Improving the quality of postabortion care services in Togo increased uptake of contraception

High-quality postabortion care (PAC) services that include family planning counseling and a full range of contraceptives at point of treatment for abortion complications have great potential to break the cycle of repeat unintended pregnancies and demand for abortions. We describe the first application of a systematic approach to quality improvement of PAC services in a West African country. This approach-IntraHealth International’s Optimizing Performance and Quality (OPQ) approach-was applied at 5 health care facilities in Togo starting in November 2014. A baseline assessment identified the following needs: Reorganizing services to ensure that contraceptives are provided at point of treatment for abortion complications, before PAC clients are discharged; improving provider competencies in family planning services, including in providing long-acting reversible contraceptive implants and intrauterine devices; ensuring that contraceptive methods are available to all PAC clients free of charge; standardizing PAC registers and enhancing data collection and reporting systems; enhancing internal supervision systems at facilities and teamwork among PAC providers; and engaging PAC providers in community talks. Solutions devised and applied at the facilities during OPQ resulted in significant increases in contraceptive counseling and uptake among PAC clients: During the 5-month baseline period, 31% of PAC clients were counseled, while during the 13-month intervention period, 91% were counseled. Of all PAC clients counseled during the baseline period, 37% accepted a contraceptive, compared with 60% of those counseled during the intervention period. Oral contraceptive pills remained the most popular method during both periods, yet uptake of implants increased significantly during the intervention period-from 4% to 27% of those accepting contraceptives. This result demonstrates that the solutions applied maintained method choice while expanding access to underused long-acting reversible contraceptives. OPQ shows great potential for sustainability and scale in Togo and for application in similar contexts where the health system struggles to offer safe, high-quality, accessible PAC services.

