Health facilities’ capability to provide comprehensive postabortion care in Sub‐Saharan Africa: Evidence from a cross‐sectional survey across 210 high‐volume facilities

To evaluate the capability of high‐volume comprehensive emergency obstetric care (CEmOC) health facilities on the provision of comprehensive postabortion care (PAC) in Sub‐Saharan Africa and to determine the frequency of women with severe abortion‐related complications in high capability facilities.


| INTRODUC TI ON
Global commitment to provide high-quality postabortion care (PAC) was prioritized at the International Conference on Population and Development (ICPD) in 1994 and re-emphasized at the 25th anniversary meeting in Nairobi. 1,2 However, rates of morbidity and mortality due to unsafe abortion remain high across many settings in Sub-Saharan Africa, 3 where abortion practice is still largely legally restricted. Many abortion-related complications are still potentially life-threatening in these contexts, 4 and key challenges remain in ensuring access to quality care for these complications. 3 In these contexts, high-quality PAC is critical to reduce mortality and prevent complications resulting from unsafe and spontaneous abortions. 5 Facility capability is key in the provision of quality PAC. Building on the model initially developed to assess emergency obstetric care availability, Healy et al. 6 proposed a framework of essential components ("signal functions") that could be used to measure the availability and implementation of key resources and procedures for the provision of safe abortion care in health facilities. The signal functions approach was then adapted by Campbell et al. 7 to define a set of composite indicators constructed from key preventive and curative services to assess health systems capability to provide basic PAC at primary level and comprehensive PAC at referral levels of care. Comprehensive PAC comprises essential components for abortion complications' management, including long-acting contraceptive methods, and surgical and blood transfusion capacities. 7 The PAC signal function framework has been used in several studies in low-and middle-income countries. [8][9][10][11] However, most of these studies were secondary data analyses and could only include signal functions for which information was available, and were almost exclusively from surveys looking at facility capabilities for a wide range of health conditions and not necessarily focused on PAC. 8,9 As such, these studies did not include important signal functions needed to support quality of care (specific PAC guidelines, clinical audits) or for the management of very severe complications of unsafe abortion, such as the availability of an intensive care unit (ICU).
Our study is a multicountry analysis assessing high-volume comprehensive emergency obstetric care (CEmOC) facilities' capabilities to provide comprehensive PAC in Sub-Saharan Africa using data from the World Health Organization (WHO) Multi-Country Study on Abortion-related morbidity (MCS-A). 12 We draw on the health facility assessment tool that was designed specifically to collect information on abortion-related services from facilities that had a designated gynecology ward and reported surgical capability. We apply similar signal functions to those used in previous studies, as well as propose an expanded set of signal functions that could measure the availability of services or components necessary for quality of care or better management of severe cases at high volume CEmOC facilities. We also explore the extent to which the most severe abortion complications are managed in facilities with optimal PAC provision capabilities.

| Study design and data source
We conducted a secondary analysis using data from the MCS-A study in Africa, a large cross-sectional study with data col- Participating countries and facilities' selection are described in the main study's protocol. 13 Briefly, three geographical provinces/ states, including the capital city plus two provinces/states with probability proportional to the population size, were first sampled in each country. Ten facilities fulfilling the inclusion criteria were then selected from the census of private and public facilities within each selected area (with up to a total of 30 facilities per country). Facilities were included based on the following criteria: more than 1000 deliveries per year, a gynecology ward, and surgical capability. When there were fewer than 10 facilities fulfilling inclusion criteria within a geographical area, all eligible facilities in that area were selected. 13 As part of the MCS-A survey, facility-level data were collected using an institutional assessment form that was completed by hospital coordinators (typically obstetrician/gynecologists or healthcare providers responsible for gynecology and obstetrics wards at identified facilities). This form was used to collect information on the location and type of facility, the capacity to provide emergency obstetric care, and a more detailed assessment of the facilities' ability to provide PAC within the previous 3 months (infrastructure, utilities, equipment, and human resources). Hospital coordinators reported, where necessary, equipment or services as available and/or functioning. Individual level information on women attending the facilities with abortion-related complications was also collected from medical records. 13 | 9 COMPAORÉ et Al.

