a decade of change in safe abortion services in ethiopia · background • in 2005, ethiopia...
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A decade of change in safe abortion services in Ethiopia: Results from national assessments in 2008 & 2014 Sally Dijkerman, Yohannes Dibaba, Tam Fetters, Hailemichael Gebreselassie, Yirgu Gebrehiwot, Ann Moore, Janie Benson, Yonas Getachew, Mengistu Hailemariam Presented by: Sally Dijkerman, MPH Research and Evaluation Advisor Ipas
Partners and Funding
• Ministry of Health • Ethiopian Public Health Association • Ethiopian Society of OBGYNs • Ipas • Guttmacher Institute
• Funding provided by Dfid (UK Aid) and Ipas
Background • In 2005, Ethiopia liberalized its abortion law
• Abortion can be performed legally in cases of:
• Rape/incest • Woman has physical or mental disabilities • To preserve the life or physical health of the woman • Woman is a minor who is physically or mentally unprepared for
childbirth
• Since then, comprehensive safe abortion services have scaled up in the health care system rapidly
• Despite this, service availability is still variable across the large and expansive country of over 90 million people
Objectives & Significance • First study in 2008 with aim to estimate
national baseline levels of abortion-related incidence and morbidity
• Repeated in 2014 to assess changes in national incidence, magnitude of abortion-related morbidity, and availability of safe abortion services
• Implications in Ethiopia and beyond • One of very few studies to… o explore incidence of unsafe abortion
morbidity over time o assess the impact of abortion policy
reform and practice over time in a low-resource setting
Methodology
Study Design • Cross-sectional descriptive survey of health facilities and the Prospective
Morbidity Methodology (PMM) developed by WHO
• 2 sources of data were collected: 1. Survey of national sample of facilities (344 in 2008; 821 in 2014)
• Including public hospitals & health centers, NGO reproductive health clinics, private & NGO hospitals, & higher private clinics
• Interviewed most senior abortion care provider or someone knowledgeable about abortion services at facilities on facility infrastructure, capacity to provide abortion services, performance and caseload, attitudes, and more
2. Prospective abortion morbidity survey of all post-abortion patients treated at those facilities (3,092 in 2008; 5,604 in 2014)
• 1 provider from each facility was selected to participate in training to learn to extract case information on the care and case management of all women who sought care for abortion services over a 30 day period
• Service statistics were collected from MSI and FGAE
Analysis methodology: Measuring SAC delivery in 2008 & 2014
Limited analysis to public sector facilities, stratifying by year and facility type (health centers and hospitals) SAC model developed by Healy, Otsea, & Benson (2006) was used as analysis framework
v Adapted from UN/WHO Emergency Obstetric Care (EmOC) model • Life-saving “signal functions” and Safe Abortion Care (SAC) indicators to
monitor: • Service availability and geographic distribution: recommends 5 SAC
facilities for every 500,000 residents, 4 basic and 1 comprehensive • Service utilization and quality
• 3 essential elements of SAC: • Induced abortion (TOP) • Treatment of abortion complications (PAC) • Post-abortion contraception (PAFP)
Sample distribution
• Health centers are eligible and expected to provide basic SAC and hospitals comprehensive SAC, respectively. Being expected to provide this care does not necessarily mean that they do.
• Since legal reform went into effect in 2006, there has been a rapid expansion of public sector health facilities eligible to provide legal abortion services, especially basic SAC
• The number of facilities eligible to provide basic SAC increased by over 300%
• The number of health facilities eligible to provide comprehensive SAC similarly increased by 28%
Results
61%
80% 84%
50%
34%
76% 82%
97% 92%
76%
39%
77%
Gives essen3al an3bio3cs
Gives IV replacement
fluids
Administers oxytocics
Performs first trimester PAC
Performs first trimester TOP
Providers PAFP
Percent & Frequency of Public Health Centers Performing 6 Signal Func3ons for Basic Safe Abor3on Care Service Delivery, 2008 & 2014
2008 (N=152) 2014 (N=368)
Performance of 6 signal functions for basic SAC service delivery at public health centers improved greatly between 2008 and 2014.
