Technical Report > Evidence Brief
Pasquier E, Owolabi OO, Fetters T, Chen H, Williams TN, et al.
2022 August 30
English
Français
Abortion complications remain a major cause of maternal mortality worldwide and abortion-related mortality has decreased very little over the last decade, unlike maternal mortality linked to other main causes such as haemorrhage, infection or obstructed labour. Global estimates suggest that most abortion-related deaths are the result of unsafe induced abortions, 97% of which occur in low- and middle-income countries which can be largely prevented by providing comprehensive abortion care, including post- abortion care, contraceptive services, and safe abortion care.
At 829 deaths for every 100,000 live births, the Central African Republic (CAR) has one of the world’s highest maternal mortality ratios. Abortion-related complications are a major contributor to maternal mortality, estimated at almost one in four (24%) of the maternal deaths in one study led by the Central African Ministry of Health and UNFPA. Further, CAR is one of the most fragile countries in the world, rating 174th out of the 178 countries in the Fund for Peace Fragility Index with different parts of the country regularly affected by decades-long armed conflict.
A lack of evidence on abortion complications in fragile settings limits the understanding of women’s needs in access to comprehensive abortion care in this context. This study describes the burden of abortion-related complications and their contributing factors in the maternity of Castors in Bangui, CAR. This evidence brief presents selected results of two components of the AMoCo Study (Abortion-related Morbidity and Mortality in Conflict-affected and Fragile Settings): 1) A quantitative observational study of clinical characteristics of women presenting with any type of abortion complications, and 2) A quantitative survey with a sub-group of these women who were hospitalized.
At 829 deaths for every 100,000 live births, the Central African Republic (CAR) has one of the world’s highest maternal mortality ratios. Abortion-related complications are a major contributor to maternal mortality, estimated at almost one in four (24%) of the maternal deaths in one study led by the Central African Ministry of Health and UNFPA. Further, CAR is one of the most fragile countries in the world, rating 174th out of the 178 countries in the Fund for Peace Fragility Index with different parts of the country regularly affected by decades-long armed conflict.
A lack of evidence on abortion complications in fragile settings limits the understanding of women’s needs in access to comprehensive abortion care in this context. This study describes the burden of abortion-related complications and their contributing factors in the maternity of Castors in Bangui, CAR. This evidence brief presents selected results of two components of the AMoCo Study (Abortion-related Morbidity and Mortality in Conflict-affected and Fragile Settings): 1) A quantitative observational study of clinical characteristics of women presenting with any type of abortion complications, and 2) A quantitative survey with a sub-group of these women who were hospitalized.
Protocol > Research Study
Pasquier E, Fetters T, Owolabi OO, Moore AM, Marquer C, et al.
2020 December 15
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
Conference Material > Video (talk)
Kumar M
MSF Scientific Days UK 2019: Innovation. 2019 May 10
Conference Material > Abstract
Chen H, Fetters T, Ngbale NR, Nguengo L, Dodane T, et al.
MSF Scientific Days International 2021: Research. 2021 May 18
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.
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.
Other > Journal Blog
PLoS Blogs. 2019 March 4
Fotheringham C, Kumar M, Schulte-Hillen C
PLoS Blogs. 2019 March 4
Journal Article > CommentaryFull Text
BMJ Glob Health. 2020 July 20; Volume 5 (Issue 7); e003175.; DOI:10.1136/bmjgh-2020-003175
Kumar M, Daly M, de Plecker E, Jamet C, McRae M, et al.
BMJ Glob Health. 2020 July 20; Volume 5 (Issue 7); e003175.; DOI:10.1136/bmjgh-2020-003175
SUMMARY BOX
• The COVID-19 pandemic has begun to severely limit access to sexual and reproductive healthcare, including contraception and safe abortion care (SAC), which have historically not been regarded as essential health services.
• Shutdown or delays of contraception and SAC during COVID-19 will disproportionately impact the most vulnerable populations, including women and girls in low-income and middle-income countries, and lead to considerable and preventable death and lifelong disability.
• Médecins Sans Frontières calls on the global health community to strengthen access to contraception and SAC for populations everywhere, and especially in poor and crisis settings, by engaging with women and their communities to develop self-managed models of care.
• The COVID-19 pandemic has begun to severely limit access to sexual and reproductive healthcare, including contraception and safe abortion care (SAC), which have historically not been regarded as essential health services.
• Shutdown or delays of contraception and SAC during COVID-19 will disproportionately impact the most vulnerable populations, including women and girls in low-income and middle-income countries, and lead to considerable and preventable death and lifelong disability.
• Médecins Sans Frontières calls on the global health community to strengthen access to contraception and SAC for populations everywhere, and especially in poor and crisis settings, by engaging with women and their communities to develop self-managed models of care.
Other > Pre-Print
Res Sq. 2023 March 20; DOI:10.21203/rs.3.rs-2671712/v1
Moore AM, Pasquier E, Williams TN, Fetters T, Powell B, et al.
Res Sq. 2023 March 20; 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
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.
Conference Material > Video (talk)
Chen H
MSF Scientific Days International 2021: Research. 2021 May 18
Journal Article > ResearchFull Text
PLOS One. 2022 December 30; Volume 17 (Issue 12); e0279692.; DOI:10.1371/journal.pone.0279692
Bossard C, Chihana ML, Nicholas S, Mauambeta D, Weinstein D, et al.
PLOS One. 2022 December 30; Volume 17 (Issue 12); e0279692.; DOI:10.1371/journal.pone.0279692
Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13–19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3–57.6] and increased with age: from 14.7% (13–19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3–97.4], ART coverage was 98.8% [95.3–99.7], and VL suppression 83.2% [77.1–88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3–43.5], gonorrhea 9.5% [6.9–12.9], and chlamydia 12.5% [9.3–16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5–52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.