Effects of implementing a postabortion care strategy in Kinshasa referral hospitals, Democratic Republic of the Congo

Reproductive Health, Volume 18, No. 1, Year 2021

Interpretação

Objectives: To evaluate the effects of the implementation of a postabortion care (PAC) strategy in Kinshasa referral hospitals, this study analyzed the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization. Methodology: We estimated the effects of the PAC strategy using a quasi-experimental study by evaluating the outcomes of 334 patients with the diagnosis of a complication of induced abortion admitted to 10 hospitals in which the PAC strategy was implemented compared to the same outcomes in 314 patients with the same diagnosis admitted to 10 control facilities from 01/01/2016 to 12/31/2018. In response to government policy, the PAC strategy included the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. The information was collected using a questionnaire and stored using open data kit software. We supplemented this information with data abstracted from patient records, facility registries of gynecological obstetrical emergencies, and family planning registries. We analyzed data and developed regression models using STATA15. Thus, we compared changes in use of specific treatments and duration of hospitalization using a “difference-in-differences” analysis. Results: The implementation of PAC strategy in Kinshasa referral hospitals has resulted in the utilization of WHO recommended uterine evacuation method MVA (29.3% more in the experimental structures, p = 0.025), a significant decline in sharp-curettage (19.3% less, p = 0.132), and a decline in the duration of hospitalization of patients admitted for PAC (1 day less, p = 0.020). We did not observe any change in the use of PAC services, mortality, and the provision of post abortion contraception. Conclusion: Despite significant improvement in the management of PAC, the uptake in WHO approved technology—namely MVA, and the duration of hospitalization, these outcomes while a significant improvement for DRC, indicate that additional quality improvement strategies for management of PAC and risk-mitigating strategies to reduce barriers to care are required. This was a quasi-experimental study of the management of postabortion service delivery before and after the implementation of a PAC strategy in intervention hospitals compared to control hospitals. The period before the intervention was from January 1, 2016 to June 30, 2017, and after was from July 1, 2017 to December 31, 2018. This study was conducted in referral hospitals in Kinshasa. Hospitals are designated as referral hospitals by the DRC Ministry of Health based on the provision of certain services. Referral hospitals support and supervise primary care in health centers, train health professionals, and perform operational and implementation research. They typically have more than 100 inpatient beds which equates to about 100 beds for a population of 100,000 inhabitants [11]. The study population only included women presenting to referral hospitals with complications of induced abortion performed elsewhere. The intervention tested in this study was PAC, which includes the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. Table Table11 presents the activities of the implementation of the PAC intervention, including the main activities, the responsible persons, and the proposed devices. Summary of the implementation strategy for PAC Overview of PAC Learning objectives: How to conduct counseling after an abortion? How to assess the patient for complications? How to treat complications How to ensure preventive measures against infections Affix PAC wall posters in health facilities Provide PAC advice cards at all health-related activity (prenatal consultations days, vaccination, …) Inform the patient about her PAC rights Perform initial assessment to identify emergency conditions Perform a complete clinical examination Request additional examinations Stabilize the patient’s condition Deal urgently with the complications of abortions Explain to the patient how to take care of her health Psychologically support the patient Provide FP and HIV counseling Advise during follow-up consultations PAC postabortion care, NPRH National Program for Reproductive Health, EONC emergency obstetric and newborn care, FP family planning, HIV human immunodeficiency virus In December 2016, the National Program for Reproductive Health (NPRH) identified the health facilities eligible for PAC implementation in Kinshasa, including the 29 referral hospitals. In February 2017, an initial 6-day training was organized by the NPRH targeting two providers per eligible hospital. In June 2017, additional training sessions under the supervision of the NPRH were organized in the hospitals that participated in the initial training. Our hypothesis was that if the human, financial, and logistical resources are mobilized for the training of the providers in PAC, the sensitization of the population, and the care of the patients with complication of abortion, then the provider clinical skills will be increased, the population sensitized, and patients admitted for an abortion complication will be properly managed. With these achievements, the outcomes of PAC will be improved, the duration of