The Division of Family Health within Togo’s Ministry of Health and E2A selected 5 health care facilities appropriate for applying quality improvement solutions. Selection was based on criteria that included the location of the facility, to ensure a balance in the Maritime and Plateaux regions; a substantial client load for PAC; the facility’s role as a referral site for PAC; and availability of a broad range of contraceptive methods and providers trained to offer PAC and family planning services. Two of the 5 facilities were part of E2A’s earlier assessment of PAC services in Togo. E2A and the Division of Family Health conducted a baseline assessment that included site visits and a review of the 5 facilities’ organization of services, clinical records, data use and reporting, supervision systems, referral systems, equipment and supply systems, cost of services to clients, and provider competencies. The baseline assessment identified shortcomings to be addressed through the quality improvement processes (Table). These shortcomings were shared with providers, used to inform action plans for improving the services, and reassessed by E2A and supervisors during on-site supportive supervision visits. Abbreviations: FP, family planning; IUD, intrauterine device; MVA, manual vacuum aspiration; OPC, Optimizing Performance and Quality; PAC, postabortion care. The Division of Family Health selected IntraHealth International’s OPQ12 approach and tools for adaptation to the Togo health system. OPQ is a cyclical process for analyzing the performance of health workers, organizations, and systems and setting up solutions to build on strengths and successes. It fosters teamwork and ownership; applies a problem-solving process to address performance gaps; and develops skills in stakeholder engagement and leadership, connecting providers at facilities with support from national, regional, and district supervisors. The Togo health system has limited capacity in both number and skills of supervisors, and the Division of Family Health selected OPQ because it can be implemented and guided by an internal team at a health care facility. The 5 facilities selected for the study had already appointed the in-charges from the maternity ward and family planning unit as internal supervisors charged with overseeing PAC services. OPQ is a cyclical process for analyzing the performance of health workers, organizations, and systems and setting up interventions to build on strengths and successes. Providers practice IUD insertion on pelvic models during postabortion care training. The Division of Family Health also formed a national quality improvement team to support the 5 health care facilities. The division national quality improvement team then developed a plan to improve access to quality family planning services during PAC, primarily by fostering teamwork and ownership of quality improvement solutions, strengthening provider competencies, addressing policy barriers, and improving how services are organized, supported, monitored, and analyzed. To establish quality improvement measures at the 5 health care facilities, the OPQ methodology was adapted for PAC. Facilities were asked to assess their current performance (based on elements of successful postabortion family planning services as defined by a High Impact Practices in Family Planning brief13); define desired performance (based on the capacity of the service delivery system); identify performance gaps; and work on solutions to address the performance gaps using best practices for strengthening service delivery. Findings from the baseline assessment were integrated into OPQ to identify performance gaps, develop quality and performance objectives, and define standards against which the facilities could measure their performance. The national quality improvement team included focal point persons for PAC, reproductive health, and maternal health. The team was trained to use OPQ tools and was tasked with documenting the quality improvement process, providing on-site and remote support to facility-based quality improvement teams, providing policies and guidelines on family planning and PAC, facilitating provider trainings, and creating links between community-based and facility-based services. The Division of Family Health’s plan required the in-charges of each facility’s family planning unit and maternity ward, as well as the district supervisors for family planning and reproductive health, to work together in facility-based quality improvement teams. The facility team provided leadership in conducting performance assessments, defining desired performance, identifying gaps, and implementing and monitoring quality improvement activities. The team was also tasked with obtaining resources from facility or district or regional managers to support implementation of quality improvement activities. The Division of Family Health, national and the facility-based quality improvement teams received a 4-day training on OPQ in November 2014. Facility teams defined their desired performance benchmarks and identified performance gaps, including their root causes. During participatory work, the teams used service data from the baseline assessment; elements of successful postabortion family planning services; and the “Ten Elements of Family Planning Success.”14 Using OPQ tools to explore factors that influence performance, the facility-based teams developed action plans that included solutions to close gaps and reach desired performance. During a 4-day training, facility-based quality improvement teams defined their goals and performance benchmarks, identified performance gaps and root causes of those gaps, and developed action plans. The quality improvement action plans emphasized the need for more providers trained to provide both PAC and family planning, including long-acting contraceptive implants and IUDs. During a second training, in February–March 2015, 14 nurses and midwives from the 5 participating facilities attended a 2-week PAC training and contraceptive technology update that emphasized competency-based skills for providing implants and IUDs. The training also addressed issues such as provider bias regarding clients, including youth; the need to provide counseling and family planning methods regardless of whether the abortion was induced or spontaneous; rights-based care; eligibility criteria for family planning methods following emergency treatment of abortion complications; and recordkeeping and data use. After guided live practice to meet required practicum objectives, in June–July 2015 the trainers conducted competency-based assessments on counseling, insertion of IUDs and implants, and manual vacuum aspiration (MVA) with all 14 trained providers. These assessments resulted in certification of all participants. In March and July 2015, the national quality improvement team and E2A offered on-site and virtual support to facility-based teams to address performance issues and barriers to implementation. Progress was assessed through observation of service delivery practices, review of registers, and interviews with providers. After each on-site support session, the national team debriefed facility managers and Division of Family Health leadership, providing feedback and soliciting needed support and resources (e.g., adequate supply of registers and contraceptives, cost waivers for PAC clients). The facility-based teams periodically updated regional and district health management teams on progress at the 5 facilities, advocating further support to improve PAC services. In August 2015, the facility-based quality improvement teams met to share preliminary results and further address performance challenges through peer-to-peer support. We adapted the postabortion register from the PAC Global Resources Guide (http://postabortioncare.org) for use in Togo. The 5 health care facilities used the standardized register to track client indicators, including age, type of abortion complication, and method of treatment, as well as whether client was counseled, a family planning method offered and accepted, and other reproductive health services provided. To measure progress over time, monthly data were compiled and submitted to facility managers and the Division of Family Health. The facility managers and head of the Division of Family Health provided feedback and support to each facility team using information from both quantitative and qualitative monitoring. During on-site monitoring and support visits, the national quality improvement team reviewed the PAC and family planning registers for accuracy and consistency, and data were collected on the referral of clients from the maternity ward to the family planning unit or, in rare cases, to mobile units for contraceptive services. The E2A technical advisors also observed services provided, supported data collection and analysis, and analyzed progress against desired performance detailed in the facilities’ action plans. The next section describes the results of the monitoring. We plan a further evaluation to inform development of scale-up plans.

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• Dima Health