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.

Examining reuse and replacement procedures for Ipas manual vacuum aspiration and cannulae in nine countries.

OBJECTIVE: To determine how many times Ipas manual vacuum aspiration (MVA) instruments are reused, for what reasons, when the instruments are replaced and/or discarded, and what the barriers are to replacing them. METHODS: We conducted a mixed-methods cross-sectional study of health care providers who provide MVA services and key stakeholders in the supply chain to understand reuse and replacement of Ipas MVA aspirators and cannulae. Qualitative interviews focused on procurement and replacement of Ipas MVA instruments. RESULTS: The authors interviewed 352 health care providers from nine countries from 2019 to 2021. Providers reported reusing MVA instruments an average of 34.4 times (standard deviation, 45). The reuse averages ranged from one time (Democratic Republic of the Congo) to 500 times (India), with figures varying between providers within the same country. Instrument malfunctioning rather than a specific number of uses drove reuse and subsequent replacement. The decision to replace was most commonly made by the provider during use. Half of the providers said that they knew of no issues with the supply chain, and 85% said they were always able to replace Ipas MVA instruments when needed. CONCLUSION: Tracking reuse of MVA instruments was uncommon at participating providers' health facilities. Providers' estimates revealed great variability in reuse frequency and tracking procedures.

Impacts of COVID-19 on reproductive health service provision, access, and utilization in Ethiopia: Results from a qualitative study with service users, providers, and stakeholders.

Ethiopia has made significant improvements to sexual and reproductive health (SRH) in recent decades, yet the COVID-19 pandemic brought new challenges to SRH service delivery. In the early months of the pandemic, health facility and health management information system data showed reductions in SRH service utilization, however more evidence is needed on ongoing SRH impacts to inform policy and program decision-making. Our study aimed to assess the impacts of COVID-19 on SRH service utilization and access from the perspective of providers, clients, and stakeholders in Addis Ababa and Amhara Regional State. We collected data from May through July 2021 via six focus group discussions with health service providers, 50 in-depth interviews with SRH service clients and 15 key informant interviews with policy and programmatic stakeholders. All audio recordings were transcribed and translated from Amharic into English. Data were coded and analyzed for content and themes using Excel and NVivo 10. We found that COVID-19 and associated public health mitigation measures had consequences on SRH prioritization, funding, and service delivery. Efforts to halt the spread of COVID-19, such as gathering and transportation restrictions, also reduced access to SRH services. Fear of infection, costly and inaccessible transportation, commodity stockouts, and limited service availability all impeded access to and use of SRH services. For some women, this meant losing timely access to contraception and subsequently facing unwanted pregnancies. Providers experienced increased workloads, anxiety, and stigma as possible sources of infection. Our findings offer useful learnings for program and policy stakeholders aiming to meet SRH needs during the pandemic, and during times of crisis more broadly.

Sexual and reproductive health experiences, access to services, and sources of information among university students in Ethiopia.

Introduction: Adolescence and youth are times of major growth and change that can place young people at elevated risk of poor sexual and reproductive health (SRH) outcomes, particularly when they are living away from home for the first time. Understanding the barriers that young people face when accessing SRH services and information is imperative for addressing their SRH needs; our study explored this topic among university students in Ethiopia. Specifically, we explore university students' SRH experiences, access to services, and preferred sources of information. Methods: We draw on mixed-methods research conducted in four public universities across Ethiopia in early 2020. A random sample of 822 male and female students completed a cross-sectional survey that explored SRH knowledge, attitudes, experiences, and sources of information. We also conducted 8 focus group discussions with students and 8 key informant interviews across the four universities. Survey data were analyzed using descriptive statistics and we used structural coding and inductive analysis to analyze qualitative data. Results: The survey data demonstrated that condoms and emergency contraceptive pills were the most used contraceptive methods. Nearly 18% of female students had experienced an unwanted pregnancy, and 14% reported having had an abortion. Approximately one-third of students reported encountering gender-based violence in the past 6 months. Most students preferred receiving SRH information from mass media, and male students were more likely than female students to seek information from friends. Our qualitative findings highlight a lack of comprehensive SRH care available on university campuses, and services that are available are often of poor quality; participants described a lack of privacy, confidentiality and respect when accessing SRH care at school. University students also lack regular opportunities to learn about SRH while on campus, and their preferred sources of information varied widely. Discussion: Ethiopian university students have considerable unmet demand for SRH services and often face significant barriers to accessing high-quality information and services on campus. Consistent commitment and investment by universities and the government is vital to meeting the SRH needs of young people during this potentially vulnerable time.

Community-based intervention improves abortion knowledge and reduces abortion stigma among women in Oromia, Ethiopia: a quasi-experimental mixed methods evaluation.

BACKGROUND: Since liberalization of the Ethiopian abortion law, there have been significant improvements in the availability and utilization of facility-based abortion services in the country. However, nearly half of abortions still take place outside of health facilities, where the quality of procedures remains unknown. Abortion stigma is one reason that unsafe abortion persists. This study aims to evaluate the effect of community interventions conducted from 2016 to 2019 on the level and manifestation of abortion stigma and knowledge in a community in Oromia region, Ethiopia. METHODS: The study is a quasi-experimental mixed methods evaluation including intervention and comparison communities. Two cross-sectional structured household surveys with independent samples, participatory evaluation wheels, and participatory impact diagrams were conducted with women of reproductive age (15-49) living in the communities. The baseline was conducted in 2016 and the endline in 2019. Difference-in-differences analysis was used to estimate the effect of the intervention on abortion knowledge and Stigmatizing Attitudes, Beliefs, and Actions Scale (SABAS) scores in the intervention community. RESULTS: One thousand five hundred fifty-five women participated in the household survey and 28 women participated in participatory evaluation meetings. Over one-third (37%) of women surveyed in the intervention community were exposed to the intervention activities. Knowledge of one or more indications of legal abortion increased from 21 to 85% in the intervention community, compared to an increase from 30 to 57% in the comparison. Mean SABAS scores decreased by 9.3 points in the intervention community and increased by 5.3 points in the comparison community. Differences-in-differences models indicate that exposure to the intervention resulted in decreased stigma scores (coefficient = - 9.33, p < 0.001) and increased knowledge (coefficient = 0.26, p < 0.001). CONCLUSIONS: This is one of the first studies to measure changes in community-level abortion stigma and knowledge over time in Ethiopia using a mixed method, quasi-experimental design. The results indicate that the community-based intervention improved abortion knowledge and reduced abortion stigma.