The effects of interventions to integrate long-acting reversible contraception with treatment for incomplete abortion: Results of a 6-year interrupted time series analysis in hospitals in mainland Tanzania and Zanzibar.

OBJECTIVE: To evaluate an intervention that aimed at strengthening voluntary access to long-acting reversible contraception (LARC) within postabortion care (PAC) in hospitals in mainland Tanzania and Zanzibar. METHODS: From 2016 to 2018, we conducted PAC quality improvement interventions, emphasizing family planning (FP) counseling and voluntary access to LARC. Researchers conducted an interrupted time-series analysis of service statistics compiled from 2014 to 2020 using segmented linear mixed effects regression models to assess the interventions' effect on postabortion contraceptive uptake. RESULTS: The intervention in mainland Tanzania was associated with an immediate 38% increase in postabortion LARC uptake, a trend that declined from late 2016 to mid-2020 to 34%. In Zanzibar, the intervention was associated with a gradual increase in LARC uptake that peaked in late 2018 at 23% and stabilized at approximately 15% by mid-2020. Whereas the interventions in mainland facilities did not generate significant changes in postabortion FP uptake overall, the launch of interventions in Zanzibar in mid-2016 was associated with a precipitous rise in that outcome over time, which plateaued at approximately 54% by 2019. CONCLUSION: Increased voluntary uptake of postabortion contraception was associated with the introduction of training in PAC, including FP, and quality improvement interventions and gains were sustained over time.

Strengthening access to long-acting reversible contraception within postabortion care in Tanzania: A pre-post evaluation.

Postabortion care services provide lifesaving treatment for abortion-related complications and addresses women's needs by offering family planning (FP) counseling and voluntary access to contraception. Between 2016 and 2020, the Government of Tanzania sought to strengthen its PAC program by enhancing FP counseling and clients' access to a wide range of contraceptive options. The project team conducted a pre-post evaluation in 17 public sector healthcare facilities in mainland Tanzania and 8 in Zanzibar. It comprised structured client exit interviews (CEIs), completed first in 2016 (n=412) and again in 2020 (n=484). These data complemented an evaluation that used routine service statistics to demonstrate the intervention's effects on client-reported outcomes. Primary outcomes of the CEIs reflected client experience and satisfaction with services, and researchers compared pre-post differences using chi-square tests. There were improvements in numerous indicators, including client waiting times, recall of emergency procedure counseling, contraceptive uptake, and satisfaction with the quality of overall counseling and FP information and services; however, triangulation of CEI data with service statistics indicated that some outcomes, though still improved since baseline, attenuated. Strengthening the FP component of PAC is feasible in Tanzania and Zanzibar, but strategies to sustain quality improvements over time are needed.

Clients' perceptions of the quality of post-abortion care in eight health facilities in Dakar, Senegal.

Post-abortion care (PAC) integrates elements that are vital for women's survival after abortion complications and their ability to meet their subsequent fertility intentions. Currently, the utilization of PAC among women in need remains too low, particularly in settings where unsafe abortion is an appreciable cause of maternal mortality. Interventions have aimed at addressing unmet need; however, these still require information on the extent to which women value different aspects of PAC. This paper presents such evidence from Dakar, Senegal. Exit interviews with 729 PAC clients in 2018 at eight health facilities obtained information on patient characteristics, content of services received and women's perceptions of the quality of care, both overall and according to subject-specific domains. These domains reflect aspects of PAC that are relevant to clients' satisfaction: accessibility, facility environment, information and counselling, family planning, provider technical competence and readiness and client-staff interaction. Ordinal logistic regression models were estimated to identify factors that were associated with women's rating of overall quality of care (on a scale of 1 to 5, 1 being lowest). Predictors that were significantly associated with the outcome were used in a multivariate ordinal logistic regression model that estimated the probability of positive differences in the outcome associated with women's classification of each predictor. Women reported a mean rating of 3.7 for overall quality of care. The lowest domain-specific rating was for quality of information and counselling (mean=2.4) and the highest was for client-staff interaction (mean=3.8). Factors associated with clients' higher odds of being more satisfied with PAC were: physical comfort during the procedure, recall of counselling on treatment procedure, privacy, perceived availability of supplies and medicines, facility admission process, facility cleanliness, waiting time, clarity of counselling and access to different contraceptive methods. Interventions that target these factors may improve the utilization of PAC in Dakar, Senegal.

Understanding the financial burden of incomplete abortion: An analysis of the out-of-pocket expenditure on postabortion care in eight public-sector health care facilities in Dakar, Senegal.

Timely access to treatment is essential for women when they experience abortion complications. Out-of-pocket (OOP) expenditure is a known barrier to health care access. In 2018, we assessed the financial burden of accessing postabortion care (PAC) borne by women in Dakar, Senegal, where studies estimate that half of poor women with complications obtain PAC. We interviewed 729 women following discharge from PAC. Women reported expenditures on transportation, admission, treatment, family planning, hospitalisation, complementary tests, prescriptions, other medicines and materials. We compare women's OOP on PAC by expenditure category, type of treatment and facility type, and use multiple generalised linear regression analysis to explain variation in overall OOP and forecast it under alternate scenarios. The average OOP was USD $93.84. At health centres it was $65.47 and at hospitals it was $120.47. The average cost of PAC using dilation and curettage was $112.37, manual vacuum aspiration was $99.84, and misoprostol $61.80. Overall OOP on PAC amounts, on average, to 15% of the average monthly salary for women living in Dakar. Strategies that emphasise timely access to misoprostol for treating complications in primary care settings will address the contribution of OOP costs to Senegal's appreciable unmet need for PAC among the poor.

