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Moxon SG, B SS, Penn-Kekana L, Sharma S, Talbott J, Campbell OMR, Freedman L. Evolving narratives on signal functions for monitoring maternal and newborn health services: A meta-narrative inspired review. Soc Sci Med 2024; 352:116980. [PMID: 38820693 DOI: 10.1016/j.socscimed.2024.116980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/16/2024] [Accepted: 05/14/2024] [Indexed: 06/02/2024]
Abstract
Emergency obstetric care (EmOC) signal functions are a shortlist of key clinical interventions capable of averting deaths from the five main direct causes of maternal mortality; they have been used since 1997 as a part of an EmOC monitoring framework to track the availability of EmOC services in low- and middle-income settings. Their widespread use and proposed adaptation to include other types of care, such as care for newborns, is testimony to their legacy as part of the measurement architecture within reproductive health. Yet, much has changed in the landscape of maternal and newborn health (MNH) since the initial introduction of EmOC signal functions. As part of a project to revise the EmOC monitoring framework, we carried out a meta-narrative inspired review to reflect on how signal functions have been developed and conceptualised over the past two decades, and how different narratives, which have emerged alongside the evolving MNH landscape, have played a role in the conceptualisation of the signal function measurement. We identified three overarching narrative traditions: 1) clinical 2) health systems and 3) human rights, that dominated the discourse and critique around the use of signal functions. Through an iterative synthesis process including 19 final articles selected for the review, we explored patterns of conciliation and areas of contradiction between the three narrative traditions. We summarised five meta-themes around the use of signal functions: i) framing the boundaries; ii) moving beyond clinical capability; iii) capturing the woods versus the trees; iv) grouping signal functions and v) measurement challenges. We intend for this review to contribute to a better understanding of the discourses around signal functions, and to provide insight for the future roles of this monitoring approach for emergency obstetric and newborn care.
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Affiliation(s)
- Sarah G Moxon
- London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 3HT, UK.
| | | | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 3HT, UK.
| | - Sudha Sharma
- CIWEC Hospital and Travel Medicine Center, GPO Box, 12895, Kapurdhara Marg, Kathmandu, Nepal.
| | - Jennifer Talbott
- Averting Maternal Death and Disability (AMDD), Columbia University Mailman School of Public Health, 60 Haven Avenue, Suite B3, New York, NY, 10032, USA; Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA.
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 3HT, UK.
| | - Lynn Freedman
- Averting Maternal Death and Disability (AMDD), Columbia University Mailman School of Public Health, 60 Haven Avenue, Suite B3, New York, NY, 10032, USA; Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA.
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Onadja Y, Compaoré R, Yugbaré DB, Thomas HL, Guiella G, Lougué S, Ouedraogo HG, Bazie F, Kouanda S, Moreau C, Bell SO. Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data. BMC Health Serv Res 2024; 24:84. [PMID: 38233874 PMCID: PMC10792903 DOI: 10.1186/s12913-023-10538-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Little is known about postabortion care (PAC) services in Burkina Faso, despite PAC's importance as an essential and life-saving component of emergency obstetric care. This study aims to evaluate PAC service availability, readiness, and accessibility in Burkina Faso. METHODS Data for this study come from the Performance Monitoring for Action (PMA) Burkina Faso project and the Harmonized Health Facility Assessment (HHFA) conducted by the Institut de Recherche en Sciences de la Santé and the Ministry of Health. PMA data from a representative sample of women aged 15-49 (n = 6,385) were linked via GPS coordinates to HHFA facility data (n = 2,757), which included all public and private health facilities in Burkina Faso. We assessed readiness to provide basic and comprehensive PAC using the signal functions framework. We then calculated distance to facilities and examined percent within 5 kms of a facility with any PAC, basic PAC, and comprehensive PAC overall and by women's background characteristics. RESULTS PAC services were available in 46.4% of health facilities nationwide; only 38.3% and 35.0% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Removal of retained products of conception was the most common missing signal function for both basic and comprehensive PAC, followed by provision of any contraception (basic) or any LARC (comprehensive). Nearly 85% of women lived within 5 km of a facility providing any PAC services, while 50.5% and 17.4% lived within 5 km of a facility providing all basic PAC and all comprehensive PAC signal functions, respectively. Women with more education, greater wealth, and those living in urban areas had greater odds of living within 5 km of a facility with offering PAC, basic PAC, or comprehensive PAC. CONCLUSIONS Results indicate a need for increased PAC availability and readiness, prioritizing basic PAC services at the primary level-the main source of care for many women-which would reduce structural disparities in access. The current deficiencies in PAC signal a need for broader strengthening of the primary healthcare services in Burkina Faso to reduce the burden of unsafe abortion-related morbidity and mortality while improving maternal health outcomes more broadly.
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Affiliation(s)
- Yentéma Onadja
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, 03 BP 7118, Burkina Faso.
| | - Rachidatou Compaoré
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Haley L Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, 03 BP 7118, Burkina Faso
| | - Siaka Lougué
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Fiacre Bazie
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, 03 BP 7118, Burkina Faso
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, F-94800, France
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Thomas HL, Alzouma S, Oumarou S, Moreau C, Bell SO. Postabortion care availability, readiness, and accessibility in Niger in 2022: results from linked facility-female cross-sectional data. BMC Health Serv Res 2023; 23:1171. [PMID: 37891572 PMCID: PMC10612209 DOI: 10.1186/s12913-023-10107-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Postabortion care (PAC), which is an essential element of emergency obstetric care, is underresearched in Niger. The study aims to assess the availability, readiness, and accessibility of facility-based PAC services in Niger. METHODS This study uses female and facility data from Performance Monitoring for Action Niger. The female data include a nationally representative sample of women aged 15-49 (n = 3,696). Using GPS coordinates, these female data were linked to a sample of public and private facilities (n = 258) that are expected to provide PAC. We assessed PAC availability and facility readiness to provide basic and comprehensive PAC using the signal functions framework, overall and by facility type. We then calculated the distance between women and their closest facility and estimated the proportion of women living within five kilometers (5 km) of a facility providing any PAC, basic PAC, and comprehensive PAC, overall and by women's background characteristics. RESULTS Only 36.4% and 14% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Oxytocics and laparotomy were the most missing signal function for basic and comprehensive PAC, respectively. Private facilities were the least ready to provide the full range of PAC services. While 47% of women lived within 5 km of a facility providing any PAC services, only 33.4% and 7.9% lived within 5 km of a facility providing all basic and all comprehensive PAC signal functions, respectively. Women who were divorced/widowed, had higher levels of education, and were living in urban areas had increased odds of living within 5 km of a facility with any or basic PAC. Women who were never married had increased odds of living within 5 km of a facility with comprehensive PAC, while urban residence was fully predictive of living within 5 km of a facility with comprehensive PAC. CONCLUSIONS This study found PAC availability and readiness to be insufficient in Niger, with inadequate and disparate accessibility to facilities providing PAC services. We recommended stakeholders ensure stock of essential commodities and availability of PAC services at primary facilities in order to mitigate the negative maternal health repercussions of unsafe abortion in this setting.
