When Mrs. Iwu arrived at the maternity ward at Atapkame Regional Hospital in Togo, she was bleeding heavily—experiencing her second miscarriage. It may have been the result of multiple closely spaced pregnancies.

At 43, Mrs. Iwu had seven children between the ages of 20 months and 10 years.

Despite the risk that she might become pregnant again too soon, Mrs. Iwu left the health center without a contraceptive method.

Culturally, she is expected to have children with the new husband or she will not be accepted in the family.

“She did not want a method because she is a recent widow who has been inherited by her husband’s brother, who has another wife,” said Ms. Akor, the in-charge of the maternity ward at the health center and the most experienced midwife on staff. “She therefore needed to get pregnant as soon as possible to secure her place in the family.”

In Togo, data on unintended pregnancies and unsafe abortion are limited; a 2002 survey of family planning clinics in Lomé determined that 39% of women aged 15–24 who had been pregnant at least once reported having had an abortion. And 34% of married women do not desire a pregnancy in the next two years, yet they are not using a modern contraceptive.

Ms. Akor had diagnosed Mrs. Iwu with anemia, prescribed her iron tablets, and assessed her for possible referral to a hospital for a blood transfusion after fellow midwife Fauzia performed the manual vacuum aspiration to treat her miscarriage—known in medical terms as an incomplete abortion—and midwife Marie had engaged her in family planning counseling that honored the concept of voluntary informed choice.

“This is a new husband,” Ms. Akor said. “Culturally, she is expected to have children with the new husband or else she will not be fully accepted in the family, and besides she is also getting old.”

According to Ms. Akor, the recommended timeframe of six months would be too long for her to wait before trying to get pregnant again, particularly now that she had a miscarriage.

Although the midwives had learned in their clinical training that multiple pregnancies—too early, or too closely spaced—put the health of both mother and baby at great risk, they also learned to honor a client’s voluntary informed choice when it comes to contraceptive decisions.

This type of counseling, which all providers should be trained to conduct, ensures the right of the client to make informed decisions based on her personal reproductive health needs, desire for timing of subsequent pregnancy and family size, and the socioeconomic and cultural context.

In counseling for voluntary informed choice, the health worker becomes a facilitator, allowing the client to exercise her autonomy.

Training and protocols do not always prepare health workers for this level of complexity.

As facilitators, health workers are trained to be unbiased, provide accurate information tailored to the client’s needs, respond to the client’s questions, respect and support the client’s choice, and make sure they do not unduly influence the client’s decisions. They skillfully help the client examine the available information and weigh the potential health benefits and consequences against their individual needs, as well as the opinions and beliefs of their families and communities.   

Typically, a health worker takes a client’s history, performs an exam, reaches a diagnosis, and prescribes a method. Normally, this is simple and straightforward.

Counseling that honors voluntary informed choice, however, is personal and complicated, and clinical training, guidelines, and protocols do not always prepare health workers to handle that complexity.  

The midwives at Atapkame Regional Hospital were torn between their clinical knowledge and their understanding of the client’s cultural circumstance. Their empathy for Mrs. Iwu and her risk of not being accepted into her new family was palpable.

I pointed out that even if Mrs. Iwu becomes pregnant again, she might still not be accepted if she cannot carry a subsequent pregnancy to term, has a premature or low-birth-weight baby, or worse, dies in pregnancy or childbirth.

Fauzia let out a heavy sigh. After Mrs. Iwu mentioned that she wanted to try for pregnancy as soon as possible, Fauzia discussed the need to wait for at least six months and the benefits of spacing soon after the miscarriage, but did not dwell on the family planning methods. Fauzia felt that Mrs. Iwu would not be interested.

“It is her voluntary choice, but a risky choice,” said Ms. Akor. 

The midwives had done the right thing in respecting Mrs. Iwu’s autonomy in her decision. But informed choice also means making sure the client is fully aware of the medical repercussions of her choice. Such conversations—where a midwife must tell a client she might die if she follows a certain plan of action—are difficult.

This was a perfect example of how health workers in Togo and beyond need more support and practice in having such difficult conversations.

My question to them was: “What is Mrs. Iwu’s uterus telling us?”    

The uterus has had enough pregnancies and needs a break, the midwives agreed.

Marie mentioned that Mrs. Iwu’s desire to have a healthy baby with her new husband and her being healthy enough to look after her children should have been the focus of the discussion.

“That might have helped her to make the decision to wait before trying too soon,” Ms. Akor said. “After nine pregnancies and two of them resulting in miscarriages, the uterus is clearly tired!”

We then discussed a few examples of similar cases, not just among postabortion clients, but also postpartum clients and clients with chronic illnesses that are likely to worsen with pregnancy or threaten the mother’s life. The midwives said that in some of these situations, they just do not know what to do.  

Since 2013, the Evidence to Action (E2A) Project, the US Agency for International Development’s flagship project for strengthening reproductive health and family planning services, has been supporting Togo’s Division of Family Health to offer high-quality postabortion care services that include family planning counseling and access to a range of contraceptives at points of treatment for incomplete abortion to break the cycle of repeat abortions. As a partner in the project, IntraHealth International focuses on gender, capacity building, performance improvement and quality improvement.