hospitalization, and maternal deaths due to complications of induced abortion will be reduced. From the original 29 hospitals, ten intervention hospitals were selected because they had completed the entire PAC intervention. This included: (1) declared eligible for PAC implementation by the NPRH in December 2016; (2) represented at the initial training on PAC in February 2017; (3) performed hospital-based training PAC in June 2017 for all providers (midwives and doctors) in the maternity ward. In total, around 100 providers were reached by these trainings in the 10 intervention hospitals. The intervention hospitals were matched with ten control hospitals. These hospitals were offered the PAC intervention during the study period but did not respond to at least one of the three criterion for the intervention hospitals. Matching was based on type of employer (private, civil state, military state, catholic denominational, protestant denominational, or salvationist denominational) and the type of neighborhood of residence (semi-rural, eccentric, residential, old cities, and planned cities) [12]. Matching according to the type of employer is taken into account because of the difference that appears in the organization and functioning of the health facilities concerned. The state health facilities have an unlimited range of services, including family planning, they are all over-staffed in the city of Kinshasa, with dilapidated equipment, health care providers with little financial motivation and with several other jobs in order to survive. Faith-based health facilities have a range of services with restrictions in terms of modern contraception for some catholic health facilities, they have understaffed staff compared to the clientele, financially motivated and exhausted each time at the end of service, they are relatively well equipped. Private health facilities, on the other hand, have an unlimited range of services like those in the state, have an adequate number of staff in relation to the clientele, are financially motivated, and are relatively well equipped. And the matching by the type of neighborhood of residence aims at the similarity of the population benefiting from the services. The impact of implementation of the PAC intervention was estimated by examining the care and outcome of all women who were evaluated at study hospitals for complications of induced abortion. Data were abstracted from all medical records and registers for patients with the diagnosis of complications of induced abortion admitted from January 1, 2016 to December 31, 2018. Data were entered into a digital database installed in the smartphones of nurse and physician investigators. The database included sociodemographic, clinical, para-clinical analysis and therapeutic information, and patient outcomes. We measured the effects of the PAC intervention using variables potentially sensitive to the main activities of the implementation of this intervention (Table (Table22). Indicators measuring the effects of PAC A comparative description of characteristics was performed at both the individual level (sociodemographic and general clinical characteristics of patients admitted for an induced-abortion related complication) and the structure level to verify the balance between experimental and control structures. At the individual level, a robust standard error linear regression model for cluster sampling was used to compare the mean age of patients in both groups after verification of data normality and homoscedasticity, and logistic regression models with robust standard error for cluster sampling to compare proportions of other categorical variables. At the structure level, the median of percentages by structure accompanied by the minimum and maximum values was used for the “types of provider” and “location of uterine evacuation” variables that were not normally distributed. For analysis of the effects of the intervention, we generated linear regression models with Robust Standard Errors for cluster sampling (ES and p-values adjusted for clustering), and considered an intra-cluster correlation coefficient being different from 0 for all the variables to be significant. The regression models included the period for the “before” and “after” the intervention for each group. We compared changes in use of specific treatments and duration of hospitalization using a “difference-in-differences” analysis. The models included the group, the period, and the interaction between group and period. For the period of hospitalization which was not normally distributed, quantile regression models were used. An α = 0.05 threshold of significance was chosen. The data were processed and analyzed using STATA15. The study was approved by the National Ethics Committee of the Kinshasa School of Public Health (NCE-KSPH). We obtained consent for data collection from administrators at each health facility. The NCE-KSPH waived the need for consent of the participants because data were drawn from the medical records of patients who had either died or had been discharged from the hospital, and they insisted on the anonymity of patients in the collection and analysis of data. We maintained confidentiality by de-identifying all personal health data. The database was password protected, and access was limited to study personnel.

