Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghana

BMC Public Health, Volume 15, No. 1, Year 2015

Interpretation

Background: Understanding what factors influence the receipt of postabortion contraception can help improve comprehensive abortion care services. The abortion visit is an ideal time to reach women at the highest risk of unintended pregnancy with the most effective contraceptive methods. The objectives of this study were to estimate the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two separate outcomes: (1) the likelihood of adopting postabortion contraception; (2) postabortion contraceptors’ likelihood of receiving a long-acting and permanent versus a short-acting contraceptive method. Methods: We used retrospective cohort data collected from 64 health facilities in three regions of Ghana. The dataset includes information on all abortion procedures conducted between 1 January 2008 and 31 December 2010 at each health facility. We used fixed effect Poisson regression to model the associations of interest. Results: More than half (65 %) of the 29,056 abortion clients received some form of contraception. When midwives performed the abortion, women were more likely to receive postabortion contraception compared to house officers (RR: 1.18; 95 % CI: 1.13, 1.24) or physicians (RR: 1.21; 95 % CI: 1.18, 1.25), after controlling for facility-level variation and client-level factors. Compared to women seen by house officers, abortion clients seen by midwives and physicians were more likely to receive a long-acting and permanent rather than a short-acting contraceptive method (RR: 1.46; 95 % CI: 1.23, 1.73; RR: 1.58; 95 % CI: 1.37, 1.83, respectively). Younger women were less likely to receive contraception than older women irrespective of provider type and indication for the abortion (induced or PAC). Conclusions: When comparing consultant physicians, house officers, and midwives, the type of abortion provider is associated with whether women receive postabortion contraception and with whether abortion clients receive a long-acting and permanent or a short-acting method. New strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception and to ensure that women seen by house officers have access to long-acting and permanent contraceptive methods. This is a retrospective cohort study that includes all abortion procedures conducted between January 1, 2008 and December 31, 2010 at 64 health care facilities in the Ashanti, Eastern, and Greater Accra regions of Ghana. The facilities included 23 public hospitals, 37 public health centers, and 4 private maternity homes which are small clinics where midwives provide reproductive health services. All facilities had partnered with Ipas, a global, non-governmental organization that advocates for women’s sexual and reproductive health and rights. The collaboration with Ipas was part of facilities’ participation in the Reducing Maternal Mortality and Morbidity (R3M) program, a Ghana Health Services program designed to improve comprehensive abortion care services [18]. Consultant physicians are physicians of varying levels of seniority who have received their Bachelor of Medicine and Bachelor of Surgery degree. House officers are pre-practice physicians who have graduated from medical school during the last year and who are trained in uterine evacuation and contraceptive counseling during their 6 month obstetrics and gynecology rotation. Midwives are either nurses who receive a year of midwifery training following 2 years of nursing school or community health officers or college graduates who receive 2 years of midwifery training. Prior to and during the study period, Ipas staff worked in collaboration with the Ghana Health Service to train abortion providers in comprehensive abortion care and visited partner facilities to monitor the quality of abortion services and to ensure abortion providers’ routine completion of facility logbooks provided through the R3M program. During the study period, 29,463 procedures were recorded in facility logbooks. Providers entered abortion case data into logbooks provided by the R3M program; data were later entered into a database by Ipas program staff. Ipas received permission from individual health facilities and from the Ghana Health Service to collect and analyze logbook data. The logbook captures demographic variables (client age), indication (induced or PAC), type of procedure (manual vacuum aspiration, electric vacuum aspiration, uterine evacuation with misoprostol alone or mifepristone and misoprostol, dilation and curettage, or extraction) and type of postabortion contraception. Short-acting (condoms, oral contraceptives, injectables) and LA/PM (intrauterine devices, contraceptive implants, and sterilization) are available at all facility levels with the exception of sterilization which is not offered at the midwife-run maternity homes. We excluded listings for 368 abortion procedures that were referred to alternate facilities and 39 procedures that were listed as molar or ectopic pregnancies or that were classified as intrauterine fetal demise. The outcomes of interest were whether women received postabortion contraception or not and, for women who received contraception, whether they received a short or LA/PM. Because odds ratios estimated using logistic regression are known to overestimate relative risks for prevalent outcomes [19], we used Poisson regression with robust standard errors to estimate 1) the relative risk of receipt of postabortion contraception; and 2) the relative risk (RR) of receiving a LA/PM rather than a short-acting method by provider type. We compared covariates (four age categories, trimester, indication for abortion, uterine evacuation procedure type, facility level, and facility region) between women who did or did not receive contraception with bivariate Poisson regression models. We constructed a directed acyclic graph to identify probable confounders based on our review of the literature and understanding of the causal relationship between provider type and women’s adoption of contraception. Women who go to the same clinic often receive the same contraceptives because of clinic-specific protocols, organization, and supplies. To eliminate the possibility of obtaining estimates that are biased by differences across facilities, we included a fixed effect for each health facility in the adjusted models. The health facility fixed effects control for all measured and unmeasured differences across facilities [20]. We identified age and indication for abortion service (induced abortion or PAC) a priori as potential effect measure modifiers [21]. Likelihood ratio tests were used to evaluate the predictive value of the predefined interaction terms (at α = 0.05) between age and type of provider, indication for abortion service and type of provider, and age and indication for abortion service. We used the modified STROBE guidelines to present the results from the interaction between client age and abortion indication [22]. We used chi-squared tests to compare the probability of the outcome for abortion cases missing information on client and/or trimester and cases that had no missing information. Cases with missing information on client age and/or trimester were as likely as included cases to have received postabortion contraception (α = 0.05) and were excluded from the multivariate regression analysis (n = 2931 or 10 % of abortion cases). The multivariate analysis was based on data from 26,125 abortion procedures. All analysis was conducted in Stata SE version 13 (College Station, TX: StataCorp LP). The research protocol was approved by the Research Ethics and Compliance Institutional Review Board at McGill University, Montréal, Canada. The McGill University Institutional Review Board functions in accordance with the Tri-Council Policy Statement and the U.S. Code of Federal Regulations, guidelines that are also used by Ghanaian IRBs [23]. The authors were not able to identify any national regulations or guidelines for human subjects research in Ghana. As the dataset did not contain any information that could be used to identify individual participants or providers we did not seek additional approval from a Ghanaian Ethics Committee for this analysis.

