Factors associated with delays in seeking post abortion care among women in Kenya

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Study Justification:
– Delays in seeking post abortion care services contribute to high levels of mortality and morbidity among women who experience unsafe abortion.
– Understanding the causes and factors associated with delays in seeking care is crucial for improving women’s access to quality sexual and reproductive health services.
Study Highlights:
– The study analyzed data from a nationally representative sample of 350 healthcare facilities in Kenya.
– Factors associated with delays in seeking care included women’s age, education level, contraceptive history, fertility intentions, and referral status.
– The study highlights the need to improve women’s access to quality sexual and reproductive health information and services, contraception, and abortion care.
– Improving post-abortion care services at lower level facilities can help minimize delays resulting from long referral processes.
Study Recommendations:
– Improve women’s access to quality sexual and reproductive health information and services.
– Increase availability and accessibility of contraception and abortion care services.
– Enhance post-abortion care services at lower level facilities to minimize delays resulting from long referral processes.
Key Role Players:
– Ministry of Health: Responsible for implementing policies and programs related to sexual and reproductive health.
– Healthcare providers: Responsible for delivering quality sexual and reproductive health services, including post-abortion care.
– Non-governmental organizations: Play a crucial role in providing comprehensive abortion care services and supporting women’s access to reproductive health information and services.
– Community health workers: Can help disseminate information and provide support to women seeking post-abortion care.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on post-abortion care.
– Procurement and distribution of contraceptives.
– Upgrading and equipping lower level facilities to provide quality post-abortion care services.
– Information, education, and communication campaigns to raise awareness about sexual and reproductive health services.
– Monitoring and evaluation of the implementation of recommendations.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a nationally representative sample of healthcare facilities in Kenya. The study collected data on socio-demographic characteristics, reproductive health, and clinical histories from women seeking post-abortion care. The study identified factors associated with delays in seeking care and concluded that improving access to sexual and reproductive health information, contraception, and abortion care, as well as improving PAC services at lower level facilities, can minimize delays. To improve the evidence, the study could have included a longer data collection period to capture a larger sample size and increase the generalizability of the findings.

Background: Delays in seeking quality post abortion care services remain a major contributor to high levels of mortality and morbidity among women who experience unsafe abortion. However, little is known about the causes of and factors associated with delays in seeking care among women who suffer complications of unsafe abortion. This study looks at factors that are associated with delays in seeking post-abortion care among women in Kenya. Methods: Data for this study were from a nationally representative sample of 350 healthcare facilities that participated in the 2012 Incidence and Magnitude of Unsafe Abortion study in Kenya. Data included socio-demographic characteristics, reproductive health and clinical histories from all women treated with PAC during a one-month data collection period. Results: Delay in seeking care was associated with women’s age, education level, contraceptive history, fertility intentions and referral status. Conclusions: There is need to improve women’s access to quality sexual and reproductive health information and services, contraception and abortion care. Improving current PAC services at lower level facilities will also minimize delays resulting from long referral processes.

