. El 70
por ciento de las clients para aborto eligen
alg6n tipo de anticoncepci6n, y la esteri-
lizaci6n simultinea es una de las opciones.
La PSS tambien ha sido innovadora en
cuanto a m6todos para el aborto. Fue una
de las primeras organizaciones en India
que utilize equipos manuales para la aspi-
raci6n al vacio, y ahora esti por participar
en pruebas clfnicas de mifepristona. La PSS
mantiene sus parimetros de calidad a
trav6s de protocolos, capacitaci6n y sub-
sidios parciales a las clinicas ubicadas en
sectors mis carenciados.
La PSS ha crecido segin las necesidades
de la comunidad, convirti6ndose poco a
poco en un proveedor de servicios inte-
grales de salud reproductive. Tambien ha
creado un program para j6venes, un pro-
grama de mercadeo social para incre-
mentar el acceso y fortalecer la cadena de
abastecimiento, y otros programs basa-
dos en la comunidad.
Cada aiio unas 78.000 nifas y mujeres
mueren innecesariamente en todo el mun-
do a causa de abortos mal practicados, y
decenas de miles de otras mujeres sufren
temor y trauma por la misma causa. Las
lecciones de estos dos programas-que
enfatizan seguridad, opciones, y com-
pasi6n-nos hacen acordar que ya no se
puede justificar el sufrimiento de cual-
quier nifia o mujer que decide abortar.

L'acces a I'avortement 16gal et sans risques
6tant soumis a de severes contraintes dans
de nombreux pays du monde, la question
de la quality des soins en cas d'avorte-
ment n'a pas beaucoup retenu I'attention
du public. Ce numero de Quality/Calidad/
Quality met en valeur deux programmes
g6r6s dans des contextes legaux permet-
tant I'acces a des services sans risques,
mais aussi don't les responsables s'effor-
cent de concevoir et d'offrir des soins de
quality en cas d'avortement.
A la Clinique d'Orthog6nie de I'h6pital
Broussais en France, une petite equipe de-
vouee dessert une population urbaine h6-
terogene. L'Uquipe a pour but non seule-
ment de pratiquer des interventions sans
risques, mais aussi d'habiliter ses clients
a d6cider des services don't elles ont be-
soin, des techniques qu'elles veulent uti-
liser, ainsi que de la quality de leur sant6
et de leur vie en general. Aussi, le person-
nel laisse-t-il autant que possible les clients
faire des choix et assumer des responsabili-
t6s. Suivant I'etat d'avancement de la gros-
sesse, les clients peuvent choisir soit un
acte chirurgical soit I'avortement medical,
qui consiste en I'association de mifepris-
tone (RU 486) et de misoprostol. La clinique
de Broussais a lance I'usage de I'avorte-
ment medical en 1983 et, bien qu'en
general le protocole n6cessite trois visits
pendant une periode de deux semaines,
I'avortement medical est actuellement la
methode la plus utilisee parmi ses clients.
Pour developper I'aptitude des clients
a refl6chir et A prendre des decisions eclai-
r6es, le programme de I'h6pital Broussais
accord la priority absolue au processus
de conseil, qui est souvent axe sur les
preoccupations des clients, leurs exp6-
riences, et leurs intentions futures en
matibre de procreation. Plusieurs membres
du personnel considerent que des conseils
adequats favorisent le developpement
individual et permettent meme er le taux de rdussite de I'avortement
medical (maintenant de 99 pourcent)
parce que les femmes plus d6tendues
reussissent plus facilement (a 6vacuer les
products de la conception).>) Les nou-
veaux conseillers recoivent 400 heures de
formation specialis6e, ce qui repr6sente

