ProvidersProviders’’ Knowledge, Attitudes Knowledge, Attitudes and competencies for the and competencies for the provision of Postprovision of Post--Abortion Abortion

Services and contraception in six Services and contraception in six districts in Uganda: districts in Uganda: Baseline Baseline

findings during trainingfindings during trainingAuthor Author

Janet AdongoJanet AdongoTraining Coordinator Training Coordinator -- MSU MSU

RN,BScNRN,BScN

Background of the problemBackground of the problemSafe abortion for unplanned pregnancy is Safe abortion for unplanned pregnancy is unacceptable in Uganda, yet unsafe (induced) unacceptable in Uganda, yet unsafe (induced) abortion is responsible for at least abortion is responsible for at least 30%30% of all of all maternal deaths. maternal deaths.

Most induced abortions carried out in Uganda Most induced abortions carried out in Uganda take place in secrecy under take place in secrecy under unhygienic unhygienic conditionsconditions..

Each year, an estimated 300,000 induced Each year, an estimated 300,000 induced abortions are performed in Ugandaabortions are performed in Uganda

85,000 women are treated for complications, as a 85,000 women are treated for complications, as a result of unsafe abortion result of unsafe abortion

What is the practice?What is the practice?Post Abortion Care is known to be the work of Post Abortion Care is known to be the work of doctors who are very few or sometimes not there doctors who are very few or sometimes not there and they commonly use instruments for D&C.and they commonly use instruments for D&C.

In most health systems, women treated for In most health systems, women treated for abortion complications rarely receive any abortion complications rarely receive any counseling or services to prevent subsequent counseling or services to prevent subsequent unplanned pregnancies. unplanned pregnancies.

According to the Post Abortion Care protocol, the According to the Post Abortion Care protocol, the provision of family pprovision of family planning counseling and lanning counseling and uptake of method is one of the requirements for uptake of method is one of the requirements for the complete continuum of Post Abortion Care, the complete continuum of Post Abortion Care, unfortunatenly this unfortunatenly this is not being done in the many is not being done in the many of our settings. of our settings.

What is the situation?What is the situation?

Whereas induced abortion Whereas induced abortion contributes to about 30% contributes to about 30% of maternal death; of maternal death;

Lack of access to adequate Lack of access to adequate family planning services is family planning services is a major contributor to the a major contributor to the global problem of unsafe global problem of unsafe abortion; conversely, abortion; conversely, unsafe abortion is a prime unsafe abortion is a prime indicator of the unmet need indicator of the unmet need for safe and effective for safe and effective contraceptive methods.contraceptive methods.

IndicatorIndicator UgandaUganda

MMRMMR 435435

CPRCPR 24%24%

Unmet Unmet need need ––FP FP

41%41%

Apac

Arua

Kotido

Moyo

Nebbi

Nakapiripirit

Pader

Yumbe Kitgum

Gulu

Lira

Moroto

Adjumani

Masindi

Hoima

Kibaale

Katakwi

KapchorwaSironkoKumi

SorotiKaberamaido

Pallisa

Tororo

Busia

KamuliKayunga

Nakasongola

LuweroKiboga

MubendeKampala

Bundibugyo

KabaroleKyenjojo

Kabale

KanunguRukungiri

Kasese

Bushenyi Mbarara

Ssembabule

Rakai

Masaka

Mpigi

Kalangala

Wakiso

MukonoMayugeBugiri

Apac

Arua

Kotido

Moyo

Nebbi

Nakapiripirit

Pader

Yumbe Kitgum

Gulu

Lira

Moroto

Adjumani

Masindi

Hoima

Kibaale

Katakwi

Kapchorwa8Kumi

SorotiKaberamaido

MbalePallisa

Tororo

Busia

Iganga

KamuliKayunga

Jinja

Nakasongola

LuweroKiboga

MubendeKampala

Bundibugyo

Kyenjojo

o

Kabale

Kanungu

Ntungamo

Kasese

Bushenyi

Kamwenge

Mbarara

Ssembabule

Rakai

Masaka

Mpigi

Kalangala

Wakiso

MukonoMayugeBugiri

Map of Uganda

Study areas – six districts in Uganda

Study Areas

Purpose of the studyPurpose of the study

Assess the providersAssess the providers’’ knowledge, knowledge, attitudes and competencies in attitudes and competencies in providing postproviding post--abortion care abortion care services and counseling for FP services and counseling for FP method uptake for mothers after method uptake for mothers after abortion. abortion.

