Post abortion care quality status in health facilities of Guraghe zone, Ethiopia

The study was conducted in Guraghe zone. In the zone there were 26 health centers and three hospital (one public and two non governmental). According to the zonal health bureau eleven health facilities have initiated PAC service (two hospitals and nine health centers). The study was conducted from January to March, 2010. In the selected health facilities the qualitative study was done by direct service delivery observation and inventorying using checklist of supplies, equipments and medications.

A facility based cross-sectional study involving both quantitative and qualitative methods was conducted. The study has measured the following aspects of quality of PAC; client satisfaction, providers technical competence, availability of equipment and supplies.

Women who sought PAC services and health care providers directly involved in PAC services in all health facilities that provide PAC service (six health centers and two hospitals) during the study period. Health facilities which were difficult to reach or inaccessible due to logistical reasons were excluded from the study. Also, those patients who have hearing problem, mentally disabled, patients who declined to participate, the severely ill, patients who left against medical advice or had a gestational age greater than 28 weeks were excluded from the study.

The sample size was determined using the following assumptions (Level of significance of the population was taken to be 95%, Zα/2 = 1.96). A 5% level of precision (d = 0.05) and 50% proportion of women satisfied with PAC service (P = 0.5). Therefore the total sample size for this study was 422 women seeking PAC service including 10% none respondent rate. All health care providers who were directly involved in PAC service at the studied health facilities during the study period were included.

All post abortion patients consecutively discharged from the selected health facilities were included in the study until the required number of cases reached. This was done through a quota sampling technique which was a recommended method to study abortion in a facility setting [2].

Client exit interviewing was done by female staff nurses working in another department in the same facility. Female staff nurses were preferred to conduct the interviews because our study participants were females and it was highly likely that they provide unbiased information to female interviewers. The data collectors were trained for three days by the principal investigator on the objectives of the study and how to conduct the interview, fill in the questionnaire and handle questions asked by clients. Data from service providers was collected using a self-administered questionnaire in English. Experienced health officers and BSc nurses who have received training on comprehensive PAC conducted the service delivery observation using a check list. They received a one day orientation on methodology of observation. Verbal consent was obtained from the patients and providers before conducting the observation. The observers were in white coats and remained inconspicuous so as not to interfere with routine service provision. The principal investigator used a standardized check list to assess availability of equipments, supplies and medications for post abortion care service in all the studied health facilities.

Responses were coded and entered using Epi info version 3.5.1. Data were then exported to SPSS version 15 for further analysis. Descriptive statistics and summary measures of the variables were conducted. A crude and adjusted odds ratio with 95% confidence interval from bivariate and multi-variate analyses was used to measure association between dependent and independent variables. Data were also obtained from inventorying and observation check list. They were extracted, organized, presented and pertinent information was examined in relation to the quantitative results in which it was triangulated with the other quantitative results and presented separately.

Standardized observation and an inventorying check list were used. A questionnaire for client exit interview was adapted from similar study in Ethiopia [6] and modified to the study context by reviewing other previous similar studies. Its English version was translated into Amharic and again back to English so as to ensure its consistency. The questionnaire was pretested on 21 clients in one of the health facility other than the selected study facilities and corrections were made on omitted, an answerable or unclear questions accordingly. Data collectors were health professionals who have experience on the area and received proper training on the data collection tool. Five percent of the data was reentered and compared with the already entered data.

Ethical clearance was obtained from Haramaya University institutional research ethics review committee. An official letter of co-operation was also written to the Guraghe zone health bureau. Written informed consent was obtained from each study participant. Confidentiality was maintained by avoiding names and other personal identification information whereas privacy was maintained by conducting the exit interview in a separate room that offered visual and auditory privacy.

Four hundred twenty two women were identified and interviewed from eight health facilities. Twenty two women refused to participate in the study making the response rate 95%. The age of post-abortion clients ranged from 15 to 41 years with a mean age of 25.3 years (SD _± 6.4). A total of 193(48.2%) participants were in the age group between 20 to 29 years. One hundred eighty five (46.2%) were housewives, 134(33.5%) were students and 29(7.2%) were daily laborers. Two hundred twenty seven (56.8%) of them were married and 222(55.5%) attended formal education varying from primary school to tertiary level.

Two hundred twenty nine (57.2%) were pregnant at least once before the current pregnancy ended in abortion. The number of children delivered by the women before the current pregnancy was ranged from having no children to eight children. Only 60(17%) gave history of previous abortion. Ninety eight (24.5%) reported that current pregnancy ended in abortion was wanted while the rest 302(75.5%) reported unwanted. Two hundred eighty two (70.5%) knew at least one contraceptive method. A history of use of contraceptives was 243(60.8%). Those who reported their current pregnancy was unwanted had partner pressure 122(40.4%) and negligence to use contraceptives regularly 102(33.8%) as a main reason for the pregnancy. The rest 31(10.3%) were uninformed about contraceptives.

The study showed that the reasons given for resorting to unsafe abortion among post abortion patients were having too close or too many pregnancies 20(40.9%), economic reason 18(36.7%), health reason 3(6.1%), partner pressure 4(8.1%), to complete their education 4(8.1%) (Table 1).