AI Digest

Study Justification:

The study aimed to evaluate the effects of implementing a postabortion care (PAC) strategy in Kinshasa referral hospitals in the Democratic Republic of the Congo (DRC). The justification for the study was to assess the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization. By analyzing the outcomes of patients with complications of induced abortion, the study aimed to determine the impact of the PAC strategy on the utilization of recommended uterine evacuation methods, the decline in sharp-curettage, and the reduction in the duration of hospitalization.

Highlights:

1. Implementation of the PAC strategy in Kinshasa referral hospitals resulted in a 29.3% increase in the utilization of the World Health Organization (WHO) recommended uterine evacuation method MVA.
2. There was a significant decline of 19.3% in the use of sharp-curettage.
3. The duration of hospitalization for patients admitted for PAC decreased by 1 day.
4. However, there were no observed changes in the use of PAC services, mortality rates, and provision of postabortion contraception.

Recommendations:

1. Additional quality improvement strategies for the management of PAC are needed to further enhance the outcomes.
2. Risk-mitigating strategies should be implemented to reduce barriers to care and improve access to PAC services.
3. Strengthening partnerships between healthcare providers and communities is crucial for effective PAC implementation.

Key Role Players:

1. Ministry of Health: Responsible for policy development, resource allocation, and oversight of PAC implementation.
2. National Program for Reproductive Health (NPRH): Identifies eligible health facilities for PAC implementation, organizes training sessions, and provides supervision.
3. Referral Hospitals: Responsible for implementing the PAC strategy, training healthcare providers, and ensuring the provision of quality PAC services.
4. Healthcare Providers: Midwives and doctors who receive training on PAC and deliver care to patients.
5. Community Leaders and Organizations: Collaborate with healthcare providers to raise awareness, promote PAC services, and reduce stigma surrounding abortion.

Cost Items for Planning Recommendations:

1. Training: Budget for organizing training sessions for healthcare providers on PAC implementation.
2. Equipment and Supplies: Allocate funds for the purchase and maintenance of recommended uterine evacuation technology, contraceptives, and other necessary medical supplies.
3. Outreach and Awareness Campaigns: Allocate resources for community engagement activities, including the development and dissemination of educational materials, posters, and cards.
4. Monitoring and Evaluation: Set aside funds for data collection, analysis, and monitoring of PAC outcomes.
5. Infrastructure and Facility Upgrades: Consider budgeting for improvements in infrastructure, equipment, and facilities to ensure the delivery of quality PAC services.
Please note that the provided cost items are general categories and do not represent actual cost estimates. The actual budget will depend on the specific context and requirements of the implementation.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is quasi-experimental, which provides some level of evidence. The study analyzed the effects of implementing a postabortion care (PAC) strategy in Kinshasa referral hospitals. The outcomes measured include the utilization of recommended uterine evacuation method, decline in sharp-curettage, and duration of hospitalization. However, the study did not observe changes in the use of PAC services, mortality, and provision of post-abortion contraception. To improve the strength of the evidence, future studies could consider using a randomized controlled trial design and include a larger sample size. Additionally, it would be beneficial to measure additional outcomes such as patient satisfaction and long-term health outcomes.