This study is descriptive, analysing cross-sectional data obtained from women seeking PAC in healthcare facilities over a 30-day period in sampled facilities. This paper uses data from the 2012 National Incidence and Magnitude of Unsafe Abortion Study led by the African Population and Health Research Center (APHRC). The study used data from a nationally representative sample of 350 level II-level VI facilities, out of all 2838 PAC-providing facilities in Kenya in 2012. The Kenyan Ministry of Health categorizes the health system into six levels which provide preventive and curative public and private health services as follows; Community health services (Level I); Primary care facilities (Level II and III) comprising of dispensaries, clinics, health centres and maternity homes; county referral health facilities (Levels IV and V) comprising of district/county hospitals, sub-district/county and provincial hospitals; and VI (national referral health facilities comprising of national hospitals) [17]. The study sampled all facilities from level II to Level VI, but excluded dispensaries, which are less likely to offer any PAC services due to staffing and equipment. The primary outcome variable, “delay in seeking care” was based on a set of responses to questions that sought to establish 1) the time it took a woman from the onset of complication (e.g. when first bleeding was spotted) to know that she was experiencing a problem, 2) The time to decide to seek care 3) the time between making the decision to seek care and arrival at health facility. We computed the delay to seek care variable used in this study as the total time of these three different durations as reported by the patient in hours. In addition, we measured the following socio-demographic characteristics: age, level of education, type of residence (rural/urban), and occupation. For all clients including referrals, delay was computed from onset of complications to arrival at health facility at which the patient was observed in this study. For patients who were referred out of the facility of observation, the duration of delay only ends at current facility of observation while patients who were referred to the current facility, the time spent in the referring facility is also captured in the total delay. As of 31st of January 2012, MoH provided a list of 2838 facilities in levels II to VI with a potential to provide PAC. All level V (17 facilities) and VI (two facilities) facilities were included in the study as well as all (thirty-seven) non-governmental facilities that provide post abortion care or known to provide comprehensive abortion care services. However, for level II-IV facilities, we drew a representative sample using varying sampling fractions at each facility level and region. Therefore, we stratified the total sample according to five geographic regions and five facility levels. We generated these five regions by merging some provinces, which are similar with respect to geographic neighborliness, proximity to shared major healthcare facilities and some level of similarity in selected health-related indicators such as maternal mortality ratios, contraceptive prevalence and total fertility rates. These regions were a) Nairobi and Central b) Nyanza and Western c) Coast and North Eastern d) Rift Valley and e) Eastern provinces. In total 350 facilities were sampled, and a national response rate of 90 % was achieved during data collection. The original survey sample was determined in order to have 80 % power to detect at regional level 10 % difference in the proportion of women with severe complications from unsafe abortion as significant, using a two-sided 5 % significance level. Trained facility-based healthcare providers who offer PAC services at the sampled facilities collected data from all patients presenting at each of the 326 facilities out of the 350 over a 30-day period. Of the remaining twenty-four facilities, twenty-two did not provide data due to low monthly caseloads while we excluded data from two facilities due to logistical challenges. This gave an average national response rate of 93 % spread according to regions as follows; Nairobi and Central (92 %), Nyanza and Western (99 %), Coast and North Eastern (94 %), Rift Valley (89 %) and Eastern provinces (99 %). The providers collected patients’ socio-demographic characteristics, reproductive and clinical histories, diagnosis, treatment and clinical procedures performed, post abortion contraception provision, and clinical management outcomes. We collected all data using paper forms, and later captured into computers using CSPro® and then exported to STATA® 12.1 for consistency checks and analysis. These analyses consisted of descriptive and inferential statistical analysis to describe some of the demand-side characteristics associated with delayed care seeking among women presenting for PAC. The analyses presented in this paper focuses on women who sought PAC. Estimates presented in this paper were weighted using sampling weights generated from the probability of a woman being interviewed in the survey. The sampling fractions were a product of the probability of a facility being selected and accepting to participate and that of a woman participating in the survey based on overall interview response rate at the regional level. To adjust our estimate’s standard errors for design effect due to the complex sampling design above, we generated all statistics presented in this article within STATA’s “svy” platform using the facility level as the primary sampling unit. We summarized delay into median time to care by woman characteristics. For this analysis, given the right-skewedness (positive) of the data (Skeweness = 7.04), we transformed the outcome variable into its natural logarithm, yielding a more symmetric outcome variable (Skeweness = −0.0152). To study factors associated with delayed care seeking, we fitted a random-effects model assuming uniform correlations and estimated the intra-cluster correlation. Past studies have categorized abortion complications into three levels based on clinical signs and symptoms. These classification categories as used in this study were adopted from two main surveys, one in South Africa [18] and another adopted in a study in Kenya [5]. The classifications are outlined in Table 1 below. Classification of severity categories of abortion complications Cases were categorized into the extreme category of abortion complications, and required only one sign or symptom to be counted in that category. (Adopted from Jewkes, Fawcus et al. [28] and Jewkes, Gumede et al. [29] The study received ethical clearance from the Ethical Review Boards of the Kenya Medical Research Institution (KEMRI), the University of Nairobi/Kenyatta National Hospital, Moi University Teaching and Referral Hospital, and Aga Khan University. The Ministries of Public Health and sanitation and the Medical Services in Kenya and the Institutional Review Board of the Guttmacher Institute also reviewed and approved the study. For ethical considerations, verbal consents were obtained from all women presenting for PAC. Deidentification of records was done before analysis to ensure that data collected on a woman, provider or facility could not be traced back to the source.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health (mHealth) applications: Develop mobile applications that provide women with access to quality sexual and reproductive health information, including information on post-abortion care. These apps can also provide reminders for contraceptive use and appointments for follow-up care.

2. Telemedicine services: Implement telemedicine services that allow women in remote or underserved areas to consult with healthcare providers remotely. This can help overcome geographical barriers and provide timely access to post-abortion care.