AI Digest

Study Justification:

This study aims to understand the factors that influence the receipt of postabortion contraception in Ghana. By examining the relationship between the type of abortion provider and contraceptive uptake, the study seeks to improve comprehensive abortion care services and reach women at the highest risk of unintended pregnancy with effective contraceptive methods.

Highlights:

– The study analyzed data from 64 health facilities in Ghana, including public hospitals, public health centers, and private maternity homes.
– The dataset included information on all abortion procedures conducted between January 1, 2008, and December 31, 2010.
– The study found that when midwives performed the abortion, women were more likely to receive postabortion contraception compared to house officers or physicians.
– Women seen by midwives and physicians were also more likely to receive a long-acting and permanent contraceptive method compared to those seen by house officers.
– Younger women were less likely to receive contraception than older women, regardless of provider type and indication for the abortion.

Recommendations:

– New strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception.
– Efforts should be made to ensure that women seen by house officers have access to long-acting and permanent contraceptive methods.
– Additional research and interventions are needed to address the lower uptake of contraception among younger women.

Key Role Players:

– Abortion providers (consultant physicians, house officers, midwives)
– Health facility staff
– Ipas (global NGO advocating for women’s sexual and reproductive health and rights)
– Ghana Health Service

Cost Items:

– Training programs for abortion providers in comprehensive abortion care
– Monitoring and quality assurance visits by Ipas staff
– Database management and data analysis
– Development and implementation of new strategies for postabortion contraception access
Please note that the cost items provided are general examples and not actual cost estimates. The specific budget items would need to be determined based on the context and requirements of the interventions and programs recommended.

Strength of Evidence

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 retrospective cohort study that includes a large number of abortion procedures conducted at multiple health facilities in Ghana. The study uses robust statistical methods to analyze the data and control for confounding factors. The findings are presented clearly and provide important insights into the relationship between the type of abortion provider and postabortion contraception uptake. However, to improve the evidence, it would be beneficial to include information on the representativeness of the health facilities and the generalizability of the findings to other settings.

