Adolescents' satisfaction with care for abortion- related complications in 11 Sub- Saharan African countries: A cross- sectional facility- based study

Objective: To assess satisfaction with care for abortion- related complications experi-enced among adolescents compared to older women. Methods: A secondary analysis of the WHO Multi- Country Survey on Abortion-related Morbidity and Mortality— a cross- sectional study conducted in health facilities in 11 Sub- Saharan African countries. Women with abortion- related complications who participated in an audio computer- assisted self- interview were included. Two composite measures of overall satisfaction were created based on five questions: (1) study participants who were either satisfied or very satisfied across all five questions; and (2) study participants who reported being very satisfied only across all five robustly evaluate adolescents’ satisfaction with the quality of their PAC to identify the associated gaps and interventions to fill those gaps. Person- centered quality of care can be measured by: (1) patient experience; and (2) patient satisfaction. A patient's experience can be categorized by three areas: effective communication, respect and dignity, and emo-tional support. These may be affected by facility/patient characteristics and the type of service. 9 Patient satisfaction is an outcome measure of experience of care. Satisfaction is de-pendent on a patient's evaluation of care received and expectations of care, needs, and values, which may also be informed by facility characteristics, individual characteristics, and type of service. Expectations of quality of abortion- related


| INTRODUC TI ON
In 2012, approximately seven million women in low-and middleincome countries received treatment for abortion-related complications as a result of unsafe abortion. 1 It has been estimated that of 49% unintended pregnancies occurring in adolescents in lowresource regions, about half result in abortions, many of which are unsafe and may result in morbidity and mortality. 2 At the 25th anniversary of the International Conference on Population and Development (ICPD), adolescent sexual and reproductive health, including abortion care, has been placed fully on numerous global, regional, and national agendas. 3 In Sub-Saharan Africa, a range of factors can prevent women from receiving quality postabortion care (PAC) services, some of which are likely to disproportionally affect adolescents. Studies have shown that young and unmarried women are more likely to face provider stigma and mistreatment. [4][5][6] In Kenya, Izugbara et al. 5 undertook in-depth interviews and focus group discussions with 152 PAC providers; the majority of providers treated young and unmarried PAC patients poorly because of the stigma associated with premarital pregnancy at such a young age. Many providers also reported risk of being stigmatized by colleagues if caught treating adolescent PAC patients politely. 5 In Ghana, Tagoe-Darko et al. 6 conducted a qualitative study among women who had been treated for postabortion complications in a large referral hospital to assess how stigma influenced the quality of PAC. They found that unmarried and young PAC patients were more susceptible to provider stigma and mistreatment than older, married women. 6 Additionally, adolescentfriendly PAC services have been found to be rare in Sub-Saharan Africa. 4,6,7 Recent data from the World Health Organization (WHO)

Multi-Country Survey on Abortion (MCS-A) across Sub-Saharan
Africa found no evidence that the severity of complications in adolescents attending facilities with abortion-related complications was more severe when compared with older women (aged ≥30 years); however, differences in experience of care and, specifically, satisfaction with care between adolescents and older women were not reported. 8 It is important to robustly evaluate adolescents' satisfaction with the quality of their PAC to identify the associated gaps and interventions to fill those gaps. Person-centered quality of care can be measured by: (1) patient experience; and (2) patient satisfaction. 9 A patient's experience can be categorized by three areas: effective communication, respect and dignity, and emotional support. 9 These areas may be affected by facility/patient characteristics and the type of service. 9 Patient satisfaction is an outcome measure of experience of care. Satisfaction is dependent on a patient's evaluation of care received and expectations of care, needs, and values, which may also be informed by facility characteristics, individual characteristics, and type of service. 9 Expectations of good quality of abortion-related care questions. Multivariable general estimating equation analyses were conducted to assess whether there was any evidence that age (adolescents 12-19 years and older women 20+) was associated with each composite measure of satisfaction, controlling for key confounders.

Results:
The study sample consisted of 2817 women (15% adolescents). Over 75% of participants reported being satisfied or very satisfied for four out of five questions.
Overall, 52.9% of study participants reported being satisfied/very satisfied across all five questions and 22.4% reported being consistently very satisfied. Multivariable analyses showed no evidence of an association between age group and being either satisfied or very satisfied (OR 1.07; 95% CI, 0.82-1.41, P = 0.60), but showed strong evidence that adolescents were 50% more likely to be consistently very satisfied with their overall care than older women (OR 1.49; 95% CI, 1.13-1.96, P = 0.005).

Conclusion:
Both adolescents and older women reported high levels of satisfaction with care when looking at different components of care individually, but the results of the composite measure for satisfaction showed that many study participants reported being less than satisfied with at least one element of their care. Further studies to explore the expectations, needs, and values of women's satisfaction with care for abortion-related complications are needed.

