Key Findings
Overall, high levels of person-centered care were reported among all surveyed clients. While variations and disparities in person-centered care were seen when disaggregated by sub-populations and settings, when analyzing all participant responses and applying threshold guidance from indicators included in the Abortion Care Quality (ACQ) Tool (50), for the majority of outcomes, over 80% of the sample reported a positive experience. This is consistent with research from Addis Ababa, which found that people who received CAC in public facilities reported high levels of satisfaction on person-centered care indicators similar to those in this study (37). Altshuler & Whaley (35) conducted a scoping review evaluating person-centered abortion care from the client perspective, finding that globally CAC services fail to provide person-centered care frequently due to institutional and legal restrictions on abortion. Likewise, there is universal consensus among health experts that liberal abortion policies and reduced institutional restrictions lead to improved CAC access, safety, and quality (32). Our findings support these conclusions; high levels of person-centered abortion care are offered within the Ethiopian context likely related to the improved abortion landscape and the concerted effort made at the national level to expand safe CAC services in public health facilities.
However, study results also indicate room for improving quality of induced abortion and PAC services for clients within public health facilities in Ethiopia with specific focus needed on three domains: autonomy, communication and supportive care, and health facility environment. Prior research further supports focusing attention and resources to these components of CAC. Specifically, induced abortion clients from Kenya and India emphasized interpersonal interactions with providers and health facility personnel as one of the most critical components of good quality abortion services – aligning well with the outcomes included in both the communication and supportive care and autonomy domains (36). Mossie Chekol et al. (37) identified interpersonal communication, receiving information related to the procedure, and the physical environment as three focus areas to improve CAC client satisfaction in Addis Ababa, corroborating our findings. Further, our results build upon these prior research findings through expanding the analysis to other regions of Ethiopia. Additionally, although CAC clients reported nearly universally good experiences of dignity and respect, any instance of abuse or discrimination should not be tolerated as it constitutes a human rights violation (32). Therefore, although less than one in six CAC clients experienced being scolded, shouted at, discriminated, or insulted due to personal attributes, critical attention must be given to address this issue.
Abortion Care Guidelines from WHO indicate that regardless of whether a client receives PAC or induced abortion services, all abortion clients deserve the same high-level of person-centered care (32). Consistent with previous studies (6), we found a high rate, nearly half, of clients seeking PAC services, despite induced abortion being available and accessible in the public sector (3,5,10). While prior research in Ethiopia has not found differences in the quality of client experiences between PAC and induced abortion services (37), our findings illuminate disparities between diagnosis categories, with induced abortion clients reporting higher levels of autonomy, communication and supportive care, as well as privacy and confidentiality than PAC clients. We hypothesize this may be indicative of the more serious and sometimes urgent nature of PAC services compared to induced care, but these differences warrant further investigation.
Consistently, our regional analysis indicated that CAC services received in the Amhara region had the lowest levels of person-centered care across all domains. There were fewer noticeable gaps between the other three regions studied. However, marginally higher levels of autonomy and trust, privacy & confidentiality were observed in Tigray and dignity & respect was highest in SNNPR. These results are consistent with a study which found that Amhara had the lowest family planning quality score and that there were only slight differences in family planning quality scores observed between the other regions studied (51). Conversely, relevant contraceptive use and antenatal care indicators calculated in the Ethiopian 2016 Demographic and Health Survey (DHS) consistently ranked Amhara as having better health outcomes than other regions, frequently finding that Oromia fared the worst (52). It is important to note that while information can be gleaned from these prior studies, they do not include induced abortion or PAC services specifically and are focused on clinical quality and accessibility indicators, rather than person-centered care (51,52).
The findings from this study also establish that CAC clients had higher levels of autonomy and communication and supportive care at health centers and secondary facilities, than at tertiary hospitals. Research assessing the quality of PAC services in the public sector in Tanzania identified results consistent with these findings. Specifically, Baynes et al. (39) concluded that the strongest predictor of high client satisfaction was related to facility type, with PAC clients more satisfied with services at lower-level facilities including health centers, than tertiary facilities. Lower-level facilities are often assumed to be understaffed and under resourced leading to the conclusion that they are unable to provide high-quality care (14,53); our findings challenge this assumption and are consistent with primary care facilities in lower- and middle- income countries being effectively leveraged to provide HIV care and treatment (14). Similarly, the lowest rates of family planning counselling and having a good experience getting information about other health services were observed at primary and tertiary hospitals, with the highest rates seen at health centers. Wake et al. (54) demonstrated the importance of focusing on the integration of reproductive health services through analysis showing that postabortion contraception acceptance in Ethiopia is directly associated with increased family planning counselling. Therefore, we see a clear need for better integration of reproductive health services including family planning counselling, particularly in primary and tertiary hospitals.
Across all domains, few disparities in person-centered care were identified between CAC clients who received MVA or MA. This conflicts with prior studies in Addis Ababa and Kenya, all which found significantly different levels of satisfaction and person-centered care by abortion procedure type (37,44,55). However, for the individual outcome of receiving pain medication, our results show that MA clients are less likely to receive pain medication, similar to the existing literature which indicates that MVA clients receive more person-centered abortion care than MA clients (37,44). We must be aware of how the question was posed to respondents, as it did not ask about receiving a prescription for pain medication or counselling and advice on pain management, only about receiving pain medication while at the facility. Regardless, pain is important to consider for MA as it is commonly noted as a reason for dissatisfaction among abortion clients (56). Low uptake of pain management among MA clients may conflict with WHO guidelines which explicitly recommends that MA clients at any gestational age are offered pain management (32). There may be misconceptions among women in Ethiopia related to pain and side effects of MA, potentially indicating a lack of pre-procedure counselling. In fact, a study in Northwest Ethiopia found that half of women selected MA over MVA as a way to avoid pain and therefore called for improved counselling on side effects and pain management (55).