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Affiliation(s)
- Haley L Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street., Baltimore, MD, 21205, USA.
| | | | - Sani Oumarou
- Institut National de la Statistique du Niger, Niamey, Niger
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street., Baltimore, MD, 21205, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, F-94800, France
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street., Baltimore, MD, 21205, USA
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Mroz EJ, Willis T, Thomas C, Janes C, Singini D, Njungu M, Smith M. Impacts of seasonal flooding on geographical access to maternal healthcare in the Barotse Floodplain, Zambia. Int J Health Geogr 2023; 22:17. [PMID: 37525198 PMCID: PMC10391775 DOI: 10.1186/s12942-023-00338-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/12/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Seasonal floods pose a commonly-recognised barrier to women's access to maternal services, resulting in increased morbidity and mortality. Despite their importance, previous GIS models of healthcare access have not adequately accounted for floods. This study developed new methodologies for incorporating flood depths, velocities, and extents produced with a flood model into network- and raster-based health access models. The methodologies were applied to the Barotse Floodplain to assess flood impact on women's walking access to maternal services and vehicular emergency referrals for a monthly basis between October 2017 and October 2018. METHODS Information on health facilities were acquired from the Ministry of Health. Population density data on women of reproductive age were obtained from the High Resolution Settlement Layer. Roads were a fusion of OpenStreetMap and data manually delineated from satellite imagery. Monthly information on floodwater depth and velocity were obtained from a flood model for 13-months. Referral driving times between delivery sites and EmOC were calculated with network analysis. Walking times to the nearest maternal services were calculated using a cost-distance algorithm. RESULTS The changing distribution of floodwaters impacted the ability of women to reach maternal services. At the peak of the dry season (October 2017), 55%, 19%, and 24% of women had walking access within 2-hrs to their nearest delivery site, EmOC location, and maternity waiting shelter (MWS) respectively. By the flood peak, this dropped to 29%, 14%, and 16%. Complete inaccessibility became stark with 65%, 76%, and 74% unable to access any delivery site, EmOC, and MWS respectively. The percentage of women that could be referred by vehicle to EmOC from a delivery site within an hour also declined from 65% in October 2017 to 23% in March 2018. CONCLUSIONS Flooding greatly impacted health access, with impacts varying monthly as the floodwave progressed. Additional validation and application to other regions is still needed, however our first results suggest the use of a hydrodynamic model permits a more detailed representation of floodwater impact and there is great potential for generating predictive models which will be necessary to consider climate change impacts on future health access.
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Affiliation(s)
- Elizabeth Jade Mroz
- School of Geography and water@Leeds, University of Leeds, Leeds, LS2 9JT, UK.
| | - Thomas Willis
- School of Geography and water@Leeds, University of Leeds, Leeds, LS2 9JT, UK
| | - Chris Thomas
- Lincoln Centre for Water & Planetary Health, University of Lincoln, Lincoln, LN6 7DW, UK
| | - Craig Janes
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Douglas Singini
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Mwimanenwa Njungu
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Mark Smith
- School of Geography and water@Leeds, University of Leeds, Leeds, LS2 9JT, UK
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Magalona S, Thomas HL, Akilimali PZ, Kayembe D, Moreau C, Bell SO. Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC. BMC Health Serv Res 2023; 23:658. [PMID: 37340470 PMCID: PMC10283295 DOI: 10.1186/s12913-023-09647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/05/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The Democratic Republic of Congo (DRC) legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care (PAC), yet little is known about the availability of abortion care services and if facilities are prepared to provide them; even less is known about the accessibility of these services. Using facility and population-based data in Kinshasa and Kongo Central, this study examined the availability of abortion services, readiness of facilities to provide them, and inequities in access. METHODS Data on 153 facilities from the 2017-2018 DRC Demographic and Health Survey Service Provision Assessment (SPA) were used to examine signal functions and readiness of facilities to provide services across three abortion care domains (termination of pregnancy, basic treatment of abortion complications, and comprehensive treatment of abortion complications). To examine PAC and medication abortion provision before and after abortion decriminalization, we compared estimates from the 2017-2018 SPA facilities to estimates from the Performance Monitoring for Action (PMA) data collected in 2021 (n = 388). Lastly, we assessed proximity to PAC and medication abortion using PMA by geospatially linking facilities to representative samples of 2,326 and 1,856 women in Kinshasa and Kongo Central, respectively. RESULTS Few facilities had all the signal functions under each abortion care domain, but most facilities had many of the signal functions: overall readiness scores were > 60% for each domain. In general, readiness was higher among referral facilities compared to primary facilities. The main barriers to facility readiness were stock shortages of misoprostol, injectable antibiotics, and contraception. Overall, provision of services was higher post-decriminalization. Access to facilities providing PAC and medication abortion was almost universal in urban Kinshasa, but patterns in rural Kongo Central showed a positive association with education attainment and wealth. CONCLUSION Most facilities had many of the necessary signal functions to provide abortion services, but the majority experienced challenges with commodity availability. Inequities in accessibility of services also existed. Interventions that address supply chain challenges may improve facility readiness to provide abortion care services, and further efforts are needed to narrow the gap in accessibility, especially among poor women from rural settings.
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Affiliation(s)
- Sophia Magalona
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Haley L Thomas
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Pierre Z Akilimali
- Department of Biostatistics and Epidemiology, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Dynah Kayembe
- Performance Monitoring for Action DRC, Kinshasa, Democratic Republic of Congo
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale, Villejuif, France
| | - Suzanne O Bell
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda. BMC Health Serv Res 2023; 23:104. [PMID: 36726121 PMCID: PMC9890752 DOI: 10.1186/s12913-022-09017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 12/28/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect. METHODS We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period. RESULTS In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%. CONCLUSIONS The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.
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Ferguson L, Jardell W, Lambert-Peck M, Guo L, Lopez S, Canaves V, Filmer-Wilson E. Mind the Gap: Understanding Differences Between Sexual and Reproductive Health-Related Legal Frameworks on Paper and in Practice. Front Glob Womens Health 2022; 3:838976. [PMID: 35602852 PMCID: PMC9120771 DOI: 10.3389/fgwh.2022.838976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/14/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction UNFPA recently developed a composite indicator to assess sexual and reproductive health (SRH)-related laws as part of the Sustainable Development Goals monitoring framework (Indicator 5.6.2). However, there is still little understanding of how best to ensure a supportive SRH-related legal framework can improve SRH outcomes. This research draws on country case studies (Colombia, Malawi, Uruguay, Zambia) to provide more generalizable lessons on the processes by which these laws are translated into practice and their impact on lived realities. Methods Peer-reviewed and gray literature on laws and policies related to maternity care, contraception, sexuality education, HIV and HPV was reviewed. Key informant interviews were carried out with 8–16 people in each country, including representatives of government, civil society and academia to understand factors affecting implementation of relevant laws and policies. Findings were thematically analyzed by country and contextualized within each country's score on Indicator 5.6.2 and relevant SRH outcome data. Findings Across these countries, some common organizational steps help move from laws on paper to impacting people's lives including budget allocation, development of technical guidance, health worker training, population awareness creation and demand generation. It is also important to address sociocultural challenges such as entrenched inequalities, conservative cultural and religious beliefs and the potential existence of customary law. Challenges can be encountered across all these steps and can vary based on the area of SRH: implementation of laws to reduce maternal mortality is generally less controversial than laws around abortion, often making the latter harder to implement. Local specificities in structures, systems and cultures bring opportunities and challenges, highlighting the need for tailored actions. Discussion A legal framework supportive to SRH is critical, particularly in the face of backlash against sexual and reproductive rights, but alone it is insufficient. Understanding that a generic pathway exists for moving laws into practice is a critical starting point for exploring the specificities of each national context as a way of identifying entry points for action. These findings can be used to inform advocacy and monitoring to help ensure that the potential benefits of supportive SRH-related laws can be realized in these four countries and around the world.
