‘I am all alone’: Factors influencing the provision of termination of pregnancy services in two South African provinces

Global Health Action, Volume 10, No. 1, Year 2017

Interpretation

Background: Globally, universal access to sexual and reproductive health care services has been re-emphasised. One-third of maternal deaths could be averted by improving access to safe abortion services. Anecdotal evidence suggests that the implementation of the Choice of Termination of Pregnancy Act has been suboptimal in South Africa. Objectives: In two South African provinces, determine: the proportion of designated termination of pregnancy (TOP) facilities that provide these services; explore the factors that influence the provision of TOP services; and explore the work experiences of health care providers at designated TOP facilities. Methods: During 2014 and 2015, we conducted a cross-sectional study at designated TOP facilities in Gauteng and North West provinces. A combination of methods was used, consisting of: site visits to, and observation of, each of the designated facilities using a checklist, and in-depth interviews with a sub-set of 30 TOP service providers, using a semi-structured interview schedule. The interview questions focused on the factors influencing TOP service provision, and the work experiences of TOP service providers. We used interpretative phenomenological analysis to analyse the data from the interviews. Results: Overall, 77% (47/61) of designated facilities were providing TOP services, with 87.5% (28/32) in Gauteng Province, compared with 65.5% (19/29) in North West Province. Service provision was influenced by health system deficiencies, human resource challenges, lack of prioritisation and lack of management support. Study participants reported a heavy burden of care provision and expressed an overwhelming feeling of loneliness, courtesy stigma and lack of support from other nurses and doctors, which further influence TOP service provision. Conclusions: South Africa has an enabling legal environment for the provision of TOP services. Supportive management, prioritisation of TOP services and employee wellness programmes to address the psychosocial issues experienced by providers are critical elements of an enabling health policy environment. The study was carried out at designated TOP facilities in Gauteng, an urban province, and North West, a mixed urban-rural province. These two provinces were selected because of geographical proximity to the researchers, logistical considerations and budgetary constraints. During 2014 and 2015, we conducted a cross-sectional study that used a combination of methods: site visits to and observation of all designated TOP facilities in Gauteng and North West provinces, using a checklist, surveys among TOP service providers and facility managers, and in-depth interviews with a sub-set of TOP service providers. In this paper, we only focus on the site visits to and observation of all designated TOP facilities and the in-depth interviews with TOP service providers. The sampling frame consisted of all public health facilities (hospitals and clinics) in Gauteng and North West provinces that are designated by the national Department of Health (DoH) to provide TOP services, whether as stand-alone or as integrated sexual and reproductive health services. We obtained a 2014 list of these designated TOP facilities from the national DoH, which was compared with the 2014 list from the provincial database from each of the study provinces. A designated facility is defined as one that meets the requirements to provide TOP services in terms of section 3 of the CTOPA, and is certified as such by the national DOH [28]. In each province, we verified the provincial database by interviewing the overall manager responsible for all sexual and reproductive health services. The population of interest was all TOP health care providers, defined as professional nurses (with four years of training) or medical doctors (practitioners), whether full time or part time, providing TOP services in the public health sector at the designated facilities in the two provinces. We selected a sub-set of 30 TOP service providers from the designated facilities that included a mix of Gauteng and North West hospitals and clinics, for in-depth interviews, using a purposive sampling technique. The University of Witwatersrand’s Human Research Ethics Committee (Medical) provided ethics approval for the study. The relevant provincial health authorities, including hospital and health centre managers, also provided study approval. We adhered to standard ethical requirements including participant-informed consent, detailed study information sheets, voluntary participation and maintaining confidentiality of information. We designed a spreadsheet/facility checklist for the site visit and observation with the following details: province identification number, name of the district, facility number, health care provider identity number, whether TOP services were provided, and the number and category (professional nurse or doctor) of TOP providers at each facility. The principal researcher visited each of the designated facilities between July 2014 and August 2015. In addition to the information on the spreadsheet, the principal researcher took detailed field notes. In those instances where TOP services were not provided at a designated facility, the researcher recorded the stated reasons for non-provision. The researcher also ascertained whether there were any facilities that were not on the original list of designated facilities, but that were providing TOP services. These additional facilities were also visited, and detailed field notes were recorded. We designed a semi-structured interview schedule to explore the work experiences of TOP providers and their perspectives on the factors that influence TOP provision. The questions focused on: perceptions of their work as TOP providers, including rewarding and challenging aspects, psychosocial issues faced in the workplace, coping strategies, availability of support mechanisms in the workplace, the factors that influence TOP provision, and their recommendations for change. The principal researcher invited the selected TOP providers to participate in the interview, and gave each person an information sheet and consent form. She explained the voluntary nature of the study, informed participants that no names would be used during the interview, and assured them of confidentiality and anonymity. Following informed consent, the researcher conducted semi-structured interviews with these TOP providers in English, which is the official business language of South Africa. Each interview lasted around 40 minutes, although the length of time ranged from 30 minutes to 60 minutes. The researcher also took detailed notes during the interview and wrote a synopsis of each interview. The information from the site visits was collected on a Microsoft Excel spreadsheet, and this programme was used to analyse the data from the site visits. We transcribed the recorded interviews verbatim. Data cleaning took one month and consisted of an iterative process of checking the transcribed interviews against the original recordings, correcting the text, checking the recordings again and making final corrections. Prior to analysis, an audit of provider interviews was done, and each provider was allocated a code number to ensure confidentiality of information. The coded interviews were consolidated into one file for ease of analysis. We used interpretative phenomenological analysis for the analysis of the semi-structured interviews with TOP providers [29,30]. To ensure reliability, two other researchers (one a medical anthropologist and the other the research supervisor of the principal investigator) participated in the development of the themes by reading four diverse transcripts. Each researcher examined the meaning of the words of participants, and developed a set of codes, rather than using a pre-existing theory to identify codes that could be applied to the data [29,30]. We held a meeting of the three researchers to discuss the codes and to reach agreement on the codes and themes, namely the recurring patterns of meaning (ideas, thoughts and feelings) that emerged throughout the provider interviews. The principal investigator merged the codes and themes into one consolidated code book, prior to analysing the data using MAXQDA® 12.