Objectives:Objectives:To assess the Health Providers knowledge To assess the Health Providers knowledge and experience with the case and experience with the case management of Postmanagement of Post--abortion abortion complications complications

Assess knowledge and skills of counseling Assess knowledge and skills of counseling for a family planning method after for a family planning method after abortion abortion

Establish the factors that hinder the Establish the factors that hinder the provision of quality Postprovision of quality Post--abortion care abortion care family planningfamily planning

Methodology:Methodology:Qualitative study and used the inQualitative study and used the in--depth depth

interviewinterview

Administered pretest questionnaire to Administered pretest questionnaire to participants at the start of the training to participants at the start of the training to obtain baseline informationobtain baseline information

A focus group discussion was used to draw A focus group discussion was used to draw common knowledge from the health workers common knowledge from the health workers on post abortion care services and family on post abortion care services and family planning counseling. planning counseling.

Thematic and content analysis was used to Thematic and content analysis was used to analyze the data. analyze the data.

Key FindingsKey FindingsSituation per districtSituation per district

33 districts had one trained Provider eachdistricts had one trained Provider each

11 district had four trained midwives but district had four trained midwives but two had left the district, two who remained two had left the district, two who remained acknowledged being trained for only three acknowledged being trained for only three days by some NGO and were not provided days by some NGO and were not provided with equipment, so they were not able to with equipment, so they were not able to provide any services. provide any services.

22 districts had one provider each who districts had one provider each who learnt on the job through Doctors learnt on the job through Doctors

Key findings ConKey findings Con’’ttOf the 109 health workers who Of the 109 health workers who

subjected to the pretest to subjected to the pretest to determine their baseline determine their baseline

knowledgeknowledge : : Inadequate knowledge Inadequate knowledge to provide PAC to provide PAC services among services among providers; scores providers; scores <50%<50%

Many question were Many question were left blank by providersleft blank by providers 0

5101520253035404550

Apac Moyo Adjumani Kisoro Rukungiri Kanungu

AttitudesAttitudesMany of the health workers displayed punitive attitudes towards Many of the health workers displayed punitive attitudes towards providing providing

PAC. These attitudes are driven by community bias and they cannoPAC. These attitudes are driven by community bias and they cannot t make a difference between inducing abortion and providing PAC. Tmake a difference between inducing abortion and providing PAC. This is his is what some had to say ; what some had to say ;

““We donWe don’’t know what to do, that is doctors workt know what to do, that is doctors work…”…”. It is . It is a new procedure, how shall we start explaining to the a new procedure, how shall we start explaining to the community about itcommunity about it’’’’,, One midwife responded during the One midwife responded during the interviewinterview

My dear, here it is difficult to discuss Abortion related My dear, here it is difficult to discuss Abortion related issues to the community because you will be mistaken to issues to the community because you will be mistaken to be advocating or promoting abortionsbe advocating or promoting abortions……, the culture here , the culture here condemns abortion and it is like an act of killingcondemns abortion and it is like an act of killing””. . Health Health provider, Rukungiri districtprovider, Rukungiri district

We fear to expose ourselves helping women with such We fear to expose ourselves helping women with such complications of abortion because the communities have complications of abortion because the communities have a negative attitude towards the procedure. They will say a negative attitude towards the procedure. They will say the provider is does abortions.the provider is does abortions.””

ConCon’’tt““Do you think this procedure of MVA is Do you think this procedure of MVA is really going to work? Is it practical with really going to work? Is it practical with these midwives/clinical officers of ours? these midwives/clinical officers of ours?

Some of them went and brought those MVA Some of them went and brought those MVA sets and they are only lying expired in the sets and they are only lying expired in the cupboardscupboards……, ,

Ok, good lackOk, good lack””. The Medical . The Medical Superintendent of one Hospital responds.Superintendent of one Hospital responds.

