Testing a framework for evaluating the quality of post-abortion care: an analysis using data from the AMoCo study in two sub-Saharan African hospitals in humanitarian settings

Abstract

Background: Abortion-related complications remain a main cause of maternal mortality. Post-abortion care (PAC) provision in humanitarian settings suffers from limited accessibility, poor quality, and lack of research on how to address these challenges. We proposed a comprehensive conceptual framework for measuring the quality of PAC and applied it using data from the AMoCo(Abortion-related Morbidity and mortality in fragile or Conflict-affected settings) study in two hospitals supported by Médecins Sans Frontières (MSF) in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR). Methods: We adapted the WHO Maternal and Newborn Health quality-of-care framework to measure PAC inputs, process (provision and experience of care) and outcomes. We analyzed data from 4 study components: an assessment of the two hospitals’ PAC signal functions, a survey of the knowledge, attitudes, practices, and behavior of 140 and 84 clinicians providing PAC, a prospective review of the medical records of 520 and 548 women presenting for abortion complications, of whom 360 and 362 hospitalized women participated in an interview survey in the Nigerian and CAR hospitals, respectively. Results: Inputs – Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26.5 in the CAR hospital. Provision of care – In both hospitals, less than 2.5% were treated with dilatation and sharp curettage, a non-recommended technology when receiving instrumental uterine evacuation. Over 80% received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients without indication. All (99%) of discharged women in CAR received contraceptive counselling but only 39% in Nigeria. Experience of care – Women reported generally good experience of respect and preservation of dignity. But only 49% in Nigeria and 59% in CAR said they were given explanations about their care and 15% felt capable of asking questions during treatment in both hospitals. Outcomes – The risk of healthcare-related abortion-near-miss (happening ≥24h after presentation) was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time. Conclusion: Our proposed framework enabled comprehensive measurement of the quality of PAC in two MSF-supported hospitals in humanitarian settings. Its application identified that hospitals provided good clinical care resulting in a low risk of healthcare-related abortion-near-miss. However, hospitals need to improve provider-patient communication and would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.