Journal Article > ResearchFull Text
Res Sq. 17 July 2023; DOI:10.21203/rs.3.rs-3153198/v1
Pasquier E, Owolabi OO, Powell B, Fetters T, Ngbale RN, et al.
Res Sq. 17 July 2023; DOI:10.21203/rs.3.rs-3153198/v1
BACKGROUND
Abortion-related complications remain a main cause of maternal mortality. Post-abortion care (PAC) provision in humanitarian settings suffers from limited accessibility, poor quality, and lack of research on how to address these challenges. We proposed a comprehensive conceptual framework for measuring the quality of PAC and applied it using data from the AMoCo (Abortion-related Morbidity and mortality in fragile or Conflict-affected settings) study in two hospitals supported by Médecins Sans Frontières (MSF) in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We adapted the WHO Maternal and Newborn Health quality-of-care framework to measure PAC inputs, process (provision and experience of care) and outcomes. We analyzed data from 4 study components: an assessment of the two hospitals’ PAC signal functions, a survey of the knowledge, attitudes, practices, and behavior of 140 and 84 clinicians providing PAC, a prospective review of the medical records of 520 and 548 women presenting for abortion complications, of whom 360 and 362 hospitalized women participated in an interview survey in the Nigerian and CAR hospitals, respectively.
RESULTS
Inputs – Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26.5 in the CAR hospital.
Provision of care – In both hospitals, less than 2.5% were treated with dilatation and sharp curettage, a non-recommended technology when receiving instrumental uterine evacuation. Over 80% received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients without indication. All (99%) of discharged women in CAR received contraceptive counselling but only 39% in Nigeria.
Experience of care – Women reported generally good experience of respect and preservation of dignity. But only 49% in Nigeria and 59% in CAR said they were given explanations about their care and 15% felt capable of asking questions during treatment in both hospitals.
Outcomes – The risk of healthcare-related abortion-near-miss (happening =24h after presentation) was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSION
Our proposed framework enabled comprehensive measurement of the quality of PAC in two MSF-supported hospitals in humanitarian settings. Its application identified that hospitals provided good clinical care resulting in a low risk of healthcare-related abortion-near-miss. However, hospitals need to improve provider-patient communication and would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
Abortion-related complications remain a main cause of maternal mortality. Post-abortion care (PAC) provision in humanitarian settings suffers from limited accessibility, poor quality, and lack of research on how to address these challenges. We proposed a comprehensive conceptual framework for measuring the quality of PAC and applied it using data from the AMoCo (Abortion-related Morbidity and mortality in fragile or Conflict-affected settings) study in two hospitals supported by Médecins Sans Frontières (MSF) in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We adapted the WHO Maternal and Newborn Health quality-of-care framework to measure PAC inputs, process (provision and experience of care) and outcomes. We analyzed data from 4 study components: an assessment of the two hospitals’ PAC signal functions, a survey of the knowledge, attitudes, practices, and behavior of 140 and 84 clinicians providing PAC, a prospective review of the medical records of 520 and 548 women presenting for abortion complications, of whom 360 and 362 hospitalized women participated in an interview survey in the Nigerian and CAR hospitals, respectively.
RESULTS
Inputs – Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26.5 in the CAR hospital.
Provision of care – In both hospitals, less than 2.5% were treated with dilatation and sharp curettage, a non-recommended technology when receiving instrumental uterine evacuation. Over 80% received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients without indication. All (99%) of discharged women in CAR received contraceptive counselling but only 39% in Nigeria.
Experience of care – Women reported generally good experience of respect and preservation of dignity. But only 49% in Nigeria and 59% in CAR said they were given explanations about their care and 15% felt capable of asking questions during treatment in both hospitals.
Outcomes – The risk of healthcare-related abortion-near-miss (happening =24h after presentation) was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSION
Our proposed framework enabled comprehensive measurement of the quality of PAC in two MSF-supported hospitals in humanitarian settings. Its application identified that hospitals provided good clinical care resulting in a low risk of healthcare-related abortion-near-miss. However, hospitals need to improve provider-patient communication and would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
Technical Report > Evidence Brief
Powell B, Chen H, Pasquier E, Fetters T, Owolabi OO, et al.
1 July 2023
English
Français
Conference Material > Abstract
Pasquier E, Lissouba P, Moore AM, Owolabi OO, Chen H, et al.
MSF Scientific Day International 2023. 7 June 2023; DOI:10.57740/pq3n-my95
INTRODUCTION
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. We aimed to describe the severity of abortion-related complications and contributing factors in two MSF-supported referral hospitals; one in a rural setting, northern Nigeria, and one in the capital city, Bangui, in the Central African Republic (CAR).
