Private medical providers' knowledge and practices concerning medical abortion in Nigeria

Assessment of relevance and actual implementation of person-centeredness in healthcare and social support services for women with unintended pregnancy in Germany (CarePreg): results of expert workshops

INTRODUCTION

Person-centeredness is a key principle in the German healthcare system. However, access to high-quality care for women with unintended pregnancy is limited due to social stigma and legal restrictions. There is little research on the adoption of person-centeredness in care for women with unintended pregnancy. The aim of this study was to analyze relevance and actual implementation of dimensions of person-centeredness in psycho-social and medical abortion care from the view of abortion care providers.

METHODS

Counselors and gynecologist working in psycho-social or medical abortion care participated in one of two digital workshops. Discussions were semi-structured based on the 16 dimensions of an integrative model of person-centeredness, audio-recorded and transcribed verbatim. During qualitative content analysis, deductive categories based on the integrative model of person-centeredness were applied and inductive categories were developed. Additionally, participants rated relevance and actual implementation of the dimensions in an online survey.

RESULTS

The 18 workshop participants most intensively discussed the dimensions "access to care", "person-centered characteristics of healthcare providers" and "personally tailored information". Four additional categories on a macro level ("stigmatization of women with unintended pregnancy", "stigmatization of healthcare providers", "political and legal aspects" and "corona pandemic") were identified. Most dimensions were rated as highly relevant but implementation status was described as rather low.

CONCLUSIONS

In Germany, high quality person-centered care for women with unintended pregnancy is insufficiently implemented through limited access to information, a lack of abortion care providers, and stigmatization. There is a need for changes in health care structures to enable nationwide person-centered care for women with unintended pregnancy. Those changes include a more easy access to evidence-based information and person-centered abortion care, more education on abortion care for healthcare providers, integration of topics of abortion care in medical schools and promotion of de-stigmatizing actions to enable abortions as part of the general healthcare.

In-country availability of medical abortion medicines: a description of the framework and methodology of the WHO landscape assessments

BACKGROUND

Availability of quality-assured medical abortion medicines plays a crucial role in providing comprehensive abortion care. However, access to these medicines is still restricted for many abortion seekers. Increasing availability of affordable, quality-assured mifepristone and misoprostol is important to improve access to safe medical abortion services. Driven by the outcomes of a global consultation hosted by the World Health Organization and the Swedish International Development Cooperation Agency in 2018, we decided to holistically examine access to medical abortion medicines from supply to demand. The overarching principle of the national landscape assessments was to generate evidence to support policy dialog and policymaking that is contextual to the needs of the country. This paper aims to describe the framework and methodological approach used in the World Health Organization landscape assessments of medical abortion medicines at country-level.

METHODS

A country assessment protocol was developed to guide the methodology of the World Health Organization landscape assessments. The assessment protocol included adaptation of an existing availability framework, an online desk review and literature review for existing data available for the country of interest, country-level key informant interviews, and analysis of the data to identify barriers and opportunities to improve medical abortion availability.

CONCLUSION

The availability framework and methodology will allow the identification of key barriers that limit readiness of medical abortion medicines, and the development of opportunities to overcome those barriers. The national landscape assessments will provide directions for future investments and offer guidance for policy and programming on medical abortion care.

Determinants of women's preferred and actual abortion provision locations in Nigeria

Background

Unsafe abortion remains a leading cause of maternal mortality globally. Many factors can influence women’s decisions around where to seek abortion care; however, little research has been done on abortion care decisions at a population-level in low-resource settings, particularly where abortion is legally restricted.

Methods

This analysis uses data from a 2019–2020 follow-up survey of 1144 women in six Nigerian states who reported an abortion experience in a 2018 cross-sectional survey. We describe women’s preferred and actual primary abortion care provider/location by distinguishing clinical, pharmacy/chemist, or other non-clinical providers or locations. We also examine factors that influence women’s decisions about where to terminate their pregnancy and identify factors hindering women’s ability to operationalize their preferences. We then examine the characteristics of women who were not able to use their preferred provider/location.

Results

Non-clinical providers (55.0%) were more often used than clinical providers (45.0%); however, clinical providers were preferred by most women (55.6%). The largest discrepancies in actual versus preferred abortion provider/location were private hospitals (7.6% actual versus 37.2% preferred), government hospitals (4.3% versus 22.6%), chemists (26.5% versus 5.9%) and pharmacies (14.9% versus 6.6%). “Privacy/confidentiality” was the most common main reason driving women’s abortion provider/location choice (20.7%), followed by “convenience” (16.9%) and “recommended” by someone (12.3%), most often a friend (60.8%), although top reasons differed by type of provider/location. Cost and distance were the two most common reasons that women did not use their preferred provider/location (46.1% and 21.9%, respectively). There were no statistically significant differences in the sociodemographic characteristics between women who were able to use their preferred provider/location and those who were not able to implement their preferred choice, with the exception of state of residence.

