Quality of post-abortion care in health facilities in Kenya

Abstract

Globally, about 22 million unsafe abortions occur annually, 21 million in developing countries. The World Health Organization (WHO) estimates that 47,000 maternal deaths are due to unsafe abortion, with only 0.2 percent of these in high income countries. Over 62% of these deaths occur in Africa [2]. Post-abortion care (PAC) is a life-saving intervention which reduces the risks of mortality and morbidity from incomplete abortion [3]. In 2002, the post-abortion care consortium (PACC) endorsed the essential elements of the post-abortion care framework, which reflects, from both a provider and a patient perspective, an enhanced vision of improved service quality and sustainable care [4]. The model’s five elements use a public health approach to respond to women’s broader sexual and reproductive health needs, and include: 1) community and service provider partnerships for the prevention of unwanted pregnancies and unsafe abortion, 2) counselling, 3) treatment, 4) contraception and family planning (FP) services and 5) reproductive and other health services [5]. Post-abortion contraception is an intervention that reduces further abortions and abortion-related deaths. However, family planning and counselling has continually been shelved by service providers [4]. The aim of this study is to examine the quality of PAC services in healthcare facilities, to understand the perspectives of PAC service providers, and to explain care seekers’ views about the quality of services in Kenya. Specifically, the research explores the following objectives: 1) to examine the state of PAC in healthcare facilities and analyse the determinants of quality PAC in Kenyan healthcare facilities; 2) to examine the level and determinants of effective contraception among women seeking PAC; 3) to explore PAC service providers’ understanding of quality PAC and their challenges in providing PAC services in Kenya; and 4) to explore PAC service seekers’ understanding of quality PAC and their experience in seeking PAC services in Kenya. This study is based on a nationally representative sample of 350 facilities across Kenya in 2012. The study included all Level 2 (dispensaries and health centres), 3 (sub-district hospitals), 4 (district hospitals), 5 (county/provincial and some large district hospitals) and 6 (national referral) facilities. Combined data on health facility characteristics (HFS) and patient management (PMS) were used in this study. Additional data were gathered from a subsample of service providers and patients, selected from Nairobi, Central and Eastern regions. The data mainly focus on understanding the quality of PAC and service providers’ challenges when offering PAC. An additional subsample of six facilities were selected for interviews with patients who sought PAC services, with the intent of interviewing five patients at each of these six facilities. The study modelled the factors associated with quality care, using a stratified mixed-effects ordered probit model. It further compared facilities based on having a separate evacuation room, whether a facility had a specialist obstetrician-gynaecologist (Ob-gyn), offered maternity services, frequency of provider training on PAC, provider perception on PAC load, number of deliveries per month and the number of contraceptive methods available for PAC patients, all stratified by facility level. The model controlled for 15 county-level characteristics obtained from Kenya Demographic and Health Survey 2014 and modelled the effect of the above facility characteristics on the level of care. From the model, while accounting for county variability, the quality of PAC in health facilities depended largely on the availability of a separate evacuation procedure room for PAC services, whether or not the facility offered specialized Ob-gyn services, whether the facility offered maternity services, and regardless of the number of deliveries conducted in the facility, and the variety of contraceptive methods available to PAC patients. Bivariate and multivariable mixed-effects ordered logit models were also fitted with the three level ordinal outcome, defined as whether a PAC patient received an effective or ineffective method of family planning, or whether patient received any method at all; all patient, facility and county characteristics were shown to be independently associated with the outcome. The first models were fitted within the frequentist/classical (maximum likelihood estimation) approach. These models were used for identification of final covariates for inclusion in the final models, using a probabilistic Bayesian approach. Higher-level facilities (Levels 4-6) were less likely to provide quality PAC compared to lower facilities, although the relationship was statistically insignificant. However, public facilities had 0.16 lower quality of care. Similarly, facilities with separate evacuation rooms had 0.33higher quality PAC, while facilities that had Ob-gyn services exhibited 0.24 higher quality PAC. Although in low proportions, facilities with more deliveries and with more FP methods available to PAC patients increased the probability of a facility reporting higher quality PAC. Patient religion, history of previous abortion and contraceptive use before index