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Affiliation(s)
- Laura Ferguson
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Laura Ferguson
| | - William Jardell
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, United States
| | - Miles Lambert-Peck
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, United States
| | - Lillie Guo
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, United States
| | - Sophia Lopez
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, United States
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Compaore R, Ouedraogo AM, Baguiya A, Kpebo DO, Sidibe S, Kouanda S. Availability and Utilization of Postabortion Care Services in Burkina Faso, Côte d'Ivoire, and Guinea: A Secondary Analysis of Emergency Obstetric and Neonatal Care Needs Assessments (EmONC). Health Serv Insights 2022; 15:11786329221092625. [PMID: 35464819 PMCID: PMC9021517 DOI: 10.1177/11786329221092625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
SYNOPSIS: Generally, there are disparities in the availability and utilization of postabortion care services within the different regions at the national level in Burkina Faso, Cote d’Ivoire, and Guinea and between the 3 countries. Access to postabortion care at the primary level must be improved and the adoption of family planning when providing postabortion care. Unsafe abortion remains one of the leading causes of maternal mortality in sub-Sahara Africa, with relatively poor access to quality postabortion care (PAC) services. This study evaluated the quantity and distribution as well as the utilization of PAC services in Burkina Faso, Cote d’Ivoire, and Guinea. We conducted a secondary data analysis using the most recent EmONC surveys in the 3 countries between 2016 and 2017. We used PAC signal functions approach to assess facilities’ capacity to provide basic PAC at both primary and referral level of care and comprehensive PAC at the referral level. We illustrated population coverage of PAC services based on the WHO benchmark, and then assessed the utilization of PAC services. Basic PAC capacity at primary level was low (36.6%), ranging from 16.2% in Burkina Faso to 36% in Cote d’Ivoire. About 82.0% of hospitals could provide comprehensive PAC. There were disparities in the geographical distribution of PAC services at both national and subnational levels. Abortion complications represented 16.2% of all obstetric emergencies, and uptake of PAC modern contraceptive was low (37.1%) in all countries. There is a need to focus on access to PAC at the primary level of care in the 3 countries.
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Affiliation(s)
- Rachidatou Compaore
- Research Institute of Health Sciences, Ouagadougou, Burkina Faso.,Doctoral School, Saint Thomas d'Aquin University, Ouagadougou, Burkina Faso
| | - Adja Mariam Ouedraogo
- Research Institute of Health Sciences, Ouagadougou, Burkina Faso.,Doctoral School, Saint Thomas d'Aquin University, Ouagadougou, Burkina Faso
| | - Adama Baguiya
- Research Institute of Health Sciences, Ouagadougou, Burkina Faso.,Doctoral School, Saint Thomas d'Aquin University, Ouagadougou, Burkina Faso
| | - Denise Olga Kpebo
- Doctoral School, Saint Thomas d'Aquin University, Ouagadougou, Burkina Faso.,Public Health Department, Felix Houphouet Boigny University, Cote d'Ivoire
| | - Sidikiba Sidibe
- Doctoral School, Saint Thomas d'Aquin University, Ouagadougou, Burkina Faso.,Department of Public Health, Gamal Abdel-Nasser University of Conakry, Guinea
| | - Seni Kouanda
- Research Institute of Health Sciences, Ouagadougou, Burkina Faso.,Doctoral School, Saint Thomas d'Aquin University, Ouagadougou, Burkina Faso.,Seni Kouanda is also affiliated to African Institute of Public Health, Ouagadougou, Burkina Faso
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Juma K, Ouedraogo R, Amo-Adjei J, Sie A, Ouattara M, Emma-Echiegu N, Eton J, Mutua M, Bangha M. Health systems' preparedness to provide post-abortion care: assessment of health facilities in Burkina Faso, Kenya and Nigeria. BMC Health Serv Res 2022; 22:536. [PMID: 35459161 PMCID: PMC9027923 DOI: 10.1186/s12913-022-07873-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background In many parts of sub-Saharan Africa, access to abortion is legally restricted, which partly contributes to high incidence of unsafe abortion. This may result in unsafe abortion-related complications that demand long hospital stays, treatment and attendance by skilled health providers. There is however, limited knowledge on the capacity of public health facilities to deliver post-abortion care (PAC), and the spread of PAC services in these settings. We describe and discuss the preparedness and capacity of public health facilities to deliver complete and quality PAC services in Burkina Faso, Kenya and Nigeria. Methods A cross-sectional survey of primary, secondary and tertiary-level public health facilities was conducted between November 2018 and February 2019 in the three countries. Data on signal functions (including information on essential equipment and supplies, staffing and training among others) for measuring the ability of health facilities to provide post-abortion services were collected and analyzed. Results Across the three countries, fewer primary health facilities (ranging from 6.3–12.1% in Kenya and Burkina Faso) had the capacity to deliver on all components of basic PAC services. Approximately one-third (26–43%) of referral facilities across Burkina Faso, Kenya and Nigeria could provide comprehensive PAC services. Lack of trained staff, absence of necessary equipment and lack of PAC commodities and supplies were a main reason for inability to deliver specific PAC services (such as surgical procedures for abortion complications, blood transfusion and post-PAC contraceptive counselling). Further, the lack of capacity to refer acute PAC cases to higher-level facilities was identified as a key weakness in provision of post-abortion care services. Conclusions Our findings reveal considerable gaps and weaknesses in the delivery of basic and comprehensive PAC within the three countries, linked to both the legal and policy contexts for abortion as well as broad health system challenges in the countries. There is a need for increased investments by governments to strengthen the capacity of primary, secondary and tertiary public health facilities to deliver quality PAC services, in order to increase access to PAC and avert preventable maternal mortalities. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07873-y.