Conclusions

These findings provide insights on barriers to abortion care in Nigeria, suggesting discretion is key to many women’s choice of abortion location, while cost and distance prevent many from seeking their preferred care provider/location. Results also highlight the diversity of women’s abortion care preferences in a legally restrictive environment.

Many factors influence a woman’s pathway to obtaining an abortion, even in a setting with strict laws prohibiting the practice. This study aims to explore where women in Nigeria would prefer to and actually obtain their abortions, reasons why they could or could not use their preferred provider/location, and differences between women who were and were not able to use their preferred provider/location.

The findings show that most women would opt to use a clinical source, such as a government or private hospital, especially among women who did not use their preferred source. Privacy/confidentiality, convenience, and recommendation from someone like a friend or partner drove women’s abortion care preferences, although these influences differed by type of provider/location (clinical, pharmacy/chemist, or other non-clinical). Issues like cost, distance, and lack of privacy were barriers that prevented women from using their preferred provider/location, instead obtaining their abortion from a less desired provider. However, the sociodemographic characteristics of women who did and did not use their preferred provider/location did not differ significantly, except by state.

These findings provide insights on barriers to safe abortion care in Nigeria, suggesting social safety drives many women to seek care outside of the healthcare system, while cost and distance prevented many from seeking clinical services. Results also highlight the diversity of women’s abortion preferences in a setting where abortion is legally restricted.

Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context

BACKGROUND

In the UK, according to the 1967 Abortion Act, all abortions must be approved by two doctors, reported to the Department of Health and Social Care (DHSC), and be performed by doctors within licensed premises. Removing abortion from the criminal framework could permit new service delivery models. We explore service delivery models in primary care settings that can improve accessibility without negatively impacting the safety and efficiency of abortion services. Novel service delivery models are common in low-and-middle income countries (LMICs) due to resource constraints, and services are sometimes provided by trained, mid-level providers via "task-shifting". The aim of this study is to explore the quality of early abortion services provided in primary care of LMICs and explore the potential benefits of extending their application to the UK context.

METHODS

We searched MEDLINE, EMBASE, Global Health, Maternity and Infant Care, CINAHL, and HMIC for studies published from September 1994 to February 2020, with search terms "nurses", "midwives", "general physicians", "early medical/surgical abortion". We included studies that examined the quality of abortion care in primary care settings of low-and-middle-income countries (LMICs), and excluded studies in countries where abortion is illegal, and those of services provided by independent NGOs. We conducted a thematic analysis and narrative synthesis to identify indicators of quality care at structural, process and outcome levels of the Donabedian model.

RESULTS

A total of 21 indicators under 8 subthemes were identified to examine the quality of service provision: law and policy, infrastructure, technical competency, information provision, client-provider interactions, ancillary services, complete abortions, client satisfaction. Our analysis suggests that structural, process and outcome indicators follow a mediation pathway of the Donabedian model. This review showed that providing early medical abortion in primary care services is safe and feasible and "task-shifting" to mid-level providers can effectively replace doctors in providing abortion.

CONCLUSION

The way services are organised in LMICs, using a task-shifted and decentralised model, results in high quality services that should be considered for adoption in the UK. Collaboration with professional medical bodies and governmental departments is necessary to expand services from secondary to primary care.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Providers, Unmarried Young Women, and Post-Abortion Care in Kenya

Young women and girls in Kenya face challenges in access to abortion care services. Using in‐depth and focus group interviews, we explored providers’ constructions of these challenges. In general, providers considered abortion to be commonplace in Kenya; reported being regularly approached to offer abortion‐related care and services; and articulated the structural, contextual, and personal challenges they faced in serving young post‐abortion care (PAC) patients. They also considered induced abortion among young unmarried girls to be especially objectionable; stressed premarital fertility and out‐of‐union sexual activity among unmarried young girls as transgressive of respectable femininity and proper adolescence; blamed young women and girls for the challenges they reported in obtaining PAC services; and linked these challenges to young women's efforts to conceal their failures related to gender and adolescence, exemplified by pre‐marital pregnancy and abortion. This study shows how providers’ distinctive emphasis that young abortion care‐seekers are to blame for their own difficulties in accessing PAC may add to the ongoing crisis of post‐abortion care for young women and adolescent girls in Kenya.