3. Community health workers: Train and deploy community health workers who can provide education, counseling, and referrals for post-abortion care. These workers can reach women in their communities and help reduce delays in seeking care.

4. Improving lower-level facilities: Enhance the capacity of lower-level healthcare facilities to provide comprehensive post-abortion care. This can include training healthcare providers, ensuring the availability of necessary equipment and supplies, and improving referral systems.

5. Strengthening family planning services: Increase access to and availability of contraception services to prevent unintended pregnancies and reduce the need for unsafe abortions. This can involve expanding the range of contraceptive methods available and improving contraceptive counseling and provision.

6. Public awareness campaigns: Conduct public awareness campaigns to educate women and communities about the importance of seeking timely post-abortion care. These campaigns can address stigma, misconceptions, and barriers to care-seeking.

7. Integration of services: Integrate post-abortion care services with other reproductive health services, such as antenatal care and family planning. This can ensure that women receive comprehensive care and support throughout their reproductive journey.

It’s important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of the population in Kenya.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health is to focus on the following areas:

1. Improve access to quality sexual and reproductive health information and services: This includes providing comprehensive and accurate information about contraception, safe abortion services, and post-abortion care. It is important to ensure that women have access to reliable sources of information and are aware of their reproductive health rights.

2. Enhance access to contraception: Increasing access to a wide range of contraceptive methods can help prevent unintended pregnancies and reduce the need for unsafe abortions. This can be achieved through the provision of affordable and accessible contraception services, including counseling and education on contraceptive options.

3. Strengthen abortion care services: Ensuring that safe and legal abortion services are available and accessible can help reduce the incidence of unsafe abortions and the associated complications. This includes training healthcare providers in safe abortion procedures, improving the availability of abortion services at lower-level healthcare facilities, and reducing delays in the referral process.

4. Address socio-demographic factors: The study identified factors such as age, education level, contraceptive history, fertility intentions, and referral status as being associated with delays in seeking post-abortion care. It is important to address these socio-demographic factors by implementing targeted interventions, such as educational programs for young women, improving access to education for all women, and addressing barriers to healthcare access for marginalized populations.

Overall, the recommendation is to adopt a comprehensive approach that addresses both the supply and demand sides of maternal health. This includes improving the availability and quality of healthcare services, increasing awareness and knowledge about reproductive health, and addressing socio-economic and cultural factors that may hinder access to care.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening Sexual and Reproductive Health Education: Increase efforts to provide comprehensive sexual and reproductive health education to women, including information on contraception, safe abortion care, and post-abortion care. This can be done through community outreach programs, school-based education, and partnerships with local organizations.

2. Improving Access to Contraception: Increase availability and accessibility of contraception methods to prevent unintended pregnancies and reduce the need for unsafe abortions. This can be achieved by expanding the range of contraceptive options, ensuring consistent supply, and providing education on contraceptive methods.

3. Enhancing Referral Systems: Improve the efficiency and effectiveness of referral systems to minimize delays in seeking care. This can be done by strengthening communication and coordination between different levels of healthcare facilities, providing training to healthcare providers on timely referrals, and implementing digital health solutions for easier tracking and monitoring of referrals.

4. Increasing Availability of Post-Abortion Care Services: Ensure that healthcare facilities, especially at lower levels, are equipped and staffed to provide quality post-abortion care services. This may involve training healthcare providers on comprehensive abortion care, improving infrastructure and equipment, and addressing any legal or policy barriers that restrict the provision of these services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the proportion of women seeking post-abortion care within a specified time period, contraceptive prevalence rate, and maternal mortality rate.

2. Collect baseline data: Gather data on the current status of these indicators to establish a baseline. This can be done through surveys, interviews, and analysis of existing data sources.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model should consider factors such as population demographics, healthcare infrastructure, and resource availability.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of each recommendation on the selected indicators. This can be done by adjusting the parameters related to each recommendation and observing the resulting changes in the indicators.

5. Analyze results: Analyze the simulation results to determine the effectiveness of each recommendation in improving access to maternal health. Compare the simulated outcomes with the baseline data to quantify the potential impact of the recommendations.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data sources or expert input. This will ensure that the model accurately represents the real-world context and can be used for future simulations.

7. Communicate findings and make recommendations: Present the findings of the simulation study, including the potential impact of each recommendation on improving access to maternal health. Use these findings to inform policy and decision-making processes, and make recommendations for implementing the identified strategies.

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