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Background: Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians’ and midwives’ perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care. Methods. In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach. Results: Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified. Conclusions: Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda. © 2014Paul et al.; licensee BioMed Central Ltd.
An inductive study approach using an emergent design was employed, utilizing the qualitative method of in-depth interviews (IDI). Thematic analysis was used to structure the data. The study was performed at seven health care facilities situated in five different districts in the Central Region of Uganda. The region was chosen because the abortion rate has been reported to be the second highest in the country, and it is above the national average (62 per 1000 women) [36]. The seven facilities were purposely selected because of their high caseloads in PAC. The caseloads were mapped through a survey done by one of the Ugandan researchers prior to the initiation of this study (2012). In addition, the employment of both doctors and midwives in a facility was regarded a criterion for inclusion, and we aimed to include facilities from rural, semi-urban and urban settings. The Ugandan health system is made up of a national referral hospital, regional and district hospitals, and health centres II-IV. Health centre IV is the most advanced, employing both doctors and midwives, and health centre II is the least advanced, employing a nurse or a clinical officer. Health centre I, also referred to as village health teams, are the lowest level and have no permanent accommodation [40]. A total of 27 IDI were carried out with health care providers in the health facilities listed above (Table 1). The majority of respondents (all the midwives and one doctor) were female (70%). The midwives had all worked for eight or more years, while the work experience of the doctors ranged between one and twenty years. The health facilities selected were staffed by doctors and midwives, and were equipped to provide basic and comprehensive emergency obstetric care in rural, semi-urban and urban areas. National, regional, district and sub-district levels were included (Table 1) to explore any discrepancies in service provision among the levels as well as differences between the cadres. Facilities included in data collection The table shows the location, setting and level of health facility as well as the number of study subjects participating in the IDI from each health facility, including the distribution between doctors and midwives. 1. Being employed in one of the hospitals/Health centres listed above (Table 1) 2. Being a nurse, a midwife, a clinical officer or a doctor 3. Actively participating in PAC The IDI were conducted in February and March 2012, and continued until no new data were encountered. Purposive sampling was employed. The person in charge at each health facility, such as the medical officer or head nurse/midwife, was used as a gatekeeper, facilitating the identification of eligible study subjects. All participants signed a written consent prior to the IDI, and the interviews were conducted in the hospital, meaning that interruptions could sometimes occur. Two pilot interviews were performed at Mulago hospital to test the interview guidelines, resulting in a revision to impart a better in-depth character to the questions. The final guideline was semi-structured, open-ended and utilized probes. Topics covered included (i) attitudes towards abortion, PAC and family planning, (ii) perceptions of methods for uterine evacuation, (iii) skills and competences needed and (iv) task sharing in PAC. The IDI were performed in English, lasted for 30–60 minutes and were tape-recorded. The research team consisted of researchers with different cultural and professional backgrounds. The first author and main researcher, a Swedish woman with a background in global health, and a Ugandan assistant, a woman with a degree in public health, conducted the data collection. All the researchers were involved in the analysis and interpretation of the data. The recorded data were transcribed verbatim, read through several times and carefully coded manually. Since little is known about the views and perceptions on PAC in Uganda, thematic analysis was used [41]. Furthermore, a thick description to reflect the content of the data was employed, and codes were organized into sub-themes using an inductive approach. Sub-themes were arranged into semantic themes focusing on identified patterns as well as on the broader meanings and implications of the data. The analysis was done with a realistic or epistemological approach, looking at experience and meaning in a straightforward way. The interpretation of the data was continuously discussed and re-evaluated by all researchers in the team. Additionally, the data were reviewed to identify extracts for illumination of the themes. Ethical approval was obtained from the Makerere University College of Health Sciences, School of Biomedical Sciences Research and Ethics Committee, Kampala. National approval was given by the Uganda National Council for Science and Technology. The study was identified as a minimal risk study since it addressed health care providers’ perspective on a work task, and their opinions on abortion. A written consent form stated the rights of the participants, and confidentiality and the anonymity of the participants were guaranteed. The data and informed consent forms are stored safely under lock and key at Karolinska Institutet and are used only by the researchers involved in the study.
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