AI Digest

Study Justification:

– Universal access to sexual and reproductive health care services is a global priority.
– Improving access to safe abortion services can significantly reduce maternal deaths.
– Anecdotal evidence suggests suboptimal implementation of the Choice of Termination of Pregnancy Act in South Africa.

Study Highlights:

– 77% of designated termination of pregnancy (TOP) facilities in two South African provinces provide TOP services.
– Factors influencing TOP service provision include health system deficiencies, human resource challenges, lack of prioritization, and lack of management support.
– TOP service providers experience a heavy burden of care provision, loneliness, courtesy stigma, and lack of support from colleagues.

Study Recommendations:

– Supportive management and prioritization of TOP services are crucial for effective provision.
– Employee wellness programs should be implemented to address the psychosocial issues experienced by TOP service providers.

Key Role Players:

– National Department of Health
– Provincial health authorities
– Hospital and health center managers
– Professional nurses and medical doctors providing TOP services

Cost Items for Planning Recommendations:

– Training and capacity building for health care providers
– Development and implementation of supportive management policies
– Employee wellness programs and support services
– Monitoring and evaluation systems for TOP service provision
Please note that the actual cost of implementing these recommendations is not provided in the given information.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a cross-sectional study at designated TOP facilities in two South African provinces, using a combination of methods including site visits, observation, surveys, and in-depth interviews. The study provides quantitative data on the proportion of facilities providing TOP services and qualitative data on the factors influencing TOP service provision. However, the study does not mention the sample size or the representativeness of the facilities and providers included. To improve the evidence, the study could have provided more details on the sampling strategy and the generalizability of the findings.

