What post-abortion care indicators don't measure: Global abortion politics and obstetric practice in Senegal

From political priority to service delivery: complexities to real-life priority of abortion services in Ethiopia

Improving access to abortion services has been coined a high priority by the Ethiopian Federal Ministry of Health. Nevertheless, many women are still struggling to access abortion services. The dedicated commitment to expanding abortion services by central authorities and the difficulties in further improving access to the services make for an interesting case to explore the real-life complexities of health priority setting. This article thus explores what it means to make abortion services a priority by drawing on in-depth interviews with healthcare bureaucrats and key stakeholders working closely with abortion service policy and implementation. Data were collected from February to April 2022. Health bureaucrats from 9 of the 12 regional states in Ethiopia and the Federal Ministry of Health were interviewed in addition to key stakeholders from professional organizations and NGOs. The study found that political will and priority to abortion services by central authorities were not necessarily enough to ensure access to the service across the health sector. At the regional and local level, there were considerable challenges with a lack of funding, equipment and human resources for implementing and expanding access to abortion services. The inadequacy of indicators and reporting systems hindered accountability and made it difficult to give priority to abortion services among the series of health programmes and priorities that local health authorities had to implement. The situation was further challenged by the contested nature of the abortion issue itself, both in the general population, but also amongst health bureaucrats and hospital leaders. This study casts a light on the complex and entangled processes of turning national-level priorities into on-the-ground practice and highlights the real-life challenges of setting and implementing health priorities.

Effect of emotion management and nursing on patients with painless induced abortion after operation

BACKGROUND

With an estimated 121 million abortions following unwanted pregnancies occurring worldwide each year, many countries are now committed to protecting women's reproductive rights.

AIM

To analyze the impact of emotional management and care on anxiety and contraceptive knowledge mastery in painless induced abortion (IA) patients.

METHODS

This study was retrospective analysis of 84 patients with IA at our hospital. According to different nursing methods, the patients were divided into a control group and an observation group, with 42 cases in each group. Degree of pain, rate of postoperative uterine relaxation, surgical bleeding volume, and postoperative bleeding volume at 1 h between the two groups of patients; nursing satisfaction; and mastery of contraceptive knowledge were analyzed.

RESULTS

After nursing, Self-Assessment Scale, Depression Self-Assessment Scale, and Hamilton Anxiety Scale scores were 39.18 ± 2.18, 30.27 ± 2.64, 6.69 ± 2.15, respectively, vs 45.63 ± 2.66, 38.61 ± 2.17, 13.45 ± 2.12, respectively, with the observation group being lower than the control group (P < 0.05). Comparing visual analog scales, the observation group was lower than the control group (4.55 ± 0.22 vs 3.23 ± 0.41; P < 0.05). The relaxation rate of the cervix after nursing, surgical bleeding volume, and 1-h postoperative bleeding volumes were 25 (59.5), 31.72 ± 2.23, and 22.41 ± 1.23, respectively, vs 36 (85.7), 42.39 ± 3.53, 28.51 ± 3.34, respectively, for the observation group compared to the control group. The observation group had a better nursing situation (P < 0.05), and higher nursing satisfaction and contraceptive knowledge mastery scores compared to the control group (P < 0.05).

CONCLUSION

The application of emotional management in postoperative care of IA has an ideal effect.

Post-abortion needs-based education via the WeChat platform to lessen fear and encourage effective contraception: a post-abortion care service intervention-controlled trial

OBJECTIVE

Our study aims to investigate post-abortion needs-based education via the WeChat platform for women who had intended abortion in the first trimester, whether they are using effective contraception or becoming pregnant again.

DESIGN

This single hospital intervention-controlled trial used a nearly 1:1 allocation ratio. Women who had intended abortions were randomly assigned to a Wechat group (needs-based education) and a control group (Traditional education). The women's ability to use effective contraception was the main result. Whether they unknowingly became pregnant again was the second result. Another result was patient anxiousness. Before and after education, women filled out questionnaires to assess their contraception methods and anxiety.