Resumo

This was a quasi-experimental study of the management of postabortion service delivery before and after the implementation of a PAC strategy in intervention hospitals compared to control hospitals. The period before the intervention was from January 1, 2016 to June 30, 2017, and after was from July 1, 2017 to December 31, 2018. This study was conducted in referral hospitals in Kinshasa. Hospitals are designated as referral hospitals by the DRC Ministry of Health based on the provision of certain services. Referral hospitals support and supervise primary care in health centers, train health professionals, and perform operational and implementation research. They typically have more than 100 inpatient beds which equates to about 100 beds for a population of 100,000 inhabitants [11]. The study population only included women presenting to referral hospitals with complications of induced abortion performed elsewhere. The intervention tested in this study was PAC, which includes the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. Table Table11 presents the activities of the implementation of the PAC intervention, including the main activities, the responsible persons, and the proposed devices. Summary of the implementation strategy for PAC Overview of PAC Learning objectives: How to conduct counseling after an abortion? How to assess the patient for complications? How to treat complications How to ensure preventive measures against infections Affix PAC wall posters in health facilities Provide PAC advice cards at all health-related activity (prenatal consultations days, vaccination, …) Inform the patient about her PAC rights Perform initial assessment to identify emergency conditions Perform a complete clinical examination Request additional examinations Stabilize the patient’s condition Deal urgently with the complications of abortions Explain to the patient how to take care of her health Psychologically support the patient Provide FP and HIV counseling Advise during follow-up consultations PAC postabortion care, NPRH National Program for Reproductive Health, EONC emergency obstetric and newborn care, FP family planning, HIV human immunodeficiency virus In December 2016, the National Program for Reproductive Health (NPRH) identified the health facilities eligible for PAC implementation in Kinshasa, including the 29 referral hospitals. In February 2017, an initial 6-day training was organized by the NPRH targeting two providers per eligible hospital. In June 2017, additional training sessions under the supervision of the NPRH were organized in the hospitals that participated in the initial training. Our hypothesis was that if the human, financial, and logistical resources are mobilized for the training of the providers in PAC, the sensitization of the population, and the care of the patients with complication of abortion, then the provider clinical skills will be increased, the population sensitized, and patients admitted for an abortion complication will be properly managed. With these achievements, the outcomes of PAC will be improved, the duration of hospitalization, and maternal deaths due to complications of induced abortion will be reduced. From the original 29 hospitals, ten intervention hospitals were selected because they had completed the entire PAC intervention. This included: (1) declared eligible for PAC implementation by the NPRH in December 2016; (2) represented at the initial training on PAC in February 2017; (3) performed hospital-based training PAC in June 2017 for all providers (midwives and doctors) in the maternity ward. In total, around 100 providers were reached by these trainings in the 10 intervention hospitals. The intervention hospitals were matched with ten control hospitals. These hospitals were offered the PAC intervention during the study period but did not respond to at least one of the three criterion for the intervention hospitals. Matching was based on type of employer (private, civil state, military state, catholic denominational, protestant denominational, or salvationist denominational) and the type of neighborhood of residence (semi-rural, eccentric, residential, old cities, and planned cities) [12]. Matching according to the type of employer is taken into account because of the difference that appears in the organization and functioning of the health facilities concerned. The state health facilities have an unlimited range of services, including family planning, they are all over-staffed in the city of Kinshasa, with dilapidated equipment, health care providers with little financial motivation and with several other jobs in order to survive. Faith-based health facilities have a range of services with restrictions in terms of modern contraception for some catholic health facilities, they have understaffed staff compared to the clientele, financially motivated and exhausted each time at the end of service, they are relatively well equipped. Private health facilities, on the other hand, have an unlimited range of services like those in the state, have an adequate number of staff in relation to the clientele, are financially motivated, and are relatively well equipped. And the matching by the type of neighborhood of residence aims at the similarity of the population benefiting from the services. The impact of implementation of the PAC intervention was estimated by examining the care and outcome of all women who were evaluated at study hospitals for complications of induced abortion. Data were abstracted from all medical records and registers for patients with the diagnosis of complications of induced abortion admitted from January 1, 2016 to December 31, 2018. Data were entered into a digital database installed in the smartphones of nurse and physician investigators. The database included sociodemographic, clinical, para-clinical analysis and therapeutic information, and patient outcomes. We measured the effects of the PAC intervention using variables potentially sensitive to the main activities of the implementation of this intervention (Table (Table22). Indicators measuring the effects of PAC A comparative description of characteristics was performed at both the individual level (sociodemographic and general clinical characteristics of patients admitted for an induced-abortion related complication) and the structure level to verify the balance between experimental and control structures. At the individual level, a robust standard error linear regression model for cluster sampling was used to compare the mean age of patients in both groups after verification of data normality and homoscedasticity, and logistic regression models with robust standard error for cluster sampling to compare proportions of other categorical variables. At the structure level, the median of percentages by structure accompanied by the minimum and maximum values was used for the “types of provider” and “location of uterine evacuation” variables that were not normally distributed. For analysis of the effects of the intervention, we generated linear regression models with Robust Standard Errors for cluster sampling (ES and p-values adjusted for clustering), and considered an intra-cluster correlation coefficient being different from 0 for all the variables to be significant. The regression models included the period for the “before” and “after” the intervention for each group. We compared changes in use of specific treatments and duration of hospitalization using a “difference-in-differences” analysis. The models included the group, the period, and the interaction between group and period. For the period of hospitalization which was not normally distributed, quantile regression models were used. An α = 0.05 threshold of significance was chosen. The data were processed and analyzed using STATA15. The study was approved by the National Ethics Committee of the Kinshasa School of Public Health (NCE-KSPH). We obtained consent for data collection from administrators at each health facility. The NCE-KSPH waived the need for consent of the participants because data were drawn from the medical records of patients who had either died or had been discharged from the hospital, and they insisted on the anonymity of patients in the collection and analysis of data. We maintained confidentiality by de-identifying all personal health data. The database was password protected, and access was limited to study personnel.

Materiais

N/A

Inovações

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

1. Mobile Health (mHealth) Solutions: Develop and implement mobile applications or SMS-based systems that provide information and reminders about postabortion care, family planning, and other reproductive health services. These tools can help increase awareness and access to maternal health services, especially in remote or underserved areas.

2. Telemedicine: Establish telemedicine platforms that allow healthcare providers to remotely consult and provide guidance to women seeking postabortion care. This can help overcome geographical barriers and ensure timely access to medical expertise.

3. Community Partnerships: Strengthen partnerships between healthcare providers and community organizations to raise awareness about postabortion care services and promote the importance of seeking timely medical assistance. Community health workers can play a crucial role in educating women and their families about available services and providing support throughout the process.

4. Task Shifting: Train and empower midwives and other healthcare workers to provide comprehensive postabortion care services, including uterine evacuation, family planning counseling, and HIV testing. This can help alleviate the burden on doctors and increase the availability of skilled providers in resource-limited settings.

5. Quality Improvement Initiatives: Implement quality improvement programs to ensure that postabortion care services adhere to recommended standards and protocols. This can involve regular monitoring and evaluation, feedback mechanisms, and continuous training and capacity building for healthcare providers.

6. Integration of Services: Integrate postabortion care services with other reproductive health services, such as family planning, STI evaluation, and HIV counseling. This can improve the overall continuity of care and increase the likelihood of women accessing multiple services during their visit.