METHODS
This cross-sectional mixed-methods study included four components: 1) a clinical study using prospective review of medical records for women presenting with abortion-related complications between November 2019 and July 2021; 2) a quantitative survey among hospitalized women, to identify contributing factors for severe complications; 3) a qualitative study to understand the care pathways of women with severe complications; and 4) a knowledge, attitude, and practice (KAP) survey among health professionals providing post-abortion care in the two hospitals. The clinical study and the quantitative survey used the methodology of the WHO multi-country study on abortion led in 11 sub-Saharan African countries in stable contexts.
ETHICS
This study was approved by the MSF Ethics Review Board, the Central African Republic’s Comité Scientifique Chargé de la Validation des Protocoles d’Etude et des Résultats de Recherche en Santé, and by the Guttmacher Institute International Review Board.
RESULTS
520 and 548 women comprised the clinical study enrollees for the Nigerian and CAR settings, respectively; of these, 360 and 362, respectively, participated in the quantitative survey. Of these women, 66 in Nigeria and 18 in CAR were interviewed for the qualitative study. Lasty, 140 and 84 health providers in Nigeria and CAR, respectively, participated in the KAP survey. The severity of abortion complications was high: 348 (67%) and 278 (50,7%) of women had a severe complication (potentially life-threatening, near-miss, or death) respectively in Nigerian and CAR hospitals. The KAP survey showed that almost 60% and 91% of health providers in Nigerian and CAR hospitals respectively, personally knew a woman who had died from abortion complications. Among women who did not have severe bleeding (146 in Nigeria and 231 in CAR), anemia was nonetheless frequent, affecting 66.7% of women in Nigeria and 37.6% in CAR. Among women participating in the quantitative survey, 23% in Nigeria and 45% in CAR reported having induced their abortion. Among them, 97% in Nigeria and almost 80% in CAR used unsafe methods. In CAR, qualitative data indicated that these included unsafe instrumental evacuations performed by unskilled individuals, and self-administered decoctions of traditional ingredients such as herbs, roots, or vegetables, ingested either alone or in combination with pharmaceutical drugs. In Nigeria, 50% did not want to be pregnant but fewer than 3% reported using contraception at the start of the index pregnancy. In CAR, 56% did not want the pregnancy, but 37% of women reported using contraception at its start. Women faced long delays accessing care, with 50% of hospitalized women in both settings taking two or more days to reach adequate post-abortion care after the onset of symptoms. Nevertheless, delays were worse in Nigeria where 27% took six days or more to access those care, versus 16% in CAR. Qualitative data indicated that factors implicated in longer delays included delayed recognition of danger signs necessitating medical care, unsuccessful attempts to self-manage symptoms, internalized stigma causing fear of disclosure among women reporting induced abortion, and in Nigeria, requiring permission to seek care. In both settings, structural barriers associated with lack of capacity and low quality of care in local health care structures, and transport difficulties to access adequate care also increased delays. Lastly, despite restrictive legal environments in both contexts, the KAP survey revealed that most health providers (74% in Nigeria and 67% in CAR) considered that access to safe abortion care was the right of every woman.
CONCLUSION
Our data suggests a higher severity of abortion-related complications, as compared to WHO data from African hospitals in more stable settings. Factors that could contribute to such high severity include greater delays in accessing post-abortion care, decreased access to contraception and safe abortion care, resulting in unsafe abortions; and food insecurity leading to iron deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high-quality post-abortion care, to prevent and manage complications of abortions in fragile and conflict-affected settings.
CONFLICTS OF INTEREST
None declared
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. We aimed to describe the severity of abortion-related complications and contributing factors in two MSF-supported referral hospitals; one in a rural setting, northern Nigeria, and one in the capital city, Bangui, in the Central African Republic (CAR).
METHODS
This cross-sectional mixed-methods study included four components: 1) a clinical study using prospective review of medical records for women presenting with abortion-related complications between November 2019 and July 2021; 2) a quantitative survey among hospitalized women, to identify contributing factors for severe complications; 3) a qualitative study to understand the care pathways of women with severe complications; and 4) a knowledge, attitude, and practice (KAP) survey among health professionals providing post-abortion care in the two hospitals. The clinical study and the quantitative survey used the methodology of the WHO multi-country study on abortion led in 11 sub-Saharan African countries in stable contexts.
ETHICS
This study was approved by the MSF Ethics Review Board, the Central African Republic’s Comité Scientifique Chargé de la Validation des Protocoles d’Etude et des Résultats de Recherche en Santé, and by the Guttmacher Institute International Review Board.
