Tamara Fetters

Caring for women with abortion complications in Ethiopia: national estimates and future implications.

CONTEXT Ethiopia liberalized its abortion law in 2005, primarily to reduce the incidence of unsafe abortion. However, little is known about the current extent and consequences of unsafe abortion. METHODS Data were collected in 2007-2008 on 1,932 women seeking postabortion care at a nationally representative sample of 344 public and private health facilities. In addition, staff respondents at 337 facilities provided information on their facilitys services and caseload. These data were used to examine patterns of abortion-related morbidity and treatment and to generate national estimates. RESULTS Almost 58,000 women sought care for complications of induced or spontaneous abortion in 2008. Three-quarters of the women received care in government facilities. Forty-one percent had moderate or severe morbidity, such as signs of infection, that were likely related to an unsafe abortion. Seven percent of all women had signs of a mechanical injury or a vaginally inserted foreign body. More than 13,000 women seeking postabortion care required a hospital stay of at least 24 hours. The case fatality rate among women seeking postabortion care in public hospitals, where the most serious complications were seen, was 628 per 100,000. CONCLUSIONS Postabortion care and safe abortion services should be further expanded and strengthened to make these services more accessible and affordable, which in turn may ease the financial burden on hospitals and allow the resources currently required for postabortion care to be used for other health needs. Ensuring that all women know that safe abortion is available and legal for many indications will further reduce morbidity from unsafe abortions.

The estimated incidence of induced abortion in Ethiopia, 2008.

CONTEXT Unsafe abortion is an important health problem in Ethiopia; however, no national quantitative study of abortion incidence exists. In 2005, the penal code was revised to broaden the indications under which induced abortion is legal. It is important to measure the incidence of legal and illegal induced abortion after the change in the law. METHODS A nationally representative survey of a sample of 347 health facilities that provide postabortion or safe abortion services and a survey of 80 professionals knowledgeable about abortion service provision were conducted in Ethiopia in 2007-2008. Indirect estimation techniques were applied to calculate the incidence of induced abortion. Abortion rates, abortion ratios and unintended pregnancy rates were calculated for the nation and for major regions. RESULTS In 2008, an estimated 382,000 induced abortions were performed in Ethiopia, and 52,600 women were treated for complications of such abortions. There were an estimated 103,000 legal procedures in health facilities nationwide--27% of all abortions. Nationally, the annual abortion rate was 23 per 1,000 women aged 15-44, and the abortion ratio was 13 per 100 live births. The abortion rate in Addis Ababa (49 per 1,000 women) was twice the national level. Overall, about 42% of pregnancies were unintended, and the unintended pregnancy rate was 101 per 1,000 women. CONCLUSIONS Unsafe abortion is still common and exacts a heavy toll on women in Ethiopia. To reduce rates of unplanned pregnancy and unsafe abortion, increased access to high-quality contraceptive care and safe abortion services is needed.

The health system cost of postabortion care in Ethiopia

To address the knowledge gap that exists in costing unsafe abortion in Ethiopia, estimates were derived of the cost to the health system of providing postabortion care (PAC), based on research conducted in 2008. Fourteen public and private health facilities were selected, representing 3 levels of health care. Cost information on drugs, supplies, material, personnel time, and out‐of‐pocket expenses was collected using an ingredients approach. Sensitivity analysis was used to determine the most likely range of costs. The average direct cost per client, across 5 types of abortion complications, was US

Meeting the need for safe abortion care in Ethiopia: Results of a national assessment in 2008

36.21. The annual direct cost nationally ranged from US

Women's Perceptions About Abortion in Their Communities: Perspectives from Western Kenya

6.5 to US

Using a harm reduction lens to examine post-intervention results of medical abortion training among Zambian pharmacists.

8.9 million. Including indirect costs and satisfying all demand increased the annual national cost to US

An assessment of postabortion care in three regions in Ethiopia, 2000 to 2004

47 million. PAC consumes a large portion of the total expenditure in reproductive health in Ethiopia. Investing more resources in family planning programs to prevent unwanted pregnancies would be cost‐beneficial to the health system.

An evaluation of a national intervention to improve the postabortion care content of midwifery education in Nigeria

Abstract Complications of an unsafe abortion are a major contributor to maternal deaths and morbidity in Africa. When abortions are performed in safe environments, such complications are almost all preventable. This paper reports results from a nationally representative health facility study conducted in Ethiopia in 2008. The safe abortion care (SAC) model, a monitoring approach to assess the amount, distribution, use and quality of abortion services, provided a framework. Data collection included key informant interviews with 335 health care providers, prospective data on 8911 women seeking treatment for abortion complications or induced abortion and review of facility logbooks. Although the existing hospitals perform most basic abortion care functions, the number of facilities providing basic and comprehensive abortion care for the population size fell far short of the recommended levels. Almost one-half (48%) of women treated for obstetric complications in the facilities had abortion complications. The use of appropriate abortion technologies in the first trimester and the provision of post-abortion contraception overall were reasonably strong, especially in private sector facilities. Following abortion law reform in 2005 and subsequent service expansion and improvements, Ethiopia remains committed to reducing complications from an unsafe abortion. This study provides the first national snapshot to measure changes in a dynamic abortion care environment.