7. Addressing Barriers: Identify and address barriers that prevent women from seeking postabortion care, such as stigma, lack of transportation, financial constraints, and cultural beliefs. This may involve community sensitization campaigns, transportation support, and financial assistance programs.

It is important to note that these recommendations are general and may need to be adapted to the specific context and resources available in the Democratic Republic of the Congo.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health would be to further enhance the implementation of the postabortion care (PAC) strategy in Kinshasa referral hospitals. While the PAC strategy has shown positive outcomes, such as increased utilization of recommended uterine evacuation method MVA and a decline in sharp-curettage, there is still room for improvement.

Here are some specific recommendations to develop into an innovation:

1. Strengthen training and capacity-building: Continue providing comprehensive training to healthcare providers on PAC, including counseling after an abortion, assessment of patients for complications, and treatment of complications. This will help improve provider clinical skills and ensure proper management of patients with abortion complications.

2. Increase community sensitization: Enhance efforts to raise awareness among the population about PAC services and their rights. This can be done through the distribution of PAC advice cards at various health-related activities, affixing PAC wall posters in health facilities, and conducting community outreach programs.

3. Improve access to preventive measures against infections: Ensure that all patients receive information and education on how to take care of their health after an abortion. This includes providing guidance on hygiene practices and preventive measures against infections.

4. Strengthen linkages with other reproductive health services: Enhance the integration of PAC services with other reproductive health services, such as STI evaluation, HIV counseling, and family planning. This will help address the comprehensive needs of women seeking postabortion care.

5. Foster partnerships between providers and communities: Encourage collaboration and partnerships between healthcare providers and communities to ensure a supportive and enabling environment for women seeking PAC services. This can involve engaging community leaders, organizations, and stakeholders in promoting access to maternal health services.

By implementing these recommendations, the quality of postabortion care services can be further improved, leading to better access to maternal health and reduced barriers to care.

AI Innovations Methodology

Based on the provided information, the study evaluated the effects of implementing a postabortion care (PAC) strategy in Kinshasa referral hospitals in the Democratic Republic of the Congo. The PAC strategy included the treatment of abortion complications, family planning counseling and service provision, linkages with other reproductive health services, and partnerships between providers and communities. The study used a quasi-experimental design, comparing outcomes of patients with abortion complications admitted to 10 hospitals where the PAC strategy was implemented to outcomes of patients admitted to 10 control facilities. The data was collected using a questionnaire and supplemented with data from patient records and facility registries. Regression models were developed using STATA15 to analyze the data and compare changes in specific treatments and duration of hospitalization using a “difference-in-differences” analysis.

To simulate the impact of recommendations on improving access to maternal health, a similar methodology could be used. Here is a brief description of a possible methodology:

1. Identify the recommendations: Start by identifying specific recommendations that could improve access to maternal health. These recommendations could be based on evidence-based practices, expert opinions, or existing guidelines.

2. Define the study population: Determine the target population for the study, such as pregnant women or women of reproductive age. Consider factors like geographic location, socioeconomic status, and existing barriers to access.

3. Select intervention and control groups: Divide the study population into intervention and control groups. The intervention group will receive the recommended interventions, while the control group will receive standard care or no intervention.

4. Data collection: Collect relevant data from both the intervention and control groups. This could include demographic information, medical history, access to healthcare facilities, and utilization of maternal health services.

5. Implement the interventions: Implement the recommended interventions in the intervention group. This could involve training healthcare providers, improving infrastructure, increasing awareness, or implementing new policies.

6. Monitor and evaluate: Continuously monitor the implementation of interventions and collect data on outcomes. This could include indicators such as the utilization of maternal health services, maternal mortality rates, access to contraception, and patient satisfaction.

7. Analyze the data: Use statistical analysis software, such as STATA, to analyze the collected data. Compare the outcomes between the intervention and control groups using appropriate statistical tests, such as regression models or difference-in-differences analysis.

8. Simulate the impact: Based on the analysis, simulate the impact of the recommendations on improving access to maternal health. This could involve extrapolating the findings to a larger population or using modeling techniques to estimate the potential impact.

9. Draw conclusions and make recommendations: Based on the simulated impact, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Make recommendations for further implementation or modifications to the interventions based on the findings.

It is important to note that the specific methodology may vary depending on the context and objectives of the study. It is recommended to consult with experts in the field and follow ethical guidelines when conducting research on improving access to maternal health.

Autor

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1186/s12978-021-01130-x

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Congo, Mali, Multi-Countries

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, Quasi Experimental Study, randomised-control-trial

Participants Gender:

Female

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