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Mahipala PG, Afzal S, Uzma Q, Aabroo A, Hemachandra N, Footman K, Johnston HB, Ganatra B, Reza TE, Ahmad AM, Hamza HB, Umar M, Hanif K, Awais S, Sarfraz M, Thom E. An assessment of facility readiness for comprehensive abortion care in 12 districts of Pakistan using the WHO Service Availability and Readiness Assessment tool. Sex Reprod Health Matters 2023; 31:2178265. [PMID: 36897212 PMCID: PMC10013260 DOI: 10.1080/26410397.2023.2178265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Although Pakistan's Essential Package of Health Services was recently updated to include therapeutic and post-abortion care, little is known about current health facility readiness for these services. This study assessed the availability of comprehensive abortion care, and readiness of health facilities to deliver these services, within the public sector in 12 districts of Pakistan. A facility inventory was completed in 2020-2021 using the WHO Service Availability and Readiness Assessment, with a newly developed abortion module. A composite readiness indicator was developed based on national clinical guidelines and previous studies. Just 8.4% of facilities reported offering therapeutic abortion, while 14.3% offered post-abortion care. Misoprostol (75.2%) was the most common method provided by facilities that offer therapeutic abortion, followed by vacuum aspiration (60.7%) and dilatation and curettage (D&C) (59%). Few facilities had all the readiness components required to deliver pharmacological or surgical therapeutic abortion, or post-abortion care (<1%), but readiness was higher in tertiary (22.2%) facilities. Readiness scores were lowest for "guidelines and personnel" (4.1%), and slightly higher for medicines and products (14.3-17.1%), equipment (16.3%) and laboratory services (7.4%). This assessment highlights the potential to increase the availability of comprehensive abortion care in Pakistan, particularly in primary care and in rural areas, to improve the readiness of health facilities to deliver these services, and to phase out non-recommended methods of abortion (D&C). The study also demonstrates the feasibility and utility of adding an abortion module to routine health facility assessments, which can inform efforts to strengthen sexual and reproductive health and rights.
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Affiliation(s)
| | - Sabeen Afzal
- Deputy Director Programs, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Qudsia Uzma
- Technical Officer RMNCAH, World Health Organization Country Office, Islamabad, Pakistan. Correspondence:
| | - Atiya Aabroo
- Deputy Director Programs, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Nilmini Hemachandra
- Technical Officer RMNCAH, World Health Organization Country Office for Myanmar, Yangon, Myanmar
| | - Katy Footman
- Consultant, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Heidi Bart Johnston
- Technical Officer, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Bela Ganatra
- Unit Head, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Tahira Ezra Reza
- Director, Centre for Global Public Health-Pakistan, collaborative centre for Institute of Global Public Health, University of Manitoba, Islamabad, Pakistan; Technical Advisor, Health Services Academy, Islamabad, Pakistan
| | - Ahsan Maqbool Ahmad
- Senior Technical Advisor, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan; Senior Technical Advisor, Centre for Global Public Health-Pakistan, collaborative centre for Institute of Global Public Health, University of Manitoba, Islamabad, Pakistan; Technical Advisor, Health Services Academy, Islamabad, Pakistan
| | - Hasan Bin Hamza
- SRHR Advisor, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Maida Umar
- Statistician/ Data analyst, Health Services Academy, Islamabad, Pakistan
| | - Kauser Hanif
- MNCH Specialist, Centre for Global Public Health-Pakistan, collaborative centre for Institute of Global Public Health, University of Manitoba, Islamabad, Pakistan; MNCH Specialist, Health Services Academy, Islamabad, Pakistan
| | - Sayema Awais
- SRHR Coordinator, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Mariyam Sarfraz
- Associate Professor, Health Services Academy, Islamabad, Pakistan
| | - Ellen Thom
- Team Lead for Healthier Population Cluster, World Health Organization, Islamabad, Pakistan
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Singla R, Gaba N, Naik AL, Singh A. Rupture of Unscarred Uterus With Intestinal Prolapse From Vagina Following Criminal Abortion. Cureus 2020; 12:e10601. [PMID: 33123421 PMCID: PMC7584304 DOI: 10.7759/cureus.10601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 21-year-old unmarried and primigravida female indulged in criminal abortion at 18 weeks of gestation with the help of a village midwife. Instrumentation was done, and it led to uterine perforation with prolapse of 200 cm of small bowel through vagina. She was managed with resection of 160 cm of necrotic small bowel, repair of the uterine defect, and end jejunostomy, which was anastomosed with distal ileum three months later. This case highlights the risks of illegal abortion and the primitive societal mindset that forces unmarried women to resort to such means.