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

Abstract Unsafe abortion in Kenya is a leading cause of maternal morbidity and mortality. In October 2012, we sought to understand the methods married women aged 24–49 and young, unmarried women aged ≤ 20 used to induce abortion, the providers they utilized and the social, economic and cultural norms that influenced women’s access to safe abortion services in Bungoma and Trans Nzoia counties in western Kenya. We conducted five focus groups with young women and five with married women in rural and urban communities in each county. We trained local facilitators to conduct the focus groups in Swahili or English. All focus groups were audiotaped, transcribed, translated, computerized, and coded for analysis. Abortion outside public health facilities was mentioned frequently. Because of the need for secrecy to avoid condemnation, uncertainty about the law, and perceived higher cost of safer abortion methods, women sought unsafe abortions from community midwives, drug sellers and/or untrained providers at lower cost. Many groups believed that abortion was safer at higher gestational ages, but that there was no such thing as a safe abortion method. Our aim was to inform the design of a community-based intervention on safe abortion for women. Barriers to seeking safe services such as high cost, perceived illegality, and fear of insults and abuse at public facilities among both age groups must be addressed. Résumé Au Kenya, l’avortement à risque est l’une des principales causes de morbidité et mortalité maternelles. En octobre 2012, nous avons tenté de comprendre les méthodes que les femmes mariées âgées de 24 à 49 ans et les célibataires âgées de 20 ans et moins utilisaient pour avorter, les prestataires auxquelles elles avaient recours et les normes sociales, économiques et culturelles qui influençaient l’accès des femmes aux services d’avortement sûr dans les comtés de Bungoma et Trans Nzoia au Kenya occidental. Nous avons réuni cinq groupes thématiques avec des jeunes femmes et cinq avec des femmes mariées dans des communautés rurales et urbaines de chaque comté. Nous avons formé des animateurs locaux pour gérer les groupes en swahili ou anglais. Toutes les discussions des groupes ont été enregistrées, transcrites, traduites, informatisées et codées pour l’analyse. L’avortement en dehors des structures de santé publique a été fréquemment mentionné. Tenues au secret pour éviter une condamnation, ignorant la loi et jugeant que le coût des méthodes d’avortement sûr était plus élevé, les femmes demandaient des avortements à risque à un prix plus modique à des sages-femmes communautaires, des vendeurs de médicaments et/ou des prestataires non formés. Beaucoup de groupes pensaient que l’avortement était moins risqué à un âge gestationnel plus avancé, mais qu’il n’existait pas de méthode sûre. Notre but était de guider la conception d’une intervention communautaire sur l’avortement sûr pour les femmes. Il faut lever les obstacles à la demande de services sûrs mentionnés par les deux groupes d’âge, tels que le coût élevé, l’illégalité perçue et la peur des insultes et de la maltraitance dans les centres publics. Resumen El aborto inseguro es una causa principal de morbimortalidad materna en Kenia. En octubre de 2012, buscamos entender los métodos que utilizaban las mujeres casadas entre 24 y 49 años de edad y las jóvenes solteras de 20 años de edad o menores, para inducir un aborto, los prestadores de servicios a quienes acudían y las normas sociales, económicas y culturales que influían en el acceso de las mujeres a los servicios de aborto en los condados de Bungoma y Trans Nzoia, en Kenia occidental. Realizamos cinco discusiones en grupos focales con mujeres jóvenes y cinco con mujeres casadas, en comunidades rurales y urbanas de cada condado. Capacitamos facilitadores locales para que realizaran las discusiones en grupos focales en swahili o inglés. Todas las discusiones en grupos focales fueron grabadas, transcritas, traducidas, computarizadas y codificadas para análisis. El aborto fuera de las unidades de salud pública fue mencionado con frecuencia. Debido a la necesidad de mantener todo en secreto para evitar condena, la incertidumbre en cuanto a la ley y la percepción de mayor costo de los métodos de aborto más seguro, las mujeres buscaban abortos inseguros a menor costo de parteras comunitarias, vendedores de medicamentos y/o prestadores de servicios no capacitados. Muchos grupos creían que el aborto era más seguro a edades gestacionales más avanzadas, pero que no existe tal cosa como un método de aborto seguro. Nuestro objetivo era influir en el diseño de una intervención comunitaria sobre aborto seguro para las mujeres. Se debe abordar las barreras que enfrentan ambos grupos etarios para buscar servicios seguros, tales como costo elevado, ilegalidad percibida y temor de recibir insultos y maltrato en unidades de salud pública.

