Development of guidelines for post care management at selected hospitals of KwaZulu-Natal Province, South Africa

Abstract

Background: Despite measures to curb unwanted pregnancies and to sustain and expand abortion services, a high number of complications and deaths still occur. The failure of these measures is evidenced by the high number of women who are admitted to the public hospitals of KwaZulu-Natal Province with complications from induced abortions. KwaZulu-Natal Department of Health has repositioned Family Planning to a key priority in its health program in order to improve the situation for women. However, in order to improve the situation, it is necessary to understand the underlying causes. This study sought to identify challenges that affect women's access to Post Abortion Care (PAC) services in KwaZulu-Natal Province, South Africa. It also sought to shed light on the challenges faced by those who render PAC services, as well as assess the skills of those workers as observed while they provided PAC services. After conducting the research on challenges related to access and rendering of post abortion care services, the researcher identified a need to develop guidelines for management of unsafe and induced abortion complications, with the aim to improve the life expectancy of women and prevent maternal deaths. Therefore, an outcome of the study was the development of a PAC management guideline. Purpose: The purpose of the study was two-fold: Phase 1: to explore the challenges faced by women when accessing PAC, and the health care workers who render PAC services, and to assess the PAC skills of the health care workers; Phase 2: to use the findings of Phase 1 to develop guidelines for post abortion care management at selected Hospitals of KwaZulu-Natal Province, South Africa. Methods: The design of the study was guided by the Andersen model of Health Care Utilization. The model focuses on the contextual factors - enabling factors, predisposing factors and need factors - that influence the individual's utilization of health care services. Five districts of KwaZulu-Natal Province, South Africa were selected for the study. A convergent parallel mixed method was used to collect and interpret the data. A qualitative study was used to explore perceptions and challenges of women when accessing PAC; this was carried out by means of in-depth interviews with 23 women who accessed PAC services. Five Focus Group Discussions (FGD) were carried out with 50 health care workers to explore the challenges they experienced when managing abortion complications. A quantitative approach was used for direct skills observation of 92 health care workers. Thematic analysis was used to analyse the qualitative data; descriptive statistics were used to analyse the quantitative data. Results: From the in-depth interview data, several main themes were identified. Women who accessed PAC identified a lack of facilities that offered PAC service, distance from the community to the hospital that provided PAC service, lack of transport, shortage of staff, unskilled staff, shortage of equipment, long waiting queues, stigma and discrimination as challenges associated with delay or avoidance of access to post abortion care services. The main themes raised by the health care providers were lack of support from the management, shortage of staff, lack of training, burnout, unavailability of the guidelines or protocols and shortage of equipment. The quality of PAC services was perceived as poor by both the women seeking care and the health care workers. The main concerns raised by the women were lack of respect, lack of privacy, sharing of bed and insufficient time with the health care provider. The results confirmed that guidelines are needed for the management of post abortion care services. The findings from the qualitative and quantitative parts of the study were used by an expert group to develop PAC management guidelines. The development of the guidelines was in accordance with the WHO models, PICOS & GRADES. The guidelines were validated by the group using a close-ended checklist, analysed with simple descriptive statistics. Conclusion: This study concludes that access to comprehensive quality post abortion care must be provided for all women at times of need. Quality PAC services should be rendered by skilled health care workers in a facility which is accessible and well equipped with functional equipments and updated guidelines. Recommendations: The study therefore recommends that measures should be taken to ensure the provision of quality PAC services. The PAC services should be accessible with the increased number of facilities, adequate trained health care workers with functional equipment and guidelines. Health care workers must receive training and management support to enhance quality PAC services. Privacy and respect must be maintained during provision of PAC services to ensure quality of care and increase demand. There must be continuous community awareness about PAC services which will encourage early-seeking behavior, and reduce fear of stigma and discrimination by the providers of PAC services before the complications arises. This study did not cover all the districts to identify the challenges on delaying PAC service. Therefore, this study recommends additional clinical, operations and community research which will give broader details and understanding on the challenges that cause delay for seeking immediate post abortion care services.