358 2,111
469 2,519
494 2,382
295 1,962
199 1,011
447 1,986
Provides PAFP
99% 100% 99% 96%
75%
93% 100% 100% 100% 99%
91% 97%
Gives essen3al an3bio3cs
Gives IV replacement
fluids
Administers oxytocics
Performs first trimester PAC
Performs first trimester TOP
Providers PAFP
Percent & Frequency of Public Hospitals Performing 6 Signal Func3ons for Basic Safe Abor3on Care, 2008 & 2014
2008 (N=90) 2014 (N=117)
93 118 94 118 93 118 90 117 70 107 87 115
Since 2008, public hospitals have increased performance of all 10 signal functions for basic and comprehensive SAC service delivery.
Provides PAFP
89%
60% 59% 50%
93% 86%
91%
65%
Performs second trimester PAC
Performs blood transfusion
Performs laparotomy Performs second trimester TOP
Percent & Frequency of Public Hospitals Performing 4 Signal Func3ons for Comprehensive Safe Abor3on Care, 2008 & 2014
2008 (N=90) 2014 (N=117)
84 107 101 110 56 55 47 77
Since 2008, public hospitals have increased performance of all 10 signal functions for basic and comprehensive SAC service delivery.
Basic SAC Service Delivery 2008 2014
Recommended Actual %
Achieved Recommended Actual %
Achieved National4 591 149 25 704 889 126
Harari 1 3 300 2 3 150 Dire Dawa 3 1 33 3 5 167 Gambella 2 4 200 3 9 300
Addis Ababa 22 1 5 26 28 108 Tigray 35 14 40 40 78 195
Oromia 217 58 27 263 265 101 Amhara 138 38 28 160 240 150 SNNPR 120 26 22 143 226 158
Benshangul-Gumuz 5 1 20 8 11 138
Afar 11 1 9 13 13 100 Somali 36 3 8 42 12 29
Recommended and achieved levels of basic SAC in public facilities nationally and by region, 2008 & 2014
Recommended and achieved levels of comprehensive SAC in public hospitals nationally and by region, 2008 & 2014
Comprehensive SAC Service Delivery 2008 2014
Recommended Actual %
Achieved Recommended Actual %
Achieved Na/onal 148 29 20 176 66 38
Harari 1 0 0 1 2 200 Dire Dawa 1 1 100 1 1 100 Gambella 1 0 0 1 1 100
Addis Ababa 5 6 120 6 7 117 Tigray 9 5 56 10 10 100
Oromia 54 6 11 66 23 35 Amhara 34 5 15 40 9 23 SNNPR 30 6 20 36 8 22
Benshangul-‐Gumuz 1 0 0 2 0 0
Afar 3 0 0 3 1 33 Somali 9 0 0 11 3 27
% of women treated for obstetric complications that are abortion
related
(95% CI: 46, 48) (95% CI: 24, 42)
(95% CI: 27, 31) (95% CI: 29, 34)
% of women treated for abortion complications that are serious
Fewer obstetric complications are abortion-related, but there was no change in severe complications.
% of women who received abortion services that were induced
procedures
% of women who received abortion services that obtained contraception
There was a shift towards safe and legal abortion and greater contraceptive acceptance.
(95% CI: 27, 36) (95% CI: 47, 55)
(95% CI: 50, 56) (95% CI: 75, 79)
% of uterine evacuations performed with appropriate technology, regardless of trimester
1st trimester
2nd trimester
Greater use of appropriate technology, but 2nd trimester
technology lags behind.
29%
(95% CI: 45, 54) (95% CI: 83, 86)
What have we learned?
Discussion • Shows tremendous progress overall in Ethiopia.
• Basic SAC availability increased six-fold & comprehensive SAC more than doubled.
• Expansion of health centers has outpaced the training of health workers to provide first trimester induced abortion.
• Access to lifesaving comprehensive SAC falls short of recommended levels almost entirely due to low provision of second trimester induced abortion.
Discussion • Increased use of appropriate technology and PAFP; however still poor use of appropriate technology for second trimester procedures.
• Higher proportion of safe and legal abortion procedures compared to complications.
• Limitations • Availability and capability is not equivalent to utilization,
accessibility • Meeting recommended level does not necessarily translate to
access, particularly for widely dispersed and remote regions
Recommendations • Need a stronger focus on basic SAC
in health centers, particularly first trimester abortion.
• Needs to be a stronger focus on second trimester safe and legal abortion.
• The severe complications indicate that there is still a lot of unsafe abortion in the country that has not been eradicated by working in health facilities only.
Ø Further research is needed to discover what methods women are using to induce outside of facilities.
Thank you!
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