A critical review of sanctioned knowledge production concerning abortion in Africa: Implications for feminist health psychology

Taking a feminist health psychology approach, we conducted a systematic review of published research on abortion featured in PsycINFO over a 7-year period. We analysed the 39 articles included in the review in terms of countries in which the research was conducted, types of research, issues covered, the way the research was framed and main findings. Despite 97 per cent of abortions performed in Africa being classifiable as unsafe, there has been no engagement in knowledge production about abortion in Africa from psychologists, outside of South Africa. Given this, we outline the implications of the current knowledge base for feminism, psychology and feminist health psychology in Africa.

Delivering medical abortion at scale: a study of the retail market for medical abortion in Madhya Pradesh, India

BACKGROUND

Medical abortion (mifepristone and misoprostol) has the potential to contribute to reduced maternal mortality but little is known about the provision or quality of advice for medical abortion through the private retail sector. We examined the availability of medical abortion and the practices of pharmacists in India, where abortion has been legal since 1972.

METHODS

We interviewed 591 pharmacists in 60 local markets in city, town and rural areas of Madhya Pradesh. One month later, we returned to 359 pharmacists with undercover patients who presented themselves unannounced as genuine customers seeking a medical abortion.

RESULTS

Medical abortion was offered to undercover patients by 256 (71.3%) pharmacists and 24 different brands were identified. Two thirds (68.5%) of pharmacists stated that abortion was illegal in India. Only 106 (38.5%) pharmacists asked clients the timing of the last menstrual period and 38 (13.8%) requested to see a doctor's prescription - a legal requirement in India. Only 59 (21.5%) pharmacists correctly advised patients on the gestational limit for medical abortion, 97 (35.3%) provided correct information on how many and when to take the tablets in a combination pack, and 78 (28.4%) gave accurate advice on where to seek care in case of complications. Advice on post-abortion family planning was almost nonexistent.

CONCLUSIONS

The retail market for medical abortion is extensive, but the quality of advice given to patients is poor. Although the contribution of medical abortion to women's health in India is poorly understood, there is an urgent need to improve the practices of pharmacists selling medical abortion.

RELIGIOUS INFLUENCE ON NON-USE OF MODERN CONTRACEPTIVES AMONG WOMEN IN NIGERIA: COMPARATIVE ANALYSIS OF 1990 AND 2008 NDHS

The role of religion in contraceptive use is an issue of significant debate. This study employed the 1990 and 2008 Nigeria Demographic and Health Survey data to examine differences and similarities in the influence of religious affiliation on non-use of modern contraceptives in Nigeria over the last two decades. The results suggest that a significant increase has occurred in the level of awareness of modern contraceptives in Nigeria over the last two decades, but that non-use remains very high. Religion could not independently predict non-use of modern contraceptives in 1990. Women of Islam and Traditional religions were more likely to have never used or not to be using modern contraceptives compared with Catholics and Protestants in 2008 (p<0.05). This can be explained by their poorer socioeconomic status relative to Catholics and Protestants. Therefore, improving women's socioeconomic status is an imperative in the promotion of modern contraception in Nigeria. Education and employment are critical in this regard and adherents of Islam and Traditional religions require special attention.

Pattern and outcome of induced abortion in abakaliki, southeast of Nigeria

Background:

Unsafe abortion accounts for a greater proportion of maternal deaths, yet it is often not adequately considered in discussions around reducing maternal mortality.

Aim:

The aim of this study is to determine the pattern of unsafe abortion and the extent to which unsafe abortion contributes to maternal morbidity and mortality in our setting as well as assess the impact of post-abortion care.

Subjects and Methods:

A descriptive study of patients who were admitted for complications following induced abortions between January 1, 2001 and December 31, 2008 at the Federal Medical Center, Abakaliki South East of Nigeria with data obtained from case records.

Results:

Out of the 1,562 gynecogical admissions, a total of 83 patients presented with the complications arising from induced abortion. The age group 20-24 years was mostly affected and adolescents constituted 32.5% (27/83). Nearly 15.7% (13/83) of these patients died while the remaining 84.3% (70/83) had various complications, which were mainly septicemia 59.0% (49/83), anemia 47.0% (39/83), peritonitis 41.0% (34/83), hemorrhages 34.9% (29/83) and uterine perforation 30.1% (25/83). During the study, there were 38 gynecological deaths and abortion related death accounted for 34.2% (13/38) of these gynecological deaths. 84.3% (70/83) of the patients had no documented evidence of counseling on family planning and 59.0% (49/83) were not aware of the different methods of contraception.

Conclusion:

Unsafe abortion remains one of the most neglected sexual and reproductive health problems in developing countries today despite its significant contribution to maternal mortality and morbidity. Solutions and remedies include prevention of unplanned and unwanted pregnancies by sex education and access to safe and sustainable family planning methods.

