Evaluating the quality and coverage of post-abortion care in Zimbabwe: a cross-sectional study with a census of health facilities.

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.

Knowledge and attitudes towards abortion from health care providers and abortion experts in Zimbabwe: a cross sectional study.

INTRODUCTION: Abortion in Zimbabwe is allowed to preserve the physical health of the woman, or in cases of rape, incest, or fetal impairment. Access even under these conditions is difficult and rare. We aimed to understand knowledge of the abortion law and attitudes towards abortion amongst health care providers' and abortion experts in Zimbabwe as these can hinder access to safe legal abortion. METHODS: In 2016, we conducted a Health Facility Survey (HFS) (n=227) among health care providers' knowledgeable about abortion services in their facility in a census of facilities offering Post Abortion Care (PAC), and a Health Professionals Survey (HPS) among 118 abortion experts. RESULTS: Twenty-five percent of providers and 47% of experts knew all four reasons under which abortion is legal in Zimbabwe. Amongst providers and experts, 31% and 50% respectively were misinformed about one or more legal criteria. Most providers and experts were in support of expanding the legal provision of abortion to cases when the woman's mental health is at risk (65% and 79%, respectively) and if the woman is mentally incapacitated (66% amongst all). Seventy-one percent of experts recommend liberalizing the abortion law in order to reduce unsafe abortions. CONCLUSION: There is incomplete and sometimes inaccurate knowledge on the legal provisions for performing abortions in Zimbabwe amongst both health care providers and abortion experts. Incomplete knowledge of the law may be further reducing abortion access, highlighting the urgent need for educating health care providers on the legal status of abortion.

A Longitudinal Assessment of Cervical Inflammation and Immunity Associated with HIV-1 Infection, Hormonal Contraception, and Pregnancy.

Hormonal contraception (HC), particularly injectable depot-medroxyprogesterone acetate (DMPA), has been associated with increased HIV acquisition and higher levels of cervical regulated upon activation, normal T-cell expressed, and secreted (RANTES), also associated with HIV seroconversion. Longitudinal changes in cervical immunity associated with DMPA and combined oral contraceptives (COCs) have not been studied. Cervical samples from 216 HIV seroconverters in Uganda and Zimbabwe with matched samples from 727 HIV-uninfected controls were collected at two quarterly visits before (t - 2, t - 1), at (t0), and two visits following (t + 1, t + 2) HIV seroconversion and corresponding visits for HIV-negative controls. We measured 10 biomarkers of inflammation and immunity and used generalized linear models to estimate and compare biomarker levels across HIV status, contraceptive, and pregnancy groups. Biomarkers remained relatively stable across visits for controls, while in HIV-infected women cervical immunity started to change before seroconversion with RANTES and BD-2 increased and secretory leukocyte protease inhibitor (SLPI) decreased at t - 1 and continued to change at t0 with ICAM-1 up and IL-8 down and with more biomarkers after seroconversion (IL-1ß, IL-6, MIP-3α, VEGF, and IL-1RA down and IL-1RA:IL-1ß ratio up). In multivariable analyses, seroconverters had higher BD-2 at t - 1, higher RANTES and lower SLPI from t - 1 through t + 2, and lower IL-8 and IL-1RA at and/or after seroconversion compared to nonseroconverters. Compared to non-HC users, DMPA users had higher RANTES at all visits and lower BD-2 at t - 2 through t0, while COC users and pregnant women had higher IL-8 and SLPI at all visits; COC users also had lower BD-2 preseroconversion; pregnant women had lower RANTES at t0 - t + 2. Longitudinal patterns of cervical immunity differ between HIV seroconverters and HIV-negative women; seroconverters demonstrate increased RANTES and decreased SLPI starting before and continuing postseroconversion. Furthermore, these patterns are differentially regulated by DMPA, COC, and pregnancy.

Male circumcision for HIV prevention: clinical practices and attitudes among healthcare providers in South Africa and Zimbabwe.

BACKGROUND: This study aimed to document the clinical practices and attitudes of health care providers in South Africa and Zimbabwe on male circumcision for human immunodeficiency virus (HIV) prevention. METHODS: We conducted national surveys of physicians and nurses in both countries in 2008-2009 (N = 1444). Data on male circumcision for HIV prevention were analyzed; outcomes were patient counseling, provision of services, and desire for training. We used multivariable logistic regression to examine associations between these outcomes and clinician, practice, and attitudinal variables. RESULTS: Overall, 57% of clinicians reported counseling male patients on male circumcision, 17% were offering services (49% referrals), and 61% desired training. In the multivariable analyses, provision of services was more common in South Africa (P ≤ 0.001) but desire for training higher in Zimbabwe (P ≤ 0.01). Provision of services was highest among physicians (P ≤ 0.01) and in hospital settings (P ≤ 0.001). However, nurses had greater desire for training (P ≤ 0.05) as did younger clinicians (P ≤ 0.001). Clinicians in rural and clinic settings were just as likely to express training interest. Clinician attitudes that patients would be upset due to cultural beliefs and would increase risky behaviors were associated with less counseling and service provision (P ≤ 0.05). CONCLUSIONS: Many clinicians in South Africa and Zimbabwe showed willingness to integrate new HIV prevention evidence into practice and to become trained to offer the procedure to patients. Results suggest that both countries should consider involving nurses in male circumcision for HIV prevention, including those in rural areas, and should help clinicians to address cultural concerns.

Audio computer-assisted self-interviewing in reproductive health research: reliability assessment among women in Harare, Zimbabwe.

PURPOSE: Research on the measurement of HIV risk demonstrates that interview mode can affect reporting; however, few studies have applied these findings to assessments of hormonal contraceptive use. This paper examines how audio computer-assisted self-interviewing (ACASI) influenced reports of hormonal contraceptive use and pregnancy among Zimbabwean women. METHODS: Using a prospective, randomized, cross-over design, we compared self-reports obtained with ACASI and face-to-face (FTF) interview among 655 women enrolled in a prospective study on hormonal contraceptive use and HIV acquisition. In addition, self-report data were compared to those collected during clinical exams. RESULTS: Compared to FTF interviews, reports of hormonal contraceptive use were lower in ACASI [odds ratio (OR)=0.6; 95% confidence interval (95% CI)=0.5-0.6], and reports of pregnancy were higher (OR=1.5; 95% CI=1.1-1.9). Both modes of self-report differed from records on contraceptive method disbursement. CONCLUSION: Although ACASI yielded higher reports of several reproductive health behaviors, discrepancies between self-reports and clinical data on method disbursement highlight persistent measurement challenges.

Screening for psychological morbidity in HIV-infected and HIV-uninfected pregnant women using community counselors in Zimbabwe.

OBJECTIVE: To examine the prevalence of psychological morbidity in HIV-infected and uninfected pregnant women seeking antenatal care in Zimbabwe. METHODS: Pregnant women were screened for psychological morbidity at the initial antenatal care visit using the 14-item Shona Symptom Questionnaire (SSQ) before voluntary HIV counseling and testing (VCT). The primary outcome measure was "cases," as determined by a SSQ score of >or= 8. Demographic characteristics and HIV status were compared between cases and noncases to determine the risk factors for psychological morbidity. RESULTS: Of the 437 participants, psychological morbidity was detected in 73 (17%) women before undergoing VCT. Risk factors for psychological morbidity included having a spouse older than 35 years of age. HIV infection by itself was not a risk factor for psychological morbidity for women. CONCLUSIONS: There is a high burden of psychological morbidity among pregnant women in Zimbabwe. Mental health services should be integrated into antenatal care to improve psychological health for all women in Zimbabwe.