Changes in Morbidity and Abortion Care in Ethiopia After Legal Reform: National Results from 2008 and 2014

Abstract Despite broad grounds for legal abortion in Zambia, access to abortion services remains limited. Pharmacy workers, a primary source of health care for communities, present an opportunity to bridge the gap between policy and practice. As part of a larger operations study, 80 pharmacy workers, both registered pharmacists and their assistants, participated in a training on medical abortion in 2009 and 2010. Fifty-five of the 80 pharmacy workers completed an anonymous, structured training pre-test, treated as a baseline questionnaire; 53 of the 80 trainees were interviewed 12–24 months post-training in face-to-face interviews to measure the retention of information and training effectiveness. Survey questions were selected to illustrate the principles of a harm reduction approach to unsafe abortion. Bivariate analysis was used to examine pharmacy worker knowledge, attitudes and dispensing behaviours pre-training and at follow-up. A higher percentage of pharmacy workers reported referring women to a health care facility between surveys (47% to 68%, p = 0.03). The number of pharmacy workers who reported dispensing ineffective abortifacients decreased from baseline to end-line (30% to 25%) but the difference was non-significant. However, study results demonstrate that Zambian pharmacy workers have a role to play in safe abortion services and some are willing to play that role. Résumé Malgré de vastes motifs d’avortement légal en Zambie, l’accès aux services d’avortement demeure limité. Les pharmacies, sources primaires de soins de santé pour les communautés, offrent la possibilité de combler l’écart entre les politiques et la pratique. Dans le cadre d’une étude plus large sur les opérations, 80 employés de pharmacie (pharmaciens agréés et leurs assistants) ont participé à une formation sur l’avortement médicamenteux en 2009 et 2010. Avant la formation, 55 des 80 employés ont complété un test structuré et anonyme, traité comme questionnaire de référence ; 53 des 80 apprenants ont été interrogés 12–24 mois après la formation dans des entretiens de suivi en face à face pour mesurer la rétention de l’information et l’efficacité de la formation. Les questions de l’enquête ont été sélectionnées pour illustrer les principes de l’approche de réduction des risques de l’avortement clandestin. Une analyse bivariée a été utilisée pour examiner les connaissances, les attitudes et les comportements de dispensation des employés de pharmacie avant et après la formation. Un pourcentage plus élevé d’employés ont répondu qu’ils avaient orienté des femmes vers des centres de soins de santé entre les enquêtes (47% à 68%, p = 0.03). Le nombre d’employés ayant indiqué qu’ils avaient dispensé des produits abortifs inefficaces a diminué entre les chiffres de référence et les données finales (30% à 25%), mais la différence était non significative. Néanmoins, les résultats de l’étude démontrent que les employés de pharmacie zambiens ont un rôle à jouer dans des services d’avortement sûr et que certains sont prêts à l’assumer. Resumen A pesar de que el aborto es permitido por amplias causales en Zambia, el acceso a los servicios de aborto continúa siendo limitado. El personal de farmacias, una fuente principal de servicios de salud para las comunidades, presenta una oportunidad para llenar la brecha entre políticas y práctica. Como parte de un estudio más extenso de operaciones, 80 trabajadores de farmacias, tanto farmaceutas titulados como sus asistentes, participaron en una capacitación sobre aborto con medicamentos en los años 2009 y 2010. Cincuenta y cinco de los 80 trabajadores de farmacias contestaron un examen preliminar estructurado anónimo, el cual fue tratado como cuestionario de línea base; 53 de las 80 personas que recibieron capacitación fueron entrevistadas cara a cara 12 a 24 meses después de la capacitación, con el fin de medir la retención de información y eficacia de la capacitación. Las preguntas de la encuesta fueron seleccionadas para ilustrar los principios de un enfoque de reducción de daños con relación al aborto inseguro. Se utilizó el análisis bivariado para examinar los conocimientos, actitudes y comportamientos del personal de farmacias relacionados con despachar medicamentos, antes de la capacitación y durante el seguimiento. Un mayor porcentaje de trabajadores de farmacias informaron referir a las mujeres a una unidad de salud entre encuestas (47% al 68%, p = 0.03). El número de trabajadores de farmacias que informaron despachar abortivos ineficaces disminuyó desde la línea base hasta la línea final (30% al 25%), pero la diferencia fue insignificante. Sin embargo, los resultados del estudio demuestran que los trabajadores de farmacias en Zambia pueden desempeñar un papel en la prestación de servicios de aborto seguro, y algunos están dispuestos a hacerlo.