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Affiliation(s)
- Kenneth Juma
- African Population and Health Research Center, P.O. Box 10787, Manga Cl, Nairobi, Kenya.
| | - Ramatou Ouedraogo
- African Population and Health Research Center, P.O. Box 10787, Manga Cl, Nairobi, Kenya
| | | | - Ali Sie
- Centre de Recherche en Santé de Nouna, Ouagadougou, Burkina Faso
| | - Mamadou Ouattara
- Centre de Recherche en Santé de Nouna, Ouagadougou, Burkina Faso
| | | | | | - Michael Mutua
- African Population and Health Research Center, P.O. Box 10787, Manga Cl, Nairobi, Kenya.,University of the Witwatersrand, Johannesburg, South Africa.,Bristol Park Group of Hospitals, Nairobi, Kenya
| | - Martin Bangha
- African Population and Health Research Center, P.O. Box 10787, Manga Cl, Nairobi, Kenya
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Compaoré R, Mehrtash H, Calvert C, Qureshi Z, Bello FA, Baguiya A, Msusa AT, Idi N, Govule P, Tunçalp Ӧ, Kouanda S. Health facilities’ capability to provide comprehensive postabortion care in Sub‐Saharan Africa: Evidence from a cross‐sectional survey across 210 high‐volume facilities. Int J Gynaecol Obstet 2022; 156 Suppl 1:7-19. [DOI: 10.1002/ijgo.14056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Rachidatou Compaoré
- Research Institute of Health Sciences Ouagadougou Burkina Faso
- Doctoral School Saint Thomas d’Aquin University Ouagadougou Burkina Faso
| | - Hedieh Mehrtash
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
| | - Clara Calvert
- Centre for Global Health Usher Institute University of Edinburgh Edinburgh UK
| | - Zahida Qureshi
- Department of Obstetrics and Gynecology Faculty of Health Sciences University of Nairobi Nairobi Kenya
| | | | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya‐HDSS) Research Institute of Health Sciences Ouagadougou Burkina Faso
| | - Ausbert Thoko Msusa
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi Blantyre Malawi
| | - Nafiou Idi
- Université Abdou Moumouni de Niamey Niamey Niger
| | - Philip Govule
- Department of Epidemiology and Disease Control School of Public Health University of Ghana Accra Ghana
| | - Ӧzge Tunçalp
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
| | - Seni Kouanda
- Research Institute of Health Sciences Ouagadougou Burkina Faso
- Doctoral School Saint Thomas d’Aquin University Ouagadougou Burkina Faso
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Pershad J, Mugerwa KY, Filippi V, Mehrtash H, Adu-Bonsaffoh K, Bello FA, Compaoré R, Gadama L, Govule P, Qureshi Z, Tunçalp Ӧ, Calvert C. Prevalence and determinants of self-reported anxiety and stress among women with abortion-related complications admitted to health facilities in Eastern and Southern Africa: A cross-sectional survey. Int J Gynaecol Obstet 2022; 156 Suppl 1:53-62. [PMID: 35014698 DOI: 10.1002/ijgo.14042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate the prevalence of women who were admitted to health facilities with abortion-related complications who reported feeling anxious/stressed during their stay, and to identify sociodemographic, facility, and abortion-related characteristics associated with self-reported experience of anxiety/stress. METHODS We used data from four countries in Eastern and Southern Africa (Kenya, Malawi, Mozambique, and Uganda) collected from 2017-2018 as part of the World Health Organization (WHO) Multi-Country Survey on Abortion-related morbidity (MCS-A). Information was extracted from women's medical records and their participation in audio computer-assisted self-interviews (ACASI). Based on a question in the ACASI, "Did you encounter any anxiety or stress during your hospital stay?", the percentage of women who self-reported feeling anxious/stressed during their facility stay was calculated. Generalized estimating equations were used to identify the determinants of anxiety/stress following a hierarchical approach whereby potential determinants were grouped from most distal to most proximal and analyzed accordingly. RESULTS There were 1254 women with abortion-related complications included in the analysis, of which 56.5% self-reported that they felt anxious/stressed during their facility stay. We found evidence that lower socioeconomic status, lower levels of education, no previous childbirth, no previous abortion, higher gestational age at abortion, and use of unsafe methods of abortion were independent determinants of self-reporting anxiety/stress. CONCLUSIONS Action should be taken to reduce experience of anxiety/stress among women attending facilities for postabortion complications, including reducing the number of women experiencing abortion-related complications by improving access to safe abortion. This issue warrants further study using more comprehensive and validated tools to understand the levels and drivers of anxiety/stress self-reported by women attending facilities with abortion-related complications.
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Affiliation(s)
- Jyoti Pershad
- Independent Researcher, Jersey City, New Jersey, USA
| | | | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana
| | | | - Rachidatou Compaoré
- Institut de Recherche en Science de la Santé, Ouagadougou, Burkina Faso.,Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | - Luis Gadama
- College of Medicine, Department of Obstetrics and Gynecology, University of Malawi, Zomba, Malawi
| | - Philip Govule
- Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Accra, Ghana
| | - Zahida Qureshi
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Ӧzge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Clara Calvert
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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Wolomby-Molondo JJ, Calvert C, Seguin R, Qureshi Z, Tunçalp Ö, Filippi V. The relationship between insecurity and the quality of hospital care provided to women with abortion-related complications in the Democratic Republic of Congo: A cross-sectional analysis. Int J Gynaecol Obstet 2021; 156 Suppl 1:20-26. [PMID: 34888865 DOI: 10.1002/ijgo.14031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the relationship between insecurity and quality of care provided for abortion complications in high-volume hospitals in the Democratic Republic of Congo (DRC). METHODS Using the WHO Multi-Country Survey on Abortion complications, we analyzed data for 1007 women who received care in 24 facilities in DRC. For inputs of care, we calculated the percentage of facilities in secure and insecure areas meeting 12 readiness criteria for infrastructure and capability. For process and outcomes of care, we estimated the association between security and eight indicators using generalized estimating equation models. RESULTS Facilities in secure areas were more likely to report functioning electricity (93.3% vs 66.7%), availability of an obstetrician 24/7 (42.9% vs 28.6%), and the ability to offer several short-acting contraceptives (83.3% vs 57.1%). However, a higher percentage of facilities in insecure areas reported the availability of a telephone or radio (100% vs 80.0%). Women in insecure areas appeared more likely to experience poor quality clinical care overall than women in secure areas (aOR 2.56; 95% CI, 1.13-5.82, P = 0.03). However, there was no association between security and incomplete medical records (P = 0.20), use of dilatation and curettage (D&C) (P = 0.84), women reporting poor experience of care (P = 0.22), satisfaction with care (P = 0.25), and severe maternal outcomes (P = 0.56). There was weak evidence of an association between security and nonreceipt of contraceptives (P = 0.07), with women in insecure areas 70% less likely to report no contraception (aOR 0.31, 95% CI, 0.09-1.09). Use of D&C was high in secure (43.7%) and insecure (60.4%) areas. CONCLUSION Quality of care did not seem to be very different in secure and insecure areas in DRC, except for some key infrastructure, supply, and human resources elements. The frequent use of D&C for uterine evacuation, the lack of good record keeping, and the lack of contraceptives should be urgently addressed.