Post-abortion fertility desires, contraceptive uptake and unmet need for family planning: voices of post-abortion care clients in Tanzania.

Post-abortion care (PAC) integrates elements of care that are vital for women's survival after abortion complications with intervention components that aid women in controlling their fertility, and provides an optimal window of opportunity to help women meet their family planning goals. Yet, incorporating quality family planning services remains a shortcoming of PAC services, particularly in low- and middle-income countries. This paper presents evidence from a mixed method study conducted in Tanzania that aimed at explaining factors that contribute to this challenge. Analysis of data obtained through client exit interviews quantified the level of unmet need for contraception among PAC clients and isolated the factors associated with post-abortion contraceptive uptake. Qualitative data analysis of interviews with a subset of these women explored the multi-level context in which post-abortion pregnancy intentions and contraceptive behaviours are formed. Approximately 30% of women interviewed (N=412) could recall receiving counselling on post-abortion family planning. Nearly two-thirds reported a desire to either space or limit childbearing. Of those who desired to space or limited childbearing, approximately 20% received a contraceptive method before discharge from PAC. The factors significantly associated with post-abortion contraceptive acceptance were completion of primary school, prior use of contraception, receipt of PAC at lower level facilities and recall of post-abortion family planning counselling. Qualitative analysis revealed different layers of contextual influences that shaped women's fertility desires and contraceptive decision-making during PAC: individual (PAC client), spousal/partner-related, health service-related and societal. While results lend support to the concept that there are opportunities for services to address unmet need for post-abortion family planning, they also attest to the synergistic influences of individual, spousal, organizational and societal factors that influence whether they can be realized during PAC. Several strategies to do so emerged saliently from this analysis. These emphasize customized counselling to enable client-provider communication about fertility preferences, structural intervention aimed at empowering women to assert those objectives in family and health care settings, availability of information and services on post-abortion fertility and contraceptive eligibility in PAC settings and interventions to facilitate constructive spousal communication on family planning and contraceptive use, after abortion and in general.

Women's Satisfaction With and Perceptions of the Quality of Postabortion Care at Public-Sector Facilities in Mainland Tanzania and in Zanzibar.

BACKGROUND: In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative. METHODOLOGY: We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients. RESULTS: Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received. CONCLUSIONS: Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.

The Quality of Postabortion Care in Tanzania: Service Provider Perspectives and Results From a Service Readiness Assessment.

INTRODUCTION: In 2015, the government of Tanzania launched an effort to strengthen the quality of postabortion care (PAC), an integrated health service that includes treatment for abortion complications and provision of family planning counseling and voluntary services, in 25 facilities in mainland Tanzania and in Zanzibar. METHODS: To help guide the government's initiative, we conducted a mixed-method study in 2016 using health facility surveys and in-depth interviews with health care workers that offer PAC. Surveys of the 25 facilities assessed the current use of services and readiness to deliver them. Provider performance in PAC was assessed through direct observation of client-provider interactions. In-depth interviews (IDIs) with 30 staff from the facilities provided qualitative information on priorities for PAC quality improvement. RESULTS: In the 6 months preceding the study, 2,175 PAC clients sought care at the facilities. Of these PAC clients, 55% chose a family planning method, of whom 6% chose a voluntary long-acting reversible contraceptive. The median facility PAC readiness scores were 45% for health centers, 49% for district hospitals, and 61% for regional referral hospitals. Direct observations of manual vacuum aspiration provision for PAC revealed that providers implemented, on average, 69% of the critical clinical steps. For misoprostol provision, PAC providers implemented, on average, 42% of the critical steps. Multilevel influences affected PAC providers' work, often adversely, by shaping their confidence in their technical competency, confusing their role as health care workers and as clients' peers, and coloring their attitudes toward clientele. The PAC providers also felt that their ability to implement their responsibilities was shaped by lapses in essential support and functionality of the health care system, as well as by social and cultural norms. CONCLUSIONS: Technical assistance approaches that blend training, clinical quality improvement, systems strengthening, and social interventions that address demand-side barriers are needed to ensure providers achieve their potential and are able to deliver high-quality PAC.

The Unit and Scale-Up Cost of Postabortion Care in Tanzania.

INTRODUCTION: Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions. METHODS: Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods. RESULTS: We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96. CONCLUSION: We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.

Expanding comprehensive postabortion care to primary health facilities in Geita District, Tanzania.

A postabortion care program was implemented in 11 primary and secondary health facilities in rural Tanzania in order to decentralize comprehensive postabortion care to community level by upgrading midlevel providers to perform manual vacuum aspiration (MVA). Information about evacuation procedure and family planning (FP) service provided was obtained from the health facilities. In all, 2025 evacuations had been performed with MVA and D&C accounting for 65.6% and 34.4%, respectively. Among the women admitted with abortion complications, 59.8% left with a FP method. The proportion of women offered FP service differed by evacuation procedure, hence the proportion was higher among women evacuated by MVA. Upgrading midlevel providers to perform MVA is an efficient means to address the problem of unsafe abortion in rural areas. However, the sustainability of MVA service provision remains a challenge. Moreover, FP services should be offered to all postabortion clients regardless of evacuation procedure.