METHODS

Based on the theoretical framework of contraceptions of IBL (inquiry-based learning), post-abortion women were included in WeChat groups. We use WeChat Group Announcement, regularly sending health education information, one-on-one answers to questions, and consultation methods to explore the possibilities and advantages of WeChat health education for women after abortion. A knowledge paradigm for post-abortion health education was established: From November 2021 until December 2021, 180 women who had an unintended pregnancy and undergone an induced or medical abortion were recruited, their progress was tracked for four months, and the PAC service team monitored the women's speech, discussed and classified the speech entries and summarized the common post-abortion needs in 8 aspects. At least 2 research group members routinely extracted records and categorized the outcomes.

RESULTS

Before education, there were no appreciable variations between the two groups regarding sociodemographic characteristics, obstetrical conditions, abortion rates, or methods of contraception (P > 0.05). Following education, the WeChat group had a greater rate of effective contraception (63.0%) than the control group (28.6%), and their SAS score dropped statistically more than that of the control group (P < 0.05). Following the education, there were no unwanted pregnancies in the WeChat group, whereas there were 2 in the traditional PAC group. Only 5 participants in the WeChat group and 32 in the conventional PAC group reported mild anxiety after the education.

Profil des utilisatrices et facteurs associés à la satisfaction des clientes de la qualité des soins après avortement au Burkina Faso: étude transversale menée dans six régions

RésuméMalgré la dépénalisation de l'avortement et la gratuité des soins après avortement (SAA), les femmes Burkinabè vivent des relations difficiles avec les soignants. Cette étude vise à déterminer le profil des femmes recevant des SAA, leur perception de la qualité des SAA et ses déterminants dans des structures sanitaires publiques et confessionnelles du pays. Une enquête quantitative a été menée auprès de 2174 femmes vues pour des SAA et recrutées de façon exhaustive de 2018 à 2020. Un questionnaire structuré a été administré à la sortie des soins. Une analyse uni-, bi- et multivariée a été faite. La majorité des clientes de SAA vivait en milieu rural (55%), avait 25 ans et plus (60%), vivait en couple (87%) et était sans-emploi (59%). La grossesse était non désirée chez 17% des femmes et 4% d'entre elles souhaitaient avorter. La satisfaction globale de la qualité des SAA était de 84%. Dans l'analyse multivariée, ses déterminants étaient la résidence en milieu rural (OR = 1.80 [1.38; 2.34]), un niveau scolaire primaire (OR = 1.48 [1.06; 2.07]) ou secondaire (OR = 1.95 [1.38; 2.74]), et avoir eu au moins un enfant (OR = 1.43 [1.02; 2.00]). Les facteurs associés à une faible satisfaction des SAA étaient une grossesse non désirée (OR = 0.64 [0.46; 0.89]) ou avoir souhaité avorter (OR = 0.09 [0.05; 0.16]). Le niveau de satisfaction globale est acceptable mais faible chez les clientes ayant souhaité avorter. Il est fondamental d'organiser un programme de formation des professionnels des SAA sur la communication, la relation interpersonnelle et l'empathie pendant les soins de santé.

"I will never wish this pain to even my worst enemy": Lived experiences of pain associated with manual vacuum aspiration during post-abortion care in Kenya

BACKGROUND AND OBJECTIVES

In Kenya, where abortion is legally restricted, most abortions are induced using unsafe procedures, and lead to complications treated in public health facilities. The introduction of Manual Vacuum Aspiration (MVA) to treat incomplete abortion has improved the management of abortion complications. However, this technology comes with pain whose management has been a challenge. This paper explores the lived experiences of pain (management) during MVA to document the contributing factors.

METHODS

We used an ethnographic approach to explore girls and healthcare providers' experiences in offering and accessing post-abortion care in Kilifi County, Kenya. The data collection approach included participant observation and informal conversations in public health facilities and neighboring communities, as well as in-depth interviews with 21 girls and young women treated for abortion complication and 12 healthcare providers.

RESULTS

Our findings show that almost all patients described the MVA as the most painful procedure they have ever experienced. The unbearable pain was explained by various factors, including the lack of preparedness of health facilities to offer PAC services (i.e. lack of pain medicine, lack of training, inadequate knowledge and grasp of pain medication guidelines, and malfunctioning MVA kits). Moreover, the attitudes of healthcare providers and facilities management toward the MVA device limited the supply and replacement of MVA kits. Moreover, the scarcity of pain medicines also gave some providers the opportunity to abuse patients guided by their values, whereby they would deny patients pain medication as a form of "punishment" if they were suspected of inducing their abortion, especially adolescent girls.