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Affiliation(s)
- Jean-José Wolomby-Molondo
- Département de Gynécologie et Obstétrique, Cliniques Universitaires de Kinshasa, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Clara Calvert
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Zahida Qureshi
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Véronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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13
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Owolabi O, Riley T, Otupiri E, Polis CB, Larsen-Reindorf R. The infrastructural capacity of Ghanaian health facilities to provide safe abortion and post-abortion care: a cross-sectional study. BMC Health Serv Res 2021; 21:1104. [PMID: 34654428 PMCID: PMC8520210 DOI: 10.1186/s12913-021-07141-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/29/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ghana is one of few countries in sub-Saharan Africa with relatively liberal abortion laws, but little is known about the availability and quality of abortion services nationally. The aim of this study was to describe the availability and capacity of health facilities to deliver essential PAC and SAC services in Ghana. METHODS We utilized data from a nationally representative survey of Ghanaian health facilities capable of providing post-abortion care (PAC) and/or safe abortion care (SAC) (n = 539). We included 326 facilities that reported providing PAC (57%) or SAC (19%) in the preceding year. We utilized a signal functions approach to evaluate the infrastructural capacity of facilities to provide high quality basic and comprehensive care. We conducted descriptive analysis to estimate the proportion of primary and referral facilities with capacity to provide SAC and PAC and the proportion of SAC and PAC that took place in facilities with greater capacity, and fractional regression to explore factors associated with higher structural capacity for provision. RESULTS Less than 20% of PAC and/or SAC providing facilities met all signal function criteria for basic or comprehensive PAC or for comprehensive SAC. Higher PAC caseloads and staff trained in vacuum aspiration was associated with higher capacity to provide PAC in primary and referral facilities, and private/faith-based ownership and rural location was associated with higher capacity to provide PAC in referral facilities. Primary facilities with a rural location were associated with lower basic SAC capacity. DISCUSSION Overall very few public facilities have the infrastructural capacity to deliver all the signal functions for comprehensive abortion care in Ghana. There is potential to scale-up the delivery of safe abortion care by facilitating service provision all health facilities currently providing postabortion care. CONCLUSIONS SAC provision is much lower than PAC provision overall, yet there are persistent gaps in capacity to deliver basic PAC at primary facilities. These results highlight a need for the Ghana Ministry of Health to improve the infrastructural capability of health facilities to provide comprehensive abortion care.
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Affiliation(s)
- Onikepe Owolabi
- Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY 10038 USA
- Vital Strategies, 100 Broadway, 4th Floor, New York, 10005 USA
| | - Taylor Riley
- Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY 10038 USA
| | - Easmon Otupiri
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Chelsea B. Polis
- Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY 10038 USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Roderick Larsen-Reindorf
- Department of Obstetrics & Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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14
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Bell SO, Shankar M, Ahmed S, OlaOlorun F, Omoluabi E, Guiella G, Moreau C. Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d'Ivoire. Health Policy Plan 2021; 36:1077-1089. [PMID: 34131700 PMCID: PMC8359750 DOI: 10.1093/heapol/czab068] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 05/25/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
Postabortion care (PAC) is an essential component of emergency obstetric care (EmOC) and is necessary to prevent unsafe abortion-related maternal mortality, but we know little regarding the preparedness of facilities to provide PAC services, the distribution of these services and disparities in their accessibility in low-resource settings. To address this knowledge gap, this study aims to describe PAC service availability, evaluate PAC readiness and measure inequities in access to PAC services in seven states of Nigeria and nationally in Côte d’Ivoire. We used survey data from reproductive-age women and the health facilities that serve the areas where they live. We linked facility readiness information, including PAC-specific signal functions, to female data using geospatial information. Findings revealed less than half of facilities provide basic PAC services in Nigeria (48.4%) but greater PAC availability in Côte d’Ivoire (70.5%). Only 33.5% and 36.9% of facilities with the capacity to provide basic PAC and only 23.9% and 37.5% of facilities with the capacity to provide comprehensive PAC had all the corresponding signal functions in Nigeria and Côte d’Ivoire, respectively. With regard to access, while ∼8 out of 10 women of reproductive age in Nigeria (81.3%) and Côte d’Ivoire (79.9%) lived within 10 km of a facility providing any PAC services, significantly lower levels of the population lived <10 km from a facility with all basic or comprehensive PAC signal functions, and we observed significant inequities in access for poor, rural and less educated women. Addressing facilities’ service readiness will improve the quality of PAC provided and ensure postabortion complications can be treated in a timely and effective manner, while expanding the availability of services to additional primary-level facilities would increase access—both of which could help to reduce avoidable abortion-related maternal morbidity and mortality and associated inequities.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA
| | - Mridula Shankar
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA
| | - Funmilola OlaOlorun
- College of Medicine, University of Ibadan, Queen Elizabeth II Road, Agodi, Ibadan, Nigeria
| | - Elizabeth Omoluabi
- Center for Research, Evaluation Resources and Development, Flat 16, Ajanaku Estate Ife-Ibadon Road, Opp RCCG Rehoboth Mega Cathedral, Ile-Ife Osun State, Nigeria.,Department of Statistics and Population Studies, University of the Western Cape, Robert Sobukwe Road, P/Bag X17, Bellville, 7530 Cape Town, South Africa
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université of Ouagadougou, 03 BP 7118, Blvd Charles De Gaulle, Ouagadougou, Burkina Faso
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA.,Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Bat 15/16 16 av PV Couturier, 94807 Villejuif Cedex, France
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15
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Filippi V, Dennis M, Calvert C, Tunçalp Ö, Ganatra B, Kim CR, Ronsmans C. Abortion metrics: a scoping review of abortion measures and indicators. BMJ Glob Health 2021; 6:bmjgh-2020-003813. [PMID: 33514592 PMCID: PMC7849886 DOI: 10.1136/bmjgh-2020-003813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/16/2020] [Accepted: 12/19/2020] [Indexed: 11/28/2022] Open
Abstract
Consensus is lacking on the most appropriate indicators to document progress in safe abortion at programmatic and country level. We conducted a scoping review to provide an extensive summary of abortion indicators used over 10 years (2008–2018) to inform the debate on how progress in the provision and access to abortion care can be best captured. Documents were identified in PubMed and Popline and supplemented by materials identified on major non-governmental organisation websites. We screened 1999 abstracts and seven additional relevant documents. Ultimately, we extracted information on 792 indicators from 142 documents. Using a conceptual framework developed inductively, we grouped indicators into seven domains (social and policy context, abortion access and availability, abortion prevalence and incidence, abortion care, abortion outcomes, abortion impact and characteristics of women) and 40 subdomains. Indicators of access and availability and of the provision of abortion care were the most common. Indicators of outcomes were fewer and focused on physical health, with few measures of psychological well-being and no measures of quality of life or functioning. Similarly, there were few indicators attempting to measure the context, including beliefs and social attitudes at the population level. Most indicators used special studies either in facilities or at population level. The list of indicators (in online supplemental appendix) is an extensive resource for the design of monitoring and evaluation plans of abortion programmes. The large number indicators, many specific to one source only and with similar concepts measured in a multitude of ways, suggest the need for standardisation.