RESULTS
520 and 548 women comprised the clinical study enrollees for the Nigerian and CAR settings, respectively; of these, 360 and 362, respectively, participated in the quantitative survey. Of these women, 66 in Nigeria and 18 in CAR were interviewed for the qualitative study. Lasty, 140 and 84 health providers in Nigeria and CAR, respectively, participated in the KAP survey. The severity of abortion complications was high: 348 (67%) and 278 (50,7%) of women had a severe complication (potentially life-threatening, near-miss, or death) respectively in Nigerian and CAR hospitals. The KAP survey showed that almost 60% and 91% of health providers in Nigerian and CAR hospitals respectively, personally knew a woman who had died from abortion complications. Among women who did not have severe bleeding (146 in Nigeria and 231 in CAR), anemia was nonetheless frequent, affecting 66.7% of women in Nigeria and 37.6% in CAR. Among women participating in the quantitative survey, 23% in Nigeria and 45% in CAR reported having induced their abortion. Among them, 97% in Nigeria and almost 80% in CAR used unsafe methods. In CAR, qualitative data indicated that these included unsafe instrumental evacuations performed by unskilled individuals, and self-administered decoctions of traditional ingredients such as herbs, roots, or vegetables, ingested either alone or in combination with pharmaceutical drugs. In Nigeria, 50% did not want to be pregnant but fewer than 3% reported using contraception at the start of the index pregnancy. In CAR, 56% did not want the pregnancy, but 37% of women reported using contraception at its start. Women faced long delays accessing care, with 50% of hospitalized women in both settings taking two or more days to reach adequate post-abortion care after the onset of symptoms. Nevertheless, delays were worse in Nigeria where 27% took six days or more to access those care, versus 16% in CAR. Qualitative data indicated that factors implicated in longer delays included delayed recognition of danger signs necessitating medical care, unsuccessful attempts to self-manage symptoms, internalized stigma causing fear of disclosure among women reporting induced abortion, and in Nigeria, requiring permission to seek care. In both settings, structural barriers associated with lack of capacity and low quality of care in local health care structures, and transport difficulties to access adequate care also increased delays. Lastly, despite restrictive legal environments in both contexts, the KAP survey revealed that most health providers (74% in Nigeria and 67% in CAR) considered that access to safe abortion care was the right of every woman.
CONCLUSION
Our data suggests a higher severity of abortion-related complications, as compared to WHO data from African hospitals in more stable settings. Factors that could contribute to such high severity include greater delays in accessing post-abortion care, decreased access to contraception and safe abortion care, resulting in unsafe abortions; and food insecurity leading to iron deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high-quality post-abortion care, to prevent and manage complications of abortions in fragile and conflict-affected settings.
CONFLICTS OF INTEREST
None declared
Conference Material > Slide Presentation
Pasquier E, Lissouba P, Chen H, Williams TN, Baudin E, et al.
MSF Scientific Day International 2023. 7 June 2023; DOI:10.57740/bxth-m543
Journal Article > Pre-PrintFull Text
Res Sq. 20 March 2023; DOI:10.21203/rs.3.rs-2671712/v1
Moore AM, Pasquier E, Williams TN, Fetters T, Powell B, et al.
Res Sq. 20 March 2023; DOI:10.21203/rs.3.rs-2671712/v1
BACKGROUND
Conducting abortion research in fragile settings presents challenges, many of which are present in other low-resourced settings to various degrees but when appearing all together, collectively served to create a set of barriers to collecting data that required creative adaptations to address and even then, we could not overcome all of them.
RESULTS
Challenges that we experienced in the course of this mixed methods research project included limited access to the study sites by research team members, research being delayed to prioritize life-saving priorities which must take precedence when resource constraints mean that both cannot be carried out, a population skeptical of participating in research due to having negative experiences with the state/other actors as well as due to being research-naïve, geographic and language constraints impacting participant recruitment because of the fact that people are coming from various displaced locations to a particular health facility, a low literacy population meant that they could not read the consent form and due to the stigmatized subject matter we did not want a family member consenting them, and respondents’ challenges participating around the time of discharge because respondents needed to travel home with family members.
CONCLUSIONS
These strategies are relevant not only to abortion research but also other research in resource-constrained/fragile and conflict-affected contexts. Improving the health of the most vulnerable can only be done through understanding barriers to care in insecure and challenging environments. Recommendations include to plan for offsite and long-distance training, supervision, and quality assurance; attempt to negotiate flexible timelines with donors; hire field staff whose only responsibility is data collection; where possible, find a way to include the most vulnerable members of the study population; adapt informed consent processes for low literacy populations; and consider including travel support for respondents. Iterating improvements in data collection innovations in these contexts will advance the field by spurring more research upon which to base policy and practices.