Giving cell phones to pregnant women and improving services may increase primary health facility utilization: a case-control study of a Nigerian project

Background

Worldwide, about 287 000 women die each year from mostly preventable complications related to pregnancy and childbirth. A disproportionately high number of these deaths occur in sub-Saharan Africa. The Abiye (‘Safe Motherhood’) project in the Ifedore Local Government Area (LGA) of Ondo-State of Nigeria aimed at improving facility utilization and maternal health through the use of cell phones and generally improved health care services for pregnant women, including Health Rangers, renovated Health Centres, and improved means of transportation.

Methods

A one-year sample of retrospective data was collected from hospital records and patients’ case files from Ifedore (the project area) and Idanre (control area) and was analyzed to determine healthcare facility utilization rates in each location. Semi-structured questionnaires were used to generate supplemental data.

Results

The total facility utilization rate of pregnant women was significantly higher in Ifedore than in Idanre. The facility utilization rate of the primary health care centres was significantly higher in Ifedore than in Idanre. The number of recorded cases of the five major causes of maternal death in the two LGAs was not significantly different, possibly because the project was new.

Conclusions

Giving cell phones to pregnant women and generally improving services could increase their utilization of the primary healthcare system.

Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam

OBJECTIVE

To assess public service providers' knowledge of medical abortion (MA) and practices, and perspectives on expanding the use of MA to primary and secondary health facilities in Vietnam.

METHODS

A cross-sectional study was conducted via an interviewer-administered questionnaire among abortion providers (n=905) from public health facilities between August 2011 and January 2012.

RESULTS

Overall, 31.1% of providers performed both surgical and medical abortions; 68.9% offered only surgical abortion. Providers were knowledgeable about the regimen/dosage of mifepristone plus misoprostol regimen; however, knowledge scores were low for gestational age limits for MA, adverse effects of the combined drug regimen, and safety and effectiveness of MA compared with surgical abortion. Knowledge scores were significantly lower among providers in rural areas than among those in urban settings. A large proportion of providers (82.9%) thought that MA should be expanded to primary and secondary health facilities. Perceived barriers to MA expansion included lack of knowledge and training, qualified staff, adequate drug supplies, equipment, or facilities, guidelines and protocols on MA, and patient awareness.

CONCLUSION

Provision of MA in Vietnam was found to be disproportionate to surgical abortion provision and to vary by region. Knowledge of MA was moderate, but poorer among providers in rural settings.

Outcome of an intervention to improve the quality of private sector provision of postabortion care in northern Nigeria

The outcomes of an intervention aimed at improving the quality of postabortion care provided by private medical practitioners in 8 states in northern Nigeria are reported. A total of 458 private medical doctors and 839 nurses and midwives were trained to offer high-quality postabortion care, postabortion family planning, and integrated sexually transmitted infection/HIV care. Results showed that among the 17009 women treated over 10 years, there was not a single case of maternal death. In a detailed analysis of 2559 women treated during a 15-month period after the intervention was established, only 33 women experienced mild complications, while none suffered major complications of abortion care. At the same time, there was a reduction in treatment cost and a doubling of the contraceptive uptake by the women. Building the capacity of private medical providers can reduce maternal morbidity and mortality associated with induced abortion in northern Nigeria.

Medical abortion service in rural areas of Henan Province, China: a provider survey

AIM

The aim of this study was to explore the knowledge, attitudes and practices on medical abortion of abortion service providers in rural areas of China.

MATERIAL AND METHODS

A cross-sectional study via self-administered questionnaire was conducted among 362 abortion service providers from family planning service centers (FPSC) and hospitals in rural areas of Henan Province, China, between November 2009 and May 2010.

RESULTS

Most of the providers were female (99.4%) and obstetricians/gynecologists (63.3%). The knowledge score achieved ranged from 9.4 to 78.1 points, with both the median and the mode of 56.3 points. Of the 52.2% (189/362) of providers having a preference on abortion method, 30.2% (57/189) preferred medical abortion, while 69.8% (132/189) preferred surgical abortion. In total, 50.7% (174/343) of the providers indicated the provision of medical abortion should be expanded, with the three biggest challenges in its further expansion being increased complications/failures, poor client knowledge/awareness, and problems with drug/equipment supplies. Of all the providers, 81.7% and 92.2% reported they had experience in providing medical abortion and surgical abortion, respectively. Medical abortion providers were mainly experienced in misoprostol with oral (81.8%)/vaginal (79.6%) prostaglandin (misoprostol/gemeprost).

CONCLUSION

Knowledge on medical abortion of providers working in rural China was at a moderate level. Providers preferred surgical abortion to medical abortion. Providers have more experience in providing surgical abortion than medical abortion. Efforts should be made to overcome the perceived challenges in future expansion of medical abortion.