Knowledge, attitudes, practices and behaviour of maternity ward staff in relation to comprehensive abortion care in a conflict-affected setting, Bangui, Central African Republic: cross-sectional survey

INTRODUCTION
Abortion-related complications remain a major cause of maternal mortality worldwide. The Castor Maternity Unit (CMU) in Bangui, CAR, serves nearly 500,000 people affected by chronic armed conflict. The country’s maternal mortality ratio (890/100,000 live births) is among the world’s highest. Abortion-related complications are a major cause of maternal death in the country and a substantial contributor to CMU admissions. To understand factors contributing to the magnitude and severity of abortion complications in this setting, we carried out a knowledge, attitudes, practices, and behavior (KAPB) survey among CMU health professionals.

METHODS
A cross-sectional quantitative survey was done using a self-administered questionnaire to all physicians, midwives, and nurses providing post-abortion care (PAC) in CMU, asking questions about PAC, contraception, and safe abortion care (SAC). We used descriptive analysis to present frequencies and proportions.

ETHICS
This study was approved by the CAR Ethics Committee, the Institutional Review Board of the Guttmacher Institute, and the MSF Ethics Review Board.

RESULTS
The provider response rate was 94% (84/89). Personal experience with unsafe abortion was common: 89% (n=75) of respondents knew someone personally who had died from an unsafe abortion. Almost 70% (n=56) considered access to SAC to be every woman’s right. Correct knowledge of the legality of abortion in CAR varied between 48-80% (n=40-67). Most of the respondents (n=47; 56%) reported having referred at least one woman for SAC. A question about providers’ conscientious objections to providing SAC found that 76% (n=59) noted strong agreement with the statement that health professionals should refer patients to another provider if they had objections to SAC provision. More than 90% (n=75) considered PAC to be every woman’s right. Despite a significant caseload of severe complications linked with abortion, only 21% of respondents (n=18) correctly identified the WHO near-miss criteria, which diagnose very severe abortion complications. Additionally, while dilatation and curettage is currently not recommended by clinical guidelines, 44% of respondents providing PAC (n=27) stated they were still using this method, at least some of the time. Contraception was provided by 85% of respondents (n=71) without issue but a smaller proportion (n=49; 59%) stated overt support when asked if they would provide contraception to minors without parental consent. While 76% (n=64) of respondents were trained in implant insertion, only 30% (n=26) were trained in inserting intrauterine devices.

CONCLUSION
CMU healthcare professionals were generally supportive of PAC, contraception and SAC. Nevertheless, we still found shortcomings in their knowledge and practices. Although limited by small sample size, the high response rate does permit drawing recommendations for this maternity unit. Innovative approaches for continuing education and capacity-building are needed, which could include workshops exploring values and attitudes about abortion, alongside efforts to simplify near-miss approaches, and training on all contraception methods to provide for women’s personal preferences. These could improve the facility towards provision of the full range of comprehensive abortion care.

CONFLICTS OF INTEREST
None declared.