Barriers to post-abortion care service provision: A cross-sectional analysis in Burkina Faso, Kenya and Nigeria.

Despite several political commitments to ensure the availability of and access to post-abortion care services, women in sub-Saharan Africa still struggle to access quality post-abortion care, and with devastating social and economic consequences. Expanding access to post-abortion care while eliminating barriers to utilization could significantly reduce abortions-related morbidity and mortality. We describe the barriers to providing and utilizing post-abortion care across health facilities in Burkina Faso, Kenya, and Nigeria. This paper draws on three data sources: health facility assessment data, patient-exit interview data, and qualitative interviews conducted with healthcare providers and policymakers. All data were based on a cross-sectional survey of a nationally representative sample of health facilities conducted between November 2018 and February 2019. Data on post-abortion care service indicators were collected, including staffing levels and staff training, availability of post-abortion care supplies, equipment and commodities. Patient-exit interviews focused on patients treated for post-abortion complications. In-depth interviews were conducted with healthcare providers within a sample of the study health facilities and national or local decision-makers in sexual and reproductive health. Few primary-level facilities in Burkina Faso (15%), Kenya (46%), and Nigeria (20%) had staff trained on post-abortion care. Only 16.6% of facilities in Kenya had functional operating theaters or MVA rooms, Burkina Faso (20.3%) and Nigeria (50.7%). Primary facilities refer post-abortion care cases to higher-level facilities despite needing to be more adequately equipped to facilitate these referrals. Several challenges that impede the provision of quality and comprehensive post-abortion care across the three countries. The absence of post-abortion care training, equipment, and inadequate referral capacity was among the critical reasons for the lack of services. There is a need to strengthen post-abortion care services across all levels of the health system, but especially at lower-level facilities where most patients seek care first.

Lived experiences of pregnant and parenting adolescents in Africa: A scoping review.

BACKGROUND: Previous studies have not synthesized existing literature on the lived experiences of pregnant and parenting adolescents (aged 10-19) in Africa. Such evidence synthesis is needed to inform policies, programs, and future research to improve the well-being of the millions of pregnant or parenting adolescents in the region. Our study fills this gap by reviewing the literature on pregnant and parenting adolescents in Africa. We mapped existing research in terms of their substantive focus, and geographical distribution. We synthesized these studies based on thematic focus and identified gaps for future research. METHODS: We used a three-step search strategy to find articles, theses, and technical reports reporting primary research published in English between January 2000 and June 2021 in PubMed, Jstor, AJOL, EBSCO Host, and Google Scholar. Three researchers screened all articles, including titles, abstracts, and full text, for eligibility. Relevant data were extracted using a template designed for the study. Overall, 116 studies met the inclusion criteria and were included in the study. Data were analyzed using descriptive and thematic analyses. RESULTS: Research on pregnant and parenting adolescents is limited in volume and skewed to a few countries, with two-fifths of papers focusing on South Africa (41.4%). Most of the studies were African-led (81.9%), received no funding (60.3%), adopted qualitative designs (58.6%), and were published between 2016 and 2021 (48.3%). The studies highlighted how pregnancy initiates a cycle of social exclusion of girls with grave implications for their physical and mental health and social and economic well-being. Only 4.3% of the studies described an intervention. None of these studies employed a robust research design (e.g., randomized controlled trial) to assess the intervention's effectiveness. Adolescent mothers' experiences (26.7%) and their education (36.2%) were the most studied topics, while repeat pregnancy received the least research attention. CONCLUSION: Research on issues affecting pregnant and parenting adolescents is still limited in scope and skewed geographically despite the large burden of adolescent childbearing in many African countries. While studies have documented how early pregnancy could result in girls' social and educational exclusion, few interventions to support pregnant and parenting adolescents exist. Further research to address these gaps is warranted.

"They talked to me rudely". Women perspectives on quality of post-abortion care in public health facilities in Kenya.

BACKGROUND: Access to safe abortion is legally restricted in Kenya. Therefore, majority women seeking abortion services in such restrictive contexts resort to unsafe methods and procedures that result in complications that often require treatment in health facilities. Most women with abortion-related complications end up in public health facilities. Nevertheless, evidence is limited on the quality of care provided to patients with abortion complications in public health facilities in Kenya. METHODS: Data for this paper are drawn from a qualitative study that included interviews with 66 women who received post-abortion care in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on mechanisms of decision-making while seeking post-abortion care services, care pathways within facilities, and perceptions of patients on quality of care received including respect, privacy, confidentiality, communication and stigma. FINDINGS: The participants' perceptions of the quality of care were characterized as either "bad care" or "good care", with the good care focusing on interpersonal aspects such as friendliness, respect, empathy, short waiting time before receiving services, as well as the physical or functional aspects of care such as resolution of morbidity and absence of death. Majority of participants initially reported that they received "good care" because they left the facility with their medical problem resolved. However, when probed, about half of them reported delays in receiving care despite their condition being an emergency (i.e., severe bleeding and pain). Participants also reported instances of abuse (verbal and sexual) or absence of privacy during care and inadequate involvement in decisions around the nature and type of care they received. Our findings also suggest that healthcare providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older). For instance, women who experienced miscarriages reported supportive care whereas women suspected to have induced their abortions felt stigmatized. CONCLUSION: These findings have far reaching implications on efforts to improve uptake of post-abortion care, care seeking behaviors and on how to assess quality of abortion care. There should be emphasis on interventions meant to enhance processes and structural indicators of post-abortion care services meant to improve patients' experiences throughout the care process. Moreover, more efforts are needed to advance the tools and approaches for assessing women experiences during post-abortion care beyond just the overriding clinical outcomes of care.

