Post abortion care in Uganda : improving access and quality of care through task sharing and exploring the perspectives of young women and healthcare providers

Sammanfattning: BACKGROUND. Unsafe abortions in Uganda continue to cause significant harm to women’s health and lives and pose a heavy burden on the health system. The consistent shortage and maldistribution of healthcare providers impede women’s access to sexual and reproductive healthcare including post abortion care. Research and government reports indicate that access to post abortion care is inequitable and that the quality of care is sometimes poor. A task share between physicians and midwifes in the diagnosis and treatment of 1st trimester incomplete abortion using misoprostol, has the potential to increase women’s access to care. Improving access and quality of care further demands better appreciation of abortion decision-making and care-seeking, as well as clarity surrounding the quality of post abortion care and aspect that contribute to sub-standard care. AIM. The aim of this thesis is to identify means to improve access and quality of post abortion care in low-resource settings through task sharing and by exploring the perspectives of young women and healthcare providers in Uganda. METHODS. Study I was a multi-centre randomised controlled equivalence trial carried out in the central region of Uganda. The study aimed to investigate the safety, effectiveness and acceptability of diagnosis and treatment of 1st trimester incomplete abortion with misoprostol provided by midwives compared with physicians. Study II focused on the perspectives of young women (15–24 years) seeking post abortion care. The study explored reproductive agency in relation to unsafe abortion through individual in-depth interviews. We wanted to understand how the social environment shaped young women’s reproductive agency and actions, and under what circumstances abortions were conducted and post-abortion care was sought. Study III focused on healthcare providers’ perspectives on post abortion care. Individual in-depth interviews were conducted with midwives providing post abortion care. We specifically wanted to shed light on the quality of care, including working conditions and the role of stigma. FINDINGS. We found that diagnosis and treatment of 1st trimester incomplete abortion with misoprostol was safe, effective and acceptable when care was provided by midwives compared with physicians. Women’s acceptability was high and influenced by treatment experience and outcome (Study I). Interviews with young women revealed that reproductive agency was constrained and heavily influenced by stigma. Abortion was described as their least-wanted yet only option. At the same time, abortion was depicted as an agentive action intended to reclaim control. Maintaining secrecy was key but also incurred risk taking, and when experiencing complications, many women struggled to access care. The abortion experience seemed to shape discourse in relation to contraceptive intentions and decision-making (Study II). We found that midwives were dedicated to prevent mortality and morbidity and considered post abortion care an essential part of midwifery. However, midwives’ personal morality conflicted with their professional duty and commitment to provide post abortion care of good quality. Together with a challenging work environment, this hampered the provision of good-quality care. Finally, we found that stigma extended to both healthcare providers and women seeking care, especially to women who had induced an abortion (Study III). CONCLUSIONS Scaling up task sharing with midwives in post abortion care using misoprostol is safe, effective and highly acceptable to women and can improve access to care (Study I). Enabling young women’s reproductive agency requires addressing harmful gender norms and stigma related to pregnancy and abortion. Improving access to safe abortion and contraceptives is paramount to young women’s empowerment and their sexual and reproductive health and rights (Study II). Safeguarding equitable and good-quality post abortion care requires an enabling environment and strengthening of the midwifery role. Furthermore, abortion stigma and its implications for both healthcare providers and care-seeking women must be addressed (Study III). Findings from this thesis may be used to guide future endeavours to improve access and quality of post abortion care, and to promote and protect the sexual and reproductive health and rights of young women.