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Affiliation(s)
- Veronique Filippi
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - Mardieh Dennis
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - Clara Calvert
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
| | - Bela Ganatra
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
| | - Caron Rahn Kim
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
| | - Carine Ronsmans
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
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16
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Atuhairwe S, Gemzell-Danielsson K, Byamugisha J, Kaharuza F, Tumwesigye NM, Hanson C. Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda. BMJ Glob Health 2021; 6:bmjgh-2020-003274. [PMID: 33547174 PMCID: PMC7871269 DOI: 10.1136/bmjgh-2020-003274] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda. Methods This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016–2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions. Results Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care. Conclusions Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.
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Affiliation(s)
- Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda .,Reproductive Endocrinology and Infertility, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | | | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda
| | - Frank Kaharuza
- Association of Obstetricians and Gynaecologists of Uganda, Kampala, Uganda
| | | | - Claudia Hanson
- Public Health Sciences, Karolinska Institute, Stockholm, Sweden.,Dept of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
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Philbin J, Soeharno N, Giorgio M, Kurniawan R, Ingerick M, Utomo B. Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis. Reprod Health 2020; 17:189. [PMID: 33239059 PMCID: PMC7687770 DOI: 10.1186/s12978-020-01033-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background The quality of obstetric care has been identified as a contributing factor in Indonesia’s persistently high level of maternal mortality, and the country’s restrictive abortion laws merit special attention to the quality of post-abortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals. Methods Using data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia’s most populous island, we applied a signal functions analysis to measure the health system’s capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures. Results Forty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia’s current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C). Conclusions Offering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/Gyns to perform this procedure would greatly improve the capacity of Java’s health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service.
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Affiliation(s)
- Jesse Philbin
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA.
| | - Nugroho Soeharno
- Center for Health Research, University of Indonesia Faculty of Public Health, Building G 211, Depok, West Java, 16424, Indonesia
| | - Margaret Giorgio
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA
| | - Rico Kurniawan
- Center for Health Research, University of Indonesia Faculty of Public Health, Building G 211, Depok, West Java, 16424, Indonesia
| | - Meghan Ingerick
- Harvard University T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Budi Utomo
- Center for Health Research, University of Indonesia Faculty of Public Health, Building G 211, Depok, West Java, 16424, Indonesia
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18
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Riley T, Madziyire MG, Owolabi O, Sully EA, Chipato T. Evaluating the quality and coverage of post-abortion care in Zimbabwe: a cross-sectional study with a census of health facilities. BMC Health Serv Res 2020; 20:244. [PMID: 32209080 PMCID: PMC7092428 DOI: 10.1186/s12913-020-05110-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/13/2020] [Indexed: 11/07/2022] Open
Abstract
Background An estimated 65,000 abortions occurred in Zimbabwe in 2016, and 40 % resulted in complications that required treatment. Quality post-abortion care (PAC) services are essential to treat abortion complications and prevent future unintended pregnancies, and there have been recent national efforts to improve PAC provision. This study evaluates two components of quality of care: structural quality, using PAC signal functions, a monitoring framework of key life-saving interventions that treat abortion complications; and process quality, which examines the standards of care provided to PAC patients. Methods We utilized a 2016 national census of health facilities in Zimbabwe with PAC capacity (n = 227) and a prospective, facility-based 28-day survey of women seeking PAC in a nationally representative sample of those facilities (n = 1002 PAC patients at 127 facilities). PAC signal functions, which are the critical services in the management of abortion complications, were used to classify facilities as having the capability to provide basic or comprehensive care. All facilities were expected to provide basic care, and referral-level facilities were designed to provide comprehensive care. We also assessed population coverage of PAC services based on the WHO recommendation for obstetric services of 5 facilities per 500,000 residents. Results We found critical gaps in the availability of PAC services; only 21% of facilities had basic PAC capability and 10% of referral facilities had comprehensive capability. For process quality, only one-fourth (25%) of PAC patients were treated with the appropriate medical procedure. The health system had only 41% of the basic PAC facilities recommended for the needs of Zimbabwe’s population, and 55% of the recommended comprehensive PAC facilities. Conclusion This is the first national assessment of the Zimbabwean health system’s coverage and quality of PAC services. These findings highlight the large gaps in the availability and distribution of facilities with basic and comprehensive PAC capability. These structural gaps are a contributing barrier to the provision of evidence-based care. This study shows the need for increased focus and investment in expanding the provision of and improving the quality of these essential, life-saving PAC services.
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Affiliation(s)
- Taylor Riley
- Guttmacher Institute, 125 Maiden Lane Suite 7, New York, NY, 10038, USA.
| | - Mugove G Madziyire
- Clinical Trials Research Centre (UZCHS-CTRC), University of Zimbabwe College of Health Science, 15 Phillips Road, Belgravia, Harare, Zimbabwe
| | - Onikepe Owolabi
- Guttmacher Institute, 125 Maiden Lane Suite 7, New York, NY, 10038, USA
| | - Elizabeth A Sully
- Guttmacher Institute, 125 Maiden Lane Suite 7, New York, NY, 10038, USA
| | - Tsungai Chipato
- Clinical Trials Research Centre (UZCHS-CTRC), University of Zimbabwe College of Health Science, 15 Phillips Road, Belgravia, Harare, Zimbabwe
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19
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Izugbara C, Wekesah FM, Sebany M, Echoka E, Amo-Adjei J, Muga W. Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review. Health Care Women Int 2019; 41:732-760. [PMID: 31855511 DOI: 10.1080/07399332.2019.1703991] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
| | | | - Meroji Sebany
- International Center for Research on Women, Washington, D.C, USA
| | - Elizabeth Echoka
- Centre for Public Health Research, Kenya Medical Research Institute - KEMRI, Nairobi, Kenya
| | - Joshua Amo-Adjei
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Winstoun Muga
- African Population & Health Research Center, Nairobi, Kenya
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Dennis ML, Owolabi OO, Cresswell JA, Chelwa N, Colombini M, Vwalika B, Mbizvo MT, Campbell OMR. A new approach to assess the capability of health facilities to provide clinical care for sexual violence against women: a pilot study. Health Policy Plan 2019; 34:92-101. [PMID: 30753452 DOI: 10.1093/heapol/czy106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2018] [Indexed: 11/15/2022] Open
Abstract
Several tools have been developed to collect information on health facility preparedness to provide sexual violence response services; however, little guidance exists on how this information can be used to better understand which functions a facility can perform. Our study therefore aims to propose a set of signal functions that provide a framework for monitoring the availability of clinical sexual violence services. To illustrate the potential insights that can be gained from using our proposed signal functions, we used the framework to analyse data from a health facility census conducted in Central Province, Zambia. We collected the geographic coordinates of health facilities and police stations to assess women's proximity to multi-sectoral sexual violence response services. We defined three key domains of clinical sexual violence response services, based on the timing of the visit to the health facility in relation to the most recent sexual assault: (1) core services, (2) immediate care, and (3) delayed and follow-up care. Combining information from all three domains, we estimate that just 3% of facilities were able to provide a comprehensive response to sexual violence, and only 16% could provide time-sensitive immediate care services such as HIV post-exposure prophylaxis and emergency contraception. Services were concentrated in hospitals, with few health centres and no health posts fulfilling the signal functions for any of the three domains. Only 23% of women lived within 15 km of comprehensive clinical sexual violence health services, and 38% lived within 15 km of immediate care. These findings point to a need to develop clear strategies for decentralizing sexual violence services to maximize coverage and ensure equity in access. Overall, our findings suggest that our proposed signal functions could be a simple and valuable approach for assessing the availability of clinical sexual violence response services, identifying areas for improvement and tracking improvements over time.