pregnancy, and fertility intentions at time of pregnancy, were all significantly associated with the adoption of an effective contraceptive method. At facility level, patient’s odds of receiving a more effective contraceptive method largely depended on the level of the facility (inversely), whether the facility had a separate procedure room from where PAC services were offered, , the variety of modern family planning methods available at the facility, and finally, whether the facility also offered maternity service (inversely). Patients seeking post-abortion care services were influenced by a range of factors including the perceived capacity of service providers (SP) to offer quality services, often driven by prior experiences with health care services. Service providers’ confidence in offering PAC is a demonstration of competence. Service providers’ skills were hampered by the availability of resources for service delivery, such as MVA kits and procedure rooms where services could be offered with maximum aural and visual privacy. Quality post-abortion care services by providers was mainly defined by providers perceiving their treatment of PAC patient as “saving lives”. Sometime, they would forego other critical short-term benefits of quality care, such as patient satisfaction with services and lower risks of repeat abortions, as well as future fertility and well being. When services were not available, service providers worried about the need for protracted referrals, which often lead to serious sequelae and poor treatment outcomes [6]. However, for patients, quality PAC refers to those critical “soft skills” such as personalized assistance during care, pain reduction and service providers who showed that they cared about patients’ experiences. In Kenya, the provision of quality PAC in healthcare facilities remains low, and there is clear evidence of high legal and policy bottlenecks that continue to obstruct access to quality care. The national roll-out of abortifacients over the past four years has increased their availability, but the generalized and unregulated access to these drugs continues to pose a safety challenge, owing to undirected and unsupervised self-administration. Within healthcare facilities, the recurrence of service interruptions and inequitable access to care further exacerbates the incidence of unsafe pregnancy terminations. At the same time, lack of services and variable availability of these services in primary healthcare facilities, including dispensaries and health centers, spur delays in receiving care and complications from unsafe abortion through the often non-specific and uncoordinated chain of referrals for common post-abortion cases. At the same time, lack of sufficient skills among service providers to offer quality post-abortion care services persists. Within these facilities, there was also evidence of inefficient infection control measures, exposing women and their caregivers to nosocomial infections. The first study, reported below, revealed urgent need for improving the capacity of lower level facilities to offer quality PAC services, and equipping service providers with the requisite skills including to offer more effective family planning and counselling. The study also pointed to the need for an inclusive approach to encompass private sector participation in order to reduce the risk of complications attributed to delays in seeking care and lengthy referrals [7]. On effective contraception after PAC, this study demonstrated that improving the reproductive health of PAC patients requires considerable effort at policy, service delivery and individual levels. These efforts must aim to empower patients to make an informed choice of whether to use contraception and the type of contraceptive method that best suits their sexual context. At a policy level, there is need to focus on service provider skills that are sensitive to patients’ needs and ability to make decisions, as well as barriers to informed patient choice. Service provider empowerment through capacity building for PAC, infrastructural improvement and contraceptive commodity options, and their security, are paramount in ensuring that service providers interact better with patients and can deliver quality PAC services. In addition, effective counselling of PAC patients requires understanding of patients’ past experiences with contraception and their future fertility intentions and desires in order to meet their specific needs. Family planning integration with PAC will ultimately reduce missed opportunities, while promising improved reproductive health of post-abortion care patients. Quality PAC, both as seen by the patients and by service providers, therefore has divergent meanings. Service providers see their key role in quality PAC as saving the lives of patients, while patients need more caring services, from providers who seem knowledgeable and confident about the services they offer. The need for guidelines for the provision of safe legal abortion care is urgent, similar to mechanisms to regulate the use of medical abortion for termination of abortion and treatment of incomplete abortion. While there are continued calls for the legalization of abortion, there is an equally urgent need to place emphasis on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities