Three Delays Model applied to prevention of unsafe abortion in Ghana: a qualitative study

BackgroundUnsafe abortion is an important public health problem in Ghana, making significant contributions to the morbidity and mortality of reproductive-aged women. Although mostly used in explaining mortality associated with perinatal care, recent calls for research on induced abortion in Africa suggest that the Three Delays Model could be used to enhance understanding of women’s experiences and access to induced abortion care.MethodsWe conducted 47 face-to-face interviews with women who had experienced unsafe abortions, with formal abortion providers (abortion providers in hospitals) and with informal and non-legal abortion providers (pharmacy workers and herb sellers). Study participants were recruited from selected hospitals, community pharmacies and markets within the Ashanti region of Ghana. We drew on phenomenology to analyse the data.FindingsThe first delay (in seeking care) occurred because of women’s poor knowledge of pregnancy, the influence of religion, and as a result of women underestimating the seriousness of abortion complications. Factors including cost, provider attitudes, stigma, and the proximity of pharmacies to women’s homes delayed their access to safe abortion and resulted in their experience of the second delay (in reaching a healthcare facility). The third delay (in receiving appropriate care) was a result of hospitals’ non-prioritisation of abortion complications and a shortage of equipment, resulting in long hospital waiting times before treatment.ConclusionThis study has shown the value of the Three Delays Model in illustrating women’s experiences of unsafe abortions and ways of preventing the first, second and third delays in their access to care.

Factors Associated with Abortion Complications after the Implementation of a Surveillance Network (MUSA Network) in a University Hospital

Objective To evaluate the factors associated with abortion complications following the implementation of the good-practice surveillance network Mujeres en Situación de Aborto (Women Undergoing Abortion, MUSA, in Spanish). Methods A cross-sectional study with women who underwent abortion due to any cause and in any age group at UNICAMP Women's Hospital (part of MUSA network), Campinas, Brazil, between July 2017 and Agust 2019. The dependent variable was the presence of any abortion-related complications during hospitalization. The independent variables were clinical and sociodemographic data. The Chi-square test, the Mann–Whitney test, and multiple logistic regression were used for the statistical analysis. Results Overall, 305 women were enrolled (mean ± standard deviation [SD] for age: 29.79 ± 7.54 years). The mean gestational age was 11.17 (±3.63) weeks. Accidental pregnancy occurred in 196 (64.5%) cases, 91 (29.8%) due to contraception failure. At least 1 complication was observed in 23 (7.54%) women, and 8 (34.8%) of them had more than 1. The most frequent complications were excessive bleeding and infection. The factors independently associated with a higher prevalence of complications were higher gestational ages (odds ratio [OR]: 1.22; 95% confidence interval [95%CI]: 1.09 to 1.37) and contraceptive failure (OR: 3.4; 95%CI: 1.32 to 8.71). Conclusion Higher gestational age and contraceptive failure were associated with a higher prevalence of complications. This information obtained through the surveillance network can be used to improve care, particularly in women more susceptible to unfavorable outcomes.

Community-Based Study of Abortion Complications and Care Sought by Rural Tribal Women of an Extremely Low Resource Setting

OBJECTIVE: Knowing about complications, care sought by women is essential for understanding the risks, services, programs, and policies for abortion care. This study aimed to know the magnitude of abortion complications and to define the care sought by rural tribal women. STUDY DESIGN: Rural community-based cross-sectional study was carried out in villages near Sewagram Wardha and Melghat, Amravati, Maharashtra, India. RESULTS: Spontaneous abortions rate was 3.30% in villages around Sewagram and 0.32% in villages of Melghat. The reported complications rate for induced abortions was 1% in Sewagram villages and 0.1%in Melghat villages. In Sewagram villages, among 24 (4.3%) women who had complications with spontaneous abortions, the reported complications were: vaginal bleeding in 33.3% (1.4% of all spontaneous abortions), abdominal pain in 33.3%, weakness in 29.16% (1.2% all spontaneous abortions), backache in16.6% (0.7%of spontaneous abortions), fever in 12.5%(0.5% of spontaneous abortions), excessive vaginal discharge in 8.33% (0.3% of spontaneous abortions), and other complications in 8.33% (0.36% of spontaneous abortions) women. Among 7 women (3.9% of all 177), who reported complications after induced abortions, 57.1% (2.2% of all induced abortions) reported, vaginal bleeding and 28.5% (1.1% of induced abortions) reported abdominal pain. In Melghat villages only 4 women reported complications with spontaneous abortions (0.32% spontaneous abortions): two (0.16% spontaneous abortions) reported abdominal pain, one (0.08% spontaneous abortions) reported vaginal bleeding, and one (0.08% of spontaneous abortions) reported backache. In villages of Melghat 2 women (3.7%) out of 27 induced abortions cases had complications: one had vaginal bleeding, discharge, pain, weakness, another only vaginal bleeding. In villages of Melghat 2 of the total 6 sought health facility care, however, no one reported to specialists despite complications. Nevertheless, there was neither abortion-related mortality nor near-miss morbidity or severe morbidity during the same duration. CONCLUSION: Research is needed about traditional therapies, reverse pharmacology, socio-behavioral issues in addition to creating awareness in women about abortion complications, long-term squeal, and the necessity of care-seeking.