Abstract

The study was carried out at designated TOP facilities in Gauteng, an urban province, and North West, a mixed urban-rural province. These two provinces were selected because of geographical proximity to the researchers, logistical considerations and budgetary constraints. During 2014 and 2015, we conducted a cross-sectional study that used a combination of methods: site visits to and observation of all designated TOP facilities in Gauteng and North West provinces, using a checklist, surveys among TOP service providers and facility managers, and in-depth interviews with a sub-set of TOP service providers. In this paper, we only focus on the site visits to and observation of all designated TOP facilities and the in-depth interviews with TOP service providers. The sampling frame consisted of all public health facilities (hospitals and clinics) in Gauteng and North West provinces that are designated by the national Department of Health (DoH) to provide TOP services, whether as stand-alone or as integrated sexual and reproductive health services. We obtained a 2014 list of these designated TOP facilities from the national DoH, which was compared with the 2014 list from the provincial database from each of the study provinces. A designated facility is defined as one that meets the requirements to provide TOP services in terms of section 3 of the CTOPA, and is certified as such by the national DOH [28]. In each province, we verified the provincial database by interviewing the overall manager responsible for all sexual and reproductive health services. The population of interest was all TOP health care providers, defined as professional nurses (with four years of training) or medical doctors (practitioners), whether full time or part time, providing TOP services in the public health sector at the designated facilities in the two provinces. We selected a sub-set of 30 TOP service providers from the designated facilities that included a mix of Gauteng and North West hospitals and clinics, for in-depth interviews, using a purposive sampling technique. The University of Witwatersrand’s Human Research Ethics Committee (Medical) provided ethics approval for the study. The relevant provincial health authorities, including hospital and health centre managers, also provided study approval. We adhered to standard ethical requirements including participant-informed consent, detailed study information sheets, voluntary participation and maintaining confidentiality of information. We designed a spreadsheet/facility checklist for the site visit and observation with the following details: province identification number, name of the district, facility number, health care provider identity number, whether TOP services were provided, and the number and category (professional nurse or doctor) of TOP providers at each facility. The principal researcher visited each of the designated facilities between July 2014 and August 2015. In addition to the information on the spreadsheet, the principal researcher took detailed field notes. In those instances where TOP services were not provided at a designated facility, the researcher recorded the stated reasons for non-provision. The researcher also ascertained whether there were any facilities that were not on the original list of designated facilities, but that were providing TOP services. These additional facilities were also visited, and detailed field notes were recorded. We designed a semi-structured interview schedule to explore the work experiences of TOP providers and their perspectives on the factors that influence TOP provision. The questions focused on: perceptions of their work as TOP providers, including rewarding and challenging aspects, psychosocial issues faced in the workplace, coping strategies, availability of support mechanisms in the workplace, the factors that influence TOP provision, and their recommendations for change. The principal researcher invited the selected TOP providers to participate in the interview, and gave each person an information sheet and consent form. She explained the voluntary nature of the study, informed participants that no names would be used during the interview, and assured them of confidentiality and anonymity. Following informed consent, the researcher conducted semi-structured interviews with these TOP providers in English, which is the official business language of South Africa. Each interview lasted around 40 minutes, although the length of time ranged from 30 minutes to 60 minutes. The researcher also took detailed notes during the interview and wrote a synopsis of each interview. The information from the site visits was collected on a Microsoft Excel spreadsheet, and this programme was used to analyse the data from the site visits. We transcribed the recorded interviews verbatim. Data cleaning took one month and consisted of an iterative process of checking the transcribed interviews against the original recordings, correcting the text, checking the recordings again and making final corrections. Prior to analysis, an audit of provider interviews was done, and each provider was allocated a code number to ensure confidentiality of information. The coded interviews were consolidated into one file for ease of analysis. We used interpretative phenomenological analysis for the analysis of the semi-structured interviews with TOP providers [29,30]. To ensure reliability, two other researchers (one a medical anthropologist and the other the research supervisor of the principal investigator) participated in the development of the themes by reading four diverse transcripts. Each researcher examined the meaning of the words of participants, and developed a set of codes, rather than using a pre-existing theory to identify codes that could be applied to the data [29,30]. We held a meeting of the three researchers to discuss the codes and to reach agreement on the codes and themes, namely the recurring patterns of meaning (ideas, thoughts and feelings) that emerged throughout the provider interviews. The principal investigator merged the codes and themes into one consolidated code book, prior to analysing the data using MAXQDA® 12.

Materials

N/A

Innovations

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

1. Telemedicine: Implementing telemedicine services can allow pregnant women in remote or underserved areas to access prenatal care and consultations with healthcare providers through video conferencing or phone calls.

2. Mobile clinics: Setting up mobile clinics that travel to rural or underserved areas can provide essential maternal health services, including prenatal care, vaccinations, and health education.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, educate pregnant women on prenatal care, and refer them to appropriate healthcare facilities when necessary.

4. Digital health records: Implementing electronic health records for pregnant women can improve the coordination of care between healthcare providers, ensuring that important information is easily accessible and reducing the risk of medical errors.

5. Maternal health apps: Developing smartphone applications that provide pregnant women with information on prenatal care, nutrition, and exercise, as well as reminders for appointments and medication schedules.

6. Transportation solutions: Addressing transportation barriers by providing subsidized or free transportation services for pregnant women to access healthcare facilities for prenatal care, delivery, and postnatal care.

7. Public-private partnerships: Collaborating with private healthcare providers to expand access to maternal health services, especially in areas with limited public healthcare facilities.