Abstract

This is a retrospective cohort study that includes all abortion procedures conducted between January 1, 2008 and December 31, 2010 at 64 health care facilities in the Ashanti, Eastern, and Greater Accra regions of Ghana. The facilities included 23 public hospitals, 37 public health centers, and 4 private maternity homes which are small clinics where midwives provide reproductive health services. All facilities had partnered with Ipas, a global, non-governmental organization that advocates for women’s sexual and reproductive health and rights. The collaboration with Ipas was part of facilities’ participation in the Reducing Maternal Mortality and Morbidity (R3M) program, a Ghana Health Services program designed to improve comprehensive abortion care services [18]. Consultant physicians are physicians of varying levels of seniority who have received their Bachelor of Medicine and Bachelor of Surgery degree. House officers are pre-practice physicians who have graduated from medical school during the last year and who are trained in uterine evacuation and contraceptive counseling during their 6 month obstetrics and gynecology rotation. Midwives are either nurses who receive a year of midwifery training following 2 years of nursing school or community health officers or college graduates who receive 2 years of midwifery training. Prior to and during the study period, Ipas staff worked in collaboration with the Ghana Health Service to train abortion providers in comprehensive abortion care and visited partner facilities to monitor the quality of abortion services and to ensure abortion providers’ routine completion of facility logbooks provided through the R3M program. During the study period, 29,463 procedures were recorded in facility logbooks. Providers entered abortion case data into logbooks provided by the R3M program; data were later entered into a database by Ipas program staff. Ipas received permission from individual health facilities and from the Ghana Health Service to collect and analyze logbook data. The logbook captures demographic variables (client age), indication (induced or PAC), type of procedure (manual vacuum aspiration, electric vacuum aspiration, uterine evacuation with misoprostol alone or mifepristone and misoprostol, dilation and curettage, or extraction) and type of postabortion contraception. Short-acting (condoms, oral contraceptives, injectables) and LA/PM (intrauterine devices, contraceptive implants, and sterilization) are available at all facility levels with the exception of sterilization which is not offered at the midwife-run maternity homes. We excluded listings for 368 abortion procedures that were referred to alternate facilities and 39 procedures that were listed as molar or ectopic pregnancies or that were classified as intrauterine fetal demise. The outcomes of interest were whether women received postabortion contraception or not and, for women who received contraception, whether they received a short or LA/PM. Because odds ratios estimated using logistic regression are known to overestimate relative risks for prevalent outcomes [19], we used Poisson regression with robust standard errors to estimate 1) the relative risk of receipt of postabortion contraception; and 2) the relative risk (RR) of receiving a LA/PM rather than a short-acting method by provider type. We compared covariates (four age categories, trimester, indication for abortion, uterine evacuation procedure type, facility level, and facility region) between women who did or did not receive contraception with bivariate Poisson regression models. We constructed a directed acyclic graph to identify probable confounders based on our review of the literature and understanding of the causal relationship between provider type and women’s adoption of contraception. Women who go to the same clinic often receive the same contraceptives because of clinic-specific protocols, organization, and supplies. To eliminate the possibility of obtaining estimates that are biased by differences across facilities, we included a fixed effect for each health facility in the adjusted models. The health facility fixed effects control for all measured and unmeasured differences across facilities [20]. We identified age and indication for abortion service (induced abortion or PAC) a priori as potential effect measure modifiers [21]. Likelihood ratio tests were used to evaluate the predictive value of the predefined interaction terms (at α = 0.05) between age and type of provider, indication for abortion service and type of provider, and age and indication for abortion service. We used the modified STROBE guidelines to present the results from the interaction between client age and abortion indication [22]. We used chi-squared tests to compare the probability of the outcome for abortion cases missing information on client and/or trimester and cases that had no missing information. Cases with missing information on client age and/or trimester were as likely as included cases to have received postabortion contraception (α = 0.05) and were excluded from the multivariate regression analysis (n = 2931 or 10 % of abortion cases). The multivariate analysis was based on data from 26,125 abortion procedures. All analysis was conducted in Stata SE version 13 (College Station, TX: StataCorp LP). The research protocol was approved by the Research Ethics and Compliance Institutional Review Board at McGill University, Montréal, Canada. The McGill University Institutional Review Board functions in accordance with the Tri-Council Policy Statement and the U.S. Code of Federal Regulations, guidelines that are also used by Ghanaian IRBs [23]. The authors were not able to identify any national regulations or guidelines for human subjects research in Ghana. As the dataset did not contain any information that could be used to identify individual participants or providers we did not seek additional approval from a Ghanaian Ethics Committee for this analysis.

