Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a qualitative study of clients and community members

Abstract

Background Unsafe abortion is a leading cause of maternal mortality. In Afghanistan, which has experienced decades of armed conflict and where abortion is highly restricted, maternal mortality is high at 638 maternal deaths per 100,000 live births. Post-abortion care (PAC) is a lifesaving package of interventions to reduce morbidity and mortality related to induced or spontaneous abortion, but is rarely provided and often of poor quality, particularly in humanitarian settings. In July 2018, we conducted a study to identify the factors that influence access to and use of PAC services at Sharana Provincial Hospital. Methods In-depth interviews (IDIs) were conducted with ten women who had received PAC services at Sharana Hospital, and eight focus group discussions (FGDs) were conducted with 40 married women and 40 married men aged 18–45 from four villages surrounding Sharana Hospital. Results PAC clients and community participants discussed similar barriers to seeking PAC, including cost, distance to the health facility, the need for male accompaniment to seek care, perceived and actual quality of care, stigma and shame. Despite the mentioned stigma around abortion, community members expressed willingness to help women to receive PAC. Conclusions Our results suggest that while some barriers are not unique to PAC, others, especially those related to stigma around abortion, may be specific to PAC. It is important for the Ministry of Public Health and its partners to prioritize addressing these barriers to ensure that women have access to this critical life-saving care.

Women’s Perceived Barriers to Accessing Post-Abortion Care Services in Selected Districts in KwaZulu Natal Province, South Africa: A Qualitative Study

“…Quinn and Chaudior found that women delay seeking postabortion care if stigmatized because they were protecting themselves from being the victims of discrimination [40]. This was confirmed by Perera et al and Yegon et al that stigma and poverty, nonetheless, also played a vital role in influencing the decision-making process [6,41]. Demtsu et al reported an association between the provision of PAC services, religious, cultural beliefs, morals, and values in terms of care of women seeking PAC services [42].…”

“…One of the main challenges for women who access PAC services in KZN is the long distances they have to travel to access proper care in the hospital; poor roads and transportation further complicate this in their areas. This was corroborated by Perera et al that delays in care-seeking due to various reasons, including lack of transport and concerns about costs [6]. Literature shows that increased distance to health facilities and poor local transportation impedes accessibility to the primary and secondary health care services as well as that the delayed health care provision can worsen people's health [11,12].…”

“…The procedures and technologies used includes manual/electrical vacuum aspiration (M/EVA), medication abortion (MA) drugs (Misoprostol and Mifepristone), digital (use of bare fingers) evacuation, forceps, and dilatation and curettage [ 5 ]. PAC is a package of interventions that has been shown to reduce abortion-related morbidity and mortality when available and of good quality [ 6 ]. Women in South Africa are affected mainly by unwanted pregnancies, which lead to illegal abortion [ 7 ].…”

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

“…Others highlighted a lack of health providers knowledge regarding manual vacuum aspiration (MVA) which is a recommended instrumental technology to evacuate the uterus (instead of the dilatation and sharp curettage (D&C)) [16]. Health providers' negative attitudes were also found to limit women's autonomy regarding their sexual and reproductive health needs [15,17]. Studies assessing interventions showed that the support of PAC services by non-governmental organizations (NGO) increased post-abortion contraception counselling and uptake [19,20], enhanced providers' use of appropriate technologies (MVA) [18][19][20] and changed their attitude towards a right-based, non-judgmental approach to women [18] leading to an overall positive experience of care for patients [21].…”

“…Studies assessing interventions showed that the support of PAC services by non-governmental organizations (NGO) increased post-abortion contraception counselling and uptake [19,20], enhanced providers' use of appropriate technologies (MVA) [18][19][20] and changed their attitude towards a right-based, non-judgmental approach to women [18] leading to an overall positive experience of care for patients [21]. All but one [14] of these studies assessed only some of Donabedian's three conceptual domains: either inputs of care (facility equipment, supplies and human resources capacity to provide PAC) [13,15,18], indicators of provision of care (number of PAC, MVA use and contraception uptake) [20], patients' experience of care [17] or a combination of the latter two components of the process of care [19,21].…”