FP knowledge and practiceFP knowledge and practiceInadequate knowledge Inadequate knowledge among providers on among providers on both PAC and FPboth PAC and FP

Inadequate supplies of Inadequate supplies of FP methods in the FP methods in the health facilities. health facilities.

Attended some Attended some training but practicing training but practicing with difficulty with difficulty –– No, No, supply, high workload. supply, high workload.

Knowledge by percentage Knowledge by percentage

50%

27%

23%

123

Lacked Information on both PAC and FP

Som

e tr

aini

ng a

nd

prac

tices

with

di

fficu

lties

No methods available in the facility

Hindrance to providing PAC/FP Hindrance to providing PAC/FP servicesservices

Lack of knowledge and counseling Lack of knowledge and counseling skills among providers for the skills among providers for the various FP methodsvarious FP methods

Lack of awareness on resumption of Lack of awareness on resumption of fertility in mothers after abortionfertility in mothers after abortion

Negative attitudes and bias among Negative attitudes and bias among providers on abortion related providers on abortion related problemsproblems

ConCon’’tt••

Lack or inadequate supply of FP Lack or inadequate supply of FP methods in the facilitiesmethods in the facilities

••

Some health workers also share Some health workers also share myths and misconception about myths and misconception about FP like the communityFP like the community

••

Lack of motivation among H/WLack of motivation among H/W

What did it mean? What did it mean? The findings in this study therefore justifies the The findings in this study therefore justifies the

need to focus onneed to focus on;;

Task shifting by effective training of midTask shifting by effective training of mid--level level service providers in order to increase provider service providers in order to increase provider numbers, improve their skills and change provider numbers, improve their skills and change provider attitudes to PAC and FP servicesattitudes to PAC and FP services

Increase knowledge of counseling for FP after Increase knowledge of counseling for FP after PAC servicesPAC services

Increase the supply of different contraceptive Increase the supply of different contraceptive methods to facilities with trained providersmethods to facilities with trained providers

Con,tCon,t

Increase sensitization to communities, mothers, Increase sensitization to communities, mothers, opinion leaders and H/W for PAC and FP servicesopinion leaders and H/W for PAC and FP services

Establish strong functional links between Establish strong functional links between emergency post abortion care and FP servicesemergency post abortion care and FP services

Make clear the protocols for post abortion Make clear the protocols for post abortion contraception in all facilities contraception in all facilities

More research to identify strategies to be More research to identify strategies to be used/support evidence for improving the quality of used/support evidence for improving the quality of post abortion care and FP among providerspost abortion care and FP among providers

ConclusionConclusionWhereas there is an assumption that there Whereas there is an assumption that there are some providers trained to provide PAC are some providers trained to provide PAC and FP services, the fact on the ground is and FP services, the fact on the ground is quite alarming in many of the districts quite alarming in many of the districts tagged as hard to reach.tagged as hard to reach.

Quality training, equipping facilities with Quality training, equipping facilities with PAC equipments and FP methods will go PAC equipments and FP methods will go along way to improve the care given to along way to improve the care given to women after abortion and help them avoid women after abortion and help them avoid unplanned pregnancy unplanned pregnancy –– hence unsafe hence unsafe abortions abortions

AcknowledgmentAcknowledgmentIPPFIPPF who sponsored the project of Post who sponsored the project of Post Abortion Care and Education in those Abortion Care and Education in those districtsdistricts

MSI and MSU MSI and MSU -- M/E teamM/E team

MoHMoH Uganda Uganda –– provided some MVA sets provided some MVA sets

DHOsDHOs and and DHTsDHTs of the six districtsof the six districts

Participants who turned up for the training Participants who turned up for the training on PAC and FP on PAC and FP

References References 1.1. SusheelaSusheela S, et alS, et al………………2005. 2005.

Unintended Pregnancy And induced Unintended Pregnancy And induced Abortion in Uganda: Causes and Abortion in Uganda: Causes and ConsequencesConsequences..

2.2. Uganda Demographic Health Survey Uganda Demographic Health Survey (2006)(2006)