K E Y W O R D S
adolescents, cross-sectional study, patient satisfaction, postabortion care, Sub-Saharan Africa may be hindered due to stigma and restrictive laws and policies. 9 Despite the importance of measuring satisfaction with care, there is a paucity of studies looking at adolescent satisfaction with PAC compared to older women in Sub-Saharan Africa. One study, conducted by Evens et al., 10 found no evidence of a difference in satisfaction between younger women (15-24 years) and older women (older than 24 years) seeking care for postabortion complications in Kenya. However, this study only included providers and patients from facilities that had just received training on the provision of adolescent-friendly services.
Given the existing evidence to suggest that adolescents may receive poor quality of care for abortion-related complication in Sub-Saharan Africa, we hypothesized that adolescents would be less likely to be satisfied with the care that they received. Using data from the WHO MCS-A, 8 the present paper assesses whether adolescents seeking care for abortion-related complications have lower satisfaction with the care they received compared to older women across Sub-Saharan Africa.

| MATERIAL S AND ME THODS
Data for the present study come from the WHO MCS-A, 8  A detailed description of this study is provided elsewhere. 11 In brief, multistage sampling was used to first select the countries and then to select the facilities for inclusion in the study. Inclusion criteria for facilities were those that had more than 1000 deliveries per year and the capability to provide comprehensive emergency obstetric care. Both public and private facilities were eligible for inclusion. Ultimately, 11 Sub-Saharan African countries were se- were collected from two sources: (1) extraction of data from medical records; and (2) an exit survey with women using audio computerassisted self-interviews (ACASI). Medical record data were collected by research assistants. A subsample of women who had their medical record data collected were eligible for inclusion in the ACASI exit survey. To be eligible, women had to be admitted for abortionrelated complications or had to have stayed in the facility for 24 h or more, to be deemed able to participate in the survey, and provide consent to participate. The ACASI exit survey was self-administered, in the participant's native language, on a computer, and in a private location to emphasize patient confidentiality. Before administration, the ACASI exit survey was translated into the local language, back translated, pretested, and then validated. It measured each participant's standard of living, abortion safety, and experience of care.
The analysis for the present paper was restricted to women who had ACASI data available.
Every PAC provider was trained as per standardized in-country guidelines and participants were informed to report to the same facility if they felt unwell or they wanted to seek further advice regarding the care that they had received. If there was an abortion-related complication that could not be handled at the facility, referral pathways were in place to a higher level of care institution.
The exposure for the present analysis was age group, which was collected from medical records. Adolescents were classified as those aged 19 years or younger, while older women were those aged 20 years and older. The outcome for the present analysis was satisfaction with care, which was created from five satisfaction questions in the ACASI exit survey. The questions explored satisfaction with services received, level of privacy during the examination and treatment, time taken to see a healthcare provider in the facility, amount paid for services, and health information received from healthcare providers.
The questions were answered on a five-point Likert scale (very dissatisfied, dissatisfied, neutral, satisfied, very satisfied). A composite measure of satisfaction was created, with study participants who reported being "very satisfied" or "satisfied" across all five satisfaction questions classified as satisfied with their care. The second composite measure of satisfaction was study participants who reported being "very satisfied" only with care across all five questions.
Potential confounders and effect modifiers of the association between age and satisfaction with care for abortion-related complications were identified based on the literature. 9 These variables have been categorized into sociodemographic factors (socioeconomic status, education level, gainful occupation, marital status), obstetric factors (gravidity, severity of complication, previous abortion status, type of abortion), and facility characteristics (facility level, facility location). Socioeconomic status was created from four questions from the ACASI exit survey. The four questions asked the woman: whether she has running water in her home; whether her household income allowed her to take care of all of her personal needs such as food and health during the past month; whether members of her household have been able to save money during the past month, after taking care of all household expenses; and whether she has had to go for a full day without a meal during the past month because of lack of food and inability to buy food in her household. A score was created for each woman, with a total of four indicating the highest socioeconomic status and zero the lowest. Those with scores of zero or one were categorized as low socioeconomic status, those with two or three were categorized as middle socioeconomic status, and those with scores of four were categorized as high socioeconomic status.
All analyses were conducted using Stata/IC version 16.1 (StataCorp LLC). Descriptive analyses were conducted to assess missing data, and to determine the distribution of the study sample by key characteristics. We used generalized estimating equations, accounting for clustering in facilities, to explore the association between age group and satisfaction. Our first model looked at the association between age group and satisfaction, adjusting for country which was included as an a priori confounder. Subsequently, each potential confounder was placed individually in the first model. Potential confounders that had a substantial impact (odds ratio changed by 10%) on the association between age and satisfaction were included in the final model as confounders. We assessed whether there was any evidence that the adjusted association between age and satisfaction varied by any of four potential effect modifiers that were identified a priori: level of facility (primary, secondary, tertiary, other referral levels), severity of complications (severe, moderate/mild), self-reported type of abortion (spontaneous, induced), and marital status (not married, married). The modelling process was undertaken twice, once for each of the two different definitions of satisfaction described above. Finally, we conducted a sensitivity analysis, rerunning our final multivariable model using a more detailed categorization of age (≤15, [16][17][18][19], and

20+ years).
This study was approved by the WHO Ethical Review Committee    Table S1 shows overall satisfaction with care in each country stratified by age group.

