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Background: Abortion is one of the major direct causes of maternal death, accounting for 7.9% globally. In Africa, 5.5 million women have unsafe abortions annually. Although maternal deaths due to complications of abortion have declined in Ethiopia, women still die from complications. Few studies have focused on providers’ clinical knowledge. This study investigates the level of health workers’ knowledge of comprehensive abortion care and its determinants in Ethiopia. Methods: Data from the national emergency obstetric and newborn care (EmONC) assessment was used. A total of 3804 facilities that provided institutional deliveries in the 12 months before the assessment were included. Provider knowledge was assessed by interviewing a single provider from each facility. Criteria for selection included: Having attended the largest number of deliveries in the last one or two months. A summary knowledge score was generated based on the responses to three knowledge questions related to immediate complications of unsafe abortion, how a woman should be clinically managed and what the counselling content should contain. The score was classified into two categories ( =50%). Logistic regression was used to determine individual and facility-level factors associated with the summary knowledge score. Result: A total of 3800 providers participated and the majority were midwives, nurses and health officers. On average, providers identified approximately half or fewer of the expected responses. The multivariate model showed that midwives and nurses (compared to health officers), being female, and absence of training or practice of manual vacuum aspiration were associated with lower knowledge levels. Important facility level factors protective against low knowledge levels included employment in Addis Ababa, being male and having internet access in the facility. Conclusion: To increase knowledge levels among providers, pre- A nd in-service training efforts should be particularly sensitive to female providers who scored lower, ensure that more midlevel providers are capable of performing manual vacuum aspiration as well as provide special attention to providers in the Gambella.
Data were used from the national 2016 emergency obstetric and neonatal care assessment. Detailed methods were presented in the assessment report [19]. Briefly, data were collected from May to October, 2016 at all facilities in all 9 regions and 2 city administrations in the country that had provided care for institutional deliveries in the 12 months preceding the assessment. The type of facilities included in this study were hospitals (referral, general and primary), health centres, Maternal Child Health (MCH) speciality centres, MCH speciality clinics and higher clinics. Rural and urban facilities were also included. From 3804 health facilities assessed, a total of 3800 health care providers were included in the analysis. Provider knowledge on abortion care was assessed by interviewing one provider from each facility. Selection criteria for the provider were: 1) the health worker who attended the largest number of deliveries in the last month or if no births had been reported in the facility in the previous 30 days, in the last two months,, and 2) was physically present when data collectors visited the facility. If the selected provider refused to provide consent, he or she was not replaced by another at that facility. The dummy variables entered in the regression were sex, qualification, MVA training and MVA service provision of health care providers were collected, the availability of internet, computers, safe abortion care, and family planning guidelines. Health care providers were asked a series of questions related to unsafe abortion: “What are the immediate complications of unsafe abortion?”; “What do you do for a woman with an unsafe or incomplete abortion?”; and, “What information do you give to clients after unsafe or incomplete abortion?” A summary knowledge score was generated based on these questions. Each knowledge question had multiple possible “correct” answers; that is, answers that respondents were expected to provide spontaneously. Respondents were scored on each question by calculating the number of correct responses provided out of the total possible, and standardizing this to a scale of 100. A one way ANOVA statistical test was used to compare the level of knowledge among different cadre of health care providers. The outcome variable was overall knowledge score, which was divided into two categories (> = 50 and < 50%). A score higher than 50% was considered acceptable [20]. The Medical Council of India recommends 50% as the minimum pass mark for all summative examinations in medical specialties. The National Board of Examination in India also accepts overall 50% marks as a minimum acceptable mark for passing in Objective Structure Clinical Examination (OSCE) [21] and a score higher than 50% was also considered acceptable [22]. Accordingly, we operationally defined those scores 50% and above as a passing score. For the logistic regression, the overall abortion care knowledge score was based on the sum of all three questions and their 22 possible responses, and classified into two categories ( =50% labelled as 0). The dependent variable of interest was those providers who scored below 50%. We used in bivariate analysis a wider confidence interval (80% CI) in order not to miss potential factors that might affect provider low knowledge. Our main interest in the dependent variable category was those providers who scored below 50. Finally, a multivariable logistic regression model was used to determine independent individual and facility-level factors associated with the knowledge score at a 5% significance level. The analysis was done using STATA Version 14. Ethical clearance was obtained from the Ethiopian Public Health Institute (EPHI) scientific and ethical review board. Informed verbal consent was taken from all facilities and all selected health workers. No incentive was provided for participation. No personal identifier was used to maintain confidentiality and data were maintained on a password protected EPHI server.
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