Postabortion Care in Java, Indonesia

Postabortion care prevents complications that result from miscarriage or unsafe abortions from escalating to severe health outcomes or death. In addition to clinical treatment comprising uterine evacuation, infection management and treatment of injuries resulting from unsafe procedures, postabortion care includes family planning services and other relevant health care.

This fact sheet presents findings from a 2018 study on the availability and methods of postabortion care in Java, Indonesia’s most populous island. It offers suggestions for how Indonesia can expand access to quality postabortion care, including through the introduction of national guidelines that support task shifting and enhanced, standardized training for midwives and general physicians in postabortion care.

Current provision and availability

• Postabortion care in Indonesia is typically administered by obstetrician-gynecologists practicing in hospitals. Other types of providers, such as general physicians and midwives, do not commonly perform uterine evacuation—a core component of postabortion care—thus curtailing the availability of this care.
• Restricting the provision of postabortion care to specialists in hospitals is unusual; in many countries, uterine evacuation for first-trimester postabortion care is routinely offered in public health centers at the primary-care level.
• Only 46% of hospitals in Java offer either basic or comprehensive postabortion care services. Facilities with either service capacity have a sufficient number of obstetrician-gynecologists on staff and offer around-the-clock access to the full set of essential postabortion care services and treatments, including uterine evacuation and provision of uterotonics and intravenous antibiotics.
• Capacity for either basic or comprehensive postabortion care services is concentrated among 86% of the largest referral hospitals; only 53% of maternity hospitals and 34% of local hospitals offer the necessary services, treatments and staffing.
• Because public health centers in Indonesia are staffed by general physicians and midwives—providers for whom postabortion care training and provision guidelines are inconsistent—these centers do not provide uterine evacuation for postabortion care.
• Family planning services are an important component of postabortion care. Currently, 68% of hospitals in Java stock short-term family planning methods, and 77% offer long-acting reversible contraceptives.

Methods of postabortion care

• The World Health Organization (WHO) recommends vacuum aspiration or misoprostol for treatment of incomplete abortion in the first trimester.
• Although 67% of all hospitals in Java possess functioning vacuum aspiration equipment, only 7% of postabortion care patients are treated with vacuum aspiration. Just 4% of patients are treated with misoprostol.

• WHO advises against treating most postabortion care patients with D&C because this method carries a higher burden of treatment and risk of complications, compared with vacuum aspiration and misoprostol, and it requires specialized training.

Improving postabortion care quality

• Training more health providers, including midwives, in WHO-recommended techniques would likely increase access to postabortion care, reduce health system costs and improve the quality of postabortion care for patients who need it.
• National guidelines should promote standard training for midwives and general physicians that includes uterine evacuation procedures and management of postabortion care patients with counseling, family planning and referral to related services.

• The International Federation of Gynecology and Obstetrics recommends task shifting uterine evacuation for postabortion care to midwives, especially for treatment of first-trimester incomplete abortions.
• Task shifting to midwives would be particularly effective in Indonesia, in part because midwives routinely work in hospital obstetrics/gynecology units, where most postabortion care patients receive treatment, and are the main providers for obstetrics/gynecology patients in public health centers.
• If authorization and training to perform uterine evacuation were extended to midwives, 78% of all health facilities in Java (88% of hospitals and 67% of public health centers) would have the capacity to offer at least basic-level postabortion care services.
• If this authorization and training were given to general physicians, 59% of all health facilities (84% of hospitals and 27% of public health centers) would have basic or comprehensive postabortion care capacity.
• National health guidelines should address the widespread overuse of D&C procedures to treat postabortion care patients.