Effects of implementing a postabortion care strategy in Kinshasa referral hospitals, Democratic Republic of the Congo

Objectives To evaluate the effects of the implementation of a postabortion care (PAC) strategy in Kinshasa referral hospitals, this study analyzed the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization. Methodology We estimated the effects of the PAC strategy using a quasi-experimental study by evaluating the outcomes of 334 patients with the diagnosis of a complication of induced abortion admitted to 10 hospitals in which the PAC strategy was implemented compared to the same outcomes in 314 patients with the same diagnosis admitted to 10 control facilities from 01/01/2016 to 12/31/2018. In response to government policy, the PAC strategy included the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. The information was collected using a questionnaire and stored using open data kit software. We supplemented this information with data abstracted from patient records, facility registries of gynecological obstetrical emergencies, and family planning registries. We analyzed data and developed regression models using STATA15. Thus, we compared changes in use of specific treatments and duration of hospitalization using a "difference-in-differences" analysis. Results The implementation of PAC strategy in Kinshasa referral hospitals has resulted in the utilization of WHO recommended uterine evacuation method MVA (29.3% more in the experimental structures, p = 0.025), a significant decline in sharp-curettage (19.3% less, p = 0.132), and a decline in the duration of hospitalization of patients admitted for PAC (1 day less, p = 0.020). We did not observe any change in the use of PAC services, mortality, and the provision of post abortion contraception. Conclusion Despite significant improvement in the management of PAC, the uptake in WHO approved technology—namely MVA, and the duration of hospitalization, these outcomes while a significant improvement for DRC, indicate that additional quality improvement strategies for management of PAC and risk-mitigating strategies to reduce barriers to care are required.

Pregnancy after the diagnosis of lymphangioleiomyomatosis (LAM)

Background Lymphangioleiomyomatosis (LAM) is a rare disease that almost exclusively affects women of reproductive age. Patients are warned of the increased risks if they become pregnant. However, information on pregnancy in patients after the diagnosis of LAM is limited. Methods Patients were collected from the LAM registry study at Peking Union Medical College Hospital, Beijing, China. Patients with a history of pregnancy after the diagnosis of LAM were included. Medical records were reviewed, and baseline information and data during and after pregnancy were collected in May 2018. Results Thirty patients with a total of 34 pregnancies after the diagnosis of LAM were included. Livebirth, spontaneous abortion and induced abortion occurred in 10, 6 and 18 pregnancies, respectively. Sirolimus treatment was common (17/34). A total of 6/10, 5/6, and 6/18 patients with livebirths, spontaneous abortions, and induced abortions respectively, had a history of sirolimus treatment. Ten pregnancies (29.4%) had LAM-associated complications during pregnancy, including the exacerbation of dyspnea in 7 patients, pneumothorax in 3 patients (2 resulting in induced abortion and 1 successful parturition), and spontaneous bleeding of renal angiomyolipomas in 2 patients (both having successful parturition). No chylothorax was found during pregnancy. There were six pregnancies in six patients (17.6%) who had a history of livebirth after sirolimus treatment for LAM (all having successful parturition and healthy infants); two of these patients reported exacerbated dyspnea after parturition compared with before pregnancy. Conclusions Patients with LAM, especially those taking sirolimus before pregnancy, were at a higher risk of spontaneous abortion. Complications such as pneumothorax, bleeding of renal angiomyolipoma, and exacerbated dyspnea during pregnancy were common. In patients without spontaneous abortion, sirolimus discontinuation before or during pregnancy did not lead to increased adverse neonatal outcomes.

