Comprehensive abortion care: Evidence of improvements in hospital-level indicators in Tigray, Ethiopia

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Study Justification:
– Approximately 18% of maternal deaths in East Africa are caused by unsafe abortion.
– Comprehensive abortion care (CAC) services, including medical abortion, can increase access to safe abortion and reduce the burden of unsafe abortion.
– This study aimed to assess trends in abortion-related morbidity indicators in referral hospitals in the Tigray region of Ethiopia.
Highlights:
– The study analyzed data from four hospitals in Tigray that participated in a CAC pilot project.
– Providers were trained in mid-2009 to provide abortion services using all available technologies.
– Trends in abortion-related services showed a significant decrease in treatment of incomplete abortion.
– Medication abortion increased steadily and represented 80% of total procedures in 2012.
– The inclusion of medication abortion and availability of CAC contributed to a decline in inpatient procedures and complications.
Recommendations:
– Increase availability of comprehensive abortion care services at all levels of the healthcare system.
– Provide training for healthcare providers on all available technologies for abortion services.
– Promote the use of medication abortion as a safe and effective method.
– Implement strategies to reduce the treatment of incomplete abortion cases.
– Continue monitoring and evaluating the impact of CAC services on abortion-related morbidity indicators.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation.
– Healthcare Providers: Trained in comprehensive abortion care services.
– Hospital Administrators: Ensure availability of necessary resources and support for CAC services.
– Community Health Workers: Educate and raise awareness about safe abortion services.
Cost Items for Planning Recommendations:
– Training Programs: Budget for training healthcare providers on comprehensive abortion care.
– Equipment and Supplies: Allocate funds for necessary equipment and supplies for abortion services.
– Monitoring and Evaluation: Set aside budget for monitoring and evaluating the impact of CAC services.
– Community Education: Allocate funds for community health workers to conduct education and awareness campaigns.
Please note that the cost items provided are general categories and not actual cost estimates.

Objective: Approximately 18% of maternal deaths in East Africa is attributable to unsafe abortion. Availability of comprehensive abortion care (CAC) services at all levels of the healthcare system, including medical abortion, has the potential to increase access to safe abortion thereby reducing the burden of unsafe abortion. This study sought to assess trends in abortion-related morbidity indicators in referral hospitals. Design: Researchers conducted a secondary data analysis on retrospectively collected data. Methods: Data analysed were collected from four hospitals in the Tigray region of Ethiopia that took part in a CAC pilot project. Providers were trained in mid-2009 to provide abortion services using all available technologies. Data records from hospitals were collected in 2012 for the years 2006 through 2012; 2006/2007 data were too sparse to include in the analyses. Results: Trends in abortion-related services show a significant decrease in treatment of incomplete abortion, inverting the relationship between safe terminations and treatment of incompletes as a percentage of total abortions. Medication abortion was nearly non-existent in 2008, but increased steadily, representing 80% of total procedures in 2012. The inclusion of medication abortion and availability of CAC also contributed to a decline in inpatient procedures and prevalence of complications. Conclusions: The trends observed in the data demonstrate how increased availability of CAC services at all levels of the healthcare system, among other factors, can contribute to reductions in the burden of unsafe abortion at referral hospitals.

A data extraction form was used to collect data from the abortion logbooks in the four Tigray hospitals that participated in the CAC pilot project; these hospitals had also previously been involved in the Ipas trainings on SAC, which included MVA. Variables of interest included total number of abortion-related services provided, type of abortion (induced abortion, treatment of incomplete abortion, other), method of treatment used (dilation and curettage (D&C), MVA, MA, other), level of complications (serious, minor, none) and inpatient versus outpatient treatment. Inpatient treatment indicates that the patient was admitted to the hospital and occupied a hospital bed for some amount of time; outpatient indicates it was an ambulatory care procedure. Data extracted correspond to the period September 2006 until May 2012. Data from 2006 to 2007 were too sparse to include in the analyses, thus the data analysed were from 2008 to 2012. Proportions for each of the indicators were calculated and then plotted using Excel. To determine whether changes in proportions between years were statistically significant, we used a two-tailed z test for comparison of two proportions. The confidence level was set at p=0.05. All statistical analyses were carried out using STATA V.11.0.28

Based on the information provided, the innovation that improved access to maternal health in Tigray, Ethiopia was the implementation of comprehensive abortion care (CAC) services. This included the availability of medical abortion and training for healthcare providers in all available technologies for abortion services. The study found the following improvements:

1. Decrease in treatment of incomplete abortion: There was a significant decrease in the treatment of incomplete abortion cases, indicating that more women were able to access safe terminations rather than needing treatment for incomplete procedures.

