Abortion-related infections across 11 countries in Sub-Saharan Africa: Prevalence, severity, and management.

OBJECTIVE: To estimate the prevalence of infection among abortion-related complications in health facilities, describe their management, and identify sociodemographic and clinical factors associated with abortion-related infections. METHODS: A secondary analysis of the WHO Multi-Country Survey on Abortion-related morbidity (MCS-A) conducted in 210 health facilities of 11 Sub-Saharan African countries between 2017 and 2018. The outcome variable was abortion-related infections, categorized into three mutually exclusive groups of abortion-related complications: infections only, infection with other complications, and other complications without infection. We described the sociodemographic and clinical characteristics and the management of abortion-related infection and identified the factors associated with abortion-related infections using a multinomial logistic model. RESULTS: A total of 9232 women with abortion-related complications were included, with infection occurring among 10.6% of women (n = 974). Infection was involved in 47.4% (n = 153) of severe maternal outcomes with a case fatality rate of 27.4% (n = 42). The most common management approach was antibiotics, uterine evacuation, and uterotonics combined: 43.2% (n = 384) in the group of women with infection only and 48.6% (n = 4235) among those with infection and other complications. In addition, 85.9% (n = 7095) of women without infection also received therapeutic antibiotics. Factors associated with an increased odds of infection only compared with complication without infection were age younger than 20 years compared with those aged over 30 (aOR 1.84; 95% CI,1.24-2.74), not living in a couple (aOR 2.05, 95% CI,1.52-2.76), and gestational age of 13 weeks or more (aOR 1.70, 95% CI,1.27-2.26). The same factors were associated with infection and other complications. CONCLUSION: Infection is frequent among severe abortion-related complications, and its case fatality rate is high. Further research to assess the relationship between abortion-related infections and outcomes is needed. There is also a need to question the quality of postabortion care and improve adequate use of antibiotics.

Health facilities' capability to provide comprehensive postabortion care in Sub-Saharan Africa: Evidence from a cross-sectional survey across 210 high-volume facilities.

OBJECTIVE: To evaluate the capability of high-volume comprehensive emergency obstetric care (CEmOC) health facilities on the provision of comprehensive postabortion care (PAC) in Sub-Saharan Africa and to determine the frequency of women with severe abortion-related complications in high capability facilities. METHODS: A cross-sectional analysis conducted across 11 countries in Sub-Saharan Africa, using facility-level information from the World Health Organization (WHO) Multi-Country Survey on Abortion-related morbidity (MCS-A) between 2017 and 2018. PAC signal functions were adapted to assess facilities' capability to deliver comprehensive PAC through infrastructure, standard comprehensive capability, and extended comprehensive capability to provide PAC. The percentage of facilities with each signal function and distribution of facilities by number of signal functions were calculated for the three capability categories. Distribution of severe abortion complications by facility capability score was assessed. RESULTS: Of 210 high-volume CEmOC facilities included, 47.9% (n = 100) had capability to provide all facility infrastructure signal functions, 54.4% (n = 105) for standard comprehensive PAC, reducing to 17.7% (n = 34) for extended comprehensive PAC capability. Overall, there were gaps in extended capabilities including availability of a functioning ICU (available in 37.3% of facilities) and providers 24/7 (65.5% of facilities reported an obstetrician available 24/7 dropping to 41.3% for anesthesiologists). Facilities' PAC capability varied across regions. Overall, 34.6% (n = 614) of women with severe abortion-related complications were treated in facilities with the maximum capability score for extended comprehensive PAC. CONCLUSION: Although high levels of capability to provide abortion-related care for most signal functions were evident, significant gaps that impact on the management of severe abortion-related complications remain, particularly related to extended facility capabilities including specialized human resources and ICU.

Level and determinants of contraceptive uptake among women attending facilities with abortion-related complications in East and Southern Africa.

OBJECTIVE: To investigate the level and determinants of nonreceipt of contraception among women admitted to facilities with abortion-related complications in East and Southern Africa. METHODS: Cross-sectional data from Kenya, Malawi, Mozambique, and Uganda collected as part of the World Health Organization (WHO) Multi-Country Survey on Abortion-related morbidity. Medical record review and the audio computer-assisted self-interviewing system were used to collect information on women's demographic and clinical characteristics and their experience of care. The percentage of women who did not receive a contraceptive was estimated and the methods of choice for different types of contraceptives were identified. Potential determinants of nonreceipt of contraception were grouped into three categories: sociodemographic, clinical, and service-related characteristics. Generalized estimating equations were used to identify the determinants of nonreceipt of a contraceptive following a hierarchical approach. RESULTS: A total of 1190 women with abortion-related complications were included in the analysis, of which 33.9% (n = 403) did not receive a contraceptive. We found evidence that urban location of facility, no previous pregnancy, and not receiving contraceptive counselling were risk factors for nonreceipt of a contraceptive. Women from nonurban areas were less likely not to receive a contraceptive than those in urban areas (AOR 0.52; 95% CI, 0.30-0.91). Compared with women who had a previous pregnancy, women who had no previous pregnancy were 60% more likely to not receive a contraceptive (95% CI, 1.14-2.24). Women who did not receive contraceptive counselling were over four times more likely to not receive a contraceptive (AOR 4.01; 95% CI, 2.88-5.59). CONCLUSION: Many women leave postabortion care having not received contraceptive counselling and without a contraceptive method. There is a clear need to ensure all women receive high-quality contraceptive information and counselling at the facility to increase contraceptive acceptance and informed decision-making.

Adolescents' satisfaction with care for abortion-related complications in 11 Sub-Saharan African countries: A cross-sectional facility-based study.

OBJECTIVE: To assess satisfaction with care for abortion-related complications experienced among adolescents compared to older women. METHODS: A secondary analysis of the WHO Multi-Country Survey on Abortion-related Morbidity and Mortality-a cross-sectional study conducted in health facilities in 11 Sub-Saharan African countries. Women with abortion-related complications who participated in an audio computer-assisted self-interview were included. Two composite measures of overall satisfaction were created based on five questions: (1) study participants who were either satisfied or very satisfied across all five questions; and (2) study participants who reported being very satisfied only across all five questions. Multivariable general estimating equation analyses were conducted to assess whether there was any evidence that age (adolescents 12-19 years and older women 20+) was associated with each composite measure of satisfaction, controlling for key confounders. RESULTS: The study sample consisted of 2817 women (15% adolescents). Over 75% of participants reported being satisfied or very satisfied for four out of five questions. Overall, 52.9% of study participants reported being satisfied/very satisfied across all five questions and 22.4% reported being consistently very satisfied. Multivariable analyses showed no evidence of an association between age group and being either satisfied or very satisfied (OR 1.07; 95% CI, 0.82-1.41, P = 0.60), but showed strong evidence that adolescents were 50% more likely to be consistently very satisfied with their overall care than older women (OR 1.49; 95% CI, 1.13-1.96, P = 0.005). CONCLUSION: Both adolescents and older women reported high levels of satisfaction with care when looking at different components of care individually, but the results of the composite measure for satisfaction showed that many study participants reported being less than satisfied with at least one element of their care. Further studies to explore the expectations, needs, and values of women's satisfaction with care for abortion-related complications are needed.

Understanding abortion-related complications in health facilities: results from WHO multicountry survey on abortion (MCS-A) across 11 sub-Saharan African countries.

INTRODUCTION: Complications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women's experience of abortion care in Africa. METHODS: A cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women's characteristics, clinical information and women's experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women's characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women's characteristics and severity of complications. RESULTS: There were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%). CONCLUSION: There is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women's experiences of abortion care.