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Affiliation(s)
- Mardieh L Dennis
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Onikepe O Owolabi
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, USA
| | - Jenny A Cresswell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Nachela Chelwa
- Population Council, Zambia office, No. 4 Mwaleshi Road, Lusaka, Zambia
| | - Manuela Colombini
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock Place, London, UK
| | - Bellington Vwalika
- School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Michael T Mbizvo
- Population Council, Zambia office, No. 4 Mwaleshi Road, Lusaka, Zambia
| | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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Owolabi OO, Biddlecom A, Whitehead HS. Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions. LANCET GLOBAL HEALTH 2018; 7:e110-e118. [PMID: 30503402 PMCID: PMC6478445 DOI: 10.1016/s2214-109x(18)30404-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/24/2018] [Accepted: 08/16/2018] [Indexed: 11/30/2022]
Abstract
Background Abortion-related mortality is one of the main causes of maternal
mortality worldwide. Laws often restrict the provision of safe abortion
care, yet post-abortion care is a service that all countries have committed
to provide to manage abortion complications. There is minimal evidence on
the capacity of national health systems to provide post-abortion care. Methods We did a multicountry analysis of data from nationally representative
Service Provision Assessment surveys done between 2007 to 2017 in ten
countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia,
Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available for all
ten countries from 2007 to 2015. We included facilities offering childbirth
delivery services and classified facilities as primary or referral level. We
measured signal functions for post-abortion care (the availability of key
equipment and ability to perform services) to assess the proportion of
primary-level and referral-level facilities in each country with the
capacity to provide basic and comprehensive post-abortion care,
respectively. We calculated the proportion of facilities providing each
post-abortion care signal function to examine specific gaps in service
provision. Findings There are critical gaps in the provision of post-abortion care at all
facilities that offer delivery services. In seven (70%) of ten countries,
less than 10% of primary-level facilities could provide basic post-abortion
care, and in eight (80%) of ten countries less than 40% of referral-level
facilities could provide comprehensive post-abortion care. In no country
could all referral facilities provide all the essential services that need
to be included in basic post-abortion care. Interpretation The capacity of primary-level and referral-level health facilities to
provide basic and comprehensive post-abortion care, respectively, is low.
The results highlight the gap between political commitments to address the
consequences of unsafe abortion and the capacity of health systems to
provide post-abortion care. Increasing the provision of good-quality
post-abortion care is essential to reduce the level of abortion-related
morbidity and mortality.
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Cresswell JA, Owolabi OO, Chelwa N, Dennis ML, Gabrysch S, Vwalika B, Mbizvo M, Filippi V, Campbell OMR. Does supportive legislation guarantee access to pregnancy termination and postabortion care services? Findings from a facility census in Central Province, Zambia. BMJ Glob Health 2018; 3:e000897. [PMID: 30233831 PMCID: PMC6135439 DOI: 10.1136/bmjgh-2018-000897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Zambia is one of the few countries in Africa to permit termination of pregnancy (TOP) on a wide range of grounds. However, substantial barriers remain to TOP and postabortion care (PAC). Methods We conducted a census of 153 facilities between March and May 2016. We defined facilities according to whether they met basic and/or comprehensive signal functions criteria for TOP and PAC. We linked our facility data to census data to estimate geographic accessibility under different policy scenarios. Results Overall, 16% of facilities reported they had performed a TOP and 39% performed a PAC in the last year. Facilities were twice as likely to use medical methods for TOP compared with surgical methods, and four times more likely for PAC. Considerably more facilities had performed TOP or PAC than met the basic or comprehensive signal functions criteria, indicating services were being performed in facilities below essential quality standards. Under current Zambian law for non-emergency scenarios, 21% of women in Central Province lived within 15 km of a facility with basic capability to provide TOP; if midlevel providers were trained to provide TOP, this would increase to 36%. Conclusion A supportive legislative framework is essential, but not in itself sufficient, for adequate access to services. Training midlevel providers, in line with WHO guidance, and ensuring equipment is available in primary care can increase accessibility of TOP and PAC. While both medical and surgical methods need to be available, medical abortion is a safe and effective method that can be provided in low-resource settings.