CONCLUSION

The study findings suggest the need for clearer guidelines on pain medication, value clarification and attitude transformation training for providers, systematizing the use of medical uterine evacuation using medical abortion drug and strengthening the supply chain of pain medication and MVA kits to reduce the pain and improve the quality of post-abortion care.

Factors Associated with the Choice of Contraceptive Method following an Induced Abortion after Receiving PFPS Counseling among Women Aged 20-49 Years in Hunan Province, China

BACKGROUND

There is limited research on postabortion family planning (PAFP) services and subsequent contraception in China. The current study aimed to identify women's contraceptive methods choices and associated factors after receiving PAFP services.

METHODS

A cross-sectional study used a cluster, stratified and multistage random sample to collect data. All eligible data were analyzed using SPSS 26.0. The chi-square test was used to assess the association between categorical variables. Significant variables (p < 0.05) and all potential variables were then included in the binary logistic regression model for analysis.

RESULTS

Approximately 84.7% (1043/1231) of participants had received pre-abortion PAFP counselling, and approximately 90% of them chose reliable methods. Farmers or workers (OR = 0.297, 95% CI: 0.130-0.683), family monthly income (3000-4999 RMB, OR = 0.454, 95% CI: 0.212-0.973; ≥5000 RMB, OR = 0.455, 95% CI: 0.228-0.909), reliable advice from services providers before abortion (OR = 0.098, 95% CI: 0.039-0.250), painless surgical abortion (OR = 3.465, 95% CI 1.177-10.201), and postabortion follow-up (OR = 0.543, 95% CI: 0.323-0.914) and were associated with contraception choice after receiving PAFP services.

CONCLUSIONS

This study emphasizes the importance of pre-abortion PAFP counselling, postabortion follow-up, and increased focus on women who have experienced painless abortion. The study provides direction for PAFP services policymakers, as well as a reference for contraceptive counselling research around the world.

'Of course, women will adopt it!': A qualitative study on the acceptability of medical menstrual regulation in Senegal

OBJECTIVE

Medical menstrual regulation (MMR) may offer a promising way to reach Senegalese women and girls in need of fertility management, especially in rural contexts. To assess the feasibility of introducing a MMR service in Senegal, the study aimed to (1) understand how women and girls manage their menses and fertility, and (2) document acceptability of MMR among women, youth, and health providers.

METHODS

Six focus group discussions and 34 in-depth interviews were conducted with women, youth, and health providers in Kaolack, Mbour, and Thiès, Senegal.

RESULTS

All participants characterized the pubescent period by a lack of sexual education, familial support, and access to reproductive health services. Reproductive health service utilization in Senegal was portrayed as highly stigmatized, creating barriers to contraception and reliable information on family planning. Unwanted pregnancy and clandestine abortion were depicted as common occurrences among many participants. Senegalese women and youth perceived MMR services as an acceptable method to manage a missed period with discretion, rid of moral and legal ramifications - and framed MMR as a needed mechanism to prevent abortion and avoid undesired pregnancies. The majority of health providers, with the exception of female health volunteers, were reluctant to endorse the service, comparing MMR to abortion.

CONCLUSIONS

In a context fraught with restrictive abortion laws and limited uptake of modern contraception, MMR is an acceptable among potential service users. Nonetheless, introduction and implementation of MMR will be feasible in Senegal only if policymakers approve and support the service and health provider buy-in is achieved.

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries

OBJECTIVE

Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity.

METHODS

Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women's experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis.

RESULTS

There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively.

CONCLUSION

There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care.