| RE SULTS
After adjusting for country, we found that adolescents were 13% less likely to be consistently satisfied/very satisfied with care compared with older women, although there was no evidence against the null hypothesis of no association between age group and satisfaction (OR 0.87; 95% CI, 0.70-1.09, P = 0.23). Gravidity and marital status were identified as confounders of the association. After controlling for gravidity, marital status, and country we found that adolescents were 7% more likely to be consistently satisfied/very satisfied with care compared with older women, although there was no evidence against the null hypothesis of no association between age group and overall satisfaction (OR 1.07; 95% CI, 0.82-1.41, P = 0.60) ( Table 3).
When adjusting for country only, there was no evidence for an association between age group and being consistently very satisfied with care (OR 1.07; 95% CI, 0.84-1.36, P = 0.57). After adjusting for gravidity, marital status, and country, adolescents were 50% more likely to be very satisfied with their overall care compared with older women (OR 1.49; 95% CI, 1.13-1.96, P = 0.005) ( Table 3).
There was no evidence that the adjusted association between age group and being satisfied/very satisfied varied by complication severity (P = 0.59), type of abortion (P = 0.20), marital status (P = 0.60), or facility level (P = 0.39). When looking at the outcome defined as study participants consistently very satisfied with care, there was no evidence that the association between age and satisfaction varied by any of the potential effect modifiers: complication severity (P = 0.66), type of abortion (P = 0.55), marital status (P = 0.42), or facility level (P = 0.07).

| DISCUSS ION
Overall, over half (52.9%) of adolescents reported being consistently either satisfied or very satisfied with care, similar to older women (aged 20+) in the sample (52.6%). We found no evidence of an association between age group and satisfaction with care, after adjusting for marital status and gravidity (P = 0.60). However, we did find strong evidence for an association between age group and being consistently very satisfied with care (P = 0.005). Adolescents were nearly 50% more likely to be very satisfied with their overall care than older women.
In this study, the majority of both adolescents and older women reported relatively high levels of satisfaction when looking at each question relating to satisfaction (>75% were either satisfied or very satisfied) for all questions, with the exception of amount paid "out of pocket" for services where 69.4% of study participants reported being satisfied or very satisfied; however, it was clear that study participants were less than satisfied with at least one aspect of care, as captured in our composite measure. These findings are consistent with studies that show satisfaction with care tends to be high in low-and middle-income countries (LMICs). 12 One quantitative study conducted in two Guinean health facilities reported that out of 426 patients, 92.5% of study participants were satisfied with their PAC. In that study, the researchers observed the care provided to the woman, possibly raising the quality of clinical care provided and leading to higher levels of satisfaction. 13 Another study in Tanzania showed moderately high levels of satisfaction with care among 412 women that presented to 25 facilities for abortion-related complications. 14 The survey included questions on satisfaction with clientstaff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment.
The authors also conducted in-depth interviews with 30 of these participants. They found that although women reported being satisfied with most domains in the survey, when interviewed qualitatively women expressed dissatisfaction with several aspects of their care. 14 A qualitative study assessing patients' satisfaction with care in Ghana reported that more than three-quarters of women in a facility reported being satisfied with care because of provider treatment and because symptoms of the complications had stopped. 15 Adolescents may have been more likely to be very satisfied with care because of their expectations. In the present study, we found that adolescents were more likely to report having an induced abortion and less likely to have an occupation, which might have made them more vulnerable to stigma and also more likely to delay seeking care because of perceived stigma. Studies show that perceived stigma impacts PAC-seeking behavior and expectations among adolescents and young women. 2,6,7 Leaving the facility healthy, alive, and without pregnancy may have increased their satisfaction, regardless of their treatment, privacy, or the information received, after their previous, more vulnerable state. It is also possible that these results are driven by differences in reporting of satisfaction between adolescents and older women. Study participants reported their satisfaction using Likert scales, and it is plausible that adolescents report differently using these compared with older women. TA B L E 2 Distribution of those who answered very dissatisfied, dissatisfied, neutral, satisfied, and very satisfied for each question on satisfaction with care, by age group (n = 2817) Indeed, a survey development guide for adolescents stated that young adolescents may have issues with reporting information using Likert scales as their brains are still developing. 16 However, the adolescents included in our study were on average older than the age group considered in the guide of survey development.

Question
Measuring satisfaction with care is widely recognized to be challenging because of its subjectivity, 9 and in the present study we were limited to only five questions. It is plausible that we did not capture all the relevant areas of care for abortion-related complications that would discriminate between the satisfaction between age groups.
In our composite measures, we weighted each component of satisfaction equally and it is possible that women would place greater importance on some of the measures of satisfaction over others.
Larson et al. 9  In conclusion, both adolescents and older women reported high levels of satisfaction with care when assessing each satisfaction question, but the results of our composite measure for satisfaction showed that many study participants also reported being less than satisfied with at least one element of their care. This study has shown that among both adolescents and older women, there are issues with satisfaction with care for abortion-related complications.
Further study is needed to understand the relationship between quality of PAC and patient satisfaction with care. Governments and ministries of health can use information like this to work toward improving the quality of PAC for all age groups, both adolescents and older women alike.

ACK N OWLED G M ENTS
The