Access to abortion is legally restricted and socially reproved in Kenya. Therefore, women requiring abortion in such restrictive contexts resort to unsafe methods that result in complications, often requiring treatment in health facilities. Nevertheless, there is limited evidence on the quality of care provided in public health facilities in Kenya to patients treated for abortion complications. This paper is drawn from a qualitative study targeting 66 women treated for abortion complication in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on the women's perceptions around the quality of care they received.Our findings show that while the majority of participants stated in first instances that they received "good care" because they left the facility with their medical problem resolved, half of them, when probed, reported delays in receiving care, yet their condition was seen as an emergency since they were bleeding and experiencing pain. Participants also reported instances of abuse (verbal and physical) or lack of privacy during care and inadequate involvement in decisions on the type of care they were to receive. Our findings also point out that providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older), with women who experienced miscarriages receiving supportive care while women suspected to have induced their abortion being stigmatized.In conclusion, our findings have far reaching implications on efforts to improve post-abortion seeking behaviors and on how to assess quality of abortion care.

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

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

Describing the safety of abortion at the population level using network-based survey approaches.

BACKGROUND: Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions. OBJECTIVE: This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted. METHODS: This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested. DISCUSSION: This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.

Representative data on how women induce abortions and their consequences are central to measurements of abortion safety. However, due to the stigmatized nature of abortion, measuring the details of the process is challenging when the latter occur out of the realm of the law and do not result in complications registered in hospital statistics. Hence, there is sparse empirical population-level data on how women terminate their pregnancies in countries where access to abortion services is highly restricted, as well as little data on the side effects and complications associated with the methods they chose and health seeking for these complications. Recent developments in indirect survey methodologies to study stigmatized/illegal behaviour and hidden populations are likely to improve the quality of data collected on abortion safety in restrictive contexts: all are based on the sharing of information on stigmatized practices in social networks. We propose to refine and pilot two such network-based methods to validate their use for collecting (quasi) representative data on abortion safety in large population health surveys. These two approaches are: (i) a modified Anonymous Third-Party Reporting method (ATPR) integrating elements of the Network-Scale-up Method (NSUM) and (ii) Respondent-Driven Sampling (RDS). We will conduct this study in two African Health and Demographic Surveillance Systems (HDSS) sites, one urban (Nairobi, Kenya), and one comprising a town and adjacent villages (Kaya, Burkina Faso).

Fertility intentions and the adoption of long-acting and permanent contraception (LAPM) among women: evidence from Western Kenya.

BACKGROUND: The use of long-acting and permanent method (LAPM) for family planning (FP) is of importance to the FP movement. A better understanding of how fertility-related intentions shape the usage of LAPM is important for programming. This paper explored the interaction of fertility intentions with LAPM use in rural western Kenya. METHODS: We draw on monitoring data from 28,515 women aged 15-49 years who received FP services between 2013 and 2015 as part of a community-based FP project. We assessed the association between the use of LAPM and fertility intentions, adjusting for age, parity, education, service delivery model, FP counseling and year of data collection. RESULTS: Of the 28,515 women who accessed FP services during the period (2013-2015), about two-thirds (57%) reported using LAPM, much higher than the national rates, and around 46% wanted another child within or after two years. In a multivariable regression model, women who desired no more children tended to use LAPM more than those wanting a child within or after some years as well as those uncertain about their future intentions. CONCLUSION: The significant rates of utilization of LAPM between both women who desired no more children and the fair proportion of use among women spacing births underscore the benefits of sustained community level interventions that address both the demand and supply barriers of contraceptive adoption and use.

Improving family planning services delivery and uptake: experiences from the "Reversing the Stall in Fertility Decline in Western Kenya Project".

OBJECTIVE: In this paper, we reflect on our experiences of implementing a multipronged intervention to improve sexual and reproductive health outcomes. The project used family planning as its entry point and was implemented in two high fertility counties-Busia and Siaya in Kenya. The intervention, implemented by a seven-member consortium, involved: family planning services delivery; regular training of service providers to deliver high quality services; monitoring and evaluation; strengthening of commodity chain delivery and forecasting; school-based and out-of-school based sexuality education; and advocacy and stakeholder engagements at the community, county and national levels. RESULTS: Over a 5-year period, the project contributed to raising demand for family planning considerably, evidenced in fertility decline. It also improved the capacity of family planning services providers, increased commitment and awareness of county government and other community stakeholders on the importance of investments in family planning. Our collaborations with organisations interested in sexual and reproductive health issues substantially enhanced the consortium's ability to increase demand for, and supply of family planning commodities. These collaborations are proving useful in the continuity and sustainability of project achievements.