Clients' perceptions of the quality of post-abortion care in eight health facilities in Dakar, Senegal

Post-abortion care (PAC) integrates elements that are vital for women's survival after abortion complications and their ability to meet their subsequent fertility intentions. Currently, the utilization of PAC among women in need remains too low, particularly in settings where unsafe abortion is an appreciable cause of maternal mortality. Interventions have aimed at addressing unmet need; however, these still require information on the extent to which women value different aspects of PAC. This paper presents such evidence from Dakar, Senegal. Exit interviews with 729 PAC clients in 2018 at eight health facilities obtained information on patient characteristics, content of services received and women's perceptions of the quality of care, both overall and according to subject-specific domains. These domains reflect aspects of PAC that are relevant to clients' satisfaction: accessibility, facility environment, information and counselling, family planning, provider technical competence and readiness and client-staff interaction. Ordinal logistic regression models were estimated to identify factors that were associated with women's rating of overall quality of care (on a scale of 1 to 5, 1 being lowest). Predictors that were significantly associated with the outcome were used in a multivariate ordinal logistic regression model that estimated the probability of positive differences in the outcome associated with women's classification of each predictor. Women reported a mean rating of 3.7 for overall quality of care. The lowest domain-specific rating was for quality of information and counselling (mean=2.4) and the highest was for client-staff interaction (mean=3.8). Factors associated with clients' higher odds of being more satisfied with PAC were: physical comfort during the procedure, recall of counselling on treatment procedure, privacy, perceived availability of supplies and medicines, facility admission process, facility cleanliness, waiting time, clarity of counselling and access to different contraceptive methods. Interventions that target these factors may improve the utilization of PAC in Dakar, Senegal.

From the shadows to light. Perceptions of women and healthcare providers of post-abortion care in Burkina Faso

Despite political commitments to address maternal deaths due to abortion, women and girls in Burkina Faso still face impediments to accessing post-abortion care (PAC) services, including stigma, high costs, and negative patient-provider relationships. Based on a three-year ethnographic study in Ouagadougou, Burkina Faso (2011-2014), this paper provides an in-depth examination of the experiences and perceptions of patients and healthcare providers when seeking or delivering PAC. Extensive participant observation of PAC service delivery was carried out in five primary and three referral health facilities, as well as in-depth interviews with 13 healthcare providers and 39 patients. Data were analyzed using a thematic analysis approach and discussed using relevant literature. Patients and providers conceptualized PAC as literally "womb washing'', vividly reflecting on the realities around health risks of abortion, procreation and role of health providers. Moreover, women described PAC as a life-saving intervention capable of averting infections and other complications, but also bears significant risks of disclosure depending on the uterine evacuation technology used (manual vacuum aspiration versus medical abortion). In delivering PAC services, healthcare providers agonize over the dilemmas they face, mainly derived from their conceptualization of PAC services and how they cope with discomfort using PAC technology options. Our findings present the intersection between patients' and providers' conceptions of PAC, and how these perceptions drive the choice of technology for uterine evacuation to mitigate stigma. We argue that these perceptions drive patient and healthcare provider practices around decision making to seek or deliver care, and patient-provider interactions in health facilities. These findings offer important guidance for interventions seeking to improve access and quality of PAC.

What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal

Introduction

Increases in facility deliveries in sub-Saharan Africa have not yielded expected declines in maternal mortality, raising concerns about the quality of care provided in facilities. The readiness of facilities at different health system levels to provide both emergency obstetric and newborn care (EmONC) as well as referral is unknown. We describe this combined readiness by facility level and region in Senegal.

Methods

For this cross-sectional study, we used data from nine Demographic and Health Surveys between 1992 and 2017 in Senegal to describe trends in location of births over time. We used data from the 2017 Service Provision Assessment to describe EmONC and emergency referral readiness across facility levels in the public system, where 94% of facility births occur. A national global positioning system facility census was used to map access from lower-level facilities to the nearest facility performing caesareans.

Results

Births in facilities increased from 47% in 1992 to 80% in 2016, driven by births in lower-level health posts, where half of facility births now occur. Caesarean rates in rural areas more than doubled but only to 3.7%, indicating minor improvements in EmONC access. Only 9% of health posts had full readiness for basic EmONC, and 62% had adequate referral readiness (vehicle on-site or telephone and vehicle access elsewhere). Although public facilities accounted for three-quarters of all births in 2016, only 16% of such births occurred in facilities able to provide adequate combined readiness for EmONC and referral.

Conclusions

Our findings imply that many lower-level public facilities—the most common place of birth in Senegal—are unable to treat or refer women with obstetric complications, especially in rural areas. In light of rising lower-level facility births in Senegal and elsewhere, improvements in EmONC and referral readiness are urgently needed to accelerate reductions in maternal and perinatal mortality.