Strengths and Limitations
This study had limitations that are important to note. First, the adapted scales used in the survey were not validated for CAC measurement. We addressed this limitation by analyzing each outcome individually rather than using a composite measure. Furthermore, the context in Northern Ethiopia has changed drastically since data collection for this study due to the COVID-19 pandemic (57) and the conflict in Tigray. Health facilities and services across Northern Ethiopia have been devastated (58,59). In fact, as of June 2021 reports indicate that only 13.5% of all health centers and hospitals were operating in the Tigray region, of course having a distressing impact on access and availability of SRH services, including induced abortion services and PAC (60,61). This change in context has likely impacted the accuracy of our findings compared to the current state of abortion services in the four study regions of Ethiopia. Lastly, known limitations of client exit surveys for those seeking CAC include social desirability bias, low expectations of quality, and universally high satisfaction rates must be considered in interpretation of findings.
Despite these limitations, this study also had a variety of strengths. First, this research fills a recognized gap in the literature by focusing on person-centered care in public health facilities using client exit surveys. Second, the unique timing of this research provides a baseline of the quality of CAC services in Tigray and the surrounding regions that can be used to benchmark future research and service quality monitoring as the region recovers from the humanitarian crisis and works to reestablish high quality CAC services in the local health system. Third, this study also explores person-centered abortion care using independent variables that few studies in Ethiopia or East Africa have used in the past, including by region and level of public health facility. Even studies which have obtained data from multiple regions in the country or multiple facility levels, have not conducted analysis or disaggregation of data by these categories (12,41,62). Regional and facility considerations are important for localizing CAC quality improvement priorities, policies, and programs (12,51).
Program and Research Implications
Our analysis highlights the need for concentrating quality improvement efforts on specific domains of person-centered abortion care and on specific populations and settings to target areas where there is the most opportunity for impact. It is critical for programs aiming to improve CAC client experiences to have components dedicated to increasing the autonomy of people seeking induced abortion or PAC services, improving the level of communication and supportive care from health care providers, and for addressing instances of abuse and discrimination experienced by CAC clients. More specific program implications are clear from this study’s key findings at facility and regional levels. Due to the continued high rates of PAC, programmatic efforts to reduce disparities between induced abortion care and PAC service quality is critical. Our results also may indicate the need for the development of guidelines and training on appropriate pain management for MA. Additionally, concentrated initiatives are needed to improve CAC service quality at primary and tertiary hospitals with a specific focus on reproductive service integration and family planning counselling. Based on our findings, contextual knowledge, and analysis of prior research, continuing to invest in task-sharing initiatives, within higher-level facilities, may be an effective intervention for regional and national health officials to consider, as an approach for both expanding access to CAC and improving client experiences (3,63,64).
With our recommendations calling for increased focus on the quality of CAC services across the country, we cannot ignore the current humanitarian crisis in the study regions. Existing research on the emergency from international humanitarian organizations have primarily focused on gender-based violence services, with little mention of the impact on CAC services (65). This study provides an in-depth picture of CAC, from the client perspective, prior to the onset of the conflict and consequently, may be useful context to understand how the conflict has affected the health system and people in need of induced abortion or PAC. Additionally, it is important to note that CAC is included in the Minimum Initial Service Package (MISP) for SRH in Crisis Situations[6], both for responding to the needs for survivors of sexual violence (Objective 2) and as an additional SRH priority (66). Resources from humanitarian organizations and national actors to evaluate the impact of the ongoing conflict on CAC are critical to identify appropriate response interventions following implementation of the MISP (61).
Lastly, this study has also identified numerous areas for additional inquiry to further understand person-centered abortion care across Ethiopia. Due to the quantitative nature of this study, qualitative inquiry and direct observation research, including the perspectives of both abortion clients and providers, would provide useful insight into the disparities in person-centered care between induced abortion and PAC clients, the continued higher-than-expected PAC rates in the country, and the provision of pain management for all CAC clients, as well as, between MA and MVA. National-level actors can also utilize these results as a basis for improving monitoring and evaluation of CAC service quality. Specifically, our findings indicate that because additional efforts are needed to study the quality of CAC across regions (12,51), this topic should be integrated into the Ethiopian DHS to ensure consistent monitoring of induced abortion and PAC services nationally and inform efforts to improve maternal health outcomes. Finally, the results of this research also provide evidence for future research to include analysis of person-centered abortion care in Ethiopia and surrounding areas by health facility level, region, and diagnosis. Specifically, we recommend DHS integration and stakeholder adoption of indicators from the new the ACQ Tool, released in 2022 (50,67). A key strength of this tool is the intentional development of indicators that are client-centered, simple, and effective. As Ethiopian public, private, and NGO health facilities were included as study sites for the ACQ Tool development, the final tool has validity and particular relevance to the Ethiopian context (67). We therefore recommend application of this tool for future investigations of person-centered abortion care in Ethiopia and beyond.