un investissement remarquable meme dans
un cadre disposant de resources ad6-
quates pour les soins de sant6 publique.
Travaillant dans un cadre tres different,
le Parivar Seva Sanstha (PSS), qui gere 33
cliniques dans I'ensemble de I'Inde, est
affili6e Marie Stopes International. Quoi-
que I'avortement soit legal en Inde, I'acces
a des services sirs et abordables fait gran-
dement defaut. Le PSS est fier non seule-
ment d'offrir des soins sirs et abordables,
mais aussi de le faire dans un cadre accueil-
lant et respectueux. Une attention toute par-
ticulibre est pretee a l'etablissement de lieux
prives pour les seances de conseil (y com-
pris un soutien supplementaire pendant
I'intervention, que la plupart des femmes
supportent sans anesth6sie) et au maintien
d'une confidentiality absolue. Soixante-dix
pour cent des clients ayant subi un avor-
tement optent pour la contraception; la
sterilisation est egalement disponible.
Le PSS a aussi et6 un novateur en ce
qui concern les methodes d'avortement.
L'un des premiers programmes en Inde a
utiliser le materiel d'aspiration manuelle
intra-uterine, il est maintenant pr&t a par-
ticiper aux essais relatifs au mif6pristone.
Les normes de quality sont maintenues
grace a des protocoles, a la formation du
personnel, ainsi qu'a des subventions par-
tielles aux cliniques situ6es dans les zones
particulibrement pauvres en resources.
En reponse aux besoins de la commu-
naute, le PSS s'est d6veloppe au fil des ans
afin de devenir un prestataire de services
complete de sante de la reproduction. II a
aussi elabore un programme pour les jeu-
nes, un programme de marketing social
pour accroitre I'acces aux services et en
assurer la prestation ininterrompue, ainsi
que d'autres programmes communautaires.
Chaque annee, 78 000 filles et femmes
meurent inutilement dans le monde des
suites d'un avortement pratique dans de
mauvaises conditions de s6curite, et de
nombreuses autres encore connaissent la
peur ainsi qu'un traitement inhumain. Les
lemons tires de ces deux programmes qui
mettent I'accent sur la s6curite, le choix,
et la compassion nous rappellent qu'il n'y
a pas de raison qu'un avortement se passe
dans la souffrance.

About the Authors
Carmen Barroso is Director of the Pop-
ulation Program at the John D. and Cath-
erine T. MacArthur Foundation.
Martha Brady is a Program Associate
with the Gender, Family, and Develop-
ment Program of the Population Council.
Shelley Clark was formerly a Program
Associate in the International Programs
Division of the Population Council.
Batya Elul is a Staff Program Associate
in the International Programs Division
of the Population Council.
Sunanda Rabindranathan is the Com-
munications and Research Executive at
the Parivar Seva Sanstha.
Sneh Vishwanath was the Medical Ad-
visor to Parivar Seva Sanstha.

Editor: Debbie Rogow
Editorial and
Production Coordinator: Monica Rocha

Advisory Group
Errol Alexis
Gary Barker
Judith Bruce
Francoise Girard
Nicole Haberland
Joan Haffey
Judith Helzner
Katherine Kurz
Ann Leonard
Elizabeth McGrory
Suellen Miller
Isaiah Ndong
Nancy Newton
John Paxman
Saumya RamaRao
Julie Reich
Jill Sheffield
Cynthia Steele
Gilberte Vansintejan
Beverly Winikoff
Margot Zimmerman

Designer: Mike Vosika

We invite your comments and ideas for projects that might be included in future edi-
tions of Quality/Calidad/QualitL. If you would like to be included on our mailing list,
please send an e-mail to: qcq@popcouncil.org. Most past editions are available on-
line at: www.popcouncil.org/publications. The following are also available in print;
single or multiple copies may be ordered by e-mail:

Celebrating Mother and Child on the
Fortieth Day: The Sfax Tunisia Postpartum
Program (English only), no. 1, 1989.
Man/Hombre/Homme: Meeting Male Re-
productive Health Care Needs in Latin
America (English, Spanish), no. 2, 1990.
Gente Joven/Young People: A Dialogue
on Sexuality with Adolescents in Mexico
(English, Spanish), no. 5, 1993.
The Coletivo: A Feminist Sexuality and
Health Collective in Brazil (English, Por-
tuguese), no. 6, 1995.
Doing More with Less: The Marie Stopes
Clinics of Sierra Leone (English only), no.
7, 1995.

Introducing Sexuality within Family Plan-
ning: Three Positive Experiences from
Latin America and the Caribbean
(English, Spanish), no. 8, 1997.
Using COPE to Improve Quality of Care:
The Experience of the Family Planning
Association of Kenya (English, Spanish),
no. 9, 1998.
Alone You Are Nobody, Together We
Float: The Manuela Ramos Movement
(English, Spanish), no. 10, 2000.

.q* j .fi 1/ Quahte

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