KNOWLEDGE AND PRACTICE OF POST-ABORTION CARE BY MIDWIVES IN SELECTED PRIMARY HEALTH CARE FACILITIES IN ASHANTI REGION, GHANA

In Ghana, abortion-related mortality is considered a major public health issue that needs to be addressed. Midwives have been trained to safely and effectively provide post-abortion care in the country, yet the expected decline in maternal deaths from abortion complications especially in the rural settings is yet to be realized. Primary Healthcare (PHC) facility is the first point of contact for the rural populace, yet there is minimal evidence on the capacity of midwives serving there to provide post-abortion care. This study assessed the knowledge and practice of post abortion care among midwives in selected primary healthcare (PHC) facilities in Ashanti region of Ghana. A cross sectional descriptive survey design was utilized for the study, and a multi-staged sampling technique was used to select 16 PHCs comprising both government (11) and private (5) owned, from which 112 participants were recruited. A pre-tested structured, self-developed questionnaire was employed to obtain information from the study participants. Obtained data were analyzed using SPSS version 21. A total of 109 questionnaires were accurately completed out of 112 administered, giving a response rate of 97.3%. The midwives’ knowledge of post abortion care (PAC) was mainly in the areas of PAC as treatment for abortion complications 49(36%), while knowledge on the other PAC components was low. Only 63(58%) of the respondents had training on PAC, which was basically on the use of Manual Vacuum Aspiration (MVA) to complete incomplete abortion 52(41%). Among the 70(64%) respondents who indicated that their PHC facilities provide PAC services, only 72(66%) of them actually carried out post abortion care. Reasons advanced by the other 39(36%) who never carried out PAC were lack of; confidence 30(815), skills 27(73%), and knowledge 20(54%). The study recommended the training of midwives serving in PHCs in all components of post-abortion care as a feasible strategy for decentralizing PAC services and reaching out to the neglected rural populace. This aspect of reproductive health need to be re-emphasized in midwifery training curricula, buttress with regular mandatory continuing professional development in the area to improve skills.

Healthcare providers’ practice and attitude towards abortion service provision in Gulu city, Northern Uganda

Background: Unsafe abortion is a growing public health problem concern globally despite being preventable. The World Health Organization estimates that about 20 million pregnancies results into unsafe abortion globally. The proportion of unsafe abortion has been increasing with developing countries contributing about 97% of unsafe abortions cases including Uganda. Unsafe abortion is among the four leading causes of pregnancy related mortality, injuries, and disability globally. The restrictive abortion laws and religious situation make abortion a highly controversial social issue in Uganda leading to high stigma in the society, and a majority of the healthcare providers are reluctant to perform an abortion even if indicated for fear of possible legal consequences.Methods: We conducted survey among health worker about knowledge of complications, practice, and attitudes of induced abortion between September and November 2019 among 252 healthcare providers in Gulu Municipality, Northern Uganda. Multivariate analysis showed associations between healthcare providers' characteristics and adequate knowledge about abortion complications. Ordinary least square regression analysis found associations between providers' characteristics and their intention for general support, generally not in support, conditional support for abortion provision, as well as their personal attitudes and beliefs against or towards abortion provision.Results: The mean attitudinal score for generally in support, generally not in support, conditional in support, personal attitude, and beliefs against and toward abortion provision were 2.80, 2.71, 2.86, 3.239, and 3.35 respectively. Participants who were married and practice Anglican religion were more likely to have good knowledge of abortion complications, p-values 0.035, and 0.042 respectively, meanwhile participants who were employed in faith-based facilities were more likely to have poor knowledge of abortion complications p-value 0.002.Conclusion: Ministry of Health and stakeholders need to provide training of health workers to improve quality of abortion services. Medical training institutions should ensure that students understand the laws and responsibilities that govern their professional actions with respect to abortion care regardless of their personal views, beliefs, and attitudes.