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Affiliation(s)
- Rimpi Singla
- Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Nayana Gaba
- Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Anil L Naik
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Anju Singh
- Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
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Bell SO, Zimmerman L, Choi Y, Hindin MJ. Legal but limited? Abortion service availability and readiness assessment in Nepal. Health Policy Plan 2018; 33:99-106. [PMID: 29136148 DOI: 10.1093/heapol/czx149] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 11/13/2022] Open
Abstract
The government of Nepal revised its law in 2002 to allow women to terminate a pregnancy up to 12 weeks gestation for any indication on request, and up to 18 weeks if certain conditions are met. We evaluated the readiness of facilities in Nepal to provide three abortion services, manual vacuum aspiration (MVA), medication abortion (MA) and post-abortion care (PAC), using the service availability and readiness assessment (SARA) framework. The framework consists broadly of three domains; service availability, general service readiness and service readiness specific to individual services (i.e. service-specific readiness). We applied the framework to data from the Nepal Health Facility Survey 2015, a nationally representative survey of 992 health facilities. Overall, we find that access to safe abortion remains limited in Nepal. Of the facilities that reported offering delivery services and were thus eligible to provide safe abortion services, 44.5, 36.0 and 25.6% had provided any MVA, MA or PAC services, respectively, in the 3 months prior to the survey, and <2% were 'ready' to provide any abortion service based on our application of the SARA criteria for service-specific readiness. Among only the facilities that reported providing an abortion service in the 3 months prior to the survey, 3.2% of facilities that provided MVA, 1.5% of facilities that provided MA and 1.1% of the facilities that provided PAC had all the components of care required. Although the private sector conducted approximately half of all abortion services provided in the 3 months prior to the survey, no private sector facilities had all the abortion service-specific readiness components. Results suggest that accessing safe abortion services remains a significant challenge for Nepalese women, despite a set of permissive laws.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Linnea Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Yoonjoung Choi
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
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Banerjee SK, Kumar R, Warvadekar J, Manning V, Andersen KL. An exploration of the socio-economic profile of women and costs of receiving abortion services at public health facilities of Madhya Pradesh, India. BMC Health Serv Res 2017; 17:223. [PMID: 28320385 PMCID: PMC5360007 DOI: 10.1186/s12913-017-2159-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 03/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal mortality, which primarily burdens developing countries, reflects the greatest health divide between rich and poor. This is especially pronounced for access to safe abortion services which alone avert 1 of every 10 maternal deaths in India. Primarily due to confidentiality concerns, poor women in India prefer private services which are often offered by untrained providers and may be expensive. In 2006 the state government of Madhya Pradesh (population 73 million) began a concerted effort to ensure access to safe abortion services at public health facilities to both rural and urban poor women. This study aims to understand the socio-economic profile of women seeking abortion services in public health facilities across this state and out of pocket cost accessing abortion services. In particular, we examine the level of access that poor women have to safe abortion services in Madhya Pradesh. METHODS This study consisted of a cross-sectional client follow-up design. A total of 19 facilities were selected using two-stage random sampling and 1036 women presenting to chosen facilities with abortion and post-abortion complications were interviewed between May and December 2014. A structured data collection tool was developed. A composite wealth index computed using principal component analysis derived weights from consumer durables and asset holding and classified women into three categories, poor, moderate, and rich. RESULTS Findings highlight that overall 57% of women who received abortion care at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary level facilities (58%) than secondary level facilities and among women presenting for postabortion complications (67%) than induced abortion. Women reported spending no money to access abortion services as abortion services are free of cost at public facilities. However, poor women spend INR 64 (1 USD) while visiting primary level facilities and INR 256 (USD 4) while visiting urban hospitals, primarily for transportation and food. CONCLUSIONS Improved availability of safe abortion services at the primary level in Madhya Pradesh has helped meeting the need of safe abortion services among poor, which eventually will help reducing the maternal mortality and morbidity due to unsafe abortion.
