Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria.

Background: Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. Methods: This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. Findings: We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. Interpretation: This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. Funding: The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.

Development and validation of a perceived abortion self-efficacy scale: results from Bolivia, Nepal and Nigeria.

The objective of this research was to develop and assess the validity of a scale to measure perceived abortion self-efficacy (PASE). Perceived abortion self-efficacy is defined as an individual's perceived confidence in their ability to carry out the tasks necessary to end a pregnancy safely and successfully. During the first phase of this study between February and April 2018, we conducted qualitative research using in-depth interviews and focus group discussions with women in Bolivia, Nepal, and Nigeria to explore domains of PASE. Using the qualitative data, we prepared a draft set of measures with 31 items. In October and November 2018, the second phase of the study included field testing 31 draft items with a convenience sample of approximately 1200 women across the three study countries. Exploratory factor analysis was conducted to identify an appropriate scale structure, resulting in a 15-item, 3-factor model. The three factors represent the concepts of enlisting social resources, accessing information and care, and resilience. In the third and final phase in September and October 2019, the validity of the 15 scale items was assessed. The scale was administered to a new sample of approximately 400 women in each country. Confirmatory factor analyses were conducted to test model fit for the scale structure identified during the second phase. The results from this study suggest that the final PASE scale has considerable potential to be a valid measure of PASE. The new 15-item PASE scale presented in this paper can be used to evaluate programmes or interventions designed to improve women's PASE and to assess the state of PASE in populations.

Drug sellers' knowledge and practices, and client perspectives after an intervention to improve the quality of safe abortion care outside of formal clinics in Nigeria.

BACKGROUND: In Nigeria, where abortion is legally restricted, individuals seek medication abortion drugs, including misoprostol, directly from pharmacies or drug sellers. However, knowledge of drug sellers or patent medicine vendors (PMVs) dispensation practices and women's experience with self-management is limited and research suggests poor quality of services. This study assesses the knowledge and practices of PMVs and women's experiences after a harm reduction intervention to improve the provision of medication abortion using misoprostol. METHODS: We conducted a retrospective descriptive analysis of anonymised logbook data collected from 141 Nigerian PMVs who provided misoprostol for abortion to 4924 clients between February 2015 and July 2018. We conducted a descriptive analysis of self-reported misoprostol dispensation practices with data from a cross-sectional survey of PMVs (n=120) from June 2016 to December 2018. We collected data on women's experience obtaining misoprostol from 37 PMVs through a cross-sectional survey of women (n=260) from 4-19 June 2018. RESULTS: For clients where the misoprostol dose dispensed was recorded (n=3784), 86% of clients were given 800 µg or more misoprostol, pain medication (97%) and a contraceptive method (92%). Most clients with an outcome recorded in the logbook (n=4431) had a complete abortion (86%). Almost all women reported that they would return to the PMV for future services (99%). CONCLUSIONS: The majority of PMVs dispensed misoprostol in appropriate dosages and provided clients with information on drug administration and methods of contraception. Interventions designed to improve PMVs' best practices around the provision of abortion care may help ensure the quality of services received by clients.