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Affiliation(s)
- Jenny A Cresswell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Onikepe O Owolabi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Mardieh L Dennis
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sabine Gabrysch
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | | | | | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Bell SO, Zimmerman L, Choi Y, Hindin MJ. Legal but limited? Abortion service availability and readiness assessment in Nepal. Health Policy Plan 2018; 33:99-106. [PMID: 29136148 DOI: 10.1093/heapol/czx149] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 11/13/2022] Open
Abstract
The government of Nepal revised its law in 2002 to allow women to terminate a pregnancy up to 12 weeks gestation for any indication on request, and up to 18 weeks if certain conditions are met. We evaluated the readiness of facilities in Nepal to provide three abortion services, manual vacuum aspiration (MVA), medication abortion (MA) and post-abortion care (PAC), using the service availability and readiness assessment (SARA) framework. The framework consists broadly of three domains; service availability, general service readiness and service readiness specific to individual services (i.e. service-specific readiness). We applied the framework to data from the Nepal Health Facility Survey 2015, a nationally representative survey of 992 health facilities. Overall, we find that access to safe abortion remains limited in Nepal. Of the facilities that reported offering delivery services and were thus eligible to provide safe abortion services, 44.5, 36.0 and 25.6% had provided any MVA, MA or PAC services, respectively, in the 3 months prior to the survey, and <2% were 'ready' to provide any abortion service based on our application of the SARA criteria for service-specific readiness. Among only the facilities that reported providing an abortion service in the 3 months prior to the survey, 3.2% of facilities that provided MVA, 1.5% of facilities that provided MA and 1.1% of the facilities that provided PAC had all the components of care required. Although the private sector conducted approximately half of all abortion services provided in the 3 months prior to the survey, no private sector facilities had all the abortion service-specific readiness components. Results suggest that accessing safe abortion services remains a significant challenge for Nepalese women, despite a set of permissive laws.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Linnea Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Yoonjoung Choi
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
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Kanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub-Saharan Africa: Evidence from nationally representative health facility assessments. J Glob Health 2018; 7:021101. [PMID: 29163936 PMCID: PMC5680531 DOI: 10.7189/jogh.07.021101] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Utilization of antenatal care (ANC) services has increased over the past two decades. Continued gains in maternal and newborn health will require an understanding of both access and quality of ANC services. We linked health facility and household survey data to examine the quality of service provision for five ANC interventions across health facilities in sub–Saharan Africa. Methods Using data from 20 nationally representative health facility assessments – the Service Provision Assessment (SPA) and the Service Availability and Readiness Assessment (SARA), we estimated facility level readiness to deliver five ANC interventions: tetanus toxoid vaccine for pregnant women, intermittent preventive treatment for malaria in pregnancy (IPTp), syphilis detection and treatment in pregnancy, iron supplementation and hypertensive disease case management. Facility level indicators were stratified by health facility type, managing authority and location, then linked to estimates of ANC utilization in that stratum from the corresponding Demographic and Health Surveys (DHS) to generate population level estimates of the ‘likelihood of appropriate care’. Finally, the association between estimates of the ‘likelihood of appropriate care’ from the linking approach and estimates of coverage levels from the DHS were assessed. Findings A total of 10 534 health facilities were surveyed in the 20 health facility assessments, of which 8742 reported offering ANC services and were included in the analysis. Health facility readiness to deliver IPTp, iron supplementation, and tetanus toxoid vaccination was higher (median: 84.1%, 84.9% and 82.8% respectively) than readiness to deliver hypertensive disease case management and syphilis detection and treatment (median: 23.0% and 19.9% respectively). Coverage of at least 4 ANC visits ranged from 24.8% to 75.8%. Estimates of the likelihood of appropriate care derived from linking health facility and household survey data showed marked gaps for all interventions, particularly hypertensive disease case management and syphilis detection and treatment. There was fairly good concordance between our estimates of high likelihood of appropriate care and DHS estimates of coverage for iron supplementation, IPTp, and tetanus toxoid vaccination. Conclusion Linking household surveys to health facility assessments revealed marked gaps in population–level coverage of quality ANC interventions and underscored the need for a double–pronged approach to increase ANC utilization and improve the quality of ANC services.
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Affiliation(s)
- Mufaro Kanyangarara
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neff Walker
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Thwala SBP, Blaauw D, Ssengooba F. Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district. PLoS One 2018; 13:e0194576. [PMID: 29596431 PMCID: PMC5875781 DOI: 10.1371/journal.pone.0194576] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 03/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Improving the delivery of emergency obstetric care (EmNOC) remains critical in addressing direct causes of maternal mortality. United Nations (UN) agencies have promoted standard methods for evaluating the availability of EmNOC facilities although modifications have been proposed by others. This study presents an assessment of the preparedness of public health facilities to provide EmNOC using these methods in one South African district with a persistently high maternal mortality ratio. METHODS Data collection took place in the final quarter of 2014. Cross-sectional surveys were conducted to classify the 7 hospitals and 8 community health centres (CHCs) in the district as either basic EmNOC (BEmNOC) or comprehensive EmNOC (CEmNOC) facilities using UN EmNOC signal functions. The required density of EmNOC facilities was calculated using UN norms. We also assessed the availability of EmNOC personnel, resuscitation equipment, drugs, fluids, and protocols at each facility. The workload of skilled EmNOC providers at hospitals and CHCs was compared. RESULTS All 7 hospitals in the district were classified as CEmNOC facilities, but none of the 8 CHCs performed all required signal functions to be classified as BEmNOC facilities. UN norms indicated that 25 EmNOC facilities were required for the district population, 5 of which should be CEmNOCs. None of the facilities had 100% of items on the EmNOC checklists. Hospital midwives delivered an average of 36.4±14.3 deliveries each per month compared to only 7.9±3.2 for CHC midwives (p<0.001). CONCLUSIONS The analysis indicated a shortfall of EmNOC facilities in the district. Full EmNOC services were centralised to hospitals to assure patient safety even though national policy guidelines sanction more decentralisation to CHCs. Studies measuring EmNOC availability need to consider facility opening hours, capacity and staffing in addition to the demonstrated performance of signal functions.
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Affiliation(s)
- Siphiwe Bridget Pearl Thwala
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand; Johannesburg, South Africa
- Faculty of Health Sciences, University of Swaziland; Mbabane, Swaziland
| | - Duane Blaauw
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand; Johannesburg, South Africa
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Aantjes CJ, Gilmoor A, Syurina EV, Crankshaw TL. The status of provision of post abortion care services for women and girls in Eastern and Southern Africa: a systematic review. Contraception 2018; 98:S0010-7824(18)30094-5. [PMID: 29550457 DOI: 10.1016/j.contraception.2018.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 03/04/2018] [Accepted: 03/05/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To conduct a systematic review of the status of post-abortion care (PAC) provision in Eastern and Southern Africa with particular reference to reach, quality and costs of these services. STUDY DESIGN We searched Pubmed, EMBASE, Science Direct, POPLINE and Web of Science for articles published between 2000 and October 2017 presenting primary or secondary data from one or more countries in the region. RESULTS Seventy articles representing data from fourteen countries were abstracted and included in the review. Implementation of PAC services was found to be patchy across countries for which data was available. However, there is evidence of efforts to introduce PAC at lower level health facilities, to use mid-level providers and to employ less invasive medical techniques. Eleven countries from the region were not represented in this review, exposing a considerable knowledge gap over the state of PAC in the region. The disparate access for rural women and girls, the suboptimal service quality and the neglect of adolescent-specific needs were critical gaps in the current PAC provision. CONCLUSION PAC provision and research in this domain cannot be detached from the broader legal and societal context, as social stigma constitutes a major blockage to the advancement of the service. Adolescent girls are a particularly vulnerable and underserved group in the region. IMPLICATIONS The next generation research on PAC should favor multi-country and interdisciplinary study designs with a view to understanding inter-regional differences and supporting advancement towards universal access of PAC by 2030.
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Affiliation(s)
- Carolien J Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban.
| | - Andrew Gilmoor
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Science, Vrije Universiteit Amsterdam
| | - Elena V Syurina
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Science, Vrije Universiteit Amsterdam
| | - Tamaryn L Crankshaw
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban
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Fetters T, Samandari G, Djemo P, Vwallika B, Mupeta S. Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia. Reprod Health 2017; 14:26. [PMID: 28209173 PMCID: PMC5314585 DOI: 10.1186/s12978-017-0289-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 01/21/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation. METHODS An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country's abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships. RESULTS After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides. CONCLUSIONS These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.
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Affiliation(s)
| | - Ghazaleh Samandari
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Patrick Djemo
- Regional program Manager, Francophone Africa, Lusaka, Zambia
| | - Bellington Vwallika
- Department of Obstetrics and Gynecology, Consultant Obstetrician and Gynecologist University of Zambia School of Medicine, Lusaka, Zambia
| | - Stephen Mupeta
- National Reproductive Health Specialist, UNFPA, Lusaka, Zambia
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