Journal Article > ResearchFull Text
Confl Health. 2024 August 5; Volume 21; 114.; DOI:10.1186/s12978-024-01835-9
Pasquier E, Owolabi OO, Powell B, Fetters T, Ngbale R, et al.
Confl Health. 2024 August 5; Volume 21; 114.; DOI:10.1186/s12978-024-01835-9
BACKGROUND
Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals’ PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.
RESULTS
Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of 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.
CONCLUSIONS
Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
Journal Article > ResearchFull Text
SSM Qual Res Health. 2023 December 1; Volume 4; 100330.; DOI:10.1016/j.ssmqr.2023.100330
Moore AM, Fetters T, Williams T, Pasquier E, Kantiok J, et al.
SSM Qual Res Health. 2023 December 1; Volume 4; 100330.; DOI:10.1016/j.ssmqr.2023.100330
Maternal near-miss events are a key measure of maternal health; abortion-related complications are one source of near-miss events. To understand the pathway to care of women with severe abortion-related events in a fragile context, we conducted in-depth semi-structured interviews with women who obtained treatment at a referral hospital in Jigawa State, Nigeria, in 2020–2021 (n = 61). We used the Three Delays Model (Thaddeus & Maine, 1994) to examine impediments in reaching care.
The first delay (from the onset of symptoms of the pregnancy loss to the decision to seek care) was characterized by the duration of time it took to recognize the pregnancy and pregnancy loss in addition to religious beliefs that it is the will of a higher power that she lost the pregnancy. The second delay (from the decision to seek care to arriving at a place that could provide adequate care for her complication, i.e. the study site); was due to lack of money, lack of passable roads and transport, use of traditional healers, challenges being seen by providers at lower-level facilities, referrals not being facilitated and misdirection by healthcare providers. The third delay was not present in our results. No respondent said she knowingly interfered with the pregnancy; understanding why these pregnancy losses resulted in near-miss complications is critical to reducing maternal morbidity and mortality in Northern Nigeria. Addressing health literacy as well as social and financial barriers holds the potential to get women to care sooner and avert these near-miss or potentially life-threatening events.
The first delay (from the onset of symptoms of the pregnancy loss to the decision to seek care) was characterized by the duration of time it took to recognize the pregnancy and pregnancy loss in addition to religious beliefs that it is the will of a higher power that she lost the pregnancy. The second delay (from the decision to seek care to arriving at a place that could provide adequate care for her complication, i.e. the study site); was due to lack of money, lack of passable roads and transport, use of traditional healers, challenges being seen by providers at lower-level facilities, referrals not being facilitated and misdirection by healthcare providers. The third delay was not present in our results. No respondent said she knowingly interfered with the pregnancy; understanding why these pregnancy losses resulted in near-miss complications is critical to reducing maternal morbidity and mortality in Northern Nigeria. Addressing health literacy as well as social and financial barriers holds the potential to get women to care sooner and avert these near-miss or potentially life-threatening events.
Technical Report > Evidence Brief
Fotheringham C, Moore AM, Owolabi OO, Fetters T, Chen H, et al.
2023 August 1
A dearth of evidence on abortion complications in fragile settings limits the understanding of women’s needs in access to comprehensive abortion care in contexts like Jigawa state. This study describes the burden of abortion-related complications and their contributing factors in the maternity ward in an MSF-supported referral hospital in Jigawa state, Nigeria. This evidence brief presents selected results for three components of the AMoCo study (Abortion-related Morbidity and Mortality in Conflict-affected and Fragile Settings):
- A quantitative observational study of clinical characteristics of women presenting with any type of abortion complications,
- A quantitative survey with a sub-group of these women who were hospitalized, and
- A qualitative study among selected women with very severe complications (potentially life-threatening and near-miss complications).
Journal Article > ResearchFull Text
Res Sq. 2023 July 17; DOI:10.21203/rs.3.rs-3153198/v1
Pasquier E, Owolabi OO, Powell B, Fetters T, Ngbale RN, et al.
Res Sq. 2023 July 17; 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, Owolabi OO, Fetters T, et al.
2023 July 1
English
Français
Technical Report > Evidence Brief
Powell B, Chen H, Pasquier E, Fetters T, Owolabi OO, et al.
2023 July 1
English
Français
Journal Article > ResearchFull Text
PLOS Glob Public Health. 2023 June 8; Volume 3 (Issue 6); e0001457.; DOI:10.1371/journal.pgph.0001457
Simons E, Nikolay B, Ouedraogo P, Pasquier E, Tiemeni C, et al.
PLOS Glob Public Health. 2023 June 8; Volume 3 (Issue 6); e0001457.; DOI:10.1371/journal.pgph.0001457
Although seroprevalence studies have demonstrated the wide circulation of SARS-COV-2 in African countries, the impact on population health in these settings is still poorly understood. Using representative samples of the general population, we evaluated retrospective mortality and seroprevalence of anti-SARS-CoV-2 antibodies in Lubumbashi and Abidjan. The studies included retrospective mortality surveys and nested anti-SARS-CoV-2 antibody prevalence surveys. In Lubumbashi the study took place during April-May 2021 and in Abidjan the survey was implemented in two phases: July-August 2021 and October-November 2021. Crude mortality rates were stratified between pre-pandemic and pandemic periods and further investigated by age group and COVID waves. Anti-SARS-CoV-2 seroprevalence was quantified by rapid diagnostic testing (RDT) and laboratory-based testing (ELISA in Lubumbashi and ECLIA in Abidjan). In Lubumbashi, the crude mortality rate (CMR) increased from 0.08 deaths per 10 000 persons per day (pre-pandemic) to 0.20 deaths per 10 000 persons per day (pandemic period). Increases were particularly pronounced among <5 years old. In Abidjan, no overall increase was observed during the pandemic period (pre-pandemic: 0.05 deaths per 10 000 persons per day; pandemic: 0.07 deaths per 10 000 persons per day). However, an increase was observed during the third wave (0.11 deaths per 10 000 persons per day). The estimated seroprevalence in Lubumbashi was 15.7% (RDT) and 43.2% (laboratory-based). In Abidjan, the estimated seroprevalence was 17.4% (RDT) and 72.9% (laboratory-based) during the first phase of the survey and 38.8% (RDT) and 82.2% (laboratory-based) during the second phase of the survey. Although circulation of SARS-CoV-2 seems to have been extensive in both settings, the public health impact varied. The increases, particularly among the youngest age group, suggest indirect impacts of COVID and the pandemic on population health. The seroprevalence results confirmed substantial underdetection of cases through the national surveillance systems.
Conference Material > Abstract
Pasquier E, Lissouba P, Moore AM, Owolabi OO, Chen H, et al.
MSF Scientific Day International 2023. 2023 June 7; 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. 2023 June 7; DOI:10.57740/bxth-m543
Conference Material > Video
Pasquier E
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/21gn-xh54