Fragile and conflict-affected settings: post-abortion care generally satisfactory, but communication needs to be improved

© Header illustration by Alice Wietzel

The AMoCo* study continues to highlight persistent challenges related to abortion care and complications in fragile and conflict-affected settings. Conducted in two hospitals in Bangui (Central African Republic) and Jigawa State (Nigeria), it reveals that a significant proportion of patients seeking post-abortion care experienced poor communication with healthcare staff and mixed experiences in terms of respect and dignity. Women with less education and adolescents appear to be particularly vulnerable. This study, which had already revealed that severe post-abortion complications were five to seven times more likely in these two hospitals, demonstrates the importance of listening to women, giving them the opportunity to ask questions, and ensuring their privacy. These elements are essential to ensuring quality care for all women, regardless of their age or level of education.

Approximately 70% of maternal deaths occur in sub-Saharan Africa (1). Among the five leading causes are abortion complications, for which little progress has been made in recent decades. However, most of these deaths are the result of unsafe induced abortions (2), which could be largely prevented by providing comprehensive abortion care, including post-abortion care, contraception services, and safe abortion services.

The AMoCo* study, conducted by Médecins Sans Frontières (MSF), Epicentre, the Institute of Tropical Medicine in Antwerp, Ghent Univeristy, the Guttmacher Institute, and Ipas, in partnership with the ministries of health of the Central African Republic (CAR) and Nigeria, (and co-funded by MSF and ELRHA/R2HC), assessed abortion-related complications in two hospitals located in fragile, conflict-affected settings in Bangui, Central African Republic, and Jigawa State, Nigeria. It has already revealed that severe complications are five to seven times more likely in these two hospitals than in African hospitals in more stable contexts assessed by the World Health Organization (WHO) using a similar methodology (3).

Post-abortion: quality of care is not enough without dialogue with women

However, another component of the AMoCo study, focusing on the knowledge, attitudes, practices, and behaviors (KAPB) among providers of abortion-related care, reveals an overall supportive attitude regarding comprehensive abortion care in the two hospitals studied.

When asked, "Would you feel comfortable personally providing safe abortion care in certain circumstances?", more than 80% responded affirmatively (82% in CAR and 87% in Nigeria). The most widely accepted reasons relate to situations where the woman's life or health is at risk, or in cases of fetal abnormality. In contrast, only 5% of professionals in Nigeria and 12% in CAR indicated that they would provide safe abortion care regardless of the reason.

Furthermore, another part of this extensive study published in Reproductive Health highlighted the high quality of post-abortion care provided in these two facilities, with the majority of indicators in the WHO quality of care framework for maternal and newborn health being met. This situation contrasts with that observed in many other African referral hospitals studied in more stable contexts. Another notable point is that almost all healthcare professionals have received specific training in post-abortion care. "This quality of care can certainly be explained in part by the significant support provided by MSF to both facilities, particularly in terms of the provision of equipment, medicines, staff, continuing education, supervision, and medical protocols," emphasizes Estelle Pasquier, PhD researcher at the Unit of Reproductive and Maternal Health at ITM and head of the AMoCo study. Overall, women say they are satisfied with the care they receive.

However, when asked more specifically about certain aspects of their healthcare experience, difficulties in communicating with healthcare providers, maintaining privacy, and waiting times emerge. These difficulties add to the already long and difficult journey women face in accessing post-abortion care, further exacerbating the complications and risks they face. In these two hospitals, more than 50% of women admitted for an abortion-related complication presented with a severe form, mainly haemorrhage (72% in the Nigerian hospital and 58% in the Central African hospital). Half of them took two days or more after the onset of the first symptoms to reach an adequate health center. Twenty-seven percent of women surveyed on the Nigerian side and 16% on the Central African side took six days or more.

These situations also occur in a context where the risk of exposure to sexual violence is high and access to contraception remains limited. These factors in turn increase the risk of unwanted pregnancy and unsafe abortions, particularly in contexts where abortion laws are restrictive.

Hospitals must strengthen their patient-centered approach by listening to women, involving them in their own care, and ensuring privacy, reduced waiting times, and quality interaction between providers and patients.