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Affiliation(s)
| | - Rakesh Kumar
- Reproductive & Child Health Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Janardan Warvadekar
- Manager- Research and Evaluation, Ipas Development Foundation, New Delhi, India
| | - Vinoj Manning
- Executive Director, Ipas Development Foundation, New Delhi, India
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Campbell OMR, Aquino EML, Vwalika B, Gabrysch S. Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia. BMC Pregnancy Childbirth 2016; 16:105. [PMID: 27180000 PMCID: PMC4868015 DOI: 10.1186/s12884-016-0872-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 04/14/2016] [Indexed: 11/26/2022] Open
Abstract
Background Annually, around 44 million abortions are induced worldwide. Safe termination of pregnancy (TOP) services can reduce maternal mortality, but induced abortion is illegal or severely restricted in many countries. All abortions, particularly unsafe induced abortions, may require post-abortion care (PAC) services to treat complications and prevent future unwanted pregnancy. We used a signal-function approach to look at abortion care services and illustrated its utility with secondary data from Zambia. Methods We refined signal functions for basic and comprehensive TOP and PAC services, including family planning (FP), and assessed functions currently being collected via multi-country facility surveys. We then used the 2005 Zambian Health Facility Census to estimate the proportion of 1369 health facilities that could provide TOP and PAC services under three scenarios. We linked facility and population data, and calculated the proportion of the Zambian population within reach of such services. Results Relevant signal functions are already collected in five facility assessment tools. In Zambia, 30 % of facilities could potentially offer basic TOP services, 3.7 % comprehensive TOP services, 2.6 % basic PAC services, and 0.3 % comprehensive PAC services (four facilities). Capability was highest in hospitals, except for FP functions. Nearly two-thirds of Zambians lived within 15 km of a facility theoretically capable of providing basic TOP, and one-third within 15 km of comprehensive TOP services. However, requiring three doctors for non-emergency TOP, as per Zambian law, reduced potential access to TOP services to 30 % of the population. One-quarter lived within 15 km of basic PAC and 13 % of comprehensive PAC services. In a scenario not requiring FP functions, one-half and one-third of the population were within reach of basic and comprehensive PAC respectively. There were huge urban-rural disparities in access to abortion care services. Comprehensive PAC services were virtually unavailable to the rural population. Conclusions Secondary data from facility assessments can highlight gaps in abortion service provision and coverage, but it is necessary to consider TOP and PAC separately. This approach, especially when combined with population data using geographic coordinates, can also be used to model the impact of various policy scenarios on access, such as requiring three medical doctors for non-emergency TOP. Data collection instruments could be improved with minor modifications and used for multi-country comparisons.
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Affiliation(s)
- Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Estela M L Aquino
- Universidade Federal da Bahia, Instituto de Saúde Coletiva, MUSA-Programa Integrado em Gênero e Saúde, Salvador, Bahia, Brazil
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia, Lusaka, Zambia
| | - Sabine Gabrysch
- Institute of Public Health, Ruprecht-Karls-Universität, Heidelberg, Germany
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Sjöström S, Essén B, Gemzell-Danielsson K, Klingberg-Allvin M. Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India. BMC MEDICAL EDUCATION 2016; 16:8. [PMID: 26758763 PMCID: PMC4710021 DOI: 10.1186/s12909-016-0532-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 01/06/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education. METHOD We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach. RESULTS The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future. CONCLUSIONS To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.
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Affiliation(s)
- Susanne Sjöström
- />Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
- />Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Birgitta Essén
- />Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Kristina Gemzell-Danielsson
- />Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Marie Klingberg-Allvin
- />Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
- />Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden
- />School of Health and Social Sciences, Dalarna University, 791 88 Falun, Sweden
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