8. Maternal health education programs: Implementing comprehensive maternal health education programs in schools, community centers, and healthcare facilities to raise awareness about the importance of prenatal care and healthy pregnancy practices.

9. Maternity waiting homes: Establishing maternity waiting homes near healthcare facilities to accommodate pregnant women who live far away, ensuring they have a safe place to stay before and after delivery.

10. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities to enhance the overall quality of maternal health services, including training healthcare providers, improving infrastructure, and ensuring the availability of essential supplies and medications.

AI Innovations Description

The study mentioned focuses on the factors influencing the provision of termination of pregnancy (TOP) services in two South African provinces. The researchers conducted site visits, observations, surveys, and interviews with TOP service providers to gather data. The study found that 77% of designated facilities were providing TOP services, with higher rates in Gauteng Province compared to North West Province. The provision of services was influenced by health system deficiencies, human resource challenges, lack of prioritization, and lack of management support. TOP service providers reported a heavy burden of care provision and expressed feelings of loneliness, courtesy stigma, and lack of support from colleagues.

Based on the findings, the study recommends several measures to improve access to maternal health:

1. Supportive management: It is crucial to have management that prioritizes TOP services and provides support to healthcare providers. This can include regular check-ins, addressing psychosocial issues, and implementing employee wellness programs.

2. Human resource management: Addressing human resource challenges is essential to ensure an adequate number of trained healthcare providers for TOP services. This may involve recruitment, training, and retention strategies.

3. Collaboration and support: Creating a supportive environment among healthcare providers by fostering collaboration, sharing experiences, and providing emotional support can help alleviate feelings of loneliness and courtesy stigma.

4. Health system strengthening: Addressing health system deficiencies, such as improving infrastructure, ensuring availability of necessary equipment and supplies, and streamlining administrative processes, can contribute to better access to TOP services.

5. Policy implementation: Continuously monitoring and evaluating the implementation of policies, such as the Choice of Termination of Pregnancy Act, can help identify gaps and barriers to access and inform necessary interventions.

By implementing these recommendations, it is possible to improve access to maternal health services, specifically termination of pregnancy services, in South Africa.

AI Innovations Methodology

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

1. Strengthen health system infrastructure: Invest in improving the physical infrastructure of healthcare facilities, including maternity wards, to ensure they are equipped to provide quality maternal health services.

2. Increase availability of skilled healthcare providers: Train and deploy more healthcare professionals, such as doctors and nurses, with specialized training in maternal health to areas with limited access to these services.

3. Improve management support: Provide adequate management support to healthcare providers working in maternal health services, including regular supervision, mentoring, and supportive policies to address their needs and challenges.

4. Enhance prioritization of maternal health services: Increase the prioritization of maternal health services at both national and provincial levels, ensuring that resources and attention are directed towards improving access to these services.

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

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of facilities providing maternal health services, the availability of skilled healthcare providers, and the utilization of maternal health services.

2. Collect baseline data: Gather data on the current status of these indicators in the target areas. This could involve conducting surveys, interviews, and site visits to healthcare facilities.

3. Develop a simulation model: Create a simulation model that incorporates the baseline data and the potential impact of the recommendations. This model should consider factors such as population demographics, healthcare infrastructure, and resource allocation.

4. Simulate the impact: Run the simulation model with different scenarios, including the implementation of the recommendations. This will allow for the comparison of the current situation with the potential improvements in access to maternal health.

5. Analyze the results: Evaluate the outcomes of the simulation to determine the potential impact of the recommendations on improving access to maternal health. This could involve analyzing changes in the key indicators and assessing the feasibility and effectiveness of the recommendations.

6. Refine the recommendations: Based on the simulation results, refine the recommendations to optimize their impact on improving access to maternal health. This may involve adjusting resource allocation, identifying additional interventions, or addressing any unforeseen challenges.

7. Implement and monitor: Once the recommendations have been refined, implement them in the target areas. Continuously monitor and evaluate the impact of the interventions to ensure they are effectively improving access to maternal health.

It is important to note that the specific methodology for simulating the impact of these recommendations may vary depending on the available data, resources, and context of the target areas.

Author

Dima Health

Statistics:

Citations: 14

Identifiers:

DOI: 10.1080/16549716.2017.1347369

Research Areas:

Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

South Africa

Study Design:

Cross Sectional Study, Phenomenological Study

Study Approach:

Mixed-methods, Qualitative, Quantitative