Materials

https://efashare.b-cdn.net/materials/1a0e969380b010306624b537fc9cb6cee9e6f9c985e3622ab32d2a19cb7953f2/12889_2015_1875_MOESM1_ESM.pdf

Innovations

The study mentioned in the description is titled “Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghana.” The study aims to understand the factors that influence the receipt of postabortion contraception and improve comprehensive abortion care services. The study found that the type of abortion provider (consultant physician, house officer, or midwife) is associated with whether women receive postabortion contraception and whether they receive a long-acting and permanent or a short-acting contraceptive method. The study suggests that new strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception and that women seen by house officers have access to long-acting and permanent contraceptive methods.

AI Innovations Description

The study mentioned in the description focuses on understanding the factors that influence the receipt of postabortion contraception in order to improve comprehensive abortion care services. The study specifically examines the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two outcomes: the likelihood of adopting postabortion contraception and the likelihood of receiving a long-acting and permanent contraceptive method.

The findings of the study indicate that when midwives perform the abortion, women are more likely to receive postabortion contraception compared to house officers or physicians. Additionally, women seen by midwives and physicians are more likely to receive a long-acting and permanent contraceptive method compared to women seen by house officers. However, younger women are less likely to receive contraception regardless of the provider type and indication for the abortion.

Based on these findings, the study suggests the need for new strategies to ensure that women seen by physicians and house officers have access to postabortion contraception and that women seen by house officers have access to long-acting and permanent contraceptive methods.

In summary, the recommendation from this study is to develop innovative strategies that address the disparities in access to postabortion contraception based on the type of abortion provider. These strategies should aim to improve access for women seen by physicians and house officers and ensure that younger women receive appropriate contraception regardless of the provider type.

AI Innovations Methodology

The study titled “Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghana” aims to understand the factors that influence the receipt of postabortion contraception in order to improve comprehensive abortion care services. The study analyzes data collected from 64 health facilities in Ghana between January 1, 2008, and December 31, 2010.

The methodology used in this study is a retrospective cohort design. The dataset includes information on all abortion procedures conducted at each health facility during the study period. The type of abortion provider (consultant physician, house officer, or midwife) is the main independent variable of interest. The study examines two outcomes: (1) the likelihood of adopting postabortion contraception, and (2) the likelihood of receiving a long-acting and permanent contraceptive method versus a short-acting method.

To analyze the data, the study uses fixed effect Poisson regression models. This statistical method allows the researchers to estimate the associations between the type of abortion provider and the outcomes of interest while controlling for facility-level variation and client-level factors. The analysis also includes covariates such as age, trimester, indication for abortion, uterine evacuation procedure type, facility level, and facility region.

The study finds that when midwives perform the abortion, women are more likely to receive postabortion contraception compared to house officers or physicians. Additionally, women seen by midwives and physicians are more likely to receive a long-acting and permanent contraceptive method compared to women seen by house officers. The study also highlights that younger women are less likely to receive contraception than older women, regardless of the provider type and indication for the abortion.

In conclusion, the study suggests the need for new strategies to ensure that women seen by physicians and house officers can access postabortion contraception and that women seen by house officers have access to long-acting and permanent contraceptive methods. The findings of this study provide valuable insights for improving access to maternal health services and can inform the development of targeted interventions to address the identified gaps.

Author

Dima Health

Statistics:

Citations: 15

Identifiers:

DOI: 10.1186/s12889-015-1875-2

Research Areas:

Community Interventions, Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce

Study Countries:

Ghana

Study Design:

Cohort Study

Study Approach:

Quantitative

Participants Gender:

Female