Conducting abortion research in fragile settings presents challenges, many of which are present in other low-resourced settings to various degrees but when appearing all together, collectively served to create a set of barriers to collecting data that required creative adaptations to address and even then, we could not overcome all of them.
RESULTS
Challenges that we experienced in the course of this mixed methods research project included limited access to the study sites by research team members, research being delayed to prioritize life-saving priorities which must take precedence when resource constraints mean that both cannot be carried out, a population skeptical of participating in research due to having negative experiences with the state/other actors as well as due to being research-naïve, geographic and language constraints impacting participant recruitment because of the fact that people are coming from various displaced locations to a particular health facility, a low literacy population meant that they could not read the consent form and due to the stigmatized subject matter we did not want a family member consenting them, and respondents’ challenges participating around the time of discharge because respondents needed to travel home with family members.
CONCLUSIONS
These strategies are relevant not only to abortion research but also other research in resource-constrained/fragile and conflict-affected contexts. Improving the health of the most vulnerable can only be done through understanding barriers to care in insecure and challenging environments. Recommendations include to plan for offsite and long-distance training, supervision, and quality assurance; attempt to negotiate flexible timelines with donors; hire field staff whose only responsibility is data collection; where possible, find a way to include the most vulnerable members of the study population; adapt informed consent processes for low literacy populations; and consider including travel support for respondents. Iterating improvements in data collection innovations in these contexts will advance the field by spurring more research upon which to base policy and practices.
Journal Article > ResearchFull Text
BMC Pregnancy Childbirth. 4 March 2023; Volume 23 (Issue 1); 143.; DOI:10.1186/s12884-023-05427-6
Pasquier E, Owolabi OO, Fetters T, Ngbale RN, Adame Gbanzi MC, et al.
BMC Pregnancy Childbirth. 4 March 2023; Volume 23 (Issue 1); 143.; DOI:10.1186/s12884-023-05427-6
BACKGROUND
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).
METHODS
We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.
RESULTS
We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).
CONCLUSION
Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).
METHODS
We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.
RESULTS
We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).
CONCLUSION
Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.
Technical Report > Evidence Brief
Fetters T, Lissouba P, Moore AM, Lagrou D, Pasquier E, et al.
1 December 2022
Protocol > Research Protocol
Pasquier E, Fetters T, Owolabi OO, Moore AM, Marquer C, et al.
15 December 2020
OVERALL AIM
To describe and estimate the burden of abortion-related complications, particularly near-miss complications and deaths, and their associated factors among women presenting for abortion-related complications in health facilities supported by Médecins Sans Frontières (MSF) in African fragile and/or conflict-affected settings.
OBJECTIVES
Primary objective:
- To describe the frequency of near-miss events and deaths among women presenting for
abortion-related complications.
Secondary objective:
- To describe the frequency of abortion-related complications overall and by types (hemorrhage, infection, perforation, etc.)
- To describe the severity of abortion-related complications overall and by types (hemorrhage, infection, perforation, etc.)
- To identify risk factors quantitatively associated with abortion-related near-miss events;
- To describe the quality of the clinical management of abortion-related complications
(including near-miss cases) and the heath facilities capacity to manage these complications
- To describe the experiences of women who present as near-miss cases, including their
decision-making processes, access, pathways to care as well as conditions and factors that
could contribute to the life-threatening conditions and near-miss event.
- To describe the knowledge, attitudes, practices, and behaviors of health care workers in
relation to abortion;
- To describe the characteristics, management, outcomes of ectopic and molar pregnancies
ClinicalTrials.gov: NCT04331847
To describe and estimate the burden of abortion-related complications, particularly near-miss complications and deaths, and their associated factors among women presenting for abortion-related complications in health facilities supported by Médecins Sans Frontières (MSF) in African fragile and/or conflict-affected settings.
OBJECTIVES
Primary objective:
- To describe the frequency of near-miss events and deaths among women presenting for
abortion-related complications.
Secondary objective:
- To describe the frequency of abortion-related complications overall and by types (hemorrhage, infection, perforation, etc.)
- To describe the severity of abortion-related complications overall and by types (hemorrhage, infection, perforation, etc.)
- To identify risk factors quantitatively associated with abortion-related near-miss events;
- To describe the quality of the clinical management of abortion-related complications
(including near-miss cases) and the heath facilities capacity to manage these complications
- To describe the experiences of women who present as near-miss cases, including their
decision-making processes, access, pathways to care as well as conditions and factors that
could contribute to the life-threatening conditions and near-miss event.
- To describe the knowledge, attitudes, practices, and behaviors of health care workers in
relation to abortion;
- To describe the characteristics, management, outcomes of ectopic and molar pregnancies
ClinicalTrials.gov: NCT04331847