Women's empowerment and attitudes towards female genital mutilation abandonment in Nigeria: A cross-sectional analysis of the Nigeria demographic health survey.

Female genital mutilation (FGM) is a human rights violation that impacts the social, physical, psychological, sexual, and gynecological wellbeing of women and girls. Even so, FGM persists in many Nigerian communities. Using data from the 2018 Nigeria Demographic and Health Survey, we investigated the association between women's empowerment and attitudes towards FGM abandonment. A weighted logistic regression adjusting for demographic factors, contraceptive use, contraceptive decision-making power, and severity of FGM was used to assess the influence of the validated African Women's Empowerment Index-West on women's favorability to abandoning FGM as a practice. This study found that higher education level, zero acceptance of violence against women, and higher access to healthcare as indicators of empowerment were associated with support for FGM abandonment. Additional research is needed to understand further the influences on decision making and to further research the various empowerment scales and their impact on FGM abandonment.

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.

Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and Trans Nzoia counties Kenya.

INTRODUCTION: The rate of unsafe abortions in Kenya has increased from 32 per 1000 women of reproductive age in 2002 to 48 per 1000 women in 2012. This is one of the highest in Sub-Saharan Africa. In 2010, Kenya changed its Constitution to include a more enabling provision regarding the provision of abortion services. Abortion-related stigma has been identified as a key driver in silencing women's ability to reproductive choice leading to seeking to unsafe abortion. We sought to explore abortion-related stigma at the community level as a barrier to women realizing their rights to a safe, legal abortion and compare manifestations of abortion stigma at two communities from regions with high and low incidence of unsafe abortion. METHODS: A qualitative study using 26 focus group discussions with general community members in Machakos and Trans Nzoia Counties. We used thematic and content analysis to analyze and compare community member's responses regarding abortion-related stigma. RESULTS: Although abortion is recognized as being very common within communities, community members expressed various ways that stigmatize women seeking an abortion. This included being labeled as killers and are perceived to be a bad influence for women especially young women. Women reported that they were poorly treated by health providers in health facilities for seeking abortion especially young unmarried women. Institutionalization of stigma especially when Ministry of Health withdrew of standards and guidelines only heightened how stigma presents at the facilities and drives women seeking an abortion to traditional birth attendants who offer unsafe abortions leading to increased morbidity and mortality as a result of abortion-related complications. CONCLUSION: Community members located in counties in regions with high incidence of unsafe abortion also reported higher levels of how they would stigmatize a woman seeking an abortion compared to community members from counties in low incidence region. Young unmarried women bore the brunt of being stigmatized. They reported a lack of a supportive environment that provides guidance on correct information on how to prevent unwanted pregnancy and where to get help. Abortion-related stigma plays a major role in women's decision on whether to have a safe or unsafe abortion.

Abortion services for sex workers in Uganda: successful strategies in an urban clinic.

Sex workers' need for safe abortion services in Uganda is greater than that of the population of women of reproductive age because of their number of sexual contacts, the inconsistent use of contraception and their increased risk of forced sex, rape or other forms of physical and sexual violence. We sought to understand sex workers' experiences with induced abortion services or post-abortion care (PAC) at an urban clinic in Uganda. We conducted nine in-depth interviews with sex workers. All in-depth interviews were audiotaped, transcribed, translated, computer recorded and coded for analysis. We identified several important programmatic considerations for safe abortion services for sex workers. Most important is creating community-level interventions in which women can speak openly about abortion, creating a support network among sex workers, training peer educators, and making available a community outreach educator and community outreach workshops on abortion. At the health facility, it is important for service providers to treat sex workers with care and respect, allow sex workers to be accompanied to the health facility and guarantee confidentiality. These programmatic elements help sex workers to access safe abortion services and should be tried with all women of reproductive age to improve women's access to safe abortion in Uganda.

Women's perceptions about abortion in their communities: perspectives from western Kenya.

Unsafe abortion in Kenya is a leading cause of maternal morbidity and mortality. In October 2012, we sought to understand the methods married women aged 24-49 and young, unmarried women aged ≤ 20 used to induce abortion, the providers they utilized and the social, economic and cultural norms that influenced women's access to safe abortion services in Bungoma and Trans Nzoia counties in western Kenya. We conducted five focus groups with young women and five with married women in rural and urban communities in each county. We trained local facilitators to conduct the focus groups in Swahili or English. All focus groups were audiotaped, transcribed, translated, computerized, and coded for analysis. Abortion outside public health facilities was mentioned frequently. Because of the need for secrecy to avoid condemnation, uncertainty about the law, and perceived higher cost of safer abortion methods, women sought unsafe abortions from community midwives, drug sellers and/or untrained providers at lower cost. Many groups believed that abortion was safer at higher gestational ages, but that there was no such thing as a safe abortion method. Our aim was to inform the design of a community-based intervention on safe abortion for women. Barriers to seeking safe services such as high cost, perceived illegality, and fear of insults and abuse at public facilities among both age groups must be addressed.