The majority of the respondents 374(93.5%) said they were treated with politeness and respect. Data from service observations also showed that majority 78(95%) of the patients were greeted in a friendly and polite manner and in 70(87.5%) of the patient the service providers were supportively speak to them during the patient provider interaction. Most of the service providers 69(86.3%) did not introduce themselves to patients by name. Providers also gave information on patient’s current illnesses 353(88.3%).

With regard to information provision; 302(75.5%) of the post abortion cases received information on current illness and family planning counseling, and 138(34.5%) of the cases were not told about danger signs that may necessitate revisiting the facilities. Follow-up appointment was given only for 76(19.0%) of the post abortion women.

When asked on how soon they could become pregnant again if they had sexual intercourse, 98(24.5%) said within two weeks, 123(30.8%) within one month, 110(27.5%) with in three months and 57(14.3%) with in six months while 10(2.5%) of them said after six months.

Majority 312(78%) of the post abortion clients have no intention to be pregnant at least within three months. Of which 178(40.5%) revealed that they never want to be pregnant, 132(33%) intended to be pregnant after two years and 18(4.5%) have intended to be pregnant within two years. But a small proportion 70(17.5%) said they intended to be pregnant within three months (Figure 1).

Two hundred twenty six (56.5%) of the post-abortion patients received at least one method of family planning method. In some of the cases, no one raised the issue of contraceptives at all and some said the contraceptive they selected was not available in the facility when mentioning the reason why they were not provided contraceptives.

Ninety six (24%) of the patients responded that the waiting time between arrival and treatment was very long. Fifty six (14%) of patients reported that they were not given pain medication though they had pain during their stay in the health facilities while the rest 257(64.3%) received pain medication and 87(21.7%) had no pain. Overall, 334(83.5%) of the patients expressed that they were satisfied with the services received.

Among those 82(20.5%) patients who have difficulty in locating the service the majority 50(61%) mentioned presence of uncooperative staff as their main reason for their difficulty in getting the service (Table 2).

Multivariate analysis (Adjusted for age, marital status, educational status, wanted current pregnancy and pain treatment) showed that statistically significant difference was observed on response to waiting time and occupational status. Those who said that waiting time was long were less satisfied (AOR = 0.230, CI = (0.118, 0.450)) than their counter part. Compared to employed post abortion clients, unemployed women were more likely to be satisfied with the post abortion service delivered (AOR = 2.566, CI = (2.12, 30.983)).

From the 34 health professionals who received the questionnaire, 9(26.5%) were health officers, 20(58.8%) were nurses and 5(14.7%) were general practitioners who provide services during data collection period. The majority of the nurses, health officers and all general practitioners handled pelvic examination, history taking and operative procedures. Some nurses were involved in taking vital signs, counseling and assisting physicians. Twelve (35.3%), 12(35.3%) and 10(29.4%) had training on STDs counseling, HIV/AIDS counseling and MVA/EVA during their basic education respectively.

Regarding training background 10(29.4%) and 17(50%) providers have taken a refresher or post basic training on FP counseling and method provision and MVA/EVA respectively. Ten (29.4%) of the providers reported FP together with other reproductive health care, followed by FP alone 5(14.7%) and emergency care with FP 4(11.8%) and emergency care with RH 4(11.8%) were not adequately provided. Regarding best place to provide family planning counseling and method 9(26.5%) reported in the MCH center, 10(29.4%) in the recovery ward while 15(44.1%) at both sites. With respect to responsibility to provide the FP service 12(35.3%) responded that it is a responsibility of staff in the MCH while 22(64.7%) reported that it is responsibility of all the staff.

Relevant equipments, supplies and medications required to provide PAC in all the studied health facilities were assessed. The availability of equipments, supplies and medications in the health facilities to fulfill the required basic equipment by the MOH, WHO and international organizations such as IPAS were examined. We have selected list of equipments recommended by WHO (such as water sink), supplies required by MOH (such as glove) and medications required by IPAS (such as from antiseptic). From the equipments, supplies and medications required, the facilities have most of the materials. Except in the two hospitals; items like emergency light source apart from backup generators were absent from most of the studied health centers. Equipments and facilities such as toilet near to PAC rooms, sinks and running water were absent in some of the health facilities. Furthermore vital equipment like ambu bags, oral airways, suction apparatus, oral air ways and oxygen apparatus were absent in most of the unit of service of the health centers and hospitals but they were available in the major operating theaters of the hospitals that were not always near to where PAC provided. Family planning methods were available in adequate amount but not in adequate mix. Especially in one faith-based hospital all types of contraceptive were totally absent except for condoms.

From eighty of the cases observed during the pre procedure 27(33.8%) of them had evidence of visual or audible pain during physical examination, and only in 11(13.8%) of them the pain seems adequately controlled. During the procedure 68(85%) of patients were asked if they were in pain, in 61(76.3%) of the cases there was evidence of pain and the pain was not adequately controlled throughout the procedure and only 17(21.3%) were given pain medication.

The strength of the study; the study has considered different assessment techniques such as patients and provider’s perspective, inventory assessment and service observation. This study also has some weaknesses. During the service observation there could be a tendency by service provider to be at their best performance due to the presence of an observer. And the study has only focused on public health facilities and doesn’t give picture of PAC practice in private health facilities.