2. Increase in medication abortion: The availability of medication abortion increased steadily over the years, representing 80% of total procedures in 2012. This indicates that more women were able to access safe abortion through medication rather than invasive procedures like dilation and curettage (D&C) or manual vacuum aspiration (MVA).

3. Decline in inpatient procedures and complications: The inclusion of medication abortion and the availability of CAC contributed to a decline in the need for inpatient procedures and a decrease in the prevalence of complications. This suggests that women were able to access safe abortion services in an outpatient setting, reducing the burden on hospital resources and minimizing the risk of complications.

These findings demonstrate how the implementation of comprehensive abortion care services, including medical abortion and training for healthcare providers, can improve access to safe abortion and reduce the burden of unsafe abortion on referral hospitals.
AI Innovations Description
The recommendation to improve access to maternal health based on the study mentioned is the implementation of comprehensive abortion care (CAC) services at all levels of the healthcare system. This includes providing medical abortion as an option for safe termination of pregnancies. The study conducted in Tigray, Ethiopia showed that the availability of CAC services led to significant improvements in hospital-level indicators related to abortion-related morbidity.

To develop this recommendation into an innovation, the following steps can be taken:

1. Training and capacity building: Healthcare providers should be trained in providing comprehensive abortion care, including medical abortion, using all available technologies. This will ensure that they have the necessary skills and knowledge to offer safe and effective abortion services.

2. Policy and guideline development: Governments and healthcare organizations should develop policies and guidelines that support the provision of comprehensive abortion care. These policies should ensure that CAC services are accessible, affordable, and of high quality.

3. Infrastructure and equipment: Healthcare facilities need to be equipped with the necessary infrastructure and equipment to provide comprehensive abortion care. This includes ensuring the availability of medications for medical abortion, as well as the necessary instruments and equipment for other abortion procedures.

4. Data collection and monitoring: It is important to collect and analyze data on abortion-related services to monitor the impact of the implementation of CAC services. This will help identify any gaps or areas for improvement and guide future interventions.

5. Community engagement and awareness: Efforts should be made to engage with communities and raise awareness about the availability and benefits of comprehensive abortion care. This can help reduce stigma and increase acceptance of these services, ultimately improving access for women in need.

By implementing these recommendations, healthcare systems can improve access to maternal health by reducing the burden of unsafe abortion and providing safe and effective abortion services to women.
AI Innovations Methodology
Based on the provided description, here is a potential innovation recommendation to improve access to maternal health:

Innovation Recommendation: Scaling up Comprehensive Abortion Care (CAC) services to more healthcare facilities in East Africa.

Brief Methodology to Simulate the Impact of the Recommendation:

1. Identify target healthcare facilities: Determine the healthcare facilities in East Africa where the implementation of CAC services can be scaled up. Consider factors such as geographical location, population density, and existing healthcare infrastructure.

2. Training and capacity building: Develop a comprehensive training program to train healthcare providers in these facilities on CAC services, including medical abortion. This training should cover the necessary skills, knowledge, and protocols for providing safe and effective abortion care.

3. Data collection: Establish a system for collecting data on abortion-related services, including the type of abortion, method of treatment used, level of complications, and inpatient/outpatient treatment. This data should be collected from the selected healthcare facilities before and after the implementation of CAC services.

4. Data analysis: Analyze the collected data using statistical software such as STATA. Calculate proportions for each indicator of interest (e.g., total number of abortion-related services, type of abortion, method of treatment, level of complications, inpatient/outpatient treatment) for the period before and after the implementation of CAC services.

5. Statistical analysis: Use appropriate statistical tests, such as a two-tailed z test for comparison of two proportions, to determine whether there are statistically significant changes in the proportions between the pre-implementation and post-implementation periods. Set the confidence level at p=0.05.

6. Visualization and interpretation: Plot the calculated proportions using a tool like Excel to visualize the trends and changes over time. Interpret the results to understand the impact of scaling up CAC services on improving access to maternal health, specifically in reducing the burden of unsafe abortion and related complications.

7. Policy and program recommendations: Based on the findings, develop policy and program recommendations to further scale up CAC services in East Africa. These recommendations should consider factors such as resource allocation, training needs, and collaboration with relevant stakeholders.

Note: The methodology described is a general outline and may need to be adapted based on the specific context and available resources.

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