| Defining the signal functions
We used a set of signal functions to assess facilities' capability to provide PAC across three categories: infrastructure, standard comprehensive capability, and extended capability to provide PAC. Table 1 describes in detail each signal function and the accompany-ing definition used in this study.
We defined an "infrastructure" category to emphasize the structural capacity of hospitals to provide quality care and included all components for which data were collected. While the elements of the infrastructure category are essential for quality care provision, they are not specific to the provision of comprehensive PAC. To measure the infrastructure category, seven signal functions were selected: availability of electricity, generator, refrigerator, telephone/ radio call, email/internet, incinerator, ambulance, water supply, and sewerage system. The Campbell et al. approach 7 was adapted to assess the standard comprehensive PAC category, which includes seven specific curative and preventive services and one staffing criteria on the availability of a provider on duty 24/7. Surgical capability was an inclusion criterion for facilities in the MCS-A study, therefore this capability was not included as a signal function in this study.
We then measured the extended comprehensive capability category by adding six components to the comprehensive category, to assess the capability of health facilities to manage all abortion complications, including severe cases, appropriately: availability of guidelines, clinical audits, an adult ICU, ultrasound services, biochemical/clinical laboratories, and at least one anesthesiologist on duty 24/7. 14 The choice of additional signal functions included in this analysis was based on recommendations from the WHO clinical management for abortion care guidelines. 14 The main author first developed these criteria, and they were then validated by a senior obstetrician and researchers involved in the study.

| Data analysis
The data were analyzed using Stata version 15 (StataCorp LLC).
We initially examined the distribution of facilities concerning key  For this analysis, both comprehensive PAC capabilities (standard and extended) scores were grouped into four categories. The first category was included facilities where all components were met ("criteria met"). The remaining facilities were categorized as follows: "criteria unmet with 1-2 signal functions missing," "criteria unmet with 3-4 signal functions missing," or "criteria unmet with 5 or more signal functions missing." The percentage of severe abortion complications treated at each facility capability level was calculated overall and by country. There was substantial variation in bed capacity and service utilization, both within and between countries ( Table 2). The overall average number of gynecologic beds in use was 19.9, ranging from 0-217. Differences were noted between countries within the same region: in West Africa, the mean number of gynecologic beds available ranged from 14.1 (range, 4-58) in Nigeria to 58.8 (range, 23-217) in Benin. On average, approximately 37 women were reported to seek care for postabortion complications in a typical month in these facilities (range, 0-350). Table 3  There were also regional differences in the availability of adult ICU.

| DISCUSS ION
We used a set of signal functions to assess facilities' capability to provide PAC across three categories: infrastructure, standard comprehensive capability, and extended capability to provide PAC. Our The levels of capabilities found in our study vary with results from referral-level facilities from previous studies in Sub-Saharan Africa. [7][8][9]15 The standard PAC comprehensive capability we found in West African countries (81.2%) was much higher than was documented in referrallevel facilities in Senegal in 2015 (37.0%). 8 There were also notable differences between our findings and those in the multicountry study of PAC capacity by Owolabi et al.. 8   The present study had some limitations inherent in the methodology used. Hospital coordinators were asked to report on the availability and functioning of most signal functions, but this was not independently verified nor were there any checks that the commodities or equipment to provide the services were available. We also noted some limitations to specific questions that were asked, notably that both methods of uterine evacuation were grouped together, whereas it would have been better to ask about each separately. We could only investigate signal functions for PAC owing to the lack of relevant data collected on procedures for safe termination. Moreover, due to the type of facilities included in our sample, we are not able to generalize to private for-profit facilities, which were not included in the study sample. However, by using a large cross-sectional approach, this study provides updated estimates on the capacity of facilities in Sub-Saharan Africa to provide comprehensive postabortion care, while allowing for comparison across regions and countries to a certain extent, albeit somewhat limited by small numbers of countries in some of our regions (i.e. Central Africa). The data collection tool that included additional indicators in the assessment of facilities' capability to provide quality comprehensive PAC is one of the key strengths of this study.
By using this tool in a standardized way, this approach could constitute one more step for more comprehensive and harmonized assessments of health facility service quality, based on global service standards.
In conclusion, this study provides important information on the availability of equipment, supplies, and services for quality PAC provision in and across 11 countries in different Sub-Saharan African regions. While overall capabilities were generally high for most signal functions, key functions important for the management of severe abortion-related complications were not always available, in particular with respect to specialized human resources and ICU, which needs to be urgently addressed. Some gaps were found by adding specific components through the extended comprehensive PAC category. There is a clear need to improve the capability of facilities, and the referral system, given the high percentage of severe abortion complications that do not reach high capability facilities.

ACK N OWLED G M ENTS
The WHO Multi-Country Survey on Abortion (MCS-A) is a research project implemented by the WHO across a network of health facilities in Africa. We sincerely thank the women who participated in this study. WHO is grateful to the extensive network of institutions and individuals who contributed to the project design and implementation, including researchers, study coordinators, data collectors, data clerks, and other partners including the staff from the Ministries of Health and WHO country offices.