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Background Unsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy. Methods A cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality. Results The provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge. Discussion Legal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination. Conclusion Greater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.
The study on which this article is based was cross-sectional, using in-depth interviews to collect qualitative data. Public and private “high volume” healthcare facilities, including general and referral hospitals at Levels 4, 5 and 6, were selected, based on the number of PAC cases reported in the facilities in the most recent data [7,49,50]. Public facilities are owned and run by the government, and private facilities are managed by individual proprietors, non-governmental organizations or faith-based organizations. In Kenya, the Ministry of Health, under the Kenya Essential Package for Health (KEPH), defines six levels of preventive and curative health services, both for public and private facilities, ranging from level 1–6. Level 1 is the lowest level, and forms the foundations of service delivery at the community level; it includes village health committees and community health units. Levels 2 and 3 (dispensaries, health centres, and maternity/nursing homes) offer promotive, preventive, and curative services. Levels 4 and 5 (primary, secondary and tertiary hospitals) offer curative and rehabilitation services, with a limited number of preventive/promotive care programs, while level 6 is the highest level of care, comprising the national referral hospitals. Sampling for this study was purposive to include only facilities that managed a high number of PAC cases, so allowing us to recruit sufficient cases over a short period (one week for data collection) when trained qualitative interviewers were able to work at each facility. Sixteen hospitals in three regions − Nairobi (5), Central (5) and Eastern (6) − were sampled purposively by regional area, level, and reported quality of care. These facilities were classified into “high,” “medium” or “low” quality [37] to ensure representation of facilities at different levels of care and to gain a wide view of provider and patient experiences according to the facility level. This categorization was based on data from an earlier study from which these facilities were sampled. The study used the essential elements of PAC framework to categorize all participating facilities into three categories above (for details, see Mutua et al., 2017)). To achieve greater diversity and in-depth opinions on care from patients we purposively selected patients from a sub-sample of six of the 16 facilities, two from each of the three levels of quality stated above. This selection was mainly based on facility distance from Nairobi and size, with the intention to focus this selection on high-volume facilities able to provide sufficient numbers of interviews within a short period. Five patients in each of the six facilities were recruited and interviewed, together with one service provider at each of the 16 facilities. This yielded a sample of 30 patients and 16 provider interviews. However, due to a low number of patients in some facilities, only 21 patients were interviewed of the targeted 30 patients. All service providers were interviewed: of the 16 interviewed, eight were nurses and eight clinical officers. Two interview guides were developed and reviewed by the lead author and all co-authors. The guides were structured specifically to encourage discussions with service providers and patients on their understanding of the different components of the quality of PAC framework. The service provider interviews lasted on average 34 minutes while patient interviews lasted 21 minutes. Both provider and patient interviews were conducted in a private room in the health facility to ensure maximum privacy of information shared. All interviews were conducted either in English or Kiswahili, and transcribed and translated into English if the interview was conducted in Kiswahili. Field data collection was conducted between May and July, 2017. The main PAC service providers in selected facilities were recruited and interviewed by one of a team of three experienced and well-trained qualitative field researchers (all female). Women who were treated for PAC in selected healthcare facilities were interviewed after discharge, prior to their return home. The principal investigator (first author, PI, male) trained and worked with the field researchers to ensure that they had a good understanding of the study objectives and were mindful of its ethics. Interviews were adapted throughout the process through a constant review of data collected. All interviews were audio-recorded, and quality control and improvement were ensured through listening to recordings and discussions for providing feedback to interviewers. Once each interview was completed, it was forwarded electronically to a central office and archived on a password-protected computer, accessible only to the PI. Once all data were received, a transcriber worked with the PI; she was well trained to understand the survey objectives and the ethics of handling sensitive data. All data were transcribed into Microsoft word and as required, translated from Kiswahili into English. All patient and provider identifiers were replaced with codes to minimize the risk of identification of patients during data coding and analysis. Ethics approval was obtained from the Ethical and Scientific Review Council of African Medical Research Foundation (AMREF), the Kenyatta National Hospital (KNH) and University of Nairobi (UoN) Ethical Review Committee (ERC), and the Human Research Ethics Committee (Medical) at University of the Witwatersrand. Survey approvals were also obtained from the Kenya National Commission for Science, Technology, and Innovation (NACOSTI) and the Ministry of Health. Written informed consent as approved by AMREF were obtained from each participant before any interview was conducted. All minors who were already securing PAC services were deemed to be independent and able to provide their own informed consent, without parental consent. Data were analyzed deductively, using a predefined set of themes from the essential elements of PAC framework. Additionally, inductive analysis was used by identifying any additional themes on quality of care at the facility as described by the providers and patients. A double coding approach was used to compare independent codes between a trained and experienced coder and the PI, and an agreement was built on the codes before final coding in NVIVO. Final analysis involved in-depth interrogation of the data for both visible and underlying meanings assigned to quality of care from the perspectives of the service providers and patients. Specific verbatim quotes were extracted from the data, which express respondent views concerning certain propositions of quality care. Below, we identify people only by broad class (provider, patient) when we quote them directly.
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